Oral cavity reconstruction with pedicled and free flaps: A single institutional experience

Zahoor Ahmad Teli; Rajesh Arvind Kantharia; Shehnaz R Kantharia; Siddharth Mahesh Vyas; Yogesh Bhatt; Piyush Doshi

doi:10.4103/oji.oji_10_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 5 | Issue : 2 | Page : 60-66

Oral cavity reconstruction with pedicled and free flaps: A single institutional experience

Zahoor Ahmad Teli, Rajesh Arvind Kantharia, Shehnaz R Kantharia, Siddharth Mahesh Vyas, Yogesh Bhatt, Piyush Doshi
Department of Head and Neck Surgical Oncology, Kailash Cancer Hospital and Research Centre, Goraj, Vadodara, Gujarat, India

Date of Submission	12-Feb-2021
Date of Decision	09-Apr-2021
Date of Acceptance	03-May-2021
Date of Web Publication	21-Aug-2021

Correspondence Address:
Rajesh Arvind Kantharia
Kailash Cancer Hospital and Research Centre, Goraj, Vadodara, Gujarat
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/oji.oji_10_21

Abstract

Background: In Indian subcontinent, oral cavity cancer is the most common cancer in males and the 4th most common in females. Seventy percent of these patients present in advanced stages and resection of these advanced cancers lead to complex orofacial defects requiring primary reconstruction to restore form, function, and cosmesis. Aim: This study aims to evaluate the results of pedicled and microvascular free flaps (MFFs) for oral cavity defects following resection of locally advanced oral cancer. Materials and Methods: A retrospective analysis of prospectively collected data of patients who underwent composite resection followed by reconstruction with pedicled or MFFs for locally advanced oral cancer from January 2018 to September 2019 was done. The demographic details, primary tumor site, tumor stage, defect type, flap type, and complication rates were analyzed. Results: Primary reconstruction was offered to 540 patients with pedicled flaps for 421 patients and MFFs for 119 patients. Patient distribution as per current Tumor, Node, and Metastasis staging was pT1/T2: 91, pT3: 179, and pT4: 270. Reconstruction offered for different oral cavity subsites was – buccal mucosa (n = 374), retromolar trigone (n = 10), alveolus (n = 75), tongue (n = 52), lower gingivobuccal sulcus (n = 11), floor of mouth (n = 4), upper gingivobuccal sulcus (n = 5), and lower lip (n = 9). We classified the types of defects into mucosal (n = 32), mucosal with bone (n = 370), mucosal with bone and skin (n = 101), mucosal with skin (n = 14), skin (n = 3), and central mandibular arch (n = 20). The overall rate of complications in pedicled flaps was 12.11% and MFFs was 20.16%. The success rate for pedicled flaps was 100% and for MFFs was 94.96%. Conclusion: In our study, MFF reconstruction had a good success rate with satisfactory functional and cosmetic outcomes.

Keywords: Microvascular free flap, oral cavity cancer defects, outcomes, pedicled flap

How to cite this article:
Teli ZA, Kantharia RA, Kantharia SR, Vyas SM, Bhatt Y, Doshi P. Oral cavity reconstruction with pedicled and free flaps: A single institutional experience. Oncol J India 2021;5:60-6

How to cite this URL:
Teli ZA, Kantharia RA, Kantharia SR, Vyas SM, Bhatt Y, Doshi P. Oral cavity reconstruction with pedicled and free flaps: A single institutional experience. Oncol J India [serial online] 2021 [cited 2023 Mar 29];5:60-6. Available from: https://www.ojionline.org/text.asp?2021/5/2/60/324228

