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Objectives: To evaluate the oncological safety and reliability of the submental island flap (SIF) technique in patients with pathologically node-negative (pN0) and node-positive (pN+) T1-2 oral squamous cell carcinoma (OSCC) undergoing surgical tumor resection and concurrent SIF reconstruction., Patients and Methods: Retrospectively, we reviewed patients with pN0 and pN+ T1-2 OSCC who underwent tumor resection and defect reconstruction with SIF from April 2008 to September 2016, focusing on flap viability, patterns and predictors of locoregional failure, salvage treatments, and oncologic prognosis., Results: Of 160 patients with primary T1-2 OSCC, 33 were pN+ and 127 were pN0. All SIFs beside two were successful (98.75%). During follow-up, 18 patients experienced locoregional tumor relapse, of which 14 were pN0 and four were pN+. The 5-year recurrence-free survival was 88.73% vs. 86.93% for the pN0 and pN+ groups, respectively (p = .847). The pN + patients had poorer prognosis than pN0 patients (5-year overall survival, 66.35% vs. 91.10% respectively [p = .005]; disease-specific survival, 74.87% vs. 91.88% respectively [p = .016]). Multivariate analyses indicated there was no independent predictor for locoregional recurrence, but pN+ was predictive for poor prognosis (p = .03)., Conclusion: SIF is a reliable flap for the reconstruction of OSCC-related small- and medium-sized soft tissue defect. With careful neck dissection and appropriate postoperative adjuvant treatment, the application of SIF did not increase the risk of locoregional tumor recurrence in patients with pN+ T1-2 OSCC compared with those with pN0 T1-2 OSCC., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Microvascular reconstruction is the standard of care in head and neck reconstruction, though its perioperative safety in an older population has been controversial due to safety concerns, warranting further investigation., Materials and Methods: An "older" (≥71 years) cohort undergoing reconstruction after mandibulectomy/glossectomy was compared to the remaining population in a National Surgical Quality Improvement Program (2008-2016) analysis. Cases required both a mandibulectomy/glossectomy and microvascular or local flap reconstruction (exclusion criteria: missing ages and simultaneous microvascular and local flap reconstruction). Demographics, comorbidities, and procedure types were analyzed on 985 patients (236 [24.4%] were ≥71). Outcomes were compared by reconstruction type. Regressions were performed calculating the impact of age on length of hospital stay (LOHS) and operative time., Results: Ablative procedures were comparable, but older patients received local flaps at higher rates (22.5% vs. 9.6%; p < .001). The older population had more comorbidities (higher ASA class [p < .001], diabetes [p < .001], and hypertension [p < .001]). After Bonferroni correction, univariate subgroup analyses of soft tissue and bone/composite microvascular flaps revealed similar outcomes (except increased medical complications in the older cohort undergoing a bone free flap [p = .002]). Controlling for a variety of factors, older age resulted in longer LOHS (B: 1.4 days; 95% CI: 0.1-2.8 days; p = .035), but not operative time (B: -21.90 min; 95% CI: -52.76 to 8.96 min; p = .164)., Conclusion: While increased age (≥70 years) was associated with a longer LOHS, complication rates were comparable. Although limited by the retrospective nature, evidence supports microvascular reconstruction in the elderly population with comparable outcomes., (© 2019 Wiley Periodicals, Inc.)

Background: Tongue resection is a surgical challenge because of its adverse effects on language articulation, swallowing, respiration, the eventual quality of life, and poor prognosis of advanced disease. To date, the currently accepted standard treatment has been based on excision of the primary lesion with a 1.5-2-cm circumferential macroscopic margin. Compartmental tongue surgery (CTS) is a surgical technique that removes an anatomo-functional compartment containing the primary tumor., Methods and Techniques: This is a prospective study that was carried out from June 2012 to January 2015 for patients with carcinoma affecting oral tongue. We enrolled all cases with ≥T2 tongue cancer with or without infiltration of floor of the mouth. Patients underwent compartmental tongue resection with reconstruction using island submental flap., Results: Pharyngeal tear occurred in two cases that were repaired by simple suture. Bleeding occurred in two cases with control of the affected vessels. Loco-regional recurrence was detected only in two cases that underwent CTS, while 18 patients who underwent traditional tongue resection had local recurrence., Conclusion: CTS via pull through technique with submental island flap reconstruction for large tongue cancer has been evolved to improve oncologic resections, obtaining a better local control of disease and increased survival rate with concomitant successful functional and esthetic outcomes especially in elderly patients with serious comorbidities.

Objective: To explore the effect of facial artery musculo-mucosal (FAMM) flap to reconstruct tongue and floor of mouth defects., Methods: Between January 2011 and January 2016, 24 cases of tongue and floor of mouth defects were repaired with FAMM flap after tumor resection. There were 16 males and 8 females, aged from 38 to 70 years with an average of 55 years. The disease duration was from 1 week to 6 months with an average of 4 months. The defect located at the floor of mouth in 4 cases, at the tongue in 15 cases, and both tongue and floor of mouth in 5 cases. There were 2 cases of carcinoma at the floor of mouth, 2 cases of adenoid cystic carcinoma at the floor of mouth, 14 cases of carcinoma at the tongue, 1 case of adenoid cystic carcinoma at the tongue, and 5 cases of carcinoma at the tongue and floor of mouth. The size of defect ranged from 4 cm×3 cm to 8 cm×7 cm. Three ipsilateral and 21 contralateral FAMM flaps were harvested (5 cases were repaired with FAMM flap and submental muscle island flap due to the large defect area). The size of FAMM flap ranged from 5 cm×4 cm to 5 cm×5 cm, the size of submental muscle island flap ranged from 4 cm×3 cm to 5 cm×4 cm., Results: All flaps survived after operation, without local necrosis. Wound dehiscence at donor site occurred in 5 cases, and healed after cleaning; primary healing was obtained in the other 19 cases. All the patients were followed up 8 months to 5 years with an average of 2 years and 4 months. No obvious facial deformity or fistula of the floor of mouth occurred after operation. Injury of the submandibular branch of the facial nerve was observed in 16 patients, who returned to normal at 3 months. All 24 patients had limitation of mouth opening after operation, which disappeared after 12 months. The functions of speech, chewing, and swallowing were normal., Conclusion: FAMM flap has many advantages of simple operation, good repair, high flap survival rate, and less injury at donor site for repairing tongue and floor of mouth defects.

