Postoperative radiotherapy versus surgery alone in pN1 oral cavity cancer patients: A meta-analysis.

Objectives: The aim of this meta-analysis is to evaluate the potential benefits of postoperative radiotherapy (PORT) in patients with pN1 oral cavity squamous cell carcinoma. Methods: A literature search through major databases was conducted until January 2023. The adjusted hazard ratio (aHR) or risk ratio (RR) with 95% confidence intervals (CIs) of different survival outcomes were extracted and pooled. Results: Ten studies published between 2005 and 2022, with a pooled patient population of 2888, were included in this meta-analysis. Due to differences in study design and reported outcomes, the studies were categorized into distinct groups. In pN1 patients without extranodal extension (ENE), PORT was associated with a significant improvement in overall survival (OS) (aHR 0.76, 95% CI: 0.61-0.94). In pN1 patients without ENE and positive margins, PORT improved OS (aHR 0.71, 95% CI: 0.56-0.89) and was associated with a lower regional recurrence rate (RR 0.35, 95% CI: 0.15-0.83). However, in pN1 patients without ENE, positive margins, perineural invasion, and lymphovascular invasion, there were no significant differences observed between the PORT and observation groups in either 5-year OS (RR 0.48, 95% CI: 0.07-3.41) or 5-year disease-free survival (RR 0.37, 95% CI: 0.07-2.06). Conclusions: The current study demonstrated that PORT has the potential to improve OS in pN1 disease. However, the decision of whether to administer PORT still hinges on diverse clinical scenarios, and additional research is necessary to furnish a more conclusive resolution. Level of Evidence: 2.

Quality-of-Life Outcomes in Oral Cancer Patients Reconstructed With Double Free Flaps: A Preoperative and Postoperative Assessment.

PURPOSE: This study aimed to evaluate quality of life (QOL) in patients with locally advanced oral cancer who underwent surgical resection followed by simultaneous double free flap reconstruction. METHODS: Institutional database was reviewed from 2015 to 2021 and prospectively collected University of Washington Quality of Life data that were extracted for patients who met the inclusion criteria. Mean, composite, and best percentage scores were computed. Wilcoxon signed rank test was used to analyze differences between groups. RESULTS: Thirteen patients completed the assessment, all of them being male with a mean follow-up of 2.2 ± 1.2 years. Most common double free flap combination was fibula osteoseptocutaneous flap and anterolateral thigh flap (n = 11). Improvement in pain ( P = 0.01) domain score with decline in speech ( P = 0.01) and taste ( P = 0.02) was noted along with an overall decline in QOL ( P = 0.001) after cancer diagnosis. A decrease in physical function was seen postoperatively. Chewing and saliva were the most cited postoperative patient-reported domain affecting QOL. CONCLUSIONS: In double free flap reconstructed patients, in the postoperative phase, pain scores improved, whereas speech and taste scores declined. The overall health-related QOL declined compared with before cancer diagnosis.

Delayed Commissuroplasty Increases Interincisal Distance in Buccogingival Cancer Patients Treated with Free Flap Reconstruction of the Oral Commissure.

BACKGROUND: Oral cavity cancers requiring excision of the oral commissure and free flap reconstruction often requires commissuroplasty to manage oral incontinence. We aimed to evaluate the implications of primary versus delayed commissuroplasty on drooling, and interincisal distance outcomes in this cohort. METHODS: A retrospective query of head and neck cancer patients operated by a single surgeon from 2017 to 2020 was performed. Patients were included if they underwent free flap reconstruction of the oral commissure, had an immediate or delayed commissuroplasty, and had 2 years of follow-up data including Thomas-Stonell and Greenberg drooling rating scales and interincisal distance measurements. RESULTS: Thirty-five patients were included in the review. Twelve patients received immediate commissuroplasty and 23 patients had delayed commissuroplasty. Interincisal distance was similar at baseline, although significantly varied between immediate and delayed commissuroplasty groups at 1 month and 2 years postoperative. Drooling scores were significantly elevated in the group treated with delayed commissuroplasty, but eventually normalized after staged surgery and follow-up. Patients treated with adjunct radiation therapy had lower interincisal distance than patients who did not have radiation. CONCLUSION: Delayed commissuroplasty increased interincisal distance and normalize drooling in patients who required full-thickness excision of the buccal mucosa and oral commissure and free tissue reconstruction. The presented data can help to educate patients on expected postoperative outcomes and likely advocates for a second-stage procedure after completion of adjunct radiotherapy to achieve optimal commissural placement and oral competence.

