Acta Oto-Laryngologica
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Primary Mandibular Reconstruction After Ablative Cancer Surgery Kimmo Lehtimäki & Juhani Pukander To cite this article: Kimmo Lehtimäki & Juhani Pukander (1992) Primary Mandibular Reconstruction After Ablative Cancer Surgery, Acta Oto-Laryngologica, 112:sup492, 160-163 To link to this article: http://dx.doi.org/10.3109/00016489209136838
Published online: 08 Jul 2009.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [University of Sydney Library]
Date: 24 October 2015, At: 15:49
Acta Otolaryngol (Stockh) 1992; Suppl. 492: 160- 163
Primary Mandibular Reconstruction After Ablative Cancer Surgery KIMMO LEHTIMAKI and JUHANI PUKANDER From the Deparfmenf of Otolaryngology, Tampere Uniuersity Central Hospital, Tampere, Finland
Downloaded by [University of Sydney Library] at 15:49 24 October 2015
Lehtimaki K, Pukander J. Primary mandibular reconstruction after ablative cancer surgery. Acta Otolaryngology (Stockh) 1992; Suppl 492: 160- 163. Restoring of the oral functions is one of the most complicated procedures in head and neck cancer surgery. For the moment “primary reconstruction” using functionally stabile reconstruction plates in recontouring and stabilizing of the remaining mandibular stumps after tumour extirpation is becoming increasingly popular. The aim of the present study was to evaluate treatment results and complications of primary reconstruction after major tumour surgery. Key words: oral cancer, mandibular, reconstruction plafes.
MATERIAL AND METHODS Our study material comprised all patients who underwent mandibular resection in Tampere University Central Hospital during a 3-year period from the 1st of September 1986 to the end of August 1989. During this period 21 patients were operated on with the use of reconstruction plates. Evaluation of the results was done at the end of February, 1990 giving a follow-up time of 6-42 months. Sixty-seven percent of the patients were males. The mean age was about 60 years with range varying from 3 to 84 years, the youngest patient being a 3-year-old girl with aggressive odontogenic fibroma (Table I). Including gingival carcinomas in mandibular tumours, 13 of the neoplasms were classified as primary mandibular, of the remaining 8 tumours originating from other parts of the mouth and just invaded the mandible. Histologically the most common tumour was squamous cell carcinoma, representing some 70% of all cases (Table 11). TNM classification of the patients showed that at the time of the diagnosis, 72% of the malignant tumours were of size T, or bigger (Table 111). SURGICAL TECHNIQUE The first 12 early cases were reconstructed with AO-steel plates, after the Wurzburg titanium reconstruction plates became available these were used in the remaining 9 patients. However, in one of the Wurzburg cases two very long miniplates were used because the standard plates were too long for the child-patient. Five of the plates also had condylar prosthesis. In addition to the use of stabilizing plates, reconstructions included the repair of soft tissues, and in some cases also primary reconstruction of bony defects. In 6 cases the soft tissue defect could be closed by primary suturing without any distant flaps. All benign tumours were in this group. When distant flaps were needed in soft tissue defect reconstruction, the pectoralis major myocutaneous flap was used, though one patient required a secondary reconstruction with deltopectoral flap. The results of the bone replacement methods varied much more. In 12 cases (57%) we did not replace the resected bone primarily at all. In those cases, recontouring of the mandibular arch and stabilization of the stumps were based solely in the reconstruction plates.
