Sensory recovery of non-innervated free flaps and nasolabial island flaps used for tongue reconstruction of oncological defects

The versatility of the reverse superior labial artery flap

BACKGROUND

The reverse superior labial artery flap was introduced in 2015 as a reconstructive option for medial cheek defects. Notably, this flap can be redesigned as a more effective repair tool for large facial defect reconstruction. In this study, we redesigned the reverse superior labial artery flap to include the vascular territories of the infraorbital and transverse facial arteries in larger sizes for the repair of large facial defects.

METHODS

A reverse superior labial artery flap was used to repair large facial defects in 17 patients with a mean age of 74 years. The defects were located in the orbital region and entirely nasal sidewall in patient two, buccal region in patient three, and in lower lip and malar areas in patient five. The flap sizes ranged from 3.5 × 10 to 7 × 15 cm. A sensory examination was performed on the flaps at 6 and 12 months postoperatively. The mean follow-up period was 12 months.

RESULTS

All flaps survived without partial or total loss. In a small number of flaps minor complications such as venous congestion, epidermolysis, and dehiscence were seen. No functional disability was observed in the lower eyelid or lower lip, and the esthetic appearance was evaluated as satisfactory by the patients. In all the flaps, the protective sensation was recovered in the postoperative 12th month.

CONCLUSIONS

The reverse superior labial artery flap has an extensive arc of rotation, a reliable vascular pedicle, and a large cutaneous paddle. Therefore, this flap may be a versatile surgical repair tool for large cheek defects.

Tongue Reconstruction with Buccinator Myomucosal Island Flaps: Technical Considerations, Oncologic Safety, Functional Outcomes and QoL Assessment-A Retrospective Observational Study

The objective of this study was to investigate the effectiveness of buccinator myomucosal island flaps for tongue reconstruction following malignant tumor resections. A retrospective study was performed on 52 patients who underwent tongue reconstructions with buccinator myomucosal island flaps between 2012 and 2020. We reviewed the flap type and size, harvesting time, recipient- and donor-site complications, postoperative oncologic outcomes, functional recovery and QoL assessment. All of the flaps were transposed successfully without any total flap loss. Neither in the primary site nor in the neck were cancer relapses observed. An evaluation of the sensitivity revealed that 96.1% of patients experienced a recovery of touch, two-point and pain sensations. There were significant differences between the flap and the native mucosa in terms of the tactile (p < 0.001), pain (p < 0.001) and two-point (p < 0.001) thresholds. The average swallowing score recorded was 6.1 out of 7, with only minor complaints. The quality of life assessments demonstrated high scores across physical (24.5 out of 28), social (25.8 out of 28), emotional (20.3 out of 24) and functional (25 out of 28) aspects. The present study showed how buccinator myomucosal island flaps represent an effective and functional tongue reconstructive option, requiring a short operative time with a low rate of donor site morbidity, and with evidence of long-term oncologic safety and high quality of life.

Evaluating Sensation Recovery in Noninnervated Free Flaps Used for Oral Reconstruction

PURPOSE

Association between time and sensation recovery in noninnervated flaps remains unclear. Our goal was to evaluate the recovery of sensation in noninnervated free flaps used for oral reconstruction.

MATERIALS AND METHODS

A prospective cohort study was designed and consecutive patients undergoing noninnervated free flap surgery for oral reconstruction from a tertiary medical center were enrolled. The primary outcome variable was sensory recovery of light touch, pain, hot, and cold temperature. Sensory recovery was scored as per the test on the central portion and 4 peripheral sections of every flap. The Kaplan-Meier method was used to estimate the functional recovery at different time points and the association between clinicopathologic variables and sensation recovery at 24 months after surgery was analyzed using the chi-squared test and logistic regression analysis.

