Pedicled Flaps versus Free Flaps for Oral Cavity Cancer Reconstruction: A Comparison of Complications, Hospital Costs, and Functional Outcomes

Sittitrai, Pichit; Ruenmarkkaew, Donyarat; Klibngern, Hanpon

doi:10.1055/s-0042-1751001

Abstract

Introduction

Free flaps have been the preferred method for reconstruction after resection of oral cavity cancer. However, pedicled flaps remain valuable alternatives in appropriate settings.

Objective

The main objective of the present study was to compare surgical complications, hospital costs, and functional outcomes of oral cavity cancer patients who underwent soft tissue reconstruction with pedicled flaps or free flaps.

Methods

A total of 171 patients were included in the study. Ninety-eight underwent reconstruction with a pectoralis major, submental, temporalis, or supraclavicular pedicled flap, and in 73 patients, a radial forearm or anterolateral thigh free flap had been used. The cases were retrospectively reviewed, and a comparative analysis was carried out between the two groups.

Results

Recipient site and flap complications, speech, and swallowing functions did not differ between groups, but donor site complications, operative time, hospital stay, and costs were significantly reduced in the pedicled flap group compared with the free flap group. However, the pectoralis major flap reconstruction resulted in a more inferior swallowing function than the free flap reconstruction.

Conclusions

With comparable complications and functional outcomes, while decreasing in costs, pedicled flaps are a useful alternative to free flaps in oral cavity cancer reconstruction. However, in an extensive defect (> 70 cm²), free flaps are the reconstruction of choice for the preservation of swallowing function.

Keywords
pedicled flap; free flap; oral cancer; reconstruction

Introduction

The mainstay of treatment of oral cavity cancer in both early and advanced stages is surgery, which often affects speech and swallowing functions and also has a significant impact on the quality of life of the patient.¹1 Kerawala C, Roques T, Jeannon JP, Bisase B. Oral cavity and lip cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016;130(S2):S83–S89,²2 Smeele LE, Goldstein D, Tsai V, et al. Morbidity and cost differences between free flap reconstruction and pedicled flap reconstruction in oral and oropharyngeal cancer: Matched control study. J Otolaryngol 2006;35(02):102–107,³3 Hsing CY, Wong YK, Wang CP, 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(06):522–527,⁴4 Goyal N, Yarlagadda BB, Deschler DG, et al. Surgical site infections in major head and neck surgeries involving pedicled flap reconstruction. Ann Otol Rhinol Laryngol 2017;126(01):20–28 The reconstruction of intraoral tissue following tumor extirpation is a major challenge, and the aims should include adequate wound healing and successful functional rehabilitation.³3 Hsing CY, Wong YK, Wang CP, 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(06):522–527

Free flaps have been referred to as the standard reconstruction of defects after resection in cases of head and neck cancer, including oral cavity cancer, because of their reliability and versatility.⁵5 Mallet Y, El Bedoui S, 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(12):1028–1031,⁶6 de Bree R, Reith R, Quak JJ, Uyl-de Groot CA, van Agthoven M, Leemans CR. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007;32(04):275–282,⁷7 Gao LL, Basta M, Kanchwala SK, Serletti JM, Low DW, Wu LC. Cost-effectiveness of microsurgical reconstruction for head and neck defects after oncologic resection. Head Neck 2017;39(03): 541–547 However, not all defects require a free flap to achieve good outcomes and not every patient is a suitable candidate for a microvascular procedure. Therefore, regional pedicled flaps may be useful in treating patients with coexisting morbidities, have a short life expectancy, have poor recipient vascularity, and also in certain circumstances, including lack of microsurgical facilities and financial issues.⁸8 Sittitrai P, Reunmakkaew D, Srivanitchapoom C. Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes. J Laryngol Otol 2019;133(05):413–418,⁹9 Paydarfar JA, Patel UA. Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 2011;137(01): 82–87,¹⁰10 Gabrysz-Forget F, Tabet P, Rahal A, Bissada E, Christopoulos A, Ayad T. Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review. J Otolaryngol Head Neck Surg 2019;48(01):13. Doi: 10.1186/s40463-019-0334-y
https://doi.org/10.1186/s40463-019-0334-... ,¹¹11 Welz C, Canis M, Schwenk-Zieger S, Spiegel JL, Weiss BG, Pilavakis Y. Oral cancer reconstruction using the supraclavicular artery island flap: comparison to free radial forearm flap. J Oral Maxillofac Surg 2017;75(10):2261–2269,¹²12 Lakshminarayana G, Venkitachalam S, Mani CS. Choice of regional flaps for oral cancer defects: relevance in current era. J Maxillofac Oral Surg 2021;20(02):246–251 There has been a recent resurgence of interest in the use of pedicled flaps in addition to the “workhorse” pectoralis major myocutaneous flap, including a submental island flap, temporalis myofascial flap, and supraclavicular island flap, which increases versatility in most of the head and neck defects.⁴4 Goyal N, Yarlagadda BB, Deschler DG, et al. Surgical site infections in major head and neck surgeries involving pedicled flap reconstruction. Ann Otol Rhinol Laryngol 2017;126(01):20–28,⁶6 de Bree R, Reith R, Quak JJ, Uyl-de Groot CA, van Agthoven M, Leemans CR. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007;32(04):275–282,¹⁰10 Gabrysz-Forget F, Tabet P, Rahal A, Bissada E, Christopoulos A, Ayad T. Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review. J Otolaryngol Head Neck Surg 2019;48(01):13. Doi: 10.1186/s40463-019-0334-y
https://doi.org/10.1186/s40463-019-0334-... ,¹¹11 Welz C, Canis M, Schwenk-Zieger S, Spiegel JL, Weiss BG, Pilavakis Y. Oral cancer reconstruction using the supraclavicular artery island flap: comparison to free radial forearm flap. J Oral Maxillofac Surg 2017;75(10):2261–2269,¹³13 Tsue TT, Desyatnikova SS, Deleyiannis FW, et al. Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer. Arch Otolaryngol Head Neck Surg 1997;123(07):731–737,¹⁴14 Sukato DC, Timashpolsky A, Ferzli G, Rosenfeld RM, Gordin EA. Systematic review of supraclavicular artery island flap vs free flap in head and neck reconstruction. Otolaryngol Head Neck Surg 2019;160(02):215–222,¹⁵15 Jørgensen MG, Tabatabaeifar S, Toyserkani NM, Sørensen JA. Submental island flap versus free flap reconstruction for complex head and neck defects. Otolaryngol Head Neck Surg 2019;161 (06):946–953,¹⁶16 Meier JK, Spoerl S, Spanier G, et al. Alternatives to free flap surgery for maxillofacial reconstruction: focus on the submental island flap and the pectoralis major myocutaneous flap. BMC Oral Health 2021;21(01):198. Doi: 10.1186/s12903-021-01563-7
https://doi.org/10.1186/s12903-021-01563... In addition, with the global strain on hospital resources during the COVID-19 pandemic, pedicled flaps can be a useful reconstruction in the current situation.¹⁷17 Gray ML, Drake VE, Desai SC. Resurgence of regional flaps for head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2021;29(04):237–243. Doi: 10.1097/MOO.0000000000000725
https://doi.org/10.1097/MOO.000000000000... ,¹⁸18 Rashid HU, Rashid M, Khan N, Ansari SS, Bibi N. Taking a step down on the reconstruction ladder for head and neck reconstruction during the COVID-19 pandemic. BMC Surg 2021;21(01):120. Doi: 10.1186/s12893-021-01134-1
https://doi.org/10.1186/s12893-021-01134...

