- Email: [email protected]
Outcomes of younger and older patients with palatal cancer undergoing pedicled facial-submental artery island flap reconstruction
YIJOM-4192; No of Pages 6
Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx https://doi.org/10.1016/j.ijom.2019.05.002, available online at https://www.sciencedirect.com
Clinical Paper Reconstructive Surgery
Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction
C.-b. Pan1, Y. Wang1, W.-l. Chen, B. Zhou, X.-m. Wang Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
C.-b. Pan, Y. Wang, W.-l. Chen, B. Zhou, X.-m. Wang: Outcomes of younger and older patients with palatal cancer undergoing pedicled facial-submental artery island flap reconstruction. Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx. ã 2019 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
Abstract. The purpose of this study was to evaluate the outcomes of younger and older patients with palatal cancer undergoing reconstruction using the pedicled facialsubmental artery island flap (FSAIF) following cancer ablation. Fifty-eight patients with palatal squamous cell carcinoma (SCC) were divided into two age groups: 60 years (n = 31) and >60 years (n = 27). By clinical SCC stage, 6.4%, 83.9%, and 9.7% of the younger group and 3.7%, 85.2%, and 11.1% of the older group were stage I, II, and III, respectively. The incidence of comorbid conditions was 35.5% (11/31) in those 60 years and 137.0% (37/27) in those >60 years. Brown class II maxillary defects (four class IIa, 44 class IIb, three class IIc, and seven class IId) were repaired using FSAIFs following cancer ablation. There were two flap failures; thus the success rate was 96.6%. Significant differences in mean age and the incidence of comorbid conditions were evident between the groups. No significant differences in TNM stage, maxillary defect classification, flap size, overall flap survival, rates of local and general complications, or survival status was evident between the groups. The FSAIF is a reliable and safe method for repairing Brown class II maxillary defects following cancer ablation, particularly in older patients.
Key words: maxillary; defects; reconstruction; pedicle flap; submental flap; palatal cancer; older patients. Accepted for publication
1 Chao-bin Pan and Yan Wang have shared first authorship.
0901-5027/000001+06
ã 2019 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002
YIJOM-4192; No of Pages 6
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Introduction
Palatal squamous cell carcinoma (SCC) is principally a disease of older adults, but it can also occur in younger adults. The incidence of oral SCC is increasing worldwide in younger patients1. The cancer is more advanced at presentation in younger than in older patients, associated with higher rates of regional metastasis and distant failure; recurrent disease is more aggressive2. Treatment decision-making may be challenging for older patients with comorbid conditions, such as cardiovascular, endocrine, and musculoskeletal diseases3. Brown class II defects require a standard hemimaxillectomy not involving the orbital floor or adnexae4, and these are the most common type of maxillary/midface defect5. In a previous study performed in the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, it was found that the pedicled facial-submental artery island flap (FSAIF) could be reliably used to repair oral and maxillofacial defects6. The aim of the present study was to perform an evaluation by age group of the outcomes of patients with palatal SCC in whom the FSAIF was used to repair Brown class II maxillary defects after cancer ablation. Patients and methods
This retrospective observational study was conducted from June 2010 to October 2017 in the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China. The Institutional Review Board of Sun Yat-sen University approved this study. The inclusion criteria were Brown class II maxillary defects and restoration using the FSAIF. The following data were collected: age, sex, TNM stage, maxillary defect classification, flap size, overall flap survival, local and general complications, and survival status. The exclusion criteria were cachexia, congestive cardiac failure, severe chronic obstructive pulmonary disease, and/or lack of follow-up data. Fifty-eight patients with palatal SCC were included in the study and divided into age groups of 60 years (n = 31) and >60 years (n = 27), using the World Health Organization recommended cutoff for ‘elderly’ of 60 years7. The patients were 42 males and 16 females, ranging in age from 31 to 81 years (median 58.3 years). Clinical staging of the SCC was performed according to the 2017 Ameri-
Fig. 1. The incision used to harvest the pedicled facial-submental artery island flap (FSAIF), and the flap itself, in two patients with stage II palatal squamous cell carcinoma: (A) a 41-yearold female patient; (B) a 75-year-old male patient.
