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Original research study

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

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For citation purposes: Song M, Li QL, Li FJ, Chen SW, Zhuang SM, Wang LP, Li H, Yang AK. Mandibular lingual release approach: an appropriate approach for total or subtotal glossectomy. Head Neck Oncol. 2013 Feb 06;5(2):11.

Mandibular lingual release approach: an appropriate approach for total or subtotal glossectomy

M Song1,2†, QL Li1,2†, FJ Li1,3, SW Chen1,2, SM Zhuang1,2, LP Wang1,2, H Li1,2, AK Yang1,2*

AbstractBackgroundWe evaluated a new approach for total or subtotal glossectomy—the mandib-ular lingual release approach (MLRA)—in place of the lip-split approach.MethodsWe retrospectively reviewed 22 patients with advanced oral cancer who had undergone total or subtotal glossectomy between April 2005 and March 2011. The MLRA was used in 15 patients and the lip-split in seven.ResultsThe gross complication rate was 31.8% (7/22), 26.7% (4/15) for the MLRA and 42.9% (3/7) for lip-split. The recurrence rate was 40.9% (9/22) and gross survival rate was 68.2% (15/22). The gross speech intelligibility satis-factory (acceptable or good) rate was 56.1% (13/22), 53.3% (8/15) for the MLRA and 71.4% (5/7) for lip-split. The gross swallowing capacity satis-factory rate was 68.2% (15/22), 73.3% (11/15) for the MLRA and 57.1% (4/7) for lip-split.ConclusionThe MLRA offers improved space and exposure for removing primary tumour, avoids facial scarring and man-dibulotomy and enables good chewing and swallowing function.

IntroductionPatients with advanced oral cancer, including that of the tongue, the base of the tongue, the floor of the mouth and other sites, usually require total or subtotal glossectomy, although this surgical option remains controversial1. There are two crucial questions to be resolved. The first is how to achieve adequate safe surgical margins and long-term survival. The second is how to improve patients’ quality of life, such as by restoring speech, swallowing and deglutition and avoiding facial scar-ring. Traditionally, the lip-split approach is the primary option for expanded tongue surgery, but this requires splitting of the lip and/or mandibul-otomy, which severely reduces the patient’s quality of life2. In this study, with regard to the questions above, we evaluate our experience of a new approach for total or subtotal glossec-tomy, the mandibular lingual release approach (MLRA).

Patients and methodsPatientsBetween April 2005 and March 2011, 22 patients with advanced oral cancer underwent total or subtotal glossec-tomy at the Sun Yat-Sen University Cancer Center. Eighteen patients were male and four were female. The mean age was 45.8 years (range 15–63 years). According to the 2002 International Union Against Cancer3 staging criteria, eight cases were T3N0M0, four were T2N1M0, two were T3N1M0, one was T3N2M0, three were T4N0M0, one was T4N1M0 and one was T4N2M0 and the remaining two were recur-rences after hemiglossectomy; there-fore, they were not TNM staged (Table 1). Before surgery, all patients underwent a thorough examination and the criteria for inclusion in the study

were as follows: (1) primary tumour located in the tongue or the floor of the mouth and pathologically diagnosed as malignant disease; (2) preoperative computed tomography (CT) or mag-netic resonance imaging (MRI) showed invasion of more than one-half of the tongue tissue by primary tumour; (3) no distant metastasis (including lung, liver, brain, bone) found on preopera-tive examination and (4) general con-dition suitable for lengthy surgery.

Surgical techniqueLip-split mandibulotomy approachThis traditional approach for the abla-tion of extensive malignant tumour in the tongue has many modifications, but we always used the typical tech-nique. First, the lower lip and anterior mandibular labial sulcus are incised, usually in continuity with the neck dissection incision. After incising the skin, mucous membrane and muscle, mandibulotomy is performed in the midline. A lingual sulcus releasing incision is then made to allow the mandible to be swung out.

