Surgery remains the preferred treatment for the majority of oral cancers. The aim of the present article was to provide a comprehensive review of complications associated with surgical treatment of oral cancer including hardware failure; complications associated with choice of reconstruction, donor site morbidity as well as functional and aesthetic issues that impact on the quality of life.
The available English language literature relevant to complications associated with surgical treatment of oral cancer was reviewed. Complications associated with potential for disfigurement, choice of reconstruction, donor site morbidity as well as functional and aesthetic issues that impact on the quality of life are summarized.
In total 35 literature sources were obtained and reviewed. The topics covered in the second part of this review series include hardware failure, scars and fistula formation; complications associated with choice of reconstruction, donor site morbidity as well as functional and aesthetic issues.
Cancer resection should be planned around two very important concepts. First and foremost is the eradication of disease. This should be the ultimate goal of the ablative team and all potential complications that may be the result of appropriately executed oncologic resection should be discussed in details with the patient. Adequate reconstruction of the defects with restoration of form and function is the second, but not of less importance, goal for the successful care of the head and neck cancer patient.
In Part I of this series of comprehensive review of long-term complications associated with surgical treatment of oral cancer we covered issues with disease eradication, speech, swallowing and mastication as well as neurological problems that are commonly encountered. The high complexity of the anatomy and functions of oral cavity and head and neck though further harbors the potential severe disfigurement. Cancer ablation in this region often results in defects that require use of local regional or distant tissue transfer very often with the combination of hardware that provides for structural support.
The aim of the present article was to provide a comprehensive review of complications associated with surgical treatment of oral cancer including hardware failure; complications associated with choice of reconstruction, donor site morbidity as well as functional and aesthetic issues that impact on the quality of life.
Literature was selected through a search of PubMed, Embase and Cochrane Central Register electronic databases. The keywords used for search were oral cancer, postoperative surgical complications, hardware failure, donor site complications, scarring, fistula. The search was restricted to English language articles and books published from February 1961 to June 2010. The included publications were relevant to long-term surgical complications associated with surgical treatment of oral cancer. The potential common as well as rarer complications that may be encountered and their treatment are summarized.
The topics covered in the second part of this review series include complications associated with potential for disfigurement, chronic fistulas and healing issues; complications associated with reconstruction and donor site morbidity, prosthetic rehabilitation and aesthetic considerations, functional limitations at donor site as well as long-term quality of life and psychological considerations.
Of primary importance in the surgical management of oral malignancies is surgical access for visualization and assessment of margins and anatomic considerations for resection. This may be considerably complicated in cases where the tumour occupies the posterior aspect of the lateral tongue and floor of mouth as well as the retromolar area, the mandibular gingiva, or the posterior maxilla. The complex anatomy of the oral cavity makes surgery more challenging and requires incorporation of various incisions and flap designs to facilitate adequate exposure and subsequent tension free closure.
For the neck dissection, on the other hand, the need to protect the carotid sheath and its contents has led to incision and flap designs that specifically address this anatomic limitation. Aesthetic considerations have not, until recently, been a primary concern when access for tumour resection is planned. Lip split and extensive facial incisions have been utilized over the years, recognizing that the main concern has been adequate exposure, and not aesthetics.
The change in the patient population demographics suffering from oral cancer, along
with concerns about long-term facial scarring, has forced surgeons to consider
incision and flap design based upon facial aesthetic units. The stigma of oral
cancer surgery are no longer acceptable in the face and neck regions due to a desire
for continued social interactions and reasonable quality of life, especially when
survival rates improve, and patients live longer lives following treatment [
Incisions in the neck, with trifurcation extensions, that do not follow natural skin
creases, have a higher incidence of dehiscence and unaesthetic scar formation. In
addition, the effects of radiation treatment further worsens the appearance of the
scars and risk exposure of the carotid artery, or other vessels, if superficial skin
necrosis occurs [
For surgical access to some of the tumours in the oral cavity, the lips may need to
be divided, and incisions on the face may be required. The original description of
the lower lip split procedure in the 1900s placed the incision at the middle of the
lip and chin causing severe scarring postoperatively. Since that time, various
modifications have been described to this technique, with the main endpoint the
achievement of an aesthetically acceptable result that does not compromise access or
restrict adequate resection. Precise alignment and restoration of the vermilion
border of the lip, and alignment and interdigitation of the orbicularis oris muscle,
and reorientation of the lip skin and oral mucosa are paramount in order to achieve
excellent lip competence, function and aesthetics [
For maxillectomy procedures, it is often necessary to elevate the skin over the
midface region to gain access to the underlying tumour. The classic Weber-Ferguson
incision, with or without an extension to involve the lower eyelid, has been used
for many years to accomplish wide surgical access in the midfacial area. This
incision incorporates splitting of the upper lip, and failure to realign the
vermilion border of the upper lip, or to reconstruct the philtrum, can lead to
aesthetic and functional limitations. The lower lid incision extension, if required,
can cause severe scarring, especially if postoperative infection further delays
healing. Despite accurate surgical attention to detail during flap elevation, normal
postsurgical scarring of the lower lid incision can result in lower lid retraction
and ectropion with ophthalmologic consequences, and present a difficult aesthetic
and functional dilemma [
Reconstruction of maxillectomy defects is commonly accomplished with a prosthetic
device or surgical "stent" that serves to obturate the surgical site
defect. While less than ideal, the obturator provides adequate support of the soft
tissues, and speech and swallowing are preserved. However, major aesthetic concerns
and functional limitations are apparent when the device is removed (Figures
Oral nasal communication post anterior maxillectomy without the obturator in place.