Objective: To investigate the application of free medial thigh chimeric myocutaneous perforator flap in the reconstruction of tongue defect after radical resection of tongue carcinoma. Methods: From June 2013 to November 2015, 17 cases with tongue carcinoma underwent radical resection and tongue and mouth floor defects after surgery were reconstructed with medial thigh chimeric myocutaneous perforator flaps at the same stage. These 17 cases included tongue carcinoma on lingual margin ( n =9), ventral tongue ( n =7) and mouth floor ( n =1). Appearance and functional results were evaluated with follow-up. Results: Medial thigh chimeric myocutaneous perforator flap was (9.0±0.3) cm in length, (4.5±0.3) cm in width , and (1.8±0.4) cm in thickness. The length of pedicle was (7.4±0.6) cm. All of the 17 flaps survived uneventfully, and the donor sites were closed directly in all cases. All patients were followed up for 10-28 months with satisfied esthetic and functional results in reconstructed tongue. Aside from linear scar in the donor sites, the functions of thighs were not affected. No local recurrence occurred. Conclusion: The free medial thigh chimeric myocutaneous perforator flap is an ideal choice to reconstruct the tongue and mouth floor defect after radical resection of tongue carcinoma.

Objective: To objectively assess donor site morbidity after harvesting the facial artery musculomucosal flap. Use of the FAMM-flap in oral cavity reconstruction remains sporadic. This case series describes our newly developed standardized assessment of this flap in a floor of mouth (FOM) reconstructive setting., Methods: Standardized postoperative assessment of the FAMM flap for donor site wound complications, functional, facial mimetic and oncologic outcomes., Results: There were no wound complications. Oral competence remained intact, tongue mobility was good to excellent, average word articulation score was 98%, and mimetic function excellent in all patients. Three patients experienced ipsilateral upper lip anesthesia, and five patients were noted to have slight dysfunction of the orbicularis oris resulting in a loss of lip height at rest., Conclusion: The FAMM flap is a reliable option for reconstruction of ablative defects of the FOM, and should be considered a workhorse flap for oral cavity defects. Unlike the submental island flap, a complete level I dissection may be concurrently performed without compromising the vascular supply to the FAMM flap., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Purpose: The fibula flap serves as the workhorse for many mandibular defect types. For massive defects that include the mandible, floor of the mouth, and tongue, reconstruction might mandate a 2-flap approach. This report describes a systematic yet flexible design of a single composite osseocutaneous fibula flap for such cases., Patients and Methods: From 2003 through 2011, 5 patients underwent surgery for T4 squamous cell carcinoma and adenoid cystic carcinoma. They underwent wide resection of the mandible and floor of the mouth with hemi- to subtotal glossectomy. A large skin paddle was designed on the leg using a customized template consisting of 3 components matching the alveolar, floor-of-mouth, and tongue segments. The round tongue component was folded using its thickness to provide 3-dimensional volume and form in place of the missing tongue. The other 2 components had a crescent shape and were adjusted intraoperatively to match the resected defect., Results: All 5 flaps survived, with 1 case of flap loss that was successfully replaced. Delayed healing of the leg donor site was encountered in 4 patients., Conclusion: The proposed single 3-dimensionally folded flap design provides ample tissue to replace bony and soft tissue elements for major anterior or lateral segment defects. There was morbidity owing to donor-site complications but these were treatable, with recorded functional restoration., (Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Squamous cell carcinoma (SCC) is a fairly common tumor of the oral cavity. This tumor may affect any part of the mucosa of the oral cavity especially the tongue, the floor of the mouth and lips. The encountered intra-oral defects after tumor resection are often large and require climbing up the reconstruction ladder to more complex reconstructive options for accepted functional and cosmetic results to be achieved. However, most of the patients are old with medical co-morbidities requiring fast, simple, less morbid reconstructive option such as local flaps. The myocutaneous submental island flap has emerged as a simple and fast reconstructive technique that provides thin, pliable tissue with adequate volume and reliable blood supply. However, one major concern regarding the utility of the submental flap for repair of post-ablative tumor defects is the presumed interference with adequate lymph node neck dissection., Methods: In this study, we present a cohort of thirty-six consecutive patients who were operated for oral SCC. All patients were offered submental island flap reconstruction of their resultant defects together with ipsilateral selective neck block dissection of levels I, II, III and IV; and the nodal yield of each level was tested pathologically., Results: Nodal harvest was ≥ 12 in 88 % of the patients. Complications were encountered in two patients (5.5 %)., Conclusion: Our data suggest that adequate cervical lymph nodes dissection, specifically level I and II cervical lymph nodes, can be fulfilled with concomitant submental island flap elevation.

