Accepted Manuscript Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects Zhen-Hu Ren , MCS, oral and maxillofacial surgery Han-Jiang Wu , DDS oral and maxillofacial surgery Kai Wang , DDS, PHD oral and maxillofacial surgery Sheng Zhang , DDS, PHD oral and maxillofacial surgery Hong Yu Tan , MCS, oral and maxillofacial surgery Zhao Jian Gong , DDS, PHD oral and maxillofacial surgery PII:
S1010-5182(14)00135-8
DOI:
10.1016/j.jcms.2014.04.012
Reference:
YJCMS 1788
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 2 February 2014 Revised Date:
28 February 2014
Accepted Date: 22 April 2014
Please cite this article as: Ren Z-H, Wu H-J, Wang K, Zhang S, Tan HY, Gong ZJ, Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects, Journal of Cranio-Maxillo-Facial Surgery (2014), doi: 10.1016/j.jcms.2014.04.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
TITLE: Anterolateral thigh myocutaneous flaps as the preferred flaps
for reconstruction of oral and maxillofacial defects
Degree: MCS, oral and maxillofacial surgery Affiliations: Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University
RI PT
First author: Zhen-Hu Ren
SC
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA
Corresponding author: Han-Jiang WU Degree: DDS oral and maxillofacial surgery
M AN U
Email: [email protected]
Affiliations: Department of Oral and Maxillofacial surgery,
The second Xiangya hospital of Central South University
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Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA Email address: [email protected]
EP
Telephone no: +86-18670369614
AC C
Third author: Kai Wang
Degree: DDS, PHD oral and maxillofacial surgery Affiliations: Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA
ACCEPTED MANUSCRIPT
Sheng Zhang Degree: DDS, PHD oral and maxillofacial surgery
The second Xiangya hospital of Central South University
RI PT
Affiliations: Department of Oral and Maxillofacial surgery,
SC
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA
Degree: MCS, oral and maxillofacial surgery
M AN U
Hong Yu Tan
Affiliations: Department of Oral and Maxillofacial surgery,
The second Xiangya hospital of Central South University
Zhao Jian Gong
TE D
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA
EP
Degree: DDS, PHD oral and maxillofacial surgery Affiliations: Department of Oral and Maxillofacial surgery,
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The second Xiangya hospital of Central South University
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA
ACCEPTED MANUSCRIPT Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects Background: The anterolateral thigh myocutaneous flap is one of the most commonly used flaps in
RI PT
reconstructive procedures, but its application in oral and maxillofacial defects has not been fully determined. Herein, we summarize the application of 1212 anterolateral thigh myocutaneous flaps in the repair of oral and maxillofacial defects and examine their benefits in maxillofacial reconstruction
SC
of these defects.
M AN U
Methods: Patients were recruited from February 2002 to June 2013 in the Department of Oral and Maxillofacial Surgery of Central South University. All patients underwent reconstructive surgery employing anterolateral thigh myocutaneous flaps. Patient ages ranged from 6 to 82 years with a mean age of 51.2 years. There are 1015 flaps showing single lobe and 197 flaps showing a multi-island
2
TE D
pedicle and one of which carries the iliac bone. The largest area among the single flaps was 28 × 12 2
cm , and the smallest was 3 × 2 cm .
Results: Among the 1212 transferred flaps, 1176 survived and 36 showed necrosis, a survival rate of
EP
about 97.0%. The common complications at flap donor site were poor wound healing (10.1%),
AC C
localized paraesthesia (50.1%), and altered quadriceps force (11.0%). No cases presented with local serious complications, and 90% of patients achieved good functional recovery and aesthetically acceptable results after reconstruction of oral and maxillofacial defects at various locations using anterolateral thigh myocutaneous flaps. The time (23–121 min; average 51 min) for anastomosis of one vein and one artery was significantly less than that for two veins and one artery (45–153 min, average 83 min; p = 0.0003), which indicates one vein anastomosis can significantly reduce the operating time.
ACCEPTED MANUSCRIPT Conclusion: The anterolateral thigh myocutaneous flaps can be easily obtained and can provide a good amount of muscle for filling dead space and fascia lata. These flaps can be prepared into a separate fat flap, multi-island fascia with iliac bone, and other composite pedicle flaps to meet the
RI PT
various requirements of oral and maxillofacial defects. The subcutaneous fat thickness of the anterolateral area can vary considerably and thus can be used to repair defects requiring different flap thickness. Therefore, the anterolateral thigh myocutaneous free flaps are more suitable for oral and
Anterolateral thigh myocutaneous flap; oral and maxillofacial defects; oral cancer;
M AN U
Key word:
SC
maxillofacial defects than other flaps.
Reconstruction Introduction
The oral and maxillofacial areas are extremely important regions for both aesthetic and
TE D
functional reasons. If defects at these regions are not promptly repaired, the adverse effects can include not only bad speech and chewing and swallowing disorders but also psychological problems caused by disfigurement.
EP
With the development of free flaps and microsurgical techniques, a variety of free flaps have
AC C
become the most commonly used tissue source for repair of maxillofacial defects (Crow and Crow, 1976; Bianchi B et al., 2008). More than a dozen free flaps can be considered, and knowing how to choose the right flap for reconstruction is an important key step for successful repair (Futran and Mendez, 2006). The ideal free flaps for oral and maxillofacial defects should have the following features: simple preparation, constant vascular anatomy, a sufficient amount of diverse tissues, few donor site complications, and vascular diameter similar to that of neck and maxillofacial vessels. Investigators around the world have made great efforts to find the best free flaps for the repair of
ACCEPTED MANUSCRIPT maxillofacial defects (Gedebou, 2002). The application of an anterolateral thigh flap was first reported by Song et al(Song, 1984), Anterolateral thigh flaps offer many features and can be prepared as perforating flaps, fat flaps, fascia
RI PT
flaps, muscle flaps, various chimeric flaps, and others(Koshima, 2000; Demirkan et al., 2000; Koshima et al., 1993; Fang et al., 2013). Therefore, these flaps have become one of the most commonly used
flaps for the repair of defects in the head and neck, limbs, torso, and other body parts. However, the
SC
clinical value of anterolateral thigh myocutaneous flaps in oral and maxillofacial surgery has not been
M AN U
widely recognized, and a large cohort-based report of the application of anterolateral thigh myocutaneous flap in oral and maxillofacial defects has not been reported. Here, we collected and summarized data of 1185 patients who underwent reconstruction of oral and maxillofacial defects using anterolateral thigh myocutaneous flaps from February 2002 to June 2013. Our results clearly
Methods
AC C
Patients
EP
maxillofacial defects.
TE D
demonstrate that anterolateral thigh myocutaneous flaps are the preferred flaps for oral and
Patients were treated from February 2002 to June 2013 in the Department of Oral and
Maxillofacial Surgery of Second Xiangya Hospital. All 1185 patients (1212 flaps) underwent reconstruction of defects caused by tumour resection or trauma using anterolateral thigh myocutaneous flaps. 904 cases were male and 281 cases were female. The youngest was 6 years old, and the oldest was 82 years. The mean age was 51.2 years. Among all of the transferred flaps, 1015 were single lobe, and 197 were multi-island pedicle flaps, of which one carried the iliac bone. The
ACCEPTED MANUSCRIPT 2
2
largest area among the single flaps was 28 × 12 cm , and the smallest was 3 × 2 cm . Postoperative follow-up was performed for 1092 patients. Follow-up time varied from 5–84 months, and the mean follow-up time was 32.6 months. Basic information for all patients including defect side, flap size and
RI PT
type, recipient vessel processing method, donor complications, and postoperative quality of life were recorded and statistically analysed Surgical technique
SC
The incision line is parallel to the iliac patellar connection line at 2 cm to the inside of the iliac
M AN U
patellar connection line (Figure 1). The position and distance of the incision line are adjusted according to the width of the prepared flap. If the flap is wide, the incision line is moved to the inside; if the flap is narrow, the incision line is moved outward. Retrograde anatomy is performed to obtain appropriate vessel and vascular pedicle as well as its concomitant vastus lateralis and motor nerves,
TE D
and all the tissues are appropriately restored. Different amounts of vascular pedicle muscle tissue are used to fill the dead space. When repairing complicated defects, we can also take advantage of the lateral femoral circumflex artery, which is characterized by multiple perforating branches, to prepare
EP
separate fat flaps, fascia, muscle flaps, or iliac pedicles of a multi-island composite flap (Case 1).
AC C
The donor wound is closed by direct suture after preparation of complete flaps. When the cut flap is too wide or under too much tension, the flap can be prepared in a region above or below the anterolateral area by cutting full-thickness skin without expanding the donor site. We also can use the lateral femoral circumflex artery to prepare the anterolateral thigh flap pedicle or tensor fascia lata flap and close the wound by local pedicle flap repair. Statistical Analysis Data were analysed using SPSS 16.0 software (SPSS, Inc., Chicago, IL, USA). χ2 test or Fisher's
ACCEPTED MANUSCRIPT exact test were used to analyse the data. A p value < 0.05 was considered to indicate a statistically significant difference.
RI PT
Results Among all 1212 anterolateral thigh myocutaneous flaps transferred, 1176 survived and 55
showed postoperative vascular crisis. Among those 55, 19 survived completely after treatment,
SC
whereas 36 showed necrosis. The overall survival rate was 97.0% (1176/1212; Table 1).
M AN U
We compared the ratio of vascular crisis between the cases of two vein anastomosis and cases of one vein anastomosis. Two vein anastomosis was performed with 1091 flaps, and 39 cases showed venous crisis, 26 of which showed necrosis. Eleven cases showed crisis within 12 hours after surgery, and 28 cases showed crisis beyond 12 hours after surgery. The incidence of venous crisis was 3.6%
TE D
(39/1091), and the survival rate after treatment was 33.3% (13/39). Necrosis occurred in 2 of 121 cases (1.7%). The survival rate after treatment was slightly higher in the one vein anastomosis group compared to that in the two vein anastomosis group. However, the incidence of venous crisis, the
EP
survival rate after treatment, and the rate of venous crisis resulting in flap necrosis were comparable
AC C
between the groups (p > 0.05; Table 2). The average micromanipulator processing time for two vein anastomosis was 83 min (range, 45–153 min). The average micromanipulator processing time for one vein anastomosis was 51 min (23–121 min), which was significantly shorter than that for two vein anastomosis (p = 0.0003).
No case showed limited knee movement, compartment syndrome, or other serious complications (Table 3). Postoperative follow-up was performed in 1092 patients (1092/1185 = 92.2%). Follow-up time
ACCEPTED MANUSCRIPT ranged from 5–84 months, and mean follow-up time was 32.6 months. Questionnaires, oral evaluation, or other methods were used to assess patients’ quality of life and obtain information about their speech, swallowing, chewing, and appearance. In addition, 150 patients with tongue, 50
RI PT
cases with buccal carcinoma, 20 cases with oropharyngeal cancer, and 20 cases with mouth cancer were randomly selected and further analysed 1 year after surgery. Patients were grouped according to chewing function as normal, only soft food, and non-masticatory function by considering foods that
SC
could be chewed by patients. Patients were also grouped according to normal verbal communication,
M AN U
barely able to verbally communicate and unable to communicate verbally according to the clarity of pronunciation and their ability to be understood. Patients were also grouped according to the patients’ opinions of their change in appearance as good and beautiful, acceptable, and unacceptable. Because the degree of mouth opening in patients with buccal cancer is an important indicator of the quality of
TE D
life, we measured the buccal opening degree and divided cases into ≥3 cm, 1–3 cm, and
S1010-5182(14)00135-8
DOI:
10.1016/j.jcms.2014.04.012
Reference:
YJCMS 1788
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 2 February 2014 Revised Date:
28 February 2014
Accepted Date: 22 April 2014
Please cite this article as: Ren Z-H, Wu H-J, Wang K, Zhang S, Tan HY, Gong ZJ, Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects, Journal of Cranio-Maxillo-Facial Surgery (2014), doi: 10.1016/j.jcms.2014.04.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
TITLE: Anterolateral thigh myocutaneous flaps as the preferred flaps
for reconstruction of oral and maxillofacial defects
Degree: MCS, oral and maxillofacial surgery Affiliations: Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University
RI PT
First author: Zhen-Hu Ren
SC
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA
Corresponding author: Han-Jiang WU Degree: DDS oral and maxillofacial surgery
M AN U
Email: [email protected]
Affiliations: Department of Oral and Maxillofacial surgery,
The second Xiangya hospital of Central South University
TE D
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA Email address: [email protected]
EP
Telephone no: +86-18670369614
AC C
Third author: Kai Wang
Degree: DDS, PHD oral and maxillofacial surgery Affiliations: Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA
ACCEPTED MANUSCRIPT
Sheng Zhang Degree: DDS, PHD oral and maxillofacial surgery
The second Xiangya hospital of Central South University
RI PT
Affiliations: Department of Oral and Maxillofacial surgery,
SC
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA
Degree: MCS, oral and maxillofacial surgery
M AN U
Hong Yu Tan
Affiliations: Department of Oral and Maxillofacial surgery,
The second Xiangya hospital of Central South University
Zhao Jian Gong
TE D
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA
EP
Degree: DDS, PHD oral and maxillofacial surgery Affiliations: Department of Oral and Maxillofacial surgery,
AC C
The second Xiangya hospital of Central South University
Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA
ACCEPTED MANUSCRIPT Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects Background: The anterolateral thigh myocutaneous flap is one of the most commonly used flaps in
RI PT
reconstructive procedures, but its application in oral and maxillofacial defects has not been fully determined. Herein, we summarize the application of 1212 anterolateral thigh myocutaneous flaps in the repair of oral and maxillofacial defects and examine their benefits in maxillofacial reconstruction
SC
of these defects.
M AN U
Methods: Patients were recruited from February 2002 to June 2013 in the Department of Oral and Maxillofacial Surgery of Central South University. All patients underwent reconstructive surgery employing anterolateral thigh myocutaneous flaps. Patient ages ranged from 6 to 82 years with a mean age of 51.2 years. There are 1015 flaps showing single lobe and 197 flaps showing a multi-island
2
TE D
pedicle and one of which carries the iliac bone. The largest area among the single flaps was 28 × 12 2
cm , and the smallest was 3 × 2 cm .
Results: Among the 1212 transferred flaps, 1176 survived and 36 showed necrosis, a survival rate of
EP
about 97.0%. The common complications at flap donor site were poor wound healing (10.1%),
AC C
localized paraesthesia (50.1%), and altered quadriceps force (11.0%). No cases presented with local serious complications, and 90% of patients achieved good functional recovery and aesthetically acceptable results after reconstruction of oral and maxillofacial defects at various locations using anterolateral thigh myocutaneous flaps. The time (23–121 min; average 51 min) for anastomosis of one vein and one artery was significantly less than that for two veins and one artery (45–153 min, average 83 min; p = 0.0003), which indicates one vein anastomosis can significantly reduce the operating time.
ACCEPTED MANUSCRIPT Conclusion: The anterolateral thigh myocutaneous flaps can be easily obtained and can provide a good amount of muscle for filling dead space and fascia lata. These flaps can be prepared into a separate fat flap, multi-island fascia with iliac bone, and other composite pedicle flaps to meet the
RI PT
various requirements of oral and maxillofacial defects. The subcutaneous fat thickness of the anterolateral area can vary considerably and thus can be used to repair defects requiring different flap thickness. Therefore, the anterolateral thigh myocutaneous free flaps are more suitable for oral and
Anterolateral thigh myocutaneous flap; oral and maxillofacial defects; oral cancer;
M AN U
Key word:
SC
maxillofacial defects than other flaps.
Reconstruction Introduction
The oral and maxillofacial areas are extremely important regions for both aesthetic and
TE D
functional reasons. If defects at these regions are not promptly repaired, the adverse effects can include not only bad speech and chewing and swallowing disorders but also psychological problems caused by disfigurement.
EP
With the development of free flaps and microsurgical techniques, a variety of free flaps have
AC C
become the most commonly used tissue source for repair of maxillofacial defects (Crow and Crow, 1976; Bianchi B et al., 2008). More than a dozen free flaps can be considered, and knowing how to choose the right flap for reconstruction is an important key step for successful repair (Futran and Mendez, 2006). The ideal free flaps for oral and maxillofacial defects should have the following features: simple preparation, constant vascular anatomy, a sufficient amount of diverse tissues, few donor site complications, and vascular diameter similar to that of neck and maxillofacial vessels. Investigators around the world have made great efforts to find the best free flaps for the repair of
ACCEPTED MANUSCRIPT maxillofacial defects (Gedebou, 2002). The application of an anterolateral thigh flap was first reported by Song et al(Song, 1984), Anterolateral thigh flaps offer many features and can be prepared as perforating flaps, fat flaps, fascia
RI PT
flaps, muscle flaps, various chimeric flaps, and others(Koshima, 2000; Demirkan et al., 2000; Koshima et al., 1993; Fang et al., 2013). Therefore, these flaps have become one of the most commonly used
flaps for the repair of defects in the head and neck, limbs, torso, and other body parts. However, the
SC
clinical value of anterolateral thigh myocutaneous flaps in oral and maxillofacial surgery has not been
M AN U
widely recognized, and a large cohort-based report of the application of anterolateral thigh myocutaneous flap in oral and maxillofacial defects has not been reported. Here, we collected and summarized data of 1185 patients who underwent reconstruction of oral and maxillofacial defects using anterolateral thigh myocutaneous flaps from February 2002 to June 2013. Our results clearly
Methods
AC C
Patients
EP
maxillofacial defects.
TE D
demonstrate that anterolateral thigh myocutaneous flaps are the preferred flaps for oral and
Patients were treated from February 2002 to June 2013 in the Department of Oral and
Maxillofacial Surgery of Second Xiangya Hospital. All 1185 patients (1212 flaps) underwent reconstruction of defects caused by tumour resection or trauma using anterolateral thigh myocutaneous flaps. 904 cases were male and 281 cases were female. The youngest was 6 years old, and the oldest was 82 years. The mean age was 51.2 years. Among all of the transferred flaps, 1015 were single lobe, and 197 were multi-island pedicle flaps, of which one carried the iliac bone. The
ACCEPTED MANUSCRIPT 2
2
largest area among the single flaps was 28 × 12 cm , and the smallest was 3 × 2 cm . Postoperative follow-up was performed for 1092 patients. Follow-up time varied from 5–84 months, and the mean follow-up time was 32.6 months. Basic information for all patients including defect side, flap size and
RI PT
type, recipient vessel processing method, donor complications, and postoperative quality of life were recorded and statistically analysed Surgical technique
SC
The incision line is parallel to the iliac patellar connection line at 2 cm to the inside of the iliac
M AN U
patellar connection line (Figure 1). The position and distance of the incision line are adjusted according to the width of the prepared flap. If the flap is wide, the incision line is moved to the inside; if the flap is narrow, the incision line is moved outward. Retrograde anatomy is performed to obtain appropriate vessel and vascular pedicle as well as its concomitant vastus lateralis and motor nerves,
TE D
and all the tissues are appropriately restored. Different amounts of vascular pedicle muscle tissue are used to fill the dead space. When repairing complicated defects, we can also take advantage of the lateral femoral circumflex artery, which is characterized by multiple perforating branches, to prepare
EP
separate fat flaps, fascia, muscle flaps, or iliac pedicles of a multi-island composite flap (Case 1).
AC C
The donor wound is closed by direct suture after preparation of complete flaps. When the cut flap is too wide or under too much tension, the flap can be prepared in a region above or below the anterolateral area by cutting full-thickness skin without expanding the donor site. We also can use the lateral femoral circumflex artery to prepare the anterolateral thigh flap pedicle or tensor fascia lata flap and close the wound by local pedicle flap repair. Statistical Analysis Data were analysed using SPSS 16.0 software (SPSS, Inc., Chicago, IL, USA). χ2 test or Fisher's
ACCEPTED MANUSCRIPT exact test were used to analyse the data. A p value < 0.05 was considered to indicate a statistically significant difference.
RI PT
Results Among all 1212 anterolateral thigh myocutaneous flaps transferred, 1176 survived and 55
showed postoperative vascular crisis. Among those 55, 19 survived completely after treatment,
SC
whereas 36 showed necrosis. The overall survival rate was 97.0% (1176/1212; Table 1).
M AN U
We compared the ratio of vascular crisis between the cases of two vein anastomosis and cases of one vein anastomosis. Two vein anastomosis was performed with 1091 flaps, and 39 cases showed venous crisis, 26 of which showed necrosis. Eleven cases showed crisis within 12 hours after surgery, and 28 cases showed crisis beyond 12 hours after surgery. The incidence of venous crisis was 3.6%
TE D
(39/1091), and the survival rate after treatment was 33.3% (13/39). Necrosis occurred in 2 of 121 cases (1.7%). The survival rate after treatment was slightly higher in the one vein anastomosis group compared to that in the two vein anastomosis group. However, the incidence of venous crisis, the
EP
survival rate after treatment, and the rate of venous crisis resulting in flap necrosis were comparable
AC C
between the groups (p > 0.05; Table 2). The average micromanipulator processing time for two vein anastomosis was 83 min (range, 45–153 min). The average micromanipulator processing time for one vein anastomosis was 51 min (23–121 min), which was significantly shorter than that for two vein anastomosis (p = 0.0003).
No case showed limited knee movement, compartment syndrome, or other serious complications (Table 3). Postoperative follow-up was performed in 1092 patients (1092/1185 = 92.2%). Follow-up time
ACCEPTED MANUSCRIPT ranged from 5–84 months, and mean follow-up time was 32.6 months. Questionnaires, oral evaluation, or other methods were used to assess patients’ quality of life and obtain information about their speech, swallowing, chewing, and appearance. In addition, 150 patients with tongue, 50
RI PT
cases with buccal carcinoma, 20 cases with oropharyngeal cancer, and 20 cases with mouth cancer were randomly selected and further analysed 1 year after surgery. Patients were grouped according to chewing function as normal, only soft food, and non-masticatory function by considering foods that
SC
could be chewed by patients. Patients were also grouped according to normal verbal communication,
M AN U
barely able to verbally communicate and unable to communicate verbally according to the clarity of pronunciation and their ability to be understood. Patients were also grouped according to the patients’ opinions of their change in appearance as good and beautiful, acceptable, and unacceptable. Because the degree of mouth opening in patients with buccal cancer is an important indicator of the quality of
TE D
life, we measured the buccal opening degree and divided cases into ≥3 cm, 1–3 cm, and
