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The prognostic significance of squamous cell carcinoma antigen (SCC-Ag) and C-reactive protein (CRP) levels and lymph node density (LND) has been individually recognized in oral squamous cell carcinoma (OSCC). We investigated the relationship between preoperative serum markers (SCC-Ag and CRP) and postoperative prognostic marker (LND) in this study. We retrospectively analyzed 277 OSCC patients who underwent primary curative resection and neck dissection with/or without adjuvant therapy between March 2008 and November 2013. Serum SCC-Ag and CRP levels were measured preoperatively. Distant metastasis, overall survival (OS), and disease-free survival (DFS) were used to evaluate the prognostic significance of preoperative SCC-Ag and CRP levels in relation to LND. LND (cutoff point ≥0.06) correlated with the pathologic tumor status, pathologic nodal metastasis, degree of differentiation, tumor stage, tumor depth (≥10 mm vs <10 mm), and perineural invasion (all P values were <0.001). LND was significantly associated with development of distant metastasis, DFS, and OS (all P values were <0.001). Preoperative elevated CRP and SCC-Ag levels were significantly associated with LND (P = 0.006), DFS (P < 0.001), and OS (P < 0.001). LND patients were further stratified into prognostic groups according to their SCC-Ag and CRP levels (DFS: P = 0.010; OS: P = 0.003). LND correlated with the incidence of DM, DFS, and OS in patients with OSCC. Concurrent elevated preoperative SCC-Ag and CRP levels are predictors for LND. In addition, SCC-Ag and CRP are markers for classifying high-risk LND patients with OSCC into subgroups., Competing Interests: The authors report no conflicts of interest.

Despite the advantages of a fibula flap, many surgeons would often be hesitant in its use in patients with a history of distal fibular fracture. The chief concern is the potential vascular damage sustained during the injury. From our experience, however, we noticed that the blood supply of various components of a fibula flap rarely relies on its distal part alone. Avoiding the use of this flap may unnecessarily forgo the optimal reconstructive option in many patients. Free fibula flap was harvested from a 41-year-old man who had a history of left fibula fracture 10 years before surgery. The fracture was treated with open reduction with internal fixation. The plate was removed 1 year after the trauma surgery. We used this fractured and healed fibula to reconstruct the intraoral and mandibular defect after tumor extirpation. The harvesting process was straight-forward and the flap survived uneventfully. On the basis of our experience and current evidence in the literature, we believe that a history of previous fibular fracture should not be considered as an absolute contraindication for free fibular flap harvesting. With a good knowledge of the lower limb anatomy and appropriate patient selection, the fibular flap can still be a safe option that incurs no additional risk., (© 2014 Wiley Periodicals, Inc.)

