Long-term evaluation of patients undergoing immediate mandibular reconstruction

Long.Term Evaluation of Patients Undergoing Immediate Mandibular Reconstruction Keith S. Heller, MD, Sanford Dubner, MD, A l e x Keller, MD, Great Neck, New York

BACKGROUND:Immediate reconstruction following segmental mandibulectomy is an accepted surgical technique. The benefits and patient selection criteria need to be established. PATIENTS AND METHODS: Forty-seven patients w h o underwent immediate reconstruction of the mandible were followed for up to 14 years. Survival, complication rates, and functional results were analyzed. RESULTS: Median survival was 39 months and actuarial 5-year survival was 40%. Two patients died in the postoperative period, and 9 suffered major reconstruction-related complications. The majority of these complications were related to the use of reconstruction plates, and occurred when the mandibular defect included the arch or when the plates were covered by pectoralis flaps. Half of the patients interviewed were able to eat a regular diet. CONCLUSIONS:Mandibular reconstruction can be performed safely and expeditiously in nearly all patients undergoing segmental mandibulectomy. Functional results and long-term survival will be a c c e p t a b l e in m a n y c a s e s . Am J Surg. 1 9 9 5 ; 1 7 0 : 517-520,

t is now possible, using a number of different surgical techniques, to reconstruct the mandible following resection of malignant tumors of the head and neck region. 1 Such reconstructions improve the cosmetic result and the patient's selfimage following radical cancer surgery. Dental rehabilitation may be possible, as welt as improvement in function. Successful mandibular reconstruction does not always result in improved function, however. Reconstruction can result in increased morbidity and expense and increase the risk of recurrence if necessary postoperative radiation therapy is delayed. 2 In 1985, when it became clear that reliable mandibular reconstruction was possible, we adopted the policy of performing immediate mandibular reconstruction in almost all operations in which segmental mandibulectomy was required. The

I

From the Head and Neck Service and the Plastic and Reconstructive Surgical Division of the Departments of Surgery, Long Island Jewish Medical Center, New Hyde Park, New York; North Shore University Hospital, Manhasset, New York; and the New York Hospital Medical Center of Queens, Flushing, New York. Requests for reprints should be addressed to Keith S. Heller, MD, 200 Middleneck Road, Great Neck, New York 11021. Presented at the 41 st Annual Meeting of the Society of Head and Neck Surgeons, Boston, Massachusetts, May 1-3, 1995.

purpose of this study is to review the results of this experience, paying particular attention to the ultimate survival and functional status of these patients.

PATIENTS AND METHODS The medical records were reviewed of all patients on whom the authors operated for malignant tumo~ of the oral cavity or oropharvnx between 1980 and 1993. Of these 469 surgical procedures, 73 included segmental mandibulectomy. Forty-seven patients underwent immediate reconstruction of the mandible at the time of resection. Surgery was performed at one of three neighboring university-affiliated teaching hospitals. All patients were under the care of the senior author (KSH) and the general surgical housestaff. Reconstructions were performed by one of four board-certified plastic and reconstructive surgeons using different techniques based on the unique requirements of each patient, as well as the personal preference of the surgeon. Twenty-two of 23 surviving patients were interviewed by either KSH or a specially trained registered nurse to determine their dietary intake and denture status. Diets were classified as regular if the patient stated he or she was able to eat virtually everything. The distinction between puree and liquid diets was the subjective opinion of the interviewer after a detailed analysis of the patients' daily intake. Survival was calculated by the Kaplan-Meier survival method. Deaths due to all causes, including operative complications and unrelated medical conditions, were included in the survSNal calculations.

RESULTS Patients who underwent iminediate mandibular reconstruction ranged in age from 13 to 82 years (median 67). Patients included 28 males and 19 females. Forty-four had epidermoid carcinoma, 1 mucoepidermoid carcinoma, 1 basal cell carcinoma, and 1 embryonal rhabdomyosarcoma. In 40 patients, mandibular resection and reconstruction were part of the initial course of treatment of tumors classified as T2 (n = 8), T3 (n = 10), mad T4 (n = 22). The 7 additional patients underwent surgery for salvage of previous treatment failures. The site of origin of these tumors included: the gingiva (18); floor of mouth (12),; retromolar trigone (6); tongue (5); oropharynx (3); buccal (1); skin (1); and submandibular gland (1). The most anterior extent of the surgical defect included the arch of the mandible in 11 patients, the body in 27, and the ascending ramus in 9. Six patients received radiation therapy prior to resection and reconstruction, and 29 patients received it postoperatively. Twelve patients received no radiation therapy. Prior to 1985, only 2 of 17 patients underwent immediate reconstruction of the mandible. Both were reconstructed successfully with nonvascularized iliac crest bone grafts and pri-

