Functional outcomes of sensate versus insensate free flap reconstruction in oral and oropharyngeal reconstruction: A systematic review

Comparison of complications and functional outcomes following total or subtotal glossectomy with laryngeal preservation using a deep inferior epigastric artery perforator free flap versus a rectus abdominis musculocutaneous free flap

OBJECTIVE

Wide defects resulting from subtotal or total glossectomy are commonly reconstructed using a bulk flap to maintain oral and speech functions. The flap, including muscle tissue, diminishes with time. This study aimed to compare the surgical outcomes of deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions after glossectomy with laryngeal preservation.

METHODS

Medical records of 13 and 26 patients who underwent deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions, respectively, from 2014 to 2022 at our institution were reviewed. Patients who underwent middle pharynx resection except for the base of the tongue, mandibular bone resection, and sensory reinnervation were excluded.

RESULTS

The rectus abdominis musculocutaneous groups showed a higher number of lymph node dissection and shorter operative time than the deep inferior epigastric artery perforator groups. No significant differences in postoperative complications or functional oral intake scale scores at 6 months were observed. Volumetric changes on computed tomography images at 6 and 12 months were significantly lower in the deep inferior epigastric artery perforator group. Cancer recurrence was significantly associated with reduced oral function.

CONCLUSIONS

Oral function in patients with cancer is influenced by various other factors. However, the deep inferior epigastric artery perforator flap may be suitable for tongue reconstruction because of the minimal postoperative changes in flap volume, easy adjustment of flap thickness, elevation of multiple flaps, and minimal complications at the donor site.

Systematic review of the free thoracodorsal artery perforator flap for head and neck reconstruction

BACKGROUND

The thoracodorsal artery perforator (TDAP) flap has gained interest as a option for reconstruction of head and neck defects while minimizing donor site morbidity as compared to traditional workhorse flaps. The primary aim of this systematic review is to assess the postoperative outcomes and efficacy of this flap.

METHODS

Several databases were screened for relevant citations. The quality of studies and risk of bias were evaluated using the MINORS scoring system.

RESULTS

Twenty articles containing 168 patients undergoing at least one TDAP flap reconstruction met the inclusion criteria. There were no incidences of total flap failure and only 10 incidences of partial flap failure (5.95 %). Flap complications and donor site morbidity was low. The average MINORS score of the studies suggested a moderately high amount of bias.

CONCLUSIONS

Based on limited quality evidence, this review suggests that TDAP flap is a safe and feasible option for head and neck reconstruction with comparable success rates as other commonly used flaps, with low complication rate and donor site morbidity. Further large-scale studies are warranted.

Depth of resection predicts loss of tongue tip sensation after partial glossectomy in oral tongue cancer: A pilot study

OBJECTIVE(S)

To characterize the change in sensory function following partial glossectomy for oral tongue cancer (OTC) and to identify predictors of loss of tongue-tip sensation (LoTTS).

MATERIALS AND METHODS

Patients with at least three months follow-up after partial glossectomy for primary OTC were included. All patients underwent a qualitative tongue sensation assessment and an objective tongue sensory exam of the native tongue tip. Additional details regarding the oncologic resection, surgical reconstruction, and pathological stage were collected. Multiple linear and logistic regressions were used for statistical analysis.

RESULTS

Sixty-four patients were enrolled, including 34 (53%) men with a median age of 65 at enrollment. Ten (15%) patients reported LoTTS. Increased depth of resection (DOR) was an independent predictor of LoTTS on multivariate analysis, with an increased risk at a threshold of 1.3 cm. LoTTS was also associated with worse subjective quality of life and perceptive speech performance in our qualitative tongue assessment.

CONCLUSIONS

In this pilot study, we found that DOR is a critical prognostic factor in predicting post treatment function. Patients with an increased DOR, particularly above 1.3 cm, are at greatest risk of LoTTS and associated morbidity. These findings may be used to predict post-operative sensory deficits, manage patients' expectations, and optimize the reconstructive approach. Future studies are needed to validate and replicate our results.

