Swallowing function and tracheotomy dependence after combined-modality treatment including free tissue transfer for advanced-stage oropharyngeal cancer

OBJECTIVES/HYPOTHESIS: There are many treatments available for advanced oropharyngeal cancer. Organ-sparing protocols reserve surgery for salvage and are thought to provide adequate rehabilitation. Surgical resection with free tissue transfer may also provide adequate functional rehabilitation. The objective was to describe swallowing status and time to decannulation in a series of patients treated with combined-modality therapy that included free flap reconstruction. STUDY DESIGN: Retrospective chart review. METHODS: Patient data were obtained from medical records of 20 patients with stage III or IV oropharyngeal carcinoma, who were consecutively treated with surgical tumor extirpation, free flap reconstruction, and postoperative irradiation at a tertiary academic center from 1985 to 2002. The following variables were identified: patient and tumor characteristics, free flap type, irradiation data, and airway and swallowing status before and after treatment. RESULTS: One patient underwent total laryngopharyngectomy, and the remaining 19 patients underwent tracheotomy at the time of definitive surgery. Free flap reconstructions included 1 ulnar and 15 radial forearm fasciocutaneous flaps and 4 fibula osteocutaneous flaps. Postoperatively, all 19 tracheotomized patients had successful decannulation. Average time to decannulation was 15 days (range, 3-42 d). After surgery and before irradiation, 13 patients initiated oral intake, on average, at 19.5 days (range, 7-28 d); 6 patients required no additional supplementation. By 4 months after surgery, having completed radiation therapy, 10 patients were consuming all nutrition orally; the other 10 patients still required tube-feed supplementation, although 6 of these patients were also eating by mouth. CONCLUSION: Combined-modality treatment that includes free flap reconstruction for advanced-stage oropharyngeal cancer may provide reasonable functional rehabilitation with respect to postoperative airway and swallowing.     

Tongue reconstruction: Concepts and practice

Total or subtotal tongue resection results in the potential for severe speech and swallowing disruption and life-threatening aspiration. This report documents the development of a new design for latissimus dorsi flaps used in tongue reconstruction. In order to create a contractile muscle sling which will raise the neotongue toward the palate for speech and swallowing, the flap is harvested with muscle fibers oriented transverse to its long, skin component axis. The flap is then transferred to the oral and oropharyngeal defect and sutured at the level of the mandibular angle to the remaining muscles of mastication. Conventional microvascular anastomosis for free flaps is followed by end-to-end reanastomosis of the hypoglossal nerve stump to the nerve to latissimus dorsi. The skin component is set into the floor of mouth with a curved wedge resected anteriorly, raising a mound to assist with articulation. Fourteen such reconstructions have been performed on patients undergoing glossectomy for cancer. If not invaded by cancer, the glottic larynx was preserved, and the decannulation rate was 80% at a median postoperative interval of 3.2 weeks. Seventy percent of patients achieved oral intake with pureed food or better, and upward motion of the flap was documented by video swallowing studies. Articulation was particularly good. This innervated latissimus dorsi flap design therefore is a viable method for rehabilitation after total or subtotal glossectomy.     

Swallowing outcomes after microvascular head and neck reconstruction: a prospective review of 191 cases

