Assessment of surgical outcomes and oncological safety for submental artery perforator flap reconstruction after ablation of oral cancer

The submental artery perforator flap (SAPF) has been a new option for the intraoral reconstruction of oral squamous cell carcinoma (OSCC) patients in recent years, but its surgical outcomes have not been well assessed. We compared the surgical outcomes and oncological safety of SAPF reconstruction for medium-sized soft-tissue defects after the ablation of primary oral cancer with traditional submental island flaps (SIF) and anterolateral thigh perforator flaps (ALTPF). Fifty-one SAPFs, 30 SIF, and 74 ALTPF were reviewed for the intraoral medium-sized reconstructions after the ablation of oral cancer from our institutional clinical oncological databases. We performed comparative assessments on the variables of surgical outcome and oncological safety among the 3 cohorts. A Kaplan-Meier estimate of survival for each flap was calculated. Operating time was significantly reduced in the SIF and SAPF groups than ALTPF (p = 0.021 and 0.014, respectively). Flap thickness of SAPF was the significantly thinnest (mean 0.5 cm) among three groups. The common complications of donor site for both SAPF and SIF group were incision dehiscence and orocutaneous fistula. There was no significant difference in disease-free survival (DFS) among the 3 groups. However, several OSCC patients with the SIF reconstruction were found to have recurrences with a metastatic lymph node under the flap after the first operation. SAPF could be a versatile choice of the intraoral reconstruction for the medium-sized soft-tissue defects after the ablation of oral cancer.     

Comparison of outcome of microvascular bony head and neck reconstructions using the fibular free flap and the iliac crest flap

Several microvascular free flaps are available for reconstruction of the osseous components after resections for head and neck cancer. We have prospectively evaluated patients treated by bony microsurgical reconstruction to identify predictors of adverse outcomes for delayed wound healing and failure of free flaps. All patients from July 2007 to June 2011 who had reconstructions with microvascular fibular or iliac crest flaps immediately after resection of the tumour were evaluated. There were a total of 156 bony free flaps: 120 (77%) fibular and 36 (23%) iliac crest flaps. A total of 133 (85%) were successful. Delayed wound healing was more common with the iliac crest flap (p = 0.01) at the intraoral site (p = 0.04). Significantly more iliac crest free flaps failed (p = 0.02). Anastomosis to the facial artery (p = 0.05) and facial vein (p = 0.04), and duration of overall operating time were associated with a significantly higher risk of failure of the flap. Patients with cancer of the head and neck who require microsurgical bony reconstruction are at increased risk of postoperative complications. Significantly more complications were found with the iliac crest flap, whereas the fibular flap was associated with a significantly longer operating time.     

Optimization of total tongue functional reconstruction with the sushi roll technique and its application in pectoralis major myocutaneous flaps

A protuberant shape and sufficient volume are the most important parameters for total tongue reconstruction. The conventional pectoralis major myocutaneous (PMMC) flap undergoes collapse due to atrophy of the denervated muscle. In a new technique, this flap was rolled up like sushi to reshape the neotongue. This study explored the feasibility and effect of the ‘sushi roll’ technique for precise total functional reconstruction of the tongue using a PMMC flap. Thirty patients scheduled for total glossectomy and PMMC flap reconstruction were recruited. The sushi roll technique was performed in 15 patients and the conventional repair in 15 patients. Outcomes were compared between the two groups. The flap survived in all 30 patients. The sushi roll group showed superior results to the conventional group in terms of time to oral alimentation (P = 0.012) and decannulation (P = 0.041), as well as swallowing function (P = 0.032), speech intelligibility (P < 0.001), shape (P < 0.001), and quality of life score (P < 0.001) at 12 months. The innovative sushi roll technique uses a folding method that utilizes the length rather than the thickness and width of the flap to maintain the volume and protuberance of the neotongue, which results in acceptable function and improved quality of life.     

