IJCRR

IJCRR - 14(14), July, 2022

Pages: 51-57

Date of Publication: 20-Jul-2022

Comparison of Outcomes of the Radial Forearm Free Flap Vs Pectoralis Major Pedicled Flap for the Reconstruction of Oral Soft Tissue Defects

Author: Abdul Malik Mujahid, Musadiq Asrar, Ifrah Rahed, Kashif Mehmood, Usman Ishaque, Noor Ali

Category: Healthcare

Abstract:Introduction: Head and neck cancers are one of common cancers with peri oral cancers are more prevailing in areas with use of tobacco, ghutka and alcohol. Peri oral soft tissue defects can occur after tumor ablation or trauma. Objectives/Aim: To assess the flap survival and oral competence in radial forearm free flap versus pedicled pectoralis major myocutaneous flap. Method: A randomized control trial was conducted at Department of Plastic Surgery BVH, Bahawalpurfrom July 2019 to December 2020. A total of 60 patients were randomly divided in two equal groups. In Group A, radial forearm free flap and in Group B pedicled pectoralis major myocutaneous flap were used for reconstruction of full-thickness defects. Data was entered and analyzed by using SPSS version 27.0. Mean and Standard Deviation were calculated for quantitative variables. Frequency and percentages were calculated for qualitative variables. Chi-square test was used to compare the flap survival and oral competence between the groups and p 0.05 which is not statistically significant. Conclusion: Radial forearm free flap is comparable option for head and neck reconstruction to the pectoralis major myocutaneous flap with fewer complication rate and overall successful outc

Keywords: Radial forearm free flap, Pedicled Pectoralis Major myocutaneous flap, Survival rate, Peri oral defects, Tumor, Oral cancers

Full Text:

INTRODUCTION

Head and neck cancers are one of the common cancers with peri oral cancer are more prevalent in areas with use of tobacco, gutka, and alcohol. Peri oral soft tissue defects can occur after tumor ablation or trauma. Surgical management of oral squamous cell carcinoma typically involves resection of the tumor with a 1 cm margin under frozen section control that may create a full-thickness defect, requiring more complex methods of reconstruction.¹ The reconstruction of peri-oral defects has been a challenge for plastic surgeons, especially with the involvement of commissure to achieve both functional and aesthetic favorable appearance. The competence of the orbicularis muscle sphincter must be maintained, as this is critical to achieving a functional recovery. The functional goals of the cheek and lip reconstruction are to maintain intraoral mucosal lining and to preserve the surface area of the oral aperture. The aesthetic goals are to provide replacement of external soft tissue following the subunit principles of vermiliocutaneous junction and lip aesthetic units.²

The basic principle of plastic surgery is to replace like with like tissue. The selection of reconstructive options is based on the nature, size and location of the defect as well as on the general health and prognosis of the patient.³ In 1979, use of the pectoralis major flap was first described for reconstruction of oral soft tissue defects. Since that it has become a commonly used option because of its relative reliability, availability, and ease of dissection.⁴ In last two decades there was a significant advancement in plastic surgery techniques and with the advent of microsurgical methods, different other options came into practice for the reconstruction of oral and peri oral soft tissue reconstruction. Nowadays, Radial forearm free flap is in routine practice in reconstructive head and neck surgery and is used as a workhorse flap because of its reliable anatomy, long pedicle length, good size vessels, suitable thinness and relative scarcity of hair and to substitute mobile oral mucosa.⁵

In 2010, O‘Neill et al. compared radial forearm free flap and Pectoralis Major Myocutaneous pedicled flap for reconstruction of oral and oropharyngeal defects and found 5.4% of flap loss with wound dehiscence with pectoralis myocutaneous flap while no flap loss and wound dehiscence in Radial forearm free flap reconstruction.⁶ In another study, C. Avery stated that free tissue transfer has become the preferred reconstructive option with success rates of 95% or higher with fewer complications and better functional outcomes.⁷ Pipkorn et al. in his study, emphasized on functional considerations in oral cavity reconstruction and mentioned Different assessment tools for oral functions.⁸ Li and Zhang et al. and Yang and Li et al. use 14 item oral health impact profile (OHIP-14) and the University of Washington quality of life (UW-QOL) questionnaire and showed better outcome in RFFF group as compared to PMMF.^{9, 10}

 The rationale of my study is that Radial forearm free flap is better choice than pedicled pectoralis major myocutaneous flap in terms of functionality and aesthetic outcome.As no local data is available regarding the comparison of both options, so this study will set a baseline data regarding the management of perioral soft tissue defects reconstruction andwill not only help in selecting the suitable option in our developing population but also addresses local patient concerns regarding functional outcome in terms of oral competence post-surgery.

