15. Isolated
› any single bone tissue resection
Compound
› two tissue layers, such as bone and oral lining or
bone and external skin
Compoiste
› three-layer-defect involving the mucosal lining,bone,
and external skin
En BLOC /extended composite
› Defect that also include loss of soft tissue
16. H (hemimandible)—
› condyle and lateral segment that does not cross the
symphysis (midline).
L (lateral)—
› lateral segment without a condylar component; not
crossing the symphysis.
C (central)—
› bony region between the mental foramina.
17.
18. Smoking,
diabetes,
malnutrition,
cardiovascular disease,
liver cirrhosis,
Renal failure,
old age,
local advanced disease,
distal metastasis,
recurrent or second primary cancer,
postoperative radiation
19. size,
volume,
and components of the involved soft tissue,
the length and location of the mandibular
defect,
the available recipient vessels, and
the quality of the external skin.
20. CT scan of mandible
Lateral cephalogram
› For febrication of
template
21.
22.
23.
24. An ideal reconstruction should mimic the missing tissue with
regard to structure, geometry, and tissue character.
1. restoration of the bony scaffold,
2. adequate oral continence and
3. deglutition,
4. obliteration of dead space, and
5. re-establishment of optimal cosmesis.
there is not a single free flap that meets all reconstructive
demands with regard to flap size, thickness, pliability, tissue
bulk, and skin turgor.
Choosing an optimal flap for reconstruction should be based
on the clinical situation and the patient’s own preference.
26. Hausamen : 1886: plates &
screw for reconstruction
Locking screws/plates with
vascularized bone grafts
Mesh trays made of dacron :
1970s
Titanium plates:
biocompatibility
27. Decrease operating time
Avoidance of bone graft
donar site
Extensive oncological
resections
absence of suitable bone
flaps,
presence of significant
medical comorbidities
28. risk of exposure
infection
risk of plate fracture
preclusion of dental reconstruction;
and a thin shape that does not provide adequate
bulk for reconstruction.
Problematic in radiation therapy
Functional limitations
29.
30. Skkoff : end of 19th
century
Anterior or posterior iliac crest.
Revascularization : recipient site
For mandibular defect of < 5cm in size
Complications
› Bone resorption
› Partial bone loss
› Pseudoarthrosis
31.
32. Hueston and McConchie :1968: pectoralis
major myocutaneous flap
first pedicled rib graft with the PM
myocutaneous flap.
PM myocutaneous flap with the sternum as a
bone graft.
Composite pedicled myocutaneous flaps
transferred with clavicle bone graft
34. Traditional PM flap + the fifth rib as a bony
scaffold
Blood supply : periosteal-muscular plexus
Disadvantages:
› Blood supply not always reliable
› The strength of the fifth rib is not as good for
hardware fixation or osseous integration
› Risks of pneumothorax and hemothorax
35. Scapula spine + pedicled trapezius muscle
Upto 10cm of bone
Limitations
› Restricted quality of bone
› Shoulder mobility
36. The vascularized cranial bone with the
temporalis muscle.
based on :the superficial temporal Artery
as the outer cortex
› inadequate bone stock for hardware fixation and can
easily fracture during shaping
as a full-thickness bone graft.
› more durable
› donor site cosmesis is a major concern.
37.
38.
39. McKee : 1978: microvascular free rib graft for
mandibular defects.
Taylor et al. :1975: free fibula flap use
Hidalgo:free fibula flap for mandibular
reconstruction.
41. Introduced by : Taylor : 1979
Advantages:
› Reliable blood supply
› Good contour of neomandible : natural curve
split lateral iliac crest chimeric flap based on
the lateral femoral circumflex vessels to
provide vascularized bone and soft tissue for
complex mandibular reconstruction.
42. Small or moderate-sized mandibular defects of
type I-a to II-a.
43.
44.
45.
46.
47. bulky skin paddle
abdominal wall weakness,
hernia,
contour deformity,
Limits early mobilization
› harvest the inner cortex of the iliac as part of this
flap
48. Lateral border of the scapula, scapular and/or
parascapular skin, and the latissimus dorsi
muscle
based on the subscapular artery
The lateral border of the scapula : circumflex
scapular artery
can be harvested up to a length of 14 cm
Skin pedicle : as long as 30cm
50. valuable options for coverage of large complex
oromandibular reconstruction
51.
52.
53.
54.
55. bone quality of the scapula is not as good
intraoperative change in position,
Weakness & decreased range of shoulder
motion
56. inner volar cortex of the distal radius
Length of segment : 10-12 cm
Skin & pedicle are of best quality
Bone : the worst
57. bone defect that is limited to the ramus and the
proximal body with a large associated intraoral
soft-tissue defect.
58.
59.
