Availability of Primary Closure for Resection of Oral Cavity Cancer
Round 1
Reviewer 1 Report
Thank you for the opportunity to review this manuscript. They are usually well written and organized.
However, authors must improve their manuscripts for publication.
1) The comparison group appears to be wrong. It would be better if the study was conducted with only stage 1 or 2 patients who could be performed primary closure or flap reconstruction.
- In addition, comparing QOL (pronunciation, chewing, aesthetic satisfaction, recurrence) of these patients will be helpful in choosing a treatment method.
2) Appropriate reference should be cited on line 203.
3) Lines 225~238 do not seem to have much relation to the contents of the study. should be deleted or supplemented.
Minor editing of English language required
Author Response
We would like to express our gratitude to Reviewer 1 for the constructive comments and valuable suggestions that have led us to improve our work significantly. Please see below for the specifics in response to the reviewer’s comments.
Comment 1-1)
The comparison group appears to be wrong. It would be better if the study was conducted with only stage 1 or 2 patients who could be performed primary closure or flap reconstruction.
Response 1-1)
We think your advice is valid. Therefore, a new statistical verification was performed targeting only patients in stage 1 and 2, and the results were added to result 3-3.
3.3. Factors Associated with Primary Closure in stage I, II patients
Among the 85 patients, a total of 44 patients had stages I and II. For these patients, the case of flap reconstruction and the case of primary closure were compared and analyzed. Mann-Whitney test and chi-square test were analyzed, and the results showed a statistically significant difference in the operation time and hospitalization period. Tables 6 and 7 show the results of 3-way ANOVA for operation time and Period of hospitalization, respectively. Interactions were verified for the presence or absence of neck dissection, reconstruction method (flap or primary closure), and stage. For each result, only the reconstruction method had a statistically significant effect on the operation time and hospitalization period.
Table 5. Clinical characteristics of stage I,II Patients – primary closure VS flap
|
Clinical characteristic |
Primary closure |
flap |
P value |
|
Gender(%) |
|
|
P=0.265 |
|
Male |
5() |
15 |
|
|
Female |
11() |
13 |
|
|
Neck dissection |
|
|
P=0.489 |
|
Surgery with SND |
8 |
20 |
|
|
Surgery with mRND |
1 |
0 |
|
|
Surgery without neck dissection |
7 |
8 |
|
|
Stage |
|
|
P=0.052 |
|
I |
13 |
13 |
|
|
II |
3 |
15 |
|
|
Operation time (hr) |
4.02 |
8.13 |
P=0.00006* |
|
Lesion site |
|
|
P= 0.076 |
|
Upper gingiva |
2 |
4 |
|
|
Lower gingiva |
3 |
8 |
|
|
Tongue |
5 |
5 |
|
|
Buccal mucosa |
1 |
4 |
|
|
Floor of the mouth |
2 |
3 |
|
|
Palate |
3 |
4 |
|
|
Period of hospitalization |
13.4 |
22.3 |
P=0.001* |
Table 6. 3-way ANOVA of Table5; dependant variable: operation time
|
|
Df |
Sum Sq |
Mean Sq |
F value |
Pr(>F) |
|
Neck Dissection |
1 |
87.21 |
87.21 |
1.2704 |
0.267153 |
|
Reconstruction Method |
1 |
741.7 |
741.7 |
10.8039 |
0.002266** |
|
Stage |
1 |
13.92 |
13.92 |
0.2027 |
0.655215 |
|
ND*Recon |
1 |
10.34 |
10.34 |
0.1506 |
0.700227 |
|
ND*Stage |
1 |
4.89 |
4.89 |
0.0712 |
0.791087 |
|
Recon*Stage |
1 |
0.09 |
0.09 |
0.0013 |
0.971476 |
|
ND*Recon*Stage |
1 |
0.03 |
0.03 |
0.0004 |
0.984249 |
Table 7. 3-way ANOVA of Table6; dependant variable: Period of hospitalization
|
|
Df |
Sum Sq |
Mean Sq |
F value |
Pr(>F) |
|
Neck Dissection |
1 |
472644184 |
472644184 |
3.6333 |
0.0646435 |
|
Reconstruction Method |
1 |
2331294720 |
2331294720 |
17.921 |
0.0001518*** |
|
Stage |
1 |
110204244 |
110204244 |
0.8472 |
0.3634855 |
|
ND*Recon |
1 |
103550227 |
103550227 |
0.796 |
0.3782159 |
|
ND*Stage |
1 |
7604504 |
7604504 |
0.0585 |
0.8103238 |
|
Recon*Stage |
1 |
29660224 |
29660224 |
0.228 |
0.6358957 |
|
ND*Recon*Stage |
1 |
2208208 |
2208208 |
0.017 |
0.8970644 |
Comment 1-2)
In addition, comparing QOL (pronunciation, chewing, aesthetic satisfaction, recurrence) of these patients will be helpful in choosing a treatment method.
