Soft tissue reconstruction of the oral cavity: a review of current options

Guided tissue regeneration with a gelatin and polycaprolactone composite membrane for repairing oral soft tissue defects: A prospective, single-blinded, randomized trial

STATEMENT OF PROBLEM

Clinical trials comparing outcomes of the guided tissue regeneration membrane (TRM), fabricated from gelatin and polycaprolactone via electronspinning technology, with collagen membrane for repairing oral soft tissue defects are lacking.

PURPOSE

The purpose of this clinical trial was to evaluate the efficacy and safety of TRM compared with collagen membrane in reconstructing oral soft tissue defects.

MATERIAL AND METHODS

This prospective, single-blinded, randomized, noninferiority trial involved 48 participants with oral lesions who were randomized (1:1) into 2 groups: surgery + TRM or surgery + collagen membrane. The primary endpoint was to establish a noninferiority margin of -10% regarding Grade A healing rates 1 month ±7 days after surgery between groups. Secondary endpoints included instrument performance, Grade A healing rate at 10 ±3 days and 3 months ±7 days after surgery, time to achieve Grade A healing, surgical area satisfaction and wound contraction at 10 ±3 days, 1 month ±7 days, and 3 months ±7 days after surgery. Adverse events were assessed to evaluate the safety of TRM. The independent samples t test was used for continuous variables between groups, and the Fisher exact test or chi-squared test was used for categorical variables (α=.05).

RESULTS

The Grade A healing rate was 100% in both groups at 1 month ±7 days after surgery in the full-analysis and per-protocol sets. The 95% confidence interval of the rate difference (0%) was -5% to +5%, within the predefined noninferiority margin of -10%, indicating that TRM was not inferior to collagen membrane. No significant differences in secondary endpoints were found between groups (P>.05). Adverse events rates were also similar between groups (serious adverse events: 3 [12.50%] for TRM and 1 [4.17%] for collagen membrane, P=.609; overall adverse events: 7 [29.17%] for TRM and 4 [16.67%] for collagen membrane, P=.303).

CONCLUSIONS

TRM demonstrated noninferiority to collagen membrane for reconstructing oral soft tissue defects.

Repair of buccal mucosa and floor of mouth defects using keystone design perforator island flap

OBJECTIVE

To assess the feasibility of utilizing the keystone design perforator island flap (KDPIF) for the repair of small to medium-sized defects in the buccal mucosa and floor of mouth (cT1-2 stage tumor).

STUDY DESIGN

We conducted a retrospective analysis of eight patients who underwent KDPIF to address oral defects at the Affiliated Hospital of Qingdao University between June 2021 and September 2022. Patient information, including medical history, defect site, flap size, operative time, hospital stay, complications, and postoperative recovery of oral function, was comprehensively evaluated.

RESULTS

Eight patients (6 females and 2 males) underwent reconstruction using KDPIF. The mean operation time was 58.5 minutes (55-63 minutes), with an average length of stay of 3.5 days (3-5 days). None of the 8 cases (100%) exhibited flap splitting necrosis or infection. Moreover, no scar contracture was observed, and oral functions, including the degree of opening, type of opening, tongue mobility, speech function, and swallowing function, were successfully restored. One patient (12.5%) experienced bleeding from the incision on the first postoperative day, but following compression, hemostasis was achieved, and the incision healed well.

CONCLUSIONS

KDPIF demonstrates technical feasibility and suitability for repairing small to medium-sized buccal mucosa and floor of mouth defects (cT1-2).

