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Oromandibular Reconstruction After Cancer Resection
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CLINICS IN PLASTIC SURGERY Clin Plastic Surg 32 (2005) 361–375
Oromandibular Reconstruction After Cancer Resection Achilleas Thoma, MD, MSc, FRCS(C), FACS*, Carolyn Levis, MD, FRCS(C), J.E.M. Young, & & & & & &
Epidemiology Classifications Preoperative assessment Principles of reconstruction Reconstructive options Commonly used free flaps
The oral cavity includes the buccal mucosa (ie, inside lining of the lips and cheeks), the teeth, the anterior two thirds of the tongue, the floor of the mouth below the tongue, the hard palate, and the retromolar trigone (area behind the wisdom teeth) [1]. For reconstructive purposes and in consideration of the functions of this anatomic entity (ie, mastication, deglutition, and speech), Yousif et al [2] divided the oral cavity into 10 functional units: Oral sphincter Lingual and buccal sulci Alveolar ridges Floor of mouth Mobile tongue Base of tongue Tonsillar pillars Soft palate Hard palate Buccal mucosa
& &
MD, FRCS(C)
Fibula flap Radial forearm osteocutaneous flap Scapula flap Iliac crest Future predictions and summary References
From a pragmatic and reconstructive point of view, the authors classify the defects as those requiring Lining only Lining and bone Bone alone Cover and bone Lining, bone, and coverage (through and through defects)
Epidemiology Head and neck cancers are common in several regions of the world where rates of tobacco use and alcohol consumption are high. The agestandardized incidence rate of head and neck cancer in males circa 1990 exceeds 30 per 100,000 in regions of France, Hong Kong, the Indian subcontinent, Central and Eastern Europe, Spain, Italy, and Brazil, and in the United States among African
Department of Surgery, McMaster University, Hamilton, Ontario, Canada * Corresponding author. Surgical Outcomes Research Centre, St. Joseph's Healthcare, 101-206 James Street South, Hamilton, Ontario L8P 3A9, Canada. E-mail address: [email protected] (A. Thoma). 0094-1298/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
doi:10.1016/j.cps.2005.01.006
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Americans. The variation in incidence of cancers by anatomic site within the head and neck is mostly related to the relative distribution of major risk factors, such as tobacco or betel quid chewing, cigarette or bidi smoking, and alcohol consumption [3]. From 1985 to 1994, the largest proportion of head and neck cancers arose in the larynx (20.9%) and the oral cavity, including the lip (17.6%) (lip = 3.5%, oral cavity = 14.1%, oropharynx = 12.3%) [4]. In a recent analysis of 221 patients with squamous cell carcinoma (SCC) of the oral cavity, 161 patients had cancer of the tongue, 28 had cancer of the oral cavity, 12 had cancer of the hard palate, 11 had cancer of the buccal mucosa, and nine had cancer of the gingival area [5]. The median age of patients with oral cavity cancers was 64.0 years. Men represented 60.2% of patients. Pathologic diagnosis was SCC in 86.3% of cases. African Americans (independent of income), lower-income patients, and patients with higher-grade disease were seen more frequently with advanced-stage SCC [6]. An estimated 28,260 new cases of oral cavity and pharynx carcinoma were expected in the United States in 2004. Incidence rates are more than twice as high in men as in women and are highest in men older than 50 years. Incidence rates for cancer of the oral cavity and pharynx continued to decline in the 1990s in African American and white men and women. An estimated 7230 deaths from oral cavity and pharynx cancer are expected in 2004. Death rates have been decreasing since the late 1970s, with this decline more rapid in the 1990s. For all stages combined, about 84% of persons with oral cavity and pharynx cancers survive 1 year after diagnosis. The 5-year and 10-year survival rates are 57% and 45%, respectively [7]. Unfortunately, this trend does not apply everywhere. Male incidence rates of head and neck cancer are rising in most regions of the world. Age-adjusted incidence rates of oral and pharyngeal cancer increased after 1970 by 11% per 5-year period and 14% per 5-year period, respectively. The prognosis has not improved substantially since the 1950s [8]. Despite dramatic improvements in surgical and reconstructive techniques in the past 3 decades, the overall mortality rates remain relatively unchanged. The overall 5-year survival rate for persons with oral cavity and pharyngeal cancer is only 52%. When we consider that the risk factors are known and the lesions in the oral cavity and pharynx are easily accessible for early detection, the lack of progress in controlling this cancer is perplexing. The lack of awareness of the disease burden and the risk factors, the tendency for occurrence in
lower socioeconomic classes and poorly compliant populations, and the lack of a simple screening test have hindered progress [9]. Scant change was seen in early detection of oral cancer or 5-year relative survival rates between the periods 1973 to 1984 and 1985 to 1996 in nine Surveillance, Epidemiology, and End Results regions. This finding suggests a deficiency in professional and public education regarding early diagnosis of oral cancer [10]. The degree of mandibular invasion influences the survival rate of patients with SCC of the oral cavity, and this difference is not due to local failure. The 5-year survival is 25.4% after segmental mandibulectomy, as compared with 40% after rim mandibulectomy. The degree of mandibular involvement does not influence the local failure treated by surgery and radiotherapy [11]. The overall 5-year survival rate of oral cavity cancer in a retrospective review of 277 patients receiving initial treatment at Washington University Medical Center between 1980 and 1989 was 46%. Survival rates by tumor, node, and metastasis (TNM) stage were as follows: stage I, 72%, stage II, 54%, stage III, 37%, and stage IV, 29%. When patients were grouped according to the clinicalseverity staging system, survival rates were as follows: stage I, 77%, stage II, 56%, stage III, 42%, and stage IV, 14%. The current TNM staging system for oral cavity cancer is based solely on the morphologic description of the tumor and disregards the clinical condition of the patient. Patient factors, such as cancer symptom severity and comorbidity, have a significant impact on survival [12]. These discouraging statistics indicate that oromandibular cancer, with its obligatory resection and reconstruction, will continue to consume scarce health care resources in the future. Third party payers and those in decision-making positions need to ensure that our institutions consider this problem in their budgeting plans.
Classifications Various classification schemes for segmental mandibular defects have been described over the years [13–16], reflecting the progress that has been made in understanding the consequences of the defects and the technical improvements that have taken place. One such classification by Boyd et al [16] is shown in Fig. 1. This classification is based on three upper case and three lower case characters: H, C, L and o, m, s. H defects are lateral defects on any length, including the condyle but not significantly crossing the midline; L defects are the same but exclude the condyle; C defects consist of the entire
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Fig. 1. The HCL classification of mandibular defects. (Adapted from Boyd JB, Gullane PJ, Rotstein LE, et al. Classification of the mandibular defects. Plast Reconstr Surg 1993;92(7):1269; with permission.)
central segment containing the four incisors and the two canines. These letters may be combined (eg, LCL would represent an angle-to-angle defect). The letter o represents the absence of mucosa and skin component, s represents skin deficit, and m represents mucosa deficit [16]. Although some microsurgeons use these classifications as a strict guide for reconstruction, the authors believe that each defect needs to be examined in terms of its anatomic extent and the effect this will have on the four functions mentioned earlier. The reconstruction needs to be tailored to providing the functions to be mentioned in the next section while, if possible, minimizing the morbidity of the donor site. To this end, an effort should be made to reconstruct as much of the normal anatomy as possible.
Preoperative assessment State of the art management of the oromandibular defect endeavors to restore function in terms of speech, deglutition, mastication, taste, oral hygiene, oral airway maintenance, and cosmesis.
Preoperative assessment and planning for patients undergoing immediate reconstruction of oromandibular defects entails a multidisciplinary team consisting of head and neck surgeons, plastic surgeons with microsurgical expertise, maxillofacial prosthodontists, radiation oncologists, medical oncologists, pathologists, occupational therapists, speech pathologists, internists, and psychologists [17]. The preoperative assessment usually includes a full head and neck examination, chest radiograph, biopsy of the lesion, quadroscopy, liver function tests, and computerized tomography (CT). Preda et al [18] investigated the use of helical CT in the pre- and postoperative management of oromandibular reconstruction of patients with oropharyngeal carcinoma using microvascular composite free flaps. The CT permitted adequate assessment of the extent of mandibular infiltration and detected early ischemic complications and distant recurrences. Postoperative assessment of correct flap positioning was possible and helpful in subsequent rehabilitation with osseointegrated implants [18]. When patients arrive in the hospital and have surgery on the same day, as in the authors’ institu-
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tion, it is important for the department of anesthesia to assess patients a week in advance and determine the need for any additional investigations. Particular attention should be paid to the risk of postoperative delirium tremens, given the high prevalence of alcohol abuse in this patient population. When a radial forearm flap is contemplated for reconstruction, an important preoperative measure is to inform the patient which forearm the surgeon intends to use as the donor site. Patients and their immediate families must ensure that no blood is drawn or intravenous lines started from this site, because this may damage the potential veins of the future flap.
