Reconstruction Of Oral Cavity Defects Research Articles

Predictors of Complications After Flap Reconstruction of Oral Cavity Defects Following Ablation of Squamous Cell Carcinoma

Background: Head and neck cancers represent the sixth most common cancer worldwide with an incidence of over 600,000 new cases per year. More than 90% of head and neck cancers are squamous cell carcinomas (SCC) that arise from the mucosal surfaces of the oral cavity, oropharynx and larynx. Objective: The aim of the current work was to investigate the predictors of complications after flap reconstruction of oral cavity defects following ablation of squamous cell carcinoma. Patients and methods: This prospective comparative study included a total of 41 patients who diagnosed to have oral SCCs, attending at the outpatient clinic of Head and Neck Surgery Unit, National Cancer Institute (NCI), Cairo University and Aswan University Hospital. Written informed consent of all the subjects was obtained after explaining the benefits and hazards for each method step. This study was conducted between 2015 to 2018. Approval of the ethical committee was obtained. Results: Patients with positive history of neoadjuvant chemoradiotherapy (CRTH) are 52% less likely to developing complications than those with negative history of neoadjuvant CRTH. Detection of the short-term oncologic outcome; in the 4 flaps was better in contralateral submental island flap (CSMIF) cases than others. CSMIF were found to be 58% less liable for recurrence in comparison with pectoralis major myocutaneous flap (PMMCF) that was why it didn't show any clinical or radiologically detectable recurrence within the period of 24 months postoperatively. Thoracodorsal artery perforator (TDAP) flaps were 2.6 times more liable for recurrence in comparison with PMMCF. RFFF flaps were found to be 1.2 times more liable for recurrence in comparison with PMMCF. Conclusion: The chosen 4 flaps for this study are applicable to be used for post ablative oral cavity reconstruction. Our flaps were equal in suitability for defect coverage (50-60%).

Pedicled Versus Microvascular Free Flaps Used for Reconstruction of Oral Cavity Defects Following Cancer Ablative Surgery: A Prospective Comparative Study

Background: Oral cancer is currently a major global health issue. In developing countries, oral cavity cancer is estimated to be the third most common malignancy after cancer of the cervix and stomach. Surgical excision plays a major role in the treatment of oral cavity cancer patients. Objective: The aim of the study was to compare between pedicled and free flaps used for oral cavity reconstruction after ablation of squamous cell carcinoma. Patients and methods: This is a prospective comparative study that included 41 patients at National Cancer Institute (NCI) of Cairo University and Aswan University Hospital in the period from 2015 to 2018. Patients were selected from those who were attending the Outpatient Clinic of Head and Neck Surgery Unit at NCI, Cairo University and Aswan University Hospital. Results: Detection of short-term functional outcome regarding the swallowing, speech and oral competence, Contralateral Submental Island Flap (CSMIF) followed by Radial Forearm Free Flap (RFFF) showed better functional results than other flaps. The cosmetic outcome was better in 50% of CSMIF & RFFF cases. The Thoracodorsal Artery Perforator Flap (TDAPF) cases showed a slightly higher care costs than other cases although in other specialized centers the care costs were found to be higher in RFFF cases than others. Conclusion: Oncologic outcomes were better with CSMIF and cosmetic outcomes were better in CSMIF and RFFF cases. Relatively, TDAP flap cases were higher than others in the overall care costs.

Pedicled Versus Microvascular Free Flaps Used for Reconstruction of Oral Cavity Defects Following Cancer Ablative Surgery: A Prospective Comparative Study