Materials and Methods:  A Randomized control trials was conducted at Department of Plastic and Reconstructive Surgery Bahawal Victoria Hospital Bahawalpur from July 2019 to December 2020.  A sample size of 60 was calculated with the 5% level of confidence, 80% power of study and taking flap loss as 0% in group A (Radial forearm free flap) and 5.4% in group B (Pectoralis Major pedicled flap).⁷ Sampling was done Through a non-Probability consecutive sampling and patients were divided into two equal groups. Patient with oral and perioral soft tissue defects of upper lip, commissure, lower lip involving mucosa and buccal mucosal defects > or =50% of the lip size after trauma or tumor resection presenting within 6 months of diagnosis, aged between 15-65 years of either gender were included. Patients with prior head and neck surgery advanced staged disease, history of diabetes mellitus or peripheral vascular disease or bleeding disorders were excluded. After approval from ethical institutional review board (Ref.No ET/12510/P-290-PF, Dated.20 June, 2019), written informed consent was taken from all the patients. All the patients were operated by a consultant plastic surgeon with 10 year of post-fellowship experience. If surgery remained uneventful, then he/she was discharged on 5th postoperative day in both groups. All the patients were followed up by researcher himself/herself on weekly basis for first month then monthly up to 6 months. The data was entered and analyzed by using SPSS version 27. Mean and Standard Deviation were calculated for quantitative variables like age, defect size. Frequency and percentage was calculated for qualitative variables like gender, defect location, type of flap used, flap loss, oral competence and flap outcome. Chi-square test was used to compare the flap survival and oral competence between the groups and p <0 .05 was taken as statistically significant. Confounder or effect modifier i.e age, gender, location of the defect and etiology was controlled through stratification and the post-stratification Chi-square test was applied using p <0.05.

Results:

Out of 60 patients, in group A, 80% were males while 20% were females. In group B, 60% were males and 40% were females. Age range in this study was from 15-65 years with mean age of 47.935 ± 12.15 years. The mean age of patients in group A was 47.47 ± 12.28 years and in group B was 48.40 ± 12.02 years. Defect size ranged from 6.01± 2.1 cm in group A while 5.97 ± 2.03cm in group B (Table No .1) Location of defect included 13% upper lip defect, 46.67% oral commissural defect and 40% of the patients with lower lip defect in Group A. Group B had 10%, 56.67% and 33.33% defect of the upper lip, oral commissure and lower lip region respectively.(Figure.1) In this study Radial Forearm Free Flap was used in group A(Figure.2 a,b,c,d) and  Pedciled Pectoralis Major Myocutaneous  Flap in group B(Figure.3.a,b,c,d).

In group A, Oral competence was present in 29 (96.67%) patients and 26 (86.67%) patients in group B. Group A had 1 (3.33%) patient while Group B had 4 (13.33%) patients with inadequate oral competence. Partial Flap lossin both groups A & B was noted as 6.67% and 10% respectively with 02 patients in group A and 03 patients in group B. However no complete loss was noted in free flap group while 1 (3.33%) of the patient in group B had complete flap loss. Overall flap survival was 93.33% in free flap group and 86.67% in pedicle flap group with the p > 0.05 which is not statistically significant. (Table No.2)

Stratification of Oral competence in both groups with respect to gender, age, location of defect and etiology is shown in Table. No.3 Stratified data of Flap Loss in both groups with respect to gender, age, location of defect and etiology is shown in Table No.4.

Figure 2: GROUP-B, Radial Forearm Free Flap Case. (Picture A, B- Pre-operative frontal and lateral view), (Picture-C. Intraoperative view with radial forearm free flap), (Picture-D. Post-operative result)

Figure 3: GROUP B. Pedicled Pectoralis Major Myocutaneous Flap Case. (Picture A,- Preoperative view), ( Picture B- Intra operative View), ( Picture C, Pectoralis Major musculocutaneous flap marking), (Picture- D, Post-operative result).

Discussion

Reconstruction of soft tissue defects after trauma or tumor resection is always a challenging task in head and neck region considering the functional and aesthetic outcome. Ariyan S was among the first to use pedicled Myocutaneous Pectoralis Major flap for head and neck defects.¹¹ In the era of the 21^st century, free flaps are more commonly used due to improved microsurgical techniques and facilities but still the use of pedicled Pectoralis Major Myocutaneous is in practice because of its advantages, including its proximity to the head and neck, simplicity of harvesting and as an alternative when microsurgical flap failure occurs. The disadvantages include reduced neck mobility, the thickness of the flap leading to possible reduced swallowing or speech function; need to rotate the vascular pedicle of the flap 180° when using the skin paddle to resurface the neck and a simultaneous two-team approach is difficult in comparison to the classical free radial forearm or anterolateral thigh flap.¹²

