Brief Clinical Studies
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
4. Baker TJ, Gordon HL, Stuzin JM. Surgical Rejuvenation of the Face. 2nd ed. St Louis, MO: Mosby, 1996 5. Stuzin JM, Baker TM. Refinements in face lifting: enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg 2000;105:290 6. Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002;110:885 7. Calderon W, Andrades PR, Israel G, et al. SMAS graft of the nasolabial area during deep plane rhytidectomy. Plast Reconstr Surg 2004;114:559–563 8. Baker TJ. Rhytidectomy a look back and a look forward. Ann Plast Surg 2005;55:565–570 9. Gosain AK, Klein M, Sudhakar PV, et al. A volumetric analysis of soft tissue changes in the aging midface using high resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg 2005;115:1143 10. Rohrich RJ, Rios JL, Smith PD. Neck rejuvenation revisited. Plast Reconstr Surg 2006;118:1251–1252 11. Stuzin JM. Restoring facial shape in face lifting: the role of the skeletal support in facial analysis and midface soft tissue repositioning. Plast Reconstr Surg 2007;119:362 12. Owsley JQ, Roberts CL. Some anatomical observations on midface aging and long-term results of surgical treatment. Plast Reconstr Surg 2008;121:258–267 13. Stuzin JM. Face lifting. Plast Reconstr Surg 2008;121:3–7 14. Matarasso A, Elkwood A, Rankin M, et al. National plastic surgery survey: face lift techniques and complications. Plast Reconstr Surg 2000;106:1185–1195 15. Grover R, Jones BM, Waterhouse N. The prevention of haematoma following rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg 2001;54:481 16. Barry MJ, Grover R. Reducing complications in cervicofacial rhytidectomy by tumescent infiltration: a comparative trial evaluating 678 consecutive face lifts. Plast Reconstr Surg 2004;113:398–401 17. Barry MJ, Grover R. Avoiding haematoma in cervicofacial rhytidectomy: a personal 8-year quest. Review of 910 patients. Plast Reconstr Surg 2004;113:381–386 18. Baker DC, Chiu ES. Bedsides treatment of early acute rhytidectomy haematomas. Plast Reconstr Surg 2005;115:2119–2122 19. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of haematoma requiring surgical evacuation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg 2005;116:1973–1983 20. Stuzin JM, Baker TJ. Aging face and neck. In: Mathes SJ, ed. Plastic Surgery, Vol. II, The Head and Neck, Part I. Philadelphia: Saunders Elsevier, 2006:159 21. Mathes SJ, ed. Plastic Surgery, Vol. II, The Head and Neck, Part I. Philadelphia, PA: Elsevier, 2006 22. Barry MJ, Grover R, Hamilton S. The efficacy of surgical drainage in cervicofacial rhytidectomy: a prospective, randomized, controlled trial. Plast Reconstr Surg 2007;120:263 23. Stuzin JM. Face lifting. Plast Reconstr Surg 2008;121:13–18 24. Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology 1992;77:162–184 25. Trope A, Raeder JC. Can postoperative nausea and vomiting be predicted. Tidsskr Nor Laegeforen 2000;120:2423–2426 26. Apfel CC, Roewer N. Risk assessment of postoperative nausea and vomiting. Int Anesthesiol Clin 2003;41:13–32 27. Gan TJ. Risk factors for postoperative nausea and vomiting. Anesth Analg 2006;102:1884–1898 28. Murphy MJ, Hooper VD, Sullivan E, et al. Identification of risk factors for postoperative nausea and vomiting in the perianesthesia adult patient. J Perianesth Nurs 2006;21:377–384 29. Gan TJ, Meyer TA, Apfel CC, et al. Society for ambulatory anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2007;105:1615–1628 30. Habib AS. A comparison of ondansetron with promethazine for treating postoperative nausea and vomiting in patients who received prophylaxis with ondansetron: a retrospective database analysis. Anesth Analg 2007;104:548–551
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31. Apfel CC, Kortilla K, Abdalla M, et al. A factorial trail of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004;350:2441–2451
Fibular Free Flap Reconstruction for the Management of Advanced Bilateral Mandibular Osteoradionecrosis Xiao-Feng Shan, DDS, MD,* Ru-Huang Li, MD,*† Xu-Guang Lu, DDS, MD,* Zhi-Gang Cai, DDS, DMD,* Jie Zhang, DDS, PhD,* Jian-Guo Zhang, DDS* Abstract: Fibular osteoseptocutaneous flap has been widely used for unilateral mandibular reconstruction. However, reports about the effects of fibular osteoseptocutaneous flap for the reconstruction of bilateral mandibular defects are limited. In this study, we used free vascularized fibular flaps to successfully manage bilateral mandibular osteoradionecrosis (ORN) in 5 patients. Functional aspects were evaluated during the reconstruction process. All 5 patients had bilateral refractory ORN of the mandible and underwent radical resection between 2003 and 2011. The reconstruction surgery was performed in 2 stages using 2 free fibular flaps in 3 patients. In the other 2 patients, reconstruction was performed in a single stage using 2 separate flaps prepared from a single fibula. All patients had a healthy mandibular symphysis and meniscus of the temporomandibular joint, and these structures were preserved during the reconstruction. Of the 10 defects involving the mandible sides, 9 were successfully reconstructed. One microvascular composite flap failed because of radiation injury to the arterial endothelium at the recipient site. After the treatments, all patients had good esthetic and functional outcomes. Preoperative clinical features such as trismus and dysphagia were also markedly improved. Our surgical method may be an effective alternative for the clinical management of advanced bilateral mandibular ORN. Key Words: Osteoradionecrosis, bilateral mandibular defects, fibular flap, reconstruction
From the *Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, and †Department of Oral Diseases, Peking University Third Hospital, Beijing, People's Republic of China. Received January 17, 2014. Accepted for publication October 9, 2014. Address correspondence and reprint requests to Zhi-Gang Cai, DDS, DMD, Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, No. 22, S Ave Zhongguancun, Haidian District, Beijing 100081, People's Republic of China; E-mail: [email protected] Xiao-Feng Shan, DDS, MD, and Ru-Huang Li, MD, are co–first authors of this article. Supported by grants from the Beijing Municipal Development Foundation (Z111107058811038 and Z131107002213093) in China. The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001391
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
O
