Reconstruction of lateral through and through oro-mandibular defects following oncological resections

Medial sural artery perforator free flap versus radial forearm free flap in oral cavity reconstruction and donor site morbidity

OBJECTIVE

Radial Forearm Free flap (RFFF) is widely used in head and neck reconstruction, yet its donor site defect remains a significant drawback. The Medial Sural Artery Perforator Free Flap (MSAPFF) is considered an alternative flap to RFFF. This study aims to comprehensively analyze their characteristics, outcomes, and their impact on patient quality of life.

METHODS

All patients who underwent oral cavity reconstruction using RFFF and MSAPFF between February 2017 and April 2023 were included in this study. Flap characteristics, outcomes and post-operative complications were recorded and compared. Subjective donor site morbidity, aesthetic and functional results, and quality of life were also analyzed.

RESULTS

The study included 76 patients: 37 underwent reconstruction with RFFF, and 39 with MSAPFF. There was no significance difference between the RFFF and MSAPFF regarding the success rate (97.2% vs 97.4%), flap size (4.8 × 8.8 cm2 vs 5 × 9.8 cm2), hospital of stay (15.5 days vs 13.5 days) and recipient site complications (P > 0.05). However, MSAPFF showed larger flap thickness (P = 0.001), smaller arterial caliber (P = 0.008), shorter pedicle length (P = 0.001), and longer harvesting time (P < 0.001). No significant difference was observed between the pre-and postoperative ranges of wrist and ankle movements or in recipient site complications. MSAPFF showed a significant difference in donor site morbidity (P < 0.05).

CONCLUSION

The MSAPFF is an excellent alternative to the RFFF for repairing oral cavity defects, with additional advantage of a well-hidden scar on the posterior calf, a larger flap thickness, accepted pedicle length and arterial caliber. However, one should consider the harvesting time and surgical skills required in comparison to the RFFF.

CLINICAL RELEVANCE

The study highlights the importance of the MSAPFF as an alternative option for RFFF with less donor site morbidity and high success rate in oral cavity reconstruction and improved patient Quality of life after ablative surgery.

Perioperative risk factors impact on intensive care unit length of stay (ICU length of stay) in oral squamous cell carcinoma

BACKGROUND

The trend in postoperative care for free flap patients is to deescalate from routine ICU admission into a specialty recovery unit. This study aims to investigate the predictive parameters in a routine perioperative clinical assessment that are expected to be directly correlated with prolonged ICU length of stay in at-risk patients who received oral reconstructive surgery for squamous cell carcinoma (OSCC).

METHODS

All patients who underwent ablative surgery for OSCC with free flap reconstruction and were managed in the ICU were included in this study. The primary outcome was ICU-length of stay. Perioperative, operative and postoperative parameters were analyzed using single test ( t-test, ANOVA analysis, correlation coefficients, effect size) and multivariate regression test. The P-value was set as < 0.005 to be considered statically significant.

RESULTS

The study included 136 homogeneous patients, with a mean ICU length of stay of 4.5 (± 4.43 day). Patients with pre-operative positive renal dysfunction (P = 0.004), peripheral vascular disease (P < 0.001), postoperative complications (P = 0.028) or positive heart failure class III (P < 0.001 ) were recognized as at-risk patients for a significantly longer ICU length of stay.

CONCLUSION

Patients with perioperative severe renal dysfunction, peripheral vascular disease, postoperative complication or high NYHA class are prone to have a significantly longer ICU length of stay. Several factors were considered as confounders contributing to increased ICU management time in combination with other variables. Additionally, in highly risk patient, the presence of the highly trained medical support, including the appropriate nursing care, is more critical than those patients without these risk factors.

Oral cavity carcinoma in patients with and without a history of lichen planus: A comparative analysis

BACKGROUND

Oral potentially malignant disorders (OPMD) are associated with the risk of malignant transformation (MT) into oral cavity carcinoma (OCC). Oral lichen planus (OLP) is one of the most common OPMDs in western countries. Although there is a substantial amount of research on progression to cancer, a specific analysis of the clinical characteristics and prognosis of cancer developed in patients with a history of OLP versus patients without a history of OLP has not been investigated so far.

METHODS

Retrospective evaluation of 82 patients treated for OCC with a known history of OLP compared to a representative sample of 82 patients treated for OCC without a known history of LP. Comparative analyses were performed on age at presentation, sex, TNM staging, clinical characteristics, pathology characteristics, 2- and 5-year overall survival (OS), and disease-free survival (DFS).

