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The free fibula bone graft for salvaging failed mandibular reconstructions
J Oral Maxillofac Surg 55:1417-1421, 1997
The Free Fibula Bone Graft for Salvaging Failed Mandibular Recons true tions JAMES
P. ANTHONY, MD,* ROBERT AND M. ANTHONY POGREL,
D. FOSTER, DDS, MD*
MD,t
Purpose: The purpose of this study was to determine the efficacy of vascularked free fibula bone grafts for mandibular salvage reconstruction. Patients and Methods: Seven patients had fibula grafts after failed attempts at mandibular reconstruction. The prior attempts involved 20 operative procedures. Four of the seven patients (57%) had a history of radiation to the affected mandible. Bony defects averaged 10.2 cm (range, 4.5 to 24 cm), and the associated soft tissue defects averaged 6 x 12 cm. Average follow-up was 16 months. Cosmetic (facial symmetry) and functional (speech quality, oral continence, deglutition, donor site morbidity, dental rehabilitation) results were evaluated by questionnaire and clinical examinations. Results: Soft tissue coverage and mandibular restoration were successful in all patients, and flap survival was 100%. Five of the seven patients (70%) achieved good or excellent functional results, and five of seven (70%) achieved good or excellent esthetic results. Complications were minimal, and the average hospital stay was 14 days. Conc/usions: When the initial attempt at mandibular reconstruction is unsuccessful, mandibular function and esthetics can be salvaged with reliable vascularized soft tissue and bone flaps. As long as appropriate flap options are considered and the patient is medically stable, successful mandibular reconstruction should be achievable despite the number or cause of prior failed attempts.
In most instances of mandibular loss due to trauma, tumor resection, or osteoradionecrosis, some form of reconstruction is indicated. The current techniques for mandibular reconstruction include nonvascularized bone grafts, synthetic trays with cancellous bone grafts, metal reconstruction bars and plates, and vascularized bone flaps.‘.’ Although each of these techniques is successful in appropriate circumstances, they also have a documented failure rate. This necessitates the ability
to perform salvage surgery to obtain a functional and cosmetically acceptable reconstruction. It does appear that many failed mandibular reconstructions are the result of failed soft tissue coverage and not necessarily failure of the bony reconstruction. Although soft tissue pedicle flaps may be useful, the most reliable soft tissue coverage is provided by vascularized free flaps, which may incorporate bone for the mandibular reconstruction. In our hands, the fibula free flaps have proved the most versatile. Over the past 4 years, 19% of our overall experience with mandibular reconstruction has involved salvage procedures after failed attempts. The purpose of this study was to examine our experience with vascularized fibula free flap salvage reconstruction of the mandible.
Received from the University of California at San Francisco, CA. * Associate Professor, Division of Plastic and Reconstructive Surgery. t Fellow, Division of Plastic and Reconstructive Surgery. $ Professor and Chair, Department of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Anthony: Division of Plastic and Reconstructive Surgery, University of California at San Francisco, 1635 Divisadero St, #530, San Francisco, CA 941151632. 0 1997 American
Association
of Oral and Maxillofacial
Materials
and Methods
Between November 1992 and March 1996, 52 consecutive mandibular reconstructions were performed at
Surgeons
0278-2391/97/5512-0009$3.00/O
1417
1418
FAILED
the University of California at San Francisco and its affiliated hospitals by the Plastic and Reconstructive Surgery Service. Of these, nine (19%) were referrals, usually from outside institutions, following failed attempts at reconstruction. In this study, a reconstructive failure was defined as either hardware exposure and infection (with or without loss of free bone grafts) requiring hardware removal, or a failed prior free flap. Patients in whom loss of part or all of their free bone graft occurred, but coverage remained intact, were not included, nor were patients with recurrent disease requiring further resection. Of the nine patients, two were elderly and in poor general health, and they were reconstructed with soft tissue flaps only (one rectus abdominus free flap and one pectoralis major pedicle flap). These patients did well but are not considered in the remainder of the study. The study group consisted of the remaining seven patients, comprising five men and two women. The mean age was 55.6 years (range, 29 to 73 years). Four patients (57%) had a history of radiation to the affected mandible, three of whom presented with defects after resection for osteoradionecrosis. No patients had received hyperbaric oxygen at any time. Prior attempts at reconstruction totaled 20 operative procedures, varying in number from one to nine procedures per patient (average, 2.8), and consisted of nonvascularized bone grafts (n = 6), synthetic trays with cancellous bone grafts (n = 5), metal prostheses (n = 5), soft tissue flaps (n = 3), or vascularized fibula flaps (n = 1). The bony defects