I'm scheduled for surgery Friday for T1N0M0 (I think) I'm new here. My second opinion doctor has a team of plastic surgeons who are recommenging that we be aggressive with the tongue and rebuild with a forearm free flap.

First, I'm not thrilled about anyone touching my veins or arteries so I have to clarify that part and secondly, it's going to bad enough that I'm getting a neck dissection. Do they have to touch my arm too?

Anyone had this procedure done or just a regular skin graph. Is one better than the other?

I can't answer your question, but I want to wish you the best with your surgery and tell you that you are among a very supportive and knowledgeable group here, many of whom will be able to answer your questions, and they will come.
Here's to a good surgery and speedy and uneventful recovery.

Marlene

Where is your tumor located? Is this at a CCC or just a doctor's office or hospital? You say that this is a second opinion, what caused you to request a second opinion? How old are you?

You have found a good location for answers and support here. You can search both the forums and the entire site for subjects such as "forearm free flap".

I have had a skin graft for cancer in the floor of my mouth, a neck dissection and a free flap from my pectoral muscle for cancer in my tongue. Whether one is better than the other is really not the question - it is more a question of which treatment is best for your situation and which treatment are you most comfortable with?

Try to take a deep breath and hopefully you will get some insight here into different treatments.

Patty

Hi! I had a forearm free flap to rebuild my tongue. The procedure also included a skin graph from my thigh to cover the hole left in my wrist. I don't know about a skin graph for the tongue, that wasn't offered as an option. What I can tell you, is that the flap makes it possible for me to speak and eat 'normally.' Every thing is a little bit slo-o-o-wer, but overall, I'm very pleased with my results.

I also had the forearem free flap. Graph from my leg to cover the arm. I am now almost a year and a half out from treatment. I can speak very close to normally. It is still hard to chew some things, but can eat close to normally. I think it would be even better if I had saliva. Still hasn't come back from radiation. I too am pleased with the results as said in the previous post. My surgeon also said to be aggresive. We were going for the cure. Just remember to take one step at a time. Things really do get better, it just may take a little longer than you had hoped. I really live just about like I did before the big C hit my life.

SCC lower floor of mouth. Tumor is lower mid tongue area. I'm 39 years old.

I was first referred to a cancer center and the doctor recommended surgery and left and right neck dissection. Skin graph from thigh with bolster technique.

Second doctor is with a good hospital. He recommended the above (left neck dessection) with removing the tumor and a forearm free flap to rebuild the tongue.

My tumor is a T1 and boardering T2. Leaning towards second doctor and have the surgery already scheduled for this Friday...I'm just not sold on the forearm free flap. I'm wondering if thigh graph with lots of physically therapy will have the same effect.

Thanks for all of the quick responses!

What part of the free flap are you questioning?

Ack, I re-read your initial post and see the vein/artery part is off-putting. My thoughts, for whatever they're worth...

If you're only 39 and your cancer is cured, you've got a lot of years ahead of you. Would you be happy with anything less than the best the docs can do for you? Will you be satisfied with that for the next 30 or 40 years? Honestly, I don't miss the vein and artery in my right arm. And the trade off is a very, very workable tongue. The scar on my arm is still pretty nasty looking, although friends tell me it isn't all that bad, but what I gained was a tongue that will work for me for a long time to come.

I've had the forearm free-flap and graft from my thigh to cover my wrist, and I'm doing fine with it. I also had a layer of integra put down under my graft to keep my graft from sticking to the tendons in my arm (but I've yet to find anyone else who had this done). My graft to cover my wrist was done in a separate surgery about a month after they took the flap to allow the integra to take and I had a wound vac put over it in between the surgeries (some kind of new fandangled negative pressure stuff). Yeah, the scar is pretty noticeable on my arm, but it's worth the trade - and it's fading a lot now. The only thing I notice with not having the artery in my arm is that the small area of skin that the artery was located under gets cold and the veins in my arm show up more than they used to. That's it, other than that, I exercise and lift weights and do things normally with my arm - I haven't tried cartwheels or handstands yet, but that is coming soon I'm sure.

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.

