Posterior tibial artery flap versus radial forearm flap in oral cavity reconstruction and donor site morbidity

The repair of soft tissue defects after oral cavity cancer resection is challenging. The aim of this study was to compare the outcomes and donor site morbidity of the radial forearm free flap (RFF) and posterior tibial artery perforator flap (PTAF) for oral cavity reconstruction after cancer ablation. All patients who underwent oral cavity reconstruction with a RFF or PTAF between January 2017 and December 2019 were included retrospectively in this study. All flaps were harvested with a long adipofascial extension. The donor site defects were closed with a triangular full-thickness skin graft harvested adjacent to the flap. Flap outcomes and donor site complications were recorded and compared. The study included 145 patients; 30 underwent reconstruction with a RFF and 115 with a PTAF. No significant difference between the PTAF and RFF was observed concerning the flap survival rate (98.3% vs 96.7%), flap harvest time (53.39 vs 49.28 min), hospital stay (12.3 vs 15.2 days), or subjective functional and cosmetic outcomes. The PTAF showed a larger vascular calibre (P < 0.05), greater flap thickness (P = 0.002), and lower frequency of surgical site infection (P = 0.055) when compared to the RFF. No significant difference was observed between the pre- and postoperative ranges of ankle and wrist movements. The PTAF is an excellent alternative to the RFF for the repair of oral cavity defects, with the additional advantages of a well-hidden scar on the lower extremity, larger vascular calibre, and lower frequencies of postoperative donor site morbidities.     

Comparison between the radial forearm and groin soft tissue free flaps for reconstruction in patients with oral cavity cancer: a quality of life analysis

The purpose of this study was to compare the effects of the radial forearm free flap (RFFF) and groin soft tissue free flap (GSFF) on the quality of life (QoL) of patients undergoing reconstructive surgery after resection for oral cancer. A retrospective analysis of 48 patients was performed. The Vancouver Scar Scale (VSS), University of Washington Quality of Life (UW-QOL) questionnaire, and 14-item Oral Health Impact Profile (OHIP-14) questionnaire were used to evaluate the donor site scars and QoL of the patients. The postoperative hospital stay was significantly longer in the RFFF group than in the GSFF group (P = 0.001). Furthermore, the total VSS score (P = 0.011), VSS score for pigmentation (P < 0.001), and OHIP-14 scores for psychological discomfort (P = 0.026) and social disability (P = 0.044) were all significantly higher in the RFFF group than in the GSFF group, while the UW-QOL scores for appearance (P = 0.037) and mood (P = 0.036) were significantly lower in the RFFF group than in the GSFF group. Compared with the RFFF, the GSFF scar is more concealed, with better aesthetics at the donor site, and this flap can result in improved postoperative QoL for patients with oral cancer.     

Clinical comparison of superior thyroid artery perforator flap and sternocleidomastoid myocutaneous flap for intraoral reconstruction

The aim was to evaluate the techniques and outcomes of superior thyroid artery perforator flaps (STAPF) for intraoral reconstruction and to compare them with those of the sternocleidomastoid myocutaneous flap (SCMMF). The cases of 43 patients who underwent reconstruction with either a SCMMF or STAPF for the repair of a medium-sized intraoral defect, between January 2013 and December 2020, were reviewed retrospectively. Although both flaps are based on the superior thyroid artery, their specific harvesting techniques largely differ. All SCMMF (n = 23) were superiorly-based rotational flaps with myocutaneous designs. The STAPF cases (n = 20) included 18 septocutaneous flaps and two chimeric flaps. The flap size was larger in the STAPF group (P = 0.008), while incomplete level IIB dissection (oncological safety) was more frequent in the SCMMF group (P = 0.002). The flap necrosis rate was lower in the STAPF group (STAPF 15% vs SCMMF 34.8%, though this was not statistically significant). Cox multivariate analysis showed that the postoperative flap outcome (total flap necrosis vs flap survival; hazard ratio 27, 95% confidence interval 2.149–336.05; P = 0.001) and complications (excluding fistula) (hazard ratio 14, 95% confidence interval 1.314–142.767; P = 0.029) were associated with overall patient survival. Both speech (P < 0.001) and neck mobility (P < 0.001) functions were superior with STAPF reconstruction. Compared with the traditional SCMMF, the STAPF was found to have a lower necrosis rate with uncompromised oncological safety during harvesting. The STAPF is a good alternative for the repair of medium-sized head and neck defects.     

