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Comparison between free flap and pectoralis major pedicled flap
for reconstruction in oral cavity cancer patients – A quality of life analysis
Chih-Yu Hsing
a, Yong-Kie Wong
b, Ching Ping Wang
a,c, Chen-Chi Wang
a,c, Rong-San Jiang
a,
Fun-Jou Chen
d, Shih-An Liu
a,c,d,⇑aDepartment of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan
bDepartment of Oral and Maxillofacial Surgery, Taichung Veterans General Hospital, Taichung, Taiwan c
Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan d
Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
a r t i c l e
i n f o
Article history:
Received 17 February 2011
Received in revised form 22 March 2011 Accepted 23 March 2011
Available online 17 April 2011 Keywords:
Free flap
Pectoralis major pedicled flap Oral cavity cancer
Quality of life Surgical site infection
s u m m a r y
We aimed to compare the differences between free flap and pectoralis major myocutaneous flap (PMMF) for reconstruction in oral cavity cancer patients. Patients who received free flap or PMMF reconstruction after ablation surgeries were eligible for the current study. The patients’ demographic data, medical history, and quality of life scores were collected and analyzed. A total of 491 patients’ records were obtained. Among them, 100 patients completed a quality of life questionnaire. No significant differences could be found in age, morbidity, stage, and hospitalization between the free flap and PMMF groups. However, there were significant differences between both groups in gender, primary site, peri-operative blood loss, and operation duration. Patients reconstructed with free flap had better speech and shoulder functions as well as better mood status. Data from this study provide useful information for physicians and patients during their discussion of treatment modalities for oral cancers.
Ó 2011 Elsevier Ltd. All rights reserved.
Introduction
Oral cancer is currently a major global health issue. In develop-ing countries, oral cavity cancer is estimated to be the third most common malignancy after cancer of the cervix and stomach.1
Surgi-cal excision plays a major role in the treatment of oral cavity cancer patients.2Significant soft tissue, bone, and skin defects are
antici-pated after tumor extirpation in locally advanced oral cavity cancer. Therefore, reconstruction is required to promote wound healing and optimize function along with cosmetic appearance. The pecto-ralis major myocutaneous flap (PMMF), based on the thoracoacro-mial artery, was described in 1979 by Ariyan.3 PMMF is well
established as one of the most important reconstructive methods in major head and neck cancer surgery due to its simple technical aspects, versatility, and proximity to the head and neck region.4
Although microsurgically vascularized skin flaps to the head and neck were introduced earlier than pedicled flap, they did not reach immediate popularity, and pedicled flaps predominated in the head and neck reconstruction surgery for over a decade.5
During the past decade, revascularized free flap has been per-formed more frequently in an attempt to enhance the functional and aesthetic results in head and neck cancer patients.6 Mallet
et al. in their study on reconstruction of tongue cancer patients found that the reliability of free flaps was higher than that of PMMF.7Another study comparing free tissue transfer and pedicled
flap reconstruction in head and neck malignancy defect showed that PMMF remained an enduring and safe flap, yet the free flap had markedly improved speech performance over the PMMF.8Tsue
et al. indicated that free flap reconstruction generally resulted in a better swallowing function when compared with that of PMMF.9A
previous study found that patients underwent reconstruction with PMMF had a significantly higher minor complication rate, a higher rate of gastrostomy tube dependence, and longer hospitalization than those who underwent reconstruction with free flap.6
How-ever, few studies have compared free flap and PMMF for recon-struction of the oral cavity. In addition, few studies have evaluated the differences in quality of life between patients with oral cavity cancers reconstructed with free flap compared with those who underwent PMMF. Therefore, the aim of this study was to compare the differences between free flap and PMMF for the reconstruction of the oral cavity in oral cancer patients. Quality of life was also evaluated in patients who underwent reconstruc-tion with free flap or PMMF.
1368-8375/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2011.03.024
⇑ Corresponding author at: Department of Otolaryngology, Taichung Veterans General Hospital, No. 160, Sec. 3, Chung-Kang Road, Taichung 40705, Taiwan. Tel.: +886 4 23592525x5401/5409; fax: +886 4 23596868.