"Submarine-Shaped" Radial Forearm Flap for Simultaneous Reconstruction of Oral and Lower Lip Defects".

BACKGROUND: Reconstruction of the oral cavity commonly results in trismus and lip incompetence. AIM AND OBJECTIVES: In this study, we aim to describe an innovative design of a radial forearm free flap for resurfacing bilateral buccal defects and simultaneous functional lower lip reconstruction in a single stage. MATERIALS AND METHODS: Between January 2010 and December 2019, 6 males underwent simultaneous buccal and lower lip reconstruction with a radial forearm free flap. The mean age of the patients was 57.3 years (range, 50-68 years). The defects were caused by trismus release and due to previous treatments. The mean size of the defects was 17.9 cm in length and 3.25 cm in width. Flaps were harvested, including the proximal perforators of the radial vessels, and the inset began in the buccal area opposite the anastomosis side. RESULTS: Flap size ranged from 16 to 21 × 2 to 4 cm. The recipient vessels used were the superficial temporal (4) and facial (2). All flaps survived. Lip infection was seen in 2 cases and managed conservatively. The mean follow-up was 19.2 months (range, 12-28 months). The mean increase in the interincisal distance was 10.7 mm. Oral continence was good in all patients. Speech intelligibility was considered total in 4 patients and partial in the remaining 2. CONCLUSION: The radial forearm flap constitutes an option for simultaneous lower lip reconstruction and resurfacing of bilateral buccal areas after trismus release. The procedure provides a thin and pliable reconstruction using only 1 donor site and 1 set of recipient vessels.

Comparison between a novel salivary marker and several clinical prognosticators in oral cavity cancer.

Objectives: This study aimed to investigate the association between salivary matrix metalloproteinase-1 (MMP-1) and clinicopathological parameters of oral cavity squamous cell carcinoma (OSCC) and compare the prognostic efficacy of salivary MMP-1 and other established circulating markers for OSCC. Methods: Saliva specimens from 479 OSCC subjects were examined using an enzyme-linked immunosorbent assay. The area under the curve (AUC) values of salivary MMP-1 and other markers were calculated, and survival analyses were conducted using Kaplan-Meier and multivariate regression methods. Results: Salivary MMP-1 showed good discrimination in predicting overall survival, with an AUC of 0.638, which was significantly higher than that of albumin (0.530, p = .021) and Charlson comorbidity index (0.568, p = .048) and comparable with neutrophil-to-lymphocyte ratio (0.620, p = .987), platelet-to-lymphocyte ratio (0.575, p = .125), and squamous cell carcinoma antigen (0.609, p = .605). Elevated levels of salivary MMP-1 were significantly associated with higher pT classification, pN classification, overall pathological stage, positive extranodal extension, tumor differentiation, positive lymphovascular invasion, positive perineural invasion, and tumor depth (p all <.05). Multivariate analyses indicated that a higher level of salivary MMP-1 (≥2060.0 pg/mL) was an independent predictive factor of poorer overall survival (adjusted hazard ratio: 1.421 [95% confidential interval: 1.014-1.989], p = .041). Conclusion: The study found that the salivary MMP-1 level was significantly associated with many adverse clinicopathological parameters of OSCC. In OSCC, it was found to have superior efficacy in predicting prognosis and was an independent prognostic factor of post-treatment outcome. Level of evidence: 3.

Microsurgical Reconstruction of Extensive Lower Lip Defects: An Algorithm for Free Flap Selection and Functional Outcomes.

