Comparison of Internal Jugular Vein System Anastomosis and External Jugular Vein System Anastomosis in Free Flaps for Head and Neck Reconstruction: A Meta-Analysis.

PURPOSE: The purpose of the present study was to investigate the differences in postoperative thrombosis and flap failure between internal jugular vein (IJV) system anastomosis and external jugular vein (EJV) system anastomosis in free flaps for the reconstruction of head and neck defects. MATERIALS AND METHODS: We searched PubMed, Web of Science, EMBASE, Chinese BioMedical Literature Database, and other databases until March 2019 for studies that had reported data for anastomosis for the 2 different venous systems in the microvascular free-flap reconstruction of head and neck defects. We assessed thrombosis and flap failure in patients undergoing anastomosis of the IJV system and patients undergoing anastomosis of the EJV system. RESULTS: Nine studies with a total of 2051 patients with venous anastomosis were included in the present meta-analysis. IJV system anastomosis showed a significantly lower incidence of venous thrombosis than did the EJV system (relative risk [RR], 0.55; 95% confidence interval [CI], 0.37 to 0.82). Eight studies were included in the analysis of the flap failure rate, which showed a lower failure rate for the IJV system anastomosis than for the EJV system (RR, 0.59; 95% CI, 0.35 to 1.00). CONCLUSIONS: The incidence of thrombosis and flap failure after venous anastomosis in the IJV system was lower than that in the EJV system. The results from the present study have shown that the IJV system should be the first choice for venous anastomosis in the reconstruction of free flaps.

Miniplates Versus Reconstruction Plates in Vascularized Osteocutaneous Flap Reconstruction of the Mandible.

PURPOSE: The main aim of this article is to compare the complication rate associated with the use of miniplates versus reconstruction plates in vascularized osteocutaneous flap reconstruction of the mandible. PATIENTS AND METHODS: The authors searched PubMed, Web of Science, EMBASE, Chinese BioMedical Literature Database (CBM), Cochrane Library, and clinicaltrials.gov up to September 2017 to identify studies that compared the complication rate of miniplates versus reconstruction plates in patients undergoing mandibular reconstruction. Two reviewers individually extracted the data and performed a quality assessment. Plate exposure, plate fracture/removal, infection, and overall complications were evaluated. RESULTS: Five studies with 511 cases were included in our analysis. No significant difference was found between the groups. However, the reconstruction plate led to fewer overall complications and plate exposure postoperatively than did the miniplate. CONCLUSION: Our meta-analysis suggests that miniplates and reconstruction plates are suitable for mandibular reconstruction with a vascularized osteocutaneous flap.

Congenital Loss of Permanent Teeth in a Patient With Congenital Insensitivity to Pain With Anhidrosis due to 2 Novel Mutations in the NTRK1 Gene.

Congenital insensitivity to pain with anhidrosis (CIPA), also known as hereditary sensory and autonomic neuropathy type IV, is an extremely rare autosomal recessive disorder. This study investigated the oral and craniofacial manifestations of a 7-year-old Chinese boy affected by CIPA and identified 2 novel mutations in the NTRK1 gene, and a new feature of the disorder was identified. The patient had typical features, including insensitivity to pain, anhidrosis, and mental retardation; recurrent fractures and osteoporosis also were noted. His oral and craniofacial manifestations included congenital blepharoptosis, a large number of missing teeth, serious tooth abrasion, severe soft tissue injuries, and dental caries. Radiographic examination showed congenital loss of the permanent tooth germs, thin and weak alveolar bone of the mandible, and a fracture of the right mandible. This study extends the spectrum of NTRK1 mutations observed in patients with a diagnosis of CIPA and is the first to propose that congenital loss of permanent teeth may occur in CIPA patients. Furthermore, it highlights the importance of including an oral and maxillofacial surgeon and a pediatric dentist on the multidisciplinary team.

Discontinuous Versus In-Continuity Neck Dissection in Squamous Cell Carcinoma of the Tongue and Floor of the Mouth: Comparing the Rates of Locoregional Recurrence.