Background and Aim: Oral submucous fibrosis (OSF) is an insidious disease with progressive limitation of mouth opening and potential malignant change of the oral mucosa. Cancer surveillance is of utmost importance, but it is often limited by severe trismus. Surgical release and free flap reconstruction is effective but its long-term efficacy has not been completely established. This work aims to review our experience in the past 15 years in surgical release of OSF-related trismus followed by free flap reconstruction., Methods: Patient's age, gender, smoking history, drinking history and betel-nut consumption history were retrieved. Surgical release and reconstructive procedures were detailed. Inter-incisor distances (IIDs) were measured preoperatively (PO-IID), intra-operatively after maximal release (IO-IID) and during the last follow-up (FU-IID). Subsequent development of oral cancers (oral squamous cell carcinoma, OSCC) and relevant details were documented. Potential predictors of long-term IID gain were analysed., Results: A total of 92 patients were included in our study. There was a significant difference (p = 0.000) in PO-IID (13.8 ± 6.6 mm) and FU-IID (27.2 ± 8.8 mm) indicating the long-term efficacy of the release procedure. The mean long-term IID gain was 13.0 ± 7.5 mm. Bilateral coronoidectomy resulted in a greater degree of intra-operative gain in IID (p = 0.025). PO-IID (r = -0.277, p = 0.001) and intra-operative gain in IID (r = 0.198, p = 0.001) were found to be predictive of long-term IID gain. Ten patients (11%) developed OSCC during our study period., Conclusions: Aggressive surgical release (with bilateral coronoidectomy if necessary) followed by free flap reconstruction is an effective treatment for OSF-related trismus. Our study has confirmed its long-term efficacy and its important role in cancer surveillance., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objectives/hypothesis: Elevated inflammatory biomarkers such as C-reactive protein (CRP) and the recently identified neutrophil/lymphocyte ratio (NLR) were demonstrated to be associated with prognosis in human cancers. The aim of our present study is to analyze the relationship of preoperative levels of CRP and NLR with clinicopathological factors and prognosis in oral squamous cell carcinoma (OSCC) patients., Study Design: Retrospective study., Methods: This study was performed on 226 OSCC patients between July 2007 and April 2012. Their serum CRP levels and NLR were measured preoperatively., Results: CRP level ≥ 5.0 mg/L was significantly associated with NLR ≥ 2.44 (linear regression, P < .001). Elevated CRP and NLR were significantly associated with pathological tumor status (P < .001), pathologic nodal metastasis (P < .001), tumor depth (≥10 mm vs. <10 mm, P < .001), disease-free survival (P < .001), and overall survival (P = .001). The influence of CRP level and NLR on disease-free survival (hazard ratio [HR] = 2.259, 95% confidence interval [CI] = 1.170-4.361) and overall survival (HR = 2.176, 95% CI = 1.116-4.245]) still existed after adjusting for tumor status, lymph node metastasis, and tumor cell differentiation., Conclusions: The present study demonstrates that elevated CRP is an independent prognostic factor in OSCC. Elevated NLR in the high CRP group identifies patients at high risks of recurrence and shorter survival. Incorporating NLR into CRP level therefore has significant potential as a biomarker for risk stratification in OSCC., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Squamous cell carcinoma of the oral tongue (SCCOT) is one of the most common malignant carcinomas in the head and neck. Recurrence and/or metastasis often results in failure of treatment and decreases the survival of the patients. The purpose of this study is to investigate the effect of gene-silence of Kif2a on SCCOT in viro and in vivo., Study Design: Plasmid-mediated expression of Kif2a-siRNA (pGPU6/GFP/Kif2a) was employed to silence the expression of Kif2a in Tca8113 cells at both mRNA and protein levels. Tca8113 cell proliferation was measured by 3-(4,5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay and growth of Tca8113 tumors was determined by intra-tumor injection of pGPU6/GFP/Kif2a in nude mice., Results: Gene-silence of Kif2a suppressed Tca8113 cell proliferation. pGPU6/GFP/Kif2a synergized the tumor suppression effect of 5-Fluorouracil (5-Fu) on Tca8113 cells., Conclusions: Our data support that Kif2a is a potential molecular target for the therapeutics of recurrent and metastatic SCCOT., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Squamous cell carcinoma antigen (SCC-Ag) level and C-reactive protein (CRP) have been shown to be associated with tumor invasion, lymph node metastasis, staging and survival in patients with oral squamous cell carcinoma (OSCC). The purpose of the present study was to analyze the relationship between preoperative levels of both SCC-Ag and CRP, with clinicopathologic factors and prognosis in OSCC patients., Methods: A retrospective study was performed on 142 OSCC patients between March 2008 and March 2011. Their serum SCC-Ag and CRP levels were measured preoperatively., Results: SCC-Ag level of ≥2.0 ng/ml and CRP level ≥5.0 mg/L were significantly associated with pathologic tumor status (P < 0.001), pathologic nodal metastasis (P = 0.001), tumor depth (≥10 mm vs. <10 mm, P < 0.001), disease-free survival (P ≤ 0.001) and overall survival (P ≤ 0.001). The influence of SCC-Ag and CRP level on disease-free survival (hazard ratio 4.046, 95 % confidence interval 1.698-9.692) and overall survival (hazard ratio 3.655, 95 % confidence interval 1.464-9.130) still existed after adjusting for tumor status, lymph node metastasis and tumor cell differentiation., Conclusions: Concurrent high levels of both preoperative SCC-Ag and CRP levels act as a predictor for lymph node metastasis, advanced tumor stage and tumor recurrence. It therefore has significant potential as a biomarker for risk stratification in OSCC.