Mandibular reconstruction
Table I. Age and sex distribution of the patients Males Females Mean age Range
14 (67%) 7 (33%) 59.8 years 3-84 years
Downloaded by [University of Sydney Library] at 15:49 24 October 2015
Table 11. Distribution of turnours according to histological type Squamous cell ca Muco-epidennoid ca Adenocystic ca Malignant histiocytoma Ameloblastoma Keratocyst Odontogenic fibroma Total
21 patients
Table 111. T N M classification of the malignant turnours 4 patients 5 patients 3 patients 1 patient 1 patient 3 patients 1 patient Total
18 patients
Free iliac crest grafts were used in 3 cases, 2 of them being primary closure cases and one in combination with pectoralis major flap. Six of the pectoralis major flaps were designed as osetomyocutaneous with a segment of the 4th or 5th rib. RESULTS Ten cases of reconstruction were successful, the plates nicely situated inside the tissues and with good function (Table IV). There were temporary problems in 2 cases of pectoralis major osteomyocutaneous flaps when both the rib segments were practically lost because of infection and resorption. After the bony infection had resolved, secondary granulation covered the extruded plates. In 7 cases the primary reconstructions failed because the plates kept extruding. However, the results show that the primary reconstruction was successful in 59% of the 17 patients who survived for more than one year. In 10 of those 17 patients the primary reconstruction included only soft tissue repair and 7 of them healed without any problems, resulting in a success rate of 70%. In 7 cases a bone graft was included in the primary reconstruction. Only 1 free iliac crest case healed without problems. She was the the 3-year-old girl with odontogenic fibroma. In
161
162 K . Lehtimaki and J . Pukander Table IV. Primary treatment results vs. reconstruction methods* Healing without problems
primary closure primary closure with free crest pectoralis major myocutaneous Temporary extrusion of the plate pectoralis major with
Downloaded by [University of Sydney Library] at 15:49 24 October 2015
Local healing uncomplicated-died
2 patients 1 patient 3 patients 2 patients of other problems
pectoralis major myocutaneous deltopectoral Permanent extrusion of the plate primary closure primary closure with free crest pectoralis major myocutaneous pectoralis major with free crest pectoralis major with rib Total
1 patient
I patient I I 2 I 2
patient patient patients patient patients
17 patients
*4 cases of primary postoperative deaths are not included.
2 cases of pectoralis major osteomyocutaneous flaps the ribs got lost although the plates were succesfully placed. In 4 bone graft cases the plates came out and were removed. Two of them were free iliac creast cases. However, part of the transplanted bone remained vital and could be used in second state reconstructions. Eight patients died after the operation. All deaths happened during the first postoperative year. Four patients died postoperatively from systemic cardiovascular complications, but no fatal regional surgical complication occurred. Of the 4 patients who survived the immediate postoperative period, but died during the first postoperative year the reasons were: two local recurrences in connection with poor general condition, one massive metastases and one death not related to the tumour or the operation. The main local complication was extrusion of the plates in 7 cases of whom 2 were, however, only temporary. When adding these 2 temporary extrusions to these 6 patients who had no healing problems, the success rate of primary reconstruction among these cases who survived for more than 1 year was 62%. Six of the plates had to be removed because of extrusion and infection. After that the fistulas closed spontaneously in all cases. DISCUSSION Concerning sex, age, anatomical locations and histological distributions our material was comparable to the well known epidemiological characteristics of oral tumours. Also the primary TNM-classification was similar with that of other recently published material ( 1,2). The reconstruction methods we used are primarily based on the classical idea of functionally stabile reconstruction plates developed by the AO-team and especially by Spiessl in 1976 (3). On the other hand, in soft tissue replacements we used mainly the pectoralis major myocutaneous flap described first by Ariyan (4) in 1979. In 9 of our 21 cases we completed the reconstructions with primary bone grafts. Three of them were free iliac grafts and in 6 cases the pectoralis major flap was done osteomyocutaneously with the 4th or 5th rib.
