The functional intraoral Glasgow scale (FIGS) in retromolar trigone cancer patients

Salvage Reconstruction of Composite Defects of the Anterior Mandible, Floor of Mouth, and Lip

Anterior mandible defects result in loss of support for the tongue, floor of the mouth and lower lip, resulting in impairment of airway, feeding, and speech. We treated four patients with these "Andy Gump" deformities. Reconstruction was performed with two free flaps: a fibula osteocutaneous flap for the anterior mandible and floor of the mouth, and a soft tissue free flap for the lip, chin, and anterior neck. The lower lip was suspended cranially with fascia or tendon grafts ± mini-temporalis turndown flaps. All flaps survived completely. All patients were tube feed-dependent before surgery; they all resumed an oral diet. All tracheostomies were decannulated. Lip competence was restored as evidenced by cessation of drooling. Speech improved from unintelligible to intelligible with frequent repetitions. Objective assessment was performed with the functional intraoral Glasgow scale; the mean FIGS score improved from 3.25 (range 3-4) to 11 (range 9-13). We conclude that composite anterior mandible and tongue defects have large tissue requirements that require multiple free flaps. Reconstruction leads to significant improvement in function.

Single-Stage Peninsular-Shaped Lateral Tongue Flap for Personalized Reconstruction of Various Small- to Moderate-Sized Intraoral Defects: A Retrospective Case Series with Tongue Function Evaluation Using the Functional Intraoral Glasgow Scale

Herein, we present our experience using a single-stage peninsular-shaped lateral tongue flap (pLTF) to cover various intraoral defects and confirm the versatile utility and effective application of pLTF in intraoral defect reconstruction. This study included eight cases (six males and two females; average age 60.3 ± 16.9 years) of intraoral defect reconstruction performed by a single surgeon between August 2020 and May 2023 using the single-stage pLTF technique. Electronic medical records and photographs of the patients were collected and analyzed. The functional intraoral Glasgow scale (FIGS) was used to evaluate preoperative and postoperative tongue function. Defect sizes ranged from 3 cm × 3 cm to 4 cm × 6 cm. Notably, all defects were successfully covered with pLTFs, and the flap sizes ranged between 3 cm × 4.5 cm and 4.5 cm × 7.5 cm. The flaps completely survived without any postoperative complications. At follow-up (average, 9.87 ± 2.74 months), no patient had tumor recurrence or significant tongue functional deficits. The mean preoperative and postoperative FIGS were 14.75 ± 0.46 and 14.00 ± 0.92, respectively (p = 0.059). Thus, the single-stage pLTF technique is a good reconstructive modality for various small to moderate intraoral defect coverage in selected cases for personalized intraoral reconstruction.

Oral-Functioning Questionnaires in Patients with Head and Neck Cancer: A Scoping Review

Background: Oral-functioning impairment can negatively affect the quality of life (QoL) of head and neck cancer (HNC) patients after receiving radiotherapy (RT). Assessment of patient-reported oral functioning throughout treatment can improve patient care. This scoping review aims to propose a definition for oral functioning for HNC patients and to map out the available questionnaires measuring patient-reported oral functioning in RT-treated HNC patients. Methods: A literature search in relevant databases was performed. Each questionnaire was scored on the domains validity, reliability, and responsiveness. Furthermore, the items from the questionnaires were analyzed to define the common denominators for oral functioning in HNC patients. Results: Of the 6434 articles assessed, 16 met the inclusion criteria and employed 16 distinct instruments to evaluate QoL. No questionnaire covered all oral-health-related QoL items nor assessed all aspects of validity, reliability, and responsiveness. Chewing, speaking, and swallowing were the common denominators for oral functioning. Conclusions: Based on the included studies, we suggest using the VHNSS 2.0 questionnaire to assess oral functioning in HNC patients. Furthermore, we suggest to more clearly define oral functioning in HNC patients by focusing on masticatory function (chewing and grinding), mouth opening, swallowing, speaking, and salivation.

Propeller Flaps in the Head and Neck

Propeller flaps have significantly expanded the reconstruction possibilities in the head and neck region. They allow for increased flap mobility and better scar concealing, and/or to perform a one-stage reconstruction with local tissue of similar color and texture, where multiple surgeries would be needed with traditional flaps or even free flaps would be required. This article describes the main propeller flaps for one-stage reconstruction in the head-neck region (facial artery perforator, supratrochlear artery axial perforator, deep lingual artery axial perforator, and anterior supraclavicular artery perforator flaps), their indications, and possible complications. Aesthetic and functional results of propeller flaps in the head and neck region are very good and the complication rate is low, but due to their surgical complexity and the availability of many simpler local flaps, they are indicated only in select cases where local flaps are unavailable or would require multiple staged procedures to complete the construction.

