- Email: [email protected]
Mandibular reconstruction with microvascular fibular flaps after large resections: Towards a functional and cosmetic goal
Theme Symposium
MANDIBULAR RECONSTRUCTION WITH MICROVASCULAR FIBULAR FLAPS AFTER LARGE RESECTIONS Towards a Functional and Cosmetic Goal Shivaram Bharathwaj*, Antony Arvind* Senior Consultant Plastic Surgeons*, Department of Plastic and Reconstructive Surgery, Apollo Speciality Hospitals, Chennai 600035, India. Correspondence to: Dr. Shivaram Bharathwaj, Apollo Speciality Hospital, Padma Complex, Anna Salai, Teynampet,Chennai 600035, India. E-mail: [email protected], [email protected]
Reconstruction after resection for intraoral malignancies has improved significantly following the widespread use of micro vascular flaps. Mandibulectomy involving more than a small segment of the bone will always leave a significant cosmetic and functional defect. Reconstruction with skin and soft tissue flaps alone results in considerable deviation of the jaw, difficulties in mastication and speech and a less than ideal result. Vascularised bone transfers have now become the mainstay of reconstruction in such defects and the free fibular transfer has become the flap of choice worldwide. The requirements are usually for combinations of loss of bone, lining, cover and soft tissue for volume. In this paper, we present our consecutive series of 59 patients who underwent a free fibula transfer for reconstruction after mandibulectomy where the defect involved loss of more than 2 components outlined above. The indications, details of the defects, modifications of the surgical technique, complications, and donor site morbidity and outcome are discussed and the literature reviewed. The free fibular osteocutaneous flap appears to be the ideal flap for postmandibulectomy defects due to its reliability, versatility and ability to be contoured to the mandibular shape as well as the associated amount of skin and soft tissue that can be harvested with it. Key words: Intra-oral tumors, Mandibulectomy, Goals of reconstruction, Microvascular flap, Fibula, Osteointegration
THE mandible constitutes a significant part of the facial skeleton, forming the profile and contour of the lower third of the face. It is the structural foundation for the lower dentition as well as the origin for the tongue muscles. The muscles of mastication are also inserted into this bone. The mandible is vital for crucial functions like speech, chewing, swallowing, oral competence as well as the facial appearance.
patients. Thus, even patients with a very limited life expectancy are routinely reconstructed if it is expected that their quality of remaining life would be significantly enhanced. The high success rate of head and neck microsurgical reconstructive procedures has allowed for significant improvement in both functional and esthetic results and has significantly changed the approach to mandibular reconstruction.
Resection of the mandible is performed as part of the surgery most commonly for benign and malignant tumors, and less frequently for osteoradionecrosis, osteomyelitis or trauma. In attempting to reconstruct the defect, the goal should be to choose a technique that will allow the maintenance of the functions mentioned above as well achieve a reasonable cosmetic appearance, both of which are crucial to a good quality of life. The concept of maintaining quality of life has become particularly important in the overall care and treatment of cancer
Until the advent of free tissue transfer, reconstruction of defects of the mandible and mid face was sub optimal. Anterior mandibular arch defects resulted in the so-called “Andy Gump” deformity - a term coined in 1978 in a dental publication referring to the appearance of a chinless cartoon character from early in the 20th century. These patients had not only an obvious cosmetic deformity, but also severe functional problems such as poor oral competence with drooling, making them in many cases social cripples. Patients with small lateral defects had less severe problems, but they too had difficulties with chewing, swallowing, and speaking. Plating across defects usually [eventually] resulted in plate exposure, particularly in irradiated patients.
This paper was presented at the 39th Annual Conference of the Association of Plastic Surgeons of India at Jaipur, November 2004.
109
Apollo Medicine, Vol.1, December 2004
Theme Symposium
Traditionally, patients with post resection mandibular defects have been reconstructed with either bulky soft tissue flaps [like the pectoralis major myocutaneous flap] or by non vascularised bone grafts. However, it is obvious that replacing a large bone defect with soft tissue interposition is far from satisfactory both from a functional as well as from a cosmetic viewpoint. The need for pre or postoperative radiotherapy, scarred bed, previous surgery, large mucosal and/or skin defects will exclude the latter option. Today, mandibular reconstruction is best performed with free vascularized bone transfer. Only patients who are medically unfit to tolerate a long operation or have a poor prognosis are excluded as candidates for resection and immediate vascularized bone reconstruction. A variety of free flaps have been used for mandible reconstruction [1-7] The iliac bone, radius, scapula and fibula remain popular. Although most publications have attempted to define the advantages and disadvantages of these donor sites, there are very few studies that objectively compared one with the other [8,9]. The choice of flap depends on factors such as the bone and soft tissue requirements and the site of the defect. Donor site availability, morbidity, ease of flap dissection and the status of the recipient vessels in the neck, as well as the patient’s overall medical condition may also influence the final decision. The fibula free flap was introduced in the mid 1970s and was first described as a technique for mandibular reconstruction in 1989 by Hidalgo [10]. It is now the most popular method of mandibular reconstruction [11-14]. The presence of both endosteal and