CLINICAL STUDY
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 Xu Zhang, MS,* Meng-Jie Li, MS,Þ Qi-Gen Fang, MS,* and Chang-Fu Sun, MD*
Abstract: Our study investigated the quality of life (QoL) of Chinese patients after immediate reconstruction surgery on individuals with head and neck cancer. In addition, we compared the differences between pectoralis major myocutaneous flap (PMMF) and anterolateral thigh free flap (ALTFF). The University of Washington Quality of Life questionnaire, version 4, was used to assess the QoL. Assessments were performed at least 24 months postoperatively. A total of 110 patients’ records were obtained. Among them, 86 patients completed a QoL questionnaire (78.2%). No significant differences could be found in age, primary site, T stage, N stage, and postoperative radiotherapy between PMMF and ALTFF groups. However, there were significant differences between both groups in sex, operation time, and complication. A matched analysis was performed to compare the differences in QoL between patients with head and neck cancers reconstructed with PMMF or ALTFF. Patients reconstructed with ALTFF had better shoulder but worse speech functions. There was a significant effect on the QoL of head and neck cancer patients who had undergone either PMMF or ALTFF reconstruction. The result of this study provide useful information for physicians and patients during their discussion of treatment modalities for head and neck cancers. Key Words: Quality of life, pectoralis major flap, free anterolateral thigh perforator flaps, head and neck cancer (J Craniofac Surg 2014;25: 868Y871)
H
ead and neck cancer is currently a major global health issue. The diagnosis of head and neck cancer and the resulting impact due to treatment have a clear and direct influence on the well-being and associated quality of life (QoL) of the individual. The pectoralis From the *Department of Oromaxillofacial-Head and Neck Surgery, Department of Oral and Maxillofacial Surgery School of Stomatology, China Medical University, Liaoning; and †Department of Endodontic, The Stomatological Hospital of Jilin University, Jilin, People’s Republic of China. Received July 15, 2013. Accepted for publication September 17, 2013. Address correspondence and reprint requests to Chang-Fu Sun, MD, Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, No. 117, Nanjing North St, Heping District, Shenyang, Liaoning 110002, People’s Republic of China; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000443
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major myocutaneous flaps (PMMFs), based on the thoracoacromial artery, was first introduced in 1979 by Ariyan.1 Pectoralis major myocutaneous flap is well established as one of the most important reconstructive methods in major head and neck cancer surgery because of its simple technical aspects, versatility, and proximity to the head and neck region.2 The anterolateral thigh free flap (ALTFF) was first reported by Song et al3 in 1984. Because of improved microsurgical techniques, ALTFF has been performed more frequently in an attempt to enhance the functional and aesthetic results in head and neck cancer patients. It has some advantages: a long pedicle with a suitable diameter to the vessel, the availability of different tissues with large amounts of skin, and adaptability as a sensate or flowthrough flap if necessary.4 Up until now, few studies have evaluated the differences in QoL between patients with head and neck cancers reconstructed with PMMF compared with those who underwent ALTFF. Therefore, the aim of our study was to compare the differences between PMMF and ALTFF for the reconstruction of the head and neck cancer patients. Quality of life was also evaluated in patients who underwent reconstruction with PMMF or ALTFF.
MATERIALS AND METHODS Patient Ethical approval was granted from the ethical review board of China Medical University. Informed consent was obtained from each participant. Patients for this study had surgery in the period 2000 to 2010, at the Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University. Our inclusion criteria for this study were as follows: (1) patients who had no previous cancers, (2) no recurrence of primary cancer, (3) patients who had no communication disorder, and (4) at least 24 months after reconstruction. From March 2000 to December 2010, a total of 110 patients with head and neck cancer underwent ablation surgery followed by either PMMF or ALTFF reconstruction. Seventy-nine patients (71.8%) received ALTFF, whereas 31 patients (28.2%) received PMMF reconstruction. Of the 110 patients, there were 97 men and 13 women with a median age of 57.3 years (range, 24Y73 years). More than half of the primary tumor sites were tongue (n = 66, 60.0%), followed by the floor of the mouth (n = 26, 23.6%) and gum (n = 10, 9.1%). Most of the responders (86.4%) were placed in the T3YT4 classification. Clinical characteristics of patients are shown in Table 1. One hundred ten patients who underwent PMMF or ALTFF were administered our QoL questionnaire. Finally, we collected 86 cases of responders (26 PMM flaps, 60 ALT flaps) by telephones, letters, and outpatient following-up visits. The ALTFF group was selected randomly from the entire cohort of patients reconstructed with ALTFF. The selection was made such that the age, sex, primary tumor sites, TNM classification, treatment, and complication match. Detailed data of PMMF group and matched ALTFF group are presented in Table 2.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
PMMF were analyzed using a W2 test or Fisher exact test. The UWQOL scores were compared for each domain using the paired t test. The significance level was set to P G 0.05.
