Changes in articulatory proficiency following microvascular reconstruction in oral or oropharyngeal cancer

Articulatory proficiency of /r/ and /s/ sounds, voice quality and resonance, speech intelligibility, and intraoral sensation were examined prospectively before operation, and at four time points during a 1-year follow-up after microvascular transfer. Forty-one patients with a large oral or oropharyngeal carcinoma undergoing tumor resection and free-flap reconstruction usually combined with radiotherapy participated in the study. Articulation, voice, and resonance were investigated both live and from recorded speech samples by two trained linguistic examiners. The patients completed a self-rating of their speech intelligibility and were assessed for anterior intraoral surface sensation by means of 2-point moving discrimination. Misarticulations of /r/ and /s/ increased significantly after the therapy. Voice quality and resonance remained essentially normal. Speech intelligibility deteriorated significantly. Intraoral sensation decreased postoperatively but was not related to speech outcome. Sensate flaps did not prove to be superior in relation to speech tasks. A multidisciplinary approach is advocated in assessment of speech outcome after cancer surgery. Speech therapy is strongly recommended, even in the absence of a gross articulatory handicap.     

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.     

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 pectoralis major myocutaneous flap in head and neck reconstruction

The pectoralis major myocutaneous flap (PMMC flap) represents a landmark in the development of head and neck reconstructive surgery. After Stephan Ariyan first described its use for head and neck reconstruction in 1979, it has become tremendously popular and has revolutionised head and neck cancer surgery. Here, we present our initial experience with fourteen PMMC flaps in head and neck reconstruction. In most of the instances it was used for oral or oropharyngeal reconstruction. It was used for five other reconstructive tasks as well. Wound infection was the most common complication. There was no case of total flap loss. It has proven to be a reliable method of reconstuction in the head and neck.     

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.     

Severe atherosclerosis of the radial artery in a free radial forearm flap precluding its use

The free radial forearm flap is the most frequently used free flap for head and neck reconstructions. Survival of free flaps is dependent on adequate blood supply. A 69-year old woman was scheduled for excision of a T3N0M0 oropharyngeal carcinoma, neck dissections and reconstruction with a free vascularized radial forearm flap. During the operation it appeared that the entire radial artery was almost completely obstructed by atherosclerotic plaques precluding microvascular anastomosis. Despite systemic risk factors certain artery types are more prone to develop clinically manifest atherosclerosis. There are no reports on the pathology of the radial artery in free flap reconstructions. In head and neck cancer patients severe atherosclerosis of the radial artery is very rare, but if present makes free radial forearm flap reconstruction impossible. Therefore, in patients with risk factors for peripheral vascular disease screening for radial artery stenosis should be considered.     

多种组织瓣在口颊缺损重建中的应用

背景与目的：合理采用组织瓣进行口颊缺损重建,可以扩大口颊癌手术指征,改善患者的生存质量,延长患者生命。本研究目的是探讨组织瓣重建口颊缺损的指征,不同组织瓣的选择以及重建的手术技巧。方法：2005年9月至2007年8月间共行26例组织瓣重建口颊缺损手术,其中单纯口颊粘膜切除8例;口颊大型缺损18例,其中包括口颊面部皮肤洞穿切除11例,口颊、皮肤以及口角全缺损切除7例。26例患者中有7例行腮腺导管切除。胸大肌肌皮瓣转移重建5例,游离前臂桡侧皮瓣重建11例,游离股前外侧皮瓣6例,胸锁乳突肌肌皮瓣4例。8例患者行术后放疗,剂量为66～70Gy。结果：围术期无死亡病例,1例皮瓣坏死,为游离前臂皮瓣重建病例;1例皮瓣部分坏死,为胸大肌肌皮瓣重建病例。皮瓣成功率为96．2％（25／26）。1例伤口积液,为涎腺瘘。所有患者均随访1-3年,7例复发患者中4例为原发灶复发,3例为颈部淋巴结复发。随访期间2例患者死亡,均为原发灶局部复发者。结论：游离股前外侧皮瓣和游离前臂皮瓣是重建口颊大型缺损的良好皮瓣,是大于4cm的口颊缺损的首选：胸大肌肌皮瓣可作为口颊大型缺损重建的备用皮瓣;小于4cm的口颊缺损可选用胸锁乳突肌肌皮瓣。     