Accurate occlusion-driven maxillary reconstruction with deep circumflex iliac artery flap using computer-assisted techniques and intraoral anastomosis: a case series

The aim of this study was to evaluate the feasibility and accuracy of occlusion-driven maxillary reconstruction with the deep circumflex iliac artery (DCIA) flap, using computer-assisted design and manufacturing (CAD/CAM) technology and intraoral anastomosis. The data of 11 patients who underwent occlusion-driven maxillary reconstruction with this method between December 2018 and December 2020 in the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology were reviewed retrospectively. Postoperative complications and functional and aesthetic outcomes were recorded. The accuracy of the postoperative restoration was assessed using Geomagic Control 2014. Reconstruction was successful in nine patients; all were satisfied with their aesthetic and functional outcomes. One patient underwent extraoral anastomosis after failure of intraoral anastomosis. In another patient, the DCIA flap had to be removed after the operation because of flap failure. Among the 10 patients with DCIA flap success, colour map analysis showed a mean deviation of 0.40 ± 0.08 mm between the preoperative and postoperative craniomaxillary models. Thus, occlusion-driven maxillary reconstruction with the DCIA flap, using CAD/CAM technology and intraoral anastomosis, appears to be a feasible and accurate method for the repair of maxillary defects.     

Perfusion of microvascular free flaps in head and neck reconstruction after prior neck dissection and irradiation

Microvascular free flaps are frequently used for head and neck reconstruction after prior neck dissection (ND) and neck irradiation (RTX). The aim of this study was to investigate the influence of ND and RTX on flap perfusion as a critical factor for flap success. Overall, 392 patients reconstructed with a microvascular fasciocutaneous flap (FF) or perforator flap (PF) in the head and neck region between 2011 and 2020 were analysed retrospectively. Flap perfusion measured intraoperatively and postoperatively with the O2C tissue oxygen analysis system was compared between patients who had received neither ND nor RTX (controls), patients who had received ND but no RTX (ND group), and patients who had received both ND and RTX (ND+RTX group). Intraoperative and postoperative flap blood flow was decreased in FFs in ND group patients compared to controls (median 66.3 AU vs 86.0 AU, P = 0.023; median 73.5 AU vs 93.8 AU, P = 0.045, respectively). In the multivariable analysis, these differences showed a tendency to persist (P = 0.052 and P = 0.056). Flap success rates were similar in control patients, ND patients, and ND+RTX patients (98.7%, 94.0%, and 97.6%, respectively). Flap perfusion is not reduced in FFs and PFs in patients who have undergone ND or ND and RTX. This indicates that neck dissection and neck irradiation should not be contraindications for microvascular free flap reconstruction.     

联合应用游离腓骨瓣和前臂皮瓣修复口腔下颌骨复合缺损

目的 :分析联合应用游离腓骨瓣和前臂皮瓣在口腔下颌骨复合缺损修复中的应用价值。方法 :对2 0 0 0 0 3～ 2 0 0 2 0 1期间完成的 2 3例联合应用游离腓骨瓣和前臂瓣行口腔下颌骨缺损修复的病例作回顾性研究 ,分析缺损的类型、受区血管、游离瓣成活情况及术后并发症的发生情况 ,并分析有可能影响游离瓣成活的各种因素。结果 :2 3例患者中男性 17例 ,女性 6例 ,年龄 3 1～ 72岁 ,平均 5 2 .9岁 ,所采用的游离腓骨复合瓣中 ,腓骨长度 6～ 15cm(平均 10 .6cm) ,皮岛最大面积 12cm× 5cm ,最小 5cm× 3cm(平均 8.4cm×3 .6cm) ,腓骨的截骨次数为 0～ 3次 (平均 1.7次 ) ,所采用前臂皮瓣最大面积 10cm× 8cm ,最小 6cm× 5cm ,平均 7.8cm× 6.4cm。 2 3例患者的 46块游离瓣全部获得成活 ,受区和供区总的并发症发生率为3 0 .4% ,但并发症均不严重 ,没有造成严重的后果。结论 :游离腓骨瓣和前臂皮瓣联合应用在大型口腔下颌骨复合缺损的修复中具有较大的灵活性 ,安全可靠 ,并能较好地恢复患者的外形和功能 ,提高了患者的生存质量     

Venous superdrainage using superficial circumflex iliac vein in deep circumflex iliac artery perforator flap with iliac crest for oromandibular reconstruction