MLRAIn this technique, an incision is made from the mastoid on one side to that on the other side, usually in continu-ity with the neck dissection incision (Figure 1). Subplatysmal skin flaps are raised up to the level of the lower border of the mandible. Bilateral level I regional dissection is performed and the suprahyoid muscles of the digastric anterior belly are identi-fied before entering the oral cavity (Figure 2). On the inner aspect of the mandible, the digastric, mylohyoid, geniohyoid, genioglossus, and, in part, the medial pterygoid muscles are carefully detached from the lingual sur-face of the mandible by subperiosteal

* Corresponding authorEmail: [email protected]† These authors contributed equally to this

study.1 State Key Laboratory of Oncology in South

China, Sun Yat-sen University Cancer Center, Guangzhou, China

2 Department of Head and Neck Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China

3 Operation Theater Services, Sun Yat-sen University Cancer Center, Guangzhou, China

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dissection. In the mouth, an alveolar crest or lingual gingival sulcus incision (depending on the location of the tumour) is made (Figure 3). The floor of the mouth and tongue can then be dropped into the neck (Figure 4), thereby providing access to all parts of the tongue and oropharynx. Resection and reconstruction are then performed under direct vision and palpation (Figure 5). When closing the wound, the digastric muscles on both sides can be sutured with subplatysmal tissue.

Total and subtotal glossectomyBefore ablation of primary tumour, all cases first required ipsilateral or bilateral neck dissection.

According to the literature, we defined total glossectomy as the resec-tion of more than 90% of oral and oro-pharyngeal tongue tissue and subtotal glossectomy as the resection of 66.6%–90%. When the mandible was invaded by a tumour, segmental resection with the primary tumour was required; if the tumour had merely spread to the lingual-side periosteum of the mandi-ble, the periosteum only was removed and the mandible retained. All cases in this study required intraoperative frozen sections to pathologically con-firm the safety of the margin. There was no pathological evidence of tumour spread to the larynx; therefore, the larynx was preserved in all cases.

Reconstruction with flap tissueIn all cases, two teams operated synchronously; one team ablated the primary tumour and performed neck dissection, while the other harvested the flap and reconstructed the oral cavity defect. All patients in this study

Table 1 Patient profiles

Case Sex Age (years) Site TNM stage Chemotherapy

1 F 35 T T3N0M0

2 M 59 T T4N0M0

3 M 51 T T3N0M0

4 M 63 T T3N1M0 PBF

5 M 46 T T3N0M0 PBF

6 M 58 T T3N0M0

7 M 31 BT T2N1M0

8 F 55 BT T3N0M0 PBF

9 M 62 T T3N0M0 TPF

10 M 34 T T4N1M0

11 F 27 T T3N2M0

12 M 58 T T3N0M0

13 M 48 T

14 M 42 T T3N0M0

15 M 15 FM T4N2M0 TPF

16 M 56 T T4N0M0 PBF

17 M 41 FM T2N1M0

18 F 27 BT T4N0M0 TPF

19 M 36 T T2N1M0

20 M 59 T TPF

21 M 57 BT T2N1M0

22 M 47 FM T3N1M0

M, male; F, female; T, tongue; BT, base of tongue; FM, floor of mouth; TPF, Taxol, DDP and 5-Fu; PBF, DDP, Bleomycin and 5-Fu.

Figure 1: Incision made using the MLRA; generally it was made from the mastoid on one side to that on the other side.

Figure 2: Before entering the oral cavity, bilateral level I regional dissection was performed and the suprahyoid muscles of the digastric anterior belly were clearly identified.

Figure 3: The anatomic sketch map of incision in the mouth. An alveolar crest or lingual gingival sulcus incision (depending on the location of the tumour) was made.

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required reconstruction by flap; four types of flap were used: free flap including anterolateral thigh (ALT)4 flap, radial forearm flap (FAF)5, vascu-lar pedicle flap including pectoralis major myocutaneous flap (PMMF)6 and trapezius myocutaneous flap (TMF)7. Flap size was determined intraoperatively and depended on the oral cavity defect (Figures 6 and 7).

