Islanded facial artery myomucosal flap versus free anterolateral thigh flap in oral reconstruction: a cost-effectiveness analysis

Islanded facial artery myomucosal flap versus free anterolateral thigh flap in oral reconstruction: a cost-effectiveness analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Islanded facial artery myomucosal flap versus free anterolateral thigh flap in oral reconstruction: a cost-effectiveness analysis Xiaodong Han, Minghao Wang, Xiaojun Shao, Zhaojie Du, Baixuan Song, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7493719/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The free anterolateral thigh (ALT) flap has long been the standard for reconstructing oral defects following the resection of squamous cell carcinoma (SCC) in the oral tongue (OT) or floor of the mouth (FOM). However, recent case-series studies suggest that the islanded facial artery myomucosal (FAMM) flap also yields satisfactory results for moderate-sized oral defects. Although the islanded FAMM flap avoids the need for vascular micro-anastomosis, its advantages over the ALT flap remain unconfirmed. This study aims to compare the cost-effectiveness of the islanded FAMM flap with the free ALT flap in the reconstruction of moderate-sized oral defects following early-stage OT/FOM SCC resection. Methods: A single-centered retrospective cohort study was conducted on patients undergoing compartmental resection of OT/FOM SCC with subsequent reconstruction using either islanded FAMM flap or free ALT flap. Data on patient characteristics, operating duration, tracheostomy rate, ICU days, post-operative days, complications, mouth opening, swallowing, speech, aesthetics, and hospitalization costs were compared. Results: Thirty-one patients with OT/FOM SCC were included; 16 underwent reconstruction with the islanded FAMM flap, while 15 received the free ALT flap. The FAMM flap group exhibited shorter operating times (514 ± 66.2 vs. 602.6 ± 95.2 min), significantly lower tracheostomy rates (12.5% vs. 100%), higher esthetic scores (6.8 ± 1.5 vs. 4.9 ± 1.3), and reduced hospitalization costs (59,286 ± 13,903 yuan vs. 95,224 ± 18,223 yuan). Functional outcomes related to mouth opening, swallowing, and speech were comparable between the two groups. Conclusions: The islanded FAMM flap emerges as a cost-effective alternative to the free ALT flap for moderate-sized tongue defects, delivering similar functional outcomes while offering superior esthetic results and lower overall costs; however, its advantages still needs to be further investigated in prospective randomized control study. plastic surgery surgical flaps mouth mucosa squamous cell carcinoma neck dissection Figures Figure 1 Figure 2 Figure 3 Introduction In managing oral squamous cell carcinoma (SCC), surgery stands as the primary treatment modality. Traditionally, for clinical early-staged node-negative oral SCC (cT1/2N0), treatment involved only wide resection of the primary tumor followed by a "wait-and-see" approach for the neck and dissection was reserved for when positive clinical signs of cervical nodal spread, termed therapeutic neck dissection. However, recent studies have uncovered significant insights. Firstly, a mere 2-3mm depth of invasion of an oral SCC in the oral tongue (OT) or floor of the mouth (FOM) can result in a nearly 20% risk of occult cervical lymph-node metastasis[1, 2].Secondly, simultaneous elective neck dissection (END) has shown to enhance long-term cancer-related outcomes compared to a therapeutic neck dissection[3]. Thirdly, compartmental resection of an OT/FOM SCC — involving the comprehensive removal of all the muscles impacted by the tumor, along with associated neurovascular and lymphatic pathways to the neck — offers superior locoregional control compared to traditional wide resection[4–8]. These revelations advocate for adopting compartmental resection combined with simultaneous END as a unified procedure, even for cT1/2N0 OT/FOM SCC. This shift in treatment approach results in a moderate-sized defect which is usually about 5cm in length by 3 cm in width by 1.5cm in thickness and is too large to close primarily, necessitating simultaneous reconstruction using surgical flaps. Free soft tissue flaps have become the mainstay in reconstructing oral and maxillofacial defects. Among them, anterolateral thigh (ALT) flap stands out due to its adaptability, particularly useful for large and complex soft tissue defects. However, for such a moderate-sized defect resulted from compartmental resection of an OT/FOM SCC, the ALT flap may not be the best option in terms of cost-effectiveness as the primary purpose is simply to reconstruct the intra-oral lining. The facial artery myomucosal (FAMM) flap is an axial pattern flap[9], typically fashioned in a long triangular shape with a base of approximately 1cm to ensures reliable vascularization. However, the rotation of this flap into the oral cavity can be hindered by dental structures. The concept of islanded FAMM flap, delineated first by Zhao in 1999 through the meticulous dissection of the facial artery and vein, marked a significant advancement[10]. This refinement not only facilitated the harvesting of larger flaps but also substantially enhanced the rotational freedom of the flap. Several case series have underscored the clinical merits of the islanded FAMM flap in repairing moderate-sized oral defects[11–17]. In this context, we aimed to evaluate the cost-effectiveness of the islanded FAMM flap as a preferable alternative to the free ALT flap in the reconstruction of moderate-sized defects following compartmental resection of an OT/FOM SCC. Patients and methods A retrospective cohort study was conducted in patients diagnosed with OT/FOM SCC at the authors' tertiary hospital from January 2017 to June 2023. The study was approved by the institutional review board of the authors’ hospital (S2024-17-01) at 15 August 2024. Written informed consent was obtained from the patient for publication of this case report and accompanying images. All the surgeries were performed by the same senior surgeon. The inclusion criteria were: 1) Patients aged 18–75 years old. 2) American Society of Anesthesiologists (ASA) Physical Status scores between I to III. 3) Unilateral oral SCC in the OT/FOM. 4) The depth of invasion (DOI) was more than 2mm and less than 10mm (cT1/2), as determined by pre-operative magnetic resonance imaging (MRI) scans. 5) No clinical positive node detected pre-operatively (cN0). 6) The patients underwent standard compartmental resection of the primary tumor with ipsilateral comprehensive END (Levels 1 to 5) in continuing monobloc fashion. 7) Reconstruction was performed using either the free ALT flap or the islanded FAMM flap. 8) Post- operative follow-up lasted twelve months or longer. The exclusion criteria were: 1) Primary tumor near or crossing midline which necessitated bilateral neck dissection. 