Reconstruction Of Composite Mandibular Defects Research Articles

Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap beyond Mandibular Reconstruction.

Background The osteocutaneous radial forearm free flap (OCRFFF) for mandibular reconstruction has been well described. Despite this flap's utility in the repair of such defects, the indications for the OCRFFF have continued to expand in recent years. The advantages of the OCRFFF allow for a high degree of versatility in the reconstruction of the various anatomical and aesthetic units of the head and neck. In this review, the authors aim to explore the successful utilization of the OCRFFF beyond the reconstruction of composite mandibular defects. Methods A retrospective chart review was performed. All subjects who underwent OCRFFF reconstruction at a tertiary academic center between January 2004 and December 2014 were identified. A total of six patients undergoing this procedure for indications other than composite mandibular defects of the head and neck were included. Results A total of six patients underwent OCRFFF reconstruction for correction of nonmandibular defects. Flap success was experienced in six of six cases (100%). Indications included midface maxillary reconstruction (N = 2), orbit reconstruction (N = 1), frontal sinus and forehead reconstruction (N = 2), and subglottic stenosis reconstruction (N = 1). There were no immediate perioperative complications. On long-term follow-up, one subject developed a nasocutaneous fistula following radiation and eventually required maxillary hardware removal. Conclusion As a result of its growing role and versatility, the OCRFFF should be incorporated as a multipurpose tool in the armamentarium of reconstructive microvascular surgeons in the repair of composite head and neck defects beyond the mandible.

Modern Mandible Reconstruction Utilizing the Chimeric Fibula Free Flap and Double-Barreling Techniques

INTRODUCTION: The fibula osteocutaneous flap is now commonly used to reconstruct composite mandibular defects. Difficulties in flap execution are invariably related to the dynamic relationship of the bone orientation and the skin paddle inset. Traditional design has been limited to a single-strut bony design in order to restore mandibular continuity, without restoration of mandibular height and contour. Full chimeric design of the fibula allows for the routine use of a double barrel strut to optimize functional and aesthetic outcomes. The purpose of this study was to critically evaluate these techniques during reconstruction of composite mandibular defects. METHODS: A retrospective review was conducted of all patients who underwent mandible reconstruction by the senior author (CHL) from 2006–2013. All patients had a chimeric fibula design, with a full posterior crural septum release and division. Only patients who underwent composite mandible reconstruction utilizing a double-barrel technique were isolated. Patient demographics, surgical techniques, and outcomes were critically evaluated. RESULTS: Fifty-nine patients were identified during the study period. Average follow-up was 148 weeks. A double free flap was utilized in 27% of patients. The average number of fibula osteotomies was 1.9. The average length of each bone segment was 4.4cm. A double skin paddle was utilized in 7% of patients, with the remainder utilizing a single skin paddle. Early perfusion-related re-operation occurred in 10% of patients. No complete flap losses occurred (0%). Partial paddle skin loss occurred in 12% of patients. Three patients (5%) experienced complications related to the barreled bone segment requiring re-operation. Few subjective patient complaints were found and no cases of drooling were documented. Overall, revision surgery related to contouring and/or plate removal occurred in 34% of patients. CONCLUSION: Utilizing a full chimeric design of the fibula osteocutaneous flap allows for greater degrees of freedom for flap insetting options. The double barrel technique more closely matches the mandibular height. With similar complication rates as traditional methods, utilizing these modern techniques may result in improved functional and cosmetic outcomes.

Temporoparietal fascial flap for reconstruction of open wounds in patients previously treated for head and neck cancer

Wound-healing problems with subsequent plate exposure are frequent in patients who have undergone reconstructive surgery for head and neck cancer. Management of these wounds is difficult. The objective of this report is to present two head and neck cancer patients with chronic facial wounds and plate exposure after radiation therapy. A temporoparietal fascial flap was used to manage the wound in both cases. From January 2009 to January 2013, there were 37 patients with head and neck cancer who required reconstruction of composite mandibular defects in Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. Plate exposure developed in 10 patients, and in two patients the chronic facial wound was treated with a temporoparietal fascial flap. Both the flaps survived, and at 6 months of follow-up the wounds were healed with minimal donor site morbidity. Neither patient experienced alopecia or injury to the facial nerve. The temporoparietal fascial flap is thin, pliable, and well vascularized with a long pedicle, and provides resistant coverage to the recipient site from infection. The temporoparietal fascial flap may be an alternative choice for the reconstruction of head and neck open wounds.