BACKGROUND: The use of microvascular free tissue flaps tailored specifically to the ablative surgical defects has allowed precise anatomic reconstructions to be performed and, in turn, has improved patient outcomes. We report here the postoperative swallowing outcomes of patients undergoing microvascular reconstructions for a range of head and neck defects at the Cleveland Clinic. METHODS: The study includes 191 consecutive reconstructions for varied defects. All patients were reconstructed with four specific microvascular flaps based on their surgical defect, and postoperative swallowing outcomes were evaluated and recorded on a prospectively maintained database. Pre- and postoperative swallowing was graded on an ordinal scale. Data were simultaneously collected on the precise anatomic ablative defect in each patient, subdividing the head and neck into 16 subsites. The data were analyzed using a multivariate analysis accounting for comorbid factors, type of flap used, and subsite of defect. RESULTS: The findings are summarized as follows. There were no flap failures. The percent of patients who were able to swallow and maintain an exclusively oral diet postoperatively was 78.5%. Only 16.8% were unable to have an oral diet (NPO) and dependent on a gastric tube (G-tube) for feeding. The factors that predicted an inability to swallow include tongue resection, preoperative radiation therapy, and hypopharyngeal defects. In contrast, floor of mouth, mandibular, and pharyngeal defects, regardless of size, had excellent long-term swallowing outcomes. Most patients with these defects were able to tolerate at least a soft solid diet. CONCLUSIONS: In summary, we report excellent postoperative swallowing outcomes after microvascular reconstructions at our institution that compare favorably with outcomes with pedicled flaps and historic controls. The type of flap used and the size of defect had minimal effects on swallowing outcomes. The most difficult subsites to reconstruct were tongue defects, which strongly correlated with poor swallowing outcomes. The other factor that strongly impacted outcomes was preoperative radiation treatment. We believe these results highlight the utility of free flaps in recreating the precise anatomy required to maintain swallowing function. These data will hopefully support numerous previous studies that have established the use of microvascular reconstruction as standard of care for ablative surgical defects in the head and neck.     

A comparison of three methods of oral reconstruction

A protocol is presented that was designed to provide comparative data on the two primary oral cavity functions affected by surgery: speech and swallowing. Three types of reconstruction (skin grafts, hemitongue flaps, and myocutaneous flaps) and results of a series of tests given to 15 surgical patients with T2 and T3 tongue and/or floor of mouth lesions were evaluated. The patients who had split-thickness skin grafts had the best oral function results. The study suggests that tongue mobility is the most significant variable in determining post-operative speech results.     

Groin and anterolateral thigh flaps for hemiglossectomy reconstruction: A comparison based on Japanese speech intelligibility

ObjectiveThe differences in speech function between groin flap reconstruction and anterolateral thigh (ALT) flap reconstruction after hemiglossectomy have not been clarified to date. This study aimed to compare Japanese speech intelligibility after hemiglossectomy reconstruction using groin and ALT flaps of similar thickness.MethodsData of patients who underwent hemiglossectomy reconstruction with groin or ALT flaps between April 2010 and March 2020 were collected from the medical chart database. The ALT flap was the first choice for hemiglossectomy reconstruction, and a groin flap was used when the ALT flap was >10 mm. Cases in which speech intelligibility assessments based on Hirose's 10-point scoring system, the TKR speech test, and the Japanese speech intelligibility test for 100 monosyllables were performed after 6 months postoperatively were extracted. The per-patient scores for each assessment were initially compared between the two flap groups. Then, the results of the Japanese speech intelligibility test for 100 monosyllables were reanalyzed on a syllable-by-syllable basis.ResultsAmong the 44 hemiglossectomy patients who underwent free-flap reconstruction during the study period, 14 (seven each in the groin flap and ALT flap groups) underwent all three conventional speech intelligibility assessments after 6 months postoperatively. The two groups showed no significant difference in postoperative speech intelligibility in any of the three patient assessment methods. However, in intergroup comparisons based on per-syllable accuracy for each of the 100 monosyllables, the groin flap group showed 19 syllables with a significantly higher accuracy, whereas the ALT flap group showed one such syllable. In particular, five out of the six alveolar consonants (/t/ and /d/) were more accurately articulated in the groin flap group. Per-syllable accuracy was significantly higher in the groin flap group (74.6% vs. 66.7%; 95% confidence interval: 4.6–11.1, p < 0.001).ConclusionIn patients undergoing hemiglossectomy reconstruction, our new analysis method, which compared intelligibility by syllables, showed that the groin flap yielded higher speech intelligibility than the ALT flap. This difference was evident at all four articulation points involving the tongue, whereas there was no significant difference at the two articulation points without tongue involvement.     