steoradionecrosis (ORN) of the mandible is a complex metabolic and tissue homeostatic deficiency caused by radiotherapy for head-and-neck cancer. Its incidence ranges from 0.8% to 35%.1 According to our current understanding of its pathophysiology, ORN is a radiation-induced fibroatrophy resulting from acute inflammation, free radical damage, and chronic fibroblast activation by a series of growth factors.2 The typical clinical characteristic is an area of exposed necrotic bone, accompanied by varying degrees of pain or anesthesia, intraoral or extraoral fistulae, trismus, drainage, and pathologic fracture.3,4 Conservative treatment modalities for superficial or partial ORN of the mandible include the use of oral antibiotics, aggressive dental maintenance, oral irrigation with fluoride, surgical curettage, hyperbaric oxygen treatment, ultrasound therapy, and a novel treatment with pentoxifylline.2,5–7 Although many protocols for managing ORN of the mandible have been proposed, the indications of radical surgery are not yet clearly defined.3,8–10 Radical surgery is only instituted when conservative methods fail or when severe bone and soft-tissue necrosis prevail. Pathologic fractures or persistent fistulas are strong indications for a radical surgical approach.8,11 Fibular osteoseptocutaneous flap has proven to be the workhorse of unilateral mandibular reconstruction.12,13 However, few cases of bilateral mandibular reconstruction have been reported in the literature.1,14
PATIENTS AND METHODS Between 2003 and 2011, a total of 98 patients with ORN were treated in our department. Of them, 5 patients (1 woman and 4 men) had refractory and bilateral ORN of the mandible and underwent segmental resection and microvascular fibular flap reconstruction (Table 1). All patients had extensive ORN with a large area of exposed necrotic bone and soft tissue, multiple discharging fistulas, severe trismus, and a coexistent pathologic fracture. The patients ranged in age from 28 to 60 years (median, 55 y). The primary cancers were nasopharyngeal carcinoma (3 patients), malignant lymphoma of the tongue (1 patient), and squamous cell carcinoma of the oropharynx (1 patient). One patient had received postoperative radiation therapy, and another had received radiotherapy and chemotherapy. The remaining 3 patients had received only radiotherapy. The total radiation dose ranged from 5000 cGy to 8000 cGy (median, 6600 cGy). The dose rate varied from 150 cGy/d to 200 cGy/d. The interval between radiotherapy and the onset of ORN varied from 36 months to 108 months (median, 72 mo). All patients had been previously treated with conservative methods, including local wound debridement, intense irrigation and rinsing with an antiseptic solution (digluconate chlorhexidine, 0.12%), systemic antimicrobial therapy, and selective removal of small bone sequestra when present. Two patients had also undergone hyperbaric oxygen therapy. In all patients, the wound failed to respond to these treatments and underwent progressive deterioration. The interval between the onset of ORN and surgical intervention for mandibular reconstruction varied from 42 months to 120 months
Brief Clinical Studies
(median, 81 mo). The decision regarding the extent of mandibular resection was based on clinical findings, along with the results of panoramic radiography or computed tomographic evaluations of the mandible. Radical resection was performed so as to include the entire necrotic segment of the mandible and soft tissues. In 3 patients, reconstruction was carried out in 2 stages, with 2 fibular osteoseptocutaneous free flaps harvested from both legs at an interval of 6 months (Fig. 1). In the other 2 patients, bilateral mandibular defects were reconstructed in a single stage, with 2 separate fibular free flaps being prepared from a single fibula (Fig. 2) through transection of the fibula and vascular pedicle (Fig. 3). Vascular anastomosis for both flaps was performed simultaneously. In all patients, a preventive tracheotomy was performed, and the flap was divided when the preparation of the recipient bed was completed.
RESULTS Despite the long operative time (5–8 h), all operations were performed successfully. The immediate postoperative period was uneventful. After the mandibular resection, 4 patients were left with bilateral mandibular body and unilateral ramus defects, whereas 1 patient was left with bilateral mandibular body and ramus defects. All patients had a healthy mandibular symphysis, and the meniscus of the temporomandibular joint was preserved. The 10 defects involving the mandible sides in the 5 patients were reconstructed with 10 fibular flaps harvested from 8 legs. Nine of these 10 mandibular reconstructions were successful in reestablishing mandibular continuity. There was only 1 microvascular composite flap failure, which resulted from a radiation injury to the arterial endothelium at the recipient site. On postoperative day 5, this patient developed late microvascular thrombosis and lost 1 fibular flap; the failed flap was substituted with a reconstruction plate. Delayed wound healing was observed in all patients. The wound healing time ranged from 1 month to 1 year. In all patients, wound healing was ultimately achieved using meticulous local wound care and topical drugs. Early postoperative ambulation was encouraged, and no serious donor-site morbidity was observed in the hospital. The patients were followed up for 2 months to 90 months (median, 49 mo). All patients had satisfactory cosmetic outcomes, intelligible speech, as well as improved mouth opening and oral intake of at least soft foods.
DISCUSSION Although free tissue transfer has become the established surgical treatment for advanced ORN, factors complicating the outcomes of reconstruction procedures remain elusive. Complication rates ranging from 24% to 44% have been reported. The rate of flap loss in ORN reconstructions is even higher than the rate of loss of ablative head-and-neck free flap reconstructions.15–17 During the long interval between radiation and ORN development, the body is seriously affected by radiation therapy at the vascular level and there is
TABLE 1. Summary of 5 Patients With Mandibular ORN Patient No. 1 2 3 4 5
Age, y/Sex
Tumor Site/Histology
Total Radiation Dose, cGy
Time Between RT and ORN*, mo
58/M 51/M 55/M 60/M 28/F
Oropharynx/SCC Tongue/malignant lymphoma Nasopharynx/NPC Nasopharynx/NPC Nasopharynx/NPC
5000 6000 7000 8000 7000
36 108 48 96 36
Mandibular Defects
*Time elapsed from the end of radiation therapy to the diagnosis of ORN. F indicates female; M, male; NPC, nasopharyngeal carcinoma; RT, radiotherapy; SCC, squamous cell carcinoma.
