A Comparison Between the Pectoralis Major Myocutaneous Flap and the Free Anterolateral Thigh Perforator Flap for Reconstruction in Head and Neck Cancer Patients: Assessment of the Quality of Life

Long-term patient-reported outcomes after reconstructive surgery for head and neck cancer: A systematic review

Current literature on reconstruction after head and neck cancer (HNC) focusses on short-term patient-reported outcomes (PROs), while there is a need for knowledge on long-term consequences. Embase, Medline, Web of Science, and Cochrane were searched for studies on health-related quality of life (HRQoL) after HNC reconstruction, using validated PROMs in at least 50 patients, and a follow-up of more than 1 year. Thirty studies were included, comprising 2358 patients with a follow-up between one and 10 years. The most used questionnaire was the UW-QoL v4. Reconstructive surgery was generally followed by diminished oral function, worsened by radiotherapy. Patients experienced anxiety and fear of cancer recurrence. However, there was a progressive decrease in pain over time with some flaps having more favorable HRQoL outcomes. Age and bony tumor involvement were not related to postoperative HRQoL. These results may lead to better patient counseling and expectation management of HNC patients.

Quality of Life and Aesthetic Satisfaction in Patients Who Underwent the “Commando Operation” with Pectoralis Major Myocutaneus Flap Reconstruction—A Case Series Study

The “commando operation” is an extensive surgical procedure used to treat patients with oral squamous carcinoma and metastasis in the cervical lymph nodes. While the procedure can be curative, it is also very mutilating, which consequently has a major impact on the patient’s quality of life. Several studies showed that the procedure is associated with loss of certain functions, such as impairments in speech, chewing, swallowing, and loss of taste and appetite. Furthermore, some of these impairments and their degree depend on the reconstruction method. However, the data regarding the functional impairments and aesthetic results in patients who underwent the “commando operation” along with the pectoralis major myocutaneus flap reconstruction are still inconclusive. This study included 34 patients that underwent partial glossectomy, ipsilateral modified radical neck dissection, pectoralis major myocutaneus flap reconstruction, and adjuvant radiotherapy. A structured questionnaire was used to evaluate aesthetical results and functional impairments as well as to grade the level of satisfaction with the functional and aesthetic outcomes both by the patients and by the operator. Most of the patients stated that their speech (N = 33; 97%) and salivation (N = 32; 94.2%) severely changed after the operation and that they cannot chew (N = 33; 97%) and swallow (N = 33; 97%) the same as before the operation. Moreover, almost half of the patients (N = 16; 47%) reported that they have severe sleep impairments. However, only few of the included patients stated that they sought professional help regarding the speech (N = 4; 11.7%), eating (N = 5; 14.7%), and sleeping (N = 4; 11.7%) disturbances. Additionally, there was a statistically significant difference between the operator and the patients in the subjective assessment of the aesthetic results (p = 0.047), as operators gave significantly better grades. Our results imply that this procedure and reconstructive method possibly cause impairments that have an impact on the patients’ wellbeing. Moreover, our outcomes also suggest that patients should be educated and rehabilitated after the “commando operation” since most of them were reluctant to seek professional help regarding their impairments. Lastly, sleep deficiency, which was observed after the procedure, should be further explored.

Pedicled Flaps versus Free Flaps for Oral Cavity Cancer Reconstruction: A Comparison of Complications, Hospital Costs, and Functional Outcomes

Introduction  Free flaps have been the preferred method for reconstruction after resection of oral cavity cancer. However, pedicled flaps remain valuable alternatives in appropriate settings. Objective  The main objective of the present study was to compare surgical complications, hospital costs, and functional outcomes of oral cavity cancer patients who underwent soft tissue reconstruction with pedicled flaps or free flaps. Methods  A total of 171 patients were included in the study. Ninety-eight underwent reconstruction with a pectoralis major, submental, temporalis, or supraclavicular pedicled flap, and in 73 patients, a radial forearm or anterolateral thigh free flap had been used. The cases were retrospectively reviewed, and a comparative analysis was carried out between the two groups. Results  Recipient site and flap complications, speech, and swallowing functions did not differ between groups, but donor site complications, operative time, hospital stay, and costs were significantly reduced in the pedicled flap group compared with the free flap group. However, the pectoralis major flap reconstruction resulted in a more inferior swallowing function than the free flap reconstruction. Conclusions  With comparable complications and functional outcomes, while decreasing in costs, pedicled flaps are a useful alternative to free flaps in oral cavity cancer reconstruction. However, in an extensive defect (> 70 cm ² ), free flaps are the reconstruction of choice for the preservation of swallowing function.

