| Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Oral Cavity Reconstruction The goal of therapy of patients with oral cavity malignancy is primarily to cure the tumor, secondly provide rehabilitation, and then thirdly try to preserve or restore some reasonable quality of life. Oral cavity reconstruction is not simply based on closure of the wound. We want to consider the form and function of this unit and I hope that is one of the take-home points you leave with today. Specifically swallowing, deglutition, cosmesis, speaking, those are the things that the oral cavity reconstruction should address. Advances in surgical techniques allow for more aggressive surgical resection and yet and still we can restore some of that function of the oral cavity. I am going to look at some of the major reconstruction options and go from there. Just briefly on the oral cavity, the oral cavity is the region that extends from the skin and junction of the lips to the junction of the hard and soft palate above the line of the circumvallate papillae. Major structures include buccal mucosa, upper and lower alveolar ridges, retromolar trigone, the oral tongue, and the hard. I want you to understand that the oral cavity is a very important functional unit within the human organism and that restoring the function of that unit is the key thing with reconstruction. I am going to talk about the different types of flaps that you can use, and then I am going to talk specifically about reconstructing the tongue, the palate, and the mandible, and then, I will conclude with the case presentation. In general, oral cavity reconstruction requires a team approach. You want specialists in tumor treatment, head and neck surgeons, dental oncologists, and reconstructive surgeons. You need specialists in rehabilitation, speech therapists, and swallowing therapists. You want to try to obtain primary wound closure, but again restore form and function. You also want to try to minimize the morbidity of the procedure and improve the patient's quality of life. And again looking at that as your goal, advanced techniques may be the first line of therapy as opposed to more simple ones. The simplest way to close a wound besides primary closure and secondary attention is skin grafts. Skin grafts are great. They can be split thickness or full thickness, they can be gathered from sites that are hidden, the groin, and the axillae. They preserve the stratified keratinizing epithelial layer necessary to preserve it or obtain a watertight seal, but it does not include skin appendages usually. A bolster is placed to help prevent fluid from collecting underneath the flap and the results of skin grafts, as everyone knows, are excellent and the complications raised are low. Here is a picture of a skin graft of a tongue lesion. Some older data even suggests that skin grafts are even superior to regional flaps if you look at hospital stay, return to oral diet, and overall complication rate. The advantages are numerous. They are easy to harvest, it takes a small amount of additional operating time, they are incredibly versatile, and they do for the most part preserve function, and they can even survive postoperative radiotherapy. The major disadvantages with skin grafts are that they contract and they lack bulk. By lacking bulk, it is difficult to rebuild a structure such as the tongue; it is difficult to rebuild other structures that require full tissue thickness in order to conform its shape. Additionally, as the graft contracts, especially after radiotherapy or with time, you can have decreased function of that unit, so a buccal mucosa graft or retromolar trigone graft can cause trismus. A graft to the tongue or floor of the mouth can cause tethering, resulting in problems with speech and swallowing. Local flaps are the next level of reconstructive options. It is composed of an adjacent tissue and in the oral cavity we typically use buccal mucosa, you can also use the tongue flap. These flaps typically are rotated to close the new defect and the donor site is generally closed primarily. They provide good color matches and they are excellent for small defects. I want to talk a little bit about tongue flaps because they were commonly used in the past and they were felt to be a good reconstructive alternative especially for the retromolar trigone in tonsillar area. The most common approach as pictured here was to split the tongue longitudinally and rotate the flap 180 degrees to close the defect. The advantages were numerous. It is easy to assess the tongue, it has an excellent blood supply, and there is no external cosmetic defect. However, despite these advantages, people now feel that the resultant speech and swallowing dysfunction is too great and that the tongue is such a specialized organ, which no other reconstructive method can reproduce, that it should be preserved at all cost, and now many authors say that tongue flap should be abandoned altogether, except under the most extreme circumstances. After local flaps, you can then proceed to regional flaps. Regional flaps allow larger volume of healthy tissue for reconstruction. They can be skin, muscle, bone, or any combination of the three. I have listed the typical types of flap here: Fasciocutaneous, myocutaneous, osteocutaneous, and again the combination myoosseous or myoosteocutaneous. The temporalis fasciocutaneous flap is perhaps the most well represented of the local regional flaps or