2) Recurrent OT/FOM SCC. 3) History of radiotherapy in the neck. Patients were followed-up with physical examination, ultrasonography imaging or MRI if necessary every month for the first year, then every 3 months for the second year, every 6 months for the third year and every twelve months for year 4–5. Compartmental resection of an OT/FOM SCC and reconstruction using free ALT flap The intraoperative biopsy was conducted upon completion of temporary per-oral intubation. Upon an SCC diagnosed through frozen section, elective tracheostomy was performed, and intubation was transitioned from per-oral to per-tracheostomy. The primary procedures were started from elective neck dissection initiating from level 5. As the dissection progressed to level 1, the submandibular gland was left connected to the floor of the mouth. The compartmental resection of the primary tumor involved the longitudinal removal of all the muscles invaded by the tumor, the sublingual gland, the intermediate neurovascular and lymphatic pathway (T-N tract), and the submandibular gland which constituted part of the completed neck dissection 6–8 . In cases where the primary tumor was situated in the posterior part of the oral cavity, mandibulectomy was performed to facilitate compartmental dissection[18]. Harvesting the anterolateral thigh (ALT) flap was carried out in a simultaneous two-team approach. End-to-end arterial anastomosis was performed using 8 − 0 or 9 − 0 sutures and one or two veins were anastomosed using vascular coupler. The anastomosis was conducted under an operative microscope (Fig. 1 ). Compartmental resection of an OT/FOM SCC and reconstruction using islanded FAMM flap The intraoperative biopsy was conducted upon the completion of definitive intra-nasal intubation. Elective tracheostomy was not necessary unless there is a significant risk after comprehensive assessment of airway risk. Upon confirmation of an SCC through frozen section analysis, elective neck dissection was carried out from level 5. When the dissection approached up to level 1, the facial artery and vein were meticulously identified and carefully dissected in a retrograde manner to their respective origins. Specifically, the facial artery originates from the external carotid artery, while the facial vein typically drains into the common facial vein. Occasionally, the facial vein may drain into the external jugular vein. Therefore, preservation of the external jugular vein is imperative until the drainage pattern of the facial vein is completely ascertained. Following this, if appropriate, the external jugular vein can be safely ligated. The harvest of an islanded FAMM flap can be performed intra-orally or using a lower-lip split approach. The anterior boundary was delineated approximately 1 cm from the commissure to protect the orbicularis oris, while the posterior boundary aligned laterally to the pterygomandibular mucosal raphe. The superior and inferior boundaries corresponded to the maxillary and mandibular vestibular grooves. Care was taken to route the superior margin around the parotid papilla. Harvesting commenced using the conventional approach for inferior-based FAMM flaps. An exploratory incision was initiated at the distal boundary and extended beneath the buccal muscle. The vascular pedicle, positioned between the buccal muscle and the buccal fat pad was subsequently identified and ligated. The flap was carefully elevated in a retrograde fashion, and directed towards the preserved facial artery and vein during neck dissection. Following the meticulous dissection of the facial artery and vein from the mandibular margin nerve and their complete skeletonization, the medial boundary was incised. The flap was then mobilized to the neck and preserved. The compartmental resection of the primary tumor was carried out uniformly as in the free ALT group (Additional file 1). After the completion of tumor resection, the islanded FAMM flap was transposed through the floor of the mouth and introduced into the oral cavity to repair the defect (Fig. 2 ). The resultant donor site defect was covered by the buccal fat pad, which would undergo metaplasia into oral mucosa in about 10–14 days. Data collection The primary parameters assessed included operative duration, duration of postoperative hospitalization, length of stay in the intensive care unit (ICU), incidence of tracheostomies, complications using the Clavien-Dindo Classifications (CDC)[19], and hospitalization costs. These data were collected via the Hospital Information System of the authors’ medical center. Secondary parameters encompassed outpatient records evaluated twelve months postoperatively, which comprised measurement of mouth opening quantified as the distance between the upper and lower middle incisors, assessment of speech quality using the Washington Seven-Point Intelligibility Rating Scale[20]. swallowing function evaluated using the Functional Oral Intake Scale[21], paralysis of the marginal mandibular branch of the facial nerve and flap esthetic outcomes assessed using the Visual Analog Scale (VAS)[22]. The VAS scoring was carried out by three dental interns. Prior to scoring, they were trained and calibrated to ensure consistency and the average of the three scores provided by these students was used. Statistical analysis For continuous data, descriptive statistics were computed in means (standard deviation) and unpaired Student-t test was used if they passed the normality test, otherwise Mann-Whitney test was used; for categorical data, Chi’s square test was used. Statistical analysis was conducted using Prism 9.4.1 (Graphpad Software, La Jolla, CA, USA ) with a P-value less than 0.05 denoting statistical significance. Results Thirty-one patients were involved. Sixteen patients were included in the islanded FAMM flap group and fifteen patients were included in the free ALT flap group. All the patients were electively admitted to ICU for sedation and airway management. Twelve patients turned out to be staged III or IVa and received post-operative adjuvant (chemo)radiotherapy. No recurrence was observed in both groups in 12-month or longer follow-ups. Clinical characteristics were comparable between groups. Patients undergoing islanded FAMM flap reconstruction exhibited less operating duration (514 ± 66.2 min. vs. 602.6 ± 95.2 min., P = 0.0054), lower tracheostomy rates (12.5% vs. 100%, P < 0.0001), higher esthetic score (6.8 ± 1.5 vs. 4.9 ± 1.3, P = 0.0009), and lower hospitalization costs (59286 ± 13903 yuan vs. 95224 ± 18223 yuan, P < 0.0001). The CDC grading was not significant, one patient in the ALT group experienced microvascular crisis on the first postoperative day and the flap was successfully salvaged ; another patient in this group developed pneumonia and was re-admitted to ICU for therapeutic purpose. No flap loss was observed in either group. Mouth opening, swallowing, and speech functions were comparable between the groups (Table 1 ; Additional file 2). Table 1 Parameters of islanded FAMM flap group vs. free ALT flap group Parameters Islanded FAMM (n = 16) free ALT (n = 15) P value Age 52.3(7.8) 46.4(11.4) 0.1767 Sex (female/male) 4/12 1/14 0.1655 ASA physical status a 0.7924 I 4 5 II 10 9 III 2 1 T stage b 0.4113 I 4 2 II 12 13 N stage b 0.5079 0 10 9 I 4 2 II 2 4 Disease stage b 0.6512 I 2 1 II 8 8 III 4 2 IVa 2 4 Operating duration (min.) 514.4 (66.2) 602.6 (95.2) 0.0054 Tracheostomy rate 2/16 15/15 < 0.0001 CDC of complications c 0.3197 II 16 13 IIIb 0 1 (Flap salvage) IVa 0 1 (Pneumonia) ICU days d 2.4 (1.6) 2.7 (1.3) 0.5804 Post-op days 11.6 (1.9) 13.2(3.7) 0.1386 Mouth opening (mm) 31.5 (15–34) λ 31.0 (26–33) 0.1354 Swallowing e 0.2938 Score 6 0 1 Score 7 16 14 Speech f 0.2331 Score 1 5 2 Score 2 11 13 Esthetics (VAS) g 6.8 (1.5) 4.9 (1.3) 0.0009 Costs (yuan Δ ) 59286 (13903) 95224 (18283) < 0.0001 a, ASA = American Society of Anesthesiologist Physical Status System (the 2020 version); b, TNM and disease staging = the 8th TNM staging system of Oral SCC by the American Joint Committee on Cancer, where T represents the primary tumor and N refers to regional invasion to the cervical lymphnodes c, CDC 22 = Clavien-Dindo Classification for grading complications: Grade I = Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions, allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgetics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside; Grade II = Requiring pharmacological treatment