TABLE 1. Clinical Data Analyses of Head and Neck Cancer Patients Who Underwent ALTFF or PMMF for Reconstruction
Variables Age, y G50 Q50 Sex Male Female Primary tumor sites Tongue Floor of mouth Gum Buccal Palate T classification T1 T2 T3 T4 N classification 0 1 2 Operation duration, min G600 Q600 Postoperative radiotherapy No Yes Complication No Yes
Total No. Patients (%)
No. Patients (%)
25 (22.7) 85 (77.3)
6 (24), 19 (76) 25 (29.4), 60 (70.6)
0.597
97 (87.3) 13 (12.7)
31 (32.0), 66 (68) 0 (0), 13 (100)
0.018
66 (60) 26 (23.6) 10 (9.1) 6 (5.5) 2 (1.8)
23 (34.8), 43 (65.2) 5 (19.2), 21 (80.8) 1 (10), 9 (90) 2 (33.3), 4 (66.7) 0 (0), 2 (100)
0.331
2 (1.8) 13 (11.8) 56 (50.9) 39 (35.5)
1 (50), 1 (50) 3 (23.1), 10 (76.9) 19 (33.9), 37 (66.1) 8 (20.5), 31 (79.5)
0.369
42 (38.2) 58 (52.7) 10 (9.1)
8 (19.0), 34 (81.0) 19 (32.8), 39 (67.2) 4 (40.0), 6 (60.0)
0.196
48 (43.6) 62 (56.4)
28 (58.3), 20 (41.7) 3 (4.8), 59 (95.2)
G0.001
PMMF (n = 31), ALTFF (n = 79)
PMMF/ALTFF for Head/Neck Cancer Patients
RESULTS P
There was no significant statistical difference between the PMMF and ALTFF groups in age, primary tumor site, T stage, N stage, and postoperative radiotherapy. However, a much lower proportion of female patients received PMMF than did male patients (0% vs 16.5%, P = 0.018). Furthermore, the PMMF group experienced higher complication rate when compared with that of the ALTFF group (45.2% vs 16.5%, P = 0.002). In addition, there were significant differences between the PMMF and ALTFF groups in the operation time. The mean operation duration was 589 T 154.8 minutes (Table 1). The postoperative follow-up period ranged from 24 months to 10 years, and the mean follow-up point was 5.9 years. No significant difference was found between the average scores of global QoL for the PMMF and ALTFF groups (67.3 T 12.9 vs 70.5 T 16.7, P = 0.860). There were also no significant differences between the 2 groups for the pain, appearance, activity, recreation, swallowing, chewing, taste, saliva, mood, and anxiety domains. However, there were significant differences between the PMMF and ALTFF groups for the speech (76.1 T 13.3 vs 57.5 T 20.1, P = 0.017) and shoulder (65.6 T 20.0 vs 87.1 T 14.4, P G 0.001) domains (Table 3). With the importance rating of domains, chewing was considered the most important issue over the past 7 days followed by swallowing, speech, and taste after allowing for patients to choose up to 3 domains. Anxiety about cancer was considered least important to patients.
DISCUSSION
52 (47.3) 58 (52.7)
14 (26.9), 38 (73.1) 17 (29.3), 41 (70.7)
0.781
83 (75.5) 27 (24.5)
17 (20.5), 66 (79.5) 14 (51.9), 13 (48.1)
0.002
Questionnaires and Data Collection Although many QoL instruments have been developed over the past 3 decades, administering the University of Washington Quality of Life (UW-QoL) is a common way among patients with head and neck cancer. Furthermore, it is available in Chinese version and has been validated for the Chinese population.5,6 The UW-QoL is a self-administered scale that provides a broad measure of QoL for patients with head and neck cancer with good acceptability, practicality, validity, reliability, and responsiveness.7,8 Version 4, the most recently improved version of the UW-QoL questionnaire, was used in our study. It consists of 15 domains: 12 are disease-specific (pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder, taste, saliva, mood, and anxiety), and 3 are overall questions. Each of the 12 questions has between 3 and 5 possible options that allow patients to describe their current functional state. The highest extent or ‘‘normal’’ function is assigned 100 points, with 0 representing the lowest extent of function. As well as the 15 questions, patients were asked to choose 3 of the 12 disease-specific domains that were the most important to them in the preceding 7 days.
