Plate and iliac crest internal oblique free flap

The need for reconstruction of mandibular defects is either due to trauma or tumor resection. The vast majority of oral cavity tumors are squamous cell carcinoma, and these arise from the floor of mouth or adjacent alveolar mucosa. These tumors are therefore adjacent to the mandible and significant growth frequently leads to invasion of the bone.

A composite resection (segmental mandibulectomy) is the treatment of choice for oral malignant tumors that invade the mandibular cortex and marrow space. It provides an oncologically sound margin for these tumors; however, it disrupts the continuity of the mandible.

Reconstruction of the mandible allows for the restoration of form and function. It must address all the tissue losses in order to provide for the best function.

The general goal of reconstruction is the:

• Restoration/maintenance of airway
• Restoration of mandibular continuity
• Restoration of dentition
• Restoration of chewing (mastication) and swallowing (deglutition)
• Restoration of facial contour
• Consistently obtain a healed wound

Mandibular fixation is best achieved with the use of a load bearing locking mandibular reconstruction plate.

A wide variety of options are currently available:

• 2.4 Uni-lock reconstruction plates
• Matrix mandible reconstruction plates of different profiles (2.0, 2.5, 2.8), and screw diameters
• Anatomically preformed mandibular reconstruction plates

For illustration purposes we will show the use of a 2.4 reconstruction plate.

The advantage of the locking plate is that it does not require 100 % adaptation to the mandibular contour. Small gaps can be tolerated since the threaded screw head locks to the plate resulting in an internal "ExFix" construct.

When the tumor extends anteriorly/anterolaterally to the mandible, the reconstruction plate cannot be fashioned by applying it directly to the mandible prior to the mandibulectomy. In this situation, special devices (ie. bridge fix) may be used to maintain the position of the proximal and distal segments in their preoperative anatomic position.

Alternatively, in the dentate patient the placement of arch bars or maxillo mandibular bridging plates and subsequent MMF on the intact part of the mandible can be used instead of the segment fixation device.

Mandibular reconstruction with microvascular free tissue transfer is generally used for complex defects following tumor resection and trauma with tissue loss. It provides:

• soft tissue and bone for the restoration of composite defects
• A one stage procedure, allowing for timely adjuvant therapy for oncologic purposes, if necessary.

The location and size of the tumor will dictate the surgical approach necessary for the performance of the ablative procedure.

The two following approaches are frequently used for the mandible:

• Lip split approach
• Visor approach

Incisions are marked out 1.5 cm around all visible and palpable tumor.

An extension of the incision is then carried posteriorly towards the mastoid and anteriorly to the submental region. Additional extensions can be made according to surgeon's preference to allow for simultaneous neck dissection.

When the neck dissection is performed, care must be taken to dissect and preserve potential recipient vessels.

It should be noted that on most occasions one or more branches of the facial nerve will need to be sacrificed due to tumor involvement.

Dissection is carried through the skin incisions marked around the tumor and continued through the subcutaneous tissues until the mandibular bone is encountered.

The periosteum is incised keeping at least 1 cm margins around the involved mandibular bone. The periosteum and soft tissues proximal and distal to the proposed mandibulectomy are elevated laterally and medially to allow for placement of the segment positioning devices and subsequent application of the locking mandibular reconstruction plate. Proposed lines for mandibular osteotomy are marked.

In a dentate patient, the teeth in the line of the osteotomies are extracted.

Given the fact that the plate adaptation using a template is not possible because of the tumor invasion, the following solutions can be applied:

Mandibulo-maxillary fixation in order to maintain both bone stumps in position. This can usually be done applying plates from the remaining mandibular stumps to the maxilla or more conventional means using arch bars.

An external fixator (eg, bridge fix) could be put in place maintaining the bone stumps in proper relationship. The external fixator should be kept in place during the tumor resection not to lose the proper position of the mandibular stumps.

Bone cuts are now carried anterior and posterior to the tumor using a saw. Care is taken to resect at least 1 cm of normal bone on each side of the tumor.

The tumor is visualized and palpated intraorally and 1.5 cm soft tissue margins are marked (eg. with an electro cautery) around the tumor in the oral cavity.

