Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
INTRODUCTION: Microvascular free flap (MVFF) surgery for patients with oral cancer is vital for the restoration of function. Surgical revision of MVFF can improve functional outcomes, but there is limited published data on revision surgery in the context of oral cavity cancer (OCC) with soft tissue reconstruction. This study investigates the etiology and functional outcomes in patients undergoing revision oral cavity reconstruction.
METHODS: Retrospective chart review of patients at a tertiary care head and neck cancer facility with OCC undergoing oncologic surgery with soft tissue MVFF for reconstruction from August 2012 to March 2024 was performed. We excluded patients who did not undergo MVFF reconstruction, mandible or maxillary resection, and those who were lost to follow-up. We collected data on demographics, type of cancer, size of defect, type of free flap performed, post-operative outcomes and complications, and patient satisfaction.
RESULTS: We identified 388 patients meeting inclusion criteria. There were 224 patients who underwent anterolateral thigh (ALT) flaps, 20 freestyle thigh or leg flaps, 140 forearm flaps, and 4 other flaps from the subscapular or epigastric system. Twenty five of these patients underwent revision (6.38%). Females had higher rates of revision, this approached significance (p=0.108). RFFF were more likely to need revision (11.4%), compared to 3.7% for ALT (p=0.009). Patients with involvement of buccal mucosa underwent more revision (p=0.026) when compared to other sites, though floor of mouth (FOM) defects approached significance (p=0.065). Patients with primarily oral tongue defects were more likely to have thigh flap reconstruction (p=0.017), whereas buccal mucosa involvement underwent more RFFF (p=0.039). No significant difference was noted for undergoing revision based on age, BMI, tobacco history, comorbidities, or adjuvant treatment.
Median time to revision was 11.65±10.54 months. Time to revision was longer in forearm group (14.40±12.12 months) than thigh group (6.72±3.36), though not statistically significant. Revision surgery was performed for issues related to tongue mobility or articulation (56%), oral dysphagia (56%), dental implants or prosthesis (32%), oral competence (28%), or trismus (24%). Data regarding improvement based on patient subjective reports: patients with dysphagia had 85.7% improvement, mobility improved in 57.1% of cases, trismus improved in 66.7% of patients, and oral competence showed consistent improvements 71.4%.
CONCLUSIONS: Though surgical revision of OCC soft tissue free flap reconstruction are rare, they appear to improve patient outcomes. For oral cavity soft tissue defects, we found that RFFF reconstruction were more likely to undergo revision especially in defects involving the buccal mucosa. Revision showed improvements across all indications for surgery, suggesting one avenue of improved survivorship. Prospective studies are needed to identify which patients would benefit most from MVFF revision.