periosteal blood supplies to the bone allows for multiple osteotomies and thereby precise contouring to obtain the shape of the native mandible. OSTEOINTEGRATION In the last few years, the concept of reconstructive surgery for defects, whether following trauma or oncological resections, has slowly metamorphosed from one of “filling a hole” to that of achieving a functional and cosmetic unit that resembles the original as closely as possible. With the advent of microvascular surgery, mandibular reconstruction has reached such a high level of sophistication that there is a debate not only about which type of living bone transplant gives the best functional and esthetic result, but also about which bone flap provides the most appropriate bed for prosthetic osteo-integrated implants. This advance in prosthodontics has paved the way for dental rehabilitation using permanent implants for teeth. In effect, the reconstruction aims, in appropriate cases, to achieve not only contour, but also excellent function as far as mastication is concerned [15]. The implants placement Apollo Medicine, Vol.1, December 2004
for osteointegration can be done either at the time of the primary reconstruction or as a secondary procedure 3 to 6 months later. MATERIALS AND METHODS This retrospective review is of a consecutive series of cases of mandibular reconstruction with free fibula over a 5-year period from September ’99 to August 2004, done by the 2 authors at Chennai. Out of a total of 135 patients who had excision of the mandible either alone or as part of larger resections, 101 underwent reconstruction with a microvascular flap. Soft tissue alone was used in 37 patients, reconstruction plate along with a microvascular skin flap in 3 patients, free bone graft along with a microvascular skin flap in 2 patients and vascularised fibular flap in 59 patients. The indications in this group are outlined in the table. While the age of the patients ranged from 12 years to 75 years, 29 of them had undergone previous surgery and 41 had received prior radiotherapy to the tumor. Of the 59, 51 had only a fibular flap while 4 patients had additional microvascular flaps [2 radial forearm and 2 anterolateral thigh flap] to provide for skin cover and 4 patients had an additional local flap. The mean operative time was 9.5 hours. Bone defect ranged from 3 cm to 15 cm and the skin paddle harvested ranged in size from 5 cm × 2 cm up to 20 cm × 8 cm. OPERATIVE TECHNIQUE A 2-team approach is used and the harvest of the flap is carried out simultaneously as the resection of the tumor is being done by the oncological surgeon. The leg is evaluated with a hand held Doppler unit to identify perforating vessels in the posterior peroneal septum. These are marked, and the skin flap is then designed to incorporate at least one vessel. The intermuscular septum is located by palpation and anatomic landmarks. The flap is raised under tourniquet control. Proximally, 5 cm of bone is preserved to avoid injury to the peroneal nerve. Distally, at least 5 cm of bone is left to support the ankle mortise. The skin paddle is outlined slightly larger than the anticipated defect size. The incision is carried out around the skin paddle. Proximal and distal
110
Table 1 : Indications for mandibular resection in the group undergoing free fibular reconstruction. Intraoral malignancy Mandibular tumours Osteoradionecrosis Trauma
46 8 4 1
Total
59
Theme Symposium
extensions allow for bone harvest and pedicle dissection. The anterior portion of the skin paddle is dissected. The peroneus longus is reflected anteriorly, and the fibular bone is identified and the muscle origins are carefully divided. The posterior crural septum is located. Once visualized, the septum is examined for perforators. According to the soft tissue requirements, a portion of the flexor hallucis muscle can be harvested along with the flap. The thick interosseous septum is identified. Posterior dissection is performed to free up the skin paddle from the soleus and gastrocnemius muscles, and the septum is identified from its posterior aspect. Bony cuts are made with an oscillating saw. The bone is pulled laterally as the interosseous membrane is transected. Dissection is continued proximally to the posterior tibial bifurcation and after complete isolation of the flap on the peroneal vessels, the tourniquet is deflated, the skin flap is checked for healthy bleeding and hemostasis achieved. The contouring of the bone is done by either preplating the mandible with a reconstruction plate before resection, or, where oncological principles preclude the exposure of the outer cortex, using a soft template to match the mandibular contour after the removal of the specimen. In some instances [very large resections], we have had to use an external fixator to fix the ends of the mandible in position to achieve the correct contour and position of the neomandibe. The length of bone needed for reconstruction is measured. Proximal elevation of periosteum along the fibula allows sizing of the bone and lengthening of the pedicle. If the bone needs contouring, osteotomies are performed, repeatedly checking for the contour by aligning it with the plate. At this point, if primary osteointegration is to be done, the implants [usually 1 to 4] are drilled into the osteotomised bone at predetermined sites. The leg wound is either closed primarily or with a split thickness skin graft A posterior plaster of Paris leg splint is fabricated and applied, either at this point or at the end of the case. The bone is plated and inset into the defect following osteotomies. The pedicle is positioned along the lingual aspect of the flap, and the skin paddle is adjusted. After tension-free positioning is achieved, the skin paddle is inset carefully to provide a watertight closure. The anastomosis is then performed to previously dissected vessels in the neck with standard microvascular techniques. The flaps are monitored in the postoperative period hourly initially and then at less frequent intervals. Feeding is through a nasogastric tube for the first 2 weeks.