Indications and outcomes for 100 patients managed with a pectoralis major flap within a UK maxillofacial unit

There are few studies reporting the role of the pedicled pectoralis major (PPM) flap in modern maxillofacial practice. The outcomes of 100 patients (102 flaps) managed between 1996 and 2012 in a UK maxillofacial unit that preferentially practices free tissue reconstruction are reported. The majority (88.2%) of PPM flaps were for oral squamous cell carcinoma (SCC), stage IV (75.6%) disease, and there was substantial co-morbidity (47.0% American Society of Anesthesiologists 3 or 4). The PPM flap was the preferred reconstruction on 80.4% of occasions; 19.6% followed free flap failure. Over half of the patients (57%) had previously undergone major surgery and/or chemoradiotherapy. Ischaemic heart disease (P = 0.028), diabetes mellitus (P = 0.040), and methicillin-resistant Staphylococcus aureus (MRSA) infection (P = 0.013) were independently associated with flap loss (any degree). Free flap failure was independently associated with total (2.0%) and major (6.9%) partial flap loss (P = 0.044). Cancer-specific 5-year survival for stage IV primary SCC and salvage surgery improved in the second half (2005–2012) of the study period (22.2% vs. 79.8%, P = 0.002, and 0% vs. 55.7%, P = 0.064, respectively). There were also declines in recurrent disease (P = 0.008), MRSA (P < 0.001), and duration of admission (P = 0.014). The PPM flap retains a valuable role in the management of advanced disease combined with substantial co-morbidity, and following free flap failure.     

Evaluation of anterolateral thigh flap dimensions with virtual flap models

Free flaps are commonly used for head and neck reconstruction. However, flap dimensions are still evaluated by visual and tactile assessment. The aim of this study was to enable preoperative planning of flap dimensions for soft tissue reconstruction based on clinical parameters. Computed tomography records from 230 patients dated from 2009 to 2019 were analysed retrospectively. A virtual, three-dimensional anterolateral thigh flap model was standardized, aligned to segmented leg models in two positions, and flap thicknesses and volumes were determined. Associations of flap thickness and volume with clinical parameters were evaluated, and an approximative calculation method was derived. The laterally positioned anterolateral thigh flap showed an average (interquartile range) thickness of 15.6 mm (8.7 mm) and volume of 1.5 cm³ (0.9 cm³) per cm². The medially positioned anterolateral thigh flap showed an average (interquartile range) thickness of 16.3 mm (8.7 mm) and volume of 1.6 cm³ (0.9 cm³) per cm². For both flap positions, leg circumference was the strongest predictor of flap thickness (β = 0.545, P < 0.001 and β = 0.529, P < 0.001) and flap volume (β = 0.523, P < 0.001 and β = 0.480, P < 0.001). Flap dimensions can be calculated based on leg circumference, and this preoperative planning of flap dimensions can help the surgeon to select the appropriate flap.     

Bone volume change following vascularized free bone flap reconstruction of the mandible

BackgroundBone volume changes following vascularized bone flaps and possible confounding factors over time are described in the literature with some controversy. The purpose of this study was to evaluate the bone volume behavior of two frequently used free flaps.Materials and methodsComputed tomography (CT) scans were examined with regard to bone volume using the software program ITK-SNAP for all patients who required mandibular reconstruction with a free fibula flap (FFF, conventionally vs assisted by computer-aided design/computer-aided manufacturing (CAD/CAM)) or iliac crest flap (DCIA) following mandibular resection because of benign or malign processes, between August 2010 and August 2015. Clinical data, complication rates, and CT scans were analyzed retrospectively. Additionally, complication rates (microvascular revision, flap loss, postoperative fistula or dehiscence, and postoperative bone exposure) were compared within early (≤30 days), late (31st–100th day), and overall (≤100th day) postoperative time intervals.Results113 cases, comprizing 89 FFF and 24 DCIA cases, were included. FFF showed superior bone volume behavior over the DCIA flap. Multivariable regression models assessed the relationships between the following and bone volume behavior: interval between operation and CT scan (p < 0.683), age (p = 0.004), gender (p = 0.006), BMI (p = 0.400), adjuvant radiation therapy (p = 0.334), reconstruction with DCIA flap (p < 0.0001), number of segments (p = 0.02), and incidence of dental implant insertion (p = 0.45).ConclusionsThe bone volume of FFFs remains stable. DCIA flaps show a higher bone volume reduction, but the postoperative course might be associated with fewer complications. Time interval between operation and CT scan, age, gender, reconstruction with DCIA flap, and number of fibula segments contributed significantly to bone volume behavior.     

