Mandibular reconstruction using a microvascular method in the transplantation of a fibular flap

The best results in mandibular reconstruction are achieved by transplantation of vascularised bone. This transplant has an own blood supply therefore its surviving is not influenced by the non-sterile environment of the oral cavity and the insufficient blood supply of the operated area (caused by scar or radiation). A new promising method for reconstruction of a wide segmented defect of the mandible is vascularised fibular flap transplantation. Eight consecutive patients treated with fibular flap transplantation in 1993 and 1994 were reviewed. Osteo- and osteo-cutan flaps were used for reconstruction of the composite tissue defects. The authors report on the surgical technique and their first experiences. The authors consider the application of the fibular flap the most successful procedure of all types of reconstruction of segmented mandibular defect.     

Reconstruction of residual alveolar cleft defects with one-stage mandibular bone grafts and osseointegrated implants

PURPOSE: This study evaluates a treatment regimen for reconstruction of residual maxillary alveolar cleft defects consisting of mandibular bone grafting and immediate implant installation. PATIENTS AND METHODS: Sixteen cleft patients (five female and 11 male) had residual cleft defects of the alveolar ridge reconstructed with bone grafts from the mandibular symphyseal region. The bone graft was pretapped at the donor site before fixation in the residual ridge with Br?nemark implants. Twenty implants were installed according to this concept. The period of observation ranged from 36 to 69 months, with a mean of 48 months after implant installation. RESULTS: Five patients developed wound dehiscenses that resulted in total or partial bone graft sequestration. Two implants were lost, one due to sequestration and the other due to mobility at the abutment procedure; 18 implants were still well functioning at the end of the observation period. However, all patients showed significant periimplant bone resorption after this one-stage treatment. CONCLUSION: Because of the observed complication rate, the one-stage procedure may not be optimal for reconstructing residual cleft defects.     

Zonal expression of angiotensin II-AT1-receptor genes in rat kidneys

The trapezius osseomyocutaneous flap is the only pedicled flap that is able to transfer vascularized bone for mandibular reconstruction as well as skin for intra-extra oral reconstruction. The trapezius muscle also helps to fill the defect created by the neck dissection and covers the vessels of the neck. This flap has been used in our maxillofacial surgery service during the past 14 years. In spite of having incorporated microvascular flaps in our reconstructive techniques it continues to be one of the flaps we use in selected patients for bone and soft tissue compound defects of the oral cavity. We describe in this article our experience using this flap with dental implants in order to achieve a functional reconstruction. We also discuss when we use this flap for mandibular reconstruction and when a free vascularized flap is used.     

Overview of quality measurement and improvement

BACKGROUND: Oro-mandibular reconstruction using vascularized bone-containing free-flaps can be accomplished with flap survival rates in the range of 95%. Primary reconstruction offers the best opportunity to achieve the optimal aesthetic and functional results. Patients presenting for secondary oro-mandibular reconstruction have a unique set of problems; these include the presence of soft tissue contracture displacing the mandibular segments in malposition and soft tissue deficiencies, that makes surgical correction more difficult and potentially more hazardous. Vascularized bone-containing free-flaps are indicated in secondary oro-mandibular reconstruction where both hard and soft tissues replacement is needed or when the recipient bed is unfavourable due to previous surgery and/or radiation. METHODS: Authors presents personal experience in ten cases of secondary oro-mandibular reconstruction treated at Maxillofacial Department of Parma from September 1995 to September 1996 with secondary oro-mandibular reconstruction using bone containing free flaps. Two different donor sites were used to harvest bone-containing free flaps: iliac crest in 2 cases and fibula in the others. In 4 cases the flap was only osseous while in the other 6 cases it was osteocutaneous. RESULTS: All flaps were transplanted successfully; in 1 case necrosis of the skin component of the flap was observed. CONCLUSIONS: The introduction of vascularized bone containing free flaps transferred from distant sites by microvascular techniques has changed mandibular reconstruction. Vascularized bone transferred into tissue beds compromised by salivary contamination and previous irradiation and the rational use of the soft tissutal components of the flap permit also the restoration of articulation, deglutition and mastication with quality of life better than non-vascularized alternatives.     

