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Mandible Reconstruction
Presenter: Int.
Date: 2012.09.24
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne
Chapter 41
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Outline
Introduction
Methods of reconstruction
Free-Flap Donor-Site Selection
Preoperative Planning
Surgical Technique
Postoperative Care
Complications
Other Postoperative Issues
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Goals of Reconstruction
Function
TMJ: maximal opening ability and maintenance
of occlusion
Normal interarch distance and alignment
Aesthetics
Symmetry
Lower facial height
Anterior chin projection
Submandibular soft-tissue neck defects3
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Etiology
Cancer
Epidermoid carcinoma
Benign cystic or fibrotic bone diseaseTrauma
Gunshot wounds
Infection
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Classification of Mandible Defects
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Osteocutaneous Free Flap
Most effective
Soft tissue + bone
Microvascular anastomosesPedicle qualities: vessel diameter and
length
Survival rates: 95%
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Free-Flap Donor-Site Selection
Ilium
Radius
Scapula Fibula
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Free-Flap Donor-Site Selection
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A: Scapula
B: Ilium
C: Radius
D: Fibula
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Ilium
Advantages
Abundant bone
Segmental blood supply from the deepcircumflex 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 11
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Ilium
Indication
Short lateral or hemimandible segment not
requiring mucosal lining replacement
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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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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: intermaxillaryfixation, 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
Vein
External jugular vein
Internal jugular vein
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Postoperative Care
Early mobilization
Tube feeding begun in 48 hours
Irrigation for oral hygiene begun after 1week
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
uncommon
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Thanks for your attention!
Presenter: Int.
Date: 2012.09.24
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