Principles of reconstruction Although it is important to be aware of the anatomic areas (functional units) described earlier during reconstruction, from the practical point of view, the authors often see defects that include various permutations of those functional units. Commonly, they are found to be in continuity. To date, it is evident that the single-stage microsurgical reconstruction of the oromandibular defect is the standard of care in North America. Komisar [19] reported that patients undergoing conventional mandibular reconstructions (ie, those not using microvascular techniques) required more hospitalization and had poorer function. Urken et al [20] compared several functional parameters in patients who had microvascular oromandibular reconstruction with those in a group of unreconstructed controls and found significantly improved function in chewing performance, dental rehabilitation, and bite force, but in not swallowing or speech. Superior masticatory function was observed in patients undergoing microvascular oromandibular reconstruction versus a control group of unreconstructed patients [21]. The microsurgical reconstruction option is chosen when the defect is of such magnitude that skin grafts and local flaps will not adequately address it. In the authors’ view, the most important considerations in reconstructing the floor of the mouth are (1) to allow freedom of the tongue, especially on the anterior floor (avoid tethering of tongue), (2) to avoid redundancy of the flap, which compromises proper hygiene as the folds trap food particles, and (3) to use thin flaps, which drape gently over the alveolus (native or reconstructed mandible) and floor of the mouth and permit denture wearing [Fig. 2]. In the authors’ experience and that of other head and neck microsurgeons, the most common defect requiring reconstruction is one of the floor of the
mouth with a segmental defect of the mandible [15,22]. Soft tissue resection at the floor of the mouth, including various amounts of tongue and mandible, has a profound, cumulative effect on function and cosmetic appearance. Despite the advances of the last 3 decades, the recovery of upper aerodigestive tract function after reconstruction of the segmental oromandibular defect still tends to be incomplete. Wagner et al [23] performed univariate and multivariate analyses in a prospective observational study of 21 patients undergoing oromandibular reconstruction. Significant univariate predictors of outcome included tongue resection, pharynx resection, and flap skin-paddle area. Increasing size of the skin paddle in the reconstructive flap was an indirect indicator of larger resection. This factor influenced functional outcome measures such as speech articulation and oral pharyngeal swallowing efficiency to a greater degree in univariate analysis. Tongue function, however, remained the only significant predictor of function in multivariate analysis [23]. Hence a whole article in this issue has been dedicated to tongue reconstruction. In the past, particular emphasis was placed on proper dental occlusion to achieve normal alignment of the reconstructed mandible; this occlusion was achieved by means of arch bars, interosseous wires, Gunning splints, or wiring of dentures of the anterior arch. The missing posterior segment was replaced with the bone graft, supported by small or large reconstructive plates. The authors have found this approach inadequate, because the freefloating posterior mandibular segment can often be ’’enforced’’ to meet the demands of the anterior occlusion in many different spatial orientations, excepting the one true orientation. This ’’true and original’’ spatial orientation can only be achieved when the mandible is preplated before the cancer is resected. This measure is feasible in the vast majority of cases. The plate is then removed and sterilized and is ready for reapplication after cancer extirpation. In the occasional case where the tumor is expansile and preplating is not possible, the authors apply an external fixator that bypasses the tumor. The fixator maintains the true spatial position of the condyle in its fossa until the reconstruction. The authors’ results have improved considerably in the decade since their adoption of this approach. The achievement of the normal contour of the mandible almost invariably requires a number of osteotomies; this is particularly true for a central defect, a central–lateral defect, or a lateral ramus– ascending ramus defect [Fig. 3]. The ’’carpentry’’ of the bone may be completed either while the flap is still attached to the donor site and perfused
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Fig. 2. (A) A 60-year-old woman with SCC invading the alveolus and floor of mouth. (B) Defect after oromandibular resection. (C ) Radial forearm osteocutaneous flap used (skin paddle 6 × 6 cm; bone 7 cm). (D) Insetting of flap at floor of mouth. (E ) Postoperative appearance of same patient. (F ) Excellent contour of the forearm flap in floor of mouth, allowing free tongue movement.
or after detachment. The authors have used both approaches. Performing the ’’carpentry’’ on an attached bone graft makes sense insofar as it minimizes ischemia; however, the authors find it simpler from the practical point of view to perform the bone adjustments at the extirpative site. As a result, they now divide the pedicle as soon as the resection team removes the tumor and prepares the recipient vessels. The ’’carpentry’’ of the neomandible is done in the head and neck area. Because this ’’carpentry’’ may take up to 1 hour, the bone and pedicle should be irrigated every 5 minutes to keep them moist and avoid desiccation. The bone fixation is achieved with reconstruction plates in the larger defects,
whereas in the small defects miniplates may also be used. Given a choice for a particular defect, some members of the authors’ unit prefer to use the smaller plates, because they limit elevation of the periosteum and minimize the risk of vascular compromise to the bone. However, the larger reconstruction plates provide superior stability and tolerate higher loads. Therefore, they are recommended in younger, more active patients in whom the teeth are preserved. If osseointegration is planned, all plates, especially the screws that traverse the ’’neomandible,’’ may interfere with the integration and need to be removed before dental restoration. If the den-
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Fig. 3. (A) Defect after oromandibular resection of SCC arising from tongue and invading the mandible in a 62-year-old woman. (B) Radial forearm osteocutaneous flap used (skin paddle 7 × 6.5 cm; bone 10.5 cm). (C ) Two osteotomies were used to reconstruct the ascending ramus and provide anterior curvature; reconstruction plate was used. (D) Postoperative appearance.
tal implants are placed immediately at the time of reconstruction, the position of the plates and screws should be considered. Some microsurgeons believe that lateral mandibulectomy defects in selected patients with poor prognosis can be reconstructed (traversed) with a plate alone and a myocutaneous flap, such as a pectoralis major, or fasciocutaneous free flaps. However, when a plate and fasciocutaneous or myocutaneous flap are employed, the anterior defects need to be managed with vascularized bone reconstruction to avoid the common problem of erosion of the plate into the oral cavity [24]. In a large, recent series where plates and free flaps were used instead of osteocutaneous flaps, the plate exposure was 46%. As a result, a secondary procedure was needed in 31% of the patients [25]. The philosophy of the authors’ center in the past decade has been that, if a patient is fit to undergo the extirpative part of the procedure, he or she is fit to undergo the free flap reconstruction of the mandible. The authors prefer to reconstruct the
bone and oral lining with a vascularized osteocutaneous flap. An effort is made to save the condyle of the mandible when possible, because of the difficulty of its reconstruction. If, however, it needs to be resected for oncologic reasons, one method of reconstruction uses the head of the fibula. This method adds complexity to the dissection, because the common peroneal nerve must be protected to avoid injury, lateral knee or leg pain, or even instability. Furthermore, if an osteocutaneous flap is required, the skin paddle is usually located very distal to this proximal fibular head, making the lining and bone reconstruction incompatible. The bone may not correspond to any acceptable perforators, and yet another problem occurs when the fibular head is too big. A novel technique is to fashion a condyle from the fibula edge (not including the head), then wrap the end of the ’’neocondyle’’ with periosteum resected beyond the required fibula [26,27]. Delayed reconstruction of the con-
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dyle is an extremely difficult problem, because the facial nerve is at a real risk for injury in a scarred and tight field where structures have been displaced. Even when the nerve has been identified initially, it can still be compressed and compromised by any bone graft used. A solution to this problem is use of the newer prostheses, which carry a ’’condyle’’ at the end of the reconstruction plate. Whenever possible, the authors make an effort to reconstruct the inferior alveolar nerve, as suggested by Urken et al [20]. Both the fibular and radius osteocutaneous flaps can be raised as sensory flaps. The lateral sural nerve in the fibular flap and the lateral antebrachial cutaneous nerves may be coapted to a recipient nerve, usually the lingual nerve. The lateral antebrachial cutaneous nerve of the radial forearm flap should be used, if possible, when a recipient nerve is available [22,28,29].
Reconstructive options In the early years of head and neck reconstruction, most surgical defects were closed by primarily suturing tongue to cheek or lip and allowing the mandible to ’’drift’’ laterally. This method was acceptable for lateral floor of mouth, alveolus, cheek, or tongue defects that were relatively small, but it became unmanageable for larger defects and was a complete disaster for midline anterior tumors. The end result was the typical ’’Andy Gump’’ deformity. Accordingly, attempts were made to use all sorts of prosthetic materials to stabilize the mandible. Various local mucosal or tongue flaps were used on the inside and cheek, and cervical flaps were used on the outside. As reconstructive surgeons gained expertise, skin was brought in from distant sites to reconstruct intraoral or external defects, using forehead flaps, scalp flaps, deltopectoral flaps, and trapezius flaps. The deltopectoral and pectoralis major myocutaneous flaps markedly changed the outcomes of major head and neck surgical cancer procedures. Although earlier attempts to attach a piece of clavicle, sternum, or rib to these cutaneous or myocutaneous flaps met with only limited success, free nonvascularized rib occasionally would help stabilize a mandible and even became revascularized in some patients. The development and increased use of progressively more complicated and reliable mandibular plates provided good long-term stabilization for lateral defects, but these plates were rarely satisfactory for anterior defects. It was only with the development of free microvascular bone and bone/soft tissue flaps that the modern era of head and neck reconstruction for oromandibular defects began. One of the earliest flaps used in this regard was the dorsalis pedis [30], which provided excellent
thin skin for intraoral reconstruction as well as some bone, although this was certainly not as reliable as the bone flaps now available to us. Similarly, vascularized rib has been used intermittently to reconstruct the mandible and is still occasionally used [31,32]. However, both of these osteocutaneous flaps have significant donor-site morbidity and as a result are rarely used today. A number of well-vascularized osteocutaneous flaps are now available for oromandibular reconstruction; their advantages and disadvantages are discussed in detail in the next section.
Commonly used free flaps For lining defects of the floor of the mouth, a number of flaps are reported to yield satisfactory results. The most common flaps used for this purpose in the authors’ center are the radial forearm fasciocutaneous [22,33] and the lateral arm flaps [34]. Other flaps used for the same purpose include the dorsalis pedis [30,35] and the scapular flaps [36]. Others have recently used the anterolateral thigh flap [37,38]. The most intricate and difficult part of reconstruction is the approach to the oromandibular defect after composite resection of the mandible. The four flaps most commonly used for this purpose are discussed in the following sections.
Fibula flap In the last decade, the free fibula and radial forearm osteocutaneous flaps have probably been the flaps most commonly used in oromandibular reconstruction. The advantage of the fibula is the long bicortical bone that can reconstruct the entire mandible if necessary. In contrast to other bone flaps that provide limited length, usually about 14 cm (radius, iliac crest, scapula), the fibula has enough bone stock to support osseointegrated dental implants, and there is generally scant morbidity to the donor extremity. It allows extirpative and harvesting teams to work simultaneously [39–41]. The reconstructive surgeon is well away from the extirpative surgeon, allowing maximum exposure for resection. This arrangement contrasts with the harvesting of the radial flap, where the field is ’’congested’’ with surgeons and assistants. Although some surgeons recommend angiography, the authors no longer perform routine angiography unless the clinical examination casts doubt on the adequacy of the leg circulation or suggests that a peroneal arteria magna exists. This condition is reported to occur in between 0.2% and 5% of the general population; it is associated with hypoplasia or absence of both the anterior and posterior tibial arteries, with
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the peroneal artery providing the sole circulation of the foot [42]. When the authors are able to palpate a dorsalis pedis and a posterior artery pulse, and the ankle/ brachial index is acceptable, they are satisfied of the adequacy of the leg circulation. The harvesting of the flap uses the lateral approach, with the patient in supine position [43]. Before surgery, the perforator vessels are mapped with the Doppler. These perforators are usually found in the middle and distal third of the leg [44,45]. In most cases, only a small portion of the fibula is used in the reconstruction; most of the harvested length is discarded, allowing a subperiosteal ’’pruning’’ to lengthen the vascular pedicle, which the authors
generally find necessary. The distal 7 to 8 cm measured from the lateral malleolus is left intact to support the ankle joint. The authors routinely identify the peroneal nerve at the neck of the fibula; they decompress it, and the resection of the fibula takes place just below the neck. In this way they protect the peroneal nerve under direct vision at all times. In the rare event that the whole fibula is harvested superiorly, it is important to reattach the lateral collateral ligament to the tibial condyle. To avoid postoperative compression of the pedicle in cases of an osteocutaneous flap, it is preferable to use the contralateral extremity for dissection. The authors’ usual technique is to keep the vascular pedicle on the lingual side and place it poste-
Fig. 4. (A) Central oromandibular defect after resection of SCC of floor of mouth invading the mandible in a 56-year-old man. (B) Osteocutaneous fibula flap used. (C ) “Carpentry” of bone graft on side table using small reconstruction plates (skin paddle 5 × 8 cm; bone 10 cm). (D) Fibula inset. (E ) Postoperative appearance; the fibula skin paddle is generally thicker than that provided by the forearm flap.