Background: Oral cancer is currently a major global health issue. In developing countries, oral cavity cancer is estimated to be the third most common malignancy after cancer of the cervix and stomach. Surgical excision plays a major role in the treatment of oral cavity cancer patients. Objective: The aim of the study was to compare between pedicled and free flaps used for oral cavity reconstruction after ablation of squamous cell carcinoma. Patients and methods: This is a prospective comparative study that included 41 patients at National Cancer Institute (NCI) of Cairo University and Aswan University Hospital in the period from 2015 to 2018. Patients were selected from those who were attending the Outpatient Clinic of Head and Neck Surgery Unit at NCI, Cairo University and Aswan University Hospital. Results: Detection of short-term functional outcome regarding the swallowing, speech and oral competence, Contralateral Submental Island Flap (CSMIF) followed by Radial Forearm Free Flap (RFFF) showed better functional results than other flaps. The cosmetic outcome was better in 50% of CSMIF & RFFF cases. The Thoracodorsal Artery Perforator Flap (TDAPF) cases showed a slightly higher care costs than other cases although in other specialized centers the care costs were found to be higher in RFFF cases than others. Conclusion: Oncologic outcomes were better with CSMIF and cosmetic outcomes were better in CSMIF and RFFF cases. Relatively, TDAP flap cases were higher than others in the overall care costs.

Subclavicular flap: A valid reconstructive option among anterior chest flaps in oral cancer patients

The subclavicular pedicled flap is based on the thoracic branch of the supraclavicular artery, and it represents a versatile reconstructive option for low-middle third face defects. Since its use in head and neck surgical oncology has not been popularized yet, we propose its application for oral cavity reconstruction after cancer resection by showing favorable results. Eighteen subclavicular pedicled flaps were used to treat intraoral defects after oral squamous-cell cancer resection between June 2015 and December 2018. Tumor dissection type, complications, donor and reconstructed area results, and functional and aesthetic outcomes were assessed. No major complications were observed and all of the flaps survived. Adjuvant therapy was administered without delay when needed, and all of the patients had normal functional outcomes and good aesthetic results. The subclavicular flap is an excellent choice for the reconstruction of oral cavity defects. Selection of patients should exclude positive lower-third neck node and include appropriate informed consent for women due to the possibility of deformity of the breast. In our opinion, this flap has the potential for common application given its consistent anatomy and donor site advantages, including long pedicle, high pivot point, and relatively unlimited flap width.

A Unifying Algorithm in Microvascular Reconstruction of Oral Cavity Defects Using the Trilaminar Concept.

Background:Although many algorithms exist to classify oral cavity defects, they are limited by either considering a single subsite or failing to provide a concise reconstructive algorithm for the breadth of defects. Based upon our experience as a tertiary referral center, a unifying algorithm is presented that guides free flap selection in this heterogenous population.Methods:All intraoral defects requiring microvascular reconstruction from February 2012 to August 2018 were reviewed. Defects were classified according to their depth as unilaminar (type U = mucosa only), bilaminar (type B = mucosa and bone), or trilaminar (type T = mucosa, bone, and skin) and the number and side of mucosal zones involved (from 1 to 5). Hard palate defects were considered separately and excluded if part of a wider maxillectomy defect.Results:A total of 118 patients were eligible for inclusion in the study. Of type U defects involving 1 mucosal zone, 98% were reconstructed with a radial forearm free flap. Ninety-two percentage of type U defects involving ≥2 mucosal zones were reconstructed with an anterolateral thigh flap. Among type B defects, 86% were reconstructed with a fibula osseocutaneous free flap if less than 4 mucosal zones were involved and 100% reconstructed with an ALT if ≥4 mucosal zones were involved. The algorithm presented was accurate for 93% of the cases. Ninety-eight percentage of patients achieved intelligible speech and 72% returned to a normal diet. Flap success rate was 100%.Conclusions:The algorithm presented provides a simple system to guide the reconstruction of oral cavity defects.

Infrahyoid Flap, a Convenient Alternative for Reconstruction of Tongue and Floor of Mouth Defects: Case Series.

The aim of this study was to share our clinical experience with the neurovascular myofasiocutan infrahyoid flap (NMIHF), which was used for the reconstruction of the defects after oral cavity cancer surgery. Records of five patients who were diagnosed with oral cavity cancer and underwent tumor resection, neck dissection, and defect reconstruction with NMIHF between 2012 and 2017 were analyzed retrospectively. The infrahyoid flap was used in five patients: four males and one female. The mean age of patients was 61.8 years. Four patients underwent tumor resection and bilateral level I-III neck dissection, whereas one patient underwent tumor resection and unilateral level I-III neck dissection. NMIHF was used for the reconstruction of the defects during the same procedure in all the patients. Mean post-operative follow-up was 30.6 months. Partial skin necrosis was observed in two patients, but none of the patients showed total necrosis of the flap. Postoperatively, oral intake was initiated after an average of 12 days in all patients. For two patients who required post-operative radiotherapy (RT), the treatment was started after an average of 50 days. NMIHF does not prolong operation time and does not cause additional scar in the neck, and the defect in the donor field can be closed without the use of a graft or flap. This is considered to be a reliable and successful alternative to free flaps for the reconstruction of oral cavity defects.