Response 1-2)
We sympathize with your opinion and regret that there was no QOL-related questionnaire as this study was a retrospective study. Considering that the lack of QOL-related assessment is a limitation of this study, the following phrase was added.
A limitation of this study is that QOL such as pronunciation, chewing, and aesthetic satisfaction were not evaluated. This is because it is a retrospective study using only recorded data, and no records were available for that part. However, it was possible to infer the evaluation of QOL to some extent through the follow-up records of each patient, the time taken to return to daily life after surgery, and the rate of recurrence. Although the proportion of recurrent patients was slightly lower in patients with primary closure, statistical significance was not found.
Comment 2)
Appropriate reference should be cited on line 203.
Response 2)
We apologize for the confusion caused by the incorrect positioning of the comments. Corrected
Comment 3)
Lines 225~238 do not seem to have much relation to the contents of the study. should be deleted or supplemented.
Response 3)
We acknowledge that the paragraph lacks relevance. deleted
We really appreciated the constructive comments and valuable suggestions again.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
The article is well written. The results written in the abstract should be written more clearly.
Minor editing of English language required.
Author Response
We would like to express our gratitude to Reviewer 2 for the constructive comments and valuable suggestions that have led us to improve our work significantly. Please see below for the specifics in response to the reviewer’s comments.
Following your advice, we modified the Abstract
Added
As a result of 3-way ANOVA analysis on operation time and hospital stay, only neck incision, reconstruction method (flap or primary suture), and intrastage reconstruction method had a statistically significant effect on operation time and period of hospitality.
Deleted
Therefore, oral and maxillofacial surgeons should carefully consider various evaluation criteria and select appropriate reconstruction methods to optimize functional and aesthetic outcomes for each patient.
Before
Resection of malignant lesions in the oral and maxillofacial area causes functional and morphological defects. To recover from these defects, reconstruction surgery is needed such as a primary closure or a flap. There are advantages and disadvantages to the method of using the primary closure and the flap, and the choice of procedure is entirely up to a surgeon. The purpose of this study is to evaluate availability of primary closure in patients. For 10 years from January 2010 to May 2020, patients who recovered using flaps after removing malignant lesions from the oral cavity and those who closed the lesion using primary closure were investigated. The investigation was conducted by searching the database of the hospital. There were 85 patients who removed malignant lesions in the oral and maxillofacial area, and among them 16 patients closed the soft tissue defects using primary closure. Operation time, histologic types, stages, wound status, and period of hospitalization according to the patients' medical records were investigated retrospectively. Between the staging and the primary closure, statistically significant differences were observed between stage I and stage II patients in 13 patients using the primary closure. (P=0.046). Statistically significant differences were identified between operation time and primary closure, with an average of 4.02 hours (P=0.015). The average period of hospitality for patients who underwent primary closure was 13.4 days, compared to 26.7 days for those who underwent flap surgery. This difference was statistically significant (P=0.0003). This study evaluated the use of primary closure in patients who underwent resection of malignant lesions in the oral and maxillofacial area. Although the majority of patients underwent reconstruction with flaps, our results showed that primary closure can be a viable option for certain patients with early-stage lesions. Therefore, oral and maxillofacial surgeons should carefully consider various evaluation criteria and select appropriate reconstruction methods to optimize functional and aesthetic outcomes for each patient.