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Fig. 5. (A) Preoperative appearance of large bone tumor of the mandible in a 15-year-old male. (B) CTT appearance of the tumor. (C ) Radiograph after reconstruction with fibula bone graft (no skin paddle was necessary; bone graft 12 cm). (D) Postoperative appearance.
riorly. These maneuvers make it less likely that the vascular pedicle will be compressed. The most common use of the flap in the authors’ center is as an osteocutaneous flap [Fig. 4]. Less commonly, it is used as a vascularized bone graft without a skin paddle [Fig. 5]. The cutaneous flap may be neurotized using a branch of the sural nerve (lateral cutaneous sural nerve). Other variations of the flap described include the double barrel arrangement to increase the height of the reconstructed mandible [27]. Multiple skin paddles may be designed on separate perforators [46]. The use of parts of the soleus muscle or flexor hallucis longus to fill soft tissue defects has been described [27,47]. A problematic aspect of this otherwise excellent flap is the reported failure of the skin paddle in the presence of viable bone [48,49]. Even in more recently reported series, this failure remains a problem. In a series of 61 patients in whom an osteocutaneous flap was raised, Sieg et al [27] experienced seven total skin paddle necroses in the presence of viable bone. The authors have also experienced
such failure, which may result from compression of the perforators, absence of perforators, shearing of the fasciocutaneous blood supply, or poor design of the cutaneous paddle. In centers where the fibula and radial forearm flaps are used with similar frequency, total flap failure is reported to be higher with the fibula than with the radial forearm osteocutaneous flap [50].
Radial forearm osteocutaneous flap This flap is a true competitor to the fibula flap. It is certainly superior to the fibula osteocutaneous flap in terms of skin paddle survival, but the bone quality is inferior. As much as 14 cm of unicortical bone has been harvested [22]. The skin paddle is thin and often superior to the fibula’s thicker skin paddle. Likewise, the skin paddle has better flexibility in relation to the bone than does the equivalent fibula flap. The radial forearm may be used as a sensory flap when one harvests the lateral antebrachial cutaneous flap with it. Its vascular pedicle is by far the best of all the common flaps used in head and
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neck reconstruction. As much as 20 cm of pedicle may be easily harvested, making this flap ideal for reconstructions in vessel-depleted necks, especially in repeat surgical cases. Strong evidence suggests that flaps requiring vein grafts have higher rates of flap loss (18.4%) than do flaps that do not require vein grafts (2.9%; P < 0.0001) [51]. The radial forearm flap vessels are of large caliber: 2 to 5 mm. This flap has dual venous drainage (deep and superficial), and both systems may be used. If the anastomotic vein is protected in the anticubital fossa, the two systems may be combined to provide a type I venous drainage pattern with two large-caliber veins for anastomosis: the median basilic and median cephalic veins [52]. In contrast to the fibula, in which the skin paddle is the tenuous component of the flap, it is the bone component of the radial forearm flap that is tenuous. Nonetheless, multiple osteotomies can be performed on the radial bone to achieve the appropriate contour [53]. Caution needs to be exercised in harvesting this flap as one approaches the bone cortex from underneath the brachioradialis tendon. The soft tissue composed of part of the flexor pollicis longus needs to remain attached to the bone. The dissection should be parallel to the undersurface of the brachioradialis to protect the small periosteal vessels through which the bone derives its vascular supply [22,53]. The major drawback of this flap is the risk of fracture of the donor radius, which runs at about 12%. This risk may be minimized by limiting the harvesting of the radius to 40% of the diameter of the bone, although the authors often harvest 50% of the diameter. Some precautions for avoiding donor radius fracture include instructing the patients preoperatively to avoid putting weight on the hand, placing a protective plaster splint, and controlling delirium tremens after the surgery. Intraoperatively, one needs to be careful with the osteotomy on the radial side of the radius at the level of the insertion of the pronator teres, where the appearance that one is osteotomizing superficially may cause one to go too deep [22]. The fear of donor fracture has kept some investigators from using this flap. Some recommend the use of prophylactic plating of the radius [54]. A recent cost-utility analysis comparing plating of the donor radius with no plating found prophylactic plating to be a non–cost-effective approach [55]. As a result of this analysis, the authors usually only plate the radius in cases of fractures or when they believe the remaining radius is too thin. A review of the function of the hand in patients who fractured the radius did not identify any limitations, in contrast to some early papers.
Skin graft failure and exposed tendons occasioned early criticisms of the radial forearm flap. These complications should never occur if one pays attention to details of skin grafting and splints the entire hand and forearm for 1 week [22]. Devascularization of the hand should never happen in the presence of an intact palmar arch, as ascertained by the Allen’s test. However, caution should be exercised in identifying an anomalous superficial ulnar artery, which occurs in 3% of the population. In this anomaly, the ulnar artery is located under the superficial fascia along the volar forearm. As a result, it can easily be mistaken for a superficial vein. Normally, in the distal forearm, the ulnar artery and the venae comitantes are found under the flexor carpi ulnaris. In the case of this anomaly, no vessels are found under the flexor carpi ulnaris. Failure to recognize this congenital anomaly can devascularize the whole hand. This problem can be prevented by not exsanguinating the forearm but simply elevating the flap before inflating the tourniquet [56]. Osteotomies may be performed on the radial bone graft to reconstruct central mandibular defects just as well as with the fibula [see Fig. 3]. Although osseointegrated implants are possible [57], the authors believe that the bone quality is not as robust as that of the fibula, where shorter osteotomized segments are tolerated and dental restoration with osteointegrated implants is more reliable.
Scapula flap This flap, subtended by the circumflex scapular vessels, may have a longer pedicle if the dissection extends deeper into the triangular space and uses the subscapular vessels [58]. The subscapular vessels are larger, and the vein is less friable at this level. One large or two venae comitantes may be anastomosed. Two variations of the osteocutaneous flap have been described. The first variation uses the lateral edge of the scapula with thicker bone but with a shorter vascular pedicle [59,60]. The second variation uses the medial edge of the scapula, in which the bone component is away from the pedicle, effectively allowing the anastomosis to be performed on the opposite neck [61]. Another advantage of the medial flap is that it minimizes the dissection around the teres major and minor and the glenohumeral joint, thereby avoiding prolonged stiffness to the shoulder. The major disadvantage of the medial scapular flap as compared with its lateral equivalent is the thickness of the bone. Twelve to 14 cm of bone may be harvested with either variation of the scapula flap [61]. Two key advantages of this flap compared with the fibula and radius flaps are the superior color match of the skin paddle when used for
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Fig. 6. (A) Malignant fistula from recurrent SCC arising from submandibular gland and invading the mandible in a 70-year-old man. (B) Resected mandible. (C ) Medial scapular osteocutaneous flap used (skin paddle 17 × 8 cm; bone graft 11 cm). (D) Intraoperative view of reconstruction. (E ) Postoperative appearance showing excellent color match (frontal view). (F ) Profile view of same patient.
coverage [Fig. 6] and the possibility of harvesting large and multiple skin paddles from the posterior thorax—ideally suited to the patient with a massive soft tissue defect or a through and through defect [61]. Even in flaps as large as 39 × 10 cm, the donor site can be closed directly [62]. The major drawback of this flap (both lateral and medial varieties) is the necessity of repositioning the patient. Rarely is it possible for the ablative and reconstructive teams to work simultaneously. As a result, it is necessary to change the patient’s position twice, which adds considerable time to the surgery. To minimize this time, the authors compromise by
estimating the defect ahead of time and harvesting the flap before the cancer is resected. They take more bone and soft tissue than they expect to use, close the defect, and let the ablative team take over. The flap is kept on ice on a side table until hours later, when the reconstructing team returns to inset it. The prolonged cold ischemia has not been a problem in the authors’ patients.
Iliac crest This free flap based on the deep circumflex artery and vein was first introduced by Ian Taylor in 1979 [63,64]. Since then, it has been used successfully by
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Table 1: Comparison of select qualities of the four osteocutaneous flaps in oromandibular reconstruction
Reliability of skin paddle (survival) Skin paddle pliability (intraoral) Color match (external coverage) Bone quality Osseointegration of dental implants Vessel quality Vascular pedicle length Sensory innervation Donor-site morbidity Donor-site cosmesis
Fibula
Radius
Scapula
Iliac crest
++ +++ ++ +++ +++ +++ +++ ++++ ++ +++
++++ ++++ ++ ++ ++ ++++ ++++ ++++ ++ +++
++++ ++ ++++ ++ ++ +++ ++ (++++) + ++ (+++) +++
+++ + + ++++ ++++ +++ ++ + + +++
++++ denotes best; + denotes worst; (+) denotes the medial scapular osteocutaneous flap.
a number of surgeons for the reconstruction of the composite oromandibular defect [13,14,65]. A large volume of unicortical or bicortical bone, up to 14 to 16 cm in length, may be harvested. This flap can be used to reconstruct various mandibular defects, and multiple osteotomies may be performed to achieve the necessary contour. Urken et al [66] used the internal oblique muscle with this bone graft to resurface soft tissue and intraoral mucosal defects. This flap is probably the best available flap for accepting osseointegrated implants [66]. Its advantages are the volume of the bone, the height, which is appropriate for accepting dental implants, and the large soft tissue mass that can be harvested with it. Unfortunately, this flap carries with it significant donor-site morbidity, including severe postoperative pain, contour irregularity, and iatrogenic hernia [67]. In the authors’ experience, the skin paddle of the iliac crest flap is usually too bulky and unsuitable for reconstruction of the lining and bone defects. For external coverage and bone defects or for through and through defects, the color match is inferior to other flaps. The iliac crest flap’s vascular pedicle is also much shorter than those of competitor flaps, such as the radial forearm, scapula, and fibula. It is still useful for isolated bone defects in which dental implants are desired, particularly for central mandibular defects. Although other flaps have been used less frequently (eg, humerus bone attached to the lateral arm flap), the authors have included here what they consider to be the four most useful osteocutaneous flaps. Table 1 presents some key distinguishing qualities of these four flaps, based on the authors’ experience of using all of them intermittently over a period of more than 20 years. The authors of this article anticipate some understandable disagreement with this assessment; they recommend reading the article in this issue that addresses, among other matters, the question of bias and hierarchy of evidence in clinical decision making. One aspect of
oromandibular reconstruction that appears to generate heated controversy at national meetings is the osseointegration of any one of the bone grafts described here. In the authors’ view, this debate is vastly overrated, because the proportion of patients who undergo this step in most reported series is small indeed. The patients undergoing oromandibular resection generally belong to a comparatively low socioeconomic class and cannot afford the added expense of osseointegration of dental implants. Certainly, we need to make progress in this area by lobbying the local and federal governments to provide this aspect of care. However, until osseointegration becomes a common practice, we should keep our minds open to the other qualities of the competing flaps.
