A ‘‘NO-TOUCH-TECHNIQUE’’ IN MANDIBULAR RECONSTRUCTION WITH RECONSTRUCTION PLATE AND FREE FLAP TRANSFER MASAHIDE FUJIKI, M.D.,1 MINORU SAKURABA, M.D.,1* SHIMPEI MIYAMOTO, M.D.,2 SHOGO NAGAMATSU, M.D.,1 and RYUICHI HAYASHI, M.D.3
Objective: Mandibular reconstruction with a mandibular reconstruction plate (MRP) and free flap transfer can involve serious plate-related complications. The aim of our study is to present our new “no-touch-technique” which keeps an MRP not contaminated to saliva during the entire operation for the reduction of plate-related complications. Patients and Methods: Data were retrospectively collected on 29 patients who had undergone segmental mandibulectomy for head and neck tumor and mandibular reconstruction with an MRP and free flap transfer from 2004 to 2013; 12 patients were reconstructed with our no-touch-technique from 2010 to 2013 (no-touch-technique group), and 17 patients with the conventional technique from 2004 to 2009 (conventional group). A rectus abdominis musculocutaneous flap or anterolateral thigh flap was transferred in all patients. The rates of perioperative recipient site complications including total flap necrosis, partial flap necrosis, wound infection, fistula formation and wound dehiscence, and reoperation for complications were compared between the groups. Results: All flaps were successfully transferred although one venous thrombosis formation occurred in the conventional group. The rate of wound infection in the no-touch-technique group (8.3%) was significantly lower than that in the conventional group (47.1%) (P 5 0.04). Additionally, the rate of fistula formation in the no-touch-technique group (8.3%) tended to be lower than that in the conventional group (29.4%) (P 5 0.35). Conclusion: The results of our study showed that our no-touch-technique may be a safe and effective procedure for the prevention of perioperative plate-related complications for mandibular reconstruction with an MRP and free flap C 2015 Wiley Periodicals, Inc. Microsurgery 36:115–120, 2016. transfer. V
Mandibular
reconstruction following segmental mandibulectomy is challenging, and free vascularized bone transfer has been the most reliable method used because of its graft viability and lower bone resorption rate.1–3 On the other hand, simple mandibular reconstruction with a mandibular reconstruction plate (MRP) and free flap transfer has been the alternative method of choice for patients with advanced age, poor prognoses, or poor general condition because free vascularized bone transfer is more invasive and the surgery takes longer operating time.4 Although mandibular reconstruction with an MRP and free flap transfer is useful for specific patients, plate-related complications are common, and plate removal is needed in most cases resulting in impaired swallowing function and poorer esthetic outcomes.5 However, an effective reconstructive procedure which minimizes plate-related complications and preserves patient quality of life has not yet been established. Because of high rate of plate-related complications, the reconstructive procedure might need to be abandoned in
1 Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Chiba, Japan 2 Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan 3 Division of Head and Neck Surgery, National Cancer Center Hospital East, Chiba, Japan *Correspondence to: Minoru Sakuraba, M.D., Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan. E-mail: [email protected] Received 30 September 2014; Revision accepted 29 January 2015; Accepted 23 February 2015 Published online 16 March 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22403
Ó 2015 Wiley Periodicals, Inc.
favor of a new procedure to keep the prosthesis clean during the entire operation that can decrease prosthesis infection.6 Therefore, we have attempted the reconstructive procedure during which an MRP is never exposed to saliva because the bacterial count in 1 mL of whole saliva is 107 aerobic micro-organisms plus 5 3 108 anaerobic ones in the oral cavity and many species found in saliva are also found in infections after head and neck surgery.7 In the present study, we evaluate our new reconstructive procedure called the ‘‘no-touchtechnique” which aims to reduce plate-related complications by keeping an MRP not contaminated to saliva during the entire operation. PATIENTS AND METHODS
Twenty-nine consecutive patients who had undergone immediate mandibular reconstruction with MRP and free flap transfer after segmental mandibulectomy for head and neck tumor were included in the present study. The diagnosis was squamous cell carcinoma in 28 patients and ameloblastoma in 1 patient. These patients were treated at the National Cancer Center Hospital from 2004 to 2013. They included 19 males and 10 females with a mean age of 70.2 610.3 years (age range, 42–84 years). The extent of the mandibular defect was classified according to the hemimandible, central, and lateral (HCL) method by Jewer et al.8,9 Mandibular fixation was performed with a titanium reconstruction plate (Stryker– Leibinger, Freiburg, Germany). In addition, a rectus abdominis musculocutaneous flap or anterolateral thigh flap was transferred to reconstruct the oral defect, cover the MRP, and fill the dead space.
