DUAL FREE FLAP TRANSFER USING FOREARM FLAP FOR MANDIBULAR RECONSTRUCTION Takashi Nakatsuka, MD, Kiyonori Harii, MD, Atsushi Yamada, MD, Kazuki Ueda, MD, and Satoshi Ebihara, MD
To reconstruct a composite mandibular defect, we have simultaneously transferred a vascularized bone graft or osteocutaneous flap together with a forearm flap. The radial forearm flap, being thin, pliable, and having a long vascular stalk, served as mucosal lining and/or an interpositionalflap acting as a vascular bridge. Between 1982 and 1989, we used this procedure in 17 patients with a mandibular defect or deformity which developed following treatment of oral cancer. Our clinical experience has demonstrated that this dual free tissue transfer has many advantages. It is useful for obtaining a good alveolar ridge in patients with a composite mandibular defect. It is applicable in cases where only a single pair of recipient vessels are present and may be useful when the recipient vessels are positioned some distance from the defect. HEAD & NECK 1992;14:452-458 0 1992 John Wiley & Sons, Inc.
T h e introduction of free flap transfer by means of microvascular technique has brought remarkable progress in reconstruction following removal of cancer in the head and neck However, the mandibular defect which remains
Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology (Dr. Nakatsuka); Division of Head and Neck Surgery, Department of Surgical Oncology (Dr. Ebihara), National Cancer Center Hospital, Tokyo, Japan; and Department of Plastic and Reconstructive Surgery (Drs. Harii, Yarnada, and Ueda), Faculty of Medicine, University of Tokyo, Tokyo, Japan. Address reprint requests to Dr. Nakatsuka at the Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan 104. Accepted for publication May 26, 1992. CCC 0148-6403/92/060452-07 0 1992 John Wiley & Sons, Inc.
452
Dual Free Flap Transfer
after surgical resection of a tumor or osteoradionecrotic bone results in functional morbidity. Difficulty with mastication, swallowing, and phonation, as well as cosmetic disfigurement, often result. Therefore, mandibular reconstruction presents the reconstructive surgeon with multiple challenges. The radial forearm flap is a thin and pliable flap which has proved useful for reconstruction of the intraoral lining.5 It is particularly useful for obtaining a good alveolar ridge. This flap has a long vascular stalk of large caliber which contributes t o its wide applicability.6 We therefore devised a simultaneous transfer of a forearm flap and a vascularized bone graft or an osteocutaneous flap to reconstruct a composite mandibular defect. The forearm flap provided mucosal lining, while the vascularized bone graft or osteocutaneous flap filled the bony defect and provided facial skin cover. When two pairs of recipient vessels (artery and vein) were present, the nutrient vessels of each flap were anastomosed to each pair of recipient vessels. When only one pair of recipient vessels was available, the two flaps were simultaneously transferred by anastomosing the nutrient vessels of the second flap to the distal ends of the nutrient vessels of the first flap. An interpositional flap, such as this forearm flap, is called a “bridge flap,’’ Thus, there “chain flap,” or “chain-link are two types of dual tissue transfer: the bridging type (Figure l a ) and the nonbridging type (Figure lb).
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NovernbedDecember 1992
forearm flap
cephalic vein /
\tnutrient
T
radial artery 81 vein
vascularized bone graft
forearm
cephalic vein
I
i' ~
. -..
I
-- --
t
f
-
radial artery 81 vein
t o recipient
vessels
vascularized bone graft
FIGURE 1. A schema of dual tissue transfer. (Top) Bridging type: The forearm flap (bridge flap) serves as an interpositional flap for vascular linkage between the recipient vessels and the distal flap. (Bottom) Nonbridging type.
iac bone graft with a forearm flap. In 10 cases, the two flaps were transferred and anastomosed to a solitary vascular source (bridging type). All but one of the forearm flaps were used for mucosal lining. In the one case, mentioned above, the forearm flap was used for facial skin cover and as a vascular conduit to the vascularized iliac bone graft. The reason for this was that there were no available recipient vessels near the defect. The average size of the skin paddle was 8 x 6 cm for a forearm flap, 13 x 10 cm for an iliac osteocutaneous flap, and 16 X 8 cm for a scapular osteocutaneous flap. Mandibular bony defect lengths ranged from 5 to 13 cm with an average of 10 cm. The types of bony defects, according to Jewer's classification," and the accompanying soft tissue defects are listed in Table 2. Eight cases underwent subtotal mandibulectomy (indicated as L + C + L or H + C + L in Table 2) and 16 of 17 cases had mucosal defects. Glossectomy was simultaneously performed in six cases (subtotal glosectomy, 2; partial glossectomy, 4). Besides these cases, two cases already had undergone subtotal glossectomy and another two had a partial glossectomy performed in a previous surgery. The superior thyroid artery and the external jugular vein were the most commonly used recipient vessels for both nonbriding and bridging anastomoses (Table 3).