The purpose of the present study is to compare postoperative outcomes, including surgical complications, duration of hospital stay, hospital costs, and functional results in oral cavity cancer patients who underwent surgical resection followed by soft tissue reconstruction with a pedicled flap including pectoralis major myocutaneous, submental island, temporalis myofascial, and supraclavicular island flaps or a free flap including radial forearm and anterolateral thigh free flaps.

Material and Methods

We conducted a retrospective study of patients with squamous cell carcinoma of the oral cavity who were surgically treated between November 2010 and October 2017. All procedures contributing to the present work complied with the ethical standards of the relevant national and institutional guidelines on human experimentation, and with the Helsinki Declaration of 1975, as revised in 2008, and were approved by the Research Ethics Committee of the institution.

Patients who underwent intraoral carcinoma resection and immediate soft tissue reconstruction with regional pedicled flaps (pectoralis major myocutaneous, submental island, temporalis myofascial, and supraclavicular island flaps) or microvascular free flaps (radial forearm and anterolateral thigh free flaps) were included in the study. The method of reconstruction was based on patient comorbidity and patient-physician agreement. Patients with a previous history of radiotherapy or of surgery and those who required bony reconstruction were excluded. Patients with stage T1 tumors were not included in the study because most of the defects were primarily closed, reconstructed with local flaps, or healed by secondary intention.

All patients underwent selective or comprehensive (radical or modified radical) neck dissection, and either unilateral or bilateral neck dissection, depending on the clinical status of the cervical lymph node. Patients with a primary tumor extending through the mylohyoid muscle, or with a level I cervical lymph node with a sign of extranodal extension of cancer or > 1.5 cm in diameter, were contraindicated for a submental island flap.

Postoperative adjuvant therapies, including radiotherapy or chemoradiotherapy, were considered if the tumors were of an advanced stage (stages III-IV), had close or invaded surgical margins, or exhibited an extracapsular extension of the lymph nodes.

Surgical complications and outcomes related to speech and swallowing functions were assessed using a scoring system, shown in ►Table 1. These were evaluated in every patient for at least 1 year after treatment. In addition, duration of hospital stay, and hospital costs were reviewed.

Thumbnail

Table 1
Postoperative functional results of speech and swallowing scores

Statistical analysis was performed using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY, USA). Clinical demographics and disease variables were analyzed using nonparametric qualitative and quantitative tests. The Fisher exact test, an independent t-test, the chi-squared test, and odds ratio (OR) with 95% confidence intervals (CIs) were used to compare the data. A p-value < 0.05 was considered statistically significant.

Results

A total of 171 patients were enrolled into the study. Ninety-eight patients underwent pedicled flap reconstruction, and 73 patients had free flap reconstruction. Patient demographics and clinical characteristics of both groups are summarized in ► Table 2. The two groups did not significantly differ in mean age, gender, preoperative risk factors (smoking, alcohol drinking, diabetes mellitus, chronic obstructive pulmonary disease, and American Society of Anesthesiologists [ASA] classification), primary site location, and Tstaging. Regarding N staging, there were more patients with clinical N0 than N+ in the pedicled flap group than in those in the free flap group (28.6 versus 12.3%, respectively, p = 0.014). However, no differences were detected when comparing the overall N stages and types of neck dissection (selective or radical or modified radical and unilateral or bilateral).

Thumbnail

Table 2
Demographics and clinical characteristics of patients reconstructed with pedicled flaps or free flaps

The mean size of the defects in the pedicled flap group was significantly smaller than that in the free flap group (33.3 versus 53.3 cm², respectively, p < 0.001). The mean operative time was significantly shorter in the pedicled flap group than in the free flap group (232 versus 413minutes, respectively, p < 0.001). Pathological reports of surgical margin (clear versus close or positive) and postoperative treatment (no versus radiotherapy or chemoradiotherapy) did not differ between the two groups.

Data pertinent to surgical complications are shown in ►Table 3. Donor site complications were significantly fewer in the pedicled flap group. However, shoulder dysfunction was the most common complication in patients with the pectoralis major myocutaneous flap. In contrast, partial loss of the skin graft and arm dysfunction, such as restriction of grip strength, of pinch strength, and of wrist movements, were frequently found in patients who had undergone a radial forearm free flap.

Thumbnail

Table 3
Surgical complications, hospital stay, and hospital costs of patients

The recipient site complication rate did not significantly differ between the two groups. However, orocutaneous fistula and wound dehiscence were recorded most frequently in the pectoralis major myocutaneous flap cases. These complications were conservatively managed with necrotic tissue debridement and resuturing, wound reopening and collection removal, and local wound care.

Although there were no differences in flap complications, 5 patients in the free flap group required revision of vascular anastomosis, and 2 patients with radial forearm free flap had total flap loss, which occurred at postoperative day 9 and day 12; 1 patient with hard palate resection required postoperative palatal prosthesis, and another with oral tongue and floor of mouth defect required pectoralis major myocutaneous flap re-reconstruction. All patients with partial flap loss were successfully managed with tissue debridement and wound resuturing.

The mean duration of hospital stay was significantly shorter in the pedicled flap group than in the free flap group (20 versus 31days,respectively, p < 0.001). Concerning mean hospital costs during admission, pedicled flap reconstruction was significantly less costly than free flap reconstruction (4,360 versus 7,935 US Dollars, respectively, p < 0.001) (►Table 3).

Regarding functional outcomes, most of the patients in both groups had excellent to good speech function (80.7% in the pedicled flap group and 79.5% in the free flap group, p = 0.947). Moreover,most patients were able to take a full or soft diet (81.7% in the pedicled flap group and 82.2% in the free flap group, p = 0.768). (►Table 4)

Thumbnail

Table 4
Speech and swallowing outcomes of patients

In comparison with the free flap group, patients undergoing reconstruction with a pectoralis major myocutaneous flap had significantly higher mean age, were more in ASA class III, more with stage T3-4, had a shorter operative time, shorter hospital stay, and lower hospital costs. However, there were no significant differences in any surgical complication, including the orocutaneous fistula rate (13% in pectoralis major myocutaneous flap and 6.8% in free flaps, p = 0.393). Although speech function was not different, there was a trend towards decreased ability to take a full or soft diet in the pectoralis major myocutaneous flap group compared with the free flap group (60.9 versus 82.2%, respectively, p = 0.057). In addition, the necessity for a prolonged feeding tube was significantly higher in the pectoralis major myocutaneous flap group (13 versus 2.7%, respectively, p = 0.046). It is noteworthy that out of all 5 patients who required a feeding tube for > 1 year, 3 patients were in the pectoralis major myocutaneous flap group, 2 of whom had a defect size of 70cm,²2 Smeele LE, Goldstein D, Tsai V, et al. Morbidity and cost differences between free flap reconstruction and pedicled flap reconstruction in oral and oropharyngeal cancer: Matched control study. J Otolaryngol 2006;35(02):102–107 and the other had a defect size of 72 cm²; whereas 2 patients were in the free flap group, and both had a defect size of 80 cm². (►Table 5)

Thumbnail

Table 5
Demographics, clinical characteristics, and outcomes of patients

In comparison with the free flap patients, the other three pedicled flaps (submental island, temporalis myofascial, and supraclavicular island flaps) had significantly more patients at stage T2 and also more at stage N0, smaller defect size, shorter mean operative time, shorter hospital stay, and lower hospital costs. The donor site and recipient site complications were also significantly fewer in this pedicled flap group when compared with the free flap group. However, the difference in flap complications and in functional results were not statistically significant (►Table 5).

