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Interim report on immediate mandibular repair
Interim Report on Immediate Mandibular Repair D. R. P. W.
A design for immediate reconstruction of the mandible after radical ablation was first carried out in 1963, presented to this Society in 1964 [I], and reviewed in 1967 [S]. The urgent need for repair of these “oral cripples” [3] cannot be denied. Justification for immediate reconstruction, however, was presented but must be continually reviewed. As many have expressed interest in this approach, it is our responsibility to report the good and bad results in the progress of the proposed method, especially if there have been important modifications. Many involved in cancer surgery are SO concerned with radical cure that the thought of a true reconstruction is not palatable to them. This is understandable and on this basis the two-team approach is still proposed. One team is to concern itself entirely with ablation and is directly responsible for the cure of the patient, The second team, which may give a suggestion as to the position of incisions or restraint at unnecessary ligation of a vital vessel, is primarily concerned with reconstruction. Under this regimen, of twenty-one immediate reconstructions it was reported [Z] that only two patients died of cancer and one other had pulmonary metastasis. Since then, ten more patients have been treated, in three of whom local recurrence developed, and the responsibility for this must be accepted by the ablation team. Actually two of these had recurrent carcinoma and in a far advanced state
R. MILLARD, M.D., Miami, Florida C. CAMPBELL, F.R.C.S., Leeds, England STOKLEY, M.D., Miami, Florida GARST, M.D., Miami, Florida
so that the advisability of operation might be questioned. (Table I.) Yet, for those patients with a reasonable prognosis there still seems to be little if any contraindication for immediate repair.
Bone Grafting The next question concerns the advisability of immediate bone grafting. Review of the first twenty-six cases revealed loss of the bone graft in seven with two others destined for eventual loss adding to a total of nine or about 30 per cent failure. The cause of the losses could be traced to distal flap necrosis after preoperative radiation in three, separation of the flap during a delirium tremens attack in two, and leakage in the oral closure in four. It then became obvious that the odds against success could be cut tremendously if bone grafting was carried out as a “delayed” immediate procedure. On further consideration it was reahzed that this could be accomplished with all assets and no costs. Although the longitudinal transfixation of the rib graft with a Kirschner wire had proved reliable, foreign bodies are better eliminated whenever possible. In two cases the bent rib graft was inserted without a K wire “spit.” In both cases the bent rib arch fractured, indicating that the original design of bent rib skewered on a K wire was the method of choice for anterior mandibular arch reconstruction.
Modification in Design From the Department of Surgery, University of Miami School of Medicine, Miami, Florida. Presented at the Fifteenth Annual Meeting of The Society of Head and Neck Surgeons, Mexico City, Mexico. March 16 19, 1969.
726
In only tive gical
general the plan of repair is the same; the timing has been altered. If preoperaradiation has been administered, a surdelay of the forehead flap is carried out The
American
Journal
of
Surgery
Immediate Mandibular Repair
As soon as the excision has shown margins free of tumor (Fig. 1) , the ablation team is excused. The reconstruction team sutures the tongue on itself and approximates the neck flaps. The forehead flap is introduced into the oral lining defect entering through the posterior end of the ablation incision near the lobe of the ear. (Fig. 2.) The flap dips under the cheek flap and is sutured in two or three layers with No. 3-O chromic catgut interrupted sutures for a saliva-tight closure. Great care is exerted to approximate the apron of mucosa dissected off the mandibular fragment to the distal portion of the forehead flap. The posterior suture line will join the forehead flap around the base of the tongue or to what tongue remains or, if the tongue has been excised, it can be sutured to the mucosa in front of the epiglottis. Anteriorly the forehead flap will be sutured to the mucosa of the lip and cheeks. (Fig. 2.) Once the lining defect had been filled with the forehead flap the immediate bent rib graft heretofore had been inserted. This is the modification in timing. Now only a bent Kirschner wire is inserted into the ends of the Fig. 1. “Commando” ablation including resection of a large part of the anterior mandible has been completed. Total forehead flap has been elevated on a unilateral base carrying the superficial temporal and the posterior auricular vessels. two weeks prior
to the ablation-reconstruction first stage. Then as previously described, while the ablation team is occupied with the “commando” excision of the neck nodes, floor of the mouth, portion of the tongue, and section of the mandible, the reconstructive team moves around to the head of the table. The total forehead flap from brow to hairline and to the opposite temple hair is elevated, maintaining a good base in front and behind the ear carrying both the superficial temporal and posterior auricular vessels. Care should be taken not to extend the inferior cut below a line from the lateral canthus to the tragus of the ear to avoid severance of the facial nerve branch to the lower eyelid. A hairless split thickness graft is sutured to the forehead donor area and extended to cover the exposed raw surface of the temporal portion of the forehead flap. This cover of the forehead donor area as one smooth unit from brow to hairline and to the opposite temple partiahy camouflages the defect. Vol. 118, November 1969
Fig. 2. Forehead flap has been turned with skin side in to fill the oral defect. A Kirschner wire stabilizes the mandibular fragments. 727
Millard
et al.