Tongue reconstruction after oncological resection: Analysis of the functional outcomes

The curative management of oral squamous cell carcinoma can be responsible for swallowing and/or speech impairments. In this study, we analyzed the functional outcomes in patients who underwent an oncological resection and a primary reconstruction of the tongue and/or of the floor of the mouth (TFM). We also investigated the predictive factors for poor functional outcomes. This retrospective study included operated patients from October 2013 to May 2021 at the TOURS University Hospital. We assessed the functional results two years after the completion of the cancer treatment with self-administered questionnaires quantifying swallowing and speech disorders. Thirty-three patients were included and reconstructed with antebrachial free flap (N = 16), local flap (N = 8) or Biodesign ® membrane (N = 9). A higher proportion of pT1 tumor was observed in patient who had a Biodesign-based reconstruction (p = 0.001). There was no significant difference between the groups in terms of postoperative complications or for the duration of enteral feeding. The 21 patients who had an adjuvant radiation therapy had no significant more altered functions. Functional scores were significantly higher in the free flap reconstruction group (DHI =24 and SHI=21) (p = 0.008). No predictive factors for poor outcomes were observed. The repair of TFM defects must be adapted to the resection size. The reconstruction techniques allow to get acceptable functional outcomes even for the greater tumors or in case of radiation therapy. Further research would be required to better identify the predictive factors for poor outcomes.

Modified nasolabial flap- the nasomentolabial flap: A new arrow in surgeon's quiver

AIMS AND OBJECTIVES

To describe an inferior extension of a naso-labial flap as an adjunct to a maleo-labial flap in reconstruction of complete thickness defects around the oral commissure in 2 cases that we performed at our institute.

METHODS

Two elderly cases of carcinoma buccal mucosa who underwent wide local excision along with neck dissection had moderately large peri-oral defects that are large to cover with nasolabial flap alone. An inferior extension to the maleo-labial flap was added, making it a naso-mento-labial flap to reconstruct the defects with an acceptable outcome aesthetically and functionally. The reconstructed defects' size was around 7 × 7cms and 8.5 × 6cms full-thickness defect in the buccal mucosa, respectively, with the extension of the defect in both the patients being almost the same with anterior extension to commissure, posteriorly to retro-molar trigone (RMT), laterally full-thickness, medially not involving alveolus.

RESULTS

The incision at the donor site was closed primarily. The reconstruction did achieve the patient acceptable aesthetics, functionality, color and texture. The mean follow up of the patients is around 1 year with no complications.

CONCLUSION

Naso-mento-labial flap, an inferiorly extended inferiorly based nasolabial flap is a useful addition to surgeon's armamentarium for reconstructing the buccal mucosa and peri-oral defects in patients whose general health prevents the using pedicled or free flaps.

Molecular and Cellular Mechanisms of Perineural Invasion in Oral Squamous Cell Carcinoma: Potential Targets for Therapeutic Intervention

Simple Summary

Squamous cell carcinoma is the most common type of oral cavity cancer. It can spread along and invade nerves in a process called perineural invasion. Perineural invasion can increase the chances of tumor recurrence and reduce survival in patients with oral cancer. Understanding how oral cancer interacts with nerves to facilitate perineural invasion is an important area of research. Targeting key events that contribute to perineural invasion in oral cavity cancer may reduce tumor recurrence and improve survival. In this review, we describe the impact of perineural invasion in oral cancer and the mechanisms that contribute to perineural invasion. Highlighting the key events of perineural invasion is important for the identification and testing of novel therapies for oral cancer with perineural invasion.

Abstract

The most common oral cavity cancer is squamous cell carcinoma (SCC), of which perineural invasion (PNI) is a significant prognostic factor associated with decreased survival and an increased rate of locoregional recurrence. In the classical theory of PNI, cancer was believed to invade nerves directly through the path of least resistance in the perineural space; however, more recent evidence suggests that PNI requires reciprocal signaling interactions between tumor cells and nerve components, particularly Schwann cells. Specifically, head and neck SCC can express neurotrophins and neurotrophin receptors that may contribute to cancer migration towards nerves, PNI, and neuritogenesis towards cancer. Through reciprocal signaling, recent studies also suggest that Schwann cells may play an important role in promoting PNI by migrating toward cancer cells, intercalating, and dispersing cancer, and facilitating cancer migration toward nerves. The interactions of neurotrophins with their high affinity receptors is a new area of interest in the development of pharmaceutical therapies for many types of cancer. In this comprehensive review, we discuss diagnosis and treatment of oral cavity SCC, how PNI affects locoregional recurrence and survival, and the impact of adjuvant therapies on tumors with PNI. We also describe the molecular and cellular mechanisms associated with PNI, including the expression of neurotrophins and their receptors, and highlight potential targets for therapeutic intervention for PNI in oral SCC.