can Joint Committee on Cancer guidelines8: of those 60 years of age, two (6.4%) had stage I, 26 (83.9%) had stage II, and three (9.7%) had stage III tumours; of those >60 years of age, one (3.7%) had stage I, 23 (85.2%) had stage II, and three (11.1%) had stage III tumours. The incidence of comorbid conditions9, including cardiovascular, endocrine, respiratory, and blood diseases, was 35.5% (11/31) in those 60 years old and 137.0% (37/ 27) in those >60 years old. All patients underwent radical resection, ipsilateral radical neck dissection, and repair of the maxillary defects with the FSAIF. The skin paddles were 3 8 to 5 16 cm (median 3.7 12.1 cm) in the younger age group and 3 8 to 5 15 cm (median 3.7 11.9 cm) in the older age group. All submandibular lymph nodes were checked during flap elevation and were pathologically negative. A FSAIF based on the distal facial pedicle was harvested (Fig. 1). The donor area was largely closed. The surgical details are described in a previous report6. According to the Brown classification of maxillary and midface defects4, the class II maxillary defects were divided into classes IIa (four cases) (Fig. 2), IIb (44 cases) (Fig. 3), IIc (three cases), and IId (seven cases) (Fig. 4). All maxillary defects were repaired with FSAIFs.
Statistical analysis
All statistical analyses were performed using IBM SPSS Statistics version 20.0 (IBM Corp., Armonk, NY, USA). The x2 test, independent samples t-test, and Mann–Whitney U-test were used, as appropriate, to compare data, and the level of significance was set at 5% (P < 0.05).
Results
Two flap failures occurred, affording an overall success rate of 96.6%. Flap failure developed in one patient (3.2%) in the younger group and one patient (3.7%) in the older group. Local complications developed in three patients (9.7%) in the 60 years group and four patients (12.8%) in the >60 years group, and general complications developed in four patients (14.8%) 60 years old and seven patients (25.9%) >60 years old. No significant differences in TNM or clinical stage, flap skin paddle size, flap failure rate, or local and general complication rates was evident between the groups (P > 0.05). However, significant differences in age and the incidence of comorbid conditions were apparent (P < 0.05). Patients were followed up for 7–62 months (median 30.6 months for those 60 years of age and 31.2 months for those >60 years of age). At the final follow-up, 77.6% patients were alive with no evidence of disease, 12.1% were alive with disease, and 10.3% had died of local recurrence or distant metastasis. No significant survival difference was evident between the groups. Table 1 provides a summary of all data. Discussion
The United Kingdom National Multidisciplinary Guidelines offer recommendations for the restoration of Brown class II maxillary defects following cancer ablation in various settings10. Obturation is often very successful; the orbit does not require support and if the defect is not too large, fewer problems with prosthesis retention and stability are apparent than when other procedures are employed. In patients with more extensive defects
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002
YIJOM-4192; No of Pages 6
Pedicled facial-submental artery island flap
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Fig. 2. Restoration of Brown class IIa maxillectomy defects after radical resection. Incision of the tongue tumours and subsequent defect repair in a 41-year-old female patient (A, B, and C) and a 75-year-old female patient (D, E, and F).
Fig. 3. (A) A 61-year-old female patient with stage II palatal squamous cell carcinoma. (B) View of the class IIb defect repaired using a FSAIF at 30 months postoperative.
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002
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Fig. 4. (A) A 64-year-old male patient with stage II palatal squamous cell carcinoma. (B) View of the class IId defect repaired with a FSAIF at 20 months postoperative.
