Fibular free flap reconstruction of the "true" lateral mandibular defect

Tenants of Mandibular Reconstruction in Segmental Defects

The premises of mandibular reconstruction are the restoration of occlusion and mandibular contour for the purpose of preserving the facial identity, oral airway, and effective speech and mastication. Establishing functional occlusion is the primary tenant in all mandibular reconstruction. In cases of segmental defects, particularly in dentate regions of the mandible, there has been a paradigm shift over the past two decades in how surgeons are approaching the restoration of load-bearing mandibular continuity with capacity for dental implantation. Here we discuss considerations for deciding the most effective method of reconstruction in segmental defects.

Orocutaneous Fistula After Oral Cavity Resection and Reconstruction: Systematic Review and Meta-Analysis

OBJECTIVE

Orocutaneous fistula (OCF) after reconstruction for oral cavity resection can lead to prolonged hospitalization and adjuvant treatment delay. Few studies have examined factors leading to OCF after oral cavity resection. Primary objective: evaluate overall incidence and factors associated with OCF after oral cavity reconstruction.

DATA SOURCES

Scopus 1960-database was searched for terms: "orocutaneous fistula," "oro cutaneous fistula," "oral cutaneous fistula," "orocervical fistula," "oral cavity salivary fistula."

REVIEW METHODS

English language studies with >5 patients undergoing reconstruction after oral cavity cancer resection were included. About 1057 records initially screened; 214 full texts assessed; 78 full-texts included. PRISMA guidelines were followed, and MINORS criteria used to assess risk of bias. Data were pooled using random-effects model. Primary outcome was OCF incidence. Meta-analysis to determine the effect of preoperative radiation on OCF conducted on 12 eligible studies. Pre-collection hypothesis was that prior radiation therapy is associated with increased OCF incidence. Post-collection analyses: free versus pedicled flaps; mandible-sparing versus segmental mandibulectomy.

RESULTS

Seventy-eight studies were included in meta-analysis of overall OCF incidence. Pooled effect size showed overall incidence of OCF to be 7.71% (95% CI, 6.28%-9.13%) among 5400 patients. Meta-analysis of preoperative radiation therapy on OCF showed a pooled odds ratio of 1.68 (95% CI, 0.93-3.06). OCF incidence was similar between patients undergoing free versus pedicled reconstruction, or segmental mandibulectomy versus mandible-sparing resection.

CONCLUSION

Orocutaneous fistula after oral cavity resection has significant incidence and clinical impact. Risk of OCF persists despite advances in reconstructive options; there is a trend toward higher risk after prior radiation.

Mandibular Condyle Reconstruction With Fibula Free-Tissue Transfer: The Role of the Masseter Muscle

BACKGROUND

Free fibula flap is an option for primary restoration after disarticulation mandibular resection, though literature on technique refinements is scarce. The authors hypothesized that inset of the masseter, the key mandibular elevator muscle, at the reconstructed mandible may optimize functional recovery.

METHODS

All patients undergoing reconstruction of mandibulectomy-condylectomy defect (January 2009 to January 2014) by means of a fibular flap were prospectively studied. The neocondyle was formed by the distal portion of the fibula and placed directly into the glenoid fossa with preservation of the temporomandibular disc. The deep portion of the masseter was inset at the angle of the reconstructed mandible.Condylar position was postoperatively evaluated by panoramic radiographs. Patients self-evaluated speech, chewing, swallowing, and facial appearance.

RESULTS

Two patients had immediate and 3 delayed reconstruction involving condyle ramus body, in the study period. During a mean follow-up of 32 months, 4 patients had satisfactory occlusion, 1 patient had an open-bite deformity, but was able to masticate solid food and maintain an oral diet. Although no significant condyle dislocation was recorded, 2 patients had slight ipsilateral deviation on mouth opening. Nevertheless, cosmesis was satisfactory and all patients maintained intelligible speech. Functional score was 13.6 ± 1.14 and facial appearance score was 4 ± 0.7.