Objective: To investigate the effectiveness of nasolabial island pedicled flap in repairing mouth floor defects., Methods: Between July 2010 and July 2013, 13 cases of mouth floor defects were repaired with nasolabial island pedicled flap. There were 7 males and 6 females, aged 36-73 years (mean, 58 years). Defects were caused by lesion resection, including 4 cases of leukoplakias, 2 cases of erythema, 1 case of mucoepidermoid carcinoma, 2 cases of the month floor cancer, and 4 cases of tongue cancer. The locations of defects were the mouth floor in 5 cases, the mouth floor and tongue body in 6 cases, and the mouth floor and gingival in 2 cases; the mucosa and submucosa were involved in 6 cases, and the sublingual gland, tongue muscle or alveolar process in 7 cases. The size of defect was 1-4 cm. The size of the flaps ranged from 4.5 cm x 2.0 cm to 6.5 cm x 3.5 cm., Results: The operation was successfully performed in all patients; the flaps survived; and the primary healing of incisions at donor site and recipient site were obtained. Thirteen patients were followed up 5-24 months (mean, 11 months). No tumor recurrence was observed; the patients had normal functions of eating, swallowing, and speech. The facial appearance was satisfactory. No obvious deformity was observed at donor sites., Conclusion: The nasolabial island pedicled flap is fit for repairing small or middle sized defects of the mouth floor, and it has the advantages of flexible flap transplantation, less injury at donor site, easy operation, and high flap survival rate.

Purpose: Oncologic patients undergoing segmental mandibulectomy with soft tissue resection develop several esthetic and functional sequelae; therefore, the defect must be reconstructed immediately. The iliac crest flap is the only flap that allows reconstruction of the previous dimensions of the mandible. However, the excessive soft tissue of this flap prevents optimal reconstruction of intraoral soft tissue defects., Materials and Methods: This report describes a reconstructive technique used in 12 patients who underwent segmental mandibulectomy because of soft tissue defects resulting from tumor resection. The technique involves reconstruction of the mandible using an iliac crest flap combined with a nasolabial flap to enable subsequent reconstruction of the intraoral soft tissue and immediate placement of osseointegrated implants., Results: The osseointegration success rate was 95.2% with a failure rate of 4.8%. Failure particularly affected the irradiated patients. Excellent functional and aesthetic results were obtained with the iliac crest free flap, nasolabial flap and osseointegrated dental implants., Conclusions: This technique has several advantages. On the one hand, it enables reconstruction of the original dimensions of the mandible, thus allowing immediate placement of implants in an ideal position for subsequent rehabilitation with a dental prosthesis. On the other hand, the nasolabial flap provides a thin layer of tissue that can be used to reconstruct the anatomy of the oromandibular soft tissue., (Copyright © 2014 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: To discuss the vascular anatomy of the anteromedial thigh (AMT) flap and to evaluate the feasibility of the AMT flap for the reconstruction of oral and maxillofacial defects., Patients and Methods: A retrospective review was performed of 18 patients who underwent reconstruction of oral and maxillofacial defects with AMT flaps from January 2009 through December 2011 in the Second Xiangya Hospital. Eleven unifoliate AMT flaps were elevated to reconstruct defects of the tongue, soft palate, and floor of the mouth and 7 chimeric anterolateral thigh (ALT) and AMT flaps were harvested to reconstruct through-and-through cheek defects., Results: The flaps were 4 × 6 to 9 × 11 cm(2). All the AMT flaps were nourished by the descending branch (DB) of the lateral circumflex femoral artery. The cutaneous perforators were derived from the rectus femoris branch of the DB in 15 cases and directly from the DB in the other 3 cases. Postoperatively, all flaps survived completely, without major complications. Of the 18 donor sites, 14 were closed directly, leaving only linear scars, and 4 were closed using full-thickness skin grafts owing to larger defects. All patients were followed for approximately 6 to 30 months, and they were satisfied with the esthetic and functional results of the donor and recipient sites after the reconstruction., Conclusions: Because of easy perforator dissection, the AMT flap can be used as an alternative to the ALT flap or harvested with the ALT flap as chimeric ALT and AMT flaps for the reconstruction of oral and maxillofacial defects., (Copyright © 2014 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

The oropharynx has a variety of functions, such as mastication, deglutition, articulation, taste, and airway protection. Because of its many roles, recent goals in head and neck reconstruction have focused on anatomic and functional reconstructions to minimize functional deficits. Since chemoradiation has earned a good reputation in the management of head and neck cancer, the manifestation of oropharyngeal defects has changed. Although we could not control the anatomic defects that were known to be related to the oropharyngeal functions, we hypothesized that optimizing the flap designs would be helpful for minimizing the functional deficits.Two hundred fifty cases of the head and neck reconstruction using free flaps were carried out between March 2006 and December 2010, where modified flap designs were applied. Among these, 37 tongue and 15 tonsillar reconstructions were analyzed for functional outcomes. The patients were of Asian ethnic background, and the average age was 52 years, including 38 males and 17 females. The average follow-up period was 20.5 months. Based on previous studies, the flap designs were categorized into type I, unilobe; type II, bilobe; type III, trilobe; type IV, quadrilobe; type V, additional lobe for lateral and posterior pharyngeal wall; and type VI, additional lobe for tongue base. The functional outcomes of both tongue and tonsillar reconstructions were investigated.To quantify the outcome in terms of swallowing and pronunciation, we analyzed the patients' function based on the 7-scale parameter. In terms of swallowing, the tongue reconstruction group scored 5.70 on average, whereas the tonsillar reconstruction group showed an average score of 4.53. With regard to speech intelligibility, the tongue reconstruction group revealed an average score of 5.67, whereas the tonsillar reconstruction group scored 5.46 on average.Our findings indicate that specification of the flap designs is helpful for minimizing the functional deficits in head and neck reconstructions.