E-mail addresses:[email protected],[email protected](S.-A. Liu).
Contents lists available atScienceDirect
Oral Oncology
Materials and methods
This study protocol was approved by the Institutional Review Board of Taichung Veterans General Hospital. We retrospectively reviewed over 2000 chart records of oral cavity cancer patients undergoing surgical intervention in the studied hospital from March 1994 to December 2008. Those who received free flap or PMMF reconstruction were eligible for the current study. Those who had received surgery due to a recurrent or a second primary disease, had been irradiated before surgery, or had inadequate chart records were excluded. The selection of free flap or pedi-cled flap was not randomized. It was depended both on the avail-ability of plastic surgeon and the decision of head and neck surgeon.
All patients were restaged according to the guidelines of the American Joint Committee on Cancer. Basic demographic data including age, gender, and tumor-related features were collected. In addition, type of surgical intervention and relevant data were re-corded. The definition of surgical site infection was purulent discharge either spontaneously or by incision and drainage from head and neck region, or presence of an orocutaneous fistula regardless of etiology within 30 days after operation.10
Patients who underwent free flap or PMMF and who were reg-ularly followed up at our clinic were administered a quality of life questionnaire. All patients signed informed consent forms and were interviewed by a trained nurse. The most recent modified version of the University of Washington Quality of Life (UW-QOL) questionnaires, version 4, was used to evaluate the functional outcome of patients who underwent free flap or PMMF reconstruc-tion.11The questionnaire is composed of 12 domains: pain,
appear-ance, activity, recreation, swallowing, chewing, speech, shoulder, taste, saliva, mood, and anxiety. The domains are scored on a scale ranging from 0 (worst) to 100 (best). There are also two ‘‘global quality-of-life’’ items. An UW-QOL composite score from 0 to 100 was obtained by averaging the scores of the domains. We scored the individual domains according to the UW-QOL guidelines.
We used descriptive statistics for general data presentation. Comparisons of nominal or ordinal variables between patients who underwent free flap or PMMF were analyzed by chi-square test or Fisher’s exact test, whereas continuous variables were examined by Student’s t test. The UW-QOL scores were compared for each domain using the nonparametric Mann–Whitney tests. Spearman’s correlation coefficients were used to assess the associ-ation between two ordinal domain scores. All statistical analyses
Table 1
Descriptive and bivariate analyses of oral cavity cancer patients who underwent free flap or PMMF reconstruction.
Variables Total no. of patients (% in column) No. of patients (%) p value
Free flap group (n = 186) PMMF group (n = 305)
Age (yr) 0.290 <50 years 245 (49.9%) 99 (40.4%) 146 (59.6%) >= 50 years 246 (50.1%) 87 (35.4%) 159 (64.6%) Gender 0.024 Female 11 (2.2%) 8 (72.7%) 3 (27.3%) Male 480 (97.8%) 178 (37.1%) 302 (62.9%)
Primary tumor sites <0.001
Lip 18 (3.7%) 17 (94.4%) 1 (5.6%) Gum 43 (8.8%) 15 (34.9%) 28 (65.1%) Floor of mouth 13 (2.6%) 7 (53.8%) 6 (46.2%) Tongue 121 (24.6%) 35 (28.9%) 86 (71.1%) Buccal 274 (55.8%) 101 (36.9%) 173 (63.1%) Palate 12 (2.4%) 7 (58.1%) 5 (41.7%) Retromolar trigone 10 (2.0%) 4 (40%) 6 (60%) Stage 0.684 I 13 (2.6%) 3 (23.1%) 10 (76.9%) II 37 (7.5%) 14 (37.8%) 23 (62.2%) III 62 (12.6%) 22 (35.5%) 40 (64.5%) IV 379 (77.2%) 147 (38.8%) 232 (61.2%) T stage 0.621 T1 109 (22.3%) 46 (42.2%) 63 (57.8%) T2 255 (51.9%) 90 (35.3%) 165 (64.7%) T3 95 (19.3%) 38 (40.0%) 57 (60.0%) T4 32 (6.5%) 12 (37.5%) 20 (62.5%) Operation duration <0.001 <720 min 303 (62.1%) 53 (17.5%) 250 (82.5%) >=720 min 185 (32.9%) 132 (71.4%) 53 (28.6%) Surgical margin 0.194 Negative 430 (87.6%) 168 (39.1%) 262 (60.9%) Positive 61 (12.4%) 18 (29.5%) 43 (70.5%) Flap necrosis 0.266 No 464 (94.5%) 179 (38.6%) 285 (61.4%) Yes 27 (5.5%) 7 (25.9%) 20 (74.1%)