Is buccal fat pad a better option than nasolabial flap for reconstruction of intraoral defects after surgical release of fibrous bands in patients with oral submucous fibrosis? A pilot study: A protocol for the management of oral submucous fibrosis

PurposeThe aim this study was to compare the buccal fat pad (BFP) and nasolabial flap for reconstruction of intraoral defects after release of fibrous bands in patients with oral submucous fibrosis (OSF).Materials and methodsThis is a comparative study. The study sample was derived from the population of patients who presented, with restricted mouth opening of less than 20 mm, to the Department of Oral and Maxillofacial Surgery, Swargiya Dada Saheb Kalmegh Dental College and Hospital Hingna Nagpur. The patients were divided into two groups. In Group I (n = 10) reconstruction was performed with a nasolabial flap and in Group II (n = 10) with BFP. Both groups were analysed separately for mouth opening (interincisal distance in millimetres) preoperatively and 20 months postoperatively, time taken for epithelialization of BFP and nasolabial flaps. Statistical analysis was performed with SPSS statistical software for Windows, version 8.0 (SPSS, Inc, Chicago, IL) using the _2 test and Student's t test.ResultsIn all 20 patients the interincisal mouth opening was (mean) 11 mm (3–19 mm) preoperatively which improved to a mean of 42 mm (23–52 mm). In Group I there were more complications as compared to Group II such as partial flap necrosis particularly at the tips, temporary widening of oral commissure and subluxation of TMJ. The unsightly extraoral scar and intraoral growth of hairs were not seen in Group II.ConclusionBFP is the better choice for reconstruction in comparison to nasolabial flap.     

Comparison between the radial forearm and superficial circumflex iliac artery perforator free flaps for oral soft tissue reconstruction

The radial forearm free flap (RFFF) is widely used for oral reconstruction. The superficial circumflex iliac artery perforator (SCIP) flap is an increasingly utilized alternative. The cases of 165 patients who received either an RFFF or SCIP flap for oral reconstruction at Chris O′Brien Lifehouse, Sydney were reviewed. The aim was to report on patient, pathology, treatment, and outcome variables and to compare these between the two flap groups. A RFFF was used in 126 patients and a SCIP flap in 39 patients. SCIP flap patients were younger (P < 0.001) and had shorter operative times (P < 0.001), shorter anaesthetic times (P < 0.001), and more frequent recipient site dehiscence (P = 0.005) when compared to RFFF patients. The SCIP flap was significantly less frequently used for composite resections including bone when compared to the RFFF (P < 0.001). The primary site distribution was more even for RFFF patients (P < 0.001). There were no SCIP flap failures; three RFFF failures occurred. SCIP flaps performed comparably in terms of operative and clinical outcomes. Most SCIP flaps were utilized in younger patients with partial glossectomy defects.     

Two designs of platysma myocutaneous flap for reconstruction of oral and facial defects following cancer surgery

This study evaluates the effects of two different designs of platysma myocutaneous flap, vertical and transverse, used in the reconstruction of defects following the excision of oral and facial tumors. Modified radical neck dissection or selected neck dissection was also performed. Out of the 48 patients, vertical and transverse platysma myocutaneous flaps were used for 41 and 7, respectively. The postoperative outcome for the vertical flaps was 37 cases surviving, two cases of complete necrosis, and two cases of partial necrosis. With the transverse flaps, six survived and there was one case of complete necrosis. The success rate was 90.2% and 85.7% for the vertical and the transverse flap, respectively. The form and function of recipient sites were well recovered. In conclusion, the platysma myocutaneous flap has clinical value in selected patients needing reconstruction of small and medium-sized intraoral or facial defects. It is recommended that the vertical design be used for reconstruction of buccal mucosa defects, and the transverse design for mouth-floor and facial defects.     

Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects

BackgroundThe anterolateral thigh myocutaneous flap is one of the most commonly used flaps in reconstructive procedures, but its application in oral and maxillofacial defects has not been fully determined. Herein, we summarize the application of 1212 anterolateral thigh myocutaneous flaps in the repair of oral and maxillofacial defects and examine their benefits in maxillofacial reconstruction of these defects.MethodsPatients were recruited from February 2002 to June 2013 in the Department of Oral and Maxillofacial Surgery of Central South University. All patients underwent reconstructive surgery employing anterolateral thigh myocutaneous flaps. Patient ages ranged from 6 to 82 years with a mean age of 51.2 years. There are 1015 flaps showing single lobe and 197 flaps showing a multi-island pedicle and one of which carries the iliac bone. The largest area among the single flaps was 28 × 12 cm², and the smallest was 3 × 2 cm².ResultsAmong the 1212 transferred flaps, 1176 survived and 36 showed necrosis, a survival rate of about 97.0%. The common complications at flap donor site were poor wound healing (10.1%), localized paraesthesia (50.1%), and altered quadriceps force (11.0%). No cases presented with local serious complications, and 90% of patients achieved good functional recovery and aesthetically acceptable results after reconstruction of oral and maxillofacial defects at various locations using anterolateral thigh myocutaneous flaps. The time (23–121 min; average 51 min) for anastomosis of one vein and one artery was significantly less than that for two veins and one artery (45–153 min, average 83 min; p = 0.0003), which indicates one vein anastomosis can significantly reduce the operating time.ConclusionThe anterolateral thigh myocutaneous flaps can be easily obtained and can provide a good amount of muscle for filling dead space and fascia lata. These flaps can be prepared into a separate fat flap, multi-island fascia with iliac bone, and other composite pedicle flaps to meet the various requirements of oral and maxillofacial defects. The subcutaneous fat thickness of the anterolateral area can vary considerably and thus can be used to repair defects requiring different flap thickness. Therefore, the anterolateral thigh myocutaneous free flaps are more suitable for oral and maxillofacial defects than other flaps.     

Oromandibular reconstruction using microvascularized bone flap: report of 1038 cases from a single institution

This retrospective study was performed to review 1038 patients who underwent mandibular reconstruction with free vascularized bone flaps at a single institution between 2006 and 2017. Of these patients, 827 (79.67%) had fibula flaps, 197 (18.98%) had deep circumflex iliac artery perforator (DCIA) flaps, and 11 (1.06%) had scapula bone flaps. The most common pathological diagnosis was ameloblastoma (n = 366, 35.26%), followed by squamous cell carcinoma (n = 278, 26.78%) and osteoradionecrosis (n = 152, 14.64%). Fifty-seven patients (5.49%) had major complications requiring surgical intervention and one patient died of a pulmonary embolism. Venous crisis was the most frequent major complication (n = 20, 1.93%), followed by haematoma (n = 17, 1.64%) and flap necrosis (n = 14, 1.35%). One-stage mandibular reconstruction was preferred whenever possible, as this generally decreases the financial and hospitalization burden. The four-segment method of jaw reconstruction appeared to achieve good aesthetic appearance results in Asian patients and this was not associated with a higher risk of segment ischemia compared with the three-segment method.     

Superficial versus deep system single venous anastomosis in the radial forearm free flap: a meta-analysis

The selection of the superficial or deep drainage system for use with the radial forearm free flap (RFFF) remains controversial. The aim of this study was to identify the optimal drainage system for single venous anastomosis. A systematic review and cumulative meta-analysis was performed to assess superficial and deep system single venous anastomosis for use with the RFFF in postoperative reconstruction of the head and neck. This study included 1073 flaps (495 superficial system-based flaps, 578 deep system-based flaps) reported in six studies. The outcomes assessed in the studies selected for this meta-analysis included venous compromise, flap failure, and the salvage success rate. Venous compromise was more common in the superficial system group (odds ratio (OR) 2.29, 95% confidence interval (CI) 1.36–3.86, P = 0.002). The rate of successful salvage was higher with the superficial system (OR 8.19, 95% CI 1.75–38.3, P = 0.008). The rate of flap failure was lower in the superficial system group (OR 0.30, 95% CI 0.04–2.48, P = 0.27). Although the deep system showed a lower risk of venous compromise, the evidence provided by the meta-analysis was insufficient to determine which type of drainage system is more suitable for single venous anastomosis in RFFF. All included studies were cohort studies; therefore, findings must be interpreted with caution.     