Neurotization of the radial forearm free flap improves swallowing outcomes in hemiglossectomy defects

BACKGROUND

We examined the effect of free tissue neurotization on speech and swallowing outcomes for patients undergoing reconstruction of hemiglossectomy defects with a radial forearm free flap (RFFF).

METHODS

A retrospective study was performed in patients with oral cavity squamous cell carcinoma undergoing a hemiglossectomy and reconstruction with a RFFF. Functional outcomes including nutritional mode, range of liquids and solids, and speech understandability were analyzed 1-year post-treatment.

RESULTS

Eighty-four patients were included in this analysis, 41 of whom had neurotized flaps (49%). No significant differences in demographic or clinical variables were seen between the neurotized and non-neurotized groups. On multivariate analysis controlling for BMI, flap area, and N-classification, patients with neurotized flaps were significantly more likely to have normal range of liquids and solids and less likely to have a G-tube.

CONCLUSIONS

Neurotization of RFFF reconstructing hemiglossectomy defects results in decreased G-tube dependence and improved range of liquids and solids.

Evaluating Sensation Recovery in Noninnervated Free Flaps Used for Oral Reconstruction

PURPOSE

Association between time and sensation recovery in noninnervated flaps remains unclear. Our goal was to evaluate the recovery of sensation in noninnervated free flaps used for oral reconstruction.

MATERIALS AND METHODS

A prospective cohort study was designed and consecutive patients undergoing noninnervated free flap surgery for oral reconstruction from a tertiary medical center were enrolled. The primary outcome variable was sensory recovery of light touch, pain, hot, and cold temperature. Sensory recovery was scored as per the test on the central portion and 4 peripheral sections of every flap. The Kaplan-Meier method was used to estimate the functional recovery at different time points and the association between clinicopathologic variables and sensation recovery at 24 months after surgery was analyzed using the chi-squared test and logistic regression analysis.

RESULTS

Eighty patients were included with a median age of 50 years. At 3 months postoperatively, no patients exhibited sensation recovery. Positive flap sensitivity began to appear mildly at 6 months postoperatively and gradually increased for at least 24 months. The 24-month sensation recovery rates of light touch, pain, and temperature were 70.0% (95% confidence interval [CI]: 59.2 to 78.9%), 42.5% (95% CI: 32.3 to 53.4%), and 33.8% (95% CI: 24.45 to 44.6%), respectively. In univariate analysis, 80.5% (95% CI: 66.0 to 89.8%) of the free radial forearm flaps showed light touch sensation recovery, which was statistically higher than 59.0% (95% CI: 43.4 to 72.9%) in other flaps (P = .036). Flap size ≤ 65 cm² predicted better pain sensation recovery with 57.5% (95% CI: 42.2 to 71.5%) compared to 27.5% (95% CI: 16.1 to 42.8%) in flap size > 65 cm² groups (P = .007). Logistic regression analysis confirmed flap size ≤ 65 cm² (P = .032, odds ratio = 1.957, 95% CI: 1.034 to 4.389) and not smoking (P = .015, odds ratio = 2.564, 95% CI: 1.673-5.482) offered better sensation recovery of pain and hot temperature, respectively.

CONCLUSIONS

Sensation recovery in noninnervated free flaps was common and related to not smoking and flap size.

Sensory nerve regeneration and reinnervation in muscle following peripheral nerve injury

Sensory afferent fibers are an important component of motor nerves and compose the majority of axons in many nerves traditionally thought of as "pure" motor nerves. These sensory afferent fibers innervate special sensory end organs in muscle, including muscle spindles that respond to changes in muscle length and Golgi tendons that detect muscle tension. Both play a major role in proprioception, sensorimotor extremity control feedback, and force regulation. After peripheral nerve injury, there is histological and electrophysiological evidence that sensory afferents can reinnervate muscle, including muscle that was not the nerve's original target. Reinnervation can occur after different nerve injury and muscle models, including muscle graft, crush, and transection injuries, and occurs in a nonspecific manner, allowing for cross-innervation to occur. Evidence of cross-innervation includes the following: muscle spindle and Golgi tendon afferent-receptor mismatch, vagal sensory fiber reinnervation of muscle, and cutaneous afferent reinnervation of muscle spindle or Golgi tendons. There are several notable clinical applications of sensory reinnervation and cross-reinnervation of muscle, including restoration of optimal motor control after peripheral nerve repair, flap sensation, sensory protection of denervated muscle, neuroma treatment and prevention, and facilitation of prosthetic sensorimotor control. This review focuses on sensory nerve regeneration and reinnervation in muscle, and the clinical applications of this phenomena. Understanding the physiology and limitations of sensory nerve regeneration and reinnervation in muscle may ultimately facilitate improvement of its clinical applications.