fasciocutaneous flaps of the head and neck. It provides a lot of different options for reconstruction of all head and neck defects, but it is also very good for the oral cavity. It is thin, it is pliable, it has an excellent blood supply, and it permits many different uses. It is a continuation of the SMAS layer anteriorly and the galea aponeurosis superiorly and its blood supply is based upon the superior temporal artery. As I said, it has a variety of uses and it can even support a skin graft. It also has minimal donor site morbidity. There is some risk to the frontal branch of the cranial nerve VII, but that risk is very minimal. The development of myocutaneous flaps such as the pectoralis major made reconstruction of the head and neck and the oral cavity much more predictable and it largely replaced local flaps. They have a large amount of healthy tissue with an excellent predictable blood supply and it can be done to reconstruct at the time of surgery. Here I have listed several flaps such as pectoralis major, latissimus dorsi, trapezius, and sternocleidomastoid. I think the pectoralis major deserves a little bit of special attention. It was once called, perhaps is still called, a workhorse of otolaryngology. It is a very reliable flap. It can be harvested in the supine position and placed immediately after tumor is removed. It offers a very large skin paddle and it can be used to reconstruct almost any oral cavity defect. Its blood supply is based upon a thoracoacromial artery, and as I said, it can be used to reconstruct almost any oral cavity defect. Other flaps include latissimus dorsi, which is one of the most versatile flaps in the head and neck, trapezius muscle, and sternocleidomastoid. Many of these flaps have been not used as commonly because of tension on the wound and limited arc of rotation. You can also do regional combined flaps, as I have mentioned myoosteocutaneous such as the pectoralis major with a rib graft or a scapular flap, which is one of the more versatile flaps in head and neck reconstruction that can be both a regional flap as well as a free flap. Here I have a picture of the regional flap with a skin paddle. The pectoralis major flap, just to reiterative, was the preferred method of reconstruction for many years. As time has gone on, microvascular free flaps have started to replace regional flaps. Originally, free flaps were used in highly selected patients because they were thought to be more technically; however, as time has gone on and the reconstructive techniques have improved, free flaps have now become the preferred method for reconstruction of large oral cavity defects. I want to talk about some of the major free flaps in head and neck and then talk about some of their applications. The primary advantage of free flaps is the ability to select the distal donor sites that match the requirements of the defect. So now if you have a large tongue defect, you can provide structure and function for that defect. The choices are plentiful. There are numerous free flaps described, it seems weekly there is new one presented, and they all are excellent. They can repair complex defects and they can also provide sensory innervation and sometime even provide motor reinnervation. Bone grafts allow for dental osteointegration, which is important. Dental implants allow for further speech and deglutition rehabilitation, and the osseous components are also easier to manage and the blood supply is more predictable than with regional flaps. The main disadvantages of microvascular free flaps are the time and expense, which some people say is lessening and in fact may not be true anymore. They are technically demanding, require specialized training, and there can be significant donor site morbidity. The radial forearm free flap is called by some of us a new workhorse in head and neck reconstruction. It has extremely reliable vascularity and has a thin pliable paddle. It can be used as a thin face flapand even can provide sensation to the skin over the mandible and it has an osseous-bearing component, so you can reconstruct the mandible itself if it is required to be resected. It is based on the radial artery, and you can include a mediolateral antecubital nerve to provide the sensation. The donor site morbidity gives the most problems with this flap. You have skin contracture from the scar that is created and placing of a skin graft in order to cover the defect and you also sacrifice a major artery in the upper extremity, so there is a chance of distal necrosis in some patients. The fibular osteocutaneous flap is another commonly used head and neck free flap. Its blood supply is reliable, it is based upon the peroneal arteries, and it has hard compact bone which allows for mandibular reconstruction. In fact you can reconstruct the entire mandible with a fibular flap, it provides up to 25 cm of bone. The bone survives many osteotomies because the blood supply is so predictable. You can have a skin flap with it and you can have muscle with it as well. The disadvantages include, again, you are sacrificing a major artery of the lower extremity and there is some weakness of plantar flexion and you can have some wound problems. The other major advantage of this flap is, again, you can use dental implants. You can have osteointegration of dental implants, which is important in dental rehabilitation, and you can even place those implants before radiotherapy. The rectus abdominus free flap