Objectives/hypothesis: Previous studies have demonstrated a relationship between elevated serum squamous cell carcinoma (SCC) antigen (SCC-Ag) levels and shorter survival in cancer patients. Few studies, however, have investigated the role of serum SCC-Ag levels in oral SCC (OSCC). This study was conducted to analyze the relationship between preoperative SCC-Ag levels, clinicopathologic factors, and prognosis in OSCC patients., Study Design: Retrospective case-control study., Methods: Seventy-nine OSCC patients from Chang Gung Memorial Hospital were retrospectively recruited between April 2008 and March 2010. Serum SCC-Ag levels were measured preoperatively., Results: An SCC-Ag level of ≥2.0 ng/mL was significantly associated with the pathologic tumor status (P < .001), pathologic nodal status (P = .037), lymph node extracapsular spread (P = .016), and tumor depth (>10 mm vs. ≤10 mm, P < .001). It was not significantly associated with histologic differentiation (P = 1.000). A univariate analysis revealed that positivity for SCC-Ag was associated with disease-free survival (DFS) (P = .034) and overall survival (OS) (P < .001). In SCC-Ag-positive patients, the distant metastatic rate was higher than in the SCC-Ag-negative patients (P = .053)., Conclusions: This study demonstrated that preoperative SCC-Ag is a good marker of pathologic lymph node metastasis, an advanced tumor stage, and a higher rate of distant metastasis. The preoperative SCC-Ag level is a potential prognostic indicator in DFS and OS, but studies with a longer follow-up period are needed to confirm these results., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives: Previous studies have demonstrated a relationship between elevated serum C-reactive protein (CRP) levels and shorter survival in cancer patients. Few studies, however, have investigated the role of serum CRP levels in oral squamous cell carcinoma. The present study was conducted to analyze the relationship between preoperative CRP levels, clinicopathologic factors, and prognosis in oral squamous cell carcinoma patients., Design: Retrospective clinical study., Setting: University teaching hospital., Participants: Eighteen oral cavity leukoplakia and 59 oral squamous cell carcinoma patients between November 2006 and November 2009 from the Chang Gung Memorial Hospital., Outcome Measures: Clinicopathologic parameters, disease-free survival and overall survival were correlated with CRP levels., Methods: Serum CRP levels were measured preoperatively, and all oral cavity cancer patients underwent curative intent radical surgery with or without postoperative adjuvant therapy., Results: The CRP levels in leukoplakia patients were used to analyze if factors (including diabetes and liver cirrhosis, smoking, alcohol drinking and areca quid chewing) influence CRP levels, and the results demonstrated they were not associated with CRP elevation (> 5.0 mg/L) (P > 0.05). In oral cancer patients, elevated CRP levels were associated with tumor status (P = 0.005), tumor stage (P = 0.054), bone invasion (P = 0.033), lymph node metastasis (P = 0.004) and lymph node extra-capsular spread (P = 0.018). Patients with higher CRP levels showed poorer disease-free survival (log rank test, P < 0.001) and overall survival (log rank test, P = 0.013)., Conclusions: Preoperative serum CRP levels are associated with advanced tumor stage, bone invasion, lymph node metastasis, lymph node extra-capsular spread and patients' survival. CRP is thus potentially a prognostic indicator, but studies with longer follow-up will be needed to confirm its reliability., (© 2011 Blackwell Publishing Ltd.)

Aim: To investigate the effect of the growth arrest- and DNA damage-inducible Gadd45a gene on the radiosensitivity of human tongue squamous cell carcinoma cell line to ionizing radiation (IR)., Methods: Short interfering ribonucleic acid (si-RNA) targeting Gadd45a or an irrelevant mRNA (nonsense si-RNA) was chemically synthesized. The constructed si-RNAs were transfected into Tca8113 cells and Gadd45a expression was determined using quantitative real-time PCR and Western-blot. After 24-h exposure to IR at a dose rate of 4 Gy/min, apoptosis of Tca8113 cells was detected using flow cytometry, and radiosensitivity was measured using MTT assays., Results: IR apparently increased the expression of Gadd45a at mRNA and protein levels in Tca8113 cells. The effect was efficiently inhibited by transfection with Gadd45a si-RNA (P<0.01). Furthermore, silencing Gadd45a gene significantly increased cell viability and decreased the percentage of apoptotic cells during irradiation, which indicated that IR-induced Gadd45a over-expression could increase the radiosensitivity of Tca8113 cells., Conclusion: These results indicated that targeting Gadd45a may have important therapeutic implications in sensitizing Tca8113 cells to IR.

Background: The medial sural artery perforator flap is a thin and pliable flap. This study investigated the perforator topography of the medial sural artery perforator flap and its clinical application in head and neck reconstruction., Methods: From January of 2005 to April of 2009, 29 patients with 29 medial gastrocnemius territories were evaluated. Among them, 26 patients underwent head and neck reconstruction using 26 medial sural artery perforator flaps. The number, location, and topographic patterns of the perforators were measured., Results: Flap sizes ranged from 8 x 4 cm to 12 x 14 cm. The mean pedicle length was 12.7 cm, the mean flap thickness was 4.8 mm, the mean number of total perforators was 2.7 +/- 1.5 (range, 1 to 5), and the mean number of sizable perforators was 1.6 +/- 0.7 (range, 1 to 3). The mean distance from the perforator perpendicular to the popliteal crease was 11.4 +/- 2.7 cm. No perforators were found less than 6 cm or more than 18 cm from the popliteal crease. Most sizable perforators (85.4 percent) entered the medial gastrocnemius muscle at a relative distance of one-fifth to one-third of the lower leg length measured from the popliteal crease. All flaps survived, with good functional and aesthetic outcomes, except for one failed case., Conclusion: The medial sural artery perforator flap is a good alternative for head and neck reconstruction, with the advantages of thin and pliable skin, a long and reliable vascular pedicle, straightforward intramuscular dissection, the possibility of chimeric flap design, and minimal donor-site morbidity.

