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Reconstruction of bony mandibular and maxillary defects with one single transfer of a free fibula osteocutaneous flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 200e203
CASE REPORT
Reconstruction of bony mandibular and maxillary defects with one single transfer of a free fibula osteocutaneous flap Boris Laure*, Florent Sury, Thomas Martin, Arnaud Chabut, Dominique Goga Department of Maxillofacial and Plastic Facial Surgery, Trousseau Hospital, University of Tours, 37044 Tours, Cedex, France Received 17 September 2006; accepted 11 June 2007
KEYWORDS Simultaneous reconstruction; Free fibula flap; Maxillo-mandibular defect; Microdialysis; Gunshot injury; Facial injury
Summary One-stage bone reconstruction of both the maxilla and the mandible with a single bone transfer is unusual in microsurgery. The authors report and describe the surgical technique of an original one-stage bone reconstruction of the maxilla and the mandible in a defect caused by a gunshot injury. The reconstruction was performed with a free fibular osteocutaneous flap. A concomitant maxillo-mandibular defect is uncommon. Gunshot injuries and tumours are the two main causes of this defect. The reconstruction of maxillary and mandibular defects can be a surgical challenge. The reconstruction was performed in one stage with the free transfer of a fibular osteocutaneous flap. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Case report A 38-year-old male was admitted to the emergency unit of the CHU Trousseau, Tours, France after a facial gunshot injury following a suicide attempt. Devastating injury resulted in an extensive destruction of both soft tissues
* Corresponding author. Address: Service de chirurgie maxillofaciale, ho ˆpital Trousseau, 37044 Tours cedex, France. E-mail address: [email protected] (B. Laure).
and facial bones. There was a midfacial soft tissue defect composed of the entire nose, the right lateral halves of the upper and lower lips and the floor of the mouth avulsion. The left eye was not involved but the right eye was ruptured and collapsed. The entire skeletal structures of the upper two-thirds of the face including hard palate, maxilla, medial orbital walls and floors, infraorbital rims, and osteocartilaginous structures of the nose were lost. The mandibular defect ranged from left to right body. All the symphyseal and parasymphyseal area were avulsed. Remaining bone structures were fractured.
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.06.007
Reconstruction of bony mandibular and maxillary defects
Figure 1
201
(a, b) Preoperative CT scan revealed multiple fractures and bone defects of the midface structures.
The preoperative CT scan revealed multiple fractures and defects in the central face (Fig. 1a, b). A tracheostomy, initial debridement, primary suture of the wounds and stabilisation with miniplates (orbital rims, left mandibular corpus) were performed in emergency surgery. A mandibular external fixator was placed to fill the mandibular defect and prevent retraction. The second CT scan revealed a complete lack of anatomic bone structure in the central face (Fig. 2a, b). Three months later, the reconstruction was performed using two teams. The first team prepared the recipient site and vessels while the second team harvested the flap. A right 23 cm fibular osteocutaneous flap was harvested with an 18 7 cm skin paddle on its vascular pedicle (Fig. 3). Two osteotomies were performed at the proximal part of the flap for the symphyseal and parasymphyseal defect reconstruction. We used the first 4 cm for the left body, the next 3 cm for the symphysa and 4 cm for the right body. Osteotomies were stabilised with miniplates. A dissection of the pedicle
Figure 2
was performed in a strictly subperiosteal plane to remove the four adjacent centimetres of bone. The remaining distal 8 cm of the flap were used to reconstruct the maxilla (Fig. 4). The skin was removed from the middle part of the skin paddle. The peroneal artery was anastomosed end-to-end to the left facial artery and the peroneal vein was anastomosed end-to-end to the left thyro-lingo-facial trunk. The proximal part of the fibula was stabilised to the mandible with miniplates to the mandibule. The distal part of the flap was rotated for the maxillary reconstruction and was stabilised between the two remnant malar bones the same way. The proximal part of the skin paddle was used to replace the skin of the chin and the mucosa of the floor of the mouth. The distal part of the skin paddle was used to replace the palatal mucosa and wrapped around the bone to reconstuct the nasal floor. The skin paddle was secured laterally to the skin and posteriorly anchored to the fibula by micro Miteck anchors. The donor site was covered with a split thickness skin graft.
(a, b) The second CT scan revealed an absence of anatomic bone structure of the midface.
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Figure 3
Free osteocutaneous fibula flap harvested.
Postoperative monitoring of the free flap was both clinical and by microdialysis.1,2 One-third of the upper part of the skin paddle was lost without any consequence on the bone part of the flap. An excision under local anaesthesia was performed. The postoperative CT scan at 2 months showed good reconstruction and good osteointegration of the flap (Fig. 5aec).