ranged from 4.5 to 24 cm (average size, 10.2 cm), with 71% (five of seven) involving the symphysis of the mandible. Associated soft tissue defects ranged from 5 X 5 cm to 10 X 23 cm (mean, 6 X 12 cm), and four of seven (57%) required both intraoral and extraoral coverage. Treatment of all seven cases consisted of a free fibula bone graft with associated skin and soft tissue. Data for follow-up of greater than 5 months postoperatively was available for all of the patients (average, 16 months). Cosmetic and functional results of the mandibular reconstruction were evaluated for all patients by questionnaire and physical examination. The physical examinations were performed by surgeons other than the primary surgeon in each case. Speech quality, oral continence, the ability to chew on the operated side, donor site morbidity, and the results of dental rehabilitation were used to determine the resultant functional level, using criteria previously established.’ Results The causes and previous surgical reconstructions are summarized in Table 1. Tissue coverage was successful in all of the patients, with 100% flap survival. Com-
MANDIBULAR
RECONSTRUCTION,
SALVAGE,
FIBULA
plications included one patient who developed a postoperative hematoma that was evacuated without further sequelae. Two patients required skin grafting to close the fibula donor site. Donor site morbidity was limited to a minor cellulitis in one patient, which resolved with intravenous antibiotics. The average hospital stay was 14 days (range, 7 to 22 days). Five of the seven patients achieved good to excellent postoperative functional results. The remaining two patients have only fair functional results because of poor tongue function attributable to prior significant tongue resection and ipsilateral hypoglossal nerve paralysis. Five of the seven patients achieved good to excellent esthetic results. All of the patients tolerated at least a soft diet, and the degree of oral continence was not disabling. The functional and cosmetic results are summarized in Table 2. All patients requiring dental rehabilitation received it. One patient received no dental rehabilitation but functioned satisfactorily, three received a lower denture that was cosmetically acceptable but functionally compromised, and three patients were dentally rehabilitated with implant-retained removable prostheses that were functionally and cosmetically acceptable. Discussion For most patients sustaining mandibular loss, reconstruction of the mandible is critical to the restoration of normal function and appearance. Unfortunately, initial attempts at mandibular reconstruction are not always successful. Failure rates with mandibular reconstruction are variable and depend on a number of factors, including the patient’s age and general health, the vascularity of the tissue bed, and the technique used. The failure rate for free vascularized bone grafts in some studies is now in the order of 5%.” The failure rate for nonvascularized bone grafts depends on a number of factors including the technique used’” and the length of the graft,” but may be around 25%.13 When a nonvascularized graft exceeds 7 cm in length, the failure rate appears to rise.14 For cases receiving a reconstruction plate only, the failure rate is around 20%.9,‘5 The management of patients requiring salvage reconstructions is more complicated than for patients undergoing an initial attempt at mandibular reconstruction. Patients requiring a salvage procedure generally have associated soft tissue or bone infection and may be debilitated from their prior surgical procedures, chronic wounds, and inability to eat normally. Such patients require optimization of their nutritional status, perioperative antibiotic treatment, and a wide debridement of involved bone and soft tissues. Potential difficulties intraoperatively include the use of favorable receptor vessels or flap sites during prior failed attempts and the extensive scarring and diminished vas-
ANTHONY,
FOSTER, AND POGREL
Table
Cases
1.
Age
Receiving
Salvage
Diagnosis
1419 Reconstruction
With
a Vascularized
Defect
64
Osteoradionecrosis
Bone 24 cm LCL* Soft tissue 5 X 17 cm Intraoral and extraoral
2.
62
GSW face
Bone 10 cm LCL*
73
Osteoradionecrosis
4.
51
Ameloblastoma
5.
29
GSW face
6.
54
Osteoradionecrosis
7.
56
SCC oral cavity (received radiation)
Free
Flap
Prior Reconstruction
1.
3.
Fibula
Soft tissue 3 x 6 cm Intraoral and extraoral Bone 4.5 cm CL* Soft tissue 10 x 23 cm Intraoral and extraoral Bone 14 cm LCL* Soft tissue 3 X 10 cm Extraoral Bone 6 cm L* Soft tissue 5 X 15 cm Extraoral Bone 6 cm L* Soft tissue 4 X 9 cm Extraoral Bone 7 cm LCL* Soft tissue 10 x 8 cm Intraoral and extraoral
Free bone grafts Pectoralis major flap Radial forearm free flap Fibula free flap Rib grafts Trapezius flap Reconstruction plate and mucosal advancement flaps Dacron mesh with free bone grafts Dacron mesh with free bone graft Metal crib with free bone graft Reconstruction plate with free bone graft Free iliac bone graft Reconstruction plate Reconstruction plate with pectoralis major coverage
*After Boyd et al, 1995.15 Abbreviations: GSW, gunshot wound; SCC, squamous cell carcinoma; L, body of mandible; CL, symphysis and left body of mandible; LCI, right body of mandible, symphysis, and left body of mandible.
