Soft tissue defects of the oral cavity are challenging in the reconstructive surgery due to loss of motility, secretion and sensory functions of mucous membrane. Reconstruction especially of tongue defects should ensure proper patient’s speech and swallowing. Skin grafts are ineffective in the case of bone exposure and have a tendency to keratinization and cicatrization, which additionally decreases the movability of the remaining, healthy oral mucosa . Also most pedicled regional and free flaps containing skin island are characterized by impaired sensitivity, keratinization, hair growth and donor site morbidity. Local musculomucosal flaps are a good method of reconstruction of moderate tongue defects . According to Massarelli et al.  all buccinator musculomucosal flaps provide proper mucus secretion and sensitivity without shrinking tendency, especially after radiotherapy.
The iFAMM flap in the tongue reconstruction is possible in case of facial vessels preservation. Massarelli et al.  suggest that iFAMM flap pedicled solely on the facial artery with the surrounding fat tissue provides the correct venous drainage, without flap congestion. However, Rahpeyma et al.  in experimental studies on dogs observed iFAMM flap loss in each case of facial vein ligation. For that reason, iFAMM flap, pedicled only on facial artery, is not acceptable for clinical usage . In our case, the patient had facial vein and artery ligated during neck dissection 18 months earlier. This was the main contraindication for tongue reconstruction by iFAMM. However, the vascularization of the buccinator muscle is derived from the branches of facial vessels in anterior part and buccal vessels in posterior region. Due to the fact, that CT revealed preserved distal part of the facial artery in buccal region (Fig. 5) and a large number of anastomoses between facial and buccal angiosome, which ensures good blood supply through buccal vessels, we decided to used dpFAMM flap for this reconstruction . The dpFAMM flap combines the advantages of both the FAMM and the Bozola flap, which allows its extension to be increased with sufficient venous drainage .
Another issue concerning reconstruction is preoperative radiotherapy. It should be pointed out that both the donor and recipient sites comprise the irradiation field, which implies a higher risk of healing process problems with potential flap necrosis. O’Leary and Bundgaard  suggested that FAMM flap is not suitable in patients, who underwent previous radiotherapy, due to the risk of such complications as trismus, bleeding, osteoradionecrosis and impaired healing followed by flap necrosis. They observed partial flap necrosis in 75% (3 from 4 patients) of cases. On the other hand, Ayad et al.  did not notice the specific complication rate in group of 10 patients previously irradiated. In our case, we also did not detect problems with healing, bleeding and proper mouth opening. Short term of the follow up did not allow for evaluation of possible mandibular osteoradionecrosis.
Healing process can also be disturbed by hormone therapy. According to Billon et al.  hormone therapy, including tamoxifen intake, seems to be associated with a higher risk of postoperative wound healing complications in patients with breast reconstruction. In addition, Parikh et al.  in their meta-analysis concluded that perioperative tamoxifen therapy may increase the risk of thrombotic flap complications and flap loss in patients undergoing free flap reconstruction due to breast cancer. They suggested that short cessation of the tamoxifen therapy, about 4 weeks prior to reconstructive treatment, might decrease the risk of complications . Our patient also suffered from synchronous mucinous carcinoma of the left breast treated with tamoxifen since 15 months before salvage surgery. This was one of the contraindication for free radial forearm flap application and choice of dpFAMM flap for tongue reconstruction. Transient discontinuation of tamoxifen before surgery was not recommend. However, healing process was uneventful.
Extension of the dpFAMM flap in the anterior part of the buccinator muscle provided ability for tongue reconstruction, even after hemiglossectomy. If the apex of the tongue can be preserved during ablative surgery, like in this case, dpFAMM flap can be doubled. Preserved apex of the tongue is rotated backward to obtain best clinical result of the reconstruction. Flap’s harvesting takes around 30-50 minutes and can be done by one surgical team. The dpFAMM flap has a perfect color and structure, matching the surrounding tissues without additional extraoral scars. This case presentation proved that dpFAMM flap can be used for reconstruction in salvage surgery, even, if facial vassels had been ligated previously and the patient was irradiated and treated with hormone therapy. Other advantages of the dpFAMM flap include its feasibility in the reconstruction of other areas, like the floor of the mouth, the alveolar ridge, the soft and hard palates, or the oropharynx.