Maxillary stent/obturator for use post maxillectomy procedures for speech, swallowing and aesthetics correction.
These patients cannot perform normal speech, mastication, or swallowing functions
without the maxillary obturator in place. Also, lack of stability of the obturator,
even with an experienced maxillofacial prosthodontist, can be a clinical challenge
[
Recently with the increasing regional availability of free flap reconstruction, many
of these limitations are no longer significant, provided that the patient is a good
surgical candidate, and the surgical team is capable of performing the
reconstructive procedure [
A myriad of aesthetic and functional limitations have been described throughout the
years in the literature using these types of soft tissue flap reconstructions. It
should be noted that the majority of patients who undergo partial or total
maxillectomy or mandibulectomy procedures for tumour resection, or mandibulotomy for
surgical access, will require postoperative radiation which may further worsen soft
tissue scarring. The deleterious effects of radiation and the use of
chemotherapeutic agents on the skin and existing scars have been discussed in the
literature [
Additionally, many oral cancer patients have a significant social history of tobacco use and abuse due to its etiologic relationship with oral cancer, and therefore, the skin and other soft and hard tissue vascularity may be already severely compromised. This prior history, and possibly continued smoking by a majority of patients, may contribute not only to poor wound healing, but also to postoperative wound dehiscence, compromised flap viability, and resultant unaesthetic scarring.
Any procedure that involves entering the mucosa of the upper aerodigestive tract via a neck incision may lead to formation of a fistulous tract due to persistent salivary leakage into the neck wound. Fistulas occur often following oral oncologic surgeries, and depend to a great deal on the general physical and nutritional status of the patient, the incision design, and the tumour type and stage, all of which may lead to an increased risk of this problem. These fistulas are more difficult to manage and completely eradicate when radiation therapy (XRT) has been employed. The effects of radiation in delaying surgical wound closure or preventing healing are generally attributed to low oxygen tensions and vasculitis that promote infection, as well as endothelial fibrosis and decreased blood supply to the surgical site. The higher the dose of radiation, and the longer the interval between radiation treatment and surgery, the higher the rate of wound complications when XRT is used preoperatively. When XRT is employed posttumour resection, adequate time is required in order to prevent delayed healing, fistula formation, and wound dehiscence.
Salivary fistulas can occur as early as 1 week, to as late as 3 - 4 weeks,
postsurgery. Fistulas that are present at one month after surgery are considered
chronic, or persistent fistulas. Patients may present with a low grade fever of
unknown origin, and other vague complaints indicating chronic inflammation. Usually
the skin flap under the area of dependant drainage becomes inflamed and indurated.
The best treatment involves prevention; but, if a developing fistula is noted, then
surgical exploration of the wound with an attempt to direct saliva away from vital
structures, such as the carotid vessels, is clinically indicated. The wound should
be irrigated and packed open, and the patient should be prescribed empiric
antimicrobial therapy for oral and skin flora, supportive care, and
hyperalimentation, or, at the minimum, adequate nutritional support. If drainage is
persistent for more than 4 weeks, then excision of the fistulous tract with closure
of the oral mucosa and the skin should be attempted [
Loose or contaminated hardware from previous infections and or wound breakdown may be
another reason for chronic fistulas (Figures
Chronic fistulas with drainage on the face and neck due to saliva leak and bacterial contamination of existing hardware.
Fractured displaced plate of the right mandible with draining fistula.
Osteotomies of the mandible used for access purposes or mandibular resection require
utilization of plates and screws to span continuity defects, stabilize bone
segments, or secure bone flaps. The complex bony anatomy and muscle attachments
require careful planning for hardware placement. Failure to adhere to basic
reconstruction principles, fatigue of the metal due to over-manipulation during
contouring and adaptation, extensive defects and unbalanced masticatory force
distribution may all lead to hardware failure. Usual problems with hardware include
fracture of the reconstruction plates, or loosening of the screws with mobility of
the mandibular segments (
Hardware exposure may occur even without fracture or mobility if the overlying tissue
is of inadequate thickness due to the resection, or scarring due to the effects of
radiation (
Exposed reconstruction plate due to contraction and scarring of the soft tissues.