with drugs other than such allowed for grade I complications, blood transfusions and total parenteral nutrition are also included; Grade III = Requiring surgical, endoscopic or radiological intervention (IIIa, intervention not under general anesthesia; IIIb, intervention under general anesthesia); Grade IV = Life-threatening complication (including central nervous system complications) requiring IC/ICU management (IVa, single organ dysfunction including dialysis; IVb, Multiorgan dysfunction); Grade V = Death of a patient d, Patients were electively transferred to ICU for airway management, which was not in compliant with Grade IV of CDC 22 , and was analyzed independently. e, Swallow quality assessed using Functional Oral Intake Scale: 1 = no oral intake, 2 = tube-dependent with minimal/inconsistent oral intake, 3 = tube supplements with consistent oral intake, 4 = total oral intake of a single consistency, 5 = total oral intake of multiple consistencies requiring special preparation, 6 = total oral intake with no special preparation, but must avoid specific foods or liquid items, 7 = total oral intake with no restrictions f, Speech quality evaluated using the Washington Seven-Point Intelligibility Rating Scale: 1 = no noticeable difference from normal, 2 = intelligible although some differences occasionally noticeable, 3 = intelligible although noticeably different, 4 = intelligible with careful listening although some words unintelligible, 5 = speech is difficult to understand with many words unintelligible, 6 = usually is unintelligible, 7 = unintelligible. g, Esthetics evaluated using the Visual Analog Scoring ranging from 0 for minimum satisfaction to 10 for maximum satisfaction. λ, Failed to pass Normality Distribution test, statistical descriptive were given in median (minimum - maximum) and Mann-Whitney test was used. Δ, The unit of Chinese currency. Discussion This study demonstrated the potential superiority of the islanded FAMM flap over the free ALT flap for reconstructing moderate-sized oral defect following compartmental resection of a clinical early-staged OT/FOM SCC. It provides comparable functional restoration and improved surgical esthetic outcomes in the cost of less invasive procedures. Specifically, tracheostomy rate in the islanded FAMM flap group was significantly lower than that in the ALT flap group. Elective tracheostomy allows the patients to better tolerate intubation and allows for facilitating re-exploration in case of microvascular crisis. As a pedicled flap, the islanded FAMM flap benefits from a reliable angiosome formed by the facial artery and veins, and has the minimal risk to develop microvascular crisis, thus most patients receiving islanded FAMM flap reconstruction had the nasotracheal intubation overnight and had it removed the next morning after confirming no risk of active bleeding at the surgical site. In terms of surgical duration, the islanded FAMM flap group averaged 80 minutes less than the ALT flap group. This is primarily attributed to the absence of microvascular anastomosis in the islanded FAMM flap group. Additionally, the lower tracheostomy rate among these patients also contributed to the overall reduction in surgical time. The saved time could be utilized to perform another small operation thus the overturn of operation room would also be quick. Compared to the free ALT flap, the islanded FAMM flap presents several additional advantages. 1) The islanded FAMM is less demanding in terms of staffing and equipment. The harvesting process is straightforward and doesn’t require specialized skills in microvascular anastomosis or specific instruments. A single chief surgeon with two assistants can successfully complete the surgery. In contrast, a free ALT flap transfer typically necessitates a more complex setup, involving at least two chief surgeons and three assistants working in a two-team approach, and microsurgery instruments were required. 2) The islanded FAMM flap adheres to the “like-for-like” principle not only in form but also in function, as the buccal mucosa bears minor salivary glands. 3) The defect at the donor site can be easily covered by pulling out the buccal fat pad, which undergo metaplasia into oral mucosa in about 7–10 days in most of the observed patients, making the donor site loss at a minimal level (Fig. 3 ). 4) After full skeletonization, the local lymph nodes that the islanded FAMM may bear are usually not significant for OT/FOM SCC lymph drainage, making it more suitable than the other regional flaps (such as the submental islanded flap or supraclavicular artery flap) for use from an oncologic surgery perspective. This study is retrospective and has a small sample size though, the results show the advantages of islanded FAMM flap in the reconstruction of medium-sized OT/FOM defects. Additionally, it is interesting to note that in patients with healthy buccal mucosa, the buccal fat pad used for donor site coverage can quickly re-epithelialize. However, in patients suffering from oral mucositis, especially oral submucous fibrosis, only partial re-epithelialization or even scar healing is achieved. We speculate that this may be related to the presence of healthy progenitor cells in the normal mucosa. Future research might also focus on this aspect. In conclusion, the islanded FAMM flap emerges as a cost-effective alternative to the free ALT flap for moderate-sized tongue defects, delivering similar functional outcomes while offering superior esthetic results and lower overall costs; future studies might be designed as prospective randomized controlled trials to compare islanded FAMM flaps with free ALT flaps or other types of free tissue flaps in the long-term survival data. Conclusions The islanded FAMM flap emerges as a cost-effective alternative to the free ALT flap for moderate-sized tongue defects, delivering similar functional outcomes while offering superior esthetic results and lower overall costs; however, its advantages still needs to be further investigated in prospective randomized control study. Abbreviations ALT Anterolateral thigh SCC Squamous cell carcinoma FAMM Facial artery myomucosal END Elective neck dissection ASA Anesthesiologists DOI Depth of invasion ICU Intensive care unit CDC Clavien-Dindo Classifications VAS Visual Analog Scale Declarations Clinical trial number Not applicable. Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the ethics committee of the Chinese People’s Liberation Army General Hospital (No. S2024-17-01). Consent for publication Written informed consent was obtained from all participants to participate in the study and for the publication of this case report and accompanying images. A copy of the written consent is available for review by the corresponding author on request. Competing interests The authors have no relevant financial or non-financial interests to disclose. Funding Financial support and sponsorship: none. Author Contribution Conceptualization, data curation: Xiaodong Han, Xiaozhen Lin, and Minghao Wang; formal analysis: Xiaojun Shao, Zhaojie Du and Minghao Wang; writing – original draft: Baixuan Song, Xiaodong Han; writing – review & editing: Xiaozhen Lin and Xiaojun Shao. Acknowledgements Not applicable. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Brockhoff HC, Kim RY, Braun TM, Skouteris C, Helman JI, Ward BB. Correlating the depth of invasion at specific anatomic locations with the risk for regional metastatic disease to lymph nodes in the neck for oral squamous cell carcinoma. 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Psychological Medicine. 