After
Resection of malignant lesions in the oral and maxillofacial area causes functional and morphological defects. To recover from these defects, reconstruction surgery is needed such as a primary closure or a flap. There are advantages and disadvantages to the method of using the primary closure and the flap, and the choice of procedure is entirely up to a surgeon. The purpose of this study is to evaluate availability of primary closure in patients. For 10 years from January 2010 to May 2020, patients who recovered using flaps after removing malignant lesions from the oral cavity and those who closed the lesion using primary closure were investigated. The investigation was conducted by searching the database of the hospital. There were 85 patients who removed malignant lesions in the oral and maxillofacial area, and among them 16 patients closed the soft tissue defects using primary closure. Operation time, histologic types, stages, wound status, and period of hospitalization according to the patients' medical records were investigated retrospectively. Between the staging and the primary closure, statistically significant differences were observed between stage I and stage II patients in 13 patients using the primary closure. (P=0.046). Statistically significant differences were identified between operation time and primary closure, with an average of 4.02 hours (P=0.015). The average period of hospitality for patients who underwent primary closure was 13.4 days, compared to 26.7 days for those who underwent flap surgery. This difference was statistically significant (P=0.0003). As a result of 3-way ANOVA analysis on operation time and hospital stay, only neck incision, reconstruction method (flap or primary suture), and intrastage reconstruction method had a statistically significant effect on operation time and period of hospitality. This study evaluated the use of primary closure in patients who underwent resection of malignant lesions in the oral and maxillofacial area. Although the majority of patients underwent reconstruction with flaps, our results showed that primary closure can be a viable option for certain patients with early-stage lesions.
We really appreciated the constructive comments and valuable suggestions again.
Author Response File: Author Response.pdf
Reviewer 3 Report
The paper entitled “Availability of primary closure for resection of oral cavity cancer” is a contribute that aims to evaluate the use of primary closure in patients who underwent resection of malignant lesions in the oral and maxillofacial area. The work did not provides relevant original data but it could be considered anyway of interest for the readers. However before it could be considered valid for publication requires some corrections.
INTRODUCTION
Overall well structured, it provides all the information necessary to understand the scientific background, the knowledge gap and the objectives of the study.
MATERIAL AND METHODS
The scientific methodology used were described in a clear and exhaustive manner. There is no iconography related to the methodology used in the research. A summary table of the data of the patients selected in the study must be inserted in the materials and methods section, reporting age, gender, site of the tumor, type of lesion, etc.
has a comparative assessment been made of the time required for full functional recovery in the two groups of patients?
the clinical data derived from this retrospective study do not appear to have been analysed adequately from a statistical point of view. Inferential statistic with ANOVA analysis should be performed. The power analysis would demonstrate whether the sample size is sufficient to obtain statistically significant results. Describe the statistical methodology used and report the data obtained in the results of the work.
RESULTS
The results are described in a precise and detailed manner; graphical representation is well executed and allows a faster understanding of the results achieved in the study. Statistical analysis results are missing.
How many recurrence have been in the group treated with flap surgery?
DISCUSSION
The discussion of the results is on the whole well articulated ; clinical relevance of the results should be emphasized more.
there are specific indications for flap surgery or primary closure depending on factors such as the site and/or size of the tumour?
CONCLUSION
Conclusions are limited to a synthetic summary of the results obtained; this section must be revised . Conclusion section should be oragnized preferably with a bulleted list, reporting only the key results of the study.
Author Response
We would like to express our gratitude to Reviewer 3 for the constructive comments and valuable suggestions that have led us to improve our work significantly. Please see below for the specifics in response to the reviewer’s comments.
MATERIAL AND METHODS
The scientific methodology used were described in a clear and exhaustive manner. There is no iconography related to the methodology used in the research.