cularity inevitably present in the surgical field. Additionally, most patients requiring mandibular salvage reconstruction lack bony continuity, and thus their facial contour must be estimated based on preoperative photos and any remaining dentition. Ultimately, careful preoperative planning and a methodical surgical approach will minimize operative time and maximize results. Despite these problems, microvascular bone and soft tissue transfer allows successful salvage of mandibular function in virtually all patients. Based on our review, patients who fail their initial reconstructive attempts uniformly do so becauseof inadequate soft tissue coverage resulting from some combination of flap loss, plate or bone graft exposure, or mucosal loss over an area of progressive osteoradionecrosis. Clearly, the first consideration in treating such patients must be to restore reliable soft tissue coverage intraorally. The next consideration, applicable for most patients, is the restoration of mandibular continuity, which is particularly critical for patients with central mandibular loss. For such patients, our preferred method is to use the fibula osteocutaneous free flap because this flap provides up to 25 cm of bone, a reliable skin island (which may be used for intraoral or extraoral coverage), and flap successrates in excess of 95%.” The
ipsilateral fibula is usually selected to maximize pedicle length, but when not available, as in the case of a prior failed free fibula flap, the contralateral side may be used. Receptor vessels can usually be found in the ipsilateral neck, but when these are unavailable the contralateral neck vessels(and vein grafts) can be used. After a wide debridement of involved soft tissue and bone, a reconstruction bar is contoured to span the defect, placed parallel to the lower border of the mandible, and rigidly fixed with three or four screws on each side to the remaining native mandible. The fibula flap is then precisely osteotomized to fit behind the reconstruction bar, and several screws are placed to rigidly fix it to the bar. After the microsurgical revascularization of the flap, the skin island is inset intraorally (and extraorally, if needed), completing the reconstruction. Although we have placed osseointegratedimplants into the fibula immediately after primary mandibular reconstructions, we have not done so during salvage reconstructions, preferring to do this at a later time, once the risk of infection has subsided. Delaying the placement of the implant(s) also allows the oral and maxillofacial surgeon to more precisely determine optimal implant positioning and angulation. Salvaged mandibular reconstructions are somewhatlessprecise than primary reconstructions, for the reasons previously outlined,
1420
FAILED
Table 2. Cosmetic
Postoperative Evaluation
Functional
and
No. of Patients Speech: Normal Easily intelligible Intelligible with effort Unintelligible Deglutition: Chewing solids on operated side Soft foods Puree Feeding tube-dependent Oral continence: Normal Decreased but manageable Disabling Dental rehabilitation: None None adversely affecting function Dentures Osseointegrated implants Donor site: Full ambulation Impaired ambulation Facial symmetry: Excellent Good Fair Poor After
Davidson
3 2 2 0
3 4 0 0 6 1 0 1 0 3 3 I 0 4 2 1 0
et al, 1991.9
and delayed implant placement can incorporate adjustments to partially compensate for this. There is relatively little literature concerning salvage reconstruction of the mandible, but other techniques are conceptually feasible. In many cases, reconstruction may not be attempted because of the patient’s general condition or relative lack of deformity or functional compromise. In other cases, soft tissue reconstruction alone may suffice, again because of a patient’s general health. This was the method used in the other two casesin this study, a rectus abdominus free flap was usedin one caseand a pectoralis major pedicle flap was used in the other. Hyperbaric oxygen can be used to improve the vascularity of the tissue bed by promoting neovascularization.‘6 This may enable subsequentnonvascularized bone grafting to be performed successfully. l7 The addition of platelet-rich plasma has also been suggestedfor a nonvascularized graft to provide a kind of fertilizer to seed growth factors and promote more rapid incorporation of a nonvascularized graft.18This might be particularly applicable to salvage surgery. The contraindications to free flap mandibular restoration include only those patients with short lateral
MANDIBULAR
RECONSTRUCTION,
SALVAGE,
FIBULA
