Reconstruction of large composite buccal defects using single soft tissue flap—analysis of functional outcome

Mandibular reconstruction in head and neck cancer: which is the gold standard?

INTRODUCTION

The aim of this study is to perform a systematic review to compare the outcomes of the different surgical options for mandibular reconstruction in head and neck cancer.

MATERIAL AND METHODS

93 articles were selected. Four groups were identified: titanium plate without flaps, titanium plate covered by soft tissue flap, bone tissue flaps and double flaps. We compared patients' characteristics, site of mandibulectomy, type of reconstruction and complications.

RESULTS

4697 patients were reported. The groups were not homogeneous regarding the type of defect and the treatment history. A significant difference in terms of post-operative complications was found between group 1 and group 2 (p < 0.00001), and between group 2 and group 3 (p < 0.00001). Total complications rate for group 4 was significantly higher when compared to group 3 (p < 0.00001), but no significant difference was found with group 2.

CONCLUSION

These results suggest that mandibular reconstruction using a microvascular bone flap is the best surgical option in patients without significant comorbidities.

Functional Outcomes of the Medial Sural Artery Perforator Flap in Oral Cavity Reconstruction

BACKGROUND

The medial sural artery perforator (MSAP) flap is an ideal option for reconstruction of oral cavity defects owing to its thin and pliable nature and favorable donor site. Our study presents an assessment of functional outcomes including speech and swallowing in patients with oral cavity tumors reconstructed with MSAP flaps.

METHODS

Patients undergoing MSAP reconstruction for oral cavity tumors between January 2014 and January 2018 were identified from our prospective head and neck cancer database. Functional outcomes were assessed in conjunction with the Speech and Language Team with a minimum follow-up of 6 months. Function (speech and swallowing) was recorded as a performance status scale set up by the assessing health care professional.

RESULTS

A total of 38 patients underwent reconstruction with the MSAP flap over the study period. The patient cohort included 10 female patients and 28 male patients. The age range was from 30 to 78 years, with a mean age of 56.8 years. Complications included 1 flap loss and 1 donor site wound dehiscence.Most patients (84.2%) had intelligible speech at 6-month follow-up and further improvement at 1 year (92.1%). All patients resumed feeding on postoperative day 4, and only 7.8% (n = 3) of the patients required assistance with feeding at 1-year follow-up.

CONCLUSIONS

The MSAP flap provides adequate small-volume replacement for oral cavity reconstructions. Our results indicate that most patients achieve a full diet with no restrictions by 1 year after reconstruction. Most of our patients demonstrated excellent speech with little or no need for repetition in conversation. Over the past few years, this has become the flap of choice for oral cavity reconstruction in our unit.

Prognostic factors associated with a restricted mouth opening (trismus) in patients with head and neck cancer: Systematic review

Background

To prescribe early trismus therapy, prognostic factors influencing the restricted mouth opening should be identified first. Our aim is to present an overview of these factors in patients with head and neck cancer.

Methods

PubMed, Cochrane, EMBASE, and CINAHL were searched using terms related to head and neck cancer and mouth opening. Risk of bias was assessed using the “Quality in Prognosis Studies” tool. A best evidence synthesis was performed.

Results

Of the identified 1418 studies, 53 were included. Three studies contained a prognostic multivariate model for a restricted mouth opening.

Conclusions

Patients with head and neck cancer will most likely develop a restricted mouth opening when they have a large tumor near the masticatory muscles that requires extensive cancer treatment. A restricted mouth opening most likely occurs within 6 months after cancer treatment. Further research is necessary on factors related to healing tendency or pain intensity.

Assessment of Masticatory Function in Oral Cancer Patients with Mandibulectomy Followed by Pectoralis Major Myocutaneous Flap Reconstruction

Mandibular resections have a dramatic effect on oral cavity functions. Ablative surgical defects are complex which are better reconstructed with free flaps. In developing countries like India, where majority of patients come from low socioeconomic status, pectoralis major myocutaneous flap is the most preferred reconstructive option. A retrospective questionnaire study was carried out to assess the mastication in patients with mandibulectomy followed by pectoralis major myocutaneous flap reconstruction. At the end of the study, it was observed that 86.6% of the patients had a good performance despite the lack of bony reconstruction. Thus, pectoralis major myocutaneous flap still stands strong in reconstructing large oral cavity defects.

Role of a two-step suture in the prevention of postoperative transoral salivary fistulas during reconstruction of the oral cavity

Transoral salivary fistulas are one of the most serious postoperative complications after operations for oral cancer, and we propose a new, two-step suture method to avoid them. From January 2005 to September 2017, 240 patients were recruited at the Shanghai Ninth People's Hospital and divided into experimental (n=89) or control (n=151) groups. The experimental group was treated by a two-step suture technique, while the control group had conventional sutures. Statistical differences were assessed using the chi squared and t tests, as appropriate. Only two patients developed transoral salivary fistulas in the experimental group, while in the control group there were 14 (9%). The incidence of fistulas in the experimental group was significantly lower than that in the control group (p=0.035). Regression analysis showed that there was a significant correlation between the groups and the incidence of salivary fistulas (p=0.032). The two-step suture technique is safe, effective, and easy to learn, and could reduce the incidence of postoperative salivary fistulas.

