Mandibular Reconstruction Using Osteocutaneous Radial ... - JCPSP

ORIGINAL ARTICLE

Mandibular Reconstruction Using Osteocutaneous Radial Forearm Flap

Mamoon Rashid1, Muhammad Sarmad Tamimy2 Sabeen Masroor3, Muhammad Zia-ul-Islam4, Tahir Manzoor5, Saad-ur-Rehman Sarwar6 and Nauman Tariq7

ABSTRACT Objective: To describe the use of radial forearm osteocutaneous free flap in complex mandibular reconstruction. Study Design: A case series. Place and Duration of Study: Combined Military Hospital, Rawalpindi, from January 1998 to January 2008. Methodology: Patients having a small bony component and a large soft tissue mandibular defect requiring reconstruction were selected. These defects include composite through-and-through defects of the cheek in the retromolar trigone, small lateral bony defects with large intra and extra oral soft tissue defects and small central bony defects with large extra oral tissue loss. Radial forearm osteocutaneous free flap was employed. Complications and graft acceptance were determined at follow-up. Results: Patients were followed-up for an average period of 28 months. Complications occurred in 8 patients. Wound infection and partial wound dehiscence were the most common complication observed in 3 patients. Non-union at recipient site was seen in 2 patients. Flap donor site healed uneventfully in all patients with no fractures at the donor site. Conclusion: The radial forearm osteocutaneous flap covers oromandibular defects with large intra-oral and extra oral soft tissue losses. Lateral and anterior mandibular defects were reconstructed satisfactorily in our series. Key words:

Micro-vascular surgery. Osteocutaneous radial forearm free flap. Mandibular reconstruction.

INTRODUCTION Micro-vascular free tissue transfer of osteocutaneous flaps has become the mainstay of reconstruction for composite mandibular defects. The commonly used free flaps are the fibular flap, the radial forearm flap, deep circumflex iliac artery (DCIA) flap and the scapular flap. The radial forearm osteocutaneous free flap (RFOFF) has waxed and waned in popularity for mandibular reconstruction despite being one of the first osteocutaneous free flaps to be used widely.1 It is relatively easy to harvest and it has the added advantage of very high survival rates. The consistent anatomy and long vascular pedicle allows for the use of contralateral neck 1

2

3

4 5 6

7

Department of Plastic Surgery, Shifa International Hospital, Islamabad. Department of Plastic Surgery, Combined Military Hospital, Pano Aqil. Department of Plastic Surgery, The Aga Khan University Hospital, Karachi. Department of Plastic Surgery, PNS Shifa, Karachi. Department of ENT, Combined Military Hospital, Rawalpindi. Department of Plastic Surgery, Fauji Foundation Hospital, Rawalpindi. Department of Plastic Surgery, Combined Military Hospital, Rawalpindi. Correspondence: Dr. Mamoon Rashid, 185, The Haven, Lane 7, Gulreiz II, Rawalpindi. E-mail: [email protected] Received November 03, 2009; accepted May 29, 2012.

vessels in case of unavailability of ipsilateral recipient vessels. The skin paddle is not only abundant in its dimensions, but also thin and pliable for reconstruction of complex oromandibular defects.2 The main concerns precluding the widespread use of RFOFF in mandibular reconstruction are the quality and quantity of bone stock and concerns regarding the donor site morbidity.2,3 The objective of this study was to describe the use of radial forearm osteocutaneous free flap in complex mandibular reconstruction.

METHODOLOGY This case series included 56 cases of mandibular reconstruction by RFOFF between January 1998 and January 2008 at Combined Military Hospital, Rawalpindi. Pre-operative variables reviewed were age and gender of the patient, tumour type and previous history of radiation. The study was approved by the institutional ethics committee and the subjects gave written informed consent. The treatment protocol included case discussion and examination of the patients in a Combined Head and Neck Cancer Clinic.4 Pre-operative work-up included biopsy of the lesion, fine needle aspiration cytology (FNAC) of the neck glands, chest X-rays, panoramic views of the mandible and CT scan of the lesion. The patients suitable for surgical resection were selected and an appropriate plan for reconstruction was made

Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (8): 519-523

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Mamoon Rashid, Muhammad Sarmad Tamimy, Sabeen Masroor, Muhammad Zia-ul-Islam, Tahir Manzoor, Saad-ur-Rehman Sarwar and Nauman Tariq

depending on the expected requirement of bone and soft tissue. All patients underwent tumour resection and neck dissection by the Head and Neck Surgeons, followed by immediate reconstruction by the plastic surgery team. The patients had a bone scan between the third and fifth postoperative day. Adjuvant radiotherapy was started following healing of the wounds. The flap was designed on the forearm by reverse planning. Flap elevation was done with tourniquet control and under loupe magnification. Flap was based on the distal 10 cm of the radius, sparing the styloid process. Soft-tissue was elevated in a standard manner used for radial forearm flap elevation. The bone was harvested using side-cutting burs in a 'boat-shaped' fashion between the insertion of pronator teres and brachioradialis and was limited to one-third of the circumference of the cortex. Meticulous closure of all exposed tendons and bone was done by muscle approximation over them. The donor site was then skin grafted and the forearm was protected in a below elbow plaster of Paris cast for 2 - 4 weeks. Bone inset was done using dental wires. The patients were followed-up in the clinic monthly for the first 6 months, 3 monthly for the next 18 months and 6 monthly thereafter. Clinical examination was carried out during each follow-up visit for recurrence, complications, function and aesthetic result. Scoring was done for the aesthetic and functional outcomes.

were 2 cases (3.57%) of bony non-union at recipient site. There was one case (1.78%) each of marginal flap necrosis, orocutaneous fistula, necrosis of native cheek skin and tumour recurrence. Most importantly, there were no fractures of the radius and donor site healing was uneventful. As shown in Table I, there was good aesthetic and functional outcome in most of the cases, after reconstruction.

Figure 1: Post-resection segmental mandibular and soft tissue defect.

Ratio was calculated for gender distribution. Mean and standard deviation values were calculated for age distribution, radial bone length harvested, age distribution, flap skin and bone length, follow-up period and aesthetic outcome. Percentages were calculated for the pathology of the operated lesions, distribution of the defects, the side of anastomosis, postoperative radiotherapy cases and complications. All the analysis was done using Statistical Package for Social Sciences (SPSS 10.0).

RESULTS The male to female ratio was 2:1, age of the patients ranged from 24 to 72 years (mean 48 ± 2.5 years) (Table I). Squamous cell carcinoma was the most common pathology seen occurring in 46 cases (82.14%). There were 36 lateral mandibulectomy (64.28%), 9 anterior mandibulectomy defects (16.07%) and 11 composite defects (19.64%) involving retro-molar trigone (Figures 1 and 2). Flap's skin dimensions ranged from 6 x 9 cm to 12 x 18 cm and the bone length was ranging from 6 to 10 cm (mean 7 ± 1.05 cm). Anastomosis was done on ipsilateral neck in 37 cases (66.07%) and contralateral neck in 19 cases (33.92%). Twelve cases (21.42%) received postoperative radiotherapy. The follow-up ranged from 18 to 60 months with a mean of 28 months (Figure 3). The commonest complications were wound infection, partial dehiscence and partial graft loss at donor site, each occurring in 3 patients (5.35%). There 520

Figure 2: Reconstruction with RFOFF.

Figure 3: Follow-up radiograph after 2 years.


Mandibular reconstruction using osteocutaneous radial forearm flap

Table I: Postoperative outcome. Parameter

Mean /No. (SD/Percent)

Follow-up Range

18 - 60 months

Mean

28 (+ 2) months

Flap survival

56 (100%)

Complications Wound dehiscence

3 (5.35%)

Marginal flap necrosis

1 (1.78%)

Oro-cutaneous fistula

1 (1.78%)

Cheek necrosis

1 (1.78%)

Infection requiring antibiotics

3 (5.35%)

Bone delayed /non-union

2 (3.57%)

Recurrence

1 (1.78%)

Donor site morbidity Partial graft loss

3 (3.57%)

Fracture radius

0

Mean postoperative aesthetic score (Excellent = 4, Good = 3, Fair = 2, Poor =1) Functional 0utcome

2.93 (+0.450)

Pre-operative

Postoperative

(Mean)

(Mean)

p-value

1.70 (+0.596)

2.41 (+0.507)

< 0.0001

1.50 (+0.507)

2.30 (+0.407)

< 0.0001

1.30 (+0.466)

1.97 (+0.103)

< 0.0001

1.45 (+0.504)

2.07 (+0.479)

< 0.0001

1.21 (+0.407)

2.65 (+0.479)

< 0.0001

Speech score (Normal = 3, Intelligible = 2, Un-intelligible = 1) Swallowing score (Normal = 3, Difficult = 2, Painful = 1) Drooling of saliva score (Absent = 2, Present = 1) Mouth opening score (Normal = 3, Restricted = 2, Severely restricted = 1) Oral hygiene score (Good = 3, Satisfactory = 2, Poor = 1)

