Lingual Artery: Lifesaver Recipient Artery for Free Flap Surgery

Appropriating a patent recipient artery and ensuring its circulation is one of the cornerstone requirements for the success of free flap surgery. Here we briefly discuss two cases and elaborate the advantages of the lingual artery as recipient for difficult cases that do not have any useful alternative vessels for free flap transfer.

The lingual artery originates from the external carotid artery and courses on the deep surface of the hyoglossus muscle. The deep lingual artery then branches into a dorsal lingual artery and the sublingual artery. The veins form venae comitantes and join with the facial vein or the internal jugular vein. To prepare the lingual artery for free flap surgery, the submandibular triangle must be exposed, after which the mylohyoid muscle must be retracted ventrally and the posterior belly of the digastric muscle caudally. Then, the fibers of the hyoglossus muscle must be separated, which in turn will reveal the lingual artery, which on average is 3 mm inferior to the hypoglossal nerve and 6 mm superior to the hyoid bone.[1] The hypoglossal nerve is an important landmark for an easy way to find the lingual artery during dissection ([Fig. 1]).

Figure 1 Trajectory of the lingual artery.

We performed free tissue transfers that used the lingual artery in two patients. The first patient had undergone extensive neck dissection due to squamous cell carcinoma of the mandible. The second patient was a referral, who was, for a similar diagnosis, subject to multiple unsuccessful free flap surgeries for mandible reconstruction, which were free fibula and iliac flaps. In both cases, we did not find any recipient arteries such as facial and superior thyroidal arteries, which are preferred by most microsurgeons. They were obliterated or unavailable for transfer because of previous neck dissection or use as a recipient artery. We transferred iliac and fibula flaps, respectively, on the lingual arteries. The diameter of the lingual artery was similar, with pedicle arteries of iliac and fibular flaps.

The lingual artery inherently possesses multiple advantages for use as a recipient artery in head and neck reconstructions. The ease of access, resistance to atherosclerosis,[2] and its low possibility of kinking due to its natural course, gives confidence with respect to patency.[3] Also, the wide diameter and robust flow ensures the success rates of the tissue transfer.[4] This vessel can be found very easily during dissection because it has apparent anatomical landmarks. Additionally, the lingual artery also possesses a concomitant vein that has similar anatomical benefits. However, there are a few disadvantages one must consider. Most significantly, if the contralateral side is jeopardized, the lingual artery cannot be used to avoid tongue ischemia.[5] Also, future use of tongue flaps is restricted after the application of this approach.

To conclude, we would like to underline the significance and worthiness of the lingual artery as a valid option as a recipient artery for difficult head and neck reconstruction, even neck dissected or previous applied radiotherapy cases.

• References

• 1 Homzbe J, Harn SD, Bavitz BJ. Extraoral ligation of the lingual artery: an anatomic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 83: 321-324
• 2 Neligan PC, She-Yue H, Gullane PJ. Reverse flow as an option in microvascular recipient anastomoses. Plast Reconstr Surg 1997; 100: 1780-1785 , discussion 1786–1787
• 3 Soikkonen K, Wolf J, Mattila K. Tortuosity of the lingual artery and coronary atherosclerosis. Br J Oral Maxillofac Surg 1995; 33: 309-311
• 4 Shemen L, Romita M, Godfrey P, Godfrey N, Hamburg R. Microvascular revascularization of the tongue. J Reconstr Microsurg 1988; 4: 267-269
• 5 Urken ML, Vickery C, Weinberg H, Buchbinder D, Biller HF. Geometry of the vascular pedicle in free tissue transfers to the head and neck. Arch Otolaryngol Head Neck Surg 1989; 115: 954-960