Statistical Analysis In this study, all data were entered into a database and evaluated using the Statistical Package Social Sciences (SPSS version 16.0; IBM, Armonk, NY). Comparisons of nominal or ordinal variables between patients who underwent surgery with ALTFF and
It is generally acknowledged that ALT flap transfer with microvascular anastomosis is becoming one of the most preferred options for soft tissue reconstruction.4,9 However, it requires specialized surgical skills and often lengthy procedures. These requisites are not available in most of head and neck centers, and the cost TABLE 2. Clinical Data Analyses of PMMF Group and Matched ALTFF Group Characteristic Age at diagnosis, n (%) G50 y Q50 y Sex, n (%) Male Female Primary tumor sites Tongue Floor of mouth Buccal T classification, n (%) T1YT2 T3YT4 N classification, n (%) 0 1 2 Postoperative radiotherapy No Yes Complication No Yes
PMMF (n = 26)
ALTFF (n =26)
6 (23.1) 20 (76.9)
6 (23.1) 20 (76.9)
26 (100) 0 (0)
26 (100) 0 (0)
19 (73.1) 5 (19.2) 2 (7.7)
19 (73.1) 5 (19.2) 2 (7.7)
3 (11.5) 23 (88.5)
3 (11.5) 23 (88.5)
7 (26.9) 16 (61.5) 3 (11.5)
7 (26.9) 16 (61.5) 3 (11.5)
12 (46.2) 14 (53.8)
12 (46.2) 14 (53.8)
15 (57.7) 11 (42.3)
15 (57.7) 11 (42.3)
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery
Zhang et al
TABLE 3. Means of Scores of Items and Scales of UW-QOL Questionnaire PMMF (n = 26)
ALTFF (n = 26)
Domains
Mean (SD)
Mean (SD)
P
UW-QOL Pain Appearance Activity Recreation Swallowing Chewing Speech Shoulder Taste Saliva Mood Anxiety Global quality of life
89.9 (11.4) 70.3 (17.1) 74.8 (10.2) 78.9 (11.2) 51.3 (21.7) 59.4 (12.9) 76.1 (13.3) 65.6 (20.0) 52.9 (19.6) 72.3 (23.1) 71.6 (18.8) 86.4 (17.5) 67.3 (12.9)
86.2 (10.8) 76.4 (18.6) 71.9 (11.5) 72.1 (10.2) 49.4 (14.7) 52.6 (17.1) 57.5 (20.1) 87.1 (14.4) 48.4 (18.3) 70.9 (9.5) 76.0 (14.7) 78.5 (9.64) 70.5 (16.7)
0.425 0.308 0.710 0.590 0.840 0.498 0.017 G0.001 0.713 0.813 0.114 0.775 0.860
involved in this type of procedure has been a matter of debate in the literature.10,11 O’Neill et al,12 in their study on free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects, found that PMMF remained an enduring and safe flap. To the best of our knowledge, this is the first study to compare the differences between PMMF and ALTFF. There were no significant differences between the PMMF and ALT groups for T stage. However, it should be noted that most of the responders (86.4%) were placed in the T3YT4 classification. This may be due to the fact that PMMF or ALTFF can cut a large skin area and usually includes a segment of muscle, which has made them popular for soft tissue defect reconstructions in T3YT4 classified patients. Chen and Tang,13 in their studies on anterolateral thigh flap, reported that the length of ALT flap can be 40 cm, and its width can be half of the thigh, with the maximal dimension as large as 40 20 cm (800 cm2). The largest skin territory in our series was 18 15 cm (270 cm2). The average size of the ALTFF was 120 cm2 in the current study; meanwhile, the PMMF is 96 cm2 (range, 40Y220 cm2). Mallet et al,14 in their study on reconstruction of tongue cancer patients, found no significant difference in the sex distribution between free flap and PMMF. However, there was a higher proportion of female patients who underwent ALTFF reconstruction in the current study. The possible explanation might be presumed greater importance placed on deformity of breast among female patients, resulting in a preference for ALTFF reconstruction in females. In the current study, we found that patients who received reconstruction with ALTFF had a longer operative duration when compared with those who were reconstructed with PMMF. These results are similar to those found by Mallet et al14 and Hsing et al.6 This could be explained by the need for microvascular anastomosis. We also found that the minor complication rate was higher in the PMMF group when compared with that of the ALTFF group (45.2% vs 16.5%, P = 0.002). Chepeha et al,15 in their study on PMMF versus revascularized free tissue transfer, had similar results. The reported complication rates after free flap or PMMF reconstruction after head and neck cancer extirpation ranged from 13% to 36.1%.2,15Y17 According to this survey, more than half of patients who responded to our questionnaires received surgical treatment including postoperative radiotherapy or chemotherapy. Connor et al,18 Petruson et al,19 and Epstein et al20 found that, after radiotherapy, salivary function, physical function, and weight were significantly reduced and that coughing, swallowing, and dry mouth symptoms increased. Our
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work revealed a similar result: adjuvant radiotherapy resulting in persistent problems with dry mouth, coughing, and chewing. Although the primary intended outcome of head and neck malignancies surgery is still the disease-free survival of the patient, QoL is now seen as an essential secondary outcome.21 Therefore, successful reconstruction should focus on both flap survival rate and the patient’s QoL. This cross-sectional study was a pilot trial that compared the QoL of Chinese patients who underwent ALTFF or PMMF reconstruction after head and neck cancer extirpation. Our study found that global QoL was considered good to excellent by 51.8% of patients with head and neck cancers. These results are similar to those found by Rogers et al.22 In addition, no significant difference was found between the average scores of global QoL for the PMMF and ALTFF groups. Chaplin and Morton,23 in their studies on pain in head and neck cancer patients, reported that 84% of patients complained of pain when they were first seen, but only 25% and 26% reported pain at 12 and 24 months after operation, respectively. Our results concur with their findings: most patients did not complain of pain. The mean score of the pain domain in the PMMF group was 89.9; in the ALTFF group, it was 86.2. However, there were no