1988; 18(4):1007–1019. https://doi.org/10.1017/s0033291700009934. Shipley K: Assessment in speech-language pathology: A resource manual, 4th edn. Clifton Park: NY: Delmar Cengage Learning; 2009. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.mp4 Additionalfile2.mp4 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7493719","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":541910229,"identity":"b2698318-f051-4054-8b46-d8963758aebf","order_by":0,"name":"Xiaodong Han","email":"","orcid":"","institution":"Hainan Hospital of Chinese People’s Liberation Army General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaodong","middleName":"","lastName":"Han","suffix":""},{"id":541910230,"identity":"e4c36dfa-2bed-4a78-aafb-489832fbe5f1","order_by":1,"name":"Minghao Wang","email":"","orcid":"","institution":"Hainan Hospital of Chinese 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1","display":"","copyAsset":false,"role":"figure","size":2118337,"visible":true,"origin":"","legend":"\u003cp\u003eA case of cT2N0 OTSCC reconstructed with free ALT flap.\u003c/p\u003e\n\u003cp\u003eA: A moderate-sized (hemi-glossal) defect was resulted from compartmental resection of a cT2N0 OTSCC; B: the specimen resected in continuous monobloc fashion; C: The defect reconstructed with free ALT flap.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7493719/v1/66199acd6caed6672eac36e1.png"},{"id":96117696,"identity":"f051ce57-16f0-4d54-afd8-63d1bf75cbf3","added_by":"auto","created_at":"2025-11-17 19:26:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1600698,"visible":true,"origin":"","legend":"\u003cp\u003eA case of cT2N0 OTSCC reconstructed with islanded FAMM flap.\u003c/p\u003e\n\u003cp\u003eA: An islanded FAMM flap (yellow asterisk) was transposed to the neck following the compartmental resection of a cT2N0 OTSCC using mandibulotomy approach; B: The flap (yellow asterisk) was pedicled on facial artery (blue arrow) and common facial vein (yellow arrow); C: The flap was delivered into oral cavity to reconstruct the tongue.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7493719/v1/acd634cfff4e826046f1cc3c.png"},{"id":96117695,"identity":"47787854-336e-48bc-b8d6-88383e902cf3","added_by":"auto","created_at":"2025-11-17 19:26:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1412897,"visible":true,"origin":"","legend":"\u003cp\u003eA: Twelve months status post of compartmental resection of a cT1N0 OTSCC and reconstructed using islanded FAMM flap (yellow arrow), mouth opening was about 31mm; B: Biopsy showed proliferation of squamous epithelial cells (red arrow) one month status post; C: The donor site covered by buccal fat pad had underwent metaplasia into oral mucosa six months status post, # is the site where the biopsy had been taken one month since surgery, when the patient revisited to remove the residual intra-oral sutures.\u003c/p\u003e\n\u003cp\u003eAdditional file 1: Harvesting an islanded FAMM flap using lower lip-split approach.\u003c/p\u003e\n\u003cp\u003eAdditional file 2: Twelve months status post of compartmental resection of a cT1N0 OTSCC and reconstructed using islanded FAMM flap.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7493719/v1/07660c8f0d584f3b862e07cb.png"},{"id":101294154,"identity":"ca87d571-5155-4628-8797-3760b311a044","added_by":"auto","created_at":"2026-01-28 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Traditionally, for clinical early-staged node-negative oral SCC (cT1/2N0), treatment involved only wide resection of the primary tumor followed by a \"wait-and-see\" approach for the neck and dissection was reserved for when positive clinical signs of cervical nodal spread, termed therapeutic neck dissection.\u003c/p\u003e\u003cp\u003eHowever, recent studies have uncovered significant insights. Firstly, a mere 2-3mm depth of invasion of an oral SCC in the oral tongue (OT) or floor of the mouth (FOM) can result in a nearly 20% risk of occult cervical lymph-node metastasis[1, 2].Secondly, simultaneous elective neck dissection (END) has shown to enhance long-term cancer-related outcomes compared to a therapeutic neck dissection[3]. Thirdly, compartmental resection of an OT/FOM SCC \u0026mdash; involving the comprehensive removal of all the muscles impacted by the tumor, along with associated neurovascular and lymphatic pathways to the neck \u0026mdash; offers superior locoregional control compared to traditional wide resection[4\u0026ndash;8].\u003c/p\u003e\u003cp\u003eThese revelations advocate for adopting compartmental resection combined with simultaneous END as a unified procedure, even for cT1/2N0 OT/FOM SCC. This shift in treatment approach results in a moderate-sized defect which is usually about 5cm in length by 3 cm in width by 1.5cm in thickness and is too large to close primarily, necessitating simultaneous reconstruction using surgical flaps.\u003c/p\u003e\u003cp\u003eFree soft tissue flaps have become the mainstay in reconstructing oral and maxillofacial defects. Among them, anterolateral thigh (ALT) flap stands out due to its adaptability, particularly useful for large and complex soft tissue defects. However, for such a moderate-sized defect resulted from compartmental resection of an OT/FOM SCC, the ALT flap may not be the best option in terms of cost-effectiveness as the primary purpose is simply to reconstruct the intra-oral lining.\u003c/p\u003e\u003cp\u003eThe facial artery myomucosal (FAMM) flap is an axial pattern flap[9], typically fashioned in a long triangular shape with a base of approximately 1cm to ensures reliable vascularization. However, the rotation of this flap into the oral cavity can be hindered by dental structures. The concept of islanded FAMM flap, delineated first by Zhao in 1999 through the meticulous dissection of the facial artery and vein, marked a significant advancement[10]. This refinement not only facilitated the harvesting of larger flaps but also substantially enhanced the rotational freedom of the flap.\u003c/p\u003e\u003cp\u003eSeveral case series have underscored the clinical merits of the islanded FAMM flap in repairing moderate-sized oral defects[11\u0026ndash;17]. In this context, we aimed to evaluate the cost-effectiveness of the islanded FAMM flap as a preferable alternative to the free ALT flap in the reconstruction of moderate-sized defects following compartmental resection of an OT/FOM SCC.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eA retrospective cohort study was conducted in patients diagnosed with OT/FOM SCC at the authors' tertiary hospital from January 2017 to June 2023. The study was approved by the institutional review board of the authors\u0026rsquo; hospital (S2024-17-01) at 15 August 2024. Written informed consent was obtained from the patient for publication of this case report and accompanying images. All the surgeries were performed by the same senior surgeon.\u003c/p\u003e\u003cp\u003eThe inclusion criteria were: 1) Patients aged 18\u0026ndash;75 years old. 2) American Society of Anesthesiologists (ASA) Physical Status scores between I to III. 3) Unilateral oral SCC in the OT/FOM. 4) The depth of invasion (DOI) was more than 2mm and less than 10mm (cT1/2), as determined by pre-operative magnetic resonance imaging (MRI) scans. 5) No clinical positive node detected pre-operatively (cN0). 6) The patients underwent standard compartmental resection of the primary tumor with ipsilateral comprehensive END (Levels 1 to 5) in continuing monobloc fashion. 7) Reconstruction was performed using either the free ALT flap or the islanded FAMM flap. 8) Post- operative follow-up lasted twelve months or longer. The exclusion criteria were: 1) Primary tumor near or crossing midline which necessitated bilateral neck dissection. 