Functional outcomes after primary mandibular resection and reconstruction with the fibular free flap

OBJECTIVE: This study examined prospectively the functional outcomes of a cohort of patients who have undergone mandibulectomy and primary fibular free flap reconstruction, with particular emphasis on longitudinal comparison of the preoperative function with that in the postoperative and post-radiation therapy time periods. METHODS: Speech and swallowing data were gathered at three evaluation times (preoperatively, pre-radiation therapy, and post-radiation therapy) for patients treated for oral cavity cancer with mandibular resection and reconstruction with a fibular free flap. Single words and sentences were recorded and analyzed for speech intelligibility. Modified barium swallows of liquid, pudding, and cookie consistencies were analyzed and graded for problems in the oral preparatory and oral phase according to the University of Chicago Center for Speech and Swallowing Disorders Oropharyngeal Mobility Data Form. RESULTS: There was no significant difference across any of the evaluation times for single-word or sentence intelligibility. The swallowing data showed no instances of post-treatment aspiration or laryngeal penetration. There were also no significant differences in any of the swallowing parameters across treatment times. CONCLUSIONS: Osteocutaneous fibular free flaps are an excellent reconstructive option for mandibular and floor of the mouth defects.     

Analysis of the relations between the shape of the reconstructed tongue and postoperative functions after subtotal or total glossectomy

OBJECTIVES/HYPOTHESIS: For reconstruction after subtotal or total glossectomy, both preserving the larynx and maintaining postoperative swallowing and speech functions can greatly improve quality of life; however, postoperative functional results are often unstable. Our experiences suggest that insufficient flap volume in the oral area and postoperative prolapse of the preserved larynx affect postoperative function. The objective was to investigate the relations of the shape of the reconstructed tongue to postoperative swallowing and speech functions. STUDY DESIGN: The shape of the reconstructed tongue was classified on the basis of magnetic resonance and intraoral inspection as protuberant, semi-protuberant, flat, or depressed. Speech intelligibility was evaluated, and body weight, which might affect the shape of the transferred flap, was measured before and after surgery. METHODS: Thirty patients who had undergone subtotal or total glossectomy and subsequent reconstruction were reviewed. RESULTS: We found that speech intelligibility (P <.001), food (P <.01), and deglutition (P <.003) scores were significantly lower in patients with flat or depressed tongues than in patients with semi-protuberant or protuberant tongues. Weight loss after surgery was significantly greater in patients with depressed tongues than in other patients (P <.013). Our results indicate that postoperative function is related to the shape of the reconstructed tongue. CONCLUSIONS: We suggest that 1) wider and thicker flaps, such as rectus abdominis musculocutaneous flaps, be used; 2) flaps be designed to be approximately 30% wider than the defect; 3) laryngeal suspension be used to prevent prolapse of the transferred flap; and 4) careful general management and sufficient nutrition are important in the early postoperative period.     

带蒂肌皮瓣及脏器瓣在咽、食管缺损修复中的应用

目的 探讨带蒂组织瓣在咽、食管术后缺损修复中的应用。 方法 2002年1月至2011年12月山东大学齐鲁医院耳鼻咽喉科对因头颈部恶性肿瘤住院的患者行手术治疗,单独或联合应用胸大肌肌皮瓣、舌瓣、喉气管瓣、胃代食管术、结肠上徙术整复咽部及食管的术后缺损,共计186例,对此类患者进行随访并分析治疗效果。 结果 喉癌4例,喉癌术后复发14例,喉癌术后咽瘘4例,喉癌术后咽狭窄1例,下咽癌87例,下咽癌术后咽瘘11例,甲状腺癌5例,扁桃体癌2例,颈段食管癌38例。应用胸大肌肌皮瓣共71例;舌瓣联合喉气管瓣、胸大肌肌皮瓣运用2例,术后均拔除鼻饲管;喉气管瓣40例;胃代食管术58例,55例恢复吞咽功能,喉功能保留率53.4%;结肠上徙术共15例,13例恢复吞咽功能,喉功能保留率93.3%。 结论 带蒂组织瓣因其血供良好,制备简单,技术成熟,无需特殊手术技巧的优势,可满足耳鼻咽喉头颈外科术后修复与重建的要求,在头颈一期整复重建中发挥重要作用。     

Functional outcomes after primary oropharyngeal cancer resection and reconstruction with the radial forearm free flap