defects who do not wish to go through bony reconstruction or those patients too medically unstable to be considered for a fibula free flap. Suitable reconstructive alternatives for patients with short lateral mandibular defects include a soft tissue free flap (radical forearm or rectus abdominus) or a pedicled flap, particularly the pectoralis major. The remaining two patients in this study were reconstructed with soft tissue only (a rectus abdominus free flap and a pectoral major pedicled flap) with successful results. The fibula free flap and its associated skin island provides a greater freedom of motion for insetting the flap than pedicled flaps. In addition, the fibula provides a platform for dentures and allows osseointegrated dental implant placement if this is indicated or desired. When mandibular loss occurs, immediate reconstruction is the optimum method to preserve both form and function of this critical region. In the event that the initial attempt at mandibular reconstruction is unsuccessful, mandibular function and esthetics can be reliably salvaged by using vascularized bone and soft tissue flaps. As long as appropriate flap options are considered and the patient is medically stable, successful mandibular reconstruction should be achievable despite the number or cause of prior failed attempts. References 1. Lawson W, Biller HF: Mandibular reconstruction: Bone graft techniques. Otolaryngol Head Neck Surg 90589, 1982 2. Albert TW, Smith JD, Everts EC, et al: Dacron mesh tray and cancellous bone in reconstruction of mandibular defects. Arch Otolaryngol Head Neck Surg 112:53, 1986 3. Irish JC, Gullane PJ, Gilbert RW, et al: Primary mandibular reconstruction with the titanium hollow screw reconstruction plate: Evaluation of 51 cases. Plast Reconstr Surg 96:93, 1995 4. Kudo K, Shoji M, Yokota M, et al: Evaluation of mandibular reconstruction techniques following resection of malignant tumors in the oral region. .I Oral Maxillofac Surg 50:14, 1992 5. Schusterman MA, Reece GB, Kroll SS, et al: Use of the A0 plate for immediate mandibular reconstruction in cancer patients. Plast Reconstr Surg 88:588, 1991 6. Taylor GI: Reconstruction of the mandible with free composite iliac bone grafts. Ann Plast Surg 9:361, 1982 7. Swartz WM, Banis JC, Newton ED, et al: The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 77:530, 1986 8. Hidalgo DA: Fibula free flap: A new method of mandible reconstruction. Plast Reconstr Surg 84:71, 1989 9. Davidson J, Boyd JB, Gullane PJ, et al: A comparison of the results following oromandibular reconstruction using a radial forearm flap with either radial bone or a reconstruction plate. Plast Reconstr Surg 88:201, 1991 10. Hidalgo DA, Rekow A: A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 96:585, 1995 11. Carlson ER, Marx RE: Mandibular reconstruction using cancellous cellular bone grafts. J Oral Maxillofac Surg 54:889, 1996 12. Chen YB, Chen HC, Hahn LH: Major mandibular reconstruction with vascularized bone grafts: Indicators and selection of donor tissue. Microsurgery 15:227, 1994
1421
ERIC R. CARLSON 13. Adamo AK, Szal RL: Timing results and complications of mandibular reconstruction surgery: Report of 32 cases. J Oral Surg 31~755, 1979 14. Pogrel MA, Podlesh S, Anthony JP, et al: A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular discontinuity defects. J Oral Maxillofac Surg (accepted for publication) 15. Boyd JB, Mulholland RS, Davidson J, et al: The free flap and plate in oromandibular reconstruction: Long-term review and indications. Plast Reconstr Surg 95:1018, 1995
J Oral Maxillofac 55:1421-1422,1997
16. Marx RE, Johnson RP: Problem wounds in oral and maxillofacial surgery: The role of hyperbaric oxygen, irz Davis JC, Hunt TK (eds): Problem Wounds: The Role of Oxygen. New York, NY, Elsevier, 1987, pp 65-123 17. Marx RE, Ames JR: The use of hyperbaric oxygen therapy in bony reconstruction of the irradiated and tissue deficient patient. J Oral Maxillofac Surg 40:412, 1982 18. Strauss JE: Platelet rich plasma: A source of growth factors for bony reconstruction of the jaws. J Oral-Maxillofac Surg 54:37, 1996 (suppl 3)
Surg
Discussion The Free Fibula Bone Graft for Salvaging Failed Mandibular Reconstructions Eric R. Carlson,
DMD
University
Miami,
of Miami,
Florida
Drs Anthony, Foster, and Pogrel present useful information for the surgeon faced with the dilemma of salvaging failed attempts at mandibular reconstruction. While tackling large soft and hard tissue defects, the reconstructions performed by these authors were reportedly uniformly successful from anastomotic, functional, and cosmetic standpoints, although only seven cases constitute the study. This notwithstanding, the authors adequately address the purpose of their study, which was to determine the efficacy of the vascularized free fibula bone graft for mandibular salvage reconstruction. The surgical histories of the patients requiring these bone grafts is quite intriguing in several instances, and the reader is quickly reminded of the great controversies associated with the management of such patients when reviewing the discussion section of the article. Of particular interest is that four of the seven patients in the study had received radiation therapy, and indeed, three patients were reconstructed because of osteoradionecrosis. Interestingly, none of these patients received hyperbaric oxygen therapy (HBO) at any time during their treatment, either as part of the original or salvage reconstmctions. The authors of this article correctly point out that many failed mandibular reconstructions are the result of failed soft tissue coverage and not the failure of the bone graft, per se. They continue by describing the prior reconstructions that failed, which