MATERIALS AND METHODS
Between 1982 and 1989, this procedure was employed in 17 patients at the National Cancer Center and the University of Tokyo Hospital. Patient profiles and overall results are summarized in Table 1. There were 14 men and three women ranging in age from 30 to 70 years (mean, 55 years). Eleven patients underwent immediate reconstruction after removal of the cancer in the oral cavity. Four patients had mandibular deformities after the initial surgery. One of them underwent subtotal mandibulectomy after resection of the cancer in the floor of the mouth, and bony reconstruction was carried out with a vascularized scapular bone and a hydroxyappatite block. Two patients presented with osteoradionecrosis as a consequence of irradiation therapy for treatment of a tongue cancer. We used a vascularized iliac bone or scapular bone t o reconstruct mandibular bony defects. The most common combination was that of an il-
Dual Free Flap Transfer
RESULTS
Seven of the 17 patients (41%) had complications. Local skin necrosis was seen in three cases, and total flap necrosis, partial flap necrosis, fistula formation, and abscess formation were observed in one case each. Total flap necrosis occurred in the vascularized iliac bone graft, and repair was achieved with a pedicled transfer of a pectoralis major musculocutaneous flap. This case was excluded from the following functional assessments. Partial flap necrosis was observed in the skin portion of an iliac osteocutaneous flap, leading to a fistula which was repaired with a deltopectoral flap. Two of three patients with local skin necrosis had undergone preoperative radiotherapy of more than 60 Gy. A fistula and an abscess occurred secondary to infection of the fixation plates but these resolved after plate removal. All but two patients could manage a soft oral diet after the operation. Of the two patients men-
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Table 1. Patient summary. Reconstruction
Diaanosis
Patient
Preoperative radiotherapy (Gy)
Size (cm) Flaps
Skin
Complication
Per 0s intake (POD)
Infection Local skin necrosis Total flap necrosis Local skin necrosis
21
(-1
Not possible
Bone
~~
1 56 M 2 54 M 3 55 M 4 47 M 5 30 M 6 57 M 7 36 M 8 61 F
9 57 F
10 47 M 11 67 M 12 55 M 13 53 M 14 70 M
15 65 F 16 57 M 17 63 M
SCC Floor of mouth SCC Lower gingiva SCC Floor of mouth SCC Lower gingiva SCC Lower gingiva SCC Lower gingiva Mandibular deformity Osteoradionecrosis Mandibular deformity SCC Lower gingiva SCC Floor of mouth Mandibular deformity SCC Buccal mucosa Mandibular deformity
SCC Tongue SCC Buccal mucosa Osteoradionecrosis
(-1
FF 12 x 6 VIB 90 FFt 12 x 8 VIB 30 FFt 6x 5 VIB (-) FF 7 x 5 IOC 12 x 10 FF 10 x 8 22 IOC 10 x 10 (-) FF 6 x 6 VI B 30 FFt 7x 6 VIE >loo FFt 7x 6 VIB >loo FFt 10 x 7 VIE (-1 FF 10 x 6 VIB 50 FFt 8 x 6 IOC 16 x 9 92 FFt 7x 5 VIB (-1 FFt 8 x 7 SOC 20 x 9 (+I FFt 8x 6 Dose: unknown SOC 20 x 7 (+ Hydroxyappatite: 6 cm) >60 FFt 8 x 6 SOC 15x7 (-) FF 10 x 9 SOC 13 x 12 FF 7 x 7 >60 SOC 13x 7
6 12
-
9
25 13 29
10 Fistula formation
56
12
17 12
Local skin necrosis
45
7 10 10 Fistula formation
63
11 33 13
Not possible
Infection 12
17 10 15 11 Local skin necrosis
24
7
16 5 26 12
SCC. squamous cell carcinoma, FF, forearm flap, VIB, vasculanzed iliac bone graft, IOC, iliac osteocutaneous flap, SOC, scapular osteocutaneous flap *Per os intake number indicates hrst postoperative day (POD) oral intake of diet began fForearm flap was used as a bridge flap
tioned above, one had a subtotal glossectomy with subtotal mandibulectomy and the other already had a subtotal glossectomy with reconstruction using an inferior rectus abdominis musculocutaneous flap. Patients began oral intake an average of 21 days postoperatively in cases where complications did not develop ( N = 9) and 42 days in cases where complications occurred ( N = 5). Five patients regained intelligible speech, but the remaining patients could be understood if the listener concentrated. Patients who had undergone glossectomy had poor speech results.