RESULTS

Eighty patients were included with a median age of 50 years. At 3 months postoperatively, no patients exhibited sensation recovery. Positive flap sensitivity began to appear mildly at 6 months postoperatively and gradually increased for at least 24 months. The 24-month sensation recovery rates of light touch, pain, and temperature were 70.0% (95% confidence interval [CI]: 59.2 to 78.9%), 42.5% (95% CI: 32.3 to 53.4%), and 33.8% (95% CI: 24.45 to 44.6%), respectively. In univariate analysis, 80.5% (95% CI: 66.0 to 89.8%) of the free radial forearm flaps showed light touch sensation recovery, which was statistically higher than 59.0% (95% CI: 43.4 to 72.9%) in other flaps (P = .036). Flap size ≤ 65 cm² predicted better pain sensation recovery with 57.5% (95% CI: 42.2 to 71.5%) compared to 27.5% (95% CI: 16.1 to 42.8%) in flap size > 65 cm² groups (P = .007). Logistic regression analysis confirmed flap size ≤ 65 cm² (P = .032, odds ratio = 1.957, 95% CI: 1.034 to 4.389) and not smoking (P = .015, odds ratio = 2.564, 95% CI: 1.673-5.482) offered better sensation recovery of pain and hot temperature, respectively.

CONCLUSIONS

Sensation recovery in noninnervated free flaps was common and related to not smoking and flap size.

Sensory recovery and oral health-related quality of life following tongue reconstruction using non-innervated radial forearm free flaps

OBJECTIVES

This study aimed to monitor the recovery of somatosensory function and oral health-related quality of life after tongue reconstruction using a non-innervated radial forearm free flap (RFFF).

METHODS

Twenty patients (9 men, age: 42-67 years) underwent tongue reconstruction with non-innervated RFFFs, and twenty age- and sex-matched controls were included in this study. Quantitative sensory testing (QST), including cold, warm, and mechanical detection thresholds (CDT, WDT, MDT); cold, heat, and mechanical pain thresholds (CPT, HPT, MPT); and static two-point, sharp/blunt, and direction discrimination (S2-PD, S/BD, DD) were determined 9 months and 18 months after surgery on the surgical (9 M, 18 M) and contralateral sides (9Mc, 18Mc). Oral Health Impact Profile-49 (OHIP-49) was used to determine the oral-related quality of life of participants.

RESULTS

All parameters showed significantly lower sensitivity at 9 M and 18 M (p < 0.001) compared to those for the controls and the contralateral side, except for DD (p = 0.101). In addition, the parameters showed a significant decrease in sensitivity for 9Mc and 18Mc (p ≤ 0.043) compared to those for the controls, except for MPT, HPT, S/SD, and DD (p ≥ 0.453). Findings on WDT, MPT, S2-PD, and DD (p ≤ 0.046) indicated significantly higher somatosensory function at 18 M than that at 9 M. MDT and MPT (p ≤ 0.038) showed significantly higher sensitivity at 18Mc than at 9Mc. Scores for all dimensions of OHIP-49 were significantly higher in patients (decrease in quality of life, p ≤ 0.002) than in controls, except for physical discomfort (p = 0.51). However, the scores were significantly higher at 18 M than at 9 M (p ≤ 0.011), except for handicap (p = 0.36). Postoperative chemotherapy was significantly correlated with impaired thermal sensitivity of the flaps (WDT, p = 0.049).

CONCLUSION

The present findings showed significant impairment in somatosensory function on both the surgical and contralateral sides of patients with RFFFs. However, a significant increase in somatosensory function was observed on both sides over time. Somatosensory disturbances observed after surgery were associated with poor oral health-related quality of life.

Clinical management of squamous cell carcinoma of the tongue: patients not eligible for free flaps, a systematic review of the literature

INTRODUCTION

The management of squamous cell carcinoma (SCC) of the tongue represents the most demanding treatment planning in head and neck surgery. Ablation followed by free flap reconstruction is considered the gold standard, but not all patients are suitable for this strategy. The aim of this review is to provide a comprehensive view of surgical reconstruction possibilities in patients not eligible for free flaps.

