# Extensive and delayed necrosis of a free flap following subtotal glossectomy and adjuvant radiotherapy

Sophie Dugast, Langé Martin, Nadia Benmoussa, Mélanie Doré, Julie Longis, Helios Bertin

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Sophie Dugast, Langé Martin, Nadia Benmoussa, Mélanie Doré, Julie Longis, et al.. Extensive and delayed necrosis of a free flap following subtotal glossectomy and adjuvant radiotherapy. Journal of Stomatology, Oral and Maxillofacial Surgery, 2025, 126 (5), pp.102491. 10.1016/j.jormas.2025.102491. hal-05460289

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Case Report

# Extensive and delayed necrosis of a free flap following subtotal glossectomy and adjuvant radiotherapy

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Sophie Dugast<sup>a</sup>, Langé Martin<sup>b</sup>, Nadia Benmoussa<sup>c</sup>, Mélanie Doré<sup>b</sup>, Julie Longis<sup>a</sup>, Helios Bertin<sup>a,d,*,1</sup>

ARTICLE INFO

Keywords:

Oral oncology

Free flap reconstruction

Radiosensitivity

ABSTRACT

Oral tongue squamous cell carcinoma is the most common malignancy of the oral cavity. Treatment of this tumor is based on surgical removal with a centimeter margin, which can be combined with radiotherapy. This case report details a late necrosis of an anterolateral thigh flap used for oncological reconstruction of a subtotal glossectomy requiring comprehensive management. A 61-year-old patient, with no medical history, was treated for a large squamous cell carcinoma with subtotal glossectomy combined with adjuvant radiotherapy. During radiotherapy, radio-mucositis appeared on the lateral sides of the flap. The ulcerations continued to progress for several months after the end of treatment, eventually leading to complete necrosis of two-thirds of the flap three months after radiotherapy. Our findings suggest that late septic necrosis can develop on severe radiomucositis in patients without significant comorbidities or traditional risk factors. This evolution may also suggest an intrinsic radiosensitivity of the patient.

1. Introduction

Oral tongue squamous cell carcinoma is the most common malignancy of the oral cavity. Although the overall incidence of Head and Neck squamous cell carcinoma continues to decline worldwide, the incidence of oral tongue cancer has been reported to be increasing [1]. The treatment of OTSCC relies on tumor resection surgery with centimeter margins that can be combined with adjuvant radiotherapy [2]. In cases of extensive oncological tongue defects, the anterolateral thigh flap is an option to restore tongue volume while preserving swallowing and speech functions [3]. In oncological head and neck reconstruction, most cases of flap necrosis occur within the first fifteen days following surgery [4,5]. Here, we report a case of extensive delayed necrosis occurring after radiotherapy in an anterolateral thigh flap used for the reconstruction of a subtotal glossectomy.

2. Case

A 61-year-old, professionally and physically active patient, with no medical history other than a 30 pack-year smoking history, was treated

in July 2024 in the maxillofacial surgery department for a large squamous cell carcinoma of the tongue. The treatment consisted of tumor resection by subtotal glossectomy, removing the entire mobile tongue and a hemi base of the tongue by pull-through, combined with ipsilateral lymph node dissection. The reconstruction was performed with an anterolateral thigh flap shaped according to the “Cathedral triptych design” technique [3]. The flap was anastomosed to the facial vessels with immediate vascular permeability and no peroperative anastomosis revision required. The surgical follow-up was marked by the occurrence of a cervical hematoma, without any consequences for the vitality of the flap, no infection occurred. The patient resumed oral feeding on the 7th day after the operation, in accordance with our department’s usual practice. As the per os intake was initially insufficient, we also requested the insertion of a gastrostomy to provide additional nutritional support. The histopathological analysis revealed a squamous cell carcinoma, measuring 7 cm with a depth of infiltration of 16 mm, likely arising from a cuniculatum carcinoma. It was classified as stage pT3N0, with the presence of perineural invasion and a lymphatic embolus, and clear surgical margin (>5 mm). Radiotherapy treatment began 6 weeks after the oncological surgery, following a check-up that confirmed good healing of the

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<footnote><sup>a</sup> University of Nantes, CHU Nantes, Department of Maxillofacial Surgery and Stomatology, F-44000 Nantes, France</footnote>

<footnote><sup>b</sup> Institut de Cancerologie de l'Ouest, Head and neck radiotherapy department Nantes, France</footnote>

<footnote><sup>c</sup> Gustave Roussy, Paris-Saclay University, Department of Head and neck Oncology, Villejuif F-94805, France</footnote>

<footnote><sup>d</sup> University of Nantes, Univ Angers, CHU Nantes, INSERM, CNRS, CRCI2NA, F-44000 Nantes, France</footnote>

<footnote>*Corresponding author at: University of Nantes, CHU Nantes, Department of Maxillofacial Surgery and Stomatology, F-44000 Nantes, France.</footnote>

<footnote>E-mail addresses: sophie.dugast@chu-nantes.fr (S. Dugast), martin.lange@ico.unicancer.fr (L. Martin), Nadia.BENMOUSSA-REBIBO@gustaveroussy.fr
(N. Benmoussa), Melanie.dore@ico.unicancer.fr (M. Doré), julie.longis@chu-nantes.fr (J. Longis), helios.bertin@chu-nantes.fr (H. Bertin).</footnote>