Filling the Upper Pole with the Pectoralis Major Muscle Flap in Profunda Femoris Artery Perforator Flap Breast Reconstruction

Background and Objectives: Among many donor site options for autologous breast reconstruction, the use of the profunda femoris artery perforator (PAP) flap has become common in patients who are not suitable for the gold standard procedure, the deep inferior epigastric artery perforator flap. However, its limited volume has precluded its wide use in breast reconstruction. The aim of this report was to demonstrate the effectiveness of a method in which the anatomical position of the pectoralis major muscle was adjusted to augment the volume of the superior pole of the breast during PAP flap transfer. A comparison was made with a conventional PAP flap breast reconstruction. Materials and Methods: Fifty-nine consecutive cases where unilateral autologous breast reconstruction was performed using the vertically designed PAP flap were retrospectively reviewed. Conventional PAP flap transfer was performed in 36 patients (Group 1), and PAP flap transfer with pectoralis major muscle augmentation was performed in 23 patients (Group 2). Results: The patient satisfaction at 12 months postoperatively was statistically greater in Group 2, with the pectoralis major muscle augmentation, than in Group 1 [23/36 (64%) vs. 22/23 (96%), p = 0.005]. There were no significant differences in postoperative complication rates at the reconstructed site [2/36 (5.6%) vs. 0/23 (0%), p = 0.52]. Conclusions: Higher patient satisfaction could be achieved with pectoralis major muscle augmentation in PAP flap breast reconstruction without increasing the postoperative complication rate at the reconstructed site.

Comparison Between Radial Forearm Free Flap and Pectoralis Major Myocutaneous Flap for Reconstruction in Oral Cavity Cancer Patients: Assessment of the Quality of Life

ABSTRACT

We aimed to evaluate the quality of life of Chinese patients after immediate reconstruction surgery on individuals with oral cavity cancer. In addition, we compared the differences between radial forearm free flap and pectoralis major myocutaneous flap. Using the University of Washington quality of life v4 questionnaire, 1:1 matched research was performed on patients received PMM or RFF flap. Chi-square test was used to analyze the variables. One hundred twenty four of 179 questionnaires were returned (69.3%). Age, N stage, and postoperative radiotherapy were similar for both groups. However, there were significant differences between two groups in gender, T stage, operation duration, and complication rate. Oral cavity cancer patients reconstructed with radial forearm free flap had better shoulder and speech functions but worse appearance domains. The results of our research provide important information for patients and physicians during their discussion of treatment programs for oral cavity cancers.

Recommendations for postoperative radiotherapy in head & neck squamous cell carcinoma in the presence of flaps: A GORTEC internationally-reviewed HNCIG-endorsed consensus

INTRODUCTION

Head and neck reconstructive surgery using a flap is increasingly common. Best practices and outcomes for postoperative radiotherapy (poRT) with flaps have not been specified. We aimed to provide consensus recommendations to assist clinical decision-making highlighting areas of uncertainty in the presence of flaps.

MATERIAL AND METHODS

Radiation, medical, and surgical oncologists were assembled from GORTEC and internationally with the Head and Neck Cancer International Group (HNCIG). The consensus-building approach covered 59 topics across four domains: (1) identification of postoperative tissue changes on imaging for flap delineation, (2) understanding of tumor relapse risks and target volume definitions, (3) functional radiation-induced deterioration, (4) feasibility of flap avoidance.

RESULTS

Across the 4 domains, international consensus (median score ≥ 7/9) was achieved only for functional deterioration (73.3%); other consensus rates were 55.6% for poRT avoidance of flap structures, 41.2% for flap definition and 11.1% for tumor spread patterns. Radiation-induced flap fibrosis or atrophy and their functional impact was well recognized while flap necrosis was not, suggesting dose-volume adaptation for the former. Flap avoidance was recommended to minimize bone flap osteoradionecrosis but not soft-tissue toxicity. The need for identification (CT planning, fiducials, accurate operative report) and targeting of the junction area at risk between native tissues and flap was well recognized. Experts variably considered flaps as prone to tumor dissemination or not. Discrepancies in rating of 11 items among international reviewing participants are shown.