METHODS

Following PRISMA recommendations, a systematic literature review was conducted searching for original papers that investigated outcomes of patients treated by surgical ablation for tongue SCC followed by reconstruction with local or pedicled flaps. Selected papers were read and data extracted for qualitative analysis.

RESULTS

Twenty articles met the inclusion/exclusion criteria. The study design was case series in sixteen papers, cohort study in the remaining four. Four different local flaps (BMM, FAMM, NLIF, SMIF) and four regional flaps have been discussed in included studies (IHF, SFIF, SCM, PMMC).

CONCLUSION

The improved anatomical knowledge makes local flaps a reliable alternative to free tissue transfer in cases requiring small-/medium-sized defects. Regional flaps still represent cornerstones in reconstruction of the tongue. Ease of execution, costs-to-benefit ratio, low-rate complications, minimal donor site morbidity represent the best advantages choosing local/regional flaps.

Microsurgical reconstruction of complex oromandibular defects: An update

Free flaps are the gold standard for reconstruction of the mandible, tongue and floor of the mouth. Free fibular flaps are the most preferable option for reconstruction of complex mandibular defects, as well as for tongue and mouth floor reconstruction, since they are harvested easily, present excellent sculptability and good functional outcomes. Alternative options for bone reconstruction include the fibular and iliac crest free flap, and for soft tissue reconstruction include the anterolateral thigh, the radial forearm free flap, and the nasolabial island flap. The principles of the surgical approach include resection of the mandibular segment, intraoperative evaluation of the defect, and various surgical manipulations of the flap on site to reconstruct the defect. Advances in computerized preoperative planning have allowed virtual simulation of the defect and fabrication of an individualized stereolithic mandibular model. This short review discusses the current trends of bone and soft tissue flaps for complex oromandibular reconstructions aiming to present a comprehensive review that the readers would find interesting and informative.

Anatomical analysis of antebrachial cutaneous nerve distribution pattern and its clinical implications for sensory reconstruction

This study aimed to reveal the distribution pattern of antebrachial cutaneous nerves and provide a morphological basis for sensory reconstruction during flap transplantation. Forearm specimens containing skin and subcutaneous fat were obtained from 24 upper extremities of 12 adult cadavers. Cutaneous nerves were visualized using modified Sihler's staining. Then the data was used to show the distribution pattern and innervation area of the forearm cutaneous nerve. The anterior branch of lateral antebrachial cutaneous nerve innervates 26% of the medial anterior forearm; the posterior branch innervates 38.21% of the lateral anterior forearm and 24.46% of the lateral posterior forearm. The anterior branch of medial antebrachial cutaneous nerve innervates the medial aspect of the forearm covering 27.67% of the anterior region; the posterior branch the lateral part of the forearm covering 7.67% and 34.75% of the anterior and posterior regions, respectively. The posterior antebrachial cutaneous nerve covers 41.04% of the posterior forearm. Coaptations were found between the branches of these cutaneous nerves. The relatively dense secondary nerve branches were found in the middle 1/3 of the lateral anterior forearm and the middle 1/3 of the medial posterior forearm. The relatively dense tertiary nerve branches were the middle 1/3 and lower 1/3 of the medial anterior forearm. The intradermal nerve branches were the relatively dense in the middle 1/3 of the medial anterior and lateral posterior forearm. The middle 1/3 of the medial and lateral forearm had the relatively dense total nerve branches. These results can be used sensory matching while designing forearm flaps for reconstruction surgeries to obtain improved recovery of sensory.