The deep circumflex iliac artery perforator flap with iliac crest (DCIAPF) is considered a favourable single-flap option for oromandibular reconstruction. The aim of this study was to evaluate the effectiveness of venous superdrainage using the superficial circumflex iliac vein (SCIV) in the DCIAPF for oromandibular reconstruction. The data of 22 patients (12 female, 10 male) aged 10–76 years (median 53 years) who underwent simultaneous oromandibular reconstruction with a DCIAPF were reviewed retrospectively. Eleven patients received the DCIAPF with SCIV for superdrainage (group A) and another 11 patients received the conventional single-pedicled DCIAPF flap (group B). No flap loss occurred in either group. Venous congestion due to relative venous insufficiency was significantly more frequent in group B (P = 0.045). There was no significant difference in the incidence of partial flap necrosis and wound dehiscence, or in the total operation time between the two groups. Superdrainage using the SCIV has the potential to reduce the incidence of venous congestion due to relative venous insufficiency in DCIAPF used for oromandibular reconstruction.     

髂骨复合瓣与前臂皮瓣串联重建大型下颌骨复合缺损

由于恶性肿瘤的根治性切除致下颌骨大型复合缺损３例，采用髂骨复合瓣与前臂皮瓣串联重建，其中１例切取双侧髂骨复合瓣。３例病人７块皮瓣全部成活，随访３～１２月，供受区外形及功能结果较满意，经Ｘ摄片随访观察显示移植骨愈合改建过程迅速，骨吸收量少。结果表明，前臂皮瓣可弥补髂骨复合瓣携带皮岛的不足，两者串联应用是重建下颌骨大型复合缺损的一种理想方法。     

颞浅动脉及静脉作为头颈部游离瓣移植受区血管的可靠性探讨

目的 探讨颞浅动、静脉作为头颈部游离瓣移植受区血管的可靠性和应用价值.方法2001年5月至2008年6月采用颞部血管作为受区血管的头颈部游离瓣移植25例,分析游离瓣的受区血管、术中及术后的血管危象及游离瓣的成活情况.结果 25例患者中,23块游离瓣采用颞浅静脉作为受区静脉,2例采用颞深静脉作为受区静脉,全部游离瓣均采用颞浅动脉作为受区动脉.全部游离瓣术后均未出现血管危象,游离瓣均获成活.结论本组结果表明,颞浅动、静脉是头颈部游离瓣移植可靠的受区血管.     

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.     

逆行面动脉-颏下动脉岛状肌皮瓣修复口腔颌面部缺损的探讨

目的评价逆行面动脉-颏下动脉岛状肌皮瓣修复口腔颌面部缺损的可行性。方法用逆行面动脉-颏下动脉岛状肌皮瓣修复18例恶性肿瘤切除术后口腔颌面部缺损。男性11例，女性7例，年龄28～90岁。舌鳞癌7例、颊黏膜鳞癌4例、腭鳞癌3例、口咽癌和面部皮肤基底细胞癌各2例。肌皮瓣面积最小为4．0cm×12．0cm，最大为5．0cm×15．0cm。结果17例肌皮瓣存活，1例缺血坏死。肌皮瓣受区外观满意、功能恢复良好，供区瘢痕隐蔽。经术后6～18个月，平均11．8个月随访，1例术后10个月对侧颈部淋巴结转移。结论逆行面动脉-颏下动脉岛状肌皮瓣是口腔颌面部中型缺损的理想修复材料。     

Comparison of islanded facial artery myomucosal flap with fasciocutaneous free flaps in the reconstruction of lateral oral tongue defects

The aim of this study was to determine whether the islanded facial artery myomucosal flap (iFAMM) is a good alternative to fasciocutaneous free flaps (FCFF) in the reconstruction of lateral oral tongue defects. This was a retrospective study of 40 patients with oral tongue cancers (lateral lesions not >4 cm) operated on between August 2014 and March 2017, who underwent primary reconstruction with either an iFAMM or FCFF. The two groups were compared with respect to intraoperative time, total intensive care unit (ICU) and hospital stay, complications, speech, swallowing, aesthetics, donor site morbidity, and economic feasibility. Patients who had an iFAMM had a reduced operating time, duration of ICU stay, and length of hospitalization; this flap was also more economically feasible. Better aesthetics and less donor site morbidity were also seen. The iFAMM is an alternative to FCFF in the reconstruction of lateral oral tongue defects, as it is less technically demanding, has good aesthetic outcomes, and is more economical, with acceptable donor site morbidity.     