significant differences between the 2 groups in this project. A previous study reported that patients who underwent free flap reconstruction had better speech function when compared with that of patients who underwent PMMF reconstruction.24 Conversely, our study found the average UW-QOL score for the speech domain was worse in patients who received ALT flaps when compared with that of patients who received PMMF flaps. Patients undergoing wider resections tended to have a smaller residual tongue, which resulted in restricted tongue movements and thus influenced speech. In the current study, 42.8% patients who underwent ALT flaps reconstruction had more than one-half defect of the tongue; however, the PMMF is less than 10%. Moukarbel et al25 conducted a casecontrol study and reported that PMMF reconstruction had a significant effect on shoulder impairment. They also demonstrated that the flap was associated with shoulder morbidity as indicated by reductions in both the range of motion and strength. There is no doubt that the average score in the shoulder domain in the PMMF group was worse than that of the ALTFF group. In our study, we were not able to see any significant differences between the PMM flaps and ALT flaps groups regarding mood domain (71.6 [18.8] vs 76.0 [14.7], P = 0.114). This finding is in contrast to that reported by Hsing et al.6 One possible reason for this discrepancy could be that all of our patients came from the Chinese east-north population who are famous for forthrightness; another reason might be that no patients had a history of recurrence. Several previous studies found that patients tended to consider speech, chewing, and swallowing as more important than the other UW-QOL domains.5,22 However, chewing was considered the most important issue in the current study followed by swallowing, taste, and speech. This is maybe because in traditional Chinese culture we pay more attention to diet than to speech. There was a significant effect on the QoL of head and neck cancer patients who had undergone either PMMF or ALTFF reconstruction. Patients reconstructed with ALTFF had better shoulder but worse speech functions. We hope that this study serves as a useful resource for physicians when they are selecting treatment schemes for head and neck cancers.
REFERENCES 1. Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in head and neck. Plast Reconstr Surg 1979;63:73Y81 2. Liu R, Gullane P, Brown D, et al. Pectoralis major myocutaneous pedicled flap in head and neck reconstruction: retrospective review of indications and results in 244 consecutive cases at the Toronto General Hospital. J Otolaryngol 2001;30:34Y40
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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& Volume 25, Number 3, May 2014
3. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap: concept based on the septocutaneous artery. Br J Plast Surg 1984;37:149 4. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:2219Y2226 5. Khadka A, Liu Y, Li JH, et al. Changes in quality of life after orthognathic surgery: a comparison based on the involvement of the occlusion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:719Y725 6. Hsing CY, Wong YK, Wang CP, et al. Comparison between free flap and pectoralis major pedicled flap for reconstruction in Oral and maxillofacial cancer patientsVa quality of life analysis. Oral Oncol 2011;47:522Y527 7. Rogers SN, Lowe D, Fisher SE, et al. Health-related quality of life and clinical function after primary surgery for oral cancer. Br J Oral Maxillofac Surg 2002;40:11Y18 8. Zhang X, Fang QG, Li ZN, et al. Quality of Life in patients under 40 years old treated for anterior tongue squamous cell carcinoma. J Craniofac Surg 2013;24:558Y561 9. Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg 2005;32:421Y430 10. 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;123:731Y737 11. 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;35:102Y107 12. O’Neill JP, Shine N, Eadie PA, et al. Free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects. Ir J Med Sci 2010;179:337Y343 13. Chen HC, Tang YB. Anterolateral thigh flap: an ideal soft tissue flap. Clin Plast Surg 2003;30:383Y401 14. Mallet Y, El Bedoui S, Penel N, et al. The free vascularized flap and the pectoralis major pedicled flap options: comparative results of reconstruction of the tongue. Oral Oncol 2009;45:1028Y1031
PMMF/ALTFF for Head/Neck Cancer Patients
15. Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer. Arch Otolaryngol Head Neck Surg 2004;130:181Y186 16. Vartanian JG, Carvalho AL, Carvalho SM, et al. Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: experience with 437 cases at a single institution. Head Neck 2004;26:1018Y1023 17. de Bree R, Reith R, Quak JJ, et al. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007;32:275Y282 18. Connor NP, Cohen SB, Kammer RE, et al. Impact of conventional radiotherapy on health-related quality of life and critical functions of the head and neck. J Radiat Oncol Biol Phys 2006;65:1051Y1062 19. Petruson KM, Silander EM, Hammerlid EB. Quality of life as predictor of weight loss in patients with head and neck cancer. Head Neck 2005;27:302Y310 20. Epstein JB, Robertson M, Emerton S, et al. Quality of life and oral function in patients treated with radiation therapy for head and neck cancer. Head Neck 2001;23:389Y398 21. Chandu A, Smith AC, Rogers SN. Health-related quality of life in oral cancer: a review. J Oral Maxillofac Surg 2006;64:495Y502 22. Rogers SN, Laher SH, Overend L, et al. Importance-rating using the University of Washington Quality of Life questionnaire in patients treated by primary surgery for oral and oro-pharyngeal cancer. J Craniomaxillofac Surg 2002;30:125Y132 23. Chaplin JM, Morton RP. A prospective, longitudinal study of pain in head and neck cancer patients. Head Neck 1999;21:531Y537 24. Su WF, Hsia YJ, Chang YC, et al. Functional comparison after reconstruction with a radial forearm free flap or a pectoralis major flap for cancer of the tongue. Otolaryngol Head Neck Surg 2003;128:412Y418 25. Moukarbel RV, Fung K, Franklin JH, et al. Neck and shoulder disability following reconstruction with the pectoralis major pedicled flap. Laryngoscope 2010;120:1129Y1134
