Orocutaneous Fistula Formation in Free Flap Reconstruction for Oral Squamous Cell Carcinoma

[Clinical efficacy of composite transplantation of fascia lata-anterolateral thigh flap in repairing complex defects after radical tumor resection in maxillofacial region]

Objective: To investigate the clinical efficacy of composite transplantation of fascia lata-anterolateral thigh flap for repairing complex defects after radical tumor resection in maxillofacial region. Methods: This study was a retrospective observational study. From January 2023 to January 2024, 12 patients (7 males and 5 females, aged 42 to 60 years) meeting the inclusion criteria with complex defects after radical tumor resection in maxillofacial region were treated at the Department of Burns and Cutaneous Surgery of the First Affiliated Hospital of Air Force Medical University. After radical tumor resection, the sizes were 6.0 cm×4.0 cm to 11.0 cm×10.0 cm for skin and soft tissue defects and 4.0 cm×3.0 cm to 11.0 cm×5.0 cm for buccal mucosa-zygomatic arch defects. The anterolateral thigh flap with area ranging from 7.0 cm×5.0 cm to 12.0 cm×11.0 cm was first designed and harvested, followed by the underlying fascia lata (ranging from 4.0 cm×3.0 cm to 11.0 cm×5.0 cm). Then, the fascia lata was used first to reconstruct the oral lining, and the anterolateral thigh flap was subsequently employed to repair the residual skin and soft tissue defects. Postoperatively, the survival of the patient's flap was observed, the epithelialization time of the fascia lata used as lining was recorded, and wound healing at the donor and recipient sites was monitored, along with whether complications such as vascular crisis, oral fistula, or infection were present at the recipient site. During follow-up, the epithelialization of the fascia lata as a lining was observed, the mouth opening degree of the patient was measured, the occlusal function was evaluated, and the facial appearance and scar condition in donor site were observed. Results: Postoperatively, all flaps of patients survived successfully, with the fascia lata used as a lining achieving complete epithelialization within 8-10 days. Only one patient with maxillary sinus squamous cell carcinoma experienced delayed wound healing at the flap margin, which was resolved after dressing changes; the recipient site wounds in the remaining patients healed well. All the donor site healed well. No vascular crisis, oral fistula, infection, or other complications occurred at the recipient sites. During 3 months of follow-up, the oral mucosa had covered the surface of the fascia lata; the vertical mouth opening was 3 transverse fingers in 9 cases, 2.5 transverse fingers in 1 case, 2 transverse fingers in 1 case, and 1.5 transverse fingers in 1 case, the horizontal mouth opening was 3-5 cm; chewing and swallowing functions were normal. All patients exhibited facial symmetry with the surgical area being full, and only linear scars were left in the donor sites. Conclusions: The composite transplantation of fascia lata-anterolateral thigh flap demonstrates excellent efficacy in repairing complex defects after radical tumor resection in maxillofacial area. Through staged reconstruction of both the oral barrier and soft tissue defects, this approach significantly reduces the risk of postoperative complications while achieving functional recovery and aesthetic reconstruction.

A Proposal for Orocutaneous Fistula Grading Following Oral Cancer Surgery

Orocutaneous fistula (OCF) is a common postoperative complication encountered following surgery for oral cancers with multiple implications. There is no grading system available for this complication which has so many implications that would help in its uniform reporting and management. In this study, we have included patients with oral squamous cell carcinoma operated on between January 2021 and December 2021 and tested a proposed three-tier grading system (grades 1-3) for OCF. Out of the 284 patients at risk of OCF, 37 (13%) patients developed OCF in this cohort. Six patients had grade 1 OCF, 20 patients had grade 2 OCF, and 11 patients had grade 3 OCF. Patients with a higher grade of OCF had prolonged hospital stays and required multiple surgical debridements and/or resuturings, and a few needed another flap, which was statistically significant. The proposed grading system for OCF appears to be useful in grading this complication. However, this needs to be validated in a prospective study across multiple centres.