CONCLUSION

The free fibula transfers with direct seating of the fibula into the condylar fossa followed by masseter muscle reinsertion provides acceptable functional reconstruction of the mandibulectomy-condylectomy defect.

Impact of mandibular condyle preservation on patterns of failure in head and neck cancer

Objective

To determine the role of native condyle preservation in local recurrence after segmental mandibulectomy in patients with head and neck squamous cell carcinoma.

Methods

Retrospective chart review with main outcome measuring local control of cancer.

Results

Between 1994 and 2003, 72 patients (48 men, 24 women) with an average age of 73.5 years without previous treatment underwent segmental mandibulectomy. Fifty-four cases (n = 54) involved the mandible posterior to the mental foramen and are the subject of this review. In 36 patients, the condyle was preserved and mandibular continuity was restored. In 18 patients, condyle and ramus were resected without mandibular reconstruction. Reconstructive modalities included primary closure (3), split-thickness skin graft (3), pedicle flap (19), and free tissue reconstructions (29). Overall local-regional recurrence rate was 22 percent (12 of 54); no recurrences were identified in patients who underwent condylar resection. Recurrences were observed in patients with mandibular reconstruction by both plate and pedicle flap (5 of 9) or (osteo) myocutaneous free flap (7 of 27).

Conclusion

Condylar preservation may predispose patients to local recurrence after segmental mandibulectomy. This does not translate into overall reduction in survival.

Reconstruction of mandibular defects

Defects requiring reconstruction in the mandible are commonly encountered and may result from resection of benign or malignant lesions, trauma, or osteoradionecrosis. Mandibular defects can be classified according to location and extent, as well as involvement of mucosa, skin, and tongue. Vascularized bone flaps, in general, provide the best functional and aesthetic outcome, with the fibula flap remaining the gold standard for mandible reconstruction. In this review, we discuss classification and approach to reconstruction of mandibular defects. We also elaborate upon four commonly used free osteocutaneous flaps, inclusive of fibula, iliac crest, scapula, and radial forearm. Finally, we discuss indications and use of osseointegrated implants as well as recent advances in mandibular reconstruction.

Dental implants in oral cancer reconstruction

Endosseous implants have revolutionized dental prosthetic rehabilitation, providing a reliable, a stable, and an aesthetic option for dental reconstruction. Dental implants have similarly improved the functionality of reconstructions following cancer surgery. The use of dental implants in oral cancer reconstruction can be divided into 2 categories: (1), for retention of a prosthetic device, for example, palatal obturator, used as the primary means of maxillary reconstruction, and (2), for dental rehabilitation after bony reconstruction of the jaws. This article discusses these different uses of endosseous implants in patients with head and neck cancer.

Dental implants in oral cancer reconstruction

Endosseous implants have revolutionized dental prosthetic rehabilitation, providing a reliable, a stable, and an aesthetic option for dental reconstruction. Dental implants have similarly improved the functionality of reconstructions following cancer surgery. The use of dental implants in oral cancer reconstruction can be divided into 2 categories: (1), for retention of a prosthetic device, for example, palatal obturator, used as the primary means of maxillary reconstruction, and (2), for dental rehabilitation after bony reconstruction of the jaws. This article discusses these different uses of endosseous implants in patients with head and neck cancer.

Clinical outcome of dental implants placed in fibula-free flaps used for the reconstruction of maxillo-mandibular defects following ablation for tumors or osteoradionecrosis

OBJECTIVES

(a) To evaluate the clinical outcome of fibula revascularized flaps used for the reconstruction of maxillary and mandibular defects due to resection for tumors or osteoradionecrosis and (b) to evaluate the survival and success rates of implants placed in the reconstructed areas.

MATERIAL AND METHODS

In a 8-year period (1995-2002), 59 patients, 38 males and 21 females, aged from 13 years to 69 years (mean age: 48.7 years), presenting with maxillary and mandibular defects due to resection for tumors or osteoradionecrosis, were reconstructed with fibula-free flaps. Of the 59 patients, 16 received 71 implants for the prosthetic rehabilitation of the reconstructed edentulous areas.

