Oromandibular reconstruction with the radial-forearm osteocutaneous flap: experience with 60 consecutive cases

Oral Cavity Reconstruction

This summary provides a concise overview of oral cavity reconstruction to optimize functional outcomes in the modern era. Soft tissue and osseous reconstruction options for a wide range of oral cavity sites including lip, oral tongue, floor of mouth, buccal, hard palate, and composite oromandibular resections are reviewed. The appropriate applications of primary closure, secondary intention, skin grafts, and dermal substitute grafts are included. Anatomic considerations, indications, contraindications, and complications of local, regional, and free flaps in oral cavity reconstruction are discussed. Specific defects and the appropriate options for reconstruction of those defects are delineated.

Iliac crest towards alveolar processes or mandibular inferior margin in mandibular reconstruction with a vascularized iliac bone flap: which is better?

OBJECTIVE

The study aims to compare differences among iliac bone flaps with different iliac crest orientations for the repair of mandibular defects with an aim to analyze their advantages, disadvantages, and effects.

MATERIAL AND METHODS

Clinical data and computed tomography scans of all patients who underwent iliac bone flap repair of the mandible in Peking University School and Hospital of Stomatology from January 2016 to April 2021 were collected. Patients were divided into the iliac crest towards alveolar process (Group A) and the iliac crest towards mandibular inferior margin (Group B). Software was used to measure corresponding indicators. The results obtained for the groups were statistically analyzed.

RESULTS

The study included 78 patients (25 and 53 in groups A and B, respectively). The symmetry of the LC-type defect was better in group A (p < 0.05). The all-bone width of the alveolar process side in group A was greater than 6 mm; in 15 cases of group B, the width was less than 6 mm (p < 0.05). The intermaxillary distance of two sites were higher in group B (p < 0.05). The bone cortical thickness was significantly thicker in group A (p < 0.05).

CONCLUSION

One year after the mandibular body defect was reconstructed with a vascularized iliac bone flap, the iliac crest towards alveolar process group showed better bone symmetry, width, intermaxillary distance, and cortical thickness to meet the planting requirements.

CLINICAL RELEVANCE

The use of an iliac crest towards alveolar process may be a better approach for mandible reconstruction.

Radial Forearm Vascularized Osteomuscular Flap for Proximal Ulnar Deficiency After Revision Total Elbow Arthroplasty: A Case Report

CASE

A 61-year-old woman presented with a failed proximal ulna allograft-prosthetic composite after revision total elbow arthroplasty (TEA). The ulnar deficiency was addressed using an osteomuscular flap from the distal radius pedicled on the radial artery. At final follow-up, she had minimal pain and a flexion-extension arc of 0° to 130°. Radiographs demonstrated graft incorporation and a stable TEA construct.

CONCLUSION

This demonstrates utilization of a vascularized osteomuscular flap from the radius for treatment of proximal ulnar deficiency in the setting of revision TEA. This technique offers an alternative option for the challenge of a failed TEA with ulnar bone loss.

Rates of bone reabsorption and union in mandibular reconstruction using the osteocutaneous radial forearm free flap

BACKGROUND

Historical concerns over bone resorption and malunion of the osteocutaneous radial forearm free flap (OCRFFF) limited its widespread adoption for head and neck reconstruction, despite lack of outcomes data evaluating this notion.

METHODS

A retrospective cohort study was performed including patients 18 years or older who underwent reconstruction of the mandible using an OCRFFF. Linear modeling and logistic regression were used to evaluate the change in bone volume and union over time.

RESULTS

One hundred and twenty-one patients were included in the study. A mixed effects linear model incorporating age, sex, treatment type, and number of bone segments did not demonstrate a significant loss of bone volume over time. A logistic regression model identified lack of adjuvant treatment and time to be significantly associated with complete union.

CONCLUSION

This study supports that the OCRFFF is a stable form of osseus reconstruction for defects of the head and neck.

Complications in oncologic mandible reconstruction: A comparative study between the osteocutaneous radial forearm and fibula free flap

BACKGROUND

The osteocutaneous radial forearm free flap (OC-RFFF) has been proposed as a safe and reliable free flap for head and neck reconstruction with low donor site morbidity. The purpose of this study is to compare the late complications (>30 days) associated with using the OC-RFFF versus the free fibula flap (FFF) for mandibular reconstruction following oncologic segmental resection.

METHODS

We conducted a single-institution, retrospective study composed of patients who underwent oncologic microvascular composite mandibular reconstruction with either the OC-RFFF or FFF. The primary predictor variable was the type of free flap used. The outcome variable was late complication postoperatively (>30 days).

RESULTS

A total of 93 patients (28, OC-RFFF and 65, FFF) were analyzed. The majority of patients were male (62%) and with AJCC stage T4a disease (72%). Mean hospital length of stay was comparable between the two flap groups (p = .50). OC-RFFF was associated with more late complications (p = .03) compared to FFF. Nonunion occurred in 10.7% of OC-RFFF and 0% of FFF. Partial or complete flap failure was seen in 7.1% and 0% in the OC-RFFF and FFF, respectively. Two-year disease-free survival was comparable in both groups (p > .05).

