Reconstruction of the buccal mucosa following release for submucous fibrosis using two radial forearm flaps from a single donor site

Reconstruction of Multiple Lip and Facial Defects With Bipaddle and Sensate Radial Forearm Free Flap

ABSTRACT

Free flaps and their modifications are used to reconstruct multiple large defects in the lip and face. In this study, we present our results on the reconstruction of these defects using bipaddle and sensate free radial forearm-palmaris longus flaps and subsequent revision surgeries. Patient medical records of 11 patients with a mean age of 63.9 ± 12.8 years were retrospectively reviewed. Functional oral competence, lip cosmetics, lip sensation, and donor forearm scars were evaluated using the drooling rating scale, visual analog scale, Semmes Weinstein Monofilament test, and patient and observer scar assessment scale, respectively. The mean dimensions of distal and proximal skin paddles of bipaddle free radial forearm-palmaris longus flaps were 12.7 ± 9.9 and 20.5 ± 3.8 cm2. Mean lengths of the bridge and proximal pedicles were 4.7 ± 1.6 and 5.5 ± 0.7 cm. All the flaps survived. No drooling was observed in the 2 patients without lower lip defects. The mean drooling scores of the 9 patients with lower lip defects were statistically different (Analysis of Variance, pANOVA < 0.00001) at 3, 6, 9, and 12 months postoperatively. The differences between 3 and 12 months were the most significant (pANOVA < 0.00001, pTUKEY < 0.000001). The lip sensation and drooling scores showed a strong positive correlation (r = 0.8504). All patients were able to speak fluently, drink fluid without leakage, and blow a balloon easily. All patients and observers were satisfied with the lip cosmetics, with no significant difference between satisfaction scores (P = 0.087615).There was a statistically significant difference (P < 0.00001) between mean sensation scores of surrounding healthy lip (2.94 ± 0.27) and free flaps (4.15 ± 0.4). All the donor scars healed uneventfully.

"Submarine-Shaped" Radial Forearm Flap for Simultaneous Reconstruction of Oral and Lower Lip Defects"

BACKGROUND

Reconstruction of the oral cavity commonly results in trismus and lip incompetence.

AIM AND OBJECTIVES

In this study, we aim to describe an innovative design of a radial forearm free flap for resurfacing bilateral buccal defects and simultaneous functional lower lip reconstruction in a single stage.

MATERIALS AND METHODS

Between January 2010 and December 2019, 6 males underwent simultaneous buccal and lower lip reconstruction with a radial forearm free flap. The mean age of the patients was 57.3 years (range, 50-68 years). The defects were caused by trismus release and due to previous treatments. The mean size of the defects was 17.9 cm in length and 3.25 cm in width. Flaps were harvested, including the proximal perforators of the radial vessels, and the inset began in the buccal area opposite the anastomosis side.

RESULTS

Flap size ranged from 16 to 21 × 2 to 4 cm. The recipient vessels used were the superficial temporal (4) and facial (2). All flaps survived. Lip infection was seen in 2 cases and managed conservatively. The mean follow-up was 19.2 months (range, 12-28 months). The mean increase in the interincisal distance was 10.7 mm. Oral continence was good in all patients. Speech intelligibility was considered total in 4 patients and partial in the remaining 2.

CONCLUSION

The radial forearm flap constitutes an option for simultaneous lower lip reconstruction and resurfacing of bilateral buccal areas after trismus release. The procedure provides a thin and pliable reconstruction using only 1 donor site and 1 set of recipient vessels.

Trismus surgery and microsurgical reconstruction after oral cancer treatment

INTRODUCTION

Trismus after oral cancer is frequent, with scarce evidence of surgical release treatment in these patients.

OBJECTIVES

The objective of this study is to determine the results of trismus release and free flap reconstruction after oral cancer treatment, establish immediate and long-term results, and detect factors that influence outcome.

MATERIALS AND METHODS

A retrospective study was performed. Preoperative, intraoperative, and follow-up interincisal distances were measured. The intraoperative, long-term gain, and postoperative loss were calculated. Analysis of the long-term results with the preoperative and intraoperative variables was performed.

RESULTS

Surgical release immediately increased the interincisal distance by 29.25 mm. Sixty-six percent of this gain was lost due to trismus recurrence, giving a long-term interincisal gain of 9.90 mm. Worse results were observed in patients with previous high-stage tumors, maxillectomies, skin resections, and previous radiotherapy. The were no significant differences in the results depending on the type of release or reconstruction performed, with the exception of the reconstruction with the sural flap, which presented worse results. Patients with trismus of ≤10 mm could have more range for improvement after this surgery.

CONCLUSIONS

The results of this surgery are moderate in the long term due to high trismus recurrence in spite of aggressive treatment.