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
871
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 Xu Zhang, MS,* Meng-Jie Li, MS,Þ Qi-Gen Fang, MS,* and Chang-Fu Sun, MD*
Abstract: Our study investigated the quality of life (QoL) of Chinese patients after immediate reconstruction surgery on individuals with head and neck cancer. In addition, we compared the differences between pectoralis major myocutaneous flap (PMMF) and anterolateral thigh free flap (ALTFF). The University of Washington Quality of Life questionnaire, version 4, was used to assess the QoL. Assessments were performed at least 24 months postoperatively. A total of 110 patients’ records were obtained. Among them, 86 patients completed a QoL questionnaire (78.2%). No significant differences could be found in age, primary site, T stage, N stage, and postoperative radiotherapy between PMMF and ALTFF groups. However, there were significant differences between both groups in sex, operation time, and complication. A matched analysis was performed to compare the differences in QoL between patients with head and neck cancers reconstructed with PMMF or ALTFF. Patients reconstructed with ALTFF had better shoulder but worse speech functions. There was a significant effect on the QoL of head and neck cancer patients who had undergone either PMMF or ALTFF reconstruction. The result of this study provide useful information for physicians and patients during their discussion of treatment modalities for head and neck cancers. Key Words: Quality of life, pectoralis major flap, free anterolateral thigh perforator flaps, head and neck cancer (J Craniofac Surg 2014;25: 868Y871)
H
ead and neck cancer is currently a major global health issue. The diagnosis of head and neck cancer and the resulting impact due to treatment have a clear and direct influence on the well-being and associated quality of life (QoL) of the individual. The pectoralis From the *Department of Oromaxillofacial-Head and Neck Surgery, Department of Oral and Maxillofacial Surgery School of Stomatology, China Medical University, Liaoning; and †Department of Endodontic, The Stomatological Hospital of Jilin University, Jilin, People’s Republic of China. Received July 15, 2013. Accepted for publication September 17, 2013. Address correspondence and reprint requests to Chang-Fu Sun, MD, Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, No. 117, Nanjing North St, Heping District, Shenyang, Liaoning 110002, People’s Republic of China; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000443
868
major myocutaneous flaps (PMMFs), based on the thoracoacromial artery, was first introduced in 1979 by Ariyan.1 Pectoralis major myocutaneous flap is well established as one of the most important reconstructive methods in major head and neck cancer surgery because of its simple technical aspects, versatility, and proximity to the head and neck region.2 The anterolateral thigh free flap (ALTFF) was first reported by Song et al3 in 1984. Because of improved microsurgical techniques, ALTFF has been performed more frequently in an attempt to enhance the functional and aesthetic results in head and neck cancer patients. It has some advantages: a long pedicle with a suitable diameter to the vessel, the availability of different tissues with large amounts of skin, and adaptability as a sensate or flowthrough flap if necessary.4 Up until now, few studies have evaluated the differences in QoL between patients with head and neck cancers reconstructed with PMMF compared with those who underwent ALTFF. Therefore, the aim of our study was to compare the differences between PMMF and ALTFF for the reconstruction of the head and neck cancer patients. Quality of life was also evaluated in patients who underwent reconstruction with PMMF or ALTFF.
MATERIALS AND METHODS Patient Ethical approval was granted from the ethical review board of China Medical University. Informed consent was obtained from each participant. Patients for this study had surgery in the period 2000 to 2010, at the Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University. Our inclusion criteria for this study were as follows: (1) patients who had no previous cancers, (2) no recurrence of primary cancer, (3) patients who had no communication disorder, and (4) at least 24 months after reconstruction. From March 2000 to December 2010, a total of 110 patients with head and neck cancer underwent ablation surgery followed by either PMMF or ALTFF reconstruction. Seventy-nine patients (71.8%) received ALTFF, whereas 31 patients (28.2%) received PMMF reconstruction. Of the 110 patients, there were 97 men and 13 women with a median age of 57.3 years (range, 24Y73 years). More than half of the primary tumor sites were tongue (n = 66, 60.0%), followed by the floor of the mouth (n = 26, 23.6%) and gum (n = 10, 9.1%). Most of the responders (86.4%) were placed in the T3YT4 classification. Clinical characteristics of patients are shown in Table 1. One hundred ten patients who underwent PMMF or ALTFF were administered our QoL questionnaire. Finally, we collected 86 cases of responders (26 PMM flaps, 60 ALT flaps) by telephones, letters, and outpatient following-up visits. The ALTFF group was selected randomly from the entire cohort of patients reconstructed with ALTFF. The selection was made such that the age, sex, primary tumor sites, TNM classification, treatment, and complication match. Detailed data of PMMF group and matched ALTFF group are presented in Table 2.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
PMMF were analyzed using a W2 test or Fisher exact test. The UWQOL scores were compared for each domain using the paired t test. The significance level was set to P G 0.05.