Prelamination of the Radial Forearm Free Flap Using Free Full-Thickness Eyelid Skin Grafts: A New Approach for Intraoral Defect Reconstruction

ABSTRACT

Free flap transfer for reconstruction of intraoral defects is a common procedure in oral and maxillofacial surgery. For tumor-related defects, the radial forearm flap is widely used for soft tissue restoration. However, transfer of free skin grafts to the donor site region is often required for wound closure after free flap harvesting, resulting in esthetic disturbances due to shrinkage of the grafted skin, attendant scarring, or mismatches in skin texture or color. Furthermore, free flap transfer may result in hair follicle transfer into the oral cavity, causing unfavorable intraoral hair growth in adult men in particular. Free flap prelamination can help reduce the potential disadvantages of free flaps, in terms of both flap design and size and donor site morbidity. For surgical treatment of oral cancer in middle-aged and elderly patients, eyelid dermatochalasis may present as a comorbidity leading to esthetic impairments or, in cases involving the upper eyelid, even a reduced field of view. In these cases, bilateral blepharoplasty can reduce the excess eyelid skin. The present study is the first to attempt to use excised skin after bilateral blepharoplasty as full-thickness skin grafts for radial forearm free flap prelamination. This approach combined surgical therapy of eyelid dermatochalasis with free flap prelamination, thereby avoiding the need to harvest free skin grafts from other anatomically healthy regions to close the donor site defect and preventing the accompanying disadvantages. The reconstruction results and clinical outcomes of patients revealed that radial forearm free flap prelamination using bilateral free full-thickness eyelid skin grafts was an easy and feasible method for intraoral defect reconstruction. In particular, this approach could avoid intraoral hair growth and additional skin grafting from other healthy anatomical regions, yielding good esthetic and functional results at the flap's recipient and donor sites.

Dual efficacy of Fasudil at improvement of survival and reinnervation of flap through RhoA/ROCK/PI3K/Akt pathway

Fasudil is reported to be effective at protecting against ischaemic diseases, and at augmenting axon growth. In this study, we aim to evaluate its efficacy in promoting flap survival and reinnervation. Ninety-two Institute of Cancer Research (ICR) mice were used and divided into the control, Fasudil, LY294002, Fasudil+LY294002 groups, receiving a daily intraperitoneal injection of normal saline, Fasudil (10 mg/kg), LY294002 (5 mg/kg), and Fasudil (10 mg/kg) + LY294002 (5 mg/kg), respectively. On days 0 and 5, the blood perfusion and diameter of the iliolumbar artery in the pedicle of the flaps in the four groups were evaluated using laser speckling contrast imaging (LSCI). On day 5, the flaps were photographed and the necrosis rate of the flaps was calculated using Photoshop CS6. In addition, tissues were harvested from the flaps and divided into two parts. One part underwent routine cryosection and immunofluorescent staining using the antibody against CD31 for evaluation of the microvascular density in the four groups. In the other part, the expression of RhoA, ROCK1+2, p-CPI-17, p-MYPT, p-PTEN, p-PI3K, p-Akt, and vascular endothelial growth factor (VEGF) within the flaps were determined using western blotting. Moreover, at days 0, 7, 15, and 30 after flap surgery, the axons within the flaps were evaluated using immunofluorescent staining with the antibody against Neurofilament-200. It turned out that the necrosis rate was (24.4 ± 7.7)%, (5.2 ± 1.6)%, (29.8 ± 4.2)%, and (30.9 ± 7.1)%, respectively, in the control, Fasudil, LY294002, LY294002+Fasudil groups. There was a significant reduction in the necrosis rate of the flaps in the Fasudil group (P < .001). The LSCI and immunofluorescent staining demonstrated that Fasudil could significantly expand the diameter of the iliolumbar artery in the pedicle, boost the overall blood perfusion, and increase the microvascular density of the flaps in the Fasudil group (P < .05), which could all be abolished by PI3K inhibitor LY294002. On day 5, the expression of p-CPI-17, p-MYPT, and p-PTEN were downregulated, whereas pPI3K, p-Akt, and VEGF were upregulated in the Fasudil group (P < .001). As for reinnervation, Neurofilament-200 fluorescent staining revealed that at days 15 and 30 after flap harvest, only in the Fasudil group could new axons be observed. It can be concluded that Fasudil could simultaneously improve the survival and axon growth after flap harvest, a dual efficacy achieved by inhibition of the RhoA/ROCK pathway, which in turn activates /PI3K/AKT pathway.