Current Concepts in the Surgical Management of Non-melanoma Skin Cancers

The surgical management of non-melanoma skin cancers has seen some significant changes over the past 20 years, as a result of developments in three equally important and overlapping specialties that deal with this specific pathology: plastic and reconstructive surgery, surgical oncology and dermatological surgery. Better understanding of vascular and particularly microvascular anatomy, coupled with technological advances in operating microscopes, microsurgical instrumentation and preoperative planning via advanced imaging, allows functional and aesthetic restoration of any radical oncological skin and soft-tissue surgery defect from head to toe. As reconstruction has practically lost its technical boundaries, resectional surgery can be executed without compromising on surgical margins, thus reducing rates of local recurrences and metastatic spread. The increasing use of Mohs surgery and its several advantages for difficult high-risk non-melanoma skin cancer in facial sites especially, offers optimal cure rates while reducing functional impairment and optimising cosmetic outcomes. Advances in preoperative planning utilising computed tomography and magnetic resonance imaging scans can help to predict the degree of resectability and tailor further treatments, including radiotherapy, accordingly. From the reconstructive point of view, these techniques provide a roadmap to select the best blood supply for the transplanted flap, thereby reducing complications and increasing success rates. The focus of skin cancer surgery has therefore shifted from pure cancer clearance and flap survival, to a high degree of functional and aesthetic reconstruction.     

Mandible reconstruction with microvascular surgery

Microvascular surgery has become the preferred method for mandible reconstruction. Whenever possible, immediate reconstruction at the time of segmental mandible resection will provide the best aesthetic and functional result. Four donor sites (fibula, iliac crest, radial forearm, and scapula) have become the primary sources of vascularized bone and soft tissue for the reconstruction. The fibula has multiple advantages, including bone length and thickness, donor site location permitting flap harvest simultaneously with tumor resection, and minimal donor site morbidity. The fibula donor site should be the first choice for most defects, particularly those with anterior or large bony defects requiring multiple osteotomies. Use of an alternative donor site is best reserved for cases with large soft tissue and minimal bone requirements. Dental rehabilitation through the use of prostheses and osseointegrated dental implants is an important part of the reconstructive process to optimize aesthetics and function. An algorithm for mandible reconstruction with microvascular osseous flaps is presented. Semin. Surg. Oncol. 19:226-234, 2000.     

扁桃体癌的手术治疗

目的 探讨扁桃体癌手术治疗的方法及其疗效。方法 对24例扁桃体癌进行手术治疗。根据病变情况不同,采用经口入路、下颌骨切开外旋入路、下颌骨切除入路、经舌骨入路等4种不同的手术入路切除肿瘤,以胸大肌肌皮瓣、胸骨舌骨肌筋膜瓣、舌瓣后置、软腭黏膜瓣修复组织缺损。所有患者术后行放疗。结果 3年生存率为76．0％,5年生存率为60．8％。患者咀嚼、吞咽、呼吸、语言功能恢复良好。结论 选择合适的手术入路,在彻底切除肿瘤的前提下,尽量减少手术创伤,最大限度地重建患者的口咽功能,并辅以术后放疗,可显著提高扁桃体癌患者的生存率和生活质量。     

Head and neck cancer surgery.

This review presents several areas of current interest in head and neck oncology including endoscopic and conservation management of early laryngeal cancer, intraoperative radiotherapy, and microvascular reconstruction techniques. Endoscopic treatment of early laryngeal cancer using the CO2 laser has been shown to be effective in several recent studies, and improved laryngeal reconstruction techniques following conservation laryngeal surgery have resulted in improved functional results. Intraoperative radiotherapy for head and neck carcinoma has received more attention recently, with encouraging results for the treatment of advanced and recurrent skull base and head and neck tumors. New techniques of free flap reconstruction following surgery for head and neck cancer continue to result in improved rehabilitation.     