Porcine small intestine graft for reconstruction of oral defects

OBJECTIVE

To evaluate the feasibility and outcomes of porcine submucosal allograft (Biodesign Sinonasal Repair Graft [Cook Medical, Bloomington, IN]) in oral cavity and oropharynx reconstruction after ablative surgery.

METHODS

We conducted a prospective and retrospective review of patients who underwent Biodesign Sinonasal Repair Graft reconstruction for oral and oropharyngeal surgical defects at a single institution between 2018 and 2020. A total of 11 patients were included in the study. Data points included their perioperative medical and demographic data, immediate postoperative course, and follow-up visits at 10 days and at 2 months. The clinicopathologic characteristics of their disease, postoperative esthetic, and functional outcomes were recorded and analyzed.

RESULTS

Eleven procedures have been performed, and all patients received Biodesign reconstruction either immediately after ablation or after they failed a previous reconstruction. None of the patients had bone exposure. The subsites included oral tongue (n = 6), floor of the mouth (n = 3), buccal mucosa (n = 1), and soft palate (n = 1). In all cases, the operations and the postoperative course were uneventful. The mean defect size was 22 cm2. The median start of oral intake was at 2 days postoperatively. The Biodesign graft healed well in all patients with no total graft loss. There was one complication that required revision surgery due to obstruction of Wharton's duct by the Biodesign material.

CONCLUSIONS

Biodesign can be a viable option for small and medium-sized oral and oropharyngeal defects in patients who are medically unfit or do not want to undergo a free flap surgery.

LEVEL OF EVIDENCE

4.

A novel application of superior thyroid artery perforator flaps for medium-sized intraoral reconstructions: Retrospective analysis of 12 cases

BACKGROUND

To describe the indications, technique, and preliminary experience in the application of the superior thyroid artery perforator flap (STAPF) for the reconstruction of various medium-sized intraoral defects.

METHODS

From September 2018 to September 2019, 12 consecutive cases of oral squamous cell carcinoma underwent reconstruction with a STAPF. Clinical details were collected, and postoperative function was analyzed.

RESULTS

The venous drainage of the STAPF is variable with drainage into the internal jugular vein in six cases, into both the internal and external jugular veins in four cases, and into the external jugular vein in two cases. Ten cases were harvested as pedicled flaps, while two cases required a venous anastomosis due to inadequate length of the venous pedicle. Ten flaps survived completely, whereas two flaps had partial necrosis that ultimately resolved with secondary healing.

CONCLUSIONS

STAPF is a reliable method for the reconstruction of medium-sized intraoral defects.

Facial artery-based islanded myomucosal and bone flaps in head and neck reconstruction

This article aims to illustrate various applications of facial artery-based islanded myomucosal (iFAMM) and osseous/osteo-myomucosal flaps (iFOMM) in head and neck reconstruction. A retrospective analysis of 75 patients who underwent the reconstruction of various head and neck mucosal defects with iFAMM/iFOMM in a tertiary head and neck cancer department from May 2015 to May 2019 was performed. The patients had surgery for cancer, which involved the oral tongue, floor of mouth, oropharynx, lower alveolus, larynx, hypopharynx, cricopharynx and trachea. iFOMM was used in 3 patients. Functional and esthetic outcomes, short-term and long-term complications were analyzed. The flap was successful in 74 out of 75 patients. Speech was intelligible in almost all patients and majority of patients could take oral feeds without any restrictions. The esthesis of reconstruction was scored high with a mean visual analog scale score of 8.4. The most commonly observed complication was marginal mandibular paresis, which improved with time. Mouth opening was >3 cm in 68/75 patients. Adjuvant radiation was a common factor in patients with <3 cm mouth opening. Flap was sensate by 4 months in majority of patients. The reach, pliability, and esthetics of the flap combined with recoverable morbidity of donor site present in the facial artery-based flap as a good option in the reconstruction of various head and neck subsites. Reduced operative time, lesser complication rates, less financial burden, and simplicity of the procedure make it a cost-effective alternate solution for reconstruction.