TABLE
I
Results A8s (yr.), Race,and Sex of Patient
of Treatment
on the Ten Latest
Patients
with Squamous
Cell Carcinoma
Preoperative Radiation
Disease
History
Flap Delay
None
None
Squamous cell carcinoma of floor of mouth and anterior tongue; bilateral neck nodes
None
5/l/67
Squamous cell carcinoma of floor of mouth, mandible, and tongue; bilateral neck
None
514167
None
6116167
None
6123167
22.
78, W, M
Chronic pulmonary insufficiency
Squamous cell carcinoma lower lip
23.
51, C, M
Renal disease
24.
71, W, M
Alcoholism
25.
54, W, M
26.
53, W, M
Alcoholism
Squamous cell carcinoma floor of mouth
27.
53, W, M
Moderate alcoholism
12127167 Left neck 2,500 R; right neck 2,250 R; anterior neck 1,500R
28.
54, W, M
Alcoholism and heavy smoking
Squamous cell carcinoma of floor of mouth with invasion of mandible; positive neck nodes Squamous cell carcinoma of floor of mouth; recurrence 9167
(5/l/67 to 6112167) Primary 4,500R; right neck 2,900 R
3127168
29.
52, W, M
Alcoholism and heavy smoking
Squamous cell carcinoma of floor of mouth; nodes in all areas of neck
None
4123168
30.
49, C, M
Squamous cell carcinoma floor of mouth
of
None
4118168
31.
50, W, M
Squamous cell carcinoma of floor of mouth; recurrence 4168
None
518168
nodes Squamous cell carcinoma of floor of mouth and mandible
Alcoholism
mandibular fragments to maintain position (Fig. 2) and chin-cheek-neck flap is now brought down over the K wire and sutured to the neck flaps. The temporal portion of the 728
of
of
forehead flap can be seen exiting at the posterior extremity of the wound closure. Two Hemova@ suction systems are set up to draw the flaps snugly around the wire and down to The American
Journal
of Surgery
Immediate
TABLE
Mandibular
Repair
I
Resection g/12/66 wedge resection with Abbe-Estlander flap; 5/3/67, tracheostomy: resection lower lip, skin of chin, mandibular arch, floor of mouth; immediate reconstruction with rib graft, forehead delay, and delay of scalp flap En bloc resection of floor of mouth, hemiglossectomy, and subtotal mandibulectomy in continuity with left radical resection; right supra hyoid dissection; immediate rib graft and forehead flap En bloc resection of floor of mouth, hemiglossectomy, hemimandibulectomy, and right radical neck dissection; immediate rib graft and forehead flap En bloc resection of floor of mouth, hemimandibulectomy, and hemiglossectomy; bilateral neck dissection; immediate rib graft and forehead flap Previous resection of floor of mouth, hemiglossectomy, marginal resection of mandible with left radical neck hemiglossectomy, and subtotal mandibulectomy; immediate rib graft and forehead flap Resection of floor of mouth, hemiglossectomy, subtotal mandibulectomy with K wire distraction; skin of chin; immediate forehead flap 2/6/67 resection of floor of mouth, hemiglossectomy; bilateral suprahyoid dissection and marginal resection of mandible; 4/17/68 resection of floor of mouth, hemimandibulectomy, subtotal glossectomy, and right neck dissection; immediate forehead flap and K wire distraction Resection of floor of mouth, hemiglossectomy, subtotal glossectomy, and bilateral neck dissections; immediate forehead flap and K wire distraction Resection of floor of mouth; hemiglossectomy, subtotal mandibulectomy, bilateral neck dissection; immediate forehead flap and K wire fixation 4/17/67 resection of floor of mouth, hemiglossectomy; reconstruction with left cervical apron flap; 7/8/68 resection of floor of mouth, hemimandibulectomy, skin of chin; immediate forehead flap and K wire distraction and right deltopectoral flap
Date
Flap Viability
513167
Good
Rib graft with K wire intact
Died 5115167
Pneumonia
5/15/67
Good
Rib graft; midline fracture; rewired; draining sinus; no K wire
Died 7/28/67; no disease
Inanition malnutrition
6/l/67
Good
Rib graft;
