(47) Resumption of Oral Feeding Following Reconstruction of Oral Cavity Defects Using the Submental Artery Island Perforator Flap (SAIPF)

Abstract: Purpose
Oral intake following major reconstructive surgery of the oral cavity can vary based on several factors: defect size, subsite location, patient comorbidities, surgeon preference, and others. To date, there does not exist a standardized algorithm for timing of oral feeding following oral cavity reconstructive procedures, however several sites, including UAB and Stanford, have shown that early oral feeding within 5 days following free flap reconstruction of the oral cavity is safe and did not result in increased surgical site complication (1, 2). Timing of oral feeding following the submental artery island perforator flap (SAIPF)for oral cavity reconstruction has not been well studied. An advantage of the SAIPF is that the submental artery and vein provide a reliable blood supply to the flap, making it a popular choice for reconstruction in the oral cavity, especially in cases where a thin skin paddle is needed to closely approximate the intraoral lining. The purpose of this study is to demonstrate that the SAIPF for oral cavity reconstruction is associated with acceptable functional outcome, and identify factors associated with delayed oral feeding postoperatively.

Patients and Methods
A retrospective study was designed and implemented after approval by the Institutional Review Board. The inclusion criteria included all patients who received a SAIPF following extirpative surgery of the oral cavity from 2014-2023. Exclusion criteria included patients who had a defect that was closed primarily or underwent a vascularized free flap for reconstruction. Demographic information along with surgical and pathology-related data (e.g., TNM staging, histopathologic features) were recorded. Patients were followed from the day of surgery to the most recent documented follow-up appointment in the outpatient clinic. Primary and secondary outcomes included timing to oral feeding postoperatively (days) and length of stay (LOS, days), respectively. Linear regression was used to determine predictor variables for the study outcomes. All statistical analyses were completed using SPSS software version 28 (SPSS Inc., Chicago, IL). For all tests, statistical significance was set at P values of < 0.05.

Results
A total of 54 patients met criteria for the study with an average age of 74 years, 59% being male, and an average follow-up of 23.72 months. The majority (92.6%) had malignant pathology that was more commonly located on the tongue (40.7%), followed by the mandibular gingiva (38.9%), floor of mouth (9.3%), buccal mucosa (7.4%), and lip/commissure (3.7%). Most had a unilateral neck dissection (87%) and 29.6% received a tracheostomy. Most tumors were stage pT1 (32%) or pT2 (46%). The flap survival rate was 96.3%. Half of the cohort (48.2%) resumed oral feeding greater than 7 days postoperatively with 42.6% being discharged on an oral diet, and 64.2% returning to a soft to regular consistency diet by the most recent follow-up appointment. The average LOS was 6.93 days. Both tumor stage (pT) and defect location were independent predictors for timing to oral feeding postoperatively (pT; 95% CI:1.216 – 8.520, P = 0.01, location; 95% CI:-4.400 – -0.617, P = 0.01). Increased LOS was correlated with the odds of needing feeding tube at the time of hospital discharge (95% CI:0.817 – 5.438, P < 0.01).

Conclusions
In older patients with oral cavity defects following extirpative surgery, the SAIPF offers an excellent reconstructive option with low morbidity and a relatively short hospitalization. While some patients may need tube feeding at the time of discharge, it is usually temporary, and most are able to regain an oral diet following dysphagia therapy and rehabilitation. Our study demonstrates increasing tumor stage (pT) and location of the floor of mouth and tongue are strong predictors for increased time to resume oral feeding following SAIPF of the oral cavity.

Table 1 - Demographics descriptive statistics

Table 2 - Pathological descriptive statistics

Table 3 - Clinical outcome descriptive statistics