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1

MANDIBULAR RECONSTRUCTION/HELLER ET AL ] TABLE I Type of Mandibular Reconstruction Reconstruction

Patients

Iliac free flap 16 Fibula free flap 5 Scapula free flap 2 Iliac (nonvascularized) 2 Rib/pectoralis major pedicled flap 1 Reconstruction plate/rectus free flap 8 Reconstruction plate/pectoralis myocutaneous flap 8 Reconstruction plate/forearm free flap 5

TABLE II Factors Contributing to Diet Following Mandibular Reconstruction Diet/Site of Primary Tumor

N

Regular Gingiva/retmmolar trigone Floor of mouth/tongue Puree/Soft Gingiva/retromolar trigone Floor of mouth Liquid Gingiva Floor of mouth/tonsil

11 9 2 5 3 2 6 1 5

Dental Status Dentulous Edentulous

6

5

0

5

0

6

mary mucosal closure. This technique was not used in any other patients. In 1985 and 1986, 10 of 15 patients underwent immediate mandibular reconstruction. From 1987 onward, only 2 of 37 patients were not reconstructed. Of the 45 mandibular reconstructions performed after 1984, 23 used bone-containing free flaps with microvascular revascularization. One reconstruction employed a pedicled osteomyocutaneous flap. The remaining 21 reconstructions were performed with stainless steel or titanium reconstruction plates covered with vascularized soft-tissue flaps (Table I). Two patients (4%) died in the postoperative period; one died of a cerebral infarct complicated by pneumonia, the other of a pulmonary embolism. Reconstruction-related complications occurred in 9 patients (19%). Two free flaps (1 fibula, 1 iliac) failed in the immediate postoperative period and could not be revascularized. The failed fibula flap was removed and reconstructed successfully 6 months later with a second fibula free flap. The failed iliac graft was immediately replaced with a reconstruction plate covered by a pectoralis major myocutaneous flap. The remaining 7 complications were related to the use of reconstruction plates. Three plates were ultimately removed. Two of these had been used to replace the resected mandible and were removed postoperatively when they became exposed and infected. Both had been covered with pectoralis major myocutaneous flaps. The third patient had been reconstructed using an iliac free flap stabilized with a single reconstruction plate that became exposed externally 5 years postoperatively. Removal of the plate was accomplished without injury to the reconstructed bone. Four reconstruction plates became exposed but did not require removal. Two were used to stabilize osseous free flaps and became exposed intraorally. The other 2 were used to replace 518

resected mandible and became exposed extraorally. One of these had been covered with a pectoralis major myocutaneous flap and the other with a rectus abdominus free flap. Because none of these exposures resulted in infection or fistula, it was elected to leave the plates in place. Of the 8 reconstruction plates covered by pectoralis major myocutaneous flaps, 3 (38%) became exposed. Only 1 (8%) of the 13 reconstruction plates covered by rectus or forearm free flaps became exposed. The duration of hospitalization for all 47 patients ranged from 3 to 47 days. For all 47 patients the median length of hospital stay was 15 days. By the use of a patient care plan designed to minimize hospital length of stay, the median length of stay for the last 23 patients was lowered to 11 days. Eleven of the 22 patients interviewed were able to eat a regular diet. Three were able to wear full lower dentures (1 implant-borne, 2 tissue-borne). Three additional patients wear partial lower dentures. The relationship of diet to the site of the primary tumor and the patients' dental status is summarized in Table II. The actuarial survival of the entire group of patients, including those who died of operative complications or causes unrelated to their cancer, was 74% at 1 year, 67% at 2 years, and 40% at 5 years. The median survival was 39 months. COMMENTS As procedures such as marginal mandibulectomy and median mandibulotomy have gained acceptance, the percentage of patients with malignant tumors of the oral cavity or oropharynx requiring segmental resection of the mandible has decreased. 3 Nevertheless, in many patients with large or recurrent tumors, segmental mandibulectomy cannot be avoided. Most mandibular reconstructions are performed using either osseous free-tissue transfer with microvascular anastomosis, or metal reconstruction plates covered with soft-tissue faps. Pedicled osteomyocutaneous flaps are described, 4 but are of limited usefulness. Overall, osseous free flaps have a success rate of 90% to 95%. 2,5"sWhile many different flaps have been described, those using iliac crest, fibula, or scapula are most commonly employed.l'7 In addition to their reliability, osseous free flaps are able to span large defects, be contoured to reconstruct the mandibular arch, include reliable soft tissue for reconstruction of skin and/or mucosal defects, and provide adequate bone stock for insertion of dental implants. 5'7'9 Mandibular reconstruction plates, when covered with pedicled or free soft-tissue flaps, have the advantages of lack of donor-site morbidity, ease of use, and excellent contour. In general, dental rehabilitation is more difficult, and complicanons--including infection, extrusion, and plate fracture--are more common than with osseous free flaps. 2'6'10 Plates are particularly prone to infection and failure when used to reconstruct the mandibular arch 6'1~ or when covered by either primary mucosal closure or pectoralis major myocutaneous flaps3214 Reconstruction plates are most useful in replacement of lateral mandibular defects and in patients in whom a shorter surgical procedure is desirable. 15a6 In spite of the preference of most authors for immediate mandibular reconstruction, some advocate mandibular reconstruction as a secondary procedure months or years after the original surgical resection, n'ls Considering an extraordinarily high complication rate and a lack of functional bene-