is another commonly used free flap in head and neck reconstruction in the oral cavity and it has an important role. This flap is easy to harvest with a two-team approach, so you can remove the tumor as well as gather the flap at the same time, which cuts down on the operating time, and you can get a variable amount of skin and variable amount of thickness. There is also potential for reinnervation again to provide sensation to the lips and the chin. The disadvantages include potential for herniation at the site, and sometimes you can have a large unattractive scar as well. The lateral thigh free flap is another flap, which is commonly used in oral cavity reconstruction. It is very popular at M.D Anderson. It is based upon the profunda femoris artery just inferior to the inguinal ligament. The advantages include a very large skin paddle and it is applicable to a two-team approach, so you can remove the tumor and harvest the flap at the same time. The disadvantages include prevalence of osteosclerotic disease in the vessels. So many older patients, as you can imagine heavy smokers, which a lot of cancer patients are, this flap is not always readily available for use. The dissection is very tedious and donor site morbidity can be a problem with seroma and wound infection. Other commonly used microvascular free flaps include the greater omentum. Advantages include its thickness. It has a lengthy pedicle, there is a large amount of tissue available for reconstruction. In fact, many authors describe using the omentum to cover the vital structures in the neck. It has rapid adherence to soft tissue and bone, which can protect those tissues in radiation, and it has potential for lymphatic outflow, which will prevent edema formation in the head and neck. The disadvantages include adhesive disease causing small bowel obstruction, potential for bleeding within the wound, which can cause sepsis and things of that sort, and you can also have herniation of the abdominal wall. For last few minutes I will address reconstruction of what I think are the three most important functional units of the oral cavity, which are the mandible, the palate, and the tongue. Just briefly before I go on, the latissimus dorsi flaps and the iliac crest flaps are also two important flaps in the head and neck. They can provide motor reinnervation. The limitations are typically with respect to the wound, but they are very excellent flaps in the head and neck as well. So, mandible reconstruction, what is the ideal treatment? This is actually a gentleman who has had his of his mandible, and you can see he has a very bulky skin paddle and his cosmesis is not as good. Osteocutaneous free flaps have really supplanted reconstruction of the mandible if it is needed. The success rate is excellent. One author reported a 96% success rate overall. The blood supply is reliable. It can survive in bacteria-rich environments, which is the oral cavity. It can survive radiation, and it maintains its rigidity and capacity. This is a woman who was corrected with a fibular free flap and she looks very well. The commonly used flaps are iliac crest, scapular free flaps, and the fibular free flaps. For palate reconstruction, we have a significant defect if the palate is removed. We have changes in speech and swallowing, as well as appearance. To reconstruct the palate, first you want the wound to heal. You want to restore palatal competence, so that swallowing and speech function are maintained, and you want to try to restore facial contour. There are two approaches, you can either use a prosthetic device or you can try to fix it surgically. Prosthetics are the ideal situation, so when it comes to palate reconstruction, prosthesis, prosthesis, prosthesis! You do need have a prosthodontic evaluation before removal. Looking at this illustration, here is a palatal defect, there is a skin graft here which is what they recommend. Here is the preserved palate, here is the defect, and that is the posterior maxillary sinus wall with a skin graft. And they say this is the way that you close this when you simply put a skin graft, and then you can reconstruct this area with an obturator. So when you remove the palate you try to preserve as much premaxilla as possible to allow for better dental rehabilitation. They recommend making custom sockets of edentulous teeth and again placement of a skin graft posteriorly to help close the wound. Prosthetics are great, they decrease the time to rehabilitation for the patients so they can drink, talk, return to normal diet, faster compared to other methods, and it is also easy to monitor for recurrence. You simply remove the prosthesis, and you can examine the area that had the cancer to see if there is any recurrent disease. The problems with prostheses are that they are a synthetic device so the lifespan is limited. They break, they can start emitting foul odors, and they are insensate so they do not help with sensation. Surgically, you can repair the palate surgically with osteocutaneous flaps. This is not done commonly. Most cases that are described in the literature are done for patients who for whatever reason do not desire prosthetic implants. It does make it difficult to monitor for tumor recurrence because you have obviously eliminated the sites, so now you have to obtain CAT scans and MRIs to monitor for tumor. The aesthetics are not as good, and it does interfere with dental rehabilitation. For total maxillectomies, they