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The oropharynx represents one of the most challenging areas to reconstruct for the head and neck surgeon. The buccinator myomucosal island flaps pedicled on the facial artery [tunnelized facial artery myomucosal island flap (t-FAMMIF)] or the buccal artery [buccal artery myomucosal island flap (BAMMIF)] are an ideal reconstructive option for moderate size defects measuring up to 8-9cm. Two fresh specimens have been used to show the step-by-step surgical technique of both island flaps. Design and flap extension, dissection plane, identification of the vascular pedicle, flap rotation and insetting are described. Reconstructive indications and the pros and cons of each one are discussed in this article. Myomucosal island flaps represent a very useful and versatile option for the functional reconstruction of the oropharynx. A detailed knowledge of the vascular anatomy of the cheek is key to obtain a large flap while minimizing the risk of complications., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

This review aims to provide a correlation between oral and oropharyngeal subsites and type of reconstruction used in the management of head and neck cancer patients. A literature search of PubMed, Embase and Web of Science was conducted. All study types describing long-term speech and swallow outcomes of adults following head and neck oncological reconstruction, which used a subsite classification, were included. Risk of bias was assessed using the Robbins-1 tool. A total of 2270 patients were found in 26 studies. The number of subsites/studies ranged from 2 to 18. Subsites were predominantly divided on an anatomical basis. Other classifications included functionally grouped subsites. Seven articles considered combinations, unilateral and bilateral defects. Base of tongue, FOM, and defects crossing the midline are negatively correlated with post-operative speech and swallow. Lateral distributions were associated with superior outcomes. The University of Washington Quality of Life Questionnaire (UW-QOL) was the most prevalent tool for speech and swallow assessment. Other factors that significantly affect speech and swallow outcomes include adjuvant therapy, size, type of reconstruction (free flap compared to pedicled or local). The role of neoadjuvant therapy remains unknown. A consistent and formalised approach including risk stratification for multiple contributing factors would be useful in clinical pre- and post-operative management., Competing Interests: Declaration of competing interest None., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. All rights reserved.)

Background: Transoral robotic surgery (TORS) for oropharyngeal malignancy optimizes oncologic outcomes while preserving functionality. This study identifies patterns of functional recovery after TORS with free flap reconstruction (FFR)., Methods: Retrospective cohort study at a tertiary care center of patients with primary oropharyngeal tumors treated with TORS with FFR between 2010 and 2022. Patients were categorized into: adjuvant chemoradiation or radiation, or no adjuvant therapy (NAT). Functional outcomes were measured by functional oral intake scale (FOIS)., Results: 241 patients were included. FOIS declined at first postoperative appointment (median = 7.0 to 2.0, IQR = [7.0, 7.0], [2.0, 4.0]), and progressively improved to 6.0 (5.0, 6.0) after 1 year, with NAT having the highest FOIS (7.0, p < 0.05). Predictors of poor long-term FOIS included RT and hypoglossal nerve (CN XII) involvement (p < 0.05)., Conclusions: TORS with FFR leads to good long-term function with minimal intake restrictions. Radiation therapy and CN XII involvement increase risk of worse functional outcomes., (© 2024 The Authors. Head & Neck published by Wiley Periodicals LLC.)

The palatal island rotation flap is a rarely used reconstructive technique. The tissue is robust and the morbidity is low. It can be used as a primary reconstructive technique in patients with limited oral cavity/pharynx lesions. Healing is uneventful. In radiated pateints healing is prolonged and should be avoided. We describe 14 patients where the flap was used to reconstruct local defects. Patients with no history of radiation all healed quickly and well. Those with a history of radiatiuon had prolonged pain and delayed healing. Laryngoscope, 134:2718-2720, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: After oropharyngeal reconstruction surgery, excessive flap volume within the oral cavity may increase the risk of pharyngeal obstruction during sleep. This prospective observational study aimed to test a hypothesis that the skin-flap oropharyngeal reconstructive surgery increases nocturnal apnea-hypopnea index (nAHI, primary variable) after surgery., Methods: Adult patients undergoing oropharyngeal reconstruction surgery participated in this study. The hypothesis was tested by comparing the results of portable type 4 sleep study and craniofacial assessments with lateral head and neck computed tomography scout image before and after surgery. Multiple linear regression analyses were performed to identify predictors for nAHI increase after the surgery., Results: In 15 patients, a postoperative sleep study was performed at 41 (27, 59) (median (IQR)) days after the surgery. nAHI did not increase after the surgery (mean (95% CI), 13.0 (7.2 to 18.7) to 18.4 (10.2 to 26.6) events.hour -1 , p = 0.277), while apnea index significantly increased after the surgery (p = 0.026). Use of the pedicle flap for the oropharyngeal reconstruction (p = 0.051), small mandible (p = 0.008), longer lower face (0.005), and larger tongue size (p = 0.008) were independent predictors for worsening of nAHI after surgery. Hospital stay was significantly longer in patients with the pedicle flap (n = 8) than in those with the free flap (n = 7) (p = 0.014), and the period of hospital stay was directly associated with increase of nAHI after surgery (r = 0.788, p < 0.001, n = 15)., Conclusions: Oropharyngeal reconstruction surgery worsens sleep-disordered breathing in some patients with craniofacial and surgical risk factors., Trial Registration: UMIN Clinical Trial Registry (UMIN000036260, March 22, 2019), https://rctportal.niph.go.jp/s/detail/um?trial&#95;id=UMIN000036260., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objective: To analyze the clinical effect of free posterior lateral peroneal artery perforator flap of lower leg in repairing postoperative defect of oropharyngeal carcinoma. Methods: Thirty-six patients with oropharyngeal carcinoma admitted to the Department of Oral and Maxillofacial Surgery, the First Affiliated Hospital of Bengbu Medical College from June 2016 to June 2019 were analyzed and followed up, eighteen patients were treated with free posterior lateral peroneal artery perforator flap of the lower leg to repair the postoperative defects（experimental group）, and eighteen patients were treated with free forearm flap（control group）. The survival rate of the transplanted flap, the wound stageⅠhealing rate and average hospitalization time were compared between the two groups. Kaplan-Meier method was used to calculate the 1-year and 3-year survival rates of patients after operation, and log-rank test was used to compare the difference between the survival curves of the two groups; The recovery of swallowing and palatopharyngeal closure function of patients in the two groups at 3, 6, 12 and 18 months after operation was calculated and statistically analyzed through the water swallow test and the air blowing method. Results: There was one case of skin flap necrosis in both the experimental group and the control group, and the survival rate was 94.4%. The wound stageⅠhealing rate in the surgical area was 94.4% in both groups. The wound healing rates of the donor area in the experimental group and the control group were 100.0% and 94.4% respectively. The average hospitalization time of the experimental group and the control group was 16.9 days and 17.2 days, respectively, with no significant difference （ P >0.05）. The overall survival rates of all patients at 1-year and 3-year were 91.2% and 66.5% respectively; The 1-year and 3-year survival rates of the experimental group and the control group were 94.1%, 69.3% and 88.2%, 63.7%, respectively, and there was no significant difference between the two groups （ P >0.05）. The 1-year and 3-year survival rates of P16+ and P16 - patients were 100.0%, 80.0% and 85.7%, 64.3%, respectively, and there was no significant difference between the two groups （ P >0.05）. There was no significant difference in the evaluation of swallowing and velopharyngeal closure function between the two groups at 3 and 6 months after operation （ P >0.05）, but there was a significant difference at 12 and 18 months after operation （ P <0.05）. Conclusion: The anatomic position of the perforating vessels of the free posterior lateral peroneal artery perforator flap of the lower leg is constant, and it can be prepared into single leaf, multi leaf, chimeric and other flaps according to the tissue defect space. And the concealed supply area can be directly drawn to suture. At the same time, the skin flap has strong plasticity. Therefore, the skin flap can be used as a common skin flap to repair the defects after the operation of oropharyngeal carcinoma., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)

