Zhuowei Tian

Microvascular Reconstruction in Elderly Oral Cancer Patients: Does Diabetes Status Have a Predictive Role in Free Flap Complications?

PURPOSE Flap complications still present challenges in the field of microsurgical reconstruction. The aim of this study was to explore the role of diabetes mellitus in free flap prognosis in elderly patients (≥60 years) after oral tumor resection. PATIENTS AND METHODS The data of aged oral cancer patients who had undergone reconstructions with free flaps in our institution were gathered in this retrospective cohort study. The samples were classified into diabetic and nondiabetic groups. The predictive roles of diabetes status and other factors in free flap prognosis were analyzed. The primary outcome variable was the presence of flap complications, which was subdivided into major (requiring re-exploration or local surgery) and minor (dressing or drug treatment) groups. Major complications were defined as the second outcome variable. Univariate and multivariable analyses were used for data statistics. RESULTS A total of 309 patients (176 men [57%] and 133 women [43%]) aged 60 years or older were included in this study. There were 105 diabetic patients (34%) and 204 nondiabetic patients (66%). A total of 75 flap complications occurred during the perioperative period, with an overall incidence of 24.3% (44 diabetic patients [41.9%] and 31 nondiabetic patients [15.2%], P ≤ .001). The odds of susceptibility for flap complication development in elderly diabetic patients was 3.413 times that of nondiabetic patients (odds ratio, 3.413; P ≤ .001). Of 75 flap complications, 43 (13.9%) were deemed major complications (24 diabetic patients [22.9%] and 19 nondiabetic patients [9.3%], P ≤ .001). This statistical association was further confirmed by multivariate analysis (odds ratio, 2.885; P = .002). CONCLUSIONS Diabetes mellitus increases the risk of the development of free flap complications in elderly patients when dealing with oral reconstruction after tumor removal.

Retrospective analysis of osteoradionecrosis of the mandible: proposing a novel clinical classification and staging system

Osteoradionecrosis of the jaw is a common radiation-induced complication that may be observed in oral cancer patients. Several classifications and staging systems have been proposed for osteoradionecrosis of the mandible based on clinical symptoms, radiological findings, and/or the response to diverse treatments. However, none has been universally accepted because of their individual deficiencies. The aim of this study was to introduce a new clinical classification that can be applied to the treatment of osteoradionecrosis in an easier and more acceptable way, through a retrospective analysis of patients with osteoradionecrosis of the mandible. A review was conducted of 99 patients diagnosed with osteoradionecrosis of the mandible in the study institution between 2000 and 2013. A novel classification was established on the basis of bone necrosis and soft tissue defects. A new staging system with four different stages (stage 0, stage I, stage II, and stage III) is proposed. We believe that this new classification and staging system is easier and more acceptable for clinical evaluation than previous ones.

Juvenile ossifying fibroma of the jaw: a retrospective study of 15 cases

The management of patients with juvenile ossifying fibroma (JOF) remains controversial. To explore the correlations between different treatments and the patient prognosis, 15 cases of JOF of the jaw were reviewed. Five patients were male and 10 were female. Patient age at the time of disease onset ranged from 7 to 18 years (mean 10.9 years). Nine tumours were located in mandible and six in the maxilla. These cases typically manifested clinically as painless swelling of the jaw (9/15, 60%); 40% (6/15) of the cases were associated with pain, diplopia, stuffy nose, and/or rapid growth. Images of JOF can show a radiolucent, mixed, or ground glass-like appearance. Pathological examinations revealed 10 cases of juvenile trabecular ossifying fibroma (JTOF) and five cases of juvenile psammomatoid ossifying fibroma (JPOF). In terms of the treatment plan, six patients initially received radical surgery; nine patients underwent conservative treatment, among whom six (6/9, 66.7%) had one or more recurrence. At the end of the follow-up period, 12 patients had no evidence of tumour recurrence and three cases were alive with a tumour. In summary, surgeons should develop the surgical plan according to the extent of the lesion, relapse status, growth rate, and family choice, and these patients should be followed up closely.