RESULTS

It was shown that patients with a history of LP were significantly younger at first presentation than patients without a history of LP (mean age difference 6.7 years, 95% CI 3.1-10.3, p < 0.05). Also, patients with a history of OLP were in higher proportion females. The main pathological stage at presentation was significantly lower in the OLP group (p < 0.05). The 2-year survival analysis showed that DFS and OS were significantly lower in patients without a known history of OLP, with a hazard ratio (HR) of 3.1 (95% CI 1.4-6.8) and HR of 2.6 (95% CI 1.3-5.3), respectively. The 5-year survival analysis showed that DFS and OS were significantly lower in patients without a known history of OLP, with a hazard ratio of 3.1 (95% CI 1.6-6.2) and of 2.9 (95% CI 1.5-5.6), respectively.

CONCLUSIONS

Cancer arising from OLP has peculiar characteristics compared to cancer in naïve patients. It most commonly affects younger patients, women, and nonsmokers. It is usually diagnosed at earlier stages and appears to have less aggressive behavior at presentation. Moreover, when 2- and 5-year survival is analyzed, it appears that patients in OLP group have an overall and a disease-free survival advantage. These results suggest that cancer from OLP is less aggressive and thus has a potential biological difference with cancer arising in non-OLP patients. Further clinical and basic investigations are needed to confirm the results of this study.

Donor Site Morbidity and Quality of Life after Microvascular Head and Neck Reconstruction with a Chimeric, Thoracodorsal, Perforator-Scapular Flap Based on the Angular Artery (TDAP-Scap-aa Flap)

Extensive defects in the head and neck area often require the use of advanced free flap reconstruction techniques. In this study, the thoracodorsal perforator-scapular free flap technique based on the angular artery (TDAP-Scap-aa flap) was postoperatively evaluated regarding the quality of life and the donor site morbidity using the standardized SF-36 and DASH questionnaires (short form health 36 and disabilities of the arm, shoulder and hand scores). Over a five-year period (2016−2020), 20 selected cases (n = 20) requiring both soft and hard tissue reconstruction were assessed. On average, the harvested microvascular free flaps consisted of 7.8 ± 2.1 cm hard tissue and 86 ± 49.8 cm2 soft tissue components. At the donor site (subscapular region), only a mild morbidity was observed (DASH score: 21.74 ± 7.3 points). When comparing the patients’ postoperative quality of life to the established values of the healthy German norm population, the observed SF-36 values were within the upper third (>66%) of these established norm values in almost all quality-of-life subcategories. The mild donor site morbidity and the observed quality of life indicate only a small postoperative impairment when using the TDAP-Scap-aa free flap for the reconstruction of extensive maxillofacial defects.

Mandibular resection in patients with head and neck cancer: acute and long-term complications after reconstruction

BACKGROUND

The treatment of head and neck cancer is an intensive multimodal treatment that has a great impact on the individual patient.

AIMS/OBJECTIVES

This study aimed to evaluate acute and long-term complications associated with mandibular resections and reconstructions.

MATERIAL AND METHODS

We retrospectively retrieved data on complications and recurrences among patients that underwent mandibular resections and reconstructions for treating oral cavity cancer (n = 190 patients) and osteoradionecrosis (ORN, n = 72). Reconstructions included composite grafts (n = 177), soft tissue flaps (n = 61), or primary closure without any graft (n = 24).

RESULTS

Forty-two patients that underwent reconstructions with composite grafts displayed serious complications (Clavien-Dindo ≥ IIIa). The complication rates were similar between patients treated for oral cavity cancer and patients treated for ORN. Patients that underwent a primary closure without any graft, had a significantly lower risk of complications compared to patients that underwent the other treatments. After hospitalization, 181 patients (69%) had at least one complication.

CONCLUSIONS

A majority of patients undergoing resection and reconstruction due to oral cancer/ORN suffered from postoperative complications regardless of indication, comorbidity status or reconstruction technique. The risk of Clavien-Dindo grade IIIa-V events was significantly lower for patients treated with primary closure without grafts.

SIGNIFICANCE

The results from this study clarifies the importance of in-depth analyse prior to decision of treatment for patients with head and neck cancer.

Effects of Pre-Operative Risk Factors on Intensive Care Unit Length of Stay (ICU-LOS) in Major Oral and Maxillofacial Cancer Surgery

OBJECTIVE

This study aimed to investigate the effect of certain pre-operative parameters directly on the post-operative intensive care unit (ICU)-length of stay (LOS), in order to identify at-risk patients that are expected to need prolonged intensive care management post-operatively.

