Long-term donor site morbidity in head and neck cancer patients and its impact on quality of life: a cross-sectional study

Head and Neck Cancer Online Support Groups: Disparities in Participation and Impact on Patients

Objective

To characterize the users of the head and neck cancer (HNC) online support group (OSG) and describe the perceived benefits of membership.

Study Design

Cross-sectional.

Setting

Online.

Methods

An administered survey with questions asking about demographics, cancer history, treatment choices, and feelings about OSGs was posted on the 5 largest HNC OSGs on Facebook.

Results

A total of 97 participants completed the survey. Mean age was 57.8 years old (standard deviation = 10.7 years). Most participants were female (50.5%) and Caucasian (92.8%). This cohort was well educated with 65.5% holding at least a college degree. Annual income was high with 41.8% reporting annual income of $100,000 or greater. The most common treatment modality was radiation (88.7%). The most common surgery was neck dissection (46.4%). Most participants preferred OSGs (70.8%) over other support group types. OSGs were heavily utilized with our cohort reporting using the OSG at least several times a week (80.0%). The top reasons for joining the OSG were sharing one's experience of HNC (76.3%) and gaining support from others with HNC (85.6%). OSGs were ranked as the #3 source of medical information for HNC behind otolaryngologists and oncologists. Membership in a HNC OSG had a minimal impact on decision-making.

Conclusion

HNC OSGs appear to provide a beneficial community for HNC patients. Otolaryngologists should consider incorporating HNC OSG as a possible supplemental resource for their HNC patients.

Free-Flap Reconstruction in Early-Stage Squamous Cell Carcinoma of the Oral Cavity-A Prospective Monocentric Trial to Evaluate Oncological Outcome and Quality of Life

Surgery is generally accepted as standard treatment in oral cancer, but the reconstructive procedures remain a matter of debate. The aim of this study was to evaluate oncological outcome and quality of life following surgical resection and free-flap reconstruction in patients with early oral squamous cell carcinoma. The presented trial was performed as a prospective, single-center observation study. Inclusion criteria were primary surgery in early-stage oral squamous cell carcinoma with free-flap reconstruction. Endpoints were overall and progression-free survival and quality of life up to 24 months after surgery. Twenty-six patients were included. Overall survival was 100% and progression-free survival was 92.3% in a maximum follow-up time of 21 months. Global quality of life showed no significant alteration after surgery. Patients reported a significant reduction in pain (p = 0.048) and a decreasing impairment of speech one year after surgery (p = 0.021). Free-flap reconstruction is a safe procedure that results in excellent oncological outcome and quality of life. Functional outcome is of high relevance in early-stage tumors of the head and neck and may mostly be affected by reconstructive procedures. Therefore, a prospective evaluation to explore success and the effects of surgical therapy is highly warranted.

Donor site morbidity after computer assisted surgical reconstruction of the mandible using deep circumflex iliac artery grafts: a cross sectional study

BACKGROUND

Computer Assisted Design and Computer Assisted Manufacturing (CAD/CAM) have revolutionized oncologic surgery of the head and neck. A multitude of benefits of this technique has been described, but there are only few reports of donor site comorbidity following CAD/CAM surgery.

METHODS

This study investigated comorbidity of the hip following deep circumflex iliac artery (DCIA) graft raising using CAD/CAM techniques. A cross-sectional examination was performed to determine range of motion, muscle strength and nerve disturbances. Furthermore, correlations between graft volume and skin incision length with postoperative donor site morbidity were assessed using Spearman's rank correlation, linear regression and analysis of variance (ANOVA).

