A New Mucosal Propeller Flap (Deep Lingual Artery Axial Propeller): The Renaissance of Lingual Flaps

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.

Analysis of risk factors for complications of perforator propeller flaps used for soft tissue reconstruction after malignant tumor resection: A systematic review and meta-analysis

BACKGROUND

Perforator propeller flaps (PPFs) have been widely used due to their numerous advantages; however, they were also associated with various complications. Herein, we analyzed the risk factors for complications of PPFs used for soft tissue reconstruction after malignant tumor resection.

METHODS

We searched databases for articles on soft tissue reconstruction using PPFs after malignant tumor resection published between January 1991 and April 2021. Studies were selected according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Fixed effects models and relative risks were used for data analysis. Funnel plots and Begg's test were used to evaluate publication bias.

RESULTS

Twenty-six articles met the inclusion criteria. Complications were found in 24.7% of all patients. The four significant risk factors were age equal or older than 60 years (pooled relative risk, 1.83; p = .04), smoking (pooled relative risk, 2.32; p = .03), diabetes (pooled relative risk, 2.59; p = .01) and radiotherapy (pooled relative risk, 2.09; p = .01). Hypertension, defects located in the extremities, flap size equal or greater than 100 cm² , and pedicle rotation equal or greater than 120 degrees were not significant risk factors for complications. No publication bias was found in the included articles.

CONCLUSION

Age equal or older than 60 years, smoking, diabetes and radiotherapy are four risk factors for complications when PPFs are used to reconstruct soft tissue defects resulting from malignant tumor resection.

Sublingual gland neoplasms: clinicopathological study of 8 cases

Background

Sublingual gland neoplasms are very rare and the majority of them are malignant. The aim of this study was to evaluate the clinical course, treatment, and outcomes of these uncommon neoplasms based on the authors’ experience and the recent literature.

Material and Methods

The medical charts of 8 patients with primary epithelial sublingual gland tumors treated between 1994 and 2020 were reviewed.

Results

Malignant tumors comprised 75% (6/8) of cases. Adenoid cystic carcinoma was the most common (50%, 3/6) and characterized by high risk of local recurrence and lung metastasis. Pleomorphic adenoma was the only representative of benign tumors with no evidence of local recurrence in follow up.

Conclusions

Treatment of choice of sublingual gland tumors is surgery. However, due to the fact that adenoid cystic carcinoma is the most common malignancy with poor prognosis, surgical treatment should be combined with postoperative radiotherapy. Benign sublingual tumors are less common and treatment of choice in these cases is tumor resection together with sublingual gland.

Key words:Salivary gland neoplasms, sublingual gland, pleomorphic adenoma, adenoid cystic carcinoma, mucoepidermoid carcinoma.

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.

How to Design and Harvest a Propeller Flap

Propeller flaps are local flaps based either on a subcutaneous pedicle, a single perforator, or vessels entering the flap in such a way so as to allow the flap to rotate on their axis. Depending on the kind of pedicle and the anatomical area, the preoperative investigation and the harvesting techniques may vary. An adequate knowledge of skin and subcutaneous tissue perfusion in the different areas of the body is very important to plan a propeller flap to be successful. The surgeon should begin by finding the most suitable perforators in the area surrounding the defect using available technology. The position, size, and shape of the flap are planned about this point. For perforator-pedicled propeller flaps, the procedure starts with an exploration from the margins of the defect or through a dedicated incision to visualize any perforators in the surroundings. The most suitable perforator is selected and isolated, the skin island is replanned, and the flap is harvested and rotated into the defect. The variations in surgical technique for other types of propellers and in specific anatomical areas are also described. Compared with free flaps, propeller flaps have the advantage of a simpler, shorter operation, without the need for a recipient vessel for microanastomosis. Yet, from a technical point of view, an adequate experience in dissecting perforators and the use of magnifying glasses are almost always required.

Our Definition of Propeller Flaps and Their Classification

The term propeller flap was introduced for the first time by Hyakusoku to define an island flap, based on a subcutaneous pedicle hub, that was rotated 90 degrees to correct scar contractures due to burns. With the popularization of perforator flaps, the propeller movement was applied for the first time to a skin island vascularized only by an isolated perforator, and the terms propeller and perforator flap were used together. Thereafter, the surgical technique of propeller flaps evolved and new applications developed. With the "Tokyo consensus," we proposed a definition and a classification schema for propeller flaps. A propeller flap was defined as an "island flap that reaches the recipient site through an axial rotation." The classification included the SPP (SPP) flap, the perforator pedicled propeller (PPP) flap, and the supercharged PPP (SCP) flap. A recent update added a new category, the axial pedicled propeller (APP) flap. Here we propose our updated and comprehensive classification of propeller flaps, taking into account the previous classification and subsequent publications. Based on their vascular pedicle, we consider the following five types of propellers: (1) SPP flap, 2.PPP flap, its subtype (2a) SCP flap, (3) APP flap, (4) muscle propeller flap, and (5) chimeric propeller flap. The variables that can be taken into account in the classification are as follows: type of nourishing pedicle, degrees of skin island rotation, position of the nourishing pedicle, artery of origin of the pedicle, and flap shape.

