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Jarefors 2016
Jarefors 2016
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ORIGINAL ARTICLE
ABSTRACT
ARTICLE HISTORY
Objective: The vascularised free fibular flap is considered to be a reliable choice for reconstruction of
oromandibular defects, especially after resection of malignant tumours in the area. This study evaluates
the functional outcome of this method.
Method: From January 2001 - May 2014, 37 patients were treated at the University Hospital of
ping using the free fibular flap. The authors present the results from 17. This study reviewed their
Linko
records and used the University of Washington Quality-of-Life questionnaire (UW-QoL), the Head and
Neck Performance Status Scale (PSS), and interviews to assess their outcome.
Results and conclusions: Functional evaluation showed a significant decrease in chewing (16 out of
17 patients), appearance (n 10), salivation (n 6), sensitivity in the mouth and skin (n 16), occlusive
problems in the mouth (n 13), and range of mouth opening (n 12). The remaining domains showed
acceptable results, although most of them probably could not compare with the preoperative function.
Out of 17 patients, six had to adjust their eating in public significantly, three thought their activity to
be considerably restricted and two their recreation to be notably diminished. Common postoperative
complications were infections or fistula in the mandible (n 6), partial or complete rejection of the
cutaneous flap (n 4), and rupture of some of the sutures (n 3). Nine patients required at least one
more operation to repair defects, and six required a new soft tissue flap.
Introduction
Among many causes for mandible deformation are cancer of
the oral cavity, congenital deformities, osteoradionecrosis
after radiotherapy, and trauma to the head [1,2]. Although
the vascularised free fibular flap has some disadvantages, it
is thought to be the best choice for reconstruction of anterior and lateral defects, as it has a long, strong, bicortical
bone, a large pedicle, and a reliable cutaneous flap [14].
Reconstruction of the lower jaw is time-consuming and
delicate. Repair of the mandible not only upholds function of
the jaw, but also contributes to cosmesis and self-confidence,
thereby enabling the patient to return to a reasonable
quality-of-life (QoL) [1,2,5].
Our aim was to measure different variables of functional
outcome in patients who had been operated on at the
Department of Plastic Surgery, Hand Surgery and Burns,
ping from January 2001May 2014.
University Hospital of Linko
Method
From January 2001May 2014, 37 patients with oromandibular defects were operated on at the Department of Plastic
Surgery, Hand Surgery and Burns, University Hospital of
ping; using the free fibular flap. The patients had either
Linko
KEYWORDS
The University of Washington Quality-of-Life (QoL) questionnaire and the Head and Neck Performance Status Scale. We
also measured the range of mouth opening (palatepalate in
teeth 1141).
Questionnaires
The University of Washington Quality-of-Life (UW-QoL) is
described in more detail by Rogers et al. [6]. The variables
we used were: pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder, taste, and saliva. We kept the
rating of importance used in the UW-QoL, and omitted the
emotional and social aspects, because these refer specifically
to patients with cancer. Each domain consisted of 35 statements about the patients function with a score system of
0100 points [7,8]. The highest total score in our UW-QoL
was 1000 points.
The Head and Neck Performance Status Scale (PSS) measures normality of diet, speech, and eating in public. Each
domain consisted of 511 statements with a score ranging
from 0100 points. Patients with normal function got the
highest score of 100 points. It is reliable, has been validated,
and is short, concise, and easy to use [9,10]. These two questionnaires have been used together successfully before [11].
Although validated in multiple languages, we could find
neither of these questionnaires a validated Swedish version,
so we had to translate them.
Results
Ten of our patients were operated on for malignant tumours
and seven for osteoradionecrosis or osteomyelitis after primary radiotherapy for cancers of the head and neck region.
Of the malignant tumours, seven were staged T4, and three
had N12 involvement; there were no distant metastases.
The causes were squamous cell carcinoma (n 8), clear cell
tumour (n 1), and relapse of salivary gland cancer of the
gingiva (n 1). Nine of the 10 were given radiotherapy preoperatively and none postoperatively.
Preoperatively, six patients already had some degree of
salivary impairment, of which five also had some range of
mouth opening deficiency. Three had involvement of their
throat and decreased deglutition, and two needed a feeding
tube. In each case the cause was the large amount of radiation needed to cure the cancer, which resulted in most
cases in osteoradionecrosis (n 5). All reported at least some
worsening of their symptoms postoperatively.
Postoperative complications were infections or fistula in
the mandible (n 6), partial or complete rejection of the
cutaneous flap (n 4), and rupture of some of the sutures
(n 3). Nine patients required at least one more operation to
repair defects, and six required a new soft tissue flap. One
patient had a relapse of squamous cell carcinoma, but was
completely cured with chemotherapy and radiation. Fourteen
out of 15 patients with osteocutaneous flaps reported
decreased or no feeling in their flaps or skin, which led to
occlusive problems in the mouth in 13 patients.
Both patients with free fibular bone flaps had decreased sensitivity in their operation-site.
At follow-up, only three patients had dentition throughout
the mouth. The remaining part had no teeth at all (n 1),
gaps at the site of resection (n 9), or anterior dentition for
cosmetic reasons (n 5). Six had some degree of rehabilitation, such as a speech therapist or a mouth clamp. None
were given rehabilitation that focused on all the mouths
functions. The range of mouth opening was 29.5 cm
(mean 4.6). Twelve patients had a considerable reduction
when compared with the normal range of mouth opening in
elderly people [12].
Discussion
In this study, functional evaluation after reconstruction of the
mandible showed a significant impact on chewing, saliva,
appearance, reduced range of mouth opening, occlusive
problems, and sensitivity decrease in at least six out of
17 patients. Further, those changes significantly influenced
Conclusion
Free fibular flaps are commonly used for reconstruction of the
oromandibular defects. In this study, functional evaluation
after reconstruction of the mandible showed a significant
impact on chewing, saliva, appearance, reduced range of
mouth opening, occlusive problems, and sensitivity decrease
in at least six out of 17 patients. Further, those changes significantly influenced some patients choice of food (n 11),
whereas they were comfortable eating in public (n 6) and
with their speech (n 2). Nevertheless, acceptable results
were achieved in the remaining domains, even if most of
them probably couldnt compare to the preoperative state.
Postoperative complications were more frequent in our
group of patients then in other comparable studies which
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Disclosure statement
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References
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