Objectives/hypothesis: To study use of the nasoseptal flap (NSF) to reconstruct lateral transoral robotic surgery (TORS) oropharyngectomy defects., Study Design: Retrospective case series., Methods: A clinical series of six patients undergoing NSF reconstruction of lateral TORS oropharyngectomy defects was retrospectively studied. All patients underwent TORS for the treatment of intermediate-risk human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma of the lateral pharyngeal wall between January and June 2017. All patients underwent NSF reconstruction of lateral TORS defects with retrospective analysis of outcomes and complications., Results: Six patients underwent NSF reconstruction of lateral TORS defects. Operative times decreased from 180 minutes to 90 minutes over the study period. There were two cases of partial flap dehiscence and partial necrosis. There were no major donor site complications. All patients had temporary nasal obstruction and crusting. Two experienced temporary aural fullness. In all patients, the lateral wall was mucosalized in 1-3 weeks. Cephalometric analysis of preoperative imaging revealed that patients with high-arched palates (>3 cm) and defect lengths that are longer than NSF flap lengths are poor candidates for this technique., Conclusions: This NSF is a vascularized, locoregional rotational flap that can reconstruct lateral TORS defects in salvages cases or those where the parapharyngeal carotid or mandibular bone are exposed. Postoperative morbidity is limited to temporary nasal dyspnea, aural fullness, and crusting. Preoperative imaging can determine which patient will have successful defect coverage., Level of Evidence: 4 Laryngoscope, 132:53-60, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To investigate the oropharyngeal function recovery of oropharyngeal squamous cell carcinoma repaired by anterolateral thigh flap and forearm flap. Methods: Retrospective study between September 2016 and September 2020 complete line 37 cases of oropharyngeal cancer postoperative soft tissue defect of femoral anterolateral flap or forearm flap to repair the patient data, in which 22 cases, using the forearm skin flap to repair 15 cases with femoral anterolateral flap, flap survival rate of preparation, compare the two groups, the incidence of vascular crisis, The functions of swallowing, speech, and velopharyngeal closure were evaluated. Results: 21 cases of forearm flaps survived, and 1 case had vascular crisis. After surgical exploration, the contralateral forearm flaps survived transplantation. Fourteen anterolateral femoral flaps survived, 2 flaps had vascular crisis, and 1 flap survived after thrombus removal. The other one was repaired with pectoralis major myocutaneous flap for necrosis. Swallowing, speech, palatopharyngeal closure and other functions of the patients after the two kinds of flap repair had higher satisfaction. Conclusion: Forearm flap and anterolateral thigh flap are good choices for soft tissue defect after oropharyngeal cancer, Must act according to the special details choice appropriate therapeutic schedule., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)

Introduction: Human papilloma virus (HPV)-positive oropharyngeal cancer carries a good prognosis when managed with primary chemoradiotherapy. However, the dramatically increasing rate of this disease means more patients are now developing recurrence, with surgery remaining the mainstay of treatment. Despite this, there is no agreed technique for excision of recurrent oropharyngeal cancer., Objective: We describe the transoral robotic technique employed by our head and neck multidisciplinary team (MDT) in the management of patients with recurrent HPV positive oropharyngeal cancer and assess their symptom severity using quality of life and swallowing questionnaires., Method: Three (2 males:1 female, mean age 60.7 years) patients with recurrent or residual p16 positive oropharyngeal cancer following radical chemoradiotherapy were identified. All patients underwent selective neck dissection, tracheostomy, and transoral robotic surgery (TORS)-assisted partial oropharyngeal resection with the resultant defect closed with a robotic assisted radial forearm free flap (RFFF). Patient quality of life, symptom severity, and swallowing were assessed pre- and postoperatively using the University of Washington Quality of Life score and MD Anderson Dysphagia Index (MDADI)., Results: Histopathological examination revealed complete clearance of the primary lesion in all cases. Two patients made uneventful recoveries, while one patient developed a chest infection and tracheocutaneous fistula managed conservatively. Mean inpatient stay was 15 days (range 8-27). University of Washington Quality of Life and MDADI scores showed a mild improvement in symptoms following surgery., Conclusion: Surgical management of recurrent oropharyngeal cancer remains a technical challenge; however, MDT discussion and judicious use of TORS oropharyngeal resection and RFFF can result in good oncological and quality of life outcomes with acceptable postoperative complications and symptoms.

Objective: To compare the recovery and quality of life of patients with oral and oropharyngeal tumors treated with three kinds of free soft tissue flaps. Methods: The clinical data of 103 patients, including 66 males and 37 females, aged 26-74 years, who underwent primary repair of defects after resection of oral and oropharyngeal tumors in Sichuan Tumor Hospital from July 2014 to August 2020 were analyzed. Anterolateral thigh flap (ALTF) was used in 43 patients, radial forearm free flap (RFFF) in 45 patients, and lateral arm free flap (LAFF) in 15 patients. Postoperative qualities of life of patients were evaluated by the university of Washington quality of life questionnaire and oral health impact scale (HIP-14 Chinese edition). SPSS 23.0 software was used for statistical analysis. Results: The T staging of RFFF or LAFF group was significantly lower than that of ALTF group ( P <0.05). There was no significant difference in mean flap areas between ALTF group ((55.87±27.38) cm 2 ) and LAFF group ((49.93±19.44) cm 2 ), while RFFF group had smaller mean flap area ((33.18±6.05) cm 2 ) than ALTF group ( t =5.311, P <0.001) and LAFF group ( t =3.284, P =0.005). In terms of oral functions including swallowing, mastication, taste and spitmouth, there were no significant differences between LAFF group and RFFF group ( P >0.05), but both groups had better oral functions than ALTF group ( P <0.05). There was no significant difference in appearance scores between LAFF group (75(75, 75)) and ALTF group (75(75,75) vs.75(75,75), Z =-1.532, P =0.126), and both groups had higher scores than RFFF group (50(50, 75), Z values were -3.447 and -3.005 respectively, P <0.05). RFFF group had higher speech score (100(67, 100)) than LAFF group (67(50, 76), Z =-2.480, P <0.05) and ALTF group (67(33, 67), Z =-5.414, P <0.05). ALTF group had lower mean score of quality of life than RFFF group [72(56,77) vs.79(69, 89), Z =-3.070, P <0.05), but there was no statistical difference in the mean scores of qualities of life between ALTF group and LAFF group ( Z =1.754, P =0.079). According to the evaluation of oral health impact scale (HIP-14 Chinese version) 1 year after surgery, individual item scores and the average score of all items in ALTF group were lower than those in RFFF and LAFF groups ( P <0.05), with no significant difference between RFFF group and LAFF group ( P >0.05). Conclusions: RFFF has unique advantages for small tissue defects, while ALTF is suitable for large tissue defects, such as buccal penetrating defect, whole tongue and near whole tongue defect, and LAFF is a compromise choice between ALTF and RFFF. ALTF is inferior to RFFF and LAFF in oral functional reconstruction, including swallowing, chewing, taste and spittle. ALTF and LAFF are superior to RFFF in postoperative appearance.