Future predictions and summary Our understanding of the reconstructive needs of the oromandibular defect is now clear. We need to return the anatomy as close to its original state as possible to improve function and cosmesis. Reconstructive surgeons’ efforts in the last 2 decades have yielded remarkable improvements in both areas. We need to acknowledge, however, that our results will continue to be suboptimal as long as we use dissimilar tissues from other parts of the body for the reconstruction. We are presently at the dawn of a new era of reconstruction of the oromandibular defect. Within a few months of this writing, the composite tissue allotransplantation of the human face, supported by immunosuppressive drugs, will become a reality. Soon afterward, the transplantation of the mandible and parts of the floor of the mouth and tongue will become feasible. Future head and neck microsurgeons will have an easier job. Banked parts of human faces will be at their disposal. An entire article in this issue has been devoted to this exciting prospect.
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At national and international microsurgical meetings and in published articles, authors tout the benefits of the flaps with which they are familiar and criticize those with which they are not. Because surgeons in general are not familiar with the principles of evidence-based microsurgery, the editors of this issue have included an article that addresses the methodologic issues of comparing free flaps and techniques (known and still undiscovered) in oromandibular reconstruction. The authors anticipate that these principles will help surgeons decide which flap to use based on the best evidence available, rather than on ‘‘expert‘‘ pronouncements— including their own!
References [1] Public Health Agency of Canada. Cancer surveillance on-line page. Available at: http://dsol-smed. phac-aspc.gc.ca/dsol-smed/cancer/index_e.html. Accessed November 30, 2004. [2] Yousif NJ, Matloub HS, Sanger JR, et al. Softtissue reconstruction of the oral cavity. Clin Plast Surg 1994;21(1):15–23. [3] Sankaranarayanan R, Masuyer E, Swaminathan R, et al. Head and neck cancer: a global perspective on epidemiology and prognosis. Anticancer Res 1998;18(6B):4779–86. [4] Hoffman HT, Karnell LH, Funk GF, et al. The National Cancer Data Base report on cancer of the head and neck. Arch Otolaryngol Head Neck Surg 1998;124(9):951–62. [5] Inagi K, Takahashi H, Okamoto M, et al. Treatment effects in patients with squamous cell carcinoma of the oral cavity. Acta Otolaryngol Suppl 2002;547:25–9. [6] Funk GF, Karnell LH, Robinson RA, et al. Presentation, treatment, and outcome of oral cavity cancer: a National Cancer Data Base report. Head Neck 2002;24(2):165–80. [7] Jemal A, Tiwari R, Murray T, et al. Cancer Statistics, 2004. CA Cancer J Clin 2004;54(1):8–29. [8] Mork J. Forty years of monitoring head and neck cancer in Norway—no good news. Anticancer Res 1998;18(5B):3705–8. [9] Freije J, Kumar JV. Prevention of cancers of oral cavity and pharynx in New York State. N Y State Dent J 2001;67(3):26–30. [10] Shiboski CH, Shiboski SC, Silverman Jr S. Trends in oral cancer rates in the United States, 1973– 1996. Community Dent Oral Epidemiol 2000; 28(4):249–56. [11] Tankere F, Golmard JL, Barry B, et al. Prognostic value of mandibular involvement in oral cavity cancers. Rev Laryngol Otol Rhinol (Bord) 2002; 123(1):7–12. [12] Pugliano FA, Piccirillo JF, Zequeira MR, et al. Clinical-severity staging system for oral cavity cancer: five-year survival rates. Otolaryngol Head Neck Surg 1999;120(1):38–45. [13] David DJ, Tan E, Katsaros J, et al. Mandibular
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reconstruction with vascularized iliac crest: a 10 year experience. Plast Reconstr Surg 1988; 82(5):792–803. 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(3):391–403. Urken ML, Weinberg H, Vickery C, et al. Oromandibular reconstruction using microvascular composite free flaps. Report of 71 cases and a new classification scheme for bony, soft-tissue and neurologic defects. Arch Otolaryngol Head Neck Surg 1991;117(7):733–44. Boyd JB, Gullane PJ, Rotstein LE, et al. Classification of the mandibular defects. Plast Reconstr Surg 1993;92(7):1266–75. Markowitz BL, Calcaterra TC. Preoperative assessment and surgical planning for patients undergoing immediate composite reconstruction of oromandibular defects. Clin Plast Surg 1994; 21(1):9–14. Preda L, Dore R, Benazzo M, et al. The role of computed tomography in the preoperative assessment and follow-up of oromandibular reconstruction with microvascular osteomyocutaneous free flaps. Dentomaxillofac Radiol 1999; 28(6):338–43. Komisar A. The functional result of mandibular reconstruction. Laryngoscope 1990;100(4): 364–74. Urken ML, Buchbinder D, Weinberg H, et al. Functional evaluation following microvascular reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients. Laryngoscope 1991;101(9): 935–50. Curtis DA, Plesh O, Miller AJ, et al. A comparison of masticatory function in patients with or without reconstruction of the mandible. Head Neck 1997;19(4):287–96. Thoma A, Khadaroo R, Grigenas O, et al. Oromandibular reconstruction with the radialforearm osteocutaneous flap: experience with 60 consecutive cases. Plast Reconstr Surg 1999; 104(2):368–78. Wagner JD, Coleman III JJ, Weisberger E, et al. Predictive factors for functional recovery after free tissue transfer oromandibular reconstruction. Am J Surg 1998;176(5):430–5. Boyd JB, Mulholland RS, Davidson J, et al. The free flap and plate in oromandibular reconstruction: long-term review and indications. Plast Reconstr Surg 1995;95(6):1018–28. Wei FC, Celik N, Yang WG, et al. Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap. Plast Reconstr Surg 2003;112(1):37–42. Iconomou TG, Zuker RM, Phillips JH. Mandibular reconstruction in children using the vascularized fibula. J Reconstr Microsurg 1999;15(2): 83–90.
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[27] Sieg P, Zieron JO, Bierwolf S, et al. Defect-related variations in mandibular reconstruction using fibula grafts. A review of 96 cases. Br J Oral Maxillofac Surg 2002;40(4):322–9. [28] Urken ML. The restoration or preservation of sensation in the oral cavity following ablative surgery. Arch Otolaryngol Head Neck Surg 1995; 121:607–12. [29] Boyd B, Mulholland S, Gullane P, et al. Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: are we making sense? Plast Reconstr Surg 1994;93(7): 1350–9. [30] Robinson DW. Microsurgical transfer of the dorsalis pedis neurovascular flap. Br J Plast Surg 1976;29(3):209–13. [31] Daniel RK. Mandibular reconstruction with free tissue transfers. Ann Plast Surg 1978;1(4):346–71. [32] Thoma A, Heddle S, Archibald S, et al. The free vascularized anterior rib graft. Plast Reconstr Surg 1988;82(2):291–8. [33] Soutar DS, Scheker LR, Tanner NS, et al. The radial forearm flap: a versatile method for intraoral reconstruction. Br J Plast Surg 1983;36(1): 1–8. [34] Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 1984;12(6):489–500. [35] Zucker RM, Manktelow RT. The dorsalis pedis free flap: technique of elevation, foot closure, and flap application. Plast Reconstr Surg 1986; 77(1):93–104. [36] Barwick WJ, Goodkind DJ, Serafin D. The free scapular flap. Plast Reconstr Surg 1982;69(5): 779–87. [37] Koshima I. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 2000; 105(7):2358–60. [38] Wei FC, Jain V, Celik N, et al. Have we found an ideal soft tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109(7):2219–26. [39] Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 1995;96(3):585–96. [40] Shpitzer T, Neligan PC, Gullane PJ, et al. The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and longterm evaluation. Head Neck 1999;21(7):639–47. [41] Babovic S, Johnson CH, Finical SJ. Free fibula donor-site morbidity: the Mayo experience with 100 consecutive harvests. J Reconstr Microsurg 2000;16(2):107–10. [42] Kim D, Orron DE, Skillman JJ. Surgical significance of popliteal artery variants: a unified angiographic classification. Ann Surg 1989;210(6): 776–81. [43] Gilbert A. Vascularized transfer of the fibula shaft. Int J Microsurg 1979;1:100–2. [44] Wei FC, Seah CS, Tsai YC, et al. Fibula osteoseptocutaneous flap for reconstruction of
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composite mandibular defects. Plast Reconstr Surg 1994;93(2):294–304. Jones NF, Monstrey S, Gambier BA. Reliability of the fibular osteocutaneous flap for mandibular reconstruction: anatomical and surgical confirmation. Plast Reconstr Surg 1996;97(4):707–16. Yang KC, Leung JK, Chen JS. Double-paddle peroneal tissue transfer for oromandibular reconstruction. Plast Reconstr Surg 2000;106(1): 47–55. Baudet J, Panconi B, Caix P, et al. The composite fibula and soleus free transfer. Int J Microsurg 1982;4:10–26. Schusterman MA, Reece GP, Miller MJ, et al. The osteocutaneous free fibula flap: is the skin paddle reliable? Plast Reconstr Surg 1992;90: 787–93. Winters HA, de Jongh GJ. Reliability of the proximal skin paddle of the osteocutaneous free fibula flap: a prospective clinical study. Plast Reconstr Surg 1999;103(3):846–9. Thoma A, Mongiardi C, Veltri K. Comparison of the free fibula and radial forearm osteocutaneous flaps in oromandibular reconstruction. Presented at the American Society for Reconstructive Microsurgery Annual Meeting. Palm Springs (CA), January 19, 2004. Kroll SS, Schusterman MA, Reece GP, et al. Choice of flap and incidence of free flap success. Plast Reconstr Surg 1996;98(3):459–63. Thoma A, Archibald S, Jackson S, et al. Surgical patterns of venous drainage of the free forearm flap in head and neck reconstruction. Plast Reconstr Surg 1994;93(1):54–9. Thoma A, Allen M, Tadeson BH, et al. The fate of the osteotomized free radial forearm osteocutaneous flap in mandible reconstruction. J Reconstr Microsurg 1995;11(3):215–9. Bowers KW, Edmonds JL, Girod DA, et al. Osteocutaneous radial forearm free flaps: the necessity of internal fixation of the donor-site defect to prevent pathological fracture. J Bone Joint Surg 2000;82A(5):694–704. Rockwell GM, Thoma A. Should the donor radius be plated prophylactically after harvest of a radial-forearm osteocutaneous flap? J Reconstr Microsurg 2004;20(4):297–306. Thoma A, Young JE. The superficial ulnar artery ‘‘trap‘‘ and the free forearm flap. Ann Plast Surg 1992;28(4):370–2. Mounsey RA, Boyd JB. Mandibular reconstruction with osseointegrated implants into the free vascularized radius. Plast Reconstr Surg 1994; 94(3):457–64. Serafin D. Atlas of microsurgical composite tissue transplantation. Philadelphia: WB Saunders; 1996. Teot L, Bosse JP, Moufarrege R, et al. The scapular crest pedicled bone graft. Int J Microsurg 1981; 3:257–62. Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap for mandibular and
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maxillary reconstruction. Plast Reconstr Surg 1986;77(4):530–45. Thoma A, Archibald S, Payk I, et al. The free scapular osteofasciocutaneous flap for head and neck reconstruction. Br J Plast Surg 1991;44(7): 477–82. Thoma A, Heddle S. The extended free scapular flap. Br J Plast Surg 1990;43(6):709–12. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for the free groin flaps. Plast Reconstr Surg 1979;64(5):595–604. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply
for the free groin flaps: clinical work. Plast Reconstr Surg 1979;64(6):745–59. [65] Moscoso JF, Urken ML. The iliac crest composite flap for oromandibular reconstruction. Otolaryngol Clin North Am 1994;27(6):1097–117. [66] Urken ML, Vickery C, Weinberg H, et al. The internal oblique–iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Report of 20 cases. Arch Otolaryngol Head Neck Surg 1989;115(3):339–49. [67] Forrest C, Boyd B, Manktelow R, et al. The free vascularized iliac crest tissue transfer: donor site complications associated with eighty-two cases. Br J Plast Surg 1992;45(2):89–93.