A 31-year review of composite radial forearm free flaps for head and neck reconstruction

The aim of this study was to report the patient characteristics and radial fracture rates in a consecutive series of composite radial forearm free flap (CRFFF) for head and neck reconstruction over a 31-year period. The patients were identified from between 1990 to 2020 inclusive from theatre records and records from previous analyses at the Unit on free flap outcomes. Electronic case notes were accessed where available, to gather information on the operation, histopathology, and radiographs. Patients were categorised into three groups for analysis: (1) new oral cancers with a composite radial being the first choice of flap, (2) new oral cancers with a composite radial being the choice of flap following compromise of another bony flap, (3) osteoradionecrosis (ORN) cases. There were 103 CRFFF cases, median (IQR) age 69 (59-80) years, comprising 78 (Group 1), 5 (Group 2) and 20 (Group 3). The CRFFF failure rate was 6% (6/103) and the radius fracture rate was also 6% (6/103), both with 95% confidence interval 2.2-12.2%. Of the 6 radius fractures, 1 underwent surgical management (rush nailing), 1 died in hospital and the others managed with cast immobilisation. Two-year overall survival after surgery for the103 patients was 54% (SE 5%), while 5-year survival was 40% (SE 5%). In conclusion, in spite of the familiarity with other bone flaps such as fibular free flap, DCIA, scapula, and the limited bone stock and potential fracture related morbidity associated with the CRFFF, this flap still has a place in the surgical reconstructive armamentarium.     

Anterolateral thigh flap with a central hole for the repair of extensive oral defects in patients treated for chemotherapy-induced trismus

Trismus is a rare complication of chemotherapy. The usefulness of a modified anterolateral thigh (ALT) flap for the repair of extensive oral defects in patients treated for chemotherapy-induced trismus was evaluated. Between 2019 and 2021, three patients with chemotherapy-induced trismus underwent scar excision. A thinned ALT flap with a central hole was designed to repair the resultant oral mucosal defects. The patients were followed up for a mean 9.3 months (range 4–18 months). The mean pre- and intraoperative maximum inter-incisal opening (MIO) was 0.7 cm (range 0–2.0 cm) and 3.6 cm (range 3.4–3.7 cm), respectively, indicating a significant operative effect. MIO at the latest follow-up was 2.4 cm (range 1.5–3.5 cm). All of the flaps survived without complications. All patients achieved a good diet and were satisfied with the aesthetics. Thorough excision of the perioral scar and restoration with a modified ALT flap achieved satisfactory mouth opening and cosmetic effects in patients with chemotherapy-induced trismus.     

股前外侧穿支皮瓣修复口腔癌术后缺损患者的生活质量评估

目的 评估应用游离股前外侧穿支皮瓣（ALTF）修复口腔颌面部恶性肿瘤切除术后组织缺损患者的生活质量（QOL）。方法 以2012年1月-2013年7月应用ALTF修复口腔颌面部恶性肿瘤切除术后组织缺损的32例患者为研究对象,应用口腔健康影响程度量表（OHIP-14）和简明健康状况调查问卷（SF-36）对患者术后12个月的QOL进行调查和评估。结果 SF-36问卷得分位于前3的项目是躯体疼痛、生理功能和躯体角色,得分分别是78.58±14.82、72.08±27.86和60.00±42.63;得分较低的是情感角色（41.67±39.62）、心理健康（50.75±13.07）和健康变化（54.17±21.75）。分析OHIP-14量表得分,恢复较好的项目是社交障碍和残障,得分分别为34.50±11.32和36.04±12.05;恢复较差的项目是生理性疼痛和心理不适,得分分别为73.50±18.96和60.17±25.66。结论 采用ALTF修复口腔颌面部恶性肿瘤切除术后组织缺损,能够恢复患者外形、语言和咀嚼功能的基本需求,提高患者的QOL。     

Use of free flaps with supermicrosurgery for oncological reconstruction of the maxillofacial region