are enumerated in Table 1. Unfortunately, there is no mention or assessment as to why each individual reconstruction failed. This is perhaps the most disappointing aspect of this study, because failure should serve as an educational experience for the surgeon. Specifically, a cause for failure should be actively sought so as to ensure that the failure is not duplicated in the salvage reconstruction. Because this information is not discussed by the authors, the reader might be left wondering why all of these grafts were successful after numerous failures. Was the salvage reconstructive system superior to prior systems or were the salvage surgeons more skillful and experienced than the original surgeons? Should a free microvascular fibula flap have been performed from the onset, in which case a salvage reconstruction would not have been required? Are the free flaps
in this study truly representative of this form of reconstruction when this study comprises only seven cases, which does not permit truly scientific conclusions to be established? All of these questions are rhetorical; however, I will make comments based on my experience in mandibular reconstruction. The very fact that these seven patients underwent 20 previous procedures is worthy of much commentary. In this sense, it is the failed reconstructions that are more fascinating than the successful, salvaged reconstructions. These cases do involve the spectrum of patients requiring mandibular reconstruction, including benign tumor resection (n = l), malignant tumor resection with postoperative radiation therapy (n = I), avulsive facial trauma (n = 2), and irradiation tissue injury (n = 3). Each group should probably be assessed separately. Perhaps the most common reasons for loss of a bone graft in a benign tumor patient with a large continuity defect are inadvertent oral mucosal perforation leading to infection when approaching the graft transcutaneously and insufficient cellular density of the particulate graft because of harvest of an insufficient volume of bone. Grafts for benign tumor reconstruction are generally the most predictable and successful of all grafts because of a well-vascularized recipient tissue bed.’ Unfortunately, when such a graft fails, each successive salvage graft is at a disadvantage from a revascularization standpoint because the failure induces the formation of an avascular scar that can serve to inhibit the revascularization of the graft. Mandibular reconstruction in avulsive facial trauma patients is not nearly as successful as benign tumor reconstruction because of relatively greater scar tissue development in the recipient tissue bed. One of the patients underwent nonbiologic reconstruction with a bone plate, and although not stated, it would seem that plate exposure occurred (patient 2). It is probably inappropriate to include this patient in the study because a bone graft had not been attempted previously. This patient likely required a soft tissue flap from the onset, in which case success might have been realized. The second avulsive trauma patient (patient 5) likely had a quantitative soft tissue deficiency requiring correction before the free iliac bone graft, in which case success similarly might have been met. Perhaps the most thought-provoking series of bone graft failures occurred in the irradiated patients (patients 1, 3, 6, 7). In fact, these patients accounted for five bone graft failures and three myocutaneous flap failures, although it is not stated why these flaps failed. In the Methods section of the
The Free Fibula Bone Graft for Salvaging Failed Mandibular Recons true tions JAMES
P. ANTHONY, MD,* ROBERT AND M. ANTHONY POGREL,
D. FOSTER, DDS, MD*
MD,t
Purpose: The purpose of this study was to determine the efficacy of vascularked free fibula bone grafts for mandibular salvage reconstruction. Patients and Methods: Seven patients had fibula grafts after failed attempts at mandibular reconstruction. The prior attempts involved 20 operative procedures. Four of the seven patients (57%) had a history of radiation to the affected mandible. Bony defects averaged 10.2 cm (range, 4.5 to 24 cm), and the associated soft tissue defects averaged 6 x 12 cm. Average follow-up was 16 months. Cosmetic (facial symmetry) and functional (speech quality, oral continence, deglutition, donor site morbidity, dental rehabilitation) results were evaluated by questionnaire and clinical examinations. Results: Soft tissue coverage and mandibular restoration were successful in all patients, and flap survival was 100%. Five of the seven patients (70%) achieved good or excellent functional results, and five of seven (70%) achieved good or excellent esthetic results. Complications were minimal, and the average hospital stay was 14 days. Conc/usions: When the initial attempt at mandibular reconstruction is unsuccessful, mandibular function and esthetics can be salvaged with reliable vascularized soft tissue and bone flaps. As long as appropriate flap options are considered and the patient is medically stable, successful mandibular reconstruction should be achievable despite the number or cause of prior failed attempts.