recommend if you are going to fix this with a free flaps to use an osteocutaneous flaps such as a fibula, the scapula, or the iliac crest, and then, some authors suggest even waiting till after radiation therapy before you attempt to reconstruct. I am going to talk lastly just about tongue reconstruction. As I mentioned, the tongue is perhaps one of the most vital structures in the oral cavity. There is no flap or reconstructive method that totally reproduces the function of the tongue, so you want to preserve as much as possible. Resection of the tongue causes impairment in speech, impairment in swallowing, impairment in chewing. And when you reconstruct the tongue, again, the goals are try to restore function, try to facilitate movement by counterbalancing the tongue, provide bulk for counterbalance as well, use pliable tissue so you do not get tongue tethering, and if possible try to maintain some sensation. Split-thickness skin grafts are good for small defects, less than 20%, but again a split- thickness skin graft, as it contracts, can cause tongue tethering, which can limit the functional capacity of the tongue. Local flaps also are good to close defects; however, they do cause tethering so you can have functional deficits afterwards. Now the preferred method of tongue reconstruction for total glossectomy, specifically, is with a free flap if possible and the rectus abdominus is the most commonly used. This is a picture of a gentleman who was reconstructed with a rectus abdominus; it provides bulk, which is necessary. It is resistant to radiotherapy, and the patients have very good outcomes. You can also use a radial forearm free flap, and there is also an obturator that can be designed for the palate that can help supplement an extracted tongue as well. Oral cavity reconstruction can vary anywhere from simple closure to complex multistage procedures; again, restoration of form and function is the challenge and goal of any reconstruction. You want to try to use a multidisciplinary approach, and the current techniques available can provide excellent reconstructive options. Case Presentation: The patient underwent a segmental mandibulectomy, supraomohyoid neck dissection, and reconstruction of the defect with a fibula free flap with dental implantation. Final pathology revealed negative margins and no metastatic disease to regional lymph nodes. She had a favorable postoperative course and was treated with additional radiation therapy. She currently has functional dental implants, no evidence of disease and is tolerating a regular diet. Bibliography: Albrektsson T, Branemark PI, Jacobsson M, Tjellstrom A. Present clinical applications of osseointegrated percutaneous implants. Plast Reconstr Surg 1987;79:721-730. Boyd JB. Use of reconstruction plates in conjunction with soft-tissue free flaps for oromandibular reconstruction. Clin Plast Surg 1994;21:69-77. Buchbinder D, Urken M.L, Vickery C, Weinberg H, Sheiner A, Biller H. Functional mandibular reconstruction of patients with oral cancer. Oral Surg Oral Med Oral Pathol 1989;68:499-503. Evans GR, Schusterman MA, Kroll SS, Miller MJ, Reece GP, Robb GL, Ainslie N. The radial forearm free flap for head and neck reconstruction: a review. Am J Surg 1994;168:446-450. Geopfert H. The Multidisplinary Care of Head and Neck Cancer Web Book. University of Texas M.D. Anderson Cancer Center, Houston, TX. www/headneckcancer.org. Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 1995;96:597-602. Jackson I. Local Flaps in Head and Neck Surgery. St. Louis: Mosby; 1985. Knoll SS, Goepfert H, Jones M, Guillamondegui O, Schusterman M. Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction. Ann Plast Surg 1990;25:93-97. Knoll SS, Reece GP, Miller MJ, Schusterman MA. Comparison of the rectus abdominis free flap with the pectoralis major myocutaneous flap for reconstructions in the head and neck. Am J Surg 1992;164:615-618. Lyos AT, Evans GR, Perez D, Schusterman MA. Tongue reconstruction: outcomes with the rectus abdominis flap. Plast Reconstr Surg 1999;103:442-447. Reece GP, Knoll SS, Schusterman MA. Free flap techniques for mandibular reconstruction. In: Kroll SS, editor. Reconstructive Plastic Surgery for Cancer. St. Louis: Mosby; 1996. pp. 94-106. Salibian AH, Allison GR, Rappaport I, Krugman ME, McMicken BL, Etchepare TL. Total and subtotal glossectomy: function after microvascular reconstruction. Plast Reconstr Surg 1990;85:513-524. Schusterman MA. Microsurgical Reconstruction of the Cancer Patient. Philadelphia: Lippincot-Raven; 1997. Shenaq SM, Kelbuc MJA. The iliac crest microsurgical free flap in mandibular reconstruction. Clin Plast Surg 1994;21:37-44. Urken ML, Buchbinder D, Weinberg H, Vickery C, Sheiner A, Biller HF. Primary placement of osseointegrated implants in microvascular mandibular reconstruction. Otolaryngol Head Neck Surg 1989;101:56-73. Urken ML, Weinberg H, Vickery C, Buchbinder D, Biller HF. Using the iliac crest free flap. Plast Reconstr Surg 1990;85:1001-1002. Urken ML. Composite free flaps in oromandibular reconstruction. Review of the literature. Arch Otolaryngol Head Neck Surg 1991;117:724-732. Urken ML, Buchbinder D, Costantino PD, Sinha U, Okay D, Lawson W, Biller HF. Oromandibular reconstruction using microvascular composite flaps: Report of 210 cases. Arch Otolaryngol Head Neck Surg 1998;124:46-55. BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2005
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