85 Int J Res Med. 2014; 3(4);85-89 e ISSN:2320-2742 p ISSN: 2320-2734
Free radial Artery Forearm Flap in Reconstruction of oral Cavity
Cancers Our Experience
Gupta Sandeep1*, Jain Devendra2, Jhala J. T.3, Saraiya H. & Kothari Parag4, Jayesh D Patel5
1
3rd Year M. Ch. Resident, 2Assistant Professor, 3Professor & Chief, 4Plastic Surgeon, 5Associate Professor, Department of Surgical Oncology, Gujarat Cancer & Research Institute, Ahmedabad, Gujarat, India
INTRODUCTION
There are various ways of reconstruction of defects created after wide excision of primary malignancy in head and neck e.g. local flaps, regional flaps, distant pedicle flaps and free flaps.1 The real challenge though lies in reconstructing the defect to improve the quality of life. It necessitates the surgeon to preserve the external appearance along with the normal functions of swallowing, oral competence and speech. Over the past two decades there has been a renaissance in the techniques and tissue types used to repair tissue defects in the oral
*Corresponding Author Dr. Gupta Sandeep
3rd Year M. Ch. Resident,
Department of Surgical Oncology, Gujarat Cancer & Research Institute, Ahmedabad, Gujarat, India
Contact: +919427966819
Mail: drsandeepbkn@rediffmail.commalign
cavity following ablation of ant neoplasms.2 Free micro vascular flap (FRAFF) is an advanced technique of reconstruction. The FRAFF provides well-vascularized and relatively thin and pliable soft tissue.3The FRAFF can often be raised fortunately with resection of the tumor without having to alter the patients’ position on the operating table. Many surgeons popularized its use as a free flap for the reconstruction of head and neck defects.2-3We present our clinical experience in terms of postoperative functional and cosmetic results and discuss donor-site morbidity of the FRAFF. We illustrate the versatility of the FRAFFs in 30 patients with various head and neck defects that were reconstructed after tumor ablation.
MATERIALS AND METHODS
A total of 30 patients had reconstruction with free micro vascular flap, from Jan. 2011 to Dec. 2012 at Gujarat Cancer & Research Institute (GCRI), Ahmedabad, were studied retrospectively. The medical
ORIGINAL ARTICLE
ABSTRCT
BACKGROUND: There are various ways of reconstruction of defects created after wide excision of primary malignancy in head and neck e.g. local flaps, regional flaps, distant pedicle flaps and free flaps. Free micro vascular flap (FRAFF) is an advanced technique of reconstruction. The FRAFF provides well-vascularized and relatively thin and pliable soft tissue. We present our clinical experience in terms of postoperative functional and cosmetic results and discuss donor-site morbidity of the FRAFF. A total of 30 patients had reconstruction with free micro vascular flap, from January 2011 to December 2012 at Gujarat Cancer & Research Institute (GCRI), Ahmedabad, were studied retrospectively. The medical records of patients were reviewed for age, gender, histopathology, diagnosis, location of primary tumor, tumor stage, preoperative chemotherapy, and preoperative and postoperative radiotherapy. Among the 30 FRAFFs, the overall complicationswere 30% (9/30) at the recipient site, 10%(3/30) were severe and 20% (6/30) were minor. All patients tolerated postoperative radiotherapy without evidence of wound breakdown. Esthetic outcomes of donor hands were rated as acceptable in 28 patients. Analyzing the results found that FRAFF recipients had excellent postoperative speech production, good oral competency and Swallowing. From our study, we may conclude that, free radial artery forearm flaps provide better cosmetic and aesthetic results, provided the technical expertise is available. FRAFF in the oral cavity provide excellent postoperative results in the form of speech production and swallowing.