Discussion In this paper we report a concomitant bone reconstruction of both maxilla and mandible defects caused by a gunshot injury. This successful reconstruction was performed with a single transfer of a free fibular osteocutaneous flap. In the literature, simultaneous bone reconstruction of the mandibule and the maxilla with a single transplant was achieved in only three cases: two in traumatology3,4 and one after oncological resection.5 In the past such facial bone defects were a major challenge because of the limited reconstruction options with pedicled flaps. The advances in microsurgery currently allow for complex facial soft-tissues and bone defects reconstruction.
Figure 5
Figure 4 Flap after osteotomies and after removal of part of the bone. The proximal part for the mandibular reconstruction and the distal part for the maxilla reconstruction.
The three main free flaps used for facial bone defect reconstructions are the iliac crest, the scapula crest and the fibula. The use of the free iliac crest flap has consequences at the donor site. The scapula crest flap is a good free flap for mandibular reconstruction but can only be up to 12 cm in length and the two team approach is not feasible. Although minor problems at the donor site and the prolonged duration of the procedure can be problematic, free fibular flap surgery is recognised as the most convenient procedure for mandibular reconstruction allowing the possibility of a two team approach. Usually when we harvest a free fibular flap, the proximal osteotomy is performed at 6 cm from the fibula’s head to allow for a good dissection of the vessels to the bifurcation of the posterior tibial artery and the peroneal artery. After severance of the pedicle, the flap is osteotomised on the table and the bone excess is cast. As described by Sadove and Oskan, we planned to use this part of the bone to reconstruct the maxilla.3,4 In the present case, a 23 cm fibular osteocutaneous flap was harvested with an 18 7 cm skin paddle.
(a, b, c) Postoperative CT scan showing the maxillo-mandibular reconstruction.
Reconstruction of bony mandibular and maxillary defects In his paper, Nisanci described using two free fibula flaps to reconstruct simultaneous mandibular and maxillary defects.6 The pedicle’s vessels of the second flap were anastomosed to the distal ends of the vessels of the first flap in a flow-through manner. In our case, we used a single free fibular flap with the advantages of less morbidity and shorter operative time. In microsurgery, the risks of failure by arterial or venous thrombosis are always present and we have to keep options in mind. In case of failure, the second fibula is still an available option. Ozkan and Sadove reported cases of a simultaneous reconstruction of maxillary and mandibular defect with a fibular osteocutaneous flap combined with an anterolateral thigh flap4 or a radial forearm flap.3 We prefer not to use a second fasciocutaneous free flap to cover the skin or mucosal defect because of the risks of two free flaps in this context and we instead used a bigger skin paddle on the osteocutaneous free fibular flap. We lost one-third of the distal skin paddle without any consequence on the bony part of the flap. We believe that loss was caused by an excessive tension applied to the skin while securing it to the surrounding mucosa. We should have oversized the skin paddle to overcome the natural retraction of the skin. The bone reconstruction result was satisfactory. The maxillary reconstruction, despite not being totally anatomical, allows for future insertion of osseointegrated intraoral implants and prosthesis.7 In conclusion, a single free fibular osteocutaneous flap is a good one-stage reconstruction option for concomitant maxillo-mandibular defect.
203
Acknowledgements The authors would like to thank Yole `ne Lacroix and Bertrand Baujat for manuscript revision.
References 1. Jyranki J, Suominen S, Vuola J, et al. Microdialysis in clinical practice: monitoring intraoral free flaps. Ann Plast Surg 2006; 56:387e93. 2. Setala L, Papp A, Romppanen EL, et al. Microdialysis detects postoperative perfusion failure in microvascular flaps. J Reconstr Microsurg 2006;22:87e96. 3. Sadove RC, Powell LA. Simultaneous maxillary and mandibular reconstruction with one free osteocutaneous flap. Plast Reconstr Surg 1993;92:141e6. 4. Ozkan O, Ozgentas HE, Dikici MB. Simultaneous reconstruction of large maxillary and mandibular defects with a fibular osteocutaneous flap combined with an anterolateral thigh flap. J Reconstr Microsurg 2004;20: 451e5. 5. Punpale AS, Rajendra Prasad JS, Shetty KP, et al. An innovative design for simultaneous reconstruction of complex maxillomandibular defects with single free fibula osteocutaneous flap. J Plast Reconstr Aesthet Surg 2006;59:96e101. 6. Nisanci M, Turegun M, Er E, et al. Reconstruction of the middle and lower face with three simultaneous free flaps: combined use of bilateral fibular flaps for maxillomandibular reconstruction. Ann Plast Surg 2003;51:301e7. 7. Goga D, Giumelli B, Fassio E, et al. Microvascular mandibular reconstruction and implantology. A study of the stability of long-term results, a propos of 2 cases followed for 8 years. Rev Stomatol Chir Maxillofac 1998;99:231e4.