Surgical site infection 0.430
No 326 (66.4%) 128 (39.3%) 198 (60.7%)
Yes 165 (33.6%) 58 (35.2%) 107 (64.8%)
Diabetes mellitus 0.875
No 463 (94.3%) 175 (37.8%) 288 (62.2%)
Yes 28 (5.7%) 11 (39.3%) 17 (60.7%)
Abbreviation: PMMF, pectoralis major myocutaneous flap. Fisher’s exact test.
were performed using SPSS for Windows, version 10.1 (SPSS, Chicago, IL), and a p < 0.05 was regarded as statistically significant. Results
From March 1994 to December 2008, a total of 491 patients with oral cavity cancer underwent ablation surgery followed by either free flap or PMMF reconstruction. One hundred and eighty six patients (37.9%) received free flaps whereas 305 patients (62.1%) received pedicled flaps reconstruction. Almost all the free flaps were fascio-cutaneous flap and bony flaps only accounted for 3.8% (7 out of 186). The majority of patients were male (N = 480, 97.8%) and the average age was 50 years (range, 27– 83 years). Over half of the primary tumor sites were buccal mucosa (N = 274, 55.8%) followed by tongue (N = 121, 24.6%), and gum (N = 43, 8.8%). One hundred and sixty-five patients (33.6%) devel-oped surgical site infection, while 27 patients (5.5%) experienced partial flap necrosis. The average operation time was 669 ± 211 min and the average peri-operative blood loss was 1074 ± 614 ml. The average hospital stay was 24.7 ± 18.7 days and the average follow up period was 38.1 ± 40.1 months.
There was no significant statistical difference between the free flap and PMMF groups in age (49.3 ± 9.0 vs. 51.0 ± 10.6 years, p = 0.068), surgical site infection rate (31.2% vs. 35.1%, p = 0.430), flap partial necrosis rate (3.8% vs. 6.6%, p = 0.266), stage (p = 0.684), T-stage (p = 0.621), positive surgical margin rate (9.7% vs. 14.1%, p = 0.194), hospital stay (23.8 ± 13.9 vs. 25.2 ± 21.1 days,
p = 0.403), and diabetes mellitus (5.9% vs. 5.6%, p = 0.875). How-ever, a greater proportion of female patients received free flap than did male patients (72.7% vs. 37.1%, p = 0.024). Furthermore, there were significant differences between the free flap and PMMF groups in the primary tumor site (p < 0.001), operation time (793 ± 248 vs. 593 ± 138 min, p < 0.001), and peri-operative blood loss (971 ± 587 vs. 1135 ± 622 ml, p = 0.004). Detailed data are pre-sented inTable 1.
From January 2010 to November 2010, patients who had been reconstructed with free flap or PMMF were interviewed during their regular visit at the clinic. UW-QOL questionnaires were com-pleted by 100 patients. Forty-two of the interviewed patients (42%) were reconstructed with free flap while the remaining 58 patients (58%) were reconstructed with PMMF. Male patients accounted for 97% of the patients who completed the QOL questionnaire and the average age was 54 years old. There was no significant difference between the free flap and PMMF groups in age (54.1 ± 9.6 vs. 54.5 ± 12.5, p = 0.839), gender (p = 0.071), stage (p = 0.763), T-stage (p = 0.904), and the average follow up period after operation (31.4 ± 34.1 vs. 38.7 ± 43.0 months, p = 0.349). The proportions of neck dissection (90.5% vs. 91.4%, p = 0.999), mandibulectomy (p = 0.205), post-operative radiotherapy (59.5% vs. 65.5%, p = 0.687), and diabetes mellitus (4.8% vs. 6.9%, p = 0.986) were also similar in both groups. The data are presented inTable 2.