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CLINICS IN PLASTIC SURGERY Clin Plastic Surg 32 (2005) 361–375
Oromandibular Reconstruction After Cancer Resection Achilleas Thoma, MD, MSc, FRCS(C), FACS*, Carolyn Levis, MD, FRCS(C), J.E.M. Young, & & & & & &
Epidemiology Classifications Preoperative assessment Principles of reconstruction Reconstructive options Commonly used free flaps
The oral cavity includes the buccal mucosa (ie, inside lining of the lips and cheeks), the teeth, the anterior two thirds of the tongue, the floor of the mouth below the tongue, the hard palate, and the retromolar trigone (area behind the wisdom teeth) [1]. For reconstructive purposes and in consideration of the functions of this anatomic entity (ie, mastication, deglutition, and speech), Yousif et al [2] divided the oral cavity into 10 functional units: Oral sphincter Lingual and buccal sulci Alveolar ridges Floor of mouth Mobile tongue Base of tongue Tonsillar pillars Soft palate Hard palate Buccal mucosa
& &
MD, FRCS(C)
Fibula flap Radial forearm osteocutaneous flap Scapula flap Iliac crest Future predictions and summary References
From a pragmatic and reconstructive point of view, the authors classify the defects as those requiring Lining only Lining and bone Bone alone Cover and bone Lining, bone, and coverage (through and through defects)
Epidemiology Head and neck cancers are common in several regions of the world where rates of tobacco use and alcohol consumption are high. The agestandardized incidence rate of head and neck cancer in males circa 1990 exceeds 30 per 100,000 in regions of France, Hong Kong, the Indian subcontinent, Central and Eastern Europe, Spain, Italy, and Brazil, and in the United States among African
Department of Surgery, McMaster University, Hamilton, Ontario, Canada * Corresponding author. Surgical Outcomes Research Centre, St. Joseph's Healthcare, 101-206 James Street South, Hamilton, Ontario L8P 3A9, Canada. E-mail address: [email protected] (A. Thoma). 0094-1298/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved.
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Americans. The variation in incidence of cancers by anatomic site within the head and neck is mostly related to the relative distribution of major risk factors, such as tobacco or betel quid chewing, cigarette or bidi smoking, and alcohol consumption [3]. From 1985 to 1994, the largest proportion of head and neck cancers arose in the larynx (20.9%) and the oral cavity, including the lip (17.6%) (lip = 3.5%, oral cavity = 14.1%, oropharynx = 12.3%) [4]. In a recent analysis of 221 patients with squamous cell carcinoma (SCC) of the oral cavity, 161 patients had cancer of the tongue, 28 had cancer of the oral cavity, 12 had cancer of the hard palate, 11 had cancer of the buccal mucosa, and nine had cancer of the gingival area [5]. The median age of patients with oral cavity cancers was 64.0 years. Men represented 60.2% of patients. Pathologic diagnosis was SCC in 86.3% of cases. African Americans (independent of income), lower-income patients, and patients with higher-grade disease were seen more frequently with advanced-stage SCC [6]. An estimated 28,260 new cases of oral cavity and pharynx carcinoma were expected in the United States in 2004. Incidence rates are more than twice as high in men as in women and are highest in men older than 50 years. Incidence rates for cancer of the oral cavity and pharynx continued to decline in the 1990s in African American and white men and women. An estimated 7230 deaths from oral cavity and pharynx cancer are expected in 2004. Death rates have been decreasing since the late 1970s, with this decline more rapid in the 1990s. For all stages combined, about 84% of persons with oral cavity and pharynx cancers survive 1 year after diagnosis. The 5-year and 10-year survival rates are 57% and 45%, respectively [7]. Unfortunately, this trend does not apply everywhere. Male incidence rates of head and neck cancer are rising in most regions of the world. Age-adjusted incidence rates of oral and pharyngeal cancer increased after 1970 by 11% per 5-year period and 14% per 5-year period, respectively. The prognosis has not improved substantially since the 1950s [8]. Despite dramatic improvements in surgical and reconstructive techniques in the past 3 decades, the overall mortality rates remain relatively unchanged. The overall 5-year survival rate for persons with oral cavity and pharyngeal cancer is only 52%. When we consider that the risk factors are known and the lesions in the oral cavity and pharynx are easily accessible for early detection, the lack of progress in controlling this cancer is perplexing. The lack of awareness of the disease burden and the risk factors, the tendency for occurrence in
lower socioeconomic classes and poorly compliant populations, and the lack of a simple screening test have hindered progress [9]. Scant change was seen in early detection of oral cancer or 5-year relative survival rates between the periods 1973 to 1984 and 1985 to 1996 in nine Surveillance, Epidemiology, and End Results regions. This finding suggests a deficiency in professional and public education regarding early diagnosis of oral cancer [10]. The degree of mandibular invasion influences the survival rate of patients with SCC of the oral cavity, and this difference is not due to local failure. The 5-year survival is 25.4% after segmental mandibulectomy, as compared with 40% after rim mandibulectomy. The degree of mandibular involvement does not influence the local failure treated by surgery and radiotherapy [11]. The overall 5-year survival rate of oral cavity cancer in a retrospective review of 277 patients receiving initial treatment at Washington University Medical Center between 1980 and 1989 was 46%. Survival rates by tumor, node, and metastasis (TNM) stage were as follows: stage I, 72%, stage II, 54%, stage III, 37%, and stage IV, 29%. When patients were grouped according to the clinicalseverity staging system, survival rates were as follows: stage I, 77%, stage II, 56%, stage III, 42%, and stage IV, 14%. The current TNM staging system for oral cavity cancer is based solely on the morphologic description of the tumor and disregards the clinical condition of the patient. Patient factors, such as cancer symptom severity and comorbidity, have a significant impact on survival [12]. These discouraging statistics indicate that oromandibular cancer, with its obligatory resection and reconstruction, will continue to consume scarce health care resources in the future. Third party payers and those in decision-making positions need to ensure that our institutions consider this problem in their budgeting plans.
Classifications Various classification schemes for segmental mandibular defects have been described over the years [13–16], reflecting the progress that has been made in understanding the consequences of the defects and the technical improvements that have taken place. One such classification by Boyd et al [16] is shown in Fig. 1. This classification is based on three upper case and three lower case characters: H, C, L and o, m, s. H defects are lateral defects on any length, including the condyle but not significantly crossing the midline; L defects are the same but exclude the condyle; C defects consist of the entire
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Fig. 1. The HCL classification of mandibular defects. (Adapted from Boyd JB, Gullane PJ, Rotstein LE, et al. Classification of the mandibular defects. Plast Reconstr Surg 1993;92(7):1269; with permission.)
central segment containing the four incisors and the two canines. These letters may be combined (eg, LCL would represent an angle-to-angle defect). The letter o represents the absence of mucosa and skin component, s represents skin deficit, and m represents mucosa deficit [16]. Although some microsurgeons use these classifications as a strict guide for reconstruction, the authors believe that each defect needs to be examined in terms of its anatomic extent and the effect this will have on the four functions mentioned earlier. The reconstruction needs to be tailored to providing the functions to be mentioned in the next section while, if possible, minimizing the morbidity of the donor site. To this end, an effort should be made to reconstruct as much of the normal anatomy as possible.
Preoperative assessment State of the art management of the oromandibular defect endeavors to restore function in terms of speech, deglutition, mastication, taste, oral hygiene, oral airway maintenance, and cosmesis.
