Indications for vascularized free rectus abdominis musculocutaneous flap in oromandibular region in terms of efficiency of anterior rectus sheath

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.

Motor Nerve Preservation and Muscle Atrophy After Pectoralis Major Musculocutaneous Flap Surgery for Oromandibular Reconstruction

OBJECTIVE

The authors investigated the clinical and histopathologic significance of medial pectoral nerve preservation/reinnervation of pectoralis major musculocutaneous flap for oromandibular reconstruction.

MATERIALS AND METHODS

The authors compared 13 patients treated with pectoralis major musculocutaneous flap reconstruction and 6 control patients treated by rectus abdominis musculocutaneous flap reconstruction without motor nerve restoration. Subjective awareness was scored to evaluate changes in the facial contour due to muscle atrophy, and objective evaluation was performed in few patients. In addition, the authors performed histopathologic analysis of both muscle atrophy and nerve regeneration in 20 patients from whom samples were available.

RESULTS

Subjective awareness of changes in the facial contour induced by muscle atrophy was low among patients with nerve preservation/reinnervation, but there were objective changes at 3 months after surgery among patients who underwent nerve resection. In the patients who had medial pectoral nerve preservation or nerve restoration by nerve suture, favorable facial symmetry was retained at 5 years after surgery. Even though the motor nerve was preserved or restored, fatty degeneration and fibrosis were noted in approximately 30% of the total surface area of the muscle, and type I fibers had decreased to 36% that of control at 7 years after surgery. However, regressive changes were inhibited for 1 year after surgery; in contrast, changes corresponding to those noted at 7 years after surgery were observed by 3 months in the patients with nerve resection.

CONCLUSION

Thus, the authors showed that preservation or restoration of nerves can delay muscle and have highlighted the potential benefits of this approach.

Diagnostic Features and Management Strategy of a Refractory Case of Osteoradionecrosis of the Mandible: Case Report and Review of Literature

INTRODUCTION

Osteoradionecrosis of the jaws produces a considerable amount of esthetic as well as functional deficits seriously affecting quality of life of the patient. Cases are often notoriously difficult to treat and manage owing to associated comorbidities of the patient, post irradiation fibrosis and decreased vascularity at the site, which complicates free tissue flap and graft transfer, that subsequently succumb to failure. Hyperbaric oxygen therapy (HBOT), in which 100 % oxygen is administered by mask under 2.4 atm pressure, in a hyperbaric oxygen chamber, helps by increasing local vascularity.

AIM AND METHODS

It was the aim of this study to show that a particularly refractory, compromised and challenging case of osteoradionecrosis can be managed successfully even without HBOT, by mandibular segmental resection followed by reconstruction using a titanium reconstruction plate enveloped within a pedicled Pectoralis Major Myocutaneous flap.

RESULT

Post operative recovery of the patient was excellent with good functional and esthetic rehabilitation of the patient with and practically nil donor site morbidity.

CONCLUSION

It is important to have a thorough knowledge of the clinical, radiographic, histopathologic, CT and MRI features of osteoradionecrosis of the jaws in order to make a quick and accurate confirmatory diagnosis and to overcome possible diagnostic dilemmas. The strategy of reconstruction of a large mandibular defect using a bridging titanium plate sandwiched by a healthy vascularized myocutaneous flap, following ablative surgery for ORN, has proved to be a safe and reliable option for composite mandibular defects, with gratifying long term functional and cosmetic results.

Risk factors and surgical refinements of postresective mandibular reconstruction: a retrospective study

Background. Postresective mandibular reconstruction is common in cases of oral and mandibular tumors. However, complications such as infection, plate exposure, or plate fracture can occur. We identified several significant risk factors of complications after reconstructive surgery and compared the effectiveness of different surgical techniques for reducing the incidence of complications. Methods. This study is a retrospective analysis of 28 oromandibular cancer cases that required reconstructive surgery between January 1999 and December 2011 at Kobe University Graduate School of Medicine in Japan. All cases were classified using Hashikawa's CAT and Eichner's classification methods. Then, we determined whether these classifications and different treatment or surgical methods were significantly related to complications. Results. Complications after mandibular reconstruction occurred in 10/28 patients (36%). Specifically, five patients had plate fractures, four had plate exposures, and one had an infection. Radiation therapy and closure without any flaps were significantly related to infection or plate exposure. The wrap-around technique of securing reconstruction plates was used in 14 cases, whereas the run-through technique was used in two cases. Conclusions. The success of mandibular reconstruction depends on both mechanical and biological factors, such as the location of defects, presence of occlusions, and the amount of vascularization of the flap.