© 2015 Mutaz B. Habal, MD
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FIGURE 1. Panoramic radiographs showing the two-stage reconstruction of bilateral mandibular defects with 2 fibular flaps harvested from both legs. A, A patient with a left mandibular defect because of osteoradionecrosis. B, The left mandibular defect has been reconstructed with a fibular flap. C, The patient received a second fibular flap to reconstruct the right side of the mandible, which was also affected by osteoradionecrosis.
a high potential for the development of soft-tissue fibrosis. These conditions render the patient susceptible to flap failure and general wound complications.18 It is difficult to appropriately define the extent of ORN. Some researchers have suggested that resection of necrotic bone should be performed at least until healthy bleeding margins are obtained. However, there were some reports of disease relapse after this resection method.15 Tetracycline bone fluorescence was introduced as a marker to determine the extent of necrosis and to optimize surgical therapy, but the evidence for this test is weak.19 Further challenges in reconstruction surgery include difficult vessel identification as well as loss of surgical plane and facial contour during the reconstruction procedure.15,18 The fibular free flap is one of the best choices for the reconstruction of the mandible, owing to its high degree of precision and long-term efficacy.20 The main goals of reconstruction in patients with bilateral ORN of the mandible include relief of intractable pain, thorough debridement of infected necrotic bone and soft tissue, provision of bone continuity, repair of soft-tissue defects, and improvement of overall function and quality of life. Among these goals, improvement of function and quality of life is the key point. Conventional reconstruction methods for bilateral mandibular defects create an angle-to-angle defect, with the native symphysis being resected regardless of its viability.21 In our experience, the mandibular symphysis is usually relatively healthy, as it receives less radiation because the rays are directed from the sides rather than from an anterior source. It is important to preserve a healthy symphysis because the symphysis serves as a landmark in the lower third of the face, and the surgical outcome is more esthetic if it is preserved during the reconstruction procedure. Furthermore, the symphysis is an important anchor for both the tongue musculature and the larynx. Removal of the symphysis is therefore associated with a high risk for speech impairment and swallowing dysfunction as well as obstructive sleep apnea. The meniscus of the temporomandibular joint is also recommended to be preserved because it is required to obtain a good
FIGURE 3. Illustration of the preparation of 2 separate fibular flaps from a single fibula. A, Blood supply of the fibular flap, with 2 perforators to a skin island. B, Two fibular flaps are harvested from 1 leg, with each flap having its own skin island. C, The 2 flaps are used to reconstruct the bilateral mandibular defects.
functional outcome.22 Their better vascular supply and higher metabolic rate tend to protect the temporomandibular joint and mandibular ramus from ORN. The arterial supply of the fibular flap is the peroneal artery, which accompanies the fibula and gives off several nutrient arteries, which enter nutrient foramina in the fibula. The mean (SD) number of skin perforators per leg was 3.58 (0.71) in 1 study.23 The fibular anatomy makes it possible to prepare 2 separate fibular flaps from a single fibula. Because the fibula has sufficient bone volume for the reconstruction of the entire mandible,24 theoretically, this method can be adopted to reconstruct all types of bilateral mandibular defects. However, in the case of ORN, the recipient vessels may be sparse or unsuitable for anastomosis owing to previous neck dissections and radiation. Furthermore, if 2 separate fibular flaps are used, the length of pedicle vessels may be limited. Therefore, before creating 2 separate fibular flaps from a single fibula for simultaneous reconstruction of bilateral mandibular defects, surgeons should perform a meticulous preoperative assessment of the defects, recipient bed, bone graft volume, and the like. If the conditions are unsuitable, a 2-stage reconstruction procedure is recommended, as was the case in 3 of the 5 patients in this study. Such treatments can minimize surgical exposure of the remaining healthy symphysis. A more extensive surgical exposure may jeopardize local bone vascularity and lead to an increased risk for secondary bone necrosis and reconstruction failure. However, the risk for donor-site morbidity also increases if both fibulas are harvested.25 Our findings provide an alternative method for the management of bilateral mandibular defects. In tissues affected by ORN, hypovascularity and hypocellularity occur with the destruction of endothelial cells. Loss of the natural endothelial cell barrier allows seepage of various cytokines that cause fibroblasts to transform into myofibroblasts, which secrete abnormal products of the extracellular matrix.26,27 Oxygen diffusion in the affected tissue becomes difficult, leading to poor wound healing. To prevent wound healing deficiencies, radical resection should be performed and should include erosion of the surrounding soft tissues. Furthermore, we consider that a preventive tracheotomy is necessary, particularly in patients undergoing simultaneous bilateral mandibular reconstruction. Postoperative swelling might occur because of interruption of the lymphatic return around the operative area. A preventive tracheotomy could reduce the risk for dyspnea or asphyxia resulting from this swelling.
CONCLUSIONS
FIGURE 2. One-stage mandibular reconstruction strategy. A, Preoperative appearance. B, Bilateral osteoradionecrosis of the mandibular body. C, The bilateral mandibular defects have been reconstructed with 2 fibular flaps harvested from 1 leg in 1 stage. The mandibular symphysis has been retained. D, Postoperative appearance.
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In this study, we used vascularized free fibular flaps to successfully manage advanced bilateral mandibular ORN. Our method facilitates the supply of useful nutrients and blood to the affected area and thereby promotes wound healing and tissue regeneration. To achieve good esthetic and functional outcomes, we recommend that the healthy mandibular symphysis and meniscus of the temporomandibular joint be preserved. We have also introduced a method for © 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
preparing 2 separate fibular flaps from a single fibula. By using this method, we could simultaneously reconstruct bilateral mandibular defects. A 2-stage reconstructive strategy with 2 fibular flaps can also be used, depending on the specific conditions of the patient. Our findings provide a new strategy for the clinical management of advanced bilateral mandibular ORN.
