Functional outcomes of soft palate free flap reconstruction following oropharyngeal cancer surgery

IntroductionThe objective of this study was to assess the impact of surgical resection and free flap reconstruction of soft palate cancer on speech, swallowing and quality of life, and to identify the factors influencing functional outcomes and quality of life.Material and methodsPatients treated with surgical resection of squamous cell carcinoma and free-flap reconstruction of the soft palate were reviewed at least 12 months after surgery. Speech was assessed using the Hirose intelligibility scoring system, nasalance scoring, GRBAS scoring and the Voice Handicap Index 30 (VHI30) questionnaire. Swallowing was assessed by fiberoptic endoscopy and the Deglutition Handicap Index (DHI). Quality of life was assessed using EORTC QLQ-C30 and QLQ-H&N35 questionnaires.Results29 patients were included. Speech outcomes were satisfactory, demonstrating normal or slightly below normal speech intelligibility in 75.9% of the patients, moderate or no rhinolalia in 72.4% of the patients and mean overall VHI30 scores indicative of slight or no handicap in 86.2% of the patients. Swallowing outcomes were satisfactory, with mean overall DHI scores indicative of slight or no handicap in 82.8% of the patients. Patient quality of life was preserved as demonstrated by mean quality of life and functioning scales scores all superior to 80%.ConclusionThe sequelae arising from surgical resection and free-flap reconstruction of soft palate cancer are tolerable, involving slight handicap in terms of speech and swallowing and relatively little impact on quality of life.     

胸大肌肌皮瓣在舌再造术中的应用

报告舌癌行全舌,或舌大部或舌根广泛切除术后,应用胸大肌皮瓣行舌再造术的经验。方法 自１９８４年１２月至１９９５年９月,我院对８６例Ｔ３或Ｔ４舌癌根治术后的舌缺损,应用带蒂胸大肌肌皮瓣同期进行了舌再造术。结果 肌皮瓣全坏死１例。术后吞咽和语言功能恢复正常分别为５９例和４４例。     

Social perception of speech in individuals with oropharyngeal reconstruction

Oral cancer affects approximately 5% of the Canadian population every year. One option for treatment of oropharyngeal cancer includes resection of the diseased tissue with primary reconstruction of the defect using a microvascular free flap, followed by post-operative adjuvant radiation therapy. The aim of reconstructive surgery is to maintain functional speech and swallowing. While the literature provides support for the maintenance of speech intelligibility following reconstructive procedures, certain aspects of resonance may be altered when the palatal structures are involved. Little is known about the effect of such alterations on the perception of speakers who have been treated with microvascular free flap reconstruction. Social perception is a process in which we infer attributes of others, with the speech signal playing an integral part in attribution. The purpose of this study was to explore the social perceptions formed about speakers both before and after surgery for oropharyngeal cancer. The results of this study revealed that positive perceptions of speakers significantly diminished as a result of surgery and negative perceptions increased. Certain variables, such as degree of resection of the soft palate and base of tongue, and sex of the speaker, had influence on the results. This research suggests that intelligibility measurements of speech, although useful, do not provide a complete indication of the social impact of reconstructive surgery on patients with oropharyngeal resections.     

个体化皮瓣在舌再造中的临床应用

目的依照头颈肿瘤外科修复重建原则,给予舌癌根治术后,采用个体化皮瓣进行舌再造,使患者的吞咽及语言功能早日恢复,提高患者对手术的依从性,最大程度的减少精神创伤。方法对67例舌鳞癌患者在根治术中应用皮瓣移位或皮瓣移植完成修复重建,在皮瓣设计上采取个体化,并从患者术后恢复情况、并发症发生情况、对手术的依从性及其可能产生的精神创伤等方面进行判定及分析。结果术后舌创面Ⅰ期愈合67例,1例血管栓塞患者抢救成功,其他无不良并发症,修复成活率为100%。再造舌外形大部分良好,吞咽功能恢复正常,语言功能恢复优或良,患者心理状况良好。结论个体化皮瓣进行舌再造术的成功率高,并发症发生率低,功能恢复良好,且患者的依从性高,精神创伤小,值得推广。     

Use of the double-paddle anterolateral thigh flap for locally advanced tongue carcinoma requiring second site reconstruction