Preoperative assessment and planning for patients undergoing immediate reconstruction of oromandibular defects entails a multidisciplinary team consisting of head and neck surgeons, plastic surgeons with microsurgical expertise, maxillofacial prosthodontists, radiation oncologists, medical oncologists, pathologists, occupational therapists, speech pathologists, internists, and psychologists [17]. The preoperative assessment usually includes a full head and neck examination, chest radiograph, biopsy of the lesion, quadroscopy, liver function tests, and computerized tomography (CT). Preda et al [18] investigated the use of helical CT in the pre- and postoperative management of oromandibular reconstruction of patients with oropharyngeal carcinoma using microvascular composite free flaps. The CT permitted adequate assessment of the extent of mandibular infiltration and detected early ischemic complications and distant recurrences. Postoperative assessment of correct flap positioning was possible and helpful in subsequent rehabilitation with osseointegrated implants [18]. When patients arrive in the hospital and have surgery on the same day, as in the authors’ institu-
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tion, it is important for the department of anesthesia to assess patients a week in advance and determine the need for any additional investigations. Particular attention should be paid to the risk of postoperative delirium tremens, given the high prevalence of alcohol abuse in this patient population. When a radial forearm flap is contemplated for reconstruction, an important preoperative measure is to inform the patient which forearm the surgeon intends to use as the donor site. Patients and their immediate families must ensure that no blood is drawn or intravenous lines started from this site, because this may damage the potential veins of the future flap.
Principles of reconstruction Although it is important to be aware of the anatomic areas (functional units) described earlier during reconstruction, from the practical point of view, the authors often see defects that include various permutations of those functional units. Commonly, they are found to be in continuity. To date, it is evident that the single-stage microsurgical reconstruction of the oromandibular defect is the standard of care in North America. Komisar [19] reported that patients undergoing conventional mandibular reconstructions (ie, those not using microvascular techniques) required more hospitalization and had poorer function. Urken et al [20] compared several functional parameters in patients who had microvascular oromandibular reconstruction with those in a group of unreconstructed controls and found significantly improved function in chewing performance, dental rehabilitation, and bite force, but in not swallowing or speech. Superior masticatory function was observed in patients undergoing microvascular oromandibular reconstruction versus a control group of unreconstructed patients [21]. The microsurgical reconstruction option is chosen when the defect is of such magnitude that skin grafts and local flaps will not adequately address it. In the authors’ view, the most important considerations in reconstructing the floor of the mouth are (1) to allow freedom of the tongue, especially on the anterior floor (avoid tethering of tongue), (2) to avoid redundancy of the flap, which compromises proper hygiene as the folds trap food particles, and (3) to use thin flaps, which drape gently over the alveolus (native or reconstructed mandible) and floor of the mouth and permit denture wearing [Fig. 2]. In the authors’ experience and that of other head and neck microsurgeons, the most common defect requiring reconstruction is one of the floor of the
mouth with a segmental defect of the mandible [15,22]. Soft tissue resection at the floor of the mouth, including various amounts of tongue and mandible, has a profound, cumulative effect on function and cosmetic appearance. Despite the advances of the last 3 decades, the recovery of upper aerodigestive tract function after reconstruction of the segmental oromandibular defect still tends to be incomplete. Wagner et al [23] performed univariate and multivariate analyses in a prospective observational study of 21 patients undergoing oromandibular reconstruction. Significant univariate predictors of outcome included tongue resection, pharynx resection, and flap skin-paddle area. Increasing size of the skin paddle in the reconstructive flap was an indirect indicator of larger resection. This factor influenced functional outcome measures such as speech articulation and oral pharyngeal swallowing efficiency to a greater degree in univariate analysis. Tongue function, however, remained the only significant predictor of function in multivariate analysis [23]. Hence a whole article in this issue has been dedicated to tongue reconstruction. In the past, particular emphasis was placed on proper dental occlusion to achieve normal alignment of the reconstructed mandible; this occlusion was achieved by means of arch bars, interosseous wires, Gunning splints, or wiring of dentures of the anterior arch. The missing posterior segment was replaced with the bone graft, supported by small or large reconstructive plates. The authors have found this approach inadequate, because the freefloating posterior mandibular segment can often be ’’enforced’’ to meet the demands of the anterior occlusion in many different spatial orientations, excepting the one true orientation. This ’’true and original’’ spatial orientation can only be achieved when the mandible is preplated before the cancer is resected. This measure is feasible in the vast majority of cases. The plate is then removed and sterilized and is ready for reapplication after cancer extirpation. In the occasional case where the tumor is expansile and preplating is not possible, the authors apply an external fixator that bypasses the tumor. The fixator maintains the true spatial position of the condyle in its fossa until the reconstruction. The authors’ results have improved considerably in the decade since their adoption of this approach. The achievement of the normal contour of the mandible almost invariably requires a number of osteotomies; this is particularly true for a central defect, a central–lateral defect, or a lateral ramus– ascending ramus defect [Fig. 3]. The ’’carpentry’’ of the bone may be completed either while the flap is still attached to the donor site and perfused
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Fig. 2. (A) A 60-year-old woman with SCC invading the alveolus and floor of mouth. (B) Defect after oromandibular resection. (C ) Radial forearm osteocutaneous flap used (skin paddle 6 × 6 cm; bone 7 cm). (D) Insetting of flap at floor of mouth. (E ) Postoperative appearance of same patient. (F ) Excellent contour of the forearm flap in floor of mouth, allowing free tongue movement.
or after detachment. The authors have used both approaches. Performing the ’’carpentry’’ on an attached bone graft makes sense insofar as it minimizes ischemia; however, the authors find it simpler from the practical point of view to perform the bone adjustments at the extirpative site. As a result, they now divide the pedicle as soon as the resection team removes the tumor and prepares the recipient vessels. The ’’carpentry’’ of the neomandible is done in the head and neck area. Because this ’’carpentry’’ may take up to 1 hour, the bone and pedicle should be irrigated every 5 minutes to keep them moist and avoid desiccation. The bone fixation is achieved with reconstruction plates in the larger defects,
whereas in the small defects miniplates may also be used. Given a choice for a particular defect, some members of the authors’ unit prefer to use the smaller plates, because they limit elevation of the periosteum and minimize the risk of vascular compromise to the bone. However, the larger reconstruction plates provide superior stability and tolerate higher loads. Therefore, they are recommended in younger, more active patients in whom the teeth are preserved. If osseointegration is planned, all plates, especially the screws that traverse the ’’neomandible,’’ may interfere with the integration and need to be removed before dental restoration. If the den-
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Fig. 3. (A) Defect after oromandibular resection of SCC arising from tongue and invading the mandible in a 62-year-old woman. (B) Radial forearm osteocutaneous flap used (skin paddle 7 × 6.5 cm; bone 10.5 cm). (C ) Two osteotomies were used to reconstruct the ascending ramus and provide anterior curvature; reconstruction plate was used. (D) Postoperative appearance.
tal implants are placed immediately at the time of reconstruction, the position of the plates and screws should be considered. Some microsurgeons believe that lateral mandibulectomy defects in selected patients with poor prognosis can be reconstructed (traversed) with a plate alone and a myocutaneous flap, such as a pectoralis major, or fasciocutaneous free flaps. However, when a plate and fasciocutaneous or myocutaneous flap are employed, the anterior defects need to be managed with vascularized bone reconstruction to avoid the common problem of erosion of the plate into the oral cavity [24]. In a large, recent series where plates and free flaps were used instead of osteocutaneous flaps, the plate exposure was 46%. As a result, a secondary procedure was needed in 31% of the patients [25]. The philosophy of the authors’ center in the past decade has been that, if a patient is fit to undergo the extirpative part of the procedure, he or she is fit to undergo the free flap reconstruction of the mandible. The authors prefer to reconstruct the
bone and oral lining with a vascularized osteocutaneous flap. An effort is made to save the condyle of the mandible when possible, because of the difficulty of its reconstruction. If, however, it needs to be resected for oncologic reasons, one method of reconstruction uses the head of the fibula. This method adds complexity to the dissection, because the common peroneal nerve must be protected to avoid injury, lateral knee or leg pain, or even instability. Furthermore, if an osteocutaneous flap is required, the skin paddle is usually located very distal to this proximal fibular head, making the lining and bone reconstruction incompatible. The bone may not correspond to any acceptable perforators, and yet another problem occurs when the fibular head is too big. A novel technique is to fashion a condyle from the fibula edge (not including the head), then wrap the end of the ’’neocondyle’’ with periosteum resected beyond the required fibula [26,27]. Delayed reconstruction of the con-
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dyle is an extremely difficult problem, because the facial nerve is at a real risk for injury in a scarred and tight field where structures have been displaced. Even when the nerve has been identified initially, it can still be compressed and compromised by any bone graft used. A solution to this problem is use of the newer prostheses, which carry a ’’condyle’’ at the end of the reconstruction plate. Whenever possible, the authors make an effort to reconstruct the inferior alveolar nerve, as suggested by Urken et al [20]. Both the fibular and radius osteocutaneous flaps can be raised as sensory flaps. The lateral sural nerve in the fibular flap and the lateral antebrachial cutaneous nerves may be coapted to a recipient nerve, usually the lingual nerve. The lateral antebrachial cutaneous nerve of the radial forearm flap should be used, if possible, when a recipient nerve is available [22,28,29].
Reconstructive options In the early years of head and neck reconstruction, most surgical defects were closed by primarily suturing tongue to cheek or lip and allowing the mandible to ’’drift’’ laterally. This method was acceptable for lateral floor of mouth, alveolus, cheek, or tongue defects that were relatively small, but it became unmanageable for larger defects and was a complete disaster for midline anterior tumors. The end result was the typical ’’Andy Gump’’ deformity. Accordingly, attempts were made to use all sorts of prosthetic materials to stabilize the mandible. Various local mucosal or tongue flaps were used on the inside and cheek, and cervical flaps were used on the outside. As reconstructive surgeons gained expertise, skin was brought in from distant sites to reconstruct intraoral or external defects, using forehead flaps, scalp flaps, deltopectoral flaps, and trapezius flaps. The deltopectoral and pectoralis major myocutaneous flaps markedly changed the outcomes of major head and neck surgical cancer procedures. Although earlier attempts to attach a piece of clavicle, sternum, or rib to these cutaneous or myocutaneous flaps met with only limited success, free nonvascularized rib occasionally would help stabilize a mandible and even became revascularized in some patients. The development and increased use of progressively more complicated and reliable mandibular plates provided good long-term stabilization for lateral defects, but these plates were rarely satisfactory for anterior defects. It was only with the development of free microvascular bone and bone/soft tissue flaps that the modern era of head and neck reconstruction for oromandibular defects began. One of the earliest flaps used in this regard was the dorsalis pedis [30], which provided excellent
thin skin for intraoral reconstruction as well as some bone, although this was certainly not as reliable as the bone flaps now available to us. Similarly, vascularized rib has been used intermittently to reconstruct the mandible and is still occasionally used [31,32]. However, both of these osteocutaneous flaps have significant donor-site morbidity and as a result are rarely used today. A number of well-vascularized osteocutaneous flaps are now available for oromandibular reconstruction; their advantages and disadvantages are discussed in detail in the next section.
