Functional Outcome
Oral incompetence, ectropion, and trismus occurred in 9 (19.1%), 8
(17.0%), and 6 patients (12.8%), respectively. Again, the extent of
resection had no significant impact on the development of any functional
impairment (Table III). Nonetheless, solely patients with malignancies
originating of the buccal mucosa and oral cavity suffered from oral
incompetence (22.7% and 66.7%; p=0.020). Performance of mandibulectomy
(p=0.003), but not maxillectomy (p=0.064), affected significantly oral
competence, which was otherwise significantly associated with the
occurrence of trismus (p=0.009). In addition, size of used free flaps
was 14.7 ± 5.1 cm in patients with oral incompetence, which was
significantly larger compared to 7.4 ± 2.7 cm in patients with oral
competence (p=0.008), while primary tumor size did not significantly
differ (4.4 ± 1.4 cm vs. 3.5 ± 1.9; p=0.206) (Table III).
DISCUSSION
We have analyzed clinical outcome of 47 patients with solid malignancies
of the cheek that underwent radical tumor resection with creation of
partial or through-and-through defects and free flap reconstruction.
Within our study, SCCs were the predominant histologic subtype (80.9%)
and malignancies mainly originated from the oral cavity (80.8%). This
is consistent with literature, reporting mostly on oral carcinomas and
rarely on skin carcinomas, requiring cheek reconstruction with free
flaps following oncological resections. 3,4Nonetheless, our data further display the great diversity of tumors
affecting the cheek region that may hamper analysis of more homogenous
subgroups with large patient numbers.
In solid malignancies, and for patients with SCCs in particular,
surgical tumor resection with adjuvant therapy in selected cases
represents the most frequent treatment modality.5,6,10However, despite radical surgical resection, recurrence rates range from
45.0% to 80.0% in patients with buccal SCCs.11,12Several authors assume that the absence of “real” anatomic boundaries
limiting tumor growth and spread might contribute to the high rate of
recurrences.11,13 This prompted Ren ZH and coworkers
(2017) to perform a more extensive resection of functional anatomic
buccal units to achieve better oncologic outcome.3 In
fact, they analyzed data of 127 patients with buccal SCCs reporting on
significantly better 2-year overall survival (OS: 83.3% vs. 60.1%) and
DFS (76.6% vs. 51.9%) in patients undergoing more extensive unit
resection compared to conventional surgery.3
Although oncologic principles must supersede reconstructive
desires7, we were particularly interested in knowing
how the extent of resection impacts functional outcome. Oral
incompetence represented the main functional complication occurring in 9
(19.1%) patients followed by occurrence of ectropion and trismus in 8
(17.0%), and 6 patients (12.8%), respectively. This is in line with
the results of other publications, reporting on problems with oral
incompetence in 4.8% up to 40% of patients with cheek
carcinomas.8,14,15 It is noteworthy to mention that
the extent of resection had no significant impact on functional outcome
in our cohort, which is in accordance to the work of Ren ZH et al.
(2017). The authors assume that insignificantly changed functional
outcomes in patients with conventional surgery compared to more
extensive unit resections, have resulted from the loss of function of
preserved structures secondary to induction of fibrosis and loss of
functional adjacent structures / attachments by tumor
resection.3 However, we found a strong association
between oral incompetence and trismus in patients after mandibulectomy.
This indicates that functional outcomes more likely depend on the
preservation of certain anatomic structures and chosen surgical approach
than on the depth of defect.
Recipient site complication rate was 55.3% (n=26), of which wound
dehiscence was the most common complication occurring in 29.8% (n=14)
of cases. Although the majority of complications were of minor concern,
10 patients developed salivary fistulae (21.3%) that occurred
significantly more often in suborbital zone I defects (p=0.035). This is
in accordance to former studies reporting on fistula rates of 4.3% to
27.3% of patients.8,14,16-18 The development of
fistulae is characteristic for maxillary reconstruction and occurs
typically near to the medial canthus (zone I) due to breakdown of suture
lines.16 In alignment to that, we observed the highest
rate of wound dehiscence (38.5%) in patients with zone I defects
compared to 18.2% and 30.4% in zone II and III defects, respectively.
Until now, a number of different free flaps have been described for
cheek reconstruction including the ALT 19, RFFF19, FFF 20 and the scapular /
parascapular free flap 21. Recently, the versatility
of the SAFF has been demonstrated for general head and neck
reconstruction, and in particular for cheek and tongue
reconstruction.22,23 In our study, the RFFF was used
in 31.9% (n=15) of cases followed by the ALT free flap and the scapular
/ parascapular free flap in 27.7% (n=13) and 21.3% (n=10) of patients,
respectively. Among those, the RFFF was mainly harvested for cutaneous
reconstruction (73.7%), the ALT flap for reconstruction of myocutaneous
defects (83.3%), and the scapular / parascapular free flap for bone
reconstruction (62.5%). Our flap survival rate was 95.7%, which is
comparable to 95% to 96% reported in former
studies.17,19
We believe that the strength of this study lies in its multicentric
nature and the analysis of functional outcomes as well as complications.
We see three limiting factors: first, the retrospective study design
bears an inherent risk of information and selection bias. Second, the
heterogeneity of our cohort with solid malignancies originating from
different parts of the cheek allows only limited conclusions. Third, the
lack of standard measures for functional outcomes in head and neck
oncology24 and the fact that functional and aesthetic
outcomes have been rated by treating head and neck surgeons as opposed
to patient reported outcomes, represent further limitations.