We have added a treatment flow-chart as Figure 1 for quick understanding of the reader.
Figure 1 schematically shows the treatment flow described above.
|
|
Figure 1. Treatment Flow-chart
A summary table of the data of the patients selected in the study must be inserted in the materials and methods section, reporting age, gender, site of the tumor, type of lesion, etc.
Following your comments, we added the summay table as Table1.
Table 1. Clinical characteristics of 85 Patients
|
Clinical characteristic |
Value |
SD |
|
Age[years old, mean,(range)] |
64.7(15~87) |
14.8 |
|
Gender(%) |
|
|
|
Male |
43(50.6%) |
|
|
Female |
42(49.4%) |
|
|
Neck dissection(%) |
|
|
|
Surgery with SND |
53(62.4%) |
|
|
Surgery with mRND |
4(4.7%) |
|
|
Surgery without neck dissection |
28(32.9%) |
|
|
Stage(%) |
|
|
|
I |
26(30.6%) |
|
|
II |
18(21.2%) |
|
|
III |
17(20%) |
|
|
IV |
24(28.2%) |
|
|
Operation time (hr,range) |
7.15(1.1~18.45) |
4.1 |
|
Lesion site(%) |
|
|
|
Upper gingiva |
17(20%) |
|
|
Lower gingiva |
33(38.8%) |
|
|
Tongue |
13(15.3%) |
|
|
Buccal mucosa |
8(9.4%) |
|
|
Floor of the mouth |
7(8.2%) |
|
|
Palate |
7(8.2%) |
|
|
Biopsy result |
|
|
|
Squamous Cell Carcinoma |
60(70.6%) |
|
|
Mucoepidermoid Carcinoma |
6(7.1%) |
|
|
Adenoid Cystic Carcinoma |
3(3.5%) |
|
|
Verrucous Carcinoma |
5(5.9%) |
|
|
Melanoma |
3(3.5%) |
|
|
Others |
8(9.4%) |
|
|
Follow-up[month,mean(range)] |
33.9(2~110) |
18.2 |
|
Recurrance(%) |
19(22.4%) |
|
|
Period of hospitalization |
24.2(5~100) |
16.3 |
has a comparative assessment been made of the time required for full functional recovery in the two groups of patients?
We do not have data relating to the time taken for full functional recovery. However, since we had data related to postoperative hospital stay, we used those data for statistical analysis. In addition, the following was added to the Discussion.
A limitation of this study is that QOL such as pronunciation, chewing, and aesthetic satisfaction were not evaluated. This is because it is a retrospective study using only recorded data, and no records were available for that part. However, it was possible to infer the evaluation of QOL to some extent through the follow-up records of each patient, the time taken to return to daily life after surgery, and the rate of recurrence. Although the proportion of recurrent patients was slightly lower in patients with primary closure, statistical significance was not found. The average length of hospitalization for each patient was 13.4 days in patients who underwent primary closure and 26.7 days in patients who underwent flap surgery, showing an average difference of about 2 weeks, and the difference between the two was statistically significant. This indicates that the patient group who underwent primary closure had a faster recovery and easier return to daily life, and there were fewer factors such as postoperative side effects that prolonged the hospitalization period. Since the grades of the lesions in the two patient groups are not the same, a simple comparison between the two would be incorrect, but if both primary closure and flap reconstruction are possible for patients, primary closure may be a sufficient alternative.
the clinical data derived from this retrospective study do not appear to have been analysed adequately from a statistical point of view. Inferential statistic with ANOVA analysis should be performed. The power analysis would demonstrate whether the sample size is sufficient to obtain statistically significant results. Describe the statistical methodology used and report the data obtained in the results of the work.
RESULTS
The results are described in a precise and detailed manner; graphical representation is well executed and allows a faster understanding of the results achieved in the study. Statistical analysis results are missing.