MATERIAL AND METHODS

Retrospectively, patients managed in an ICU after undergoing major oral and maxillofacial surgery were analyzed. Inclusion criteria entailed: age 18-90 years, major primary oral cancer surgery including tumor resection, neck dissection and microvascular free flap reconstruction, minimum operation time of 8 h. Exclusion criteria were: benign/borderline tumors, primary radiation, other defect reconstruction than microvascular, treatment at other centers. Separate parameters used within the clinical routine were set in correlation with ICU-LOS, by applying single testing calculations (t-tests, variance analysis, correlation coefficients, effect sizes) and a valid univariate linear regression model. The primary outcome of interest was ICU-LOS.

RESULTS

This study included a homogenous cohort of 122 patients. Mean surgery time was 11.4 (±2.2) h, mean ICU-LOS was 3.6 (±2.6) days. Patients with pre-operative renal dysfunction (p < 0.001), peripheral vascular disease-PVD (p = 0.01), increasing heart failure-NYHA stage categories (p = 0.009) and higher-grade categories of post-operative complications (p = 0.023) were identified as at-risk patients for a significantly prolonged post-operative ICU-LOS.

CONCLUSIONS

At-risk patients are prone to need a significantly longer ICU-LOS than others. These patients are those with pre-operative severe renal dysfunction, PVD and/or high NYHA stage categories. Confounding parameters that contribute to a prolonged ICU-LOS in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.

Clinical Importance and Risk Factors for Postoperative Late-Onset Pneumonia After Major Oral Cancer Surgery With Microvascular Reconstruction

BACKGROUND

Pulmonary complications are common among patients who have undergone major oral cancer surgery with microvascular reconstruction. Current literatures focused on early-onset pneumonia in the postoperative acute stage. In contrast, we are aiming to identify the clinical importance and the risk factors associated with late-onset pneumonia in oral cancer patients after acute stage.

METHODS

In total, 195 patients were included from May 2014 to December 2016 and followed up for up to 1 year after surgery. Their medical histories were reviewed to identify the risk factors of late-onset pneumonia and outcome. Primary outcome was late-onset pneumonia. Other outcome measures included early-onset pneumonia, tumor recurrence, and death within 1 year after surgery.

RESULTS

Patients with late-onset pneumonia have demonstrated a significantly higher rate of tumor recurrence (P < 0.001) and death within 1 year (P < 0.001). Independent risk factors of late-onset pneumonia identified were age (P = 0.031), previous radiotherapy (P = 0.017), postoperative radiotherapy (P = 0.002), flap size (P = 0.001), flap type other than osteocutaneous fibula flap (P = 0.009), and tumor recurrence (P < 0.001).

CONCLUSIONS

Late-onset pneumonia can act as a warning sign for oral cancer patients who have received microsurgical reconstruction, for its high correlation with tumor recurrence and mortality rate.

Biomechanical In Vitro Study on the Stability of Patient-Specific CAD/CAM Mandibular Reconstruction Plates: A Comparison Between Selective Laser Melted, Milled, and Hand-Bent Plates

Study Design

An experimental in vitro study.

Objective

Plate fractures are a recurrent problem in alloplastic mandibular reconstruction. Hypothetically it can be assumed that computer-aided design (CAD)/computer-aided manufacturing (CAM) reconstruction plates have a higher stability than conventional hand-bent plates. The aim of the study was to compare additive and subtractive fabricated CAD/CAM mandibular reconstruction plates as well as conventional plates with regard to their biomechanical properties.

Methods

In a chewing simulator, plates of 2 conventional locking plate systems and 2 CAD/CAM-fabricated plate systems were compared. The plates were loaded in a fatigue test. The maximum number of cycles until plate fracture and the plate stiffness were compared.

Results

While all conventional plates fractured at a maximum load between 150 and 210 N (Newton) after a number of cycles between 40 000 and 643 000, none of the CAD/CAM plates broke despite a nearly doubled load of 330 N and 2 million cycles. Both CAD/CAM systems proved to be significantly superior to the hand-bent plates. There was no difference between the 2 CAD/CAM systems.

Conclusions

Concerning the risk of plate fracture, patient-specific CAD/CAM reconstruction plates appear to have a significant advantage over conventional hand-bent plates in alloplastic mandibular reconstruction.

Use of multiple free flaps in head and neck reconstruction

PURPOSE OF REVIEW

To review the recent literature on the use of multiple flaps in head and neck reconstruction with attention to form, function, outcomes, and complications.