Global quality of life was considered good to excellent by 33 pa-tients (33%), and 36 papa-tients (36%) reported that their health status was the same or worse than that before treatment. No significant
Table 2
Descriptive and bivariate analyses of oral cavity cancer patients who underwent free flap or PMMF reconstruction and completed a quality of life questionnaire.
Variables Total no. of patients (% in column) No. of patients (%) or Mean (Standard deviation) p value
Free flap group (n = 42) PMMF group (n = 58)
Age (year) 100 54.1 (9.6) 54.5 (12.5) 0.839
Gender 0.071
Female 3 (3%) 3 (100%) 0 (0%)
Male 97 (97%) 39 (40.2%) 58 (59.8%)
Primary tumor sites 0.745
Lip 5 (5.0%) 2 (40.0%) 3 (60.0%) Gum 8 (8.0%) 3 (37.5%) 5 (62.5%) Floor of mouth 4 (4.0%) 1 (25.0%) 3 (75.0%) Tongue 24 (24.0%) 8 (33.3%) 16 (66.7%) Buccal 44 (44.0%) 19 (43.2%) 25 (56.8%) Palate 9 (9.0%) 5 (55.6%) 4 (44.4%) Retromolar trigone 6 (6.0%) 4 (66.7%) 2 (33.3%) Stage 0.763 II 10 (10.0%) 5 (50.0%) 5 (50.0%) III 9 (9.0%) 3 (33.3%) 6 (66.7%) IV 81 (81.0%) 34 (42.0%) 47 (58.0%) T stage 0.904 T1 3 (3.0%) 1 (33.3%) 2 (66.7%) T2 32 (32.0%) 15 (46.9%) 17 (53.1%) T3 16 (16.0%) 6 (37.5%) 10 (62.5%) T4 49 (49.0%) 20 (40.8%) 29 (59.2%)
Concurrent neck dissection 0.999
No 9 (9.0%) 4 (44.4%) 5 (55.6%) Yes 91 (91.0%) 38 (41.8%) 53 (58.2%) Mandibulectomy 0.205 No 45 (45%) 14 (31.1%) 31 (68.9%) Marginal 34 (34%) 16 (47.1%) 18 (52.9%) Segmental 11 (11%) 6 (54.5%) 5 (45.5%) Hemi 10 (10%) 6 (60.0%) 4 (40.0%) Post-operative radiotherapy 0.687 No 37 (37.0%) 17 (45.9%) 20 (54.1%) Yes 63 (63.0%) 25 (39.7%) 38 (60.3%) Diabetes mellitus 0.986 No 94 (94.0%) 40 (42.6%) 54 (57.4%) Yes 6 (6.0%) 2 (33.3%) 4 (66.7%)
Abbreviation: PMMF, pectoralis major myocutaneous flap.
difference was found in the average score of global quality of life between the free flap and PMMF groups (41.9 ± 15.2 vs. 41.4 ± 22.4, p = 0.808) (Table 3). There were also no significant dif-ferences between the two groups in the pain, appearance, activity, recreation, swallowing, chewing, taste, saliva, and anxiety do-mains. However, there were significant differences between the free flap and PMMF flap groups in the speech (66.7 ± 27.2 vs. 44.7 ± 35.0, p = 0.002), shoulder (81.4 ± 14.7 vs. 50.5 ± 29.8, p < 0.001), and mood (76.2 ± 24.7 vs. 60.8 ± 32.8, p = 0.022) do-mains (Fig. 1). The Spearman’s correlation between the mood and speech domains was r = 0.444 (p < 0.01), whereas the correla-tion between the mood and shoulder domains was r = 0.398 (p < 0.01). With the importance rating of domains, chewing was considered most important issue over the past 7 days followed by swallowing, speech, and pain after allowing for patients to choose up to three domains. Anxiety about cancer was considered least important to patients.