Functional reconstruction of total lower lip defects using innervated gracilis flap in the setting of high-energy ballistic injury to the lower face: Preliminary report

Reconstruction of total full-thickness lower lip defects combined with extensive composite mandibular defects particularly in the setting of close-range high-energy ballistic injury presents a formidable challenge for the reconstructive plastic surgeon. While the fibular flap has been widely accepted for its usefulness in the reconstruction of composite mandibular defects, to date, there is no definitive widely established method of total lower lip reconstruction. The article presents authors' approach using innervated gracilis muscle flap for total lower lip reconstruction in the setting of high-energy gunshot injuries to the face. Three patients underwent composite mandibular defect reconstruction using fibular osteocutaneous flap and functional lower lip reconstruction using innervated gracilis muscle flap. Lip lining was reconstructed using the skin paddle of the fibular flap. The external surface of the gracilis muscle was skin-grafted. Facial artery myomucosal flap provided vermilion reconstruction in two patients. All fibular (n=3) and gracilis flap transfers (n=3) were viable. An electromyographic study at 1 year postoperatively demonstrated successful re-innervation of the gracilis muscle. Starting at about 10 weeks postoperatively, patients exhibited voluntary lip movements and oral competence. In addition, all patients achieved near-normal speech, evidence of recovered protective sensitivity and satisfactory appearance. The mean follow-up was 16.1 months. Our preliminary report in three patients demonstrated that innervated gracilis muscle transfer combined with fibular flap provides a successful reconstruction of extensive composite mandibular and total lower lip defects resulting from gunshot injuries to the face. Oral continence was achieved by combination of regained tonicity and voluntary movement of the gracilis muscle following re-innervation and assistance of the cheek muscles on the gracilis muscle. The described technique was reliable and the results were promising.

Reconstruction of Oromandibular Defects by Vascularized Free Flaps: The Radial Forearm Free Flap and Fibular Free Flap as Major Donor Sites

Since the advent of the modern microvascular techniques, the radial forearm free flap (RFFF) and the vascularized fibular free flap (VFFF) have become reliable methods for reconstructing oromandibular defects. The purpose of this study is to evaluate our experience with the use of both free flaps in the reconstruction of oral cavity defects after tumoral ablation. Over a 9-year period, 103 consecutive patients were treated in our department for the reconstruction of oral defects after tumor ablation by means of microvascularized free flaps. A total of 55 patients underwent reconstruction using RFFFs; 42 patients underwent reconstruction using VFFFs with or without skin paddles. Patients were treated for benign (n = 15) and malignant (n = 82) entities. All but 7 patients received donor site covering with abdominal full-thickness skin grafts. Of the 55 patients who received RFFFs, 5 (9.09%) developed necrosis at the end of the postsurgical period, and 7 patients developed complications of the donor site. Of the 42 patients who received VFFFs, an overall flap survival rate of 92.85% was achieved, and complications at the donor site occurred in 5 patients. For both free flaps, anesthesia time lasted from 6 to 15 hours (mean, 9.57 hours), whereas the mean flap ischemic time was 82.86 minutes. Our results reveal that the RFFF is a reliable method for reconstructing a wide range of oral cavity defects with an acceptably low morbidity rate. It provides adequate bulk and pliability, enabling the reconstruction of a wide variety of locations within the oral cavity. The VFFF allows good reconstruction of composite mandibular defects and provides adequate support for dental implants.

Vascularized free fibular flap for the reconstruction of mandibular defects: clinical experience in 42 cases