2) Recurrent OT/FOM SCC. 3) History of radiotherapy in the neck.\u003c/p\u003e\u003cp\u003ePatients were followed-up with physical examination, ultrasonography imaging or MRI if necessary every month for the first year, then every 3 months for the second year, every 6 months for the third year and every twelve months for year 4\u0026ndash;5.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eCompartmental resection of an OT/FOM SCC and reconstruction using free ALT flap\u003c/h2\u003e\u003cp\u003eThe intraoperative biopsy was conducted upon completion of temporary per-oral intubation. Upon an SCC diagnosed through frozen section, elective tracheostomy was performed, and intubation was transitioned from per-oral to per-tracheostomy. The primary procedures were started from elective neck dissection initiating from level 5. As the dissection progressed to level 1, the submandibular gland was left connected to the floor of the mouth.\u003c/p\u003e\u003cp\u003eThe compartmental resection of the primary tumor involved the longitudinal removal of all the muscles invaded by the tumor, the sublingual gland, the intermediate neurovascular and lymphatic pathway (T-N tract), and the submandibular gland which constituted part of the completed neck dissection\u003csup\u003e6\u0026ndash;8\u003c/sup\u003e. In cases where the primary tumor was situated in the posterior part of the oral cavity, mandibulectomy was performed to facilitate compartmental dissection[18].\u003c/p\u003e\u003cp\u003eHarvesting the anterolateral thigh (ALT) flap was carried out in a simultaneous two-team approach. End-to-end arterial anastomosis was performed using 8\u0026thinsp;\u0026minus;\u0026thinsp;0 or 9\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures and one or two veins were anastomosed using vascular coupler. The anastomosis was conducted under an operative microscope (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCompartmental resection of an OT/FOM SCC and reconstruction using islanded FAMM flap\u003c/h3\u003e\n\u003cp\u003eThe intraoperative biopsy was conducted upon the completion of definitive intra-nasal intubation. Elective tracheostomy was not necessary unless there is a significant risk after comprehensive assessment of airway risk. Upon confirmation of an SCC through frozen section analysis, elective neck dissection was carried out from level 5. When the dissection approached up to level 1, the facial artery and vein were meticulously identified and carefully dissected in a retrograde manner to their respective origins. Specifically, the facial artery originates from the external carotid artery, while the facial vein typically drains into the common facial vein. Occasionally, the facial vein may drain into the external jugular vein. Therefore, preservation of the external jugular vein is imperative until the drainage pattern of the facial vein is completely ascertained. Following this, if appropriate, the external jugular vein can be safely ligated.\u003c/p\u003e\u003cp\u003eThe harvest of an islanded FAMM flap can be performed intra-orally or using a lower-lip split approach. The anterior boundary was delineated approximately 1 cm from the commissure to protect the orbicularis oris, while the posterior boundary aligned laterally to the pterygomandibular mucosal raphe. The superior and inferior boundaries corresponded to the maxillary and mandibular vestibular grooves. Care was taken to route the superior margin around the parotid papilla. Harvesting commenced using the conventional approach for inferior-based FAMM flaps. An exploratory incision was initiated at the distal boundary and extended beneath the buccal muscle. The vascular pedicle, positioned between the buccal muscle and the buccal fat pad was subsequently identified and ligated. The flap was carefully elevated in a retrograde fashion, and directed towards the preserved facial artery and vein during neck dissection. Following the meticulous dissection of the facial artery and vein from the mandibular margin nerve and their complete skeletonization, the medial boundary was incised. The flap was then mobilized to the neck and preserved. The compartmental resection of the primary tumor was carried out uniformly as in the free ALT group (Additional file 1).\u003c/p\u003e\u003cp\u003eAfter the completion of tumor resection, the islanded FAMM flap was transposed through the floor of the mouth and introduced into the oral cavity to repair the defect (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The resultant donor site defect was covered by the buccal fat pad, which would undergo metaplasia into oral mucosa in about 10\u0026ndash;14 days.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe primary parameters assessed included operative duration, duration of postoperative hospitalization, length of stay in the intensive care unit (ICU), incidence of tracheostomies, complications using the Clavien-Dindo Classifications (CDC)[19], and hospitalization costs. These data were collected via the Hospital Information System of the authors\u0026rsquo; medical center.\u003c/p\u003e\u003cp\u003eSecondary parameters encompassed outpatient records evaluated twelve months postoperatively, which comprised measurement of mouth opening quantified as the distance between the upper and lower middle incisors, assessment of speech quality using the Washington Seven-Point Intelligibility Rating Scale[20]. swallowing function evaluated using the Functional Oral Intake Scale[21], paralysis of the marginal mandibular branch of the facial nerve and flap esthetic outcomes assessed using the Visual Analog Scale (VAS)[22]. The VAS scoring was carried out by three dental interns. Prior to scoring, they were trained and calibrated to ensure consistency and the average of the three scores provided by these students was used.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eFor continuous data, descriptive statistics were computed in means (standard deviation) and unpaired Student-t test was used if they passed the normality test, otherwise Mann-Whitney test was used; for categorical data, Chi\u0026rsquo;s square test was used. Statistical analysis was conducted using Prism 9.4.1 (Graphpad Software, La Jolla, CA, USA ) with a P-value less than 0.05 denoting statistical significance.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThirty-one patients were involved. Sixteen patients were included in the islanded FAMM flap group and fifteen patients were included in the free ALT flap group. All the patients were electively admitted to ICU for sedation and airway management. Twelve patients turned out to be staged III or IVa and received post-operative adjuvant (chemo)radiotherapy. No recurrence was observed in both groups in 12-month or longer follow-ups.\u003c/p\u003e\u003cp\u003eClinical characteristics were comparable between groups. Patients undergoing islanded FAMM flap reconstruction exhibited less operating duration (514\u0026thinsp;\u0026plusmn;\u0026thinsp;66.2 min. vs. 602.6\u0026thinsp;\u0026plusmn;\u0026thinsp;95.2 min., P\u0026thinsp;=\u0026thinsp;0.0054), lower tracheostomy rates (12.5% vs. 100%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), higher esthetic score (6.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 vs. 4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3, P\u0026thinsp;=\u0026thinsp;0.0009), and lower hospitalization costs (59286\u0026thinsp;\u0026plusmn;\u0026thinsp;13903 yuan vs. 95224\u0026thinsp;\u0026plusmn;\u0026thinsp;18223 yuan, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The CDC grading was not significant, one patient in the ALT group experienced microvascular crisis on the first postoperative day and the flap was successfully salvaged ; another patient in this group developed pneumonia and was re-admitted to ICU for therapeutic purpose. No flap loss was observed in either group. Mouth opening, swallowing, and speech functions were comparable between the groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Additional file 2).