From January, 2008 to January, 2014, there had been 30 patients (n = 30) who had received advanced tongue cancer resection and flap reconstruction in our hospital. The parameters of care including operation time (A: 627.13 ± 112.43 minutes, B: 661.33 ± 152.35 minutes; P = .49) and hospital stay (A: 26.20 ± 7.25 days, B: 30.06 ± 13.04 days; P = .32) showed improvement in group A. There is also improvement in infection rate between the 2 groups (A: 13%, B: 20%; P = .64). Surgical efficacy in tumor-free resection had been noted statistical difference, and this part will be discussed later (tumor-free margin: A: 11.66 ± 3.53 mm, B: 7.80 ± 4.05 mm; P = .01). The flap survival rates are both 100% without revision (Table 1).
The reconstructive goal of head and neck cancer surgery should not only be focused on rebuilding anatomic continuity, minimizing the complications for wound healing, achieving on-time oncologic therapy, but the functional restoration. Any residual visual or functional deficit may bring psychological impact and social disability. As above, the head and neck cancer surgeons hope to excise the tumor with enough safe margin, but destruct the structure of the face as less as possible, just like cardiovascular surgeons developing novel technique to prevent injury to the heart. The less damage we cause in the process of operation, the less possibilities nerve injuries, inadvertent fracture of the osteotomy segment, malocclusion, fistula, wound dehiscence, and infection are made. In addition, to take aesthetic and psychological aspects into consideration, the facial scar will affect patient's psychological health and interpersonal relationship. People with facial disfigurement are often stigmatized for appearing different than “normal” and may be considered “dysfunctional” by others.[12–14] In these series, we demonstrated the oncological safety in such a facial non-scar procedure. Apart from this, the parachute flap technique provides a great access when we face the difficulty of reconstruction due to narrow operation field in these series. Our results show that there are several advantages. Firstly, we performed the suture of the flap to the defect completely from outside the oral cavity instead of working in a narrow deep space, which could explain the reduction of the operation time in patients receiving parachute technique. The broader operative vision assists us to minimize inappropriate manipulation of the flap, such as overstretching, twisting, or kinking of the pedicle or perforator. Secondly, accurate edge-to-edge matches from flap margin to defect can be done and consequently enhance the wound healing process and further prevent the saliva leakage from the mouth floor to the neck, which could explain the reduction of the infection rate in patients receiving parachute technique. The similar rationale was applied in operations for colorectal anastomosis with lower postoperative complications. The intact lip and jaw structure and the shorter healing duration of the skin-to-mucosal flap also could explain why the parachute technique presented with lower infection rate of surgical site and hospital stay. Thirdly, no iatrogenic facial wound was made, and hence no accompanying contracture followed with. Also, mandibular bone was kept intact, which decreases the possibility of intractable osteoradionecrosis. Last, but also important, this procedure requires no extra medical expenditure and no steep learning curve compared with robotic-assisted surgery.
In Taiwan, many patients have betel quid chewing habit, which caused submucosal fibrosis and subsequent trismus of oral cavity. The trismus will increase the difficulty of intraoral suture technique. Our method provides a good solution especially to this condition, and also provides a good edge-to-edge wound suture. To suture the flap before “pull-up,” the tongue in the oral cavity may cause tissue distortion, and it pays much effort to perform water-seal mucosa-flap skin edge suture in conventional method. With our method, to perform the flap suture from outside the oral cavity with the connecting strings will be more accessible for surgeons to complete the subsequent edge-to-edge flap and mucosa sutures to the residual tongue more ergonomically and provides good outcomes.
Since mandibulotomy is not done in this technique, the surgical field is limited, and we prefer to perform the flap suture to the root of tongue through the oral cavity rather than through the tunnel from the neck region. Compared with parachute method, “pull-through” method may cause more stretch force on the pedicle vessel after flap suture when the tongue is lifted up into the oral cavity. In contrast, our parachute method can protect and minimize the possibility of damage of pedicle vessels because the pedicle passes through the tunnel before the flap suture. Therefore, in our opinion, parachute technique is more accessible for the surgeon to perform water-seal mucosa-flap skin edge suture and get expected surgical outcomes.
