Outcomes after free tissue transfer for composite oral cavity resections involving skin

Transcription

1 Received: 21 March 2017 Revised: 13 September 2017 Accepted: 22 November 2017 DOI: /hed ORIGINAL ARTICLE Outcomes after free tissue transfer for composite oral cavity resections involving skin Sameer A. Alvi MD Chelsea S. Hamill MD Jason P. Lepse MD Marco Ayala MD Douglas A. Girod MD Terance T. Tsue MD Yelizaveta Shnayder MD Kiran Kakarala MD Department of Otolaryngology - Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas Correspondence Kiran Kakarala, Department of Otolaryngology - Head and Neck Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS kkakarala@kumc.edu Abstract Background: Resections involving oral cavity mucosa, bone, and skin present a unique challenge. Optimizing outcomes often requires technically demanding reconstruction. The purpose of this study is to evaluate outcomes of several reconstructive approaches for patients with composite through-and-through defects, with a focus on the osteocutaneous radial forearm free flap (RFFF). Methods: We conducted a retrospective evaluation of the cohort of patients treated for composite through-and-through defects with cutaneous involvement who underwent free flap reconstruction from August 2012 through October Results: Seventeen patients received a single flap (12 cases of osteocutaneous RFFF), whereas 10 patients underwent a combination of flaps. Complication rates and functional outcomes were favorable in patients who underwent osteocutaneous RFFFs. The supraclavicular artery island flap (SCAIF) was used as a second flap in 3 cases. Conclusion: The osteocutaneous RFFF provides a valuable reconstructive option for complex composite resection defects involving skin. When 2 flaps are required, the SCAIF is a viable alternative to a second free flap or pectoralis flap. KEYWORDS composite resection, free flap reconstruction, head and neck cancer, microvascular reconstruction, oral cavity cancer, osteocutaneous radial forearm free flap 1 INTRODUCTION Free tissue transfer provides a safe and reliable method to reconstruct complex surgical defects that arise from head and neck cancer resection. 1,2 Despite progress in microsurgery, extensive composite mandibular resections with cutaneous involvement can create challenging defects for reconstruction. 3 Patients requiring these types of procedures often have This article was presented as a poster at the American Head and Neck Society ninth International Conference on Head and Neck Cancer, Seattle, Washington, July 16-20, very advanced disease and poor survival outcomes despite aggressive treatment. Therefore, the ideal reconstruction maximizes function and quality of life and does not delay the initiation of adjuvant treatments. Free flap reconstruction techniques are the first choice for major composite through-and-through defects. 4 Various reconstructive techniques have been described using single free flaps, double free flaps, or free flaps combined with local or regional flaps. 5 8 Osteocutaneous free flap donor sites best suited for single flap reconstruction of these defects include the scapula, 5 fibula, 6 and the radius. 7 Various permutations of 2 flaps have been described, ranging from the use Head & Neck. 2018;40: wileyonlinelibrary.com/journal/hed VC 2018 Wiley Periodicals, Inc. 973

2 974 ALVI ET AL. of 2 separate free flaps, such as the combination of the anterolateral thigh flap with the fibula, as proposed by Koshima et al 8 in 1998, or using a free flap with a local or regional flap, as suggested by Deleyiannis et al 9 in Although these articles have carefully described each reconstructive technique, there is limited information in the literature regarding the comparisons between approaches for these complicated defects. 7 The use of the RFFF as a single flap for this application has also not been previously well described. Additionally, the supraclavicular artery island flap (SCAIF) has recently emerged as a versatile option for head and neck reconstruction; its use as a second flap in complex reconstruction has not been previously described, to the best of our knowledge. The purpose of this study was to review our experience in the reconstruction of extensive composite oral cavity resections creating through-and-through defects. We examined the different surgical options used, with particular focus on the osteocutaneous RFFF, and evaluated the functional and survival outcomes. 2 MATERIALS AND METHODS Approval was sought and obtained by the Institutional Review Board at the University of Kansas before commencement of this research study. A retrospective cohort was assembled of all patients with free flap operations by the corresponding author between August 2012 and October Patients were identified utilizing the Healthcare Enterprise Repository for Ontological Narration database. These charts were reviewed and all patients with composite through-andthrough defects with cutaneous involvement who underwent free flap reconstruction were included. Patients without a full thickness defect were excluded from the study. These charts were then further reviewed to collect demographics, cancer staging, surgical procedures, and patient outcomes. Statistical analysis was performed using the SPSS software version 22 (IBM, Armonk, NY). Descriptive statistics were utilized to describe demographic variables. 