CASE REPORT
Reconstruction of bony mandibular and maxillary defects with one single transfer of a free fibula osteocutaneous flap Boris Laure*, Florent Sury, Thomas Martin, Arnaud Chabut, Dominique Goga Department of Maxillofacial and Plastic Facial Surgery, Trousseau Hospital, University of Tours, 37044 Tours, Cedex, France Received 17 September 2006; accepted 11 June 2007
KEYWORDS Simultaneous reconstruction; Free fibula flap; Maxillo-mandibular defect; Microdialysis; Gunshot injury; Facial injury
Summary One-stage bone reconstruction of both the maxilla and the mandible with a single bone transfer is unusual in microsurgery. The authors report and describe the surgical technique of an original one-stage bone reconstruction of the maxilla and the mandible in a defect caused by a gunshot injury. The reconstruction was performed with a free fibular osteocutaneous flap. A concomitant maxillo-mandibular defect is uncommon. Gunshot injuries and tumours are the two main causes of this defect. The reconstruction of maxillary and mandibular defects can be a surgical challenge. The reconstruction was performed in one stage with the free transfer of a fibular osteocutaneous flap. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Case report A 38-year-old male was admitted to the emergency unit of the CHU Trousseau, Tours, France after a facial gunshot injury following a suicide attempt. Devastating injury resulted in an extensive destruction of both soft tissues
* Corresponding author. Address: Service de chirurgie maxillofaciale, ho ˆpital Trousseau, 37044 Tours cedex, France. E-mail address: [email protected] (B. Laure).
and facial bones. There was a midfacial soft tissue defect composed of the entire nose, the right lateral halves of the upper and lower lips and the floor of the mouth avulsion. The left eye was not involved but the right eye was ruptured and collapsed. The entire skeletal structures of the upper two-thirds of the face including hard palate, maxilla, medial orbital walls and floors, infraorbital rims, and osteocartilaginous structures of the nose were lost. The mandibular defect ranged from left to right body. All the symphyseal and parasymphyseal area were avulsed. Remaining bone structures were fractured.
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.06.007
Reconstruction of bony mandibular and maxillary defects
Figure 1
201
(a, b) Preoperative CT scan revealed multiple fractures and bone defects of the midface structures.
The preoperative CT scan revealed multiple fractures and defects in the central face (Fig. 1a, b). A tracheostomy, initial debridement, primary suture of the wounds and stabilisation with miniplates (orbital rims, left mandibular corpus) were performed in emergency surgery. A mandibular external fixator was placed to fill the mandibular defect and prevent retraction. The second CT scan revealed a complete lack of anatomic bone structure in the central face (Fig. 2a, b). Three months later, the reconstruction was performed using two teams. The first team prepared the recipient site and vessels while the second team harvested the flap. A right 23 cm fibular osteocutaneous flap was harvested with an 18 7 cm skin paddle on its vascular pedicle (Fig. 3). Two osteotomies were performed at the proximal part of the flap for the symphyseal and parasymphyseal defect reconstruction. We used the first 4 cm for the left body, the next 3 cm for the symphysa and 4 cm for the right body. Osteotomies were stabilised with miniplates. A dissection of the pedicle
Figure 2
was performed in a strictly subperiosteal plane to remove the four adjacent centimetres of bone. The remaining distal 8 cm of the flap were used to reconstruct the maxilla (Fig. 4). The skin was removed from the middle part of the skin paddle. The peroneal artery was anastomosed end-to-end to the left facial artery and the peroneal vein was anastomosed end-to-end to the left thyro-lingo-facial trunk. The proximal part of the fibula was stabilised to the mandible with miniplates to the mandibule. The distal part of the flap was rotated for the maxillary reconstruction and was stabilised between the two remnant malar bones the same way. The proximal part of the skin paddle was used to replace the skin of the chin and the mucosa of the floor of the mouth. The distal part of the skin paddle was used to replace the palatal mucosa and wrapped around the bone to reconstuct the nasal floor. The skin paddle was secured laterally to the skin and posteriorly anchored to the fibula by micro Miteck anchors. The donor site was covered with a split thickness skin graft.
(a, b) The second CT scan revealed an absence of anatomic bone structure of the midface.
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Figure 3
Free osteocutaneous fibula flap harvested.
Postoperative monitoring of the free flap was both clinical and by microdialysis.1,2 One-third of the upper part of the skin paddle was lost without any consequence on the bone part of the flap. An excision under local anaesthesia was performed. The postoperative CT scan at 2 months showed good reconstruction and good osteointegration of the flap (Fig. 5aec).
