2. ORAL RECONSTRUCTION AFTER EXCISION OF SOFT TISSUE MALIGNANCIES

3. DR SHERIF KOTB ASS. PROFESSOR OF SURGICAL ONCOLOGY MANSOURA FACULTY OF MEDICINE

4. INTRODUCTION

5. Major ablative surgery for tumours of the oral cavity may result in loss of mucosa,submucosal soft tissues, underlying musculature, and overlying skin or underlying bony framework. The brunt of major cancer ablative surgery in the head and neck region can be disturbing for the patient.

6. In order to restore form and function and totally rehabilitate the patient, the efforts necessary require reconstruction of anatomic defects created by ablative surgery to restore esthetic appearance and physiological function. In addition to rehabilitation, psychosocial, vocational and emotional counseling is necessary for total recovery.

7. The aim of this work was evaluation of various methods of oral reconstruction after excision of intraoral malignancies as regard : Functional restorations (included : food intake, oral competence, clarity of speech, tongue shape and mobility, mastication capacity, bolus formation, manipulation & transport, restoration of tactile sensations, swallowing capacity, oral transit time, degree of malocclusion,& trismus).

8. Esthetic considerations (include restoration of bony framework, soft tissue contour, chin protrusion, and mobility of the lower jaw).

9. PATIENTS AND METHODS

10. A randomized prospective study was done at Mansoura Surgical Oncology Unit, and ENT department - Mansoura University Hospital. In which 30 patients were operated upon for soft tissue oral malignancies (14 patients with cancer tongue and floor of the mouth and 16 patients with cancer cheek).

11. cancer tongue and floor of the mouth, for whom reconstruction was done by: Patients were classified into two groups: = Superiorly- based anterior cervical flap: four cases. = Pectoralis major myocutaneous flap: six cases. = Posteriorly- based tongue flap: four cases. cancer cheek, for whom reconstruction was done by: = The forehead flap: five cases. = Pectoralis major myocutaneous flap: six cases. = Free rectus abdominis flap: five cases.

12. [1] Superiorly based anterior cervical flap

13. Incision for myocutaneous flap

14. The Flap Was Folded 180 Degrees And Axially rotated Over Its Base To Enable Its Delivery Into The Oral Cavity

15. The Suture Line Between The Flap And The Oral Mucosa Was Completed

16. [2] Pectoralis major myocutaneous flap

17. Defect After Excision Of Cancer Tongue Infiltrating The Floor Of The Mouth

18. Pectoralis Major Myocutaneous flap

19. Pectoralis Major Myocutaneous Flap Tunneled To Oral Cavity

20. Pectoralis Major Flap Used For Mucosal Reconstruction

21. Patient After Closure Of PM Flap Site

22. [3] Posteriorly based tongue flap

23. Mandibulotomy Site For Carcinoma Of Middle Third Of The Tongue

24. Surgical Defect After Excision Of Cancer Tongue

25. Closure Of The Floor Of The Mouth By Posteriorly –Based Tongue Flap

26. II- CANCER CHEEK: [1] The forehead flap

27. Defect After Through And Through Resection Of The Cancer Cheek With Neck Dissection

28. Folded Forehead Flap

29. [2] Folded pectoralis major myocutaneous flap

30. Two Islands Pectoralis Major Myocutaneous Flap

31. [3] Free Rectus abdominis flap

32. Free Rectus Abdominus Myocutaneous Flap

33. RESULTS

34. TABLE (1): PATIENT CHARACTERISTICS ITEMS GROUP I GROUP II TOTAL Number141630 Mean Age (years) 42 + 6.4 48+ 4.7 51+5.6 Males/ Females 9/77/716/14 Methods of reconstruction = Superiorly based anterior cervical flap: 4 cases. = Pectoralis major myocutaneous flap: 6 cases. = Tongue flap: 4 cases. = The forehead flap: 5 cases. = Rectus abdominis flap: 5 cases. = Pectoralis major myocutaneous flap: 6 cases.

