Abstract
Background
Reconstruction of composite oral cavity defects in the setting of prior surgery and radiotherapy presents a significant challenge. Although free tissue transfer has shown success in such situations, it is not without considerable risk. Regional pedicled flaps may provide a more suitable alternative. In certain patients, however, severe soft tissue fibrosis makes more conventional regional flaps impractical or impossible. In these situations, temporalis flaps (temporalis muscle and temporoparietal fascia flaps) are versatile options for coverage of complex defects.
Objective
To report our experience using pedicled temporalis flaps for reconstruction of composite oral cavity defects in patients with significant co-morbidities and prior treatment.
Methods
Three patients were identified and their medical records were reviewed. Their clinical courses and functional outcomes are described. We include a discussion of the operative technique and relevant literature.
Results
All patients had previously undergone extensive treatment. One patient needed reconstruction after resection of a third head and neck malignancy and two patients presented for treatment of osteoradionecrosis. A temporalis muscle flap was used to reconstruct composite oral cavity defects in two patients and a combined temporalis muscle and temporoparietal fascia flap was used for independent defects in one patient. All flaps survived. Functional status and pain improved or stabilized in all patients. There were no major or minor complications.
Conclusion
In previously treated fields, where more conventional flaps are impractical, temporalis flaps are a suitable alternative to achieve a stable healing wound and prevent worsening of functional status.
1
Introduction
The reconstruction of composite oral cavity defects in the setting of prior treatment presents a significant therapeutic challenge. Late complications of radiotherapy include severe fibrosis leading to trismus and soft tissue contraction, as well as the development of osteoradionecrosis of the maxilla or mandible . These situations can limit reconstructive options and make conventional methods of repair impractical. Although advances in free tissue transfer have allowed for successful reconstruction of many of these defects, there is an increased risk of using free flaps in previously treated fields . Up to 25 percent of patients experience disease relapse after reconstruction for osteoradionecrosis and significant complication rates have been reported, including partial and total flap loss . The changes to regional anatomy from prior treatment may lead to vessel depletion or microvascular damage, creating an environment that may not be suitable for anastomosis . In addition, many patients have significant associated comorbidities and pre-existing functional deficits from prior therapies, increasing the risk of free flap reconstruction while decreasing the potential reward . Finally, severe soft tissue fibrosis in the neck can limit the use of more conventional regional pedicled flaps, such as the pectoralis major flap, if they cannot be tunneled through the neck for inset into the defect. For these patients, the goal of reconstruction is to create a stable healing wound and to prevent worsening of functional status. To achieve this end, we describe three cases using pedicled temporalis muscle flaps (TMF) and temporoparietal fascia flaps (TPFF) to reconstruct composite oral cavity defects after prior treatment.
2
Materials and methods
A retrospective review of patient records was performed to identify patients who underwent reconstruction of composite oral cavity defects using temporalis flaps at Barnes-Jewish Hospital in St. Louis. Data collected included demographics, clinical presentations, review of surgical anatomy, operative techniques, and outcome. This study was approved by the Institutional Review Board at Washington University.
The CIDER (Clinical Investigation Data Exploration Repository) database, a catalogue of clinical data for Barnes-Jewish Hospital, was used to identify patients that were reconstructed with temporalis flaps between 1994 and 2014. Inclusion criteria were: patient age of 18 years or greater, presence of a composite oral cavity defect after prior surgery and radiation treatment, and available follow-up data. The primary outcome measure was successful wound repair, defined as a stable healing wound without fistula or dehiscence. Secondary outcome measures included flap survival, intraoperative blood loss, operative time, donor-site morbidity, length of hospital stay, subjective trismus and pain, functional outcome of swallowing score (FOSS) , persistent gastrostomy tube, tracheostomy, and complication rates. Major complications were defined as previously described by Patel et al . These included any unanticipated adverse events, such as flap loss, hematoma, or wound infection, which required intervention or prolonged length of hospital stay, or complications occurring after discharge within 30 days of surgery that required readmission. Minor complications included partial flap necrosis requiring no further surgery, seroma not requiring admission or return to the operating room, or surgical site infection.
2
Materials and methods
A retrospective review of patient records was performed to identify patients who underwent reconstruction of composite oral cavity defects using temporalis flaps at Barnes-Jewish Hospital in St. Louis. Data collected included demographics, clinical presentations, review of surgical anatomy, operative techniques, and outcome. This study was approved by the Institutional Review Board at Washington University.