Commonly used free flaps For lining defects of the floor of the mouth, a number of flaps are reported to yield satisfactory results. The most common flaps used for this purpose in the authors’ center are the radial forearm fasciocutaneous [22,33] and the lateral arm flaps [34]. Other flaps used for the same purpose include the dorsalis pedis [30,35] and the scapular flaps [36]. Others have recently used the anterolateral thigh flap [37,38]. The most intricate and difficult part of reconstruction is the approach to the oromandibular defect after composite resection of the mandible. The four flaps most commonly used for this purpose are discussed in the following sections.
Fibula flap In the last decade, the free fibula and radial forearm osteocutaneous flaps have probably been the flaps most commonly used in oromandibular reconstruction. The advantage of the fibula is the long bicortical bone that can reconstruct the entire mandible if necessary. In contrast to other bone flaps that provide limited length, usually about 14 cm (radius, iliac crest, scapula), the fibula has enough bone stock to support osseointegrated dental implants, and there is generally scant morbidity to the donor extremity. It allows extirpative and harvesting teams to work simultaneously [39–41]. The reconstructive surgeon is well away from the extirpative surgeon, allowing maximum exposure for resection. This arrangement contrasts with the harvesting of the radial flap, where the field is ’’congested’’ with surgeons and assistants. Although some surgeons recommend angiography, the authors no longer perform routine angiography unless the clinical examination casts doubt on the adequacy of the leg circulation or suggests that a peroneal arteria magna exists. This condition is reported to occur in between 0.2% and 5% of the general population; it is associated with hypoplasia or absence of both the anterior and posterior tibial arteries, with
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the peroneal artery providing the sole circulation of the foot [42]. When the authors are able to palpate a dorsalis pedis and a posterior artery pulse, and the ankle/ brachial index is acceptable, they are satisfied of the adequacy of the leg circulation. The harvesting of the flap uses the lateral approach, with the patient in supine position [43]. Before surgery, the perforator vessels are mapped with the Doppler. These perforators are usually found in the middle and distal third of the leg [44,45]. In most cases, only a small portion of the fibula is used in the reconstruction; most of the harvested length is discarded, allowing a subperiosteal ’’pruning’’ to lengthen the vascular pedicle, which the authors
generally find necessary. The distal 7 to 8 cm measured from the lateral malleolus is left intact to support the ankle joint. The authors routinely identify the peroneal nerve at the neck of the fibula; they decompress it, and the resection of the fibula takes place just below the neck. In this way they protect the peroneal nerve under direct vision at all times. In the rare event that the whole fibula is harvested superiorly, it is important to reattach the lateral collateral ligament to the tibial condyle. To avoid postoperative compression of the pedicle in cases of an osteocutaneous flap, it is preferable to use the contralateral extremity for dissection. The authors’ usual technique is to keep the vascular pedicle on the lingual side and place it poste-
Fig. 4. (A) Central oromandibular defect after resection of SCC of floor of mouth invading the mandible in a 56-year-old man. (B) Osteocutaneous fibula flap used. (C ) “Carpentry” of bone graft on side table using small reconstruction plates (skin paddle 5 × 8 cm; bone 10 cm). (D) Fibula inset. (E ) Postoperative appearance; the fibula skin paddle is generally thicker than that provided by the forearm flap.
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Fig. 5. (A) Preoperative appearance of large bone tumor of the mandible in a 15-year-old male. (B) CTT appearance of the tumor. (C ) Radiograph after reconstruction with fibula bone graft (no skin paddle was necessary; bone graft 12 cm). (D) Postoperative appearance.
riorly. These maneuvers make it less likely that the vascular pedicle will be compressed. The most common use of the flap in the authors’ center is as an osteocutaneous flap [Fig. 4]. Less commonly, it is used as a vascularized bone graft without a skin paddle [Fig. 5]. The cutaneous flap may be neurotized using a branch of the sural nerve (lateral cutaneous sural nerve). Other variations of the flap described include the double barrel arrangement to increase the height of the reconstructed mandible [27]. Multiple skin paddles may be designed on separate perforators [46]. The use of parts of the soleus muscle or flexor hallucis longus to fill soft tissue defects has been described [27,47]. A problematic aspect of this otherwise excellent flap is the reported failure of the skin paddle in the presence of viable bone [48,49]. Even in more recently reported series, this failure remains a problem. In a series of 61 patients in whom an osteocutaneous flap was raised, Sieg et al [27] experienced seven total skin paddle necroses in the presence of viable bone. The authors have also experienced
such failure, which may result from compression of the perforators, absence of perforators, shearing of the fasciocutaneous blood supply, or poor design of the cutaneous paddle. In centers where the fibula and radial forearm flaps are used with similar frequency, total flap failure is reported to be higher with the fibula than with the radial forearm osteocutaneous flap [50].
Radial forearm osteocutaneous flap This flap is a true competitor to the fibula flap. It is certainly superior to the fibula osteocutaneous flap in terms of skin paddle survival, but the bone quality is inferior. As much as 14 cm of unicortical bone has been harvested [22]. The skin paddle is thin and often superior to the fibula’s thicker skin paddle. Likewise, the skin paddle has better flexibility in relation to the bone than does the equivalent fibula flap. The radial forearm may be used as a sensory flap when one harvests the lateral antebrachial cutaneous flap with it. Its vascular pedicle is by far the best of all the common flaps used in head and
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neck reconstruction. As much as 20 cm of pedicle may be easily harvested, making this flap ideal for reconstructions in vessel-depleted necks, especially in repeat surgical cases. Strong evidence suggests that flaps requiring vein grafts have higher rates of flap loss (18.4%) than do flaps that do not require vein grafts (2.9%; P < 0.0001) [51]. The radial forearm flap vessels are of large caliber: 2 to 5 mm. This flap has dual venous drainage (deep and superficial), and both systems may be used. If the anastomotic vein is protected in the anticubital fossa, the two systems may be combined to provide a type I venous drainage pattern with two large-caliber veins for anastomosis: the median basilic and median cephalic veins [52]. In contrast to the fibula, in which the skin paddle is the tenuous component of the flap, it is the bone component of the radial forearm flap that is tenuous. Nonetheless, multiple osteotomies can be performed on the radial bone to achieve the appropriate contour [53]. Caution needs to be exercised in harvesting this flap as one approaches the bone cortex from underneath the brachioradialis tendon. The soft tissue composed of part of the flexor pollicis longus needs to remain attached to the bone. The dissection should be parallel to the undersurface of the brachioradialis to protect the small periosteal vessels through which the bone derives its vascular supply [22,53]. The major drawback of this flap is the risk of fracture of the donor radius, which runs at about 12%. This risk may be minimized by limiting the harvesting of the radius to 40% of the diameter of the bone, although the authors often harvest 50% of the diameter. Some precautions for avoiding donor radius fracture include instructing the patients preoperatively to avoid putting weight on the hand, placing a protective plaster splint, and controlling delirium tremens after the surgery. Intraoperatively, one needs to be careful with the osteotomy on the radial side of the radius at the level of the insertion of the pronator teres, where the appearance that one is osteotomizing superficially may cause one to go too deep [22]. The fear of donor fracture has kept some investigators from using this flap. Some recommend the use of prophylactic plating of the radius [54]. A recent cost-utility analysis comparing plating of the donor radius with no plating found prophylactic plating to be a non–cost-effective approach [55]. As a result of this analysis, the authors usually only plate the radius in cases of fractures or when they believe the remaining radius is too thin. A review of the function of the hand in patients who fractured the radius did not identify any limitations, in contrast to some early papers.
Skin graft failure and exposed tendons occasioned early criticisms of the radial forearm flap. These complications should never occur if one pays attention to details of skin grafting and splints the entire hand and forearm for 1 week [22]. Devascularization of the hand should never happen in the presence of an intact palmar arch, as ascertained by the Allen’s test. However, caution should be exercised in identifying an anomalous superficial ulnar artery, which occurs in 3% of the population. In this anomaly, the ulnar artery is located under the superficial fascia along the volar forearm. As a result, it can easily be mistaken for a superficial vein. Normally, in the distal forearm, the ulnar artery and the venae comitantes are found under the flexor carpi ulnaris. In the case of this anomaly, no vessels are found under the flexor carpi ulnaris. Failure to recognize this congenital anomaly can devascularize the whole hand. This problem can be prevented by not exsanguinating the forearm but simply elevating the flap before inflating the tourniquet [56]. Osteotomies may be performed on the radial bone graft to reconstruct central mandibular defects just as well as with the fibula [see Fig. 3]. Although osseointegrated implants are possible [57], the authors believe that the bone quality is not as robust as that of the fibula, where shorter osteotomized segments are tolerated and dental restoration with osteointegrated implants is more reliable.