REFERENCES 1. Kildal M, Wei FC, Chang YM, et al. Reconstruction of bilateral extensive composite mandibular defects after osteoradionecrosis with two fibular osteoseptocutaneous free flaps. Plast Reconstr Surg 2001;108:963–967 2. Delanian S, Lefaix JL. The radiation-induced fibroatrophic process: therapeutic perspective via the antioxidant pathway. Radiother Oncol 2004;73:119–131 3. Marx RE, Johnson RP. Studies in the radiobiology of osteoradionecrosis and their clinical significance. Oral Surg Oral Med Oral Pathol 1987;64:379–390 4. Store G, Boysen M. Mandibular osteoradionecrosis: clinical behaviour and diagnostic aspects. Clin Otolaryngol Allied Sci 2000;25:378–384 5. Harris M. The conservative management of osteoradionecrosis of the mandible with ultrasound therapy. Br J Oral Maxillofac Surg 1992;30:313–318 6. Wong JK, Wood RE, McLean M, et al. Conservative management of osteoradionecrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:16–21 7. Jham BC, Aguiar MC, Jham AC, et al. Successful conservative treatment of osteoradionecrosis of the mandible associated with pathological fracture. Minerva Stomatol 2008;57:65–69 8. Aitasalo K, Niinikoski J, Grenman R, et al. A modified protocol for early treatment of osteomyelitis and osteoradionecrosis of the mandible. Head Neck 1998;20:411–417 9. Notani K, Yamazaki Y, Kitada H, et al. Management of mandibular osteoradionecrosis corresponding to the severity of osteoradionecrosis and the method of radiotherapy. Head Neck 2003;25:181–186 10. Peterson DE, Doerr W, Hovan A, et al. Osteoradionecrosis in cancer patients: the evidence base for treatment-dependent frequency, current management strategies, and future studies. Support Care Cancer 2010;18:1089–1098 11. Lyons A, Ghazali N. Osteoradionecrosis of the jaws: current understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg 2008;46:653–660 12. Wei FC, Seah CS, Tsai YC, et al. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg 1994;93:294–306 13. Shan XF, Cai ZG, Zhang J, et al. Bimaxillary reconstruction with vascularised and non-vascularised fibula. J Plast Reconstr Aesthet Surg 2009;62:e474–e476 14. Jacobson AS, Buchbinder D, Urken ML. Reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular free flap. Laryngoscope 2010;120:273–275 15. Chang DW, Oh HK, Robb GL, et al. Management of advanced mandibular osteoradionecrosis with free flap reconstruction. Head Neck 2001;23:830–835 16. Epstein JB, Emerton S, Kolbinson DA, et al. Quality of life and oral function following radiotherapy for head and neck cancer. Head Neck 1999;21:1–11 17. Sandel HT, Davison SP. Microsurgical reconstruction for radiation necrosis: an evolving disease. J Reconstr Microsurg 2007;23:225–230 18. Cannady SB, Dean N, Kroeker A, et al. Free flap reconstruction for osteoradionecrosis of the jaws—outcomes and predictive factors for success. Head Neck 2011;33:424–428 19. Pautke C, Bauer F, Bissinger O, et al. Tetracycline bone fluorescence: a valuable marker for osteonecrosis characterization and therapy. J Oral Maxillofac Surg 2010;68:125–129 20. Santamaria E, Wei FC, Chen HC. Fibula osteoseptocutaneous flap for reconstruction of osteoradionecrosis of the mandible. Plast Reconstr Surg 1998;101:921–929
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21. Lutz BS, Bagenholm T, Adell R. Angle-to-angle mandibular reconstruction with two free fibular flaps in a patient with two consecutive gingival cancers. Scand J Plast Reconstr Surg Hand Surg 2004;38:46–49 22. Potter JK, Dierks EJ. Vascularized options for reconstruction of the mandibular condyle. Semin Plast Surg 2008;22:156–160 23. Cho BC, Kim SY, Paik JW, et al. Blood supply to osteocutaneous free fibula flap and peroneus longus muscle: prospective anatomic study and clinical applications. Plast Reconstr Surg 2001;108: 1963–1971 24. Paley MD, Lloyd CJ, Penfold CN. Total mandibular reconstruction for massive osteolysis of the mandible (Gorham-Stout syndrome). Br J Oral Maxillofac Surg 2005;43:166–168 25. Lin JY, Djohan R, Dobryansky M, et al. Assessment of donor-site morbidity using balance and gait tests after bilateral fibula osteoseptocutaneous free flap transfer. Ann Plast Surg 2009;62:246–251 26. Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg 1983;41:283–288 27. Lyons A, Ghazali N. Osteoradionecrosis of the jaws: current understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg 2008;46:653–660
Surgical Management of Osteoradionecrosis of the Jaws Tianguo Dai, DDS, MD,* Zhuowei Tian, DDS, MD,* Zhonghe Wang, PhD,† Weiliu Qiu, DDS, MD,* Zhiyuan Zhang, DDS, MD,* Yue He, DDS, MD* Objective: The objective of this study is to evaluate our 10-year clinical experience in surgical management of patients with osteoradionecrosis (ORN) unresolved with conservative nonoperative treatment. Patients and Methods: The medical records of 120 patients who had been surgically treated for ORN during a 10-year period (January 2003 to January 2013) were retrospectively reviewed. Results: The most predilection ORN site was mandible (82.5%), followed by the maxilla (11.7%). ORN developed within initial 12 months in 39.2% and within the first 3 years in 68.3%. The median radiation dose was 68.1 Gy (range, 35–148 Gy), but 51 patients (42.5%) experienced ORN even though radiation doses were controlled under 60 Gy. Surgical trauma, as we believed, was the most
From the *Department of Oromaxillofacial Head and Neck Oncology, Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai; and †Department of Oral Radiology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. Received September 11, 2014. Accepted for publication December 1, 2014. Address correspondence and reprint requests to Yue He, DDS, MD, PhD, Department of Oromaxillofacial Head and Neck Oncology, Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, No. 639 Zhi Zao Ju Road, Shanghai 200011, China; E-mail: [email protected] The authors report no conflicts of interest. This work was supported by grants from the National Natural Science Foundation of China (No. 81271112), Development Foundation of Shanghai Municipal Human Resources and Social Security Bureau (No. 201312), and SMC Rising Star-A of Shanghai Jiao Tong University (No. 201312). Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001445