The buccinator musculo-mucosal island or Zhao flap can be used to reconstruct a wide range of intra-oral defects including floor of mouth, tonsillar fossa and lateral tongue. We describe our experience with the inferiorly based facial artery buccinator musculo-mucosal flap for a novel use in the reconstruction of oropharyngeal tumours at the tongue base and lateral pharyngeal wall. We prospectively reviewed all patients who underwent buccinator musculo-mucosal island flap reconstruction examining indication, operative details, and post-operative outcomes. We describe our technique for its novel use in lateral pharynx/tongue base reconstruction through neck dissection access. Deeper flaps were adequately visualised and monitored using flexible nasoendoscopy. There were no flap failures with all patients achieving primary healing with minimal complications. All donor sites closed directly with minimal scarring. Two patients reported mild tightness on mouth opening and two patients reported transient weakness of the mandibular branch of the facial nerve. In our experience the buccinator musculo-mucosal island flap is an extremely versatile 'like for like' local flap option due to its long arc of rotation. As inset can be achieved via neck dissection access, this avoids lip/jaw split as per conventional oropharyngeal surgical management further minimising morbidity. We present the first series of its effective use in oropharyngeal reconstruction., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The purpose of this study is to review our experience with the use of the local mandible myofascial (LMM) flap for anterior floor of mouth (AFOM) reconstruction following cancer ablation to assess its reliability, associated complications and functional results., Methods: This is a retrospective analysis of 13 LMM flaps (nine patients) performed for AFOM reconstruction from March 2010 to June 2012. All patients underwent surgical resection and immediate reconstruction with LMM flaps. They were followed up for 3-30 months to evaluate the survival rate of the flaps, mobility of tongue and aesthetic outcome of the lower lip and mental region., Results: All the flaps were successfully transferred. No obvious complications were found in either the AFOM or the donor region. The majority of patients resumed to a regular diet (89%, 8/9) and speech was considered as functional and/or understandable by the surgeon in all of the patients. Dental restoration was successful for 89% (8/9) of the patients. The shape and motion of the lower lip and the mental region of all patients were acceptable., Conclusions: The LMM flap is well suited for AFOM reconstruction because it is reliable, has few significant complications and allows preservation of oral function., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Despite the well-known high donor site morbidity of the radial forarm flap, it has still remained the first option for the reconstruction of the tongue and the floor of mouth. However, a desire for an alternative, thin fasciocutaneous flap has led to the use of the median sural artery perforator flap., Methods: Three patients had reconstructive surgery used MSAP flaps, after radical tumor excision., Results: The flap was based in all cases on a dominant perforator vessel. The size of the skin paddles ranged between 20-32 cm2, and the length of the vascular pedicle between 8.2-11 cm. The mean thickness of the flap was 6.5 mm., Conclusion: MSAP flap is an ideal solution for surgical reconstruction in the oral cavity.

The reconstruction of intraoral defects can be challenging due to the different characteristics of the region, importance of preserving the anatomy and function, and shortage of available donor areas. The location and size of the defect guides the reconstructive surgeon through the treatment plan. Among the options available, tongue flaps have been found useful in intraoral defect reconstruction.In this study, we presented the use of tongue flaps in different kinds of intraoral defects, and compared the advantages and disadvantages with other methods. Between 2004 and 2011, tongue flaps were used in intraoral reconstruction of 11 patients (6 male and 5 female) with a mean age of 30.1. Six patients had palatal fistula, 3 had alveolar region and mouth floor defects, and 2 had lower lip defects. All of the tongue flaps planned were anterior based, 6 dorsal and 5 ventral. Second operations were carried out on the 15th or 20th postoperative days.Despite the disadvantages of being an interpolation flap which requires a second session and good patient cooperation, tongue flap is a choice for reconstruction of intraoral defects with its highly vascular structure, good mobility, localization, texture match, and low donor area morbidity.

This study evaluated the applicability of pedicled buccal fat pad grafting for the reconstruction of defects surgically created during oral surgery. A buccal fat pad graft was applied in 23 patients (5 males, 18 females; mean age 68.3 years) between 2003 and 2011. The graft was used to cover surgical defects of the palate, maxilla, upper gingiva, buccal mucosa, lower gingiva, oral floor, and temporomandibular joint region. Size of the surgical defects ranged from 15mm×12mm to 30mm×40mm; size of the buccal fat pad ranged from 15mm×12mm to 43mm×38mm. A pedicled buccal fat pad was prepared by incising the maxillary vestibule following primary surgery, and the surrounding connective tissue was preserved to supply nutrition to the pedicle during surgery. The buccal fat pad was placed on the raw surface of soft tissue or bone surface and sutured to the surrounding tissue of the defect. Complete epithelialization was observed within 4 weeks postoperatively. There were no complications or functional disorders during follow-up. Buccal fat pad grafting appears to be feasible for the reconstruction of surgically induced defects, and can be extended to the palate, mandible, mouth angle, and temporomandibular joint region., (Copyright © 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: To investigate the method and efficacy of reconstruction of anterior mouth floor defects with depressor labii inferioris flap., Methods: Between March 2010 and August 2011, 4 patients with cancer in the anterior part of oral floor underwent tumour resection and simultaneous reconstruction with depressor labii inferioris flap. The patients were followed up for 2 - 18 months. The survival of the flaps, mobility of tongue and esthetic outcome of lip and mental region were evaluated., Results: All the flaps survived completely, tongues moved well, and functional and esthetic results were good., Conclusions: The depressor labii inferioris flaps are suitable for repairing defects of anterior oral floor.

A mouth floor mucosal flap was developed to reconstruct medium-sized intraoral buccal defects, too large for primary closure if major functional and aesthetic impairment is to be avoided. Although free flaps, perforator flaps, or even skin grafts can be designed for buccal reconstruction, they may not provide good mucosal sensitivity, motility, volume, and texture to replace lost structures with similar tissue. Moreover, secondary morbidity can be avoided with this adjacent flap.In our study, 8 flap reconstruction procedures were performed from March 2009 to July 2011: 4 cases of leukoderma, 2 cases of buccal cancer (T1 N0 M0), and 2 cases of papillary epithelioma. The largest size amount to 5.3 × 3.8 cm (length × width), with a mean of 4.3 × 3.4 cm. Compared with free flaps (forearm arm flap for example) for buccal reconstruction, application of the mouth floor flap has its indications. First, to secure the motility of tongue and function of mouth opening, the upper bound of the defects was below the occlusion line. Generally, the width between top and bottom was less than 4 cm. Second, at least a partial buccinator muscle can be preserved after lesion resection and then facial collapse can be avoided. Third, patients had molar absence or relevant teeth had to be extracted during surgery.All patients recovered from intraoral surgeries with good objective and subjective speech and swallowing and aesthetics and without injury to the lingual nerve, the submandibular gland duct, and the sublingual gland. Results indicate that the mouth floor mucosal flap is reliable and technically easy for reconstructing medium-sized intraoral buccal defects, with good function and aesthetics with little secondary morbidity.