The patient is allowed to ambulate in a non-weightbearing fashion on the third postoperative day. The splint is removed and the skin graft assessed on the fifth postoperative day. The patient is then allowed to slowly increase the mobility. When a skin graft is not used, the splint is not placed, and the patient is allowed to bear weight on the second day following surgery. A speech pathologist, physical therapist, and other specialists, as required, also evaluate the patient. Patients generally resume an oral diet approximately 2-3 weeks following discharge if no complications arise. Continuing dental/oral surgery evaluation and management allows for placement of dentures or implants at an appropriate time in selected patients. In this series, osteointegration was done in a total of 7 patients, of whom 2 had surgery for intraoral malignancy, and the remaining were for mandibular tumors. Four patients had implants at the time of the primary reconstruction and secondary osteointegration was done in 3 patients. A further 4 patients are currently in the process of undergoing osteointegration. RESULTS The primary consultant as well as the reconstructive team followed up all patients and the follow-up ranged from 5 years to 6 months. A total of 5 flaps were lost completely and in 2 patients part of the skin paddle used for external skin cover was lost. All these losses occurred in the initial cases and there have been no losses in the latter half of the series. Seven patients developed a wound infection and 5 developed a salivary leak. The donor site healed quite well in all except 3 patients who had a partial skin graft loss and one of these required a secondary grafting procedure. All the patients were able to swallow normal food and by 3 to 6 months, and most patients had good intelligible speech. The extent of recovery of good speech and swallowing will depend to a large extent on the amount of soft tissue resection and resection of structures such as the lingual and hypoglossal nerves and tongue base limits restoration of normal function. Trismus, which occurred in about half the patients, is possible a result of surgical manipulation and/or resection of the masticator muscles and disturbances in mandibular integrity. However most of them recovered good mouth opening in 3-6 months. All the patients were given speech and swallowing therapy to facilitate quicker rehabilitation. Dental rehabilitation for the patients with implants was done 3 to 4 months following implant placement. Most patients had a good to excellent cosmetic result although a few had slight asymmetry, particularly inferomedial to the
111
Apollo Medicine, Vol.1, December 2004
Theme Symposium
Key Messages •
Large mandibular resections leave a significant cosmetic and functional deficit.
•
Reconstruction has improved dramatically with microvascular tissue transfer.
•
The fibular osteoseptocutaneous flap is very versatile and provides bone, lining, cover as well as soft tissue bulk.
•
Success rates are high and donor site morbidity is low.
•
The good cosmetic and functional results of reconstruction justify the extensive procedure.
angle of the neomandible. Objective evaluations of appearance, speech and swallowing are currently underway. Figures 1 and 2 are illustrative examples of a central and lateral segment reconstruction, respectively. DISCUSSION Free vascularised osteocutaneous flap is now a wellestablished technique of reconstruction with numerous
Fig. 1(c). Flap outlined over the fibula, yellow circles over perforators located with Doppler and skin paddle marked. Fig. 1(a). Large ameloblastoma of the mandible, intraoral view.
Fig. 1(b). Excised specimen, angle-to-angle resection. Apollo Medicine, Vol.1, December 2004
Fig. 1(d). Fibular flap osteotomised, implants inserted. 112
Theme Symposium
Fig. 1(e).Flap inset and fixed to plate [intraoral view from above].
Fig. 1(g). Occlusal view with teeth fitted.
Fig. 2(a). Intraoperative picture of defect of a 68 yr old patient following radical left hemimandibulectomy for post RT cheek Ca involving mandible. Fig. 1(f). Six months postoperative, profile.
advantages [16-19]. Healing by callus replaces the creeping substitution of conventional bone grafts [20], while the vascularity of the attached soft tissue promotes primary healing and reduces the risk of fistula formation. In particular, where the bed is already compromised due to prior irradiation, scarring or infection, these flaps bring in fresh blood supply and are not dependent on the bed for their
survival. The versatility of these flaps is such that large segments of bone can not only be transferred with similar success to that of smaller segments [21], but multiple osteotomies can safely be done to contour the bone to the required shape. This procedure is done in a single stage, thus cutting down on the number of hospitalizations as well as the overall hospital stay. This has significant implications for the older patient who has a limited life span and also the social and financial resources, which are already tightly
113
Apollo Medicine, Vol.1, December 2004
Theme Symposium
Fig. 2(d). Two year postoperative views. Fig. 2(b).Fibular flap fixed to condylar\reconstruction plate, note muscle used\for soft tissue augmentation.
Fig. 2(c). Flap inset and microvascular anastomosis done.
stretched. In younger patients, the reliability and durability of vascularised bone grafts and their ability to accept osteointegrated implants for full dental rehabilitation make them a desirable choice, even within a hostile bed [22]. In fact, in spite of reservations on this issue, even patients who have had postoperative radiotherapy have had successful dental implants in our series. Those patients who are not candidates for osteointegration may be fitted with dentures but chewing will be less optimal than those with implants. Apollo Medicine, Vol.1, December 2004
Fig. 2(e). Two year postoperative views.
All donor sites have their limitations. The use of the radius, which was once popular for mandibular reconstruction, is associated with a risk of fracture particularly when large segments are used. Use of the scapula is made difficult by positioning problems and hence a longer operating time and is reported to often result in shoulder stiffness and a decreased range of motion [5,9]. The ilium is commonly associated with delayed ambulation
114
Theme Symposium
because of pain. Moreover, in a composite oromandibular defect, the iliac crest is limited due to the inherent bulkiness of the soft tissue component [8,9]. The vascularised fibula has more recently become a universally preferred donor tissue [25]. The advantages include availability of a long bone segment, adequate strong bicortical bone to support osteo-integrated implants, a segmental blood supply that allows osteotomies at suitable sites, and muscle, which can be included for replacing soft tissue bulk. Contrary to earlier belief, the skin island is not only very reliable but when raised on perforators, can be placed intra or extra orally with considerable independence from the bone segment. In fact, we have raised as many as 3 different skin islands to fill such defects [Fig. 3] Further advantages include large vessels of sufficient length for easy anastomosis and an ideal location that facilitates a twoteam approach during ablation and reconstruction [10-14]. In adults, a straight (20-26 cm) fibular segment can be harvested, providing great versatility for reconstruction of extensive mandibular defects. Although the fibula can tolerate osteotomies at 2 cm intervals to enable accurate reconstruction [10], the tendency now is to do as few osteotomies as compatible with good contour [23]. The cosmetic result of the reconstruction, as evaluated by the patient or others, is usually rated as good to excellent in most series. The best results are obtained in those with mainly bony defects with little mucosal or skin loss, typified by those with mandibular tumors. The donor site usually heals well [Fig.4]. Head and neck oncological surgery has advanced tremendously in the last two decades, thanks to several factors like advances in diagnostic imaging, bold new approaches to resection made possible by sophisticated reconstructive techniques and good teamwork.. Mutilating surgery that earlier left cosmetically unacceptable defects
Fig. 4. Donor site, 6 months (different patient).