BackgroundAdvanced oral tongue carcinoma can present with extension beyond the oral cavity. Operative defects after resection may involve multiple anatomical sites and significantly impact speech and swallowing. Dependence on long-term enteral feeding is not uncommon for these patients. The anterolateral thigh (ALT) flap is one of the most reliable and flexible flaps used in the reconstruction of total and subtotal tongue defects. The double-paddle flap modification may be a more suitable option for complex oral tongue defects after advanced tumor ablation.MethodsCase series of 31 patients with oral tongue squamous cell carcinoma that were classified as stage IV. The age of patients ranged from 32 to 63 years. We designed the double-paddle ALT flaps to reconstruct the two-site surgical defects (tongue defect and pharynx or neck skin defect). Postoperative viability of the flap was checked by clinical observation. The last examination was performed at 3-months after the completion of adjuvant chemoradiotherapy. The functional capacity of our patients was evaluated by three physicians (Head and Neck Surgeon, Radiation Oncologist, and Physiatrist) using a Speech Intelligibility Score and the Functional Oral Intake Scale.ResultsA total of 31 patients with surgical defects after total or subtotal tongue resection for cancer underwent double-paddle ALT flaps for reconstruction from March 2018 to December 2019. The dimension of flaps from 8 × 12 cm to 10 × 18 cm were divided into double-paddle from 8 × 5 cm to 10 × 10 cm. There was one case of pedicle thrombosis, one case of postoperative bleeding, three cases of neck infection, and six cases of salivary fistula. Our patients were seen in follow up from 6 to 36 months, with median follow-up of 23.5 months. The survival rate of ALT flap was 100%. All of our patients achieved an oral diet by 9 months after surgery. The mean score speech intelligibility was 2.74 ± 0.68 (4-point ordinal scale). The 2-year disease-free survival rate was 61.3%.ConclusionsThe double-paddle ALT flap is a reliable flap suitable for oral defects involving multiple subsites after ablative procedures. The majority of patients demonstrated acceptable functional rehabilitation.Clinical question/ level of evidenceTherapeutic, IV.     

The reliability of submental flap for soft tissue reconstruction in patients with carcinoma of the oral cavity

BackgroundThe submental island flap (SIF) is a reliable option for reconstruction of the defects of the oral cavity following cancer resection. Advantages include reliable axial vascular pedicle, low donor site morbidity, good functional and cosmetic outcome, shorter operative time and lower cost compared to free flap reconstruction.Materials and methodsA total of 32 consecutive patients with carcinoma of the oral cavity were included in this study. All patients underwent resection and immediate reconstruction with SIF pedicled the submental vessels. Donor and recipient site morbidity, functional outcome, and locoregional recurrences are reported.ResultsThe study included 22 males (69%) and 10 females. The mean age was 54 years (range of 31–79 years). The most common primary tumor site was the tongue (15 patients, 47%), followed by the buccal mucosa, alveolar margin, floor of mouth, lower lip and hard palate. In 25 patients (78%) the flap survived completely. Complete flap loss occurred in one patient (3%). Six patients (19%) developed complications related to flap vascularity. 21 patients (66%) resumed normal diet, while 11 patients (34%) tolerated only soft diet. Over a median follow up was of 15 months (range of 3–62 months), 21 patients (66%) are alive and disease free, while 8 patients died, of whom 4 of locoreginal recurrences.ConclusionsSIF is reliable for reconstruction of the intraoral soft tissue defects following cancer resection. The functional and cosmetic outcomes are satisfactory and donor site morbidity is low. Careful patient selection is necessary for favorable outcome.     

21例舌癌游离股前外侧皮瓣舌再造术临床体会

[目的]探讨游离股前外侧皮瓣在舌癌缺损修复舌再造术中的应用价值.[方法]回顾并分析2004年2月～2005年12月,应用游离股前外侧皮瓣修复舌癌术后缺损舌再造术21例.[结果]21块游离瓣全部成活,术后血栓发生率4.8%(1/21).随访3个月～2年,再造舌形态丰满、功能满意.1例(T4N1M0)术后1年因颈淋巴结转移死亡,未发现舌局部复发者.[结论]游离股前外侧皮瓣移植安全可靠,供区隐蔽功能影响小,皮瓣厚度适宜,是修复舌癌术后缺损舌再造术的优良供区,值得推广普及.     

舌癌根治术后游离前臂皮瓣一期舌再造术的改进

背景与目的：舌癌根治术造成半舌缺损,严重影响患者的生存质量。术中行一期舌再造术可保证手术创面的Ⅰ期愈合,使患者的吞咽及语言功能早日恢复,然而游离皮瓣再造舌时常发生的血管危象问题一直阻碍着这项手术的广泛开展。本文报告在应用游离前臂皮瓣行一期舌再造术中所做的一些改进方法,旨在提高其成功率。方法：对32例舌鳞癌患者在根治术中应用游离前臂皮瓣行一期舌再造,在皮瓣设计、制备和血管吻合等方面加以改进。结果：术后口腔和颈部创面均一期愈合,无涎瘘、乳糜漏、口底颌下瘘和感染等并发症发生;术后出现血管危象6例,5例抢救成功,1例失败,最终放弃皮瓣,移植成活率为96．9％。再造舌外形大部分良好,语言和吞咽功能恢复良好。结论：改进的游离前臂皮瓣舌再造术再造舌的成功率较高。     

Free flap reconstruction in the treatment of tumors involving the hard palate.