Endosseous implant and autogenous bone graft reconstruction of mandibular discontinuity: a 12-year longitudinal study of 31 patients

Surgical, medical, and prosthodontic records of 61 consecutively treated patients with mandibular discontinuity were reviewed retrospectively. All 61 patients had undergone discontinuity reconstruction with autogenous bone grafts; 31 of 61 had also received endosseous dental implants and a dental osseoprosthesis. Of these 31 implant-reconstructed patients, 23 had free autogenous nonvascularized and 8 had vascularized bone grafts. The surgical-prosthetic protocol consisted primarily of secondary, free autogenous nonvascularized bone graft reconstruction and secondary root-form endosseous implant and fixed prosthesis dental reconstruction. Vascularized bone (8 patients) or soft tissue (4 patients) grafts were utilized selectively for severely compromised patients after extensive oncologic resection, avulsive trauma, or after previous radiation treatment. Endosseous implant survival (95.5% in 31 patients), autogenous bone graft success (98.4% in 61 patients), and dental osseoprosthesis success (100% in 31 patients) were favorable. A high incidence (9.1%) of nonfunctioning (sleeping) implants was recorded for this patient population. The need to remove the titanium mesh tray for various reasons (17.6%) and the need to reconstruct soft tissue in the irradiated patient (12%) were noteworthy.     

A historical review of mental health services in Hong Kong (1841 to 1995)

OBJECTIVE: To review the experience of 1 microvascular surgeon during an 11-year period in performing 210 vascularized bone-containing free flaps for oromandibular reconstruction. DESIGN: Retrospective medical records review of patients who underwent primary and secondary oromandibular reconstruction with the use of vascularized bone free flaps. SETTING: Academic medical center. PATIENTS: A total of 201 patients underwent 210 composite free-flap reconstructions of the mandible for various disorders and with a range of bony and soft tissue defects. INTERVENTION: All patients underwent the microvascular transfer of vascularized bone flaps from the ilium, fibula, or scapula. In selected cases, 2 simultaneous free flaps were transferred to achieve an optimal bone and soft tissue reconstruction. Endosteal dental implants were used in 81 patients, with a total of 360 fixtures placed during these 11 years. MAIN OUTCOME MEASURES: The success of microvascular free tissue transfer, dental implant extrusion, and short- and long-term complications at the recipient and donor sites. RESULTS: Of the 210 mandibular reconstructions that were performed, 202 were successful in reestablishing mandibular continuity. Reexploration for vascular-related complications was done in 16 patients, 8 of whom were successfully treated, yielding an overall success rate of 96%. The overall success rate for endosteal dental implants was 92%. The implant success rate was 86% when the bone in which the fixtures were placed was irradiated postoperatively. The success rate was 64% in the 14 fixtures that were placed into previously irradiated bone. CONCLUSIONS: The success of the use of vascularized bone free flaps in restoring continuity to the mandible is clearly demonstrated in this series. There was an acceptable incidence of donor- and recipient-site complications that resulted in minimal long-term morbidity. The careful selection of a donor site(s) for oromandibular reconstruction allows for an optimal restoration of bony and soft tissue defects. Dental implants can be safely used in oromandibular reconstruction with a high level of success. Placing these implants during the initial surgery shortens the duration for achieving dental rehabilitation and enhances the success of the implants when postoperative radiotherapy is administered.     

Reconstruction of the long bones of the legs in children via free vascularized transplant of the fibula after resection for sarcoma