Prefabricated bony radial forearm flap for secondary mandible reconstruction after radiochemotherapy

BACKGROUND

Primary reconstruction of the mandible is the golden standard of surgical treatment after ablative tumor surgery. Many different microvascular bone grafts are used to reduce wound healing complications at the severely compromised recipient site. The loss of primary grafts due to radiotherapy or osteoradionecrosis can make secondary mandibular reconstruction necessary. To address this problem, we developed the technique of the prefabrication of a radial forearm flap with cancellous bone. The aims were to establish these techniques into the clinical routine and to create a safe and reliable flap with low donor site morbidity.

METHODS

In patients who had undergone ablative tumor surgery radiochemotherapy, and primary reconstruction, prefabricated bony radial forearm flaps (PBRFFs) were applied for secondary reconstruction of the mandible. Cylinders of cancellous bone taken from the iliac crest were implanted in the lower forearm to allow the necessary vascularization. After a healing period of 4 weeks, the PBRFF was elevated and grafted into the mandibular defect.

RESULTS

All grafts healed uneventfully. However, 1 case required revision of the venous anastomosis after 2 days. The transplants improved the contour of the lower face enabling a good correction of the facial asymmetry. During the follow-up of up to 4 years, the radiographic controls showed good bony consolidation between the graft and the stumps of the mandible as well as formation of cortical bone around the cancellous bone cylinders.

CONCLUSION

These results demonstrate that the PBRFF is a safe and reliable graft which provides alternate solution in which other microvascular bone grafts have already failed. In the future, the iliac bone graft may be replaced with scaffold seeded with stem cells for further reduction of donor site morbidity.

Reconstruction of skull base and dura using rectus abdominis muscle combined with a vascularised fascial perforator flap

The goal of reconstruction of the skull base is to repair dural defects with a watertight seal and separate it from the nasopharynx and the exterior environment with well vascularised tissue. This prevents cerebro-spinal fluid leakage and secondary contamination leading to the potentially life threatening complications of meningitis or extradural abscess. Following large composite resections, traditional techniques to repair the dura involve the use of an autologous fascial graft or a pericranial flap, whilst a regional pedicled or free muscle flap is used to close the dead space defect. We describe a technique performed in two cases, whereby a single flap, the rectus abdominis muscle free flap, can be used to provide vascularised reconstruction both of the dura and the skull base. The anterior rectus sheath, islanded on a single perforator vessel, is used as a vascularised layer to reconstruct dura, whilst the supporting rectus abdominis muscle provides bulk to obliterate dead space. We show that this flap is suitable for reconstruction even in the presence of chronic infection. Advantages of a vascularised reconstruction are the rapid healing of the wound, even after radiotherapy, the delivery of systemic antibiotics to the site of the operation, and that it may allow early postoperative radiotherapy to be planned.

Free Rectus Abdominis Myocutaneous Flap With Anterior Rectus Sheath to Provide the Orbital Support in Globe-Sparing Total Maxillectomy