CONCLUSIONS

The results of this study suggest that the rate of nonunion and odds of having a late complication were significantly greater in the OC-RFFF compared to the FFF following oncologic mandibular reconstruction. However, flap success, early complications (<30 days), and length of hospital stay were comparable between the two flaps.

Cancellous Tibial Bone Graft for Malunion after Mandibular Reconstruction in Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

While nonunion after mandibular reconstruction for head and neck surgery is rare, literature exploring management is scarce. Our primary objective was to determine success rates of tibial bone graft (TBG) in achieving mandibular union. Secondary objectives include determining factors that contribute to failure of TBG.

STUDY DESIGN

Retrospective Chart Review.

METHODS

Retrospective chart review between January 1, 2008 and December 31, 2018. Patients who underwent a mandibulotomy or mandibulectomy with osteocutaneous free flap reconstruction were identified. Patients who were pursuing dental rehabilitation, subsequently diagnosed with mandibular nonunion and received a cancellous TBG were assessed.

RESULTS

The 15 patients meeting inclusion criteria were mostly male (67%), white (87%), and nonsmokers (67%) with a median age of 64 (IQR = 60-73). Successful union occurred in 13 of 18 (72%) TBGs and the majority (63%) had a partial union documented at the time of surgery. Five patients (83%) who initially had a mandibulotomy achieved union compared to 78% of those with osteocutaneous reconstruction (P = 1.0). Postoperative radiation did not affect rates of union: 80% for both (P = 1.0). Patients with osteoradionecrosis (ORN) achieved union in 67% of cases compared to 75% of cases who did not have ORN (P = .86). There were similar rates of union for those who required perioperative antibiotics for infection and those without infection (67% vs. 75%, P = .86). Dental rehabilitation was achieved in 55% of patients, most commonly dentures.

CONCLUSIONS

This study shows that TBG can be used to achieve union for patients with malunion after head and neck cancer reconstruction. We show its successful use within the reconstructive algorithm for patients regardless of postoperative radiation for very small defects.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1291-1296, 2021.

The versatility of the thoracodorsal artery based composite flaps with vascularized rib and a systematic review of the literature

Pedicled and free composite flaps derived from the thoracodorsal artery system, including the latissimus dorsi-rib (LD-R) and the serratus anterior-rib (SA-R) osteo-muscular or osteo-myocutaneous flaps, are potential options to address head and neck, thorax, upper and lower extremity bone, and soft tissue defects' reconstruction. We aimed to report our series of LD/SA-R composite pedicled and free flaps, evaluating outcomes and complications, and to systematically identify all literature reporting results following LD/SA-rib reconstructions.

Review of surgical resection and reconstruction in head and neck cancer. Traditional versus current concepts

This review summarizes the development of head and neck cancer resection and reconstruction. The developments in the treatment of cancer patients are reflected in their surgical outcomes, in addition to functional and aesthetic improvements. New technologies, such as surgical simulation and planning, minimally invasive surgery, and microsurgery have been added to the field to improve surgical resection of the tumor and reconstruction. The field is still growing to optimize the management of head and neck cancer.

Osteocutaneous flaps for head and neck reconstruction: A focused evaluation of donor site morbidity and patient reported outcome measures in different reconstruction options

With significant improvements in success rates for free flap reconstruction of the head and neck, attention has turned to donor site morbidity associated with osteocutaneous free flaps. In this review, we address the morbidity associated with harvest of the four most commonly used osteocutaneous flaps; the free fibula flap, the scapula flap, the iliac crest flap and the radial forearm flap. A comprehensive literature search was performed to identify articles relevant to donor site morbidity for these flaps. We assessed morbidity in terms of incidence of delayed healing, chronic pain, aesthetic outcomes, site specific complications and patient satisfaction/quality of life. Weighted means were calculated when sufficient studies were available for review. The radial forearm and free fibula flaps are associated with high rates of delayed healing of approximately 20% compared to the scapular (<10%) and iliac flaps (5%). The radial forearm flap has higher rates of chronic pain (16.7%) and dissatisfaction with scar appearance (33%). For the majority of these patients harvest of one of these four osteocutaneous does not limit daily function at long-term follow-up. The scapular osteocutaneous flap is associated with the lowest relative morbidity and should be strongly considered when the recipient defect allows. The radial forearm is associated with higher morbidity in terms of scarring, fractures, chronic pain and wrist function and should not be considered as first choice when other flap options are available.

Osteocutaneous radial forearm free flap in nonmandible head and neck reconstruction

BACKGROUND

The osteocutaneous radial forearm free flap (RFFF) is a versatile flap primarily used to reconstruct composite defects involving the mandible. The purpose of this study was to describe our experience with this flap for nonmandible reconstruction.

METHODS

All patients undergoing nonmandible osseous reconstruction with free-tissue transfer were reviewed. Patients with osteocutaneous RFFF reconstructions were evaluated. The retrospective review of all osteocutaneous RFFFs was performed from 1998 to 2014.