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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4. Baker TJ, Gordon HL, Stuzin JM. Surgical Rejuvenation of the Face. 2nd ed. St Louis, MO: Mosby, 1996 5. Stuzin JM, Baker TM. Refinements in face lifting: enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg 2000;105:290 6. Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002;110:885 7. Calderon W, Andrades PR, Israel G, et al. SMAS graft of the nasolabial area during deep plane rhytidectomy. Plast Reconstr Surg 2004;114:559–563 8. Baker TJ. Rhytidectomy a look back and a look forward. Ann Plast Surg 2005;55:565–570 9. Gosain AK, Klein M, Sudhakar PV, et al. A volumetric analysis of soft tissue changes in the aging midface using high resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg 2005;115:1143 10. Rohrich RJ, Rios JL, Smith PD. Neck rejuvenation revisited. Plast Reconstr Surg 2006;118:1251–1252 11. Stuzin JM. Restoring facial shape in face lifting: the role of the skeletal support in facial analysis and midface soft tissue repositioning. Plast Reconstr Surg 2007;119:362 12. Owsley JQ, Roberts CL. Some anatomical observations on midface aging and long-term results of surgical treatment. Plast Reconstr Surg 2008;121:258–267 13. Stuzin JM. Face lifting. Plast Reconstr Surg 2008;121:3–7 14. Matarasso A, Elkwood A, Rankin M, et al. National plastic surgery survey: face lift techniques and complications. Plast Reconstr Surg 2000;106:1185–1195 15. Grover R, Jones BM, Waterhouse N. The prevention of haematoma following rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg 2001;54:481 16. Barry MJ, Grover R. Reducing complications in cervicofacial rhytidectomy by tumescent infiltration: a comparative trial evaluating 678 consecutive face lifts. Plast Reconstr Surg 2004;113:398–401 17. Barry MJ, Grover R. Avoiding haematoma in cervicofacial rhytidectomy: a personal 8-year quest. Review of 910 patients. Plast Reconstr Surg 2004;113:381–386 18. Baker DC, Chiu ES. Bedsides treatment of early acute rhytidectomy haematomas. Plast Reconstr Surg 2005;115:2119–2122 19. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of haematoma requiring surgical evacuation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg 2005;116:1973–1983 20. Stuzin JM, Baker TJ. Aging face and neck. In: Mathes SJ, ed. Plastic Surgery, Vol. II, The Head and Neck, Part I. Philadelphia: Saunders Elsevier, 2006:159 21. Mathes SJ, ed. Plastic Surgery, Vol. II, The Head and Neck, Part I. Philadelphia, PA: Elsevier, 2006 22. Barry MJ, Grover R, Hamilton S. The efficacy of surgical drainage in cervicofacial rhytidectomy: a prospective, randomized, controlled trial. Plast Reconstr Surg 2007;120:263 23. Stuzin JM. Face lifting. Plast Reconstr Surg 2008;121:13–18 24. Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology 1992;77:162–184 25. Trope A, Raeder JC. Can postoperative nausea and vomiting be predicted. Tidsskr Nor Laegeforen 2000;120:2423–2426 26. Apfel CC, Roewer N. Risk assessment of postoperative nausea and vomiting. Int Anesthesiol Clin 2003;41:13–32 27. Gan TJ. Risk factors for postoperative nausea and vomiting. Anesth Analg 2006;102:1884–1898 28. Murphy MJ, Hooper VD, Sullivan E, et al. Identification of risk factors for postoperative nausea and vomiting in the perianesthesia adult patient. J Perianesth Nurs 2006;21:377–384 29. Gan TJ, Meyer TA, Apfel CC, et al. Society for ambulatory anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2007;105:1615–1628 30. Habib AS. A comparison of ondansetron with promethazine for treating postoperative nausea and vomiting in patients who received prophylaxis with ondansetron: a retrospective database analysis. Anesth Analg 2007;104:548–551
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31. Apfel CC, Kortilla K, Abdalla M, et al. A factorial trail of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004;350:2441–2451
Fibular Free Flap Reconstruction for the Management of Advanced Bilateral Mandibular Osteoradionecrosis Xiao-Feng Shan, DDS, MD,* Ru-Huang Li, MD,*† Xu-Guang Lu, DDS, MD,* Zhi-Gang Cai, DDS, DMD,* Jie Zhang, DDS, PhD,* Jian-Guo Zhang, DDS* Abstract: Fibular osteoseptocutaneous flap has been widely used for unilateral mandibular reconstruction. However, reports about the effects of fibular osteoseptocutaneous flap for the reconstruction of bilateral mandibular defects are limited. In this study, we used free vascularized fibular flaps to successfully manage bilateral mandibular osteoradionecrosis (ORN) in 5 patients. Functional aspects were evaluated during the reconstruction process. All 5 patients had bilateral refractory ORN of the mandible and underwent radical resection between 2003 and 2011. The reconstruction surgery was performed in 2 stages using 2 free fibular flaps in 3 patients. In the other 2 patients, reconstruction was performed in a single stage using 2 separate flaps prepared from a single fibula. All patients had a healthy mandibular symphysis and meniscus of the temporomandibular joint, and these structures were preserved during the reconstruction. Of the 10 defects involving the mandible sides, 9 were successfully reconstructed. One microvascular composite flap failed because of radiation injury to the arterial endothelium at the recipient site. After the treatments, all patients had good esthetic and functional outcomes. Preoperative clinical features such as trismus and dysphagia were also markedly improved. Our surgical method may be an effective alternative for the clinical management of advanced bilateral mandibular ORN. Key Words: Osteoradionecrosis, bilateral mandibular defects, fibular flap, reconstruction
From the *Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, and †Department of Oral Diseases, Peking University Third Hospital, Beijing, People's Republic of China. Received January 17, 2014. Accepted for publication October 9, 2014. Address correspondence and reprint requests to Zhi-Gang Cai, DDS, DMD, Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, No. 22, S Ave Zhongguancun, Haidian District, Beijing 100081, People's Republic of China; E-mail: [email protected] Xiao-Feng Shan, DDS, MD, and Ru-Huang Li, MD, are co–first authors of this article. Supported by grants from the Beijing Municipal Development Foundation (Z111107058811038 and Z131107002213093) in China. The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001391
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
O