3 RESULTS Twenty-seven patients with through-and-through defects of the oral cavity were identified in our review. There were 18 men and 9 women with a mean age of 62.5 years (SD 11.22). Twenty-four patients underwent surgery for squamous cell cancer of the oral cavity, whereas 3 surgeries were performed for osteoradionecrosis of the mandible. These patients were examined based on reconstructive technique. Seventeen patients underwent reconstruction with a single free flap, and 10 patients underwent reconstruction with more than just a single free flap. The various reconstructive techniques used within each cohort are described in Table 1. The majority of patients (12; 71%) who received a single free flap underwent an osteocutaneous RFFF for reconstruction. Two of these single flap cases involved the latissimus dorsi scapular mega free flap for repair. This flap included both the parascapular and latissimus skin paddles with the scapular bone for mandibular repair. In patients requiring 2 flaps, the majority (8; 80%) underwent an osteocutaneous fibula free flap for intraoral bony reconstruction, with the addition of either a regional pectoralis myocutaneous flap or SCAIF for internal or external coverage. Patients 1 and 19 were reconstructed without an osteocutaneous free flap because they were edentulous with lateral mandibular defects and the soft tissue reconstruction was optimized without bone. Patients were followed up for a mean of days (SD 293.9). A description of the defects, including sizes, is included in Table Complications In our series of 27 patients, there were 3 cases of partial flap loss, but no cases of total flap loss. In the 12 patients who received the osteocutaneous RFFFs, there were no cases of partial or total flap loss. Flap complications were classified as either immediate (ie, occurring intraoperatively or during the postoperative hospitalization) or delayed (ie, any flap complication that happened after discharge from the hospital). These can be seen in detail in Table 3. Overall, 12 patients (45%) experienced immediate complications, including 2 flap takebacks for evaluation or revision of the microvascular anastomosis. In the patients who underwent osteocutaneous RFFF for reconstruction, 2 (17%) underwent immediate complications, including 1 flap takeback, which was salvaged. Overall, 5 patients (19%) experienced delayed complications with hardware exposure. In patients reconstructed with the osteocutaneous RFFF, 3 patients (25%) experienced delayed wound breakdown. Depending on the complication, patients were managed either conservatively or taken back to the operating room (Table 3). 3.2 Functional outcomes To assess functional outcomes, we first examined tracheostomy decannulation according to data available at the last follow-up visit. Overall, the average time to decannulation was 62 days (SD 127). Four patients remained tracheostomy dependent at last follow-up. These data are outlined in Table 4. When looking at patients with osteocutaneous RFFF specifically, all 12 were able to be decannulated, with a mean tracheostomy duration time of 13 days (SD 12). We also evaluated clearance for oral diet based on their postoperative swallow study results. Our swallow studies are performed by a dedicated team of head and neck speech

3 ALVI ET AL. 975 TABLE 1 Patient characteristics ID Sex Age, years Indication TNM Reconstruction 1 F 66 Cutaneous SCC T3N0M0 RFFF 2 M 87 Oral cavity SCC T2N2bM0 Osteocutaneous RFFF 3 M 54 Oral cavity SCC T4aN2cM0 Osteocutaneous RFFF 4 F 80 ORN mandible j N/A Osteocutaneous RFFF 5 F 78 Oral cavity SCC T2N0M0 Osteocutaneous RFFF 6 M 65 Oral cavity SCC T4aN0M0 Osteocutaneous RFFF 7 F 65 Oral cavity SCC T4aN0M0 Osteocutaneous RFFF 8 M 67 Oral cavity SCC T4aN1M0 Osteocutaneous RFFF 9 M 54 Oral cavity SCC T4aN2bM0 Osteocutaneous RFFF 10 M 60 Oral cavity SCC 1 BCC T4N0M0 Osteocutaneous RFFF 11 F 68 ORN mandible N/A Osteocutaneous RFFF 12 M 47 Oral cavity SCC T3N0M0 Osteocutaneous RFFF 13 M 70 ORN mandible N/A Osteocutaneous RFFF 14 M 68 ORN mandible N/A Fibula 15 F 55 Oral cavity SCC T4aN1M0 Fibula 16 M 63 Oral cavity SCC T4aN2bM0 Fibula 1 pectoralis 17 F 79 Oral cavity SCC T4aN0M0 Fibula 1 pectoralis 18 M 52 Oral cavity SCC T4aN2cM0 Fibula 1 pectoralis 19 M 63 Oral cavity SCC T4aN0M0 ALT 1 pectoralis 20 M 60 Oral cavity SCC T4aN2bM0 Fibula 1 pectoralis 21 F 70 Oral cavity SCC T4aN1M0 Fibula 1 supraclavicular 22 M 48 Oral cavity SCC T4aN0M0 Fibula 1 supraclavicular 23 F 67 Oral cavity SCC T4aN0M0 Fibula 1 supraclavicular 24 M 53 Oral cavity SCC T4aN2cM0 Osteocutaneous RFFF 1 pectoralis 25 M 47 Oral cavity SCC T4aN2bM0 Scapula 1 latissimus 26 M 61 Oral cavity SCC T4aN1M0 Fibula 1 RFFF 27 M 40 Oral cavity SCC T3N0M0 Scapula 1 latissimus Abbreviations: ALT, anterolateral thigh flap; BCC, basal cell carcinoma; N/A, not applicable; ORN, j osteoradionecrosis; RFFF, radial forearm free flap; SCC, squamous cell carcinoma. language pathologists, and studies are based on the National Outcomes Measurement System grading scale. For the purposes of this study, any patient who was cleared to begin a trial of oral nutrition was deemed as passing their swallow study. In total, 17 of our 27 patients (63%) with through-andthrough defects were able to pass their swallow study at last follow-up. The average strict NPO time was 43 days (SD 48). In the patients who underwent osteocutaneous RFFFs, all but 2 patients were cleared to start an oral diet. The average NPO duration in these patients was 35 days (SD 39). 3.3 Additional outcomes In addition to the functional outcomes discussed above, we also looked at operative times and duration of hospital stay.