Introduction

Resections of oral cavity cancers produce defects which should be adequately reconstructed to restore various functions such as speech, swallowing, mouth opening, and esthetics.^[1] Reconstructive options for oral cavity cancer defects range from pedicled flaps to microvascular free flaps (MFFs). Pedicled flaps include pectoralis major myocutaneous (PMMC) flap and deltopectoral (DP) flap, and the MFFs include free radial artery forearm, anterolateral thigh (ALT), and free fibula osteocutaneous (FFOC) flaps. With the option of MFFs now available in most of the centres, the reconstructive surgeon uses it for complex oral cavity defects to achieve better cosmesis and function. In cancer centres having good infrastructure and availability of full time reconstructive surgeons, free tissue transfer has become the first choice of reconstruction. However, the use of microvascular technique is demanding for some patients, sometimes financially not viable and not always feasible in a resource-constraint setting. Pedicled flap for reconstruction of oral cavity cancer defects is still an invaluable option to treat those patients in high-volume centers with a long waiting for microvascular reconstruction. In our center in spite of good infrastructure and available resources, pedicled flap is still the choice of primary reconstruction with high success rate and less flap-related complications. Herein, we present our center's experience on reconstruction of oral cavity cancer defects following resection of advanced cancers. Our center is a high-volume rural tertiary comprehensive cancer center with the required infrastructure, support, and resources.

Materials and Methods

A retrospective analysis of prospectively collected data was done in the department of head-and-neck surgery of a tertiary care cancer hospital. Advanced stage oral cavity cancer patients who underwent composite resection followed by primary reconstruction from January 2018 to September 2019 were analyzed. This study was approved by the institutional review board (IRB), and all participants signed an informed consent agreement. Patients requiring either pedicled flaps or MFFs were included in the study. The patients in whom we used local flaps and split-thickness skin grafts were excluded. All the MFFs were done by a senior plastic and reconstructive surgeon and pedicled flaps by senior head-and-neck consultants and surgical fellows undergoing training. Our Institutional protocol for reconstruction of oral cavity cancer defects is mentioned in [Table 1]. Patient's demographic details, primary tumor site, tumor stage, defect type, flap type, and complications were analyzed. The postoperative complications were divided into major and minor categories. A major complication was defined to be the one which required an additional surgical procedure and minor complication was the one that resolves of its own with conservative treatment or minimal intervention.

Table 1: Institutional protocol for reconstruction of oral cavity cancer defects

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Results

The study population consisted of advanced-stage oral squamous cell carcinoma patients requiring either pedicled or MFFs for reconstruction. Total of 540 patients were enrolled in the study, of which 453 were male and 87 females. The age ranged from 25 to 79 years, with a mean age of 47 years. The age-wise distribution of patients is presented in [Table 2]. The distribution of patients as per the American Joint Committee on Cancer 8^th edition of Tumor, Node, and Metastasis staging was pT1/T2: 91 cases, pT3: 179 cases, and pT4: 270 cases.

Table 2: Distribution of patients according to age and sex

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The reconstruction offered for malignancy of different subsites of oral cavity and the distribution of flaps is mentioned in [Table 3]. Among subsites of oral cavity malignancies, buccal mucosa was the most common (n = 374) followed by alveolus (n = 75), tongue (n = 52), gingivobuccal sulcus, retromolar trigone, lower lip, and floor of mouth. The types of flaps used were pedicled flaps (n = 421) and MFFs (n = 119). The pedicled flaps used were PMMC flap with single paddle (n = 341), PMMC flap with double paddle (n = 36), flap DP (n = 3), and PMMC + DP (n = 41). The types of MFFs used were free radial artery forearm flap (FRAFF): n = 45, ALT: n = 50, FFOC flap: n = 20, and medial sural artery perforator flap: n = 4. The classification of oral cavity defects and the type of reconstruction is depicted in [Table 4]. Patients with mucosal defects and central mandibular arch defects underwent MFF reconstruction. Whereas, pedicled flap (PF) was performed for majority of mucosal plus bone defects (337 out of 370 patients) and mucosal plus bone plus skin defects (77 out of 101 patients).