AIM: To report our experience in free flap reconstruction of the hard palate after malignant tumor resection, in terms of reconstruction method, immediate post-operative course and subjective functional results. PATIENTS AND METHODS: Files from 1988 to 1999 were reviewed for patients having undergone microvascular reconstruction of the hard palate. The immediate post-operative course (during the first month) was reviewed to determine the occurrence of complications. The surgeon's evaluation 1 year post-operatively was used to determine the intelligibility of speech, type of diet and the quality of nasal permeability. RESULTS: Thirty eight patients (28 men and 10 women) with malignant tumors involving the hard palate had undergone surgical reconstruction using microvascular free flap techniques: free radial forearm flap (13 cases), scapular flap (24 cases) or fibular flap (five cases). Two different flaps were employed in two cases (scapula plus fibula). A second flap was used with success in two cases of failure of the first flap, for a total of 42 free flaps for 38 patients. Complications occurred in seven cases, with two cases of flap necrosis. At 1 year, 33 patients achieved a normal diet and 35 normal or easily intelligible speech. CONCLUSIONS: Microsurgical reconstruction using free tissue transfer allows reconstruction of large defects of the hard palate, with low morbidity and an excellent functional outcome. We propose criteria for free flap reconstruction and choice of flap.     

侧斜方肌肌皮瓣修复头颈肿瘤术后缺损的初步探索

目的探索侧斜方肌肌皮瓣在头颈肿瘤术后缺损中的作用及其优缺点。方法自2005年6月至2006年6月共采用带蒂侧斜方肌肌皮瓣移植修复头颈肿瘤术后缺损6例,其中舌根癌3例,鼻咽癌放疗后颈淋巴结复发累及皮肤3例,观察肌皮瓣的存活情况、组织移植后功能状态和肿瘤控制的近期疗效。结果全部肌皮瓣存活,无手术并发症,舌根缺损修复后进食、咀嚼、发音均满意,颈部缺损修复后外形满意,无垂肩畸形;全部病例随访6～18个月,1例舌根癌术后6个月死于肿瘤复发,1例鼻咽癌放疗后复发者术后6个月复发,挽救治疗中,其余4例均无瘤生存至今。结论侧斜方肌肌皮瓣可以安全地应用于舌根、颈部缺损修复;手术方便,对供区影响小是该皮瓣的优点;颈横静脉缺如偶有存在,确保充足的静脉回流是手术成功的关键。     

Physical Properties of Meals that are Suitable for Patients after Surgery to Treat Oral Cavity Cancers

Objectives: To determine proper characteristics of food which would be safe and satisfactory for swallowing in oral cavity cancer patients undergoing surgery and to create a recipe that provides adequate nutrients, energy, good taste, and can be easily made at home. Materials and methods: Patients who were enrolled in this study underwent oral cancer surgery in the Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital from September 2017 to July 2018. This experimental research was conducted postoperatively before receiving chemoradiation. Each type of food was prepared by the researchers to have a combination of two physical properties, which were 3 different consistencies (liquid, nectar-like, and honey-like) and 2 different temperatures (room temperature (25ºC) and cold temperature (4ºC)). Each patient had to swallow six different types of prepared food by random sequences. Flexible endoscopic evaluation of swallowing (FEES) was used to evaluate objective swallowing function by 3 parameters, including premature oropharyngeal spillage, laryngeal penetration or aspiration, and post-swallow retaining residues. Satisfaction measurement was evaluated with visual analog scale (VAS). Results: There were 42 postoperative oral cavity cancer patients enrolled in this study. Subjects consisted of 23 males (54.8%) and 19 females (45.2%) with the mean age of 62 ± 13 years.  Most patients had oral tongue carcinoma (64.3 %). FEES revealed nectar at room temperature was the safest with score of 0.83 ± 0.82 (possible score of 0-3, with 0 was best). However, patients significantly preferred liquid at room temperature more than other kinds of food (VAS taste = 8.26 ± 1.52 and VAS easy swallowing = 8.05 ± 1.74). When evaluating specifically in patients with oral tongue cancer, FEES scores, VAS taste, and VAS easy swallowing showed similar results the liquid at room temperature was the best. Conclusions: We suggested that the nectar-like thickened food at room temperature was determined to be the most proper food characteristic for oral cancer patients undergoing surgery in order to prevent aspiration. However, patients’ satisfaction analysis suggested that they preferred other type of food. The physician should advise patients of the proper kind of food for safe swallowing and avoidance of serious complication especially aspiration pneumonia.     