Possible factors predicting dissatisfaction in speech function (fair or poor speech) and swallowing function (liquid diet, oral diet plus feeding tube, or obligated feeding tube) were evaluated. In the univariate analysis, T staging (T3-4 versus T2), defect size at a cutoff point of > 43 cm², and recipient site complications, were associated with a significantly increased risk of poor speech function. In addition, T staging (T3-4 versus T2), defect size > 55 cm², recipient site complications, and flap complication were significantly related to poor swallowing function. It is noteworthy that pedicled versus free flap reconstruction, flap types, and primary site location were not associated with poor speech and swallowing results (►Table 6). In the multivariate analysis, T staging was the only factor shown to influence poor speech function, while T staging and large defect size were the factors associated with poor swallowing function (►Table 7).

Thumbnail

Table 6
Univariate analysis of factors predicting dissatisfaction of speech and swallowing

Thumbnail

Table 7
Multivariate analysis of factors predicting dissatisfaction of speech and swallowing

Discussion

Microvascular free flaps are currently the preferable flaps for soft tissue reconstruction of the oral cavity because of their reliability, versatility, and good functional results.⁵5 Mallet Y, El Bedoui S, 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(12):1028–1031,⁶6 de Bree R, Reith R, Quak JJ, Uyl-de Groot CA, van Agthoven M, Leemans CR. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007;32(04):275–282,⁷7 Gao LL, Basta M, Kanchwala SK, Serletti JM, Low DW, Wu LC. Cost-effectiveness of microsurgical reconstruction for head and neck defects after oncologic resection. Head Neck 2017;39(03): 541–547,¹³13 Tsue TT, Desyatnikova SS, Deleyiannis FW, et al. Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer. Arch Otolaryngol Head Neck Surg 1997;123(07):731–737,¹⁹19 Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer: complications, gastrostomy tube dependence, and hospitalization. Arch Otolaryngol Head Neck Surg 2004;130(02):181–186 However, free flap reconstruction requires substantial perioperative resources, which may not be available in many head and neck cancer centers. In addition, with the current COVID-19 pandemic situation, the more complex reconstruction with longer operative time and longer hospital stay may potentially increase risk of viral transmission.¹⁷17 Gray ML, Drake VE, Desai SC. Resurgence of regional flaps for head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2021;29(04):237–243. Doi: 10.1097/MOO.0000000000000725
https://doi.org/10.1097/MOO.000000000000... ,¹⁸18 Rashid HU, Rashid M, Khan N, Ansari SS, Bibi N. Taking a step down on the reconstruction ladder for head and neck reconstruction during the COVID-19 pandemic. BMC Surg 2021;21(01):120. Doi: 10.1186/s12893-021-01134-1
https://doi.org/10.1186/s12893-021-01134... Therefore, a variety of pedicled flaps have been performed more frequently in these situations.⁸8 Sittitrai P, Reunmakkaew D, Srivanitchapoom C. Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes. J Laryngol Otol 2019;133(05):413–418,¹⁰10 Gabrysz-Forget F, Tabet P, Rahal A, Bissada E, Christopoulos A, Ayad T. Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review. J Otolaryngol Head Neck Surg 2019;48(01):13. Doi: 10.1186/s40463-019-0334-y
https://doi.org/10.1186/s40463-019-0334-... ,¹⁷17 Gray ML, Drake VE, Desai SC. Resurgence of regional flaps for head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2021;29(04):237–243. Doi: 10.1097/MOO.0000000000000725
https://doi.org/10.1097/MOO.000000000000... ,¹⁸18 Rashid HU, Rashid M, Khan N, Ansari SS, Bibi N. Taking a step down on the reconstruction ladder for head and neck reconstruction during the COVID-19 pandemic. BMC Surg 2021;21(01):120. Doi: 10.1186/s12893-021-01134-1
https://doi.org/10.1186/s12893-021-01134... Nevertheless, the difference in the cost-effectiveness of surgery involving these two types of flaps has been a matter of debate in the literature.⁵5 Mallet Y, El Bedoui S, 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(12):1028–1031,⁶6 de Bree R, Reith R, Quak JJ, Uyl-de Groot CA, van Agthoven M, Leemans CR. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007;32(04):275–282,⁷7 Gao LL, Basta M, Kanchwala SK, Serletti JM, Low DW, Wu LC. Cost-effectiveness of microsurgical reconstruction for head and neck defects after oncologic resection. Head Neck 2017;39(03): 541–547,¹¹11 Welz C, Canis M, Schwenk-Zieger S, Spiegel JL, Weiss BG, Pilavakis Y. Oral cancer reconstruction using the supraclavicular artery island flap: comparison to free radial forearm flap. J Oral Maxillofac Surg 2017;75(10):2261–2269,¹³13 Tsue TT, Desyatnikova SS, Deleyiannis FW, et al. Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer. Arch Otolaryngol Head Neck Surg 1997;123(07):731–737,¹⁴14 Sukato DC, Timashpolsky A, Ferzli G, Rosenfeld RM, Gordin EA. Systematic review of supraclavicular artery island flap vs free flap in head and neck reconstruction. Otolaryngol Head Neck Surg 2019;160(02):215–222,²⁰20 Vartanian JG, Carvalho AL, Carvalho SM, Mizobe L, Magrin J, Kowalski LP. Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: experience with 437 cases at a single institution. Head Neck 2004;26(12):1018–1023,²¹21 Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg 2014; 25(03):868–871

In the present study, patients with oral cavity cancer who underwent soft tissue reconstruction with pedicled flaps or free flaps were compared. There were no differences in demographics and preoperative risks between the two groups, which are comparable to those of previous studies.³3 Hsing CY, Wong YK, Wang CP, 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(06):522–527,⁵5 Mallet Y, El Bedoui S, 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(12):1028–1031,⁷7 Gao LL, Basta M, Kanchwala SK, Serletti JM, Low DW, Wu LC. Cost-effectiveness of microsurgical reconstruction for head and neck defects after oncologic resection. Head Neck 2017;39(03): 541–547,⁸8 Sittitrai P, Reunmakkaew D, Srivanitchapoom C. Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes. J Laryngol Otol 2019;133(05):413–418,⁹9 Paydarfar JA, Patel UA. Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 2011;137(01): 82–87,¹³13 Tsue TT, Desyatnikova SS, Deleyiannis FW, et al. Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer. Arch Otolaryngol Head Neck Surg 1997;123(07):731–737,¹⁹19 Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer: complications, gastrostomy tube dependence, and hospitalization. Arch Otolaryngol Head Neck Surg 2004;130(02):181–186,²¹21 Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg 2014; 25(03):868–871,²³23 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;21(06):e737–e742,²⁴24 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(06): e856–e861,²⁵25 Zhang S, Chen W, Cao G, Dong Z. Pedicled supraclavicular artery island flap versus free radial forearm flap for tongue reconstruction following hemiglossectomy. J Craniofac Surg 2015;26(06): e527–e530 However, some studies reported that patients in the pedicled flap group were significantly older than those in the free flap group.⁴4 Goyal N, Yarlagadda BB, Deschler DG, et al. Surgical site infections in major head and neck surgeries involving pedicled flap reconstruction. Ann Otol Rhinol Laryngol 2017;126(01):20–28'¹⁶16 Meier JK, Spoerl S, Spanier G, et al. Alternatives to free flap surgery for maxillofacial reconstruction: focus on the submental island flap and the pectoralis major myocutaneous flap. BMC Oral Health 2021;21(01):198. Doi: 10.1186/s12903-021-01563-7
https://doi.org/10.1186/s12903-021-01563... '²⁶26 Deganello A, Gitti G, Parrinello G, Muratori E, Larotonda G, Gallo O. Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps. Acta Otorhinolaryngol Ital 2013;33(06):380–387 In addition, the proportion of patients with ASA class I-II to those with ASA class III-IV was variably reported as lower,⁴4 Goyal N, Yarlagadda BB, Deschler DG, et al. Surgical site infections in major head and neck surgeries involving pedicled flap reconstruction. Ann Otol Rhinol Laryngol 2017;126(01):20–28 similar,⁵5 Mallet Y, El Bedoui S, 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(12):1028–1031 or higher,⁶6 de Bree R, Reith R, Quak JJ, Uyl-de Groot CA, van Agthoven M, Leemans CR. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007;32(04):275–282,²⁷27 Sinha S, Puram SV, Sethi RK, et al. Perioperative deep vein thrombosis risk stratification. Otolaryngol Head Neck Surg 2017;156(01):118–121 in the pedicled flap group compared with in the free flap group. Concerning disease characteristics, there were no differences in primary tumor location, T staging, and overall N staging, which are similar to those recorded in previous studies.³3 Hsing CY, Wong YK, Wang CP, 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(06):522–527,⁵5 Mallet Y, El Bedoui S, 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(12):1028–1031,⁸8 Sittitrai P, Reunmakkaew D, Srivanitchapoom C. Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes. J Laryngol Otol 2019;133(05):413–418,⁹9 Paydarfar JA, Patel UA. Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 2011;137(01): 82–87,¹⁹19 Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer: complications, gastrostomy tube dependence, and hospitalization. Arch Otolaryngol Head Neck Surg 2004;130(02):181–186,²¹21 Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg 2014; 25(03):868–871,²⁴24 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(06): e856–e861 However, the number of patients with NO stage was significantly higher in the pedicle flap group than in the free flap group. It is noteworthy that 42.5% of submental island flap patients had NO neck because obvious signs of level I lymph node metastasis in patients is a contraindication for this flap.