Sensory recovery and oral health-related quality of life following tongue reconstruction using non-innervated radial forearm free flaps

OBJECTIVES

This study aimed to monitor the recovery of somatosensory function and oral health-related quality of life after tongue reconstruction using a non-innervated radial forearm free flap (RFFF).

METHODS

Twenty patients (9 men, age: 42-67 years) underwent tongue reconstruction with non-innervated RFFFs, and twenty age- and sex-matched controls were included in this study. Quantitative sensory testing (QST), including cold, warm, and mechanical detection thresholds (CDT, WDT, MDT); cold, heat, and mechanical pain thresholds (CPT, HPT, MPT); and static two-point, sharp/blunt, and direction discrimination (S2-PD, S/BD, DD) were determined 9 months and 18 months after surgery on the surgical (9 M, 18 M) and contralateral sides (9Mc, 18Mc). Oral Health Impact Profile-49 (OHIP-49) was used to determine the oral-related quality of life of participants.

RESULTS

All parameters showed significantly lower sensitivity at 9 M and 18 M (p < 0.001) compared to those for the controls and the contralateral side, except for DD (p = 0.101). In addition, the parameters showed a significant decrease in sensitivity for 9Mc and 18Mc (p ≤ 0.043) compared to those for the controls, except for MPT, HPT, S/SD, and DD (p ≥ 0.453). Findings on WDT, MPT, S2-PD, and DD (p ≤ 0.046) indicated significantly higher somatosensory function at 18 M than that at 9 M. MDT and MPT (p ≤ 0.038) showed significantly higher sensitivity at 18Mc than at 9Mc. Scores for all dimensions of OHIP-49 were significantly higher in patients (decrease in quality of life, p ≤ 0.002) than in controls, except for physical discomfort (p = 0.51). However, the scores were significantly higher at 18 M than at 9 M (p ≤ 0.011), except for handicap (p = 0.36). Postoperative chemotherapy was significantly correlated with impaired thermal sensitivity of the flaps (WDT, p = 0.049).

CONCLUSION

The present findings showed significant impairment in somatosensory function on both the surgical and contralateral sides of patients with RFFFs. However, a significant increase in somatosensory function was observed on both sides over time. Somatosensory disturbances observed after surgery were associated with poor oral health-related quality of life.

Outcomes of primary radiotherapy with or without chemotherapy for advanced oral cavity squamous cell carcinoma: Systematic review

BACKGROUND

Surgery with adjuvant radiotherapy is the accepted standard for treatment of advanced oral cavity squamous cell carcinoma (OCSCC); however, alternative evidence suggests that definitive (chemo)radiotherapy may have similar outcomes.

METHODS

Systematic review was performed to assess the therapeutic value of radiotherapy or chemoradiotherapy as a primary modality for treating OCSCC. Meta-analysis of outcomes was performed between articles comparing radiotherapy and primary surgical treatment.