Nineteen children were operated on between 1985 and 1994. All the patients presented a sarcoma of long bones: osteosarcoma: 12 and Ewing's sarcoma: 7. They were operated on: resection and reconstruction of the long bones with a free vascularised fibula. Pre and post-operative chemotherapy was used. The average follow-up was 3 years (between 10 years and 1 year). The mean bone defect was 20 cm (between 32 and 11 cm). Boys were more frequently encountered [12]. Average age was 9.5 years. The pathological bone was: femur: 14, tibia: 4, humerus 1. The approach needs usually two incisions for femoral bone: the internal incision allows us to prepare the recipient vessels: deep femoral vessels in 11 cases. In 18 cases, union occurred in less than 14 months. One case of pseudarthrosis occurred. Immediate follow-up was simple in 17 cases. Infection was observed in 2 cases. Secondly, the most frequent complications were: fracture of the fibula: 6 cases, vicious cal: 2 cases; delayed union: 6 cases; stiffness: 2 cases. One patient died later from pulmonary metastasis. Solid osteosynthesis of the member and of the free vascularised fibula permit to shorten these delays. Success depends on two criteria: the graft thickening of the fibula and union of the fibula at both ends. The micro vascular anastomoses must be excellent. Twelve children had bone union with only one operation. In the 6 cases of delayed union, secondary bone grafts give consolidation. The comparison of this technique with standard treatment showed an evident superiority of the free vascularised fibula transplant in extensive defects of bone. The fibula is a life bone which permits rapid union with a short hospitalization, a quick recovery and an early return to school. Free vascularised fibula permit to ameliorate the quality of survival.     

Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage

In our attempts to salvage massive lower-extremity injuries, even in the presence of severe peripheral vascular pathology, adequate soft-tissue coverage is no longer a limiting factor due to recent advances in microvascular composite tissue transfer. Restoration of tibial continuity without shortening has emerged as the last obstacle in the formidable task of salvaging lower extremities with grade III B and III C defects. Proposed solutions to this problem include conventional free cancellous bone-grafting applicable to small defects only, vascularized bone grafts, or shortening of the leg with subsequent elongation using the Ilizarov technique. We present our experience with 3 consecutive cases of lower-limb salvage, utilizing a new approach in which microsurgical soft-tissue reconstruction has been combined with bony reconstruction by distraction osteosynthesis. Bone transport by distraction osteosynthesis under a free flap performed while preserving the initial limb length throughout the treatment period proved to be superior to other methods in selected cases and is presented as a new technique for the management of problematic lower-limb injuries.     

Autologous fibrin adhesive in mandibular reconstruction with particulate cancellous bone and marrow

Displacement of bone graft particles during their placement, neck flap closure, and insertion of the freeze-dried mandibular crib housing the graft to the glenoid fossa is a commonly encountered problem during major mandibular reconstruction with autogenous particulate cancellous bone and marrow. Autologous fibrin adhesive proved to be a solution as demonstrated in a series of 33 cases. In addition to adhesive and hemostatic properties, it helped the remodeling process begin about 50% earlier by providing the substratum for migration of mesenchymal cells, accelerating revascularization and migration of fibroblasts, stimulating the growth of both fibroblasts and osteoblasts, and slowing the multiplication of microorganisms. Bony incorporation and remodeling were detected radiographically at the fourth postoperative week compared with the eighth week in bone grafts without autologous fibrin adhesive.     

A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects

PURPOSE: This study compared vascularized and nonvascularized bone grafts for the reconstruction of segmental defects of the mandible. PATIENTS AND METHODS: The results in 39 patients having vascularized bone grafts (38 fibulas and one iliac crest) and 29 patients having nonvascularized bone grafts (26 iliac crest [22 corticocancellous block grafts, four cancellous bone grafts in a tray] and three rib grafts) for segmental mandibular reconstruction were evaluated in terms of overall success rate, total number of surgeries performed, total blood loss, total number of hospital days, and total number of hours in the operating room. RESULTS: Of 39 vascularized bone grafts, two failed (95% success rate), whereas of 29 nonvascularized bone grafts, seven failed (76% success rate). Failure for the nonvascularized bone grafts was closely correlated to the length of the defect. Nonvascularized bone graft patients underwent an average of one more surgical procedure for total reconstruction than vascularized bone graft patients, including osseointegrated implants. However, vascularized bone graft patients spent a mean of over 14 additional days in the hospital for all of their reconstructive procedures and an additional 3 hours in the operating room as compared with nonvascularized bone graft patients. Blood loss was similar in both groups (1,100 mL). Only 20% to 24% of patients in each treatment group have completed reconstruction to include osseointegrated implants. CONCLUSIONS: The success rate for vascularized bone grafting is high and is the treatment of choice when primary reconstruction is required, when the patient has been previously irradiated, or when simultaneous replacement of soft tissue is required. Vascularized bone grafts are also the treatment of choice for mandibular replacements over 9 cm in length. Nonvascularized bone grafts create a better contour and bone volume for facial esthetics and subsequent implant insertion, and may be the treatment of choice for secondary reconstruction of defects less than 9 cm in length.     