Although the mean defect size of the pedicled flap group was significantly smaller than that of the free flap group (33.3 versus 53.3 cm², respectively), the submental island flap and pectoralis major myocutaneous flap were able to be used for reconstruction of a defect as large as between 60 and 72 cm².

Regarding surgical complications, donor site complications were significantly higher in patients with free flap reconstruction. Most of them were skin graft loss (18.6%) and restricted arm function (22.1%), exclusive to radial forearm free flaps. However, 34% of the patients who underwent pectoralis major myocutaneous flap reconstruction had shoulder dysfunction. These common complications were also reported in previous studies.⁷7 Gao LL, Basta M, Kanchwala SK, Serletti JM, Low DW, Wu LC. Cost-effectiveness of microsurgical reconstruction for head and neck defects after oncologic resection. Head Neck 2017;39(03): 541–547,⁸8 Sittitrai P, Reunmakkaew D, Srivanitchapoom C. Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes. J Laryngol Otol 2019;133(05):413–418,²¹21 Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg 2014; 25(03):868–871,²³23 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;21(06):e737–e742,²⁴24 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(06): e856–e861,²⁵25 Zhang S, Chen W, Cao G, Dong Z. Pedicled supraclavicular artery island flap versus free radial forearm flap for tongue reconstruction following hemiglossectomy. J Craniofac Surg 2015;26(06): e527–e530 Although no significant differences were found between overall recipient site complications and flap complications, 2 patients with radial forearm free flaps had late total flap failure occurring between postoperative day 7 and day 14. Both of them had no evidence of delayed infection or residual tumor; therefore, this incidence was most likely to be attributed to vascular pedicle compression during oral rehabilitation.²⁸28 Forner D, Williams BA, Makki FM, Trites JR, Taylor SM, Hart RD. Late free flap failure in head and neck reconstruction: A systematic review. Ear Nose Throat J 2018;97(07):213–216,²⁹29 Wang W, Ong A, Vincent AG, Shokri T, Scott B, Ducic Y. Flap failure and salvage in head and neck reconstruction. Semin Plast Surg 2020;34(04):314–320 Operative time and hospital stay were longer in the free flap patients, and hospital costs were almost twice as much in the free flap group. These results were also reported in previous studies.⁶6 de Bree R, Reith R, Quak JJ, Uyl-de Groot CA, van Agthoven M, Leemans CR. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007;32(04):275–282,⁸8 Sittitrai P, Reunmakkaew D, Srivanitchapoom C. Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes. J Laryngol Otol 2019;133(05):413–418,¹¹11 Welz C, Canis M, Schwenk-Zieger S, Spiegel JL, Weiss BG, Pilavakis Y. Oral cancer reconstruction using the supraclavicular artery island flap: comparison to free radial forearm flap. J Oral Maxillofac Surg 2017;75(10):2261–2269,²²22 Kroll SS, Evans GR, Goldberg D, et al. A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps. Plast Reconstr Surg 1997;99(05): 1282–1286,²⁵25 Zhang S, Chen W, Cao G, Dong Z. Pedicled supraclavicular artery island flap versus free radial forearm flap for tongue reconstruction following hemiglossectomy. J Craniofac Surg 2015;26(06): e527–e530

Regarding functional outcomes, no difference in speech function was detected, a finding similar to that of other studies,⁸8 Sittitrai P, Reunmakkaew D, Srivanitchapoom C. Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes. J Laryngol Otol 2019;133(05):413–418,⁹9 Paydarfar JA, Patel UA. Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 2011;137(01): 82–87,¹¹11 Welz C, Canis M, Schwenk-Zieger S, Spiegel JL, Weiss BG, Pilavakis Y. Oral cancer reconstruction using the supraclavicular artery island flap: comparison to free radial forearm flap. J Oral Maxillofac Surg 2017;75(10):2261–2269,²³23 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;21(06):e737–e742,²⁵25 Zhang S, Chen W, Cao G, Dong Z. Pedicled supraclavicular artery island flap versus free radial forearm flap for tongue reconstruction following hemiglossectomy. J Craniofac Surg 2015;26(06): e527–e530,²⁶26 Deganello A, Gitti G, Parrinello G, Muratori E, Larotonda G, Gallo O. Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps. Acta Otorhinolaryngol Ital 2013;33(06):380–387 and ~ 80% of the patients in both groups in the study had excellent to good speech. In addition, the number of patients who were able to take a full or soft diet did not significantly differ between the two groups. Again, a finding similar to that reported in other studies.²2 Smeele LE, Goldstein D, Tsai V, et al. Morbidity and cost differences between free flap reconstruction and pedicled flap reconstruction in oral and oropharyngeal cancer: Matched control study. J Otolaryngol 2006;35(02):102–107,³3 Hsing CY, Wong YK, Wang CP, 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(06):522–527,⁸8 Sittitrai P, Reunmakkaew D, Srivanitchapoom C. Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes. J Laryngol Otol 2019;133(05):413–418,⁹9 Paydarfar JA, Patel UA. Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 2011;137(01): 82–87,¹¹11 Welz C, Canis M, Schwenk-Zieger S, Spiegel JL, Weiss BG, Pilavakis Y. Oral cancer reconstruction using the supraclavicular artery island flap: comparison to free radial forearm flap. J Oral Maxillofac Surg 2017;75(10):2261–2269,¹²12 Lakshminarayana G, Venkitachalam S, Mani CS. Choice of regional flaps for oral cancer defects: relevance in current era. J Maxillofac Oral Surg 2021;20(02):246–251,²³23 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;21(06):e737–e742,²⁴24 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(06): e856–e861,²⁵25 Zhang S, Chen W, Cao G, Dong Z. Pedicled supraclavicular artery island flap versus free radial forearm flap for tongue reconstruction following hemiglossectomy. J Craniofac Surg 2015;26(06): e527–e530,²⁶26 Deganello A, Gitti G, Parrinello G, Muratori E, Larotonda G, Gallo O. Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps. Acta Otorhinolaryngol Ital 2013;33(06):380–387