CONCLUSION

International GORTEC and HNCIG-endorsed recommendations were generated for the management of flaps in head and neck radiotherapy. Considerable knowledge gaps hinder further consensus, in particular with respect to tumor spread patterns.

Microvascular reconstruction for maxillofacial defects: a retrospective analysis of outcomes and complications in 121 consecutive cases

Background

Microvascular reconstruction is the treatment of choice after oral cancer ablation surgery. There are few published studies of free flap survival among Korean populations. This study aimed to determine the survival rate after 121 consecutive cases of maxillofacial microvascular reconstruction and to analyze the complications associated with microsurgery.

Methods

This study included consecutive patients who underwent microsurgical reconstruction with free flaps, from January 2006 through September 2019, performed by a single surgeon at the oral and maxillofacial surgery department of a tertiary medical center. A total of 121 cases were reviewed retrospectively. The flap survival rate, flap type, radiotherapy history, complications, and treatment results were analyzed.

Results

Four different flap types were used for microvascular reconstruction: radial forearm (n = 65), fibula (n = 34), latissimus dorsi (n = 21), and serratus anterior muscle with rib bone free flap (n = 1). Total necrosis of the flap was found in four cases (two latissimus dorsi flaps and two fibular flaps). The free flap survival rate was 97.5%. Nineteen patients received radiotherapy before surgery, and none of them experienced flap failure. The mean operation time was 334 ± 83.1 min, and the mean ischemic time was 48.9 ± 12.7 min.

Conclusions

The success rate was reliable and comparable with previous studies. The success rate was not affected by radiation therapy. Free flaps can be safely used even after radiation treatment.

Reconstruction After Salvage Total Laryngectomy: A Cost-effectiveness Analysis

Objective

To determine the most cost-effective reconstruction method after salvage total laryngectomy.

Study Design

Cost-effectiveness analysis

Setting

Tertiary care hospitals with head and neck oncologic and reconstructive surgeons.

Subjects and Methods

We constructed a Markov-based decision model to compare reconstruction by primary closure to pectoralis flap and free flap after salvage total laryngectomy. The model simulated disease with transition probabilities and health utilities found in primary literature and estimated the average overall cost of each reconstructive method using Medicare billing codes. Effectiveness was compared using quality-adjusted life years (QALYs). One-way and probabilistic sensitivity analyses were performed to scrutinize the conclusions of our model. Reconstruction methods were compared using incremental cost-effectiveness ratios (ICERs). In the United States, less than $150,000 per QALY gained is considered cost-effective (2019 US dollars).

Results

Our base case analysis revealed that primary closure was less expensive ($44,370) and yielded more QALYs (0.91) than both pectoralis ($45,163, 0.81 QALYs) and free flap ($46,244, 0.85 QALYs), making it the most cost-effective option. Between flaps, free flap was cost-effective over pectoralis flap (ICER = $27,025/QALY gained). Sensitivity analyses showed primary closure as cost-effective 69% of the time over either flap. These conclusions were sensitive to the health utilities (quality of life) of each method of reconstruction.

Conclusion

Tissue flaps to augment closure after salvage total laryngectomy are not always the most cost-effective reconstructive option. The long-term morbidity of flap surgery oftentimes outweighs the benefit of lowering fistula rates after surgery. Careful consideration must be taken when advising patients of their reconstructive options.

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.

Free Flap Selection and Outcomes of Soft Tissue Reconstruction Following Resection of Intra-oral Malignancy

Introduction: Surgery to resect intra-oral malignancy is a well-established mode of primary treatment. The tissue requirement in this area is for a thin, pliable flap with minimal bulk and this has historically been provided by free tissue transfer with a radial forearm free flap (RFFF). More recently, a role for the anterolateral thigh free flap (ALTFF) has been described, although in populations with a westernized diet, body habitus may preclude use of an ALTFF due to flap thickness, relative to a radial forearm free flap.

Methods: An analysis of data was performed retrospectively for 90 consecutive patients with intra-oral malignancy, requiring immediate soft tissue reconstruction by the senior author, at Addenbrooke's Hospital between July 2008 and April 2016. Cases requiring bony reconstruction were excluded. Data on patient age, sex, indication for surgery, tumor location and defect type, complications, success rates, and length of stay were recorded.