(those of classes IIc–d), it is possible to attain very good retention using implantretained prostheses, although reconstructions employing fibula flaps are also associated with good outcomes. High-level vascularized bone, such as that of the deep circumflex iliac artery flap, better supports the peri-nasal area10. However, free tissue transfer techniques are not appropriate in elderly patients, those with systemic disease who cannot endure long operations, or those who have undergone previous surgery and thus lack adequate recipient vessels. Treatment decision-making may be even more challenging in older patients with comorbid conditions, such as cardiovascular, endocrine, and musculoskeletal diseases3. In the series of patients presented here, the Brown class II maxillary defects of 58 patients were repaired using FSAIFs; the surgical success rate was 96.6%. Flap failure occurred in two patients with comorbid conditions, including cardiovascu-
lar and blood diseases, which may have triggered haemorrhage when the pedicle was pressed and the flap infused. The digastric muscle should be included in harvested flaps to prevent flap failure6. The median skin paddle was 3.7 (11.9–12.1) cm in area, facilitating maxillary defect repair following palatal SCC ablation. No major complications developed in any patient. Urgent exploratory operations were performed to stop haemorrhagic bleeding. Flap failures and orocutaneous fistulae were treated successfully with debridement. Although many more of the older patients presented with one or more comorbid conditions (cardiovascular, endocrine, respiratory, or blood diseases) than younger patients, no significant difference in the frequency of any of the four types of maxillary defect were apparent between the groups. No differences in the flap, local, or general complication rates were evident between the groups.
A previous study that explored the immediate restoration of maxillary defects using pedicled and free flaps found that 11.7% (7/60) of patients developed systemic complications, and four (6.7%) died within 30 days of hospitalization11. The submental flap can be raised easily and involves a shorter operative time and hospital stay compared to the free flap procedure. It can be an excellent choice in patients with a high American Society of Anesthesiologists (ASA) risk score, particularly in elderly patients, where the potential complications linked to microsurgical procedures are avoided12. Maxillary defects are caused by ablative tumour surgery affecting the stomatognathic system, including the palate, teeth, nasal cavity, and maxillary sinus. Functional and aesthetic restorations remain challenging. In the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, reverse facial-submental artery mandibular osteomuscular flaps have been used to repair maxillary defects after the removal of benign tumours, combined with the placement of titanium dental implants and subsequent restoration with implant-supported fixed prostheses13. This facilitates the functional repair of maxillary defects after benign tumour removal14. In a review, Yetzer and Fernandes found that Brown class III, IV, V, and VI defects had been restored using radial forearm, anterolateral thigh, thoracodorsal artery perforator fasciocutaneous, thoracodorsal angular arterial composite, latissimus dorsi myofasciocutaneous, and composite fibula flaps15. Craniofacial reconstruction remains therapeutically challenging. Skull base reconstructions seek to provide brain support, prevent brain herniation, minimize intracranial infections by reducing the risk of cerebrospinal fluid leakage, and avoid pneumocephalus. The extended, vertical, lower trapezius island myocutaneous flap is large, easy to obtain, and reliable when used to repair major defects evident after craniofacial resection16. In the present study, six patients died of local recurrence and seven remained alive with disease, but there was no significant difference in the survival rate between patients aged 60 years and those aged >60 years. FSAIF is simple to harvest and can be raised rapidly. It produces a contour match without a conspicuous site and was found to be appropriate in terms of size, thickness, and texture for the restoration of Brown class II maxillary defects after cancer ablation. Patients aged 60 years appeared to perform similarly postopera-
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002
YIJOM-4192; No of Pages 6
Pedicled facial-submental artery island flap Table 1. Demographics, clinical characteristics, and outcomes of patients with palatal cancer undergoing defect reconstruction after cancer ablation using a facial-submental artery submental island pedicled flap. 2.
3.
4.
5.
6.
7.
8.
9.
SD, standard deviation; ICD10, International Statistical Classification of Diseases and Related Health Problems 10th revision.
tively than their younger counterparts. Older age was not a contraindication for FSAIF reconstruction.
Ethical approval
Funding
Patient consent
This work was supported by grants from the National Natural Science Foundation of China (No. 81772888 to Wei-liang Chen; No. 81702695 to Bin Zhou).
Patient consent obtained.
Competing interests
None declared.
10.
11.
Not required.
12.