Pectoralis major myocutaneous flap is one of the essential reconstructive pedicled flaps in head and neck cancer. The flap was most frequently compared with free flaps in the oral cavity and various head and neck defects.²2 Smeele LE, Goldstein D, Tsai V, et al. Morbidity and cost differences between free flap reconstruction and pedicled flap reconstruction in oral and oropharyngeal cancer: Matched control study. J Otolaryngol 2006;35(02):102–107,³3 Hsing CY, Wong YK, Wang CP, 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(06):522–527,⁵5 Mallet Y, El Bedoui S, 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(12):1028–1031,⁶6 de Bree R, Reith R, Quak JJ, Uyl-de Groot CA, van Agthoven M, Leemans CR. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007;32(04):275–282,¹³13 Tsue TT, Desyatnikova SS, Deleyiannis FW, et al. Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer. Arch Otolaryngol Head Neck Surg 1997;123(07):731–737,¹⁹19 Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer: complications, gastrostomy tube dependence, and hospitalization. Arch Otolaryngol Head Neck Surg 2004;130(02):181–186,²¹21 Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg 2014; 25(03):868–871,²²22 Kroll SS, Evans GR, Goldberg D, et al. A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps. Plast Reconstr Surg 1997;99(05): 1282–1286,²³23 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;21(06):e737–e742 We analyzed these two flap groups and demonstrated that patients undergoing pectoralis major myocutaneous flap reconstruction were significantly older, associated with more comorbidities, and having more extensive primary tumor staging. Surgical complication rates were not different between the two groups. Although orocutaneous fistula was observed more frequently in the pectoralis major myocutaneous flap group than in the free flap group, no significant difference was detected (13 versus 6.8%, respectively, p = 0.393), which is similar to a previous study (12 versus 6%, respectively).¹⁹19 Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer: complications, gastrostomy tube dependence, and hospitalization. Arch Otolaryngol Head Neck Surg 2004;130(02):181–186 In addition, patients who underwent pectoralis major myocutaneous flap reconstruction had a shorter operative time, shorter hospital stay, and lower hospital costs. Regarding functional outcomes, no difference in speech function was demonstrated between the two groups. However, Hsing et al. reported a more inferior speech function in the pectoralis major myocutaneous flap group than in the free flap group.³3 Hsing CY, Wong YK, Wang CP, 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(06):522–527 In contrast, Zhang et al. demonstrated a better outcome in cases involving a pectoralis major myocutaneous flap than an anterolateral thigh free flap.²¹21 Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg 2014; 25(03):868–871 Although fewer patients in the pectoralis major myocutaneous flap group were able to take a full or soft diet, no significant difference was demonstrated, similar to previous studies.²2 Smeele LE, Goldstein D, Tsai V, et al. Morbidity and cost differences between free flap reconstruction and pedicled flap reconstruction in oral and oropharyngeal cancer: Matched control study. J Otolaryngol 2006;35(02):102–107,³3 Hsing CY, Wong YK, Wang CP, 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(06):522–527,¹²12 Lakshminarayana G, Venkitachalam S, Mani CS. Choice of regional flaps for oral cancer defects: relevance in current era. J Maxillofac Oral Surg 2021;20(02):246–251,²¹21 Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg 2014; 25(03):868–871,²⁴24 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(06): e856–e861 The pectoralis major myocutaneous flap group has a higher rate of a prolonged feeding tube than the free flap group (13 versus 2.7%, respectively, p = 0.046). However, the rates in both groups were lower than those found in previous reports (23–34 versus 8–21%, respectively).²2 Smeele LE, Goldstein D, Tsai V, et al. Morbidity and cost differences between free flap reconstruction and pedicled flap reconstruction in oral and oropharyngeal cancer: Matched control study. J Otolaryngol 2006;35(02):102–107,¹⁹19 Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer: complications, gastrostomy tube dependence, and hospitalization. Arch Otolaryngol Head Neck Surg 2004;130(02):181–186

Comparing the group that had undergone submental island, temporalis myofascial, and supraclavicular island flaps with the free flap group, there were no differences in demographics and comorbidities, but the pedicled flap group had significantly less extensive T staging and N staging, and also a smaller mean defect size. In addition, these three pedicled flaps had a significantly shorter operative time, shorter hospital stay, lower hospital costs, and fewer donor site and recipient site complications, without significant differences in speech and swallowing functions compared with the free flaps.

Some previous studies reported that patients with pedicled flap reconstruction had higher surgical complications and more unsatisfactory functional results than those with free flap reconstruction.^5,6,13,19 In the present study, pedicled flaps did not increase the risk of speech and swallowing dissatisfaction. Still, high tumor staging and large defect size were found to be the influencing factors in the multivariate analysis. In addition, pedicled flaps had comparable complications and functional outcomes to free flaps with shorter operative time, shorter hospital stay, and lower hospital costs. However, with a substantial defect (between 70 and 72 cm²), a pectoralis major myocutaneous flap resulted in a more inferior swallowing function than free flaps regarding prolonged feeding tube use.

These four pedicled flaps have particular characters that might be appropriate in some specific conditions of oral cavity defects. In a significant (up to 70 cm²) defect, a pectoralis major myocutaneous flap can be helpful, especially in patients unsuitable for a free flap. A submental island flap with good flap volume is suitable for a small to a large (up to 60 cm²) oral tongue and buccal mucosa defect. A temporalis myofascial flap is ideal for a small to a medium defect of the hard palate, retromolar trigone, and posterior buccal mucosa. The supraclavicular island flap, a very pliable flap, is suitable for the floor of the mouth and buccal mucosa reconstruction.

Conclusions

The oral cavity is involved in a substantial range of functions, including speech, mastication, and deglutition, which require appropriate reconstruction in the cases of any defects. Pedicled flaps, including pectoralis major myocutaneous, submental island, temporalis myofascial, and supraclavicular island flaps, are reliable, have acceptable complication rates, and acceptable functional results with a shorter operative time, shorter hospital stay, and lower hospital costs when compared with the radial forearm and anterolateral thigh free flaps insoft tissue reconstruction of the oral cavity. In addition, these pedicled flaps are accessible in both academic and community settings. However, in a substantial defect (> 70 cm²), free flaps are the reconstruction of choice in preserving swallowing function. Each of these pedicled flaps has its particular character, suitable for a selected oral cavity defect. Therefore, pedicled flaps can be a beneficial option for the reconstruction of many oral cavity defects.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of the present article.

We received no specific grant from any funding agency, commercial or not-for-profit sectors, and we have no conflicts of interest to disclose.