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records of 30 patients were reviewed for age, gender, histopathology, diagnosis, location of primary tumor, tumor stage, preoperative chemotherapy, and preoperative and postoperative radiotherapy. The size of flap harvested, results of flap transfer, flap related complications, donor site morbidity, harvest time, and clinical course were analyzed. Preoperative Allen test and Doppler study of upper limb arteries done in all patients. The donor site at the forearm was covered with a split thickness skin graft from the thigh.
RESULTS
Table: 1 The summary of patients
Gender (n)* Male(25), Female(5) Age (yr) Mean, 39.3; range, 28 to 55 Diagnosis Number of patients Squamous cell
carcinoma 29
Verrucous carcinoma 1
Tumor location Buccalmucosa 21
Angle of mouth 1
Lip 4
Tongue 1
Mandibular alveolus 1
Maxillary alveolus 1
Floor of the mouth 1
Table: 2 The characteristics of flaps harvest Harvest time (minutes) Mean, 76; Range, 60 to 85 FRFF size(cm2) Mean, 65; range, 40 to 105 Vascular pedicle (cm) Mean, 9; range, 7 to 12 Skin graft size (cm2) Mean, 70; range, 40 to 98 Follow-up(months) Mean, 14; range, 3 to 26 Vascularanastomoses Number of flaps Donor artery (Radial artery) 30 Donor vein (Venae comitantes & Cephalic vein) 30 Recipient arteries Superior thyroid 10
Facial 20
Recipient veins Superior thyroid 10
External jugular vein 10
Internal jugular vein 10
Out of 30 patients, the majority of patients were male (N = 25, 83%) and the average age was 39.3 years (range, 28–55 years). 29 out of 30 tumors were squamous cell carcinomas and 1 was verrucous carcinomas. The primary site of the cancer was the buccal mucosa in 21 patients, the angle of mouth in 1 patient, the lip in 4, the tongue in 1, the mandibular alveolus in 1, the maxillary alveolar in 1, and the floor of the mouth in 1 patient (Table 1). The mean harvest time was 76 minutes (range 60 to 85 minutes) and the mean flap size was 65 cm2 (range 40 to 105 cm2), while the length of vascular pedicle used varied from 7 to 12 cm with an average of 9 cm. The most commonly used artery for our series was the facial artery (20/30), followed by the superior thyroid artery (10/30). The superior thyroid vein, external jugular vein and internal jugular vein were used in 10 patients each. The follow up period ranged from 3 to 26 months, with an average of 14 months (Table 2). Table: 3 Complications of recipient site and donor site Recepient site Number of flaps Severe complications Total flap loss 3 Minor complications Fistula 3
Dehiscence 2 Hematoma 1 Donor site Number of hands Partial loss of skin graft Without tendon exposure 2
With tendon exposure 2 Abnormal sensation Hypoesthesia 2
Paresthesia 1
Hyperesthesia 1
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(30%) at the recipient site,10%(3/30) were severe and 20% (6/30) were minor. All patients tolerated postoperative radiotherapy without evidence of wound breakdown. In the donor site, 4 patients had partial loss of skin grafts, which lead to tendon exposure. Two patients complained of hypoesthesia, 1 of paresthesia, and 1 of hyperesthesia (Table 3).
Table: 4 Postoperative Functional Results
Oral Competence
Swallowing Speech
Good 13 (43%) 15 (50%) 12 (40%) Fair 15 (50%) 13 (50%) 16 (53%) Poor 2 (7%) 2 (7%) 2 (7%) Mean duration of surgery was 7.30hrs. Mean hospital stay was 18.5 days.
On follow up recurrence was seen in 2 patient For the donor site complications, four patients had partial loss of skin grafts, which lead to tendon exposure in 2 patients. Esthetic outcomes of donor hands were rated as acceptable in 28 patients. Analyzing the results found that FRAFF recipients had excellent postoperative speech production, good oral competency and Swallowing (Table 4).
