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Reconstruction for Oral Neoplasms in Indian Setup: Redebating
the Utility of Radial Artery Free Flaps

Authors:  Ranjan G Aiyer*, Rahul Gupta**, Virag Damania***, Mittal Shah***, Abhishek Sharma***
* Professor and Head, ** Senior Resident, *** Junior Resident

Institution:   Dept of Otorhinolaryngology and Dept of Reconstructive Surgery, Medical College and Shree Sayaji General Hospital, Baroda, India

Corresponding Author: 

Dr. R.G. Aiyer
3/2 Jesal Apartment,
Abhishek Colony,
Race Cource,
Vadodara, Inida 390007

Abstract:

Oral neoplasms represents one of the most common operable tumors in the country of India.  After performing local tumor excision, proper reconstruction of the defect is important to maintain the quality of life.   Of the myriad options available to the reconstructive surgeon, free radial artery forearm flaps have proved to be one of the best techniques.  In this study, the operative technique and results of 17 patients who underwent reconstructions with a free radial artery forearm flap are reported.  These flaps were found to be most beneficial in patients who underwent extensive soft tissue resection without a transsecting mandibular defect, as the flaps provide abundant pliable tissue for skin and mucosal reconstruction.  Postoperative functional and cosmetic results were excellent.

Introduction:

Head and neck malignancies represent more than a third of all malignancies in India.1  The incidence is on the rise with a recent inclination towards the younger age group.  The ultimate goal of management is long term cancer control.  Achievement of this goal may require a wide excision of the tumor and appropriate neck dissection, along with appropriate chemoradiation.  The real challenge though lies in reconstructing the defect to improve the quality of life.  It necessitates the surgeon to preserve the external appearance along with the normal functions of swallowing, oral competence and speech. Reconstruction may involve repair or replacement of the mucosal lining, skin cover and the bony tissue.  Over the past two decades there has been a renaissance in the techniques and tissue types used to repair tissue defects in the oral cavity following ablation of malignant neoplasms.2  Today a myriad of options are available to the surgeon for managing this extremely intricate problem.   Free radial artery forearm flaps (FRAFF) have been considered to be the gold standard in reconstruction of post excision defects caused by oral neoplasms.  Along with the refinement in reconstructive techniques comes an increase in the scope of possible complications.

Methods:

The present study is a prospective report conducted between February 2002 and Nov. 2008.  A major portion of our patients had a rural background and belonged to a lower socioeconomic class.  Central Gujarat (including the large tribal belt of Vadodara, Chota Udaipur and Panchmahals), western Madhya Pradesh and bordering areas of Rajasthan in India served as the referral areas to our hospital.   A total of 17 patients entered into this study with a mean age of 42 years with the oldest one 70 years old.

All the patients presented in the outpatient department of the hospital with oral cavity malignancies and were examined systematically.  A Computerized Tomographic scan (CT) was usually performed from base of skull to root of neck to further outline the bony and soft tissue involvement of the tumor along with nodal status.  The extent of the tumor was determined and a clinical TNM stage was assigned for the tumor on the basis of clinical and CT examination.  A decision was made regarding the operability of the primary tumor and appropriate neck dissection.  Suitable patients were then selected for surgical management.   The principal aim was always a wide excision of tumor along with, if appropriate, a neck dissection.   Reconstructions were more often than not performed by a separate team of surgeons.  Preoperative preparation was made for all possible reconstructive techniques with the final decision being made intraoperatively.

Factors governing the use of a particular reconstructive modality included the nature of the defect (mucosa, skin or/and bone), type of neck dissection (incision placement), availability of appropriate donor sites (good caliber of and unthrombosed veins) and technical expertise available at hand.  Only those patients who were found suitable for reconstruction with a FRAFF were included in this study.  Major vessels to be used in the anastomosis were always found and preserved in the neck dissection.  Anticipating the final defect size, a simultaneous flap harvesting was started by the reconstruction team, thus saving crucial operative time.  Skin grafts are used to cover the donor site after harvesting of FRAFF.

The below pictures shows the surgical plan and the surgical elevation of the flap -- Click on pictures to enlarge.
  

Surgical Plan for a Radial Artery Free Flap Operative Photograph of Radial Arm Free Flap
Surgical Plan for
Radial Arm Free Flap
Intraoperative Photograph
Radial Arm Free Flap

Results:

Seventeen cases of oral cavity malignancies that were excised and underwent reconstruction with free radial artery forearm flap (FRAFF) are studied in this series.  The majority of our patients were between 41-50 yrs of age.  58% of the patients were males.  Lower lip carcinomas were most commonly reconstructed by FRAFF in our study.  This was followed by carcinomas of the buccal mucosa.  Click on below pictures to enlarge

Radial Artery Free Flap Used For Cheek Reconstruction Intra Oral Appearance of Radial Artery Free Flap Used For Cheek Reconstruction Radial Artery Free Flap Used For Upper Lip Reconstruction
Cheek Reconstruction Using
Radial Artery Free Flap
Intraoral Appearance of Radial Artery Free Flap Used For Cheek Reconstruction Upper Lip Reconstruction Using Radial Artery Free Flap

Mandibular involvement was assessed preoperatively by radiologic imaging studies.  However, a final decision of mandibulectomy (partial, or total) was made intraoperatively, giving due consideration to oncological margins.  Edentulous mandibles, when involved with malignancy, were always removed radically requiring at least a hemimandibulectomy.  Marginal (rim) mandibulectomy was performed in only those cases where it was feasible to do so without compromising oncologic margins.  Marginal mandibulectomy defects were more suitable for reconstruction by FRAFF as they did not require bony tissue for repair.  Most of the patients also underwent a supraomohyoid type of selective neck dissection.  Modified radical neck dissections were performed only in a few patients.  FRAFF were used most often when mandibular continuity and the sternomastoid muscle were preserved, and the defect involved large parts of the oral mucosa.  Preserving the sternomastoid muscle limited the soft tissue bulk required for reconstruction, and creates a surgical defect favorable for FRAFF reconstruction.  All the patients had a hospital stay of less than two weeks.  Complications of FRAFF were flap edema, infection and necrosis.    Click on picture below to enlarge