Scapula flap This flap, subtended by the circumflex scapular vessels, may have a longer pedicle if the dissection extends deeper into the triangular space and uses the subscapular vessels [58]. The subscapular vessels are larger, and the vein is less friable at this level. One large or two venae comitantes may be anastomosed. Two variations of the osteocutaneous flap have been described. The first variation uses the lateral edge of the scapula with thicker bone but with a shorter vascular pedicle [59,60]. The second variation uses the medial edge of the scapula, in which the bone component is away from the pedicle, effectively allowing the anastomosis to be performed on the opposite neck [61]. Another advantage of the medial flap is that it minimizes the dissection around the teres major and minor and the glenohumeral joint, thereby avoiding prolonged stiffness to the shoulder. The major disadvantage of the medial scapular flap as compared with its lateral equivalent is the thickness of the bone. Twelve to 14 cm of bone may be harvested with either variation of the scapula flap [61]. Two key advantages of this flap compared with the fibula and radius flaps are the superior color match of the skin paddle when used for
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Fig. 6. (A) Malignant fistula from recurrent SCC arising from submandibular gland and invading the mandible in a 70-year-old man. (B) Resected mandible. (C ) Medial scapular osteocutaneous flap used (skin paddle 17 × 8 cm; bone graft 11 cm). (D) Intraoperative view of reconstruction. (E ) Postoperative appearance showing excellent color match (frontal view). (F ) Profile view of same patient.
coverage [Fig. 6] and the possibility of harvesting large and multiple skin paddles from the posterior thorax—ideally suited to the patient with a massive soft tissue defect or a through and through defect [61]. Even in flaps as large as 39 × 10 cm, the donor site can be closed directly [62]. The major drawback of this flap (both lateral and medial varieties) is the necessity of repositioning the patient. Rarely is it possible for the ablative and reconstructive teams to work simultaneously. As a result, it is necessary to change the patient’s position twice, which adds considerable time to the surgery. To minimize this time, the authors compromise by
estimating the defect ahead of time and harvesting the flap before the cancer is resected. They take more bone and soft tissue than they expect to use, close the defect, and let the ablative team take over. The flap is kept on ice on a side table until hours later, when the reconstructing team returns to inset it. The prolonged cold ischemia has not been a problem in the authors’ patients.
Iliac crest This free flap based on the deep circumflex artery and vein was first introduced by Ian Taylor in 1979 [63,64]. Since then, it has been used successfully by
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Table 1: Comparison of select qualities of the four osteocutaneous flaps in oromandibular reconstruction
Reliability of skin paddle (survival) Skin paddle pliability (intraoral) Color match (external coverage) Bone quality Osseointegration of dental implants Vessel quality Vascular pedicle length Sensory innervation Donor-site morbidity Donor-site cosmesis
Fibula
Radius
Scapula
Iliac crest
++ +++ ++ +++ +++ +++ +++ ++++ ++ +++
++++ ++++ ++ ++ ++ ++++ ++++ ++++ ++ +++
++++ ++ ++++ ++ ++ +++ ++ (++++) + ++ (+++) +++
+++ + + ++++ ++++ +++ ++ + + +++
++++ denotes best; + denotes worst; (+) denotes the medial scapular osteocutaneous flap.
a number of surgeons for the reconstruction of the composite oromandibular defect [13,14,65]. A large volume of unicortical or bicortical bone, up to 14 to 16 cm in length, may be harvested. This flap can be used to reconstruct various mandibular defects, and multiple osteotomies may be performed to achieve the necessary contour. Urken et al [66] used the internal oblique muscle with this bone graft to resurface soft tissue and intraoral mucosal defects. This flap is probably the best available flap for accepting osseointegrated implants [66]. Its advantages are the volume of the bone, the height, which is appropriate for accepting dental implants, and the large soft tissue mass that can be harvested with it. Unfortunately, this flap carries with it significant donor-site morbidity, including severe postoperative pain, contour irregularity, and iatrogenic hernia [67]. In the authors’ experience, the skin paddle of the iliac crest flap is usually too bulky and unsuitable for reconstruction of the lining and bone defects. For external coverage and bone defects or for through and through defects, the color match is inferior to other flaps. The iliac crest flap’s vascular pedicle is also much shorter than those of competitor flaps, such as the radial forearm, scapula, and fibula. It is still useful for isolated bone defects in which dental implants are desired, particularly for central mandibular defects. Although other flaps have been used less frequently (eg, humerus bone attached to the lateral arm flap), the authors have included here what they consider to be the four most useful osteocutaneous flaps. Table 1 presents some key distinguishing qualities of these four flaps, based on the authors’ experience of using all of them intermittently over a period of more than 20 years. The authors of this article anticipate some understandable disagreement with this assessment; they recommend reading the article in this issue that addresses, among other matters, the question of bias and hierarchy of evidence in clinical decision making. One aspect of
oromandibular reconstruction that appears to generate heated controversy at national meetings is the osseointegration of any one of the bone grafts described here. In the authors’ view, this debate is vastly overrated, because the proportion of patients who undergo this step in most reported series is small indeed. The patients undergoing oromandibular resection generally belong to a comparatively low socioeconomic class and cannot afford the added expense of osseointegration of dental implants. Certainly, we need to make progress in this area by lobbying the local and federal governments to provide this aspect of care. However, until osseointegration becomes a common practice, we should keep our minds open to the other qualities of the competing flaps.
Future predictions and summary Our understanding of the reconstructive needs of the oromandibular defect is now clear. We need to return the anatomy as close to its original state as possible to improve function and cosmesis. Reconstructive surgeons’ efforts in the last 2 decades have yielded remarkable improvements in both areas. We need to acknowledge, however, that our results will continue to be suboptimal as long as we use dissimilar tissues from other parts of the body for the reconstruction. We are presently at the dawn of a new era of reconstruction of the oromandibular defect. Within a few months of this writing, the composite tissue allotransplantation of the human face, supported by immunosuppressive drugs, will become a reality. Soon afterward, the transplantation of the mandible and parts of the floor of the mouth and tongue will become feasible. Future head and neck microsurgeons will have an easier job. Banked parts of human faces will be at their disposal. An entire article in this issue has been devoted to this exciting prospect.
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At national and international microsurgical meetings and in published articles, authors tout the benefits of the flaps with which they are familiar and criticize those with which they are not. Because surgeons in general are not familiar with the principles of evidence-based microsurgery, the editors of this issue have included an article that addresses the methodologic issues of comparing free flaps and techniques (known and still undiscovered) in oromandibular reconstruction. The authors anticipate that these principles will help surgeons decide which flap to use based on the best evidence available, rather than on ‘‘expert‘‘ pronouncements— including their own!
References [1] Public Health Agency of Canada. Cancer surveillance on-line page. Available at: http://dsol-smed. phac-aspc.gc.ca/dsol-smed/cancer/index_e.html. Accessed November 30, 2004. [2] Yousif NJ, Matloub HS, Sanger JR, et al. Softtissue reconstruction of the oral cavity. Clin Plast Surg 1994;21(1):15–23. [3] Sankaranarayanan R, Masuyer E, Swaminathan R, et al. Head and neck cancer: a global perspective on epidemiology and prognosis. Anticancer Res 1998;18(6B):4779–86. [4] Hoffman HT, Karnell LH, Funk GF, et al. The National Cancer Data Base report on cancer of the head and neck. Arch Otolaryngol Head Neck Surg 1998;124(9):951–62. [5] Inagi K, Takahashi H, Okamoto M, et al. Treatment effects in patients with squamous cell carcinoma of the oral cavity. Acta Otolaryngol Suppl 2002;547:25–9. [6] Funk GF, Karnell LH, Robinson RA, et al. Presentation, treatment, and outcome of oral cavity cancer: a National Cancer Data Base report. Head Neck 2002;24(2):165–80. [7] Jemal A, Tiwari R, Murray T, et al. Cancer Statistics, 2004. CA Cancer J Clin 2004;54(1):8–29. [8] Mork J. Forty years of monitoring head and neck cancer in Norway—no good news. Anticancer Res 1998;18(5B):3705–8. [9] Freije J, Kumar JV. Prevention of cancers of oral cavity and pharynx in New York State. N Y State Dent J 2001;67(3):26–30. [10] Shiboski CH, Shiboski SC, Silverman Jr S. Trends in oral cancer rates in the United States, 1973– 1996. Community Dent Oral Epidemiol 2000; 28(4):249–56. [11] Tankere F, Golmard JL, Barry B, et al. Prognostic value of mandibular involvement in oral cavity cancers. Rev Laryngol Otol Rhinol (Bord) 2002; 123(1):7–12. [12] Pugliano FA, Piccirillo JF, Zequeira MR, et al. Clinical-severity staging system for oral cavity cancer: five-year survival rates. Otolaryngol Head Neck Surg 1999;120(1):38–45. [13] David DJ, Tan E, Katsaros J, et al. Mandibular
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[27] Sieg P, Zieron JO, Bierwolf S, et al. Defect-related variations in mandibular reconstruction using fibula grafts. A review of 96 cases. Br J Oral Maxillofac Surg 2002;40(4):322–9. [28] Urken ML. The restoration or preservation of sensation in the oral cavity following ablative surgery. Arch Otolaryngol Head Neck Surg 1995; 121:607–12. [29] Boyd B, Mulholland S, Gullane P, et al. Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: are we making sense? Plast Reconstr Surg 1994;93(7): 1350–9. [30] Robinson DW. Microsurgical transfer of the dorsalis pedis neurovascular flap. Br J Plast Surg 1976;29(3):209–13. [31] Daniel RK. Mandibular reconstruction with free tissue transfers. Ann Plast Surg 1978;1(4):346–71. [32] Thoma A, Heddle S, Archibald S, et al. The free vascularized anterior rib graft. Plast Reconstr Surg 1988;82(2):291–8. [33] Soutar DS, Scheker LR, Tanner NS, et al. The radial forearm flap: a versatile method for intraoral reconstruction. Br J Plast Surg 1983;36(1): 1–8. [34] Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 1984;12(6):489–500. [35] Zucker RM, Manktelow RT. The dorsalis pedis free flap: technique of elevation, foot closure, and flap application. Plast Reconstr Surg 1986; 77(1):93–104. [36] Barwick WJ, Goodkind DJ, Serafin D. The free scapular flap. Plast Reconstr Surg 1982;69(5): 779–87. [37] Koshima I. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 2000; 105(7):2358–60. [38] Wei FC, Jain V, Celik N, et al. Have we found an ideal soft tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109(7):2219–26. [39] Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 1995;96(3):585–96. [40] Shpitzer T, Neligan PC, Gullane PJ, et al. The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and longterm evaluation. Head Neck 1999;21(7):639–47. [41] Babovic S, Johnson CH, Finical SJ. Free fibula donor-site morbidity: the Mayo experience with 100 consecutive harvests. J Reconstr Microsurg 2000;16(2):107–10. [42] Kim D, Orron DE, Skillman JJ. Surgical significance of popliteal artery variants: a unified angiographic classification. Ann Surg 1989;210(6): 776–81. [43] Gilbert A. Vascularized transfer of the fibula shaft. Int J Microsurg 1979;1:100–2. [44] Wei FC, Seah CS, Tsai YC, et al. Fibula osteoseptocutaneous flap for reconstruction of
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