Following your advice, we added ANOVA to all statistical analyses. The revised and added tables are as follows:
3.2. Factors Associated with Primary Closure (Table 2,3,4)
We investigated the associations between age, gender, stage, neck dissection, operation time, lesion site, and other factors to determine the patient factors associated with primary closure compared to patients with flap reconstruction. The average age of patients with primary closure was 65.25 years, with no statistically significant difference (P=0.779). Among primary closure patients, there were 11 women and 5 men, and there was no statistically significant difference between gender and primary closure (P=0.107). Of the 16 total patients, eight underwent surgery with selective neck dissection, one with modified neck dissection, and seven without neck dissection. No statistically significant difference was found between neck dissection and primary closure (P=0.307). Statistically significant differences were observed between staging and primary closure, with 13 stage I and three stage II patients using primary closure (P=0.046). Statistically significant differences were identified between operation time and primary closure, with an average of 4.02 hours (P=0.015). In patients with primary closure, the distribution of lesion sites was as follows: tongue (5), lower gingiva (3), palate (3), upper gingiva (2), floor of the mouth (2), and buccal mucosa (1); however, no significant difference was noted in primary closure by lesion site (P=0.120). The average period of hospitality for patients who underwent primary closure was 13.4 days, compared to 26.7 days for those who underwent flap surgery. This difference was statistically significant (P=0.0003).
Tables 3 and 4 show the results of 3-way ANOVA for operation time and Period of hospitalization, respectively. Interactions were verified for the presence or absence of neck dissection, reconstruction method (flap or primary closure), and stage. For each result, only the reconstruction method had a statistically significant effect on the operation time and hospitalization period.
Table 2. Clinical characteristics of Patients – primary closure VS flap
|
Clinical characteristic |
Primary closure |
flap |
P value |
|
Age[years old, mean,(range)] |
65.25(44~87) |
64.55(15~86) |
P=0.779 |
|
Gender(%) |
|
|
P=0.107 |
|
Male |
5(5.88) |
37(43.52) |
|
|
Female |
11(12.94) |
32(37.64) |
|
|
Neck dissection |
|
|
P=0.307 |
|
Surgery with SND |
8 |
45 |
|
|
Surgery with mRND |
1 |
3 |
|
|
Surgery without neck dissection |
7 |
21 |
|
|
Stage |
|
|
P=0.046* |
|
I |
13 |
13 |
|
|
II |
3 |
15 |
|
|
III |
0 |
17 |
|
|
IV |
0 |
24 |
|
|
Operation time (hr) |
4.02 |
8.81 |
P=0.015* |
|
Lesion site |
|
|
P= 0.120 |
|
Upper gingiva |
2 |
15 |
|
|
Lower gingiva |
3 |
30 |
|
|
Tongue |
5 |
8 |
|
|
Buccal mucosa |
1 |
7 |
|
|
Floor of the mouth |
2 |
5 |
|
|
Palate |
3 |
4 |
|
|
Follow-up[month,mean(range)] |
38.37(12~80) |
32.92(2~110) |
|
|
Period of hospitalization |
13.4(7~21) |
26.7(6~99) |
P=0.0003* |
Table 3. 3-way ANOVA of Table2; dependant variable: operation time
|
|
Df |
Sum Sq |
Mean Sq |
F value |
Pr(>F) |
|
Neck Dissection |
1 |
87.21 |
87.21 |
1.2704 |
0.267153 |
|
Reconstruction Method |
1 |
741.7 |
741.7 |
10.8039 |
0.002266** |
|
Stage |
1 |
13.92 |
13.92 |
0.2027 |
0.655215 |
|
ND*Recon |
1 |
10.34 |
10.34 |
0.1506 |
0.700227 |
|