 In our study, partial flap loss in both group A &B was 6-67 percent and 10 percent respectively while No complete flap loss was noted in free flap group which is comparable to the results by Sheikh et al.¹³ Oral competence was good in upper lip defects with no drooling of saliva or liquids while in oral commissural defects and lower lip defects, one patient had poor oral competence in Radial Forearm Free Flap group. Three patients in pedicled pectoralis major myocutaneous flap had drooling of saliva and problems in speech due to poor oral competence. Poor competence was seen in the same patients who had partial necrosis or complete flap failure. Revision surgeries were performed in pedicled pectoralis major myocutaneous flap for competence. Flap failure was noted in patient who was chronic smoker and had venous congestion. Partial flap loss was also reported to be 13.3% in the descriptive case series on pedicled pectoralis major myocutaneous flap by Abid.¹⁴ Another local study by Khan F had 67.59% overall complication in pedicled pectoralis major myocutaneous flap group¹⁵. Flap salvage techniques were used and a Deltopectoral flap was used to cover the defect in salvage cases.¹⁶ Unfortunately most female patients were in Group B i.e. 12 patients. Breast tissue was affected, which can have a major cosmetic impact in female patients.¹⁷ It can also sometimes affect shoulder function.

Khalid FA et al. suggested that despite minimal complications quoted with free microsurgical reconstruction, yet the pedicled flaps are useful alternative in selected cases, and are quick to perform with lesser secondary procedures requirement¹⁸. Our previous experience reported 25% complication rate with pectoralis flap.¹⁹ Mallet et al. in 2009,²⁰ outlined the same post-operative complications rate between these two flaps. O'Neill reported that significant differences found insuture dehiscence complication in pectoralis major myocutaneous flap and atelectasis was more frequent in Radial Forearm free flap; major flap complications, leading to another surgery were more frequent in the Radial Forearm free flap group.⁶

Hsing et al. in 2011, presented their series of 491 patients treated for oral cavity cancer. They found no significant difference in overall quality of life between patients treated with pedicled pectoralis major myocutaneous flap versus free flaps. Nevertheless, they reported significant differences between two groups in speech, shoulder mobility and mood domains with better outcomes for the free flap group.²¹ Xiao et al. found no significant differences between two  groups (ALT flap and  pectoralis major myocutaneous flap) for activity, swallowing, speech, saliva, or  mood and anxiety domains.²²

After introduction of radial forearm free flap by Yang et al.²³ in 1981, conventional locoregional flap were replaced by Radial Forearm free flap for head and neck reconstruction due to its pliability, thinness, pedicle length and vessel size. Although radial forearm flap results in excellent soft tissue reconstruction, it is usually associated with donor site morbidity that may include visible scar, wound breakdown, tendon exposure and skin graft loss. Long-term complications include reduced wrist mobility, wrist or hand weakness, sensory deficits, persisting pain, decreased hand dexterity and cosmetic deformity in objective and subjective assessments.²⁴

 Limitation of our study is that patient satisfaction regarding donor site complications in Radial Forearm free flap group was not evaluated. Further limitation was the operative time which was not included in the observation. In the settings of developing country with emerging expertise, it is suggested that conventional pedicled workhorse flap are a preferable option to the free flaps. However with the advent of advanced microsurgical technique one must opt for better outcome. 

Conclusion:

This study concluded that Radial forearm free flap is comparable option for head and neck reconstruction to the pectoralis major myocutaneous flap with fewer complication rate and overall successful outcome. However, further research regarding time and cost analysis is deficient in our low socio-economic population. Thus definitive procedure for head and neck reconstruction in review of our results depends on the patient factors and expertise of the team for maximal outcome.

Acknowledgement

Authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of this manuscript

Source of Funding

None

Conflict of interest

None

Authors Contribution

Dr. Abdul Malik Mujahid

Principal contributor, conceptualization and design of research work

Dr. Musadiq Asrar

Co contributor, plagiarism correction, final approval

Dr. Ifrah Rashed

 Co contributor, data analysis,

Dr. Kashif Mehmood

Statistical analysis, literature search

Dr. Usman Ishaque

Writing of manuscript, collection of data, drafting

Dr Noor Ali

Literature search, result analysis, review of the manuscript

References:

1. Closmann JJ, Pogrel MA, Schmidt BL. Reconstruction of perioral defects following resection for oral squamous cell carcinoma. J Oral Maxillofac Surg2006;64:367–74.

2. Baumann D, Robb G. Lip reconstruction. Semin Plast Surg 2008;22:269–80.

3. Heller L, Cole P, Kaufman Y. Cheek reconstruction: current concepts in managing facial soft tissue loss. Semin Plast Surg.2008;22:294–305.