Role of computed tomography angiography in the diagnosis of vascular stenosis in head and neck microvascular free flap reconstruction

The aim of this study was to evaluate the role of computed tomography angiography (CTA) in the diagnosis of vascular stenosis at the vascular pedicle of head and neck microvascular free flaps. A prospective study was done of 65 consecutive patients (49 male, 16 female; mean age 55 years) who had undergone head and neck microvascular free flap reconstruction. All patients underwent 64-slice CTA of the carotid artery. Post-processing with volume rendering reconstruction of CTA images was done. There was excellent inter-observer agreement (weighted kappa = 0.82, 95% confidence interval (CI) 0.74–0.93) in grading of the degree of vascular stenosis. The true sensitivity of CTA for diagnosis of stenosis of the vascular pedicle to the flap was 63% (95% CI 63–100%). Patients with failed flaps showed complete occlusion (n = 2) on CTA and underwent a replacement flap procedure. Patients with failing flaps showed severe stenosis (n = 6) of the vascular pedicle on CTA and underwent revision surgery. There was no change in the degree of stenosis on follow-up CTA for patients with moderate stenosis (n = 9). CTA is a reliable, non-invasive, high-quality imaging tool for the diagnosis and grading of vascular stenosis of the vascular pedicle of head and neck microvascular free flaps.     

胸大肌肌皮瓣修复口腔癌术后大面积缺损临床总结

目的:探讨晚期口腔癌术后组织缺损的修复,介绍胸大肌肌皮瓣修复口腔癌术后大面积组织缺损的临床经验。方法:总结分析2005—2009年40例晚期口腔癌患者根治术后胸大肌肌皮瓣修复口内组织缺损的临床资料。结果:40例用胸大肌肌皮瓣关闭口内创面;39例肌皮瓣全部成活;1例部分成活,远端皮肤坏死;术后外形及张口度均恢复良好。结论:胸大肌肌皮瓣组织量大,血运丰富,是修复晚期口腔癌术后大面积组织缺损的一种有效方法。     

Soft palate functional reconstruction with buccinator myomucosal island flaps

Oropharyngeal reconstruction after ablative surgery is a challenge. The results of a retrospective study of 17 patients who underwent total or sub-total soft palate reconstruction with a buccinator myomucosal island flap, between 2008 and 2016, are reported herein. An analysis of flap type and size, harvesting time, and postoperative complications was performed. Patients underwent standardized tests to assess the recovery of sensitivity, deglutition, quality of life (QoL), and donor site morbidity, at >6 months after surgery or the end of adjuvant therapy, if performed. All flaps were transposed successfully. Only minor donor and recipient site complications occurred. The sensitivity assessment showed that touch, two-point discrimination, and pain sensations were recovered in all patients. Significant differences between the flap and native mucosa were reported for tactile (P = 0.004), pain (P = 0.001), and two-point discrimination (P = 0.001) thresholds. The average deglutition score reported was 6.1/7, with only minimal complaints regarding deglutition. The QoL assessment showed high physical (24.6/28), social (25/28), emotional (19.1/24), and functional (24.6/28) scores. No major donor site complications were noted in any patient; the average donor site morbidity score was 8.1/9. Buccinator myomucosal island flaps represent a valuable functional oropharyngeal option for reconstruction, requiring a short operating time and presenting a low donor site morbidity rate.     

Donor-site morbidity after fibula free flap transfer: a comparison of subjective evaluation using a visual analogue scale and point evaluation system

The aims of this study were: (1) to compare the visual analogue scale (VAS) with the point evaluation system (PES) in the subjective evaluation of donor-site morbidity after fibula free flap transfer; (2) to compare the functional outcomes of fibula free flap surgery between patients with a normal body mass index (BMI) and patients with a high BMI, and between skin paddle and non-skin paddle harvesting; and (3) to determine the correlation between functional outcomes and related factors. This study included 15 patients who underwent a vascularized fibula free flap transfer for oral and maxillofacial reconstruction. Demographic data, preoperative, intraoperative, and postoperative data were collected. Subjective self-evaluation of functional outcomes was done using a VAS followed by a PES. Comparison of the VAS and PES scores was assessed with Pearson's correlation coefficient. The statistical significance was set at P < 0.05. The VAS score was significantly correlated with the PES score (r = 0.63, P = 0.01). The tourniquet times for the skin paddle group were longer than for the non-skin paddle group (P = 0.02), while the satisfaction score of the non-skin paddle group was higher than that of the skin paddle group (P = 0.03). The VAS is a potential option for the subjective evaluation of donor-site morbidity after fibula free flap transfer.     