The CIDER (Clinical Investigation Data Exploration Repository) database, a catalogue of clinical data for Barnes-Jewish Hospital, was used to identify patients that were reconstructed with temporalis flaps between 1994 and 2014. Inclusion criteria were: patient age of 18 years or greater, presence of a composite oral cavity defect after prior surgery and radiation treatment, and available follow-up data. The primary outcome measure was successful wound repair, defined as a stable healing wound without fistula or dehiscence. Secondary outcome measures included flap survival, intraoperative blood loss, operative time, donor-site morbidity, length of hospital stay, subjective trismus and pain, functional outcome of swallowing score (FOSS) , persistent gastrostomy tube, tracheostomy, and complication rates. Major complications were defined as previously described by Patel et al . These included any unanticipated adverse events, such as flap loss, hematoma, or wound infection, which required intervention or prolonged length of hospital stay, or complications occurring after discharge within 30 days of surgery that required readmission. Minor complications included partial flap necrosis requiring no further surgery, seroma not requiring admission or return to the operating room, or surgical site infection.
3
Results
3.1
Surgical technique
During flap harvest of a combined TMF and TPFF, the TPFF is raised first and left pedicled at the superficial temporal artery inferiorly. The TMF is then raised completely off the underlying bone and the temporalis muscle fascia is incised above the zygoma. The muscle is freed of its attachments except for the tendinous insertion on the coronoid which is left undisturbed. A tunnel is made between the intraoral wound and the temporalis fossa and the separate flaps can be applied to independent defects ( Fig. 1 ). The muscle must be passed deep to the zygomatic arch for transposition into the oral cavity. In two patients, the superior aspect of the muscle was pulled gently through the infratemporal fossa using suture traction and the zygomatic arch was able to be preserved undisturbed. The anatomic restrictions in one patient required complete removal of the arch to allow transposition of the flap and full coverage of the intraoral defect. A colored suture can be placed on the lateral surface of the muscle to maintain appropriate orientation and avoid twisting of the pedicle. The TPFF can be used for further oral cavity reconstruction or it can be rolled and placed back in the temporal fossa for reconstruction of the defect left by the temporalis muscle harvest. No hardware was used since the reconstructive goal for these patients was to create a safe stable healing wound with soft tissue alone. The expected complications related to hardware were felt to be prohibitive for placement. For dentate patients, ivy loops with guiding elastics were applied for two weeks. All patients were prescribed a therabite device to limit progression of trismus starting two to three weeks post-operatively.
3.2
Patients
A total of 121 patients were identified that underwent temporalis flap reconstruction of a head and neck defect during the time period studied. Of these, three patients were identified who underwent reconstruction of composite oral cavity defects with temporalis flaps after prior surgical and radiation treatment. All patients had severe, extensive soft tissue fibrosis of the both the primary site and neck. Ages ranged from 44 to 84 years and all had significant comorbidities ( Table 1 ). All patients had undergone at least one major oral cavity resection for squamous cell carcinoma with post-operative radiation ranging from 60 to 70 Gy. A combined TMF and TPFF approach was used for reconstruction of independent oral cavity defects in one patient after her third major oral cavity resection for squamous cell carcinoma. The other two patients developed severe pain and trismus from osteoradionecrosis related to treatment of a head and neck cancer. Their condition necessitated a hemi-mandibulectomy. TMFs were used to reconstruct their composite oral cavity defects and TPFFs were rolled and used to fill the temporal fossa. Time from prior treatment ranged from 1 to 9 years. Operative time ranged from 4 to 7 hours with 100 cc to 400 cc of blood loss. None of the muscle flaps were skin grafted and all remucosalized. There were no major or minor post-operative complications and hospital stay ranged from 5 to 8 days. Post-operative FOSS scores were unchanged from pre-operative scores. Patients 2 and 3 were gastrostomy tube dependent and remained so post-operatively. No patient required tracheostomy. Their levels of pain were significantly less post-operatively and trismus either stabilized or improved. Follow up ranged from 4 to 14 months ( Table 2 ). Patient 1 died after last follow up due to an aggressive fourth primary post-cricoid carcinoma.
| Patient | Age | Gender | Comorbidities | Prior treatments | Time from prior treatments to reconstruction | Indications for reconstruction | Pre-reconstruction FOSS |
|---|---|---|---|---|---|---|---|
| 1 | 84 | F | HTN, PE | 1. Composite resection of T4a oral cavity squamous cell carcinoma with fibula free flap reconstruction and 60Gy of post-operative radiation | 1.9 years | Reconstrution after infrastructure maxillectomy, buccal, and masticator space resection, and partial glossectomy for T4a squamous cell carcinoma. | 1 |
| 2. Resection of T3 retromolar trigone and skin graft reconstruction | 2.7 years | ||||||
| 2 | 73 | F | CVA, AF | Transoral resection of T2 tongue base squamous cell carcinoma and 66 Gy of post-operative radiation | 5 years | Reconstruction after hemi-mandibulectomy for resection of osteoradionecrosis | 4 |
| 3 | 44 | M | AI | Resection of T3 lower lip squamous cell carcinoma and 70 Gy of post-operative radiation | 1 year | Reconstruction after hemi-mandibulectomy resection of osteoradionecrosis | 4 |
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