The Effects of Forearm and Perforator Flaps in Oral Cavity Reconstruction

The oral cavity is a region that is special because its structures and functions are closely related. After tumor resection, the defect is reconstructed by a flap which “covers” the defect and restores the functions of chewing, swallowing, articulation, and speech after the surgery.

The current literature consists of many published reports that compare different types of oral cavity reconstruction. However, the sum total data are relatively small and in some cases contradictory.

New defect closure techniques were introduced during the 1960s and 1970s, facilitating the reconstruction of large defects of the oral cavity. These reports spoke little of the functional and aesthetic results and patients' quality of life. Bakamjian and Littlewood were among the first authors to “measure the quality of reconstruction.” The use of microvascular flaps in oral cavity reconstruction has become a standard since the 1990s.

The aim of the current study was to evaluate success rate of forearm and thigh microvascular flaps in oral reconstruction as well as to determinate whether the reconstructive method influences patients' postoperative quality of life. General patients' characteristics were analyzed to establish which general characteristics as well as which tumor parameters influence postoperative quality of life.

The research included patients treated at the Department of Maxillofacial Surgery at Dubrava Clinical Hospital in Zagreb, Croatia, where there were plans for microvascular reconstruction using forearm or thigh perforator flaps. A total of 40 patients with oral cavity cancer were evaluated (20 in each group).

To equalize these two groups according to reconstruction type, the groups were limited to patients who had primary cancer of tongue and floor of the mouth without statistical differences in stage of disease, continuity of the mandible preserved after tumor resection, and no signs of recurrence at the minimum 3 months follow-up.

Postsurgical function results were checked during regular follow-up visits through specially designed questionnaires. Each questionnaire consisted of two sections. The first section had general information about patient and tumor specifics. The second section included target questions about postsurgical evaluation of oral functions and aesthetics appearance. A series of categorized replies were offered to each query dependent on investigated parameter.

Moreover, an objective voice analysis was conducted using a Multidimensional Voice Program (MDVP; Kay-Pentax) for acoustic voice analysis which included the information about the average frequency, the span of average laryngeal frequency, jitter, percent, shimmer, noise-to-harmonic ratio, voice turbulence index, soft phonation index, and duration of the analyzed signal.

The Articulation test was modified for the purpose of this study, because of a specific casuistics. In this way the articulation could be analyzed through spontaneous speech and repetition of logatomes and words. It was recorded on Sony digital recorder (model MDS 303, Sony, Tokyo, Japan) on MiniDiscs, using a microphone placed at a 15-cm distance from the lips. Each examinee pronounced 54 words.

Based on the current study, none of microvascular flaps used for reconstruction was superior to the other in regards to all parameters. The results showed no significant difference concerning local complications, which differs from previously published data.

Patients' speech after the surgery did not depend significantly on the type of resection and type of dissection. For patients in both groups postoperative speech was, according to patients' testimonies, significantly better in the first months after the surgery than a year later. This worsening of speech can be explained by scar changes and atrophy of the flap itself.

According to the results of our study, the stage of disease and extent of resection are most important parameters that affected postoperative functional and aesthetic results. The data showed that the success of oral cavity reconstruction and better quality of life in patients with head and neck do not directly depend of reconstruction method (type of microvascular flap), because the extent of resection and the sacrifice of neck structures also play an important role.