Functional evaluation of speech and swallowingAt least 6 months after surgery, a ques-tionnaire was given to the patients to investigate their speech and swallow-ing function.

Speech was rated on a scale of 1 to 5, according to its understandability by a speech therapist during conver-sation. The scores were defined as follows: 1, speech clearly understood; 2, speech occasionally misunderstood; 3, speech understood only when the context of the text was known to the listener; 4, speech occasionally under-stood and 5, speech not understood at all. To grade the results and to analyse the final outcome in relation to other clinical factors, speech was also clas-sified more broadly as good (score 1 or 2), acceptable (score 3) or poor (score 4 or 5).

The Swallowing Ability Scale was used to assess swallowing capacity. The scoring system is based on the MTF classification, in which the method of food intake (M) is classified and scored as follows: M5, capacity for swallowing unlimited (5 points); M4, capacity for swallowing anything, but care must be taken to avoid aspiration (4 points); M3, capacity to eat any-thing if the food is prepared in a suit-able form (3 points); M2, capacity to eat small portions of food, but tube feeding is the main means of inges-tion (2 points) and M1, tube feeding is the only method of ingestion (1 point). We defined a score of 1 or 2 as good, 3 as acceptable and 4 or 5 as poor.

The time required for food intake (T) is assessed according to the aver-age time required to eat a daily meal

(irrespective of its nature and con-sistency). This parameter is classified and scored as follows: T5, normal food intake time, viz. <15 min (5 points); T4, intake of food requires 15–25 min (4 points); T3, intake requires 25–35 min (3 points); T2, intake requires 35–45 min (2 points) and T1, intake requires >50 min or is impossible (1 point).

The consistency of the food that the patient is able to ingest (F) is classi-fied and scored as follows: F5, capa-city to eat food of any consistency (5 points); F4, capacity to eat soft, chewable food such as cooked rice or cooked vegetables (4 points); F3, capac-ity to eat gruel (3 points); F2, capacity to swallow viscous fluids (2 points) and F1, capacity to swallow only non-viscous fluids (1 point). We defined swallowing function as the total MTF score, with 9–15 good, 7 or 8 accept-able and 3–6 poor8.

ResultsIn our study, 9 of the 22 patients underwent total glossectomy and 13 underwent subtotal glossectomy. The pathological diagnoses were 20 squa-mous cell carcinomas (SCC), 1 adenoid cystic carcinoma (ACC) and 1 primi-tive neuroectodermal tumour (PNET). No patient died during the periopera-tive period, and no patient underwent laryngectomy. In all cases, the tongue defects were reconstructed by flap tis-sue; 15 were microvascular free-flap transfers and 7 were vascular pedicle flap transfer. All flaps survived post-operatively. The gross complication rate was 31.8% (7/22), 26.7% (4/15) for the MLRA and 42.9% (3/7) for the lip-split approach. Ten patients received post-operative radiotherapy, with doses of 66–70 cGy; the average dose was 68 cGy. The follow-up time was 12–72 months. Recurrence was found in nine patients during the follow-up period; the recurrence rate was 40.9% (9/22) [33.3% (5/15) for the MLRA and 57.1% (4/7) for lip-split]. The recurrent sites were three local, two neck, two neck/local and two distant metastasis (lung).

Figure 4: The floor of the mouth and tongue (including tumour) was dropped into the neck.

Figure 5: Huge defect of oral cavity after tumour ablation; only a little oropharyngeal tongue tissue was left (the forcep dragged it out).

Figure 6: Harvest of the ALT free flap.

Figure 7: Reconstruction of the oral cavity by the ALT free flap.

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The gross survival rate was 31.8% (7/22); seven patients died during the follow-up period, but only sur-vived for less than one year. All deaths were caused by tumour (Table 2).