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Figure 1. Mandibular reconstruction with the no-touch technique. a: MRP bent preoperatively to adapt to the outline of a threedimensional mandibular model. b: Plate fixation following flap suture and microsurgical vascular anastomosis. c: MRP surrounded with the muscle and fat of the transferred flap.
From 2004 to 2009, 17 patients underwent the mandibular reconstruction with the conventional technique (conventional group), and from 2010 to 2013, 12 patients with the no-touch technique (no-touch-technique group). Surgical Procedures
Preoperatively, a threeNo-touch technique. dimensional (3D) mandibular model was manufactured from computed tomography data, and the MRP was accurately molded to the outline of the 3D mandibular Microsurgery DOI 10.1002/micr
model and the site of each screw hole was planned (Fig. 1a). The pre-bent MRP was sterilized for use during the actual surgery. During surgery, tumor resection and flap harvest were simultaneously performed using a two-team approach, and segmental mandibulectomy was performed by head and neck surgeons according to the preoperative planning. Following the completion of tumor resection, vascular pedicle of the flap was detached, and the skin island of the flap was sutured to the oral defect. The most difficult part of the flap suturing is determination of the flap size while the remaining mandible was unsecured
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transferred flap (Fig. 1c). Surgery was completed by placing the suction drains in place and closing the wound in layers.
Figure 2. Mandibular reconstruction with the conventional technique. Plate fixation prior to suturing of the skin island of the transferred flap and microsurgical vascular anastomosis.
Conventional technique. During conventional surgery, the MRP was bent to adapt to the outline of the native mandible prior to segmental mandibulectomy. After bending was completed, the holes were predrilled to the native mandible in preparation for the securing of the MRP later. Following the completion of tumor resection, the bent MRP was reattached and fixed to the remaining mandible (Fig. 2). Subsequently, the skin island of the flap was sutured to the oral cavity defect with the MRP in place. After the completion of flap suturing to the oral defect, microsurgical vascular anastomosis was performed. The rest of the reconstructive procedure performed was similar to that described above. The perioperative (30 days after surgery) data was extracted from each patient’s medical records, and the rates of recipient site complications and reoperation for complications were compared between the groups for evaluation of outcomes. The recipient site complications included total flap necrosis, partial flap necrosis, wound infection, fistula formation, and wound dehiscence. Statistical analysis was performed between the no-touchtechnique group and the conventional group using Fisher’s exact test and Student’s t test. Differences with a P values of
Objective: Mandibular reconstruction with a mandibular reconstruction plate (MRP) and free flap transfer can involve serious plate-related complications. The aim of our study is to present our new “no-touch-technique” which keeps an MRP not contaminated to saliva during the entire operation for the reduction of plate-related complications. Patients and Methods: Data were retrospectively collected on 29 patients who had undergone segmental mandibulectomy for head and neck tumor and mandibular reconstruction with an MRP and free flap transfer from 2004 to 2013; 12 patients were reconstructed with our no-touch-technique from 2010 to 2013 (no-touch-technique group), and 17 patients with the conventional technique from 2004 to 2009 (conventional group). A rectus abdominis musculocutaneous flap or anterolateral thigh flap was transferred in all patients. The rates of perioperative recipient site complications including total flap necrosis, partial flap necrosis, wound infection, fistula formation and wound dehiscence, and reoperation for complications were compared between the groups. Results: All flaps were successfully transferred although one venous thrombosis formation occurred in the conventional group. The rate of wound infection in the no-touch-technique group (8.3%) was significantly lower than that in the conventional group (47.1%) (P 5 0.04). Additionally, the rate of fistula formation in the no-touch-technique group (8.3%) tended to be lower than that in the conventional group (29.4%) (P 5 0.35). Conclusion: The results of our study showed that our no-touch-technique may be a safe and effective procedure for the prevention of perioperative plate-related complications for mandibular reconstruction with an MRP and free flap C 2015 Wiley Periodicals, Inc. Microsurgery 36:115–120, 2016. transfer. V
Mandibular
reconstruction following segmental mandibulectomy is challenging, and free vascularized bone transfer has been the most reliable method used because of its graft viability and lower bone resorption rate.1–3 On the other hand, simple mandibular reconstruction with a mandibular reconstruction plate (MRP) and free flap transfer has been the alternative method of choice for patients with advanced age, poor prognoses, or poor general condition because free vascularized bone transfer is more invasive and the surgery takes longer operating time.4 Although mandibular reconstruction with an MRP and free flap transfer is useful for specific patients, plate-related complications are common, and plate removal is needed in most cases resulting in impaired swallowing function and poorer esthetic outcomes.5 However, an effective reconstructive procedure which minimizes plate-related complications and preserves patient quality of life has not yet been established. Because of high rate of plate-related complications, the reconstructive procedure might need to be abandoned in
1 Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Chiba, Japan 2 Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan 3 Division of Head and Neck Surgery, National Cancer Center Hospital East, Chiba, Japan *Correspondence to: Minoru Sakuraba, M.D., Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan. E-mail: [email protected] Received 30 September 2014; Revision accepted 29 January 2015; Accepted 23 February 2015 Published online 16 March 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22403
Ó 2015 Wiley Periodicals, Inc.