Complications and Solutions in Propeller Flap Surgery

Propeller perforator flaps (PPFs) have long been proven as valid reconstructive tools for a wide range of soft tissue defects in different body regions. During the last decade, despite their numerous advantages, many authors have thoroughly analyzed outcomes of these flaps, sometimes discouraging their use mainly because of a high failure rate. Accurate patient selection, adequate preoperative planning, and an appropriate dissection technique seem to potentially improve outcomes. Our study provides a review of the relevant literature related to PPF complications and of our experience, describing reasons for failure, measures for preventing them, and approaches for a prompt evaluation and management of complications.

Reconstruction of Large Anterior Palatal Fistulae Using Anteriorly Based Dorsal Tongue Flaps

BACKGROUND

An anterior palatal fistula in a bilateral cleft lip and palate is a challenging clinical dilemma. The authors evaluate the feasibility and outcomes of the reconstruction of large anterior palatal fistulae using anteriorly based dorsal tongue flaps.

METHODS

Eight patients with anterior palatal fistulae after repair of a bilateral cleft lip and palate using anteriorly based dorsal tongue flaps. The defect size varied from 1.0 × 1.0 cm to 1.5 × 2.0 cm, and the tongue flap size varied from 1.5 × 3.5 cm to 2.0 × 3.5 cm.

RESULTS

All patients underwent successful reconstruction of palatal defects using anteriorly based tongue flaps, and no case of spontaneous detachment of the tongue flap occurred. The patients with palatal fistulae were followed up for 10 to 30 months, and no recurrence was encountered.

CONCLUSION

An anteriorly based dorsal tongue flap is a safe and feasible surgical technique for the closure of anterior palatal fistulae.

The Facial Artery Perforator Flap as a New Option for Reconstruction of Intraoral Defects: Surgical Tips and Clinical Series

BACKGROUND

The authors have recently 1st described the use of the facial artery perforator flap (FAP) for intraoral reconstruction. In this study, they discuss technical notes and surgical tips associated with the procedure and the application of this flap in 4 patients with intraoral defects resulting from cancer or osteoradionecrosis.

METHODS

A retrospective study of 4 consecutive patients was performed on all patients who underwent reconstruction of an intraoral defect with a FAP flap, over a 12-month period from March 2017 to March 2018.The flap was designed according to the size of the defect centered on the perforator and was tunneled intraorally by means of a 90° rotation or advanced medially. The most constantly encountered perforator 1.5 cm lateral to the oral commissure was used in 3 cases; a cranial perforator was selected in 1 patient.

RESULTS

Four FAP flaps were used in 4 patients with intraoral defects. Follow-up was 6 to 12 months. Median defect size was 9.15 cm (range, 3.4-21.5 cm). All reconstructions were successful, without major flap loss or infections. One patient with severe osteoradionecrosis and fungal infection developed minor flap loss and dehiscence, which was treated conservatively. There were no signs of local recurrence and functional outcomes were satisfactory.

CONCLUSIONS

The FAP flap is an effective and versatile solution for reconstruction of intraoral defects until 5 cm × 4 cm (20 cm) without significant donor-site morbidity. It may be considered a new reconstructive option for intraoral defects, which warrants further study in a larger series or patients.

The facial artery perforator flap for intraoral reconstruction of a mouth floor defect

Facial artery perforator flaps have been recently reported by different authors for perioral, nasal alar and cheek defects, but not for intraoral reconstruction. We have extended the use of the facial artery perforator flap in a 56-year-old man with a squamous cell carcinoma of left mouth floor, who was submitted to tumor resection with marginal mandibulectomy and left supraomohyoid neck dissection. The flap was designed according to the size of the defect (5 × 3 cm), centered on the perforator to create a symmetric flap and was tunnelled intraorally by means of a 90° rotation. The postoperative period was uneventful, allowing timely initiation of adjuvant radiotherapy. After 8 months, there were no signs of local recurrence or wound dehiscence, and functional outcomes were satisfactory. The main advantages of this flap in this case were the reduction in morbidity at the donor site with preservation of nerves, muscles and facial artery, and it allowed greater freedom. To the best of the authors' knowledge, this technique has not been reported before. It may constitute an important reconstructive option when dealing with similar defects, if our results are confirmed in larger series.

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.