With the development of robotic-assisted surgery, to operate in the narrow operation field seems to become an enjoyable procedure. O’Malley et al have reported the potential of transoral robotic surgery (TORS) in head and neck tumors in preclinical and early clinical studies in 2006. Nowadays, much experience had been mentioned in using TORS to do tumor excision and reconstruction in head and neck area, and these also showed great outcomes in the disease control, organ function, and quality of life.[17–21] However, some research showed the operational time for TORS is longer than conventional methods,[22,23] which was mainly a result of raising the flap and creating the working space. Although the TORS gives us a great solution to overcome the narrow operation field in the oral cavity, it requires much more medical expenditure than the manual operation, and also needs the doctors to overcome the steep learning curve.[24–26]
The parachute technique is not only applied to tongue reconstruction. Theoretically, it can also be broadly applied for any other flap surgeries performed in a narrow and deep space. Apart from the bulky flap-like ALT and thin flap-like radial forearm we demonstrate, this technique can be fit any other type of flaps. Pectoralis major myocutaneous (PMMC) flap is still playing a role in head and neck cancer reconstruction.[27–30] The bulkiness of this flap can increase the difficulty of flap inset. The “reverse upward” parachute technique can also be a good solution once we face this situation in our practice for a mouth floor reconstruction.
The tumor-free resection margin had been noted statistically difference between these 2 groups. During the surgery, the otolaryngologist performed 1.5 cm resection margin from the tumor in all patients. However, we still encountered with the close margin problem. The situation may relate to the specimen shrinkage after formaldehyde fixation, microscopic satellite lesion, and the location of the primary tumor. In group B, the primary tumor location of some cases extended to the tongue base, parapharyngeal wall, and masticator space. The very advanced cancer status in these cases caused surgical difficulty and less tumor-free resection margin due to anatomy limitation.[31–33] Also, in these patients, we may not get enough free margin, no matter using which kind of surgical approach. After discussion of these cases in the head and neck cancer conference, we transferred them to oncologic ward for further chemoradiotherapy, if needed. The decision of the management is based on National Comprehensive Cancer Network treatment guideline.
We did not use any scale to evaluate the aesthetic outcome because the aesthetic comparison for facial appearance between these 2 surgical methods were nonscarring versus scaring, rather than scarless versus apparent scar. We believe the patients in group A can avoid from scar pain and itching during recovery and get rid of skin dyspigmentation and scar contracture after recovery.
Certain limitation should be considered when evaluating the findings from this study. If the tumor is located posteriorly and may not achieve the proper and wider excisional tumor-free margin for the oncologic safety, the otolaryngologists would split the lip and jaw to get better vision for resection, which could possibly affect operative time because the extra time would be spent on splitting and fixation. The study did not evaluate or compare the postoperative tongue function because the functional performance is mainly related to the intensity of cancer invasion, the irradiation therapy, possible flap choice, and the compliance of rehabilitation.[34–36] It cannot purely contribute to the procedure of splinting the jaw or not. There was no data provided for follow-up after the hospitalization.
The facial scar will affect the quality of life and human relationship, which had been well studied in the other literatures.[37,38] But the oncological safety is still the first priority for any cancer ablation surgery. Once we face the advanced cases with tumor involving or nearly invading the adjacent skin or bone, the parachute method and lip-jaw-preserving procedure cannot be adopted even though the anesthetic and wound healing outcome are considered.
The intact structures of lip and jaw let the patients avoid the annoyance of scar formation and also let them have no scar on the face. The parachute technique makes us overcome the difficulty of sutures in a narrow operation field in oral cavity with accurate flap inset while possibly shortening the operation time, reducing infection rate, and decreasing hospital stay.
We would like to thank Dr Joe Chi-Cheng Fang of Greenslopes Private Hospital, Australia, for his assistance in editing the manuscript.
Conceptualization: Chin-Jui Liu, Yao-Te Tsai.
Data curation: Chin-Jui Liu, Erh-Ti Lin, Jen-Hsiang Shen.
Formal analysis: Yu-Tsung Chen.
Methodology: Chang-Cheng Chang, Geng-He Chang.
Project administration: Erh-Ti Lin.
Resources: Chang-Cheng Chang.
Software: Erh-Ti Lin.
Supervision: Ku-Hao Fang, Chang-Cheng Chang, Geng-He Chang, Yao-Te Tsai.
Visualization: Erh-Ti Lin, Geng-He Chang.
Writing – original draft: Chin-Jui Liu.
Writing – review & editing: Chin-Jui Liu, Chang-Cheng Chang, Erh-Ti Lin, Yu-Tsung Chen, Yao-Te Tsai.
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Keywords:Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
free flap reconstruction; parachute technique; tongue cancer