can now be reconstructed well, thanks to innovative plastic surgical techniques, particularly microvascular tissue transfer. One such challenging defect is that following large segment mandibular resection. The fibular osteoseptocutaneous free flap with a reliable skin paddle, a favourable vascular anatomy for osteotomies, adjacent soft tissue availability and low donor site morbidity is an ideal donor for reconstruction of the post mandibular defect, providing not only good cosmesis but also excellent function with minimal complications. SUMMARY
Fig. 3. Fibular flap with 3 skin paddles islanded on perforators.
This a review of a consecutive series of mandibular reconstructions following large segment resections using a fibular osteoseptocutaneous free tissue transfers over a 5-year period. The indications, rationale for the procedure, operative technique, technical modifications, postoperative care, results and follow-up are discussed. Flap failure occurred completely in 5 patients and partially in 2. Speech, swallowing and mouth opening were the main problems in the postoperative period but improved significantly with therapy. The donor site morbidity is minimal and the long-term functional and cosmetic results are very encouraging.
115
Apollo Medicine, Vol.1, December 2004
Theme Symposium REFERENCES 1. Serafin D, Villarrel-Rios A, Georgiade NA. A rib-containing free flap to reconstruct mandibular defects. Br J Plast Surg 1977; 30: 263-266. 2. Bell M, Barron PT. A new method of oral reconstruction using a free composite foot flap. Ann Plast Surg 1980; 5: 281-287.
13. Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 1995; 96: 585-596. 14. Shpitzer T, Neligan P, Gullane P, et al. Oromandibular reconstruction with the free fibula flap: analysis of 50 consecutive flaps. Arch Otolaryngol Head Neck Surg 1997; 123: 939-944.
3. Duncan MJ, Manktelow RT, Zuker RM, Rosen IB. Mandibular reconstruction in the radiated patient: the role of osteocutaneous free-tissue transfers. Plast Reconstr Surg 1985;76: 829-840.
15. Zlotow IM, Huryn JM, Piro JD, Lenchewski E, Hidalgo DA. Osteointegrated implants and functional prosthetic rehabilitation in microvascular fibula free flap reconstructed mandibles. Am. J. Surg. 1992; 164: 677-683.
4. Swartz WM, Banis JC, Newton ED, Ramasastry S, Jones N, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986; 77: 530-545.
16. Daniel RK. Mandibular reconstruction with free tissue transfers. Ann Plast Surg 1978; 1: 346-371.
5. Soutar DS, Scheker LR, Tommer NS, Mc Gregor ZA. The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 1983; 36: 1-8.
17. Rosen IB, Bell MS, Barron P, Zuker RM, Manktelow RT. Use of microvascular flaps including free osteocutaneous flaps in reconstruction after composite resection for radiation-recurrent oral cancer. Am J Surg 1979; 138: 544550.
6. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps: experimental work. Plast Reconstr Surg 1979; 64: 595-604.
18. Zuker RM, Manktelow RT, Palmer JA, Rosen IB. Head and neck reconstruction following resection of carcinoma, using microvascular free flaps. Surgery 1980; 88: 461-467.
7. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps: clinical work. Plast Reconstr Surg 1979; 64: 745-759.
19. Taylor GI. Reconstruction of the mandible with free composite iliac bone grafts. Ann Plast Surg 1982; 9: 361376.
8. Jewer DB, Boyd JB, Manktelow RT, et al. Orofacial and mandibular reconstruction with the iliac crest free flap: a review of 60 cases and a system of classification. Plast Reconstr Surg 1989; 84:391-403.
20. Weiland AJ, Phillips TW, Randolph MA. Bone grafts: a radiologic, histologic and biomechanical model comparing autografts, allografts and free vascularized bone grafts. Plast Reconstr Surg 1984; 74: 368-379.
9. Boyd JB, Rosen I, Rotstein L, Freeman J, et al. The iliac crest and the radial forearm flap in vascularized oromandibular reconstruction. Am J Surg 1990; 159: 301308.
21. Osterman AL, Bora FW. Free vascularized bone grafting for large-gap non-union of long bones. Orthop Clin North Am 1984; 15: 131-141.
10. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989; 84: 71-79. 11. Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai, MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg 1994; 93: 294304. 12. Cheung SW, Anthony JP, Singer MI. Restoration of anterior mandible with the free fibula osseocutaneous flap. Laryngoscope 1994; 104: 105-113.
Apollo Medicine, Vol.1, December 2004
22. Boyd JB. Mandibular reconstruction in the young adult using free vascularized iliac crest. Microsurgery 1988; 9: 141-149. 23. Wei FC, Personal communication, 2001. 24. Anthony JP, Rawnsley JD, Benhaim P: Donor leg morbidity and function after fibula free flap mandible reconstruction. Plast Reconstr Surg 1995; 96: 146-152. 25. Hidalgo DA: Fibula free flap mandibular reconstruction. Clin Plast Surg 1994; 21: 25-35.
