Three-Dimensional Tongue Reconstruction Using a Trishul-Pattern Sensate Suprafascial Anterolateral Thigh Flap

Background: Tongue reconstruction after oncologic glossectomy requires restoration of 3-dimensional contour, palatal contact, sensation, and floor-of-mouth support. A flat fasciocutaneous inset may close the defect but may not recreate the functional anatomy of the tongue. We describe a Trishul-pattern sensate suprafascial anterolateral thigh flap for subtotal and near-total tongue reconstruction, with selective use of a chimeric motor-innervated vastus lateralis component for floor-of-mouth reconstruction. Methods: This descriptive case series was conducted from March 2023 to March 2025. Sixteen patients with carcinoma of the tongue underwent reconstruction using a sensate suprafascial anterolateral thigh flap after oncologic resection. Seven patients underwent Trishul-pattern fasciocutaneous ALT reconstruction alone, while 9 required a chimeric reconstruction using an additional motor-innervated vastus lateralis component for floor-of-mouth support. All cases were performed through a pull-through approach. Sensory coaptation was performed between the lateral cutaneous nerve of the thigh and the lingual nerve. In chimeric cases, the motor branch to the vastus lateralis was coapted to the hypoglossal nerve. Functional outcomes were assessed at 6 months using speech intelligibility score, Functional Oral Intake Scale, MD Anderson Dysphagia Inventory, EORTC QLQ-H&N35, and 2-point discrimination. Results: The cohort included 14 male and 2 female patients, aged 36 to 61 years. All patients resumed solid oral intake by 6 months. FOIS scores were 7 in 12 patients and 6 in 4 patients. Speech intelligibility score was 5 in 10 patients and 4 in 6 patients. The mean MDADI composite score was 91.2±5.5. EORTC QLQ-H&N35 scores showed low symptom burden for pain, swallowing difficulty, speech difficulty, and social eating. Static 2-point discrimination ranged from 8 to 15 mm. Donor sites were closed primarily in 14 cases and with bilateral keystone advancement in 2 cases. Conclusions: The Trishul-pattern sensate suprafascial ALT flap provides a reproducible 3-dimensional template for tongue reconstruction. When floor-of-mouth or suprahyoid support is lost, the addition of an innervated vastus lateralis component allows separation of neotongue shaping from floor reconstruction. This defect-oriented strategy was associated with favorable early outcomes in speech, swallowing, sensory, and donor-site.