RESULTS

Meta-analysis showed less favorable results of radiotherapy compared to surgery: overall survival at 3-years (odds ratio [OR] = 0.51; 95% confidence interval [CI] = 0.34-0.77) and 5-years (OR = 0.42; 95% CI = 0.29-0.60); disease-specific survival at 3-years (OR = 0.55; 95% CI = 0.32-0.96) and 5-years (OR = 0.55; 95% CI = 0.32-0.96). Odds of feeding tube dependency were higher in primary radiotherapy group (OR = 2.67; 95% CI = 1.27-5.64).

CONCLUSIONS

Results of this study support the current perspective favoring primary surgical treatment for OCSCC in the absence of surgical contraindications.

Function-Preserving Neurotized Lateral Arm Free Flap in the Reconstruction of Hemiglossectomy Defects

Introduction and Methods  The glabrous, thin, and pliable texture of lateral arm flap with no loss of any axial vessel of the limb renders it a good choice for hemiglossectomy defect reconstruction. The main caveat of this flap harvest is the loss of sensation in the distribution of posterior antebrachial cutaneous nerve (PABCN). In this article, we present two strategic sites and techniques to preserve the integrity of PABCN and at the same time harvesting lateral arm flap with a lengthy lower lateral cutaneous nerve of arm for the neurotization. The outcome of this function-preserving neurotized lateral arm free flap in the reconstruction of hemiglossectomy defects is analyzed and presented in this article.

Results  Ninety percent of the patients attained grade 3 score in objective assessment, leading to a significant p -value of 0.02 with this technique. All had preservation of sensation in the distribution of PABCN.

Conclusion  Our technique of harvest and neurotization has brought good functional recovery of the oral cavity with preservation of PABCN.

Long-term donor site morbidity after radial forearm flap elevation for tongue reconstruction: Prospective observational study

BACKGROUND

To assess long-term donor site morbidity after radial forearm free (RFF) flap harvesting.

METHODS

Enrolled patients were asked to complete the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and undergo wrist motion and hand strength examinations at different time points. The data were prospectively collected and retrospectively analyzed.

RESULTS

The postoperative DASH score did not return to normal until 24 months after the operation. The mean postoperative wrist motion degree of flexion was significantly decreased compared to the preoperative level and returned to normal at 12 months after the operation. Similar trends were noted regarding extension, radial abduction, and ulnar abduction. The mean postoperative grip strength was significantly decreased compared to the preoperative level and remained dysfunctional at 24 months after the operation. A similar trend was also noted with regard to tip pinch and key pinch.

CONCLUSION

The long-term negative effect on hand strength is sustained.

Quantification of axonal ingrowth and functional recovery in a myocutaneous flap model in rats with strong clinical implications

The process of reinnervation, an important component of functional restoration after flap transfer, is understudied, making it necessary to carry out a further investigation for delineation of the exact timeline. Seventy-six Sprague-Dawley rats were used as the experimental animals. An anatomic study was first conducted to clarify the pattern of nerve distribution in the dorsal skin of 16 rats. Afterward, a myocutaneous flap was harvested on the right flanks of 40 rats, which were then assigned into seven time points. At each time point, skin samples were harvested and immunofluorescent staining was performed using α-Bungarotoxin, and antibodies against NF-200, p75, α-SMA, and TH. One-way analysis of variance was adopted for comparison of nerve density after surgery. For evaluation of functional return, cutaneous trunci muscle reflex (CTMr) test was performed on 10 additional rats, and the Chi-square test was used for comparison of reflex intensity among six time points after surgery. The outcomes revealed that the cutaneous branches from the intercostal nerves and the dorsothoracic nerve from the brachial plexus could be found entering the dorsal skin, distributed in the skin proper and the panniculus carnosus, respectively. After flap surgery, full spontaneous reinnervation of the skin proper and vessels within the flaps could be achieved at day 180. However, if the stumps of cutaneous branches of the intercostal nerves were damaged, the nerve density in the skin proper underwent a 2/3 decline. The panniculus carnosus in the cranial part had a much better reinnervation than that in the caudal part. The CTMr test showed that the flap could regain most of its sensate and motor activity. Our study shows that strong spontaneous reinnervation could be expected after flap surgery. The pattern of the original nerve distribution in both the recipient and donor sites may have a big impact on the reinnervation of the flap.