In most instances of mandibular loss due to trauma, tumor resection, or osteoradionecrosis, some form of reconstruction is indicated. The current techniques for mandibular reconstruction include nonvascularized bone grafts, synthetic trays with cancellous bone grafts, metal reconstruction bars and plates, and vascularized bone flaps.‘.’ Although each of these techniques is successful in appropriate circumstances, they also have a documented failure rate. This necessitates the ability
to perform salvage surgery to obtain a functional and cosmetically acceptable reconstruction. It does appear that many failed mandibular reconstructions are the result of failed soft tissue coverage and not necessarily failure of the bony reconstruction. Although soft tissue pedicle flaps may be useful, the most reliable soft tissue coverage is provided by vascularized free flaps, which may incorporate bone for the mandibular reconstruction. In our hands, the fibula free flaps have proved the most versatile. Over the past 4 years, 19% of our overall experience with mandibular reconstruction has involved salvage procedures after failed attempts. The purpose of this study was to examine our experience with vascularized fibula free flap salvage reconstruction of the mandible.
Received from the University of California at San Francisco, CA. * Associate Professor, Division of Plastic and Reconstructive Surgery. t Fellow, Division of Plastic and Reconstructive Surgery. $ Professor and Chair, Department of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Anthony: Division of Plastic and Reconstructive Surgery, University of California at San Francisco, 1635 Divisadero St, #530, San Francisco, CA 941151632. 0 1997 American
Association
of Oral and Maxillofacial
Materials
and Methods
Between November 1992 and March 1996, 52 consecutive mandibular reconstructions were performed at
Surgeons
0278-2391/97/5512-0009$3.00/O
1417
1418
FAILED
the University of California at San Francisco and its affiliated hospitals by the Plastic and Reconstructive Surgery Service. Of these, nine (19%) were referrals, usually from outside institutions, following failed attempts at reconstruction. In this study, a reconstructive failure was defined as either hardware exposure and infection (with or without loss of free bone grafts) requiring hardware removal, or a failed prior free flap. Patients in whom loss of part or all of their free bone graft occurred, but coverage remained intact, were not included, nor were patients with recurrent disease requiring further resection. Of the nine patients, two were elderly and in poor general health, and they were reconstructed with soft tissue flaps only (one rectus abdominus free flap and one pectoralis major pedicle flap). These patients did well but are not considered in the remainder of the study. The study group consisted of the remaining seven patients, comprising five men and two women. The mean age was 55.6 years (range, 29 to 73 years). Four patients (57%) had a history of radiation to the affected mandible, three of whom presented with defects after resection for osteoradionecrosis. No patients had received hyperbaric oxygen at any time. Prior attempts at reconstruction totaled 20 operative procedures, varying in number from one to nine procedures per patient (average, 2.8), and consisted of nonvascularized bone grafts (n = 6), synthetic trays with cancellous bone grafts (n = 5), metal prostheses (n = 5), soft tissue flaps (n = 3), or vascularized fibula flaps (n = 1). The bony defects ranged from 4.5 to 24 cm (average size, 10.2 cm), with 71% (five of seven) involving the symphysis of the mandible. Associated soft tissue defects ranged from 5 X 5 cm to 10 X 23 cm (mean, 6 X 12 cm), and four of seven (57%) required both intraoral and extraoral coverage. Treatment of all seven cases consisted of a free fibula bone graft with associated skin and soft tissue. Data for follow-up of greater than 5 months postoperatively was available for all of the patients (average, 16 months). Cosmetic and functional results of the mandibular reconstruction were evaluated for all patients by questionnaire and physical examination. The physical examinations were performed by surgeons other than the primary surgeon in each case. Speech quality, oral continence, the ability to chew on the operated side, donor site morbidity, and the results of dental rehabilitation were used to determine the resultant functional level, using criteria previously established.’ Results The causes and previous surgical reconstructions are summarized in Table 1. Tissue coverage was successful in all of the patients, with 100% flap survival. Com-
MANDIBULAR
RECONSTRUCTION,
SALVAGE,
FIBULA
plications included one patient who developed a postoperative hematoma that was evacuated without further sequelae. Two patients required skin grafting to close the fibula donor site. Donor site morbidity was limited to a minor cellulitis in one patient, which resolved with intravenous antibiotics. The average hospital stay was 14 days (range, 7 to 22 days). Five of the seven patients achieved good to excellent postoperative functional results. The remaining two patients have only fair functional results because of poor tongue function attributable to prior significant tongue resection and ipsilateral hypoglossal nerve paralysis. Five of the seven patients achieved good to excellent esthetic results. All of the patients tolerated at least a soft diet, and the degree of oral continence was not disabling. The functional and cosmetic results are summarized in Table 2. All patients requiring dental rehabilitation received it. One patient received no dental rehabilitation but functioned satisfactorily, three received a lower denture that was cosmetically acceptable but functionally compromised, and three patients were dentally rehabilitated with implant-retained removable prostheses that were functionally and cosmetically acceptable. Discussion For most patients sustaining mandibular loss, reconstruction of the mandible is critical to the restoration of normal function and appearance. Unfortunately, initial attempts at mandibular reconstruction are not always successful. Failure rates with mandibular reconstruction are variable and depend on a number of factors, including the patient’s age and general health, the vascularity of the tissue bed, and the technique used. The failure rate for free vascularized bone grafts in some studies is now in the order of 5%.” The failure rate for nonvascularized bone grafts depends on a number of factors including the technique used’” and the length of the graft,” but may be around 25%.13 When a nonvascularized graft exceeds 7 cm in length, the failure rate appears to rise.14 For cases receiving a reconstruction plate only, the failure rate is around 20%.9,‘5 The management of patients requiring salvage reconstructions is more complicated than for patients undergoing an initial attempt at mandibular reconstruction. Patients requiring a salvage procedure generally have associated soft tissue or bone infection and may be debilitated from their prior surgical procedures, chronic wounds, and inability to eat normally. Such patients require optimization of their nutritional status, perioperative antibiotic treatment, and a wide debridement of involved bone and soft tissues. Potential difficulties intraoperatively include the use of favorable receptor vessels or flap sites during prior failed attempts and the extensive scarring and diminished vas-
ANTHONY,
FOSTER, AND POGREL
Table
Cases
1.
Age
Receiving
Salvage
Diagnosis
1419 Reconstruction
With
a Vascularized
Defect
64
Osteoradionecrosis
Bone 24 cm LCL* Soft tissue 5 X 17 cm Intraoral and extraoral
2.
62
GSW face
Bone 10 cm LCL*
73
Osteoradionecrosis
4.
51
Ameloblastoma
5.
29
GSW face
6.
54
Osteoradionecrosis
7.
56
SCC oral cavity (received radiation)
Free
Flap
Prior Reconstruction
1.
3.
Fibula
Soft tissue 3 x 6 cm Intraoral and extraoral Bone 4.5 cm CL* Soft tissue 10 x 23 cm Intraoral and extraoral Bone 14 cm LCL* Soft tissue 3 X 10 cm Extraoral Bone 6 cm L* Soft tissue 5 X 15 cm Extraoral Bone 6 cm L* Soft tissue 4 X 9 cm Extraoral Bone 7 cm LCL* Soft tissue 10 x 8 cm Intraoral and extraoral
Free bone grafts Pectoralis major flap Radial forearm free flap Fibula free flap Rib grafts Trapezius flap Reconstruction plate and mucosal advancement flaps Dacron mesh with free bone grafts Dacron mesh with free bone graft Metal crib with free bone graft Reconstruction plate with free bone graft Free iliac bone graft Reconstruction plate Reconstruction plate with pectoralis major coverage
*After Boyd et al, 1995.15 Abbreviations: GSW, gunshot wound; SCC, squamous cell carcinoma; L, body of mandible; CL, symphysis and left body of mandible; LCI, right body of mandible, symphysis, and left body of mandible.