PURPOSE: To date, consensus has not been reached on which treatment modality, that is, in-continuity neck dissection or discontinuous neck dissection, is more appropriate for managing patients with squamous cell carcinoma (SCC) of the tongue and floor of the mouth. This study aimed to perform a meta-analysis to compare discontinuous neck dissection with in-continuity neck dissection as a treatment modality for SCC of the tongue and floor of the mouth. MATERIALS AND METHODS: The PubMed, Web of Science, China National Knowledge Infrastructure, and Wanfang databases were searched for articles that compared discontinuous neck dissection with in-continuity neck dissection in SCC of the tongue and floor of the mouth until March 1, 2017. The predictor variable was whether discontinuous neck dissection or in-continuity neck dissection was performed in each group. The primary outcome variable was the incidence of locoregional recurrence. Two authors individually extracted the data and assessed the study quality. The meta-analysis was performed using Stata (version 13.0; StataCorp, College Station, TX). RESULTS: We included 8 studies with 796 patients in our meta-analysis. The results showed that in-continuity neck dissection had a statistically significantly lower incidence of locoregional recurrence than discontinuous neck dissection (random-effects model: relative risk, 0.459; 95% confidence interval, 0.240 to 0.877; P = .019). Because significant heterogeneity among studies (I2 = 74.5%, P < .001) was found in the heterogeneity evaluation, a separate analysis was performed. However, the results still showed that in-continuity neck dissection had a statistically significantly lower rate of locoregional recurrence than discontinuous neck dissection in patients with T2 and T3 SCC of the tongue and floor of the mouth (fixed-effects model: relative risk, 0.281; 95% confidence interval, 0.183 to 0.433; P < .001). CONCLUSIONS: Compared with discontinuous neck dissection, in-continuity neck dissection can significantly reduce the rate of locoregional recurrence in patients with SCC of the tongue and floor of the mouth.

The application of fibular free flap with flexor hallucis longus in maxilla or mandible extensive defect: a comparison study with conventional flap.

BACKGROUND: The repair and reconstruction of maxillary and mandibular extensive defects have put huge challenges to surgeons. The fibular free flap (FFF) is one of the standard treatment choices for reconstruction. The conventional FFF has deficiencies, such as forming poor oral mucosa, limited flap tissue, and perforator vessel variation. To improve the use of FFF, we add the flexor hallucis longus (FHL) in the flap (FHL-FFF). In this paper, we described the advantage and indication of FHL-FFF and conducted a retrospective study to compare FHL-FFF and FFF without FHL. METHODS: Fifty-four patients who underwent FFF were enrolled and divided into two groups: nFHL group (using FFF without FHL, 38 patients) and FHL group (using FHL-FFF, 16 patients). The perioperative clinical data of patients was collected and analyzed. RESULTS: The flaps all survived in two groups. We mainly used FHL to fill dead space, and the donor-site morbidity was slight. In FHL group, flap harvesting time was shorter (118.63 ± 11.76 vs 125.74 ± 11.33 min, P = 0.042), the size of flap's skin paddle was smaller (16.5 (0-96) vs 21.0(10-104) cm2, P = 0.027) than nFHL group. There were no significant differences (P > 0.05) in hospital days, hospitalization expense, rate of perioperative complications, etc. between the two groups. Compared with FFF without FHL, FHL-FFF will neither affect the use of flap nor bring more problems. CONCLUSION: The FHL-FFF simplifies the flap harvesting operation. The FHL can form good mucosa and make FFF rely less on skin paddle. It can be used for adding flap tissue and dealing with perforator vessel variation in reconstruction of maxillary and mandibular extensive defects.

Reconstruction of Complex Total Parotidectomy Defect With a Chimeric Anterolateral Thigh Perforator Flap and Vascularized Motor Branch of Femoral Nerve Grafting.