Background: The aim of this study was to evaluate the association and the related risk factors between postoperative complications and mortality and the severity of liver cirrhosis in head and neck cancer patients undergoing tumor ablation followed by microsurgical free tissue transfer., Methods: Between January 2000 and December 2008, a total of 3108 patients were retrospectively reviewed. The diagnosis of liver cirrhosis was made mainly by abdominal ultrasonography. The Child's classification was used to assess the severity of liver cirrhosis., Results: There were 60 men and 2 women enrolled. Preoperatively, 42, 17, and 3 patients were classified as Child's class A, B, and C, respectively. Class B patients had statistically significantly prolonged stay in the intensive care unit and hospital stay compared to class A patients. Patients with class B or C cirrhosis had more complications than those with class A cirrhosis (80% vs. 19.1%, P < .001). This included significantly increased rates of pulmonary complications, acute renal failure, and sepsis. The mortality rate was also significantly higher for patients with class B/C cirrhosis than for those with class A cirrhosis (30% vs. 4.8%, P = .011). By logistic regression model, preoperative platelet count, intraoperative blood transfusion > or =2 units, and Child's class were found to be significant predictive factors for morbidities. Likewise, Child's class, albumin level, intraoperative blood transfusion > or =2 units, intraoperative blood loss >500 ml, and prothrombin time were significant predictive factors for mortality., Conclusions: Child's class, along with its several components, and intraoperative blood transfusion of > or =2 units are predictive factors for morbidity and mortality.

The aim of this study was to examine the Kif2a expression and its role in tumor progression, invasion and metastasis in squamous cell carcinoma of the oral tongue (SCCOT). The study included 44 cases of primary tumor and the corresponding adjacent tissues, 20 cases of primary tumor with lymph node metastasis. Immunohistochemistry was used to observe the Kif2a expression and its correlation with clinicopathologic factors in oral tongue cancer. The immunohistochemistry showed that Kif2a expression was stronger in oral tongue cancer tissues than in paired adjacent tissues (P<0.01), and the higher expression of Kif2a was also significantly associated with lymph node metastasis (P<0.01), tumor clinical stage (P<0.01). In addition, in vitro results from transwell chamber assay showed that Tca8113 cells transfected with Kif2a-siRNA had a decreased migratory ability (P<0.01) compared to nonsense-siRNA-transfected cells. Therefore we speculate the overexpression of Kif2a might be involved in the progression, invasion and metastasis of SCCOT and Kif2a should be as a predictor for prognosis.

To investigate the expression of carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) and its effects on angiogenesis and lymphangiogenesis in oral carcinoma. Immunohistochemistry was used to study the expression of CEACAM1, LYVE1 and CD31, double-labelling immunofluorescence was used to detect the co-expression of CEACAM1 and LYVE1, and double-labelling immunohistochemistry was performed to observe the co-expression of LYVE1 and CD31 in vessels. Membranous CEACAM1 was expressed in well-differentiated squamous cell carcinoma and cytoplastic CEACAM1 in poorly and moderately differentiated carcinoma (P<0.05). More CEACAM1-positive vessels were observed in CEACAM1-positive tumors with cytoplasmic expression than with membranous expression (P<0.001). Co-expression of CEACAM1 and LYVE1, LYVE1 and CD31 in vessels was more common in CEACAM1-positive tumors with cytoplasmic expression than with membranous expression (P<0.001). CEACAM1 has different distribution in oral carcinoma. Membranous CEACAM1 inhibits angiogenesis and lymphangiogenesis, but cytoplasmic CEACAM1 promotes angiogenesis, and even promotes lymphangiogenesis by mediating the transformation of vascular endothelial cells (VECs) into lymphatic endothelial cells (LECs).

The aim was to analyze the survival and prognostic factors in 232 patients with squamous cell carcinoma of the buccal mucosa (BSCC) treated with radical surgery with or without neck dissection (ND). The 5-year survivals for local, locoregional control, overall, disease-free, and disease-specific were demonstrated. Pathologic nodal status was the independent risk factor for local and locoregional control. Both pathologic nodal status and cell differentiation were the significant prognostic factors of disease-free survival. For cT1N0, 11.1% had neck metastases. All were tumor depth of > or =6 mm. Our result showed a relatively better tumor control and survivals in BSCC with radical surgery with or without ND. The possible reason may be due to the benefit from widely surgical resection with ND and post-operative radiotherapy or concurrent chemoradiotherapy in those with risk factors. In treating early cT1N0, we suggest that elective ND is indicated only when tumor depth > or =6 mm.