steoradionecrosis (ORN) of the mandible is a complex metabolic and tissue homeostatic deficiency caused by radiotherapy for head-and-neck cancer. Its incidence ranges from 0.8% to 35%.1 According to our current understanding of its pathophysiology, ORN is a radiation-induced fibroatrophy resulting from acute inflammation, free radical damage, and chronic fibroblast activation by a series of growth factors.2 The typical clinical characteristic is an area of exposed necrotic bone, accompanied by varying degrees of pain or anesthesia, intraoral or extraoral fistulae, trismus, drainage, and pathologic fracture.3,4 Conservative treatment modalities for superficial or partial ORN of the mandible include the use of oral antibiotics, aggressive dental maintenance, oral irrigation with fluoride, surgical curettage, hyperbaric oxygen treatment, ultrasound therapy, and a novel treatment with pentoxifylline.2,5–7 Although many protocols for managing ORN of the mandible have been proposed, the indications of radical surgery are not yet clearly defined.3,8–10 Radical surgery is only instituted when conservative methods fail or when severe bone and soft-tissue necrosis prevail. Pathologic fractures or persistent fistulas are strong indications for a radical surgical approach.8,11 Fibular osteoseptocutaneous flap has proven to be the workhorse of unilateral mandibular reconstruction.12,13 However, few cases of bilateral mandibular reconstruction have been reported in the literature.1,14
PATIENTS AND METHODS Between 2003 and 2011, a total of 98 patients with ORN were treated in our department. Of them, 5 patients (1 woman and 4 men) had refractory and bilateral ORN of the mandible and underwent segmental resection and microvascular fibular flap reconstruction (Table 1). All patients had extensive ORN with a large area of exposed necrotic bone and soft tissue, multiple discharging fistulas, severe trismus, and a coexistent pathologic fracture. The patients ranged in age from 28 to 60 years (median, 55 y). The primary cancers were nasopharyngeal carcinoma (3 patients), malignant lymphoma of the tongue (1 patient), and squamous cell carcinoma of the oropharynx (1 patient). One patient had received postoperative radiation therapy, and another had received radiotherapy and chemotherapy. The remaining 3 patients had received only radiotherapy. The total radiation dose ranged from 5000 cGy to 8000 cGy (median, 6600 cGy). The dose rate varied from 150 cGy/d to 200 cGy/d. The interval between radiotherapy and the onset of ORN varied from 36 months to 108 months (median, 72 mo). All patients had been previously treated with conservative methods, including local wound debridement, intense irrigation and rinsing with an antiseptic solution (digluconate chlorhexidine, 0.12%), systemic antimicrobial therapy, and selective removal of small bone sequestra when present. Two patients had also undergone hyperbaric oxygen therapy. In all patients, the wound failed to respond to these treatments and underwent progressive deterioration. The interval between the onset of ORN and surgical intervention for mandibular reconstruction varied from 42 months to 120 months
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(median, 81 mo). The decision regarding the extent of mandibular resection was based on clinical findings, along with the results of panoramic radiography or computed tomographic evaluations of the mandible. Radical resection was performed so as to include the entire necrotic segment of the mandible and soft tissues. In 3 patients, reconstruction was carried out in 2 stages, with 2 fibular osteoseptocutaneous free flaps harvested from both legs at an interval of 6 months (Fig. 1). In the other 2 patients, bilateral mandibular defects were reconstructed in a single stage, with 2 separate fibular free flaps being prepared from a single fibula (Fig. 2) through transection of the fibula and vascular pedicle (Fig. 3). Vascular anastomosis for both flaps was performed simultaneously. In all patients, a preventive tracheotomy was performed, and the flap was divided when the preparation of the recipient bed was completed.
RESULTS Despite the long operative time (5–8 h), all operations were performed successfully. The immediate postoperative period was uneventful. After the mandibular resection, 4 patients were left with bilateral mandibular body and unilateral ramus defects, whereas 1 patient was left with bilateral mandibular body and ramus defects. All patients had a healthy mandibular symphysis, and the meniscus of the temporomandibular joint was preserved. The 10 defects involving the mandible sides in the 5 patients were reconstructed with 10 fibular flaps harvested from 8 legs. Nine of these 10 mandibular reconstructions were successful in reestablishing mandibular continuity. There was only 1 microvascular composite flap failure, which resulted from a radiation injury to the arterial endothelium at the recipient site. On postoperative day 5, this patient developed late microvascular thrombosis and lost 1 fibular flap; the failed flap was substituted with a reconstruction plate. Delayed wound healing was observed in all patients. The wound healing time ranged from 1 month to 1 year. In all patients, wound healing was ultimately achieved using meticulous local wound care and topical drugs. Early postoperative ambulation was encouraged, and no serious donor-site morbidity was observed in the hospital. The patients were followed up for 2 months to 90 months (median, 49 mo). All patients had satisfactory cosmetic outcomes, intelligible speech, as well as improved mouth opening and oral intake of at least soft foods.
DISCUSSION Although free tissue transfer has become the established surgical treatment for advanced ORN, factors complicating the outcomes of reconstruction procedures remain elusive. Complication rates ranging from 24% to 44% have been reported. The rate of flap loss in ORN reconstructions is even higher than the rate of loss of ablative head-and-neck free flap reconstructions.15–17 During the long interval between radiation and ORN development, the body is seriously affected by radiation therapy at the vascular level and there is
TABLE 1. Summary of 5 Patients With Mandibular ORN Patient No. 1 2 3 4 5
Age, y/Sex
Tumor Site/Histology
Total Radiation Dose, cGy
Time Between RT and ORN*, mo
58/M 51/M 55/M 60/M 28/F
Oropharynx/SCC Tongue/malignant lymphoma Nasopharynx/NPC Nasopharynx/NPC Nasopharynx/NPC
5000 6000 7000 8000 7000
36 108 48 96 36
Mandibular Defects
*Time elapsed from the end of radiation therapy to the diagnosis of ORN. F indicates female; M, male; NPC, nasopharyngeal carcinoma; RT, radiotherapy; SCC, squamous cell carcinoma.