Functional requirements for polymeric implant materials in head and neck surgery

BACKGROUND

The pharyngeal reconstruction is a challenging aspect after pharyngeal tumor resection. The pharyngeal passage has to be restored to enable oral alimentation and speech rehabilitation. Several techniques like local transposition of skin, mucosa and/or muscle, regional flaps and free vascularized flaps have been developed to reconstruct pharyngeal defects following surgery, in order to restore function and aesthetics. The reconstruction of the pharynx by degradable, multifunctional polymeric materials would be a novel therapeutical option in head and neck surgery.

MATERIALS AND METHODS

Samples of an ethylene-oxide sterilized polymer (diameter 10 mm, 200μm thick) were implanted for the reconstruction of a standardized defect of the gastric wall in rats in a prospective study. The stomach is a model for a "worst case" application site to test the stability of the implant material under extreme chemical, enzymatical, bacterial, and mechanical load.

RESULTS

Fundamental parameters investigated in this animal model were a local tight closure between the polymer and surrounding tissues, histological findings of tissue regeneration and systemic responses to inflammation. A tight anastomosis between the polymer and the adjacent stomach wall was found in all animals after polymer implantation (n = 42). Histologically, a regeneration with glandular epithelium was found in the polymer group. No differences in the systemic responses to inflammation were found between the polymer group (n = 42) and the control group (n = 21) with primary wound closure of the defect of the gastric wall.

CONCLUSIONS

A sufficient stability of the polymeric material is a requirement for the pharyngeal reconstruction with implant materials.

Usefulness of a template-based anterolateral thigh flap for reconstruction of head and neck defects

BACKGROUND

One of the challenges in head and neck reconstruction is to have an adequate understanding of the three-dimensionalities of the defects created after resections due to the high variability of clinical scenarios. Consequently, it is essential to design the flap to match the requirements of the defect in order to facilitate the insetting and to achieve a successful outcome. The anterolateral thigh flap (ALT) is a robust and versatile flap commonly used in head and neck reconstruction. In this study the authors use a hand-made template as a tool to customize ALT flaps and its variations to fit more accurately the different shapes, volume, and components of the resulting defects. The aim of this study is to describe in detail this surgical approach and present the clinical experience in 100 consecutive cases using a template-based ALT flaps in head and neck reconstruction.

METHODS

A retrospective review was performed on all microvascular head and neck reconstruction cases between January 2013 and December 2017 in our institution where a template-based ALT flap design was performed. We describe in detail the surgical technique used and present the clinical outcomes. In addition, we analyzed the use of different designs of the ALT flaps including different flap components in relation to the location of the defect.

RESULTS

One hundred reconstructions for head and neck defects were performed in 97 patients. Seven types of ALT free flaps were performed: fasciocutaneous (46%), suprafascial (8%), adipofascial (9%), vastus lateralis muscle (3%), composite fasciocutaneous/adipofascial (9%), chimeric flaps (21%), and vascularized nerve grafts (4%). Oropharyngeal and periauricular defects were mostly reconstructed with fasciocutanoues design. In more complex three-dimensional defects such as skull base or midface defects, a chimeric flap was selected. In all cases the used of template facilitated the insetting of the free flap. The total flap loss was 2%.

CONCLUSIONS

Customization of ALT flaps using intraoperative templates is a useful method for flap design which facilitates fitting of the flap to a variety of defects in head and neck reconstruction.

A systematic review of functional outcomes after nerve reconstruction in extremity soft tissue sarcomas: A need for general implementation in the armamentarium