5th Rib Osteo-pectoralis Major Myocutaneous Flap—Still a Viable Option for Mandibular Defect Reconstruction

Reconstruction of mandible is of paramount importance following ablative surgery for oral cancer. Though osteocutaneous micro-vascular free flap is generally accepted to be the mainstay of mandibular reconstruction, other reconstructive options are also done for mandibular reconstruction with good results. Seventeen patients of oral cavity cancer involving the alveolus who had underwent hemi-mandibulectomy were reconstructed using 5th rib osteo-pectoralis major myocutaneous flap. Procedure related pleural tear occurred in 3 patients during harvesting of the rib which were repaired intra-operatively with no post-operative complications. There were 2 failures in our series, in the rest 15 patients the flap had taken up; have good oral continence taking semi-solid diet and have satisfactory cosmetic appearance. This study shows that 5th rib osteo-pectoralis major myocutaneous flap is a quick, easy to learn, one stage reconstructive procedure with a good predictable cosmetic and functional outcomes.     

Influence of irradiation and oncologic surgery on head and neck microsurgical reconstructions

Despite the refinement of microsurgical techniques, microsurgical free flap transfer in patients with a history of previous radiotherapy, neck dissection or free flaps remains a challenge in oncologic reconstructive surgery. Previous studies on the prognostic factors for postoperative complications have been largely retrospective and shown conflicting results. Our aim was to design a prospective study to identify negative outcome predictors of free flap surgery in previously treated oral cancer patients. Prospective study including all patients who required microsurgical free flap transfer for reconstruction of the oral cavity between July of 2007 and June of 2010 with subset analysis of those cases in whom previous surgical or nonsurgical oncological treatment for head and neck cancer had been carried out. A total of 360 free flaps were performed in 358 patients, of whom 61 had previous neck dissection and 58 had undergone radiation therapy. Operation time was significantly found to be longer in irradiated patients. The need for microsurgical revision, postoperative wound infection and free flap loss were significantly associated with the ASA score and a previous neck dissection. Wound infection was seen significantly more often after radiotherapy. Previous neck dissections and radiotherapy as well as the ASA score are significant negative predictors for success in free flap transfer. For patients with prior oncologic treatments in their medical history, we recommend detailed preoperative assessment of the vascular status and an intensified postoperative care to reduce complication rates to improve outcome in oncologic reconstructive surgery.     

Selective reconstructive options for the anterior skull base

Carcinomas of the ethmoid, frontal, or maxillary sinuses sometimes invade the anterior skull base. It is necessary to perform en-bloc resection for this invasive carcinoma according to the concepts of surgical treatment for head and neck cancer. The anterior skull base consists of two parts, the orbital roof as the lateral portion and the roofs of the frontal sinus, ethmoid sinus, and/or sphenoid sinus as the central portion. Selective reconstructive options for the anterior skull base depend on the size of the defect of the skull base. A dural defect is repaired by a fascia lata or a pericranial flap. After the dura has been tacked up, reconstruction of the anterior skull base is performed simultaneously with augmentation of the defect of extracranial structures. Larger defects that consist of both central and lateral portions with orbitomaxillary structures are reconstructed by a bulky musculocutaneous flap such as a rectus abdominis or latissimus dorsi flap. The bony reconstruction of supraorbital structures is also to be considered esthetically. On the other hand, intraorbital tissues are basically preserved in cases of central defects of the anterior skull base. These defects are reconstructed by a free forearm flap or a local flap such as a de-epithelialized midline forehead flap or a pericranial flap. We have selected and applied these flaps in 37 patients as reconstructive options for the anterior skull base since 1989. Eleven of the 37 patients had larger defects and 26 had central defects. De-epithelialized midline forehead flaps were used in 20 patients and were recognized to be a very useful and reliable reconstructive option for central defects of the anterior skull base.     

Functional and sensitive outcomes after tongue reconstruction: about a series of 30 patients