Since the advent of modern microvascular techniques, the fibula has become a reliable method for the reconstruction of partial or total mandibular defects. The purpose of this study is to evaluate our experience with the use of the vascularized free fibular flap for the reconstruction of mandibular defects following surgical resection. During a 5-year period, 102 consecutive patients were treated in our department for reconstruction of oral and maxillofacial defects, using microvascularized free flaps. Forty-two patients were reconstructed by means of the free vascularized fibular flap with or without a skin paddle. Patients underwent resection for benign (n = 15) and malignant (n = 27) entities. Fourteen patients received preoperative radiotherapy and only 1 patient received preoperative chemotherapy. The donor site was closed primarily in 7 cases, whereas an abdominal full-thickness skin graft was used in 35 cases. Thirty-eight patients were treated by means of an osteocutaneous flap, whereas only 4 developed an osseous flap. Five patients developed complications related to the vascular anastomosis and needed a second surgical look. One patient died in the immediate postoperative period. The skin island flap was completely viable in 37 cases (88%). Considering bone survival as the main objective, an overall flap survival rate of 92.85% was achieved in the whole series. Endosseous dental implants were placed in 11 patients with adequate outcome. In 5 of these cases the double-barrel technique was performed. Our results reveal that the vascularized free fibular flap is a reliable method for reconstructing mandibular defects with an acceptable low morbidity rate. The use of the osteocutaneous flap provides good reconstruction of composite mandibular defects. It constitutes an adequate support for dental implants.

The in vitro evaluation of a local pedicled osteomyocutaneous mandibular flap for the reconstruction of composite mandibular defects

Purpose: The purpose of this study was to develop and assess the potential feasibility of reconstructing composite defects of the mandible with a local pedicled osteomyocutaneous mandibular flap. Materials and Methods: The flap design was established based on anatomic principles. A prospective evaluation of the flap was then performed in a fresh cadaver model, and, subsequently, its vascular integrity was documented with angiography. Results: The pedicled osteomyocutaneous mandibular flap was technically simple to raise and had an exceptionally long arc of rotation, which should enable it to fill most compound segmental defects of the mandible. Angiographic studies of the harvested flaps done under fluoroscopic guidance confirmed that excellent vascularity of all components of the flap was present. Conclusions: The pedicled osteomyocutaneous mandibular flap appears to have a sound anatomic basis. Clinical evaluation is needed to fully elucidate its potential role in head and neck reconstruction.

Experience with the osteocutaneous fibula flap: an analysis of 24 consecutive reconstructions of composite mandibular defects

Based on findings from anatomical dissections of the skin of the peroneal artery, we used the osteocutaneous fibula flap for combined replacement of the mandible and floor of the mouth in 24 patients, form November 1993 to December 1995. There were 22 primary and 2 secondary reconstructions; the mean age of the patients (2 women and 22 men) was 64 years. The length of the fibula segments ranged between 5.5 and 18 cm, the size of the skin component between 3 x 5 and 6 x 15 cm. Corresponding to the results of our anatomical studies, the skin island was exclusively raised form the distal third of the lower leg, and the donor sites were generally covered with split thickness skin grafts. The average length of the dissected vascular pedicle was 11 cm, so that a vein graft was only required in one case. Flap raising and tumour resection were always carried out simultaneously. Fibula osteosynthesis was done with titanium miniplates; the insertion of endosseous implants followed secondarily. The success rate was 95.8% with one transplant loss and pseudarthrosis in one case. Despite the limited width of the fibula, the shape of the mandible was satisfactorily reconstructed in all patients, and the thin, pliable component enabled intraoral coverage with only negligible surplus volume. Chronic wound-healing disturbances at the donor site of the skin island occurred in two cases; impairment of walking ability was not detected. According to our experience, the use of the osteocutaneous fibula flap is a valuable method for the reconstruction of composite mandibular defects.

Evolution in mandibular reconstruction in oncologic surgery of the oral cavity

Since the advent of modern microvascular techniques, the fibula has become a reliable method for the reconstruction of partial or total mandibular defects. The purpose of this study is to evaluate our experience with the use of the vascularized free fibular flap for the reconstruction of mandibular defects following surgical resection.During a 5-year period, 102 consecutive patients were treated in our department for reconstruction of oral and maxillofacial defects, using microvascularized free flaps. Forty-two patients were reconstructed by means of the free vascularized fibular flap with or without a skin paddle. Patients underwent resection for benign (n = 15) and malignant (n = 27) entities. Fourteen patients received preoperative radiotherapy and only 1 patient received preoperative chemotherapy. The donor site was closed primarily in 7 cases, whereas an abdominal full-thickness skin graft was used in 35 cases.Thirty-eight patients were treated by means of an osteocutaneous flap, whereas only 4 developed an osseous flap. Five patients developed complications related to the vascular anastomosis and needed a second surgical look. One patient died in the immediate postoperative period. The skin island flap was completely viable in 37 cases (88%). Considering bone survival as the main objective, an overall flap survival rate of 92.85% was achieved in the whole series. Endosseous dental implants were placed in 11 patients with adequate outcome. In 5 of these cases the double-barrel technique was performed.Our results reveal that the vascularized free fibular flap is a reliable method for reconstructing mandibular defects with an acceptable low morbidity rate. The use of the osteocutaneous flap provides good reconstruction of composite mandibular defects. It constitutes an adequate support for dental implants.