Results: The majority of patients received an ALTFF (n = 56) with 38% receiving a RFFF (n = 34). Surgical resection took place in the floor of the mouth most frequently. These were closed with ALTFF and RFFF in 41 and 28 occasions, respectively. A success rate of 97% was observed in the RFFF group; 1 flap developed partial necrosis and required complete revision. In the ALTFF group, there was a 100% flap success rate. ALTFF usage resulted in a reduction in the number of intraoperative (p = 0.021) in addition a reduction in the number of days in ITU (p = 0.01) and post-operative clinic visits (p = 0.025).

Conclusion: We present a series that used predominately the ALTFF to reconstruct intra-oral defects following resection of squamous cell carcinoma in a Western population. The results demonstrate that this treatment can produce at least as comparable results as to the use of a RFFF repair in this population, whilst avoiding the donor site morbidity and aesthetic compromise of a RFFF.

Health-related quality of life: a retrospective study on local vs. microvascular reconstruction in patients with oral cancer

BACKGROUND

New medicinal and surgical oncological treatment strategies not only improve overall survival rates but continually increase the importance of Health-Related Quality of Life (HRQOL). The purpose of this retrospective cross-sectional study was to analyze HRQOL of patients with oral squamous cell carcinoma after ablative surgery and to evaluate predictive factors for HRQOL outcome.

METHODS

The study included 88 patients with histologically confirmed oral squamous cell carcinoma of whom 42 had undergone local reconstruction (LR) and 46 microvascular reconstruction (MVR). During follow-up, all patients completed the University of Washington Quality of Life Questionnaire (UW-QOL) containing 12 targeted questions about the head and neck. Descriptive analyses were made for the tumor site, the T-stage, and adjuvant therapies. HRQOL was compared between the LR and the MVR group with parametric tests. Further analyses were impact of the tumor site, the T-status, and the time from surgery to survey on HRQOL. Statistics also included multivariate correlations and different interaction effects.

RESULTS

HRQOL in the LR group was 'very good' with 84.3 ± 13.7 and 'good' in the MVR group with 73.3 ± 16.5 points. The physical domains swallowing (p = 0.00), chewing (p = 0.00), speech (p = 0.01), taste (p = 0.01), and pain (p = 0.04) were significantly worse in the MVR group. An increase in the T-status had a significant negative effect on swallowing (p = 0.01), chewing (p = 0.01), speech (p = 0.03), recreation (p = 0.05), and shoulder (p = 0.01) in both groups. Regarding the tumor site and subsequent loss of HRQOL, patients with squamous cell carcinoma on the floor of the mouth had significantly worse results in the categories pain (p = 0.002), speech (p = 0.002), swallowing (p = 0.03), activity (p = 0.02), and recreation (p = 0.01) than patients with tumors in the buccal mucosa. Speech (p = 0.03) and pain (p = 0.01) had improved 1 year after surgery.

CONCLUSION

Patients with flap reconstruction because of oral squamous cell carcinoma showed very good overall HRQOL. Outcomes for microvascular reconstruction were good, even in the case of larger defects. The T-status is a predictor for HRQOL. Swallowing, chewing, speaking, taste, and pain were the most important issues in our cohort. Implementing HRQOL questionnaires for the assessment of quality of life could further increase the treatment quality of patients with oral cancer.

Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review

Objective

The present review focuses on comparative studies of reconstruction with free flaps (FF) versus pedicled flaps (PF) after oncologic resection.

Method

A systematic review was developed in compliance with PRISMA guidelines and performed using the Pubmed, Medline, EMBASE, Amed and Biosis databases.

Results

A total of 30 articles were included. FF are associated with a longer operative time, a higher cost and a higher incidence of postoperative revisions compared to PF. FF are associated with a longer stay at the intensive care unit than the supraclavicular artery island flap (SCAIF) and with a more extended hospital stay compared to the submental island flap (SMIF). FF are associated with fewer infections and necrosis compared to the pectoralis major myocutaneous flap (PMMF).

Conclusion

The comparison of both type of flaps is limited by the inherent design of the studies included. In sum, FF seem superior to the PMMF for several outcomes. SMIF and SCAIF compare favorably to FF for some specific indications achieving similar outcomes at a lower cost.

Effect of induction chemotherapy on the quality-of-life in patients with advanced stage tongue cancer by a prospective study

Objective

To assess how induction chemotherapy affects the quality-of-life (QoL) in patients with advanced tongue cancer.

Methods

This prospective study included patients who were diagnosed with advanced tongue cancer. Each patient was asked to complete the University of Washington QoL (UW-QoL), version 4, questionnaire preoperatively and at 12 months after surgery. Patients were divided into two groups based on whether or not they received induction chemotherapy.

Results

Of the 192 patients included in the analysis, 145 patients had received induction chemotherapy. There were no significant differences regarding age, sex, tumour stage, node stage, flap reconstruction, tumour resection range and radiotherapy between the two groups. The mean total hospital cost was significantly higher in patients who underwent induction chemotherapy compared with those who did not (68 000 versus 44 000 Yuan Renminbi, respectively). The two groups had similar pre-treatment and post-treatment composite QoL scores and in the 12 individual domains.

Conclusion

Induction chemotherapy had a limited effect on postoperative QoL in patients with advanced tongue cancers, but it cost significantly more to administer.

Case Reports of Two Unusual Donor Site Complications of the Pectoralis Major Myocutaneous Flap and Literature Review

The pectoralis major myocutaneous flap (PMMF), once considered a workhorse flap for head and neck reconstruction, is still used for a wide range of head and neck reconstruction in the era of microvascular free tissue transfer flap (MFTF) for many reasons including low donor site morbidity. Numerous studies have reported the flap-related complications of PMMF in depth but have seldom discussed the donor site complications in detail. This article reports 2 unusual donor site complications and reviews the published data on general donor site complications resulting from PMMF use.

Pectoralis Major Myocutaneous Flap in Primary and Salvage Head and Neck Cancer Surgery

PURPOSE

To analyze the oncologic, functional, and esthetic results of using the pectoralis major myocutaneous flap (PMMF) from November 2001 to April 2012 at the Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Center Ljubljana (Ljubljana, Slovenia).

PATIENTS AND METHODS

Patients with squamous cell carcinoma of the head and neck (SCCHN) who underwent tissue defect reconstruction with a PMMF were identified from a prospective database. Medical and surgical records were reviewed for information on clinical characteristics, treatment, and outcome and specifically for indications for the PMMF, wound healing, flap vitality, functional results, and esthetics.

RESULTS

Forty PMMFs were used in 39 patients with SCCHN. With respect to previous therapy and prognosis, patients were sorted into a primary surgery group (19 patients) and a salvage surgery group (20 patients with recurrent disease). Statistically better locoregional control and disease-free survival were observed in the first group. Wound healing was completed in 32 patients (median time from surgery, 22 days). Three cases exhibited partial PMMF necrosis. Functional results, occlusion of pharyngocutaneous fistula, speech intelligibility, upper limb dysfunction, and esthetic outcome did not differ between the 2 groups.

CONCLUSION

The PMMF is a reasonable choice for primary head and neck cancer surgery and in salvage procedures. Its use is characterized by vitality, a reasonably short recovery time, and a favorable esthetic outcome at the donor site in most patients.

Extended vertical lower trapezius island myocutaneous flap versus pectoralis major myocutaneous flap for reconstruction in recurrent oral and oropharyngeal cancer

BACKGROUND

The purpose of this study was to compare the use of an extended vertical lower trapezius island myocutaneous flap (TIMF) and a pectoralis major myocutaneous flap (PMMF).

METHODS

A total of 39 patients with advanced recurrent oral and oropharyngeal squamous cell carcinoma (SCC) underwent salvage surgery followed by placement of either an extended lower vertical TIMF or PMMF for reconstruction. Twenty-one patients received extended lower vertical TIMFs, whereas 18 received PMMFs.

RESULTS

The pedicle length of the TIMF was longer than that of the PMMF, and the skin paddle of the TIMF was both wider and longer than the PMMF. No major complication developed in any of the patients. The TIMF group experienced a lower rate of minor flap failure than did the PMMF group.

CONCLUSION

Use of an extended vertical lower TIMF, which has a longer pedicle flap and a larger skin paddle than a PMMF, is optimal for reconstruction of major defects. © 2015 Wiley Periodicals, Inc. Head Neck 38: E159-E164, 2016.