In the cases of fractured, or loose and infected plates and screws with cutaneous
fistulas, removal of the existing hardware is usually required. Early intervention
is preferred, but the majority of the patients requiring bone resection receive
adjuvant radiation therapy. Radiation therapy causes severe scarring of the soft
tissues and compromises healing ability. Preoperative preparation with hyperbaric
oxygen treatments may be indicated to improve the healing abilities of the soft
tissue envelope prior to removal and replacement of hardware [
The ultimate goal once disease is controlled and the patient is cancer-free is
appropriate prosthetic and functional rehabilitation. Reestablishment of a
functional maxillomandibular complex that provides an adequate dentition for
mastication, adequate underlying bony support for the facial features, and adequate
soft tissue for restoration of speech and swallowing represent the desired endpoint,
and there are many potential options for reconstruction (
Potential reconstruction options
1. Simple closure |
a) Skin grafts |
b) Allogenic material |
c) Primary closure |
d) Healing by secondary intention |
e) Prosthetic devises |
2. Local flaps |
a) Tongue flaps |
b) Buccal mucosa advancement flap |
c) Buccal fat pad |
d) Palatal flap |
3. Regional flaps |
a) Temporalis myocuteneous flap |
b) Deltopectoral muscle flap |
c) Latissimus muscle flap |
d) Nasolabial flap |
4. Free Flaps |
a) Soft tissue free flaps |
i) Radial forearm free flap |
ii) Anterolateral thigh free flap |
iii) Rectus abdominus free flap |
iv) Latissimus free flap |
b) Hard tissue free flaps |
i) Fibula free flap (osseous or composite) |
ii) Deep circumflex iliac artery free flap |
iii) Scapula free flap |
iv) Radial composite free flap |
Donor site scarring post pectoralis major myocutaneous flap harvest.
Local and regional flaps, and free tissue transfer, employed for reconstruction of surgical defects inherently create an additional defect at the donor site. Even with the most carefully planned incisions, these defects may lead to unaesthetic scars, contraction, and tissue deficits at the donor site.
The tongue, buccal mucosa, and buccal fat pad are local tissues frequently used to address small defects in the oral cavity. Usual limitations from use of these sites are functional due to scarring and postsurgical tissue contraction.
For larger defects, regional tissue such as the delto-pectoral, temporalis and
latissimus myocutaneous flaps are used. These tissues have served well over the
years, but the defect at the donor site remains a testament to the procedure
performed [
Quality of life issues for the oral cancer patient are addressed in detail in other
chapters of this text, but for completeness, the influence of surgical intervention
on quality of life is briefly discussed here. Quality of life is a critical outcome
measure in head and neck cancer management, mainly due to the inability to improve
survival, especially in cases of advanced disease. Unlike other malignancies, oral
cancer treatment has not drastically changed over the last 30 years. Except for
modifications in the types and extent of neck dissections, surgery remains, for the
most part, the treatment modality most commonly offered, with addition of radiation
and chemotherapy when indicated. The focus on patient care has shifted towards
preservation of form and function with the careful selection of appropriate
reconstruction techniques [
Chronic pain, difficulty with chewing, swallowing, and speech influences function and
adversely impacts on the quality of life. In general, studies have demonstrated that
improved function post resection is achieved with utilization of free tissue
composite flaps that correct bone continuity defects and can support dental implants
as well as a future prosthesis. Furthermore, free tissue transfer for reconstruction
of tongue defects, and avoidance of primary closure typically improves tongue
mobility. These reconstruction options improve patients' ability to chew and
swallow their food appropriately, and to articulate and speak fluently. Both patient
subjective perception of improved quality of life, and objectively measured
improvement, has been demonstrated in multiple studies in the head and neck cancer
literature [
We have provided a comprehensive review of the potential commonly encountered long-term complications faced when treating oral cancer. As it has been demonstrated above and in Part I of this review series, the oncology team and the cancer patient can be faced with various serious long-term problems. It is emphasized here again that cancer resection should be planned around two very important concepts.
1. First and foremost been eradication of the disease. This should be the ultimate goal of the ablative team and all potential complications that may be the result of appropriately executed oncologic resection should be discussed in details with the patient.
2. Adequate reconstruction of the defects with restoration of form and function is the second, but not of less importance, goal for the successful care of the head and neck cancer patient. The key in providing the best results are detailed understanding of the complexity of the tissues and functions of the oral cavity and maxillofacial skeleton. This requires close collaboration between the ablative and reconstructive team with input from the radiation oncology team and dental rehabilitation team.
3. The patients' comormidities, limitations, preoperative functional status and expectations as well as the treating teams' abilities and limitations ought to be seriously considered for long-term success.
The author reports no conflicts of interest related to this study.