RESULTS

One hundred forty-two nonmandible osseous reconstructions were performed. Twenty-five patients underwent nonmandible osteocutaneous RFFF reconstruction. Eleven patients failed previous nonmicrovascular reconstruction. Reconstruction was for defects of the: palatomaxillary complex (n = 15), orbitomaxillary complex (n = 4), nasomaxillary complex (n = 4), larynx (n = 1), and clavicle (n = 1). There were no flap compromises. Postoperative complications included: 2 partial intraoral dehiscences; 1 recipient-site infection; and 1 seroma. Eight reconstructions required secondary procedures to improve functional and/or cosmetic outcomes.

CONCLUSION

The osteocutaneous RFFF is a robust flap that can be used to reconstruct composite defects involving bone and soft-tissue beyond the mandible.

The use of the radial styloid in the extended osteocutaneous radial forearm free flap

BACKGROUND

The osteocutaneous radial forearm free flap (OC-RFFF) remains a useful tool in head and neck reconstruction; however, it can be challenging to harvest sufficient bone for large reconstructions. The extended OC-RFFF is a modification that involves harvest of the distal border of the radius to the tip of the styloid. This increases the length of the bone flap by 2 cm to 3 cm, and the inherent contour of the styloid can be used to reconstruct the anterior curvature of the mandible or maxilla without additional osteotomies that may reduce blood supply.

METHODS

The key steps in harvesting the extended OC-RFFF are described. Six patients with mandibular or maxillary defects underwent reconstruction with the extended OC-RFFF. Patient data including demographics, defect features, reconstruction details and outcomes were collected.

RESULTS

Of the six patients who underwent the extended OC-RFFF, four had mandibular reconstruction and two had maxillary reconstruction. Two patients underwent reconstruction for osteoradionecrosis and the remainder for malignant disease. The average patient age at the time of surgery was 64.5 years. The length of radius harvested ranged from 8 cm to 14 cm (mean 9.7 cm). Two of six patients required a single osteotomy of their bone flap. Donor site complications included partial skin graft loss in 50% and a radius fracture in two patients. Recipient site complications included one patient with intraoral plate exposure. There have been no cases of nonunion.

CONCLUSIONS

The extended OC-RFFF was a safe and reliable option for bony reconstruction in the head and neck.

The use of the radial styloid in the extended osteocutaneous radial forearm free flap

Background

The osteocutaneous radial forearm free flap (OC-RFFF) remains a useful tool in head and neck reconstruction; however, it can be challenging to harvest sufficient bone for large reconstructions. The extended OC-RFFF is a modification that involves harvest of the distal border of the radius to the tip of the styloid. This increases the length of the bone flap by 2 cm to 3 cm, and the inherent contour of the styloid can be used to reconstruct the anterior curvature of the mandible or maxilla without additional osteotomies that may reduce blood supply.

Methods

The key steps in harvesting the extended OC-RFFF are described. Six patients with mandibular or maxillary defects underwent reconstruction with the extended OC-RFFF. Patient data including demographics, defect features, reconstruction details and outcomes were collected.

Results

Of the six patients who underwent the extended OC-RFFF, four had mandibular reconstruction and two had maxillary reconstruction. Two patients underwent reconstruction for osteoradionecrosis and the remainder for malignant disease. The average patient age at the time of surgery was 64.5 years. The length of radius harvested ranged from 8 cm to 14 cm (mean 9.7 cm). Two of six patients required a single osteotomy of their bone flap. Donor site complications included partial skin graft loss in 50% and a radius fracture in two patients. Recipient site complications included one patient with intraoral plate exposure. There have been no cases of nonunion.

Conclusions

The extended OC-RFFF was a safe and reliable option for bony reconstruction in the head and neck.

Ulnar forearm osteocutaneous flap harvesting using Kapandji procedure for pre-existing complicated fibular flap on mandible reconstruction--cadaveric and clinical study

It is not uncommon that after using a fibular flap for lower gum cancer reconstruction, nonunion, chronic osteomyelitis, or fibular bone exposure occurs, which requires a composite bone and soft tissue reconstruction. Radial forearm osteocutaneous flap possesses the risk of stress fracture. Ulnar forearm osteocutaneous flap can be another option for small bone defect reconstruction.

PATIENTS AND METHOD

Six patients who had undergone fibular flap for mandible reconstructions and sustained either bone exposure (3 patients), chronic osteomyelitis (1 patient), malocclusion (1 patient), or osteoradionecrosis (1 patient) underwent ulnar forearm osteocutaneous flap with 3-cm ulnar bone for touch-up procedure. The distal radioulnar joints were fused with a screw. Six ulnar forearm osteocutaneous flap dissections were also performed on 4 fresh frozen cadavers to clarify the anatomic distribution of the distal ulnar artery.

RESULT

All 6 ulnar forearm osteocutaneous flaps survived with one re-exploration for venous occlusion. All presented bone union. Comparable to the clinical dissection, the cadaveric distal ulnar artery demonstrates a periosteal branch that runs between the proper ulnar nerve and dorsal sensory nerve. This periosteal branch comes out of an ulnar artery approximately 3 cm proximal to the wrist joint.

CONCLUSION

Ulnar forearm osteocutaneous flap can provide a secondary flap of wide skin paddle and small segment bone for specific mandibular defect after a fibular flap transfer.