Table 3: Subsites of oral cavity malignancies and distribution of flaps used for reconstruction of oral cavity cancer defects

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Table 4: Classification of oral cavity cancer defects with the type of reconstruction offered

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The complications arising from pedicled and MFF are mentioned in [Table 5]. The overall rate of complications in our study was 13.89% (75 out of 540). The complication rate for pedicled flaps was 12.11% (51 out of 421) and for MFFs was 20.16% (24 out of 119). There was no major complication seen in pedicled flaps. The minor complications seen in pedicled flaps (12.11%) were partial flap loss (n = 15), wound dehiscence (n = 20), wound infection (n = 5), bleeding/hematoma (n = 5), orocutaneous fistula (n = 4), and donor site complications (n = 2).

Table 5: Complications seen in both pedicled and microvascular flaps

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In MFFs (n = 119), major complications were seen in 11.76% of patients (n = 14) and minor complications in 8.40% of cases (n = 10). Vascular compromise was the most common cause for the major complications, with venous congestion seen in 9 patients, arterial insufficiency in 3 patients, and bleeding/hematoma in 2 patients. Re-exploration was done in 14 patients having major complications: 6 for FRAFF, 4 for ALT, and 4 for FFOC. Re-exploration with flap salvage was possible in 8 patients (57.14%). The salvage rate was more in patients with venous congestion and in FRAFF patients. Total flap loss was seen in the rest 6 out of 14 patients (42.86%): 2 for FRAFF, 2 for ALT, and 2 for FFOC. Four out of six patients with flap loss were reconstructed with PMMC flap and two patients with tongue defects were closed primarily. Minor complications were wound dehiscence (n = 3), wound infection (n = 2), reconstruction plate exposure (n = 2), and donor site complications (n = 3).

Discussion

Primary reconstruction of complex oral cavity defects following resection of advanced oral squamous cell carcinoma is of prime importance to achieve acceptable functional and cosmetic results for a better quality of life in these patients. With the increase in the number of advanced cases, the options for reconstruction from commonly used pedicled flaps to MFFs have also increased considerably. With proper planning and accurate evaluation of these defects, good functional outcomes can be achieved. Currently, MFFs are considered to be the first option for reconstruction of complex oral cavity defects. Reconstruction with free flaps gives excellent functional and esthetic outcomes, however, the use of microvascular techniques is demanding for some patients, sometimes financially not viable and not always feasible in a resource-constraint setting. Pedicled flap for reconstruction of oral cavity cancer defects is still used and is an invaluable option to treat those patients that are not deemed good candidates for microvascular reconstruction due to advanced age or poor general conditions or associated comorbidities.

Most of the patients in our study were in the fifth decade of their life, with an age ranging between 25 and 79 years, with around one-third of the patients in the age group below 40 years. Gupta et al.^[2] and Bhanja et al.^[3] have shown in their studies that middle age group was the commonly affected, followed by younger age group. Seventy percent of our patients presented in advanced stage which is also seen in other studies. Chakrabarti et al.^[4] have seen in their study that most of the oral cancer patients operated in India are in advanced stage.

The types of reconstruction offered to our patients were pedicled flaps (n = 421) and MFFs (n = 119). In spite of good infrastructure and available resources, pedicled flap is still the choice of primary reconstruction of oral cavity cancer defects in our population because of higher patient load and long waiting period for microvascular reconstruction. The other indications where we use pedicled flaps is for vessel depleted neck, in post irradiation setting, salvage surgery defects for recurrent oral cancer, after MFF failure and in combination with MFF for larger skin/mucosal defects.^[5],[6] We used pedicled flaps for majority of mucosal plus bone defects, mucosal plus bone plus skin defects, only skin defects, and few mucosal plus skin defects. While MFFs were mostly used for only mucosal defects and central mandibular arch defects as shown in [Table 1] and [Table 4]. The PMMC flap and ALT flap were used for reconstruction of posterior segment mandibular defects, and FFOC flap was used for reconstruction of central mandibular arch defects.

