Reconstruction of large composite oromandibulomaxillary defects with free vertical rectus abdominis myocutaneous flaps

Large composite oromandibulomaxillary defects resulting from oncologic resection can be challenging to reconstruct with a single flap, and functional outcomes remain anecdotal. The purpose of this study was to evaluate the authors' surgical experience and scientifically analyze and describe the functional outcomes associated with the use of the vertical rectus abdominis myocutaneous flap for reconstruction of these defects. The records of seven patients (mean age, 62 years) who underwent composite resection including hemimandibulectomy, partial maxillectomy, partial pharyngectomy, and floor-of-mouth resection followed by immediate free vertical rectus abdominis myocutaneous flap reconstruction at The University of Texas M. D. Anderson Cancer Center (1998 to 2002) were retrospectively reviewed. The tumor type was squamous cell carcinoma in all seven cases; four patients had T4 primary lesions and three had local recurrences. Radiotherapy was used preoperatively in each of the three recurrent cases (mean dose, 70.6 Gy) and postoperatively in three of the four patients with primary tumors (mean dose, 63.0 Gy). The mean length of hospitalization was 8.7 days. There were no major flap complications, fistulas, or donor-site complications. Partial flap necrosis (4 percent of flap area) occurred in one patient and dehiscence of the neck incision occurred in another. Both cases were managed with surgical debridement and closure. A third patient developed a 0.75-cm superficial suture line abscess that healed with dressing changes. The mean postoperative follow-up was 15 months. Six of the seven patients remained tube dependent for their nutrition despite some swallowing improvement; one patient returned to full oral intake. The most common swallowing deficit was impaired laryngeal excursion, which occurred in all six patients evaluated with videofluoroscopic examination and resulted in risk for aspiration in patients and frank aspiration in 83 percent. Speech was intelligible on routine follow-up visits in all patients except one. Four patients died as a result of their cancer, one was alive with metastatic disease, and two were alive with no evidence of disease at last follow-up. The goal for patients undergoing extensive composite oromandibulomaxillary resection for advanced cancer is to restore structure, minimize postoperative morbidity, and optimize the quality of remaining life. Reconstruction with the free vertical rectus abdominis myocutaneous flap achieves early wound healing, allows timely delivery of adjuvant therapy, and can be accomplished with predictable success and minimal morbidity. To our knowledge, this study represents the first to scientifically analyze and quantify swallowing function following free vertical rectus abdominis myocutaneous flap reconstruction for large oromandibulomaxillary defects. Understanding of the specific physiologic swallowing deficits that typically occur after such reconstructions will provide clinicians with important surgical and reconstructive information to enable future improvements in functional success in a population for whom the prognosis is poor and treatment options are limited.