References 1. Dos Santos Costa SF, Brennan PA, Gomez RS, Fregnani ER, Santos-Silva AR, Martins MD, de Castro-Junior G, Rahimi S, Fonseca FP. Molecular basis of oral squamous cell
13.
5
carcinoma in young patients: is it any different from older patients? J Oral Pathol Med 2018;47:541–6. Hilly O, Shkedy Y, Hod R, Soudry E, Mizrachi A, Hamzany Y, Bachar G, Shpitzer T. Carcinoma of the oral tongue in patients younger than 30 years: comparison with patients older than 60 years. Oral Oncol 2013;49:987–90. Hamelinck VC, Bastiaannet E, Pieterse AH, van de Velde CJH, Liefers GJ, Stiggelbout AM. Preferred and perceived participation of younger and older patients in decision making about treatment for early breast cancer: a prospective study. Clin Breast Cancer 2018;18:e245–53. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol 2010;11:1001–8. Yu S, Wang Y, Mao C, Guo CB, Yu GY, Peng X. Classification and reconstruction of 1,107 cases of maxillary defects. Beijing Da Xue Xue Bao Yi Xue Ban 2015;47:509–13. Chen WL, Li JS, Yang ZH, Huang ZQ, Wang JU, Zhang B. Two submental island flaps for reconstructing oral and maxillofacial defects following cancer ablation. J Oral Maxillofac Surg 2008;66:1145–56. World Health Organization. Proposed working definition of an older person in Africa for the MDS Project. WHO; 2002 [Accessibility verified May 22, 2019]http://www.who.int/ healthinfo/survey/ageingdefnolder/en/index. html. Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK, Gershenwald JE, Compton CC, Hess KR, Sullivan DC, Jessup JM, Brierley JD, Gaspar LE, Schilsky RL, Balch CM, Winchester DP, Asare EA, Madera M, Gress DM, Meyer LR. AJCC Cancer staging manual. Eighth edition. New York: Springer; 2017. World Health Organization. International statistical classification of diseases and related health problems 10th revision. WHO; 2010 [Accessibility verified May 22, 2019] http://apps.who.int/classifications/icd10/ browse/2010/en. Ragbir M, Brown JS, Mehanna H. Reconstructive considerations in head and neck surgical oncology: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016;130(S2):S191–7. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;105:2331–46. discussion 2347–2348. Schonauer F, Di Martino A, Nele G, Santoro M, Dell’Aversana Orabona G, Califano L. Submental flap as an alternative to microsurgical flap in intraoral post-oncological reconstruction in the elderly. Int J Surg 2016;33(Suppl. 1):S51–6. Chen WL, Ye JT, Yang ZH, Huang ZQ, Zhang DM, Wang K. Reverse facial artery-submental artery mandibular osteomus-
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002
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cular flap for the reconstruction of maxillary defects following the removal of benign tumors. Head Neck 2009;31:725–31. 14. Chen WL, Zhou M, Ye JT, Yang ZH, Zhang DM. Maxillary functional reconstruction using a reverse facial artery-submental artery mandibular osteomuscular flap with dental implants. J Oral Maxillofac Surg 2011;69:2909–14. 15. Yetzer J, Fernandes R. Reconstruction of orbitomaxillary defects. J Oral Maxillofac Surg 2013;71:398–409.
16. Chen WL, Yang ZH, Huang ZQ, Fan S, Zhang DM, Wang YY. Craniofacial resection and reconstruction in patients with recurrent cancer involving the craniomaxillofacial region. J Oral Maxillofac Surg 2017;75:622–31.