Downloaded by [University of Sydney Library] at 15:49 24 October 2015
Mandibular reconstruction
Our patients experienced reasonably many postoperative general and local healing problems, which seem to be quite common in this type of surgery. According to a review by Wenig & Keller (5) the complication rates were 54-67% (local) and 35% (general). Extrusion of the plate was the main local problem and could be considered as a failure of the whole treatment process. However, this was not the case in the present study. Though the extruded plate had to be removed it had acted as a temporary tissue expander and stabilizator. That is why the degree of collapses or shrinking of the tissues were surprisingly small. Also the persistent fistulas closed spontaneously in all cases. In our material the local complications were clearly related to the patients operated on with bone grafts. This is an observation also made by Lam et al. (6) and Baek et al. (7). In fact, Baek’s conclusion was not to use rib segments in connection with pectoralis major flaps. Also the AO-team have recommended to leave bony reconstruction to second phase operations (8). This is in accordance with our experience, too. In recent years there has been growing interest in the use of free microvascularized composite flaps for reconstruction of resected mandibles and surrounding tissues (5, 9). The results have been very encouraging and this technique may lead to a “revolution” in reconstructive surgery after major cancer ablations of the mandible. REFERENCES I. Hemprich A, Miiller R-P. Long term results in treating squamous cell carcinoma of the lip, oral cavity and oropharnyx. Int J Oral Maxillofac Surg 1989; 18: 39. 2. Soderholm A-L, Lindqvist C, Laine P, Kontio R. Primary reconstruction of the mandible in cancer surgery. Int J Oral Maxillofac Surg 1988; 17: 198. 3. Spiessl B, Prein Y,Schmoker R. Anatomical reconstruction and functional rehabilitation of mandibular defects after ablative surgery. In: Spiessl B, New concepts in maxillofacial bone surgery. Berlin: Springer, 1876, 160. 4. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979; 63: 73. 5. Wenig BL, Keller AJ. Rigid internal fixation and vascularized bone grafting in mandibular reconstruction. Clin Plast Surg 1989; 16: 125. 6. Lam KH, Wei WI, Siu KF. The pectoralis major costomyocutaneous flaps for mandibular reconstruction. Plast Reconstr Surg 1984; 73: 905. 7. Baek S-M, Lawson W, Biller HF. An analysis of 133 pectoralis major myocutaneous flaps. Plast Reconstr Surg 1982; 69: 460. 8. Spiessl B. Internal fixation of the mandible. Berlin: Springer Verlag, 1989. 9. Taylor GI, Townsend P, Russel C. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Plast Reconstr Surg 1979; 64: 745. Address for correspondence: Juhani Pukander, Department of Clinical Sciences, University of Tampere, Teiskontie 35, SF-33520 Tampere, Finland
163
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Primary Mandibular Reconstruction After Ablative Cancer Surgery Kimmo Lehtimäki & Juhani Pukander To cite this article: Kimmo Lehtimäki & Juhani Pukander (1992) Primary Mandibular Reconstruction After Ablative Cancer Surgery, Acta Oto-Laryngologica, 112:sup492, 160-163 To link to this article: http://dx.doi.org/10.3109/00016489209136838
Published online: 08 Jul 2009.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [University of Sydney Library]
Date: 24 October 2015, At: 15:49
Acta Otolaryngol (Stockh) 1992; Suppl. 492: 160- 163
Primary Mandibular Reconstruction After Ablative Cancer Surgery KIMMO LEHTIMAKI and JUHANI PUKANDER From the Deparfmenf of Otolaryngology, Tampere Uniuersity Central Hospital, Tampere, Finland
Downloaded by [University of Sydney Library] at 15:49 24 October 2015
Lehtimaki K, Pukander J. Primary mandibular reconstruction after ablative cancer surgery. Acta Otolaryngology (Stockh) 1992; Suppl 492: 160- 163. Restoring of the oral functions is one of the most complicated procedures in head and neck cancer surgery. For the moment “primary reconstruction” using functionally stabile reconstruction plates in recontouring and stabilizing of the remaining mandibular stumps after tumour extirpation is becoming increasingly popular. The aim of the present study was to evaluate treatment results and complications of primary reconstruction after major tumour surgery. Key words: oral cancer, mandibular, reconstruction plafes.