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParameters of islanded FAMM flap group vs. free ALT flap group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIslanded FAMM (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003efree ALT (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52.3(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46.4(11.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.1767\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (female/male)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4/12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.1655\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA physical status\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.7924\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT stage\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.4113\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN stage\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.5079\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisease stage\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.6512\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIVa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating duration (min.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e514.4 (66.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e602.6 (95.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0054\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTracheostomy rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2/16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15/15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCDC of complications\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.3197\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIIIb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (Flap salvage)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIVa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (Pneumonia)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU days\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.4 (1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.7 (1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.5804\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-op days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.6 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.2(3.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.1386\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMouth opening (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.5 (15\u0026ndash;34) \u003csup\u003eλ\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.0 (26\u0026ndash;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.1354\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSwallowing\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.2938\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScore 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScore 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpeech\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.2331\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScore 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScore 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEsthetics (VAS)\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.8 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.9 (1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCosts (yuan\u003csup\u003eΔ\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59286 (13903)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95224 (18283)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ea, ASA\u0026thinsp;=\u0026thinsp;American Society of Anesthesiologist Physical Status System (the 2020 version);\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eb, TNM and disease staging\u0026thinsp;=\u0026thinsp;the 8th TNM staging system of Oral SCC by the American Joint Committee on Cancer, where T represents the primary tumor and N refers to regional invasion to the cervical lymphnodes\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ec, CDC\u003csup\u003e22\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;Clavien-Dindo Classification for grading complications: Grade I\u0026thinsp;=\u0026thinsp;Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions, allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgetics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside; Grade II\u0026thinsp;=\u0026thinsp;Requiring pharmacological treatment with drugs other than such allowed for grade I complications, blood transfusions and total parenteral nutrition are also included; Grade III\u0026thinsp;=\u0026thinsp;Requiring surgical, endoscopic or radiological intervention (IIIa, intervention not under general anesthesia; IIIb, intervention under general anesthesia); Grade IV\u0026thinsp;=\u0026thinsp;Life-threatening complication (including central nervous system complications) requiring IC/ICU management (IVa, single organ dysfunction including dialysis; IVb, Multiorgan dysfunction); Grade V\u0026thinsp;=\u0026thinsp;Death of a patient\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ed, Patients were electively transferred to ICU for airway management, which was not in compliant with Grade IV of CDC\u003csup\u003e22\u003c/sup\u003e, and was analyzed independently.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ee, Swallow quality assessed using Functional Oral Intake Scale: 1\u0026thinsp;=\u0026thinsp;no oral intake, 2\u0026thinsp;=\u0026thinsp;tube-dependent with minimal/inconsistent oral intake, 3\u0026thinsp;=\u0026thinsp;tube supplements with consistent oral intake, 4\u0026thinsp;=\u0026thinsp;total oral intake of a single consistency, 5\u0026thinsp;=\u0026thinsp;total oral intake of multiple consistencies requiring special preparation, 6\u0026thinsp;=\u0026thinsp;total oral intake with no special preparation, but must avoid specific foods or liquid items, 7\u0026thinsp;=\u0026thinsp;total oral intake with no restrictions\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ef, Speech quality evaluated using the Washington Seven-Point Intelligibility Rating Scale: 1\u0026thinsp;=\u0026thinsp;no noticeable difference from normal, 2\u0026thinsp;=\u0026thinsp;intelligible although some differences occasionally noticeable, 3\u0026thinsp;=\u0026thinsp;intelligible although noticeably different, 4\u0026thinsp;=\u0026thinsp;intelligible with careful listening although some words unintelligible, 5\u0026thinsp;=\u0026thinsp;speech is difficult to understand with many words unintelligible, 6\u0026thinsp;=\u0026thinsp;usually is unintelligible, 7\u0026thinsp;=\u0026thinsp;unintelligible.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eg, Esthetics evaluated using the Visual Analog Scoring ranging from 0 for minimum satisfaction to 10 for maximum satisfaction.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eλ, Failed to pass Normality Distribution test, statistical descriptive were given in median (minimum - maximum) and Mann-Whitney test was used.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eΔ, The unit of Chinese currency.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated the potential superiority of the islanded FAMM flap over the free ALT flap for reconstructing moderate-sized oral defect following compartmental resection of a clinical early-staged OT/FOM SCC. It provides comparable functional restoration and improved surgical esthetic outcomes in the cost of less invasive procedures.