4. Schusterman MA, Kroll SS, Weber RS, Byers RM, Guillamondegui O, Goepfert H: Intraoral soft tissue reconstruction after cancer ablation: a comparison of the pectoralis major flap and the free radial forearm flap. Am J Surg1991, 162:397-99.

5. Fang QG, Li ZN, Zhang X, Liu F-Y, Xu Z-F, Sun C-F. Clinical reliability of radial forearm free flap in repair of buccal defects. World J Surg Oncol. 2013; 11:26.

6. O‘Neill JP, Shine N, Eadie PA, Beausang E, Timon C. Free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects. Ir J Med Sci 2010;179:337–43.

7. Avery C. A perspective on the role of the pectoralis major flap in oral and maxillofacial oncology surgery. Oral Surg. 2014;7:130.

8. Patrik P, Kelsey R, Joseph Z. Functional considerations in oral cavity reconstruction. Curr Opin Otolaryngol Head and Neck Surg. 2018, 26: 000-000.

9. Li W, Zhang P, Li R, Liu Y, Kan Q. Radial free forearm flap versus pectoralis major pedicled flap for reconstruction in patients with tongue cancer: Assessment of quality of life. Med Oral Patol Oral Cir Bucal.2016 Nov 1;21 (6):e737-42.

10. Yanjie Y, Feng Li, Wenlu Li. Factors that affect the quality of life of patients with oral cancer who have had their defects reconstructed immediately after excision of the tumour. Br J Oral Maxillofac Surg.2015, http://dx.doi.org/10.1016/j. bjoms.2015.12.004

11. Ariyan S. Further experiences with the pectoralis major myocutaneous flap for the immediate repair of defects from excisions of head and neck cancers. Plast Reconstr Surg. 1979;64:605– 612.

12. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg. 1979;63:73–81.

13. Shaikh SA, Bawa A, Shahzad N, Yousufzai Z, Ghani MS. Reducing the donor site morbidity in radial forearm free flaps by utilizing a narrow radial forearm free flap. Arch Plast Surg. 2018 Jul. 45 (4):345-50.

14. Abid H, Ahmad S, Warraich RA. The versatility of pectoralis Myocutaneous Flap in head and neck Reconstruction. Ann K E Med Col. 2008; 14(3): 100-105.

15. Khan F, Shah SA, Hameed H, Khan NU. Head and neck reconstruction; our experience of pectoralis major myocutaneous pedicled flap. Professional Med J. 2011;18(2): 310-316.

16. Abrar Y, Muntaha S, Khan K, Hameed U. Successful use of Deltopectoral flap in reconstruction of Defect caused by Squamous cell carcinoma. J Coll Physicians Surg Pak. 2018, (supply) 28; 125-127.

17. Shinichi A, Hirohiko K, Kazuhide M, Mitsuhiro W, Norita K. The pectoralis major myocutaneous pedicled flap. Surgical Sci.2013; 4:380-4.

18. Khalid FA, Saleem M, Yousaf MA, Mujahid AM, Shehzad I, Tarar MN. Oropharyngeal, hypopharyngeal and cervical esophagus Reconstruction: An Experience of Pedicle Flaps. J Coll Physicians Surg Pak 2019; 29(2): 168-172.

19. Amin MM, Naseer U, Akhtar A, Awan AA. Pectoralis major my cutaneous flap for reconstruction of major neck defects. J Surg Pak (Int) 2014; 19:70-4.

20. Mallet Y, Bedoui S El, Penel N, Ton Van J, Fournier C, Lefebvre JL. The free vascularized flap and the pectoralis major pedicled flap options: comparative results of reconstruction of the tongue. Oral Oncol. 2009; 45:1028–103.

21. Hsing CY, Wong YK, Wang CP, Wang CC, Jiang R-S, Chen F-J et al. Comparison between free flap and pectoralis major pedicled flap for reconstruction in oral cavity cancer patients - a quality of life analysis. Oral Oncol. 2011; 47:522–527.

22. Xiao Y, Zhu J, Cai X, Wang J, Liu F, Wang H. Comparison between anterolateral thigh perforator free flaps and pectoralis major pedicled flap for reconstruction in oral cancer patients- -a quality of life analysis. Med Oral Patol Oral Cir Bucal. 2013;18:e856–e861.

23. Yang GF, Chen PJ, Gao YZ, Liu XY, Li J, Jiang SX, et al. Forearm free skin flap transplantation: a report of 56 cases. 1981. Br J Plast Surg 1997;50:162-5.

24. Sardesai MG, Fung K, Yoo JH, Bakker H. Donor-site morbidity following radial forearm free tissue transfer in head and neck surgery. J Otolaryngol Head Neck Surg 2008; 37