Few studies reported both functional and sensitive long-term evaluations after tongue reconstruction. The aim of this study was to assess functional outcomes and sensitive recovery after tongue reconstruction with fasciocutaneous free flap (FCFF) or musculocutaneous pedicled flap (MCPF) without nerve anastomosis. We enrolled 30 patients having no recurrence from a consecutive series of 79 tongue reconstructions as part of a cancer treatment. All patients were submitted to functional and sensitive tests. The functional study included intelligibility, tongue motility, food, and swallowing scores. Flap sensibility was evaluated too. Male-to-female sex ratio was 6.5 with a mean age of 52 years old. The lesions were mainly advanced (T3-T4 73%). Mobile tongue and base of tongue resection was carried out in 43% of cases, and resection was limited to the oral tongue for 53%. Twenty-one FCFF and nine MCPF were performed. The mean follow-up was 2 years and 11 months. Swallowing (slightly impaired 63%), food (normal 40%), and intelligibility (excellent 77%) assessments were satisfactory. Spontaneous sensory recovery was regularly observed (mean response 62%). The two groups FCFF and MCPF were similar regarding population and tumors characteristics. Functional results were higher in case of FCFF (food score p=0.05; intelligibility p=0.04). No difference was observed on sensitive recovery. This study emphasizes good functional results either for swallowing or intelligibility, with higher scores for the FCFF, strengthening the opinion that FCFF is the best choice for tongue reconstruction whenever possible.     

下颌骨裂开外旋切除晚期口咽癌

目的 探讨切除晚期口咽癌的有效手术径路。方法 对采用下颌骨裂开外旋径路切除的17例晚期口咽癌患者进行回顾性分析,其中扁桃体癌13例,软腭癌2例,舌根癌2例。分别采用下颌骨裂开外旋及其联合术式切除肿瘤,以舌瓣、胸大肌肌皮瓣、胸骨舌骨肌肌筋膜瓣、颞肌肌筋膜瓣及额瓣修复缺损。术后均给予放疗。结果 全组肿瘤切除率100％,吞咽、呼吸、语言功能恢复良好。3年生存率为54．5％,5年生存率为40.0％。结论 应用下颌骨裂开外旋及其联合术式切除晚期口咽癌,可充分暴露口咽、声门上、下咽、咽旁间隙及颅底．手术安伞有效。     

Microvascular radial forearm fasciocutaneous free flap in hard palate reconstruction.

THE AIM OF THIS STUDY: To report the reconstruction of palatal defects by microvascular radial forearm fasciocutaneous free flap (RFFF) and to report patient's quality of life outcomes after this procedure. MATERIAL AND METHODS: During the period 1990-2002, 30 cases of palatal defects were reconstructed using RFFF in our institution. RFFF allowed restoration of a vestibular sulcus to maintain dental prostheses. Outcome measurements included post-operative assessment of speech, swallowing and diet evaluation 6 months, 1 year and 2 years after reconstruction. Quality of life outcomes were measured 1 and 2 years post-reconstruction. RESULTS: RFFF surgery was successful in 28 cases. Six months after resection 28 patients reported satisfactory speech and swallowing. Two years after surgery, 92% (n=26) of patients resumed a normal diet. All patients underwent dental evaluation and 68% (n=19) of patients required dental rehabilitation over a post-operative period of 3-18 months. Patients self assessed their quality of life on a scale of 0-2. First year post-operatively, 21 patients reported a good quality of life (score=2). After the second year, 26 patients reported a good quality of life and the remaining two patients reported an intermediate quality of life (score=1) because they did not resume a normal diet. CONCLUSION: RFFF for palatal reconstruction is a reliable technique and provides a definitive separation between oral and sinusonasal cavities. Furthermore, it improves quality of life by improving speech, swallowing and chewing. It should be considered an integral component of head and neck cancer therapy and rehabilitation.     

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.     

口腔癌游离皮瓣修复术后早期喂养的研究

目的 探讨口腔癌切除术后游离皮瓣修复术患者早期经口进流食对患者伤口愈合的影响.方法 分析32例口腔癌游离皮瓣修复术患者的资料,记录术后经口进水、进流食、拔除鼻饲管的时间、平均住院天数及并发症,并归纳总结.结果 32例患者均于术后6 h进食温开水,其中29例术后第5天9 Am经口进流食无不适后,于术后第5天10 Pm拔除鼻饲管;其余3例患者术后第7天9 Am经口进食,术后第7天10 Pm拔除鼻饲管.所有患者未出现皮瓣坏死、皮肤瘘管等并发症.尽管平均住院天数为12.8(范围10~19)天,但并非因为进食问题而推迟.住院超过14天主要因为等待术前确认病理结果(n=1)以及家属对手术的支持不足(n=2).结论 口腔癌切除游离皮瓣修复术后早期经口进流食不影响皮瓣的成活及伤口的愈合.