BACKGROUND: Large defects of the lower lip pose a difficult challenge for any reconstructive surgeon. When there is limited local tissue available to resurface the defects, free flaps are the preferred option. AIM AND OBJECTIVES: We reported our experience in the reconstruction of extensive lower lip defects. The authors propose a new algorithm for microsurgical technique selection and assessment of the functional outcomes obtained. MATERIALS AND METHODS: A retrospective review of all microsurgical reconstructions of extensive lower lip defects by the senior author for 10 years was performed. The functional outcomes assessed included speech, feeding, and oral continence. Patients were stratified according to their status of simultaneous mandible resection (none, marginal, segmental). RESULTS: Fifty-one patients were included in this study. Almost all patients (96.1%) achieved intelligible speech. Only 1 patient experienced severe drooling. Most patients could eat a solid or soft diet (72.5%). Mandible resection was associated with the worst feeding outcomes. CONCLUSIONS: Microsurgical reconstruction of extensive lip defects is safe and provides good results. Free flap selection should take into account the location of the defect, the resected structures, and the body mass index of the patient. Feeding status seems to be inversely correlated with the amount of mandibular resection.

Quantization of extraoral free flap monitoring for venous congestion with deep learning integrated iOS applications on smartphones: a diagnostic study.

BACKGROUND: Free flap monitoring is essential for postmicrosurgical management and outcomes but traditionally relies on human observers; the process is subjective and qualitative and imposes a heavy burden on staffing. To scientifically monitor and quantify the condition of free flaps in a clinical scenario, we developed and validated a successful clinical transitional deep learning (DL) model integrated application. MATERIAL AND METHODS: Patients from a single microsurgical intensive care unit between 1 April 2021 and 31 March 2022, were retrospectively analyzed for DL model development, validation, clinical transition, and quantification of free flap monitoring. An iOS application that predicted the probability of flap congestion based on computer vision was developed. The application calculated probability distribution that indicates the flap congestion risks. Accuracy, discrimination, and calibration tests were assessed for model performance evaluations. RESULTS: From a total of 1761 photographs of 642 patients, 122 patients were included during the clinical application period. Development (photographs =328), external validation (photographs =512), and clinical application (photographs =921) cohorts were assigned to corresponding time periods. The performance measurements of the DL model indicate a 92.2% training and a 92.3% validation accuracy. The discrimination (area under the receiver operating characteristic curve) was 0.99 (95% CI: 0.98-1.0) during internal validation and 0.98 (95% CI: 0.97-0.99) under external validation. Among clinical application periods, the application demonstrates 95.3% accuracy, 95.2% sensitivity, and 95.3% specificity. The probabilities of flap congestion were significantly higher in the congested group than in the normal group (78.3 (17.1)% versus 13.2 (18.1)%; 0.8%; 95% CI, P <0.001). CONCLUSION: The DL integrated smartphone application can accurately reflect and quantify flap condition; it is a convenient, accurate, and economical device that can improve patient safety and management and assist in monitoring flap physiology.

A Comparison Study of Outcomes and Complications Between Marginal Mandibulectomy With or Without Additional Mandibulotomy in Tongue Cancers.

BACKGROUND: Marginal mandibulectomy with or without additional mandibulotomy could represent the alternatives to avoid segmental mandibulectomy in carefully selected tongue cancers. AIM AND OBJECTIVES: This study investigated a subgroup of tongue cancers with suspected involvement to the alveolar bone because of the shallow and deformed mouth floor. We aimed to compare the functional outcomes, postoperative complications, and disease control efficacy between the 2 different marginal mandibulectomy approaches, with or without additional mandibulotomy. MATERIALS AND METHODS: A retrospective study of 29 marginal mandibulectomies and 26 combined mandibulotomies for tongue cancer wide excisions and flap reconstruction at Chang Gung Memorial Hospital Linkou Branch during 2014 to 2019 was performed. RESULTS: The combined mandibulotomy group had more advanced T-status ( P < 0.001) and greater tumor diameters ( P < 0.001) but not increased preexisting trismus, bone invasions, or positive margins. The additional mandibulotomy increased flap necrosis ( P = 0.044), late infections ( P = 0.004), and tongue movement limitations ( P = 0.044) but not osteoradionecrosis. Osteoradionecrosis was unrelated to the resected mandibular length or the mandibulotomy sites. Feeding tube dependence was greater in the combined group at discharge ( P = 0.014), but no long-term differences were noted. Kaplan-Meier overall survival ( P = 0.052) and disease-free survival ( P = 0.670) were both comparable between the 2 groups. CONCLUSIONS: The combined procedure of mandibulotomy and marginal mandibulectomy in large tongue cancers without bone invasions is associated with increased soft tissue-related complications but not bone-related complications. However, comparable disease control, survival, and long-term tube feeding outcomes were noted.