Differential giant cell epulis diagnosis--malignant melanoma of the mouth mucosa]

Between 1990 and 1996, 16 cases of bone defects were treated by vascularised bone grafting by the authors. Free vascularised fibula was used in 10 cases and one free iliac crest graft was used for upper extremity bone defects. Four vascular pedicled first metacarpal bone and one radial styloid bone were used for scaphoid nonunion. Average follow-up was 26 months (6-78 months) and success rate was 94%. We recommend vascularised bone grafts in the upper extremity when there is risk of infection; the defect is greater than five centimeters when the forearm rotation is unlimited. The avascularity of the scaphoid pseudarthrosis must be verified radiologically or through magnetic resonance imaging. This technique should only be used when other reconstructive techniques are unlikely to succeed.     

3-dimensional computed tomography with model preparation before mandibular reconstruction

Extended mandibular defects resulting from cancer resection are amenable to reconstruction with a free vascularized bone graft transplantation. Between 1992 and 1995, 12 patients were enrolled in a protocol including a preoperative 3D-CT used to develop a custom-made acrylic model of the mandible. Besides contributing to the assessment of tumor extension, 3D-CT helps determine the adequate limits of mandibular resection. 3D-CT has the advantage of providing the surgeon with a more familiar image of the mandible and the mandibular model, allowing better and quicker conformation of the bone flap. The graft can be shaped at the donor site before cutting its vascular pedicle, resulting in a shorter period of ischemia. This series demonstrated that preoperative mandibular modeling with 3D-CT helps improve functional and cosmetic results in mandibular reconstruction.     

Efficacy of perichondrium and a trabecular demineralized bone matrix for generating cartilage

A pedicled auricular perichondrial flap wrapped around trabecular demineralized bovine bone matrix can generate an autologous cartilage graft. In earlier experimental studies, it was demonstrated that this graft could be used for nasal and cricoid reconstruction. It was assumed that the vascularization of the perichondrial flap was obligatory, but it was never proven that the flap should be pedicled. Moreover, for clinical use, the dimensions of the auricle would set restrictions to the size of the graft generated. Therefore, the possibility to generate cartilage with a composite graft of a free perichondrial flap wrapped around demineralized bovine bone matrix, by using young New Zealand White rabbits, was studied. This composite graft was implanted at poorly (subcutaneously in the abdominal wall; n = 12), fairly (subcutaneously in the pinna; n = 12), and well-vascularized sites (quadriceps muscle; n = 12). As a control, trabecular demineralized bovine bone matrix was implanted without perichondrial cover. Half of these grafts (n = 6) were harvested after 3 weeks, and the remaining grafts (n = 6) after 6 weeks of implantation. In histologic sections of these grafts, the incidence of cartilage formation was scored. Furthermore, the amount of newly formed cartilage was calculated by computerized histomorphometry. Trabecular demineralized bovine bone matrix without perichondrial cover demonstrated early resorption; no cartilage or bone was formed. In demineralized bovine bone matrix wrapped in perichondrium, early cartilage formed after 3 weeks at well- and fairly vascularized sites. No cartilage could be detected in grafts placed at a poorly vascularized site after 3 weeks; minimal cartilage formed after 6 weeks. In summary, the highest incidence of cartilage formed when trabecular demineralized bovine bone matrix was wrapped either in a pedicled auricular perichondrial flap or in a free perichondrial flap, which was placed at a well-vascularized site. Second, a significantly higher percentage of the total area of the graft was cartilaginized at well-vascularized sites after 3 weeks. The newly generated cartilage contained collagen type II and proteoglycans with hyaluronic acid binding regions, whereas collagen type I was absent, indicating the presence of hyaline cartilage. This study demonstrates that new cartilage suitable for a graft can be generated by free perichondrial flaps, provided that the site of implantation is well vascularized. Consequently, the size of such a graft is no longer limited to the dimensions of the auricle.     

