Microsurgical free-tissue transfer has recently been used in the head and neck region. Pedicle flap reconstruction, however, may be safer and more useful than free tissue transfer in patients with problems, including systemic complications and graft bed vascularization. In this study, we evaluated the usefulness of pedicle flap reconstruction using a pectoralis major musculocutaneous (PMMC) flap, deltopectoral (D-P) flap or cervical island skin (CIS) flap following resection of oral cancer. Tissue defects after resection of oral cancer were reconstructed with a pedicle flap in 45 patients, including the PMMC flap in 25 patients, D-P flap in 9 patients, and CIS flap in 13 patients. Of the 45 patients, 2 patients underwent reconstructive surgery requiring 2 flaps each, the PMMC flap and D-P flap.
The flap survival rate was 96% for the PMMC flap, and 100% for the other flaps. Among patients for whom data were available, the operation times required for reconstruction with the PMMC flap (n = 11) and D-P flap (n = 6) were 3.1 ± 0.7 hours and 2.6 ± 1.1 hours, respectively. The harvesting time for the CIS flap was about 20 to 30 minutes. The most common postoperative complication was fistula formation due to suture failure, which was cured by irrigation in every patient.
Use of a pedicle flap is considered to be one of the useful options for reconstruction after resection of oral cancer.

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A radial forearm flap is thin and flexible, and has a long vascular pedicle. Therefore, this flap is suitable for reconstructing soft tissue defects in the head and neck region. From 1987 to September 2011, we carried out 401 free flap transfers in 395 patients for reconstruction of ablative defects of the head and neck. The free radical forearm flap was most commonly used (193), followed by the rectus abdominis (155), scapular flap (42), fibula flap (8), anterolateral thigh flap (2), and latissimus dorsi flap (1). The free radical forearm flap could be useful for reconstructing various kinds of defects including almost half of the tongue, floor of the mouth, buccal mucosa, and oropharynx. The overall success rate of this flap was 99% (191/193). The overall rate of complication of the recipient site was 20.1% (39/193), and that of the donor site was 13.9% (27/193).
This review presents our surgical procedures in flap elevation, venous anastomosis, and donor site coverage, and indications and inventions in reconstruction using this flap. The future problems of this flap in clinical applications are also discussed.

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Resection of oral cancers often results in impairing both oral functions and facial esthetics due to large defects. It is important to reconstruct not only resurfacing skin but also achieve a satisfactory functional and cosmetic outcome. We introduce the anterolateral thigh (ALT) flaps as a reconstructive option for head and neck defects after oncologic surgery. The ALT flap could provide thin tissue to fill large oral defects with suitable pliability. Donor site morbidity is minimal and direct closure of thigh defects could be primarily achieved. A preoperative assessment of perforators has to be performed with several devices because of their variable vascular anatomy. It is helpful to perform color Doppler ultrasonography and 3D CT to preoperatively assess the perforating vessels for the ALT flap. Color Doppler ultrasonography could identify the different velocities and directions of blood flow in vessels and map the blood vessels. 3D CT could be applied in order to understand the variety of anatomy. The elevated ALT could be an adequate candidate as a reconstructive option for oral defects to improve patients' quality of life.

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One hundred and forty-seven patients who underwent oral and maxillofacial reconstruction using rectus abdominis musculocutaneous (RAM) flaps between 1995-2012 were available for this study. Reconstruction sites were subdivided into the effects on the mandible (N = 39), maxilla (N = 33), tongue (N = 35), floor of mouth (N = 19), buccal mucosa (N = 16), soft palate (N = 5). The overall free flap success rate was 98% (144/147). Four patients with abdominal hernias were observed in the donor site, but no operative procedure was performed.The RAM flap is a reliable reconstruction choice for oral and maxillofacial defects, and is useful for reconstruction of large defects. For example, mandibular continuity was restored by a metal plate and the muscle bulk fills the defect between the metal plate and the mandible, while the small defect cases need to reduce the size of harvested subcutaneous fat and rectus abdominal muscle. The possibilities of a suitable harvested volume can provide many modifications for the RAM flap for various reconstruction sites.

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In this paper, a lattissimus dorsi musculocutaneous flap is treated as one of the various flaps vascularized with the thoracodorsal vessels. Variations and characteristics of the flap, its applications in reconstruction of the oral cavity following resection of head and neck cancers, technical points and problems in operative procedures of harvesting the flap, and complications including a donor site and solutions to them are discussed, demonstrating some of the reconstructive cases using a lattissimus dorsi musculocutaneous flap.

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Results of a preliminary study, in which the University of Washington Quality of Life Scale (UW-QOL) was used for 26 patients who had undergone immediate reconstruction with free flap against oral cancer, were evaluated and showed 4 important domains for better QOL; swallowing, speech, shoulder, and taste. Additionally, a more focused study on the shoulder domain among 41 patients showed that resection of the sternocleidomastoid muscle (SCM) is a negative factor. Based on the results of these 2 studies, we performed SCM dynamic reconstructive surgery on 6 patients whose SCM was resected through neck dissection.
For the graft we used the free rectus abdominis musculocutaneous flap. The primary sites of the patient were the tongue (5 patients) and buccal mucosa (1 patient), and all patients underwent postoperative radiotherapy. The muscular flap was fixed with both stumps of the SCM with enough longitudinal tension, and one costal nerve selected through confirmation of the muscle excursion with the nerve stimulator was anastomosed to the stump of the accessory nerve. Regrettably, the results for the shoulder domain in UW-QOL for these 6 cases have not improved after 6 months postoperatively. We consider the causes to be that the muscle graft did not work enough or that the SCM itself is not a truly important factor for shoulder functions.

