The radial forearm flap as a carrier for the osteocutaneous fibula graft in mandibular reconstruction

According to the concept of a free flap carrier we transferred an osteocutaneous fibula graft after microanastomosis to a pedicled radial forearm flap for reconstruction of the lower face in a patient with a total occlusion of the left and a subtotal occlusion of the right common carotid artery. The fibula was osteotomized in three segments to form the new mandible, and the skin paddle was placed extraorally. An external fixation device was connected to the radial bone, and a halo frame was fixed to the skull, and the forearm was thus stabilized rigidly in a suitable position. After 2 weeks, serial occlusion of the pedicle was begun twice daily. Blood flow and haemoglobin oxygenation of the skin paddle were measured by laser Doppler flowmetry and photometry. At the 14th day of ischaemic preconditioning, the flap could tolerate 3h of occlusion. Then the carrier vessels and the forearm flap were excised. The flap survived completely based on neovascularization from the recipient site.     

Oral rehabilitation after mandibular reconstruction using an osteocutaneous fibula free flap with endosseous implants. Factors affecting the functional outcome in patients with oral cancer

BACKGROUND: The development of endosseous implants and free vascularized bone grafting has permitted increased possibilities of oromandibular reconstruction in patients with oral cancer. In this study, a concept combining surgical and prosthodontic treatments for mandibular fibula free flap reconstruction after tumor surgery was made based on a classification of bone defects. A follow-up study was performed to evaluate the treatment concept for oral rehabilitation in order to identify possible factors which may influence the functional result. MATERIAL AND METHODS: A follow-up examination included 28 patients who underwent the ablative tumor surgery and mandibular reconstruction during a 4-year period. The follow-up protocol included clinical examination, radiological evaluation, and an interview using a standardized questionnaire. The timing of the study was set to allow for a minimum 2-year follow-up (mean 45 months). RESULTS AND CONCLUSION: At the time of examination, prosthesis-based oral rehabilitation was completed in six patients (21%), and the prosthodontic work was still unfinished in four other patients. The other 18 had no dental prosthetic rehabilitation. Thirteen patients received a total of 37 oral implants, and 23 implants were functionally loaded. No implant loss was recorded. Oral functions such as speech, diet tolerance and oral competence were not directly affected by the presence of dentures. A decisive factor affecting the oral function was the extent of soft-tissue loss. According to the classification described here, the extent of the mandibular defect did not correlate with oral functions. The application of oral implants seemed to be advantageous for the oral rehabilitation of patients who had undergone intraoral resections.     

胸大肌肌皮瓣修复口腔癌术后缺损并发症原因分析

目的:分析胸大肌肌皮瓣修复口腔癌术后缺损出现并发症的原因。方法:对40例晚期口腔癌患者行扩大根治术后采用胸大肌肌皮瓣修复口内组织缺损,对出现并发症的原因进行总结分析。结果:1例皮瓣部分坏死(2.5%),2例术后伤口裂开形成颏下瘘管(5%),2例颈部伤口感染(5%)。结论:细致的手术操作,术中充分止血,术后通畅的引流及口腔护理可有效避免并发症的发生,提高胸大肌肌皮瓣的移植成活率。     

Stable vertical distraction osteogenesis of highly atrophic mandibles after ablative tumour surgery of the oral cavity – a salvage pathway for mandibular reconstruction prior to oral rehabilitation with dental implants

Mandibular reconstruction is still a challenge for surgeons. Distraction osteogenesis (DO) might contribute in certain instances to solve this problem. A principal advantage of DO is the expansion of the surrounding soft tissues that accompanies the bony regeneration. In addition there is no donor site morbidity when compared with reconstruction by autologous bone grafting. However its application may be limited by the thinness of the mandible and the attendant fracture risk.This article describes a technique that combines stable internal fixation with vertical distraction of the alveolar ridge in six patients with critical mandibular thickness after ablative surgery for cancer of the oral cavity. Prior to implant insertion for further prosthodontic restoration stable vertical mandibular distraction produced an additional 11–20 mm. Improvement of the surrounding soft tissues, especially intraorally was achieved and dental implants were inserted after bony consolidation.This method can be a useful salvage technique for the augmentation of the atrophic mandible in patients who are not able or willing to undergo the risks and disadvantages of established methods such as free autologous bone transfer or microsurgical techniques.     

经口内入路切除下颌骨良性肿瘤及同期血管化腓骨肌瓣精确重建下颌骨

目的： 首次介绍口内入路行下颌骨良性肿瘤切除和显微血管吻合的腓骨肌瓣即刻精确重建的经验。方法： 2018年1月—3月,对我科收治的4例下颌骨良性肿瘤患者行经口内入路的下颌骨节断性切除及显微血管吻合的腓骨肌瓣即刻重建术。3例术前行虚拟手术计划设计,并行钛板数字化压模成型。术中先在口内颊部显露面动、静脉并保护,按截骨导板完成下颌骨节断性切除和腓骨瓣塑形、钛板固定后,用导航验证重建下颌骨的位置。显微镜下将腓动脉与面动脉作端-端吻合,腓静脉与面静脉用微血管吻合器Coupler吻合。术后常规采用手提超声多普勒监测血管血流信号;术后1周复查全景片,检查重建下颌骨的位置。结果： 4例患者均顺利完成经口内入路的下颌骨节断性切除、腓骨重建,其中3例顺利完成口内显微血管吻合,1例因术区瘢痕、面静脉不理想而引至下颌下吻合。术后超声多普勒监测显示血流信号正常,口内及供区伤口均一期愈合。术中导航及术后全景片显示重建的下颌骨位置理想,咬合关系正常,面部外形对称,无面瘫及开口受限。结论： 经口内入路行下颌骨良性肿瘤的节断性切除及腓骨肌瓣精确重建和口内显微血管吻合是完全可行的,能够达到口外入路同样的效果,同时口外无瘢痕。     

Long-term quality of life measured by the University of Washington QoL questionnaire (version 4) in patients with oral cancer treated with or without reconstruction with a microvascular free flap

We used the University of Washington Quality of Life (UW-QoL) questionnaire (version 4) to assess the long-term quality of life (QoL) of patients with oral squamous cell carcinoma treated with or without reconstruction with a microvascular free flap, and all patients with T2–T4 oral squamous cell carcinoma (SCC) treated in this way were eligible for the study. A total of 139 patients’ personal details, medical history, and QoL scores were collected and analysed. The mean (SD) overall QoL score was 73.09 (14.8) for patients with T2–T4 oral SCC. The mean (SD) global QoL scores of patients who had had reconstructions was 75.68 (13.85) and of patients who had not 71.00 (15.34) (t = 1.864, df = 137, p = 0.064). Univariate and multivariate analyses indicated that site of tumour, T stage, and the need for postoperative radiotherapy had significant effects on the global QoL scores. Among patients with T2 oral SCC there was no significant difference between patients who did and did not have reconstructions. However, there were significant differences among patients with T3/T4 SCC in scores for appearance, recreation, mood, anxiety, chewing, swallowing, and speech depending on whether they did or did not have reconstructions. There were significant differences in the domains recreation, chewing, speech, and taste, depending on the primary site of the tumour. We conclude that reconstruction with a microvascular free flap had a beneficial effect on the treatment of SCC and improved the QoL of patients with oral SCC.