Superficial circumflex iliac artery perforator flap's imaging, anatomy and clinical applications in oral maxillofacial reconstruction

PURPOSE To assess the feasibility of superficial circumflex iliac artery perforator (SCIP) flap for oral maxillofacial reconstruction and evaluate computed tomography angiography (CTA) and color Doppler sonography (CDS) in mapping superficial circumflex iliac artery (SCIA) and its perforators. MATERIAL AND METHODS Fifteen patients were carried out surgery. Perforator identification and the relationship between SCIA, deep circumflex iliac artery (DCIA) and superficial inferior epigastric artery (SIEA) were performed preoperatively and intra-operatively. RESULTS The relationship between SCIA, DCIA and SIEA was depicted and subdivided into type 1 (8/15), type 2 (2/15), type 3 (2/15), type 4 (2/15) and type 5 (1/15). Surgical procedures and SCIP flap anatomy were described. 14/15 of the SCIP flaps survived and one with necrosis. CONCLUSIONS The SCIP flap is a reliable, thin and pliable flap with hidden donor site morbidity for oral maxillofacial reconstruction. CTA and CDS are valuable methods for preoperative assessment of the perforators location and type.

Re: ‘Preoperative color Doppler ultrasound assessment in planning of SCIP flaps’

Summary Introduction Superficial circumflex iliac artery perforator (SCIP) flap is based on the perforator of superficial circumflex iliac artery (SCIA) system, and is a highly useful surgical tool with a wide variety of clinical applications. The SCIA system is associated with considerable anatomical variation, however, rendering transfer of a SCIP flap technically difficult. Patients and methods Using preoperative color Doppler ultrasound (US), we examined a total of 11 flaps of 11 patients who had undergone reconstruction with SCIP flap from April to August of 2014. The origin of SCIA from femoral artery and the bifurcation of its superficial branch and deep branch were easily identifiable in all patients. Perforator courses and their penetration points were marked to guide dissection. Results Although one patient required secondary revision and skin grafting because of partial necrosis, there were no serious postoperative complications such as total necrosis or resulting absorption of the transferred adiposal flap. In all cases, findings from the preoperative color Doppler US were useful in delineating the dominant vessel within the groin lesion. Conclusion Using the technique described above, difficulties arising from the anatomical variation within the SCIA system are easily overcome, simplifying SCIP flap harvest. In addition to being relatively easy, the technique is also quick to administer and safe.

Surgical management of osteoradionecrosis of the jaws.

ObjectiveThe objective of this study is to evaluate our 10-year clinical experience in surgical management of patients with osteoradionecrosis (ORN) unresolved with conservative nonoperative treatment. Patients and MethodsThe medical records of 120 patients who had been surgically treated for ORN during a 10-year period (January 2003 to January 2013) were retrospectively reviewed. ResultsThe most predilection ORN site was mandible (82.5%), followed by the maxilla (11.7%). ORN developed within initial 12 months in 39.2% and within the first 3 years in 68.3%. The median radiation dose was 68.1 Gy (range, 35–148 Gy), but 51 patients (42.5%) experienced ORN even though radiation doses were controlled under 60 Gy. Surgical trauma, as we believed, was the most important factor leading to this result. Among all the patients, 12 (10.0%) patients were found ineligible for operative treatment due to comorbid systematic diseases whereas none healed or improved. In terms of surgical management of the rest of the 108 patients, 90 (75.0%) patients underwent radical resection (4 patients unhealed), and 18 (15.0%) patients underwent mild surgical procedures such as sequestrectomy or debridement (1 patient unhealed). Of the 90 radical resection patients, 58 patients underwent radical resections and immediate microvascular flap reconstruction (19 bone flaps and 39 soft flaps), and 32 patients only experience radical resection (5 patients received second-stage reconstruction). According to follow-up information, 55 patients were free of disease. ConclusionThough priority should be given to surgical treatment for the patient whose ORN does not respond to conservative nonoperative treatment, we may as well take into account more individualized regimens based on ORN severity. A hard lesson learned from our article is that the oral maxillofacial surgeon should minimize the trauma for jaws as possible as he can, especially to patients who need to receive postoperative radiotherapy.

Interferon-a promotes the expression of cancer stem cell markers in Oral squamous cell carcinoma

Objectives: IFNα can stimulate an antitumor immune response and has a direct inhibition on cancer cells. This study is to test whether IFNα can activate dormant cancer stem cell (CSC) in oral squamous cell carcinoma (OSCC) to facilitate their elimination by chemotherapy. Materials and methods: Nude mouse transplantation tumor model was established and administrated with IFNα and saline. The influence on CD44 and ALDH1A1 expression under IFNα treatment was detected by in vivo experiments. Flow cytometry, western blot, and immunofluorescence were used to detect the expression of CD44 and ALDH1A1 after INFa treatment in OSCC cell lines. Tumorsphere formation assay was conducted under incubation with IFNα for 2 weeks. Chromatin immunoprecipitation (ChIP) assays was used to examine the IFNα-induced transcriptional regulation of CD44 and ALDH1A1 expression. That IFNα-primed enhanced killing effect of chemotherapy was evaluated by MTT and western blot. Results: IFNα transcriptionally activated the expression of CD44 and ALDH1A1 expression both in vivo and in vitro. IFNα-primed enhanced the cytotoxic inhibition effect of CDDP, erlotinib and nimotuzumab on OSCC cells. Conclusion: These results suggest that IFNα could be administrated to patients prior to chemotherapeutic drugs, which will facilitate the killing of cancer stem cells in OSCC.