Failure of hypertrophy in revascularised fibula grafts due to stress protection

Three cases of long bone reconstruction with vascularised fibula grafts are described. Hypertrophy of the graft did not occur after a follow-up of 3-5 years. Three different kinds of stress shielding appeared to prevent transformation of the graft.     

Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction

Twelve patients with segmental mandibular defects were reconstructed with fibula osteoseptocutaneous flaps and simultaneous placement of osseointegrated implants. Decision to perform this procedure was based on the facts that all patients had benign diseases, did not require postoperative radiotherapy, were in good general and oral conditions, and were psychologically motivated. A total of 34 fixtures was inserted in the first stage. Eight patients underwent second stage surgery, which consisted of connection of the implant abutments to the fixtures and the use of palatal mucosal grafts around the implants. Final dental prostheses were fixed 1 month later in seven patients, at this time. All flaps survived after surgery, and no implant failure was observed after a mean follow-up period of 25 months. Only one fixture was not used during the subsequent stage and was left as a sleeper. Fixed dental prostheses were used in five patients and removable overlay prostheses in the other two. Chewing function was recovered between 4 and 6 weeks after the start using the definitive dental prosthesis. In contrast to previous results, we conclude that excellent results can be achieved when this combined procedure is used in carefully selected patients. In addition, it is confirmed that the fibula osteoseptocutaneous flap is a versatile, reliable composite tissue that facilitates primary placement of osseointegrated dental implants during mandible reconstruction, thus allowing full oral rehabilitation in a shorter period of time.     

Reconstruction of total maxillectomy defects with preservation of the orbital contents

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. Reconstruction of such defects should (1) provide support to the orbital contents, (2) obliterate any communication between the orbit and nasopharynx, (3) reconstruct the palatal surface, and (4) achieve facial symmetry and a good aesthetic result. We report our experience in performing reconstructive surgery on 14 patients who had a total maxillectomy and preservation of the orbital contents using nonvascularized bone grafts for reconstruction of the orbital floor and maxilla, in conjunction with a soft-tissue free flap or pedicled muscle flap. The orbital floor was reconstructed using split ribs in six cases (42.9 percent), split calvaria in six cases (42.9 percent), and iliac crest graft in two cases (14.3 percent). A myocutaneous rectus abdominis free flap was used for soft-tissue reconstruction and resurfacing of the palatal mucosa in twelve patients (85.7 percent), and a temporalis muscle transposition was used in two elderly patients (14.3 percent). One patient died 2 days after surgery. Mean follow-up and aesthetic and functional results were assessed in the remaining 13 patients a minimum of 6 months postoperatively. In 9 of these 13 patients (69.2 percent), postoperative radiotherapy was administered. No reexplorations or free flap failures were observed. One rectus flap developed partial necrosis of the skin island intraorally without affecting the final result. All patients had adequate functional vision. One patient had a mild vertical dystopia; there were no cases of enophthalmos. Ectropion was the most common undesirable result and was present in 10 of 13 cases (76.9 percent). It was graded as mild in four cases (40.0 percent), moderate in four cases (40.0 percent), and severe in the remaining two cases (20.0 percent). Speech was considered normal in six cases (46.2 percent), near normal in six cases (46.2 percent), and intelligible in one case (7.7 percent). Chewing function was considered good (soft to unrestricted diet) in all cases except for one patient who was only able to eat a pureed diet. Aesthetic results after immediate reconstruction were considered good in nine cases (69.2 percent) and fair in four cases (30.8 percent). Primary reconstruction of total maxillectomy defects with orbital content preservation remains a complex problem without a perfect solution. The combination of nonvascularized bone grafts for orbital/maxillary reconstruction with a soft-tissue free flap is a safe, reliable, and effective method of maximizing postoperative functional and aesthetic results.     

