To compare functional and oncologic outcomes between vertical rectus abdominis musculocutaneous (VRAM) and anterolateral thigh (ALT) flap reconstruction following total or near-total glossectomy in patients with T4 tongue squamous cell carcinoma.

This comparative study included 75 patients (Group A: VRAM, n=30; Group B: ALT, n=45) treated between February 2019 and February 2023. Flap selection was based on preoperative pinch test of anterolateral thigh subcutaneous fat thickness (<1.5 cm for VRAM, ≥1.5 cm for ALT). Functional outcomes (speech and swallowing) were assessed at 1 month postoperatively and at 6 months after completion of radiotherapy using validated scales. Disease-free survival (DFS) was analyzed using the Kaplan–Meier method and Cox proportional hazards regression.

Group B demonstrated significantly better speech and swallowing function at 1 month and 6 months postoperatively (p < 0.05). However, in the subgroup analysis of patients with type V (total) glossectomy, functional differences were significant only at 1 month and became comparable by 6 months. The median follow-up was 21.0 months overall and 34.5 months among disease-free patients. The estimated 2-year DFS rates were 50.9% in Group A and 43.0% in Group B (p = 0.557). Multivariate analysis identified lower BMI, positive extranodal extension (ENE), and greater depth of invasion (DOI >20 mm) as independent predictors of worse DFS. Flap type was not an independent prognostic factor.

Both VRAM and ALT flaps provide comparable long-term functional outcomes when appropriately oversized. Depth of invasion >20 mm was a strong independent adverse prognostic factor in this cohort of T4 tongue squamous cell carcinoma and was associated with significantly worse disease-free survival. This finding is hypothesis-generating and warrants further investigation as a potential refinement to risk stratification within T4 disease.