PMMC flap has been widely used for reconstruction of oral cavity cancer defects. The advantages being easy harvest, short learning curve for trainees, abundant soft tissue volume, large skin paddle, short operating time, good versatility, and reliability.^[6] The versatility of the flap is due to various modifications of the flap as single or bipaddle, only myofascial flap, vascularized flap with rib, as a double flap with other pedicled flaps or in combination with free flaps for large defects. The disadvantages of the flap include the excessive bulk in obese or muscular patients and the functional and cosmetic donor site morbidity.^[7]

In our center, bipaddle PMMC flap is commonly used for buccal mucosa cancer patients with skin involvement with satisfactory postoperative functional and cosmetic results. [Figure 1] shows mucosal plus bone plus skin defect of left buccal mucosa reconstructed with bipaddle PMMC flap. Xiao et al.[8] did a comparative study between ALT flap and PMMC flaps for oral cavity cancer defects. They found that patients had a significant effect on the quality of life irrespective of the flaps used. The significant differences were for shoulder function, emotional domain, and cosmesis which were better with ALT flap than PMMC flap.

Figure 1: (a) Left buccal mucosa carcinoma involving the lower gingivobuccal sulcus and skin, (b) mucosal bony skin defect (c) reconstruction done with bipaddle pectoralis major myocutaneous flap

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Some patients in our study showed T Stage 1 or 2 on the final histopathology report. These patients required pedicled flap or MFF reconstruction because of the clinical T stage, location of the primary tumor (posterior tongue and retromolar trigone), restricted mouth opening, or paramandibular disease.

MFF is currently the first choice of reconstruction for all complex oral cavity cancer defects because of their superior versatility, reliability, tissue match, better functional and cosmetic outcome, and low donor site morbidity.^[9] In our study, MFF reconstruction was done in 119 patients with a total success rate of 94.96% which is in congruence with the current literature.^{[10],[11],[12],[13]} The most frequently used MFF used in our patients was ALT flap and is also seen in the literature due to the versatility in harvesting fat, fascia, or skin, considerable reliability, and lower donor site morbidity.[Figure 2] shows mucosal plus bone plus skin defect following left buccal mucosa SCC excision and reconstructed with bipaddle ALT flap. Radial artery forearm flap is commonly used for reconstruction of intraoral defects of tongue, floor of mouth, and buccal mucosa as it is thin and pliable, highly vascular with a constant vascular anatomy and its ease in harvesting.^[13] [Figure 3] shows lower lip defect reconstructed with free radial artery forearm flap. In our study, FFOC flap was the flap used for bony reconstruction of the mandible. The advantages include harvesting of bicortical bone up to 25 cm, double barreling of bone which can help in placement of endosseous implants, coverage of through and through defects with chimeric flap, and minimal donor site morbidity. [Figure 4] shows central mandibular arch and lower lip defect reconstructed with chimeric FFOC flap.

Figure 2: (a) Mucosal bony and skin defect following left buccal mucosa SCC excision, (b) reconstruction done with bipaddle anterolateral thigh flap, (c) 5-month follow-up post adjuvant treatment

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Figure 3: (a) Lower lip squamous cell carcinoma, (b) lower lip defect reconstructed with free radial artery forearm flap, (c) 2-month follow-up with acceptable oral competence

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Figure 4: (a) Middle one-third mandibular alveolus carcinoma involving gingivolabial sulcus and lower lip, (b) central mandibular arch lower lip defect, (c) reconstruction done with chimeric free fibula osteocutaneous flap with reconstruction plate, (d) postoperative status

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As per our institutional protocol, all MFF patients are kept in intensive care unit for the first 48 hrs for better postoperative care and flap monitoring. The monitoring of the flap was done for color, temperature, swelling, and capillary refill. Needle prick test is commonly used to assess the viability of the flap. The frequency of monitoring is every hourly for the first 24 hours, followed by 2 hourly for the next 24 hours and every 3-4 hourly then onward. Clinical assessment is the commonly used method for flap monitoring, and handheld Doppler is not used in our institute for flap monitoring. In postoperative period, all patients receive antibiotics, amoxicillin-clavulanic acid 1.2 g, and amikacin 500 mg intravenous 12 hourly for 7 days.

