Pedicled mandible myo-osseous flaps combined with free skin flaps for reconstruction of complex lateral mandibular defects

Mandibular reconstruction in head and neck cancer: which is the gold standard?

INTRODUCTION

The aim of this study is to perform a systematic review to compare the outcomes of the different surgical options for mandibular reconstruction in head and neck cancer.

MATERIAL AND METHODS

93 articles were selected. Four groups were identified: titanium plate without flaps, titanium plate covered by soft tissue flap, bone tissue flaps and double flaps. We compared patients' characteristics, site of mandibulectomy, type of reconstruction and complications.

RESULTS

4697 patients were reported. The groups were not homogeneous regarding the type of defect and the treatment history. A significant difference in terms of post-operative complications was found between group 1 and group 2 (p < 0.00001), and between group 2 and group 3 (p < 0.00001). Total complications rate for group 4 was significantly higher when compared to group 3 (p < 0.00001), but no significant difference was found with group 2.

CONCLUSION

These results suggest that mandibular reconstruction using a microvascular bone flap is the best surgical option in patients without significant comorbidities.

Novel Technique with Double Free Flap Design for Advanced Mandibular Osteoradionecrosis: A Case Series

Advanced mandibular osteoradionecrosis is arguably among the most challenging cases for reconstructive head and neck surgeons. Several reconstructive methods for complex mandibular defects have been reported; however, for advanced mandibular osteoradionecrosis, a safe option that minimizes the risk of renewed fistulation and infections is needed. For this purpose, we present a new technique using a fascia-sparing vertical rectus abdominis musculocutaneous flap as protection for a vascularized free fibula graft (FFG). This technique also optimizes recipient site healing and functionality while minimizing donor site morbidity. Our initial experiences from a 4 patient case series are included. Mean operative time was 551 minutes (SD: 81 minutes). All donor sites were closed primarily. Mean time to discharge was 13 days (SD: 7 days), and mean time to full mobilization was 2 days (SD: 1 days). This double free flap technique completely envelops the FFG and plate with nonirradiated muscle. It allows for the transfer of an FFG without a skin island, thus avoiding the need for split skin graft closure. This results in faster healing and minimizes the risk of fibula donor site morbidity. The skin island of the vertical rectus abdominis musculocutaneous flap has the added benefit of providing intraoral lining, which minimizes contractures and trismus. Although prospective long-term studies comparing this approach to other double flap procedures are needed, we argue that this technique is an optimal approach to safeguard the mandibular FFG reconstruction against the inherent risks of renewed complications in irradiated unhealthy tissue.

Analysis of surgical margins in cases of mandibular osteoradionecrosis that progress despite extensive mandible resection and free tissue transfer

INTRODUCTION

Approximately 1 of 4 patients with osteoradionecrosis (ORN) of the mandible develop ongoing disease despite extensive mandible resection to margins determined by the presence of bleeding bone at the time of surgery.

OBJECTIVE

To determine whether pathologic examination of bony margins in assessing for the presence of necrotic edges is correlated with ongoing ORN.

METHODS

Resected mandible specimens from 34 patients with severe mandibular ORN were examined histologically for the presence of necrotic margins and compared with clinical outcome of ORN persistence at follow-up.

RESULTS

Median follow-up was 17.4 months. Eight specimens had histologic evidence of necrotic, nonviable bone at the margins of resections; however, there was no progression of disease among patients in this group. Twenty-six specimens were clear of necrotic margins; however, 8 patients from this group developed persistent disease.

CONCLUSIONS

Irradiated mandible is susceptible to ORN progression even if clinical and final histopathologic assessments confirm complete resection of necrotic bone margins. Progression of disease in ORN is not related to inadequate resection of necrotic bone.

Oromandibular reconstruction: the history, operative options and strategies, and our experience

Oromandibular reconstruction resulting from resection of benign tumor, malignant cancer, osteomyelitic or osteoradionecrotic mandible remains a challenge for plastic surgeons today. At present, fibula osteocutaneous flap is the perhaps most commonly used technique for oromandibular reconstruction because of its potential for contouring, immediate dental implant placement, and favorable donor site morbidity. In this study, we review the history of oromandibular reconstruction, summarize the characteristics of different osteocutaneous flaps, offer surgical options of different osteocutaneous flaps, and provide reconstructive strategies for different locations of mandibular defects. Furthermore, we give a detailed description of various modifications in oromandibular reconstruction: (1) the myoosseous flap for lateral segmental defect repair may reduce donor site complication; (2) to improve the function of oral commissure in patients with obscure recipient vessels, we modify the fibula osteocutaneous flap with anterolateral thigh flap and combine the tensor fascia lata using one set of recipient vessel for composite oromandibular reconstruction; (3) to decrease the likelihood of neck infection and improve aesthetic result, we add the segmental soleus muscle to the fibula osteocutaneous flap to obliterate and augment submandibular dead space. Lastly, dental rehabilitation considerations associated with mandibular reconstruction have been given to help assist in surgical treatment planning.