MATERIAL AND METHODS Our study material comprised all patients who underwent mandibular resection in Tampere University Central Hospital during a 3-year period from the 1st of September 1986 to the end of August 1989. During this period 21 patients were operated on with the use of reconstruction plates. Evaluation of the results was done at the end of February, 1990 giving a follow-up time of 6-42 months. Sixty-seven percent of the patients were males. The mean age was about 60 years with range varying from 3 to 84 years, the youngest patient being a 3-year-old girl with aggressive odontogenic fibroma (Table I). Including gingival carcinomas in mandibular tumours, 13 of the neoplasms were classified as primary mandibular, of the remaining 8 tumours originating from other parts of the mouth and just invaded the mandible. Histologically the most common tumour was squamous cell carcinoma, representing some 70% of all cases (Table 11). TNM classification of the patients showed that at the time of the diagnosis, 72% of the malignant tumours were of size T, or bigger (Table 111). SURGICAL TECHNIQUE The first 12 early cases were reconstructed with AO-steel plates, after the Wurzburg titanium reconstruction plates became available these were used in the remaining 9 patients. However, in one of the Wurzburg cases two very long miniplates were used because the standard plates were too long for the child-patient. Five of the plates also had condylar prosthesis. In addition to the use of stabilizing plates, reconstructions included the repair of soft tissues, and in some cases also primary reconstruction of bony defects. In 6 cases the soft tissue defect could be closed by primary suturing without any distant flaps. All benign tumours were in this group. When distant flaps were needed in soft tissue defect reconstruction, the pectoralis major myocutaneous flap was used, though one patient required a secondary reconstruction with deltopectoral flap. The results of the bone replacement methods varied much more. In 12 cases (57%) we did not replace the resected bone primarily at all. In those cases, recontouring of the mandibular arch and stabilization of the stumps were based solely in the reconstruction plates.
Mandibular reconstruction
Table I. Age and sex distribution of the patients Males Females Mean age Range
14 (67%) 7 (33%) 59.8 years 3-84 years
Downloaded by [University of Sydney Library] at 15:49 24 October 2015
Table 11. Distribution of turnours according to histological type Squamous cell ca Muco-epidennoid ca Adenocystic ca Malignant histiocytoma Ameloblastoma Keratocyst Odontogenic fibroma Total
21 patients
Table 111. T N M classification of the malignant turnours 4 patients 5 patients 3 patients 1 patient 1 patient 3 patients 1 patient Total
18 patients
Free iliac crest grafts were used in 3 cases, 2 of them being primary closure cases and one in combination with pectoralis major flap. Six of the pectoralis major flaps were designed as osetomyocutaneous with a segment of the 4th or 5th rib. RESULTS Ten cases of reconstruction were successful, the plates nicely situated inside the tissues and with good function (Table IV). There were temporary problems in 2 cases of pectoralis major osteomyocutaneous flaps when both the rib segments were practically lost because of infection and resorption. After the bony infection had resolved, secondary granulation covered the extruded plates. In 7 cases the primary reconstructions failed because the plates kept extruding. However, the results show that the primary reconstruction was successful in 59% of the 17 patients who survived for more than one year. In 10 of those 17 patients the primary reconstruction included only soft tissue repair and 7 of them healed without any problems, resulting in a success rate of 70%. In 7 cases a bone graft was included in the primary reconstruction. Only 1 free iliac crest case healed without problems. She was the the 3-year-old girl with odontogenic fibroma. In
161
162 K . Lehtimaki and J . Pukander Table IV. Primary treatment results vs. reconstruction methods* Healing without problems
primary closure primary closure with free crest pectoralis major myocutaneous Temporary extrusion of the plate pectoralis major with
Downloaded by [University of Sydney Library] at 15:49 24 October 2015
Local healing uncomplicated-died
2 patients 1 patient 3 patients 2 patients of other problems
pectoralis major myocutaneous deltopectoral Permanent extrusion of the plate primary closure primary closure with free crest pectoralis major myocutaneous pectoralis major with free crest pectoralis major with rib Total
1 patient
I patient I I 2 I 2
patient patient patients patient patients
17 patients
*4 cases of primary postoperative deaths are not included.
