Chapter 41

Mandible Reconstruction
Presenter: Int. Date: 2012.09.24

Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne

Outline
Introduction Methods

of reconstruction Free-Flap Donor-Site Selection Preoperative Planning Surgical Technique Postoperative Care Complications Other Postoperative Issues

Goals of Reconstruction
Function

TMJ: maximal opening ability and maintenance of occlusion Normal interarch distance and alignment Symmetry Lower facial height Anterior chin projection Submandibular soft-tissue neck defects
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Aesthetics

Etiology
Cancer

Epidermoid carcinoma

Benign

cystic or fibrotic bone disease Trauma

Gunshot wounds

Infection

Classification of Mandible Defects

Methods of reconstruction
Nonvascularized

bone grafts

Short bone gap (<3 cm)

Metal

plates Pedicled flaps

Trapezius and pectoralis osteomyocutaneous flaps

Free

flaps
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Osteocutaneous Free Flap

Most

effective Soft tissue + bone Microvascular anastomoses Pedicle qualities: vessel diameter and length Survival rates: 95%

Free-Flap Donor-Site Selection

Ilium
Radius Scapula Fibula

Free-Flap Donor-Site Selection

A: Scapula B: Ilium C: Radius D: Fibula

Ilium
Advantages

Abundant bone Segmental blood supply from the deep circumflex iliac artery, allowing segmental osteotomies

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Ilium
Disadvantages

Bone with predetermined shape Less robust, even marginal circulation at distal end Unreliable circulation to skin island Bulky and less mobile soft tissue Arduous closure at donor site Donor site morbidity: hernia, attenuation of the lateral abdominal wall, painful, limit early mobilization

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Ilium
Indication

Short lateral or hemimandible segment not requiring mucosal lining replacement

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Radius
Advantages

Best quality skin island: thin, pliable, abundant Ideal vascular pedicle

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Radius
Disadvantages

Worst bone quality Post-operative fracture Limited segment (10 cm): between insertion of the pronator teres and the brachioradialis Insufficient soft tissue Poor donor site appearnce

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Radius
Indication

Bone defect limited to the ramus and the proximal body with a large associated intraoral soft-tissue defect Soft-tissue free flap without bone coverage of a metal plate

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Scapula
Advantages

Greatest amount of soft tissue (30 cm, include latissimus dorsi) Independent bone and soft-tissue components 14 cm of bone available

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Scapula
Disadvantages

No segmental blood supply Donor site location: delay in flap harvest Compromised shoulder function

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Scapula
Indication

Repair of a bone gap with a large soft-tissue defect Simultaneous intraoral and external soft-tissue replacement Large defect from a radical neck dissection

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Fibula
Advantages

Bone: adequate length, height, thickness and straight quality ideal for shaping Functional segmental blood supply Good vascular pedicle Flexor hallucis longus muscle Reliable skin island: 91% Most convenient
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Fibula
Disadvantages

Unreliability of the skin blood supply: 9%

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Fibula
Indication

All anterior defects and most lateral defects Flap of choice for the majority of mandible defects

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Free-Flap Donor-Site Selection

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Preoperative Planning
Cardiopulmonary

evaluation: pulmonary function studies and cardiac stress testing Consult dental service: intermaxillary fixation, intraoperative tooth extraction, splints fabrication and prosthetic rehabilitation Aesthetics: CT (1:1) and MRI
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Surgical Technique
Donor

site dissection

with ablation in progress

Graft

shaping

with ablation in progress or after

Bony

fixation Microvascular anastomoses Final wound closure

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Graft Shaping
Lateral

graft shaping

Angle of mandible planned where vascular pedicle enters the bone Condyle harvested from the surgical specimen

Anterior

graft shaping

Central segment first Transverse template

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Bony Fixation
Miniplate:

efficient, safe and strong Reconstruction plate: does not allow subtle nuances of mandible shape Interosseous wires: not enough resistance Intermaxillary fixation: maintain occlusion External fixator: no longer popular

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Microvascular Anastomoses
Artery

Facial artery External carotid (end-to-side) Superior thyroid artery External jugular vein Internal jugular vein

Vein

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Final Wound Closure

Watertight

closure of the intraoral wound Suction drains placed away from the microvascular anatomoses Feeding tube

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Postoperative Care
Early

mobilization Tube feeding begun in 48 hours Irrigation for oral hygiene begun after 1 week Tracheostomy left in place for 10 to 14 days Doppler ultrasonography

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Complications
General

medical problems

Pulmonary and cardiac problems

Head

and neck wound problems

Free-flap failure (total flap loss < 5%) Reconstruction plate exposure Intraoral wound dehiscence

Donor-site

problems
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uncommon

Other Postoperative Issues

Postoperative

radiation therapy

Begin as soon as complete wound healing is assured (4 weeks)

Dental

restoration

Conventional dentures Osseointegrated implant: immediate placement not recommended

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Thanks for your attention!

Presenter: Int. Date: 2012.09.24

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