The conventional pedicled sternocleidomastoid (SCM) flap has a poor arc of rotation, limited volume and precarious vascularity. This report describes a new technique for raising a SCM flap based on the perforating vessels of the superior thyroid vascular pedicle. The upper and lower attachments of the sternocleidomastoid muscle are divided. Four medically and/or surgically compromised patients have successfully undergone reconstruction of hemiglossectomy (1), partial glossectomy (1) and rim of mandible (2) defects for malignancy. The arc of rotation of the SCM flap is greatly increased and the potential applications for the flap expanded., (Copyright © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to analyze our experience with donor site morbidity after harvesting a buccinator myomucosal island flap (BUMIF) for reconstructing surgical defects involving the tongue and floor of the mouth after oncological resections in 15 consecutive patients., Study Design: Donor site morbidity was evaluated using 5 parameters: mouth opening, oral commissure symmetry, inner vestibule restoration, cheek mucosal lining, and the esthetic result. The clinical evaluation was performed by a blinded panel of 2 clinicians and the patient him- or herself, assessing each parameter with a score ranging from 0 to 3. The 3 scores for each parameter were summed to obtain a score reflecting the overall parameter assessment., Results: The mean mouth opening score was 8.6 out of a maximum of 9 (range, 6-9). The mean commissure symmetry was 8.6 (range, 7-9), the mean inferior vestibule score was 8 (range, 6-9), the mean cheek lining score was 8.2 (range, 7-9), and the mean final esthetic score was 8.5 (range, 6-9)., Conclusion: The results of this retrospective evaluation demonstrate that when special care is taken in the management of the BUMIF donor site, its morbidity is extremely low, allowing optimal functional and cosmetic results and confirming the major role of this flap in reconstructing moderate-size defects following tongue and floor of the mouth resections., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Objective: To investigate the application of free anterolateral thigh myocutaneous flap in the reconstruction of tongue and mouth floor defect after radical resection of tongue carcinoma., Methods: From June 2006 to April 2009, 14 cases with tongue carcinoma underwent radical resection, leaving tongue and mouth floor defects which were reconstructed by anterolateral thigh myocutaneous flaps at the same stage. These 14 cases included tongue carcinoma at lingual margin (n=9), at ventral tongue (n=3) and at mouth floor (n=2). The flap size ranged from 7 cm x 9 cm to 5 cm x 7 cm., Results: All the 14 flaps survived completely with primary healing. There was no functional morbidity in the lower extremities. The patients were followed up for 12-26 months with satisfied esthetic and functional results in reconstructed tongue. Only one case (T4 N1 M0) died of metastasis carcinoma 14 months after operation. No local recurrence happened., Conclusions: The anterolateral thigh myocutaneous flap has abundant tissue volume to reconstruct the tongue and mouth floor defect, while leaving less morbidity at donor site. Both satisfied esthetic and functional results can be achieved.

We describe what is, to the best of our knowledge, the first use of a double bilobed radial forearm free flap in reconstructive surgery of the tongue and floor of the mouth following bilateral tumor resection. Our patient was a 78-year-old man who had experienced tumor recurrence in the anterior floor of the mouth after previous resection and radiotherapy. Eleven weeks postoperatively, the patient could extend his tongue to his hard palate and past his mandibular alveolus anteriorly. Within 6 months, he was able to tolerate an oral diet of soft food and exhibited understandable speech quality. Although the use of a single bilobed radial forearm flap is widely used after hemiglossectomy, our double bilobed modification extends this technique to anterior tongue and floor-of-mouth defects. This technique provides adequate bulk while allowing for depth of a ventral sulcus that will minimize tethering of the tongue and reduce oral incompetence. We recommend that this technique be included in the armamentarium of any reconstructive head and neck cancer surgeon.

Objective: The use of myomucosal flaps harvested from the cheek area for intraoral reconstruction has been recently popularized in the literature. Several surgical techniques have been reported, and each study has described the outcomes and advantages of each method. However, the literature lacks a summary of the various surgical techniques utilizing buccinator myomucosal flaps. This paper examines the use of the 3 most important buccinator myomucosal flaps: the buccinator musculomucosal flap, the facial artery musculomucosal flap, and the buccinator musculomucosal island flap. We clarify the applications of each technique in intraoral reconstruction and discuss the indications for, and advantages and disadvantages of, each flap., Study Design: Forty-six patients who underwent surgical resection for malignancies of the oral cavity and reconstructions with cheek flaps were retrospectively studied., Results: All flaps were harvested and transposed. Complete loss of the flap occurred in only 1 case. In 2 cases, marginal necrosis of the flap took place, with complete spontaneous healing in 2 weeks., Conclusion: Buccinator musculomucosal flaps are a good option for reconstruction of moderately sized oral cavity defects. A key point in this procedure is flap selection based on not only the size and site of the defect, but also the patient's characteristics and type of surgical procedure.