Ablation of Buccal Cancer and Functionality Buccal Reconstruction Using an Individuation Anterolateral Thigh Flap

The complex area for reconstruction of the head and the neck is the buccal because of difficult anatomy of this region. This article aimed to describe our individualized design for the reconstruction of the buccal using an different categories anterolateral thigh (ALT) flap. Ninety-four patients were involved in this study. Among 94cases, the number of using the musculocutaneous ALT flap was 57, using the fasciocutaneous ALT flap was 25, and using the thin ALT flap was 12. Postoperative vessel thrombosis occurred in 8 flaps, and required operative exploration in the perioperative period, 6 flaps were complete survival after the salvages, 2 flap was failure. The ALT flap represents a very good choice for the reconstruction of the complex defects at the cheek level. The flap can replace large volumes of tissues and the skin island is large and can be used both for the tegument reconstruction and for the oral mucosa reconstruction.

Medial Sural Artery Perforator Flap for Head and Neck Reconstruction

Aim:

The aim is to study the assessment of feasibility of medial sural artery perforator (MSAP) free flap for head and neck reconstruction at our center.

Materials and Methods:

Oral cancer patients with squamous cell carcinoma of the tongue, buccal mucosa, and floor of mouth cancer attending our center were reconstructed using MSAP flap after oncologic resection. Handheld 8 MHz Doppler was used to identify the perforator preoperatively.

Results:

We reconstructed 10 patients using MSAP flap. The flap was designed according to defect and donor site was primarily closed in all cases. Excellent results were seen in nine patients reconstructed with MSAP flap without any postoperative complication. Flap failure occurred in one patient due to venous thrombosis. The thickness of flap ranged from 4 to 8 mm. The vascular pedicle length ranged from 9 to 13 cm.

Conclusion:

The MSAP flap is appropriate for medium-sized oral defect reconstruction, with a long pedicle of matching caliber, adequate tissue volume, and minimal donor-site morbidity which makes it comparable to other microvascular free flaps such as radial artery free flap (RAFF) and anterolateral thigh flap.

Induction Chemotherapy in Technically Unresectable Locally Advanced T4a Oral Cavity Squamous Cell Cancers: Experience from a Regional Cancer Center of South India

Objectives:

The present study aimed to investigate the efficacy, toxicity, and impact of induction chemotherapy (IC) in technically unresectable T4a oral cavity squamous cell cancers (OSCCs).

Materials and Methods:

Patients diagnosed with technically unresectable locally advanced T4a OSCC from January 2013 and November 2016 at our center, who received 2–3 cycles of IC and then assessed for resectability, were reviewed retrospectively. Patients' profile, response rates and toxicity of IC, resectability status, and overall survival (OS) were evaluated. Statistical analyses were performed using SPSS version 17.0 for Windows (SPSS Inc., Chicago, IL, USA).

Results:

Totally 80 patients received IC, and of them 58 (72.5%) were males. Median age at diagnosis was 44 years (range, 34–62 years). All our patients received IC with doublet regimen. Majority of the patients had buccal mucosa cancers (73.8%), followed by gingivobuccal complex (21.2%) and oral tongue (5%) primaries. After IC, partial response was achieved in 17 (21.3%) patients, stable disease in 49 (61.3%) patients and disease progression was noted in 14 (17.4%) patients. Post-IC, resectability was achieved in 19 (23.8%) of 80 patients, but 4 of them did not undergo surgery due to logistic and personal reasons. The median OS of patients who underwent surgery followed by adjuvant local therapy (n = 15) was 16.9 months (95% CI: 15.2–19.8 months) and for those treated with nonsurgical local therapy (n = 65) was 8.8 months (95% CI: 6.8–10.6 months) (log-rank P = 0.000).

Conclusions:

IC had a manageable toxicity profile and achieved resectability in 23.8% of our patients with technically unresectable T4a OSCC. Patients underwent resection had a significantly better median OS than those who received nonsurgical local treatment.

Oral and Oropharyngeal Reconstruction with a Free Flap

Extensive surgical resection of the aerodigestive track can result in a large and complex defect of the oropharynx, which represents a significant reconstructive challenge for the plastic surgery. Development of microsurgical techniques has allowed for free flap reconstruction of oropharyngeal defects, with superior outcomes as well as decreases in postoperative complications. The reconstructive goals for oral and oropharyngeal defects are to restore the anatomy, to maintain continuity of the intraoral surface and oropharynx, to protect vital structures such as carotid arteries, to cover exposed portions of internal organs in preparation for adjuvant radiation, and to preserve complex functions of the oral cavity and oropharynx. Oral and oropharyngeal cancers should be treated with consideration of functional recovery. Multidisciplinary treatment strategies are necessary for maximizing disease control and preserving the natural form and function of the oropharynx.