ND*Stage |
1 |
4.89 |
4.89 |
0.0712 |
0.791087 |
|
Recon*Stage |
1 |
0.09 |
0.09 |
0.0013 |
0.971476 |
|
ND*Recon*Stage |
1 |
0.03 |
0.03 |
0.0004 |
0.984249 |
Table 4. 3-way ANOVA of Table2; dependant variable: Period of hospitalization
|
|
Df |
Sum Sq |
Mean Sq |
F value |
Pr(>F) |
|
Neck Dissection |
1 |
472644184 |
472644184 |
3.6333 |
0.0646435 |
|
Reconstruction Method |
1 |
2331294720 |
2331294720 |
17.921 |
0.0001518*** |
|
Stage |
1 |
110204244 |
110204244 |
0.8472 |
0.3634855 |
|
ND*Recon |
1 |
103550227 |
103550227 |
0.796 |
0.3782159 |
|
ND*Stage |
1 |
7604504 |
7604504 |
0.0585 |
0.8103238 |
|
Recon*Stage |
1 |
29660224 |
29660224 |
0.228 |
0.6358957 |
|
ND*Recon*Stage |
1 |
2208208 |
2208208 |
0.017 |
0.8970644 |
3.3. Factors Associated with Primary Closure in stage I, II patients
Among the 85 patients, a total of 44 patients had stages I and II. For these patients, the case of flap reconstruction and the case of primary closure were compared and analyzed. Mann-Whitney test and chi-square test were analyzed, and the results showed a statistically significant difference in the operation time and hospitalization period. Tables 6 and 7 show the results of 3-way ANOVA for operation time and Period of hospitalization, respectively. Interactions were verified for the presence or absence of neck dissection, reconstruction method (flap or primary closure), and stage. For each result, only the reconstruction method had a statistically significant effect on the operation time and hospitalization period.
Table 5. Clinical characteristics of stage I,II Patients – primary closure VS flap
|
Clinical characteristic |
Primary closure |
flap |
P value |
|
Gender(%) |
|
|
P=0.265 |
|
Male |
5() |
15 |
|
|
Female |
11() |
13 |
|
|
Neck dissection |
|
|
P=0.489 |
|
Surgery with SND |
8 |
20 |
|
|
Surgery with mRND |
1 |
0 |
|
|
Surgery without neck dissection |
7 |
8 |
|
|
Stage |
|
|
P=0.052 |
|
I |
13 |
13 |
|
|
II |
3 |
15 |
|
|
Operation time (hr) |
4.02 |
8.13 |
P=0.00006* |
|
Lesion site |
|
|
P= 0.076 |
|
Upper gingiva |
2 |
4 |
|
|
Lower gingiva |
3 |
8 |
|
|
Tongue |
5 |
5 |
|
|
Buccal mucosa |
1 |
4 |
|
|
Floor of the mouth |
2 |
3 |
|
|
Palate |
3 |
4 |
|
|
Period of hospitalization |
13.4 |
22.3 |
P=0.001* |
Table 6. 3-way ANOVA of Table5; dependant variable: operation time
|
|
Df |
Sum Sq |
Mean Sq |
F value |
Pr(>F) |
|
Neck Dissection |
1 |
87.21 |
87.21 |
1.2704 |
0.267153 |
|
Reconstruction Method |
1 |
741.7 |
741.7 |
10.8039 |
0.002266** |
|
Stage |
1 |
13.92 |
13.92 |
0.2027 |
0.655215 |
|
ND*Recon |
1 |
10.34 |
10.34 |
0.1506 |
0.700227 |
|
ND*Stage |
1 |
4.89 |
4.89 |
0.0712 |
0.791087 |
|
Recon*Stage |
1 |
0.09 |
0.09 |
0.0013 |
0.971476 |
|
ND*Recon*Stage |
1 |
0.03 |
0.03 |
0.0004 |
0.984249 |
Table 7. 3-way ANOVA of Table6; dependant variable: Period of hospitalization
|
|
Df |
Sum Sq |
Mean Sq |
F value |
Pr(>F) |
|
Neck Dissection |
1 |
472644184 |
472644184 |
3.6333 |
0.0646435 |
|
Reconstruction Method |
1 |
2331294720 |
2331294720 |
17.921 |
0.0001518*** |
|
Stage |
1 |
110204244 |
110204244 |
0.8472 |
0.3634855 |
|
ND*Recon |
1 |
103550227 |
103550227 |
0.796 |
0.3782159 |
|
ND*Stage |
1 |
7604504 |
7604504 |
0.0585 |
0.8103238 |
|
Recon*Stage |
1 |
29660224 |
29660224 |
0.228 |
0.6358957 |
|
ND*Recon*Stage |
1 |
2208208 |
2208208 |
0.017 |
0.8970644 |
How many recurrence have been in the group treated with flap surgery?