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We report a case of maxillary gingival metastasis from lung cancer, the first symptom of which occurred in an oral cavity.
The patient was an 80-year-old man. On his initial visit, a soft elastic mass, with an 18mm diameter, was on his right maxillary gingiva. A biopsy revealed the lesion was a large cell carcinoma. Since the large cell carcinoma is less likely to firstly occur in the gingiva, we inspected the whole body of the patient. As a result, tumors were found in the upper left lung, stomach and brain. The metastatic gingival tumor increased rapidly after the biopsy. We conducted concurrent chemoradiotherapy using S-1 with a total dose of 38.4Gy irradiation to the oral and brain lesion. This treatment reduced the maxillary gingival tumor. He died from a stroke; however, due to reduction of the gingival tumor, he could continue to have oral nutrition until immediately before his death.
It was suggested that we should consider palliative chemoradiotherapy for a maxillary gingival metastasis, even if it was impossible to cure the patient to maintain his Quality of Life.

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T1/T2 exophytic tongue cancer is supposed to be in the favorable prognosis group and has a relatively high 5-year recurrence-free survival rate. Here we reported a case of Stage I exophytic tongue cancer that metastasized to the cervical lymph nodes and the liver within a short period after removal of the primary tumor. The patient was a 79-year-old male who visited our hospital with a chief complaint of a pain in the left side of the tongue. An exophytic mass, 19 × 19 × 7mm in size, was found on the posterior left lateral border of the tongue. The mass was excised by a partial glossectomy with clinical diagnosis of Stage I tongue cancer. Histopathological diagnosis was squamous cell carcinoma of WHO Grade 2 and YK classification 4C. Three months after the removal of the primary tumor, a modified radical neck dissection was conducted due to a late metastasis in the neck lymph node. Five months later, the patient had recurrence in the neck and liver metastases. Thirteen months after his first examination, he died. In relation to the occurrence of lymph node and distant metastases of this exophytic tongue cancer, histopathological examination of the primary lesion showed that the tumor lesion was well-circumscribed without invasion into the deeper muscular layer but clusters of carcinoma cells had infiltrated into lymphatic vessels in the intra-tumor region. Immunohistochemistry further indicated malignant phenotypic indicators of this exophytic tongue cancer, characterized by down-regulation of E-cadherin and overexpression of p53 for carcinoma cells and accumulation of D2-40-positive lymphatic endothelial cells and αSMA/S100A4 double-positive myofibroblasts in the intra-tumor stroma. To improve prognostic diagnosis of early exophytic tongue cancer, it is of importance to establish histopathological indicators of malignancy.

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Carcinoma ex pleomorphic adenoma usually arises from an untreated benign pleomorphic adenoma known to be present for many years or from a benign pleomorphic adenoma that has had multiple recurrences over many years.
We report a case of carcinoma ex pleomorphic adenoma of the buccal region. A 60-year-old woman was referred to our hospital because of painless swelling in the right buccal region. Clinical examination showed an elastic hard, movable, painless mass measuring 60 × 50mm in the right buccal region. MR revealed a well-defined mass in the right buccal area of moderate intensity on T1-weighted images and moderate to high intensity on T2-weighted images. When the tumor was surgically removed via an intraoral approach, the parenchyma of the tumor was exposed. Histopathological examination of the specimen showed carcinoma ex pleomorphic adenoma, with the component of poorly differentiated adenocarcinoma, not otherwise specified. Postoperative adjuvant chemoradiotherapy was performed. There has been no sign of recurrence or metastasis for 2 years, 2 months postoperatively.

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The patient was a 92-year-old male, who had sequestrum-like hard tissue in the left lower second premolar removed in December 2010. After 1 month, the patient had severe spontaneous pain around the surgical wound, and showed osteonecrosis of 30mm in diameter. Based on the clinical diagnosis of malignant tumor of the mandible, a biopsy was performed. No malignant cells were found in the inflammatory granulated tissue in the biopsy specimen. We diagnosed osteomyelitis of the mandible, and the patient received infection control and pain management, but the osteonecrosis slowly increased in size.
Later, the necrosis progressed to the tongue, oral floor and buccal mucosa, and the left upper jugular lymph nodes swelled rapidly in May 2011, so a biopsy was performed again. Diffuse proliferation of Reed-Sternberg-like giant cells with varying degrees of inflammatory components such as small lymphocytes, plasma cells and histocytes accompanied by necrosis and angiocentric pattern were found on histopathological examinations. Immunohistochemically, these tumor cells were positive for CD20, CD30 and EBER on in situ hybridization. A definitive diagnosis of EBV positive diffuse large B-cell lymphoma in this elderly patient was made.
We decided that systemic chemotherapy was not suitable in view of his advanced age and past illness of chronic heart failure. We provided the best supportive care including pain control, however, the patient died in August 2011.

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