Address: Wei-liang Chen Department of Oral and Maxillofacial Surgery Sun Yat-sen Memorial Hospital of Sun Yat-
sen University 107 Yan-jiang Road 510120 Guangzhou China Tel.: +86 020 81332429 fax: +86 020 81332853 E-mail: [email protected]
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002
Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx https://doi.org/10.1016/j.ijom.2019.05.002, available online at https://www.sciencedirect.com
Clinical Paper Reconstructive Surgery
Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction
C.-b. Pan1, Y. Wang1, W.-l. Chen, B. Zhou, X.-m. Wang Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
C.-b. Pan, Y. Wang, W.-l. Chen, B. Zhou, X.-m. Wang: Outcomes of younger and older patients with palatal cancer undergoing pedicled facial-submental artery island flap reconstruction. Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx. ã 2019 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
Abstract. The purpose of this study was to evaluate the outcomes of younger and older patients with palatal cancer undergoing reconstruction using the pedicled facialsubmental artery island flap (FSAIF) following cancer ablation. Fifty-eight patients with palatal squamous cell carcinoma (SCC) were divided into two age groups: 60 years (n = 31) and >60 years (n = 27). By clinical SCC stage, 6.4%, 83.9%, and 9.7% of the younger group and 3.7%, 85.2%, and 11.1% of the older group were stage I, II, and III, respectively. The incidence of comorbid conditions was 35.5% (11/31) in those 60 years and 137.0% (37/27) in those >60 years. Brown class II maxillary defects (four class IIa, 44 class IIb, three class IIc, and seven class IId) were repaired using FSAIFs following cancer ablation. There were two flap failures; thus the success rate was 96.6%. Significant differences in mean age and the incidence of comorbid conditions were evident between the groups. No significant differences in TNM stage, maxillary defect classification, flap size, overall flap survival, rates of local and general complications, or survival status was evident between the groups. The FSAIF is a reliable and safe method for repairing Brown class II maxillary defects following cancer ablation, particularly in older patients.
Key words: maxillary; defects; reconstruction; pedicle flap; submental flap; palatal cancer; older patients. Accepted for publication
1 Chao-bin Pan and Yan Wang have shared first authorship.
0901-5027/000001+06
ã 2019 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002
YIJOM-4192; No of Pages 6
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Introduction
Palatal squamous cell carcinoma (SCC) is principally a disease of older adults, but it can also occur in younger adults. The incidence of oral SCC is increasing worldwide in younger patients1. The cancer is more advanced at presentation in younger than in older patients, associated with higher rates of regional metastasis and distant failure; recurrent disease is more aggressive2. Treatment decision-making may be challenging for older patients with comorbid conditions, such as cardiovascular, endocrine, and musculoskeletal diseases3. Brown class II defects require a standard hemimaxillectomy not involving the orbital floor or adnexae4, and these are the most common type of maxillary/midface defect5. In a previous study performed in the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, it was found that the pedicled facial-submental artery island flap (FSAIF) could be reliably used to repair oral and maxillofacial defects6. The aim of the present study was to perform an evaluation by age group of the outcomes of patients with palatal SCC in whom the FSAIF was used to repair Brown class II maxillary defects after cancer ablation. Patients and methods
This retrospective observational study was conducted from June 2010 to October 2017 in the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China. The Institutional Review Board of Sun Yat-sen University approved this study. The inclusion criteria were Brown class II maxillary defects and restoration using the FSAIF. The following data were collected: age, sex, TNM stage, maxillary defect classification, flap size, overall flap survival, local and general complications, and survival status. The exclusion criteria were cachexia, congestive cardiac failure, severe chronic obstructive pulmonary disease, and/or lack of follow-up data. Fifty-eight patients with palatal SCC were included in the study and divided into age groups of 60 years (n = 31) and >60 years (n = 27), using the World Health Organization recommended cutoff for ‘elderly’ of 60 years7. The patients were 42 males and 16 females, ranging in age from 31 to 81 years (median 58.3 years). Clinical staging of the SCC was performed according to the 2017 Ameri-
Fig. 1. The incision used to harvest the pedicled facial-submental artery island flap (FSAIF), and the flap itself, in two patients with stage II palatal squamous cell carcinoma: (A) a 41-yearold female patient; (B) a 75-year-old male patient.