The bone is retracted laterally. Soft tissue cuts are made through the previously marked resection limits in the floor of mouth/tongue mucosa and the mylohyoid muscle.

The specimen is submitted en bloc for permanent pathological examination.

Surgical soft tissue margins are now checked with frozen section to ensure the adequacy of the tumor resection.

A template is contoured to the external mandible to bridge the defect staying just superior to the inferior border. A minimum of 3 screw holes should be placed on either side of the defect.

A locking mandibular reconstruction plate is chosen to bridge the defect. This should be a load bearing plate (eg. 2.4 mm). Alternatively a preshaped anatomical reconstruction plate can also be used. The plate is then bent to match the template. The plate is placed onto the mandible and final adjustments are made to produce a near perfect fit.

A stereolithographic model with mirroring of the non-compromised side of the mandible can be used to bend the plate.

The plate is placed and secured to the remaining mandibular segments with bicortical screws (minimum 3 on each side). After this step is accomplished, the external fixator is removed or the MMF is released.

Iliac crest-internal oblique osteomyocutaneous free flap is harvested in the standard fashion with the following considerations:

• Because of the thickness of the skin paddle with this flap, the internal oblique muscle is used to reconstruct the mucosal defect.
• The external skin of the flap is positioned so as to reconstruct the skin defect of the face/neck
• In order to position the vessels near the angle of the neomandible, the ipsilateral iliac crest is used as the donor site.
• The bone should be harvested to a thickness similar to the native mandible to provide the best reconstruction possible
• Alternative orientations of the pedicle can be accomplished by using the contralateral iliac crest as the donor site

The harvested bone graft is now measured against the mandibulectomy defect.

It is best to measure a small excess of bone when first trimming, particularly if osteotomies will be necessary to shape the bone, in order to compensate for bone loss during the subsequent steps. Any excess bone can then be trimmed prior to final insertion and fixation.

Excess bone of the flap is measured,and stripped of periosteum,..

The bone is now trimmed with a saw to fit the defect. Care is taken to avoid injury to the vascular pedicle during this procedure.

Pitfall: If a burr is used to trim the bone, it may catch the periosteum and hence, damage the vascular pedicle

The bone should be contoured to the overlying plate as much as possible to avoid large bone-plate gaps. This will usually require performing osteotomies (wedge) on the bone flap. The individual segments should not be less than 2.5 cm in length.

Care must be taken to not injure the vascular pedicle during the osteotomies. The pedicle is adherent to the inner aspect of the iliac crest and therefore the osteotomy is carried out lateral to medial. The saw should barely penetrate the inner bony cortex when making the cut.

This technique creates an open osteotomy when the bone is inset to the plate and this can be packed with cancellous bone harvested from the patient's residual iliac crest.

Locking screws are placed in a monocortical fashion to secure the bone graft to the overlying mandibular reconstruction plate.

The detailed procedure for the revascularization is outside the scope of this surgery reference. However, in short the procedure consists of the following steps:

• Appropriate recipient vessels are selected in the neck and dissected so as to be available for anastomosis
• The recipient and the donor vessels adventitia are cleaned under a microscope
• Appropriate vessel geometry is assured and the vessels are placed into a microvascular clamp and anastomosis carried out using 9-0 nylon sutures
• Revascularization is restored after both arterial and venous anastomoses are completed

The internal oblique muscle is rotated medial to the neomandible into its preplanned position in the oral cavity with care not to create undue torsion or tension within the pedicle. In order to minimize tension, cuts can be made at the lateral edges of the muscle near its bony insertion towards the muscle perforator, with care to not disrupt the blood supply. The muscle can usually be rotated nearly 270 degrees and the distal end may be used to provide coverage of the plate.

In most oral cavity defects, the native oral mucosa is closed directly to the internal oblique fascia with interrupted absorbable suture in a vertical mattress fashion. A water tight closure is essential to avoid a salivary leak into the neck with subsequent infection in the surgical site and an orocutaneous fistula. The muscle fascia is usually left to mucosalize but may be skin grafted depending on surgeon's preference.