References

¹
Kerawala C, Roques T, Jeannon JP, Bisase B. Oral cavity and lip cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016;130(S2):S83–S89
²
Smeele LE, Goldstein D, Tsai V, et al. Morbidity and cost differences between free flap reconstruction and pedicled flap reconstruction in oral and oropharyngeal cancer: Matched control study. J Otolaryngol 2006;35(02):102–107
³
Hsing CY, Wong YK, Wang CP, 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(06):522–527
⁴
Goyal N, Yarlagadda BB, Deschler DG, et al. Surgical site infections in major head and neck surgeries involving pedicled flap reconstruction. Ann Otol Rhinol Laryngol 2017;126(01):20–28
⁵
Mallet Y, El Bedoui S, 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(12):1028–1031
⁶
de Bree R, Reith R, Quak JJ, Uyl-de Groot CA, van Agthoven M, Leemans CR. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007;32(04):275–282
⁷
Gao LL, Basta M, Kanchwala SK, Serletti JM, Low DW, Wu LC. Cost-effectiveness of microsurgical reconstruction for head and neck defects after oncologic resection. Head Neck 2017;39(03): 541–547
⁸
Sittitrai P, Reunmakkaew D, Srivanitchapoom C. Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes. J Laryngol Otol 2019;133(05):413–418
⁹
Paydarfar JA, Patel UA. Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 2011;137(01): 82–87
¹⁰
Gabrysz-Forget F, Tabet P, Rahal A, Bissada E, Christopoulos A, Ayad T. Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review. J Otolaryngol Head Neck Surg 2019;48(01):13. Doi: 10.1186/s40463-019-0334-y
» https://doi.org/10.1186/s40463-019-0334-y
¹¹
Welz C, Canis M, Schwenk-Zieger S, Spiegel JL, Weiss BG, Pilavakis Y. Oral cancer reconstruction using the supraclavicular artery island flap: comparison to free radial forearm flap. J Oral Maxillofac Surg 2017;75(10):2261–2269
¹²
Lakshminarayana G, Venkitachalam S, Mani CS. Choice of regional flaps for oral cancer defects: relevance in current era. J Maxillofac Oral Surg 2021;20(02):246–251
¹³
Tsue TT, Desyatnikova SS, Deleyiannis FW, et al. Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer. Arch Otolaryngol Head Neck Surg 1997;123(07):731–737
¹⁴
Sukato DC, Timashpolsky A, Ferzli G, Rosenfeld RM, Gordin EA. Systematic review of supraclavicular artery island flap vs free flap in head and neck reconstruction. Otolaryngol Head Neck Surg 2019;160(02):215–222
¹⁵
Jørgensen MG, Tabatabaeifar S, Toyserkani NM, Sørensen JA. Submental island flap versus free flap reconstruction for complex head and neck defects. Otolaryngol Head Neck Surg 2019;161 (06):946–953
¹⁶
Meier JK, Spoerl S, Spanier G, et al. Alternatives to free flap surgery for maxillofacial reconstruction: focus on the submental island flap and the pectoralis major myocutaneous flap. BMC Oral Health 2021;21(01):198. Doi: 10.1186/s12903-021-01563-7
» https://doi.org/10.1186/s12903-021-01563-7
¹⁷
Gray ML, Drake VE, Desai SC. Resurgence of regional flaps for head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2021;29(04):237–243. Doi: 10.1097/MOO.0000000000000725
» https://doi.org/10.1097/MOO.0000000000000725
¹⁸
Rashid HU, Rashid M, Khan N, Ansari SS, Bibi N. Taking a step down on the reconstruction ladder for head and neck reconstruction during the COVID-19 pandemic. BMC Surg 2021;21(01):120. Doi: 10.1186/s12893-021-01134-1
» https://doi.org/10.1186/s12893-021-01134-1
¹⁹
Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer: complications, gastrostomy tube dependence, and hospitalization. Arch Otolaryngol Head Neck Surg 2004;130(02):181–186
²⁰
Vartanian JG, Carvalho AL, Carvalho SM, Mizobe L, Magrin J, Kowalski LP. Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: experience with 437 cases at a single institution. Head Neck 2004;26(12):1018–1023
²¹
Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg 2014; 25(03):868–871
²²
Kroll SS, Evans GR, Goldberg D, et al. A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps. Plast Reconstr Surg 1997;99(05): 1282–1286
²³
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;21(06):e737–e742
²⁴
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(06): e856–e861
²⁵
Zhang S, Chen W, Cao G, Dong Z. Pedicled supraclavicular artery island flap versus free radial forearm flap for tongue reconstruction following hemiglossectomy. J Craniofac Surg 2015;26(06): e527–e530
²⁶
Deganello A, Gitti G, Parrinello G, Muratori E, Larotonda G, Gallo O. Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps. Acta Otorhinolaryngol Ital 2013;33(06):380–387
²⁷
Sinha S, Puram SV, Sethi RK, et al. Perioperative deep vein thrombosis risk stratification. Otolaryngol Head Neck Surg 2017;156(01):118–121
²⁸
Forner D, Williams BA, Makki FM, Trites JR, Taylor SM, Hart RD. Late free flap failure in head and neck reconstruction: A systematic review. Ear Nose Throat J 2018;97(07):213–216
²⁹
Wang W, Ong A, Vincent AG, Shokri T, Scott B, Ducic Y. Flap failure and salvage in head and neck reconstruction. Semin Plast Surg 2020;34(04):314–320

Publication Dates

Publication in this collection
06 Mar 2023
Date of issue
Jan-Mar 2023

History

Received
06 Oct 2020
Accepted
04 Aug 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivative License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the original work is properly cited and the work is not changed in any way.

[1] Funding

The author(s) received no financial support for the research, authorship, and/or publication of the present article.

We received no specific grant from any funding agency, commercial or not-for-profit sectors, and we have no conflicts of interest to disclose.

Score	Speech	Swallowing
5	all speech is understood (excellent)	full diet
4	speech is sometimes not understood (good)	soft diet
3	speech can be understood when conversational content is already known (fair)	liquid diet
2	speech can sometimes be understood (poor)	combined oral and feeding tube
1	nothing is understood (bad)	exclusively by feeding tube