Reconstructive Surgery for Head and Neck Cancer Patients

The field of head and neck surgery has gone through numerous changes in the past two decades. Microvascular free flap reconstructions largely replaced other techniques. More importantly, there has been a paradigm shift toward seeking not only to achieve reliable wound closure to protect vital structures, but also to reestablish normal function and appearance. The present paper will present an algorithmic approach to head and neck reconstruction of various subsites, using an evidence-based approach wherever possible.

[Maxillofacial reconstruction with radial forearm osteofasciocutaneous free flap]

INTRODUCTION

Maxillofacial defects often affect various type of tissues and require reconstruction using composite flaps. The radial forearm osteofasciocutaneous free flap is one of the least used. We present the preliminary results of maxillofacial reconstruction using this free flap.

MATERIALS AND METHODS

We reviewed the records of patients having undergone a radial forearm osteofasciocutaneous flap procedure between 2009 and 2011. Mandibular defect were staged according to HCL classification. Maxillary defects were staged according to Cordeiro and Santamaria's classification. Functional results (swallowing and speech) were assessed at the sixth month.

RESULTS

The mean age of the 10 patients was 60.2 years. The average length of bone defect was 8 cm. The average cutaneous defect area was 36.8 cm(2). The mandibular defect was LCL in six cases, L in one case, and C in one case. The two cases of maxillary bone loss were classified IIIa. Six of the 10 microsurgical anastomoses were contralateral to the lesion. There was no reconstruction failure. Three patients had mild speech disorders, five had moderate speech disorders, and two major speech disorders. Four patients had a normal food intake, three patients needed mixed food, and three patients liquid food.

DISCUSSION

The indications of radial forearm osteofasciocutaneous free flap for complex maxillofacial reconstructions should be extended. Its vascularization is less compromised by arteritis. Its pedicle may be long and adequate for a contralateral anastomosis. It is reliable and easy to harvest. But the bone quality is not as good as fibula.

Refinements in osteotomy design to improve structural integrity: a finite element analysis study

Osteotomy cuts are typically made using a saw, and the meeting point acts as a focus for the concentration of stress and failure. We have studied the impact of different designs of osteotomy cut. Cadaver sheep tibias were scanned by computed tomography (CT) and transformed into a computer-aided design (CAD) model. A standard marginal resection defect was created and then modified, and a finite element analysis made. The relative stress concentrations at the intersection of osteotomy cuts were recorded using principal stresses S1, S3, and von Mises stress, von Mises under both 4-point bending and torsion testing. The osteotomy designs studied were: right-angled and bevelled osteotomy end cuts, overcutting, and a stop drill hole. Peak stress values for 4-point bending and torsion were 24-30% greater at the right-angled osteotomy than the bevelled end cut. Overcutting dramatically increased peak stress values caused by bending and torsion by 48% and 71%, respectively. Substantially lower concentrations of stress were noted with a stop hole using both a 90° (bending 38% and torsion 56%), and a tangential (bending 58% and torsion 60%) cut. A bevelled osteotomy has substantially lower concentrations of stress than a right-angled osteotomy. It is important to avoid creating an overcut as this causes an appreciable increase in the concentration of stress, while a stop drill hole substantially reduces the stress. The creation of a stop hole and the use of judicious bevelling techniques are modifications in the design of an osteotomy that are readily applicable to surgical practice.

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.

Safe osteocutaneous radial forearm flap harvest with prophylactic internal fixation

We studied the efficacy of prophylactic plate fixation technique and a modified harvest of the osteocutaneous radial forearm free flap (OCRFFF) to minimize the incidence of postoperative donor radius pathological fracture. We retrospectively studied of the first 70 consecutive patients undergoing OCRFFF harvest by the University of Kansas Head and Neck Microvascular Reconstruction Team. Mean follow-up was 13 months. One of two patients undergoing OCRFFF harvest without prophylactic fixation developed a pathological radius fracture. The 68 subsequent OCRFFF patients underwent prophylactic fixation of the donor radius, and none developed a symptomatic radius fracture. Five of 68 patients did have a radiographically visible fracture requiring no intervention. The plate fixation technique was further modified to exclude monocortical screws in the radius bone donor defect (subsequent 39 patients), without any further fractures detected. One patient required forearm hardware removal for an attritional extensor tendon tear. The described modified OCRFFF harvest and prophylactic plate fixation technique may eliminate postoperative pathological fracture of the donor radius. Donor morbidity is similar to that of the fasciocutaneous radial forearm free flap , affording safe use of OCRFFF in head and neck reconstruction.

Free flap reconstruction of self-inflicted submental gunshot wounds

In this study, we review outcomes for 15 patients with self-inflicted submental gunshot wounds requiring free flap reconstruction. Patients presented to two tertiary care centers over a 7-year period. Mean age was 46 years (range, 16 to 76 years), 67% (n = 10) had a psychiatric history, and four were known to abuse illicit substances. Patients with oromandibular involvement required on average a total of 2.8 procedures, and those with midface (3.7) or combined defects (6) required more total procedures (p = 0.21). Donor sites included osteocutaneous radial forearm (n = 8), fibula (n = 4), fasciocutaneous radial forearm (n = 5), and anterior lateral thigh (n = 1). Median length of hospitalization was 8 days. Overall complication rate was 33% (n = 5), and included hematoma (n = 1), fistula (n = 1), and mandibular malunion (n = 2). Most patients were able to tolerate a regular or soft diet (92%), maintain oral competency (58%), and demonstrate intelligible speech (92%) at a median time to follow-up of 12 months. Despite the devastating nature of this injury, free flap reconstruction of self-inflicted submental gunshot wounds results in acceptable functional results for the majority of patients.