TABLE 1. Clinical Data Analyses of Head and Neck Cancer Patients Who Underwent ALTFF or PMMF for Reconstruction
Variables Age, y G50 Q50 Sex Male Female Primary tumor sites Tongue Floor of mouth Gum Buccal Palate T classification T1 T2 T3 T4 N classification 0 1 2 Operation duration, min G600 Q600 Postoperative radiotherapy No Yes Complication No Yes
Total No. Patients (%)
No. Patients (%)
25 (22.7) 85 (77.3)
6 (24), 19 (76) 25 (29.4), 60 (70.6)
0.597
97 (87.3) 13 (12.7)
31 (32.0), 66 (68) 0 (0), 13 (100)
0.018
66 (60) 26 (23.6) 10 (9.1) 6 (5.5) 2 (1.8)
23 (34.8), 43 (65.2) 5 (19.2), 21 (80.8) 1 (10), 9 (90) 2 (33.3), 4 (66.7) 0 (0), 2 (100)
0.331
2 (1.8) 13 (11.8) 56 (50.9) 39 (35.5)
1 (50), 1 (50) 3 (23.1), 10 (76.9) 19 (33.9), 37 (66.1) 8 (20.5), 31 (79.5)
0.369
42 (38.2) 58 (52.7) 10 (9.1)
8 (19.0), 34 (81.0) 19 (32.8), 39 (67.2) 4 (40.0), 6 (60.0)
0.196
48 (43.6) 62 (56.4)
28 (58.3), 20 (41.7) 3 (4.8), 59 (95.2)
G0.001
PMMF (n = 31), ALTFF (n = 79)
PMMF/ALTFF for Head/Neck Cancer Patients
RESULTS P
There was no significant statistical difference between the PMMF and ALTFF groups in age, primary tumor site, T stage, N stage, and postoperative radiotherapy. However, a much lower proportion of female patients received PMMF than did male patients (0% vs 16.5%, P = 0.018). Furthermore, the PMMF group experienced higher complication rate when compared with that of the ALTFF group (45.2% vs 16.5%, P = 0.002). In addition, there were significant differences between the PMMF and ALTFF groups in the operation time. The mean operation duration was 589 T 154.8 minutes (Table 1). The postoperative follow-up period ranged from 24 months to 10 years, and the mean follow-up point was 5.9 years. No significant difference was found between the average scores of global QoL for the PMMF and ALTFF groups (67.3 T 12.9 vs 70.5 T 16.7, P = 0.860). There were also no significant differences between the 2 groups for the pain, appearance, activity, recreation, swallowing, chewing, taste, saliva, mood, and anxiety domains. However, there were significant differences between the PMMF and ALTFF groups for the speech (76.1 T 13.3 vs 57.5 T 20.1, P = 0.017) and shoulder (65.6 T 20.0 vs 87.1 T 14.4, P G 0.001) domains (Table 3). With the importance rating of domains, chewing was considered the most important issue over the past 7 days followed by swallowing, speech, and taste after allowing for patients to choose up to 3 domains. Anxiety about cancer was considered least important to patients.
DISCUSSION
52 (47.3) 58 (52.7)
14 (26.9), 38 (73.1) 17 (29.3), 41 (70.7)
0.781
83 (75.5) 27 (24.5)
17 (20.5), 66 (79.5) 14 (51.9), 13 (48.1)
0.002
Questionnaires and Data Collection Although many QoL instruments have been developed over the past 3 decades, administering the University of Washington Quality of Life (UW-QoL) is a common way among patients with head and neck cancer. Furthermore, it is available in Chinese version and has been validated for the Chinese population.5,6 The UW-QoL is a self-administered scale that provides a broad measure of QoL for patients with head and neck cancer with good acceptability, practicality, validity, reliability, and responsiveness.7,8 Version 4, the most recently improved version of the UW-QoL questionnaire, was used in our study. It consists of 15 domains: 12 are disease-specific (pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder, taste, saliva, mood, and anxiety), and 3 are overall questions. Each of the 12 questions has between 3 and 5 possible options that allow patients to describe their current functional state. The highest extent or ‘‘normal’’ function is assigned 100 points, with 0 representing the lowest extent of function. As well as the 15 questions, patients were asked to choose 3 of the 12 disease-specific domains that were the most important to them in the preceding 7 days.