颏下岛状瓣修复口腔缺损的初步报告

目的旨在以颏下动脉和颏下静脉为血管蒂的颏下岛状瓣（SMIF）整复口腔缺损。方法7例口腔癌肿患者接受了口腔肿瘤切除加同侧颈淋巴清扫术，并同期行SMIF整复口腔缺损，其中1例施行了根治性颈清扫术，1例施行了保留颈外静脉的改良颈清扫术，其余5例施行了保留颈内静脉的改良颈清扫术。结果除行根治性颈清者外，6例行改良颈清者的SMIF均成活。结论SMIF血供恒定，成活可靠；其最大面积可达7cmX16cm，且活动度大，可达到距供区较远的部位，可广泛用于口腔颌面缺损的整复；因颈内外静脉系统是颏下静脉的回流通路，著作颈淋巴清扫术应保留两颈静脉系统之一及其与颠下静脉连通的中介静脉方能确保SMIF的成活。     

Immediate reconstruction following resection of oral cancer with free rectus abdominis myocutaneous flap

目的：研究游离腹直肌肌皮瓣即刻修复口腔颌面部恶性肿瘤切除术后缺损的方法并评价其作用。方法：６例患者在进行广泛的口腔癌切除术后,应用游离腹直肌肌皮瓣进行缺损即刻修复,３例颊癌患者分别切除唇,颊,下颌骨及上颌骨后造成大面积洞穿性缺损,２例舌癌及１例下颌骨恶性肿瘤患者在进行舌切除及下颌骨切除后造成大面积及复杂的缺损,缺损修复的转移皮瓣最大面积达１１０ｍｍ×２３０ｍｍ。结果：游离腹直肌肌皮瓣及供区无严重的手术并发症,６例游离腹直肌肌皮瓣有５例愈合无并发症,１例皮瓣出现部分坏死,供皮区腹壁无组织感染及裂开。结论：游离腹直肌肌皮瓣使口腔颌面部缺损修复在功能和美观上达到满意的效果,提高了口腔颌面部恶性肿瘤患者广泛切除术后的生存质量。     

The pectoralis major myocutaneous flap for intraoral reconstruction: surgical complications and their treatment

The pectoralis major myocutaneous (PM-MC) flap was used for intra-oral reconstruction in 7 patients. Major necrosis did not occur in any of the cases, but minor necrosis did in two cases. In 2 cases an oro-cutaneous fistula was observed. Furthermore, in 2 cases severe facial oedema was experienced, which seemed attributable to circulatory disturbance in the part of the face where the flap was inserted. Muscle atrophy of the flap was observed in greater or lesser degree in all cases. In all cases the pectoralis major myocutaneous flap was used for the purpose of intraoral reconstruction. Intraoral reconstruction involves considerations different from transplantation in other sites. It is the purpose of this paper to present an updated review of our experience with 7 consecutive pectoralis major myocutaneous flaps, including the complications and their treatment.     

Surgical anatomy of the submental artery perforator flap and assessment for application in postoperative reconstruction following oral cancer surgery: a prospective clinical study

The submental artery perforator flap (SMAPF) has an elongated pedicle, allowing good cosmetic outcomes to be achieved following oral reconstruction surgery. The improper dissection of perforators often leads to a vascular flap crisis. To avoid this, some surgeons choose to carry amounts of connective tissue around the pedicle. However the inclusion of connective tissue on the pedicle raises concerns about oncological safety. A surgical anatomical study of the submental vessel patterns and subdivisions of the cervical level I lymph nodes was conducted on 33 patients with primary oral cancer who underwent reconstruction with a SMAPF after tumour resection. The variations in vessels and cervical level I lymph nodes observed during SMAPF harvesting were recorded and analyzed. Two patterns of submental artery perforators and three patterns of submental veins were identified. The different characteristics of the lymph node distribution were elucidated for five subdivisions. All SMAPFs survived (n = 33, 100%); however, two SMAPFs exhibited partial losses. The 3-year survival rate of patients was 84.5 ± 6.4%, and there were no suspected flap-related recurrences. With detailed anatomical information on the vascular system and lymph node subdivision, SMAPFs are a reliable choice for postoperative reconstruction following oral cancer surgery, meeting the standards for oncological safety.