Discussion
This study was a pilot trial which compared the quality of life of patients in an East Asian population who underwent free flap or PMMF reconstruction after oral cavity cancer extirpation. Pres-ently, it is generally acknowledged that free tissue transfer with micro-vascular anastomosis is the favored method for reconstruc-tion after major head and neck cancer surgery.3,5 However,
microsurgical reconstructions are not without potential morbidi-ties, require specialized surgical skills, and are often lengthy proce-dures. These requisites are not available in many head and neck centers and the cost involved in this type of procedure has been a matter of debate in the literature.3,9,12To the best of our
knowl-edge, this study is the largest series to compare the differences be-tween patients who have undergone PMMF and free flap reconstruction after ablation of oral cavity cancer.
Several previous studies found no significant difference in the gender distribution between free flap and PMMF.6–9,12However,
there was a higher proportion of female patients who underwent free flap reconstruction in the current study. This could be ex-plained by the small number of female patients which might have skewed the results. Another possible explanation might be pre-sumed greater importance placed on cosmetic outcome (deformity of breast) among female patients resulting in a preference for free flap reconstruction in female.
We found that patients who received reconstruction with free flap had a longer operative duration when compared with those who were reconstructed with PMMF, which was a similar finding to that reported in previous studies.7,9,12The need for
microvascu-lar anastomosis is likely the main reason for the longer duration of procedure. We also found a higher proportion of patients with tu-mors located over lip, mouth floor, and palate underwent free flap reconstruction. One reason might be that those structures are thin-ner when compared with other subsites of the oral cavity and are thus reconstruction with bulky PMMF would be more challenging. Another explanation could be that mouth floor and palate tumors only accounted for a small proportion of the studied population, which may have confounded the final results. The average peri-operative blood loss was abundant in the PMMF group when com-pared with that of the free flap group in this study. Smeele et al. in their study comparing morbidity and cost differences between pedicled flap and free flap reconstruction had similar results (1345 vs. 1168 ml) yet no statistically significant difference was found.12The possible explanation is the surgeon’s factor as other variables between patients reconstructed with free flaps and ped-icled flaps were comparable. The pedped-icled flaps were performed by head and neck surgeon whereas the free flap were performed by plastic surgeon in our study.
There were no significant differences between free flap and PMMF groups in age, surgical site infection rate, flap partial necro-sis rate, tumor stage, positive surgical margin rate, and hospital stay in this study. Although most previous studies also reported similar results, some disparity existed among different studies.6– 9,12,13
Chepeha et al. found that the minor complication rate was higher in the PMMF group when compared with that of the free flap group (51% vs. 21%, p < 0.001). Also, hospitalization was longer in the PMMF group when compared with that of free flap group.6
de Bree et al. in their study about free radial forearm flap versus pedicled flap reconstruction of oral and oropharyngeal defect indi-cated that the wound healing problems were more frequently ob-served in the pedicled flap group when compared with the free flap group. The mean hospital stay was significantly shorter in the free flap group than in the pedicled flap group (24 vs. 28 days, p = 0.005).13The reason might be the different definition of
compli-cation between the aforementioned studies and that used in our study. In addition, the studied populations were different as the abovementioned studies included patients who underwent a sec-ond extirpation as well as those whose primary tumor originated other than oral cavity, whereas our study only included patients with cancer of the oral cavity which was treated primarily with surgery. A lower rate of positive margins was found in patients who underwent free flap reconstruction when compared with that of patients who received PMMF reconstruction (9.4% vs. 15.7%). The authors propose that free flap reconstruction allowed the
abla-Table 3
Quality of life scores of oral cavity cancer patients underwent different type of reconstruction.