35. ITEMS GROUP I GROUP II TOTALNumber141630 Sq. c.c. 12 (85.71%) 11 (68.75%) 23 (76.66%) Mucoepidermoid carcinoma 2 (14.29%) 2 (12.50%) 4 (13.34%) Adenocarcinoma0 1 (06.25%) 1 (03.34%) Melanoma0 2 (12.50%) 2 (06.66%) TABLE (2): PATHOLOGICAL TYPES:

36. ITEMS GROUP I GROUP II TOTALNumber141630 Exophytic mass 3 (21.43%) 13 (81.25%) 16 (53.34%) Ulcerative lesion 10 (71.43%) 4 (25.00%) 14 (46.66%) Bleeding 2 (14.28%) 0 2 (06.66%) Pain 1 (07.14%) 1 (06.25%) 2 (06.66%) Numbness of chin 0 2 (12.50%) Widening of the inferior alveolar canal 1 (07.14%) 0 1 (03.34%) TABLE (3): CLINICAL PRESENTATION:

37. TABLE (4): SURGICAL APPROACHES:ITEMSINDICATIONS GROUP I GROUP II TOTALNumber141630 Transhyoid Small lesions of posterior tongue 2 (14.28%) 0 2 (06.66%) Median mandibulotomy approach Posterior oral cavity tumours that do not involve the mandible 6 (42.86%) 0 6 (20.00%) Stair- step incision + lateral mandibulotomy Cancer base of the tongue 6 (42.86%) 0 6 (20.00%) Full thickness buccal resection Cancer cheek 0 16 (100.0%) 16 (53.34%)

38. TABLE (5): VARIOUS METHODS OF ORAL CAVITY RECONSTRUCTION:ITEMS Superiorly based cervical flap Pectoralis major myocutan- eous flap Tongue flap Forehead flap Free Rectus abdominis flap TotalNumber4 (13.33%) (13.33%) 12 (40.00%) 4 (13.33%) 5(16.66%)5(16.66%) 30 (100.0%) Size of flap LimitedGenerouLimitedLargeGenerous Stages2OneOne3One Arc of rotation 90 Adequate for cheek and floor of the mouth Limited180Free Blood supply RandomReliableRandomAxialAxial

39. TABLE (5): VARIOUS METHODS OF ORAL CAVITY RECONSTRUCTION:ITEMS Superiorly based cervical flap Pectoralis major myocutan- eous flap Tongue flap Forehead flap Free Rectus abdominis flap Donor site Has no deficit Primary closed Skin graft Primary closure Oral fistula 1(25.00%)1(08.33%) 2 (50.00%) 00 Oral defect Coverage Excellent, with satisfactory color match ExcellentPoor Excellent Food intake FairGood Fluid only GoodGood Oral competence GoodGoodGoodFairGood

40. TABLE (5): VARIOUS METHODS OF ORAL CAVITY RECONSTRUCTION:ITEMS Superiorly based cervical flap Pectoralis major myocutan- eous flap Tongue flap Forehead flap Free Rectus abdominis flap Clarity of speech Disturbed Only a lisp Distur- bed NormalNormal Tongue shape & mobility Normal Closure was severely compromis- ed Severely compro- mised NormalNormal Mastication capacity NormalReducedReducedNormalNormal Bolus formation ReducedPoorPoorPoorPoor Bolus manipulation ReducedPoorPoorPoorPoor

41. TABLE (5): VARIOUS METHODS OF ORAL CAVITY RECONSTRUCTION:ITEMS Superiorly based cervical flap Pectoralis major myocutan- eous flap Tongue flap Forehead flap Free Rectus abdominis flap Tactile sensation NormalReducedNormalNormalNormal Swallowing Capacity NormalDelayerDelayedNormalNormal Oral transit time NormalProlonged Prolong- ed NormalNormal Degree of malocclusion NoNoNoNoNo Restoration of bony framework NoNoNoNoNo

42. TABLE (5): VARIOUS METHODS OF ORAL CAVITY RECONSTRUCTION:ITEMS Superiorly based cervical flap Pectoralis major myocutan- eous flap Tongue flap Forehead flap Free Rectus abdominis flap Soft tissue contour AcceptableAcceptableNormalNormalNormal Chin protrusion AcceptableNormalNormalNormalNormal Lower jaw mobility NormalReducedNormalNormalNormal

43. CONCLUSION

44. = Superiorly - based anterior cervical flap is an excellent regional flap in the repair of relatively small defects in the anterior oral cavity. = The pectoralis major myocutaneous flap provides a generous area of skin, for transfer to the oral cavity. So in situations where both internal (mucosal) lining and external (skin) coverage are required, two skin islands may be created on the same paddle of muscle for total one-stage reconstruction of a through-and-through cheek defect.

45. = The optimal choice for reconstruction of defects in the oral cavity is a microvascular free flap. = Cervical flap provide excellent surface and substance for reconstruction of a through -and- through defect of the anterior oral cavity and floor of the mouth.