Functionally, speech intelligibility was satisfactory (good = 1 or 2) in 56.1% patients (13/22) [60.0% (9/15) for the MLRA and 57.1% (4/7) for lip-split] and swallowing capacity was satisfactory (good = 9–15) in 68.2% patients (15/22) [73.3% (11/15) for the MLRA and 57.1% (4/7) for lip-split]. There were no statistically significance differences in function. No patient needed per-manent tube feeding, but 1 of 19 patients required tracheotomy that

subsequently could not be decannu-lated (Table 3).

Case report (No. 10)A 34-year-old Chinese man experi-enced pain in the right side of his tongue for about 3 years accompanied by slight swelling of the tongue for about 18 months. At the hospital, oral examination indicated that the patient had limited lingual movement. A lymph node was palpated in the right level IIA of the neck; it measured about 20 × 15 mm and was stiff and mobile with a clear border. Preoperative biopsy was performed, and the pathological diagnosis was ACC. MRI showed a tumour in the right side of the tongue

measuring 50 × 54 × 46 mm that had infiltrated the floor of the mouth (Figure 8). Chest radiography and abdominal ultrasonography were nor-mal. The patient underwent subtotal glossectomy and total resection of the floor of the mouth and the right lateral wall of the oropharynx using the MLRA (Figure 9), along with ipsilat-eral modified radical neck dissection and tongue reconstruction using a TMF. The neck specimen was removed in continuity with the primary tumour using a pull-through approach. The patient received radiation therapy 6 weeks after surgery, with a dose of 68 Gy. The combined-modality treat-ment was tolerated well. He was

Table 2 Treatment of patients

Case Approach Resection Flap Pathology Complication Post-operative radiotherapy

Recurrence metastasis

Follow-up (months)

Condition

1 Lip-split TG PMMF SCC Necrosis/fistula Local 30 D

2 MLRA STG FAF SCC Fistula Local 9 D

3 Lip-split STG ALT SCC 52

4 Lip-split STG PMMF SCC Fistula Neck 14 D

5 MLRA TG FAF SCC 50

6 Lip-split TG PMMF SCC 68 Local 46

7 MLRA STG ALT SCC 41

8 Lip-split STG ALT SCC 70 30

9 MLRA TG ALT SCC 66 26

10 MLRA STG TMF ACC 68 Lung 32

11 Lip-split STG TMF SCC Effusion 66 26

12 MLRA TG ALT PNET Fistula 68 Local/lung 18 D

13 Lip-split TG ALT SCC Neck/local 12 D

14 MLRA STG ALT SCC 17

15 MLRA STG PMMF SCC 68 Neck/local 15 D

16 MLRA TG ALT SCC 12

17 MLRA STG ALT SCC 70 11

18 MLRA TG ALT SCC 11

19 MLRA STG ALT SCC Fistula Neck 23 D

20 MLRA TG PMMF SCC 66 16

21 MLRA STG ALT SCC Bleeding/fistula 15

22 MLRA STG ALT SCC 70 12

TG, total glossectomy; STG, subtotal glossectomy; D, death.

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followed-up closely, and he was found to have lung metastasis 2 years after treatment. No further treatment is available for this patient.

DiscussionTraditionally, transoral resection is often possible for early and anterior tongue tumours, but this approach is difficult for deeply infiltrating and posterior cancers. There are four major approaches in this situation. First is the parapharyngeal approach, which is usually employed for small tumours located in the base of the tongue9. Second is lip-split mandibulotomy, which is suitable for extensive oral surgery, but causes facial scarring and labial asymmetry (Figure 10)2,10,11. Third is the visor flap; with this approach, it is

easy to access the anterior oral cavity, but the mental nerve usually needs to be cut to raise the chin and cheek flap, and this causes labial anesthesia11. Fourth is the MLRA, which was first reported by Stanley in 198412. This is a good approach for exposure of the whole tongue, particularly its posterior side.