2 cases of pectoralis major osteomyocutaneous flaps the ribs got lost although the plates were succesfully placed. In 4 bone graft cases the plates came out and were removed. Two of them were free iliac creast cases. However, part of the transplanted bone remained vital and could be used in second state reconstructions. Eight patients died after the operation. All deaths happened during the first postoperative year. Four patients died postoperatively from systemic cardiovascular complications, but no fatal regional surgical complication occurred. Of the 4 patients who survived the immediate postoperative period, but died during the first postoperative year the reasons were: two local recurrences in connection with poor general condition, one massive metastases and one death not related to the tumour or the operation. The main local complication was extrusion of the plates in 7 cases of whom 2 were, however, only temporary. When adding these 2 temporary extrusions to these 6 patients who had no healing problems, the success rate of primary reconstruction among these cases who survived for more than 1 year was 62%. Six of the plates had to be removed because of extrusion and infection. After that the fistulas closed spontaneously in all cases. DISCUSSION Concerning sex, age, anatomical locations and histological distributions our material was comparable to the well known epidemiological characteristics of oral tumours. Also the primary TNM-classification was similar with that of other recently published material ( 1,2). The reconstruction methods we used are primarily based on the classical idea of functionally stabile reconstruction plates developed by the AO-team and especially by Spiessl in 1976 (3). On the other hand, in soft tissue replacements we used mainly the pectoralis major myocutaneous flap described first by Ariyan (4) in 1979. In 9 of our 21 cases we completed the reconstructions with primary bone grafts. Three of them were free iliac grafts and in 6 cases the pectoralis major flap was done osteomyocutaneously with the 4th or 5th rib.
Downloaded by [University of Sydney Library] at 15:49 24 October 2015
Mandibular reconstruction
Our patients experienced reasonably many postoperative general and local healing problems, which seem to be quite common in this type of surgery. According to a review by Wenig & Keller (5) the complication rates were 54-67% (local) and 35% (general). Extrusion of the plate was the main local problem and could be considered as a failure of the whole treatment process. However, this was not the case in the present study. Though the extruded plate had to be removed it had acted as a temporary tissue expander and stabilizator. That is why the degree of collapses or shrinking of the tissues were surprisingly small. Also the persistent fistulas closed spontaneously in all cases. In our material the local complications were clearly related to the patients operated on with bone grafts. This is an observation also made by Lam et al. (6) and Baek et al. (7). In fact, Baek’s conclusion was not to use rib segments in connection with pectoralis major flaps. Also the AO-team have recommended to leave bony reconstruction to second phase operations (8). This is in accordance with our experience, too. In recent years there has been growing interest in the use of free microvascularized composite flaps for reconstruction of resected mandibles and surrounding tissues (5, 9). The results have been very encouraging and this technique may lead to a “revolution” in reconstructive surgery after major cancer ablations of the mandible. REFERENCES I. Hemprich A, Miiller R-P. Long term results in treating squamous cell carcinoma of the lip, oral cavity and oropharnyx. Int J Oral Maxillofac Surg 1989; 18: 39. 2. Soderholm A-L, Lindqvist C, Laine P, Kontio R. Primary reconstruction of the mandible in cancer surgery. Int J Oral Maxillofac Surg 1988; 17: 198. 3. Spiessl B, Prein Y,Schmoker R. Anatomical reconstruction and functional rehabilitation of mandibular defects after ablative surgery. In: Spiessl B, New concepts in maxillofacial bone surgery. Berlin: Springer, 1876, 160. 4. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979; 63: 73. 5. Wenig BL, Keller AJ. Rigid internal fixation and vascularized bone grafting in mandibular reconstruction. Clin Plast Surg 1989; 16: 125. 6. Lam KH, Wei WI, Siu KF. The pectoralis major costomyocutaneous flaps for mandibular reconstruction. Plast Reconstr Surg 1984; 73: 905. 7. Baek S-M, Lawson W, Biller HF. An analysis of 133 pectoralis major myocutaneous flaps. Plast Reconstr Surg 1982; 69: 460. 8. Spiessl B. Internal fixation of the mandible. Berlin: Springer Verlag, 1989. 9. Taylor GI, Townsend P, Russel C. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Plast Reconstr Surg 1979; 64: 745. Address for correspondence: Juhani Pukander, Department of Clinical Sciences, University of Tampere, Teiskontie 35, SF-33520 Tampere, Finland
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