Vertical hemipharyngolaryngectomy: reconstruction with the radial forearm free flap

A considerable body of literature defines techniques to restore glottic function after partial laryngectomy. The authors of this paper describe a new original technique for glottic and hypopharyngeal reconstruction after vertical hemipharyngolaryngectomy. Using a radial forearm free flap including the tendon of the palmaris longus and a sensitive branch of the radial nerve, they were able to reconstruct the missing vocal cord and a pyriform fossa. This procedure permits an extended resection without the usual phonatory or swallowing inconveniences. There is no contraindication for postoperative radiotherapy. The technique and preliminary functional results are reported.     

Predictors of chewing and swallowing disorders after surgery for locally advanced oral cancer with free flap reconstruction: A prospective,observational study

Objective

Surgery for locally advanced oral cancer often requires wide resections of multiple subsites of the oral cavity, including the oral tongue, floor of the mouth, and lower gingiva, and it causes chewing and swallowing disorders. The aim of this prospective, observational study was to determine which subsites have a greater impact on chewing and swallowing disorders after surgery.

Deltopectoral Flap Reconstruction of the Posterior Pharyngeal Wall: A Single Stage Pedicle Flap Alternative Solution to the Free Flap Reconstruction of Circumferential Laryngopharyngeal Defects

The first option for reconstruction of a circumferential pharyngeal defect following extensive pharyngo-laryngectomy is free tissue transfer. Despite that, pedicled flaps can be used when microsurgical expertise is not available or if other patient related or region related issues deem free tissue transfer unfavourable. The aim of this study was to review the operative feasibility and functional outcomes following dual flap reconstruction of circumferential pharyngeal defects.This was a retrospective study of all patients (n = 8) who underwent either primary (n = 5) or salvage (n = 3) circumferential laryngopharyngectomy + /– cervical oesophagectomy, followed by dual flap reconstruction, with a deltopectoral flap to reconstruct the posterior wall from 2005 to 2020. The main outcome measures were operative complications, hospital stay and functional outcomes (speech and swallowing). The operation was feasible in all patients, with dual flap reconstruction using a deltopectoral flap, combined with a pectoralis major flap (n = 5) or a supraclavicular flap (n = 3). All patients developed a small, lateralised, self-healing fistula at the site of the deltopectoral flap 3-point junction. This did not require any intervention, or impact on adjuvant treatment. Functional outcomes were favourable, with all patients achieving oral diet. One patient required gastrostomy diet supplementation, and one patient required stricture dilatation. Of the patients able to receive a speech valve (n = 4), all achieved intelligible speech. Dual flap reconstruction of circumferential pharyngeal defects represents a feasible alternative option for a complex reconstructive problem. The predictable operative recovery and favourable functional outcomes indicate that the use of both a deltopectoral flap and a second flap is a robust reconstructive solution.     

Predictors of swallowing outcome in patients treated with surgery and radiotherapy for advanced oral and oropharyngeal cancer

Retaining effective swallowing is a key element when optimising outcomes in the management of head and neck cancer. We report the functional swallowing outcomes for a cohort of 31 individuals with advanced oral and oropharyngeal cancer who underwent free or pedicled flap reconstruction of surgical defects. Swallowing was assessed pre and immediately post surgery and at four months post treatment. Swallowing assessments were related to site, size and volume of defect and composition of flap reconstruction. The effect of radiotherapy on swallowing was assessed among 17 of the 31 individuals who were submitted to radiotherapy after surgery.The proportion of patients on a total oral diet four months post treatment varied significantly by site of defect (Fishers exact test p = 0.006), from 100% (7/7) of patients with a lateral defect to only 22% (2/9) of patients with a central defect.The proportion of patients on a total oral diet at the final assessment did not vary by flap reconstruction or radiotherapy.     

The Bozola flap in oral cavity reconstruction

The buccinator musculomucosal flaps are actually considered the main reconstructive option for small-moderate defects of the oral mucosa. In this paper we present our experience with the posteriorly based buccinator musculomucosal flap. A retrospective review was performed of all patients who had had a Bozola flap reconstruction at the Operative Unit of Maxillo-Facial Surgery of Parma, Italy, between 2003 and 2010. The Bozola flap was used in 19 patients. In most cases they had defects of the palate (n=12). All flaps were harvested successfully and no major complications occurred. Minor complications were observed in two cases. At the end of the follow up all patients returned to a normal diet without alterations of speech and swallowing. We consider the Bozola flap the first choice for the reconstruction of defects involving the palate, the cheek and the postero-lateral tongue and floor of the mouth.     