\u003c/p\u003e\u003cp\u003eSpecifically, tracheostomy rate in the islanded FAMM flap group was significantly lower than that in the ALT flap group. Elective tracheostomy allows the patients to better tolerate intubation and allows for facilitating re-exploration in case of microvascular crisis. As a pedicled flap, the islanded FAMM flap benefits from a reliable angiosome formed by the facial artery and veins, and has the minimal risk to develop microvascular crisis, thus most patients receiving islanded FAMM flap reconstruction had the nasotracheal intubation overnight and had it removed the next morning after confirming no risk of active bleeding at the surgical site. In terms of surgical duration, the islanded FAMM flap group averaged 80 minutes less than the ALT flap group. This is primarily attributed to the absence of microvascular anastomosis in the islanded FAMM flap group. Additionally, the lower tracheostomy rate among these patients also contributed to the overall reduction in surgical time. The saved time could be utilized to perform another small operation thus the overturn of operation room would also be quick.\u003c/p\u003e\u003cp\u003eCompared to the free ALT flap, the islanded FAMM flap presents several additional advantages. 1) The islanded FAMM is less demanding in terms of staffing and equipment. The harvesting process is straightforward and doesn\u0026rsquo;t require specialized skills in microvascular anastomosis or specific instruments. A single chief surgeon with two assistants can successfully complete the surgery. In contrast, a free ALT flap transfer typically necessitates a more complex setup, involving at least two chief surgeons and three assistants working in a two-team approach, and microsurgery instruments were required. 2) The islanded FAMM flap adheres to the \u0026ldquo;like-for-like\u0026rdquo; principle not only in form but also in function, as the buccal mucosa bears minor salivary glands. 3) The defect at the donor site can be easily covered by pulling out the buccal fat pad, which undergo metaplasia into oral mucosa in about 7\u0026ndash;10 days in most of the observed patients, making the donor site loss at a minimal level (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). 4) After full skeletonization, the local lymph nodes that the islanded FAMM may bear are usually not significant for OT/FOM SCC lymph drainage, making it more suitable than the other regional flaps (such as the submental islanded flap or supraclavicular artery flap) for use from an oncologic surgery perspective.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThis study is retrospective and has a small sample size though, the results show the advantages of islanded FAMM flap in the reconstruction of medium-sized OT/FOM defects. Additionally, it is interesting to note that in patients with healthy buccal mucosa, the buccal fat pad used for donor site coverage can quickly re-epithelialize. However, in patients suffering from oral mucositis, especially oral submucous fibrosis, only partial re-epithelialization or even scar healing is achieved. We speculate that this may be related to the presence of healthy progenitor cells in the normal mucosa. Future research might also focus on this aspect.\u003c/p\u003e\u003cp\u003eIn conclusion, the islanded FAMM flap emerges as a cost-effective alternative to the free ALT flap for moderate-sized tongue defects, delivering similar functional outcomes while offering superior esthetic results and lower overall costs; future studies might be designed as prospective randomized controlled trials to compare islanded FAMM flaps with free ALT flaps or other types of free tissue flaps in the long-term survival data.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe islanded FAMM flap emerges as a cost-effective alternative to the free ALT flap for moderate-sized tongue defects, delivering similar functional outcomes while offering superior esthetic results and lower overall costs; however, its advantages still needs to be further investigated in prospective randomized control study.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eALT Anterolateral thigh\u003c/p\u003e\u003cp\u003eSCC Squamous cell carcinoma\u003c/p\u003e\u003cp\u003eFAMM Facial artery myomucosal\u003c/p\u003e\u003cp\u003eEND Elective neck dissection\u003c/p\u003e\u003cp\u003eASA Anesthesiologists\u003c/p\u003e\u003cp\u003eDOI Depth of invasion\u003c/p\u003e\u003cp\u003eICU Intensive care unit\u003c/p\u003e\u003cp\u003eCDC Clavien-Dindo Classifications\u003c/p\u003e\u003cp\u003eVAS Visual Analog Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003c/p\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the ethics committee of the Chinese People’s Liberation Army General Hospital (No. S2024-17-01).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e Written informed consent was obtained from all participants to participate in the study and for the publication of this case report and accompanying images. A copy of the written consent is available for review by the corresponding author on request.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eFinancial support and sponsorship: none.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization, data curation: Xiaodong Han, Xiaozhen Lin, and Minghao Wang; formal analysis: Xiaojun Shao, Zhaojie Du and Minghao Wang; writing – original draft: Baixuan Song, Xiaodong Han; writing – review \u0026amp; editing: Xiaozhen Lin and Xiaojun Shao.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Brockhoff HC, Kim RY, Braun TM, Skouteris C, Helman JI, Ward BB. Correlating the depth of invasion at specific anatomic locations with the risk for regional metastatic disease to lymph nodes in the neck for oral squamous cell carcinoma. \u003cem\u003eHead \u0026amp; Neck.\u003c/em\u003e 2017; 39(5):974\u0026ndash;979. https://doi.org/10.1002/hed.24724.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Feng Z, Cheng A, Alzahrani S, Li B, Han Z, Ward BB. Elective neck dissection in t1n0m0 oral squamous cell carcinoma: When is it necessary? \u003cem\u003eJournal of Oral and Maxillofacial Surgery.\u003c/em\u003e 2020; 78(12):2306\u0026ndash;2315. https://doi.org/10.1016/j.joms.2020.06.037.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e D' Cruz AK, Vaish R, Kapre N, Dandekar M, Gupta S, Hawaldar R, \u003cem\u003eet al\u003c/em\u003e. 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Resection for oral tongue squamous cell carcinoma: A paradigm shift from conventional wide resection towards compartmental resection. \u003cem\u003eInternational Journal of Oral and Maxillofacial Surgery.\u003c/em\u003e 2014; 43(6):784\u0026ndash;786. https://doi.org/10.1016/j.ijom.2014.02.017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Piazza C, Grammatica A, Montalto N, Paderno A, Del Bon F, Nicolai P. Compartmental surgery for oral tongue and floor of the mouth cancer: Oncologic outcomes. \u003cem\u003eHead \u0026amp; Neck.\u003c/em\u003e 2018; 41(1):110\u0026ndash;115. https://doi.org/10.1002/hed.25480.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Missale F, Marchi F, Iandelli A, Subramaniam N, Dokhe Y, Sampieri C, \u003cem\u003eet al\u003c/em\u003e. Oncological outcomes of compartmental surgery and wide local excision in oral tongue and floor of the mouth cancer. \u003cem\u003eOral Oncology.\u003c/em\u003e 2022; 135:1\u0026ndash;11. https://doi.org/10.1016/j.oraloncology.2022.106210.