RECENT FINDINGS

Multiple free flap reconstructions are technically feasible with high flap survival rates, tolerable complication rates, and overall adequate functional and aesthetic outcomes, given the large extent of the defects and the high surgical complexity of these cases.

SUMMARY

Multiple free flap reconstructions should be considered in cases of large defects involving multiple functional regions and tissue types, which most often arises following resection of advanced malignancies. As there is mortality benefit with clear surgical margins and eradication of malignant lymph nodes, larger resections should be pursued if necessary, followed by a multiple flap reconstruction.

The "Flap Suture Anchoring" Technique for Safe Oral Floor Reconstruction With Preservation of Alveolar Process

Flaps-based microsurgery is routinely applied to reconstruct oral floor defects caused by oncologic resection. To prevent orocutaneous fistulae, flaps are frequently sutured with buccal vestibule mucosa after sacrificing the alveolar process. The patients suffered denture loss and irreversible structural damage. For reliable oral floor reconstruction with preservation of alveolar process, the authors introduced the flap "suture anchoring" technique. Oral floor, hemiglossal-oral floor, and tongue base-parapharyngeal wall-oral floor defects were included in this study. The flap anchoring technique involves structural oral floor reconstruction with a chimeric anterolateral thigh-free flap or radial forearm flap with adipofascial tissue extension. The dead space in oral floor is filled with vastus lateralis muscle or adipofascial tissue, then holes are drilled on the alveolar bone among tooth root, beneath the attached gingiva. Skin paddle is sutured with 4-0 sutures through the alveolar holes thus anchored to the mandible. By applying this technique, there was no wound infection or orocutaneous fistulae in all patients postoperatively, even experienced postoperative radiotherapy. In addition, a soft and natural jaw-tongue furrow could be formed to allow the free movement of tongue. Taken together, the flap anchoring technique offers a safe and reliable approach to recover oral function and preservation of occlusion.

Standard morphology of the oral commissure and changes resulting from reconstruction for defects involving the commissure

The aim of this study was to characterize the standard morphology of the oral commissure and to describe the changes after reconstruction in patients with through-and-through cheek defects involving the oral commissure. Indices for the morphological analyses of the commissure were derived from examinations of 50 normal Japanese volunteers. Ten patients with full-thickness cheek defects involving the commissure were then evaluated. All of these patients underwent free flap reconstruction with vermilion advancement flaps from the remaining vermilion. The morphology of the commissure with the mouth closed was classified based on the point of entrance of the vermilion into the oral cavity. In normal volunteers, the commissure pattern consisting of the entrance of the upper vermilion into the oral cavity before the lower vermilion and just prior to forming the oral commissure was considered to be the standard. However, in the reconstructed cases, there was an increase in the pattern in which the lower vermilion enters the oral cavity before the upper vermilion for the remaining commissure postoperatively, especially when the lower lip defects were greater than those of the upper lip. It is important to refer not only to the standard morphology of the commissure, but also to the changes according to the extent of resection and the method of reconstruction.

Expression of cyclooxygenase-2, peroxiredoxin I, peroxiredoxin 6 and nuclear factor-κB in oral squamous cell carcinoma

Tumor development and progression are multistep processes that involve local tumor growth and invasion, followed by metastasis. The aggressiveness of the tumor is the major determinant of the mortality of oral cancer patients. The present study investigates whether the expression levels of cyclooxygenase-2 (COX-2), nuclear factor-κB (NF-κB), peroxiredoxin 1 (PRDX1) and PRDX6 are associated with the development, proliferation, differentiation and recurrence of oral squamous cell carcinoma (OSCC). The mRNA expression levels of COX-2, NF-κB, PRDX1 and PRDX6 were examined in 50 OSCC specimens and 19 normal oral mucosae by quantitative polymerase chain reaction (qPCR). qPCR analysis showed that the mRNA levels of COX-2 in OSCC were significantly higher than those in the normal oral mucosae (P=0.021). The expression levels of PRDX1 in high-stage tumors (T3 and T4) were significantly elevated compared with those in low-stage tumors (T1) (P=0.047). Additionally, the expression levels of NF-κB in the high-grade tumor were significantly elevated compared with those in the low-grade tumors (P=0.030). Overall, it was indicated that the expression of COX-2 is strongly associated with the development of OSCC. Moreover, the enhanced expression of PRDX1 and NF-κB may function in the progression of OSCC, which serves as a useful marker for prognosis in patients with oral cancer.