Purpose: To introduce modified submental platysmal adipomyofascial flap as a new and viable hairless locoregional option for reconstruction of small- to mid-sized defects after ablative surgery in oral/oropharyngeal cancer patients keeping in mind the present pandemic situation., Methods: An observational retrospective study was conducted using modified submental platysmal adipomyofascial flap as a locoregional reconstructive option for both intraoral and oropharyngeal defects in early-stage oral/oropharyngeal cancer patients, from Jan 2016 to May 2020 in a tertiary care hospital. All patients in this study were male and the overall flap outcome was evaluated with post-operative follow-up., Results: Out of 18 patients, in 4 patients modified submental platysmal adipomyofascial flap was used as a combination of flaps for reconstruction. Six patients (33.33%) underwent adjuvant radiation therapy/radiation chemotherapy. The long-term functions (speech and swallowing) and cosmetic outcomes were good in the majority of the patients. One patient (5.55%) had pinhole oroantral fistula. No patient had any major flap failure., Conclusion: Modified submental platysmal adipomyofascial flap can be considered as a good alternative in male patients for reconstruction of small- to mid-sized oral cavity/oropharyngeal defects post-resection, especially during the prevailing pandemic crisis. It is an oncologically safe procedure with the major advantage of providing a hairless flap for oral cavity, tonsillar and BOT resection defects with lesser donor site morbidity.

Objectives: Guidelines for transoral robotic surgery (TORS) have generally regarded patients with retropharyngeal carotid arteries as contraindicated for surgery due to a theoretical risk of intraoperative vascular injury and/or perioperative cerebrovascular accident. We aimed to demonstrate that careful TORS-assisted resection and free flap coverage could not only avoid intraoperative injury and provide a physical barrier for vessel coverage but also achieve adequate margin control., Study Design: Retrospective cohort analysis., Methods: Retrospective review of patients with oropharyngeal malignancies and radiologically confirmed retropharyngeal carotid arteries who underwent TORS, concurrent neck dissection, and free flap reconstruction between 2015 and 2019., Results: Twenty patients were included, 19 (95.0%) with tonsillar tumors and one (5.0%) with a tongue base tumor with significant tonsillar extension. Eighteen patients (90.0%) received a radial artery forearm flap, one (5.0%) an ulnar artery forearm flap, and one (5.0%) an anteromedial thigh flap. All 20 (100%) flaps were inset through combined transcervical and transoral approaches without mandibulotomy. There were no perioperative mortalities, carotid injuries, oropharyngeal bleeds, cervical hematomas, or cerebrovascular accidents. One patient (5.0%) had a free flap failure requiring explant. All patients underwent decannulation and resumed a full oral diet. The mean length of hospitalization was 6.8 (standard deviation 1.2) days. One (5.0%) patient had a positive margin., Conclusion: In this analysis, 20 patients with oropharyngeal malignancy and retropharyngeal carotid arteries underwent TORS, neck dissection, and microvascular reconstruction without serious complication (perioperative mortality, vascular injury, or neurologic sequalae) with an acceptable negative margin rate. These results may lead to a reconsideration of a commonly held contraindication to TORS., Level of Evidence: 3 Laryngoscope, 131:E821-E827, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Oropharyngeal tumors can cause severe dysfunctions, which are often worsened by surgical and/or radiotherapy. The severity and type of dysfunction depends on the extent and localization of the resection. In general, entire organ resections lead to greater impairment than partial resections, whereas extended partial resection often equates to total resection. Plastic reconstructive surgery can help to preserve and reconstruct specific functions. Herein, the various surgical techniques with different flaps and tissue grafts are described, and the indications are presented depending on the dysfunctions, the defect location, and the extent of resection (partial versus total).

Background: Surgery of the soft palate in patients with oropharyngeal cancer can result in functional deficiencies of swallowing and speech. Reconstruction of the resected structures can contribute to regaining sufficient functionality after therapy., Objective: The current study used frequency analysis to evaluate the change in speech characteristics after resection and reconstruction of the soft palate during post-therapeutic follow-up., Materials and Methods: In 18 patients with oropharyngeal carcinoma and involvement of the soft palate, resection and reconstruction by free radial forearm graft (FRFG) and adjuvant chemoradiotherapy was conducted. The spoken German numbers "eins", "zwei", "drei", "vier", "fünf" were recorded during follow-up and objectively assessed by frequency analysis. Additionally, food intake status and the necessity of a tracheostomy were evaluated., Results: The maximum peak frequencies of the numbers analysed increased from 150-300 Hz before up to 1000 Hz after therapy. Two years post therapy, the peak frequencies again declined to levels comparable to those before tumour therapy. One year after therapy, complete oral nutrition was possible in two thirds of patients and the tracheostomy was closed in 80%., Conclusion: Reconstruction of the soft palate by FRFG during the course of oropharyngeal cancer treatment allows function to be regained with respect to speech and swallowing. In the majority of patients, it is possible to reach a level of function comparable to the state before tumour treatment.

Objectives: To assess the factors associated with long-term quality of life (QoL) and patient concerns in elderly oral or oropharyngeal cancer (OOPC) patients after oncologic surgery and free-flap reconstruction., Methods: Patients aged over 70 years who were still alive and disease-free at least 1 year after surgery were enrolled in this cross-sectional multicentric study. Patients completed the EORTC QLQ-C30, -H&N35 and -ELD14 QoL questionnaires, and the Hospital Anxiety and Depression Scale (HADS). Patient needs were evaluated using the Patient Concerns Inventory (PCI). Factors associated with these clinical outcomes were determined in univariate and multivariate analysis., Results: Sixty-four patients were included in this study. Long-term QoL, functioning scales and patient autonomy were well-preserved. Main persistent symptoms were fatigue, constipation and oral function-related disorders. Salivary and mastication/swallowing problems were the main patient concerns. The mean number of patient concerns increased with the deterioration of their QoL. Psychological distress (HADS score ≥ 15) and patient frailty (G8 score < 15) were significantly associated with poor QoL outcomes., Conclusions: We found a negative correlation between the number of patient concerns and QoL. Dental rehabilitation and psychological and nutritional supportive measures are of critical importance in the multidisciplinary management of elderly OOPC patients., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: While transoral robotic surgery (TORS) is widely used for the management of lateral wall oropharyngeal carcinomas (OPC), open surgical techniques are still used in some cases. A pull-through method for open surgical resections of OPC has recently been introduced. We improved on this method by eliminating the need for subsequent free-flap reconstruction., Methods: 16 patients with lateral wall OPC underwent pull-through resections. After resection, we used the digastric muscle, stylohyoid muscles, submandibular gland and the surrounding tissues to block the neck and oral cavity and to avoid reconstruction., Results: This novel technique was performed without major complications or morbidities. The average post-operative hospital stay was 14.6 ± 6.1 days, and the average duration until initiation of oral intake post-operation was 6.5 ± 2.9 days. Oncological outcomes, post-operative course and function were acceptable., Conclusions: Our novel method provides an efficient and less invasive surgical technique than conventional open approaches., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