Reconstruction of complex total parotidectomy defects after ablation is always a challenge for surgeons. The surgical technique in reconstructing total parotidectomy defects using an anterolateral thigh (ALT) flap has not been described in detail. This report describes the treatment of a difficult case with a complex total parotidectomy defect. An ALT flap composed of a vascularized motor branch of the femoral nerve and a narrow portion of the vastus lateralis muscle was harvested. An 8-cm-long vascularized nerve was transplanted into the gap, which can be considered a cable transplant graft, and a myocutaneous paddle was used to cover and fill in the soft tissue defect. There were no complications after surgery, and the patient was satisfied with the reconstructed facial contours. This case shows that using a chimeric ALT flap for reconstruction is possible in a complex total parotidectomy defect.

Transverse cervical vessels as recipient vessels in oral and maxillofacial microsurgical reconstruction after former operations with or without radiotherapy.

BACKGROUND: The purpose of this study was to investigate the reliability and outcome of using the transverse cervical vessel (TCV) as a recipient vessel for microvascular reconstruction in patients whose vessels in the neck region are unavailable because of previous surgery or radiotherapy. METHODS: Between January 2012 and August 2014, secondary head and neck reconstruction was performed using the TCV as a recipient vessel in eight patients who had undergone previous neck dissection and radiation therapy (n = 5). Five patients had a recurrent carcinoma, one had undergone an operation for scar release and two had been treated surgically for a second primary cancer. The anterolateral thigh flap (ALT), anteromedial thigh flap (AMT), and fibular flap were used for the reconstruction. Clinical data were recorded for each patient. RESULTS: All of the ipsilateral transverse cervical arteries were found to be free of disease. The second free flap was revascularized using the TCVs (n = 6) or the external (n = 1) or internal (n = 1) jugular vein. The free flaps used for the reconstruction included the ALT flap (n = 6), AMT flap (n = 2), and fibular flap (n = 1). All of the flaps survived without vascular events, and the patients healed without major complications. The mean follow-up time was 11 months. One patient died of distant metastases during follow-up. CONCLUSIONS: In patients who have previously undergone neck surgery with or without radiotherapy, the TCVs are reliable and easily accessible recipient vessels for microsurgical reconstruction in the oral and maxillofacial region. If the transverse cervical vein is unavailable, the internal or external jugular vein should be dissected carefully to serve as an alternative for microvascular anastomoses.

Tuberculous osteomyelitis of the mandible with diffuse swelling of the floor of the mouth: a case report.

Primary orofacial tuberculosis (TB) is uncommon, especially with regard to the jaw. We report an unusual case for which the final diagnosis was tuberculous osteomyelitis of the mandible with cervical tuberculous lymphadenitis. The follow-up examinations for our patient showed complete regression of the swelling and healing of the mandibular lesion after 4 months of TB antibiotic therapy. The purpose of the present study was to alert clinicians to our findings and encourage them to consider oral TB in the differential diagnosis for jaw lesions with multiple enlarged cervical lymph nodes.

Free flap reconstruction versus non-free flap reconstruction in treating elderly patients with advanced oral cancer.

PURPOSE: Our goal was to evaluate whether elderly patients can benefit from free flaps. MATERIALS AND METHODS: The clinical information from the included patients was reviewed, and these patients were asked to complete the University of Washington Quality of Life, version 4, questionnaire. Comparisons of the different scales between the 2 groups were performed. RESULTS: The difference in the mouth-opening width before and after surgery did not differ significantly (P = .621) in the patients with and without free flap reconstruction. However, free flap placement tended to preserve the original mouth-opening width. No significant differences were found in recurrence-free survival or disease-specific survival between the 2 groups. The mean quality of life score of the 2 groups was 77.5 ± 10.4 and 72.1 ± 10.8. Significant differences were found in the chewing domain scores between the 2 groups (P = .039). Patients with free flap reconstruction tended to score better in the appearance and taste domains (P = .073 and P = .053, respectively); however, they required longer operative times, and longer postoperative hospital stays and incurred hospital costs. CONCLUSIONS: Free flap reconstruction did not benefit elderly patients in mouth-opening width or survival analyses; the only quality of life domain that was significantly improved in patients undergoing free flap reconstruction was chewing. Free tissue transfer should be cautiously suggested for elderly patients with advanced oral cancer.