cularity inevitably present in the surgical field. Additionally, most patients requiring mandibular salvage reconstruction lack bony continuity, and thus their facial contour must be estimated based on preoperative photos and any remaining dentition. Ultimately, careful preoperative planning and a methodical surgical approach will minimize operative time and maximize results. Despite these problems, microvascular bone and soft tissue transfer allows successful salvage of mandibular function in virtually all patients. Based on our review, patients who fail their initial reconstructive attempts uniformly do so becauseof inadequate soft tissue coverage resulting from some combination of flap loss, plate or bone graft exposure, or mucosal loss over an area of progressive osteoradionecrosis. Clearly, the first consideration in treating such patients must be to restore reliable soft tissue coverage intraorally. The next consideration, applicable for most patients, is the restoration of mandibular continuity, which is particularly critical for patients with central mandibular loss. For such patients, our preferred method is to use the fibula osteocutaneous free flap because this flap provides up to 25 cm of bone, a reliable skin island (which may be used for intraoral or extraoral coverage), and flap successrates in excess of 95%.” The
ipsilateral fibula is usually selected to maximize pedicle length, but when not available, as in the case of a prior failed free fibula flap, the contralateral side may be used. Receptor vessels can usually be found in the ipsilateral neck, but when these are unavailable the contralateral neck vessels(and vein grafts) can be used. After a wide debridement of involved soft tissue and bone, a reconstruction bar is contoured to span the defect, placed parallel to the lower border of the mandible, and rigidly fixed with three or four screws on each side to the remaining native mandible. The fibula flap is then precisely osteotomized to fit behind the reconstruction bar, and several screws are placed to rigidly fix it to the bar. After the microsurgical revascularization of the flap, the skin island is inset intraorally (and extraorally, if needed), completing the reconstruction. Although we have placed osseointegratedimplants into the fibula immediately after primary mandibular reconstructions, we have not done so during salvage reconstructions, preferring to do this at a later time, once the risk of infection has subsided. Delaying the placement of the implant(s) also allows the oral and maxillofacial surgeon to more precisely determine optimal implant positioning and angulation. Salvaged mandibular reconstructions are somewhatlessprecise than primary reconstructions, for the reasons previously outlined,
1420
FAILED
Table 2. Cosmetic
Postoperative Evaluation
Functional
and
No. of Patients Speech: Normal Easily intelligible Intelligible with effort Unintelligible Deglutition: Chewing solids on operated side Soft foods Puree Feeding tube-dependent Oral continence: Normal Decreased but manageable Disabling Dental rehabilitation: None None adversely affecting function Dentures Osseointegrated implants Donor site: Full ambulation Impaired ambulation Facial symmetry: Excellent Good Fair Poor After
Davidson
3 2 2 0
3 4 0 0 6 1 0 1 0 3 3 I 0 4 2 1 0
et al, 1991.9
and delayed implant placement can incorporate adjustments to partially compensate for this. There is relatively little literature concerning salvage reconstruction of the mandible, but other techniques are conceptually feasible. In many cases, reconstruction may not be attempted because of the patient’s general condition or relative lack of deformity or functional compromise. In other cases, soft tissue reconstruction alone may suffice, again because of a patient’s general health. This was the method used in the other two casesin this study, a rectus abdominus free flap was usedin one caseand a pectoralis major pedicle flap was used in the other. Hyperbaric oxygen can be used to improve the vascularity of the tissue bed by promoting neovascularization.‘6 This may enable subsequentnonvascularized bone grafting to be performed successfully. l7 The addition of platelet-rich plasma has also been suggestedfor a nonvascularized graft to provide a kind of fertilizer to seed growth factors and promote more rapid incorporation of a nonvascularized graft.18This might be particularly applicable to salvage surgery. The contraindications to free flap mandibular restoration include only those patients with short lateral
MANDIBULAR
RECONSTRUCTION,
SALVAGE,
FIBULA
defects who do not wish to go through bony reconstruction or those patients too medically unstable to be considered for a fibula free flap. Suitable reconstructive alternatives for patients with short lateral mandibular defects include a soft tissue free flap (radical forearm or rectus abdominus) or a pedicled flap, particularly the pectoralis major. The remaining two patients in this study were reconstructed with soft tissue only (a rectus abdominus free flap and a pectoral major pedicled flap) with successful results. The fibula free flap and its associated skin island provides a greater freedom of motion for insetting the flap than pedicled flaps. In addition, the fibula provides a platform for dentures and allows osseointegrated dental implant placement if this is indicated or desired. When mandibular loss occurs, immediate reconstruction is the optimum method to preserve both form and function of this critical region. In the event that the initial attempt at mandibular reconstruction is unsuccessful, mandibular function and esthetics can be reliably salvaged by using vascularized bone and soft tissue flaps. As long as appropriate flap options are considered and the patient is medically stable, successful mandibular reconstruction should be achievable despite the number or cause of prior failed attempts. References 1. Lawson W, Biller HF: Mandibular reconstruction: Bone graft techniques. Otolaryngol Head Neck Surg 90589, 1982 2. Albert TW, Smith JD, Everts EC, et al: Dacron mesh tray and cancellous bone in reconstruction of mandibular defects. Arch Otolaryngol Head Neck Surg 112:53, 1986 3. Irish JC, Gullane PJ, Gilbert RW, et al: Primary mandibular reconstruction with the titanium hollow screw reconstruction plate: Evaluation of 51 cases. Plast Reconstr Surg 96:93, 1995 4. Kudo K, Shoji M, Yokota M, et al: Evaluation of mandibular reconstruction techniques following resection of malignant tumors in the oral region. .I Oral Maxillofac Surg 50:14, 1992 5. Schusterman MA, Reece GB, Kroll SS, et al: Use of the A0 plate for immediate mandibular reconstruction in cancer patients. Plast Reconstr Surg 88:588, 1991 6. Taylor GI: Reconstruction of the mandible with free composite iliac bone grafts. Ann Plast Surg 9:361, 1982 7. Swartz WM, Banis JC, Newton ED, et al: The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 77:530, 1986 8. Hidalgo DA: Fibula free flap: A new method of mandible reconstruction. Plast Reconstr Surg 84:71, 1989 9. Davidson J, Boyd JB, Gullane PJ, et al: A comparison of the results following oromandibular reconstruction using a radial forearm flap with either radial bone or a reconstruction plate. Plast Reconstr Surg 88:201, 1991 10. Hidalgo DA, Rekow A: A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 96:585, 1995 11. Carlson ER, Marx RE: Mandibular reconstruction using cancellous cellular bone grafts. J Oral Maxillofac Surg 54:889, 1996 12. Chen YB, Chen HC, Hahn LH: Major mandibular reconstruction with vascularized bone grafts: Indicators and selection of donor tissue. Microsurgery 15:227, 1994