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fit using reconstruction plates or metal cribs, Komisar 15 concludes that there is little benefit from aggressive reconstruction. While advocating delaying reconstruction for 1 year, Tucker Is reports that only 15 of 48 patients eligible for reconstruction opted to undergo an additional surgical procedure. Nevertheless, in comparing two groups of patients undergoing primary and secondary mandibular reconstruction, Markowitz et al I'~ were not able to demonstrate any advantage for delayed reconstruction. In addition, secondary or twostage reconstruction is associated with a greater cost, higher ~verall complication rate, and longer total length of hospitalization than immediate reconstruction. 6 Beginning in 1985, we adopted the policy of performing immediate reconstruction in virtually all patients undergoing segmental mandibulectomy. Patients healthy enough to tolerate the extirpative procedure are assumed to be healthy enough to undergo immediate reconstruction. This lack of selectivity in our series resulted in a median age of 67 years, considerably older than patients in other reported series whose median ages ranged from 47 to 61 years) °'I1'17']9"2~We try to restrict the use of reconstruction plates to defects limited to the ascending ramus and posterior body of the mandible. Whenever possible, free-tissue flaps rather than pedicled flaps ~re used to cover reconstruction plates. In spite of these preferences, the lack of availability of suitable donor sites in some patients, and the desire to perform a more expeditious reconstruction in others resulted in deviations from our usual practice on several occasions. In this relatively elderly group of patients, our operative mortality (2/47) was little different from other series. Urken et al 2~ report 2 deaths in 71 patients, Boyd et al s 2 deaths in 60 patients, and Hidalgo > 1 death in 60 patients. Two of 23 osseous free flaps were lost in this series. This is a slightly higher loss rate than in other reported series. While Kroll et al6 reported a similar 10% failure rate, Urken et al and Boyd et al report the loss of about 5% of lilac free flaps, and Hidalgo 1 of 60 fibula free flaps. Our failure rate may be related to our relative lack of experience in the use of these flaps in the early years ~f this series, as well as more extensive atherosclerosis m this elderly group of patients. In the 21 patients in whom the mandible was reconstructed with a plate and soft-tissue flap, only 2 plates required removal and 2 plates remained exposed. Three of these 4 plates had been covered with pectoralis flaps and 3 of the 4 had been used t(~ reconstruct defects spanning the mandibular arch. Other authors have reported similar high failure rates. Kroll et al ~'experienced a failure of 33% of primary reconstructions with plates and Davidson and Gullane 24 report a 16% rate of major complications. In a series of 40 patients, Boyd 16reports the removal of 20% of plates, all of which were covered by fbream~ free flaps. He noted, however, that while there was a 35% failure rate of plates used to reconstruct the mandibular arch, the ti~ilure rate was only 5% for reconstruction of the lateral portion of the mandible. A similar disparity between reconstructions of the mandibular arch and more lateral portions of the mandible was noted by Schustennan et al. il Cordeiro and Hidalgo 15 and Disher et a125 report particularly high extrusion rates for plates covered by pectoralis flaps. Considering our results and those discussed above, reconstructk,n plates should be used to replace defects in the ramus