OBJECTIVE: To report prospectively collected aeromechanical, acoustical, and perceptual speech outcomes, as well as preliminary swallowing data, in patients having reconstruction with radial forearm free flaps after primary resection for oropharyngeal cancer. STUDY DESIGN: Prospective cohort study. METHODS: Acoustical, aeromechanical, and perceptual speech data and swallowing data were gathered at three evaluation times (preoperatively and before and after radiation therapy) for patients treated for oropharyngeal cancer by means of primary resection and reconstruction with a radial forearm free flap. Degree of involvement of the soft palate and base of tongue, along with reconstructive techniques, were entered as between-group factors in the analysis. RESULTS: There were no significant differences in speech intelligibility between the patient groups based on the degree of palate and tongue resected. However, patients with resections of half or more than half of the soft palate had significantly higher nasalance values and larger velopharyngeal orifice areas than individuals who had less than half of the soft palate resected. Significant within-subject differences were revealed across evaluation times for the dependent variables nasalance, velopharyngeal orifice area, and word intelligibility. Ninety-four percent of the patients were able to resume a normal or soft diet. There was a 6% incidence of aspiration in 128 swallows that were analyzed. The amount of base of tongue resected did not significantly affect any of the speech or swallowing parameters. CONCLUSIONS: Radial forearm free flaps are a good reconstructive option after oropharyngeal cancer extirpation. Our acoustic and aeromechanical results indicated that issues related to quality of the speech signal require further study for resections of half or more than half of the soft palate.     

Radial forearm free flap pharyngoesophageal reconstruction

OBJECTIVES: This study evaluates the outcome of pharyngoesophageal reconstruction using radial forearm free flaps with regard to primary wound healing, speech, and swallowing in patients requiring laryngopharyngectomy. STUDY DESIGN: Retrospective review in the setting of a tertiary, referral, and academic center. PATIENTS AND METHODS: Twenty patients underwent reconstruction of the pharyngoesophageal segment using fasciocutaneous radial forearm free flaps. RESULTS: All free flap transfers were successful. An oral diet was resumed in 85% of the patients after surgery. Postoperative pharyngocutaneous fistulas occurred in 4 patients (20%) with 3 resolving spontaneously. Distal strictures also occurred in 20% of the patients. Five patients who underwent tracheoesophageal puncture achieved useful speech. CONCLUSIONS: Advantages of radial forearm free flaps for microvascular pharyngoesophageal function include high flap reliability, limited donor site morbidity, larger vascular pedicle caliber, and the ability to achieve good quality tracheoesophageal speech. The swallowing outcome is similar to that achieved after jejunal flap pharyngoesophageal reconstruction. The main disadvantage of this technique relates to a moderately high incidence of pharyngocutaneous fistulas, which contributes to delayed oral intake in affected patients.     

Sensate radial forearm free flaps in tongue reconstruction.

BACKGROUND: Successful rehabilitation after ablative surgery requires not only the reconstruction of 3-dimensional form but also the restoration of physiologic function. OBJECTIVE: To assess sensory recovery of reinnervated radial forearm flaps used for tongue reconstruction. PATIENTS AND METHODS: Seventeen patients, who underwent reconstruction of glossectomy defects with reinnervated radial forearm free flaps, formed the study group. Recovery of sensation was measured by both subjective and detailed objective tests 8 months after surgery. Sensory function of the flap was compared with that of the normal residual tongue or the adjacent oral mucosa and the contralateral forearm donor site. RESULTS: All patients involved in this study had tongue defects of hemiglossectomy or greater and adjacent floor of the mouth. Sensory recovery was observed in all of the 17 patients within 8 months. Detailed sensory testing showed that median static 2-point discrimination, moving 2-point discrimination, and pressure sensitivity (1.2 cm, 0.8 cm, and 3.7 psi, respectively) were subjectively greater in the innervated forearm flaps than in the contralateral forearm donor site (2.3 cm, 1.7 cm, and 4.6 psi, respectively) (P= .064) and similar to those of the normal tongue (0.9 cm, 0.5 cm, and 3.6 psi). CONCLUSIONS: In all modalities examined, sensate free flaps proved superior in sensory fidelity to the native forearm donor site and closely approached that of the normal tongue. Microsurgical reinnervation of flaps should be considered in tongue reconstruction.     