454
Dual Free Flap Transfer
CLINICAL CASES Case I (patient 5 in Table 1, Figure 2). A 30-year-old man was referred for treatment of squamous cell carcinoma of the lower gingiva which had invaded facial skin (T4NO). After irradiation of 22 Gy, tumor ablation included segmental resection of the mandible and resection of the facial skin with right upper neck dissection. Immediate reconstruction of this extensive full-thickness defect was achieved with a forearm flap and a n iliac osteocutaneous flap. The former was anastomosed to the lingual artery and vein, and the latter to the facial artery and
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November/December 1992
A
B
C D E FIGURE 2. Case 1 (patient 5): A 30-year-old man with carcinoma of the lower gingiva (T4NO). (A) Preoperative view. The tumor invaded the facial skin. (B)lntraoperativeview demonstrating the through-and-throughdefect. (C) X-ray 3 years after operation. (D)Frontal view 4 years after operation. (E) lntraoral view with dentures in place.
external jugular vein. The patient had an uncomplicated postoperative course, and the intermaxillary fixation was removed 28 days after surgery. The patient remains free of disease 6 years after reconstruction and can take an almost normal diet with the aid of his dentures.
A 63-year-old man had undergone radiotherapy of more than 60 Gy for treatment of a tongue cancer at an-
Case 2 (patient 17 in Table 1, Figure 3).
Dual Free Flap Transfer
other hospital 4 years previously. He was referred with exposed necrotic bone in the oral cavity, radiologic signs of osteoradionecrosis in the left side of the mandible, and draining sinuses in the left cheek. A mandibulectomy was performed from the right lateral incisor to the left ramus, leaving the condyle intact. A 7 x 7 cm forearm flap and a scapular osteocutaneous flap with a 13 X 7 cm skin paddle and a 12 x 3 cm bone segment were transferred. The facial artery and the external
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C
A
D
E
F
FIGURE 3. Case 2 (patient 17): A 63-year-old man with osteoradionecrosis. (A) Preoperative x-ray showing osteomyelitis in right mandibular body. (B)Preoperative lateral view. Abscess formation was observed in the left cheek. (C) Intraoperative view. (D) Complete isolation of the scapular osteocutaneous flap. One osteotomy was performed to conform to the defect. (E, F) Frontal and lateral view 2 years after operation.
jugular vein were used for revascularization of the forearm flap and the lingual artery and the facial vein for the scapular flap. The patient had an uneventful postoperative course, and the intermaxillary fixation was removed 26 days after surgery. He could accept a normal diet, and good contour was obtained. He remains free of diseaes 2 years after surgery.
456
Dual Free Flap Transfer
DISCUSSION
Free flap transfers have gained popularity for reconstruction of defects that result from removal of cancers in the head and neck region.lP6 The use of a vascularized bone graft or an osteocutaneous flap, such as the iliac osteocutaneous the fibular osteocutaneous flap," and the scapular osteocutaneous flap,13 adds a very useful weapon to the surgeons armamentarium
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Table 2. Summary of bone and soft tissue defects
No. of patients
Defect Bone*
L L+C L+C+L H H+C+L Soft tissue Mucosa only Skin only Mucosa and skin
7 1 9
‘Defect s/ze accordmg to Jewer’s c/ass/hcat/on L, lateral segment excludmg condyle, C, enbre central segment /nclud/ng both lower canmes, H, lateral segment mcludmg condyle
when facing the challenge of mandibular reconstruction. Ablative surgery for advanced oral cancers results in extensive composite tissue defects. The defects frequently include oral mucosa, facial skin, and mandibular bone, and reconstruction inevitably requires one or more flaps. We consider the autogenous vascularized bone graft as a first choice for mandibular reconstruction14and have preferably used the iliac osteocutaneous flap.15 The skin paddle of this flap, however, has an unreliable blood supply, is bulky, especially in the obese patient, making it unsuitable for intraoral lining. We therefore began using the thin and pliable forearm flap for mucosal coverage, combining this with the vascularized iliac bone graft for reconstruction of the bony defect. Presently, we prefer to use a scapular osteocutaneous flap rather than an iliac osteocutaneous flap because of its numerous advantages. It has an extensive, reliable vascular supply to the ~~
Table 3. Recbient vessels used for apastomoses Nonbridging type Bridging type (N = 10) (N = 7) Artery Superior thyroid artery Lingual artery Facial artery Superficial cervical artery Others Vein External jugular vein Facial vein Lingual vein Others
Dual Free Flap Transfer
6 4 3
1 0 9 2 2
I
5 2 1 0 2 6 2 1 1
skin, a larger less bulky skin paddle, better color match, and less postoperative morbidity.16 The fibular osteocutaneous flap is another choice, but the blood supply to the skin paddle is not reliable and, postoperatively, immobilization is required for about a week,12717thus delaying recovery in older patients. In addition to suitability for the oral lining, the forearm flap has a long vascular pedicle of large caliber and is nourished by several septocutaneous perforators arising from the radial artery. This structure enables this flap to serve as an interpositional flap for vascular linkage to the second flap. Thus, one pair of recipient vessels is sufficient to transfer two free flaps simultaneously. Although there have been scattered reports on such “bridging” free flap transfers7-’ our series is the first collection involving mandibular reconstruction. We believe this procedure can expand the applicability in head and neck reconstruction because available recipient vessels are often limited after neck dissection or after previous treatment. The rate of complications in our series was not low (41%),but most of them were related to preoperative irradiation or infection of the fixation plates. Although the risk of flap necrosis may be higher in bridging free flap transfers because of double microanastomosis, flap necrosis occurred in only one vascularized iliac bone graft, and there was no loss of the forearm flap. Of the 10 bridging-type transfers, the cephalic vein was used for venous drainage in five cases and the radial vena commitantes in three cases. In the remaining two cases (patients 11 and 13), the venous drainage between the first and second bridging flaps differed from that between the first flap and the recipient vessels (eg, cephalic vein between the flaps but vena commitantes between the first flap and the recipient vessels; Figure 4). This arrangement was successful. Functional results of mandibular reconstruction are related to the extent of the resection. Although 10 patients in our series underwent resection of the tongue, four patients underwent subtotal glossectomy and eight cases underwent subtotal, mandibulectomy, most (14 of 16, 88%) could take a soft or regular diet perorally, and five patients regained intelligible speech. The bulkiness of the iliac osteocutaneous flap transferred to the oral cavity prevents normal function of the tongue remnants, leading to difficulties in swallowing and phonation. It fre-
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forearm flap
cephalic vein
-
recipient vein
recipient artery
nutrient vessels cephalic vein
forearm flap
recipient vessels
FIGURE 4. The different venous channels in the forearm flap can be used as drainage passages from the distal flap to the recipient vein.