4 976 ALVI ET AL. TABLE 2 Defect sizes ID Reconstruction Mucosal defect surface area, cm 2 Bone length, cm Skin defect surface area, cm 2 1 RFFF 35 N/A 42 2 Osteocutaneous RFFF Osteocutaneous RFFF Osteocutaneous RFFF Osteocutaneous RFFF Osteocutaneous RFFF Osteocutaneous RFFF Osteocutaneous RFFF Osteocutaneous RFFF Osteocutaneous RFFF Osteocutaneous RFFF Osteocutaneous RFFF Osteocutaneous RFFF Fibula Fibula Fibula 1 pectoralis Fibula 1 pectoralis Fibula 1 pectoralis ALT 1 pectoralis 96 N/A Fibula 1 pectoralis Fibula 1 supraclavicular Fibula 1 supraclavicular Fibula 1 supraclavicular Osteocutaneous RFFF 1 pectoralis Scapula 1 latissimus Fibula 1 RFFF Scapula 1 latissimus Abbreviations: ALT, anterolateral thigh flap; N/A, not applicable; RFFF, radial forearm free flap. Using our available data, the mean operative time, including resection, was 10 hours and 27 minutes (SD 2 hours 18 minutes). In patients who underwent osteocutaneous RFFFs, the mean operative time was 9 hours and 6 minutes (SD 1 hour and 1 minute). The mean hospital stay in all patients after reconstruction of through-and-through defects was 12 days (SD 10 days). Patients who underwent a single osteocutaneous RFFF had an average stay of 9 days in the hospital (SD 3 days). These additional outcomes are listed in Table 5. Survival outcomes are detailed in Table Selected cases Figures 1 and 2 show composite through-and-through defects, which illustrate the use of a single osteocutaneous RFFF with 2 skin paddles. The radius bone is first used to

5 ALVI ET AL. 977 TABLE 3 Complications ID Reconstruction Immediate flap complication Delayed complications Complication management Flap survival 1 RFFF No failure 2 Osteocutaneous RFFF No failure 3 Osteocutaneous RFFF Hardware exposure Conservative No failure 4 Osteocutaneous RFFF Superior flap dehiscence Hardware exposure Hardware removal No failure 5 Osteocutaneous RFFF No failure 6 Osteocutaneous RFFF No failure 7 Osteocutaneous RFFF Venous congestion Flap takeback No failure 8 Osteocutaneous RFFF No failure 9 Osteocutaneous RFFF No failure 10 Osteocutaneous RFFF No failure 11 Osteocutaneous RFFF No failure 12 Osteocutaneous RFFF Hardware exposure, wound breakdown Unknown No failure 13 Osteocutaneous RFFF No failure 14 Fibula Fluid collection/ hematoma Wound breakdown Conservative No failure 15 Fibula No failure 16 Fibula 1 pectoralis No failure 17 Fibula 1 pectoralis Wound infection, wound dehiscence Conservative No failure 18 Fibula 1 pectoralis Intraoral necrosis Conservative Partial failure 19 ALT 1 pectoralis Seroma at ALT Conservative No failure 20 Fibula 1 pectoralis Venous clot, hematoma Flap takeback No failure 21 Fibula 1 supraclavicular Wound dehiscence Hardware exposure Pectoralis salvage, Hardware repair with supraclavicular No failure 22 Fibula 1 supraclavicular Supraclavicular flap breakdown, partial necrosis 23 Fibula 1 supraclavicular Fibula seroma, wound dehiscence 24 Osteocutaneous RFFF 1 pectoralis 25 Scapula 1 latissimus Scapula oral skin paddle loss Pectoralis salvage Hardware removal Pectoralis salvage Partial Failure No failure No failure Partial failure 26 Fibula 1 RFFF Venous congestion Flap takeback No failure 27 Scapula 1 latissimus No failure Abbreviations: ALT, anterolateral thigh flap; RFFF, radial forearm free flap.