Background: Oral cancer patients receive wide excision of oral structures and reconstruction of the intraoral defects with skin grafts and/or local, regional, or free flaps. Trismus is a common postoperative sequela, even without postoperative radiotherapy. Trismus decreases patients' quality of life and can have detrimental effects on their oral hygiene and nutritional status., Methods: Between May of 1999 and June of 2003, 11 patients were operated on for release of trismus and reconstruction after previous intraoral reconstructions. The patients had been reconstructed with skin grafts (n = 4), radial forearm flaps (n = 3), anterolateral thigh flaps (n = 1), artificial dermis (n = 1), radial forearm flaps with skin grafts (n = 1), and pedicled pectoralis major flaps with skin grafts (n = 1). Eight patients had received postoperative radiotherapy. The patients presented with a mean interincisal distance of 3.1 mm (range, 0 to 10 mm)., Results: After trismus release, the intraoral soft-tissue defects were reconstructed with one or two free flaps (six anterolateral thigh flaps, nine forearm flaps, and one fibula osteoseptocutaneous flap). Fifteen of the 16 flaps were successful, with one flap failure. Average interincisal distance was 33.4 mm immediately after the release (range, 27 to 35 mm) and 18.9 mm (range, 5 to 30 mm) at a mean follow-up time of 22.7 months (16.1 mm in the radiated group and 26.3 mm in the nonradiated group). The mean amount of improvement was 15.8 mm., Conclusion: The use of free flaps to reconstruct the defects created after trismus release in patients with previous intraoral reconstruction is a viable option that yields reasonable, long-lasting improvements in mouth opening, intraoral hygiene, and quality of life.

Objective: To study the clinical characteristics, diagnosis and treatment strategy of oral and maxillofacial malignancies in multiple primary malignant neoplasms (MPMNs)., Methods: 21 cases of oral and maxillofacial malignancies associated with MPMNs admitted to our hospital between 1985 and 2000 were studied respectively., Results: There were 44 malignant cases in the 21 MPMNs patients. Among the 44 cases, there were 24 cases in alimentary and respiratory tract such as oral, pharynx, esophagus, stomach and lung, and 10 cases in salivary gland, breast and female reproductive system. There were 25 cases malignant neoplasms in oral and maxillofacial region where squamous cell carcinoma was the most common pathologic type, secondly adenoid cystic carcinoma. In oral and maxillofacial region, MPMNs were often found in tongue, parotid and submandibular gland, buccal mucosa and gingival., Conclusion: Tongue and salivary gland were the common locations with MPMNs, and they were closely associated with alimentary and respiratory tract. Patients with malignancies of oral and maxillofacial region associated with MPMNs must be submitted to a long-term and careful follow-up. For female patients, breast and female reproductive system should be examined specially. Regular follow-up, early detection, early diagnosis, active and effective treatment can help to improve the survival quality of MPMNs patients.

Background: The treatment of severe trismus requires a combination of surgical release and postoperative rehabilitation; the latter is essential for preventing a relapse due to postoperative inactivity and scarring. Mouth-opening devices for this purpose are placed between or fixed to the teeth to keep the dental arches apart; but patients suffering from severe trismus often present with partially or totally edentulous arches, decayed teeth, or periodontitis, which do not allow for the use of such devices., Methods: In this article, a new mouth-opening device is described. It applies force to two intraoral screws placed in the vestibulum of the maxillary and mandibular bones. It can be used in patients with poor dental conditions and allows rehabilitation to start immediately after trismus release., Result: A case is presented. The interalveolar distance was improved from 5 mm to 45 mm and maintained at 6-month follow-up., Conclusion: Our non-tooth-borne mouth opening device is useful for postoperative rehabilitation after surgical release of trismus.

Background: Extensive composite mandibular defects involving large lip defects are the most difficult to repair among head and neck reconstructions. This study presents the authors' approach using double free flaps and fascia lata grafts for oral sphincters., Methods: Ten patients were studied after ablative oral cancer surgery. Segmental defects of the mandible ranged from 6 to 14 cm. Cheek defects ranged from 9 x 6 cm to 15 x 12 cm, and intraoral defects ranged from 9 x 7 cm to 16 x 16 cm. Upper lip defects ranged from 10 percent to 50 percent, and lower lip defects ranged from 50 percent to 90 percent. A fibula osteocutaneous flap was used for reconstruction of mandibular defects and intraoral lining, and an anterolateral thigh flap was used for cheek and lip defects. Then, a sheet of fascia lata graft was used to reconstruct the oral sphincter. The tendon graft was passed into the subcutaneous layers of the reconstructed lip, woven into the remaining orbicularis oris muscle of the lip, and anchored to the upper lip near the philtral columns to complete the oral ring with adequate tension., Results: Free flap survival was 100 percent. Complications included one patient with neck hematoma and distal anterolateral thigh flap necrosis, three patients with neck wound infection, and one patient with osteomyelitis of the mandible. All but one patient had adequate oral competence. All the patients were able to resume a soft diet. The speech ability was nearly normal for all the patients, and all the patients had gained an acceptable appearance., Conclusions: For extensive composite mandibular defects combined with large lip defects, immediate reconstruction with double free flaps and a fascia lata graft for oral sphincter has proved to be a useful option for better functional and cosmetic results.