Total lower lip reconstruction with a double mental neurovascular V-Y island advancement flap.

PURPOSE: To assess the effectiveness of double mental V-Y island advancement flaps for total lower lip reconstructions. MATERIALS AND METHODS: During a 6-year period, from 2006 to 2012, total lower lip reconstruction was performed in 12 patients using double mental V-Y island advanced flaps. The resulting lip function and superiority of each flap were analyzed. To assess any cosmetic implications, patients were asked to answer the Appearance Domain section from the University of Washington Quality of Life Questionnaire at least 12 months after discharge from the hospital. RESULTS: All flaps survived completely and no short-term postoperative complications occurred. The mean follow-up time was 34.5 months (range, 15 to 69 months) and there was no recurrence of disease. All patients were capable of consuming a regular oral diet and no patients complained of an inability to eat in a public setting, drooling, or microstomia. The mean preoperative and postoperative open-mouth widths were 4.1 and 3.7 cm, respectively, and the mean reduced open-mouth width was 10%. The intercommissural width varied from 4.6 to 6.8 cm (mean, 5.5 cm). The mean postoperative 2-point discrimination was 11.2 mm (range, 9 to 13 mm). The mean score for the Appearance Domain section was 93.8 (range, 75 to 100). CONCLUSION: The mental V-Y island advancement flap reconstruction is a reliable procedure for total lower lip reconstruction.

Parotid gland metastasis of lung cancer: a case report.

BACKGROUND: Parotid gland metastasis in lung cancer is extremely rare, very few cases have been reported. CASE PRESENTATION: We report on the case of a 61-year-old Chinese male patient who presented with parotid swelling metastasizing from advanced lung cancer. We therefore performed an operation of partial parotidectomy with preservation of the facial nerve and advised the patient receive chemotherapy, however, the patient died four months later. CONCLUSION: Although it is extremely rare, a potential metastasis of lung cancer should not be ignored in the diagnosis of parotid tumor. Preoperative routine examination, such as a chest X-ray and lung computational tomography scan, may play an important role in differential diagnosis. The management of the metastatic tumor to the parotid gland was controversial however, despite combined treatment modalities, long-term survival was not attained.

Odontogenic lesions in pediatric patients.

The purpose was to evaluate our 20-year experience of pediatric odontogenic lesions. Pediatric patients with a diagnosis of odontogenic lesion were identified. Three hundred ten patients were odontogenic; dentigerous cyst was seen in 62.0% of the cases. Most (70.2%) of them occurred in mixed dentition period, and it had a male preponderance. Odontogenic keratocystic tumor occurred in the permanent dentition period. It had an equal site distribution. Odontoma was seen in 20.0% of the cases. Its site of predilection was the mandible. Ameloblastoma was the most common odontogenic tumor. Most of the cases occurred in the permanent dentition period. It affected the male and female equally. Calcifying epithelioma odontogenic tumor was seen in 11.8% of the cases. All the lesions occurred in the primary dentition period. It had no sex or site preponderance. Myxoma was seen in 3.6% of the cases. It was most common in the permanent dentition period, and it was more frequent in the male. Iliac crest bone graft was successfully performed in 28 patients, postoperative infection occurred in 2 patients, and no donor-site dysfunctions were reported. The observed differences in lesion type and distribution in this study compared with previous researches may be attributable to genetic and geographic variation in the populations studied. Iliac crest bone graft was suggested for pediatric mandible reconstruction.

Squamous cell carcinoma of the oral cavity in ever smokers: a matched-pair analysis of survival.