Discovering the Clinical and Prognostic Role of Pan-Immune-Inflammation Values on Oral Cavity Squamous Cell Carcinoma.

A newly introduced pan-immune-inflammation value (PIV) was not evaluated for its role in oral cavity squamous cell carcinoma (OSCC). In this study, the PIV was calculated with the following equation (neutrophil count × platelet count × monocyte count)/lymphocyte count from the results of the automated hematology analyzers in 853 OSCC patients from 2005 to 2017. The optimal cutoff for the preoperative PIV was 268, as determined by a receiver operating characteristic curve. Significant differences were observed for alcohol consumption, smoking, pT status, pN status, overall pathological status, extranodal extension, cell differentiation, depth of invasion, and perineural invasion between higher and lower PIV patients (all p values < 0.05). Kaplan-Meier and univariate regression analyses indicated that higher PIV was associated with worse overall survival, disease-free survival, locoregional recurrence-free survival, and distant metastasis-free survival (all p values < 0.001). Multivariate analyses adjusted by various factors further demonstrated that PIV was an independent prognostic factor for overall and distant metastasis-free survival (p = 0.027, HR: 1.281 and p = 0.031, HR: 1.274, respectively). In conclusion, a higher PIV level was associated with poor clinicopathological factors in OSCC patients and could be used to predict poor posttreatment outcomes, especially for overall and distant metastasis-free survival.

Plasma Matrix Metalloproteinase-1 as a Prognostic Biomarker in Oral Cavity Squamous Cell Carcinoma.

Purpose: Plasma matrix metalloproteinase-1 (MMP-1) is a collagenase encoded by the MMP-1 gene. However, the prognostic value of plasma MMP-1 levels in oral cavity squamous cell carcinoma (OSCC) has yet to be elucidated. The study is the first to use a cohort of OSCC patients to assess the association of plasma MMP-1 levels with clinicopathological factors/survival outcomes in OSCC patients. Patients and Methods: A total of 677 patients were retrospectively enrolled, including 276 oral potentially malignant disease (OPMD) and 401 OSCC patients from 2013 to 2021. Pretreatment plasma MMP-1 levels were measured with an enzyme-linked immunosorbent assay, and the values were compared between OPMD and OSCC patients. Furthermore, the association of plasma MMP-1 levels and clinicopathological characteristics/survival outcomes in OSCC patients was investigated. Results: Plasma MMP-1 levels were significantly higher in OSCC patients than in OPMD patients (p = 0.04). In the OSCC group, plasma MMP-1 levels were significantly higher in females, tumor depth ≥10 mm, advanced pT classification and advanced overall stage (p = 0.04, <0.001, <0.001, 0.002, respectively). Higher plasma MMP-1 levels were significantly associated with poorer overall, disease-specific, disease-free, locoregional recurrence-free and distant metastasis-free survival (p = 0.003, 0.02, 0.005, 0.01, 0.001, respectively). Multivariate analysis revealed that plasma MMP-1 levels were a significant predictor for overall, disease-free, and distant metastasis-free survival (p = 0.03, 0.02, and 0.010, respectively). Conclusion: Plasma MMP-1 levels are associated with more severe clinicopathological manifestations and can also be regarded as a significant prognostic factor for OSCC posttreatment outcomes.

Current Concepts for Reconstruction of Oral Tissues Following Ablative Surgery: A Comprehensive Approach.

Appropriate concepts of reconstruction can eliminate contraindications, reduce the incidence of complications, increase the success rates, and promote the outcomes. Besides, appropriate concepts can also help economical use of expensive technology or assistant tools on the patients who are necessary and beneficial. This paper provides a comprehensive approach to select reconstructive methods for oral defects following ablative surgery. A comprehensive approach should have a thorough understanding of the reconstructive goals, the patient's information, the surgeon's ability, and the hospital's support. To achieve a basic structural and functional restoration of oral cavity, "reconstruction ladder" could be skipped to free flap transfer. Goal-oriented thinking process with rethinking the feasibility assessment can help the surgeon to find the most appropriate method of reconstruction. Appropriate methods can mostly achieve the above-average results and rarely lead to inadequate results. Current concepts for reconstruction of oral tissue are the balance between maximal outcome and minimal complication, maximal accuracy and minimal cost, maximal efficacy and minimal investment. A comprehensive approach to select flap, a reliable method to harvest flap, and a customized flap design/inset are keystones to achieve a relatively better outcome. The awesome of limitations from the surgeon's ability, hospital's support, and the patient's condition can minimize the complications.