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. It results in severe complications if the orbital content is not supported. We would like to introduce a new technique using free rectus abdominis myocutaneous (RAM) flap with anterior rectus sheath to support the orbital content in a patient who underwent globe-sparing total maxillectomy. The large resection of the recurrent maxillary peripheral nerve sheath tumor was performed in a 34-year-old male patient. Right free RAM flap was harvested simultaneously with the tumor resection. The anterior sheath of upper portion of the rectus muscle was also incorporated into the flap. The free edge of the upper anterior rectus sheath was anchored to three different points: Lateral rim, medial rim and the posterior remnant of the bony orbital floor with non-absorbable suture. Consequently, orbital support was achieved with well-vascularized, thin, strong fascia with smooth surface. Right facial artery and vein were chosen as recipient vessel. Duration of the operation was 5.5 hours. Postoperative period was uneventful. Six months after the surgery, the right eye was in good position without inferior dystopia. Eyeball movement could be done without restriction. The patient also denied diplopia. Reconstruction of globe-sparing total maxillectomy defects with free RAM flap with anterior rectus sheath has several advantages that enable the reconstructive surgeon to solve the multiple complex reconstructive task with one flap: 1) elimination of the secondary donor site morbidity; 2) more simply addressing the challenging task of the eye support than the other techniques; 3) obliterating the maxillectomy defect and closing the palate; 4) restoring the large skin defect; and 5) reducing the operation time. It is difficult to conclude that this technique is the best choice in such cases based on a report of the single case. However, presented technique should be kept in mind as a practical and effective reconstructive option in cases that have underwent the total maxillectomy with the preservation of the orbit.

Orbital Exenteration Reconstruction With Rectus Abdominis Microvascular Free Flap

OBJECTIVES

To determine the course of reconstructive treatment and outcomes with use of the rectus abdominis free flap after orbital exenteration with or without total maxillectomy.

STUDY DESIGN

Retrospective chart review of treatment and outcomes of patients who had rectus abdominis free-tissue transfer for orbital exenteration with or without total maxillectomy at the Mayo Clinic between 1994 and 2004.

METHODS

Charts of patients who had rectus abdominis free flap reconstruction after orbital exenteration were retrospectively reviewed and the surgical technique evaluated. An explanation of the surgical technique for rectus abdominis free-tissue transfer to the orbital cavity is provided, along with a discussion of the advantages and disadvantages of this reconstructive method.

RESULTS

Twelve of 13 patients who underwent reconstruction with rectus abdominis free-tissue transfer had a successful outcome (flap viability 92%). Cosmetic results were acceptable both to patients and to surgeons.

CONCLUSIONS

Rectus abdominis microvascular free-tissue transfer for repair of orbital exenteration defects is a safe and reliable alternative to the use of the temporalis or the pectoralis major muscle as a pedicle flap; it provides a larger volume of well-vascularized tissue and greater placement flexibility without associated orientation problems; and the long vascular pedicle facilitates the use of multiple donor vessels within the head and neck, which is an advantage in previously irradiated patients. Postoperative care and the donor site defect are well tolerated. The flap allows reliable obturation of the oral maxillectomy defect, and it negates the need for cavity care in these patients.

Mandibular reconstruction in 2004: an analysis of different techniques

PURPOSE OF REVIEW

The field of mandibular reconstruction has evolved dramatically over the past fifty years. Numerous advances in microsurgical technique, plating technology and instrumentation, and an understanding of donor site angiosomes have made consistent and reliable mandibular reconstruction possible. Refinements in technique continue to improve the functional and aesthetic outcomes of oromandibular reconstruction. This review discusses the current state-of-the-art techniques for mandibular reconstruction and highlights the latest innovations in technique.

RECENT FINDINGS

The most common indication for oromandibular reconstruction remains ablative surgery for advanced neoplastic processes of the oral cavity and oropharynx. Reconstruction of these complex three-dimensional composite bony and soft-tissue defects is paramount for rehabilitation of form and function. Vascularized osseous free tissue transfer is the state-of-the-art for mandibular reconstruction. The long-term excellent functional and aesthetic outcomes of this technique have recently been reported. The most commonly used free flaps for mandibular reconstruction are the fibula, iliac crest, and scapula. Each of these typically accepts endosseous implants improving functional outcomes. The use of mandibular reconstruction plates and coverage with a soft-tissue flap remains a reconstructive option for selected patients. The latest refinements in technique include temporary intraoperative external fixation, the use of periosteal free flaps, distraction osteogenesis, and development of biodegradable biopolymer scaffolds for mandibular defects.

SUMMARY

Oromandibular reconstruction, although a challenge for the head and neck reconstructive surgeon, is now reliable and highly successful with excellent long-term functional and aesthetic outcomes.