RESULTS

Out of 59 fibula-free flaps, three failed and had to be removed, nine underwent partial necrosis involving the bone segment and/or the skin paddle but survived, while the remaining 47 healed uneventfully. The mean follow-up of patients after the reconstruction was 55 months (range: 24-120 months). The cumulative survival rate of fibula-free flaps was 94.9%. The mean follow-up of the 16 patients treated with dental implants and implant-supported prostheses was 50.2 months (range: 24-96 months). The cumulative implant success and survival rates of implants were 98.6% and 93.1% respectively.

CONCLUSION

The reconstruction of maxillo-mandibular defects following ablation for tumors or osteoradionecrosis with fibula-free flaps has been demonstrated to be a reliable technique with good long-term results. Implants placed in the reconstructed areas were demonstrated to integrate normally, with success and survival rates comparable to those obtained in case of implants placed in native bone.

Efficacy of small reconstruction plates in vascularized bone graft mandibular reconstruction

BACKGROUND

Utilization of vascularized bone grafts rigidly fixated with titanium reconstruction plates is the method of choice for reconstruction of segmental mandibular defects. We hypothesized that the use of the newer 2.0-mm locking reconstruction plate (LRP) is not associated with higher rates of complications when compared with larger, previously used plating systems.

METHODS

A retrospective case series of 184 patients undergoing 185 vascularized bone graft reconstruction procedures of the mandible was conducted.

RESULTS

There were 37 plate complications. There was no significant difference in complication rates for the 2 most used plate types (14.5% with the 2.0-mm LRP and 22.2% with the 2.4-mm LRP).

CONCLUSIONS

Use of the smaller 2.0-mm LRP was not associated with an increase in the complications of plate fracture, exposure, infection, or nonunion. Because of its lower profile and ease of application, the 2.0-mm LRP is our plate of choice for mandibular reconstruction.

Prognosis as a determinant of free flap utilization for reconstruction of the lateral mandibular defect

BACKGROUND

The purpose of this study was to determine whether patients with a poor prognosis for survival were more likely to undergo reconstruction with a pectoralis flap versus a free flap and whether the use of a pectoralis flap offered any perioperative advantage, such as a reduction in medical complications.

METHODS

Fifty-five consecutive patients who underwent immediate reconstruction after a lateral mandibulectomy were retrospectively reviewed.

RESULTS

Age >or=70 years (p = .03), moderate or severe comorbidity (p = .02), and involvement of the base of tongue by tumor (p = .04) were significantly associated with decreased utilization of a free flap (n = 36). Comorbidity was the main determinant of medical complications (p = .001) and length of hospital stay (p = .03).

CONCLUSIONS

Expectations of prognosis bias the surgeon's decision regarding flap selection. Reconstruction with a pectoralis flap does not necessarily contribute toward the desired outcome of reduced medical complications. Any functional comparison between reconstructive groups needs to account for those differences in health status and prognosis that might explain any observed postoperative differences.

Vascularization of the peroneal muscles. Critical evaluation in fibular free flap harvesting

This anatomical study was carried out in order to discover the etiology of partial necrosis of the peroneus longus and brevis muscles after fibular osteocutaneous flap harvest. The vascular supply to the lateral compartment peroneal muscles was investigated in 10 fresh cadaveric lower limbs. The peroneal muscles are supplied by two principal sources arteries, the anterior tibial artery (ATA) and the peroneal artery (PA). The ATA is the dominant artery and supplies the proximal and middle thirds of these muscles. The PA is considered to be a supplementary vascular source and supplies the distal thirds of these muscles. After harvesting the PA in a fibular flap, regions of the peroneal muscles preoperatively vascularized by its branches become supplied through the anastomotic "choke" vessels between the ATA and the PA. Primary closure of the cutaneous defect increases the possibility of developing a pseudo-compartment syndrome with necrosis of the more precariously vascularized portions of the peroneal muscles. This complication is difficult to diagnosis early and the reason why we advocate that direct skin closure following composite harvest must be avoided. Moreover, conservation of the inferior and superior lateral branches of the ATA is imperative in order to preserve the peroneal muscles vascularization.