quently obstructs placement of dentures. In contrast, the present procedure using a radial forearm flap provides a thin mucosal lining, facilitating installation of dentures and intelligible speech. Nine patients had lost all mandibular teeth, and only a few patients had sufficient teeth remaining for placing of dentures. The use of osteointegrated implants can be a solution for precise fitting and functional use of a dental prosthesis18 when combined with this procedure. Since this procedure is complicated and timeconsuming, the indications include cases with too large a soft tissue defect to be covered by a single flap and those patients with recipient vessels located some distance from the defect. In conclusion, this reconstructive method, using a forearm flap with a vascularized bone graft or an osteocutaneous flap, has numerous advantages. Internal and external soft tissue coverage, as well as mandibular bony reconstruction, are achieved in one stage. An alveolar ridge of good shape can be obtained. Only one pair of recipient vessels is required for simultaneous transfer of two flaps. Dual free tissue transfer provides a very versatile procedure for composite mandibular reconstruction.
REFERENCES
1. Zuker RM, Manktelow RT, Palmer JA, et al: Head and neck reconstruction following resection of carcinoma, using microvascular free flaps. Surgery 1980;88:461-466. 2. Harii K. The free flap in head and neck reconstruction. In: Fee WE Jr, et al., eds. Head and neck cancer. Philadelphia: B.C. Decker, 1990:33-35. 3. Cohen SR, Baker DC, Shaw WW. Microvascular flap reconstruction of the head and neck: an overview. Clin Plast Surg 1983;10:73-83.
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Dual Free Flap Transfer
4. Hardesty RA, Jones NF, Swartz WM, et al. Microsurgery for macro defects: microvascular free-tissue transfer for massive defects of the head and neck. Am J Surg 1987;154:399-405. 5. Soutar DS, Scheker LR, Tanner NSB, et al. The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 1983;36:1-8. 6. Harii K, Ebihara S, On0 I, et al. Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 1985;75:463-474. 7. Hallock GG. Simultaneous transposition of anterior thigh muscle and fascia flap: a n introduction to the chimera flap principle. Ann Plast Surg 1991;27:126-131. 8. Chen HC, Tang YB, Noordhoff MS. Reconstruction of the entire esophagus with “chain flaps” in a patient with severe corrosive injury. Plast Reconstr Surg 1989;84:980984. 9. Hung LK, Chen SZ, Leung PC. Resurfacing difficult wounds: selective use of the posterior tibia1 flap. J Reconstr Microsurg 1990;6:13- 19. 10. Jewer DD, Boyd JB, Manketelow RT, et al. Orofacial and mandibular reconstruction with the iliac crest free flap: a review of 60 cases and a new method of classification. Plast Reconstr Surg 1989;84:391-403. 11. Taylor GI. Reconstruction of the mandible with free composite iliac bone grafts. Ann Plast Surg 1982;9: 361-376. 12. Hidalgo DA. Fibular free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84:71- 79. 13. Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77:530-545. 14. Nakatsuka T, Harii K, Yamada A, et al. A clinical evaluation of reconstructive procedure for a mandibular defect. J Jpn Plast Reconstr Surg 1991;11:283-298. 15. Harii K, Yamada A, Nakatsuka T, et al. Reconstruction of the mandible with a vascularized iliac bone or osteocutaneous flap. J Jpn Plast Reconstr Surg 1991;34:47-58. 16. Nakatsuka T, Harii K, Ebihara S, et al. Mandibular reconstruction using a free scapular osteocutaneous flap. J Jpn Plast Reconstr Surg 1991;34:35-45. 17. Wei FC, Chen HC, Chuang CC, et al. Fibular osteocutaneous flap: anatomic study and clinical application. Plast Reconstr Surg 1986;78:191- 199. 18. Riediger D. Restoration of masticatory function by microsurgically revascularized iliac crest bone grafts using enosseous implants. Plast Reconstr Surg 1988;81:861876.