The Microvascular Corticocancellous Femur Flap for Reconstruction of the Anterior Maxilla in Adult Cleft Lip, Palate, and Alveolus Patients

Objective

Free nonvascularized alveolar bone grafting in severe defects of the cleft region often results in poor implant bed conditions. Here an alternative augmentation technique using a new technique of vascularized bone transfer is described.

Design

In five patients with clefts of the lip, palate, and alveolus (four unilateral, one bilateral) there was a severe defect of the anterior maxillary alveolar ridge after tooth loss. The patients previously had augmentative surgery one to three times without success. The defect was covered using a microvascular corticocancellous transplant from the medial distal femur. The defects to be corrected measured 2.5 to 4.0 cm long, 1.0 to 1.5 cm wide, and 1 to 1.5 cm high. The microvascular pedicle of the femur bone flap was 3 to 7 cm long. The descending genicular artery was anastomosed to the facial or labial superior artery and the accompanying veins accordingly. In every case, the anastomoses were performed via an intraoral transmucosal approach.

Results

There were no serious complications and no flap loss. In all patients the defect was covered by a flap of the correct size and design. All patients were treated with dental implants (13 total) 6 months after successful reconstruction of the ridge. The implants were loaded 4 to 6 months after placement with fixed superstructures. There were good peri-implant conditions and no implant loss.

Conclusion

The microvascular osteoperiosteal femur flap can be used successfully in individual reconstruction of segmental defects of the alveolar ridge in adult cleft patients.

Assessment of donor site morbidity for free radial forearm osteocutaneous flaps

PURPOSE

Assessment of donor site morbidity and recipient site complications following free radial forearm osteocutaneous flap (FRFOCF) harvest and evaluation of patient perceived upper limb disability for free radial forearm osteocutaneous versus fasciocutaneous flaps (FRFF).

METHODS

First a case series was undertaken of 218 patients who underwent an FRFOCF at two tertiary referral centers between February 1998 and November 2010. Outcomes included forearm donor site morbidity and recipient site complications. Second, the disability of the arm, shoulder, and hand (DASH) questionnaire assessing patient perceived arm disability was administered by phone to 60 consecutive patients who underwent an FRFOCF or FRFF.

RESULTS

Mean patient age was 63 years with male predominance (62.8%). Median bone length harvested was 8 cm (range, 3-12 cm) with prophylactic plating of the radius following harvest. Donor site morbidity included fracture (1 patient, 0.5%) and sensory neuropathy (5 patients, 2.3%). Mean DASH scores were comparative between groups and to established normative values. Mandibular malunion rate was 3.2% and hardware extrusion at the recipient site occurred in 15.6%.

CONCLUSION

Reluctance to perform FRFOCF by surgeons usually centers on concerns regarding potential donor site morbidity and adequacy of available bone stock; however, we identified minimal objective or patient perceived donor site morbidity or recipient site complications following harvest of FRFOCFs. Mild wrist weakness and stiffness are common but do not impede ability to perform activities of daily living. Data from this and other reports suggest this flap is particularly useful for midfacial and short segment mandibular reconstruction.

Free flap reconstruction of lateral mandibular defects: indications and outcomes

OBJECTIVE

To compare outcomes following osteocutaneous radial forearm and fibula free flap reconstruction of lateral mandibular defects.

STUDY DESIGN

Retrospective case-controlled study.

SETTING

Historical cohort study.

SUBJECTS AND METHODS

All patients who underwent free flap reconstruction of lateral mandibular defects from 1999 to 2010 were included in this study. Patients were classified into 2 groups based on type of reconstruction: (1) osteocutaneous radial forearm (n = 73) and (2) fibula free flap reconstruction (n = 51). Patient characteristics, length of hospital stay, recipient and donor site complications, and long-term outcomes including postoperative diet were evaluated.

RESULTS

Most patients were male (68%) and presented with advanced T-stage (71%) squamous cell carcinoma (94%) involving the alveolus (21%), retromolar trigone (23%), or oral tongue (21%). Median length of hospital stay was 8 days (range, 4-22 days). The recipient site complication rate approached 27% and included infection (n = 11), mandibular malunion (n = 9), exposed bone or mandibular plates (n = 9), and flap failure (n = 5). Most patients demonstrated little to no trismus following reconstruction (94%) and were able to resume a regular or edentulous diet (73%). No difference in complication rates or postoperative outcomes was seen between osteocutaneous radial forearm and fibula free flap groups (P > .05). One patient underwent dental implantation following osteocutaneous radial forearm free flap reconstruction. No patients from the fibula free flap group underwent dental implantation.