6 978 ALVI ET AL. TABLE 4 Functional outcomes ID Reconstruction Decannulation Days to decannulation Passed swallow study NPO duration, days 1 RFFF Y 7 Y 7 2 Osteocutaneous RFFF Y 11 Y 7 3 Osteocutaneous RFFF Y 8 Y 7 4 Osteocutaneous RFFF Y 6 N N/A 5 Osteocutaneous RFFF Y 7 N N/A 6 Osteocutaneous RFFF Y 7 Y 20 7 Osteocutaneous RFFF Y 7 Y 76 8 Osteocutaneous RFFF Y 6 Y Osteocutaneous RFFF Y 47 Y Osteocutaneous RFFF Y 26 Y Osteocutaneous RFFF Y 7 Y Osteocutaneous RFFF Y 6 Y Osteocutaneous RFFF Y 19 Y Fibula Y 4 Y 6 15 Fibula N N/A Y Fibula 1 pectoralis Y 16 N N/A 17 Fibula 1 pectoralis Y 297 N N/A 18 Fibula 1 pectoralis Y 246 N N/A 19 ALT 1 pectoralis N N/A N N/A 20 Fibula 1 pectoralis Y 523 N N/A 21 Fibula 1 supraclavicular Y 132 Y Fibula 1 supraclavicular Y 21 Y Fibula 1 supraclavicular Y 8 N N/A 24 Osteocutaneous RFFF 1 pectoralis N N/A N N/A 25 Scapula 1 latissimus N N/A N N/A 26 Fibula 1 RFFF Y 9 Y Scapula 1 latissimus Y 10 Y 48 Abbreviations: ALT, anterolateral thigh flap; N/A, not applicable; RFFF, radial forearm free flap. reconstruct the mandible with or without 1 or 2 osteotomies as needed. The microvascular anastomosis is then performed, followed by the reconstruction of the oral cavity and external skin defects. The oral cavity defect is first addressed and then a strip of skin is deepithelialized to create an external skin paddle, which is then inset to complete the reconstruction. Figure 3 demonstrates the use of a scapula latissimus mega flap in a patient with a lateral mandible defect with large soft tissue volume loss. This flap allows for harvest of 2 independent skin paddles (scapular or parascapular fasciocutaneous and latissimus myocutaneous) along with 10 to 12 cm of bone from the scapula. In this case, the parascapular skin paddle was inset intraorally, and the latissimus myocutaneous paddle was used to replace the large soft tissue volume deficit and provide external coverage. Composite defects with a bony defect of >10 cm are usually reconstructed with the fibula osteocutaneous free

7 ALVI ET AL. 979 TABLE 5 Additional outcomes ID Reconstruction Operative time Hospital stay, days 1 RFFF 8 h 53 min 8 2 Osteocutaneous RFFF 9 h 27 min 11 3 Osteocutaneous RFFF 9 h 11 min 8 4 Osteocutaneous RFFF 7 h 54 min 7 5 Osteocutaneous RFFF 7 h 54 min 8 6 Osteocutaneous RFFF 9 h 24 min 7 7 Osteocutaneous RFFF 11 h 30 min 7 8 Osteocutaneous RFFF 8 h 15 min 7 9 Osteocutaneous RFFF 10 h 12 min Osteocutaneous RFFF 9 h 1 min Osteocutaneous RFFF 8 h 42 min 7 12 Osteocutaneous RFFF 8 h 24 min 7 13 Osteocutaneous RFFF 9 h 20 min 7 14 Fibula 8 h 53 min 8 15 Fibula 9 h 45 min 7 16 Fibula 1 pectoralis 14 h 43 min Fibula 1 pectoralis 13 h 9 min Fibula 1 pectoralis 13 h 10 min 7 19 ALT 1 pectoralis 10 h 38 min 7 20 Fibula 1 pectoralis N/A Fibula 1 supraclavicular 11 h Fibula 1 supraclavicular 10 h 11 min Fibula 1 supraclavicular 12 h 2 min 8 24 Osteocutaneous RFFF 1 pectoralis 17 h 33 min 8 25 Scapula 1 latissimus 8 h 57 min Fibula 1 RFFF 12 h 48 min 9 27 Scapula 1 latissimus 10 h 58 min 12 Abbreviations: ALT, anterolateral thigh flap; N/A, not applicable; RFFF, radial forearm free flap. flap. Figure 4 shows a large composite defect of the lower lip, oral cavity mucosa, anterior mandible, and mental skin and soft tissue. An osteocutaneous fibula free flap was used to repair the mandibular defect, and an additional fasciocutaneous RFFF was used to repair the lower lip orbicularis sling, mental soft tissue, and skin. The palmaris tendon was harvested with the forearm and was suspended to the modiolus bilaterally to give some tone to the lower lip and restore oral competence. Figure 5 shows a large composite resection of the right hemimandible, intraoral mucosa, and facial soft tissue with skin. The mandible bone defect was 12-cm long, which required the use of the fibula free flap for mandibular reconstruction. However, a large defect of the external skin remained, and, thus, a right SCAIF was harvested from the right shoulder for repair of this skin defect.

