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Safety and efficacy of secondary mandibular reconstruction using a free osteo-cutaneous fibula flap after segmental mandibular resection: a retrospective case-control study.

ABSTRACT:

Background

Free osteocutaneous fibula flap (FFF) is currently considered the best option for segmental mandibular reconstruction; however, there are only a few reports comparing secondary with primary reconstructions using FFF. This study aimed to evaluate the safety and efficacy of secondary mandibular reconstruction using FFF when compared with primary mandibular reconstruction.

Methods

From October 2018 to February 2020, patients who underwent mandibular reconstruction using FFF after segmental mandibulectomy were retrospectively reviewed. The size and location of the mandibular defect, the segment length and number of osteotomies in the fibula, types of the mandibular plating system, kinds and laterality of the recipient vessels were recorded from the surgical notes. Flap survival, duration of nasogastric tube use, and implant installation after reconstruction were recorded as postoperative evaluation indices.

Results

Twelve patients underwent mandibular reconstruction using FFF during the study period. There were no significant differences in demographic characteristics other than body mass index between the primary (n = 8) and secondary (n = 4) reconstruction groups. No significant differences were observed in the size and location of defects, the segment length and number of osteotomies in the fibula, and the types of mandibular plating system. There was no significant difference in the kinds of recipient vessels; however, the laterality of recipient vessels was ipsilateral in all cases of primary reconstructions and contralateral in all cases of secondary reconstructions. Three out of eight patients with primary FFF reconstruction developed partial flap necrosis. Four patients in the secondary FFF reconstruction group achieved complete flap survival. The duration of use of the nasogastric tube and implant installation after reconstruction was comparable between the two groups.

Conclusion

Safe and effective secondary mandibular reconstruction can be performed in this clinical case study using FFF.

SUBMITTER: Yamakawa S

PROVIDER: S-EPMC8035737 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:INTRODUCTION:Functional and cosmetic defects in maxillofacial region are caused by various ailments like trauma, neoplasm, developmental, infections and iatrogenic causes. Reconstruction of these defects with free flaps remains the gold standard but demerits like need for surgical expertise and equipment, prolonged duration of surgery, compliance of the patient and increased cost are associated with microvascular reconstruction. Hence reconstruction with nonvascular bone grafts can be considered when defect is nonirradiated and <9 cm and with sufficient soft tissue cover available. PURPOSE:To retrospectively evaluate clinical, radiological outcome and complications encountered with mandibular reconstruction using non vascular fibula graft. PATIENTS AND METHODS:This retrospective study included 7 patients who were treated in the Department of Oral and Maxillofacial Surgery, Narayana Dental College and Hospital, Nellore, AP between 2011 and 2013 with histologically proven benign osteolytic lesions of mandible that require a segmental mandibulectomy and primary reconstruction using autogenous non-vascularised fibular graft. The clinical case records of the patients and personal patient assessment forms (Quality of Life Assessment Forms) were analysed. They were recalled every 3rd, 6th and 9th month after surgery for evaluation of clinical, radiological outcome of the graft and complications occurring at recipient and donor sites. RESULTS:In all the 7 patients, the lower border continuity was maintained except in one where the graft was dislodged. Tongue movements in all the patients were unrestricted. Jaw movements were affected in cases of ramus defects with slight deviation to operated side and reduced mouth opening. Radiological observations revealed no significant changes in 3 months except for slight reduction in graft height. The radioopaque bridging with continuity of lower border of mandible was noticed in 6th month indicating the take of the graft. This was achieved in every case except in one where the graft was lost due to dislodged reconstruction plate. In 9th month the edges of the graft i.e., graft to native mandible junction showed more resorption (3 mm) especially where there is >2 mm of gap. Whereas increase in height of graft in other areas especially in graft to graft junction was seen. Significant graft resorption was seen in two cases. There were no major complications associated with the donor site. CONCLUSION:Avascular fibula graft although a second choice to vascularised fibula, is a favourable option for mandible defects of 6-10 cm under optimum conditions especially in developing countries where financial and/or surgical resources are limited. An attempt for primary reconstruction with this is never futile as it prevents aesthetic deformity even in the event of failure and thus makes secondary reconstruction easy. However in order to confirm the results a prospective study with large scale of patients is necessary.

Project description:BackgroundExtensive through-and-through oromandibular defects after advanced oral carcinoma excision pose a reconstructive challenge for the head and neck surgeon. These complex oromandibular wounds often involve the mandible, oral and/or aerodigestive mucosa, and the external skin. As a result, these defects are often not amenable to reconstruction with a single flap due to the volume of soft tissue needed and the three-dimensional reconstructive requirement. The use of two free flaps has often been suggested to overcome this reconstructive challenge. A simpler and less technically demanding way to deal with this may involve the use of a free flap in combination with a pedicled regional flap. We present our experience of the use of a simultaneous microvascular fibula free flap (FFF) with a pectoralis major myocutaneous flap (PMMC) for addressing these defects.MethodsA retrospective chart review was performed of patients treated with a FFF and PMMC combination for the reconstruction of oromandibular defects at the University of Mississippi Medical Center (Jackson, MS) between October 2013 and February 2016. A minimum follow-up of 12 months was required. Data collected included the extent and location of tumor involvement, size of the postablative defect, tumor histology, clinical and pathological staging, length of follow-up, functional outcomes, and associated complications.ResultsA total of three patients were identified to have been treated with the above technique. Defects repaired involved through-and-through mandibular defects with associated oral mucosa and external skin defects. In all cases, the FFF was used for restoring bony continuity with the skin paddle used to reconstruct the intraoral lining. The PMMC was used for reconstruction of the external skin defect and for providing soft tissue bulk. The average size of the fibula skin paddle used for intraoral reconstruction was 7.7 cm × 11.7 cm. The average size of the PMMC paddle was 7.3 × 9 cm. The mean follow-up was 21.7 months. Both the FFF and PMMC survived in all cases, although postoperative wound healing complications occurred in two of the three patients. There was one partial flap loss. Two patients regained good oral intake while one patient tolerated oral intake but was PEG tube-dependent.ConclusionsThe combination of pectoralis major myocutaneous flap and a vascularized free fibular flap is a viable option for the reconstruction of complex through-and-through oromandibular defects. This technique may be useful when a single microvascular free flap is not sufficient for reconstruction of such defects.