or posterior body of the mandible and, whenever possible, should be covered by free-tissue flaps. Their use to reconstruct defects in the arch of the mandible should be avoided. In the cmTent economic environment, the routine performance of a procedure that is expensive and results in prolonged hospitalization may be difficult to justify, particularly in a group of patients with a limited life expectancy. Other authors have reported average lengths of hospitalization for patients undergoing immediate mandibular reconstruction ranging from 15 to 39 days. <1t'13'~9':2''~The median duration of hospitalization in the last 23 patients in this series, 11 days, is the result of an intensive effort by the nursing staff responsible for the care of these patients. The care plan emphasizes early oral feeding and speech and swallowing therapy beginning on the first or second postoperative day. Patients are admitted on lhe day of surgery, spend the first postoperative night in the: Post Anesthesia Care Unit, and are then transferred to the Head and Neck nursing unit. ICU care is only required for serious medical complications. Virtually all patients are decannulated prior to discharge; few require enteral feeding afte:: discharge. In spite of the high technical success rate in this and other series, the restoration of function is much more difficult to achieve than the restoration of form. Only 50% of the patients interviewed in this series were able to eat a relatively normal diet, although all but 1 of the patients limited to puree or liquid diets also had successful mandibular reconstructions. In 1989, Jewer et aF 6 commented that the " . . . worst results occurred in large defects in conjunction with extensive tongue resection or denervation." A similar conclusion can be drawn from the patients reported in this series. The ability to eat a regular diet is least likely in those patients with primary tumors involving the floor of mouth, tongue, or oropharynx. These patients are far more likely to have extensive soft-tissue resections than are patients whose tumors arise on the gingiva or retromolar trigone. The patients' remaining teeth also improve their ability to eat a regular diet. Of the 11 patients eating a regular diet, only 5 were fully edentulous. All patients limited to puree or liquid diets were edentulous. In a study of 212 patients, many of whom did not have a mandibulectomy performed, lVlcConnel et a127 noted that function was most dependent on the degree of tongue mobility. In a careful comparison of four different groups of patients, Urken et a[2:: were unable to demonstrate a difference in the ability to speak or swallow between patients undergoing immediate mandibular reconstruction including implant-borne dentures and a similar group of patients with lateral mandibular defects without reconstruction. Komisar t5 found that deglutition, mastication, and the ability to wear a denture were actually worse in patients undergoing reconstruction than in unreconstructed patients. This unexpected observation may be the result of the numerous complications and resultant scarring suffered by the reconstructed patients. While successful reconstruction may not necessarily improve the ability to swallow or eat a regular diet~ it can permit successful prosthetic rehabilitation and restoration of the ability to chew. Traditional tissue-borne dentures are usually merely a cosmetic exercise, s The ability to successfully wear a denture is greatly enhanced by the use of osseous integrated implants in the grafted bone. 2° In fact, Urken 7 and col-

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leagues2s state that the choice of bone to be used in a reconstruction should be dictated by suitability for dental implants. In a series of 71 patients undergoing reconstruction, 29 had implants placed at the time of iliac free flap, 12 received postoperative radiation, and only 3 implants were lost.21 Zlotolow et a129report similar successful placement of implants in fibula free flaps, but note that the ability to chew is also affected by the loss of tongue function. Dental rehabilitation is almost never possible following reconstruction using reconstruction plates. 5 Our own experience supports these observations. Only 3 patients were able to wear full lower dentures and none of them, including 1 with an implant-borne denture, was able to eat a regular diet. All 3 of these patients had extensive softtissue resections of the floor of mouth and tongue. It is legitimate to question the wisdom of performing such extensive reconstructive procedures in patients with advanced disease and poor prognosis. Boyd et als report a mean survival after reconstruction of only 12 months. Disher et a125 note similarly high mortality with only 2 of 12 patients surviving after successful reconstruction. Our results are somewhat more encouraging. In this series in which patients were not selected based on age or extent of disease, median survival was 39 months, and 40% of patients were alive and free of disease after 5 years. This substantial number of patients surviving long periods of time justifies the extent of surgery performed. In conclusion, this study supports our usual practice of performing immediate reconstruction of the mandible in virtually all patients undergoing segmental mandibulectomy. Operative morbidity and mortality are acceptable in spite of the advanced age of the patients we have treated. While many patients achieve acceptable levels of function without dental rehabilitation, extensive soft-tissue resection is frequently associated with the inability to eat a regular diet even after successful reconstruction. Long-term survival is sufficiently common to justify the extensive surgery required.