Statistical Analysis In this study, all data were entered into a database and evaluated using the Statistical Package Social Sciences (SPSS version 16.0; IBM, Armonk, NY). Comparisons of nominal or ordinal variables between patients who underwent surgery with ALTFF and
It is generally acknowledged that ALT flap transfer with microvascular anastomosis is becoming one of the most preferred options for soft tissue reconstruction.4,9 However, it requires specialized surgical skills and often lengthy procedures. These requisites are not available in most of head and neck centers, and the cost TABLE 2. Clinical Data Analyses of PMMF Group and Matched ALTFF Group Characteristic Age at diagnosis, n (%) G50 y Q50 y Sex, n (%) Male Female Primary tumor sites Tongue Floor of mouth Buccal T classification, n (%) T1YT2 T3YT4 N classification, n (%) 0 1 2 Postoperative radiotherapy No Yes Complication No Yes
PMMF (n = 26)
ALTFF (n =26)
6 (23.1) 20 (76.9)
6 (23.1) 20 (76.9)
26 (100) 0 (0)
26 (100) 0 (0)
19 (73.1) 5 (19.2) 2 (7.7)
19 (73.1) 5 (19.2) 2 (7.7)
3 (11.5) 23 (88.5)
3 (11.5) 23 (88.5)
7 (26.9) 16 (61.5) 3 (11.5)
7 (26.9) 16 (61.5) 3 (11.5)
12 (46.2) 14 (53.8)
12 (46.2) 14 (53.8)
15 (57.7) 11 (42.3)
15 (57.7) 11 (42.3)
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Zhang et al
TABLE 3. Means of Scores of Items and Scales of UW-QOL Questionnaire PMMF (n = 26)
ALTFF (n = 26)
Domains
Mean (SD)
Mean (SD)
P
UW-QOL Pain Appearance Activity Recreation Swallowing Chewing Speech Shoulder Taste Saliva Mood Anxiety Global quality of life
89.9 (11.4) 70.3 (17.1) 74.8 (10.2) 78.9 (11.2) 51.3 (21.7) 59.4 (12.9) 76.1 (13.3) 65.6 (20.0) 52.9 (19.6) 72.3 (23.1) 71.6 (18.8) 86.4 (17.5) 67.3 (12.9)
86.2 (10.8) 76.4 (18.6) 71.9 (11.5) 72.1 (10.2) 49.4 (14.7) 52.6 (17.1) 57.5 (20.1) 87.1 (14.4) 48.4 (18.3) 70.9 (9.5) 76.0 (14.7) 78.5 (9.64) 70.5 (16.7)
0.425 0.308 0.710 0.590 0.840 0.498 0.017 G0.001 0.713 0.813 0.114 0.775 0.860
involved in this type of procedure has been a matter of debate in the literature.10,11 O’Neill et al,12 in their study on free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects, found that PMMF remained an enduring and safe flap. To the best of our knowledge, this is the first study to compare the differences between PMMF and ALTFF. There were no significant differences between the PMMF and ALT groups for T stage. However, it should be noted that most of the responders (86.4%) were placed in the T3YT4 classification. This may be due to the fact that PMMF or ALTFF can cut a large skin area and usually includes a segment of muscle, which has made them popular for soft tissue defect reconstructions in T3YT4 classified patients. Chen and Tang,13 in their studies on anterolateral thigh flap, reported that the length of ALT flap can be 40 cm, and its width can be half of the thigh, with the maximal dimension as large as 40 20 cm (800 cm2). The largest skin territory in our series was 18 15 cm (270 cm2). The average size of the ALTFF was 120 cm2 in the current study; meanwhile, the PMMF is 96 cm2 (range, 40Y220 cm2). Mallet et al,14 in their study on reconstruction of tongue cancer patients, found no significant difference in the sex distribution between free flap and PMMF. However, there was a higher proportion of female patients who underwent ALTFF reconstruction in the current study. The possible explanation might be presumed greater importance placed on deformity of breast among female patients, resulting in a preference for ALTFF reconstruction in females. In the current study, we found that patients who received reconstruction with ALTFF had a longer operative duration when compared with those who were reconstructed with PMMF. These results are similar to those found by Mallet et al14 and Hsing et al.6 This could be explained by the need for microvascular anastomosis. We also found that the minor complication rate was higher in the PMMF group when compared with that of the ALTFF group (45.2% vs 16.5%, P = 0.002). Chepeha et al,15 in their study on PMMF versus revascularized free tissue transfer, had similar results. The reported complication rates after free flap or PMMF reconstruction after head and neck cancer extirpation ranged from 13% to 36.1%.2,15Y17 According to this survey, more than half of patients who responded to our questionnaires received surgical treatment including postoperative radiotherapy or chemotherapy. Connor et al,18 Petruson et al,19 and Epstein et al20 found that, after radiotherapy, salivary function, physical function, and weight were significantly reduced and that coughing, swallowing, and dry mouth symptoms increased. Our
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work revealed a similar result: adjuvant radiotherapy resulting in persistent problems with dry mouth, coughing, and chewing. Although the primary intended outcome of head and neck malignancies surgery is still the disease-free survival of the patient, QoL is now seen as an essential secondary outcome.21 Therefore, successful reconstruction should focus on both flap survival rate and the patient’s QoL. This cross-sectional study was a pilot trial that compared the QoL of Chinese patients who underwent ALTFF or PMMF reconstruction after head and neck cancer extirpation. Our study found that global QoL was considered good to excellent by 51.8% of patients with head and neck cancers. These results are similar to those found by Rogers et al.22 In addition, no significant difference was found between the average scores of global QoL for the PMMF and ALTFF groups. Chaplin and Morton,23 in their studies on pain in head and neck cancer patients, reported that 84% of patients complained of pain when they were first seen, but only 25% and 26% reported pain at 12 and 24 months after operation, respectively. Our results concur with their findings: most patients did not complain of pain. The mean score of the pain domain in the PMMF group was 89.9; in the ALTFF group, it was 86.2. However, there were no significant differences between the 2 groups in this project. A previous study reported that patients who underwent free flap reconstruction had better speech function when compared with that of patients who underwent PMMF reconstruction.24 Conversely, our study found the average UW-QOL score for the speech domain was worse in patients who received ALT flaps when compared with that of patients who received PMMF flaps. Patients undergoing wider resections tended to have a smaller residual tongue, which resulted in restricted tongue movements and thus influenced speech. In the current study, 42.8% patients who underwent ALT flaps reconstruction had more than one-half defect of the tongue; however, the PMMF is less than 10%. Moukarbel et al25 conducted a casecontrol study and reported that PMMF reconstruction had a significant effect on shoulder impairment. They also demonstrated that the flap was associated with shoulder morbidity as indicated by reductions in both the range of motion and strength. There is no doubt that the average score in the shoulder domain in the PMMF group was worse than that of the ALTFF group. In our study, we were not able to see any significant differences between the PMM flaps and ALT flaps groups regarding mood domain (71.6 [18.8] vs 76.0 [14.7], P = 0.114). This finding is in contrast to that reported by Hsing et al.6 One possible reason for this discrepancy could be that all of our patients came from the Chinese east-north population who are famous for forthrightness; another reason might be that no patients had a history of recurrence. Several previous studies found that patients tended to consider speech, chewing, and swallowing as more important than the other UW-QOL domains.5,22 However, chewing was considered the most important issue in the current study followed by swallowing, taste, and speech. This is maybe because in traditional Chinese culture we pay more attention to diet than to speech. There was a significant effect on the QoL of head and neck cancer patients who had undergone either PMMF or ALTFF reconstruction. Patients reconstructed with ALTFF had better shoulder but worse speech functions. We hope that this study serves as a useful resource for physicians when they are selecting treatment schemes for head and neck cancers.
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* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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3. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap: concept based on the septocutaneous artery. Br J Plast Surg 1984;37:149 4. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:2219Y2226 5. Khadka A, Liu Y, Li JH, et al. Changes in quality of life after orthognathic surgery: a comparison based on the involvement of the occlusion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:719Y725 6. Hsing CY, Wong YK, Wang CP, et al. Comparison between free flap and pectoralis major pedicled flap for reconstruction in Oral and maxillofacial cancer patientsVa quality of life analysis. Oral Oncol 2011;47:522Y527 7. Rogers SN, Lowe D, Fisher SE, et al. Health-related quality of life and clinical function after primary surgery for oral cancer. Br J Oral Maxillofac Surg 2002;40:11Y18 8. Zhang X, Fang QG, Li ZN, et al. Quality of Life in patients under 40 years old treated for anterior tongue squamous cell carcinoma. J Craniofac Surg 2013;24:558Y561 9. Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg 2005;32:421Y430 10. 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;123:731Y737 11. 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;35:102Y107 12. O’Neill JP, Shine N, Eadie PA, et al. Free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects. Ir J Med Sci 2010;179:337Y343 13. Chen HC, Tang YB. Anterolateral thigh flap: an ideal soft tissue flap. Clin Plast Surg 2003;30:383Y401 14. Mallet Y, El Bedoui S, Penel N, et al. The free vascularized flap and the pectoralis major pedicled flap options: comparative results of reconstruction of the tongue. Oral Oncol 2009;45:1028Y1031
PMMF/ALTFF for Head/Neck Cancer Patients
15. Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer. Arch Otolaryngol Head Neck Surg 2004;130:181Y186 16. Vartanian JG, Carvalho AL, Carvalho SM, et al. Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: experience with 437 cases at a single institution. Head Neck 2004;26:1018Y1023 17. de Bree R, Reith R, Quak JJ, et al. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007;32:275Y282 18. Connor NP, Cohen SB, Kammer RE, et al. Impact of conventional radiotherapy on health-related quality of life and critical functions of the head and neck. J Radiat Oncol Biol Phys 2006;65:1051Y1062 19. Petruson KM, Silander EM, Hammerlid EB. Quality of life as predictor of weight loss in patients with head and neck cancer. Head Neck 2005;27:302Y310 20. Epstein JB, Robertson M, Emerton S, et al. Quality of life and oral function in patients treated with radiation therapy for head and neck cancer. Head Neck 2001;23:389Y398 21. Chandu A, Smith AC, Rogers SN. Health-related quality of life in oral cancer: a review. J Oral Maxillofac Surg 2006;64:495Y502 22. Rogers SN, Laher SH, Overend L, et al. Importance-rating using the University of Washington Quality of Life questionnaire in patients treated by primary surgery for oral and oro-pharyngeal cancer. J Craniomaxillofac Surg 2002;30:125Y132 23. Chaplin JM, Morton RP. A prospective, longitudinal study of pain in head and neck cancer patients. Head Neck 1999;21:531Y537 24. Su WF, Hsia YJ, Chang YC, et al. Functional comparison after reconstruction with a radial forearm free flap or a pectoralis major flap for cancer of the tongue. Otolaryngol Head Neck Surg 2003;128:412Y418 25. Moukarbel RV, Fung K, Franklin JH, et al. Neck and shoulder disability following reconstruction with the pectoralis major pedicled flap. Laryngoscope 2010;120:1129Y1134
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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