Alive and well; no disease
715167
Good
7/19/67
Good
l/3/68
Good
Rib graft; no K wire; fracture with partial debridement Rib graft; K wire; fracture of left side; rib graft removed Septern ber 1968 Rib graft with K wire 11/15/68; intact
4117168
Good
4129168
intact
Patient Status
Cause
Alive and well; no disease
Alive and well; no disease
Alive and well
In process of reconstruction
Rib graft 713168; intact
Widespread local recurrence; 10/4/68 biopsy; died January 1969
Residual car cinema
Good
None
Aspiration and renal failure
513168
Good
Rib graft 617168; intact
718168
Good
Delayed rib bone graft inserted January 1969
Died 7130168; massive local recurrence; aspiration Alive; clinical buccal mucosal recurrence, right Alive and well
their recipient sites. If a distal portion of the forehead flap becomes necrosed or is pulled away from its closure, it is no great tragedy and by six weeks all should be well healed and Vol. 116, November 1969
Bone Graft (type and fate)
the oral cavity well sealed off from the mandibular fragments. At six weeks, as previously proposed, division of the forehead flap pedicle, closure of 729
Millard et al.
Medical Center, ber, 1967.
Washington,
D. C., in Decem-
Advantages of Delayed Immediate Bone Grafting
The chin-cheek-neck flap has been re-eleFig. 3. vated, the pedicle divided, the oral fistula closed, the initial K wire removed, and the bent rib graft mortised into position.
1. It gives time for the oral cavity to become sealed off prior to introduction of the bone graft and reduces the chance of leakage. Small losses of the lining flap or its separation from adjacent edges is no longer of any consequence. 2. There is a reduction in the dead space around the bone graft which offers a better bed for the graft. 3. By delaying bone grafting until the second procedure it reduces the time of the extensive ablation-reconstruction first stage. A moderate extension in the time of the second minor final stage is of no great importance. 4. Total reconstruction of the lining, bone graft, and forehead repair is complete within the same six weeks time as in the immediate bone grafting approach. 5. There has been an almost 100 per cent reduction in bone graft failures from the previous causes under this modified regimen.
Preparation for Dentures the small posterior oral fistula, and replacement of the hairy scalp to its original temporal area are accomplished. At the same time the cheek-chin-neck flap is re-elevated, the ends of the mandibular fragments are exposed, and the K wire is removed. A bony rib is taken with its strip of periosteum as previously described. A medium Kirschner wire bent to the exact curve of the rib is passed along its medullary cavity and slots are cut from its concave side to facilitate the bending of the rib into the semblance of an anterior mandibular arch. The ends of the K wire extending from the bent rib are inserted up the medullary cavity of the mandibular fragments. Slots in the mandibular fragments and in the rib ends, when interlocked and transfixed with interosseous wiring, present efficient fixation. (Fig. 3.) Adjacent soft tissue is used to cover these joins and the cheek-chinneck flap is brought over the bone graft arch snugly and resutured. This modification in timing was described first at the Maxillofacial Trauma Symposium at, Walter Reed Army 730
In certain cases the ablation of lining has been so extensive that the width of the forehead is inadequate to close off the oral cavity and produce an alveolar ridge on which a denture will fit comfortably. In these cases four months after the insertion of the bone graft a sulcus is dissected between the lower lip and cheek and into this is placed a split skin graft on a gutta percha mold. The mold is replaced by a temporary and later by a permanent denture.
