Oral functional outcome after intraoral reconstruction with nasolabial flaps

Transcription

1 The British Association of Plastic Surgeons (2004) 57, Oral functional outcome after intraoral reconstruction with nasolabial flaps E.I. Hofstra a, S.O.P. Hofer b, *, J.M. Nauta c, J.L.N. Roodenburg c, D.H.E. Lichtendahl a a Department of Plastic Surgery, University Hospital Groningen, Groningen, The Netherlands b Department of Plastic, Reconstructive and Hand Surgery, Erasmus University Medical Center Rotterdam, P.O. Box 2040, Rotterdam 3000, The Netherlands c Department of Oral and Maxillofacial Surgery, University Hospital Groningen, Groningen, The Netherlands Received 28 February 2003; accepted 7 November 2003 KEYWORDS Nasolabial flap; Oral function; Tumor surgery; Floor of mouth; Intraoral reconstruction Summary In this study, the functional and aesthetic outcome of patients with nasolabial flaps in the floor of the mouth was examined. Sixteen patients underwent reconstruction of the floor of the mouth with 19 nasolabial flaps after resection of a squamous cell carcinoma. Eight patients received postoperative radiotherapy. The patients were questioned concerning oral disabilities. Speech, mastication, deglutition, oral continence and the aesthetic result were evaluated. Two-point discrimination, temperature sensation and blunt-sharp discrimination of the intraoral flaps were tested. Speech and the wearing of dentures were hardly affected. Consumption of solid foods caused moderate problems in half of the patients. No sensibility problems were found. The aesthetic deformity was minimal. The use of nasolabial flaps in patients with limited defects of the anterior floor of the mouth after tumor resection showed adequate functional and aesthetic results. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. The nasolabial flap is a type C fasciocutaneous flap based on the underlying angular artery. 1 It provides a good reconstructive option for regional intraoral defects of limited dimensions. Advantages are the relatively easy and short operative procedure compared to other reconstructive techniques, whereas its aesthetic deformity of the donor site is minimal. 2 4 The reliability of nasolabial flaps has *Corresponding author. Tel.: þ ; fax: þ address: sophofer@hotmail.com been reported previously, 5 7 but little has been mentioned about oral function. Rökenes et al. 8 found few complaints of oral function cosmetic outcome in a group of 10 patients after reconstruction with nasolabial flaps. After healing, the mobility of this flap is limited. Therefore, in the present study, the functional and aesthetic outcome of patients with nasolabial flaps in the floor of the mouth was examined: oral function (speech, mastication, deglutition), sensibility and aesthetic appearance were evaluated. S /$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps

2 Oral functional outcome after intraoral reconstruction with nasolabial flaps 151 Patients and methods Between 1990 and 1998, 53 patients at the University Hospital Groningen had a reconstruction of the floor of the mouth with nasolabial flaps after tumor resection. Sixteen patients with unilateral or bilateral reconstruction of the floor of the mouth were included in this study. Thirty-seven patients were not available for follow-up: 25 died, nine had tumor-recurrence with secondary reconstruction and three had moved. The study group consisted of nine male and seven female patients with an average age of 56 years (range years; median 55 years) at the time of operation. All patients were diagnosed with squamous cell carcinoma of the floor of the mouth. Prior to operation, seven patients had natural teeth in the mandible and nine patients were edentulous. During surgery, a mandibular dental extraction was performed in five patients, including the edentulous maxilla patient. Eight patients were treated with surgery alone and eight patients needed subsequent radiotherapy (70 Gy at the primary tumor site). Surgical resection of the tumor was combined with a neck-dissection in 14 cases. The defects of the floor of the mouth were closed in a two-stage procedure with inferiorbased nasolabial flaps sized according to the defects in all cases (Fig. 1(A) (D)). In one case, a partial resection of the tongue was performed and in nine cases a marginal resection of the mandible was necessary. In 13 patients the defects were closed with single flaps (nine left, four right). In three patients bilateral nasolabial flaps were used. All bilateral flaps were used for defects extending across the midline. Defects were always closed with a combination of primary closure and nasolabial flaps. None of the defects could be closed primarily. Skin grafting was never performed. Nasolabial flaps offer good skin quality and were used to provide a wider sulcus or a more mobile tongue. The followup averaged 4 years 8 months (range: 1 year 4 months 9 years) at the time of the study (Table 1). All patients were questioned about the quality of life after reconstruction of their oral defects with nasolabial flaps. For this purpose, a previously validated questionnaire was used, concerning oral disabilities. Speech, mastication and deglutition, oral continence and the aesthetic result were evaluated (Appendix A). Questions could be answered on a five point scale with 1 being excellent and 5 being poor. The sensibility of the nasolabial flaps was tested by means of two-point discrimination (range 4 14 mm), temperature sensation (hot cold) and blunt sharp discrimination. Two-point discrimination Table 1 Demographic data of study patients Stage of tumor Donor site Radiotherapy Marginal mandibula resection/partial glossectomy Tumor location Follow-up (months) Patient Sex Age at operation (years) 1 F pt2n2b Left Yes Floor of mouth, left 2 M T2N0 Left Yes Floor of mouth, left 3 F T1N0 Right No Mandibularesection Floor of mouth, right lingual 4 M pt4n1 Right Yes Mandibularesection Floor of mouth, right 5 M T3N0 Bilateral Yes Mandibularesection Floor of mouth/gingiva, anterior 6 M T2N1 Left Yes Floor of mouth, left paramedian 7 M T2N0 Left No Mandibularesection Gingiva, left 8 M T2N0 Left No Partial glossectomy Floor of mouth, left paramedian 9 F T2N0 Left No Mandibularesection Floor of mouth/gingiva, left 10 F pt2n0 Left No Floor of mouth, left lingual 11 F T2N0 Bilateral Yes Mandibularesection Floor of mouth, anterior 12 M ct2n0 Left No Floor of mouth, anterior 13 F T4N2b Right Yes Mandibularesection Floor of mouth, right 14 M pt2n0 Bilateral No Mandibularesection Floor of mouth/gingiva, anterior 15 M T4N2a Right Yes Mandibularesection Floor of mouth, right 16 F T1N0 Left No Floor of mouth, left

3 152 E.I. Hofstra et al. Figure 1 (A) Intraoral defect right anterior floor of the mouth. (B) Raised nasolabial flap on right side. (C) Nasolabial flap in anterior floor of the mouth defect. (D) Intraoral flap after division of the pedicle at 3 weeks. of the flaps was tested in 12 patients (14 flaps). This was compared to the sensibility of the cheek skin adjacent to the donor area in six patients. For this purpose, custom-made two-point discriminators were developed. For hot cold discrimination, small warm and cold iron bars were used. Blunt sharp discrimination was performed with regular neurologic pins. Results Dentition In the patients with a natural dentition, there was sufficient space for interposition of the flap.

4 Oral functional outcome after intraoral reconstruction with nasolabial flaps 153 Speech Eleven patients found their speech unchanged. Five patients said their speech had changed moderately to very much since the operation. Eleven patients had little or no pronunciation problems. Five patients experienced problems with pronunciation. Thirteen patients thought their clarity of speech was excellent or good; three patients found their speaking unclear. Intelligibility in a dialogue, telephone or group conversation were regarded as excellent or good by the majority of patients (respectively, 14, 11 and 9 patients) and moderate by the others. Hardly any of the patients avoided a dialogue, telephone conversation or group conversation (respectively, 1, 2 and 3 patients). Mastication and deglutition Nine patients had little or no problems with the consumption of food. Seven patients had considerable problems with masticating solid foods. Thirteen patients did not have to adapt their meals. Thirteen of the 16 patients had no problems swallowing any food. Three patients had some trouble swallowing solid food of whom one had problems swallowing mashed food and liquids. In this last case the tongue was partly immobile. The other two patients underwent dental extraction, experienced loss of sensibility of the tongue and suffered from xerostomia due to radiation. Minor problems with wearing of dentures were found postoperatively. One patient complained about a looser fit of his dentures and one patient did not wear dentures because of swallowing problems. Another patient claimed that the function of his dentures improved since the procedure, because of the better care that was given by the prosthodontist. Ten patients suffered from xerostomia of who eight had received radiotherapy postoperatively. Oral continence Oral incontinence was not a major problem, but occurred in four patients. Drooling during the day was a problem for two patients, due to a loss of sensibility in the lips. One patient had problems with oral incontinence during eating and speaking, and another during drinking. Sensibility All patients claimed to feel the food in their mouth excellent/well (13 patients) or moderately well (three patients). Two-point discrimination showed sensibility of the transposed flaps comparable to the original cheek (range 4 12 mm (intraoral flap) and 6 14 mm (cheek)) in four patients. In three of these patients the sensibility of the intraoral flap was even slightly better than the sensibility of the cheek. Seven patients had protective sensibility of the intraoral flap, but this could not be measured in mm. One patient had no sensibility of the intraoral flap. Testing for temperature sensation and blunt sharp discrimination provided no reproducible data. Aesthetic outcome Aesthetic outcome was judged as good by 12 patients and moderate by three. One patient was not satisfied. Nine patients said there was little or no change in their appearance since the operation. Seven patients noted some change. The three patients with bilateral flaps did not score differently from the group with unilateral flaps. The donor site scar was not considered disturbing by any of the patients. The overall score for functional outcome in 16 patients averaged 1.5 (range ). The overall score for aesthetic outcome in 16 patients averaged 1.6 (range ). Discussion The aim of this study was to determine whether closure of small defects of the anterior floor of the mouth after tumor surgery with nasolabial flaps caused significant problems with oral function, speech or appearance. It was hypothesised that the use of nasolabial flaps for these defects would not cause significant functional or aesthetic problems. In order to study this hypothesis, 16 patients who had received an anterior floor of the mouth reconstruction, with nasolabial flaps were questioned about their current situation. The indication for using a nasolabial flap in floor of the mouth reconstruction is on a sliding scale. There is not a fixed size defect that needs either a primary closure, a nasolabial flap or a free flap. It is important to evaluate the depth of the sulcus for future dental restoration and mobility of the tongue for speech and deglutition when considering intraoral reconstruction. Similar size defects in different patients will require different reconstructive procedures. Especially in smaller to medium size defects that do not cross the midline a marginal mandibular resection in combination with a nasolabial flap can be a sound option. In our institution,