Nasotracheal Intubation: The Preferred Airway in Oral Cavity Microvascular Reconstructive Surgery?

We aimed to describe the safety and effectiveness of nasotracheal intubation (NTI) in a cohort of patients undergoing reconstruction of oral cavity defects with free tissue transfer (FTT). We implemented a retrospective cohort study and enrolled a sample composed of consecutive patients undergoing FTT reconstruction of oral cavity, maxillary, or mandibular defects between 2013 and 2017. These patients were all subject to a newly developed enhanced recovery-after-surgery protocol. The primary outcome measurement was hospital length of stay (LOS). The secondary outcome variables were the duration of mechanical ventilation, intensive care unit (ICU) LOS, need for gastrostomy, and airway-related complications directly associated with either NTI or tracheostomy. Descriptive statistics and a multivariate logistic regression analysis were completed. The sample was composed of 141 patients who had undergone oral cavity FTT for both benign and malignant diseases (NTI, n=111; tracheostomy, n=30). Patients managed with NTI had a statistically significantly shorter hospital LOS (8days vs 15.5days, P<.0001) and ICU LOS (1day vs 2days, P=.0006), as well as a decreased requirement for gastrostomy (17.1% vs 76.7%, P<.0001). Airway-related complications were rare in both the tracheostomy (13.3%) and NTI (3.6%) groups. Multivariate analysis showed that patients undergoing tracheostomy were 3.14 (P=.004) times more likely to have a prolonged hospitalization and 10.4 (P<.0001) times more likely to require a gastrostomy. A sensitivity analysis of only patients with malignant diagnoses had similar statistically significant results. The delayed tracheostomy rate in the NTI group was 3.6%. To date, this is the largest study to evaluate the use of NTI in patients undergoing oral cavity reconstruction with FTT. Our results suggest that in the appropriate institutional setting, most patients can be safely managed with NTI. This approach results in a decreased hospital LOS and ICU LOS and an earlier resumption of oral intake with less need for gastrostomy.

Cervicofacial-facial artery myocutaneous flap (C-FAM flap): A novel flap in oral cavity reconstruction.

Reconstruction is an integral part of the surgical management of oral cancer. Local flaps are one of the options in reconstruction of small to moderate sized defects of oral cavity. Reconstruction is an integral part of the surgical management of oral cancer. Every defect needs to be assessed individually to tailor made the reconstruction because of its multidimensionality and complexity. Varieties of autologous tissues are being used in reconstruction like local, regional, or free flaps which can be simple or complex tissues. There is always a trend to identify the newer flaps/technique to personalize reconstruction. Local flaps are also one of the options in reconstruction of small to moderate sized defects of oral cavity. Local tissue if it is available is in the primary surgeon's purview and the flap can be raised without much technical difficulty and morbidity. We used perforator based tissue from the face and neck which is richly supplied by the facial vessels and named as the Cervicofacial- Facial Artery Myocutaneous flap (C-FAM flap) for reconstruction of oral cavity. We used perforator based local tissue from the face and neck which is supplied by facial vessels and named it as the C-FAM flap for the reconstruction of oral cavity defects. Twenty-eight patients underwent C-FAM flap reconstruction in different subsites of the oral cavity with acceptable functional rehabilitation. There was no flap loss. The C-FAM flap is a robust flap, which is reliable, pliable, and rich in its vascularity. It has to be one of the armamentarium for the oral cavity reconstruction. C-FAM flap: A Novel flap in Oral cavity reconstruction.

A Retrospective Volume Matched Analysis of the Submental Artery Island Pedicled Flap as Compared to the Forearm Free Flap: Is It a Good Alternative Choice for the Reconstruction of Defects of the Oral Cavity and Oropharynx?