Cross cheek dumbbell-shaped radial forearm free flap for bilateral trismus release

Trismus in post-radiotherapy patients is mostly secondary to fibrosis of buccal mucosa and muscles of mastication. After releasing trismus, mucosal defect needs to be covered with soft and supple tissue. We used a non-conventional method to cover this defect i.e. dumbbell-shape forearm free-flap based on a single radial artery.

What is the Optimal Reconstructive Option for Oral Submucous Fibrosis? A Systematic Review and Meta-analysis of Buccal Pad of Fat Versus Conventional Nasolabial and Extended Nasolabial Flap Versus Platysma Myocutaneous Flap

Background

To systematically review the reconstructive options for oral submucous fibrosis utilizing buccal pad of fat versus conventional nasolabial and extended nasolabial flap versus platysma myocutaneous flap.

Objective

The succeeding systematic review and meta-analysis addresses the following question, what is the optimal reconstructive option for oral submucous fibrosis?

Study Design

A systematic electronic and manual database search revealed five relevant articles comparing buccal fat pad, nasolabial flap and platysma myocutaneous flap as reconstructive options in oral submucous fibrosis.

Methods

A total of 1538 articles were found across PubMed, Cochrane and clinical trials.gov. Only five relevant articles were selected for the study. Quality assessment of the selected studies was executed by Newcastle-Ottawa scale. Statistical software RevMan (Review Manager [Computer program], version 5.3, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) was used for meta-analysis. Differences in means and risk ratios were used as principal summary measures. The overall estimated effect was categorized as significant where p < 0.05.

Results

Three of the five studies selected favoured buccal fat pad over nasolabial flap owing to its ease of harvest and lesser number of post-operative complications. One study favoured nasolabial flap because of the progressive increase in mouth opening and bulk of the tissue obtained for reconstruction. A single study favoured platysma flap over nasolabial flap although no difference was obtained in mouth opening, owing its excellent tissue bulk, fewer complications compared to the nasolabial flap.

Conclusion

Definitive conclusions cannot be drawn as there are number of limitations in the studies included. However, a general consensus has been towards favouring buccal fat pad over nasolabial flap. The platysma flap owing to its excellent tissue bulk and fewer complications can be considered as an alternative when dealing with defects which are challenging to reconstruct with the buccal fat pad.

One plus one: Two free flaps from same donor thigh for simultaneous coverage of two different defects

Introduction:

Primary microvascular reconstruction of multiple defects is challenging particularly if it has to be simultaneous. In trauma cases, harvesting two independent free flaps from different sites is very time-consuming and adds to morbidity. To eliminate these disadvantages, we sought to find out a reliable alternative method of harvesting two independent free flaps based on the descending branch of circumflex femoral artery, i.e., one anterolateral thigh (ALT) flap and one rectus femoris muscle flap.

Aim:

To study the feasibility of transferring two free flaps, i.e., ALT and rectus femoris muscle flap simultaneously from the same thigh for coverage of two different limb defects.

Materials and Methods:

From 2003 to 2012, five patients with two defects each were managed with a total of ten flaps harvested from five donor sites based on independent pedicles of descending branch of lateral circumflex femoral artery and used to cover severe injuries of extremities. Three cases had both lower limb defects and two cases had one upper limb and one lower limb defect. In each case, one ALT flap and one rectus femoris muscle flap were used for coverage.

Results:

All reconstructive procedures were completed without any major complications. All flaps survived well. There were no re-explorations and no complications related to donor sites.

Conclusion:

We conclude that our approach of simultaneous harvest of ALT and rectus femoris muscle from the same thigh offers two flaps for two different defects in terms of economy of donor site and operating time.

Comparison of Extended Nasolabial Flap Versus Buccal Fat Pad Graft in the Surgical Management of Oral Submucous Fibrosis: A Prospective Pilot Study

AIM

To evaluate the application of extended nasolabial flap versus buccal fat pad graft in the surgical management of oral submucous fibrosis.

SETTINGS AND DESIGN

This prospective study was carried out in the Department of Oral and Maxillofacial Surgery, Tamil Nadu Government Dental College and Hospital, Chennai.

MATERIAL AND METHODS

A total of 8 patients (6 men and 2 women) with age range from 21 to 65 years were selected for study. These 8 patients were randomly divided into two groups of four namely group 1 and group 2. In group 1 patients, reconstruction was planned with extended nasolabial flaps and in group 2 patients, reconstruction was planned with buccal fat pad graft respectively.

STATISTICAL ANALYSIS USED

Paired t test, Independent sample t test, ANOVA test.

RESULTS

The mean preoperative mouth opening in group 1 was 8.5 mm and in group 2 was 11.75 mm. The mean increase in group 1 after one year of postoperative period was 21.50 mm and in group 2 was 24.75 mm.

