Squamous cell carcinoma of the oral mucosa after release of submucous fibrosis and bilateral small radial forearm flap reconstruction

Oral submucous fibrosis is a collagen disorder that affects the submucosal layer of the upper digestive tract. The major cause is the habit of betel quid chewing, which is common in central, southern, and southeast Asia. The progressive and irreversible course of disease results with trismus, dysphagia, xerostomia, and rhinolalia. The most serious complication of this disorder is the development of oral carcinoma, and the incidence in different series varies from 1.9 to 10 percent. A sufficient mouth opening can be achieved by complete release of fibrotic tissue, and coronoidectomy and temporal muscle myotomy when needed, and reconstruction of the resultant defect can be best achieved by microsurgical free-tissue transfer because of the discouraging results with skin grafting or local flaps. From April of 1997 to May of 2001, a total of 26 patients received reconstructive surgery with small radial forearm flaps after release of submucous fibrosis with or without temporalis muscle myotomy and coronoidectomy. All patients were men, with a mean age of 40.1 years (range, 18 to 62 years) and all had a history of betel nut chewing ranging from 8 to 40 years. The interincisal distance ranged from 5 to 29 mm, with a mean of 15 mm, before operation. After the release procedure, the interincisal distance increased to 40 mm (range, 35 to 50 mm). At a follow-up period of 3 to 48 months, the interincisal distance was a mean of 35 mm (range, 18 to 57 mm), with an average increase of 20 mm compared with the preoperative distance. During follow-up, three patients developed squamous cell carcinoma of the oral cavity 24 to 36 months after submucous fibrosis release. Two of them occurred in the release site and the other one occurred at the soft palate. Oral cancer occurred in three of 13 patients who had received release of submucous fibrosis and who were followed for longer than 2 years (range, 24 to 48 months), which means that 23 percent of these patients developed squamous cell carcinoma of the intraoral mucosa. High risk of cancer occurrence strongly indicates the importance of an earlier and more aggressive surgical approach toward submucous fibrosis, and long-term follow-up on a regular basis. The purpose of an early and aggressive approach to submucous fibrosis is to provide a good quality of life to the patient by improving oral hygiene and oral intake quality and at the same time to obtain a sufficient mouth opening, which is mandatory for the inspection of the excision site and the remaining oral mucosa during follow-up.