The simultaneous use of two different free flaps, harvested from distinct donor sites, has demonstrated a reasonable degree of safety and success rates in head and neck composite defects reconstruction. Unfortunately, their relatively low frequent use, together with the lack of proper statistics on their management strategies, make their indications weak of robust conclusions to better define their role in common practice. The aim of the present study was to review the literature of the last 15 years regarding simultaneous free flap transposition, presenting advantages, disadvantages, and results of this technique, with the final purpose to propose an up-to-date panorama for the use of double free flap for complex head and neck defects reconstruction. Depending on which factors are present, surgeons may choose to select an approach that is theoretically safer, but yields less-than-ideal functional outcomes, such as local flap. Two free flaps may be necessary when the defect contains both a large, complex bony defect, large soft tissue needs, and proper surgical planning and meticulous monitoring continues to be the cornerstone of success., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: This study was carried out to characterize the clinical and histological changes in the cutaneous portion of the transferred pedicled pectoralis major myocutaneous flaps used in intraoral reconstruction in patients with head and neck malignancy., Methods: This was a prospective cohort study carried out from July 2016 to 2018. All patients underwent ablative surgery for oropharyngeal cancers and primary reconstruction with pedicled pedicled pectoralis major myocutaneous flaps. The intraoral flaps were examined for color, texture, presence of hair, chronic inflammatory changes, and ulceration. At 12 months, incisional biopsies were taken from the skin paddle of the intraoral flap and contralateral normal buccal mucosa, and flap histology was compared with that of the contralateral buccal mucosa., Results: Twenty patients were included in the final analysis (M/F, 4:1; mean ± SD age, 51.38 ± 6.76 years). Fourteen flaps resembled oral mucosa, 3 had a mixed appearance of both skin and mucosa, and 3 had appearance of normal skin at 1 year follow-up. The epidermis and stratum corneum were retained in all the flap biopsies; however, severe attenuation was noted in 7 patients (had mucosal appearance) but was significantly different from oral mucosa(P = 0.0003). Cutaneous appendages were found in all the flap epithelia. Thirteen flaps showed grossly attenuation, of which 11 patients had a gross appearance resembling oral mucosa and 2 had a mixed appearance. The biopsies showed varied degree of chronic changes like desquamation in around 35% (7 patients), hyperkeratosis in 35% (7 patients), and chronic candidiasis in 30% (6 patients)., Conclusions: Although the intraorally transferred flaps demonstrate a morphological appearance similar to oral mucosa, there is a histological preservation of skin elements and architecture.

Since the first description of the submental island flap 24 years ago, advances in techniques have expanded the indications for its use and improved its characteristics to make it a favourable reconstructive option for orofacial oncological defects. We describe our experience (particularly perioperatively) of its use, the complications, and the precautions adopted. We retrospectively reviewed the cases of 25 patients and focused on the operating time, use of tracheostomy, duration of postoperative inpatient stay, oropharyngeal function, and associated morbidities. Eighteen patients had defects of the tongue. Other defects were retromolar (n=2), buccal (n=1), mandibular (n=2), and maxillary (n=2). The mean (range) operating time was 250 (152-370) minutes and the mean (range) postoperative stay was 11 (4-16) days. Only four patients required a tracheostomy, and four required postoperative monitoring in the intensive care unit (ICU). The complications were partial flap loss (n=6), sialocele (n=1), and seroma (n=1). The flap has shown its merit as an option for oral reconstruction because of its reliability, versatility, and relative ease of application. To our knowledge, our case series is the largest in the United Kingdom, and we hope that in future, this humble flap will be a standard reconstructive option for small to medium oral resection defects., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Background: The da Vinci Surgical System has facilitated considerable advancements in surgery. The process and results of robot-assisted microvascular anastomosis in real clinical situations have rarely been reported. This study presents our experience of performing robot-assisted microvascular anastomosis in free flap reconstruction in patients with oropharyngeal cancer., Patients and Methods: This was a retrospective study of reconstructive operations using a free radial forearm flap for oropharyngeal defects after tumor extirpation in 15 consecutive adult patients (12 men and 3 women). In total, 17 robot-assisted microvascular vessel anastomoses (2 arteries and 15 veins) were performed; moreover, 13 arteries and 13 veins were anastomosed using the standard operating microscope and hand-sewing technique., Results: The recipient and donor vessel diameters were 2.5 ± 0.7 and 2.1 ± 0.8 mm, respectively. The donor blood vessel diameter selected for anastomosis using da Vinci Surgical System was significantly smaller (2.1 ± 0.8 vs. 2.5 ± 0.6 mm) than that for a standard operating microscope and hand-sewing technique (p = .021), the operating time spent (38.4 ± 10.4 vs. 28.0 ± 7.7 min) was significantly longer (p < .001). The vascular patency rate was 100%, and all flaps survived without requiring additional operation for revision., Conclusion: Robotic surgical systems can facilitate vascular microanastomosis and provide a blood vessel patency rate comparable to that of a standard operating microscope and hand-sewing technique., (© 2019 Wiley Periodicals, Inc.)

Background: To report the experience with sternomastoid (SM) myofascial flap for reconstruction/buttressing of lateral pharyngeal wall and floor of mouth defects following transoral onco-surgery., Methods: Prospectively collected data from February 2012-January 2018. SM flap harvested as a superiorly based flap supplied by the occipital artery and consisting of only the anterior SM head., Results: A total of 42 patients were included (TORS, n = 40; TOUSS, n = 2). Three of 42 patients developed transient pharyngo-cervical communications with subsequent spontaneous healing. Flap loss was not noted in any patient. Forty-one of 42 patients resumed normal swallowing and one patient was PEG dependent. Fifteen of 42 patients had pretreatment metastatic neck nodes. No patient however developed nodal recurrence over a median follow-up of 30 months., Conclusion: The modified SM flap as reported here is a simple locally available reconstructive option when undertaking transoral surgery. Oncological concerns may however limit its use in situations with large nodal metastasis or extracapsular spread., (© 2019 Wiley Periodicals, Inc.)

Objectives: The main purpose of this study was to evaluate the perioperative morbidity of free flap head and neck reconstructive surgery in patients aged 70 years and over (Group A) by comparison with a cohort of younger patients (Group B). Secondary objectives included assessment of survival rates and functional outcomes in these older patients, likewise by comparison with a cohort of younger patients., Methods: A retrospective study was conducted on all patients aged 70 years and over who underwent free flap reconstruction between 2012 and 2017. They were compared to a control group of younger patients to investigate hospital length of stay, postoperative complications and survival rates, and functional outcomes., Results: No significant difference was observed between the two groups in terms of variables such as hospital length of stay and medical/surgical complications. In multivariate analysis, comorbidity was the only predictive factor for postoperative medical complications, and pharyngolaryngeal location the only significant predictive factor for surgical complications. Factors significantly associated with hospital length of stay were older age, active smoking, pharyngolaryngeal location and the Charlson Comorbidity Index (CCI). Overall survival was the only factor that was substantially lower in the over 70 group, while disease-specific and relapse-free survival were comparable in both groups., Conclusion: Old age per se should not be considered a contraindication to major surgery combined with free flap reconstruction in older patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

This research sought to analyze the functional results of free flap reconstruction in two groups of patients with head and neck cancer: first group started with radiochemotherapy followed by reconstructive surgery, second group underwent initiative surgery. MATERIALS AND METHODS: In a group of 100 patients, surgery was used as the primary form of treatment in 55 (55%) patients, and the remaining 45 patients (45%) had chemoradiotherapy introduced first. Statistical analysis was performed with Statistica v. 12. The chi-square test and test of proportion were used for categorical data. Student's t-test was used for continuous data. Probability of survival was calculated using the Kaplan-Meier method where the censoring variable was time to death. To compare survival between cohorts, we used the Cox's test. The level of significance was set at p < 0.05. RESULTS AND CONCLUSIONS: Initial radiochemotherapy prior to surgical treatment indicated an increased risk of local tumor recurrence, flap degeneration, and other local complications., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: To determine the impact of Human Papillomavirus (HPV) status on speech, swallowing, and quality of life (QOL) outcomes after surgical treatment of oropharyngeal cancer (OPSCC)., Methods: A retrospective review of a prospectively collected database of all patients with OPSCC diagnosed and treated from 1998 to 2009. Speech, swallowing, and quality of life data were gathered at 3 different evaluation points. HPV status was determined using p16 positivity as a surrogate marker. Univariate and multivariate statistical analyses were performed to identify whether p16 status is a significant predictor of functional outcome and QOL., Results: One hundred twelve patients with OPSCC and known p16 status were treated with primary surgery between 1998 and 2009, with mean age of 56 years. Out of those patients 63 (56%) were p16 positive. Speech intelligibility remained high at 1-year post operation (95.4%). Only 11.5% of the patients required a feeding tube at 1 year after surgery to maintain their daily caloric requirements and the risk of aspiration after surgery was not significant (p = 0.097). There was no statistically or clinically significant difference in speech, swallowing ability, swallowing safety and QOL outcomes between p16-positive and negative OPSCC., Conclusions: Surgically treated OPSCC patients demonstrate excellent swallowing function and can achieve excellent speech perception. P16 status may not be predictive of functional outcomes or QOL in surgically treated OPSCC.

Objective: To assess long-term quality of life (QoL) and psycho-social outcomes, and to determine their predictive factors after oropharyngeal cancer (OPC) surgery and radial forearm free-flap (RFFF) reconstruction., Methods: Patients who had undergone OPC surgery and RFFF reconstruction who were still alive and disease-free at least 1 year after surgery were enrolled in this prospective multicentric study. Patients completed the European Organization for Research and Treatment of Cancer (EORTC) Core (QLQ-C30) and Head and Neck Cancer (QLQ-H&N35) QoL questionnaires, the Voice Handicap Index (VHI-10) questionnaire and the Hospital Anxiety and Depression Scale (HADS). The level of dysphagia was evaluated using the Dysphagia Handicap Index (DHI) and the Dysphagia Outcomes and Severity Scale (DOSS). Predictive factors of these clinical outcomes were determined in univariate and multivariate analysis., Results: A total of 58 patients were included in this study. Long-term QoL and functioning scales scores were well-preserved (all superior to 70%). Main persistent symptoms were fatigue, reduced sexuality and oral function-related disorders (swallowing, teeth, salivary and mouth-opening problems). HADS anxiety and depression scores were 7.2 and 5.4, respectively. Twenty-one (36%) patients presented an anxiodepressive disorder (HADS global score ≥ 15). Among the 21 patients who were still working before surgery, 11 (52%) had returned to work at the time of our study. The HADS global score (p < 0.001) was the main predictor of QoL, VHI-10 and DOSS scores., Conclusions: Psychological distress is the main determinant of long-term QoL and is therefore of critical importance in the multidisciplinary management of OPC patients., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Purpose: Functional outcomes and complication rates after open surgery for advanced-stage oropharyngeal cancers are rarely reported. These measures are critical for choice of treatment modality and patient counseling. We describe the long term functional outcomes and associated complications of primary surgical management of T4 oropharyngeal cancers reconstructed with radial forearm free flaps., Materials and Methods: A retrospective review was performed of 40 patients with T4 oropharyngeal cancers treated between 2005 and 2015 at a tertiary care center., Results: Forty patients with T4 oropharyngeal cancers underwent open surgical resection and radial forearm free flap reconstruction at the time of surgery. Mandibulotomy was required in 33 (82.5%) cases. Thirty-five (87.5%) patients received adjuvant radiation or combined chemotherapy and radiation. Tracheostomy was performed in all patients, but every patient was eventually decannulated. Twenty (57.1%) patients required gastrostomy tube placement at some point during treatment; however, 91.4% were on a completely oral diet with a mean FOSS score of 1.6 by 1year after completion of treatment. The addition of adjuvant treatment was the only factor significantly associated with poorer FOSS scores. The overall rates of short and long-term complications were 60.0% and 57.1% respectively. The most common short and long-term complications were infection (30.0%) and velopharyngeal insufficiency (25.7%) respectively., Conclusions: Traditional open surgical approaches to large tumors of the oropharynx carry higher complication rates than more recent advanced transoral approaches. However, they can still be utilized with excellent long-term functional results in certain cases of advance oropharyngeal cancers not amenable to transoral approaches. With careful reconstruction of oropharyngeal defects, over 90% of patients can achieve a completely oral diet., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: The submental artery island pedicled flap (SMIF) is an underused alternative for reconstruction of head and neck defects after tumor ablation. The purpose of this study was to perform a comparative evaluation of reconstructive outcomes based on surgical site and ablative defect volume in patients who underwent reconstruction with the SMIF versus the forearm free flap (FFF)., Materials and Methods: A retrospective cohort study of all patients with oral cavity and oropharyngeal defects reconstructed with the SMIF and a cohort of patients with similar volume defects reconstructed with the FFF were compared for oncologic safety and viability of equivalent reconstructive outcomes. All statistical comparisons were assessed by analysis of variance and Fisher exact test., Results: Average age was 61.8 years in the SMIF group versus 57.9 years in the FFF group. The most common defect was located in the tongue, with squamous cell carcinoma being the most common pathology identified. Flap volumes were similar (SMIF, 38.79 cm 3 ; FFF, 39.77 cm 3 ). Significant comparative outcomes identified with SMIF versus FFF reconstruction included shorter anesthesia times (815 vs 1,209 minutes; P < .001), shorter operative times (653 vs 1,031 minutes; P < .001), and less blood loss (223 vs 398 mL; P = .04). Postoperative Eastern Co-operative Oncology Group performance score increased more for the FFF than for the SMIF group (+0.33 vs + 1.25; P = .0019). Recipient site complication rates were lower for the FFF group (0.17 vs 0.42 per patient) but were not statistically relevant. There were equal rates of recurrence at the local surgical site and no differences in speech and swallowing function. Mean follow-up was 15.5 months., Conclusions: This is the first study to compare the SMIF with the FFF for reconstruction of oral cavity defects based on ablative volume deficit. The SMIF is a viable surgical option compared with the FFF that can be considered oncologically safe in the N0 neck, allowing for an excellent esthetic reconstruction, with decreased operative time, hospital stay, and donor site morbidity., (Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study compared the outcomes of an extensive segmental pectoralis major myocutaneous flap (esPMMF) and a conventional pectoralis major myocutaneous flap (PMMF)., Methods: The study enrolled 91 patients with primary oral and oropharyngeal squamous cell carcinoma (SCC) who underwent radical resection followed by reconstruction of the defect using either an esPMMF via the anterior axillary line or a PMMF. The pedicle lengths of the esPMMF and PMMF were 22-28 and 18-22 cm, respectively. The esPMMF and PMMF had skin paddle dimensions of 5 × 8 to 7 × 14 cm and 6 × 7 to 8 × 17 cm, respectively., Results: The esPMMF pedicle was longer than that of the PMMF. The range of shoulder abduction was significantly greater in the esPMMF group and the donor-site aesthetic results were better., Conclusion: The esPMMF has a longer pedicle flap, enables a greater range of shoulder abduction, and has a better aesthetic result than the conventional technique., (© 2017 Wiley Periodicals, Inc.)

Rationale: The nasoseptal flap has been widely used to reconstruct skull base defects with excellent success rates. Recently, there were several attempts to use this flap for other defects. Patient concerns: We present the case of the nasoseptal flap reconstruction after oropharyngeal cancer resection., Diagnosis: The diagnosis of this patient was oropharyngeal T3 squamous cell carcinoma., Interventions: The surgical resection included the right radical tonsillectomy, uvular, and part of the soft palate and hard palate. The nasoseptal flap was sutured to the oropharyngeal defect., Outcomes: In spite of the radiation therapy, the nasoseptal flap was well healed to the oropharyngeal defect., Lessons: We suggest that the nasoseptal flap may be a feasible reconstruction option for oropharyngeal defect after oropharyngeal cancer resection.

Background: The resection of large oropharyngeal tumors traditionally involves a lip-splitting mandibulotomy for adequate margin visualization and free flap reconstruction of the surgical defect. Transoral robotic surgery (TORS) has emerged as a technique that can resect large and complex oropharyngeal tumors, avoiding a lip-splitting approach. The aim of this study is to compare the lip-splitting mandibulotomy approach versus TORS for the management of advanced stage oropharyngeal carcinomas., Methods: Prospectively collected data from 18 patients with advanced stage oropharyngeal squamous cell carcinoma (OPSCC) who received TORS with radial forearm free flap reconstruction (RFFF) was compared to a matched cohort of 39 patients who received a lip-splitting mandibulotomy and RFFF. Patients were matched for stage, p16 positivity, smoking, age and gender. Length of hospital stay (LOHS), tracheostomy decanulation time, operative time, surgical margin status, and post-operative complications were compared between groups., Results: Patients who received TORS with RFFF had a significantly lower mean LOHS, compared to patients who were treated by lip-splitting mandibulotomy and RFFF (14.4 vs 19.7 days, p = 0.03). No significant differences were seen between groups in terms of operative time, tracheostomy decannulation time, margin positivity and post-operative complications., Conclusion: TORS with radial forearm free flap reconstruction is a safe, effective and cost-saving alternative to the lip-splitting mandibulotomy approach for the treatment of advanced stage OPSCC.

Transoral robotic surgery (TORS) is a fascinating new technique that has been proved to be a safe and feasible for selected oropharyngeal cancers. Furthermore, TORS offers several advantages in the treatment of locoregionally advanced cancers. Nevertheless, the careful selection of patients is the keypoint for a successful application of this therapeutic modality. However, the reconstruction of large oropharyngeal defects is challenging due to the restoration of velopharyngeal competency and swallowing. Moreover, the absence of mandibular splitting increases the difficulties faced by reconstructive surgeons. The paradigm for oropharyngeal reconstruction has undergone changes reflecting the overall change in the trend of the treatment alternatives over the last few decades. The flap choice and harvesting should be tailored in order to obtain significant advantages both in terms of function and should be easy to inset. In this review, we analysed the strengths and weaknesses of the various flaps used in the TORS framework., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background  More than 45,000 Americans are diagnosed with oropharyngeal cancer annually and multimodal treatment often requires wide excision, lymphadenectomy, chemotherapy, and radiation. Total and subtotal lingual resection severely impairs speech, swallow, and quality of life (QoL). This study investigates functional outcomes and QoL following subtotal and total tongue resection with free tissue transfer reconstruction. Materials and Methods  A systematic review of the English language literature was performed using PubMed, Ovid, Embase, and Cochrane databases based on predetermined inclusion/exclusion criteria. Included studies were reviewed for surgical technique, adjuvant treatment, surgical and functional outcomes, and QoL. Results  From an initial search yield of 1,467 articles, 22 studies were included for final analysis. Speech intelligibility was correlated with the volume and degree of protuberance of the neotongue. Adjuvant therapy (radiation) and large tumor size were associated with worse speech and swallow recovery. At 1 year follow-up, despite 14 to 20% rates of silent aspiration, 82 to 97% of patients resumed oral feeding. Neurotized flaps have been demonstrated to improve flap sensation but have not yet demonstrated any significant impact on speech or swallow recovery. Finally, many patients continue to experience pain after surgery, but patient motivation, family support with physician, and speech therapist follow-up are associated with improved QoL scores. Conclusion  Tongue reconstruction is dictated by the amount of soft tissue resection. Taking into consideration the most common factors involved after tongue resection and reconstruction, further studies should focus on more objective measurements to offer solutions and maximize final outcomes., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: The long-term survival benefit of neoadjuvant radiotherapy for oropharyngeal tumors is controversially discussed in the literature. To bring more light into this important debate, we evaluated our cases., Patients and Methods: In this retrospective study the main focus was the relationship between neoadjuvant irradiation and anastomosis failure. Other influencing factors including previous operative treatment and tumor stage and type also were studied., Results: In total, 7 anastomoses failed (total failure rate, 8.4%; n = 83); 1 of the 7 underwent neoadjuvant irradiation (failure rate, 3.1%; n = 32). All 7 anastomosis failures were in squamous cell carcinoma cases, with 5 of them staged as T4., Conclusion: Our data suggest that neoadjuvant radiotherapy for oropharyngeal carcinoma does not increase the risk of postoperative anastomosis failure compared with surgical reconstruction alone. Furthermore, the data suggest a correlation between the stage and type of tumor., (Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Tracheocutaneous fistula (TCF) is one of the recognized sequelae of a long-term tracheostomy resulting from mucocutaneous overgrowth which prevents closure of the artificial lumen at the site of tracheostomy. Primary closure of TCF has disappointing results and may lead to complications like pneumothorax, pneumomediastinum, cervicofacial subcutaneous emphysema, and depressed scar., Objective: To compare TCF repair using fistulectomy followed by rhomboid flap versus fistulectomy followed by Z plasty repair., Methods: In this prospective study, 40 patients of either sex with persistent TCF were included. All patients were randomly divided into two groups. Group I had 20 patients who underwent TCF repair using a technique in which fistulectomy was done followed by its closure in layers, and finally closing the defect using a rhomboid flap. The remaining 20 were included in group II who underwent TCF repair using a technique in which fistulectomy was done followed by layered closing, and final closure of the defect was done using Z plasty. The follow-up period was 3 months., Results: Out of 40 patients, all but 8 experienced a successful outcome without any complications, and complete aesthetic satisfaction, with improvement in phonation, and no soiling of clothes with mucus or sputum. The 8 unsuccessful patients belonged to group II (Z plasty group)., Conclusion: Both techniques have been described in the literature and are proven to give good results. Our study emphasizes the fact that in our experience, the rhomboid flap was a better alternative for TCF repair than Z plasty., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The purposes of this article were to review the literature regarding subjective outcomes, objective functional outcomes, and objective sensation return after sensate and/or insensate free flap reconstruction of the oral cavity and oropharynx. Sensate radial forearm and anterolateral thigh free flaps tend to have better static 2-point discrimination and pressure threshold sensitivity than insensate flaps. There is insufficient evidence to draw conclusions on whether sensate flaps improve functional speech and swallowing outcomes measured by videofluoroscopic swallowing studies and percentage of word intelligibility by a listener blinded to the study. These data highlight the complexity and number of variables affecting functional outcomes in patients who have undergone reconstructive surgery after oral and oropharyngeal cancer ablative operations. A prospective randomized multicenter study that properly and rigidly stratifies patients by defect, flap and recipient nerve choice, adjuvant therapies, and uses widely agreed upon pretreatment and posttreatment evaluation tools could help to answer this important question. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016., (© 2016 Wiley Periodicals, Inc.)