CONCLUSION

The osteocutaneous radial forearm and fibula free flap provide equivalent wound healing and functional outcomes in patients undergoing lateral mandibular defect reconstruction.

Reconstruction of osteomyelitis defects of the craniofacial skeleton

Osteomyelitis of the craniofacial skeleton closely resembles osteomyelitis elsewhere in the body in its pathophysiology and medical management; subsequent reconstruction after debridement remains distinctly challenging. The goals of reconstruction must include the restoration of the complex and readily visible morphology of the cranium and face, as well as the adequate return of vital sensory, expressive, and digestive functions. In this article, the various reconstructive modalities will be discussed including pedicled and nonpedicled flaps with or without an osseous component, nonvascularized bone grafts, alloplastic implants, and bone regeneration using protein therapy. Although reconstruction of craniofacial defects after osteomyelitis commonly proves formidable, the satisfactory return of form and function remains a plausible reconstructive goal.

Topological optimization for designing patient-specific large craniofacial segmental bone replacements

Restoring normal function and appearance after massive facial injuries with bone loss is an important unsolved problem in surgery. An important limitation of the current methods is heuristic ad hoc design of bone replacements by the operating surgeon at the time of surgery. This problem might be addressed by incorporating a computational method known as topological optimization into routine surgical planning. We tested the feasibility of using a multiresolution three-dimensional topological optimization to design replacements for massive midface injuries with bone loss. The final solution to meet functional requirements may be shaped differently than the natural human bone but be optimized for functional needs sufficient to support full restoration using a combination of soft tissue repair and synthetic prosthetics. Topological optimization for designing facial bone tissue replacements might improve current clinical methods and provide essential enabling technology to translate generic bone tissue engineering methods into specific solutions for individual patients.

Nonunion of mandibular midline osteotomy after tumor surgery and radiation repaired by endosseous implants

Nonunion of the mandible after microvascular flap reconstruction of defects resulting from tumor surgery is a known but rare complication, occurring in 5% of cases. When nonunion results with the use of microvascular flaps, rigid internal fixation, and radiotherapy, other options to treat the nonunion carry a greater risk of osteomyelitis, osteoradionecrosis, and/or persistent nonunion. Although endosseous implants have been reported to cause mandibular fracture in some cases, our case proposes and supports the use of implants for immobilization and/or prevention of nonunion of the mandible in patients who have a high probability of this complication developing, thereby avoiding plating across the nonunion site with the risk of plate exposure and osteoradionecrosis. This technique permitted a good quality of life in our patient during the healing period. He was able to masticate and phonate properly when compared with other treatment options that would have required external and/or intermaxillary fixation devices.

[Role of fibula in replacement of mandible]

The mandible and the fibula are two totally different bones of the human skeleton. The fibula is a long straight bone of the lower leg playing secondary role compared with the tibia. The mandible, or jaw bone, is the only facial bone that moves and has complex spatial structure. The blood supply of the mandible is mainly endosteal, the inferior mandibular artery, which is one of the more important branch of the maxillary artery is responsible for its arterial supply. The fibula shows the uniform pattern of periosteal blood supply receiving many small branches from the peroneal artery, and having only weak endosteal supply. The mandible articulates with the two temporal bone, and the fibula articulates with the tibia at the tibio-fibular syndesmosis and distally has a role in the formation of the lateral talocrural joint. The demand for mandibular replacement was approved simultaneously with the appearance of ablative surgery for head and neck cancer. As knowledge of physiology and pharmacology expanded in the twentieth century, major developments in the field of anesthesiology and surgery opened new windows of ablative cancer surgery that were previously unimaginable. Soldiers were badly wounded with extensive soft-tissue defects during World Wars and in certain countries, high gun ownership rates show substantial correlations with gun-related injuries. Health care development and the invention and wide-spread use of antibiotics revolutionized medical treatment and improved recovery rates and reduced mortality following trauma. Total or partial loss of the mandible without reconstruction incurs serious functional and psychological morbidity for patients. Prior to the development of advanced reconstruction options for mandibular defects, they were left with terrible cosmetic deformities. Throughout the second half of the twentieth century, various attempts were made to replace the mandible but the major breakthrough was the appearance of the microvascular technique at the end of the seventies and the beginning of the eighties.

Treatment of hydroxyapatite scaffolds with fibronectin and fetal calf serum increases osteoblast adhesion and proliferation in vitro

BACKGROUND

The use of hydroxyapatite in reconstructive surgery has been hampered by the fact that it is very slowly invaded by host tissues, a process that is critical to graft incorporation. Implant compatibility may be augmented by providing cellular binding sites and by seeding cells before implantation.

METHODS

Bone-forming cells were seeded onto hydroxyapatite disks, and precoated with fibronectin and fetal calf serum or phosphate-buffered saline. Cellular adhesion and proliferation was analyzed in vitro. For in vivo studies, experimental and control hydroxyapatite disks were seeded with green fluorescent protein-expressing cells and implanted into mice.