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To reconstruct a composite mandibular defect, we have simultaneously transferred a vascularized bone graft or osteocutaneous flap together with a forearm flap. The radial forearm flap, being thin, pliable, and having a long vascular stalk, served as mucosal lining and/or an interpositionalflap acting as a vascular bridge. Between 1982 and 1989, we used this procedure in 17 patients with a mandibular defect or deformity which developed following treatment of oral cancer. Our clinical experience has demonstrated that this dual free tissue transfer has many advantages. It is useful for obtaining a good alveolar ridge in patients with a composite mandibular defect. It is applicable in cases where only a single pair of recipient vessels are present and may be useful when the recipient vessels are positioned some distance from the defect. HEAD & NECK 1992;14:452-458 0 1992 John Wiley & Sons, Inc.
T h e introduction of free flap transfer by means of microvascular technique has brought remarkable progress in reconstruction following removal of cancer in the head and neck However, the mandibular defect which remains
Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology (Dr. Nakatsuka); Division of Head and Neck Surgery, Department of Surgical Oncology (Dr. Ebihara), National Cancer Center Hospital, Tokyo, Japan; and Department of Plastic and Reconstructive Surgery (Drs. Harii, Yarnada, and Ueda), Faculty of Medicine, University of Tokyo, Tokyo, Japan. Address reprint requests to Dr. Nakatsuka at the Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan 104. Accepted for publication May 26, 1992. CCC 0148-6403/92/060452-07 0 1992 John Wiley & Sons, Inc.
452
Dual Free Flap Transfer
after surgical resection of a tumor or osteoradionecrotic bone results in functional morbidity. Difficulty with mastication, swallowing, and phonation, as well as cosmetic disfigurement, often result. Therefore, mandibular reconstruction presents the reconstructive surgeon with multiple challenges. The radial forearm flap is a thin and pliable flap which has proved useful for reconstruction of the intraoral lining.5 It is particularly useful for obtaining a good alveolar ridge. This flap has a long vascular stalk of large caliber which contributes t o its wide applicability.6 We therefore devised a simultaneous transfer of a forearm flap and a vascularized bone graft or an osteocutaneous flap to reconstruct a composite mandibular defect. The forearm flap provided mucosal lining, while the vascularized bone graft or osteocutaneous flap filled the bony defect and provided facial skin cover. When two pairs of recipient vessels (artery and vein) were present, the nutrient vessels of each flap were anastomosed to each pair of recipient vessels. When only one pair of recipient vessels was available, the two flaps were simultaneously transferred by anastomosing the nutrient vessels of the second flap to the distal ends of the nutrient vessels of the first flap. An interpositional flap, such as this forearm flap, is called a “bridge flap,’’ Thus, there “chain flap,” or “chain-link are two types of dual tissue transfer: the bridging type (Figure l a ) and the nonbridging type (Figure lb).
HEAD & NECK
NovernbedDecember 1992
forearm flap
cephalic vein /
\tnutrient
T
radial artery 81 vein
vascularized bone graft
forearm
cephalic vein
I
i' ~
. -..
I
-- --
t
f
-
radial artery 81 vein
t o recipient
vessels
vascularized bone graft
FIGURE 1. A schema of dual tissue transfer. (Top) Bridging type: The forearm flap (bridge flap) serves as an interpositional flap for vascular linkage between the recipient vessels and the distal flap. (Bottom) Nonbridging type.
iac bone graft with a forearm flap. In 10 cases, the two flaps were transferred and anastomosed to a solitary vascular source (bridging type). All but one of the forearm flaps were used for mucosal lining. In the one case, mentioned above, the forearm flap was used for facial skin cover and as a vascular conduit to the vascularized iliac bone graft. The reason for this was that there were no available recipient vessels near the defect. The average size of the skin paddle was 8 x 6 cm for a forearm flap, 13 x 10 cm for an iliac osteocutaneous flap, and 16 X 8 cm for a scapular osteocutaneous flap. Mandibular bony defect lengths ranged from 5 to 13 cm with an average of 10 cm. The types of bony defects, according to Jewer's classification," and the accompanying soft tissue defects are listed in Table 2. Eight cases underwent subtotal mandibulectomy (indicated as L + C + L or H + C + L in Table 2) and 16 of 17 cases had mucosal defects. Glossectomy was simultaneously performed in six cases (subtotal glosectomy, 2; partial glossectomy, 4). Besides these cases, two cases already had undergone subtotal glossectomy and another two had a partial glossectomy performed in a previous surgery. The superior thyroid artery and the external jugular vein were the most commonly used recipient vessels for both nonbriding and bridging anastomoses (Table 3).