Discussion In this paper we report a concomitant bone reconstruction of both maxilla and mandible defects caused by a gunshot injury. This successful reconstruction was performed with a single transfer of a free fibular osteocutaneous flap. In the literature, simultaneous bone reconstruction of the mandibule and the maxilla with a single transplant was achieved in only three cases: two in traumatology3,4 and one after oncological resection.5 In the past such facial bone defects were a major challenge because of the limited reconstruction options with pedicled flaps. The advances in microsurgery currently allow for complex facial soft-tissues and bone defects reconstruction.
Figure 5
Figure 4 Flap after osteotomies and after removal of part of the bone. The proximal part for the mandibular reconstruction and the distal part for the maxilla reconstruction.
The three main free flaps used for facial bone defect reconstructions are the iliac crest, the scapula crest and the fibula. The use of the free iliac crest flap has consequences at the donor site. The scapula crest flap is a good free flap for mandibular reconstruction but can only be up to 12 cm in length and the two team approach is not feasible. Although minor problems at the donor site and the prolonged duration of the procedure can be problematic, free fibular flap surgery is recognised as the most convenient procedure for mandibular reconstruction allowing the possibility of a two team approach. Usually when we harvest a free fibular flap, the proximal osteotomy is performed at 6 cm from the fibula’s head to allow for a good dissection of the vessels to the bifurcation of the posterior tibial artery and the peroneal artery. After severance of the pedicle, the flap is osteotomised on the table and the bone excess is cast. As described by Sadove and Oskan, we planned to use this part of the bone to reconstruct the maxilla.3,4 In the present case, a 23 cm fibular osteocutaneous flap was harvested with an 18 7 cm skin paddle.
(a, b, c) Postoperative CT scan showing the maxillo-mandibular reconstruction.
Reconstruction of bony mandibular and maxillary defects In his paper, Nisanci described using two free fibula flaps to reconstruct simultaneous mandibular and maxillary defects.6 The pedicle’s vessels of the second flap were anastomosed to the distal ends of the vessels of the first flap in a flow-through manner. In our case, we used a single free fibular flap with the advantages of less morbidity and shorter operative time. In microsurgery, the risks of failure by arterial or venous thrombosis are always present and we have to keep options in mind. In case of failure, the second fibula is still an available option. Ozkan and Sadove reported cases of a simultaneous reconstruction of maxillary and mandibular defect with a fibular osteocutaneous flap combined with an anterolateral thigh flap4 or a radial forearm flap.3 We prefer not to use a second fasciocutaneous free flap to cover the skin or mucosal defect because of the risks of two free flaps in this context and we instead used a bigger skin paddle on the osteocutaneous free fibular flap. We lost one-third of the distal skin paddle without any consequence on the bony part of the flap. We believe that loss was caused by an excessive tension applied to the skin while securing it to the surrounding mucosa. We should have oversized the skin paddle to overcome the natural retraction of the skin. The bone reconstruction result was satisfactory. The maxillary reconstruction, despite not being totally anatomical, allows for future insertion of osseointegrated intraoral implants and prosthesis.7 In conclusion, a single free fibular osteocutaneous flap is a good one-stage reconstruction option for concomitant maxillo-mandibular defect.
203
Acknowledgements The authors would like to thank Yole `ne Lacroix and Bertrand Baujat for manuscript revision.
References 1. Jyranki J, Suominen S, Vuola J, et al. Microdialysis in clinical practice: monitoring intraoral free flaps. Ann Plast Surg 2006; 56:387e93. 2. Setala L, Papp A, Romppanen EL, et al. Microdialysis detects postoperative perfusion failure in microvascular flaps. J Reconstr Microsurg 2006;22:87e96. 3. Sadove RC, Powell LA. Simultaneous maxillary and mandibular reconstruction with one free osteocutaneous flap. Plast Reconstr Surg 1993;92:141e6. 4. Ozkan O, Ozgentas HE, Dikici MB. Simultaneous reconstruction of large maxillary and mandibular defects with a fibular osteocutaneous flap combined with an anterolateral thigh flap. J Reconstr Microsurg 2004;20: 451e5. 5. Punpale AS, Rajendra Prasad JS, Shetty KP, et al. An innovative design for simultaneous reconstruction of complex maxillomandibular defects with single free fibula osteocutaneous flap. J Plast Reconstr Aesthet Surg 2006;59:96e101. 6. Nisanci M, Turegun M, Er E, et al. Reconstruction of the middle and lower face with three simultaneous free flaps: combined use of bilateral fibular flaps for maxillomandibular reconstruction. Ann Plast Surg 2003;51:301e7. 7. Goga D, Giumelli B, Fassio E, et al. Microvascular mandibular reconstruction and implantology. A study of the stability of long-term results, a propos of 2 cases followed for 8 years. Rev Stomatol Chir Maxillofac 1998;99:231e4.