Venous Size Discrepancy Is a Critical Factor When Using Superficial Temporal Vessels as Recipient Vessels for Free Flaps.

BACKGROUND: Superficial temporal vessels have been used successfully as recipient vessels for head and neck reconstruction. This study evaluates the impact of several treatment variables on flap failure and take-back rate when using these recipient vessels. METHODS: We conducted a retrospective study of all microsurgical reconstructions using superficial temporal vessels as recipient vessels in a period of 10 years. Variables collected included previous treatments (radiotherapy, chemotherapy, neck dissection, free flap reconstruction), type of flaps used (soft tissue, osteocutaneous), and vessel size discrepancy between donor and recipient vessels. RESULTS: A total of 132 patients were included in the study. The flap success rate was 98.5%. The take-back rate was 10.6%. The most frequent reason for take-back was venous congestion secondary to thrombosis. None of the studied variables was associated with flap failure. Reconstructions using osteocutaneous flaps and vein diameter discrepancy (ratio ≥ 2:1) had significantly higher take-back rates. CONCLUSION: Flaps with a significant size discrepancy between donor and recipient veins (ratio ≥ 2:1) and fibula flaps (compared with soft tissue flaps) were associated with a higher risk of take-back. It is crucial to minimize venous engorgement during flap harvest and anastomosis, and limit vein redundancy during flap in-setting.

Two-Layer Palatal Reconstruction Reduces Postoperative Intraoral Complications in Head and Neck Surgery.

BACKGROUND: Although microvascular free flaps are commonly performed and have high success rates, postoperative oronasal fistulas or infections do occur. The authors hypothesized that a two-layer closure is effective for prevention of intraoral complications. METHODS: Patients who underwent palatal reconstruction with a microvascular free flap were evaluated retrospectively. The cases were divided into two groups (palatal reconstruction with or without a two-layer closure). A two-layer closure involves unilateral reconstruction with a free flap, then reconstruction of the nasal lining with a local flap or folding free flap. The postoperative complication rates between these two groups were compared. RESULTS: One hundred fifty-five cases were evaluated. A two-layer closure was performed in 65 cases (41.9 percent). The incidence of infections, dehiscence of the recipient site, and oronasal fistula were significantly higher in the single-layer closure group than in the two-layer closure group [10.0 percent versus 0 percent (p = 0.011); 15.6 percent versus 4.6 percent (p = 0.036); and 17.8 percent versus 4.6 percent (p = 0.013), respectively]. CONCLUSIONS: A two-layer closure in palatal reconstruction was shown to reduce the rate of infection, intraoral wound dehiscence, and oronasal fistula in the current study. A two-layer closure provides greater support and stability and reduces the risk of failure in reconstruction of the palate with a microvascular free flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Prognostic Value of Lymph Node Burden in Oral Cavity Cancer: Systematic Review and Meta-Analysis.

OBJECTIVES: Lymph node burden has been proposed to estimate the cumulative adverse effect of nodal metastasis. In this study, a meta-analysis was conducted to evaluate the prognostic value of lymph node burden in oral cavity squamous cell carcinoma. STUDY DESIGNS: Systemic review and meta-analysis. METHODS: PubMed, EMBASE and the Cochrane Library as well as manual searches were performed until April 2020. The adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of overall survival, disease-specific survival, and disease-free survival were extracted and pooled. RESULTS: Eleven included studies were published between 2009 and 2019. The cumulative number of patients was 20,607 (range 35-14,554). Extranodal extension was adjusted or evaluated in all of the studies. The meta-analysis indicated that a higher lymph node burden was significantly related to worse overall survival (HR 2.62, 95% CI 2.12-3.25), worse disease-specific survival (HR 3.14, 95% CI 1.85-5.33) and worse disease-free survival (HR 2.30, 95% CI 1.62-3.26). The highest hazard ratio was observed when the cutoff value was 3 for overall survival, 3 for disease-specific survival, and 4 for disease-free survival. The hazard ratio showed an upward trend before the cutoff value of 3 but no significant incremental change when the cutoff exceeded 3. CONCLUSIONS: In oral squamous cell carcinoma, lymph node burden is an independent prognosticator for survival outcomes. However, more prospective or high-quality studies are required to determine the optimal cutoff. LEVEL OF EVIDENCE: NA Laryngoscope, 132:88-95, 2022.

