From hemiglossopelvectomy to total glossectomy: a volumetric and functional study for the optimization of microsurgical reconstruction in the era of ERAS protocols

Background and study objective: Surgical management of mobile tongue squamous cell carcinoma (OTSCC) requires a tailored reconstructive approach, particularly for extensive resections. Enhanced Recovery After Surgery (ERAS) protocols have reshaped perioperative care, aiming to promote early functional recovery and reduce complications. Evaluating reconstructive efficacy according to glossectomy type is crucial to define optimal surgical strategies. Materials and Methods: Seventeen patients with cM0 OTSCC undergoing hemiglossectomy to total glossectomy with microsurgical free flap reconstruction were prospectively assessed. Exclusion criteria included total laryngectomy, segmental mandibulectomy, or reconstructive failure. Reconstructions were classified by defect size (type IIIb–V glossectomy), flap type (RFFF, ALTFF, MSAP, etc.), reinnervation, and static suspension. Patients were divided into pre-ERAS and ERAS groups. Static outcomes included flap volumetry at baseline, 6, and 12 months. Dynamic outcomes included tongue mobility, swallowing (FEES, VFS, DIGEST, PAS, YALE), speech intelligibility in quiet and noise, and patient-reported quality of life (EORTC QLQ-H&N35, MDADI). Complications and adjuvant therapies were recorded. Preliminary Results: Mean flap volume decreased by 44.4% at 12 months (range 22–66%). All patients resumed oral intake: 100% tolerated liquids (IDDSI 0), 91.6% semisolids (IDDSI 3), and 33.3% solids (IDDSI 7). Median FOIS was 5.16; mean DOSS 5.08. Tongue protrusion was significantly reduced in subtotal/total glossectomy (p = 0.05) and after ALT flap reconstruction (p = 0.038). Vallecular residue for liquids correlated with glossectomy extent (p = 0.043) and radiotherapy (p = 0.027). Trisyllabic word intelligibility decreased with greater flap volume loss (p = 0.046). ERAS enrollment was associated with a trend toward reduced pyriform sinus residue (p = 0.083) but longer eating times (p = 0.043). Mean MDADI score was 62.2; EORTC domains highlighted highest burden for nutritional supplements (77.8) and sticky saliva (75). Discussion and Conclusion: Long-term functional outcomes after glossectomy are influenced by defect extent, flap stability, and adjuvant treatments. Integration of ERAS pathways with reconstructive planning guided by defect volumetry and functional objectives supports a “best-of-reconstruction” approach, optimizing swallowing, speech, and quality of life.