Long-term speech and swallowing function after primary resection and sentinel node biopsy for early oral squamous cell carcinoma

OBJECTIVES

Analysis of long-term speech and swallowing function and subjective quality of life (QOL) after primary resection and sentinel node biopsy (SNB) in patients with early stage (cT1/T2) oral squamous cell carcinomas (OSCC).

MATERIAL AND METHODS

Eighty-one consecutive patients treated primarily by transoral resection without flap reconstruction and SNB for a cT1/T2 OSCC were included. Completion neck dissection (CND) was indicated in case of occult disease in the sentinel nodes. Adjuvant radiation (aRT) was administered according to the ultimate lymph node status. All patients showed no evidence of disease at time of analysis. Speech and swallowing function were assessed using standardized clinical examinations (11-item, articulation test) and validated questionnaires on subjective QOL (MDADI, FIGS). Median follow-up was 60 months (range 13-159 months) after initial treatment.

RESULTS

In all assessments for speech and swallowing, the entire study cohort achieved very high scores, with mean values located in the highest 10% of the scales. Neither tumor size nor site, age, pN-category, CND, and aRT had significant impact on functional outcomes and subjective QOL with the exception of lower scores in the global and physical scores of MDADI after CND or aRT, and articulation in the population over 60 years of age.

CONCLUSION

Transoral resection without reconstruction and SNB for early OSCC achieves excellent outcome with regard to speech, swallowing and subjective QOL.

Functional outcomes after glossectomies: Pilot study on use of a thrombin-fibrinogen biosponge (TachoSil)

OBJECTIVE

The aim of this study was to investigate whether the use of a thrombin-fibrinogen biosponge (TachoSil) has any advantage in tongue healing.

STUDY DESIGN

A retrospective study with 30 patients treated with partial glossectomy (below half a tongue) was designed. We compared the results from a group using the biosponge (n =15 patients) and a control group (n = 15). Variables taken into consideration were bolus clearance, frenulum flexibility, and oral transit time. With these parameters, we formulated a "tongue remaining functional" (TRF) scale to assess tongue functionality after the surgery. We also evaluated long-term quality of life by using the Functional Intraoral Glasgow Scale (FIGS).

RESULTS

In this study, TRF score, bolus clearance, oral transit time, and frenulum flexibility were significantly improved in the biosponge group. However, there were no differences between the 2 groups in the FIGS scores.

CONCLUSIONS

The use of the biosponge in this pilot study showed positive long-term effects in lingual healing and functionality after partial glossectomies.

Current Limitations of Surgical Robotics in Reconstructive Plastic Microsurgery

Surgical robots have the potential to provide surgeons with increased capabilities, such as removing physiologic tremor, scaling motion and increasing manual dexterity. Several surgical specialties have subsequently integrated robotic surgery into common clinical practice. Plastic and reconstructive microsurgical procedures have not yet  benefitted significantly from technical developments observed over the last two decades. Several studies have successfully demonstrated the feasibility of utilising surgical robots in plastic surgery procedures, yet limited work has been done to identify and analyse current barriers that have prevented wide-scale adaptation of surgical robots for microsurgery. Therefore, a systematic review using PubMed, MEDLINE, Embase and Web of Science databases was performed, in order to evaluate current state of surgical robotics within the field of reconstructive microsurgery and their limitations. Despite the theoretical potential of surgical robots, current commercially available robotic systems are suboptimal for plastic or reconstructive microsurgery. Absence of bespoke microsurgical instruments, increases in operating time, and high costs associated with robotic-assisted provide a barrier to using such systems effectively for reconstructive microsurgery. Consequently, surgical robots provide currently little overall advantage over conventional microsurgery. Nevertheless, if current barriers can be addressed and systems are specifically designed for microsurgery, surgical robots may have the potential of meaningful impact on clinical outcomes within  this surgical subspeciality.

Functional Outcomes and Complications of Robot-Assisted Free Flap Oropharyngeal Reconstruction

BACKGROUND

Robotic surgical systems provide a clear, magnified 3-dimensional visualization as well as precise, stable instrumental movement, thereby minimizing technical difficulties that may be encountered in the surgical treatment of oropharyngeal tumors. This study assessed the outcomes of robotic-assisted free flap oropharyngeal reconstruction compared with those of conventional free flap reconstruction.

