Oral Cavity

Successful reconstruction in the oral cavity is measured by the ability to restore speech, swallowing, and airway function.29 The ultimate functional outcome is generally influenced more by the volume of soft tissue loss and its reconstruction than by the reconstruction of the mandible.30 The surface of the oral cavity and oropharynx consists of thin, pliable, sensate, lubricated tissue; it should be replaced by similar tissue whenever possible. Bulky tissue is needed only in the area of the base of tongue, where it aids in the oral phase of swallowing.30 The anterior and lateral regions of the floor of mouth are vitally important because of their effect on tongue mobility and in maintaining salivary flow. Studies indicate that as the percentage of oral tongue and base of tongue resected increased, the efficiency of swallowing decreased.31

Split-thickness skin grafts are well suited for the reconstruction of defects in the oral cavity and oropharynx unless the resection involves extensive areas of the base of the tongue or mandible. In a recent study of relatively limited resections of the oral tongue (< 30%) and base of the tongue (< 60%), patients in whom primary closure or skin grafting was used had more efficient swallowing of liquids, less pharyngeal residue, and shorter pharyngeal delay times than were noted in similarly matched patients whose reconstruction involved a free flap.31 In our department, split-thickness skin grafting is the technique most often used for reconstructing surgical defects of the tongue, floor of mouth, and buccal and oropharyngeal defects, as well as for re-creating the alveolar sulcus.

For larger defects in the oral cavity, our preferred alternative is the radial forearm flap. This flap is thin and pliable enough to be used in the oral cavity. The radial artery and its venae com-mitantes are relatively straightforward to harvest and, as the arm is out of the field, the reconstructive team can harvest the flap simultaneously with the resection. Bulky flaps such as the pec-toralis myocutaneous (PMC) flap often interfere with mobility of the tongue and flow of saliva, and reliability is variable. In a study of 211 patients who underwent immediate reconstruction with a PMC flap, 63% developed flap-related complications and 26% required reoperation.24 In contrast, the radial forearm flap has had a greater than 90% success rate when used at our department and at other institutions.2-6 Donor site morbidity with the radial forearm flap consists mainly of partial loss of the skin graft with exposure of the flexor carpi radialis tendon, numbness in the distribution of the radial nerve, and dissatisfaction with the appearance of the skin graft.11 The radial forearm has become the most frequently used flap for reconstruction of the oral cavity at our institution despite these problems.

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