I see the free flap work as separate from the actual cancer work, so the term "aggressive" seems a bit out of place here. Maybe some sort of synthetic hole filler would be considered less aggressive? Or should we be using the word invasive...

I don't know of any case where just a skin graft has been used -- Seems to me that would be a waste of time -- One could easily get by with a tongue smaller than the thickness of a graft, and a graft would not 'back fill' a larger portion of missing tongue.

The purpose of the flap is to fill in on the tongue when there is not much left, especially in the oral or mobile tongue (front part). My first partial glossectomy surgeries didn't involve flaps because there was plenty of working tongue left after the tumor was removed and good margins obtained.

My next glossectomy removed so much of the front of my mobile tongue that something was needed to fill the hole to avoid food and air currents (as in speech)from being trapped there. The flap was constructed using tissue from my forearm, plus the veins and arteries needed to keep the tissue alive (spliced into neck veins and arteries for blood supply). BTW, remaining blood vessels will expand to meet the situation (aka collateral growth) and grow new paths as needed, so over time that isn't going to be a problem.

Gonna do a flap, have to mess with veins and arteries or you might as well make something out of an old shoe to stick in there. Not at all sure why that would be a problem -- The ability to splice all these blood vessels together under a microscope is the basis for being able to do the flaps in the first place.

The thigh graft (not graph) is almost an after-thought in the whole process, being just the removal of a layer of skin from my thigh to cover the forearm because all the surface skin was now in my mouth -- They even left the hair behind. I just looked at my thigh and I can hardly tell where they harvested the graft. My friend was looking at my wrist donor site a few days ago and remarked that it wasn't very noticeable any longer, with the scars and color matching the surrounding skin (but it is missing hair, the original hair went into my mouth and the graft hair was left behind on my thigh).

However, with the discovery of more cancer on BOT and the subsequent total glossectomy that went with correcting that, a much larger free flap donor site was needed for the new flap than my other wrist could provide, so they chose to get the flap material from my other thigh. No graft involved because they just pulled the edges of the donor area together and stapled them.

Subsequent failure of some of that flap from lack of adequate blood flow (as evidenced by pin pricks on the flap for the first week after surgery) shows the need for messing with veins and arteries.