116
MANDIBULAR RECONSTRUCTION WITH MICROVASCULAR FIBULAR FLAPS AFTER LARGE RESECTIONS Towards a Functional and Cosmetic Goal Shivaram Bharathwaj*, Antony Arvind* Senior Consultant Plastic Surgeons*, Department of Plastic and Reconstructive Surgery, Apollo Speciality Hospitals, Chennai 600035, India. Correspondence to: Dr. Shivaram Bharathwaj, Apollo Speciality Hospital, Padma Complex, Anna Salai, Teynampet,Chennai 600035, India. E-mail: [email protected], [email protected]
Reconstruction after resection for intraoral malignancies has improved significantly following the widespread use of micro vascular flaps. Mandibulectomy involving more than a small segment of the bone will always leave a significant cosmetic and functional defect. Reconstruction with skin and soft tissue flaps alone results in considerable deviation of the jaw, difficulties in mastication and speech and a less than ideal result. Vascularised bone transfers have now become the mainstay of reconstruction in such defects and the free fibular transfer has become the flap of choice worldwide. The requirements are usually for combinations of loss of bone, lining, cover and soft tissue for volume. In this paper, we present our consecutive series of 59 patients who underwent a free fibula transfer for reconstruction after mandibulectomy where the defect involved loss of more than 2 components outlined above. The indications, details of the defects, modifications of the surgical technique, complications, and donor site morbidity and outcome are discussed and the literature reviewed. The free fibular osteocutaneous flap appears to be the ideal flap for postmandibulectomy defects due to its reliability, versatility and ability to be contoured to the mandibular shape as well as the associated amount of skin and soft tissue that can be harvested with it. Key words: Intra-oral tumors, Mandibulectomy, Goals of reconstruction, Microvascular flap, Fibula, Osteointegration
THE mandible constitutes a significant part of the facial skeleton, forming the profile and contour of the lower third of the face. It is the structural foundation for the lower dentition as well as the origin for the tongue muscles. The muscles of mastication are also inserted into this bone. The mandible is vital for crucial functions like speech, chewing, swallowing, oral competence as well as the facial appearance.
patients. Thus, even patients with a very limited life expectancy are routinely reconstructed if it is expected that their quality of remaining life would be significantly enhanced. The high success rate of head and neck microsurgical reconstructive procedures has allowed for significant improvement in both functional and esthetic results and has significantly changed the approach to mandibular reconstruction.
Resection of the mandible is performed as part of the surgery most commonly for benign and malignant tumors, and less frequently for osteoradionecrosis, osteomyelitis or trauma. In attempting to reconstruct the defect, the goal should be to choose a technique that will allow the maintenance of the functions mentioned above as well achieve a reasonable cosmetic appearance, both of which are crucial to a good quality of life. The concept of maintaining quality of life has become particularly important in the overall care and treatment of cancer
Until the advent of free tissue transfer, reconstruction of defects of the mandible and mid face was sub optimal. Anterior mandibular arch defects resulted in the so-called “Andy Gump” deformity - a term coined in 1978 in a dental publication referring to the appearance of a chinless cartoon character from early in the 20th century. These patients had not only an obvious cosmetic deformity, but also severe functional problems such as poor oral competence with drooling, making them in many cases social cripples. Patients with small lateral defects had less severe problems, but they too had difficulties with chewing, swallowing, and speaking. Plating across defects usually [eventually] resulted in plate exposure, particularly in irradiated patients.
This paper was presented at the 39th Annual Conference of the Association of Plastic Surgeons of India at Jaipur, November 2004.
109
Apollo Medicine, Vol.1, December 2004
Theme Symposium
Traditionally, patients with post resection mandibular defects have been reconstructed with either bulky soft tissue flaps [like the pectoralis major myocutaneous flap] or by non vascularised bone grafts. However, it is obvious that replacing a large bone defect with soft tissue interposition is far from satisfactory both from a functional as well as from a cosmetic viewpoint. The need for pre or postoperative radiotherapy, scarred bed, previous surgery, large mucosal and/or skin defects will exclude the latter option. Today, mandibular reconstruction is best performed with free vascularized bone transfer. Only patients who are medically unfit to tolerate a long operation or have a poor prognosis are excluded as candidates for resection and immediate vascularized bone reconstruction. A variety of free flaps have been used for mandible reconstruction [1-7] The iliac bone, radius, scapula and fibula remain popular. Although most publications have attempted to define the advantages and disadvantages of these donor sites, there are very few studies that objectively compared one with the other [8,9]. The choice of flap depends on factors such as the bone and soft tissue requirements and the site of the defect. Donor site availability, morbidity, ease of flap dissection and the status of the recipient vessels in the neck, as well as the patient’s overall medical condition may also influence the final decision. The fibula free flap was introduced in the mid 1970s and was first described as a technique for mandibular reconstruction in 1989 by Hidalgo [10]. It is now the most popular method of mandibular reconstruction [11-14]. The presence of both endosteal and periosteal blood supplies to the bone allows for multiple osteotomies and thereby