The submental artery island pedicled flap (SMIF) is an underused alternative for reconstruction of head and neck defects after tumor ablation. The purpose of this study was to perform a comparative evaluation of reconstructive outcomes based on surgical site and ablative defect volume in patients who underwent reconstruction with the SMIF versus the forearm free flap (FFF). A retrospective cohort study of all patients with oral cavity and oropharyngeal defects reconstructed with the SMIF and a cohort of patients with similar volume defects reconstructed with the FFF were compared for oncologic safety and viability of equivalent reconstructive outcomes. All statistical comparisons were assessed by analysis of variance and Fisher exact test. Average age was 61.8years in the SMIF group versus 57.9years in the FFF group. The most common defect was located in the tongue, with squamous cell carcinoma being the most common pathology identified. Flap volumes were similar (SMIF, 38.79cm3; FFF, 39.77cm3). Significant comparative outcomes identified with SMIF versus FFF reconstruction included shorter anesthesia times (815 vs 1,209minutes; P<.001), shorter operative times (653 vs 1,031minutes; P<.001), and less blood loss (223 vs 398mL; P=.04). Postoperative Eastern Co-operative Oncology Group performance score increased more for the FFF than for the SMIF group (+0.33 vs+1.25; P=.0019). Recipient site complication rates were lower for the FFF group (0.17 vs 0.42 per patient) but were not statistically relevant. There were equal rates of recurrence at the local surgical site and no differences in speech and swallowing function. Mean follow-up was 15.5months. This is the first study to compare the SMIF with the FFF for reconstruction of oral cavity defects based on ablative volume deficit. The SMIF is a viable surgical option compared with the FFF that can be considered oncologically safe in the N0 neck, allowing for an excellent esthetic reconstruction, with decreased operative time, hospital stay, and donor site morbidity.

Ulnar fasciocutaneous free flap for reconstruction of oral cavity defects: a retrospective review

Ulnar fasciocutaneous free flap for reconstruction of oral cavity defects: a retrospective review

Calf Perforator Flaps: A Freestyle Solution for Oral Cavity Reconstruction.

Reconstruction of oral cavity defects requires a thin, pliable flap for optimal functional results. Traditional flap choices are imperfect: the anterolateral thigh flap is excessively thick, whereas the radial forearm flap has a poor donor site. The authors therefore favor calf perforator flaps such as the medial sural artery perforator flap to provide thin tissue with an acceptable donor site. This two-part study aims to demonstrate their suitability for intraoral reconstruction. In the radiologic part of the study, the authors compared thigh and calf tissue thickness by examining lower limb computed tomographic scans of 100 legs. For their clinical study, they collected data prospectively on 20 cases of oral cavity reconstruction using calf perforator flaps. The mean thickness of the calf tissue envelope was significantly less than that of the thigh (8.4 mm compared with 17 mm) based on computed tomographic analysis. In the clinical study, a medial sural artery perforator was used in the majority of cases (17 of 20). The mean pedicle length was 10.2 cm and the mean time to raise a flap was 85 minutes. There were no flap losses. One patient was returned to the operating room for management of late hematoma and wound dehiscence. Calf perforator flaps provide ideal tissue for intraoral reconstruction and are significantly thinner than anterolateral thigh flaps. In addition to medial sural artery perforator flaps, the authors raised both sural and soleal artery perforator flaps in this series. Opportunistic use of the calf donor site allows the harvest of thin tissue with minimal donor-site morbidity. Therapeutic, IV.

Quantitative analysis of chronological changes in the volume of flaps used for reconstruction of oral cavity defects.

Reconstruction of oral defects using flaps following resection of oral cancer has become a standard approach for restoration of oral function. The purpose of this study was to investigate chronological changes in the volume of such flaps used for reconstruction and the factors affecting flap volume. We performed a retrospective analysis of 17 patients who had undergone oral cancer resection and reconstruction with flaps. Measurements were performed using data from computed tomography, and the flaps were selected semi-automatically using a computer-operated region-of-interest system. The data indicated that the change in total flap volume at 1 year after surgery was 30.6%, and that body weight loss was a risk factor for volume reduction. Our results suggested that flaps should be at least 30% larger than the defects they are intended to repair. However, as large flaps have the potential to cause upper airway obstruction, flap volume should be determined on an individual basis according to defect size and location.