REFERENCES 1. Haller JR, Sullivan MJ. Contemporary techniques in mandibular reconstruction. Am J Otolaryngol. 1995;16:19-23. 2. Shockley WW, Weissler MC. Reconstructive alternatives following segmental mandibulectomy. AmJ Otolaryngol. 1992;13:156-167. 3. O'Brien CJ, Nettle WJ, Lee KK. Changing trends in the management of carcinoma of the oral cavity and oropharynx. Aust NZ J Surg. 1993;63:270-274. 4. Savant DN, Kavarana NM, Bhathena HM, et al. Osteomyocutaneous flap reconstruction for major mandibular defects.J Surg Oncol. 1994;55:122-125. 5. Kuriloff DB, Sullivan MJ. Mandibular reconstruction using vasculamed bone grafts. Otolaryngol Clin North Am. 1991;24:1391-1417. 6. Kroll SS, Schusterman MA, Reece GP. Costs and complications in mandibular reconstruction. Ann Plast Surg. 1992;29:341-347. 7. Urken ML. Composite free flaps in oromandibular reconstruction. Arch Otolaryngol Head Neck Surg. 1991;117:724-732. 8. Boyd JB, Rosen I, Rotstein L, et al. The iliac crest and the radial forearm flap in vascularizedoromandibular reconstruction. Am J Surg. 1990;159:301-308.

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9. Moscoso JE Keller J, Genden E, et al. Vascularizedbone flaps in oromandibular reconstruction. Arch Otolaryngol Head Neck Surg. 1994; 120:36-43. 10. Davidson J, Boyd B, Gullane P, et al. A comparison of the results following oromandibular reconstruction using a radial forearm flap with either radial bone or a reconstruction plate. Plast Reconstr Surg. 1991;88: 201-208. 11. Schusterman MA, Reece GP, Kroll SS, Welclon ME. Use of the AO plate for immediate mandibular reconstruction in cancer patients. Plast Reconstr Surg. 1991;88:588-593. 12. Futran ND, Urken ML, Buchbinder D, et al. Rigid fixation of vascularized bone grafts in mandibular reconstruction. Arch Otolaryngol Head Neck Surg. 1995;121:70-76. 13. Cordeiro PG, Hidalgo DA. Soft tissue coverage of mandibular reconstruction plates. Head Neck. 1994;16:112-115. 14. Freitag V, Hell B, Fischer H. Experience with AO reconstruction plates after partial mandibular resection involving its continuity. J Craniomaxillo fac Surg. 1991;19:191-198. 15. Komisar A. The functional result of mandibular reconstruction. Laryngoscope. 1990;100:364-374. 16. Boyd JB. Use of reconstruction plates in conjunction with soft-tissue free flapsfor oromandibular reconstruction. Clin Plast Surg. 1994;21: 69-77. 17. Lowlicht RA, Delacure MD, Sasaki CT. Allogeneic (Homograft) reconstruction of the mandible. Laryngoscope. 1990;100:837443. 18. Tucker HM. Nonrigid reconstruction of the mandible. Arch Otolaryngol Head Neck Surg. 1989;115:1190-1192. 19. Markowitz B, Taleisnik A, Calcaterra T, Shaw W. Achieving mandibular continuity with vascular bone flaps.J Oral Maxillofac Surg. 1994;52:114-118. 20. Haughey BH, Fredrickson JM, Lerrick AJ, et al. Fibular and iliac crest osteomuscular free flap reconstruction of the oral cavity. Laryngoscope. 1994;104:1305-1313. 21. Urken ML, Weinberg H, Vickery C, et al. Oromandibular reconstruction using microvascular composite free flaps. Arch Otolaryngol Head Neck Surg. 1991;117:733-744. 22. Urken ML, Buchbinder D, Weinberg H, et al. Functional evaluation following microvascular oromandibular reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients. Laryngoscope. 1991;101:935-950. 23. Hidalgo DA. Fibula free flap mandibular reconstruction. Clin Hast Surg. 1994;21:25-35. 24. Davidson MJ, Gullane PJ. Prosthetic plate mandibular reconstruction. Otolaryngol Clin North Am. 1991;24:1419-1431. 25. Disher MJ, Esclamado RiM, Sullivan MJ. Indications for the AO plate with a myocutaneous flap instead of revascularizedtissue transfer for mandibular reconstruction. Laryngoscope. 1993;103:1264-1268. 26. Jewer DD, Boyd JB, Manktelow RT, et al. Orofacial and mandibular reconstruction with the iliac crest free flap: a review of 60 cases and a new method of classification. Plast Reconstr Surg. 1989;84:391~r03. 27. McConnel FMS, TeichgraeberJF, Adler RK. A Comparison of three methods of oral reconstruction. Arch Otolaryngol Head Neck Surg. 1987;113:496-500. 28. Urken ML, Weinberg H, Vickery C, et al. The combined sensate radial forearm and iliac crest free flaps for reconstruction of significant glossectomy-mandibulectomydefects. Laryngoscope. 1992;102:543-558. 29. Zlotolow IM, Huryn JM, Piro JD, et al. Osseointegrated implants and functional prosthetic rehabilitation in microvascularfibula free flap reconstructed mandibles. Am J Surg. 1992;165:677-681.

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