Introduction: The infrahyoid myocutaneous flap was described by Wang et al. in 1986. The horizontal design of the skin paddle is a modification of this technique allowing for a smaller scar. We have been systematically using this modified technique for 10 years. We had for aim to describe the interest of the horizontal infrahyoid myocutaneous flap for cervicofacial carcinology., Patients and Methods: A horizontal infrahyoid myocutaneous flap procedure was performed in 276 cervicofacial carcinology patients for lesions of the mouth floor, the mandibular gum, the oropharynx and the tongue between March 1997 and March 2007., Results: No complications were observed in 252 patients. No patient presented with total flap necrosis., Discussion: Modifying the infrahyoid myocutaneous flap technique with a horizontal design of the skin paddle does not modify the reliability of the flap and prevents more extensive scars. The main indications of this technique are defects of the mouth floor, the tongue and the oropharynx.

Introduction: Anomalies of the radial artery are uncommon. A brief tabulated review of the literature is presented., Case Report: We report a rare anomaly of the forearm vascular anatomy we encountered when elevating a radial forearm free flap. This is a previously unreported anatomical variation. The radial artery divided into medial and lateral branches (accompanied by their respective venae commitantes) about 1.5 cm below the bifurcation of the brachial artery. The skin paddle was predominantly supplied by the aberrant medial branch and was raised on this branch along with its venae commitantes up to the point of division., Conclusion: This case highlights the need for vigilance when raising free flaps and the techniques employed to avoid compromising both limb and skin paddle perfusion.

Resections of malignant tumors involving the mandible and anterior tongue result in complex defects that are still real challenges for reconstructive surgeons. Whereas there are preferred methods for mandible reconstruction involving isolated or limited loss of soft tissues, there are no standards for extended bone-soft tissue intraoral defects. This article documents the modification of the fibula free flap where triple skin islands are used for reconstruction of anterior tongue and floor of the mouth. The technique also includes filing the submandibular space with an isolated part of the flexor hallucis longus muscle, based on individual perforator. The details of flap designing, harvesting, and insetting are also presented. Eight such reconstructions have been performed on patients who underwent complex resection of the anterior mandible together with the mobile part of the tongue. Flap survival rate was 100%. In all eight cases, understandable speech and return to unrestricted diet mastication and swallowing were achieved. Analysis of aesthetic effects showed generally very good results. The presented modification of fibula free flap can be an alternative to double flaps in complex reconstruction of the mandible and mobile tongue.

Three-dimensional reconstruction of the anterior mouth floor and ventral tongue after ablative surgery can be achieved using several techniques. The ideal reconstruction should be accomplished with the same or similar type of tissue, and cheek axial myomucosal flaps based on the branches of facial or internal maxillary arteries seem ideal for this purpose. From March 2005 to May 2007, 23 patients underwent cheek axial myomucosal flap reconstruction after oral cancer surgical ablation. Thanks to their thinness and pliability, these flaps were frequently shaped to obtain an accurate reconstruction. According to Whetzel's hypothesis, an intraoral flap designed to include the axial vessel of one area can safely carry the mucosa of a neighbouring vascular area. The authors describe a large buccinator myomucosal island flap based on the branches of the facial artery and formed in a trilobed shape in order to capture the adjacent buccal mucosal angiosome from the internal maxillary artery. The flap provided the correct anatomical oral reconstruction for the anterior mouth floor and ventral tongue. The function of the tongue, oral intake and mastication were not impaired. The trilobed buccinator myomucosal island flap is a suitable option for the three-dimensional reconstruction of the anterior mouth floor and ventral tongue.

In oral cavity reconstruction, the fasciocutaneous flaps of the distal extremities have always been preferred to any other kind of flap because of their thinness and pliability, which makes them adaptable to different areas in the oral cavity. The radial forearm flap is frequently considered the first choice for intraoral reconstruction, but the disadvantages of donor site morbidity include sacrificing a major artery to the hand and leaving a conspicuous donor site scar. The search for another primarily thinned skin flap as an alternative has led to the application of the medial sural artery perforator flap, which is harvested from the medial aspect of the upper calf. Between June 2003 and March 2007, 22 free medial sural artery perforator flaps were transferred for intraoral defects after cancer ablation, including tongue and floor of mouth (15 cases), buccal mucosa (5 cases), retromolar trigone (1 case), and anterior floor of mouth (1 case). We paid attention to the major perforator (vein > or =1 mm), which was confirmed by the endoscope, as the vascular relay for the skin flap. The size of the skin paddle varied from 7.5 x 4 cm to 17 x 8 cm. The main advantage of this flap is that it provides thin and pliable coverage to achieve better accuracy in the oral cavity. Other advantages of minimizing donor site morbidity include maintaining the function of the medial gastrocnemius muscle, avoiding the need to sacrifice major arteries of the leg, and possible primary closure of the donor defect.

Objectives/hypothesis: The purpose of this report is to describe our recent experience using a double-skin paddle fibular free flap (DSPFFF) for reconstruction of the through-and-through anterior mandibulectomy defect and to present a reconstructive algorithm based on the extent of lip and mental skin resection., Study Design: Retrospective review of 10 consecutive patients with through-and-through anterior mandibulectomy defects., Methods: Outcomes that were examined included methods of reconstruction based on the cutaneous defect, flap complications, fistula rate, and donor site complications., Results: Seven patients were reconstructed with a DSPFFF. For lip reconstruction, two patients were also concomitantly reconstructed with Karapandzic or lip advancement flaps. Three patients were reconstructed with both a fibular free flap and a second free flap (1 radial forearm fasciocutaneous flap and 2 anterolateral thigh flaps). The transverse dimensions of the DSPFFFs were as great as 15 cm. None of the patients developed a fistula. All free tissue transfers were successful. One patient developed partial loss of the fibular skin paddle used for submental skin replacement., Conclusions: DSPFFF is a safe and reliable way to reconstruct an anterior through-and-through mandibular defect. Indications for using a DSPFFF are 1) a cutaneous defect that lies at or below the plane of the reconstructed mandible, 2) a transverse width of the oral mucosa and cutaneous defect that does not exceed 15 cm (the approximate distance from the mid-calf to the anterior midline), and 3) a lip defect that, if present, can be reconstructed with local flaps.