Large Skin Loss When the orginal ablation includes extensive lip, chin, and cheek skin, the forehead flap for lining and the K wire for support get priority. This is followed by division of the forehead flap and replacement of the temporal portion. At this same time, if there is adequate tissue, the bone graft can be inserted. Meanwhile the process of transporting chest skin by the Bakamjian pedicle [4], a lined Gillies bipedicle [5], or a tube pedicle to rebuild the chin, cheek, and neck soft tissues The American Journal of Surgery
Immediate Mandibular Repair
can be in progress. Fan flaps [51 for the lower lip repair. In certain be necessary to transport the chest chin area prior to insertion of the
can be used cases it will skin to the bone graft.
Summary Immediate reconstruction of the resected mandibular arch using the total forehead as a lining flap and a bent rib on a Kirschner wire as the bone graft has been used for six years in thirty-one cases. Due to a 30 per cent failure in survival of the immediate bone graft, delayed immediate reconstruction is now favored. At the time of ablation the forehead flap replaces the lining but a K wire maintains position of the mandibular fragments. Six weeks later when the forehead pedicle is divided and the temporal portion replaced, the wire is removed and the bent rib graft on a
Vol. 118, November 1969
K wire inserted. This has been responsible for an increase in the survival rate of the bone grafts.
References 1.
2.
3. 4.
5.
D. R. Forehead flap in immediate repair of head, face and jaw. Am. J. Surg.,
MILLARD,
108: 508, 1964. MILLARD, D. R., DEMBROW,V., SHOCKET, E., ZAVERTNIK, J., and CLINTON-THOMAS, C. Immediate reconstruction of the resected mandibular arch. Am. J. Surg., 114: 605, 1967. CONLEY,J. J. The crippled oral cavity. Plast. & Reconstruct. Surg., 30: 469, 1962. BAKAMJIAN, V. Y. A two stage method for pharyngoesophageal reconstruction with a primary nectoral skin flav. Plast. & Reionstrict.- Surg., 36: 173, -1965. GILLIES, H. D. and MILLARD,D. R. The Principles and Art of Plastic Surgery. Boston, 1957. Little, Brown & Co.
731
A design for immediate reconstruction of the mandible after radical ablation was first carried out in 1963, presented to this Society in 1964 [I], and reviewed in 1967 [S]. The urgent need for repair of these “oral cripples” [3] cannot be denied. Justification for immediate reconstruction, however, was presented but must be continually reviewed. As many have expressed interest in this approach, it is our responsibility to report the good and bad results in the progress of the proposed method, especially if there have been important modifications. Many involved in cancer surgery are SO concerned with radical cure that the thought of a true reconstruction is not palatable to them. This is understandable and on this basis the two-team approach is still proposed. One team is to concern itself entirely with ablation and is directly responsible for the cure of the patient, The second team, which may give a suggestion as to the position of incisions or restraint at unnecessary ligation of a vital vessel, is primarily concerned with reconstruction. Under this regimen, of twenty-one immediate reconstructions it was reported [Z] that only two patients died of cancer and one other had pulmonary metastasis. Since then, ten more patients have been treated, in three of whom local recurrence developed, and the responsibility for this must be accepted by the ablation team. Actually two of these had recurrent carcinoma and in a far advanced state
R. MILLARD, M.D., Miami, Florida C. CAMPBELL, F.R.C.S., Leeds, England STOKLEY, M.D., Miami, Florida GARST, M.D., Miami, Florida
so that the advisability of operation might be questioned. (Table I.) Yet, for those patients with a reasonable prognosis there still seems to be little if any contraindication for immediate repair.
Bone Grafting The next question concerns the advisability of immediate bone grafting. Review of the first twenty-six cases revealed loss of the bone graft in seven with two others destined for eventual loss adding to a total of nine or about 30 per cent failure. The cause of the losses could be traced to distal flap necrosis after preoperative radiation in three, separation of the flap during a delirium tremens attack in two, and leakage in the oral closure in four. It then became obvious that the odds against success could be cut tremendously if bone grafting was carried out as a “delayed” immediate procedure. On further consideration it was reahzed that this could be accomplished with all assets and no costs. Although the longitudinal transfixation of the rib graft with a Kirschner wire had proved reliable, foreign bodies are better eliminated whenever possible. In two cases the bent rib graft was inserted without a K wire “spit.” In both cases the bent rib arch fractured, indicating that the original design of bent rib skewered on a K wire was the method of choice for anterior mandibular arch reconstruction.