游离腹壁下动脉穿支皮瓣应用于舌癌术后缺损修复与舌再造

目的探讨游离腹壁下动脉穿支皮瓣应用在舌癌术后缺损修复与舌再造中的效果。方法2008年12月~2016年1月应用游离腹壁下动脉穿支皮瓣对42例舌癌患者行舌癌根治术同期行舌口底缺损修复与舌再造，其中舌缘癌22例，舌腹癌17例，口底癌累及舌3例，肿瘤根治术后形成6.5 cm×3.5 cm～11.0 cm×7.5 cm大小缺损。术中将腹壁下动脉与甲状腺上动脉吻合，伴行静脉与甲状腺上静脉或颈内静脉吻合。结果皮瓣长(8.6±0.3)cm、宽(5.1±0.2)cm、厚(2.3±0.5)cm。腹壁下动脉穿支皮瓣血管蒂长度为(9.6±0.4)cm。42例肌皮瓣全部存活，供区直接闭合。皮瓣外观满意，供区仅遗留线性瘢痕，腹直肌功能未见明显影响。随访14～64个月。再造舌形态良好，吞咽、语言功能满意，肿瘤局部无复发。结论腹壁下动脉穿支皮瓣组织量丰富，质地好，再造舌外形及功能良好，供区损伤小，是舌癌术后舌、口底缺损修复与舌再造的理想选择。     

Swallowing function following extensive resection of oral or oropharyngeal cancer with laryngeal suspension and cricopharyngeal myotomy

OBJECTIVE: To investigate factors that influence postoperative swallowing function in patients who underwent tongue and oropharynx resection. METHODS: Sixty-two subjects who had undergone extensive resection of oral or oropharyngeal cancer between 1993 and 2005 participated in this study. All surgical procedures involved excision of the bilateral suprahyoid muscles or of >or=50% of the tongue base. Laryngeal suspension and cricopharyngeal myotomy were performed on all subjects. A multivariate analysis of the effects of extensive tongue and oropharynx resection on swallowing function was performed. RESULTS: A total of 53 (85.5%) of the 62 subjects achieved independent oral intake and no longer required tube feeding. Six months after surgery, better eating capabilities had been attained by younger patients as compared with older patients; patients with less extensive tongue base resections; patients who had not undergone radiotherapy; and patients reconstructed with free flaps rather than pedicled flaps. CONCLUSIONS: Age was found to be the most important factor in determining whether a patient could achieve independent oral intake after extensive oral or oropharyngeal resection. The main factors in determining the quality of diet attained by the patient were found to be age, the percentage of tongue base resection, and the method of postoperative reconstruction.     

Supraclavicular flap in head and neck reconstruction: experience in 50 consecutive patients

The supraclavicular flap (SCF) is a fasciocutaneous flap used to cover head, oral, and neck region defects after tumor resection. Its main vascular supply is the supraclavicular artery and accompanying veins and it can be harvested as a vascularised pedicled flap. The SCF serves as an excellent outer skin cover as well as a good inner mucosal lining after oral cavity and head-neck tumor resections. The flap has a wide arc of rotation and matches the skin colour and texture of the face and neck. Between March 2006 and March 2011, the pedicled supraclavicular flap was used for reconstruction in 50 consecutive patients after head and neck tumor resections and certain benign conditions in a tertiary university hospital setting. The flaps were tunnelized under the neck skin to cover the external cervicofacial defects or passed medial to the mandible to give an inner epithelial lining after the oral cavity and oropharyngeal tumor excision. Forty-four of the 50 patients had 100% flap survival with excellent wound healing. All the flaps were harvested in less than 1 h. There were four cases of distal tip desquamation and two patients had complete flap necrosis. Distal flap desquamation was observed in SCFs used for resurfacing the external skin defects after oral cavity tumor ablation and needed only conservative treatment measures. Total flap failure was encountered in two patients who had failed in previous chemoradiotherapy for squamous cell cancer of the floor of mouth and tonsil, respectively, and the SCF was used in mucosal defect closure after tumor ablation. The benefits of a pedicled fasciocutaneous supraclavicular flap are clear; it is thin, reliable, easy, and quick to harvest. In head, face and neck reconstructions, it is a good alternative to free fasciocutaneous flaps, regional pedicled myocutaneous flaps, and the deltopectoral flap.     