DISCUSSION Reconstruction of composite oromandibular defects is best done with a flap having thin pliable soft tissue and vascularized bone. McKee was one of the first to perform micro-vascular osteocutaneous reconstruction and employed a vascularized rib for this purpose.5 With the introduction of the radial forearm flap by Song, plastic surgeons were quick to realize its potential in head and neck reconstruction.6,7 Today radial forearm free flap is still considered the gold standard for head and neck reconstruction to which newer flaps are compared.8-11 Soutter published a series in which he utilized osteocutaneous flaps for composite oromandibular defects.12 As this was one of the first osteocutaneous flaps used widely, it was employed for all types of bony defects which stretched the spectrum of its usage. Despite the initial enthusiasm, the flap started falling out of favour because of the poor bone stock and the high donor site fracture rates reported by some authors.13 In 1989, Hidalgo introduced the fibular flap for mandibular reconstruction which very quickly gained popularity.14

The fibula is currently the most commonly used flap for mandibular reconstruction.15,16 Despite its good and reliable bone stock, the skin paddle is of limited size, bulky and difficult to mould. Newer techniques for improving skin harvest with fibula have been described;17 still the skin paddle can be unreliable in about 9% of cases.18 The radial forearm osteocutaneous free flap is ideally suited for a subset of oromandibular defects in which soft tissue needs are more critical than the bony component. These defects include composite through and through defects of the cheek in the retro-molar trigone, small lateral bony defects with large intra-oral and extra-oral soft tissue loss, and small central bony defects with large extra-oral soft tissue loss. The long reliable vascular pedicle is also useful in postradiotherapy wounds requiring salvage, where ipsilateral vessels are poor and anastomosis can be done with contralateral vessels without the need for intervening vein grafts. Overall, the primary site longterm morbidity, donor site morbidity, and postoperative function of osteocutaneous radial forearm free flaps have been shown to be comparable to those of other commonly used osteocutaneous free flaps such as the fibula19 and scapula when used in single-stage oromandibular reconstruction.20 In a series of 60 mandibular defects reconstructed by RFOFF, the most commonly reconstructed defects were lateral and central-lateral (40%).21 In the present study the composite through and through cheek defect was found to be the best suited for reconstruction with RFOFF, because of the pliability of its soft tissue component that conforms well to both the intra-oral as well as the extra-oral component of the composite defect. The donor site fracture rate has been variously reported from zero to 30%.22-24 There has been no donor site fracture in the present study despite the fact that prophylactic internal fixation of the radius was not employed. This favourable result may be attributed to the bone harvest technique and the policy of careful patient selection. In this study, only those patients who required a thin segment of bone as a strut between two ends on the mandible were considered as suitable candidates for this flap. As many oral/mandibular tumour patients are edentulous to start with and in almost all cases require postoperative irradiation, future osteointegration is rendered less favourable. In this study, no attempt was made to harvest thicker bone for osteointegrated implants or for multiple osteotomies. When defect dynamics require multiple osteotomies or are suitable for osteo-integration / dental implants, the authors prefer sturdy bone flaps such as the fibula. In RFOFF the bone is carefully harvested in a boat-shaped manner limiting the bone thickness to one-third of the cortical circumference. Using this technique the


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Mamoon Rashid, Muhammad Sarmad Tamimy, Sabeen Masroor, Muhammad Zia-ul-Islam, Tahir Manzoor, Saad-ur-Rehman Sarwar and Nauman Tariq

authors have harvested upto 10 cm length of bone. Immobilization of the donor site by internal fixation has been shown to reduce incidence of donor radius fractures.24,25 However, in some cases an improper internal fixation can probably even increase the chances of fracture.26 In the present study, our method of immobilization has been external splinting using a plaster of Paris cast with favourable results. Similarly, there has been no graft loss or tendon exposure in this series which can be attributed to the coverage of exposed bone and tendons by muscles.

7.

Evans HB, Lampe HB. The radial forearm flap in head and neck reconstruction. J Otolaryngol 1987; 16:382-6.

8.

Kao HK, Chang KP, Wei FC, Cheng MH. Comparison of the medial sural artery perforator flap with the radial forearm flap for head and neck reconstructions. Plast Reconstr Surg 2009; 124: 1125-32.

9.

Tamimy MS, Rashid M, Islam MZ, Sarwar SR, Aman S, Aslam A. A comparison of free transfer of radial forearm and anterolateral thigh flaps for head and neck reconstruction. Eur J Plast Surg 2009; 32:95-102.

10. Valentini V, Cassoni A, Marianetti TM, Battisti A, Terenzi V, Iannetti G. Anterolateral thigh flap for the reconstruction of head and neck defects: alternative or replacement of the radial forearm flap? J Craniofac Surg 2008; 19:1148-53.

The complications in this series were minor and mostly amenable to limited debridement under local anaesthesia. Based on the experience of present study, the authors recommend radial forearm osteocutaneous flap as the flap of choice in most cases of through and through lateral cheek defects, small central and lateral composite defects with large soft tissue loss, composite defects of retro-molar trigone and, post-radiotherapy salvage. However, there has been a recent trend towards use of double free flaps for complex mandibular defects.27,28 The authors consider these the very cases, which may be dealt with by using only the RFOFF. The authors suggest that in future, randomized control trials comparing this flap with other osteocutaneous flaps and double free flaps may be conducted to define the exact indications and limitations of using RFOFF.