Smoking is associated with oral cancer, and to adopt a more healthy lifestyle, increasing numbers of people are choosing to give up the habit. However, the occurrence of oral cancer in ever smokers is still apparent. In this study, we investigated the survival of ever smokers with oral squamous cell carcinoma compared with nonsmokers and current smokers with oral squamous cell carcinoma. A matched-pair study was performed between 2005 and 2012, which matched 66 ever smoker patients with oral cancer to both current smokers and never smokers: each ever smoker was matched with 1 never smoker and 1 current smoker. A Chi-squared test was used to evaluate the significance of the variables, and the Kaplan-Meier method was used to analyze the recurrence-free survival and disease-specific survival rates. The recurrence-free survival (P = 0.006) and disease-specific survival (P = 0.027) rates were worse for ever smokers compared with never smokers, but the former group shared a similar prognosis with current smokers. The matched-pair analysis showed that smoking was associated with an approximately 2-fold increase in the risk for recurrence and 5-fold increase in risk for disease-related death. Ever smokers and current smokers had a similar chance of recurrence and disease-related death, but ever smokers had a poorer prognosis than never smokers do and they tended to have a local recurrence. The recurrence-free survival and disease-specific survival rates did not differ between ever and current smokers, and smoking cessation did not affect the chance of recurrence and diseases-related death in ever smokers compared with current smokers.

A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life.

Our study investigated the quality of life (QoL) of Chinese patients after immediate reconstruction surgery on individuals with head and neck cancer. In addition, we compared the differences between pectoralis major myocutaneous flap (PMMF) and anterolateral thigh free flap (ALTFF). The University of Washington Quality of Life questionnaire, version 4, was used to assess the QoL. Assessments were performed at least 24 months postoperatively. A total of 110 patients' records were obtained. Among them, 86 patients completed a QoL questionnaire (78.2%). No significant differences could be found in age, primary site, T stage, N stage, and postoperative radiotherapy between PMMF and ALTFF groups. However, there were significant differences between both groups in sex, operation time, and complication. A matched analysis was performed to compare the differences in QoL between patients with head and neck cancers reconstructed with PMMF or ALTFF. Patients reconstructed with ALTFF had better shoulder but worse speech functions. There was a significant effect on the QoL of head and neck cancer patients who had undergone either PMMF or ALTFF reconstruction. The result of this study provide useful information for physicians and patients during their discussion of treatment modalities for head and neck cancers.

Submental versus platysma flap for the reconstruction of complex facial defects following resection of head and neck tumors.

OBJECTIVE: To compare the platysma flap with submental flap in terms of tumor and flap characteristics, operative properties and the functional outcomes. METHODS: A total of 65 patients presented with tumors of head and neck and underwent curative tumor resection with different neck dissections at the Department of Oromaxillofacial-Head and Neck Surgery, School of Stomatology of China Medical University; from March 2005 to December 2012 were included in the study. After radical tumor excision and neck dissection the resultant complex defects were reconstructed with either platysma flap or the submental flap. The extent of surgical resection, the type of neck dissection and choice of flap reconstruction was at the discretion of the surgical team. The functional outcomes, operative time and characteristics of both platysma and submental flaps were compared and the statistical tests of significance were applied accordingly. RESULTS: The mean age was 60 years. The complex facial defects of 30 patients were reconstructed with platysma flap and of 35 patients with submental flap. Mean operation time of submental flap including flap harvesting (5.58±1.96hrs) was shorter than platysma flap (6.2±1.4hrs). The majority of the flaps (88-93%) were taken successfully in both groups. Submental flap was associated with significantly higher patients' satisfaction regarding acceptable functional outcomes (p-value 0.027). The mean reduction in mouth opening was significantly smaller in platysma group (0.37 ±0.18cms) than the submental group (0.47±0.16). CONCLUSION: This study demonstrates that both platysma and submental flap techniques can be used for the reconstruction of complex facial defects with the acceptable functional outcome. The platysma flap can be harvested to medium size defects up to 70cm(2) with good mouth opening. The submental flap is simpler, faster with a wider range of application and more acceptable functional outcomes.

Assessment of the quality of life of patients with oral cancer after pectoralis major myocutaneous flap reconstruction with a focus on speech.