The skin component of the flap is now positioned into the neck/face defect and closed in layered fashion.

The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative medications.

• Analgesia as necessary
• Antibiotics (many surgeons use perioperative antibiotics). There is no clear advantage of any one antibiotic but evidence supports their use for 24h. The spectrum should be according to the oral bacterial flora, but the physician should be aware of changes that may occur after the use of radiation therapy.
• Steroids may help with postoperative edema.
• Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care, etc.
• Antibiotic ointment is used on the wounds for 72 hours
• If a free flap is utilized for the reconstruction, 80-100 mg of aspirin/day is recommended.

Remove any sutures from skin after approximately 7 days if nonresorbable sutures have been used. If the patient has had previous radiation, the sutures should be left in for 10 – 14 days.
Wound should be cleaned at least twice daily with hydrogen peroxide or mild soap and water. Moisturizing lotion should be used on the skin wounds to minimize excessive scarring after sutures are removed.
Avoid sun exposure and tanning to skin incisions for several months.

Diet depends on the reconstructive method. In general patients with superficial wounds can begin an oral diet within 48h postoperatively. Patients who have undergone a more significant surgery eg. flap reconstruction are kept NPO for 5-10 days and nutrition is administered via nasogastric tube. Oral feedings are begun using thickened liquids only after swallowing is assessed by the surgeon or the speech pathologist, and the risk of aspiration is minimal. Diet can be advanced as tolerated by the patient.

Typically the patients are seen in clinical follow-up one week after discharge, and then on a weekly basis until such time the clinician determines that less frequent follow ups are needed.

Patients with intraoral incisions and/or wounds must be instructed in appropriate oral hygiene procedures. A soft toothbrush (dipped in warm water to make it softer) or water flosser should be used to clean the surfaces of the teeth. Chlorhexidine oral rinses should be prescribed and used at least 3 times a day to help sanitize the mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris.

When a free flap is utilized, it should be regularly monitored to ensure vascular integrity. Physical examination, assessing the flap color, turgidity, and capillary refill should be routine for at least the first 48 hours postoperatively. Hand-held Doppler probes can be used to assess blood flow. In case of doubt of the vitality of the flap, pin-prick assessment with a 25 gauge needle to look for bright red bleeding.. In cases of buried flaps, an implantable Doppler placed just distal to the venous anastomosis can be utilized.

Closed suction drains are routinely used at the donor site. The drain is removed when output is <30cc per 8 hour period, for three consecutive periods. Patients are typically discharged from the hospital 5-10 days after surgery, depending on their postoperative course and comorbidites. Close outpatient follow-up after discharge is recommended for evaluation of surgical sites.

Radial forearm free flap
The radial forearm free flap donor site should be closed with a skin graft and a bolster placed over the area. The arm is then cast or placed in a volar splint for 7 days prior to removal to ensure graft take.

Fibula free flap
After a fibula free flap, the donor lower leg should be cast with the ankle slightly dorsiflexed for 5 days. The patient can touch-down their body weight as tolerated. After the cast is removed they can ambulate and work with physical therapy to optimize leg function. A splint should be placed to keep the foot flexed when in bed. The routine use of a compression stocking for one month postoperatively will reduce the amount of lower leg dependent edema and aid in improved wound healing.

Scapula free flap
In the initial postoperative recovery, the ipsilateral arm should be positioned anteriorly and medially, usually supported on the patient’s abdomen by a pillow. Once the patient is ambulating, the arm is supported by a shoulder sling which supports the elbow and prevents inferior drift of the arm. Inpatient physical therapy is initiated once the patient is mobile. A post-operative physical therapy regimen is established with the patient to be maintained after hospital discharge. The sling is used for 2-3 weeks and physical therapy maintained until postoperative function is optimized, usually 4-6 weeks.

Iliac crest
The iiliac crest donor site requires that the patient not strain or lift heavy objects for at least 4 weeks to avoid hernia formation. Patients are typically limited to a bed or chair for 48h postoperatively and then physical therapy is begun with the patient initially ambulating with the aid of a walker or cane and progressing as tolerated.

Latissimus dorsi
No specific rehabilitation is necessary following the use of this flap.