Background: Osteocutaneous microvascular free tissue transfer (OMFTT) is the gold standard in reconstruction of large bony defects of the head and neck, usually incurred due to oncologic or traumatic etiologies. Due to the relatively low incidence of procedures, loss to follow up from disease-related mortality, and varying donor sites for reconstruction, literature on swallow outcomes has been limited. Our objective was to describe the rate of total oral diet (PO) achievement in this patient population, and to identify possible pre-, intra-, and post-operative factors associated with achievement following OMFTT.
Methods: Retrospective review of consecutive patients undergoing OMFTT reconstruction of head and neck defects between 1/2010 to 3/2018 was conducted at two tertiary academic centers. Independent variables collected included sociodemographics, Head and Neck Charleson comorbidity index (HNCCI), treatment-related characteristics including surgical details and any adjuvant therapies, post-operative complications, and dental rehabilitation rendered. Time to achievement of total oral diet was analyzed and plotted using the competing risk method, where death was treated as a competing risk. A subdistribution hazard model was performed to include all individual significant variables into a single multivariable model for competing risk analysis. All analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC, USA).
Results: 260 patients underwent OMFTT during the study time period, 11 of which were excluded due to lack of follow up of at least 6 months or perioperative death. 68% of patients were male, with a median age of 60 years. Overall, 61.1% of patients achieved a total PO diet post-operatively. While increased hospital length of stay, high HNCCI, normal or low BMI, smoking, and history of prior radiation therapy were found significant on univariate analysis, multivariate analysis identified only concurrent need for glossectomy (p=0.0239), N2 disease (p=0.001), postoperative fistula formation(p=0.011), and preoperative G-tube use (p<0.001) to be independently significantly associated with inability to achieve total oral diet. Patients who underwent dental rehabilitation by means of denture prosthetic or dental implants (p=0.0063) were significantly more likely to achieve total oral diet postoperatively than those who did not.
Conclusion: While numerous risk factors were found associated with failure to achieve total PO diet on univariate analysis, multivariate analysis identified only composite resection requiring glossectomy, N2 disease, postoperative fistula formation, preoperative G-tube use, and lack of post-treatment dental rehabilitation to have independent associations. Further studies are warranted to increase our understanding of this patient population, including prospective studies on dental restoration and implementation of more objective measures of swallow function.