In the past two decades, treatment of advanced oral cancer with total or subtotal glossectomy has been con-troversial. This procedure can cause significant morbidity and mortality, resulting in poor quality of life and inevitable functional deficits such as problems with swallowing and loss of speech. Increasingly, head and neck oncologists13 believe that advanced oral cancer requires multimodality

therapy, and surgical resection is the preferred initial modality. The prog-nosis of resectable cases is better than that of unresectable cases, meaning that, in some patients, extensive abla-tion by, for example, total or subtotal glossectomy can now improve the prognosis of cancers that were previ-ously regarded as unresectable14,15. In the present study, only one patient died less than one year after surgery, showing that surgery can dramatically prolong the survival and free-disease

Table 3 Functional evaluation of patients

Case Approach Flap Speech score Swallowing score

1 Lip-split PMMF 4 M2 T2 F2 6

2 MLRA FAF 3 M3 T2 F3 8

3 Lip-split ALT 2 M3 T2 F3 8


5 MLRA FAF 2 M4 T4 F4 12


7 MLRA ALT 2 M4 T3 F4 11



10 MLRA TMF 2 M5 T4 F4 13

11 Lip-split TMF 2 M5 T4 F5 14




15 MLRA PMMF 3 M3 T3 T3 9

16 MLRA ALT 2 M3 T3 T4 10

17 MLRA ALT 2 M4 T4 T4 12



20 MLRA PMMF 3 M3 T2 F3 8



Figure 8: As the No. 10 case patient, the axial section of the MRI showed that the malignant tumour had infiltrated almost the whole tongue (around the white arrows).

Figure 9: The defect of oral cavity after subtotal glossectomy and total resection of the floor of the mouth and the right lateral wall of the oropharynx using the MLRA.

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time of patients with advanced oral cancer. The key to avoiding recurrence following surgical treatment is achiev-ing a safe surgical margin. The stand-ard acceptable criterion is a 1–1.5 cm soft tissue margin around the gross tumour16, which is a challenge for head and neck surgeons. Our data showed patients in whom the MLRA was used for total or subtotal glossec-tomy had a lower recurrence rate (33.3%) than those treated with the lip-split approach (57.1%). One reason for this may be that use of the MLRA enables direct vision and palpation to remove the primary tumour; another resection of the base of the tongue and the oropharynx is easier and safer with the MLRA than with the traditional approach. Conventionally, the lip-spilt approach is used for tumours located at the base of the tongue (even T2 tumours). In the pre-sent study, however, we successfully treated three patients with base of the tongue cancer using the MLRA.

The other controversial issue is the poor quality of life of patients who have undergone total or subtotal

glossectomy. Surgical reconstruction plays a crucial role in extended tongue resection, not only to repair the large defect, but also to restore tongue function. Yun et al.17 and Sakuraba et al.18 reported that correct choice of reconstruction can improve outcome. All patients in the present study underwent auto-flap tissue transplan-tations, all of which were successful. Some patients remained able to swal-low and speak as usual; our data showed good speech intelligibility in 56.1% (13/22) and satisfactory swallowing in 68.2% (15/22) patients. No patient totally lost his speech or capacity to swallow.

There are various options for the reconstruction of tongue defects; we used four types of flap: two free flaps and two vascular pedicle flaps. There are no significant differences in the use of different flaps; selection criteria depend on the condition of the indi-vidual and the preferences of the institute. Kimata et al.19 indicated that using a flap of sufficient volume is asso-ciated with good function; PMMFs and ALTs are usually suitable for this purpose, but precise closing of defects in the oral cavity is difficult using a bulk flap. We found that use of the

MLRA creates obstacle-free access for reconstruction, especially when closing oropharyngeal and hypopharyngeal defects (Figure 11). Thus, restoration of function may be improved in patients treated with the MLRA.