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FIGURE 1. Panoramic radiographs showing the two-stage reconstruction of bilateral mandibular defects with 2 fibular flaps harvested from both legs. A, A patient with a left mandibular defect because of osteoradionecrosis. B, The left mandibular defect has been reconstructed with a fibular flap. C, The patient received a second fibular flap to reconstruct the right side of the mandible, which was also affected by osteoradionecrosis.
a high potential for the development of soft-tissue fibrosis. These conditions render the patient susceptible to flap failure and general wound complications.18 It is difficult to appropriately define the extent of ORN. Some researchers have suggested that resection of necrotic bone should be performed at least until healthy bleeding margins are obtained. However, there were some reports of disease relapse after this resection method.15 Tetracycline bone fluorescence was introduced as a marker to determine the extent of necrosis and to optimize surgical therapy, but the evidence for this test is weak.19 Further challenges in reconstruction surgery include difficult vessel identification as well as loss of surgical plane and facial contour during the reconstruction procedure.15,18 The fibular free flap is one of the best choices for the reconstruction of the mandible, owing to its high degree of precision and long-term efficacy.20 The main goals of reconstruction in patients with bilateral ORN of the mandible include relief of intractable pain, thorough debridement of infected necrotic bone and soft tissue, provision of bone continuity, repair of soft-tissue defects, and improvement of overall function and quality of life. Among these goals, improvement of function and quality of life is the key point. Conventional reconstruction methods for bilateral mandibular defects create an angle-to-angle defect, with the native symphysis being resected regardless of its viability.21 In our experience, the mandibular symphysis is usually relatively healthy, as it receives less radiation because the rays are directed from the sides rather than from an anterior source. It is important to preserve a healthy symphysis because the symphysis serves as a landmark in the lower third of the face, and the surgical outcome is more esthetic if it is preserved during the reconstruction procedure. Furthermore, the symphysis is an important anchor for both the tongue musculature and the larynx. Removal of the symphysis is therefore associated with a high risk for speech impairment and swallowing dysfunction as well as obstructive sleep apnea. The meniscus of the temporomandibular joint is also recommended to be preserved because it is required to obtain a good
FIGURE 3. Illustration of the preparation of 2 separate fibular flaps from a single fibula. A, Blood supply of the fibular flap, with 2 perforators to a skin island. B, Two fibular flaps are harvested from 1 leg, with each flap having its own skin island. C, The 2 flaps are used to reconstruct the bilateral mandibular defects.
functional outcome.22 Their better vascular supply and higher metabolic rate tend to protect the temporomandibular joint and mandibular ramus from ORN. The arterial supply of the fibular flap is the peroneal artery, which accompanies the fibula and gives off several nutrient arteries, which enter nutrient foramina in the fibula. The mean (SD) number of skin perforators per leg was 3.58 (0.71) in 1 study.23 The fibular anatomy makes it possible to prepare 2 separate fibular flaps from a single fibula. Because the fibula has sufficient bone volume for the reconstruction of the entire mandible,24 theoretically, this method can be adopted to reconstruct all types of bilateral mandibular defects. However, in the case of ORN, the recipient vessels may be sparse or unsuitable for anastomosis owing to previous neck dissections and radiation. Furthermore, if 2 separate fibular flaps are used, the length of pedicle vessels may be limited. Therefore, before creating 2 separate fibular flaps from a single fibula for simultaneous reconstruction of bilateral mandibular defects, surgeons should perform a meticulous preoperative assessment of the defects, recipient bed, bone graft volume, and the like. If the conditions are unsuitable, a 2-stage reconstruction procedure is recommended, as was the case in 3 of the 5 patients in this study. Such treatments can minimize surgical exposure of the remaining healthy symphysis. A more extensive surgical exposure may jeopardize local bone vascularity and lead to an increased risk for secondary bone necrosis and reconstruction failure. However, the risk for donor-site morbidity also increases if both fibulas are harvested.25 Our findings provide an alternative method for the management of bilateral mandibular defects. In tissues affected by ORN, hypovascularity and hypocellularity occur with the destruction of endothelial cells. Loss of the natural endothelial cell barrier allows seepage of various cytokines that cause fibroblasts to transform into myofibroblasts, which secrete abnormal products of the extracellular matrix.26,27 Oxygen diffusion in the affected tissue becomes difficult, leading to poor wound healing. To prevent wound healing deficiencies, radical resection should be performed and should include erosion of the surrounding soft tissues. Furthermore, we consider that a preventive tracheotomy is necessary, particularly in patients undergoing simultaneous bilateral mandibular reconstruction. Postoperative swelling might occur because of interruption of the lymphatic return around the operative area. A preventive tracheotomy could reduce the risk for dyspnea or asphyxia resulting from this swelling.
CONCLUSIONS
FIGURE 2. One-stage mandibular reconstruction strategy. A, Preoperative appearance. B, Bilateral osteoradionecrosis of the mandibular body. C, The bilateral mandibular defects have been reconstructed with 2 fibular flaps harvested from 1 leg in 1 stage. The mandibular symphysis has been retained. D, Postoperative appearance.
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In this study, we used vascularized free fibular flaps to successfully manage advanced bilateral mandibular ORN. Our method facilitates the supply of useful nutrients and blood to the affected area and thereby promotes wound healing and tissue regeneration. To achieve good esthetic and functional outcomes, we recommend that the healthy mandibular symphysis and meniscus of the temporomandibular joint be preserved. We have also introduced a method for © 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
preparing 2 separate fibular flaps from a single fibula. By using this method, we could simultaneously reconstruct bilateral mandibular defects. A 2-stage reconstructive strategy with 2 fibular flaps can also be used, depending on the specific conditions of the patient. Our findings provide a new strategy for the clinical management of advanced bilateral mandibular ORN.