5 154 E.I. Hofstra et al. the entire range from primary closure to free flap reconstruction has been available during the entire study period. In the study, patients with the nasolabial flap were chosen as the best option for reconstruction. It would be interesting to compare the study group with a group of patients that had received primary closure or free flap reconstruction for similar defects. In our institution, these other groups represent completely different defects, which would add considerable bias to comparison. Another argument against nasolabial flaps would be that surgical margins were most likely to be positive because of the limited size of the flap. In our institution, however, tumor resection is performed by a different team than the defect reconstruction and a radical excision is always the main goal. Speech was hardly affected. Almost all patients could be well understood after the procedure. Five patients felt that speech had changed, but only three of them experienced moderate problems with speaking. The minor change in intraoral proportions by the nasolabial flaps, in combination with a mobile tongue, is probably to be credited for the good outcome in speech results. In this study, only three patients had moderate problems with swallowing solid food. Deglutition is mainly a function of the tongue base. Anterior tongue mobility is maintained by the interposition of nasolabial flaps in the closure of floor of the mouth defects, which helps to manipulate food towards the back of the oral cavity. Good anterior tongue mobility will be a major contributor to the absence of major swallowing problems. These findings agree with the conclusion of Konstantinović and Dimić, 9 that articulatory function and tongue mobility were good in patients reconstructed with local flaps. In patients, who received radiotherapy, xerostomia was an additional factor complicating oral function. The fact that oral function was good in radiated patients is additional evidence that nasolabial flaps are a valuable adjunct for intraoral reconstruction. Radiotherapy in the head and neck region causes xerostomia and salivary production problems. 10 Mutimer et al. 7 found that only few patients wore dentures postoperatively, because they were unstable and uncomfortable. In our study, only one patient complained of unstability. Good care by the prosthodontist appears to be important for a good fit of the dentures. Dental implants may also improve the function of dentures. 11,12 Finlay et al. 13 also emphasise in their study the importance of well fitting dentures for returning to a solid diet. As with other functional criteria, oral incontinence after closure of defects of the floor of the mouth with nasolabial flaps was not a major problem. Disturbed sensibility in the lower lip due to the ablative procedure and fixation of the tongue seemed to be important causes of oral incontinence. Testing sensibility of the intraoral nasolabial flap proved to be difficult because of anxiety of patients with foreign objects in their mouth. The flaps in this study are so small that determination of a valid twopoint discrimination is questionable. Still, the results indicate that sensibility of nasolabial flaps in the mouth can recur to at least the same level as the sensibility of the donor area. This phenomenon of reinnervation by surrounding tissues has been described by others for intraoral flaps. 14,15 The results of the questionnaire showed that the patients had no problems associated with sensibility in the mouth. The use of nasolabial flaps is an aesthetically pleasing procedure. The change of appearance is minimal and very acceptable for the patients. Conclusion The overall good to excellent functional outcome in the use of nasolabial flaps in patients, with very limited defects in the anterior floor of the mouth, after tumor resection proves the efficiency of this reconstructive technique. The subjective opinion of the patient is at least as important as an objective measurement of the oral function. Appendix A. Questionnaire Speech Do you have trouble speaking clearly? Has your speech changed since the operation? Have other people trouble understanding you? Can you make yourself understood in a dialogue? Can you make yourself understood during a telephone-conversation? Can you make yourself understood during a group-conversation? Do you avoid a dialogue, telephone-conversation or group-conversation? Eating Do you have trouble with chewing solid food? Do you have trouble with chewing mashed food? Do you have trouble with drinking?