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Calabrese L, Tagliabue M, Grammatica A, De Berardinis R, Corso F, Gazzini L, \u003cem\u003eet al\u003c/em\u003e. Compartmental tongue surgery for intermediate-advanced squamous cell carcinoma: A multicentric study. \u003cem\u003eHead \u0026amp; Neck.\u003c/em\u003e 2023; 45(11):2862\u0026ndash;2873. https://doi.org/10.1002/hed.27517.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Pribaz J SW, Crespo L and Gifford G. A new intraoral flap: Facial artery musculomucosal (famm) flap. \u003cem\u003ePlast Reconstr Surg.\u003c/em\u003e 1992; 90(3):421\u0026ndash;429. https://doi.org/10.1097/00006534-199209000-00009.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Zhao ZM, Li SK, Yan YP, Li YQ, Yang MY, Mu LH, \u003cem\u003eet al\u003c/em\u003e. New buccinator myomucosal island flap: Anatomic study and clinical application. \u003cem\u003ePlast Reconstr Surg.\u003c/em\u003e 1999; 104(1):55\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Ferrari S, Balestreri A, Bianchi B, Multinu A, Ferri A, Sesenna E. Buccinator myomucosal island flap for reconstruction of the floor of the mouth. \u003cem\u003eJournal of Oral and Maxillofacial Surgery.\u003c/em\u003e 2008; 66(2):394\u0026ndash;400. https://doi.org/10.1016/j.joms.2006.10.036.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Massarelli O, Gobbi R, Raho MT, Tullio A. Three-dimensional primary reconstruction of anterior mouth floor and ventral tongue using the 'trilobed' buccinator myomucosal island flap. \u003cem\u003eInternational Journal of Oral and Maxillofacial Surgery.\u003c/em\u003e 2008; 37(10):917\u0026ndash;922. https://doi.org/10.1016/j.ijom.2008.07.020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Massarelli O, Baj A, Gobbi R, Soma D, Marelli S, De Riu G, \u003cem\u003eet al\u003c/em\u003e. Cheek mucosa: A versatile donor site of myomucosal flaps. Technical and functional considerations. \u003cem\u003eHead \u0026amp; Neck.\u003c/em\u003e 2012; 35(1):109\u0026ndash;117. https://doi.org/10.1002/hed.22933.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Joseph ST, Naveen BS, Mohan TM. Islanded facial artery musculomucosal flap for tongue reconstruction. \u003cem\u003eInternational Journal of Oral and Maxillofacial Surgery.\u003c/em\u003e 2017; 46(4):453\u0026ndash;455. https://doi.org/10.1016/j.ijom.2016.11.010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Shivanand NB, Mohan MT, Joseph ST. Contralateral islanded facial artery myomucosal flap for the reconstruction of floor of the mouth defect. \u003cem\u003eCraniomaxillofacial Trauma \u0026amp; Reconstruction.\u003c/em\u003e 2018; 11(2):157\u0026ndash;160. https://doi.org/10.1055/s-0037-1604071.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e B.S N, Mohan MT, Tharayil J, Joseph ST. Islanded facial artery osteomyomucosal/osseous flap in head and neck reconstruction. \u003cem\u003eInternational Journal of Oral and Maxillofacial Surgery.\u003c/em\u003e 2021; 50(8):1003\u0026ndash;1008. https://doi.org/10.1016/j.ijom.2020.11.010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Joseph ST, Mohan MT, Naveen BS, Anand A, Tharayil J. Facial artery-based islanded myomucosal and bone flaps in head and neck reconstruction. \u003cem\u003eJournal of Plastic, Reconstructive \u0026amp; Aesthetic Surgery.\u003c/em\u003e 2021; 74(6):1269\u0026ndash;1278. https://doi.org/10.1016/j.bjps.2020.10.058.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Han X, Shao X, Lin X. Paramedian lateral-angled mandibulotomy for resection of squamous cell carcinoma in the oral cavity. \u003cem\u003eJournal of Craniofacial Surgery.\u003c/em\u003e 2023; 34(5):528\u0026ndash;529. https://doi.org/10.1097/scs.0000000000009414.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. \u003cem\u003eAnnals of Surgery.\u003c/em\u003e 2004; 240(2):205\u0026ndash;213. https://doi.org/10.1097/01.sla.0000133083.54934.ae.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Crary MA, Mann GDC, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. \u003cem\u003eArchives of Physical Medicine and Rehabilitation.\u003c/em\u003e 2005; 86(8):1516\u0026ndash;1520. https://doi.org/10.1016/j.apmr.2004.11.049.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e McCormack HM, de L. Horne DJ, Sheather S. Clinical applications of visual analogue scales: A critical review. \u003cem\u003ePsychological Medicine.\u003c/em\u003e 1988; 18(4):1007\u0026ndash;1019. https://doi.org/10.1017/s0033291700009934.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Shipley K: Assessment in speech-language pathology: A resource manual, 4th edn. Clifton Park: NY: Delmar Cengage Learning; 2009.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"plastic surgery, surgical flaps, mouth mucosa, squamous cell carcinoma, neck dissection","lastPublishedDoi":"10.21203/rs.3.rs-7493719/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7493719/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe free anterolateral thigh (ALT) flap has long been the standard for reconstructing oral defects following the resection of squamous cell carcinoma (SCC) in the oral tongue (OT) or floor of the mouth (FOM). However, recent case-series studies suggest that the islanded facial artery myomucosal (FAMM) flap also yields satisfactory results for moderate-sized oral defects. Although the islanded FAMM flap avoids the need for vascular micro-anastomosis, its advantages over the ALT flap remain unconfirmed. This study aims to compare the cost-effectiveness of the islanded FAMM flap with the free ALT flap in the reconstruction of moderate-sized oral defects following early-stage OT/FOM SCC resection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA single-centered retrospective cohort study was conducted on patients undergoing compartmental resection of OT/FOM SCC with subsequent reconstruction using either islanded FAMM flap or free ALT flap. Data on patient characteristics, operating duration, tracheostomy rate, ICU days, post-operative days, complications, mouth opening, swallowing, speech, aesthetics, and hospitalization costs were compared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThirty-one patients with OT/FOM SCC were included; 16 underwent reconstruction with the islanded FAMM flap, while 15 received the free ALT flap. The FAMM flap group exhibited shorter operating times (514 ± 66.2 vs. 602.6 ± 95.2 min), significantly lower tracheostomy rates (12.5% vs. 100%), higher esthetic scores (6.8 ± 1.5 vs. 4.9 ± 1.3), and reduced hospitalization costs (59,286 ± 13,903 yuan vs. 95,224 ± 18,223 yuan). Functional outcomes related to mouth opening, swallowing, and speech were comparable between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe islanded FAMM flap emerges as a cost-effective alternative to the free ALT flap for moderate-sized tongue defects, delivering similar functional outcomes while offering superior esthetic results and lower overall costs; however, its advantages still needs to be further investigated in prospective randomized control study.\u003c/p\u003e","manuscriptTitle":"Islanded facial artery myomucosal flap versus free anterolateral thigh flap in oral reconstruction: a cost-effectiveness analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-17 19:26:24","doi":"10.21203/rs.3.rs-7493719/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1cdef9f1-a5bd-44ba-bb28-586d566b3272","owner":[],"postedDate":"November 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-28T08:43:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-17 19:26:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7493719","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7493719","identity":"rs-7493719","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}