Modification in Design From the Department of Surgery, University of Miami School of Medicine, Miami, Florida. Presented at the Fifteenth Annual Meeting of The Society of Head and Neck Surgeons, Mexico City, Mexico. March 16 19, 1969.
726
In only tive gical
general the plan of repair is the same; the timing has been altered. If preoperaradiation has been administered, a surdelay of the forehead flap is carried out The
American
Journal
of
Surgery
Immediate Mandibular Repair
As soon as the excision has shown margins free of tumor (Fig. 1) , the ablation team is excused. The reconstruction team sutures the tongue on itself and approximates the neck flaps. The forehead flap is introduced into the oral lining defect entering through the posterior end of the ablation incision near the lobe of the ear. (Fig. 2.) The flap dips under the cheek flap and is sutured in two or three layers with No. 3-O chromic catgut interrupted sutures for a saliva-tight closure. Great care is exerted to approximate the apron of mucosa dissected off the mandibular fragment to the distal portion of the forehead flap. The posterior suture line will join the forehead flap around the base of the tongue or to what tongue remains or, if the tongue has been excised, it can be sutured to the mucosa in front of the epiglottis. Anteriorly the forehead flap will be sutured to the mucosa of the lip and cheeks. (Fig. 2.) Once the lining defect had been filled with the forehead flap the immediate bent rib graft heretofore had been inserted. This is the modification in timing. Now only a bent Kirschner wire is inserted into the ends of the Fig. 1. “Commando” ablation including resection of a large part of the anterior mandible has been completed. Total forehead flap has been elevated on a unilateral base carrying the superficial temporal and the posterior auricular vessels. two weeks prior
to the ablation-reconstruction first stage. Then as previously described, while the ablation team is occupied with the “commando” excision of the neck nodes, floor of the mouth, portion of the tongue, and section of the mandible, the reconstructive team moves around to the head of the table. The total forehead flap from brow to hairline and to the opposite temple hair is elevated, maintaining a good base in front and behind the ear carrying both the superficial temporal and posterior auricular vessels. Care should be taken not to extend the inferior cut below a line from the lateral canthus to the tragus of the ear to avoid severance of the facial nerve branch to the lower eyelid. A hairless split thickness graft is sutured to the forehead donor area and extended to cover the exposed raw surface of the temporal portion of the forehead flap. This cover of the forehead donor area as one smooth unit from brow to hairline and to the opposite temple partiahy camouflages the defect. Vol. 118, November 1969
Fig. 2. Forehead flap has been turned with skin side in to fill the oral defect. A Kirschner wire stabilizes the mandibular fragments. 727
Millard
et al.
TABLE
I
Results A8s (yr.), Race,and Sex of Patient
of Treatment
on the Ten Latest
Patients
with Squamous
Cell Carcinoma
Preoperative Radiation
Disease
History
Flap Delay
None
None
Squamous cell carcinoma of floor of mouth and anterior tongue; bilateral neck nodes
None
5/l/67
Squamous cell carcinoma of floor of mouth, mandible, and tongue; bilateral neck
None
514167
None
6116167
None
6123167
22.
78, W, M
Chronic pulmonary insufficiency
Squamous cell carcinoma lower lip
23.
51, C, M
Renal disease
24.
71, W, M
Alcoholism
25.
54, W, M
26.
53, W, M
Alcoholism
Squamous cell carcinoma floor of mouth
27.
53, W, M
Moderate alcoholism
12127167 Left neck 2,500 R; right neck 2,250 R; anterior neck 1,500R
28.
54, W, M
Alcoholism and heavy smoking
Squamous cell carcinoma of floor of mouth with invasion of mandible; positive neck nodes Squamous cell carcinoma of floor of mouth; recurrence 9167
(5/l/67 to 6112167) Primary 4,500R; right neck 2,900 R
3127168
29.
52, W, M
Alcoholism and heavy smoking
Squamous cell carcinoma of floor of mouth; nodes in all areas of neck
None
4123168
30.