Following a set of principles, free style free flaps may be harvested from any region of the body where a Doppler signal is heard. By using a retrograde dissection technique, the skin vessel is traced through its subfascial course (intramuscular or septocutaneous), until adequate length or vessel size is achieved. If a "free style free flap" is not originally planned, this approach can be usedwhen anatomic variations or unexpected events are encountered. The thigh, a region that is familiar to the surgical team at Chang Gung Memorial Hospital, was chosen as the site to begin exploring this style of flap harvest. Nine flaps were harvested as free style free flaps from the thigh and were used successfully for the reconstruction of complex defects.

Reconstruction of composite defects of the mandible is a challenging problem. Although the use of an osteocutaneous free flap, alone or in combination with another soft-tissue free flap, is generally accepted to be optimal, the bony reconstruction is sometimes undervalued, especially when the cancer is advanced. In such situations, reconstruction is often performed with a reconstruction plate covered with a soft-tissue free flap. Between January of 1997 and July of 2000, 80 patients with composite or extensive composite oromandibular defects underwent treatment with a reconstruction plate and a soft-tissue free flap. All of the patients were male, and the ages of the patients at the time of treatment ranged from 32 to 78 years (mean, 51 years). Tumors were classified as stage IV in 56 patients (70 percent), whereas the remaining 24 patients (30 percent) had recurrent carcinomas. The titanium mandibular reconstruction system manufactured by Stryker (Freiburg, Germany) was used to bridge the mandibular defects. The soft-tissue free flaps used for wound and plate coverage were as follows: anterolateral thigh flap (n = 75), radial forearm flap (n = 3), transverse rectus abdominis myocutaneous flap (n = 1), and tensor fasciae latae flap (n = 1). Five patients with recurrent carcinomas and 10 with stage IV carcinomas (18.75 percent) died 2 to 6 months after the operation and were excluded from the study. The remaining 65 patients were monitored for an average follow-up period of 22 months (range, 6 to 40 months). During that period, one or more complications occurred for 45 patients (69.2 percent). Plate exposure was the most common complication and was observed for 30 patients (46.15 percent). Twenty of the 65 patients (30.8 percent) required secondary salvage reconstruction with a fibula osteoseptocutaneous flap. The decision to perform a secondary salvage procedure was based on the general health of the patient, the extent of local disease, and the severity of the complications. Patients underwent salvage operations after an average of 11.5 months (range, 6 to 26 months). The major reasons for the second operation were as follows: reconstruction plate exposure (n = 12), soft-tissue deficiency and mandibular contour deformation of the lateral face (n = 7), intraoral contracture and lack of a gingivobuccal sulcus (n = 6), trismus (n = 4), and osteoradionecrosis of the mandible (n = 2). The total flap survival rate was 90 percent (18 of 20 free flaps). In two cases, the skin paddles of the fibula osteoseptocutaneous flaps exhibited partial failure and were revised with pedicled pectoralis major and deltopectoral flaps. The reconstruction plate and free soft-tissue flap procedure for the reconstruction of composite defects of the oromandibular region has many late complications, which eventually necessitate reconstruction of the mandible with an osteocutaneous free flap.

The radial forearm flap has been one of the most popular flaps used to reconstruct defects after oral cancer ablation. However, it sometimes may not provide sufficient soft tissue to obliterate the dead space after tumor excision and lymph node dissection, which can result in deep wound infection of the neck or even orocervical fistula. The authors modified the radial forearm flap with a sheet of adipofascial tissue extension to prevent such postoperative complications. From January 1997 to December 2000, 52 patients who underwent ablative oral cancer surgery were studied. A total of 29 patients (group I) underwent reconstruction with the traditional radial forearm flap retrospectively, and 23 patients (group II) underwent reconstruction with the radial forearm flap along with a sheet of adipofascial tissue extension. The radial forearm flap was designed on the axis of the radial artery, was 8 x 4 to 12 x 10 cm in size, and was sufficient to resurface the intraoral defect. In group II, the radial forearm skin flap along with a sheet of adipofascial tissue 8 x 8 to 12 x 10 cm was used to obliterate the dead space of the oral floor and neck. The donor site of both groups was resurfaced with a split-thickness skin graft. In group II, the skin flap of the adipofascial tissue was resutured to its original site. Two flaps in group I failed because of arterial occlusion and required other skin flaps for reconstruction. Postoperative hematoma, which required surgical treatment for drainage, developed in five patients in group I. None of the patients in group II had hematoma formation. Nine patients in group I had a neck wound infection compared with only 2 patients in group II (a significant difference). The average volume of drainage and days of hospitalization were similar in both groups. The morbidity of the donor site of both groups was not significant. The advantages of this modification include 1) suitable soft tissue available for dead space obliteration to decrease the chance of postoperative hematoma; 2) the important vessels in the neck can be protected; 3) there is a decrease in neck wound infections; and 4) donor site morbidity is similar to the traditional group.