Prospective speech outcome study in patients with soft palate reconstruction in tonsillar cancer

For advanced stage tonsil cancer, extensive resection of the soft palate is unavoidable. The purpose of this study is to report on the speech outcome according to the various types of defects and reconstruction techniques. This prospective study was performed on 53 patients of tonsil cancer. The postoperative speech function was evaluated for three factors: nasalance, speech intelligibility, and velopharyngeal insufficiency. Four reconstruction methods used for the soft palate defect: local flap, patch method, Gehanno method, and Denude method. Univariate analysis showed that the Denuded reconstruction technique, more than one-half of the soft palate resection, and T stage was significantly associated for nasalance, speech intelligibility, and velopharyngeal insufficiency. Multivariate analysis showed that the Denuded reconstruction technique (for patients with extensive soft palate and posterior pharyngeal wall defect) was the most significant variable. When the defect of tonsil cancer is extensive, especially when it extends to the posterior pharyngeal wall, a reconstruction method that can reduce the velopharyngeal cross-sectional area efficiently, such as the Gehanno method, is preferred.     

The submental island flap for reconstruction of intraoral defects in oral cancer patients

The submental artery island flap (SIF) is gaining acceptance as a simple and reliable option in selected oral oncologic reconstructions. The present study aims to assess the usefulness of submental artery flap in oral reconstruction with respect to flap reliability, cosmesis, function, donor site morbidity and oncological safety. Thirty (30) patients who underwent ablative surgery and reconstruction using the submental artery island flap for oral cancer at Regional Cancer Centre, Trivandrum, India, between October 2004 and December 2006 were prospectively studied for the flap viability, cosmesis, function (speech and swallowing) and locoregional recurrence. The site and stage of the tumour, type of resection, management of the neck and the technique of flap transfer were recorded and the patients were followed up to assess the status of the flap and its donor site and the oncologic outcomes. There were 19 men and 11 women, ages of whom ranged from 30 years to 78 years with a mean+/-SD of 53+/-11 years. With the exception of one patient who had undergone neck dissection as part of a previous surgery, all patients underwent neck dissection or at least a level I clearance along with the wide excision of the primary lesion. The follow up period ranged from 4 to 25 months with a median of 13.5 months. Six patients either recurred locoregionally or had metachronous second primary constituting an over all recurrence rate of 20%. The size of the skin paddle ranged from 3 x 3 cm to 7 x 6 cm, with a mean size of 4.9 x 4 cm. One total and one partial flap loss were observed. One patient had intractable hair growth on the flap even 3 months after surgery. Donor site healing was excellent in all cases and the donor site scar was well hidden. The long term cosmesis and functions were good in all the patients. The submental artery island flap is a simple and reliable option for oral cancer reconstruction in carefully selected cases, with acceptable cosmetic and functional results and reasonable oncological safety.     

Ablation of advanced tongue or base of tongue cancer and reconstruction with free flap: functional outcomes.

AIM: To evaluate the functional outcomes of patients who underwent total or nearly total glossectomy for advanced tongue or base of tongue cancer. MATERIAL AND METHODS: We used the radial forearm free flap (RFFF), anterior lateral thigh flap (ALTF) or fibular osteocutaneous flap (FOCF) to reconstruct the oral defect after radical resection in 39 patients undergoing total or nearly total glossectomy with laryngeal preservation. RESULTS: Good functional outcomes, measured by independent feeding, speech and swallowing were achieved in 35, 36 and 35 patients, respectively. The cumulative 4-year survival rates were 63.8% for tongue cancer and 42.9% for base of tongue cancer. CONCLUSION: Reconstruction with free flaps is a feasible method to restore the functional outcomes in speech and deglutition among patients who undergo total or nearly total glossectomy with laryngeal preservation.     

舌癌224例根治性手术后立即整复

本文报告我科1978年1月～1987年12月10年间224例舌癌联合根治术后应用各类组织瓣一期重建缺损的治疗经验。移植234块组织瓣的总成功率为94.0％。作者指出:游离前壁皮瓣手术简单,成功率高,是理想的半舌切除后舌再造的首选皮瓣。胸大肌肌皮瓣或背阔肌肌皮瓣能提供丰厚的组织,适用于全舌、全口底切除后的整复。肋骨背阔肌或肋骨胸大肌肌皮瓣则适用于全舌、口底和下领骨联合根治性切除术后缺损的立即整复。