precise contouring to obtain the shape of the native mandible. OSTEOINTEGRATION In the last few years, the concept of reconstructive surgery for defects, whether following trauma or oncological resections, has slowly metamorphosed from one of “filling a hole” to that of achieving a functional and cosmetic unit that resembles the original as closely as possible. With the advent of microvascular surgery, mandibular reconstruction has reached such a high level of sophistication that there is a debate not only about which type of living bone transplant gives the best functional and esthetic result, but also about which bone flap provides the most appropriate bed for prosthetic osteo-integrated implants. This advance in prosthodontics has paved the way for dental rehabilitation using permanent implants for teeth. In effect, the reconstruction aims, in appropriate cases, to achieve not only contour, but also excellent function as far as mastication is concerned [15]. The implants placement Apollo Medicine, Vol.1, December 2004
for osteointegration can be done either at the time of the primary reconstruction or as a secondary procedure 3 to 6 months later. MATERIALS AND METHODS This retrospective review is of a consecutive series of cases of mandibular reconstruction with free fibula over a 5-year period from September ’99 to August 2004, done by the 2 authors at Chennai. Out of a total of 135 patients who had excision of the mandible either alone or as part of larger resections, 101 underwent reconstruction with a microvascular flap. Soft tissue alone was used in 37 patients, reconstruction plate along with a microvascular skin flap in 3 patients, free bone graft along with a microvascular skin flap in 2 patients and vascularised fibular flap in 59 patients. The indications in this group are outlined in the table. While the age of the patients ranged from 12 years to 75 years, 29 of them had undergone previous surgery and 41 had received prior radiotherapy to the tumor. Of the 59, 51 had only a fibular flap while 4 patients had additional microvascular flaps [2 radial forearm and 2 anterolateral thigh flap] to provide for skin cover and 4 patients had an additional local flap. The mean operative time was 9.5 hours. Bone defect ranged from 3 cm to 15 cm and the skin paddle harvested ranged in size from 5 cm × 2 cm up to 20 cm × 8 cm. OPERATIVE TECHNIQUE A 2-team approach is used and the harvest of the flap is carried out simultaneously as the resection of the tumor is being done by the oncological surgeon. The leg is evaluated with a hand held Doppler unit to identify perforating vessels in the posterior peroneal septum. These are marked, and the skin flap is then designed to incorporate at least one vessel. The intermuscular septum is located by palpation and anatomic landmarks. The flap is raised under tourniquet control. Proximally, 5 cm of bone is preserved to avoid injury to the peroneal nerve. Distally, at least 5 cm of bone is left to support the ankle mortise. The skin paddle is outlined slightly larger than the anticipated defect size. The incision is carried out around the skin paddle. Proximal and distal
110
Table 1 : Indications for mandibular resection in the group undergoing free fibular reconstruction. Intraoral malignancy Mandibular tumours Osteoradionecrosis Trauma
46 8 4 1
Total
59
Theme Symposium
extensions allow for bone harvest and pedicle dissection. The anterior portion of the skin paddle is dissected. The peroneus longus is reflected anteriorly, and the fibular bone is identified and the muscle origins are carefully divided. The posterior crural septum is located. Once visualized, the septum is examined for perforators. According to the soft tissue requirements, a portion of the flexor hallucis muscle can be harvested along with the flap. The thick interosseous septum is identified. Posterior dissection is performed to free up the skin paddle from the soleus and gastrocnemius muscles, and the septum is identified from its posterior aspect. Bony cuts are made with an oscillating saw. The bone is pulled laterally as the interosseous membrane is transected. Dissection is continued proximally to the posterior tibial bifurcation and after complete isolation of the flap on the peroneal vessels, the tourniquet is deflated, the skin flap is checked for healthy bleeding and hemostasis achieved. The contouring of the bone is done by either preplating the mandible with a reconstruction plate before resection, or, where oncological principles preclude the exposure of the outer cortex, using a soft template to match the mandibular contour after the removal of the specimen. In some instances [very large resections], we have had to use an external fixator to fix the ends of the mandible in position to achieve the correct contour and position of the neomandibe. The length of bone needed for reconstruction is measured. Proximal elevation of periosteum along the fibula allows sizing of the bone and lengthening of the pedicle. If the bone needs contouring, osteotomies are performed, repeatedly checking for the contour by aligning it with the plate. At this point, if primary osteointegration is to be done, the implants [usually 1 to 4] are drilled into the osteotomised bone at predetermined sites. The leg wound is either closed primarily or with a split thickness skin graft A posterior plaster of Paris leg splint is fabricated and applied, either at this point or at the end of the case. The bone is plated and inset into the defect following osteotomies. The pedicle is positioned along the lingual aspect of the flap, and the skin paddle is adjusted. After tension-free positioning is achieved, the skin paddle is inset carefully to provide a watertight closure. The anastomosis is then performed to previously dissected vessels in the neck with standard microvascular techniques. The flaps are monitored in the postoperative period hourly initially and then at less frequent intervals. Feeding is through a nasogastric tube for the first 2 weeks.