Clinical Application of the Dorsalis Pedis Free Flap for Reconstruction of Oral Cancer Defects

PURPOSE The purposes of this study were to evaluate the clinical application and efficacy of the dorsalis pedis fasciocutaneous flap in the reconstruction of oral cavity defects and to assess the associated donor-site morbidity. PATIENTS AND METHODS From September 2009 to December 2012, 7 patients with associated oral cavity defects resulting from tumor resection underwent reconstruction with a dorsalis pedis fasciocutaneous flap. Surgical anatomy and harvesting procedure of the dorsalis pedis flap are described. Special consideration was given to the associated donor-site morbidity. RESULTS All flaps survived without any complications. All 7 flaps were based on the dorsalis pedis artery and the greater saphenous vein for perfusion and drainage respectively. In all 7 cases, the donor site was closed with a full-thickness skin graft, with no associated healing complications or functional deficit of the foot. The resulting scar was well hidden in the lower extremity. CONCLUSIONS The dorsalis pedis fasciocutaneous flap is a thin and pliable flap sharing many similarities with the radial forearm flap, thus making it ideal for intraoral reconstruction. Proper intraoperative and postoperative care of the donor site can result in minimal morbidity, as shown in this study. This flap may provide an ideal alternative to the radial forearm free flap, with the added advantages of a well-hidden scar and a high level of patient satisfaction.

Superficial Circumflex Iliac Artery Perforator Flap: A Promising Candidate for Large Soft Tissue Reconstruction of Retromolar and Lateral Buccal Defects After Oncologic Surgery.

PURPOSE Surgical reconstruction of extensive retromolar and lateral buccal defects after oncologic resection remains a major challenge because early and aggressive invasion by retromolar malignancies generally entails wider resection of several local anatomic structures to attain tumor-free margins. The superficial circumflex iliac artery perforator (SCIP) flap, which is a promising candidate with multiple advantages, provides a better choice of quality and esthetics for such reconstruction. PATIENTS AND METHODS Three patients (median age, 44.7 yr; age range, 23 to 63 yr) diagnosed with retromolar or lateral buccal squamous cell carcinoma (or mucoepidermoid carcinoma) underwent ablative surgery and simultaneous SCIP flap reconstruction. Preoperative computed tomographic angiographic (CTA) and color ultrasonographic images were used for confirmation and positioning of the SCIPs. Volumes of defects and corresponding SCIP flaps were recorded and analyzed. In addition, pre- and postoperative functions of speech, swallowing, and mouth opening and donor-site morbidity were compared. RESULTS The SCIP flaps were raised according to information gathered from CTA and sonographic imaging. The median pedicle length reached 8.2 cm and the flap sizes ranged from 5 × 6 to 6.0 × 8.0 cm. All flaps survived uneventfully during the perioperative period and subsequent follow-up showed no recurrence. Compatible donor-recipient volume, easy harvesting, acceptable postoperative functions, and inconspicuous donor-site scars were regarded as the main advantages of the SCIP flaps. CONCLUSION For defects after resection of retromolar and lateral buccal tumors, the SCIP flap might play an innovative and supplementary role to traditional soft tissue reconstruction approaches.

Superficial circumflex iliac artery perforator flap: identification of the perforator by computed tomography angiography and reconstruction of a complex lower lip defect

The purpose of this article is to present our approach to the reconstruction of head and neck defects using the superficial circumflex iliac artery perforator (SCIP) flap with the aid of preoperative computed tomography angiography (CTA) mapping. We describe the reconstruction procedure of a lower lip defect with a SCIP flap in a patient who underwent resection for a lower lip squamous cell carcinoma (SCC). Preoperative CTA is an effective method for detecting and predicting the course of perforator vessels. The SCIP flap may provide a superior functional and aesthetic restoration in selected cases, with an inconspicuous donor site scar and lower donor site morbidity. We believe that the SCIP flap is a viable option for soft tissue reconstruction of defects in the head and neck region with the aid of preoperative CTA mapping.