Early Feeding After Free Flap Reconstruction for Oral Cavity Cancer: A Single Institution Retrospective Review

OBJECTIVE

Patients undergoing free flap reconstruction of the oral cavity have traditionally received nothing by mouth for 6-14 days postoperatively to limit the risk of wound complications. Growing evidence suggests that initiation of oral intake may not increase the morbidity. This study further investigates the utility of "early feeding."

METHODS

This was a retrospective cohort study conducted at a large, urban tertiary healthcare system. Patients who underwent free flap reconstruction for oral cavity cancer between June 1, 2020, and October 31, 2022, were grouped as early feeding (oral intake on or before Postoperative Day 5) or late feeding (LF) (oral intake after Postoperative Day 5). Outcomes included rate of orocutaneous fistula, development of other local or systemic complications, and hospital length of stay (LOS).

RESULTS

Sixty six patients were studied, with 26 belonging to the LF group and 40 to the early feeding (EF) group. The LF group was significantly older (median age 64.5 vs. 80 years, p = 0.027) and more likely to have a defect extending beyond the oral cavity (25.0% vs. 50.0%, p = 0.037). No significant differences were found in orocutaneous fistula formation between the LF and EF groups (7.7% vs. 0%, p = 0.152), but the rate of total complications was significantly higher in the LF group (38.5% vs. 12.5%, p = 0.014). LOS was significantly longer in the LF group (12.5 vs. 6 days, p < 0.001).

CONCLUSION

These findings suggest that in the correctly suggested patient population, early postoperative oral intake may facilitate earlier hospital discharge without increasing the risk of postoperative complications.

Use of Flow-through Free Flaps in Head and Neck Reconstruction

Background

Reconstructive obstacles in composite head and neck defects are compounded in reoperated, traumatized, irradiated, and vessel-depleted surgical fields. In cases that require multiple free flaps, recipient vessel accessibility and inset logistics become challenging. Strategic flow-through flap configurations mitigate these issues by supplying arterial inflow and venous outflow to a second flap in a contiguous fashion. This approach (1) permits the use of a singular native recipient vessel, (2) increases the reach of the vascular pedicle, avoiding the need for arteriovenous grafting, and (3) allows for a greater three-dimensional flexibility in configuring soft tissue and bony flap inset.

Methods

To demonstrate this technique, we conducted a retrospective review of all head and neck reconstruction patients presenting to us from March 2019 to April 2021.

Results

We present seven oncological and two traumatic patients (N = 9) who received flow-through free flaps for head and neck reconstruction. The most common flap used as the flow-through flap was the anterolateral thigh flap (N = 7), followed by the fibula flap (N = 2). Mean follow-up time was 507 days. No flap failures occurred.

Conclusion

In head and neck reconstruction, the use of the flow-through principle enables uninterrupted vascular flow for two distinct free flaps in single-stage reconstruction for patients with vessel-depleted, irradiated, and/or reoperated fields. We demonstrate that flow-through flaps in the head and neck may be used successfully for a variety of cases and flaps.

Anchored sutures for fixation of the anterolateral thigh flap and prevention of orocutaneous fistula in oral and oropharyngeal cancer reconstruction

OBJECTIVE

This study aims to assess the efficacy of anchored sutures (AS) in securing the anterolateral thigh (ALT) flap during oral and oropharyngeal reconstructions, and its impact on the occurrence of orocutaneous fistula (OCF).

MATERIALS AND METHODS

A retrospective study was performed on patients who underwent ALT flap reconstruction in our department in the year 2022. The patients were divided into two groups based on whether the AS technique was used. The incidence of OCF was compared between the two groups, and AS-related complications were reported. Fisher's exact test was employed to assess the differences in baseline characteristics and the incidence of OCF between the two groups.

RESULTS

The study included 214 patients, with 156 in the conventional suture (CS) group and 58 in the AS group. The incidence of OCF in the AS group was significantly lower compared to that in the CS group (P = 0.039). However, there was a weak correlation between OCF and the AS technique (φ = -0.149). Among the 58 cases in the AS group, three (5.17%) experienced AS-related granuloma (ASRG) as complications.

CONCLUSION

The use of ALT flap reconstruction with the AS technique reduces the incidence of OCF; however, ASRG may be a potential complication.