An alternative to skin graft for superficial surgical defect in oral cancer surgery

Introduction

After surgery for oral cavity cancer, superficial surgical defects are usually covered with a skin graft that can be harvested with different thicknesses depending on the reconstructive need. Despite its popularity and efficacy, this solution has the disadvantage of excessive harvesting times and scarring of the donor site. Other surgeons have proposed the use of bovine pericardium as a reconstructive solution. Its use in otorhinolaryngology especially after oral cavity surgery has never been reported.

Objective

The aim of this manuscript is to present our preliminary experience with the use of a collagen membrane obtained from bovine pericardium in the reconstruction of small and superficial defects after transoral resection of oral cavity tumors.

Methods

A bovine collagen membrane was used to cover surgical defects in 19 consecutive patients undergoing transoral resection of small/superficial oral cancers. Photographs were obtained in the postoperative period to follow the healing process. We analyzed the pro and cons of this tool, recorded data on postoperative chewing-, speech- and taste-related quality of life, and tested the most appropriate settings providing the best reconstructive result.

Results

The bovine collagen membrane allowed us to cover surgical defects of varying size in different oral sites. Shaping and placement proved to be simple. The membrane facilitated physiologic tissue repair: after one month it was completely absorbed and replaced by the patient’s own mucosa. No adverse features were observed in the cohort.

Conclusion

A bovine collagen membrane can represent a fast and easy solution in cases of split-thickness defect. Unlike a skin graft, it is not associated with donor site morbidity and allows the patient’s own mucosa to be restored with a more physiological result.

Oral recipient site infections in reconstructive surgery - impact of the graft itself and the perioperative antibiosis

OBJECTIVES

This study was designed to assess the influence of peri/post-operative antibiotic prophylaxis (POABP) and the reconstructive graft itself on recipient sites infections in head and neck surgery.

MATERIALS AND METHODS

In this retrospective cohort study, 322 consecutive patients with reconstructive surgery were investigated. The primary objective was to analyze the differences of commonly applied reconstructive grafts on the occurrence of oral recipient site infections. Moreover, differences of POABP regimes (namely: ampicillin/sulbactam, 2^nd generation cephalosporins, clindamycin) and antibiotic alternatives were investigated. In addition, patients' length of in-hospital stay was analyzed in regard to reconstructive graft and POABP regime.

RESULTS

The free radial forearm flap and split-thickness skin graft presented significantly less recipient site infections and shorter length of in-hospital stays (LOS) in comparison to further six reconstructive technique with pedicled tissue transfer or bone transfers. LOS was significantly shorter for patients with ampicillin/sulbactam than with 2^nd generation cephalosporins as POABP. 91% of the harvested pathogens (n=193) were susceptible to the combination of 2^nd and 3^rd generation cephalosporins. Secondly, 92 out 113 (81%) harvested pathogens presented susceptibility to moxifloxacin.

CONCLUSION

Smaller tissue transfers are less prone to infections of the recipient site and present low LOS. For an POABP regime, the combination of 2^nd and 3^rd generation cephalosporins presents substantial results in recipient site infections. In cases of allergy, potential pathogens show adequate susceptibility to moxifloxacin.

CLINICAL RELEVANCE

A combination of 2^nd and 3^rd generation cephalosporins may be used to prevent recipient sites in head and neck surgery.

Oral recipient site infections in reconstructive surgery - impact of the graft itself and the perioperative antibiosis

OBJECTIVES

This study was designed to assess the influence of peri/post-operative antibiotic prophylaxis (POABP) and the reconstructive graft itself on recipient sites infections in head and neck surgery.