Supermicrosurgery involves the dissection and anastomosis of vessels<0.8 mm in diameter with minimal donor site morbidity. This study evaluated the feasibility and outcomes of free flaps using supermicrosurgery to repair oncological defects in the maxillofacial region. Forty-two patients were treated with supermicrosurgery to repair oncological defects in the maxillofacial region between December 2015 and February 2021. The supermicrosurgery technique was used for different types of free flap, including 24 superficial circumflex iliac artery perforator flaps, seven anterolateral thigh flaps, three peroneal artery perforator flaps, five medial femoral condyle osteo-adipofascial flaps, and three profunda artery perforator flaps. An artery-to-artery approach was used in 38 patients; venous grafts for anastomosis were used in four patients to resolve an arterial discrepancy. Forty-one flaps (97.6%) survived. Thirty-six patients (85.7%) healed without any complications; three flaps required revision surgery including one lost, one demonstrated wound dehiscence, and two demonstrated wound infection. Supermicrosurgery is a useful complement to conventional microsurgery in head and neck reconstruction.     

多种组织瓣在口腔颌面部组织缺损中的应用

目的：总结12种组织瓣整复口腔颌面部软组织缺损的临床应用价值、技术特点及适应症。方法：对68例口腔颌面部大、中型组织缺损的患者，立即用带蒂肌皮瓣和游离组织瓣进行舌、口底、面颊部、腮腺区等部位的修复重建，并对效果进行观察。结果：54块带蒂肌皮瓣成功率为96．3％（52／54），使用最多的是胸大肌皮瓣；17块游离组织瓣成功率为88．3％（15／17），使用最多的是前臂游离皮瓣。所用各类组织瓣修复效果良好。结论：用组织瓣立即整复口腔颌面部组织缺损，可及时恢复口腔颌面部功能，对提高患者生存质量起到积极作用。     

游离腓肠内侧动脉穿支皮瓣修复头颈部缺损的初步研究

目的 探讨游离腓肠内侧动脉穿支皮瓣在头颈部缺损修复中的应用.方法 2010年4月至2011年1月16例患者头颈部肿瘤切除后拟用游离腓肠内侧动脉穿支皮瓣修复组织缺损,术前采用超声多普勒血流仪或彩色多普勒超声检测穿支血管,设计皮瓣,术中记录皮瓣大小、穿支血管的数目和血管蒂长度,术后观察游离瓣成活情况,随访记录供区愈合情况及评价术后并发症.结果 最终完成游离腓肠内侧动脉穿支皮瓣修复16例,15例皮瓣术后成活,1例术后因静脉危象手术探查后皮瓣部分存活.供区15例直接缝合,1例植皮.15例供区Ⅰ期愈合,1例因术后供区肌肉坏死行清创手术后愈合.14例术后随访3～ 12个月,所有患者供区除因瘢痕致远端皮肤触觉异常外,远期无明显功能障碍.结论 游离腓肠内侧动脉穿支皮瓣供区并发症轻微,适用头颈部中小型缺损修复.     

Perioperative risk factors that predict complications of radial forearm free flaps in oral and maxillofacial reconstruction

The aim of the study was to find out what perioperative risk factors predicted complications in patients having reconstructions with radial forearm free flaps (RFFF). We organised a retrospective study of 169 patients (mean (range) age 54 (22–86) years, 100 of whom were female) who had oral and maxillofacial tumours resected, and reconstructed with RFFF, from January 2011–December 2016. We recorded predictive variables, subdivided into: personal and clinical (sex, age, weight, coexisting conditions, history of smoking, radiotherapy, and primary lesions); haemodynamic (perioperative concentrations of haemoglobin and albumin, blood loss, blood transfusion, urinary output (ml), and rate (ml/kg/hour), and infusion rates for crystalloids and colloids (ml/kg/hour, and volumes given intraoperatively and postoperatively for 24 hours); and anaesthetic and surgical (American Society of Anesthesiologists(ASA) grade, visual analogue pain score (VAS), and duration of tourniquet and operation). The primary outcome was the presence of a postoperative complication, and the secondary outcome the types of complications (medical and surgical). The significance of differences among the variables was assessed by univariate and multivariate analysis, and probabilities of less than 0.05 were accepted as significant. There were 26 complications, of which 15 were surgical and 11 medical. Risk factors were: preoperative radiotherapy, postoperative haemoglobin and albumin concentrations, VAS for pain, and volume of crystalloids transfused during the first 24 hours. Although reconstruction with a RFFF is a common and safe treatment for patients with oral and maxillofacial tumours, regulating perioperative risk factors, particularly those related to anaesthesia (including VAS and management of fluids) is important in the reduction of the number of complications.