Neoadjuvant chemotherapy in oral cancers: Selecting the right patients

The standard of care treatment for oral squamous cell carcinoma (OSCC) at present, consist of surgical resection followed by adjuvant radiotherapy and chemotherapy as indicated. Despite recent advances the overall prognosis remains guarded. Role of neoadjuvant chemotherapy is being explored with premise of reducing extent of surgical resection, improving loco-regional control and decreasing distant metastasis, thereby improving treatment outcomes by decreasing mortality and morbidity. However, indications of neoadjuvant chemotherapy in oral cancers are not clearly defined. Majority of studies have failed to demonstrate a significant benefit of neoadjuvant chemotherapy in terms of loco regional control and overall survival in resectable OSCC. In a select subset of patients with locally very advanced and unresectable OSCC, neoadjuvant chemotherapy has been shown to cause tumor shrinkage and improve resectability. These hypothesis generating findings of reduction in distant metastasis, improved resectability and functional outcome, however need further validation. In summary, the role of neoadjuvant chemotherapy for OSCC remains investigational and has a limited role outside clinical trial.

Double anterior (anterolateral and anteromedial) thigh flap for oral perforated defect reconstruction

OBJECTIVE

The purpose of this study was to assess the therapeutic efficacy of oral perforated defect reconstruction with a double anterior (anterolateral and anteromedial) thigh flap through the modified lateral lip-submandibular approach.

MATERIALS AND METHODS

From July 2010 to August 2013, eight patients with oral perforated defects secondary to oral cancer ablation involving the superior partial mandible or the posterior partial maxilla, with immediate reconstruction by double anterior (anterolateral and anteromedial) thigh flaps, were retrospectively enrolled into this study.

RESULTS

All double anterior flaps were musculocutaneous flaps. Seven double flaps resulted in good functional and aesthetic outcomes with complete flap survival. One patient required operative exploration in the postoperative period due to thrombosis in the external jugular vein. After the salvage, one of the double flaps in the intraoral region resulted in partial failure of the superficial skin of the flap. No functional impairment at the donor sites occurred in any of the cases.

CONCLUSION

The double anterior (anterolateral and anteromedial) thigh flap is a feasible and acceptable technique for reconstruction of an oral perforated defect involving the mandible or the maxilla through the modified lateral lip-submandibular approach. It presents a very acceptable aesthetic and functional result with the additional advantage of low morbidity at the donor site.

Transfer of anterolateral thigh flaps in elderly oral cancer patients: complications in oral and maxillofacial reconstruction

PURPOSE

Although a promising approach, the use of anterolateral thigh (ALT) free flaps has been limited in the reconstruction of oral and maxillofacial defects in elderly patients. The aim of this study was to estimate the frequency of postoperative complications and identify factors associated with complications.

PATIENTS AND METHODS

The authors designed and implemented a retrospective study on the frequency of postoperative complications in elderly patients. They enrolled a sample composed of patients who underwent ALT free flap transfers for the repair of defects created during oral and maxillofacial cancer surgery from February 2002 to March 2013. The χ(2) test, t test, and multivariate regression model were used.

RESULTS

A total of 1,100 patients were studied (859 men and 241 women). One hundred four patients (9.5%) were at least 70 years old (elderly group) at the time of surgery; the other 996 patients were younger than 70 years (younger group). The overall success rate of ALT free flap transfer was 97.2% (97.0% in the younger group, 99.0% in the elderly group; P > .05). The overall complication rate was 27.5% (27.2% in the younger group, 29.8% in the elderly group; P = .572). Multivariate analysis showed that operation time, American Society of Anesthesiologists class, and comorbidity were independent risk factors for postoperative complications in elderly patients.

CONCLUSIONS

Oral and maxillofacial reconstruction using ALT free flaps in elderly patients can achieve outcomes similar to those obtained in younger patients. Limiting the operation time is important for improving surgical outcomes.

Versatility of adipofascial anterolateral thigh flap for reconstruction of maxillary defects with infratemporal fossa extension

Tumors arising from the posterior hard palate or posterolateral maxilla may extend to involve the infratemporal fossa (ITF). Resection of these tumors results in infrastructural maxillectomy with ITF defects. In this study, we describe the use of an adipofascial anterolateral thigh flap (ALT) specifically for such defects. This case series includes four patients who underwent an infrastructure maxillectomy with ITF clearance and the resultant defects were reconstructed using adipofascial anterolateral thigh flaps. The complications as well as the functional outcomes were assessed. This study included patients with lesions involving the hard palate, posterolateral part of maxilla with extension into the ITF. The mean flap dimension was 150 cm(2) (range, 120-180 cm(2)). All flaps were harvested based on a single perforator. The flap was used to obliterate the ITF defect and also to achieve oroantral separation. All flaps mucosalized well within 6 weeks. All patients were on oral diet and had adequate mouth opening. There were no donor-site complications. Adipofascial ALT is an excellent choice for infrastructural maxillectomy defects with ITF extension. The intraoral part got mucosalized well and provided a smooth and taut surface. A large adipofascial tissue flap helps obliterate the ITF, thus minimizing complications.