8 980 ALVI ET AL. TABLE 6 Survival outcomes ID Reconstruction Disease-free interval, months Recurrence Overall survival, months Death 1 RFFF 9 Y 32 N 2 Osteocutaneous RFFF 40 N 40 Y 3 Osteocutaneous RFFF 10 Y 21 N 4 Osteocutaneous RFFF (ORN j ) N/A N/A N/A N/A 5 Osteocutaneous RFFF 1 N 1 Y 6 Osteocutaneous RFFF 8 Y 11 Y 7 Osteocutaneous RFFF 17 Y 23 N 8 Osteocutaneous RFFF 13 N 13 Y 9 Osteocutaneous RFFF 18 N 18 N 10 Osteocutaneous RFFF 17 N 17 Y 11 Osteocutaneous RFFF (ORN) N/A N/A N/A N/A 12 Osteocutaneous RFFF 14 Y 17 N 13 Osteocutaneous RFFF (ORN) N/A N/A N/A N/A 14 Fibula (ORN) N/A N/A N/A N/A 15 Fibula 6 N 6 Y 16 Fibula 1 pectoralis 2 N 2 Y 17 Fibula 1 pectoralis 19 N 19 Y 18 Fibula 1 pectoralis 8 N 8 Y 19 ALT 1 pectoralis N/A N/A 9 Y 20 Fibula 1 pectoralis 31 N 31 N 21 Fibula 1 supraclavicular 41 N 41 N 22 Fibula 1 supraclavicular 5 N 19 Y 23 Fibula 1 supraclavicular 16 Y 16 Y 24 Osteocutaneous RFFF 1 pectoralis 10 N 10 N 25 Scapula 1 latissimus 5 N 5 Y 26 Fibula 1 RFFF 21 Y 23 N 27 Scapula 1 latissimus 19 N 19 N Abbreviations: ALT, anterolateral thigh flap; N/A, not applicable; ORN, j osteoradionecrosis; RFFF, radial forearm free flap. 4 DISCUSSION This study explored reconstructive techniques utilizing free tissue transfer in patients with complex defects involving the oral cavity mucosa, bone, and soft tissue with skin. We observed that patients who underwent reconstruction with a single osteocutaneous RFFF had favorable outcomes with respect to the complication rate, operative time, hospital stay, decannulation, and resumption of oral intake. We also demonstrated a novel used for the SCAIF as a second flap for complex head and neck reconstruction in lieu of a free flap or other regional flap. There are many advantages to the osteocutaneous RFFF that have made it a popular choice among some

9 ALVI ET AL. 981 FIGURE 1 Use of 2 skin paddles in a radial forearm free flap for reconstruction. A, Defect after composite resection of cm oral cavity mucosa, 8cmmandible,and735cm skin. B, The mid portion of the skin paddle of the osteocutaneous radial forearm is de-epithelialized after bone inset. C, Partial inset with proximal skin paddle intraoral and distal skin paddle external, commissure recreated with Estlander flap [Color figure can be viewed at wileyonlinelibrary.com] reconstructive surgeons. The osteocutaneous RFFF allows for simultaneous resection and harvest with no repositioning of the patient needed. The flap can be raised with a long vascular pedicle that is usually less affected by peripheral vascular disease than the fibula free flap vessels. 10 A large and pliable skin paddle can be harvested that is relatively free from the bone and, therefore, has the ability to be customized and contorted to provide more functional soft tissue reconstruction compared with other bulkier flaps. Deepithelializing a small portion allows one portion of the flap to be closed to the intraoral mucosa and the remaining skin paddle to be used externally for repair of the skin defect. Depending on the size and bulk of the forearm donor site, even large volume and surface area defects can be reconstructed with this single flap. However, the osteocutaneous RFFF is not without its limitations. The forearm does not easily allow for dental implants due to limited bone stock, although implants can be achieved with additional bone grafting or by double-barreling the bony reconstruction. In our center s experience, very few patients pursue dental implants secondary to cost and reluctance to undergo further procedures. Another suggested concern with the osteocutaneous RFFF is high donor site morbidity secondary to radial fractures. 7,11 The rate of this potential morbidity after harvest of the osteocutaneous RFFF has significantly decreased with the introduction of donor site prophylactic plating. In a previous study from our institution, the risk of pathologic fracture of the radius after routine prophylactic plating in a large cohort was roughly 1% with mean follow-up of 25.9 months. 12 No fractures are reported in our present series. Our series of osteocutaneous RFFF reconstructions did well from a functional standpoint. The rate of resumption of oral intake in the subgroup of patients who underwent osteocutaneous RFFF in our study is similar to a study conducted by Bianchi et al, 7 in which the majority of osteocutaneous flaps were fibula free flaps. Patients with increased bulk from the use of multiple flaps for reconstruction may do worse with aerodigestive function in the immediate postoperative period. This is particularly true with the pectoralis major flap, where the muscle bulk can compromise the airway and impede swallowing function. 