Effect of low-level laser therapy on tooth-related pain and somatosensory function evoked by orthodontic treatment

Low-level laser therapy (LLLT) may have an effect on the pain associated with orthodontic treatment. The aim of this study was to evaluate the effect of LLLT on pain and somatosensory sensitization induced by orthodontic treatment. Forty individuals (12–33 years old; mean ± standard deviations: 20.8 ± 5.9 years) scheduled to receive orthodontic treatment were randomly divided into a laser group (LG) or a placebo group (PG) (1:1). The LG received LLLT (810-nm gallium-aluminium-arsenic diode laser in continuous mode with the power set at 400 mW, 2 J·cm^–2) at 0 h, 2 h, 24 h, 4 d, and 7 d after treatment, and the PG received inactive treatment at the same time points. In both groups, the non-treated side served as a control. A numerical rating scale (NRS) of pain, pressure pain thresholds (PPTs), cold detection thresholds (CDTs), warmth detection thresholds (WDTs), cold pain thresholds (CPTs), and heat pain thresholds (HPTs) were tested on both sides at the gingiva and canine tooth and on the hand. The data were analysed by a repeated measures analysis of variance (ANOVA). The NRS pain scores were significantly lower in the LG group (P = 0.01). The CDTs, CPTs, WDTs, HPTs, and PPTs at the gingiva and the PPTs at the canine tooth were significantly less sensitive on the treatment side of the LG compared with that of the PG (P < 0.033). The parameters tested also showed significantly less sensitivity on the non-treatment side of the LG compared to that of the PG (P < 0.043). There were no differences between the groups for any quantitative sensory testing (QST) measures of the hand. The application of LLLT appears to reduce the pain and sensitivity of the tooth and gingiva associated with orthodontic treatment and may have contralateral effects within the trigeminal system but no generalized QST effects. Thus, the present study indicated a significant analgesia effect of LLLT application during orthodontic treatment. Further clinical applications are suggested.

Repeated applications of low-level laser therapy during and after orthodontic procedures could help reduce pain and discomfort. Many orthodontic patients experience pain in the hours and days following treatment, which impacts on treatment participation. Wenjing Chen at Nanjing Medical University and co-workers assessed whether low-level laser therapy (LLLT) can reduce pain and sensitivity in teeth and surrounding tissues. They divided 40 patients into two groups; one was given repeated LLLT in the hours and days following procedures, while the other group received a placebo course. They tested both groups for sensitivity to stimuli including heat and pressure, in the mouth and on the hands. LLLT significantly reduced pain in the mouth relative to the placebo group. No differences were found in tests on the hands, suggesting LLLT works as a targeted analgesia.

Somatosensory changes at forearm donor sites following three different surgical flap techniques

BACKGROUND

The aim of this study was to investigate the somatosensory changes at the forearm donor region after using different types of modified flap surgical techniques.

METHODS

Thirty-one patients, who underwent oral and maxillofacial reconstructive surgery involving the use of a traditional radial forearm flap (TRFF) or two modified radial forearm flap techniques (MRFF-I; MRFF-II), participated in the study. Cold detection threshold (CDT), warm detection threshold (WDT), cold pain threshold (CPT), heat pain threshold (HPT), pressure pain threshold (PPT), mechanical detection threshold (MDT), and mechanical pain threshold (MPT) were assessed at four sites of the forearms corresponding to the middle of the vascular pedicle (VP) area, the middle of the forearm flap area, and the corresponding contralateral sites (cVP and cFF) at about 5.0 ± 1.9 months after the surgery. Data were analysed with one-way ANOVA, and post-hoc tests were performed using Tukey's Honest Significant Difference test.

RESULTS

Significant differences between the VP and cVP sites were detected for WDT (P < 0.001) in TRFF and for WDT (P < 0.001) and MDT (P = 0.006) in MRFF-I. Significant differences among TRFF, MRFF-I, and MRFF-II at the VP site were detected for CDT (P = 0.022), WDT (P < 0.001), and MDT (P = 0.015). MRFF-II was associated with significantly higher sensitivity compared to that of TRFF for WDT (P = 0.017) and higher sensitivity compared to that of MRFF-I for CDT (P = 0.017), WDT (P < 0.001), and MDT (P = 0.013).

CONCLUSIONS

Significant sensory loss was detected for all types of surgical procedures with free forearm flaps. However, the MRFF-II was associated with a better sensory recovery at short follow-up after surgery. These results suggest that a longer follow-up period and larger sample size should be included in future studies.