MATERIALS AND METHODS

In this retrospective cohort study, 322 consecutive patients with reconstructive surgery were investigated. The primary objective was to analyze the differences of commonly applied reconstructive grafts on the occurrence of oral recipient site infections. Moreover, differences of POABP regimes (namely: ampicillin/sulbactam, 2^nd generation cephalosporins, clindamycin) and antibiotic alternatives were investigated. In addition, patients' length of in-hospital stay was analyzed in regard to reconstructive graft and POABP regime.

RESULTS

The free radial forearm flap and split-thickness skin graft presented significantly less recipient site infections and shorter length of in-hospital stays (LOS) in comparison to further six reconstructive technique with pedicled tissue transfer or bone transfers. LOS was significantly shorter for patients with ampicillin/sulbactam than with 2^nd generation cephalosporins as POABP. 91% of the harvested pathogens (n=193) were susceptible to the combination of 2^nd and 3^rd generation cephalosporins. Secondly, 92 out 113 (81%) harvested pathogens presented susceptibility to moxifloxacin.

CONCLUSION

Smaller tissue transfers are less prone to infections of the recipient site and present low LOS. For an POABP regime, the combination of 2^nd and 3^rd generation cephalosporins presents substantial results in recipient site infections. In cases of allergy, potential pathogens show adequate susceptibility to moxifloxacin.

CLINICAL RELEVANCE

A combination of 2^nd and 3^rd generation cephalosporins may be used to prevent recipient sites in head and neck surgery.

Comparison of the hospitalization period after microvascular reconstruction flap in trismus patients: free anterolateral thigh flap versus free forearm flap

OBJECTIVES

The primary strategy for treating oral squamous cell carcinoma (OSCC) is therapeutic resection, with the trismus resection defect reconstructed via free flap. The most popular free flaps include the radial forearm free flap (RFFF) and anterolateral thigh free flap (ALT). This study investigated the relationships between the hospitalization period and a variety of surgical outcomes, as well as maximum inter-incisor distance (IID), in trismus patients who chewed betel nuts.

MATERIALS AND METHODS

Forty-nine primary OSCC patients who chewed betel nuts and underwent surgical resection and reconstruction between 2010 and 2016 were enrolled in this retrospective study. The data were from a single center in Taiwan. The outcome variable after flap recovery surgery was the duration of postoperative hospitalization. Other factors that were analyzed comprised correlations between hospitalization and a variety of factors, including postoperative inter-incisor distances (IIDs), operative time, gender, and WBC count, upon stratification into two reconstruction groups.

RESULTS

The mean postoperative hospitalization duration in the ALT group was 22.9 ± 7.2 days, which was significantly shorter than that in the RFFF group (27.8 ± 7.0 days; p = 0.019). Two-week postoperative IID (ALT group: 16.1 ± 0.8 mm; RFFF group: 7.0 ± 0.6 mm) was inversely related to the duration of hospitalization (p = 0.022, r = - 0.372).

CONCLUSIONS

The ALT flap is more effective than the RFFF flap to reduce the length of hospitalization in trismus patients.

CLINICAL RELEVANCE

The ALT flap should be considered as a first-line technique in OSCC reconstruction in trismus patient reconstruction.

Reconstruction of cheek mucosal defect with a buccal fat pad flap in a squamous cell carcinoma patient: a case report and literature review

Background

Squamous cell carcinoma (SCC) is the most commonly occurring malignant tumor in the oral cavity. In South Korea, it occurs most frequently in the mandible, tongue, maxilla, buccal mucosa, other areas of the oral cavity, and lips. Radial forearm free flap (RFFF) is the most widely used reconstruction method for the buccal mucosal defect. The scar of the forearm donor, however, is highly visible and unsightly, and a secondary surgical site is needed when such technique is applied. For these reasons, buccal fat pad (BFP) flap has been commonly used for closing post-surgical excision sites since the recent decades because of its reliability, ease of harvest, and low complication rate.