49, C, M
Squamous cell carcinoma floor of mouth
of
None
4118168
31.
50, W, M
Squamous cell carcinoma of floor of mouth; recurrence 4168
None
518168
nodes Squamous cell carcinoma of floor of mouth and mandible
Alcoholism
mandibular fragments to maintain position (Fig. 2) and chin-cheek-neck flap is now brought down over the K wire and sutured to the neck flaps. The temporal portion of the 728
of
of
forehead flap can be seen exiting at the posterior extremity of the wound closure. Two Hemova@ suction systems are set up to draw the flaps snugly around the wire and down to The American
Journal
of Surgery
Immediate
TABLE
Mandibular
Repair
I
Resection g/12/66 wedge resection with Abbe-Estlander flap; 5/3/67, tracheostomy: resection lower lip, skin of chin, mandibular arch, floor of mouth; immediate reconstruction with rib graft, forehead delay, and delay of scalp flap En bloc resection of floor of mouth, hemiglossectomy, and subtotal mandibulectomy in continuity with left radical resection; right supra hyoid dissection; immediate rib graft and forehead flap En bloc resection of floor of mouth, hemiglossectomy, hemimandibulectomy, and right radical neck dissection; immediate rib graft and forehead flap En bloc resection of floor of mouth, hemimandibulectomy, and hemiglossectomy; bilateral neck dissection; immediate rib graft and forehead flap Previous resection of floor of mouth, hemiglossectomy, marginal resection of mandible with left radical neck hemiglossectomy, and subtotal mandibulectomy; immediate rib graft and forehead flap Resection of floor of mouth, hemiglossectomy, subtotal mandibulectomy with K wire distraction; skin of chin; immediate forehead flap 2/6/67 resection of floor of mouth, hemiglossectomy; bilateral suprahyoid dissection and marginal resection of mandible; 4/17/68 resection of floor of mouth, hemimandibulectomy, subtotal glossectomy, and right neck dissection; immediate forehead flap and K wire distraction Resection of floor of mouth, hemiglossectomy, subtotal glossectomy, and bilateral neck dissections; immediate forehead flap and K wire distraction Resection of floor of mouth; hemiglossectomy, subtotal mandibulectomy, bilateral neck dissection; immediate forehead flap and K wire fixation 4/17/67 resection of floor of mouth, hemiglossectomy; reconstruction with left cervical apron flap; 7/8/68 resection of floor of mouth, hemimandibulectomy, skin of chin; immediate forehead flap and K wire distraction and right deltopectoral flap
Date
Flap Viability
513167
Good
Rib graft with K wire intact
Died 5115167
Pneumonia
5/15/67
Good
Rib graft; midline fracture; rewired; draining sinus; no K wire
Died 7/28/67; no disease
Inanition malnutrition
6/l/67
Good
Rib graft;
Alive and well; no disease
715167
Good
7/19/67
Good
l/3/68
Good
Rib graft; no K wire; fracture with partial debridement Rib graft; K wire; fracture of left side; rib graft removed Septern ber 1968 Rib graft with K wire 11/15/68; intact
4117168
Good
4129168
intact
Patient Status
Cause
Alive and well; no disease
Alive and well; no disease
Alive and well
In process of reconstruction
Rib graft 713168; intact
Widespread local recurrence; 10/4/68 biopsy; died January 1969
Residual car cinema
Good
None
Aspiration and renal failure
513168
Good
Rib graft 617168; intact
718168
Good
Delayed rib bone graft inserted January 1969
Died 7130168; massive local recurrence; aspiration Alive; clinical buccal mucosal recurrence, right Alive and well
their recipient sites. If a distal portion of the forehead flap becomes necrosed or is pulled away from its closure, it is no great tragedy and by six weeks all should be well healed and Vol. 116, November 1969
Bone Graft (type and fate)
the oral cavity well sealed off from the mandibular fragments. At six weeks, as previously proposed, division of the forehead flap pedicle, closure of 729
Millard et al.
Medical Center, ber, 1967.
Washington,
D. C., in Decem-
Advantages of Delayed Immediate Bone Grafting
The chin-cheek-neck flap has been re-eleFig. 3. vated, the pedicle divided, the oral fistula closed, the initial K wire removed, and the bent rib graft mortised into position.