MATERIALS AND METHODS
Between 1982 and 1989, this procedure was employed in 17 patients at the National Cancer Center and the University of Tokyo Hospital. Patient profiles and overall results are summarized in Table 1. There were 14 men and three women ranging in age from 30 to 70 years (mean, 55 years). Eleven patients underwent immediate reconstruction after removal of the cancer in the oral cavity. Four patients had mandibular deformities after the initial surgery. One of them underwent subtotal mandibulectomy after resection of the cancer in the floor of the mouth, and bony reconstruction was carried out with a vascularized scapular bone and a hydroxyappatite block. Two patients presented with osteoradionecrosis as a consequence of irradiation therapy for treatment of a tongue cancer. We used a vascularized iliac bone or scapular bone t o reconstruct mandibular bony defects. The most common combination was that of an il-
Dual Free Flap Transfer
RESULTS
Seven of the 17 patients (41%) had complications. Local skin necrosis was seen in three cases, and total flap necrosis, partial flap necrosis, fistula formation, and abscess formation were observed in one case each. Total flap necrosis occurred in the vascularized iliac bone graft, and repair was achieved with a pedicled transfer of a pectoralis major musculocutaneous flap. This case was excluded from the following functional assessments. Partial flap necrosis was observed in the skin portion of an iliac osteocutaneous flap, leading to a fistula which was repaired with a deltopectoral flap. Two of three patients with local skin necrosis had undergone preoperative radiotherapy of more than 60 Gy. A fistula and an abscess occurred secondary to infection of the fixation plates but these resolved after plate removal. All but two patients could manage a soft oral diet after the operation. Of the two patients men-
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Table 1. Patient summary. Reconstruction
Diaanosis
Patient
Preoperative radiotherapy (Gy)
Size (cm) Flaps
Skin
Complication
Per 0s intake (POD)
Infection Local skin necrosis Total flap necrosis Local skin necrosis
21
(-1
Not possible
Bone
~~
1 56 M 2 54 M 3 55 M 4 47 M 5 30 M 6 57 M 7 36 M 8 61 F
9 57 F
10 47 M 11 67 M 12 55 M 13 53 M 14 70 M
15 65 F 16 57 M 17 63 M
SCC Floor of mouth SCC Lower gingiva SCC Floor of mouth SCC Lower gingiva SCC Lower gingiva SCC Lower gingiva Mandibular deformity Osteoradionecrosis Mandibular deformity SCC Lower gingiva SCC Floor of mouth Mandibular deformity SCC Buccal mucosa Mandibular deformity
SCC Tongue SCC Buccal mucosa Osteoradionecrosis
(-1
FF 12 x 6 VIB 90 FFt 12 x 8 VIB 30 FFt 6x 5 VIB (-) FF 7 x 5 IOC 12 x 10 FF 10 x 8 22 IOC 10 x 10 (-) FF 6 x 6 VI B 30 FFt 7x 6 VIE >loo FFt 7x 6 VIB >loo FFt 10 x 7 VIE (-1 FF 10 x 6 VIB 50 FFt 8 x 6 IOC 16 x 9 92 FFt 7x 5 VIB (-1 FFt 8 x 7 SOC 20 x 9 (+I FFt 8x 6 Dose: unknown SOC 20 x 7 (+ Hydroxyappatite: 6 cm) >60 FFt 8 x 6 SOC 15x7 (-) FF 10 x 9 SOC 13 x 12 FF 7 x 7 >60 SOC 13x 7
6 12
-
9
25 13 29
10 Fistula formation
56
12
17 12
Local skin necrosis
45
7 10 10 Fistula formation
63
11 33 13
Not possible
Infection 12
17 10 15 11 Local skin necrosis
24
7
16 5 26 12
SCC. squamous cell carcinoma, FF, forearm flap, VIB, vasculanzed iliac bone graft, IOC, iliac osteocutaneous flap, SOC, scapular osteocutaneous flap *Per os intake number indicates hrst postoperative day (POD) oral intake of diet began fForearm flap was used as a bridge flap
tioned above, one had a subtotal glossectomy with subtotal mandibulectomy and the other already had a subtotal glossectomy with reconstruction using an inferior rectus abdominis musculocutaneous flap. Patients began oral intake an average of 21 days postoperatively in cases where complications did not develop ( N = 9) and 42 days in cases where complications occurred ( N = 5). Five patients regained intelligible speech, but the remaining patients could be understood if the listener concentrated. Patients who had undergone glossectomy had poor speech results.
454
Dual Free Flap Transfer
CLINICAL CASES Case I (patient 5 in Table 1, Figure 2). A 30-year-old man was referred for treatment of squamous cell carcinoma of the lower gingiva which had invaded facial skin (T4NO). After irradiation of 22 Gy, tumor ablation included segmental resection of the mandible and resection of the facial skin with right upper neck dissection. Immediate reconstruction of this extensive full-thickness defect was achieved with a forearm flap and a n iliac osteocutaneous flap. The former was anastomosed to the lingual artery and vein, and the latter to the facial artery and
HEAD & NECK
November/December 1992
A
B
C D E FIGURE 2. Case 1 (patient 5): A 30-year-old man with carcinoma of the lower gingiva (T4NO). (A) Preoperative view. The tumor invaded the facial skin. (B)lntraoperativeview demonstrating the through-and-throughdefect. (C) X-ray 3 years after operation. (D)Frontal view 4 years after operation. (E) lntraoral view with dentures in place.
external jugular vein. The patient had an uncomplicated postoperative course, and the intermaxillary fixation was removed 28 days after surgery. The patient remains free of disease 6 years after reconstruction and can take an almost normal diet with the aid of his dentures.