We added missing patient information including recurrence rates.
3.1. Patient Characteristics Analysis (Table 1)
From January 2010 to May 2020, a total of 85 patients with malignant lesions in the maxillofacial area underwent surgical removal. Among these 85 patients, 42 were male and 43 were female, with an average age of 64.57 years (range: 15 to 87 years). The most common stage was stage I, with 26 patients, followed by 24 stage IV patients, 18 stage II patients, and 17 stage III patients. Fifty-seven patients underwent malignant lesion removal with neck dissection, and 28 patients had the procedure without neck dissection. Among the 57 patients who underwent neck dissection, 53 had selective neck dissection, and 4 had modified radical neck dissection. The most common site of malignant lesions was the lower gingiva (33 cases), followed by the upper gingiva (17), tongue (13), buccal mucosa (8), floor of the mouth (7), and palate (7). In the biopsy results, squamous cell carcinoma was the most common. The average follow-up period was 33.9 months, and recurrence occurred in 19 patients during this period. The rate was 22.4%. The average length of hospitalization, which means the time taken to return to normal activities, was 24.2 days, and the standard deviation was 16.3 days.
DISCUSSION
The discussion of the results is on the whole well articulated ; clinical relevance of the results should be emphasized more.
there are specific indications for flap surgery or primary closure depending on factors such as the site and/or size of the tumour?
Based on your advice, we have modified the discussion part as follows.
4. Discussion
Malignant lesions in the oral and maxillofacial areas can lead to functional and aesthetic issues after surgical removal, such as impaired mastication and pronunciation.[7-9] To address these defects, various types of flaps are used for reconstruction, including free grafts, local flaps, remote flaps, and free flaps by microvascular anastomosis.[10,11] In this study, anterolateral thigh free flap, deep circumflex iliac artery flap, and radial forearm flap were used to recover the defects. Although flap reconstruction provides a basis for implants and restores continuity, it can result in problems like the loss of essential soft tissue for chewing function.[12] In particular, tongue reconstruction may lead to a decrease in normal tongue mobility.[13]
Using flaps to recover the functional defect on Oral and maxillofacial area, but in Fred MS McConnel's study comparing flaps and primary closure in patients with localized tongue removal of 30% and base 60%, the use of flaps did not show a significant difference in swallow efficiency.[14] In fact, it was confirmed that the swallowing efficiency was higher in the case of the patient who are primary closured than the patient with using the flap. Also, when comparing tongue movements to evaluate pronunciation function, there was no significant difference, but it was confirmed that the case with the primary closure scored higher than the case with the flap.[14] In the study of Martin Canis and Fred MS MnConnel, when lesions exceeding 30% to 40% were removed, flap restoration was beneficial for functional recovery, but when lesions within the range of 20 to 30% or less were removed, it was confirmed that the use of primary closure did not have a significant difference in functional recovery.[15-17] In addition, the loss of chewing function was confirmed in Giovanni Nicoletti's study that it occurred in extensive resection of the mouth or anterior region or retromolar trigone, and did not occur in any size of tongue resection.[18,19]
In this study, primary closure was performed in patients in the early stage, Stage I and II, and in the lesions of squamous cell carcinoma, mucoepidermoid carcinoma, and verrucous carcinoma. Statistically significant correlation was confirmed between stage and primary closure(P<0.05). This means that primary closure may be useful after removal of early stage (stage I or II) malignant lesions. The lesions are occurred on the tongue, gingiva and buccal mucosa can be closed with adjacent soft tissue. Figure 1 is a patient was followed-up after resection under the diagnosis of squamous cell carcinoma on the left lateral border of the tongue. Primary closure was performed with remained the tongue and mucosa of the floor of the mouth. Figure 2 is a patient who was followed-up after resection under the diagnosis of squamous cell carcinoma on left floor or mouth. Primary closure was performed with mucosa of floor of mouth and buccinator muscle flap.