	Pedicled flaps				Free flaps		Pedicled flap group n = 98 (%)	Free flap group n = 73 (%)	p-value (Pedicled flap group vs Free flap group)
	PMMF n = 23 (%)	SMF n = 47 (%)	TMF n = 16 (%)	SCF n = 12 (%)	RFF n = 59 (%)	ALT n = 14 (%)	Pedicled flap group n = 98 (%)	Free flap group n = 73 (%)	p-value (Pedicled flap group vs Free flap group)
Age (mean (range); years old	65 (56–72)	61.3 (48–70)	62.8 (57–70)	63.7 (54–76)	61.4 (45–71)	60.6 (49–69)	62.7 (48–76)	61.3 (45–71)	0.057
Gender									0.495
- Male	17 (73.9)	31 (66)	10 (62.5)	7 (58.3)	42 (71.2)	10 (71.4)	65 (66.3)	52 (71.2)
- Female	6 (26.1)	16 (34)	6 (36.7)	5 (41.7)	17 (28.8)	4 (28.6)	33 (33.7)	21 (28.8)
Smoke									0.178
- Yes - No	19 (82.6)	35 (74.5)	10 (62.5)	9 (75)	37 (62.7)	10 (71.4)	73 (74.5)	47 (64.4)
	4 (17.4)	12 (25.5)	6 (37.5)	3 (25)	22 (37.3)	4 (28.6)	25 (25.5)	26 (35.6)
Alcohol									0.876
- Yes	12 (52.2)	28 (59.6)	8 (50)	9 (75)	33 (55.9)	8 (57.1)	57 (58.2)	41 (56.2)
- No	11 (47.8)	19 (40.4)	8 (50)	3 (25)	26 (44.1)	6 (41.9)	41 (41.8)	32 (42.8)
DM									0.518
- Yes	4 (17.4)	10 (21.3)	1 (6.2)	1 (8.3)	7 (11.9)	2 (14.3)	16 (16.3)	9 (12.3)
- No	19 (82.6)	37 (78.7)	15 (93.7)	11 (91.7)	52 (88.1)	12 (85.7)	82 (83.7)	64 (87.7)
COPD									0.217
- Yes	6 (26.1)	10 (21.3)	2 (12.5)	1 (8.3)	7 (11.9)	2 (14.3)	19 (19.4)	9 (12.3)
- No	17 (73.9)	37 (78.7)	14 (87.5)	11 (91.7)	52 (88.1)	12 (85.7)	79 (80.6)	64 (87.7)
ASA classification									0.146
- I-II	17 (73.9)	42 (89.4)	14 (87.5)	11 (84.7)	54 (91.5)	14 (100)	84 (85.7)	68 (93.2)
- III	6 (21.1)	5 (10.6)	2 (12.5)	1 (8.3)	5 (8.5)	0 (0)	14 (14.3)	5 (6.8)
Primary site location									0.562
- Tongue	9 (39.1)	28 (59.6)	-	9 (75)	27 (45.8)	8 (57.2)	46 (46.9)	36 (49.3)
- FOM	7 (30.4)	10 (21.3)	-	1 (8.3)	13 (22)	5 (35.7)	18 (18.4)	17 (23.3)
- Buccal	6(26.1)	5 (10.6)	4 (25)	2 (16.7)	11 (18.6)	1 (7.1)	17 (17.3)	12 (16.4)
- Palate	-	-	5 (31.2)	-	3 (5.1)	-	5 (5.1)	3 (4.1)
- RTM	1 (4.4)	3 (6.4)	7 (43.8)	-	3 (5.1)	-	11 (11.2)	3 (4.1)
- Alveolar ridge	-	1 (2.1)	-	-	2 (3.4)	-	1 (3.1)	2 (2.7)
T stage									0.435
- T2	-	27 (57.4)	11 (68.8)	5(41.7)	23 (39)	2(14.3)	43 (43.9)	25 (34.3)
- T3	6(26.1)	8(17.1)	4(25)	3(25)	15 (25.4)	4 (28.6)	21 (21.4)	19(26)
- T4	17 (73.9)	12(25.5)	1 (6.2)	4 (33.3)	21 (35.6)	8(57.1)	34 (34.7)	29 (39.7)
N stage									0.054
- NO	-	20 (42.5)	6 (37.5)	2(16.7)	8(13.6)	1 (7.1)	28 (28.6)	9(12.3)
- N1	5(21.7)	17 (36.2)	9 (56.3)	3(25)	24 (40.7)	1 (7.1)	34 (34.7)	25 (34.3)
- N2	11 (47.8)	8(17)	1 (6.2)	4 (33.3)	17 (28.8)	7(50)	24 (24.5)	24 (32.9)
- N3	7 (30.5)	2 (4.3)	-	3(25)	10 (16.9)	5 (35.7)	12(12.2)	15 (20.5)
Neck dissection Side									0.218 0.143
- Unilateral	7 (30.4)	26 (55.3)	9 (56.2)	8 (66.7)	27 (45.8)	3(21.4)	50(51)	30(41.1)
- Bilateral	16(69.6)	21 (44.7)	7 (43.8)	4 (33.3)	32 (54.2)	11 (78.6)	48 (49)	43 (58.9)
Type
- Selective	1 (4.3)	19(40.4)	6 (37.5)	2(16.7)	10 (16.9)	2(14.3)	28 (28.6)	12 (16.4)
- Modified	18(78.3)	27 (57.5)	10 (62.5)	10(83.3)	47 (79.7)	10(71.4)	65 (66.3)	57 (78.1)
- Radical	4(17.4)	1 (2.1)	-	-	2 (3.4)	2(14.3)	5(5.1)	4(5.5)
Defect size									< 0.001^* * indicates significant difference at p < 0.05.
(mean (range); cm²	52.7 (36-72)	33 (24-60)	17.7 (12-24)	18.3 (9-48)	51.2 (28-80)	62.1 (36-80)	33.3 (9-72)	53.3 (28-80)	< 0.001^* * indicates significant difference at p < 0.05.
Operation time									< 0.001^* * indicates significant difference at p < 0.05.
(mean (range); minutes	312 (280-360)	189 (125-250)	163 (140-210)	334 (300-420)	411 (365-480)	422 (370-490)	232 (125-420)	413 (365-490)	< 0.001^* * indicates significant difference at p < 0.05.
Pathological margin - Clear	-	20 (42.6)	6 (37.5)	2 (16.7)	16 (27.1)	1 (7.1)	28 (28.6)	17 (23.3)	0.486
- Close/Positive	23 (100)	17 (57.4)	10(62.5)	10 (83.3)	43 (72.9)	13 (92.9)	70 (71.4)	56 (76.7)
Postoperative treatment
- No	-	20 (42.6)	5 (31.2)	-	10 (16.9)	-	25 (25.5)	10 (13.7)	0.069
- RT/CRT	23 (100)	27 (57.4)	11 (68.2)	12 (100)	49 (83.1)	14 (100)	73 (74.5)	63 (86.3)

	Pedicled flaps				Free flaps		Pedicled flaps n = 98 (%)	Free flaps n = 73 (%)	p-value (Pedicled flaps vs Free flaps)
	PMMF n = 23 (%)	SMF n = 47 (%)	TMF n = 16 (%)	SCF n = 12 (%)	RFF n = 59 (%)	ALT n = 14 (%)	Pedicled flaps n = 98 (%)	Free flaps n = 73 (%)	p-value (Pedicled flaps vs Free flaps)
Donor site complications									< 0.001^* * indicates significant difference at p < 0.05.
- No	13 (56.5)	47 (100)	16 (100)	11 (91.7)	35 (59.3)	13 (92.9)	87 (88.8)	48 (65.8)
- Yes	10 (43.5)	–	–	1 (8.3)	24 (40.7)	1 (7.1)	11 (11.2)	25 (34.2)
- Wound dehiscence	2 (8.7)	–	–	1 (8.3)	–	1 (7.1)	3 (3.1)	1 (1.4)
- Partial loss of skin graft	–	–	–	–	11 (18.6)	–	–	11 (15.1)
- Restricted arm function	–	–	–	–	13 (22.1)	–	–	13 (17.8)
- Shoulder dysfunction	8 (34.8)	–	–	–	–	–	8 (8.1)	–
Recipient site complications									0.163
- No	12 (52.2)	42 (89.4)	13 (81.2)	9 (75)	41 (69.5)	8 (57.1)	76 (77.6)	49 (67.1)
- Yes	11 (47.8)	5 (10.6)	3 (18.8)	3 (25)	18 (30.5)	6 (42.9)	22 (22.4)	24 (32.9)
- Orocutaneous fistula	3 (13)	–	–	1 (8.3)	4 (6.8)	1 (7.1)	4 (4.1)	5 (6.8)
- Wound dehiscence	6 (26.1)	2 (4.3)	1 (6.2)	–	8 (13.6)	2 (14.3)	9 (9.2)	10 (13.7)
- Minor infection	1 (4.3)	2 (4.3)	2 (12.5)	–	4 (6.8)	2 (14.3)	5 (5.1)	6 (8.2)
- Hematoma	1 (4.3)	1 (2.1)	–	2 (16.7)	2 (3.4)	1 (7.1)	4 (4.1)	3 (4.1)
Flap complications									0.317
- No	21 (91.3)	41 (87.2)	13 (81.2)	8 (66.7)	46 (77.9)	11 (78.6)	83 (84.7)	57 (78.1)
- Yes	2 (8.7)	6 (12.8)	3 (18.8)	4 (33.3)	13 (22.1)	3 (21.4)	15 (15.3)	16 (21.9)
- Partial loss	2 (8.7)	6 (12.8)	3 (18.8)	4 (33.3)	7 (11.9)	2 (14.3)	15 (15.3)	9 (12.3)
- Total loss	–	–	–	–	2 (3.4)	–	–	2 (2.7)
- Revision of the anastomosis	–	–	–	–	4 (6.8)	1 (7.1)	–	5 (6.8)
Hospital stay									< 0.001^* * indicates significant difference at p < 0.05.
(mean (range); days)	24 (18-36)	20 (14-30)	17 (14-24)	21 (10-41)	31 (22-36)	30 (24-39)	20 (10-41)	31 (22-39)	< 0.001^* * indicates significant difference at p < 0.05.
Hospital cost									< 0.001^* * indicates significant difference at p < 0.05.
(USD)	5,226	4,023	3,958	4,555	8,023	7,598	4,360	7,935	< 0.001^* * indicates significant difference at p < 0.05.