RESULTS

Fifteen patients with a mean graft volume of 21.2 ± 5.7 cm³ and a mean incision length of 228.0 ± 30.0 mm were included. Patients reported of noticeable physical limitations in daily life activities (12.3 ± 11.9 weeks) and athletic activities (38.4 ± 40.0 weeks in mean) following surgery. Graft volume significantly correlated with the duration of the use of walking aids (R = 0.57; p = 0.033) and impairment in daily life activities (R = 0.65; p = 0.012). The length of the scar of the donor-site showed a statistically significant association with postoperative iliohypogastric nerve deficits (F = 4.4, p = 0.037). Patients with anaesthaesia of a peripheral cutaneous nerve had a larger mean scar length (280 ± 30.0 mm) than subjects with hypaesthesia (245 ± 10.1 mm) or no complaints (216 ± 27.7 mm).

CONCLUSIONS

Despite sophisticated planning options in modern CAD/CAM surgery, comorbidity of the donor site following  iliac graft harvesting is still a problem. This study is the first to investigate comorbidity after DCIA graft raising in a patient group treated exclusively with CAD/CAM techniques. The results indicate that a minimal invasive approach in terms of small graft volumes and small skin incisions could help to reduce postoperative symptomatology. Trial registration Retrospectively registered at the German Clinical Trials Register (DRKS-ID: DRKS00029066); registration date: 23/05/2022.

A New Strategy for Patient-Specific Implant-Borne Dental Rehabilitation in Patients With Extended Maxillary Defects

Purpose of the Study

Patients undergoing ablative tumor surgery of the midface are faced with functional and esthetic issues. Various reconstructive strategies, such as implant-borne obturator prostheses or microvascular tissue transfer, are currently available for dental rehabilitation. The present study shows the first follow-up of patients treated with patient-specific implants (IPS Implants^® Preprosthetic) for the rehabilitation of extended maxillary defects following ablative surgery.

Patients and Methods

All patients treated with patient specific implants due to postablative maxillary defects were included. 20 implants were placed in the 19 patients (bilateral implants were placed in one of the cases). In 65.75% of the cases, resection was performed due to squamous cell carcinoma. In addition to the primary stability, the clinical implant stability, soft tissue management, successful prosthodontic restoration, and complications were evaluated at a mean follow-up period of 26 months.

Results

All patient-specific implants showed primary stability and were clinically stable throughout the observation period. Definitive prosthodontic restorations were performed in all patients. No implant loosening was observed. Major complications occurred only in previously irradiated patients with insufficient soft tissue conditions (p = 0.058). Minor complications such as exposure of the underlying framework or mucositis were observed, but they never led to failure of restorations or implant loss.

Conclusions

Treatment of postablative maxillary defects with patient-specific implants offers a safe alternative with predictable results for full and rapid dental rehabilitation, avoiding time-consuming augmentation procedures and additional donor-site morbidity.

The sub-fascial pattern of the myocutaneous platysma flap - The anatomical basis and preliminary cases for oral reconstruction

To verify the feasibility of the SF-MPF for oral reconstruction, the anatomic, sonographic and histologic features of the SF-MPF were investigated and the outcome in a series of patients was evaluated. The sonographic and histologic results showed a supra-fascial arterio-venous vascular blood supply to the sub-fascial design of the MPF. The clinical course of 12 consecutive patients who underwent oral reconstruction using the SF-MPF along with ipsi- or lateral neck dissection for treatment of oral cancer showed sufficient pedicle length and reliable blood supply. The SF-MPF is a reliable and safe pedicled myocutaneous flap. Therefore, it should be considered being an additional option when a pedicled flap has to be selected.

Multiple Sequential Free Flap Reconstructions of the Head and Neck: A Single-Center Experience

BACKGROUND

Free flap reconstruction is the standard of care in extensive defects of the head and neck area, and although most patients may be treated sufficiently with one flap, recurrence of a malignant tumor or failure of a previous reconstruction may make the use of a second (or more) flap necessary. The aim of this study was to evaluate the indications and success rates of multiple consecutive reconstructive procedures in a large cohort of patients.

METHODS

Nine hundred ninety-six free flap reconstructions were retrospectively analyzed and cases of sequential reconstructions in the same patient were identified. Indications, success rates, perioperative procedures, and frequently used flaps were evaluated.