A 63-year-old man had undergone radiotherapy of more than 60 Gy for treatment of a tongue cancer at an-
Case 2 (patient 17 in Table 1, Figure 3).
Dual Free Flap Transfer
other hospital 4 years previously. He was referred with exposed necrotic bone in the oral cavity, radiologic signs of osteoradionecrosis in the left side of the mandible, and draining sinuses in the left cheek. A mandibulectomy was performed from the right lateral incisor to the left ramus, leaving the condyle intact. A 7 x 7 cm forearm flap and a scapular osteocutaneous flap with a 13 X 7 cm skin paddle and a 12 x 3 cm bone segment were transferred. The facial artery and the external
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455
C
A
D
E
F
FIGURE 3. Case 2 (patient 17): A 63-year-old man with osteoradionecrosis. (A) Preoperative x-ray showing osteomyelitis in right mandibular body. (B)Preoperative lateral view. Abscess formation was observed in the left cheek. (C) Intraoperative view. (D) Complete isolation of the scapular osteocutaneous flap. One osteotomy was performed to conform to the defect. (E, F) Frontal and lateral view 2 years after operation.
jugular vein were used for revascularization of the forearm flap and the lingual artery and the facial vein for the scapular flap. The patient had an uneventful postoperative course, and the intermaxillary fixation was removed 26 days after surgery. He could accept a normal diet, and good contour was obtained. He remains free of diseaes 2 years after surgery.
456
Dual Free Flap Transfer
DISCUSSION
Free flap transfers have gained popularity for reconstruction of defects that result from removal of cancers in the head and neck region.lP6 The use of a vascularized bone graft or an osteocutaneous flap, such as the iliac osteocutaneous the fibular osteocutaneous flap," and the scapular osteocutaneous flap,13 adds a very useful weapon to the surgeons armamentarium
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Table 2. Summary of bone and soft tissue defects
No. of patients
Defect Bone*
L L+C L+C+L H H+C+L Soft tissue Mucosa only Skin only Mucosa and skin
7 1 9
‘Defect s/ze accordmg to Jewer’s c/ass/hcat/on L, lateral segment excludmg condyle, C, enbre central segment /nclud/ng both lower canmes, H, lateral segment mcludmg condyle
when facing the challenge of mandibular reconstruction. Ablative surgery for advanced oral cancers results in extensive composite tissue defects. The defects frequently include oral mucosa, facial skin, and mandibular bone, and reconstruction inevitably requires one or more flaps. We consider the autogenous vascularized bone graft as a first choice for mandibular reconstruction14and have preferably used the iliac osteocutaneous flap.15 The skin paddle of this flap, however, has an unreliable blood supply, is bulky, especially in the obese patient, making it unsuitable for intraoral lining. We therefore began using the thin and pliable forearm flap for mucosal coverage, combining this with the vascularized iliac bone graft for reconstruction of the bony defect. Presently, we prefer to use a scapular osteocutaneous flap rather than an iliac osteocutaneous flap because of its numerous advantages. It has an extensive, reliable vascular supply to the ~~
Table 3. Recbient vessels used for apastomoses Nonbridging type Bridging type (N = 10) (N = 7) Artery Superior thyroid artery Lingual artery Facial artery Superficial cervical artery Others Vein External jugular vein Facial vein Lingual vein Others
Dual Free Flap Transfer
6 4 3
1 0 9 2 2
I
5 2 1 0 2 6 2 1 1
skin, a larger less bulky skin paddle, better color match, and less postoperative morbidity.16 The fibular osteocutaneous flap is another choice, but the blood supply to the skin paddle is not reliable and, postoperatively, immobilization is required for about a week,12717thus delaying recovery in older patients. In addition to suitability for the oral lining, the forearm flap has a long vascular pedicle of large caliber and is nourished by several septocutaneous perforators arising from the radial artery. This structure enables this flap to serve as an interpositional flap for vascular linkage to the second flap. Thus, one pair of recipient vessels is sufficient to transfer two free flaps simultaneously. Although there have been scattered reports on such “bridging” free flap transfers7-’ our series is the first collection involving mandibular reconstruction. We believe this procedure can expand the applicability in head and neck reconstruction because available recipient vessels are often limited after neck dissection or after previous treatment. The rate of complications in our series was not low (41%),but most of them were related to preoperative irradiation or infection of the fixation plates. Although the risk of flap necrosis may be higher in bridging free flap transfers because of double microanastomosis, flap necrosis occurred in only one vascularized iliac bone graft, and there was no loss of the forearm flap. Of the 10 bridging-type transfers, the cephalic vein was used for venous drainage in five cases and the radial vena commitantes in three cases. In the remaining two cases (patients 11 and 13), the venous drainage between the first and second bridging flaps differed from that between the first flap and the recipient vessels (eg, cephalic vein between the flaps but vena commitantes between the first flap and the recipient vessels; Figure 4). This arrangement was successful. Functional results of mandibular reconstruction are related to the extent of the resection. Although 10 patients in our series underwent resection of the tongue, four patients underwent subtotal glossectomy and eight cases underwent subtotal, mandibulectomy, most (14 of 16, 88%) could take a soft or regular diet perorally, and five patients regained intelligible speech. The bulkiness of the iliac osteocutaneous flap transferred to the oral cavity prevents normal function of the tongue remnants, leading to difficulties in swallowing and phonation. It fre-
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forearm flap
cephalic vein
-
recipient vein
recipient artery
nutrient vessels cephalic vein
forearm flap
recipient vessels
FIGURE 4. The different venous channels in the forearm flap can be used as drainage passages from the distal flap to the recipient vein.