can Joint Committee on Cancer guidelines8: of those 60 years of age, two (6.4%) had stage I, 26 (83.9%) had stage II, and three (9.7%) had stage III tumours; of those >60 years of age, one (3.7%) had stage I, 23 (85.2%) had stage II, and three (11.1%) had stage III tumours. The incidence of comorbid conditions9, including cardiovascular, endocrine, respiratory, and blood diseases, was 35.5% (11/31) in those 60 years old and 137.0% (37/ 27) in those >60 years old. All patients underwent radical resection, ipsilateral radical neck dissection, and repair of the maxillary defects with the FSAIF. The skin paddles were 3 8 to 5 16 cm (median 3.7 12.1 cm) in the younger age group and 3 8 to 5 15 cm (median 3.7 11.9 cm) in the older age group. All submandibular lymph nodes were checked during flap elevation and were pathologically negative. A FSAIF based on the distal facial pedicle was harvested (Fig. 1). The donor area was largely closed. The surgical details are described in a previous report6. According to the Brown classification of maxillary and midface defects4, the class II maxillary defects were divided into classes IIa (four cases) (Fig. 2), IIb (44 cases) (Fig. 3), IIc (three cases), and IId (seven cases) (Fig. 4). All maxillary defects were repaired with FSAIFs.
Statistical analysis
All statistical analyses were performed using IBM SPSS Statistics version 20.0 (IBM Corp., Armonk, NY, USA). The x2 test, independent samples t-test, and Mann–Whitney U-test were used, as appropriate, to compare data, and the level of significance was set at 5% (P < 0.05).
Results
Two flap failures occurred, affording an overall success rate of 96.6%. Flap failure developed in one patient (3.2%) in the younger group and one patient (3.7%) in the older group. Local complications developed in three patients (9.7%) in the 60 years group and four patients (12.8%) in the >60 years group, and general complications developed in four patients (14.8%) 60 years old and seven patients (25.9%) >60 years old. No significant differences in TNM or clinical stage, flap skin paddle size, flap failure rate, or local and general complication rates was evident between the groups (P > 0.05). However, significant differences in age and the incidence of comorbid conditions were apparent (P < 0.05). Patients were followed up for 7–62 months (median 30.6 months for those 60 years of age and 31.2 months for those >60 years of age). At the final follow-up, 77.6% patients were alive with no evidence of disease, 12.1% were alive with disease, and 10.3% had died of local recurrence or distant metastasis. No significant survival difference was evident between the groups. Table 1 provides a summary of all data. Discussion
The United Kingdom National Multidisciplinary Guidelines offer recommendations for the restoration of Brown class II maxillary defects following cancer ablation in various settings10. Obturation is often very successful; the orbit does not require support and if the defect is not too large, fewer problems with prosthesis retention and stability are apparent than when other procedures are employed. In patients with more extensive defects
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002
YIJOM-4192; No of Pages 6
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Fig. 2. Restoration of Brown class IIa maxillectomy defects after radical resection. Incision of the tongue tumours and subsequent defect repair in a 41-year-old female patient (A, B, and C) and a 75-year-old female patient (D, E, and F).
Fig. 3. (A) A 61-year-old female patient with stage II palatal squamous cell carcinoma. (B) View of the class IIb defect repaired using a FSAIF at 30 months postoperative.
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002
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Fig. 4. (A) A 64-year-old male patient with stage II palatal squamous cell carcinoma. (B) View of the class IId defect repaired with a FSAIF at 20 months postoperative.
(those of classes IIc–d), it is possible to attain very good retention using implantretained prostheses, although reconstructions employing fibula flaps are also associated with good outcomes. High-level vascularized bone, such as that of the deep circumflex iliac artery flap, better supports the peri-nasal area10. However, free tissue transfer techniques are not appropriate in elderly patients, those with systemic disease who cannot endure long operations, or those who have undergone previous surgery and thus lack adequate recipient vessels. Treatment decision-making may be even more challenging in older patients with comorbid conditions, such as cardiovascular, endocrine, and musculoskeletal diseases3. In the series of patients presented here, the Brown class II maxillary defects of 58 patients were repaired using FSAIFs; the surgical success rate was 96.6%. Flap failure occurred in two patients with comorbid conditions, including cardiovascu-
lar and blood diseases, which may have triggered haemorrhage when the pedicle was pressed and the flap infused. The digastric muscle should be included in harvested flaps to prevent flap failure6. The median skin paddle was 3.7 (11.9–12.1) cm in area, facilitating maxillary defect repair following palatal SCC ablation. No major complications developed in any patient. Urgent exploratory operations were performed to stop haemorrhagic bleeding. Flap failures and orocutaneous fistulae were treated successfully with debridement. Although many more of the older patients presented with one or more comorbid conditions (cardiovascular, endocrine, respiratory, or blood diseases) than younger patients, no significant difference in the frequency of any of the four types of maxillary defect were apparent between the groups. No differences in the flap, local, or general complication rates were evident between the groups.