Background: We undertook this study to describe three cases of reconstruction of the floor of the mouth with two simultaneous free flaps., Methods: Three patients with cancer of the anterior floor of the mouth were subjected to segmental resection of the mandible and resection of the floor of the mouth with subsequent reconstruction using two simultaneous osseous and fasciocutaneous free flaps., Results: All patients had a satisfactory evolution. Two patients underwent adjuvant radiotherapy, one due to the initial clinical stage and the other due to positive surgical margins. The third patient had neoadjuvant postoperative radiotherapy and concomitant chemoradiotherapy., Conclusions: If a tumor involves osseous structures of the anterior floor of the mouth, it is best to perform surgery with wide margins with segmental resection of the mandible. Surgical technique is the decision of the surgeon: how many and which types of flaps will be used for reconstruction of the anterior floor of mouth. When there is necrosis of a free flap in the head and neck region, attempt with another free flap is recommended.

In this preliminary report, the surgical technique of an oral defect coverage using the microvascular osteocutaneous flap from the distal medial femur is described and three clinical cases are reported. The new flap was used for covering combined defects of the alveolar ridge and the neighboring floor of the mouth after tumor surgery and irradiation. The bone part of the flap was supplied by the descending genicular artery and the soft tissue part by their first emission-the saphenous artery. Anastomoses were performed between the common part of the flap pedicle and cervical arteries or veins. There were no severe complications or transplant loss. All patients were successfully treated with dental implants (n = 12) 4 to 6 months after ridge reconstruction. The microvascular osteocutaneous femur transplant can be used successfully in individual reconstruction of the alveolar ridge and the neighboring floor of the mouth after tumor resection.

Background: The radial forearm flap is frequently considered the first choice for tongue reconstruction, but the disadvantages of donor site morbidity are well known. The search for another thin skin flap as an alternative has led to the application of the medial sural artery perforator flap., Methods: We used 12 medial sural artery perforator flaps to reconstruct tongue and floor of mouth following cancer ablation. We paid attention to the major perforator (vein >or= 1 mm) as the vascular relay., Results: Most flaps were raised with a single perforator. The size of the skin paddle varied from 9 cm x 5 cm to 14 cm x 12 cm. The mean thickness of the flap was 5.2 mm. We reexplored 1 patient for venous insufficiency and could not salvage the flap., Conclusions: The thin medial sural artery perforator flap permits high accuracy of tongue restoration and reduces the morbidity at the donor site., ((c) 2007 Wiley Periodicals, Inc. Head Neck, 2008.)

Objectives: The goal this presentation is to: 1) Review the reconstructive options for anterior mandible through-and-through composite defects and 2) Instruct the audience in the application of the double-skin paddle fibular flap in selected patients., Methods: Case presentation with review of the literature., Results: A 70-year old male with an anterior floor of mouth squamous cell carcinoma underwent composite resection that included resection of a 5-cm ovoid component of overlying chin skin. The defect was reconstructed with a fibular osteocutaneous flap with a double skin paddle technique., Conclusions: Several reconstructive options have been described in the literature for extended oral cavity defects including the use of multiple free flaps, combinations of regional and distant flaps, and sequential reconstruction. This case report reviews the use of a single flap reconstruction of these defects for selected patients., ((c) 2008 Wiley-Liss, Inc. Microsurgery, 2008)

We treated two patients requiring nasolabial flap reconstruction. The first patient was a 75-year-old man with mucoepidermoid carcinoma in the left-side floor of the mouth; requiring resection of the floor of the mouth, partial mandibulectomy, and left supraomohyoid neck dissection. The second patient was a 74-year-old man with recurrent acinic cell carcinoma in the anterior oral floor infiltrating as far as the mandible. This patient required wide excision of the anterior part of the oral cavity, including amputation of the mandible. After tumor resection, both cases had a nasolabial flap reconstruction. The postoperative course of both cases was good; neither postoperative flap necrosis nor infection developed.

Introduction: Mandibular reconstruction continues to challenge most head and neck reconstructive surgeons despite the tremendous advances in surgical and fixation techniques. We recently described the clavipectoral osteocutaneous flap for mandibular reconstruction. This flap encompasses the clavicle and the clavicular head of the pectoralis major with overlying skin., Objectives: The purpose of this article is to report our prospective clinical experience with the use of clavipectoral osteocutaneous flap in the reconstruction of oromandibular defects., Study Design: Prospective case series., Methods: Five patients with significant mandibular defects underwent reconstruction using the newly described clavipectoral flap. All patients had shoulder range of motion testing preoperatively and at 3 and 6 months postoperatively. Panorex and bone scans were obtained on the seventh postoperative day., Results: All five flaps survived. The transferred clavicles demonstrated good vascularity on the postoperative bone scans. The shoulder morbidity was minimal, with all patients resuming their preoperative level of activity., Conclusions: The clavipectoral flap has bone and soft tissue components that are especially suited for composite mandibular defects, but it should be used as a second-line flap owing to the short pedicle and the regular need for vein grafts.

Background: There are several techniques described for the reconstruction of the anterior floor of mouth after tumour surgery. Here, we point out the advantages of the central island tongue flap for this indication., Patients and Methods: We report on 20 patients with medium sized defect in the anterior floor of mouth, which was reconstructed with the central island tongue flap. Besides this surgical technique, we discuss the results of oral rehabilitation after a follow-up period of at least 3 months., Results: There was now flap necrosis or loss, and the median time for flap formation was less than 45 min. In the follow-up we found successful oral rehabilitation in speech and swallowing.