Oral submucous fibrosis is a collagen disorder that affects the submucosal layer of the upper digestive tract. The major cause is the habit of betel quid chewing, which is common in central, southern, and southeast Asia. The progressive and irreversible course of disease results with trismus, dysphagia, xerostomia, and rhinolalia. The most serious complication of this disorder is the development of oral carcinoma, and the incidence in different series varies from 1.9 to 10 percent. A sufficient mouth opening can be achieved by complete release of fibrotic tissue, and coronoidectomy and temporal muscle myotomy when needed, and reconstruction of the resultant defect can be best achieved by microsurgical free-tissue transfer because of the discouraging results with skin grafting or local flaps. From April of 1997 to May of 2001, a total of 26 patients received reconstructive surgery with small radial forearm flaps after release of submucous fibrosis with or without temporalis muscle myotomy and coronoidectomy. All patients were men, with a mean age of 40.1 years (range, 18 to 62 years) and all had a history of betel nut chewing ranging from 8 to 40 years. The interincisal distance ranged from 5 to 29 mm, with a mean of 15 mm, before operation. After the release procedure, the interincisal distance increased to 40 mm (range, 35 to 50 mm). At a follow-up period of 3 to 48 months, the interincisal distance was a mean of 35 mm (range, 18 to 57 mm), with an average increase of 20 mm compared with the preoperative distance. During follow-up, three patients developed squamous cell carcinoma of the oral cavity 24 to 36 months after submucous fibrosis release. Two of them occurred in the release site and the other one occurred at the soft palate. Oral cancer occurred in three of 13 patients who had received release of submucous fibrosis and who were followed for longer than 2 years (range, 24 to 48 months), which means that 23 percent of these patients developed squamous cell carcinoma of the intraoral mucosa. High risk of cancer occurrence strongly indicates the importance of an earlier and more aggressive surgical approach toward submucous fibrosis, and long-term follow-up on a regular basis. The purpose of an early and aggressive approach to submucous fibrosis is to provide a good quality of life to the patient by improving oral hygiene and oral intake quality and at the same time to obtain a sufficient mouth opening, which is mandatory for the inspection of the excision site and the remaining oral mucosa during follow-up.

This paper introduces a technique of lip reconstruction using free flaps in which recognisable landmarks are mimicked by strategic placement of flap junctions. The technique was applied in 15 patients undergoing reconstruction of combined cheek and lip defects using single (n= 9) or double (n= 6) free flaps. Attention to flap design and strategic placement of flap junctions successfully created the vermilion-cutaneous junction, oral commissure and labiomental groove. The presence of these distinguishing features improved the appearance of the reconstructed lip., (Copyright 2001 The British Association of Plastic Surgeons.)

In search of an alternative soft tissue free flap donor site to radial forearm flap and rectus abdominis flap in head and neck reconstruction, we used the anterolateral thigh flap for reconstruction of various defects in the head and neck in 59 patients. The aim was to demonstrate the versatility of this donor site and propose a new approach to achieve a safer flap dissection. With the exception of three cases, all defects resulted from excision of malignant tumours. The defects were categorised as full thickness defects of the mandible (33.9%), full thickness defects of the cheek (52.5%) and others (13.6%). During the flap dissection a direct septocutaneous pedicle was observed in 12% of the cases. In the remaining cases there were only musculocutaneous perforators and the flaps were raised either as a split vastus lateralis musculocutaneous flap (72%) or as a perforator flap (16%), depending on the required thickness. Total flap survival was 96.7% with one total and one partial failure and two re-explorations (3.3%). The mean follow-up time was 7.1 months (range: 1-12 months). In conclusion, the anterolateral thigh flap is a versatile and dependable flap that can be adapted to any type of defect by modifying the flap design and composition. It should be considered to be a musculocutaneous flap of the vastus lateralis muscle that can also be raised as a perforator flap. When harvested and used in this context, the flap dissection becomes very safe and consistent, nullifying the only major disadvantage associated with this donor site., (Copyright 2000 The British Association of Plastic Surgeons.)

This report describes free transfer of transverse colon for reconstruction of the hypopharynx and cervical oesophagus. The transverse colon based on the middle colic vessels was used in three patients following laryngo-pharyngo-oesophagectomy for hypopharyngeal squamous carcinoma. There were no flap failures or intra-abdominal complications. Solid diet was well tolerated. Transverse colon is easy to harvest, has a long vascular pedicle, wide diameter and good ischaemic tolerance. Contrast studies showed it to be a wide bore passive conduit. Compared with currently available options these features may allow better outcome in pharyngo-oesophageal reconstruction and warrant further evaluation., (Copyright 2000 The British Association of Plastic Surgeons.)