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ERIC R. CARLSON 13. Adamo AK, Szal RL: Timing results and complications of mandibular reconstruction surgery: Report of 32 cases. J Oral Surg 31~755, 1979 14. Pogrel MA, Podlesh S, Anthony JP, et al: A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular discontinuity defects. J Oral Maxillofac Surg (accepted for publication) 15. Boyd JB, Mulholland RS, Davidson J, et al: The free flap and plate in oromandibular reconstruction: Long-term review and indications. Plast Reconstr Surg 95:1018, 1995
J Oral Maxillofac 55:1421-1422,1997
16. Marx RE, Johnson RP: Problem wounds in oral and maxillofacial surgery: The role of hyperbaric oxygen, irz Davis JC, Hunt TK (eds): Problem Wounds: The Role of Oxygen. New York, NY, Elsevier, 1987, pp 65-123 17. Marx RE, Ames JR: The use of hyperbaric oxygen therapy in bony reconstruction of the irradiated and tissue deficient patient. J Oral Maxillofac Surg 40:412, 1982 18. Strauss JE: Platelet rich plasma: A source of growth factors for bony reconstruction of the jaws. J Oral-Maxillofac Surg 54:37, 1996 (suppl 3)
Surg
Discussion The Free Fibula Bone Graft for Salvaging Failed Mandibular Reconstructions Eric R. Carlson,
DMD
University
Miami,
of Miami,
Florida
Drs Anthony, Foster, and Pogrel present useful information for the surgeon faced with the dilemma of salvaging failed attempts at mandibular reconstruction. While tackling large soft and hard tissue defects, the reconstructions performed by these authors were reportedly uniformly successful from anastomotic, functional, and cosmetic standpoints, although only seven cases constitute the study. This notwithstanding, the authors adequately address the purpose of their study, which was to determine the efficacy of the vascularized free fibula bone graft for mandibular salvage reconstruction. The surgical histories of the patients requiring these bone grafts is quite intriguing in several instances, and the reader is quickly reminded of the great controversies associated with the management of such patients when reviewing the discussion section of the article. Of particular interest is that four of the seven patients in the study had received radiation therapy, and indeed, three patients were reconstructed because of osteoradionecrosis. Interestingly, none of these patients received hyperbaric oxygen therapy (HBO) at any time during their treatment, either as part of the original or salvage reconstmctions. The authors of this article correctly point out that many failed mandibular reconstructions are the result of failed soft tissue coverage and not the failure of the bone graft, per se. They continue by describing the prior reconstructions that failed, which are enumerated in Table 1. Unfortunately, there is no mention or assessment as to why each individual reconstruction failed. This is perhaps the most disappointing aspect of this study, because failure should serve as an educational experience for the surgeon. Specifically, a cause for failure should be actively sought so as to ensure that the failure is not duplicated in the salvage reconstruction. Because this information is not discussed by the authors, the reader might be left wondering why all of these grafts were successful after numerous failures. Was the salvage reconstructive system superior to prior systems or were the salvage surgeons more skillful and experienced than the original surgeons? Should a free microvascular fibula flap have been performed from the onset, in which case a salvage reconstruction would not have been required? Are the free flaps
in this study truly representative of this form of reconstruction when this study comprises only seven cases, which does not permit truly scientific conclusions to be established? All of these questions are rhetorical; however, I will make comments based on my experience in mandibular reconstruction. The very fact that these seven patients underwent 20 previous procedures is worthy of much commentary. In this sense, it is the failed reconstructions that are more fascinating than the successful, salvaged reconstructions. These cases do involve the spectrum of patients requiring mandibular reconstruction, including benign tumor resection (n = l), malignant tumor resection with postoperative radiation therapy (n = I), avulsive facial trauma (n = 2), and irradiation tissue injury (n = 3). Each group should probably be assessed separately. Perhaps the most common reasons for loss of a bone graft in a benign tumor patient with a large continuity defect are inadvertent oral mucosal perforation leading to infection when approaching the graft transcutaneously and insufficient cellular density of the particulate graft because of harvest of an insufficient volume of bone. Grafts for benign tumor reconstruction are generally the most predictable and successful of all grafts because of a well-vascularized recipient tissue bed.’ Unfortunately, when such a graft fails, each successive salvage graft is at a disadvantage from a revascularization standpoint because the failure induces the formation of an avascular scar that can serve to inhibit the revascularization of the graft. Mandibular reconstruction in avulsive facial trauma patients is not nearly as successful as benign tumor reconstruction because of relatively greater scar tissue development in the recipient tissue bed. One of the patients underwent nonbiologic reconstruction with a bone plate, and although not stated, it would seem that plate exposure occurred (patient 2). It is probably inappropriate to include this patient in the study because a bone graft had not been attempted previously. This patient likely required a soft tissue flap from the onset, in which case success might have been realized. The second avulsive trauma patient (patient 5) likely had a quantitative soft tissue deficiency requiring correction before the free iliac bone graft, in which case success similarly might have been met. Perhaps the most thought-provoking series of bone graft failures occurred in the irradiated patients (patients 1, 3, 6, 7). In fact, these patients accounted for five bone graft failures and three myocutaneous flap failures, although it is not stated why these flaps failed. In the Methods section of the