Health-related quality of life after maxillectomy: obturator rehabilitation compared with flap reconstruction

Abstract

Health-related quality of life (QoL) reported by patients has the potential to improve care after ablative surgery of the midface, as existing treatment algorithms still generally revolve around outcomes assessed traditionally only by clinicians. Decisions in particular relate to reconstruction with a flap compared with rehabilitation with an obturator, the need for adjuvant treatment, and morbidity related to the size of the defect. We prospectively collected health-related QoL assessments for 39 consecutive patients treated by maxillectomy between 01 January 2010 and 31 December 2014 using the University of Washington Quality of Life Questionnaire, and who had a mean (SD) duration of follow-up of 14 (4). We made sub-group analyses using paired t tests and analysis of variance (ANOVA) to compare reconstruction with a flap with rehabilitation with obturators, size of the vertical defect, and whether adjuvant treatment with radiotherapy or chemoradiotherapy adversely affected it. Overall there was a significant decrease in health-related QoL after treatment compared with before (p < 0.001), but there was no significant difference in the effects of any of the paired reconstructive and rehabilitation treatments on it. Obturators remain an important option for rehabilitation in selected patients in addition to reconstruction with a flap. We found that neither increasing the size of the vertical defect (in an attempt to ensure clear margins) nor the use of postoperative radiotherapy seemed to have any adverse effect on QoL. More patients are required before we can conclude that the potential survival benefits of such measures may outweigh any adverse effects.

Introduction

The reconstruction and rehabilitation of patients after ablative surgery of the maxilla and midface remains one of the greatest challenges currently faced by head and neck surgeons. Ablative surgery affects physical function, particularly speech, chewing, and swallowing. 1, 2 Treatment of the maxillectomy defect should aim to minimise the facial deformity, restore oral function, and preserve psychological wellbeing. 2, 3 The most common options are rehabilitation with a prosthetic obturator, or reconstruction with a flap. Each option has its advantages and disadvantages, and there is a need to tailor treatment to patients individually.

Obturator rehabilitation remains the most common option worldwide, and acceptance has been greatly improved through retention provided by implants.4, 5 Provision of an obturator is a quick surgical option, with low cost, low morbidity, and the possibility of modification according to the patients’ needs, and it can supply missing teeth and support soft tissues.² Success is related in part to the extent of resection of the soft and hard palate, ³ with larger obturators causing more problems with appearance, pain, and soreness in the mouth than reconstruction with a flap.¹ Retention and stability of an obturator in particular can vary among patients, and have the greatest impact on function and overall acceptability.²

Reconstruction with a flap can potentially overcome the problems associated with prosthetic obturators, particularly nasal leakage and the need to clean and repeatedly refine the prosthesis.¹ Various flaps have been advocated, most commonly the temporalis flap; the osteocutaneous scapular, iliac crest, and fibular flaps; and the fasciocutaneous radial forearm and anterolateral thigh flaps. 4, 5 This potentially overwhelming choice can be aided by classifying the defect into its horizontal and vertical components.4, 5 There is, however, an appreciable potential morbidity for patients in undertaking free flaps in terms of both the donor site, the potential for failure, and the increased anaesthetic time and duration of hospital stay.

Making the choice between rehabilitation with a flap or an obturator is still not clear cut, and authors have suggested that it is the surgeon who makes the final decision.⁴ The choice varies depending on the size and shape of the defect, the extent of disease, the requirement for postoperative radiotherapy, and the patient's preference.⁶ Comparisons in outcome between flap and obturator after maxillectomy have traditionally focused on measures such as intelligibility of speech and postoperative diet.⁷ Although the psychological effects and quality of life (QoL) are recognised, much less has been done to quantify this outcome.⁴

Health-related QoL has become one of the primary determinants of outcome after treatment in head and neck cancer. Unlike the more traditional measures of survival, locoregional disease control and function, QoL is assessed by the patient independently of the clinician.⁸ A number of papers have looked at it after maxillectomy, 1, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 with a generally agreed reduction in overall scores in nearly all patients.¹⁶ In patients who have had a maxillectomy it is influenced by type and stage of tumour, skin loss, extent of resection, postoperative radiotherapy, number and condition of remaining maxillary teeth, and sociodemographic variables.2, 3, 6, 9, 10, 11, 12, 13 Many different questionnaires have been proposed for ascertaining health-related QoL after maxillectomy,3, 8, 9, 10, 13, 14, 15, 17, 18, 19 with the most common being the University of Washington Quality of Life (UoW-QoL).2, 8, 11, 15 Although the Obturator Functioning Scale has been well validated in terms of how well an obturator is tolerated by a patient, 3, 10 such a tool does not enable comparisons with outcomes after reconstruction. In addition, most of these assessments were either retrospective, 2, 3, 8, 9, 10, 11, 15, 17, 18, 19 or were not measured preoperatively. 3, 9, 10, 13, 14, 17, 18 We know of only a single paper to date that has directly compared QoL after maxillectomy between obturators and flaps.¹ In addition, the effects of size of defect and the use of postoperative radiotherapy in both groups are not clear.

The aim of this study was to ascertain the effects of differing treatments on QoL in patients after maxillectomy using a standard questionnaire measured both before and after treatment.