Compared with the lip-split approach, the MLRA has two other advantages. First, it provides a good aesthetic outcome; there is no facial scarring; therefore, patients are happier to participate in social activi-ties20. Second, using the MLRA avoids mandibulotomy, which is good for patients who receive post-operative radiotherapy, because mandibulotomy can increase the risk of osteoradione-crosis21. Merrick et al.22 suggested that accurate repositioning and permanent fixation of the genioglossus, geniohy-oid and digastric muscles will improve outcomes in terms of speech, chewing and swallowing, but this requires a small osteotomy of the anterior man-dible. Our experience shows that this is unnecessary because, after total or subtotal glossectomy, there are only few or no intrinsic lingual muscles attached to the residual tongue, and it would be difficult to reposition the extrinsic lingual muscles to provide tongue movement. Generally, only the digastric muscle could be reused, and we usually reattach this with subplat-ysmal tissue and improve the floor of the mouth. The genioglossus and geniohyoid muscles are always close to the primary tumour, and thus need be detached from the mandible and mostly removed; the muscles then contract and would be difficult to reattach. Moreover, osteotomy is dis-advantageous to patients who require post-operative radiotherapy because it increases the risk of osteomyelitis; as a consequence, we do not recom-mend using this method to improve tongue function.

We searched the current medical literature and found only a few stud-ies reporting use of the MLRA for oral cavity tumour treatment, and only we have used it for total or subtotal glossectomy. Given the advantages

Figure 10: The patient after lip-split mandibulotomy after about one year; it causes obviously facial scarring and labial asymmetry.

FPOFigure 11: One of the advantages of the MLRA is that it creates obstacle-free access for reconstruction, especially when closing oropharyn-geal and hypopharyngeal defects. As shown, we used absorbable sutures to close the wound from posterior to anterior site, and then held the sutures to pull the posterior tissue out, so that it is more convenient to manipulate.

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discussed above, we strongly recom-mend the MLRA as an appropriate approach for total or subtotal glossec-tomy. Treatment of patients with advanced oral cancer remains a chal-lenge for head and neck oncologists. Use of the MLRA for total or subtotal glossectomy provides convenient access for surgery and ensures the success of the procedure, but cannot bring about any essential change to the survival of patients with advanced oral cancer. Such treatment requires a multidisciplinary approach combining surgery with radiotherapy and chem-otherapy. Humanized monoclonal antibodies targeted against the epi-dermal growth factor receptor, such as cetuximab, are promising agents combined with cisplatin-based chem-otherapy and radiotherapy for high-risk advanced oral cancer23,24. We believe that effective surgical treat-ment can contribute to the survival of these patients combined with new treatment strategies.

AcknowledgementsThis study was supported by grants from the National Natural Science Foundation of China (No. 81172568), and the Science and Technology Pro-gram Fund of Guangdong Province (No. 303041017005).

References1. Bova R, Cheung I, Coman W. Total glos-sectomy: is it justified? Anz J Surg. 2004 Mar;74(3):134–8.2. Devine JC, Rogers SN, McNally D, Brown JS, Vaughan ED. A comparison of aesthetic, functional and patient subjective outcomes following lip-split mandibulotomy and mandibular lingual releasing access procedures. Int J Oral Maxillofac Surg. 2001 Jun;30(3): 199–204.3. Greene FL, Page DL, Fleming ID, Fritz A, Balch CM. AJCC Cancer staging manual. 6th edition. New York: Springer; 2002.

4. Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction. Head Neck. 2004 Dec;26(12):1038–44.5. Chien CY, Hwang CF, Chuang HC, Jeng SF, Su CY. Comparison of radial forearm free flap, pedicled buccal fat pad flap and split-thickness skin graft in reconstruc-tion of buccal mucosal defect. Oral Oncol. 2005 Aug;41(7):694–7.6. Song M, Chen WK, Guo ZM, Li QL. Reconstruction with pectoralis major myocutaneous flap for surgical defect in advanced head and neck cancer patients. Ai Zheng. 2008 Jan;27(1):58–61.7. Netterville JL, Panje WR, Maves MD. The trapezius myocutaneous flap. Depend-ability and limitations. Arch Otolaryngol Head Neck Surg. 1987 Mar;113(3): 271–81.8. Yanai C, Kikutani T, Adachi M, Thoren H, Suzuki M, Iizuka T. Functional outcome after total and subtotal glossectomy with free flap reconstruction. Head Neck. 2008 Jul;30(7):909–18.9. Harris PF, Rosenfeld L, Ward PH. Lateral pharyngotomy approach for lesions of the base of the tongue, pharynx and larynx. South Med J. 1968 Dec;61(12): 1276–80.10. Brown J, Chatterjee R, Lowe D, Lewis-Jones H, Rogers S, Vaughan D. A new guide to mandibular resection for oral squa-mous cell carcinoma based on the Cawood and Howell classification of the mandible. Int J Oral Maxillofac Surg. 2005 Dec;34(8): 834–9.11. Cilento BW, Izzard M, Weymuller EA, Futran N. Comparison of approaches for oral cavity cancer resection: lip-split ver-sus visor flap. Otolaryngol Head Neck Surg. 2007 Sep;137(3):428–32.12. Stanley RB. Mandibular lingual releasing approach to oral and oropharyn-geal carcinomas. Laryngoscope. 1984 May; 94(5 Pt 1):596–600.13. Ow TJ, Myers JN. Current manage-ment of advanced resectable oral cavity squamous cell carcinoma. Clin Exp Otorhi-nolaryngol. 2011 Mar;4(1):1–10.14. Barry B, Baujat B, Albert S, Nallet E, Depondt J, Guedon C, et al. Total glossec-tomy without laryngectomy as first-line or salvage therapy. Laryngoscope. 2003 Feb;113(2):373–6.

15. Vartanian JG, Magrin J, Kowalski LP. Total glossectomy in the organ preserva-tion era. Curr Opin Otolaryngol Head Neck Surg. 2010 Apr;18(2):95–100.16. Ow TJ, Myers JN. Current manage-ment of advanced resectable oral cavity squamous cell carcinoma. Clin Exp Otorhi-nolaryngol. 2011 Mar;4(1):1–10.17. Yun IS, Lee DW, Lee WJ, Lew DH, Choi EC, Rah DK. Correlation of neotongue volume changes with functional outcomes after long-term follow-up of total glossectomy. J Craniofac Surg. 2010 Jan;21(1):111–6.18. Sakuraba M, Asano T, Miyamoto S, Hayashi R, Yamazaki M, Miyazaki M, et al. A new flap design for tongue reconstruction after total or subtotal glossectomy in thin patients. J Plast Reconstr Aesthet Surg. 2009 Jun;62(6):795–9.19. Kimata Y, Sakuraba M, Hishinuma S, Ebihara S, Hayashi R, Asakage T, et al. Anal-ysis of the relations between the shape of the reconstructed tongue and postoperative functions after subtotal or total glossectomy. Laryngoscope. 2003 May;113(5):905–9.20. Devine JC, Rogers SN, McNally D, Brown JS, Vaughan ED. A comparison of aesthetic, functional and patient subjec-tive outcomes following lip-split mandib-ulotomy and mandibular lingual releasing access procedures. Int J Oral Maxillofac Surg. 2001 Jun;30(3):199–204.21. Dai TS, Hao SP, Chang KP, Pan WL, Yeh HC, Tsang NM. Complications of mandibulotomy: midline versus paramid-line. Otolaryngol Head Neck Surg. 2003 Jan;128(1):137–41.22. Merrick GD, Morrison RW, Gallagher JR, Devine JC, Farrow A. Pedicled genial osteotomy modification of the mandibu-lar release access operation for access to the back of the tongue. Br J Oral Maxillofac Surg. 2007 Sep;45(6):490–2.23. Murthy V, Agarwal JP, Laskar SG, Gupta T, Budrukkar A, Pai P, et al. Analysis of prog-nostic factors in 1180 patients with oral cavity primary cancer treated with defini-tive or adjuvant radiotherapy. J Cancer Res Ther. 2010 Jul–Sep;6(3):282–9.24. Moon C, Chae YK, Lee J. Targeting epidermal growth factor receptor in head and neck cancer: lessons learned from cetuximab. Exp Biol Med (Maywood). 2010 Aug;235(8):907–20.

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