The role of postoperative radiotherapy in pN1 oral cavity cancer without extranodal extension.

BACKGROUND: The administration of postoperative radiotherapy remains controversial in pN1 oral cavity cancer patients without extranodal extension. The aim is to determine whether postoperative radiotherapy reduces the neck recurrence rate and improves the survival outcomes of pN1 patients. METHODS: This study consecutively enrolled 1056 patients with newly diagnosed oral squamous cell carcinoma who underwent tumor wide excision and neck dissection from September 2002 to November 2019. One hundred two pN1 patients without extranodal extension were eligible for analysis. Then, a subgroup analysis of 40 patients was performed after patients with other adverse risk factors (positive margins, close margins, lymphovascular invasion, perineural invasion, tumor depth ≥ 10 mm, and poor histological differentiation) were excluded. RESULTS: Of the 102 eligible pN1 patients, 26 patients received surgery alone, and 76 received postoperative radiotherapy. No significant differences were observed in the neck recurrence rate (7.7% vs. 15.8%, p = 0.30). Similarly, in patients without other adverse risk factors, no significant differences were observed in the neck recurrence rate (5% vs. 20%, p = 0.15) between surgery alone group and postoperative radiotherapy group. Moreover, no significant difference was found in the neck recurrence-free survival rate, overall survival, and disease-specific survival (77.1% vs. 52.5%, p = 0.42, 83.5% vs. 64.5%, p = 0.81, and 88.2% vs. 67.9%, p = 0.34, respectively). CONCLUSION: Postoperative radiotherapy did not significantly decrease the probability of neck recurrence and survival outcomes in pN1 patients without extranodal extension. Radical surgery alone may be considered sufficient treatment for pN1 patients without other adverse risk factors.

The "Safe Index" Considering Body Surface Area for Prolonged Dexamethasone Regimen in Airway Control After Head and Neck Microsurgical Reconstruction.

BACKGROUND: Dexamethasone (Dexa) is frequently administrated to patients receiving head and neck microsurgical reconstruction with nasotracheal intubation postoperatively for airway control. Infection is the greatest concern when prolonging the treatment course. We aimed to find out the relationship between flap infection and the safe dose of Dexa. MATERIALS AND METHODS: A retrospective review of enrolling total 156 patients underwent microsurgical free flap reconstruction for head and neck cancers with nasotracheal intubation from December 2015 to December 2016 was conducted. Among them, 139 patients had received prolonged Dexa treatment course (>2 days). Safe index was then defined as the total amount of used Dexa (in milligrams) over body weight (in kilograms), body mass index (in kilograms per square meter) and body surface area (BSA, in square meter). Statistics were performed for the cutoff level of the safe index and to find out the independent risk factors. RESULTS: The cutoff level of the safe index was 0.76 for body weight group, 2.28 (10-3 m2) for body mass index group, and 33.84 mg/m2 for BSA group. Safe index for BSA group also outweighed other risk factors in multivariant analysis (odds ratio = 6.242, 95% confidence interval = 2.292-17.002, P = 0.000), which is the only independent risk factors for flap infection in our cohort. CONCLUSIONS: Throughout our study, the "safe index" helps clinician easily predict flap infection risk when using Dexa as the medication for airway control after head and neck microsurgical reconstruction.

Musculoseptocutaneous Perforator of Anterolateral Thigh Flap: A Clinical Study.