13 In certain composite through-and-through defects, other reconstructive choices may be preferred over the osteocutaneous RFFF. Baker and Sullivan 14 and Sullivan et al 15 popularized the subscapular system of flaps for head and neck reconstruction. A single vascular pedicle can be used to supply a variety of reconstructive flaps, including bone with multiple, independent skin paddles. Deschler and Hayden 3 described using the composite scapular free flap with scapular and parascapular skin paddles, allowing one paddle to be used for intraoral coverage and the second for external coverage with good success for through-and-through defects. A FIGURE 2 Use of 2 skin paddles in a radial forearm free flap for reconstruction. A, Defect after composite resection of cm oral cavity mucosa, 8cmmandible,and635cm skin. B, The mid portion of the skin paddle of the osteocutaneous radial forearm is de-epithelialized after bone inset. C, Final inset with distal skin paddle placed intraorally and proximal skin paddle externally [Color figure can be viewed at wileyonlinelibrary.com]

10 982 ALVI ET AL. FIGURE 3 Use of a scapular and latissimus mega free flap for reconstruction. A, Composite resection defect including cmoralcavitymucosa, 10 cm mandible, cm skin. B, Subscapular system mega flap with the fasciocutaneous parascapular and myocutaneous latissimus dorsi skin paddles and 11 cm of scapula bone. C, Parascapular skin paddle inset intraorally, bone inset to the mandible. D, Latissimus used for volume replacement and external coverage [Color figure can be viewed at wileyonlinelibrary.com] major downside of this flap is the need to reposition the patient for flap harvest after the completion of the resection; this adds time and complexity to an already lengthy procedure. Another drawback of this flap is the donor site morbidity, in particular, pain and decreased shoulder function; physical therapy services may be required to optimize arm function. Despite these limitations, the subscapular system of flaps is an excellent choice for selected patients with bony defects <12 cm who require large volume soft tissue reconstruction. The soft tissue skin paddles have almost complete freedom from the bone, allowing for functional reconstruction of complex structures, such as the mobile tongue, which are often included in these resections. For these cases, we have used a combination of the latissimus myocutaneous and parascapular fasciocutaneous skin paddles with the scapula bone. The fibula osteocutaneous free flap is certainly an excellent option for reconstruction of composite resection defects, and is indeed the flap of choice for bony reconstruction at many institutions. It can be harvested with multiple skin paddles to facilitate a single flap reconstruction of through-andthrough composite defects. 6 Alternatively, it can be used either with a second free flap or with a local or regional pedicled flap. Although there has been reported success of the use of double free flaps in these advanced cases, 8,16 19 one study by Gabr et al 20 showed that single flap use had a lower complication rate when compared with cases utilizing 2 free flaps. Furthermore, these patients have a return to only modest functional outcomes. 21 Our data also show that there is an increased operative time as well as an increased hospital stay in these patients. Longer hospital stay in cases of double flap reconstruction may be accounted for by the increased morbidity, drain management, and pain control associated with 2 donor sites. This idea of days of life lost becomes increasingly important as it has been shown that patient quality of life improves if they can spend more time at home. 22 Despite these drawbacks, in selected patients, a second free flap may be used to optimize functional and aesthetic outcomes, as demonstrated in Figure 4, where the radial forearm flap harvested with palmaris longus tendon was combined with the fibula flap to optimize oral competence in a patient with near total lower lip loss. In this series, we demonstrated the use of the SCAIF as a second flap for complex head and neck reconstruction. The SCAIF is a fasciocutaneous regional flap based off of the supraclavicular artery that is pliable and has a wide arc of rotation, allowing it to be used for many sites in the head and neck The SCAIF can be used in this setting for either intraoral mucosal reconstruction or external skin reconstruction. The flap is suitable for large surface area defects that may not require a large amount of soft tissue volume. Care must be taken when insetting the flap not to place too much FIGURE 4 Use of fibula free flap with radial forearm free flap for reconstruction. A, Defect after composite resection of cmoralcavity mucosa, 12 cm mandible, and cm skin. B, Fibula osteocutaneous free flap with 2 osteotomies. C, Radial forearm fasciocutaneous free flap including palmaris longus for lower lip resuspension. D, Fibula used for intraoral and mandible defects, radial forearm used for lower lip and chin reconstruction, palmaris tendon suspended to modiolus [Color figure can be viewed at wileyonlinelibrary.com]