RESULTS

Two hundred twenty cases of sequential microvascular reconstructions were identified, ranging from two to six flaps per patient. The overall flap success rate was 89.1 percent. A history of diabetes was identified as a risk factor for flap failure (p = 0.029). There was no association of flap loss with the number of reconstructive procedures per patient.

CONCLUSIONS

The use of several free flaps in the same patient is a feasible option for patients suffering from recurrent tumors or to improve quality of life by a secondary reconstruction. A salvage free flap transfer to replace a lost transplant exhibits good success rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Scapular osseous free flap in head and neck reconstruction: An assessment of the postoperative function of the donor site

BACKGROUND

The scapular osseous free flap (SOFF) has become an important reconstructive option for complex head and neck defects. Postoperative donor site function is, however, an important consideration. The objective of this study was to prospectively investigate SOFF donor site morbidity and to relate the findings to hand dominance and neck dissection.

METHODS

Objective assessment included bilateral measurement of shoulder, elbow, and hand range of motion (ROM), hand strength, and distal nerve function in consecutive patients with head and neck cancer SOFF reconstruction at a tertiary referral center in Sweden between 2016 and 2019. The subjective function was assessed by the Disability of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

Sixteen of 20 consecutive patients were evaluated (median follow-up 10 months [range 3-17]). Significant side differences in shoulder range of motion (ROM) (flexion, abduction, external and internal rotation) were observed for patients where the SOFF had been harvested from the same side as their dominant hand (n = 9; Ps ≤ 0.04). For patients where the SOFF was harvested from the non-dominant hand side, no significant shoulder ROM side differences were observed (n = 7; Ps ≥ 0.08). There were significant side differences in shoulder ROM for patients who underwent neck dissections (n = 12; Ps ≤ 0.03), not for the other four patients. Patients reported low but varying DASH scores (median 2.5, range 0-57).

CONCLUSION

Postoperative donor site morbidity seems to be quite acceptable after SOFF surgery. The results indicate possible benefits of choosing the non-dominant hand side for the SOFF and that a neck dissection affects postoperative shoulder outcome. Further studies are however needed.

Higher incidences of neuropathic pain and altered sensation following radial forearm free flap: A systematic review

BACKGROUND

The radial forearm free flap (RFFF) has been used extensively for complex tissue defect reconstructions; however, the potential for significant donor-site morbidity remains a major drawback. Despite an abundance of literature on donor-site morbidities, no consensus has been reached on exact incidences of sensory morbidities that vary largely between 0% and 46%. Incidences of neuropathic pain in the donor site following RFFF still lack, even though clinical experience shows it often occurs. Therefore, the purpose of this systematic review was to identify the incidence of neuropathic pain and altered sensation in the hand following harvesting of a RFFF.

METHODS

A systematic search was performed in multiple databases (Embase, Medline, Cochrane, Web of Science, and Google Scholar). Studies from 1990 onwards that reported donor-site morbidities following harvest of the RFFF were included. Analyzed parameters included hand pain, hypoesthesia, cold intolerance, hyperesthesia, neuroma formation, paresthesia, sharp sensation loss, light sensation loss, and defect closure.

RESULTS

Of the 987 selected studies, 51 eligible articles were selected. The mean level of evidence was 3 (SD 0.6). Twenty articles reported pain as a donor-site morbidity, and the mean incidence of pain reported was 23% (SD 7.8). Hypoesthesia was reported by 37 articles and had a mean incidence of 34% (SD 25). Locations of pain and hypoesthesia included, amongst others, the area of the radial sensory nerve and the skin graft area. The mean incidences of cold intolerance and hyperesthesia were 13% (SD 13) and 16% (SD 15), respectively.

CONCLUSION

The results of this systematic review suggest that 23% of all patients are dealing with neuropathic pain in the donor-site following harvest of an RFFF. Future studies should therefore focus on the prognostic factors and preventive measures of neuropathic pain to further improve clinical outcomes of this widely used flap.