Complete reconstruction of the chin and floor of the mouth.

A method of reconstruction of the entire floor of the mouth and chin is presented, utilizing interdigitated ventral tongue flaps for reconstruction of the floor of the mouth, and a deltopectoral flap for reconstruction of the chin, which, even with loss of bony support of the mandible, provides a watertight, competent oral sphincter with adequate communication and nutrition.     

Outcome of surgical and adjuvant radiotherapy treatment of T3-T4 squamous cell carcinoma of the floor of the mouth: evaluation of oncological control and treatment related morbidity

OBJECTIVE: The aims of this study were to evaluate the therapeutic outcome and morbidity associated with management of squamous cell carcinoma (SCC) T3-T4 of the floor of the mouth. PATIENTS AND METHODS: This was a retrospective study (1993 and 2005). Inclusion criteria were: 1) Presence of a locally advanced (T3-T4) lesion of the floor of the mouth; 2) Pathological confirmation of SCC; 3) No previous treatment of the floor of the mouth; 4) Absence of any synchronous lesions at the primary endoscopic work-up; 5) Absence of distant metastasis outside the aero-digestive tract; 6) Karnofsky performance index > 70. All patients were treated by surgery and adjuvant radiotherapy. The statistical analysis was conducted using the stat-view software; categorical variables were compared using the Fisher's exact test; analysis of recurrence-free survival rate was done following the Kaplan-Meier method, and the log-rank test was used for the comparison of survival graphs. RESULTS: Fourty-seven patients were included in this study (42 men), of a mean age of 53.3 years. The majority of patients (93.6%) presented with a stage IVa tumour and no clinical evidence of cervical lymphadenopathy in 60% of cases. All patients underwent bilateral neck dissection adapted to the cervical lymph node status. Forty-one (87%) patients underwent partial mandibulectomy with fibula free-flap reconstruction in 32 cases (78%). Early local complication rate was of 32%. The mean duration of hospitalization was 34 days. Late local complication rate was of 17%. The immediate post-operative death rate was 2%. The rate of survival and recurrence free survival was of 47.5% and 47% respectively. The 3 survival-influencing factors were age (p = 0.02), margins of surgical resection (p = 0.002), and histologic cervical lymph node status (p = 0.03). CONCLUSION: T3-T4 tumours of the floor of the mouth are managed by surgical resection and adjuvant radiotherapy. There is a high rate of treatment-associated complications. The prognosis of locally advanced tumours of the floor of the mouth remains humble.     

The central island tongue flap for the reconstruction of the anterior floor of the mouth]

BACKGROUND: There are several techniques described for the reconstruction of the anterior floor of mouth after tumour surgery. Here, we point out the advantages of the central island tongue flap for this indication. PATIENTS AND METHODS: We report on 20 patients with medium sized defect in the anterior floor of mouth, which was reconstructed with the central island tongue flap. Besides this surgical technique, we discuss the results of oral rehabilitation after a follow-up period of at least 3 months. RESULTS: There was now flap necrosis or loss, and the median time for flap formation was less than 45 min. In the follow-up we found successful oral rehabilitation in speech and swallowing.     