	Pedicled flaps				Free flaps		Pedicled flap group n = 98 (%)	Free flap group n = 73 (%)	p-value (Pedicled flaps vs Free flaps)
	PMMF n = 23 (%)	SMF n = 47 (%)	TMF n = 16 (%)	SCF n = 12 (%)	RFF n = 59 (%)	ALT n = 14 (%)	Pedicled flap group n = 98 (%)	Free flap group n = 73 (%)	p-value (Pedicled flaps vs Free flaps)
Speech									0.947
- Excellent	5 (21.7)	28 (59.6)	13 (81.2)	6 (50)	34 (57.6)	6 (42.9)	52 (53.1)	40 (54.8)
- Good	–	10 (21.3)	3 (18.8)	4 (33.3)	14 (23.7)	4 (28.6)	27 (27.6)	18 (24.7)
- Fair	10 (43.5)	8 (17)	0 (0)	2 (16.7)	8 (13.6)	2 (14.3)	14 (14.3)	10 (13.7)
- Poor	4 (17.4)	1 (2.1)	0 (0)	0 (0)	3 (5.1)	2 (14.3)	5 (5.1)	5 (6.8)
- Bad	4 (17.4)	–	–	–	–	–	–	–
Swallowing									0.768
- Full	7 (30.4)	29 (61.7)	12 (75)	5 (41.7)	32 (54.2)	4 (28.6)	53 (54.1)	36 (49.3)
- Soft	7 (30.4)	11 (23.4)	3 (18.8)	6 (50)	20 (33.9)	4 (28.6)	27 (27.6)	24 (32.9)
- Liquid	2 (8.7)	7 (14.9)	1 (6.2)	1 (8.3)	5 (8.5)	1 (7.1)	11 (11.2)	6 (8.2)
- Oral + feeding tube	4 (17.4)	–	–	–	1 (1.7)	3 (21.4)	4 (4.1)	4 (5.5)
- Feeding tube	3 (13)	–	–	–	1 (1.7)	1 (7.2)	3 (3.1)	2 (2.7)

	PMMF vs Free flaps			Other pedicle flaps vs Free flaps
	PMMF group n = 23 (%)	Free flap group n = 73 (%)	p-value	Other pedicled flap group n = 75 (%)	p-value
Age (mean (range; years old)	65 (56–72)	61 (45–71)	< 0.001^* * indicates significant difference at p < 0.05.	62 (48–76)	0.355
Gender
- Male	17 (73.9)	52 (71.2)	1	48 (64)	0.383
Smoke
- Yes	19 (82.6)	47 (64.4)	0.126	54 (72)	0.378
Alcohol
- Yes	12 (52.2)	41 (56.2)	0.812	45 (60)	0.739
DM
- Yes	4 (17.4)	9 (12.3)	0.504	12 (16)	0.639
COPD
- Yes	6 (26.1)	9 (12.3)	0.184	13 (17.3)	0.49
ASA
- I-II	17 (73.9)	68 (93.2)	0.021^* * indicates significant difference at p < 0.05.	67 (89.3)	0.446
Primary site location			0.764		0.325
T stage					0.016^* * indicates significant difference at p < 0.05.
- T2	–	25 (34.3)	0.002^* * indicates significant difference at p < 0.05.	43 (57.3)	0.016^* * indicates significant difference at p < 0.05.
	- T3-4	23 (100)	48 (65.7)		32 (42.7)
N stage					< 0.001^* * indicates significant difference at p < 0.05.
- N0	–	9 (12.3)	0.138	28 (37.3)
- N1-3	23 (100)	64 (87.7)		47 (62.7)
Neck dissection Side
- Unilateral Type	7 (30.4)	30 (41.1)	0.463	43 (57.3)	0.051
- Selective	1 (4.3)	12 (16.4)	0.061	27 (36)	0.087
- Modified	18 (78.3)	57 (78.1)		47 (62.7)
- Radical	4 (17.4	4 (5.5)		1 (1.3)
Defect size (cm²)	52.7	53.3	0.835	26.9	< 0.001^* * indicates significant difference at p < 0.05.
Donor site complication					< 0.001^* * indicates significant difference at p < 0.05.
- Yes	10 (43.5)	25 (34.2)	0.462	1 (1.3)	< 0.001^* * indicates significant difference at p < 0.05.
Recipient site complication					0.012^* * indicates significant difference at p < 0.05.
- Yes	11 (47.8)	24 (32.9)	0.22	11 (14.7)	0.112
- Orocutaneous fistula	3 (13)	5 (6.8)	0.393	1 (1.3)
Flap Complication
- Yes	2 (8.7)	16 (21.9)	0.224	13 (17.3)	0.538
Hospital stay (days)	24	31	< 0.001^* * indicates significant difference at p < 0.05.	19	< 0.001^* * indicates significant difference at p < 0.05.
Hospital cost (USD)	5,226	7,935	< 0.001^* * indicates significant difference at p < 0.05.	4,178	< 0.001^* * indicates significant difference at p < 0.05.
Speech
- Excellent-Good	15 (65.2)	58 (79.5)	0.262	64 (85.3%)	0.392
Swallowing
- Full-Soft	14 (60.9)	60 (82.2)	0.057	66 (88%)	0.262
- Obligate Feeding tube	3 (13.0)	2 (2.7)	0.046^* * indicates significant difference at p < 0.05.	–	0.242

Brasil

Brasil

Pedicled Flaps versus Free Flaps for Oral Cavity Cancer Reconstruction: A Comparison of Complications, Hospital Costs, and Functional Outcomes

Abstract

Introduction

Objective

Methods

Results

Conclusions

Introduction

Material and Methods

Results

Discussion

Conclusions

References

Publication Dates

History

Factors	Speech dissatisfaction		Swallowing dissatisfaction
Factors	OR (95%CI)	p-value	OR (95%CI)	p-value
Flap^a a pedicled flaps versus free flaps.	0.50 (0.18–2.29)	0.851	0.43 (0.23–1.98)	0.842
Flap type^b b ptoralis major myocutaneous flap versus submental island flap versus temporalis myofascial flap versus supraclavicular island flap versus radial forearm free flap versus anterolateral thigh free flap.	0.89 (0.61–1.22)	0.922	1.00 (0.81–1.63)	0.995
Primary site location	0.54 (0.25–1.04)	0.086	0.56 (0.27–1.07)	0.114
T staging (T3-4 vs T2)	9.14 (3.79–21.98)	< 0.001^* * indicates significant difference at p < 0.05.	7.61 (3.41–16.96)	< 0.001^* * indicates significant difference at p < 0.05.
Defect size^c c cutoff point for speech dissatisfaction is 43 cm2 and for swallowing dissatisfaction is 55 cm2.	1.12 (1.08–1.28)	< 0.001^* * indicates significant difference at p < 0.05.	1.08 (1.04–1.12)	< 0.001^* * indicates significant difference at p < 0.05.
Recipient complications	6.53 (2.16–17.14)	< 0.001^* * indicates significant difference at p < 0.05.	7.15 (3.14–16.27)	< 0.001^* * indicates significant difference at p < 0.05.
Flap complications	0.77 (0.46–1.50)	0.061	3.39 (1.44–7.96)	0.005^* * indicates significant difference at p < 0.05.