Prelaminated flaps in head and neck cancer reconstructive surgery: A systematic review

Background

Prelamination is a reconstructive technique providing fasciomucosal or composite flaps with low donor‐site morbidity. We conducted a systematic review of retrospective studies to assess the application of prelaminated flaps in reconstructive surgery of head and neck cancer patients, and to evaluate the advantages and disadvantages of this technique.

Methods

This systematic review adhered to the recommendations of the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta‐analysis) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine (www.pubmed.org) and Scopus database (www.scopus.com), running the following search string: “prelamination OR prelaminated AND flap.” Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes and complications.

Results

A total of 19 articles were selected and reviewed from 128 identified. Seven of 19 articles were case reports, 12 articles were case series. One‐hundred‐two patients underwent reconstructive treatment by prelamination technique using a wide variety of flaps (92 free, 10 pedicled). The sites of reconstruction were oral cavity (66 floor of the mouth, 3 retromolar trigone, 6 hard palate, 4 cheek, 4 tongue), 8 facial skin (5 of them sited on the nose), 4 oropharyngeal defects, 1 laryngotracheal region. No case of total flap loss was reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 18 patients (17.6%). Primary closure of the donor site was achieved in 97 cases (97%) and 3 (3%) required revision surgery of the donor site.

Conclusion

Prelamination is an effective and versatile technique, with low donor‐site morbidity. Further studies would be needed to investigate the impact on the patient's oncologic outcome. More comparative studies with standard reconstructive techniques are essential to understand when it is worth performing this sophisticated procedure.

Observational study of the long-term impact of donor-site sequelae after head and neck reconstruction by free anterolateral thigh flap

OBJECTIVE

Free anterolateral thigh flap has many applications in head and neck reconstruction surgery. The aims of the present study were: (1) to assess functional and esthetic sequelae of harvesting for oncologic purposes; and (2) to assess long-term impact of harvesting on quality of life according to patient and to physician.

MATERIALS AND METHODS

Forty-one patients undergoing reconstruction by free anterolateral thigh flap following oncologic head and neck surgery were assessed by questionnaire at>6 months postoperatively. Donor site sequelae were assessed in consultation. Harvesting impact was assessed on 5-point Likert scales by patient and by surgeon.

RESULTS

Thirty nine percent of patients showed≥1 sequelae. Donor site sequela impact on sport, daily living and work was assessed by patients as none or mild in 94%, 98% and 100% of cases, respectively. Sixty-one percent of patients and 58.5% of surgeons considered scar esthetics to be discreet or very discreet.

CONCLUSION

Morbidity related to anterolateral thigh flap harvesting was low, and functional sequelae at the donor site were well tolerated. The scar was only moderately satisfactory, but could easily be hidden.

The Iliac Crest Osteomuscular Flap for Bony Reconstruction: Beast or Beauty? A Reassessment of the Value and Donor Site Morbidity in the CAD/CAM Era

BACKGROUND

 The iliac crest bone flap (ICBF), based on the deep circumflex iliac artery, has a bad reputation regarding donor site morbidity. However, the ICBF has an ideal curvature and shape for occlusion-based hemimandibular reconstructions with rapid dental rehabilitation and for vertical class III maxillary reconstructions that require bony support and muscular bulk to fill cavities and to provide intraoral lining. Is this notorious donor site reputation still valid with modern flap procurement using computer aided design/computer aided manufacturing (CAD/CAM) and recipient-site closure techniques?

MATERIALS AND METHODS

 We performed a literature search of the public databases PubMed, Cochrane, Google Scholar, and Web of Science for papers using mesh keywords related to donor site morbidity of the ICBF. We report three illustrative case reports using our current protocols for oncologic bony resection and reconstruction, using in-house CAD/CAM and three-dimensional printing to procure a tight-fit ICBF and minimizing donor site morbidity.