The patient is allowed to ambulate in a non-weightbearing fashion on the third postoperative day. The splint is removed and the skin graft assessed on the fifth postoperative day. The patient is then allowed to slowly increase the mobility. When a skin graft is not used, the splint is not placed, and the patient is allowed to bear weight on the second day following surgery. A speech pathologist, physical therapist, and other specialists, as required, also evaluate the patient. Patients generally resume an oral diet approximately 2-3 weeks following discharge if no complications arise. Continuing dental/oral surgery evaluation and management allows for placement of dentures or implants at an appropriate time in selected patients. In this series, osteointegration was done in a total of 7 patients, of whom 2 had surgery for intraoral malignancy, and the remaining were for mandibular tumors. Four patients had implants at the time of the primary reconstruction and secondary osteointegration was done in 3 patients. A further 4 patients are currently in the process of undergoing osteointegration. RESULTS The primary consultant as well as the reconstructive team followed up all patients and the follow-up ranged from 5 years to 6 months. A total of 5 flaps were lost completely and in 2 patients part of the skin paddle used for external skin cover was lost. All these losses occurred in the initial cases and there have been no losses in the latter half of the series. Seven patients developed a wound infection and 5 developed a salivary leak. The donor site healed quite well in all except 3 patients who had a partial skin graft loss and one of these required a secondary grafting procedure. All the patients were able to swallow normal food and by 3 to 6 months, and most patients had good intelligible speech. The extent of recovery of good speech and swallowing will depend to a large extent on the amount of soft tissue resection and resection of structures such as the lingual and hypoglossal nerves and tongue base limits restoration of normal function. Trismus, which occurred in about half the patients, is possible a result of surgical manipulation and/or resection of the masticator muscles and disturbances in mandibular integrity. However most of them recovered good mouth opening in 3-6 months. All the patients were given speech and swallowing therapy to facilitate quicker rehabilitation. Dental rehabilitation for the patients with implants was done 3 to 4 months following implant placement. Most patients had a good to excellent cosmetic result although a few had slight asymmetry, particularly inferomedial to the
111
Apollo Medicine, Vol.1, December 2004
Theme Symposium
Key Messages •
Large mandibular resections leave a significant cosmetic and functional deficit.
•
Reconstruction has improved dramatically with microvascular tissue transfer.
•
The fibular osteoseptocutaneous flap is very versatile and provides bone, lining, cover as well as soft tissue bulk.
•
Success rates are high and donor site morbidity is low.
•
The good cosmetic and functional results of reconstruction justify the extensive procedure.
angle of the neomandible. Objective evaluations of appearance, speech and swallowing are currently underway. Figures 1 and 2 are illustrative examples of a central and lateral segment reconstruction, respectively. DISCUSSION Free vascularised osteocutaneous flap is now a wellestablished technique of reconstruction with numerous
Fig. 1(c). Flap outlined over the fibula, yellow circles over perforators located with Doppler and skin paddle marked. Fig. 1(a). Large ameloblastoma of the mandible, intraoral view.
Fig. 1(b). Excised specimen, angle-to-angle resection. Apollo Medicine, Vol.1, December 2004
Fig. 1(d). Fibular flap osteotomised, implants inserted. 112
Theme Symposium
Fig. 1(e).Flap inset and fixed to plate [intraoral view from above].
Fig. 1(g). Occlusal view with teeth fitted.
Fig. 2(a). Intraoperative picture of defect of a 68 yr old patient following radical left hemimandibulectomy for post RT cheek Ca involving mandible. Fig. 1(f). Six months postoperative, profile.
advantages [16-19]. Healing by callus replaces the creeping substitution of conventional bone grafts [20], while the vascularity of the attached soft tissue promotes primary healing and reduces the risk of fistula formation. In particular, where the bed is already compromised due to prior irradiation, scarring or infection, these flaps bring in fresh blood supply and are not dependent on the bed for their
survival. The versatility of these flaps is such that large segments of bone can not only be transferred with similar success to that of smaller segments [21], but multiple osteotomies can safely be done to contour the bone to the required shape. This procedure is done in a single stage, thus cutting down on the number of hospitalizations as well as the overall hospital stay. This has significant implications for the older patient who has a limited life span and also the social and financial resources, which are already tightly
113
Apollo Medicine, Vol.1, December 2004
Theme Symposium
Fig. 2(d). Two year postoperative views. Fig. 2(b).Fibular flap fixed to condylar\reconstruction plate, note muscle used\for soft tissue augmentation.
Fig. 2(c). Flap inset and microvascular anastomosis done.
stretched. In younger patients, the reliability and durability of vascularised bone grafts and their ability to accept osteointegrated implants for full dental rehabilitation make them a desirable choice, even within a hostile bed [22]. In fact, in spite of reservations on this issue, even patients who have had postoperative radiotherapy have had successful dental implants in our series. Those patients who are not candidates for osteointegration may be fitted with dentures but chewing will be less optimal than those with implants. Apollo Medicine, Vol.1, December 2004
Fig. 2(e). Two year postoperative views.
All donor sites have their limitations. The use of the radius, which was once popular for mandibular reconstruction, is associated with a risk of fracture particularly when large segments are used. Use of the scapula is made difficult by positioning problems and hence a longer operating time and is reported to often result in shoulder stiffness and a decreased range of motion [5,9]. The ilium is commonly associated with delayed ambulation
114
Theme Symposium
because of pain. Moreover, in a composite oromandibular defect, the iliac crest is limited due to the inherent bulkiness of the soft tissue component [8,9]. The vascularised fibula has more recently become a universally preferred donor tissue [25]. The advantages include availability of a long bone segment, adequate strong bicortical bone to support osteo-integrated implants, a segmental blood supply that allows osteotomies at suitable sites, and muscle, which can be included for replacing soft tissue bulk. Contrary to earlier belief, the skin island is not only very reliable but when raised on perforators, can be placed intra or extra orally with considerable independence from the bone segment. In fact, we have raised as many as 3 different skin islands to fill such defects [Fig. 3] Further advantages include large vessels of sufficient length for easy anastomosis and an ideal location that facilitates a twoteam approach during ablation and reconstruction [10-14]. In adults, a straight (20-26 cm) fibular segment can be harvested, providing great versatility for reconstruction of extensive mandibular defects. Although the fibula can tolerate osteotomies at 2 cm intervals to enable accurate reconstruction [10], the tendency now is to do as few osteotomies as compatible with good contour [23]. The cosmetic result of the reconstruction, as evaluated by the patient or others, is usually rated as good to excellent in most series. The best results are obtained in those with mainly bony defects with little mucosal or skin loss, typified by those with mandibular tumors. The donor site usually heals well [Fig.4]. Head and neck oncological surgery has advanced tremendously in the last two decades, thanks to several factors like advances in diagnostic imaging, bold new approaches to resection made possible by sophisticated reconstructive techniques and good teamwork.. Mutilating surgery that earlier left cosmetically unacceptable defects
Fig. 4. Donor site, 6 months (different patient).