Domains Mean score ± standard deviation p
value Free flap group
(n = 42) PMMF group (n = 58) Pain 76.8 ± 23.0 68.1 ± 27.2 0.138 Appearance 67.3 ± 25.0 69.8 ± 25.5 0.535 Activity 67.9 ± 24.2 66.8 ± 27.9 0.760 Recreation 69.1 ± 32.6 62.5 ± 32.2 0.221 Swallowing 49.3 ± 37.2 48.6 ± 32.7 0.962 Chewing 34.5 ± 39.0 33.6 ± 36.7 0.973 Speech 66.7 ± 27.2 44.7 ± 35.0 0.002 Shoulder 81.4 ± 14.7 50.5 ± 29.8 <0.001 Taste 55.0 ± 43.2 45.9 ± 39.6 0.226 Saliva 71.7 ± 34.8 73.8 ± 28.1 0.964 Mood 76.2 ± 24.7 60.8 ± 32.8 0.022 Anxiety 75.9 ± 26.3 68.9 ± 33.9 0.423
Global quality of life 41.9 ± 15.2 41.4 ± 22.4 0.808 UW-QOL composite
scare
66.0 ± 18.5 57.8 ± 18.2 0.090
Abbreviation: PMMF, pectoralis major myocutaneous flap; UW-QOL, University of Washington Quality of Life.
Figure 1 UW-QOL scores in PMMF and free flap groups (mean). Scores in PMMF group and free flap group differed significantly (p < 0.05) in speech, shoulder, and mood domains.
tive surgeon more freedom to take wider margins.12 Although a
higher proportion of patients who underwent PMMF had positive margins in our study, the statistical difference was not significant.
The reported complication rates after free flap or PMMF recon-struction after head and neck cancer extirpation ranged from 13% to 36.1%.3,4,6,7,12,13These results are comparable with those of our
study. A previous study found that the gastrostomy tube depen-dent rate was higher in the PMMF group when compared with that of the free flap group.6However, Mallet et al. did not find a
signif-icant difference between the free flap and the PMMF group in the duration of use of a feeding tube. As our study did not collect these data, no comparison could be made.
A previous study reported that global quality of life was consid-ered good to excellent by 59.3% of patients with advanced head and neck cancers who underwent major surgical procedures and the mean UW-QOL composite score was 79.3.14 Rogers et al. in
their study about patients treated by primary surgery for oral and oropharyngeal cancer also found global quality of life was rated good to excellent in 58.1% of participants.15Conversely, our
study found only 33% of patients rated their global quality of life as good or very good and no one rated his/her global quality of life as excellent. The disparity might be due to the different studied population as the aforementioned studies consisted of a variety of tumor that included locations other than the oral cavity. In addi-tion, previous studies included a variety of patients who under-went various surgical treatments, while our study enrolled only patients with oral cavity cancers reconstructed with free flap or PMMF. Other explanations could involve cultural, ethnic, and envi-ronmental factors as most of the aforementioned studies concern-ing quality of life were conducted in Western countries while our study was conducted in East Asia.
Although most of our patients with oral cavity cancers under-went PMMF reconstruction, not all patients completed the second phase of the study which was concerned with quality of life. The reason for this is that the timeframe of the first phase included pa-tients who were followed for over 14 years, whereas the second phase of the study only enrolled patients who were followed at our clinic for a duration of just 11 months. However, the patients’ demographic data were similar in the free flap and PMMF groups. Even though there was no significant difference between the free flap and PMMF groups in their average UW-QOL composite scores, patients who underwent free flap reconstruction reported better average scores than those who underwent PMMF reconstruction in the speech, shoulder, and mood domains. Su et al. in their study on functional comparison after reconstruction of the tongue found that patients who underwent free flap reconstruction had better speech function when compared with that of patients who under-went PMMF reconstruction.16A possible explanation is that
recon-struction of intra-oral defect with thin and supple tissue using free flap might allow the residual tongue to maintain maximum mobil-ity and pliabilmobil-ity, which in turn facilitates articulation. As 16 out of 58 patients underwent pedicled flaps reconstruction in our study had defects over tongue region, there is no doubt that the average UW-QOL score for the speech domain was worse in patients received pedicled flaps when compared with that of patients re-ceived free flaps. Theoretically, a free flap is more superior in ton-gue than buccal mucosa defects as compared to pedicled flap. When we compare the average score for the speech domain in ton-gue cancer patients in our study, the average score in patients reconstructed with free flap was 50 whereas that in patients recon-structed with pedicled flap was 28 (p = 0.046). Conversely, when it comes to the buccal cancer patients, the average score for speech domain in patients reconstructed with free flap was 69 whereas that in patients reconstructed with pedicled flap was 55.6 (p = 0.153).