A previous study that explored the immediate restoration of maxillary defects using pedicled and free flaps found that 11.7% (7/60) of patients developed systemic complications, and four (6.7%) died within 30 days of hospitalization11. The submental flap can be raised easily and involves a shorter operative time and hospital stay compared to the free flap procedure. It can be an excellent choice in patients with a high American Society of Anesthesiologists (ASA) risk score, particularly in elderly patients, where the potential complications linked to microsurgical procedures are avoided12. Maxillary defects are caused by ablative tumour surgery affecting the stomatognathic system, including the palate, teeth, nasal cavity, and maxillary sinus. Functional and aesthetic restorations remain challenging. In the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, reverse facial-submental artery mandibular osteomuscular flaps have been used to repair maxillary defects after the removal of benign tumours, combined with the placement of titanium dental implants and subsequent restoration with implant-supported fixed prostheses13. This facilitates the functional repair of maxillary defects after benign tumour removal14. In a review, Yetzer and Fernandes found that Brown class III, IV, V, and VI defects had been restored using radial forearm, anterolateral thigh, thoracodorsal artery perforator fasciocutaneous, thoracodorsal angular arterial composite, latissimus dorsi myofasciocutaneous, and composite fibula flaps15. Craniofacial reconstruction remains therapeutically challenging. Skull base reconstructions seek to provide brain support, prevent brain herniation, minimize intracranial infections by reducing the risk of cerebrospinal fluid leakage, and avoid pneumocephalus. The extended, vertical, lower trapezius island myocutaneous flap is large, easy to obtain, and reliable when used to repair major defects evident after craniofacial resection16. In the present study, six patients died of local recurrence and seven remained alive with disease, but there was no significant difference in the survival rate between patients aged 60 years and those aged >60 years. FSAIF is simple to harvest and can be raised rapidly. It produces a contour match without a conspicuous site and was found to be appropriate in terms of size, thickness, and texture for the restoration of Brown class II maxillary defects after cancer ablation. Patients aged 60 years appeared to perform similarly postopera-
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002
YIJOM-4192; No of Pages 6
Pedicled facial-submental artery island flap Table 1. Demographics, clinical characteristics, and outcomes of patients with palatal cancer undergoing defect reconstruction after cancer ablation using a facial-submental artery submental island pedicled flap. 2.
3.
4.
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SD, standard deviation; ICD10, International Statistical Classification of Diseases and Related Health Problems 10th revision.
tively than their younger counterparts. Older age was not a contraindication for FSAIF reconstruction.
Ethical approval
Funding
Patient consent
This work was supported by grants from the National Natural Science Foundation of China (No. 81772888 to Wei-liang Chen; No. 81702695 to Bin Zhou).
Patient consent obtained.
Competing interests
None declared.
10.
11.
Not required.
12.
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Address: Wei-liang Chen Department of Oral and Maxillofacial Surgery Sun Yat-sen Memorial Hospital of Sun Yat-
sen University 107 Yan-jiang Road 510120 Guangzhou China Tel.: +86 020 81332429 fax: +86 020 81332853 E-mail: [email protected]
Please cite this article in press as: Pan C, et al. Outcomes of younger and older patients with palatal cancer undergoing pedicled facialsubmental artery island flap reconstruction, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.ijom.2019.05.002