MATERIALS AND METHODS

A retrospective review of 47 patients who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects was conducted over a 20-month period (May 2013-December 2014). Complications were evaluated for a robot-assisted reconstruction group and a conventional reconstruction group; postoperative complication rates and revision rates were further evaluated. The Functional Intraoral Glasgow Scale (FIGS) was adopted for functional outcome assessment.

RESULTS

This study recruited 47 people who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects (14 robot-assisted and 33 conventional reconstructions). The mean postoperative FIGS score was 10.29 ± 2.02 in the robot-assisted group (P = 0.010) and 8.42 ± 2.29 in the conventional group at 1 month postoperatively. The mean postoperative FIGS score was 12.57 ± 1.91 in the robot-assisted group (P = 0.005) and 9.91 ± 3.09 in the conventional group at 3 months postoperatively. Complication rates between the robot-assisted and conventional groups were similar for flap failure (P = 0.531), partial necrosis, wound infection, hematoma or seroma formation (P = 0.893), wound dehiscence, and fistula formation (P = 0.515). The number of flap revision operations requiring additional surgery (P = 0.627) was comparable between the cohorts.

CONCLUSIONS

There is no significant difference in complications or revision rates between the robot-assisted and conventional oropharyngeal reconstructions. The functional postoperative outcomes of robot-assisted reconstructions are superior to those of conventional reconstructions. Robotic surgical systems provide a safe option with optimal postoperative oral function for the free flap reconstruction of oropharyngeal defects without lip or mandible splitting.

FLiGS Score: A New Method of Outcome Assessment for Lip Carcinoma-Treated Patients

Background:

Lip cancer and its treatment have considerable functional and cosmetic effects with resultant nutritional and physical detriments. As we continue to investigate new treatment regimens, we are simultaneously required to assess postoperative outcomes to design interventions that lessen the adverse impact of this disease process. We wish to introduce Functional Lip Glasgow Scale (FLiGS) score as a new method of outcome assessment to measure the effect of lip cancer and its treatment on patients’ daily functioning.

Methods:

Fifty patients affected by lip squamous cell carcinoma were recruited between 2009 and 2013. Patients were asked to fill the FLiGS questionnaire before surgery, 1 month, 6 months, and 1 year after surgery. The subscores were used to calculate a total FLiGS score of global oral disability. Statistical analysis was performed to test validity and reliability.

Results:

FLiGS scores improved significantly from preoperative to 12 months postoperative values (P = 0.000). Statistical evidence of validity was provided through r_s (Spearman correlation coefficient) that resulted >0.30 for all surveys and for which P < 0.001. FLiGS score reliability was shown through examination of internal consistency and test-retest reliability.

Conclusions:

FLiGS score is a simple way of assessing functional impairment related to lip cancer before and after surgery; it is sensitive, valid, reliable, and clinically relevant: it provides useful information to orient the physician in the postoperative management and in the rehabilitation program.

The functional intraoral Glasgow scale in floor of mouth carcinoma: longitudinal assessment of 62 consecutive patients

The functional integrity of the floor of the mouth (FOM) is essential in maintaining tongue mobility, deglutition, and control and disposal of saliva. The present study focused on reporting oral function using functional intraoral Glasgow scale (FIGS) in patients who had surgical ablation and reconstruction of FOM carcinoma with or without chemo-radiotherapy. The study included patients who had surgical treatment of floor of mouth cancer in two regional head and neck units in Glasgow, UK between January 2006 and August 2007. Patients were assessed using FIGS before surgery, 2 months, 6 months and 1 year after surgery. It is a five-point scale self-questionnaire to allow patients to self-assess speech, chewing and swallowing. The maximum total score is 15 points. The influence of socio-demographic parameters, tumour characteristics and surgical parameters was addressed in the study. A total of 62 consecutive patients were included in the study; 41 (66.1 %) were males and 21 (33.9 %) were females. The patients' mean age at the time of diagnosis was 60.6 years. Fifty (80.6 %) patients had unilateral origin of FOM tumours and 10 (19.4 %) had bilateral origin. Peroral approach was the most common approach used in 35 (56.4 %) patients. The mean preoperative FIGS score was 14. Two months after surgery, it droped to 9.4 then started to increase gradually thereafter and recorded 10.1 at 6 months and 11 at 1 year. Unilateral FOM resection recorded better score than bilateral and lateral FOM tumours than anterior at 1 year postoperatively. Furthermore, direct closure showed better functional outcome than loco-regional and free flaps. The FIGS is a simple and comprehensive way of assessing a patient's functional impairment following surgery in the FOM. Tumour site and size, surgical access, surgical resection and method of reconstruction showed significant influence on oral function following surgical resection. A well-designed rehabilitation programme is required to improve oral function after surgical resection of oral cancer.