Cost and Outcome of Osteocutaneous Free-Tissue Transfer versus Pedicled Soft-Tissue Reconstruction for Composite Mandibular Defects

Thirty-nine patients underwent reconstruction of composite mandibular defects following resection for squamous cell carcinoma. Thirty-four underwent immediate reconstruction, while 5 were reconstructed secondarily. Twenty-one received soft-tissue reconstruction only with a pectoralis major myocutaneous flap, 14 underwent osteocutaneous free-tissue transfer, and 4 received a reconstruction plate with free-tissue transfer for soft-tissue coverage. The mandibular defects in the pectoralis major myocutaneous flap group tended to be posterolateral, while free-tissue transfer defects were more severe, usually involving the anterior mandible. Length of surgery and duration of intensive care unit care were significantly longer for free-tissue transfer patients, while flap complications were more common in the pectoralis major myocutaneous flap patients. Facial appearance scores were higher for the free-tissue transfer group by both patient and physician assessment. Social function, speech, and oral function did not differ significantly. Patients reconstructed secondarily with free-tissue transfer reported significant improvement in appearance, oral continence, and social function, with little change in speech intelligibility, deglutition, or diet tolerance. The cost of the main hospitalization was significantly higher in the free-tissue transfer group than in the pectoralis major myocutaneous flap group, although when the costs of subsequent hospitalizations are included, the difference in total cost narrows. Despite more adverse defects, free-tissue transfer provided more predictable aesthetic results and expeditious return to normal social function than did pectoralis major myocutaneous flap reconstruction. The fiscal impact of these complex reconstructions is, however, significant. Cost-containment issues are presented and recommendations are made.

The effects of steel and titanium mandibular reconstruction plates on photon and electron beams

The use of metal plates, designed to be screwed into the bone in reconstruction of composite mandibular defects is an accepted and widely used procedure in oral cancer therapy (Castillo et al, 1988; Sindet-Pedersen, 1988). Many of these patients must receive post-surgical radiotherapy in the course of their treatment because of possible residual microscopic disease. The effects of radiation on tissue-metal interfaces have been studied for photon (Dutreix & Bernard, 1966; Gibbs et al, 1976; Hudson et al, 1984) and electron beams (Weatherburn et al, 1975; Khan et al, 1976; Gagnon & Cundiff, 1980; Klevenhagen et al, 1982). They have been found to result in an enhancement of the dose to the tissue in the immediate vicinity of the interface on the side facing the beam. A search through the literature has revealed limited studies on the effects of radiation beams on metal mandibular implants of the oral cavity (Castillo et al, 1988; Scher et al, 1988). These investigations were confined to stainless steel and vitallium plates irradiated with 6 MV photons. In the last few years, titanium reconstruction plates have become available and are growing in popularity because of the increased strength relative to the thickness of the plate, greater tissue compatibility and easier adaptation to the bony fragments.

血管柄付肩甲骨皮弁による下顎即時再建術の１症例

A case of mandibular reconstruction using a vascularized osteocutaneous scapular flap was reported.The patient was a 52-year-old man with squamous cell carcinoma of the floor of the mouth. An osteocutaneous scapular flap of 10 × 14 cm in size was designed based on the circumflex scapular branch of the subscapular artery to reconstruct a surgically-made defect at the floor of the mouth including the tongue and gingival mnucosa.A bone fragment of 12 cm long was cut at two points and fixed with Kirschner's wires and interosseous wiring. The donor artery and vein were anastomosed with the right superior thyroid artery and external jugular vein respectively.Bone scan was positive at eight weeks postoperatively despite osteotomies. To enable the patient to wear his denture, flap debulking was carried out. Donor site morbidity was minimal.We concluded that a vascularized osteocutaneous scapular flap was useful for reconstruction of composite mandibular defects in place of a vascularized osteocutaneous groin flap.