15. Papadopulos NA, Schaff J, Sader R, Kovacs L, Deppe H, Kolk A, et al. Mandibular reconstruction with free osteofasciocutaneous fibula flap: a 10 years experience. Injury 2008; 39:S75-82. Epub 2008 Aug 13.

CONCLUSION

16. Shah JP, Gil Z. Current concepts in management of oral cancersurgery. Oral Oncol 2009; 45:394-401. Epub 2008 Jul 31.

The use of osteocutaneous radial forearm free flap is an efficacious method for reconstructing the complex mandibular segmental defects especially where accompanied by extensive intra or extra oral soft tissue loss or through and through cheek defects. Disclosure: Presented in part at 10th International Congress on Oral Cancer, Crete, Greece, April 2005.

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Soutar DS, McGregor IA. The radial forearm flap in intraoral reconstruction: the experience of 60 consecutive cases. Plast Reconstr Surg 1986; 78:1-8.

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Richardson D, Fisher SE, Vaughan ED, Brown JS. Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg 1997; 99:109-15. Rashid M, Ahmad T, Ansari TN, Ahmed B, Ahmed S, Gul AA, et al. Management of oromandibular cancers. J Coll Physicians Surg Pak 2004; 14:29-34. McKee D. Microvascular rib transposition for reconstruction of the mandible [Internet]. Toronto: Annual Meeting of the American Society of Plastic Reconstructive Surgeons; 1971. Song R, Gao Y, Song Y, Yu Y, Song Y. The forearm flap. Clin Plast Surg 1982; 9:21-6.

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11. Paydarfar JA, Patel UA. Submental island pedicled flap vs. radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 2011; 137:82-7. 12. Soutar DS, Widdowson WP. Immediate reconstruction of the mandible using a vascularized segment of radius. Head Neck Surg 1986; 8:232-46.

13. Delacure M. Reconstruction of the mandible. Indian J Plast Surg 2007; 40:28-34. 14. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989; 84:71-9.

17. Yu P, Chang EI, Hanasono MM. Design of a reliable skin paddle for the fibula osteocutaneous flap: perforator anatomy revisited. Plast Reconstr Surg 2011; 128:440-6. 18. Disa JJ, Hidalgo DA. Mandible reconstruction. In: Thorne CH, editor. Grabb and Smith's plastic surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2007.p. 428-37. 19. Virgin FW, Iseli TA, Iseli CE, Sunde J, Carroll WR, Magnuson JS, et al. Functional outcomes of fibula and osteocutaneous forearm free flap reconstruction for segmental mandibular defects. Laryngoscope 2010; 120:663-7. 20. Militsakh ON, Werle A, Mohyuddin N, Toby EB, Kriet JD, Wallace DI, et al. Comparison of radial forearm with fibula and scapula osteocutaneous free flaps for oromandibular reconstruction. Arch Otolaryngol Head Neck Surg 2005; 131:571-5. 21. Thoma A, Khadaroo R, Grigenas O, Archibald S, Jackson S, Young JE, et al. Oromandibular reconstruction with the radialforearm osteocutaneous flap: experience with 60 consecutive cases. Plast Reconstr Surg 1999; 104:368-78. 22. Werle AH, Tsue TT, Toby EB, Girod DA. Osteocutaneous radial forearm free flap: its use without significant donor site morbidity. Otolaryngol Head Neck Surg 2000; 123:711-7. 23. Boorman JG, Brown JA, Sykes PJ. Morbidity in the forearm flap donor arm. Br J Plast Surg 1987; 40:207-12. 24. Avery CM. Review of the radial free flap: still evolving or facing extinction? Part two: osteocutaneous radial free flap. Br J Oral Maxillofac Surg 2010; 48:253-60. Epub 2010 Feb 4. 25. Karamanoukian R, Gupta R, Evans GR. A novel technique for


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26. Ya'ish F, Waton A, B'Durga H, Nanu A. Osteocutaneous radial forearm free flaps: prophylactic fixation of donor site using locking plate augmented with mineral cement. Hand Surg 2011; 16:215-22. 27. Posch NA, Mureau MA, Dumans AG, Hofer SO. Functional and

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28. Guillemaud JP, Seikaly H, Cote DW, Barber BR, Rieger JM, Wolfaardt J, et al. Double free-flap reconstruction: indications, challenges, and prospective functional outcomes. Arch Otolaryngol Head Neck Surg 2009 ; 135:406-10. l l l l l


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