RESULTS

Fibronectin/fetal calf serum pretreatment improved cell attachment and cell growth significantly in vitro. After 48 hours, experimental disks (n = 5) contained 2.8 times more attached cells than controls (p < 0.001), and after 7 days this difference had increased further (4.2 times) (p < 0.001). In the in vivo part of the study, sections from implants (n = 4) harvested 3 days after implantation demonstrated an average of 122 +/- 50 green fluorescent protein-labeled cells/mm in the fibronectin/fetal calf serum group compared with 85 +/- 21 cells/mm in the phosphate-buffered saline controls. After 10 days, the cells had in general decreased in number in both groups, but the relation in cell density was similar to the first time point (19 +/- 11 versus 12 +/- 11 cells/mm).

CONCLUSION

In vitro attachment and proliferation of bone-forming cells on hydroxyapatite is significantly increased by pretreatment with fibronectin/fetal calf serum, but this difference is less profound and not significant in vivo.

Prophylactic internal fixation of the radial osteocutaneous donor site

The technique of prophylactic internal fixation (PIF) of the radial osteocutaneous donor site is described and reviewed. Twenty-two donor sites were reinforced with a 3.5mm dynamic compression plate across the anterior defect. The incidence of fracture was 4.5% (1 out of 22). The single fracture was due to a technical error and was managed conservatively. Fracture at a donor site that has not been plated is more frequent and often becomes displaced, requiring secondary surgery. In contrast, the incidence of fracture, displacement and secondary surgery following prophylactic internal fixation (PIF) is relatively low. There have been no significant long-term complications with PIF. It is now the method of choice for managing the radial osteocutaneous donor site.

Biomechanical study of prophylactic internal fixation of the radial osteocutaneous donor site using the sheep tibia model

This study investigated the strengthening effect of different types of plate and position after osteotomy of the sheep tibia, which is a model for the radial osteocutaneous donor site. Fifty matched pairs of adult sheep tibias were tested in torsion and four-point bending. Firstly, the weakening effect of an osteotomy was compared with the intact bone. Then pairs of bones with an osteotomy were compared with and without reinforcement with different types of 3.5mm plate. The plate was placed in either the anterior (over the defect) or posterior (on the intact cortex) position. In torsion the mean strength of the intact bone was 45% greater than after osteotomy (P=0.02). The reinforced bone was on average 61% stronger than the unreinforced bone (P<0.001). In bending the mean strength of the intact bone was 188% greater than after osteotomy (P=0.02). The reinforced bone was on average 184% stronger then the unreinforced bone (P<0.001). The tibia was able to withstand much greater loads in bending. The dynamic compression plate was the strongest reinforcement in both torsion and bending. The position of the plate did not alter the strengthening effect in torsion but the posterior position resisted greater bending loads (P=0.01). This may not be relevant in clinical practice as the radius is likely to fracture first as a result of lower torsional forces.

Reconstruction of the Lateral Mandibulectomy Defect: Management Based on Prognosis and Location and Volume of Soft Tissue Resection

OBJECTIVE

To examine how the accompanying soft tissue resection of the oral cavity, oropharynx, neck, or face affects the reconstructive management of the lateral mandibulectomy defect.

STUDY DESIGN

Retrospective review of 76 consecutive patients.

METHODS

Patient and tumor variables were extracted from the medical records. Outcomes that were examined included method of reconstruction, medical complications, flap complications, and survival.

RESULTS

Age greater than 70 years (P = .03), moderate or severe comorbidity (P = .01), and tumor involvement of the base of tongue (P = .03) were significantly associated with decreased use of a free flap and with decreased 3-year survival rates. For choice of free (osteocutaneous radial forearm free flap or fibula vs. rectus abdominis) and regional flaps (pectoralis or cervicodeltopectoral), lateral defects could be classified into one of three types: type 1 (n = 60), lateral defect with a soft tissue resection limited to the oral cavity and oropharynx; type 2 (n = 11), lateral defect with a through and through defect of the lower one third of the face (skin overlying the mandible) or neck; and type 3 (n = 5), lateral defect with an associated large-volume resection of the midface, parotid, or cheek skin.

CONCLUSION

When the lateral mandible is resected with an accompanying large soft tissue defect of the neck or face (type 2 or type 3 defect), the reconstructive challenge becomes the determination of how best to cover the planned bony reconstruction or whether to perform only a soft tissue reconstruction. When placed in the context of expected prognosis, the proposed classification system based on the location and volume of the associated soft tissue resection can help guide the reconstructive options for these decisions.

Choice of osseous and osteocutaneous flaps for mandibular reconstruction

Microvascular free flap transfer currently represents one of the most popular methods for mandibular reconstruction. With the various free flap options now available, there is a general consensus that no single kind of osseous or osteocutaneous flap can resolve the entire spectrum of mandibular defects. A suitable flap, therefore, should be selected according to the specific type of bone and soft tissue defect. We have developed an algorithm for mandibular reconstruction, in which the bony defect is termed as either "lateral" or "anterior" and the soft-tissue defect is classified as "none," "skin or mucosal," or "through-and-through." For proper flap selection, the bony defect condition should be considered first, followed by the soft-tissue defect condition. When the bony defect is "lateral" and the soft tissue is not defective, the ilium is the best choice. When the bony defect is "lateral" and a small "skin or mucosal" soft-tissue defect is present, the fibula represents the optimal choice. When the bony defect is "lateral" and an extensive "skin or mucosal" or "through-and-through" soft-tissue defect exists, the scapula should be selected. When the bony defect is "anterior," the fibula should always be selected. However, when an "anterior" bone defect also displays an "extensive" or "through-and-through" soft-tissue defect, the fibula should be used with other soft-tissue flaps. Flaps such as a forearm flap, anterior thigh flap, or rectus abdominis musculocutaneous flap are suitable, depending on the size of the soft-tissue defect.

Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions

OBJECTIVES/HYPOTHESIS

The radial forearm osteocutaneous free flap is an excellent reconstructive modality for oromandibular and maxillofacial reconstruction in certain well-defined circumstances. The initial concern over donor site morbidity and the ability of the bone to reconstruct mandibular defects have led to only a few published series.

STUDY DESIGN

Retrospective study of the experience of two tertiary medical centers with radial forearm osteocutaneous free flap.

METHODS

Retrospectively, 52 patients were studied who underwent radial forearm osteocutaneous free flap reconstruction for cancer (49 cases) and trauma (3 cases). Bone length and skin paddle harvested, general morbidity (hematoma, wound infection, and dehiscence), recipient site morbidity (nonunion of neomandible, flap failure, and bone or plate exposure), and donor site morbidity (radius bone fracture, plate exposure, and skin graft failure) were reviewed.

RESULTS

The average skin paddle size was 55.1 cm (range, 15-112 cm). The average radius bone harvest length was 6.3 cm (range, 2.5-11 cm). Donor site complications included tendon exposure (3 cases), radius bone fracture (1 case), and exposure of the plate (0). Recipient site complications included nonunion of the mandible (4), exposed mandible (1), exposed mandibular plates (2), exposed maxillary plates or bone (0), venous compromise (1), and flap failure (1). Two patients had perioperative deaths.

CONCLUSION

Radial forearm osteocutaneous free flap is a valuable and viable option for oromandibular and maxillofacial reconstruction.

Oromandibular reconstruction after cancer resection

The goals of this article are (1) to summarize the epidemiology of oromandibular cancer, (2) to describe the classification of defects after cancer extirpation, and (3) to discuss the principles of and state of the art in reconstruction of the oromandibular defect. The four commonly used flaps (fibula flap, radial forearm flap, scapula flap, and the iliac crest) and their key characteristics are summarized. Finally, some future speculations are entertained.

The role of the osteocutaneous radial forearm free flap in the treatment of mandibular osteoradionecrosis

OBJECTIVE

To evaluate the role of the osteocutaneous radial forearm free flap (OCRFFF) in the treatment of mandibular osteoradionecrosis (ORN).

STUDY DESIGN AND SETTING

Retrospective case review of patients who underwent OCRFFF oromandibular reconstruction after resection of nonviable tissue at an academic tertiary care center because of ORN. Patients with reconstructions other than OCRFFF were excluded from this study.

RESULTS

Nine patients underwent a composite oromandibular resection for ORN with a reconstruction using an OCRFFF between April 1998 and February 2003. All patients had failed previous less aggressive surgical and medical management of the ORN. Mean follow-up was 36 months (range, 14-67 months). There were no flap failures or significant immediate postoperative or long-term complications observed. All patients had successful restoration of mandibular integrity and continuity, with 100% success rate of stabilization of ORN. All patients were able to tolerate PO diet, with only one third having to supplement their diet with gastrostomy feedings, compared with 89% gastrostomy dependence preoperatively.

CONCLUSIONS

Primary or adjuvant radiotherapy for head and neck malignancies can result in ORN of the mandible. This difficult problem often requires surgical intervention. In our experience, the OCRFFF can be successfully used for oromandibular reconstruction, even in the setting of the heavily radiated tissue with excellent postoperative outcomes.

SIGNIFICANCE

This is the first study that demonstrates the efficacy of the OCRFFF as a treatment of mandibular ORN.

[Microvascular osteoseptocutaneous radial flap in reconstruction of mandible following war injury]

BACKGROUND

Vascularized osteoseptocutaneous radial flap is commonly used in the reconstruction of composite bony and soft tissue defects of the lower third of the face due to the outstanding quality of its cutaneous component. The aim was to evaluate the primary and overall success in the reconstruction of mandibular defects, following war injuries, with vascularized osteoseptocutaneous radial flap.

METHODS

At the Department of Maxillofacial Surgery of the Military Medical Academy Belgrade, there were eight patients with this kind of defect following war injury, and the mandible was reconstructed with a vascularized osteoseptocutaneous radial flap. Bony compartment of the graft was harvested as up to 11 cm long segment of radial circumference.

RESULTS

The localization and structure of the defect, features of a harvested compound graft, the procedure of the reestablishment of the mandibular continuity was presented as well as immediate and late complications during the consolidation period, and the primary successful reconstruction in 87.5% of the patients.

CONCLUSION

The primary and overall success in the mandibular defects reconstruction with a vascularized osteoseptocutaneous radial flap was equal or even better than those presented in the literature on the reconstruction of the similar defects after tumor resections.