6 Oral functional outcome after intraoral reconstruction with nasolabial flaps 155 To what extent have you changed your meals since the operation? Do you have trouble with swallowing solid food? Do you have trouble with swallowing mashed food? Do you have trouble with swallowing liquid food? Do you have a dry mouth? Has the function of your dentures changed for the worse since the operation? Can you feel the food in your mouth? Does food remain in the mouth without noticing? Do you find it difficult to eat in the company of your family? Do you find it difficult to eat in the company of strangers? Do you splutter during speaking? Did you splutter during speaking prior to the operation? Do you have problems with drooling? On which side? Do you have problems with drooling during speaking, eating, drinking or sleeping? Aesthetics How would you rate your present appearance? Is your present appearance different from your appearance before the operation? Are you satisfied with your present appearance? Do you find the scar(s) in your face annoying? Is your appearance a hindrance during everydaylife? References 1. Ducic Y, Burye M. Nasolabial flap reconstruction of oral cavity defects: a report of 18 cases. J Oral Maxillofac Surg 2000;58: Cohen IK, Edgerton MT. Transbuccal flaps for reconstruction of the floor of the mouth. Plast Reconstr Surg 1971;48: Cohen IK, Theogaraj SD. Nasolabial flap reconstruction of the floor of the mouth after extirpation of oral cancer. Am J Surg 1975;130: Varghese BT, Sebastian P, Cherian T, et al. Nasolabial flaps in oral reconstruction: an analysis of 224 cases. Br J Plast Surg 2001;54: Van Wijk MP, Damen A, Nauta JM, et al. Reconstruction of the anterior floor of the mouth with the inferiorly based nasolabial flap. Eur J Plast Surg 2000;23: Bundgaard T, Tandrup O, Elbrønd O. A functional evaluation of patients treated for oral cancer. Int J Oral Maxillofac Surg 1993;22: Mutimer KL, Poole MD. A review of nasolabial flaps for intraoral defects. Br J Plast Surg 1987;40: Rökenes HK, Bretteville G, Lövdal O, et al. The nasolabial skinflap in intraoral reconstruction. ORL J Otorhinolaryngol Relat Spec 1991;53: Konstantinović VS, Dimić ND. Articulatory function and tongue mobility after surgery followed by radiotherapy for tongue and floor of the mouth cancer patients. Br J Plast Surg 1998;51: Franzén L, Funegård U, Ericson T, et al. Parotid gland function during and following radiotherapy of malignancies in the head and neck. A consecutive study of salivary flow and patient discomfort. Eur J Cancer 1992;28: Meijer HJA, Raghoebar GM, Van t Hof MA, et al. Implantretained mandibular overdentures compared with complete dentures; a 5-years follow-up study of clinical aspects and patient satisfaction. Clin Oral Implant Res 1999;10: Boerrigter EM, Stegenga B, Raghoebar GM, et al. Patient satisfaction and chewing ability with implant-retained mandibular overdentures: a comparison with new complete dentures with or without preprosthetic surgery. J Oral Maxillofac Surg 1995;53: Finlay PM, Dawson F, Robertson AG, et al. An evaluation of functional outcome after surgery and radiotherapy for intraoral cancer. Br J Oral Maxillofac Surg 1992;30: Vriens JPM, Acosta R, Soutar DS, et al. Recovery of sensation in the radial forearm free flap in oral reconstruction. Plast Reconstr Surg 1996;98: Close LG, Truelson JM, Milledge RA, et al. Sensory recovery in noninnervated flaps used for oral cavity and oropharyngeal reconstruction. Arch Otolaryngol Head Neck Surg 1995;121: