ORIGINAL ARTICLE

Intraoral lining with the fibular osteomyofascial flap without a skin paddle during maxillary and mandibular reconstruction Song Fan, MD,1 You-yuan Wang, MD,1 Dong-hui Wu, MD,2 Dong-li Lai, MD,3 Yu-huan Feng, MD,1 Xin Yu, MD,1 Zhao-yu Lin, MD,1 Da-ming Zhang, MD,1 Wei-liang Chen, DDS,1 Jian-qiang Liang, MD, PhD,2 Jin-song Li, MD, PhD1* 1

Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China, 2Stomatological Hospital of Haizhu District, Guangzhou, People’s Republic of China, 3Department of Stomatology, Hospital of TCM in Bao’an District, Shenzhen, People’s Republic of China.

Accepted 22 April 2015 Published online 15 July 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.24109

ABSTRACT: Background. To achieve an ideal intraoral lining, we harvest the fibular osteomyofascial flap to avoid the common embarrassment caused by the fibular osteomyocutaneous flap, and we report on our experience with this technique in this article. Methods. Twenty-eight patients underwent reconstruction of the maxilla and mandible using an osteomyofascial free fibula flap after oncologic ablation. Data, including the size of the fascial flaps, the number of debulking operations, the complications at both the donor and recipient sites, and the dental rehabilitation, were collected. Results. All fascial flaps survived and were remucosalized, except one with partial necrosis. None of the patients in the osteomyofascial group

INTRODUCTION Advancements in microvascular techniques over the last 2 decades have made free flap reconstruction of the maxilla and mandible common in most patients after ablative oncologic surgery. The regeneration of bony defects of the jaws using free vascularized tissue grafts has become a reliable procedure, and various donor sites are available to provide vascularized bone grafts for mandibular or maxillary reconstruction, such as the fibula flap, scapula flap, iliac flap, and radius flap.1 Among these alternatives, the fibula osteocutaneous flap has emerged as the accepted favorite technique for maxillary and mandibular reconstruction because of the potential for contouring, the implant osseointegration, the favorable pedicle length, the decreased donor site morbidity, the skin paddle reliability, and the potential for 2 teams to work simultaneously during the operation.1–3 Prosthodontic rehabilitation is the ultimate aim of jaw reconstruction, and many studies have provided clinical data on patient eligibility for dental rehabilitation using

*Corresponding author: J. Li, Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou 510120, China. E-mail: [email protected] Song Fan and You-yuan Wang contributed equally to this work. Additional Supporting Information may be found in the online version of this article.

E832

HEAD & NECK—DOI 10.1002/HED

APRIL 2016

required an additional debulking operation, and 82% of the patients (23 of 28) had conventional dentures and showed good chewing function and cosmetic results. Conclusion. The fibular osteomyofascial flap yielded a more anatomic solution for oral mucosal defects, obviating the need for additional C 2015 debulking and potentially reducing donor-site wound problems. V Wiley Periodicals, Inc. Head Neck 38: E832–E836, 2016

KEY WORDS: fibular osteomyofascial flap, fibular osteomyocutaneous flap, reconstruction, maxilla, mandible

implants or conventional dentures followed by transplantation with free vascularized fibular osteocutaneous or osteomyocutaneous flaps.3–5 However, some questions have been raised during the clinical follow-up of these patients with respect to the prosthetic reconstruction of the vertical height of the fibula and its soft tissue conditions. Generally, depending on the adiposity of the patient, the definite disadvantages of using free osteocutaneous or osteomyocutaneous flaps is that they contain skin and adipose tissue, causing significant soft tissue bulk, movement of the skin paddle, mobility upon labial or tongue movement, and buccal vestibule absence.6,7 Shaping and debulking are necessary, especially over the course of several procedures for implant or conventional denture placement.8 Meanwhile, chronic inflammation and hypertrophy in peri-implant areas pose challenges for the long-term management of peri-implant soft tissues surrounding osteocutaneous or osteomyocutaneous flap reconstructions.3,4,6 To harvest the ideal intraoral lining, which is a lining that is moist, thin, and without hair, for subsequent functional rehabilitation, researchers have shifted from the osteocutaneous fibula flap to prelaminated osteomucosal or skin grafts for jaw defect reconstruction.3,5,9–11 Prelamination of the fibula with buccal mucosa replacements has been demonstrated for the replacement of like tissue with like tissue, obviating the need for a skin paddle and facilitating the placement of osseointegrated implants in a single stage.3 However, such techniques require a 2-stage

INTRAORAL

surgical protocol, which increases the financial burden and surgical invasiveness. Additionally, they do not facilitate a second fibula insetting or skin grafting in certain patients with cancer because of adjuvant radiotherapy.12 To develop a favorable workflow for jaw reconstruction while facilitating a healthy soft tissue, we have shifted from using an osteocutaneous fibula flap to a fibula osteomyofascial flap. In this article, we report on our experience with the fibula osteomyofascial flap for mandibular and maxillary reconstruction after oncologic ablation.

PATIENTS AND METHODS Between May 2011 and November 2013, 51 patients underwent mandibular or maxillary reconstruction using a free fibula flap after ablative surgery for oral cancer in the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University. Conventional free fibula osteocutaneous flaps were used in 23 patients in this study, and osteomyofascial free fibula flaps were used in the remaining 28 patients. Data, including the patient’s age, sex, cause of defects, classification of the mandibular and maxillary defect type, length of the harvested fibula bone, size of the fascial flaps, number of debulking operations, complications at both the donor and recipient sites, adjuvant radiotherapy, and prosthesis placement, were collected.

Operative technique An incision was made in the fibular osteomyofascial flaps on the lateral aspect of the leg. After exposure of the myofascia and septocutaneous perforators at the distal end of the fibula,13 fascial flaps above the peroneus longus and soleus muscles were preserved and dissected along the center of the distal perforators while the skin flap and subcutaneous adipose tissue were evaluated. The fascial flaps were harvested such that they were approximately 2 cm larger in length and width than the primary mucous lining defect of the oral cavity to allow for potential contraction. Then, the surgical procedure was performed using a conventional technique, and a cuff of muscle approximately 0.3 cm around the periosteum of the fibula was carefully preserved. The fibular graft length was harvested according to the jaw defects, and we added the segmental peroneus longus or soleus muscle to obliterate and augment the submandibular, floor of the mouth, or maxillary dead space. After setting the modified fibular bone at the jaw defects, the fascial flap was loosely sutured to close the native mucosa and cover the transferred fibular bone and exposed muscle. If the harvested fascial flaps were larger than the recipient sites, they were folded or packed into the dead spaces. The donor site was closed primarily over a closed suction drain (Figure 1). Before prosthodontic rehabilitation, the skin islands of the osteocutaneous flap group may be debulked while vestibuloplasty is performed to ensure an optimal thickness for denture stability.

RESULTS The age, sex, and other clinical characteristics of the 2 groups are presented in Table 1. Adopting the classifica-

LINING WITH THE FIBULAR OSTEOMYOFASCIAL FLAP

tion system for bony defects that was suggested by Brown and Shaw14 for the maxilla and that by Jewer et al15 for the mandible resulted in the classifications of the patients into corresponding groups (Supplemental Table S1, online only). All bone reconstruction procedures were primarily performed at the time of tumor surgery. Although most patients underwent jaw reconstruction using mono-barrel fibular flaps, 5 and 2 patients underwent double-barrel reconstruction of the mandible in the fibular osteomyofascial flap group and osteocutaneous flap group, respectively. All patients had at least 1 distal perforator, and the average size of the fascial flaps was 7.5 3 5.0 cm, whereas that of the skin paddles was 6.5 3 4.5 cm. There was no total flap failure in either group, but 1 patient presented with partial fascial flap necrosis in the fibular osteomyofascial flap group, and 3 patients in the osteocutaneous flap group presented with partial cutaneous flap necrosis. None of the patients developed seroma, infection, or skin necrosis at the donor site, and all of the leg donor sites were primarily closed in the fibular osteomyofascial flap group. However, of the 23 patients in the osteocutaneous flap group, 21 patients needed a skin graft, and only 2 patients presented with primary closure. Meanwhile, 4 patients needed subsequent local debridement at the donor sites because of partial necrosis of the grafting skin, and the wound underwent second-intention healing within 1.5 months. Fascial fibular flaps were found to be integrated without problems in all cases, and the flaps were remucosalized by surrounding mucosa within 1 month; additionally, the surface of the flaps became hard and immobile. Although the fascial flaps resulted in an approximately one-third decrease in the total size, the remucosalized fascial flaps did not exhibit significant contracture at the recipient sites because of our advanced planning and loose suturing to close the native mucosa. The patients who received postoperative radiotherapy in the 2 groups were comparable, we found some radiation ulcer in remucosalized fascial flaps but not any loss of fascial flap. When the patients were examined for definitive prosthodontic treatment 3 months after reconstruction, intraoral examination revealed a stable mucosa with optimal thickness and no mobility, and none of the patients required debulking for conventional dentures in the osteomyofascial group. However, all patients in the osteocutaneous group exhibited inadequate soft tissue and needed at least one additional debulking operation and vestibuloplasty before dental prosthesis placement in the osteocutaneous group. Twenty-three patients (82%) underwent conventional prosthodontic treatment in the osteomyofascial group, whereas only 12 patients (52%) in the osteocutaneous group underwent conventional prosthodontic treatment; the other patients received no further prosthodontic treatment. All patients in the osteomyofascial flap group who underwent prosthodontic rehabilitation were able to use the dental prosthesis for chewing and were satisfied with the cosmetic results (Figure 1). Nevertheless, 4 patients in the osteocutaneous flap group stopped using their removable partial dentures because of poor retention. None of the patients were selected or could afford oral rehabilitation with implants because of financial limitations or adjuvant radiotherapy. HEAD & NECK—DOI 10.1002/HED

APRIL 2016

E833

FAN ET AL.

FIGURE 1. A 41-year-old woman had an “LC” type mandible defect because of adamantoblastoma. The patient underwent surgery with a monobarrel fibular osteomyofascial flap to reconstruct the mandibular and mucosal defects. A 10.0- 3 5.0-cm fascial flap was harvested and loosely sutured to close the native mucosa. The fascial flap exhibited favorable remucosalization and provided an appropriate base for the dental prosthesis. The patient had a removable partial denture 3 months after reconstruction and was satisfied with the cosmetic results.

E834

HEAD & NECK—DOI 10.1002/HED

APRIL 2016

INTRAORAL

LINING WITH THE FIBULAR OSTEOMYOFASCIAL FLAP

TABLE 1. Demographic and clinical characteristics of the patients in the 2 groups.

No. of patients Age, y Gender, M:F Cause of defects Gingival carcinoma Carcinoma of the floor of mouth Carcinoma of maxillary sinus Central carcinoma of the jaws Adamantoblastoma Osteoradionecrosis Sarcoma No. of flaps Size of bone defect, cm No. of mono/double-barrel reconstructions Size of fascial flap/skin paddle, cm Donor site closure Skin graft complication Flap complication Adjuvant radiotherapy Patients with conventional dentures No. of operations for debulking

Osteomyofascial

Osteocutaneous

28 48 (range, 27–69) 11:17

23 53 (range, 19–71) 9:14

11 2 4 1 4 2 4 28 7.8 (range, 3.5–17.5) 23/5 7.5 3 5.0 (range, 3.5 3 4.0–10.5 3 7.5) Primary closure, 28 — Partial necrosis, 1 17 23 0

9 4 3 0 2 3 2 23 8.3 (range, 2.8–18.9) 21/2 6.5 3 4.5 (range, 2.5 3 3.0–9.5 3 7.2) Skin graft, 21; primary closure, 2 Partial necrosis, 4 Partial necrosis, 3 13 12 19

DISCUSSION The primary goals of jaw reconstruction are to achieve primary wound closure and obtain functional and aesthetic restoration. After jaw reconstruction, dental rehabilitation can aid in restoring facial appearance, speech, and masticatory functions that are critical for nutritional intake and the psychological well-being of patients.2,16 Therefore, the surgeon must keep in mind that reconstruction procedures should facilitate dental rehabilitation. The osteocutaneous microvascular fibula graft provides an excellent source of bone stock that meets all of the osseous requirements of maxillary and mandibular reconstruction and is suitable for prosthodontic treatment, whereas the cutaneous section can be used to cover soft tissue defects after tumor ablation. Therefore, the use of fibular osteocutaneous flaps is a well-accepted alternative for the treatment of these patients. This graft has been used extensively for the reconstruction of mandibular and maxillarydefects.17 However, the intraoral soft-tissue component can be less than ideal. The skin paddle can be quite bulky and mobile after vestibule ablation, requiring secondary procedures for denture placement, and the paddle is almost uniformly hair-bearing in both men and women, which could be cosmetically unattractive, uncomfortable, trap food particles, and affect oral hygiene.3,9 Meanwhile, the excessive thickness and mobility of the cutaneous flap is a limitation to the introduction of these implants, requiring multiple secondary procedures to achieve a solid interface between the dermis and fibular periosteum.18 Additionally, such soft tissue surrounding endosseous implants often promotes soft tissue inflammation, hypertrophy, pain, bleeding, compromised aesthetics, and implant failure.19 Based on 19 years of experience with masticatory rehabilitation after upper and lower jaw reconstruction using vascularized free fibula flap and endosseous implants, Hakim et al4 concluded that soft tissue management around the implants is required in the

vast majority of cases (62.2%) and always excised the voluminous overlying tissue of the skin paddle. It is a particular challenge to rehabilitate the intraoral lining using a reliable and practical flap that drapes over the alveolus, palate, and floor of the mouth.2 To provide an appropriate oral lining for conventional dental rehabilitation or implant placement, researchers have developed prelaminated graft techniques in oromandibular reconstruction. Prelaminated grafts are the integration of skin grafts and mucosal grafts placed on the periosteum in the first stage of reconstruction several weeks before the final transplantation. Generally, the skin grafts or mucosal grafts are fixed and used to cover the periosteum of the fibula, and the wound is closed for 8 to 12 weeks before the skin-covered or mucosa-covered bone is harvested in a secondary jaw reconstruction procedure.3,9–11,18,20–22 Therefore, prelaminated grafts are not bulky; they provide a thin and immobile surface on the fibular bone, allowing it to serve as a favorable base for the dental prosthesis and avoiding multiple sequential procedures required to manage the skin paddles of a fibular osteocutaneous flap.5 However, it is easy to demonstrate that prelaminated grafts provide an ideal oral lining, but their use requires an additional surgical procedure and the potential added morbidity associated with an additional anesthetic. Additionally, this technique is not suitable for some patients with cancer who require adjuvant radiotherapy. Adjuvant radiotherapy, which usually takes 6 to 7 weeks, should be performed within 6 weeks of tumor ablation.23 Therefore, the development of a 1stage procedure that achieves favorable solid skeletal and soft lining structures may result in a more practical method for functional rehabilitation in oncologic cases. In the present study, we developed a method involving the use of fibular osteomyofascial flaps to reconstruct jaw defects and the oral lining. The perforators of fibular osteocutaneous flaps have been well demonstrated; Yu et al13 HEAD & NECK—DOI 10.1002/HED

APRIL 2016

E835

FAN ET AL.

reported that all patients had at least 1 distal perforator, and 51% of patients presented with more than 1 perforator. In this study, we harvested all fibular fascial flaps based on the distal perforators of the fibula, and all patients presented with distal perforators; additionally, all fascial flaps survived and remucosalized, with the exception of 1 flap that exhibited partial necrosis. To the best of our knowledge, there has been only 1 case report on the use of a fibular osteo-adipofascial flap to reconstruct the upper alveolar.5 The surface of the adipofascial flap was covered by mucosa within 1 month. However, the remucosalized area had decreased by half just after the first operation, which may be caused by contracture of the surrounding mucosa. Before the surgery, we harvested fibular fascial flaps that were 2 cm larger than the primary mucosal defects, which intentionally did not include any adipose tissue, to cover the fibular bone segments and reconstruct the oral mucosal defect. Meanwhile, our fascial flaps, which were easier to suture than osteocutaneous flaps, could easily be folded or packed into dead spaces when they were larger than the recipient sites. Generally, the fascial flaps exhibited an approximately one-third decrease in total size, but the remucosalized fascial flaps did not exhibit significant contracture at the receipt sites in our study. Our fibular osteomyofascial flap can introduce mucosal tissue, a thin, stable tissue that lacks hair, into the mouth, as well as provide a clean, comfortable intraoral environment for dental rehabilitation. Because of the continuity and stability of the alveolar process, 82% of the patients (23 of 28) in the osteomyofascial group had conventional dentures and showed good chewing function and cosmetic results. However, only 52% of the patients (12 of 23) in the osteocutaneous group had a definitive prosthesis, and 33% of the patients (4 of 12) stopped using their removable partial denture because of poor retention. All patients required an additional operation to debulk the flaps because of the bulky and mobile nature of cutaneous flaps, which could possibly impair the retention and stability of the dentures. Therefore, additional management of soft tissue may have prevented some patients in the osteocutaneous group from undergoing further dental rehabilitation and may not have facilitated favorable retention and stability of the denture. Notably, none of the patients in our study had an implant prosthesis, which may be due to financial limitations and the patients’ adjuvant radiotherapy. Peri-implant soft tissue proliferation is a common phenomenon associated with implants used in fibular osteocutaneous flap jaw reconstructions.1 Even after repeated debulking, a skin paddle will still have a thick and mobile lining, putting the patient at risk for peri-implantitis.8 However, we believe that our fibular osteomyofascial flaps may provide appropriate soft tissue for implant placement, which requires further experimental and clinical study. Additionally, with the fibular osteomyofascial flap technique, it is not necessary to include an ellipse of skin from the leg. An extra advantage of this technique is that the skin incision in the donor area can be closed without tension or a skin graft, reducing possible donor site complications.

E836

HEAD & NECK—DOI 10.1002/HED

APRIL 2016

CONCLUSIONS In summary, fibular osteomyofascial flaps can be a better anatomic solution for maxillary and mandibular reconstruction compared with conventional fibular osteocutaneous flaps. Fibular osteomyofascial flaps can provide tissue with which to correct oral mucosal defects, obviating the need for additional debulking before dental rehabilitation and reducing donor site primary closure.

REFERENCES 1. Wu YQ, Huang W, Zhang ZY, Zhang ZY, Zhang CP, Sun J. Clinical outcome of dental implants placed in fibula-free flaps for orofacial reconstruction. Chin Med J (Engl) 2008;121:1861–1865. 2. Lin PY, Lin KC, Jeng SF. Oromandibular reconstruction: the history, operative options and strategies, and our experience. ISRN Surg 2011;2011:824251. 3. Santamaria E, Correa S, Bluebond–Langner R, Orozco H, Ortiz– Monasterio F. A shift from the osteocutaneous fibula flap to the prelaminated osteomucosal fibula flap for maxillary reconstruction. Plast Reconstr Surg 2012;130:1023–1030. 4. Hakim SG, Kimmerle H, Trenkle T, Sieg P, Jacobsen HC. Masticatory rehabilitation following upper and lower jaw reconstruction using vascularised free fibula flap and enossal implants-19 years of experience with a comprehensive concept. Clin Oral Investig 2015;19:525–534. 5. Nakayama B, Ikuo H, Kamei Y, Hachiya H, Torii S. Successful upper alveolar reconstruction for gingival cancer using a fibular osteoadipofascial flap without osseointegrated implants. Ann Plast Surg 2005;54:323–327. 6. Dhima M, Rieck KL, Arce K, Salinas TJ. Development of stable periimplant soft tissue and mentolabial sulcus depth with an implant-retained soft tissue conformer after osteocutaneous flap reconstruction. Int J Prosthodont 2013;26:265–267. 7. Pigno MA. Conventional prosthetic rehabilitation after free flap reconstruction of a maxillectomy defect: a clinical report. J Prosthet Dent 2001;86:578–581. 8. Rohner D, Bucher P, Hammer B. Prefabricated fibular flaps for reconstruction of defects of the maxillofacial skeleton: planning, technique, and longterm experience. Int J Oral Maxillofac Implants 2013;28:e221–e229. 9. Rath T, Tairych GV, Frey M, Lang S, Millesi W, Glaser C. Neuromucosal prelaminated flaps for reconstruction of intraoral lining defects after radical tumor resection. Plast Reconstr Surg 1999;103:821–828. 10. Greensmith AL, Boustred AM, Worthington JB, Blake GB. Prelaminated osseointegrated fibula free flap for the repair of a rare congenital maxillary deficiency. Plast Reconstr Surg 2003;112:812–818. 11. Rohner D, Kunz C, Bucher P, Hammer B, Prein J. New possibilities for reconstructing extensive jaw defects with prefabricated microvascular fibula transplants and ITI implants [in German]. Mund Kiefer Gesichtschir 2000;4:365–372. 12. Fan S, Tang QL, Lin YJ, et al. A review of clinical and histological parameters associated with contralateral neck metastases in oral squamous cell carcinoma. Int J Oral Sci 2011;3:180–191. 13. Yu P, Chang EI, Hanasono MM. Design of a reliable skin paddle for the fibula osteocutaneous flap: perforator anatomy revisited. Plast Reconstr Surg 2011;128:440–446. 14. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol 2010;11:1001–1008. 15. Jewer DD, Boyd JB, Manktelow 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; discussion 404–405. 16. Pruyn JF, de Jong PC, Bosman LJ, et al. Psychosocial aspects of head and neck cancer – a review of the literature. Clin Otolaryngol Allied Sci 1986;11:469–474. 17. Chang YM, Santamaria E, Wei FC, et al. Primary insertion of osteointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction. Plastic Reconstr Surg 1998;102:680–688. 18. Ortiz Monasterio F, Santamarıa E, Morales D, Morales C, Yudovich M, Sanchez Ramos F. Reconstruction of the premaxilla: an option for mutilated bilateral clefts. J Craniofac Surg 2009;20 Suppl 2:1768–1770. 19. Chiapasco M, Biglioli F, Autelitano L, Romeo E, Brusati R. Clinical outcome of dental implants placed in fibula-free flaps used for the reconstruction of maxillo-mandibular defects following ablation for tumors or osteoradionecrosis. Clin Oral Implants Res 2006;17:220–228. 20. Chang YM, Chan CP, Shen YF, Wei FC. Soft tissue management using palatal mucosa around endosteal implants in vascularized composite grafts in the mandible. Int J Oral Maxillofac Surg 1999;28:341–343. 21. Carls FR, Jackson IT, Behl AK, Lebeda R, Webster H. Prefabrication of mucosa-lined flaps: a preliminary study in the pig model. Plast Reconstr Surg 1998;101:1022–1028. 22. Nazerani S, Behnia H, Motamedi MH. Experience with the prefabricated free fibula flap for reconstruction of maxillary and mandibular defects. J Oral Maxillofac Surg 2008;66:260–264. 23. Pfister DG, Ang KK, Brizel DM, et al. Head and neck cancers, version 2.2013. Featured updates to the NCCN guidelines. J Natl Compr Canc Netw 2013;11:917–923.

Intraoral lining with the fibular osteomyofascial flap without a skin paddle during maxillary and mandibular reconstruction.

To achieve an ideal intraoral lining, we harvest the fibular osteomyofascial flap to avoid the common embarrassment caused by the fibular osteomyocuta...
2MB Sizes 0 Downloads 7 Views