Development and preliminary validation of the Lip Reanimation Outcomes Questionnaire

OBJECTIVE: Lip paralysis is associated with eating, speaking, and appearance impairments. The lip reanimation outcome questionnaire is designed to assess these functional impairments after lip reanimation.

STUDY DESIGN: Cross-sectional validation study.

SETTING: Tertiary care academic center.

SUBJECTS AND METHODS: Patients who underwent lip reanimation and control subjects. A disease-specific instrument was created by systematic literature review and expert opinion. The 15-item patient completed subscale was administered to 20 lip reanimation patients. Photographs of 19 patients and three control subjects were taken in four poses and rated by six raters (2 surgeons, 2 residents, and 2 novices) by the use of a external rater subscale, and reliability was determined by the use of intraclass correlation coefficients (ICC). Content and construct validity were assessed.

RESULTS: Internal consistency (ICC range 0.813-0.915 for each domain), test—retest reliability (ICC range 0.616-0.981 for each item) for the patient completed subscale, and interrater (ICC = 0.852) and interlevel reliability (ICC = 0.929) for the external rater subscale were substantial to excellent. The content validity index was 0.87. Construct validity was demonstrated by poorer scores in patients with transected nerves versus intact nerves for appearance ( P = 0.04) and oral competence ( P = 0.011). Photographs of control patients had lower asymmetry scores ( P < 0.001), and the instrument detected greater asymmetry in patients with progressively more exaggerated smile ( P < 0.001).

CONCLUSION: The lip reanimation outcome questionnaire has promising reliability and validity in this preliminary study, but additional psychometric testing with larger samples is required before the survey can be recommended for clinical use.

© 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

The osteomuscular dorsal scapular (OMDS) flap: an alternative technique of mandibular reconstruction

Free tissue transfer has become the dominant reconstructive tool for segmental defects of the mandible, except in case of severe peripheral vascular disease. In these cases, we propose to use the osteomuscular dorsal scapular (OMDS) flap as an alternative technique. This flap is pedicled on the dorsal scapular vessels with the harvesting of the medial border of the scapula and the lateral part of the rhomboid muscles.

METHODS

Thirteen cadaveric dissections have been performed after arterial injection of coloured latex in order to describe the surgical landmarks of the dorsal scapular pedicle. Six patients have been operated after lateral resection of the mandible.

RESULTS

The mean length of the pedicle was 66 mm (+/-2.61). The pedicle was located 41.2 mm (+/-5.51) lateral to the superior angle and 24.6 mm (+/-7.50) lateral to the medial angle. The size of the medial border that could be used for mandibular reconstruction was 116.4 6 mm (+/-7.48). The width of the medial border was 2.62 mm (+/-0.77) on the upper part and 3.35 mm (+/-0.90) on the inferior part. The clinical results were satisfying; good symmetry of the mandible was restored with normal opening of the mouth. Normal elevation of the shoulder was retained without recourse to physiotherapy.

DISCUSSION

The advantages of this method over other pedicled flaps include the length of the bone that can be harvested (>12 cm) allowing reconstruction of defects from the condylar process to the canine region and the preservation of scapular elevation. The superior part of the trapezius was not harvested, in order to allow passage of the flap in the tunnel under the upper trapezius to preserve the scapular elevation. The main disadvantages of the OMDS flap are the impossibility of placing implants in the bone that have been harvested because of its thickness and the lateral position that has to be changed to supine to allow access for resection of the tumour.

The effect of surgical resection in the region of the retromolar trigone

Tumours in the mucosa of the retromolar trigone (RMT) are rare, but develop insidiously and spread rapidly into surrounding structures. Resection may require radical dissection beginning usually on the medial side of the mandible. Such surgery can put important structures at risk. The normal anatomy of the RMT and its relations has been studied together with simulated surgical incisions and resections. Tissue removed was processed by histological techniques in order to demonstrate structures excised or damaged by the operation. The simulated incision showed that the lingual nerve, submandibular duct and palatoglossus were at particular risk. This could affect sensation, speech, swallowing and movements of the tongue. The findings pose immediate concerns for surgeons operating in this area. Although cancer surgery often involves sacrificing tissue, care should be taken to preserve structures vital to the patient's oral function without compromising oncological principles.