CLINICAL RELEVANCE

This study demonstrates the effectiveness of AS technique in securing ALT flaps, leading to a decreased risk of OCF in oral and oropharyngeal defect reconstruction.

Reconstruction of head and neck oncological soft tissue defects post-resection using robotic surgery: a systematic review of the current literature

Head and neck cancer (HNC) resection often leaves soft tissue defects and exposure of vital structures. In recent years, there has been an increase in the use of robotic surgery for HNC resections. This allows for achieving smaller defects by using a tissue-sparing approach. However, this poses a challenge for reconstruction with less space available to perform microsurgery. We reviewed the efficacy of robotic surgery in the reconstruction of HNC defects by assessing the impact on flap success and complication rates. A literature search was conducted on Pubmed, Prospero, Dynamed, DARE, EMBASE, and COCHRANE databases. A total of 14 articles fulfilled the inclusion criteria with 96 patients aged mean (range) 60.7 (29-87) years, undergoing robotic reconstruction. The radial forearm flap was the most commonly used flap for robot-assisted reconstruction (n = 47). Robotic graft inset was performed in 94 cases and robotic assisted microvascular anastomoses for 25 vessels. One hundred per cent of flaps survived with a total of 25 (26.0%) complications (wound healing (n = 7), fistula formation (n = 2), haematoma (n = 4), dehiscence (n = 10), and wound infection (n = 2). Seven (12.2%) patients required additional surgery for managing complications and revision of the flap. Fewer complications were seen in patients undergoing robotic-assisted microvascular anastomoses compared with open anastomoses (4.0% versus 34.2%, p < 0.05). Robot-assisted reconstruction in HNC defects demonstrates 100% success rate with minor associated complications. Our results also support feasibility in both flap inset and microvascular anastomoses. Our results also demonstrate feasibility in both flap inset and microvascular anastomoses. Significantly fewer complications were seen with robotic-assisted microvascular anastomoses compared with open anastomoses.

Clinical analysis of factors affecting the failure of free flaps used in head and neck reconstruction

BACKGROUND

Free tissue transfer is the preferred method of reconstructing head and neck defects, with a success rate of approximately 95%. Although flap failure is uncommon, it has a major impact on patient morbidity and diminishes quality of life, making it is important to investigate the causes of flap failure.

METHODS

This retrospective chart review analyzed patients who underwent free tissue transfer during head and neck reconstruction at a single institution between 2016 and 2021.

RESULTS

During the study period, 58 patients underwent 60 free flap procedures. Revision surgery was needed in 14 patients. Subsequent free flap surgery was performed in one patient, and three free flaps (5%) could not be salvaged. Cardiovascular disease was significantly associated with flap failure, and venous congestion (thrombosis) was the most common reason for revision surgery.

CONCLUSION

Cardiovascular disease clearly emerged as a factor related to the failure of free flap surgery, and this issue warrants particular attention in patients for whom free tissue transfer is planned.

Predictors predisposing to orocutaneous fistula occurrence following free flap reconstruction

Objectives

To explore the possible risk factors of orocutaneous fistula (OCF) development in free flap reconstruction of the tongue/floor of the mouth (TFOM).

Methods

Data of patients who underwent free flap reconstruction of the TFOM were retrospectively analyzed. The association between clinicopathologic variables and OCF occurrence was analyzed using univariate and multivariate analyses.

Results

Altogether, 469 patients were enrolled. OCF occurred in 43 patients with a rate of 9.2%. The univariate analysis revealed the negative effects of smoking, preoperative albumin level, cachexia, T4 stage, neck dissection, entire resection of the floor of the mouth (FOM), segmental mandibulectomy, and surgical site infection on OCF occurrence. The multivariate analysis confirmed the independence of cachexia (p<0.001, 4.386[1.883–9.472]), tumor stage (p<0.001, 2.738[1.482–6.629]), entire FOM resection (p<0.001, 6.332[2.110–14.432]), and surgical site infection (p<0.001, 5.376[1.998–11.218]) in affecting the OCF development.

Conclusions

OCF development following free flap reconstruction of the TFOM was relatively uncommon, but significantly associated with presence of cachexia, T4 stage, entire FOM resection, and surgical site infection.