Reconstruction of Oral Cavity Defects With FAMM (Facial Artery Musculomucosal) Flaps. Our Experience

Introduction and objectivesThe facial artery musculomucosal (FAMM) flap is a good option for covering small and medium-sized defects in the oral cavity because of its similar tissue characteristics and easy implementation. MethodsWe reviewed our results using this flap between 2006 and 2014. A total of 20 patients were included and 25 FAMM flaps were performed, 16 right (64%) and 9 left (36%) flaps. Five patients had simultaneous bilateral reconstructions. The indications for flap surgery were reconstruction after resection of tumours in the floor of the mouth (8 cases, 40%), tumours in other sites of the oral cavity (4 cases, 20%), mandibular osteoradionecrosis (4 cases, 20%), oroantral fistula (3 cases, 15%), and postoperative ankyloglossia (one case, 5%). ResultsReconstruction was successful in 92% of cases (n=23). Total flap necrosis occurred in one case and dehiscence with exposure of bone in another. Oral function and ingestion were satisfactory in all patients. ConclusionsThe facial artery musculomucosal flap is reliable and versatile for reconstruction of small and medium-sized intraoral defects. It allows functional reconstruction of the oral cavity with a low risk of complications.

Head and Neck Reconstruction Using the Superiorly Based Reversed-Flow Facial Artery Myomucosal Flap

The use of myomucosal buccinator flaps in the reconstruction of oral cavity defects is well established in the international literature; however, their use for the reconstruction of defects not in the oral cavity has been largely underestimated. The purpose of this report was to describe and review the applications of the superiorly based facial artery myomucosal (FAMM) flap in head and neck reconstruction. This study was a retrospective evaluation of 12 patients who underwent reconstruction of the palate, lip, nasal septum, and conjunctiva with reversed-flow FAMM flaps. Mouth opening, speech, reconstruction effectiveness, and esthetic outcomes were analyzed. The patient cohort consisted of 7 men and 5 women 33 to 80 years old (mean, 56.2 yr old). No major complication occurred. Cosmetic results were excellent in most patients. Functionally, the best reconstruction results were obtained in the palate, lip, and conjunctiva. Nasal reconstruction led to mild airway obstruction in 2 cases and severe obstruction in 1 case. The superiorly based FAMM flap plays an important role in the reconstruction of particular defects involving the oral cavity and other distant sites of the head and neck area. The reliability, low morbidity, and optimal results that can be achieved using this technique make this flap a good option for such reconstructions.

Clinical Application of the Dorsalis Pedis Free Flap for Reconstruction of Oral Cancer Defects

The purposes of this study were to evaluate the clinical application and efficacy of the dorsalis pedis fasciocutaneous flap in the reconstruction of oral cavity defects and to assess the associated donor-site morbidity. From September 2009 to December 2012, 7 patients with associated oral cavity defects resulting from tumor resection underwent reconstruction with a dorsalis pedis fasciocutaneous flap. Surgical anatomy and harvesting procedure of the dorsalis pedis flap are described. Special consideration was given to the associated donor-site morbidity. All flaps survived without any complications. All 7 flaps were based on the dorsalis pedis artery and the greater saphenous vein for perfusion and drainage respectively. In all 7 cases, the donor site was closed with a full-thickness skin graft, with no associated healing complications or functional deficit of the foot. The resulting scar was well hidden in the lower extremity. The dorsalis pedis fasciocutaneous flap is a thin and pliable flap sharing many similarities with the radial forearm flap, thus making it ideal for intraoral reconstruction. Proper intraoperative and postoperative care of the donor site can result in minimal morbidity, as shown in this study. This flap may provide an ideal alternative to the radial forearm free flap, with the added advantages of a well-hidden scar and a high level of patient satisfaction.

Reconstruction of oral cavity defects by locoregional flaps: our experience

Reconstruction of intraoral defects is a challenging task which has known a progressive development from the use of prosthesis, to local, regional and free flaps. Although reconstruction with free flaps guarantees excellent rehabilitation both functionally and esthetically, however the use of microvascular techniques is demanding for the patients, and not always feasible. A variety of local flaps for reconstruction of intraoral defects have been described, and they represent an invaluable option to treat those patients that are not deemed good candidates for more complex reconstruction due to advanced age or poor general conditions.