For anastomosis, the vascular pedicle of the recipient site is usually a branch of external carotid artery and tributaries from internal jugular vein. We prefer the facial artery or superior thyroid artery as recipient artery for anastomosis because these arteries are in close proximity to the defect and the diameter of the vessels is almost similar to the donor vessels. The difficulty in choosing vessels for anastomosis is to find a suitable vein because of larger diameter of donor veins compared to the recipient. Mismatch in the diameter of veins leads to difficulty in anastomosis and blood backflow.^[13] We prefer tributaries from internal jugular vein for venous anastomosis. It is still debatable whether to do single-vein or two-vein anastomosis. In our experience, we did not find any significant difference in venous compromise after anastomosis of a single or double vein. In our institute, the protocol for anastomosis is one artery and one vein in almost all cases and two-vein anastomosis in FFOC cases. In our study, re-exploration was done in 14 patients, with two vein anastomosis in 4 patients and one vein in 10 patients. Flap failure was seen in two patients with two-vein anastomosis and four patients with single-vein anastomosis. Chaput et al.^[14] did a meta-analysis to compare the usefulness of single- and double-venous anastomosis in head-and-neck MFF reconstruction and concluded that performing a second vein anastomosis significantly reduces the rate of microvascular venous thrombosis and hence the re-exploration rates. Christianto et al.^[15] also did a cumulative meta-analysis to analyze the effectiveness of single- versus double-venous anastomosis and showed the same results as Chaput B et al. They also concluded that the salvage success rate did not significantly differ between the two groups. A randomized trial is required to identify the difference between the two groups taking into consideration all the variables from these meta-analyses.

In our study, the success rate for pedicled flaps was 100% and for MFFs was 94.96%. The rate of complications for pedicled flaps was 12.11% and for MFFs 20.16%. A review of relevant literature shows that the complication rate for pedicled flaps varies from 4.5% to 60%^{[3],[16],[17]} and for MFFs between 9.3% and 64%.^[12],[13] In our study, re-exploration for MFFs was done in 14 patients (11.76%) and is reported in the literature between 3% and 20%.^[11],[18] The flap was salvaged in eight patients (57.14%), with the literature reported between 30% and 70%.^[18] During re-exploration, we found venous insufficiency in nine patients (77.4%) and it was found to be more common than the arterial insufficiency which was seen in three patients (21%). In two patients, flap compromise was due to bleeding/hematoma. Vascular compromise seen in our patients might have resulted from multiple causes such as tight dressing over the neck, tight wound closure, improper patient positioning, atherosclerotic vessels, improper vessel handling, kinking of the pedicle, improper positioning of the vessels, cervical hematoma, and hemodynamic compromise. Total flap loss was seen in 6 out of 14 patients undergoing re-exploration (42.86%): 2 for FRAFF, 2 ALT, and 2 FFOC.

[Table 6] provides a comparison of our data with the findings of some of the published literature.^{[2],[4],[7],[19]}

Table 6: The comparative analysis of our study with other studies in the literature

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Conclusion

The primary goal of reconstruction of oral cavity defects is to replace like with like and to best restore integrity, function, and form. MFF reconstruction provides a wide range of options not only for isolated soft tissue or bony defects but also for complex tissue defects. In our study, microvascular reconstruction was safe with a high success rate and with acceptable functional and cosmetic outcome. The PMMC flap was the most reliable and versatile form of reconstruction in our patients with medium- and large-sized oral cavity defects with reasonable functional results and low rate of complications. Hence, in the current epoch of MFF reconstruction, the PMMC flap still remains a valuable option in the armamentarium of head and neck and plastic and reconstruction surgeon for reconstruction of complex oral cavity cancer defects.

Ethical approval

This study was approved by the IRB of Kailash Cancer Hospital and Research Centre and all participants signed an informed consent agreement.

Consent

Patients have signed an informed consent form separately for photographs to be used for research purposes and for publication in the journals.

Data

All data and materials related to the study are available to review.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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