<footnote n="1">¹ Given his role as Editor, Hélios Bertin had no involvement in the peer-review of this article and has no access to information regarding its peer-review. Full responsibility for the editorial process for this article was delegated to another journal editor.</footnote>
<figure><img src="image_6.png" /><figcaption>**Fig. 1.** Pre-treatment (a) and radiotherapy planning (b, c) images: On the left, an MRI image of the lesion in a T1 sequence with gadolinium injection. On the right, the dose distribution is shown: in transparent yellow, the high-risk volume (flap) treated at 60 Gy in 30 sessions; in transparent purple, the low-risk peritumoral volume and the areas treated prophylactically at 54 Gy in 30 sessions. The preoperative volume is shown in red, and the reconstructed tongue with the flap is highlighted in pink.</figcaption></figure>

flap and cervical area. Hélicoidal radiotherapy treatment was delivered in 30 sessions with 5 sessions per week. The doses were 60 Gy on the surgical bed in the oral cavity, and 54 Gy on the ipsilateral left cervical lymph node areas and the peritumoral volume (Fig. 1). The patient's nutritional status remained stable throughout the treatment thanks to enteral nutrition. During radiotherapy, he developed grade III radiation mucositis and grade II dysphagia, which were treated with significant doses of morphine, mouth rinses with lidocaine and corticosteroids and photobiomodulation sessions several times a week. Three weeks after the start of radiotherapy, the patient developed radiomucositis on the lateral sides of his flap. Oral feeding was stopped to promote local healing and morphine-based analgesics had to be continued due to significant pain. The bilateral ulcerations on the flap gradually spread for several months after the end of treatment, until they caused complete necrosis of the anterior two-thirds of the flap (Fig. 2). The patient underwent reference scanner three months after the end of radiotherapy, which showed no sign of tumor recurrence. The vascularization of the pedicle of the flap was preserved on this injected CT scan. Given the extent of the necrosis and the increasing pain, a collegial decision was

made to perform complete resection of the necrotic tissue and simultaneous secondary reconstruction using a radial forearm free flap. This surgery was performed 4 months after the end of radiotherapy. The posterior part of the flap reconstructing the base of the tongue was still well vascularized and could be preserved. We sent various samples for anatomo-pathological, bacteriological, fungal, and mycobacteriological analysis. The bacteriological analysis revealed an anaerobic germ of intestinal origin, *Bacteroides ovatus/xylanisolvens*, while the mycological and mycobacteriological analyses were negative. After consulting with infectious disease specialists, we have introduced high-dose antibiotic therapy with amoxicillin - clavulanic acid 1 g combined with amoxicillin 1 g three times a day for one week. The anatomo-pathological analysis found no evidence of a recurrence of the known squamous cell carcinoma. The postoperative course was uneventful, without complications. The patient resumed oral feeding on the seventh postoperative day. Pain had completely subsided, allowing for a gradual reduction of morphine. The gastrostomy was removed six weeks after surgery, as the patient could eat sufficiently.

<figure><img src="image_7.png" /><figcaption>**Fig. 2.** Clinical evolution of the anterolateral tight free flap: a - Three weeks after initiating radiotherapy; b - One month after completion of radiotherapy, c - Two months after completion of radiotherapy; d,e - Three months after radiotherapy; f Postoperative aspect six weeks after secondary reconstructive surgery.</figcaption></figure>
## 3. Discussion

We present a rare case of delayed necrosis of a free flap following radiotherapy in a patient with no significant medical history, apart from previous smoking. To our knowledge, no similar case has been described in the literature. In an 18-year follow-up study, Wax et al. reported only 13 cases of late free flap necrosis out of 1530 flaps. These necroses occurred on average 21 days [7–90] following surgery and were attributed to episodes of compression of the pedicle, late episodes of infection and tumor recurrence [4]. In this case, the vascular hypothesis is unlikely given the initial topography of the ulcerations, which developed on the lateral sides of the flap and the centripetal progression of the necrosis. The post-radiotherapy reference CT scan confirmed good vascularization of the flap pedicle, and the posterior part of the reconstruction remained well vascularized. In our opinion, the most likely hypothesis for this late necrosis is the association of severe radiomucositis with bacterial colonization. Infections can also lead to thromboembolic complications due to systemic inflammation and microcirculatory thrombotic lesions [6]. This clinical presentation should prompt early collection of multiple bacteriological samples to limit the spread of necrosis and preserve the reconstruction. This evolution may also suggest an intrinsic radiosensitivity of the patient. Currently, no reliable test is available in routine clinical practice to predict such radiosensitivity before treatment, although this remains an active area of research [7,8]. The current approach focuses on reducing the irradiation dose to the flap, thereby minimizing side effects on the healthy transplanted tissues [9,10]. Several studies have shown that reducing the dose of radiation to the center of the flap reduces toxicity without increasing the risk of tumor recurrence [10–12]. Finally, the optimal timing for secondary reconstruction post-radiotherapy remains widely debated. Bengtson et al. suggest that immediate reconstruction (<4 months after radiotherapy) is associated with a higher complication rate compared to delayed reconstruction, while other authors recommend early reconstruction within the first 6 weeks post-irradiation [13,14]. In our patient's case, complete necrosis occurred three months after radiotherapy. Given the intense pain and difficulty resuming oral intake, we opted for secondary reconstruction at 4 months post-radiotherapy. The outcome was favorable.

### Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The author is an Editorial Board Member/Editor-in-Chief/Associate Editor/Guest Editor for this journal and was not involved in the editorial review or the decision to publish this article.

### CRediT authorship contribution statement

Sophie Dugast: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Conceptualization.

Langé Martin: Writing – review & editing, Validation, Formal analysis, Data curation, Conceptualization. Nadia Benmoussa: Validation, Investigation, Formal analysis. Mélanie Doré: Validation, Investigation, Data curation. Julie Longis: Writing – review & editing, Validation, Supervision. Helios Bertin: Writing – review & editing, Writing – original draft, Formal analysis.

### References

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