Moukarbel et al. in their study about shoulder disability follow-ing PMMF reconstruction found that PMMF was associated with objectively detectable limitation in shoulder function. PMMF not only reduced the range of motion but also reduced the strength across more than one domain.17This could explain why the
aver-age score in the shoulder domain in the PMMF group was worse than that of the free flap group. The average score in the mood do-main in the PMMF group was also worse than that of the free flap group. Impaired speech and shoulder function in the PMMF group may explain why more patients reported depressed status as indi-cated by the strong correlation between scores in the mood and speech domains as well as between the mood and shoulder do-mains in our study.
We found that the average scores for the swallow domain were similar in both groups. A previous study found out that the tongue provided the major driving force for swallowing liquid. Therefore, if more residual tongue can be preserved, greater improvements in oral manipulation and swallowing will be obtained.16The lack
of a significant difference between free flap and PMMF in the UW-QOL swallow scores may be explained in part by the small proportion of tongue cancer patients who completed the quality of life questionnaire. A previous study found that the type of recon-struction was an independent factor that influenced the UW-QOL composite score.18However, our study did not demonstrate such
results. One reason might be due to the different method used to evaluate outcomes as the aforementioned study subdivided partic-ipants into three major categories according to their total UW-QOL scores for comparison, while our study compared absolute UW-QOL composite scores. In addition, the aforementioned study used UW-QOL version 2 questionnaire while we used UW-QOL version 4 in the present study.
Rogers et al. in their study on importance-rating using the UW-QOL questionnaire in patients treated by primary surgery for oral and oro-pharyngeal cancer found that patients tended to rate speech, chewing, and swallowing as more important than the other UW-QOL domains.15Our study found the same results. This finding highlights the crucial impact of the capacity to communicate and eat on patients’ overall sense of well-being. This also draws atten-tion to the need for a multidisciplinary team which can explain the possible functional changes after reconstruction and their impacts on the patient’s life when presenting the patient with treatment options.19 Data from this study may provide useful information
for physicians and patients which may be of value during discus-sion of treatment modalities for oral cavity cancers.
There were some limitations in our study. First, this was not a randomized study. Selection bias inevitably existed. Second, this study included various subsites of oral cavity tumors, which may have different characteristics. Third, although the treatment guide-lines are standardized at the studied institute, individual variations among surgeons certainly exist. Finally, the time from treatment to questionnaire was not uniform for each patient. Some patients’ quality of life results may have been affected by chemotherapy or radiotherapy treatment that may last 3–6 months after comple-tion of treatment (6 out of 100 of patients completed the quescomple-tion- question-naires within 6 months after the end of the treatment).
Conclusion
Patients with oral cavity cancers who underwent major ablation surgery followed by reconstruction with PMMF had comparable morbidity when compared with patients reconstructed with free flap. However, patients reconstructed with free flap had better speech and shoulder function as well as better mood status when compared with those of patients reconstructed with PMMF. It is important to emphasize the need for a multidisciplinary team
which can explain the possible functional changes that patients may experience and their impact on well-being when presenting the patient with treatment modality options.
Conflicts of interest statement None declared.
Acknowledgement
The authors thank Ms. Hui-Ching Ho for her statistical assis-tance. No potential conflict of interest was involved in this research.
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