11 ALVI ET AL. 983 FIGURE 5 Use of fibula free flap plus supraclavicular artery island flap (SCAIF) for reconstruction. A, Composite resection, including cm oral cavity mucosa, 12 cm mandible, cm external skin. B, The SCAIF harvested from the right shoulder for external coverage. C, Fibula flap used for the oral cavity and mandible and the SCAIF used externally (the proximal SCAIF can also be de-epithelialized and tunneled) [Color figure can be viewed at wileyonlinelibrary.com] tension on the pedicle as this is the most common cause of partial flap loss, as occurred in 1 of our patients. There is relatively low morbidity with this reconstructive technique with complications reported to be as low as 4%, with more recent reports suggesting between 13% and 28%. 26,27 Comparatively, pectoralis major flap complication rates have been reported to be between 16% and 63%. 13,28 Pectoralis flaps have also been associated with arm morbidity with increased stiffness and decreased range of motion, which is not the case with the SCAIF. 29 The majority of patients in our study had stage IV cancer of the oral cavity, and survival outcomes were poor, in keeping with other series on this subject. The 5-year survival in patients requiring this type of reconstruction has been reported to be between 30% and 50%. 19,20,30 It may be suggested that T4a tumors extending to the skin have a worse prognosis, but we cannot make this conclusion definitively with this small sample size without a comparison group. Despite the poor survival outcomes, other series have also demonstrated that these procedures are safe and effective leading to improved quality of life and increasing the number of days spent outside the hospital. 19,31 An efficient and reliable reconstruction could benefit patients in terms of quality of life, days of life lost, as well as giving a last chance for a curative resection. In addition to optimizing the functional and aesthetic outcomes, the reconstructive surgeon must optimize healing to allow timely initiation of adjuvant therapy. Simplifying the reconstruction may sometimes be the best the way to achieve this last goal. Limitations of this study include its retrospective nature and small patient cohort. Naturally, it is not feasible to blind patients and surgeons as to what reconstructive operation the patient will undergo. A retrospective analysis of outcomes is our best attempt to evaluate these operations. Additionally, a true comparison between the osteocutaneous RFFF and other reconstructive options in terms of complications and functional outcomes is not possible because patients were not matched in terms of the defect. There is also a natural bias toward reconstructive technique based on the experience at our institution; however, we do believe success with the osteocutaneous RFFF can be reproduced elsewhere by reconstructive surgeons. 5 CONCLUSION Composite oral cavity defects involving the intraoral mucosa, mandible, and cutaneous tissue are challenging reconstructions from both a functional and cosmetic standpoint. Various reconstructive techniques have been utilized, including single free flaps with multiple skin paddles, double free flaps, and combinations of free flaps with local or regional flaps. The subscapular system of using free flaps and fibula free flaps has been previously well described for these defects. We show that the use of a single osteocutaneous RFFF provides an alternative reconstructive option for these challenging defects. The flap provides up to 10 cm of bone and can accommodate 2 osteotomies. The osteocutaneous RFFF has a pliable and versatile skin paddle that can be used for intraoral mucosa and extraoral skin reconstruction simultaneously. Prophylactic plating of the radius bone has minimized donor site morbidity. In this study, patients reconstructed with a single osteocutaneous RFFF had favorable outcomes in terms of operative time, hospital stay, complications, and functional status. The SCAIF provides an alternative to the pectoralis flap if a regional flap without significant volume is required to augment a free flap reconstruction. It can be used for facial or neck coverage, and is pliable in nature with relatively low complication rate and donor site morbidity. These flaps provide valuable additional options for reconstructive surgeons to use in addressing these challenging defects. ORCID Sameer A. Alvi MD Chelsea S. Hamill MD

