DOI: http://dx.doi.org/10.18203/2349-2902.isj20200054

Combining free tissue transfer with pedicled flap in reconstruction of extensive oromandibular malignancy defects: a clinical study

Naveen Narayan, Kamal Kumar Manakchand

Abstract


Background: Extensive composite defects of the oromandibular site involve skin, mandible, soft tissue and oral mucosa. Though many opine that with the coming on of free flap surgery, the pedicled flap is an outdated surgical option, the latter still has its uses. Free flaps are criticized as being medically risky, expensive, and time-consuming. Combining both these flaps in a single surgery would bring in the baggage of all negatives along with the benefits of these flaps.

Methods: Over a period of 3 years, 13 patients with expected large composite oral defects after ablative surgery for malignancy were included in the study requiring both skin cover and mucosal lining. A one-stage reconstructive procedure employing combination of free and pedicled flaps was used. Data was abstracted pertaining to cancer demography and surgical outcome.

Results: The free fibula osteocutaneous flap (FFOCF)- deltopectoral fasciocutaneous flap (DPF) combination was most commonly used (n=5), secondly by free radial forearm flap (FRAFF)-DPF combination (n=4), FRAFF- pectoralis major myocutaneous flap (PMMF) amalgamation and FFOCF-PMMF (n=2). The complete flap survival rate was 88.5 percent with 3.8% percent total (1 of 26 flaps) and 7.7% partial (2 of 26 flaps) flap failures. Minimum follow-up period was 6 months with 2 (7.7%) recurrences and 2 (7.7%) mortalities.

Conclusions: We believe that in combined use of free-flap and pedicled flap procedure for one-stage reconstruction of massive mandibular defects with through-and-through cheek defects is justified because it is safe and effective and improves the quality of life for these patients albeit a bit prolonged surgery which can effectively be shortened with 2 reconstructive team approach as in our study.


Keywords


Free flap, Pedicled flap, Oral cancer, Oromandibular defect, Oncoreconstruction

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References


Ferlay J, Soerjomataram I, Dikshit R. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136:359-86.

Su WF, Hsia YJ, Chang YC, Chen SG, Sheng H. Functional comparison after reconstruction with a radial forearm free ß ap or a pectoralis major ß ap for cancer of the tongue. Otolaryngol Head Neck Surg. 2003;128:412-8.

Suh JD, Sercarz JA, Abemayor E. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2004;130:962-6.

Joo YH, Sun DI, Park JO, Cho KJ, Kim MS. Risk factors of free flap compromise in 247 cases of microvascular head and neck reconstruction: A single surgeon's experience. Eur Arch Otorhinolaryngol. 2010;267:1629-33.

Gisquet H, Gangloff P, Graff P. Microsurgical reconstruction and full management of patients with head and neck cancer: Importance of a quality approach and a patient care team. Rev Laryngol Otol Rhinol (Bord). 2009;130:249-54.

Rigby MH, Hayden RE. Regional flaps: A move to simpler reconstructive options in the head and neck. Curr Opin Otolaryngol Head Neck Surg. 2014;22:401-40.

Deganello A, Gitti G, Parrinello G, Muratori E, Larotonda G. Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps. Acta Otorhinolaryngol Ital. 2013;33:380-7.

Deganello A, Manciocco V, Dolivet G, Leemans CR, Spriano G. Infrahyoid fascio-myocutaneous flap as an alternative to free radial forearm flap in head and neck reconstruction. Head Neck. 2007;29:285-91.

Deganello A, Bree RD, Dolivet G, Leemans CR. Infrahyoid myocutaneous flap reconstruction after wide local excision of a Merkel cell carcinoma. Acta Otorhinolaryngol Ital. 2005;25:50-3.

Urken ML. Atlas of Regional and Free Flaps for Head and Neck Reconstruction. New York: Raven Press. 1995; 35-42.

Kevin WL Mo, Vlantis A, Wong E W Y, Chiu T W. Double free flaps for reconstruction of complex/composite defects in head and neck surgery. Hong Kong Med J. 2014;20(4):279-84.

Bianchi B, Ferri A, Ferrari S. Reconstruction of lateral through and through oro-mandibular defects following oncological resections. Microsurgery. 2010;30:517-25.

Wei FC, Yazar S, Lin CH, Cheng MH, Tsao CK, Chiang YC. Double free flaps in head and neck reconstruction. Clin Plastic Surg. 2005;32:303-8.

Guillemaud JP, Seikaly H, Cote DW. Double free-flap reconstruction: indications, challenges, and prospective functional outcomes. Arch Otolaryngol Head Neck Surg. 2009;135:406-10.

Wei FC, Celik N, Yang WG, Chen IH, Chang YM, Chen HC. Complications after reconstruction plate and soft tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap. Plast Reconstr Surg. 2003;112:37-42.

Chen HC, Demirkan F, Wei FC, Cheng SL, Cheng MH, Chen IH. Free fibula osteoseptocutaneous-pedicled pectoralis major myocutaneous flap combination in reconstruction of extensive composite mandibular defects. Plast Reconstr Surg. 1999;103:835-45.

Shah JP, Haribhakti V, Loree TR, Sutaria P. Complications of the pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg. 1990;160:352-5.

Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg. 1995;96:585-96.

Tan BK, Wong CH. An anomalous septocutaneousperforator to the skin paddle of the fibula osteocutaneous flap originating from the posterior tibial artery. J Plast Reconstr Aesthet Surg. 2009;62:690-2.

Schusterman MA, Horndeski G. Analysis of the morbidity associated with immediate microvascular reconstruction in head and neck cancer patients. Head Neck. 1991;13:51-5.

Urken ML, Weinberg H, Vickery C, Buchbinder D, Lawson W, Biller HF. Oromandibular reconstruction using microvascular composite free flaps. Reports of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects. Arch Otolaryngol Head Neck Surg. 1991;117:733-44

Urken ML, Weinberg H, Vickery C. The combined sensate radial forearm and iliac crest free flaps for reconstruction of significant glossectomy-mandibulectomy defects. Laryngoscope. 1992;102:543-8.