CONCLUSIONS

In the present study, buccal fat pad graft proved to give better results as the interposition material as it has good patient acceptance, rapid epithelization, minimal donor site morbidity and minimal intra and postoperative complications.

Surgical defect coverage in oral submucous fibrosis patients with single-stage extended nasolabial flap

PURPOSE

Long standing oral submucous fibrosis (OSMF) is associated with involvement of the oral submucosa and the muscles of mastication leading to difficulty in mouth opening. Various surgical modalities are mentioned for release but each has its own limitations. The aim of the study was to evaluate the postoperative mouth opening in patients of OSMF after excision of fibrous bands followed by coronoidotomy and surgical defect coverage by extended nasolabial flap.

METHODS

We evaluated the use of extended nasolabial flaps and coronoidectomy in the management of 11 randomly selected patients with histologically confirmed oral submucous fibrosis. They all had interincisal opening of less than 25 mm and were treated by bilateral release of fibrous bands, coronoidectomy or coronoidotomy, and extended grafting with a nasolabial flap.

RESULT

Their interincisal opening improved significantly from a mean of 8.68±7 mm to a mean of 36.75±4.05 mm at 6-month follow-up.

CONCLUSION

The procedure was effective in the management of patients with oral submucous fibrosis, the main disadvantage being the extraoral scars.

Bipaddled anterolateral thigh perforator flap for simultaneous reconstruction of bilateral buccal defects following oral cancer ablation or release of oral submucous fibrosis

It is a challenge to simultaneously reconstruct bilateral buccal defects following oral cancer ablation or release of oral submucous fibrosis. In this study, we report two cases where bipaddled anterolateral thigh perforator flaps were used to resurface two separate buccal defects.

Cross-Cheek Dumbbell-Shaped Radial Forearm Flap for Simultaneous Correction of Oral Cancer and Submucous Fibrosis

Simultaneous occurrence of oral submucous fibrosis along with carcinoma of the buccal mucosa is common. We report a novel technique of a single dumbbell-shaped, cross-cheek radial forearm free flap to repair bilateral defects caused by oral cancer resection on one side and the release of fibrosis on the other side in two patients. The dumbbell-shaped flap provided tissue for both the buccal mucosa defects and central released soft palate preventing fibrosis and reapproximation. The interincisor distance improved in both the patients.

Oral submucous fibrosis: a review of the current management and possible directions for novel therapies

This literature review addresses the attempted interventions for the management of oral submucous fibrosis. The literature supports the use of several medical interventions, including micronutrients, antioxidants, proteolytic enzymes, immune modulators (mainly steroids), and agents to promote blood flow. However, the numbers of reported randomized controlled trials are limited. Therefore, no recommendation can be made for any specific intervention. Until now, no single molecular pathway has been identified that is either necessary or sufficient for the development of fibrosis. This has been a bar for any molecular-targeted therapies. Because areca nut (an ingredient of betel quid) plays a major etiologic role in oral submucous fibrosis, cessation of areca nut use remains pivotal in the management of this disorder.

Thoraco dorsal artery perforator flap for trismus release in a young girl

Trismus is a frequent complication occurring after treatment of tumors of the pterygomaxillary fossa. Local flaps and full-thickness skin grafts fail to release it because they usually lead to scar contracture in previously irradiated tissues. We propose to release it with a thoracodorsal artery perforator flap, which is feasible in children like other perforator flaps. It is interesting because it is thinner than the anterolateral thigh flap and its scar may be less disgraceful and easier to hide.

Surgery for extra-articular trismus: a systematic review

The aim of this systematic review was to identify operations that are used to improve mouth opening in patients with extra-articular trismus (caused by cancer and its treatment, oral submucous fibrosis, or noma) and to find out if they work. We searched the electronic databases PubMed, Embase, Cinahl, and the Cochrane collaboration, and then systematically selected papers before we assessed their quality, extracted the data, and did a meta-analysis. We analysed 32 studies that included 651 patients, the median (IQR) size of which was 11 (7-26). The quality of the methods used and of reporting were relatively low. Median (IQR) duration of follow-up was 12 (8-22) months. Operations resulted in a weighted mean (SD) increase in mouth opening of 19.3 (6.3) mm. None of the operations was better than the others for the improvement of mouth opening. We conclude that operations can improve mouth opening in extra-articular trismus, but the evidence is of moderate quality and there is a need for further research.

Surgical Interventions in Oral Submucous Fibrosis: A Systematic Analysis of the Literature

BACKGROUND

Oral submucous fibrosis (OSMF) is a potentially malignant disorder of the oral cavity. The surgical management of this condition involves excision of the fibrotic bands and interpositional grafts to retain the increased oral opening. Various procedures and graft material have been utilised with differing success rates.

OBJECTIVES

The present review aims to collate and analyze from world literature the different modalities utilized in the surgical management of OSMF. The reasons for the choice of a particular surgical procedure, the study protocol, the average follow-up period and the results were scrutinized.