REFERENCES 1. Kildal M, Wei FC, Chang YM, et al. Reconstruction of bilateral extensive composite mandibular defects after osteoradionecrosis with two fibular osteoseptocutaneous free flaps. Plast Reconstr Surg 2001;108:963–967 2. Delanian S, Lefaix JL. The radiation-induced fibroatrophic process: therapeutic perspective via the antioxidant pathway. Radiother Oncol 2004;73:119–131 3. Marx RE, Johnson RP. Studies in the radiobiology of osteoradionecrosis and their clinical significance. Oral Surg Oral Med Oral Pathol 1987;64:379–390 4. Store G, Boysen M. Mandibular osteoradionecrosis: clinical behaviour and diagnostic aspects. Clin Otolaryngol Allied Sci 2000;25:378–384 5. Harris M. The conservative management of osteoradionecrosis of the mandible with ultrasound therapy. Br J Oral Maxillofac Surg 1992;30:313–318 6. Wong JK, Wood RE, McLean M, et al. Conservative management of osteoradionecrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:16–21 7. Jham BC, Aguiar MC, Jham AC, et al. Successful conservative treatment of osteoradionecrosis of the mandible associated with pathological fracture. Minerva Stomatol 2008;57:65–69 8. Aitasalo K, Niinikoski J, Grenman R, et al. A modified protocol for early treatment of osteomyelitis and osteoradionecrosis of the mandible. Head Neck 1998;20:411–417 9. Notani K, Yamazaki Y, Kitada H, et al. Management of mandibular osteoradionecrosis corresponding to the severity of osteoradionecrosis and the method of radiotherapy. Head Neck 2003;25:181–186 10. Peterson DE, Doerr W, Hovan A, et al. Osteoradionecrosis in cancer patients: the evidence base for treatment-dependent frequency, current management strategies, and future studies. Support Care Cancer 2010;18:1089–1098 11. Lyons A, Ghazali N. Osteoradionecrosis of the jaws: current understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg 2008;46:653–660 12. Wei FC, Seah CS, Tsai YC, et al. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg 1994;93:294–306 13. Shan XF, Cai ZG, Zhang J, et al. Bimaxillary reconstruction with vascularised and non-vascularised fibula. J Plast Reconstr Aesthet Surg 2009;62:e474–e476 14. Jacobson AS, Buchbinder D, Urken ML. Reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular free flap. Laryngoscope 2010;120:273–275 15. Chang DW, Oh HK, Robb GL, et al. Management of advanced mandibular osteoradionecrosis with free flap reconstruction. Head Neck 2001;23:830–835 16. Epstein JB, Emerton S, Kolbinson DA, et al. Quality of life and oral function following radiotherapy for head and neck cancer. Head Neck 1999;21:1–11 17. Sandel HT, Davison SP. Microsurgical reconstruction for radiation necrosis: an evolving disease. J Reconstr Microsurg 2007;23:225–230 18. Cannady SB, Dean N, Kroeker A, et al. Free flap reconstruction for osteoradionecrosis of the jaws—outcomes and predictive factors for success. Head Neck 2011;33:424–428 19. Pautke C, Bauer F, Bissinger O, et al. Tetracycline bone fluorescence: a valuable marker for osteonecrosis characterization and therapy. J Oral Maxillofac Surg 2010;68:125–129 20. Santamaria E, Wei FC, Chen HC. Fibula osteoseptocutaneous flap for reconstruction of osteoradionecrosis of the mandible. Plast Reconstr Surg 1998;101:921–929
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21. Lutz BS, Bagenholm T, Adell R. Angle-to-angle mandibular reconstruction with two free fibular flaps in a patient with two consecutive gingival cancers. Scand J Plast Reconstr Surg Hand Surg 2004;38:46–49 22. Potter JK, Dierks EJ. Vascularized options for reconstruction of the mandibular condyle. Semin Plast Surg 2008;22:156–160 23. Cho BC, Kim SY, Paik JW, et al. Blood supply to osteocutaneous free fibula flap and peroneus longus muscle: prospective anatomic study and clinical applications. Plast Reconstr Surg 2001;108: 1963–1971 24. Paley MD, Lloyd CJ, Penfold CN. Total mandibular reconstruction for massive osteolysis of the mandible (Gorham-Stout syndrome). Br J Oral Maxillofac Surg 2005;43:166–168 25. Lin JY, Djohan R, Dobryansky M, et al. Assessment of donor-site morbidity using balance and gait tests after bilateral fibula osteoseptocutaneous free flap transfer. Ann Plast Surg 2009;62:246–251 26. Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg 1983;41:283–288 27. Lyons A, Ghazali N. Osteoradionecrosis of the jaws: current understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg 2008;46:653–660
Surgical Management of Osteoradionecrosis of the Jaws Tianguo Dai, DDS, MD,* Zhuowei Tian, DDS, MD,* Zhonghe Wang, PhD,† Weiliu Qiu, DDS, MD,* Zhiyuan Zhang, DDS, MD,* Yue He, DDS, MD* Objective: The objective of this study is to evaluate our 10-year clinical experience in surgical management of patients with osteoradionecrosis (ORN) unresolved with conservative nonoperative treatment. Patients and Methods: The medical records of 120 patients who had been surgically treated for ORN during a 10-year period (January 2003 to January 2013) were retrospectively reviewed. Results: The most predilection ORN site was mandible (82.5%), followed by the maxilla (11.7%). ORN developed within initial 12 months in 39.2% and within the first 3 years in 68.3%. The median radiation dose was 68.1 Gy (range, 35–148 Gy), but 51 patients (42.5%) experienced ORN even though radiation doses were controlled under 60 Gy. Surgical trauma, as we believed, was the most
From the *Department of Oromaxillofacial Head and Neck Oncology, Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai; and †Department of Oral Radiology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. Received September 11, 2014. Accepted for publication December 1, 2014. Address correspondence and reprint requests to Yue He, DDS, MD, PhD, Department of Oromaxillofacial Head and Neck Oncology, Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, No. 639 Zhi Zao Ju Road, Shanghai 200011, China; E-mail: [email protected] The authors report no conflicts of interest. This work was supported by grants from the National Natural Science Foundation of China (No. 81271112), Development Foundation of Shanghai Municipal Human Resources and Social Security Bureau (No. 201312), and SMC Rising Star-A of Shanghai Jiao Tong University (No. 201312). Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001445
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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