I would still try to get another opinion from a CCC. Here's the link:

http://www.oralcancerfoundation.org/resources/cancer_centers.htm

I got 5 different opinions before I was fortunate to find Moffitt.

Pete,

Excellent post! This should be on a list of FAQs or something.

Well done.

- Margaret

[quote]I would still try to get another opinion from a CCC[/quote] Parovis is scheduled to have this done tomorrow...

The whole free flap thing is dependent on how much tongue needs to be removed and if a flap is proposed, then that implies a significant amount of tongue to be lost.

The procedure is quite complex -- Both my flaps were scheduled for ten hours in the OR -- Since this is not a simple thing, I infer that either a CCC or serious cancer facility is already involved -- This is not something a lone practitioner would do.

Here's what my 'radial forearm free flap' procedure involved:

The gas-passer had to put me out for the ten hours.

The naso-gastric tube had to be installed (not needed if PEG in place).

The tracheostomy had to be done.

The throat had to be opened for the neck dissection and anything removed prepared for the pathology lab.

The cancer had to be removed from the tongue and prepared for the pathology lab. The remaining tongue had to be prepped for fastening the flap to it and floor of mouth.

The free flap had to be harvested from the wrist donor site.

The flap's blood vessels had to be attached to the neck dissection blood vessels by surgeon with trusty hooded microscope -- Eight micro-sutures per vessel.

The flap had to be installed and fastened to remaining tongue and floor of mouth.

The skin graft had to be harvested from the thigh and the resulting wound covered with that nifty 'crumble as it heals' gizmo and sutured to stay put for a while.

The graft had to be installed and sutured to the wrist donor site and the drain(s) installed.

All the throat-cutting done by the Cutthroats had to be closed and sutured (literally hundreds of sutures and staples were involved) and the drains were installed (I think I had about five drains at first).

Very good and descriptive posts Pete. My surgery for my free flap and mandible replacement was 18 hours and there was quite a team involved. I still have shaken the hand of everyone that made it possible yet - probably only 1/2.

Parovis it is still your decision, but at 39 you have a lot of years ahead of you. There are no guarantees with cancer - you can do a lot or a little in the surgery/treatment and it may or may nor come back. Do what you are most comfortable with and know that we will all be here supporting you both during and after your surgery.

Patty

The free flap surgery is a loooong procedure. Mine was 14 1/2 hours followed by an 11 day hospital stay.

That was a really good description of the procedure, Pete. I didn't have the graft put on my arm in the same surgery as I've mentioned before, but everything else was the same.

Had much the same as others have mentioned including Pete's first free flap surgery.
Have had a few issues since then with the section between the flap and tongue.
In fact had another (day surgery only) operation yesterday.
The operation went well and even though I had a fair bit of pain and swelling yesterday I am feeling a lot better his morning.
With the help of Panadeine Forte I managed to sleep well for 5 hours straight last night.
Counted 15 stiches which means there are probably more.
They did take a small graft from inside of cheek to put over the area as a barrier but from the same side which is good!
On a liquid diet again for a week.
Gabriele

Gabe I hope that you get more than 5 hours sleep tonight and heal rapidly.

Patty

Thanks for all of the replies. Don't know if I made a hasty decision but once I found out I had cancer, I was ready to make a move for fear of spreading.

I went with the free flap. I made the decision the morning of surgery. Everything went well. About 25% of tongue removed. 10 and half hours of surgery and as of yesterday, back home and recovering.

Other than it looking pretty bad, overall, i'm feeling pretty good. Trusted my doctor and plastic surgeons on the free flap. Think I made the right decision. So far, clear margins and negative on the nodes.

Just trying to heal. Would also like to find out why this happened, although probably won't. I'm not a smoker or drinker so not sure what else could have caused this, if anything other than genes. Would be very curious though to do a study on lifestyle products we use as I read oral cancer jumped 11% in 2007 alone and mainly in younger people.

Makes you wonder....

Glad to hear that you are home and on your way to recovery. Clear margins and negative nodes are great.

Try doing a search on the site for HPV. There was also a thread recently on alcohol in mouthwashes. There are many different thoughts on the causes.

Patty