Oromandibular reconstruction using a keel-shaped modification of the radial forearm osteocutaneous flap

The keel-shaped modification for harvest of the radial forearm osteocutaneous flap has been used to reconstruct 19 oromandibular defects in 18 patients. Fourteen men and 4 women ranging in age from 22 to 72 years have undergone composite mandibular reconstruction, with follow-up ranging from 3 to 36 months. Sixteen patients (17 reconstructions) had resection of advanced malignancies, and 2 patients sustained shotgun wounds. Twelve symphyseal and 7 lateral or posterior defects were reconstructed with donor radius bone ranging in length from 5 to 13.5 cm. Double osteotomies were performed in 7 patients. Two skin paddles were used in 4 patients to provide simultaneous intraoral lining and external skin coverage. The radial forearm osteocutaneous flap is still an excellent choice for oromandibular reconstruction. Anterior and lateral composite mandibular defects were satisfactorily reconstructed both aesthetically and functionally using the keel-shaped modification of the radial forearm flap. Donor-site problems were uncommon and minor, and long-term forearm function was minimally affected. Radius fracture occurred in only 1 patient.     

Idiotype vaccination strategies against a murine B-cell lymphoma: dendritic cells loaded with idiotype and bispecific idiotype x anti-class II antibodies can protect against tumor growth

BACKGROUND: Following extensive resections of head and neck tumors, re-establishing speech and masticatory function are of crucial importance for the patient. METHODS: In 23 patients with vascularised jejunal grafts for reconstruction of the intraoral mucosa, tongue and floor of mouth, a speech intelligibility test was performed, tongue and floor of mouth mobility was investigated using a 3.5 MHz ultrasound scanner. In another 18 patients with vascularised bone grafts for reconstruction of the mandible, masticatory function was analysed using a T-scan system and a miniature pressure transducer. RESULTS: Speech results with jejunal grafts in the lateral floor of mouth/tongue region may attain 91.4%, in anterior floor of mouth reconstructions 63.4%. Patients with implant-bone dentures and vascularised bone grafts prefer the non-reconstructed side for chewing. Masticatory force is significantly diminished compared to a control group. DISCUSSION: Lack of neurosensitive feedback mechanisms may be responsible for diminished chewing pressure and also for inferior speech results despite good floor-of-mouth/tongue mobility. CONCLUSIONS: Despite complex microvascular tissue reconstructions, severe functional impairments remain and necessitate further investigations on improvement of postoperative speech, swallowing and chewing function.     

Pectoralis major myocutaneous flap for reconstruction of defects following resections in head and neck area

Pectoralis major myocutaneous flap (PMMF) has become the standard for reconstruction of major defects in head and neck area. Eleven cases, operated over a three year period, in which PMMF was used for reconstruction have been reviewed retrospectively. Nine patients had oral squamous cell carcinoma, one had a basal cell carcinoma of the external ear and one had lost skin and soft tissue of neck following synergistic gangrene. Ten of the eleven flaps survived (success rate 91%). One of the three rib grafts used to reconstruct mandible got infected and had to be removed. Three patients developed wound infections and one had a temporary orocutaneous fistula which closed spontaneously. This brief experience confirms the reliability and efficiency of PMMF for head and neck reconstruction.     

Pain, music creativity and music therapy in palliative care

In 75 patients following ablative surgery of head and neck cancer, reconstruction was attempted with free tissue transfer techniques under magnification. It was possible to do free tissue transfers in 69 cases. In 6 cases it was not possible to harvest free flaps successfully and alternative reconstructive procedure was carried out due to unavoidable circumstances and various reasons: 1. unsuitable venous drainage, as in Anterior Rib Osteomyocutaneous Composite Flap, AROCF (2 cases), 2. injury to vessels during flap harvest, as in parascapular flap (1 case), 3. residual disease unable to excise (2 cases) and 4. unsuitable proposition (1 case), due to emergency curfew imposed suddenly. These 6 cases were not included in the study. Free tissue transfer was successful in 64 cases (92.7%) and there was a total failure in 5 cases where delayed secondary salvage surgery was performed. Out of 69 cases, in 65 cases reconstructions were carried out immediately, primarily as one-stage operative procedure. Their functional, cosmetic results and complications during the operative and post-operative period are analyzed and discussed. Inter-maxillary fixation was never used to maintain the bite alignment. All cases were given a bite guide prosthesis in the early post-operative period, to improve the bite alignment when it was necessary.