can now be reconstructed well, thanks to innovative plastic surgical techniques, particularly microvascular tissue transfer. One such challenging defect is that following large segment mandibular resection. The fibular osteoseptocutaneous free flap with a reliable skin paddle, a favourable vascular anatomy for osteotomies, adjacent soft tissue availability and low donor site morbidity is an ideal donor for reconstruction of the post mandibular defect, providing not only good cosmesis but also excellent function with minimal complications. SUMMARY
Fig. 3. Fibular flap with 3 skin paddles islanded on perforators.
This a review of a consecutive series of mandibular reconstructions following large segment resections using a fibular osteoseptocutaneous free tissue transfers over a 5-year period. The indications, rationale for the procedure, operative technique, technical modifications, postoperative care, results and follow-up are discussed. Flap failure occurred completely in 5 patients and partially in 2. Speech, swallowing and mouth opening were the main problems in the postoperative period but improved significantly with therapy. The donor site morbidity is minimal and the long-term functional and cosmetic results are very encouraging.
115
Apollo Medicine, Vol.1, December 2004
Theme Symposium REFERENCES 1. Serafin D, Villarrel-Rios A, Georgiade NA. A rib-containing free flap to reconstruct mandibular defects. Br J Plast Surg 1977; 30: 263-266. 2. Bell M, Barron PT. A new method of oral reconstruction using a free composite foot flap. Ann Plast Surg 1980; 5: 281-287.
13. Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 1995; 96: 585-596. 14. Shpitzer T, Neligan P, Gullane P, et al. Oromandibular reconstruction with the free fibula flap: analysis of 50 consecutive flaps. Arch Otolaryngol Head Neck Surg 1997; 123: 939-944.
3. Duncan MJ, Manktelow RT, Zuker RM, Rosen IB. Mandibular reconstruction in the radiated patient: the role of osteocutaneous free-tissue transfers. Plast Reconstr Surg 1985;76: 829-840.
15. Zlotow IM, Huryn JM, Piro JD, Lenchewski E, Hidalgo DA. Osteointegrated implants and functional prosthetic rehabilitation in microvascular fibula free flap reconstructed mandibles. Am. J. Surg. 1992; 164: 677-683.
4. Swartz WM, Banis JC, Newton ED, Ramasastry S, Jones N, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986; 77: 530-545.
16. Daniel RK. Mandibular reconstruction with free tissue transfers. Ann Plast Surg 1978; 1: 346-371.
5. Soutar DS, Scheker LR, Tommer NS, Mc Gregor ZA. The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 1983; 36: 1-8.
17. Rosen IB, Bell MS, Barron P, Zuker RM, Manktelow RT. Use of microvascular flaps including free osteocutaneous flaps in reconstruction after composite resection for radiation-recurrent oral cancer. Am J Surg 1979; 138: 544550.
6. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps: experimental work. Plast Reconstr Surg 1979; 64: 595-604.
18. Zuker RM, Manktelow RT, Palmer JA, Rosen IB. Head and neck reconstruction following resection of carcinoma, using microvascular free flaps. Surgery 1980; 88: 461-467.
7. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps: clinical work. Plast Reconstr Surg 1979; 64: 745-759.
19. Taylor GI. Reconstruction of the mandible with free composite iliac bone grafts. Ann Plast Surg 1982; 9: 361376.
8. Jewer DB, Boyd JB, Manktelow RT, et al. Orofacial and mandibular reconstruction with the iliac crest free flap: a review of 60 cases and a system of classification. Plast Reconstr Surg 1989; 84:391-403.
20. Weiland AJ, Phillips TW, Randolph MA. Bone grafts: a radiologic, histologic and biomechanical model comparing autografts, allografts and free vascularized bone grafts. Plast Reconstr Surg 1984; 74: 368-379.
9. Boyd JB, Rosen I, Rotstein L, Freeman J, et al. The iliac crest and the radial forearm flap in vascularized oromandibular reconstruction. Am J Surg 1990; 159: 301308.
21. Osterman AL, Bora FW. Free vascularized bone grafting for large-gap non-union of long bones. Orthop Clin North Am 1984; 15: 131-141.
10. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989; 84: 71-79. 11. Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai, MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg 1994; 93: 294304. 12. Cheung SW, Anthony JP, Singer MI. Restoration of anterior mandible with the free fibula osseocutaneous flap. Laryngoscope 1994; 104: 105-113.
Apollo Medicine, Vol.1, December 2004
22. Boyd JB. Mandibular reconstruction in the young adult using free vascularized iliac crest. Microsurgery 1988; 9: 141-149. 23. Wei FC, Personal communication, 2001. 24. Anthony JP, Rawnsley JD, Benhaim P: Donor leg morbidity and function after fibula free flap mandible reconstruction. Plast Reconstr Surg 1995; 96: 146-152. 25. Hidalgo DA: Fibula free flap mandibular reconstruction. Clin Plast Surg 1994; 21: 25-35.
116