Introduction: Postoperative monitoring of free flaps with microdialysis allows early diagnosis of anastomotic complications. Feasibi-lity studies are required to examine flap accessibility for oral cavity reconstruction., Cases: We present our preliminary findings in two patients who underwent radial free flap reconstruction of the floor of the mouth. For the first patient, a microprobe was used to monitor the flap for 45 hours. In the second case, an abdominal microprobe served as a control in healthy skin with another probe located in the cutaneous flap for 4 days. Flap monitoring, starting from the recovery room, was successful with easy manipulations for the nurse. Correlation between the monitoring curves and the clinical aspect of the flap was excellent., Discussion: The microprobe should be short (1 cm), and carefully anchored. Naso-gastric feeding is required during monitoring. A close correlation has been found between glucose level and systolic pressure. The use of a comparative microprobe in healthy abdominal skin is helpful in learning to use the dialysis curves.

Background: Individual flap design and minor donor site morbidity are main criteria in the treatment of facial defects after tumour surgery. Microvascular perforator flaps seem to follow these criteria well. In the following study our experiences with microvascular anterolateral thigh perforator flaps (ALTPF) in reconstruction of the face following ablative tumour surgery are described and discussed in comparison to the present literature., Patients and Methods: In 19 patients with squamous cell carcinomas of the floor of the mouth (8), the cheek (6) or the mandible (5) of stadium T3 or T4 ablative tumour surgery followed by reconstruction was performed. For covering the soft tissue defects 19 ALTPF were used. In the five patients with carcinomas of the mandible a microvascular iliac crest transplant was combined with the anterolateral thigh perforator flap for complete chin reconstruction., Results: In one patient an intraoperative dissection of the perforator vessels happened. In all other patients surgery and postoperative period was free of complications. Five patients had minor second surgery for aesthetic of functional reasons. At the end there were good aesthetic and functional results in every patient., Conclusions: The anterolateral thigh perforator flap is of great advantage in reconstruction of the face after tumour surgery. Individual designing, central and save perfusion, easy to be controlled, and a low incidence of donor site morbidity are their main advantages.

Objective: To explore the clinical value and safety of using rib-major pectoralis myocutaneous flap carrying costal parietal pleura in combined repair of large soft and hard tissue defect caused by radical surgery of advanced tongue cancer., Methods: Six patients with advanced tongue carcinoma involving the floor of mouth and mandible were performed combined radical neck dissection with glossectomy and mandibulectomy, which caused large soft and hard tissue defect. Six rib-major pectoralis myocutaneous flaps carrying costal parietal pleura were transferred for immediate repair of the large defects. The rib flaps were applied for the repair of mandible, and the major pectoralis myocutaneous flaps were applied for the reconstruction of tongue and floor of mouth., Results: Six patients recovered well after operation. Six rib-major pectoralis myocutaneous flaps carrying costal parietal pleura survived well; the wounds of surgical incision of the oral cavity, neck, and chest healed up. The reconstructed tongue and the lower face appearance were satisfactory, the occlusion relationships were normal; the speaking as well as swallowing functions recovered., Conclusions: It's safe and reliable to use rib-major pectoralis myocutaneous flap carrying costal parietal pleura to repair large soft and hard tissue defect in oral and maxillofacial region. Opening pleural cavity and harvest costal parietal pleura would not influence patients' thoracic movement and breath function and would not cause other complications. It's simple and safe for harvesting the composite flap. Carrying costal parietal pleura assures the sufficient blood supply of rib in the composite flap.

The facial artery musculomucosal flap, technically a combination of the nasolabial flap and the buccal mucosal flap, has been a reliable, versatile flap, either superiorly or inferiorly based for reconstruction of a wide variety of postcancer excision intraoral mucosal defects including defects of the palate, alveolus, lips and floor of mouth. We have used it 17 times in 16 patients with no failures and one flap with terminal necrosis. Almost all flaps developed venous congestion which settled on its own by conservative management.

Objective: To evaluate the clinical significance of submental island flap in repairing tongue defects., Methods: Nine patients (6 men and 3 women) with tongue squamous cell carcinoma underwent subtotal or partial glossectomy, resection of mandible, radical neck dissection and immediate reconstruction of tongue defects with submental island flap. The age ranged from 48 years to 71 years, the lesion locations were right part of tongue (5 cases) and left part of tongue (4 cases). The defect sizes were 4.2 cm x 3.2 cm to 5.5 cm x 4.0 cm. The flap area ranged from 6.0 cm x 3.0 cm to 7.0 cm x 4.0 cm. The flap pedicle included submental artery in 8 cases and both submental artery and facial artery in 1 case., Results: The submental island flap survived in 8 cases. Postoperative articulation and swallowing were investigated in all cases. The static shape of tongue after reconstruction with submental island flap was acceptable. The dynamic speech, swallowing and food transport function were well preformed. No complication occurred. Three patients were given radiotherapy 3 weeks after operation., Conclusion: It is simple and convenient to repair defects of tongue and oral floor with submental island flap.

This study evaluates the effects of two different designs of platysma myocutaneous flap, vertical and transverse, used in the reconstruction of defects following the excision of oral and facial tumors. Modified radical neck dissection or selected neck dissection was also performed. Out of the 48 patients, vertical and transverse platysma myocutaneous flaps were used for 41 and 7, respectively. The postoperative outcome for the vertical flaps was 37 cases surviving, two cases of complete necrosis, and two cases of partial necrosis. With the transverse flaps, six survived and there was one case of complete necrosis. The success rate was 90.2% and 85.7% for the vertical and the transverse flap, respectively. The form and function of recipient sites were well recovered. In conclusion, the platysma myocutaneous flap has clinical value in selected patients needing reconstruction of small and medium-sized intraoral or facial defects. It is recommended that the vertical design be used for reconstruction of buccal mucosa defects, and the transverse design for mouth-floor and facial defects.