RESULTS

 We found 191 articles in the PubMed database of which we considered 176 nonrelevant. Cochrane Library and Google Scholar database searches resulted in the inclusion of 11 additional papers. The second search resulted in 172 articles of which we used five after excluding nonrelevant papers. Accurate preoperative (CAD/CAM) planning, preservation of the anterior superior iliac spine (ASIS), and paying attention to thoroughly donor site closure make the ICBF a very valuable option for accurate maxillofacial reconstructions with very acceptable comorbidities. This corresponds with our clinical findings.

CONCLUSION

 Dogma never is a good teacher; it remains elementary that routine "knowledge" is (re)questioned. Donor site morbidity of the ICBF is comparable to other bone flaps. The shape and bone stock of the ICBF is ideal and often may be first choice. In combination with CAD/CAM planning, the ICBF is an excellent option for specific maxillofacial reconstructions.

Donor-Site Morbidity after Fibula Transplantation in Head and Neck Tumor Patients: A Split-Leg Retrospective Study with Focus on Leg Stability and Quality of Life

The free fibula flap has been one of the most important microvascular grafts for orofacial reconstruction for more than 30 years. The complication rates at the donor-site reported in literature are considered to be low, but the published data vary greatly in some cases. In particular, restrictions in the stability and balance of the involved leg and their effects on the quality of life have been described very inconsistently to date. Therefore, this study mainly focuses on the stability and balance of the affected leg in a split-leg design. Between December 2014 and January 2018, out of 119 subjects who underwent mainly jaw ablative tumor surgery and reconstruction using a fibula flap, 68 subjects were examined for donor site morbidity. Besides reporting general types of complications, two specific test procedures were used. The Star Excursion Balance Test (SEBT) as a practical test for ankle function and the Foot and Ankle Disability Index (FADI) as a questionnaire in order to assess quality of life, depending on the lower leg function. SEBT revealed an average of 55.3 cm with the operated leg as the supporting leg, which corresponds to 95.5% of 57.9 cm achieved with the healthy leg as the supporting leg. An average FADI score of 89.4% was recorded. SEBT and FADI seem to be suitable methods of examination for subjects post fibular transplantation and pointed out minimal limitations of the involved legs in comparison to the unaffected legs. These limitations were clinically not relevant and they had minor influence on the subjects’ quality of life and their daily activities.

Reconstruction of a Large Posttraumatic Mandibular Defect Using Bone Tissue Engineering With Fresh-Frozen Humeral Allograft Seeded With Autologous Bone Marrow Aspirate and Vascularized With a Radial Forearm Flap

INTRODUCTION

Currently, vascularized autologous bone transplantation is considered the gold standard for large mandibular continuity defect reconstruction. Donor site morbidity is a major concern. Therefore, bone tissue engineering (BTE) seems to be the ideal solution. Fresh-frozen bone allograft is the closest material to autologous bone. The purpose of this clinical report is to show a new technique of large mandibular continuity defect reconstruction using a fresh-frozen humeral allograft seeded with autologous iliac bone marrow aspirate and vascularized with a radial forearm flap.

METHODS

A 33-year-old man presented with severe cranio-facial trauma resulting in several fractures of the facial skeleton including a comminuted mandibular fracture from left parasymphysis to left angle, which caused a large continuity defect.

RESULTS

Result at 6 months was aesthetically and functionally satisfactory with osseointegration of the bone graft.

DISCUSSION

The authors chose to use iliac bone marrow aspirate to seed the allograft scaffold since hematopoietic stem cells and mesenchymal stem cell are able to differentiate into osteoblasts, ease of harvest of the iliac crest and its low rate of morbidity. Contemporary biomaterials used for BTE are bioceramic but bone is still the better scaffold to engineer bone and only allografting avoids donor site morbidity. Vascularization is one of the main challenges of BTE; insertion of autologous vascular bundles from pedicle or free flaps is 1 solution. The authors chose the radial forearm flap since the pedicle is long and the authors did not need a great amount of soft tissue.