quently obstructs placement of dentures. In contrast, the present procedure using a radial forearm flap provides a thin mucosal lining, facilitating installation of dentures and intelligible speech. Nine patients had lost all mandibular teeth, and only a few patients had sufficient teeth remaining for placing of dentures. The use of osteointegrated implants can be a solution for precise fitting and functional use of a dental prosthesis18 when combined with this procedure. Since this procedure is complicated and timeconsuming, the indications include cases with too large a soft tissue defect to be covered by a single flap and those patients with recipient vessels located some distance from the defect. In conclusion, this reconstructive method, using a forearm flap with a vascularized bone graft or an osteocutaneous flap, has numerous advantages. Internal and external soft tissue coverage, as well as mandibular bony reconstruction, are achieved in one stage. An alveolar ridge of good shape can be obtained. Only one pair of recipient vessels is required for simultaneous transfer of two flaps. Dual free tissue transfer provides a very versatile procedure for composite mandibular reconstruction.
REFERENCES
1. Zuker RM, Manktelow RT, Palmer JA, et al: Head and neck reconstruction following resection of carcinoma, using microvascular free flaps. Surgery 1980;88:461-466. 2. Harii K. The free flap in head and neck reconstruction. In: Fee WE Jr, et al., eds. Head and neck cancer. Philadelphia: B.C. Decker, 1990:33-35. 3. Cohen SR, Baker DC, Shaw WW. Microvascular flap reconstruction of the head and neck: an overview. Clin Plast Surg 1983;10:73-83.
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4. Hardesty RA, Jones NF, Swartz WM, et al. Microsurgery for macro defects: microvascular free-tissue transfer for massive defects of the head and neck. Am J Surg 1987;154:399-405. 5. Soutar DS, Scheker LR, Tanner NSB, et al. The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 1983;36:1-8. 6. Harii K, Ebihara S, On0 I, et al. Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 1985;75:463-474. 7. Hallock GG. Simultaneous transposition of anterior thigh muscle and fascia flap: a n introduction to the chimera flap principle. Ann Plast Surg 1991;27:126-131. 8. Chen HC, Tang YB, Noordhoff MS. Reconstruction of the entire esophagus with “chain flaps” in a patient with severe corrosive injury. Plast Reconstr Surg 1989;84:980984. 9. Hung LK, Chen SZ, Leung PC. Resurfacing difficult wounds: selective use of the posterior tibia1 flap. J Reconstr Microsurg 1990;6:13- 19. 10. Jewer DD, Boyd JB, Manketelow RT, et al. Orofacial and mandibular reconstruction with the iliac crest free flap: a review of 60 cases and a new method of classification. Plast Reconstr Surg 1989;84:391-403. 11. Taylor GI. Reconstruction of the mandible with free composite iliac bone grafts. Ann Plast Surg 1982;9: 361-376. 12. Hidalgo DA. Fibular free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84:71- 79. 13. Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77:530-545. 14. Nakatsuka T, Harii K, Yamada A, et al. A clinical evaluation of reconstructive procedure for a mandibular defect. J Jpn Plast Reconstr Surg 1991;11:283-298. 15. Harii K, Yamada A, Nakatsuka T, et al. Reconstruction of the mandible with a vascularized iliac bone or osteocutaneous flap. J Jpn Plast Reconstr Surg 1991;34:47-58. 16. Nakatsuka T, Harii K, Ebihara S, et al. Mandibular reconstruction using a free scapular osteocutaneous flap. J Jpn Plast Reconstr Surg 1991;34:35-45. 17. Wei FC, Chen HC, Chuang CC, et al. Fibular osteocutaneous flap: anatomic study and clinical application. Plast Reconstr Surg 1986;78:191- 199. 18. Riediger D. Restoration of masticatory function by microsurgically revascularized iliac crest bone grafts using enosseous implants. Plast Reconstr Surg 1988;81:861876.
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