Background: The nasoseptal flap has revolutionized reconstruction of ventral skull base defects. The past decade is also noticeable by the evolution of transoral robotic surgery (TORS). Reconstruction of the oropharyngeal defect is challenging. Good reconstructive options with less cicatricial retraction are desirable and still lacking in the literature., Methods: Cadaver dissection and illustrative case are used to show the feasibility of harvesting a nasoseptal flap to reconstruct oropharyngeal defect after radical tonsillectomy. Surgical resection included part of the soft palate and tongue base., Results: The flap was sufficient to cover two-thirds of the tonsillar defect during the cadaver dissection. In our illustrative case, the flap filled the palatal defect and also was sufficient to cover the superior half of the tonsillar defect., Conclusion: The nasoseptal flap has shown to be feasible and reliable for reconstruction of the oropharyngeal defect after TORS. When soft palate resection is warranted, this flap provides excellent coverage. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2495-E2498, 2016., (© 2016 Wiley Periodicals, Inc.)

Purpose: Outcomes of salvage surgery and carotid artery (CA) management were evaluated in patients with oral and oropharyngeal cancer., Patients and Methods: Eighteen patients with recurrent oral and oropharyngeal squamous cell carcinoma involving the CA underwent salvage surgeries consisting of wide resection of the tumor, CA resection without and with reconstruction, and CA subadventitial dissection without and with encapsulation. Major tissue defects were reconstructed using a flap., Results: One patient showed postoperative transient hemiplegia, and wound dehiscence occurred at the recipient site in 2 patients. Two patients had carotid blowout. One patient who underwent CA resection and reconstruction had a carotid embolism. After 5 to 42 months of follow-up, 12 patients were free of disease, 2 remained ill, and 4 died of local recurrence or distant metastases., Conclusions: Salvage surgery remains an effective treatment modality. CA sacrifice offers a viable treatment strategy. Major defects can be reconstructed with a trapezius flap., (Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Dysphagia is still a treatment-related morbidity, despite advances in treatment modalities for oral and oropharyngeal squamous cell carcinoma. This systematic review aimed to analyze the effects of swallowing outcomes of patients with oral or oropharyngeal squamous cell carcinoma treated with primary surgery with primary free flap reconstruction, with or without adjuvant therapy, for patients undergoing treatment with curative intent., Study Design: A comprehensive search strategy was undertaken across MEDLINE, CINAHL, Embase, and Scopus. Gray literature was sought through Cochrane Central Register of Controlled Trials, MedNar, and ProQuest., Methods: Studies included patients with oral cavity or oropharyngeal squamous cell carcinoma treated with primary surgery with primary free flap reconstruction. Swallowing function was the primary outcome, evaluated at 6 months or later following surgery. Methodological quality and data extraction was conducted as per the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument and standardized data extraction tool., Results: Fifteen articles comprising eight cohort studies and seven case series were included. Postoperative radiotherapy and oropharyngeal resections were demonstrated to be associated with increased dysphagia., Conclusion: Advanced tumor-node-metastasis stage and use of adjuvant radiotherapy has been shown to have negative impacts on swallowing function. The majority of patients were able to have gastrostomy tubes removed at 6 months following curative therapy. Larger flap mass for the reconstruction of oral and oropharyngeal defects appeared to improve swallowing outcomes. A protocol for the identification of patients at high and low risk of developing dysphagia is proposed., Level of Evidence: N/A. Laryngoscope, 126:1572-1580, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Recipient-site infection after oropharyngeal reconstruction is a potentially disastrous complication. Although studies suggest that perioperative antibiotics reduces infection rates in these patients from 87% to 20%, there is no consensus regarding what constitutes the most appropriate antibiotic regimen and duration of treatment., Methods: A retrospective review of perioperative antibiotic administration was performed of all patients who underwent local, pedicled, or free flap oropharyngeal reconstruction after oncologic resection by a single surgeon at a single institution between 2007 and 2013 to assess for recipient-site complications., Results: Ninety-seven patients underwent 100 reconstructions (61 free flap reconstructions, 39 pedicled/local flap reconstructions) and all received a combination of intravenous (IV) antibiotic agents designed to cover oral flora. There were 23 (23%) recipient-site complications, which included cellulitis (9%), mucocutaneous fistula (5%), abscess (5%), and wound dehiscence (4%). Duration of antibiotic prophylaxis, defined as less than 48 hours (short-course) or greater than 48 hours (long-course), was not a significant predictor of recipient-site complication. Significant risk factors for recipient-site complications were clindamycin prophylaxis (P < 0.008), increased duration of surgery (P < 0.047), and advanced age (P < 0.034). Recipient-site complication was found to be a significant predictor of both increased length of hospital stay (P < 0.001) and increased time to the resumption of enteral feeds (P < 0.035)., Conclusions: These data suggest that extended courses of perioperative antibiotics do not confer additional benefits in patients undergoing oropharyngeal reconstruction. We recommend a limited 48-hour course of prophylactic antibiotics with sufficient aerobic and anaerobic coverage to help minimize the incidence of antibiotic-related morbidities.

Background: The purpose of this study was to compare the use of an extended vertical lower trapezius island myocutaneous flap (TIMF) and a pectoralis major myocutaneous flap (PMMF)., Methods: A total of 39 patients with advanced recurrent oral and oropharyngeal squamous cell carcinoma (SCC) underwent salvage surgery followed by placement of either an extended lower vertical TIMF or PMMF for reconstruction. Twenty-one patients received extended lower vertical TIMFs, whereas 18 received PMMFs., Results: The pedicle length of the TIMF was longer than that of the PMMF, and the skin paddle of the TIMF was both wider and longer than the PMMF. No major complication developed in any of the patients. The TIMF group experienced a lower rate of minor flap failure than did the PMMF group., Conclusion: Use of an extended vertical lower TIMF, which has a longer pedicle flap and a larger skin paddle than a PMMF, is optimal for reconstruction of major defects. © 2015 Wiley Periodicals, Inc. Head Neck 38: E159-E164, 2016., (© 2015 Wiley Periodicals, Inc.)

Background and Objectives: Lateral and superior oropharyngeal reconstruction is technically challenging and can be complicated by postoperative dysphagia. The aim of this retrospective study was to identify the predictive factors of dysphagia after lateral and superior oropharyngeal reconstruction with free flap transfer and to establish better management for cases with these predictive factors., Methods: We performed a retrospective chart review of 109 patients who had undergone lateral and superior oropharyngeal reconstruction with free flap transfer for oropharyngeal cancer. Preoperative, operative, and postoperative variables were examined, and possible predicative factors for dysphagia were subjected to univariate analysis and multivariate logistic regression analysis., Results: Dysphagia occurred in 16 patients (14.7%). Multivariate logistic regression analysis identified extensive tongue base resection, postoperative radiotherapy, and history of radiotherapy to the head and neck region as independent factors contributing to dysphagia after lateral and superior oropharyngeal reconstruction. Of these factors, extensive tongue base resection was the most important., Conclusions: Early intervention to minimize the risk of dysphagia should be performed for patients identified with these predictive factors., (© 2016 Wiley Periodicals, Inc.)