Successful results of a second microsurgical reconstructive attempt have been reported previously in recurrent oral carcinoma. However, the feasibility of a third free flap following a third excision has remained to be determined. Six oral carcinoma patients with multiple recurrences, surgical excisions and free flap reconstructions on three separate occasions are presented. Resections had a curative intent in all cases in the first and second ablations and in four of the six cases in the third one. Five radial forearm flaps and one double free flap were used for the first reconstruction. During the second reconstruction two radial forearm, two fibula osteoseptocutaneous, one double free flap and one rectus femoris flap were used to reconstruct the larger defects resulting from excision of the recurrent tumours. However, no vascularised bone transfers were performed following the third excision and soft tissue free flap plus plate option was used for segmental mandibular defects. There was one partial flap loss among 21 free flaps performed. Three patients died within an average of 8 months following the third reconstruction while the others remained alive, surviving an average of 6 months. In conclusion, a third free tissue transfer for reconstruction in multiply recurrent oral carcinoma was found to be feasible, safe and effective. The use of free flaps contributed to the prevention of complications in these difficult cases and enabled the patients to spend the remaining days of their lives outside hospital.

Primary microsurgical reconstruction is the treatment of choice for ablative defects of oral carcinoma. As a result of this trend, more and more patients with recurrent oral carcinoma who have been initially treated with surgical excision and reconstructed with free flaps are being seen. However, a second microsurgical reconstruction attempt in these cases raises questions about the flap choices, availability of recipient vessels, and effects of previous treatment modalities. Herein, 35 patients with perioral carcinoma who had two successive tumor resections and reconstruction with free flaps on each occasion are presented. A total of 75 free tissue transfers were carried out for the first and second reconstructions. After the first tumor resection, 28 radial forearm fasciocutaneous flaps, 7 fibula osteoseptocutaneous flaps, 1 iliac osteomyocutaneous flap, and 2 rectus abdominis myocutaneous flaps were used. For reconstruction after the recurrence, 17 radial forearm fasciocutaneous flaps, 13 fibula osteoseptocutaneous flaps, 3 rectus abdominis myocutaneous flaps, 2 anterolateral thigh flaps, 1 jejunum flap, and 1 tensor fasciae latae flap were used. More vascularized bone transfers were performed during the second reconstruction since the excision for the recurrence frequently required segmental mandibulectomy. The complete flap survival rate was 97.3 percent and 94.6 percent with a reexploration rate of 7.9 percent and 13.5 percent for the first and second free tissue transfers, respectively. The mean follow-up time throughout the procedures was 37.5 months. Disease-free interval between reconstructions was 20.8 months. At the time of evaluation, 54.3 percent of the patients were surviving an average of 19 months since the second reconstruction. The results suggest that free flaps represent an important option in reconstruction of recurrent perioral carcinoma cases undergoing reexcision. When used in this indication they are as safe and effective as the initial procedure.

Lateral composite mandibular defects resulting from excision of advanced oral carcinoma often require mandible, intra-oral lining, external face, and soft-tissue bulk reconstruction. Ignorance of importance soft-tissue deficit in those patients may cause significant morbidity and functional loss. Such defects, therefore, can be reconstructed best with a double free flap technique. However, this procedure may not be feasible for every patient or surgeon. An alternative procedure is a free fibula osteoseptocutaneous flap combined with a pedicled pectoralis major myocutaneous flap. This combination was used in reconstruction of extensive composite mandibular defects in 14 patients with T3/T4 oral squamous cell carcinoma. All patients were men, and the average age was 54.3 years. The septocutaneous paddle of the fibula flap was used for the mucosal lining of the defects while the bony part established the rigid mandibular continuity. The pectoralis major flap then covered the external skin defect in the face and cheek, and the dead spaces left by the extirpated masticator muscles, buccal fat, and parotid gland. One free fibula flap failed totally, and one pectoralis major flap developed marginal necrosis. At the time of final evaluation, nine patients (64.3 percent) were alive, surviving an average of 25.7 months. All patients eventually regained their oral continence and an acceptable cosmetic appearance. In conclusion, the fibula osteoseptocutaneous flap plus regional myocutaneous flap choice is a successful and technically less demanding alternative to the double free flap procedures in reconstruction of extensive lateral mandibular defects.

The skin paddle in the fibula osteoseptocutaneous flap is thin, soft, and pliable, and it can be used for external skin coverage and intraoral linings. The flexibility of the fibula in three-dimensional positioning after multiple osteotomies is desirable in complex spatial skeletal reconstruction. The fibula osteoseptocutaneous flap is suitable for one-stage reconstruction of composite maxillary defects. The unique characteristics of the fibula osteoseptocutaneous flap and its application in the one-stage composite maxillary defect are discussed.

Squamous cell carcinoma is a complication of chronic tibial osteomyelitis treated with limb-preserving surgery. A 61-year-old man with 42-year history of chronic osteomyelitis of the left tibia was found to have malignant change. A curettage procedure was performed by a general surgeon. He then was referred to the osteomyelitis service; local wide excision was followed by staged microvascular latissimus dorsi muscle flap and fibular osteoseptocutaneous flap transfer. The patient remains well 36 months later with no clinical or radiologic evidence of local recurrence or distant metastasis. This kind of limb-sparing treatment is an excellent alternative treatment for malignancy.