12 984 ALVI ET AL. REFERENCES [1] Haughey BH, Wilson E, Kluwe L, et al. Free flap reconstruction of the head and neck: analysis of 241 cases. Otolaryngol Head Neck Surg. 2001;125(1): [2] Suh JD, Sercarz JA, Abemayor E, et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2004;130(8): [3] Deschler DG, Hayden RE. The optimum method for reconstruction of complex lateral oromandibular-cutaneous defects. Head Neck. 2000;22(7): [4] Boyd JB, Morris S, Rosen IB, Gullane P, Rotstein L, Freeman JL. The through-and-through oromandibular defect: rationale for aggressive reconstruction. Plast Reconstr Surg. 1994;93(1): [5] Takushima A, Harii K, Asato H, Nakatsuka T, Kimata Y. Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases. Plast Reconstr Surg. 2001;108(6): [6] Gal TJ, Jones KA, Valentino J. Reconstruction of the throughand-through oral cavity defect with the fibula free flap. Otolaryngol Head Neck Surg. 2009;140(4): [7] Bianchi B, Ferri A, Ferrari S, et al. Reconstruction of lateral through and through oro-mandibular defects following oncological resections. Microsurgery. 2010;30(7): [8] Koshima I, Hosoda S, Inagawa K, Urushibara K, Moriguchi T. Free combined anterolateral thigh flap and vascularized fibula for wide, through-and-through oromandibular defects. J Reconstr Microsurg. 1998;14(8): [9] Deleyiannis FW, Rogers C, Lee E, et al. Reconstruction of the lateral mandibulectomy defect: management based on prognosis and location and volume of soft tissue resection. Laryngoscope. 2006;116(11): [10] M uller-richter UD, Driemel O, M ortl M, et al. The value of Allen s test in harvesting a radial forearm flap: correlation of exvivo angiography and histopathological findings. Int J Oral Maxillofac Surg. 2008;37(7): [11] Clark S, Greenwood M, Banks RJ, Parker R. Fracture of the radial donor site after composite free flap harvest: a ten-year review. Surgeon. 2004;2(5): [12] Arganbright JM, Tsue TT, Girod DA, et al. Outcomes of the osteocutaneous radial forearm free flap for mandibular reconstruction. JAMA Otolaryngol Head Neck Surg. 2013;139(2): [13] You YS, Chung CH, Chang YJ, Kim KH, Jung SW, Rho YS. Analysis of 120 pectoralis major flaps for head and neck reconstruction. Arch Plast Surg. 2012;39(5): [14] Baker SR, Sullivan MJ. Osteocutaneous free scapular flap for one-stage mandibular reconstruction. Arch Otolaryngol Head Neck Surg. 1988;114(3): [15] Sullivan MJ, Baker SR, Crompton R, Smith-Wheelock M. Free scapular osteocutaneous flap for mandibular reconstruction. Arch Otolaryngol Head Neck Surg. 1989;115(11): [16] Koshima I, Fukuda H, Soeda S. Free combined anterolateral thigh flap and vascularized iliac bone graft with double vascular pedicle. J Reconstr Microsurg. 1989;5(1): [17] Wei FC, Celik N, Chen HC, Cheng MH, Huang WC. Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects. Plast Reconstr Surg. 2002;109(1): [18] Wei FC, Celik N, Yang WG, Chen IH, Chang YM, Chen HC. Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap. Plast Reconstr Surg. 2003;112(1): [19] Wei FC, Demirkan F, Chen HC, Chen IH. Double free flaps in reconstruction of extensive composite mandibular defects in head and neck cancer. Plast Reconstr Surg. 1999;103(1): [20] Gabr E, Kobayashi MR, Salibian AH, et al. Mandibular reconstruction: are two flaps better than one? Ann Plast Surg. 2004;52(1): [21] Posch NA, Mureau MA, Dumans AG, Hofer SO. Functional and aesthetic outcome and survival after double free flap reconstruction in advanced head and neck cancer patients. Plast Reconstr Surg. 2007;120(1): [22] Boyd JB, Mulholland RS, Davidson J, et al. The free flap and plate in oromandibular reconstruction: long-term review and indications. Plast Reconstr Surg. 1995;95(6): [23] Emerick KS, Herr MA, Deschler DG. Supraclavicular flap reconstruction following total laryngectomy. Laryngoscope. 2014;124(8): [24] Emerick KS, Herr MW, Lin DT, Santos F, Deschler DG. Supraclavicular artery island flap for reconstruction of complex parotidectomy, lateral skull base, and total auriculectomy defects. JAMA Otolaryngol Head Neck Surg. 2014;140(9): [25] Giordano L, Bondi S, Toma S, Biafora M. Versatility of the supraclavicular pedicle flap in head and neck reconstruction. Acta Otorhinolaryngol Ital. 2014;34(6): [26] Kokot N, Mazhar K, Reder LS, Peng GL, Sinha UK. Use of the supraclavicular artery island flap for reconstruction of cervicofacial defects. Otolaryngol Head Neck Surg. 2014;150(2): [27] Kozin ED, Sethi RK, Herr M, et al. Comparison of perioperative outcomes between the supraclavicular artery island flap and fasciocutaneous free flap. Otolaryngol Head Neck Surg. 2016;154(1): [28] Avery CM, Gandhi N, Peel D, Neal CP. Indications and outcomes for 100 patients managed with a pectoralis major flap within a UK maxillofacial unit. Int J Oral Maxillofac Surg. 2014;43(5): [29] Refos JW, Witte BI, de Goede CJ, de Bree R. Shoulder morbidity after pectoralis major flap reconstruction. Head Neck. 2016; 38(8): [30] Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of extensive composite mandibular defects with large lip involvement by using double free flaps and fascia lata grafts for oral sphincters. Plast Reconstr Surg. 2005;115(7): [31] Jang DW, Teng MS, Ojo B, Genden EM. Palliative surgery for head and neck cancer with extensive skin involvement. Laryngoscope. 2013;123(5): How to cite this article: Alvi SA, Hamill CS, Lepse JP, et al. Outcomes after free tissue transfer for composite oral cavity resections involving skin. Head & Neck. 2018;40: