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Functional Outcomes in Free Flap Reconstruction of Intraoral Defects with Lip-Split Versus Non-Lip-Split Incisions
Leslie E. Cohen, MD1, Kerry A. Morrison, BA1, Erin Taylor, MD1, Jason A. Spector, MD2, Salvatore Caruana, MD3, Christine Rohde, MD1.
1Division of Plastic Surgery, New York Presbyterian Hospital-Columbia University Medical Center, New York, NY, USA, 2Division of Plastic Surgery, New York Presbyterian Hospital- Weill Cornell Medical Center, New York, NY, USA, 3Department of Otorhinolaryngology, New York Presbyterian Hospital-Columbia University Medical Center, New York, NY, USA.

Free flap reconstruction of complex intraoral defects often requires the use of large incisions in cosmetically sensitive areas such as a lip-splitting incision. In order to reduce morbidity and preserve aesthetic outcomes, when feasible, we have adopted a more technically demanding visor technique obviating an incision through the lower lip. The resection and reconstruction is performed through a neck visor incision, with access through the neck and oral cavity rather than a midline split. We examined if this technique had long-term functional or aesthetic benefits.
We performed a retrospective review of all head and neck patients who underwent free flap reconstruction of intraoral defects over a seven-year period by a single plastic surgeon. Patients who had reconstruction utilizing a face or neck access incision only (i.e.: total laryngectomy or a cancer resection through facial skin) were excluded. Wound complications including fistula formation were noted. Functional outcomes evaluated included return to oral feeds, oral competence, and speech quality. Pre- and post-operative photos from patients were assessed (Figure 1). Patients were given two questionnaires meant to assess their quality of life with respect to aesthetic outcome, speech quality, and oral competence. They completed the Derriford Appearance Scale Short Form (DAS24), which evaluates psychological distress and dysfunction of patients with disfigurements and aesthetic problems, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire for Head and Neck Cancer (QLQ-H&N35) form, which evaluates the quality of life of head and neck cancer patients after surgery.
Of the 27 patients who met inclusion criteria, there were 13 women (48%) and 14 men (52%) with a mean age of 58.3 ± 13.0 years. Reconstructed areas included the mandible, tongue and floor of mouth. Fourteen patients (52%) had non-lip-split reconstructions. Thirteen patients (48%) had lip-splitting reconstructions: 5/15 free fibula, 3/7 radial forearm, and 5/5 rectus. Operative times for lip-splitting procedure were longer on average compared to non-lip-splitting techniques (14 hours 29 minutes vs. 12 hours 35 minutes). Sixteen patients (59%) received post-operative radiation. There were equal rates of postoperative fistula formation (2), intraoral wound dehiscence (1) and neck abscesses (1) in both groups. There was no difference in return to oral feeds at 9-month follow up. In the follow-up period, 9 patients died, and 8 patients were lost to follow up. Survey results for 8 patients surviving their disease (3 lip-split, 5 no lip-split) showed that lip-split patients had the same quality overall body image as those who did not, but subjectively rated their quality of eating and speech worse than those reconstructed with the visor technique. Patients and clinical staff subjectively felt that having a non-lip-split approach resulted in less visible sequelae from the reconstruction.
A visor technique with non-lip-split incision for intraoral free flap reconstruction is a safe technique that may improve cosmetic and functional outcomes for head and neck reconstruction patients.

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