1. It gives time for the oral cavity to become sealed off prior to introduction of the bone graft and reduces the chance of leakage. Small losses of the lining flap or its separation from adjacent edges is no longer of any consequence. 2. There is a reduction in the dead space around the bone graft which offers a better bed for the graft. 3. By delaying bone grafting until the second procedure it reduces the time of the extensive ablation-reconstruction first stage. A moderate extension in the time of the second minor final stage is of no great importance. 4. Total reconstruction of the lining, bone graft, and forehead repair is complete within the same six weeks time as in the immediate bone grafting approach. 5. There has been an almost 100 per cent reduction in bone graft failures from the previous causes under this modified regimen.
Preparation for Dentures the small posterior oral fistula, and replacement of the hairy scalp to its original temporal area are accomplished. At the same time the cheek-chin-neck flap is re-elevated, the ends of the mandibular fragments are exposed, and the K wire is removed. A bony rib is taken with its strip of periosteum as previously described. A medium Kirschner wire bent to the exact curve of the rib is passed along its medullary cavity and slots are cut from its concave side to facilitate the bending of the rib into the semblance of an anterior mandibular arch. The ends of the K wire extending from the bent rib are inserted up the medullary cavity of the mandibular fragments. Slots in the mandibular fragments and in the rib ends, when interlocked and transfixed with interosseous wiring, present efficient fixation. (Fig. 3.) Adjacent soft tissue is used to cover these joins and the cheek-chinneck flap is brought over the bone graft arch snugly and resutured. This modification in timing was described first at the Maxillofacial Trauma Symposium at, Walter Reed Army 730
In certain cases the ablation of lining has been so extensive that the width of the forehead is inadequate to close off the oral cavity and produce an alveolar ridge on which a denture will fit comfortably. In these cases four months after the insertion of the bone graft a sulcus is dissected between the lower lip and cheek and into this is placed a split skin graft on a gutta percha mold. The mold is replaced by a temporary and later by a permanent denture.
Large Skin Loss When the orginal ablation includes extensive lip, chin, and cheek skin, the forehead flap for lining and the K wire for support get priority. This is followed by division of the forehead flap and replacement of the temporal portion. At this same time, if there is adequate tissue, the bone graft can be inserted. Meanwhile the process of transporting chest skin by the Bakamjian pedicle [4], a lined Gillies bipedicle [5], or a tube pedicle to rebuild the chin, cheek, and neck soft tissues The American Journal of Surgery
Immediate Mandibular Repair
can be in progress. Fan flaps [51 for the lower lip repair. In certain be necessary to transport the chest chin area prior to insertion of the
can be used cases it will skin to the bone graft.
Summary Immediate reconstruction of the resected mandibular arch using the total forehead as a lining flap and a bent rib on a Kirschner wire as the bone graft has been used for six years in thirty-one cases. Due to a 30 per cent failure in survival of the immediate bone graft, delayed immediate reconstruction is now favored. At the time of ablation the forehead flap replaces the lining but a K wire maintains position of the mandibular fragments. Six weeks later when the forehead pedicle is divided and the temporal portion replaced, the wire is removed and the bent rib graft on a
Vol. 118, November 1969
K wire inserted. This has been responsible for an increase in the survival rate of the bone grafts.
References 1.
2.
3. 4.
5.
D. R. Forehead flap in immediate repair of head, face and jaw. Am. J. Surg.,
MILLARD,
108: 508, 1964. MILLARD, D. R., DEMBROW,V., SHOCKET, E., ZAVERTNIK, J., and CLINTON-THOMAS, C. Immediate reconstruction of the resected mandibular arch. Am. J. Surg., 114: 605, 1967. CONLEY,J. J. The crippled oral cavity. Plast. & Reconstruct. Surg., 30: 469, 1962. BAKAMJIAN, V. Y. A two stage method for pharyngoesophageal reconstruction with a primary nectoral skin flav. Plast. & Reionstrict.- Surg., 36: 173, -1965. GILLIES, H. D. and MILLARD,D. R. The Principles and Art of Plastic Surgery. Boston, 1957. Little, Brown & Co.
731