favor of a new procedure to keep the prosthesis clean during the entire operation that can decrease prosthesis infection.6 Therefore, we have attempted the reconstructive procedure during which an MRP is never exposed to saliva because the bacterial count in 1 mL of whole saliva is 107 aerobic micro-organisms plus 5 3 108 anaerobic ones in the oral cavity and many species found in saliva are also found in infections after head and neck surgery.7 In the present study, we evaluate our new reconstructive procedure called the ‘‘no-touchtechnique” which aims to reduce plate-related complications by keeping an MRP not contaminated to saliva during the entire operation. PATIENTS AND METHODS
Twenty-nine consecutive patients who had undergone immediate mandibular reconstruction with MRP and free flap transfer after segmental mandibulectomy for head and neck tumor were included in the present study. The diagnosis was squamous cell carcinoma in 28 patients and ameloblastoma in 1 patient. These patients were treated at the National Cancer Center Hospital from 2004 to 2013. They included 19 males and 10 females with a mean age of 70.2 610.3 years (age range, 42–84 years). The extent of the mandibular defect was classified according to the hemimandible, central, and lateral (HCL) method by Jewer et al.8,9 Mandibular fixation was performed with a titanium reconstruction plate (Stryker– Leibinger, Freiburg, Germany). In addition, a rectus abdominis musculocutaneous flap or anterolateral thigh flap was transferred to reconstruct the oral defect, cover the MRP, and fill the dead space.
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Fujiki et al.
Figure 1. Mandibular reconstruction with the no-touch technique. a: MRP bent preoperatively to adapt to the outline of a threedimensional mandibular model. b: Plate fixation following flap suture and microsurgical vascular anastomosis. c: MRP surrounded with the muscle and fat of the transferred flap.
From 2004 to 2009, 17 patients underwent the mandibular reconstruction with the conventional technique (conventional group), and from 2010 to 2013, 12 patients with the no-touch technique (no-touch-technique group). Surgical Procedures
Preoperatively, a threeNo-touch technique. dimensional (3D) mandibular model was manufactured from computed tomography data, and the MRP was accurately molded to the outline of the 3D mandibular Microsurgery DOI 10.1002/micr
model and the site of each screw hole was planned (Fig. 1a). The pre-bent MRP was sterilized for use during the actual surgery. During surgery, tumor resection and flap harvest were simultaneously performed using a two-team approach, and segmental mandibulectomy was performed by head and neck surgeons according to the preoperative planning. Following the completion of tumor resection, vascular pedicle of the flap was detached, and the skin island of the flap was sutured to the oral defect. The most difficult part of the flap suturing is determination of the flap size while the remaining mandible was unsecured
No-Touch Mandibular Surgery
117
transferred flap (Fig. 1c). Surgery was completed by placing the suction drains in place and closing the wound in layers.
Figure 2. Mandibular reconstruction with the conventional technique. Plate fixation prior to suturing of the skin island of the transferred flap and microsurgical vascular anastomosis.
Conventional technique. During conventional surgery, the MRP was bent to adapt to the outline of the native mandible prior to segmental mandibulectomy. After bending was completed, the holes were predrilled to the native mandible in preparation for the securing of the MRP later. Following the completion of tumor resection, the bent MRP was reattached and fixed to the remaining mandible (Fig. 2). Subsequently, the skin island of the flap was sutured to the oral cavity defect with the MRP in place. After the completion of flap suturing to the oral defect, microsurgical vascular anastomosis was performed. The rest of the reconstructive procedure performed was similar to that described above. The perioperative (30 days after surgery) data was extracted from each patient’s medical records, and the rates of recipient site complications and reoperation for complications were compared between the groups for evaluation of outcomes. The recipient site complications included total flap necrosis, partial flap necrosis, wound infection, fistula formation, and wound dehiscence. Statistical analysis was performed between the no-touchtechnique group and the conventional group using Fisher’s exact test and Student’s t test. Differences with a P values of