PURPOSE: The aim of the present study was to evaluate the quality of life (QoL) of patients with oral cancer who had undergone resection of the tongue and floor of the mouth and reconstruction with the pectoralis major flap. MATERIALS AND METHODS: The present study assessed 21 patients who had undergone pectoralis major flap reconstruction using the University of Washington QoL, version 4, questionnaire. A nonparametric Mann-Whitney U test was used to analyze the data. RESULTS: Of the 12 disease-specific domains, the best 3 scores from the patients were for pain, saliva, and anxiety, and the worst 3 scores were for taste, chewing, and swallowing. The mean UW-QoL composite score was 73.4. Swallowing was considered to be the most important issue within the previous 7 days, followed by chewing and speech. Those patients who had undergone wider excision had poorer speech. CONCLUSIONS: A significant effect was found on the QoL of patients with oral cancer who had undergone resection of the tongue and floor of the mouth with pectoralis major flap reconstruction.

Clinical reliability of radial forearm free flap in repair of buccal defects.

BACKGROUND: The ideal method for buccal defects should provide good outcome of both function and appearance; our goal is to highlight the reliability of radial forearm flap in buccal reconstruction. METHODS: A retrospective study was conducted. From 2005 to 2012, 20 radial forearm flaps were used to repair the defects. We analyzed the superiority and reliability of the flap; in addition, we reviewed some related literature and made a comparison between radial forearm flap and platysma flap. RESULTS: All radial forearm flaps totally survived, but two flaps suffered venous obstruction, hematoma, respectively. Radial forearm flap preserved the original interincisal distance well. In our follow-up, all patients had sufficient mouth-opening width (mean: 4.3 cm). CONCLUSION: Radial forearm flap is a reliable method for buccal defect reconstruction.

Vertical platysma myocutaneous flap that sacrifices the facial artery and vein.

BACKGROUND: Platysma myocutaneous flap (PMF) is a generally used technique for defect reconstruction after an oral cancer resection. The aim of the study is to present our experience using vertical PMF that sacrificed the facial artery and vein for intraoral reconstruction. METHODS: A retrospective review of the medical records of 54 patients who underwent vertical PMF that sacrificed the facial artery and vein for intraoral reconstruction was performed. A comparison between PMF that sacrificed and that preserved the facial vessels was made, and we also compared PMF that sacrificed the facial vessels with radial forearm free flap (RFFF). Statistics concerning the patients' clinical factors were gathered. RESULTS: The mean age of the 54 patients who underwent PMF that sacrificed the facial artery and vein was 62.0 ± 10.98 years. The co-morbid disease rate of PMF was 53.7%. The flap size ranged from 12 × 5.5 cm to 7 × 5 cm. Survival of the flap was found in all of the cases, with partial necrosis in four cases (7.4%) and total loss in none of the cases. The operation time was 5.7 ± 1.17 h. The complication and success rates were 27.8% and 92.6%, respectively. The 3-year and 5-year survival rates were 77.8% (21/27) and 69.23% (9/13), respectively. The majority of the patients (87.0%) in our series were satisfied with the results of the surgery. There was no significant difference between PMF that sacrificed or that preserved the facial vessels, both in success rate (P = 1) or complication rate (P = 0.72). The patients in the PMF group were older than the patients in the RFFF group (P = 0.011), the operation time was shorter (P < 0.001), and the co-morbid disease rate was higher (P = 0.002). Although the complication rate of PMF (15/54, 27.8%) was higher than that of RFFF (2/34, 5.9%) (P = 0.011), their success rates were similar (92.6%, 94.1%) (P = 1.00). CONCLUSIONS: Vertical PMF that sacrifices the facial artery and vein has specific advantages including in ease preparation and limitations. This technique may provide an effective method for intraoral reconstruction. Our experience in handling the flap may contribute to the success rate.

Recurrent submandibular gland swelling as a first manifestation in a child with primary Sjögren syndrome.

We reported 1 case of primary Sjögren syndrome in a child. The patient complained recurrent submandibular inflammation for more than 2 years without apparent sicca presentations, and Schirmer test resulted negative. However, ultrasound showed hypoechoic areas in the gland, laboratory tests reported the positivity of Sjögren's syndrome A antigen and Sjögren's syndrome B antigen, and biopsy presented periductal lymphocytic infiltration. Therefore, a diagnosis of primary Sjögren syndrome was conducted. Treatment of it required a multidisciplinary team.