Even when only patients with Stage I and II were compared, the operation time and hospitalization period were statistically significantly shorter in patients who underwent primary closure. In addition, the analysis of variance results showed that the reconstruction method had a statistically significant effect on the operation time and hospitalization period.
In the follow-up observation of 16 patients who had been treated the defect with the primary closure, the patients did not complain of discomfort, but at the initial follow-up of the outpatient clinic after discharge, 5 patients complained of a feeling of pulling at the operation site. Patients complaining of abnormal pronunciation in functional aspects were also observed. However, during follow-up, the discomfort disappeared, and it was confirmed that there was no particular discomfort in the final follow-up record. In the case of patients who was performed neck dissection, some patients complained of more discomfort in the neck dissection area than in the malignant lesion resection area, but it was confirmed that the discomfort was resolved later. However, this evaluation itself was difficult to obtain validity because the frequency of investigation was different for each patient, and there were differences between patients who received additional treatment and those who did not.
A limitation of this study is that QOL such as pronunciation, chewing, and aesthetic satisfaction were not evaluated. This is because it is a retrospective study using only recorded data, and no records were available for that part. However, it was possible to infer the evaluation of QOL to some extent through the follow-up records of each patient, the time taken to return to daily life after surgery, and the rate of recurrence. Although the proportion of recurrent patients was slightly lower in patients with primary closure, statistical significance was not found. The average length of hospitalization for each patient was 13.4 days in patients who underwent primary closure and 26.7 days in patients who underwent flap surgery, showing an average difference of about 2 weeks, and the difference between the two was statistically significant. This indicates that the patient group who underwent primary closure had a faster recovery and easier return to daily life, and there were fewer factors such as postoperative side effects that prolonged the hospitalization period. Since the grades of the lesions in the two patient groups are not the same, a simple comparison between the two would be incorrect, but if both primary closure and flap reconstruction are possible for patients, primary closure may be a sufficient alternative.
In patients with primary closure, recurrence was observed in two patients. In the case of one patient, who got the malignant lesion on the floor of mouth removed it but the recurrence of Lt. lymph node Level II was observed. For resecting recurred lesion, neck dissection was performed. In the other, the malignant lesion on the Rt. upper gingiva was removed, but the recurrence of the Rt. lymph node level II, III was observed, and a neck dissection was performed. In both cases, recurrence was in the lymph node area, and no recurrence was observed at the safety margin set by the surgeon. In patients who underwent primary closure, the safety margin area was clearly visible. Therefore, if a recurrence occurs in the margin area, it will be easier to detect than a patient reconstructed using a flap. This is considered to be easier to determine recurrence because the lesion removal site is less obscured by other flap structures.
It was confirmed that the use of primary closure was shorter in terms of operation time compared to the defect repair using flaps. Since the flap was not used, the evaluation of the primary lesion was easy, and the evaluation of recurrence was also smooth. Also most of the patients' discomfort was the feeling of pulling due to the primary closure after removal of the lesion, and it was confirmed that it disappeared during follow-up after stitch out.
Further studies are needed to evaluate to which lesions the primary closure is useful and further patient analysis is needed. In addition, data analysis on patients who have radiation therapy prior to or after surgical treatment will also be necessary.
CONCLUSION
Conclusions are limited to a synthetic summary of the results obtained; this section must be revised . Conclusion section should be oragnized preferably with a bulleted list, reporting only the key results of the study.
The conclusion section has been modified to concisely present only the results of this study.
5. Conclusions
Performing primary closure after resection the malignant lesions in the oral cavity can reduce the surgical time and hospitalization period. In particular, it can be a useful treatment option for patients with Stage I and II.
We really appreciated the constructive comments and valuable suggestions again.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
It looks much better than before.
Minor editing of English language required