BACKGROUND: The anterolateral thigh flap is one of the most useful workhorse flaps for microsurgical reconstruction. However, it can pose a great challenge to surgeons because of its anatomical variability. As the technology advances, not only septocutaneous or musculocutaneous courses of anterolateral thigh perforators but also a hybrid musculoseptocutaneous perforator pattern have been identified on computerized imaging and on cadaveric study. However, there is a paucity of clinical study in the literature. The aim of this investigation was to identify the features of this pattern. METHODS: All patients undergoing anterolateral thigh flap harvest between September of 2017 and May of 2018 performed by a single surgeon are included. Every pulsatile perforator was dissected to document its location on the thigh, emerging location (septum/muscle), size, course, and origin. RESULTS: Thirty-seven patients with 115 perforators were identified. Ten percent of perforators were septocutaneous, 37 percent were musculoseptocutaneous, and 52 percent were musculocutaneous. Forty-seven percent of perforators emerged on the septum between the rectus femoris and the vastus lateralis. Eighty-one percent of patients had one or more perforators in the "hot zone." Medium and large perforators were more frequently located in the proximal and hot zones. All perforators originated from the vascular tree of the lateral circumflex femoral artery, with 10 percent originating from the transverse branch, 28 percent originating from the oblique branch, and 62 percent originating from the descending branch. CONCLUSIONS: A high proportion of musculoseptocutaneous perforators were identified. The clinical relevance of this is to be very cautious on the skin paddle design while harvesting the flap.

The Benefits of the Supercharged Ileocolic Flap in Patients Who Underwent Total Esophagectomy and Gastrectomy.

BACKGROUND: Patients who undergo total esophagectomy and gastrectomy present a challenging scenario for reconstructive surgeons. Several techniques have been described. However, the best choice is still a matter of debate. We aim to report our experience with the supercharged ileocolic flap, then to compare the long-term functional outcomes in cancer and caustic injury patients. We investigate the safest route of transposition and demonstrate the importance of supercharging the flap. Last, we perform a literature review to compare our results with the ones reported in the literature. METHODS: A total of 36 patients underwent the supercharged ileocolic flap procedure. The details reviewed included the type of defect, flap characteristic, route of transposition, complications, patient survival, and swallowing evaluation. Survival and long-term function preservation were considered as the main outcomes. A secondary end-point was the identification of the safest route of transposition. We extracted the pertinent literature on supercharged bowel flaps from 1995 to July 2020 RESULTS: All flaps survived; only two flaps were partially lost. Thirty-three percent of the cohort experienced postoperative complications; the most common was leakage of the cervical anastomosis (17%), followed by neck wound infection (8%). The 5-year dysphagia-free survival rate was 87% in corrosive injury patients and 78% in cancer patients. The mean time to be free from dysphagia after surgery was 25.12 ± 4.55 months for corrosive patients and 39.56 ± 9.45 months for cancer patients (p = 0.118). The safest route of transposition was retrosternal extra-mediastinal. From the literature review, the data from 11 studies were extracted. CONCLUSION: The supercharged ileocolic flap is a robust option for total esophageal replacement when the stomach is not available and the retrosternal route is the safest for transposition. The functional outcomes are excellent, with acceptable morbidity and a good life expectancy, either in cancer and noncancer patients. Supercharging the flap is recommended.

Complication analysis of three different designs of temporary mandibulotomy in tongue cancer treatment.

BACKGROUND: Mandibulotomy helps access posterior oral cavity tumors. If osteotomy designs affect postoperative and postradiotherapy complications, needs to be tested clinically. METHODS: Two hundred and eighteen patients who underwent midline mandibulotomy for primary tongue cancer wide excision and flap reconstruction at Chang Gung Memorial Hospital during 2014-2019. RESULTS: There were 114 straight, 54 notched, and 50 stair-stepped osteotomy cases. Stair-stepped osteotomy had less advanced tumor stages (P = .009) and notched osteotomy more common single-plate fixations (P = .012). The former showed higher mandibular heights (P = .000) and more intact midline teeth (P = .011) than notched and straight ones. Straight osteotomy cases showed lower early infection rates (P = .039). Single-plate fixation was related to more flap dehiscence (P = .001) and oro-cutaneous fistulas (P = .035). CONCLUSIONS: Complex osteotomy does not offer long-term benefits in midline mandibulotomies for primary tongue cancers and has higher early infections. Single-plate fixation increases postoperative complications.