Vibratory segment function after free flap reconstruction of the pharyngoesophagus

Reconstructive options following total laryngo-pharyngectomy include thin, pliable free tissue segments, approximating the natural thickness of the pharyngeal wall. The authors have investigated outcomes in the following clinical series, emphasizing speech and swallowing. Twelve cancer patients underwent laryngopharyngectomy with or without glossectomy. Eight jejunal, 1 radial forearm, and 3 innervated latissimus dorsi flaps were used for vibratory segment (VS) reconstruction, and all 12 patients underwent tracheoesophageal puncture (TEP). Eleven patients achieved intelligible speech, with a median intelligibility of 93%. The vibrating segments showed fluttering of the free flap tissue when studied by videopharyngography. Vocal quality was lower pitched and softer than “conventional” TEP speech. All patients achieved oral intake as their primary mode of nutrition. Free flaps are a successful option for VS reconstruction in patients undergoing laryngopharyngectomy or glossopharyngolaryngectomy, obviating the need for written or electrolarynx communication.     

Functional outcomes following palatal reconstruction with a folded radial forearm free flap

Defects of the soft palate often occur after extirpative procedures are performed to treat oropharyngeal cancers. These defects usually result in velopharyngeal insufficiency and an alteration in speech and deglutition. Palatal prostheses have been used to circumvent this problem in the past. Recently, however, folded radial forearmfreeflaps have been introduced for reconstruction of the soft palate to eliminate velopharyngeal insufficiency and the need for a prosthesis. We conducted a study to evaluate pharyngeal and palatal functions following reconstruction of soft-palate defects with radial forearm free flaps in 16 patients who had undergone resection of the soft palate for squamous cell carcinoma. Nine patients had partial soft-palate defects and 7 had total defects. All patients had lateral pharyngeal-wall defects. In addition, 14 patients had defects of the base of the tongue. Patients were followed for 3 to 40 months. Outcome measures were determined according to several parameters, including postoperative complications, resumption of diet, intelligibility of speech, and decannulation. All patients were evaluated by a speech pathologist and an otolaryngologist with a bedside swallowing evaluation and flexible nasopharyngoscopy. Twelve patients underwent videofluoroscopic studies. There was no incidence of flap failure. One patient developed a transient salivary fistula, which resolved with conservative management. Four patients without dysphagia resumed oral intake 2 weeks after surgery. The 12 patients with dysphagia underwent swallowing therapy. Ten of them responded and were able to resume oral intake, while the other 2 required a palatal prosthesis. Overall, 10 patients resumed a normal diet and 4 tolerated a soft diet within 6 weeks. The 2 patients who required a palatal prosthesis were able to take purees. All patients were decannulated, and all were able to speak intelligibly. Speech was hypernasal in 2 patients and hyponasal in 3. We conclude that the folded radial forearm free flap procedure is a useful alternative for reconstruction of palatal and pharyngeal defects. It is safe and effective, and it results in excellent functional outcomes.     

Free tissue transfer versus pedicled flap in head and neck reconstruction

OBJECTIVES: Free flaps are often criticized as being medically risky for the patient, expensive, and too time-consuming when compared with the traditional rotational flap repair. Perhaps the costs do not outweigh the benefits. The study analyzes many aspects of resource utilization and patient outcome to determine whether these criticisms hold true. STUDY DESIGN: Retrospective patient review. METHODS: Sixty-five patient charts were reviewed. The following data were abstracted: flap type, tumor location and stage, preoperative American Society of Anesthesiologists score, preoperative irradiation, postoperative medical complications, flap outcome, length of hospital stay, date of first intake by mouth, and date of decannulation. The data were analyzed for free flaps and rotational flaps. Then data were analyzed again for free and rotational flaps performed for only patients who underwent a composite resection, to further standardize the results. RESULTS: For all defect types, free flap operative time was statistically greater (9 h 35 min for free flaps vs. 4 h 58 min for rotational flaps). Regarding hospital charges, only patients who had a free flap after composite resection differed in amount charged when free versus rotational flaps were compared (53,585 dollars for free flaps vs. 32,984 dollars for rotational flaps). Length of intensive care unit stay differed between patients having composite resection of the two flap types (0.1 d after rotational flap vs. 1.4 d after free flap). CONCLUSIONS: The differences between the two reconstruction methods are only a few. We do not think that longer operative time, longer length of intensive care unit stay, and increased hospital charges are significant enough to deny a patient a superior repair. We also think that as surgeons' experience increases, these differences may one day no longer hold true.