The purpose of this study was to report our experience with the free thoracodorsal artery perforator flap for reconstruction of the oropharynx and soft palate in head and neck cancer using a retrospective review of the medical charts of all patients undergoing oropharyngeal reconstruction by free thoracodorsal artery perforator flap during the same procedure as cancer resection between January 2011 and April 2013. Evaluation of speech, feeding and the presence of nasal emissions was performed 6 months after treatment in accordance with the Declaration of Helsinki. Nine patients were evaluated. Clear understanding of the patient was reported by the family and the examiner for seven patients, while understanding difficulties were reported for two patients (1 case of flap dehiscence and 1 technical error of flap fixation). The results indicated that, due to its complex anatomy and function, reconstruction of the soft palate remains a delicate procedure. The free thoracodorsal artery perforator flap allows functional soft palate reconstruction, while limiting donor site morbidity.

Reconstructing oral and/or oropharyngeal defect after tumor ablation requires anatomic restoration of the complex structures to maximize functional outcomes. This study introduces a simple and adjustable way of designing and insetting of a free flap in such reconstruction. Patients who received free flap reconstruction of oral and/or oropharyngeal defect with 33% to 66% of the native tongue left intact after resection of the tumor were enrolled and reviewed. Flap was designed as an oval shape according to the maximum width and length of the defect, and sutured from the most posterior part. Natural imbrication of the flap formed by anterior pulling of the tongue was marked and de-epithelized to create a three-dimensional shape. A total of 30 patients met the inclusion criteria of this study and the median follow-up was 32 months. All flaps survived after 1 case of venous reanastomosis. The average hospital stay was 23.7 days. All patients were decannulated. Twenty (66.7%) patients could eat a normal or soft diet, and 19 (63.3%) patients had normal or intelligible speech. Simplified designing of the flap with adjustable tailoring allowed for easy and effective way of free flap oral and/or oropharyngeal reconstruction. De-epithelization (or trimming) of the naturally imbricated area during the procedure of insetting created a bilobed shape in effect to conform to the three-dimensional defect.

Purpose: The use of suture anchors has been described in orthopedic, hand, oculoplastic, temporomandibular joint and in aesthetic surgery, but no study reports the use of the Mitek® anchors (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts) for fixing the free flaps used in oncologic oral and oropharyngeal reconstruction., Materials and Methods: In this prospective non-randomized study, 9 patients underwent surgical resection of oral or oropharyngeal cancer followed by a free flap reconstruction; mini anchors were used to fix the flap directly to the bone. We collected data regarding the patients, the tumor stage, the surgical procedure, the radiotherapy and the number of anchors used., Results: The average follow-up was 28months (range 24-38).We observed no complications with trans-oral, sub-mandibular and trans-mandibular approach in both oral and oropharyngeal reconstructions. All anchors became osteo-integrated and no complications occurred after radiotherapy., Conclusions: In our opinion this device favors free flap adhesion to the bone. We registered no postoperative complications related to the use of the device which looks suitable for use in irradiated tissues. The radiotherapy did not cause any long-term complications related to the use of Mitek® mini bone anchors., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Conclusions: Surgery for oral or oropharyngeal cancer with free-flap reconstruction is associated with moderate but persistent functional and quality of life (QoL) problems. Patient age, tumor stage, tumor site, and radiotherapy were the main predictors of functional outcome., Objectives: To evaluate long-term functional outcomes and QoL, and to determine their predictive factors in patients with oral or oropharyngeal cancer after oncologic surgery and free-flap reconstruction., Methods: Patients who underwent surgery with free-flap reconstruction for oral or oropharyngeal cancer between 2000 and 2009 who were alive at least 1 year after therapy were included in this study. Patients completed the Voice Handicap Index (VHI-10) questionnaire and the European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaires QLQ-C30 and H&N35. Swallowing was evaluated using the Dysphagia Outcome and Severity Scale (DOSS) and by flexible fiberoptic laryngoscopy., Results: Sixty-four patients were included in the study. VHI-10 mean score was 11.2 ± 9 and its predictive factors were T stage (p = 0.005) and tumor involvement of the tongue base (p = 0.01). The mean DOSS score was 4 ± 0.8. Age (p = 0.008), gender (p = 0.04), and radiotherapy (p = 0.001) were the main predictive factors of the DOSS score.

The use of the supraclavicular island flap (SCIF) for the reconstruction of facial and neck skin defects is increasing. The value of this fasciocutaneous flap as a reconstructive modality for oropharyngeal defects in cancer patients is unclear. In the present study, a SCIF was used for reconstruction of mucosal defects following resection of the tumour in a group of four patients with T2 squamous cell carcinoma of the oropharynx and a clinical N0 neck. Reconstruction was performed following transoral tumour resection and selective neck dissection at levels I-III in the same session. Intraoperative and postoperative complications were analyzed, and functional and aesthetic results for the neck and shoulder region were evaluated in follow-up examinations. In addition, sensation to the flap was evaluated. No flap failures were observed. Only minor surgical complications were evident, which did not cause any relevant functional or aesthetic impairments. Sensation to the flap was observed in all cases. The SCIF appears to be a good and time-saving alternative to free flaps for oropharyngeal reconstruction following oncological resection in selected patients., (Copyright © 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The growth of aging populations in an increasing number of countries has led to a concomitant increase in the incidence of chronic diseases. Accordingly, the proportion of older aged patients with oral cavity and oropharyngeal cancers and comorbidities has also increased. Thus, improvements must be made in the tolerance and safety of surgical procedures for these patients with complex medical conditions. In this study, we investigated combined submandibular gland flap and sternocleidomastoid musculocutaneous flap for postoperative reconstruction in older aged patients with oral cavity and oropharyngeal cancers in terms of surgical methods, safety, and clinical outcome., Methods: Between January 2011 and May 2012, 8 patients over the age of 65 years (7 men, 1 woman; aged 66 to 75 years (median, 69.6)) with oral cavity and oropharyngeal cancers underwent combined submandibular gland and sternocleidomastoid myocutaneous flaps for postoperative reconstruction at Ganzhou Tumor Hospital. All eight patients had comorbid cardiovascular, cerebrovascular, or chronic respiratory disease or diabetes. Clinical outcomes, complications, and tolerance to surgical treatment were observed., Results: Surgical treatment was successful in all eight patients. All submandibular gland flaps survived with well-mucosalized surfaces and with no complications. During the postoperative follow-up period of 12 to 28 months, no patient developed local recurrence or distant metastasis, and all had good recovery of function and local contour., Conclusions: This combined reconstruction technique enables appropriate restoration of oral function, facial aesthetics and improved quality of life. Further, this technique has several advantages: it is easier to perform, reduces operation time and surgical risk, causes less surgical injury, and has minor impact on contour. The technique provides a new and safe reconstruction option for older aged patients with oral cavity and oropharyngeal cancers.