Resection of nerves in extremity soft tissue sarcomas (STS) can lead to large functional deficits. Nerve reconstructions are rarely performed and little is known on their outcomes and indications for their use, even though they are essential in restoring sensation in limb salvage procedures. This study investigated current knowledge on functional outcomes and considerations to be taken before performing such reconstructions after sarcoma resection. A systematic search was performed in July 2018 in PubMed and Embase databases according to PRISMA guidelines. Search terms related to "soft tissue sarcoma" and "nerve reconstruction" were used. Studies evaluating functional outcomes after nerve grafting or nerve transfers in extremity STS were included. Qualitative synthesis was performed on all studies. Nineteen studies were included after full-text screening, describing 26 patients. The majority of patients had a nerve reconstruction in the upper extremity (65%). Perioperative radiotherapy was administered in 67% and perioperative chemotherapy in 29% of patients. Nerve grafting was most commonly performed (n = 23) and nerve transfers were performed in six patients. A wide variety of outcome measures were used. Most patients recovered at least some motor function and sensation, but success rates were higher after upper than lower extremity defects. Multimodal treatment did not preclude successful reconstructions. Nerve reconstructions in extremity STS allow the restoration of sensation in limb salvation, even motor nerve function can be restored with satisfactory function. The use of multimodal therapy does not seem to interfere with success. Nerve reconstructions should therefore be considered in STS patients.

Anatomy of the lingual nerve: Application to oral surgery

The purpose of this research is to obtain morphological information about the traveling route, branching pattern, and distribution within the tongue of the lingual nerve, all of which are important for oral surgical procedures. Using 20 sides from 10 Japanese cadaveric heads, we followed the lingual nerve from its merging point with the chorda tympani to its peripheral terminal in the tongue. We focused on the collateral branches in the area before reaching the tongue and the communication between the lingual and hypoglossal nerves reaching the tongue. The collateral branches of the lingual nerve were distributed in the oral mucosa between the palatoglossal arch and the mandibular molar region. Two to eight collateral branches arose from the main trunk of the nerve, and the configuration of branching was classified into three types. More distally, the lingual nerve started to communicate with the hypoglossal nerve before passing the anterior border of the hyoglossus muscle. Nerve communications were also found in the main body and near the apex of the tongue. A thorough understanding of the collateral branches near the tongue, and the communication with the hypoglossal nerve inside the tongue, will help to prevent functional disorders from local anesthesia and oral surgical procedures associated with the lingual nerve. Clin. Anat. 32:635-641, 2019. © 2019 Wiley Periodicals, Inc.

Free-Flap Reconstruction of the Tongue

The tongue is paramount to natural speech and swallowing, and good tongue function is important in the overall quality of life. Autologous free-flap reconstruction of the tongue after glossectomy allows for adequate speech, swallow, and quality-of-life outcomes in a majority of patients. Herein, the authors review autologous free-flap reconstruction of the tongue with a focus on different flap options, speech and swallow outcomes, quality-of-life outcomes, and factors that affect how patients perform after tongue reconstruction.

Treatment guidelines and patterns of care in oral cavity squamous cell carcinoma: Primary surgical resection vs. nonsurgical treatment

BACKGROUND

The 2017 National Comprehensive Cancer Network Clinical Practice Guidelines recommend surgical resection or definitive radiation therapy for early-stage oral cavity malignancies, and surgical resection or multimodality clinical trials for late-stage disease. Few studies have been conducted to identify predictors of choice of treatment modality for oral cavity malignancies.

METHODS

All patients in the National Cancer Data Base (NCDB) diagnosed with oral cavity squamous cell carcinoma (OCSCC) between 1998 and 2011 were identified. Chi-square and binary logistic regression were used to identify factors predictive of surgical or nonsurgical treatment; multiple imputation was used for missing data. Cox proportional hazards models were generated to identify associations between treatment modality and overall survival (OS).

RESULTS

Of 23,459 patients, 4139 (17.6%) underwent primary nonsurgical treatment. Among NCDB-registered facilities, there has been a decrease in use of nonsurgical treatment for OCSCC (OR 0.97, p<0.001). Older age, non-white race, Medicaid insurance, low income, low education, and later-stage disease were associated with nonsurgical therapy, while patients at academic/research programs were more likely to undergo surgery (OR 0.38, p<0.001). Nonsurgical treatment was associated with decreased OS (HR=2.02, p<0.001); this was upheld on subgroup analysis of early- and late-stage disease.

CONCLUSIONS

Use of primary nonsurgical treatment for OCSCC has decreased over time among NCDB-registered facilities and is associated with factors related to access to care. Surgical resection for the primary treatment of oral cavity cancer may be associated with improved OS, though conclusions regarding survival are limited by the non-randomized nature of the data.