Restoration of oral competence in double free flap reconstructions of massive lower facial defects with fascia lata slings - Case series and review of the literature

Restoration of adequate oral competence is especially challenging in double free flap reconstructions of massive head and neck defects resulting from composite resections. Our report illustrates that oral competence in double free flap reconstructions of extensive oromandibular defects can be successfully restored with tensor fascia lata suspension slings.

Pedicled lingual flap to provide keratinized tissue regeneration over dental implants: a description of the technique and a case report

The aim of this study is to report the efficacy of a lingual pedicle flap for soft tissue pre-prosthetic surgery in implant rehabilitation. While it has been demonstrated that keratinized gingiva is an important factor for implant success, there remains a dearth of case reports concerning the use of a lingual pedicle flap to achieve this desired outcome in such a large reconstructive effort. For this case report, the patient underwent an anterior mandibular resection of an ameloblastoma and subsequent reconstruction, resulting in soft tissue loss. To satisfy the patient's desires, both functionally and esthetically, a bilateral rotated pedicled lingual flap was performed to augment keratinized tissue on the anterior mandibular ridge. An additional vestibuloplasty with two collagen matrices was also performed, and an acrylic splint was then applied to achieve better stabilization. The primary outcome was to evaluate the efficacy of this technique, which, until now, was used only for exposed root coverage. The site demonstrated excellent healing over time, even resulting in an excess of healthy and pink soft tissue, which later had to be corrected with a small gingivectomy. Although the patient reported slight discomfort for a few days after surgery, she was nonetheless pleased both with her ability to function and her appearance. The results of this study show that the bilateral rotated pedicled lingual flap is a viable technique for the correction of soft tissue defects in implant dentistry, providing a good amount of keratinized gingiva.

Free flap reconstruction in patients with advanced oral squamous cell carcinoma: analysis of patient survival and cancer recurrence

BACKGROUND

The purpose of this study was to compare the initial conditions and treatment outcomes of patients with advanced stage IV oral squamous cell carcinoma (OSCC) treated with or without free flap reconstruction following ablative tumor resection.

METHODS

Two hundred forty-two pathological stage IV OSCC patients (without distant metastasis) treated by tumor ablation with free flap reconstruction (Group 1; n = 93) or without free flap reconstruction (Group 2; n = 149 treated with split-thickness skin grafts, primary closure of defects, secondary granulation of defects, and local or regional flaps) were recruited. We compared patient survival and cancer recurrence rates between these two groups.

RESULTS

Group 1 had significantly more advanced tumor stage than group 2. Despite the unfavorably expected prognosis in group 1, both positive margin rate (17.2% in Group 1 versus 23.5% in Group 2, P = 0.213) and cancer recurrence rate (36.6% in Group 1 versus 38.3% in Group 2; P = 0.792) were not significantly different between the two groups. The 5-year disease-specific survival were also the same (51.4% in Group 1 versus 52.6% in Group 2; P = 0.493).

CONCLUSIONS

Although cancer stages were more advanced in patients requiring free flap reconstruction, patient survival, and cancer recurrence in the patients with free flap reconstruction were maintained as patients without free flap.

Reconstructive indications of simultaneous double free flaps in the head and neck: a case series and literature review

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo-radiotherapy. Forty-two free flaps were used in these patients. The predominant combination was that of free fibula osteo-cutaneous flap with free anterolateral thigh (ALT) fascio-cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro-mandibular bone and soft tissue defects (n = 13), (b) large oro-mandibular soft tissue defects (n = 4), (c) complex skull-base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow-up period was 11 months. Twelve patients were alive and free of disease at the end of the follow-up. Eighteen of 19 patients with oro-mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro-mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed.

Current role of the iliac crest flap in mandibular reconstruction

The purpose of this study was to examine the current role of the iliac crest osteocutaneous flap in mandibular reconstruction, with a focus on the reliability of its skin island. We reviewed outcomes in 18 cases of immediate mandibular reconstruction with the iliac crest flap. Intraoral mucosal defects were closed with the skin island of the iliac crest flap in 13 patients (iliac crest flap group) and were closed with another free flap, because of poor circulation of the iliac crest skin island, in five patients (double-flap group). Postoperative results were poor in the iliac crest flap group. The rate of partial or total loss of the skin island was 46.2% in the iliac crest flap group and 20.0% in the double-flap group. The presence of a dominant perforator did not reduce the overall rate of recipient-site complications or reoperation. Combined use of another skin flap for intraoral lining provided better results. These results suggest that the skin island of the iliac crest flap should not be used for intraoral lining, unless adequate circulation of the skin island can be confirmed. If the circulation is questionable, combined use of another skin flap is strongly recommended.