Case presentation

In the case reported herein, BFP flap was used to reconstruct a cheek mucosal defect after excision. The defect was completely covered by the BFP flap, without any complications.

Conclusion

Discussed herein is the usefulness of BFP flap for the repair of the cheek mucosal defect. Also, further studies are needed to determine the possibility of using BFP flap when the defect is deep, and the maximum volume that can be harvested considering the changes in volume with age.

A Gingiva-Derived Mesenchymal Stem Cell-Laden Porcine Small Intestinal Submucosa Extracellular Matrix Construct Promotes Myomucosal Regeneration of the Tongue

In the oral cavity, the tongue is the anatomic subsite most commonly involved by invasive squamous cell carcinoma. Current treatment protocols often require significant tissue resection to achieve adequate negative margins and optimal local tumor control. Reconstruction of the tongue while preserving and/or restoring its critical vocal, chewing, and swallowing functions remains one of the major challenges in head and neck oncologic surgery. We investigated the in vitro feasibility of fabricating a novel combinatorial construct using porcine small intestinal submucosa extracellular matrix (SIS-ECM) and human gingiva-derived mesenchymal stem cells (GMSCs) as a GMSC/SIS-ECM tissue graft for the tongue reconstruction. We developed a rat model of critical-sized myomucosal defect of the tongue that allowed the testing of therapeutic effects of an acellular SIS-ECM construct versus a GMSC/SIS-ECM construct on repair and regeneration of the tongue defect. We showed that the GMSC/SIS-ECM construct engrafted at the host recipient site, promoted soft tissue healing, and regenerated the muscular layer, compared to the SIS-ECM alone or nontreated defect controls. Furthermore, our results revealed that transplantation of the GMSC/SIS-ECM construct significantly increased the expression of several myogenic transcriptional factors and simultaneously suppressed the expression of type I collagen at the wounded area of the tongue. These compelling findings suggest that, unlike the tongue contracture and fibrosis of the nontreated defect group, transplantation of the combinatorial GMSC/SIS-ECM constructs accelerates wound healing and muscle regeneration and maintains the overall tongue shape, possibly by both enhancing the function of endogenous skeletal progenitor cells and suppressing fibrosis. Together, our findings indicate that GMSC/SIS-ECM potentially served as a myomucosal graft for tongue reconstruction postsurgery of head and neck cancer.

Retromolar trigone reconstructive surgery: prospective comparative analysis between free flaps

PURPOSE

Retromolar trigone (RMT) tumours are rare and aggressive malignancies, which require an aggressive surgical approach. The reconstruction oral cavity defects represent a challenge because of the critical role of this area both aesthetically and functionally. Free radial forearm (RF) or anterolateral thigh (ALT) flap are the first choice for the repair of intraoral defects. In reviewing the literature, there is lack of evidence pertaining to the differences between RF and ALT flaps in the reconstruction of patients with RMT tumours. This study evaluates the better microvascular reconstruction after RMT cancer resection.

METHODS

Thirty patients with RMT cancer underwent oropharingectomy and microvascular reconstruction using the free RF flap (RF group) and the ALT perforator flap (ALT group). The two groups were homogeneous for sex, age, anatomic area, body mass index, and clinicopathologic profile. Viability, complications, scarring, cosmetic appearance, disorder of sensations, ROM, disease-specific items and satisfaction rate were analyzed, and statistical analysis was performed.

STUDY DESIGN

Prospective study.

RESULTS

There were differences between the RF and ALT groups in the morphofunctional outcomes, both short-term and long-term follow-up. These differences were statistically significant (p < 0.05) for donor site complications, cosmetic appearance, and scar evaluations. Manual dexterity was slower on the operated donor side than on the nonoperated side in the 33.3 % in the RF group.

CONCLUSIONS

The study showed that the free ALT perforator flap provides better results in appearance and scarring than the RF flap for intraoral reconstruction after RMT cancer resection.