Single perforator based anterolateral thigh flap for reconstruction of large composite defects of oral cavity

Composite defects of oral cavity are a reconstructive challenge. Anterolateral thigh flap provides large and pliable tissue for reconstruction of these defects. However, wide variations in the vascular anatomy, variable perforator number and location are reported. The aim of this study was to evaluate the reliability of single perforator based large anterolateral thigh for reconstruction of complex oral cavity defects following ablative surgery. We report a series of 25 consecutive patients who underwent reconstruction of oral cavity defects with anterolateral thigh flap based on single perforator between August 2009 and August 2010. The mean flap dimension was 261cm(2) (range 80-540cm(2)). In 21 patients the flap was bi-paddled and used for inner and outer lining for cheek. None of the flaps developed perforator insufficiency. Two flaps were lost due to delayed neck wound sepsis after 7th post operative day. This study establishes safety and reliability of using a large and/or bi-paddled anterolateral thigh flap based on single perforator for reconstruction of complex oral cavity defects.

Platysma myocutaneous flap for oral cavity reconstruction

A retrospective study was conducted to assess outcomes of reconstruction of the oral cavity with the platysma myocutaneous flap, in terms of flap survival, complications, and quality of life. Included were 10 patients with squamous cell carcinoma (stage T1 to T4; nodal status N0 to N2) of the oral cavity who were treated between 2002 and 2006. Each patient underwent tumor resection, modified radical neck dissection, and primary reconstruction with a platysma myocutaneous flap. Operating time, length of stay, time to swallow, and complications were assessed, and the University of Washington Quality of Life questionnaire was administered. Mean operating time was <4 hours, mean length of stay was 11 days, and mean time to swallow was 9 days. One patient had distal flap necrosis and one had wound dehiscence. No total flap failures or fistulas occurred. The authors conclude that the platysma myocutaneous flap provides thin, pliable, reliable tissue for use in the oral cavity. The additional operating room time is negligible, the surgical complications minimal, and the overall quality of life very good. This flap should be used more frequently in the reconstruction of oral cavity defects.

O6. Free flap arterial and venous anastomosis monitoring in post-operative head and neck reconstruction of oral cavity defects

O6. Free flap arterial and venous anastomosis monitoring in post-operative head and neck reconstruction of oral cavity defects

Reconstruction of Oromandibular Defects by Vascularized Free Flaps: The Radial Forearm Free Flap and Fibular Free Flap as Major Donor Sites

Since the advent of the modern microvascular techniques, the radial forearm free flap (RFFF) and the vascularized fibular free flap (VFFF) have become reliable methods for reconstructing oromandibular defects. The purpose of this study is to evaluate our experience with the use of both free flaps in the reconstruction of oral cavity defects after tumoral ablation. Over a 9-year period, 103 consecutive patients were treated in our department for the reconstruction of oral defects after tumor ablation by means of microvascularized free flaps. A total of 55 patients underwent reconstruction using RFFFs; 42 patients underwent reconstruction using VFFFs with or without skin paddles. Patients were treated for benign (n = 15) and malignant (n = 82) entities. All but 7 patients received donor site covering with abdominal full-thickness skin grafts. Of the 55 patients who received RFFFs, 5 (9.09%) developed necrosis at the end of the postsurgical period, and 7 patients developed complications of the donor site. Of the 42 patients who received VFFFs, an overall flap survival rate of 92.85% was achieved, and complications at the donor site occurred in 5 patients. For both free flaps, anesthesia time lasted from 6 to 15 hours (mean, 9.57 hours), whereas the mean flap ischemic time was 82.86 minutes. Our results reveal that the RFFF is a reliable method for reconstructing a wide range of oral cavity defects with an acceptably low morbidity rate. It provides adequate bulk and pliability, enabling the reconstruction of a wide variety of locations within the oral cavity. The VFFF allows good reconstruction of composite mandibular defects and provides adequate support for dental implants.