The below pictures shows the surgical plan and the surgical elevation of the flap
Fig: 1 Pre-operative photograph
Fig: 2 Intra operative
Fig: 3 Post-operative (Donor site)
Fig: 4 Post-operative (Recipient site)
DISCUSSION
Repair of defects after head and neck cancer surgery is one of the most challenging areas of medicine, with widely diverse surgical reconstruction options for the surgeon to choose from. Micro vascular free flap reconstruction of the head and neck in cancer patients offers a significant improvement in the functional and esthetic rehabilitation and improve quality of life of these patients.1In this study, we present a total of 30 patients who underwent FRAFF reconstruction of oral defects created after cancer resection.
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flap loss, venous thrombosis was the cause in 2 patients and thrombosis was in 1 patient. Our study shows that thrombosis of a free flap pedicle was the most common during the first postoperative week. It is likely that the success rate could be improved if greater care was taken to identify and salvage failing free flaps.10 It is advisable to monitor free flap carefully and frequentlyduring the first week postoperatively to minimize flap losses.Flap can tolerate radical radiotherapy early in the postoperative period without significant detrimental effects and in particular with no evidence of wound breakdown or subsequent fistula.Donor site morbidity was mainly due to loss of the skin grafts over the tendons. The reports in the literature showed a wide range of frequencies for complications in donor wound healing, such as 2% to 53% partial skin graft failure and 0% to 33%tendon exposure.11 In our studies, the partial skin grafts failure was (13%) at the donor site and healing occurred without further skin grafting in allcases but one. Regardingsubjective assessment, 28 patients (93%) rated theesthetic outcome at the donor site as acceptable. Nopatient expressed a desire for corrective or estheticsurgery. Other researchers reported similar results, with 94% to 98% of patients rating the esthetic outcomesas satisfactory.12-13
CONCLUSION
Free radial artery forearm flaps provide better cosmetic and aesthetic results, provided the technical expertise is available.FRAFF in the oral cavity provide excellent postoperative results in the form of speech production and swallowing.
REFERENCES
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2. Gleeson Mj, Jones NS, Clarke R, Luxon L, Hibbert J, Watkinson J (Eds). Scott-Brown’s Otorhinolaryngology, Head and
Neck Surgery: Seventh edition. http://www.scottbrownent.com/
3. Soutar DS, Scheker LR, Tanner NS, McGregor IA. The radial forearm flap: a versatilemethod for intra-oral reconstruction. Br J Plast Surg 1983;36:1-8.
4. Suh JD, Sercarz JA, Abemayor E, Calcaterra TC, Rawnsley JD, Alam D, Blackwell KE. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2004 Aug;130(8):962-6 5. Blackwell KE. Unsurpassed reliability of
free flaps for head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1999 Mar;125(3):295-9. 6. Haughey BH, Taylor SM, Fuller
D. Fasciocutaneous flap reconstruction of the tongue and floor of mouth: outcomes and techniques. Arch Otolaryngol Head Neck Surg. 2002 Dec;128(12):1388-95.
7. Reinsert S. The free revascularized lateral upper arm flap in maxillofacial reconstruction following ablative tumor surgery. J Craniomaxillofac Surg. 2000 Apr; 28(2):69-73.
8. Markkanen - Leppänen M, Suominen E, Lehtonen H, Asko-Seljavaara S. Free flap reconstructions in the management of oral and pharyngeal cancer. Acta Otolaryngol. 2001 Apr;121(3):425-9. 9. Savant DN, Patel SG, Deshmukh SP,
Gujarati R, Bhathena HM, Kavarana NM. Folded free radial forearm flap for reconstruction of full-thickness defects of the cheek. Head Neck 1995;17:293-6. 10.Kroll SS, Schusterman MA, Reece GP,
Miller MJ, Evans GR, Robb GL, et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996;98:1230-3.
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12.Lutz BS, Wei FC, Chang SC, Yang KH, Chen IH. Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective study in 95 consecutive cases. Plast Reconstr Surg 1999;103:132-7.