MATERIALS AND METHODS

The PRISMA protocol was followed for the systematic review. Search engines and medical databases like Ovid, Medline, Pubgate, Researchgate, PubMed, Google etc. were tapped for information related to the subject. The search words "OSMF", "surgical interventions in OSMF", "flaps and grafts in treatment of OSMF" were employed for retrieval of data. An analysis of the treatment modalities, the reason for the selection of a particular modality, the organization of the sample selection and the follow-up periods including the proclaimed success rates was done.

RESULTS

The review resulted in a total of 56 articles on the subject from the sources mentioned above. A total of 995 surgically treated cases were included in the analysis. Interestingly the review revealed very few controlled clinical trials, most being random trials on surgical procedures in small groups of patients with very short follow up periods. The choice of procedure seems to be determined entirely by the preference of the operator/s.

CONCLUSIONS

There exist no definite protocols for the adoption of a particular treatment mode in OSMF. Adequate documentation and follow up need to be established to statistically analyse the results and proclaimed successes of various treatment modalities.

Using pneumo-computerized tomography as a quantitative assessment of result in submucous fibrosis patients treated with surgical release and free flap reconstruction

OBJECTIVE

This study investigates the efficacy of oral submucous fibrosis release and free flap reconstruction.

STUDY DESIGN

Pneumo-computerized tomography (pneumo-CT) was used to evaluate postoperative changes in the buccal vestibular volume during maximum blowing.

METHODS

From March 2003 to November 2008, 9 patients underwent 18 microvascular flap reconstructions after oral submucous fibrosis release. The preoperative and postoperative buccal vestibular volumes were determined by capturing the air density in the selected region on CT images, which were composed of 0.75-mm-thick slices that were then summated using analysis software (Biomedical Imaging Resource; Mayo Foundation, Rochester, MN).

RESULTS

Postoperative results were measured for a mean follow-up period of 15 months (range, 6-36 mo). There was significant improvement in the interincisal distance from 12.44 (8.35) mm preoperatively to 32.56 (7.322) mm postoperatively (P = 0.000). There was an accompanying significant increase in the buccal vestibular volume from 5.66 (3.92) mL preoperatively to 9.38 (4.96) mL postoperatively on the right side (P = 0.032) and from 6.44 (4.20) mL preoperatively to 9.64 (4.65) mL postoperatively (P = 0.048) on the left side.

CONCLUSIONS

Adequate release of the mucosa and resurfacing with a free flap can increase the interincisal distance and improve the maximal buccal vestibular volume. Air-contrast pneumo-CT studies demonstrate an improvement in buccal mucosal elasticity.

Epithelial-mesenchymal interactions as a working concept for oral mucosa regeneration

Oral mucosa consists of two tissue layers, the superficial epithelium and the underlying lamina propria. Together, oral mucosa functions as a barrier against exogenous substances and pathogens. In development, interactions of stem/progenitor cells of the epithelium and mesenchyme are crucial to the morphogenesis of oral mucosa. Previous work in oral mucosa regeneration has yielded important clues for several meritorious proof-of-concept approaches. Tissue engineering offers a broad array of novel tools for oral mucosa regeneration with reduced donor site trauma and accelerated clinical translation. However, the developmental concept of epithelial-mesenchymal interactions (EMIs) is rarely considered in oral mucosa regeneration. EMIs in postnatal oral mucosa regeneration likely will not be a simple recapitulation of prenatal oral mucosa development. Biomaterial scaffolds play an indispensible role for oral mucosa regeneration and should provide a conducive environment for pivotal EMIs. Autocrine and paracrine factors, either exogenously delivered or innately produced, have rarely been and should be harnessed to promote oral mucosa regeneration. This review focuses on a working concept of epithelial and mesenchymal interactions in oral mucosa regeneration.

Management of oral submucous fibrosis: an overview

Oral submucous fibrosis is a disease due to a chronic, insidious change in fibroelasticity, characterized by burning sensation in the oral cavity, blanching, and stiffening of the oral mucosa and oro-pharynx leading to trismus and inability to open the mouth. The symptoms and signs depend on the progression of the lesions and number of affected sites. It is predominantly seen in Indians and other Asians. Once, the disease has developed, there is neither regression nor any effective treatment. It is considered as a pre-malignant stage of oral cancer and reported risk of malignant transformation varies from 2.3-7.6%.The common etiological factor considered for this unremitting disease is use of areca nut; however, the precise pathogenesis still remains elusive and controversial. A wide range of treatment consisting of drug management, surgical therapy, and physiotherapy have been attempted till date; with varying degrees of benefit, but none of them have proved to be a cure for this disease. This field remains open for clinical trials and research. This paper aims to provide an overview on various management modalities available for oral submucous fibrosis.