Free Flap Necrosis

TABLE 1:  Complications of FRAFF   Total Cases = 17

Complications Number of
Patients
Flap Edema 3
Hematoma -
Infection 1
Partial Necrosis 1
Total Necrosis 2
Orocutaneous Fistula -

 
Analyzing the results found that FRAFF recipients had excellent postoperative speech production.   Results were extremely good for the FRAFF, except in the two cases where there was failure of the flap.  These excellent results were possible even though no neural anastomosis was performed.

TABLE 2:  Post Operative Results
N=17 Oral
Competence
Swallowing Speech
Good 8 8 7
Fair 8 7 8
Poor 1 2 2


Discussion

Repair of defects after head and neck cancer surgery is one of the most challenging areas of medicine, with widely diverse surgical reconstruction options for the surgeon to choose from.  Current surgical techniques using FRAFF allow not only wound closure but also restore function and improve the quality of the patient's life.  Microvascular techniques have caused a revolution in surgical reconstructiion and greatly improved surgical outcomes.  FRAFF have been studied extensively for use in various surgical defects.  In this study, we present a total of 17 patients who underwent FRAFF reconstruction of oral defects created after cancer resection.

Studies by Jeffrey D. Suh, et al3, Keith E. Blackwell, et al,4 and Bruce H. Haughey, et a,l5 reported a greater portion of older people.  In our study the mean age was 42 years old and there was no statistically significant gender difference.  The majority of patients in our study had lip and buccal mucosal malignancies.  Reinert S., et al,6 and Markkanen, et al, 7 had a majority of tongue and floor of mouth malignancies.

The greatest concern of the patient is always “when am I going to look normal again”.8   FRAFF have proven to be the gold standard for oral reconstructions.2   The chief advantages include an extremely low donor site morbidity and option for a second surgical team to simultaneously harvest the flap while the primary tumor is still being excised.  Concern has been raised about the reliability of these tissue transfers citing their frequent necrosis.  But as our study and multiple others in the literature clearly illustrates, is that when performed by competent surgeons with adequate facilities, FRAFF are extremely reliable and seldom die.  

FRAFF provide extremely well contoured replacement of mucosa and skin for surgical reconstruction.  Reconstruction of the oral cavity facilitates the postoperative inspection of the operated region.  This is specially useful to allow the early diagnosis of tumor recurrence.   A failure of FRAFF is uncommon but sometimes does occur when performed by beginners or in the presence of unfavorable patient factors (coagulation abnormalities, prolonged immobilization, etc.).  Management of flap failure is a tricky problem in the head and neck.  Partial failures are best managed by debridement and primary closure, if possible.  The ever reliable pectoralis muscle myocutaneous flap (PMMC) also serves as an effective lifeboat in case of complete failures.   A failure of the salvage modality calls for the defect to be left open for healing by secondary intention.  Orocutaneous fistulas usually developing at the flap-mucosal junction which is a common problem in cases of bulky pedicle flaps (PMMC & Deltopectoral) but almost never develops in FRAFF.   Flap edema is very common in the immediate post- operative period but regresses over time on its own.

Conclusion

Key Concepts:

• Head and neck defects provide an opportunity for the reconstructive surgeon to choose a diverse array of modalities to repair the surgical defect.
• Free radial artery forearm flaps (FRAFF) provide better cosmetic and aesthetic results, provided the technical expertise is available.
• FRAFF in the oral cavity provide excellent postoperative results in the form of speech production and swallowing.
• There is a learning curve for surgeons performing microvascular reconstructions.
 

References:

1.  Park JE.  Park’s textbook of Preventive and Social Medicine, 16th Edition: Chapter 6, Cancer.

2.  Gleeson Mj, Jones NS, Clarke R, Luxon L, Hibbert J, Watkinson J  (Eds).  Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery: Seventh edition.   http://www.scottbrownent.com/

3.  Suh JD, Sercarz JA, Abemayor E, Calcaterra TC, Rawnsley JD, Alam D, Blackwell KE. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2004 Aug;130(8):962-6.  View Abstract

4. Blackwell KE. Unsurpassed reliability of free flaps for head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1999 Mar;125(3):295-9.  View Abstract

5. Haughey BH, Taylor SM, Fuller D.  Fasciocutaneous flap reconstruction of the tongue and floor of mouth: outcomes and techniques. Arch Otolaryngol Head Neck Surg.  2002 Dec;128(12):1388-95.  View Abstract

6. Reinsert S.  The free revascularized lateral upper arm flap in maxillofacial reconstruction following ablative tumor surgery. J Craniomaxillofac Surg.  2000 Apr; 28(2):69-73.  View Abstract

7. Markkanen-Leppänen M, Suominen E, Lehtonen H, Asko-Seljavaara S. Free flap reconstructions in the management of oral and pharyngeal cancer.  Acta Otolaryngol. 2001 Apr;121(3):425-9.   View Abstract

8.  P. Zade MP.  Study of Microvascular Reconstructions in Head and Neck defects,  Medical College and S.S.G. Hospital, Baroda, India  2005.  

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World Articles in Ear, Nose and Throat  www.waent.org                 April 24, 2010              Vol 3-1

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