60. Post operative radius fractures
› Postoperative full-length plaster cast for 3–4 weeks
› the use of a dynamic compression plate for rigid
61. reconstructive standard for successful
mandibular reconstruction
Wei et al. demonstrated the reliability of
harvesting the fibula bone flap along with a skin
paddle based on identifiable septocutaneous
perforators
62. The bone is available with enough length
The straight quality of the bone with adequate
height thickness.
Flap contouring process
vascular pedicle has sufficient length
for filling adjacent soft-tissue defects in the
submandibular portion.
63. signs and symptoms of peripheral vascular
disease or
an abnormal pedal pulse examination.
› overt peroneal artery atherosclerotic disease
64. Simple intermaxillary fixation is performed to
obtain good dental occlusion
reconstruction plate
with at least two or three screws on each end.
Template
65. four possible arteries
1. the facial artery,
2. superior thyroid artery,
3. Superficial temporal artery, and
4. the transverse cervical artery.
May be demaged by operative scars, radiations
fibrosis, neck dissection.
Veins:
› External juglar vein
› Internal juglar vein: less kinking
66. unique triangular bone,
peroneal vessels, usually
› one artery
› two concomitant veins,
located on the posteromedial aspect of the
fibula, posterior to the fascia of the posterior
tibialis, inside the flexor hallucis longus (FHL),
and anterior to the posterior crucial septum.
67. The skin paddle :
› based on
osteocutaneous
perforators, which run
inside the posterior
crucial septum
The lateral surface is the
safest and preferred site
for reconstruction plate
fixation
Soleus along with the
flap: better soft tissue
coverage & contour.
68. The left fibula
osteocutaneous flap is
transferred to left
mandibular defect type
II-a
The pedicle of peroneal
vessels is placed toward
the right side to reach
the recipient vessels of
the ipsilateral side.
69. An osteomyocutaneous
peroneal artery
combined flap was
harvested
with a skin paddle of 12 ×
8 cm based on two
septocutaneous
perforators
70. Mandibular defect
type II-a included
a bone defect of 9
cm in length;
a buccal mucosal
and adjunct soft-
tissue defect
tailored template
for measurement
of the length,
angle, and
number of
osteotomies
72. The three fibula
segments were
fixed to the
reconstruction
plate with one
screw for each.
The pedicle was
placed forward to
right-sided and
curved to reach
the ipsilateral
superior thyroid
artery and facial
vein
73. The soleus muscle
could be flipped
over on top of the
fibula and the
reconstruction
plate to prevent
exposure of the
reconstruction
plate and
potential
osteoradionecrosis
better cheek
contouring.
74.
75. further osteotomies are performed with an
electric saw according to the tailored paper ruler
templates
Protect the vascular pedicle and septocutaneous
perforators to the skin paddle during the
osteotomies to prevent injury to these
structures
76. flap is inset from the osteotomized fibula segments
that are contoured to fit the reconstruction plate.
single screw fixation for each bone segment:
minimize vascular compromise
One skin paddle :for the intraoral lining, and
a second skin paddle :for the external cheek
soleus muscle : placed on top of the fibula and
reconstruction plate to :
› improve cosmesis
› prevent possible osteoradionecrosis
› plate exposure after postoperative radiation
77. Intermaxillary fixation with screws or wires
titanium reconstruction plate : to bridge both
residual mandibular ends, with at least two
screws for each end
Errors:
› prognathism,
› retrognathia,
› increased or decreased lower facial height,.
› asymmetry caused by a twist in the flap, or
› a shift in the midline to one side as a result of unequal
lengths of the mandible body.
78.
79. Watertight closure of the intraoral wound
Contamination of the miniplates
Orocutaneous fistula
Suction drains
positioned away from the microvascular
anastomoses.
80. malocclusion
Trismus
Options :
› avascular bone graft,
› Rounding off the end of the fibula
› costochondral graft attached to the fibula end
› a titanium condyle prosthesis
81. Dead space created by the extirpation of masticator
muscles, the buccal fat pad, and the parotid gland
can lead to fluid accumulation and infection
sunken appearance from soft-tissue contracture, trismus,
plate exposure, and impaired speech and swallowing
function
exacerbated by postoperative radiotherapy.
Radial forearm flap,
anterolateral thigh, rectus abdominis,
pectoralis major flaps
82.
83.
84. Transferred to ICU for 3-7 days
Tracheostomy /ETT
Restricted neck movements
Prophylactic antibiotics— 7 days
PPI--- 3 days
Hydration status/IOP monitering
Enteral feeding
85. Every hour : for 24 hours
Every 2 hours : next 24 hours
Every 4 hours : 3rd
post op till discharge
Physical examination
Hand held doppler
Irrigation of oral cavity for hygeine : 3rd
day
Mobilization
Weight bearing : 3rd
week
Follow up : periodic panorex radiographs
88. occur between 1 week and 1 month
postoperatively,
infection,
skin flap loss,
wound dehiscence,
donor site morbidity, and
fibula bone loss.
89. beyond the 1-month period
infection,
malocclusion,
donor site morbidity,
skin flap loss,
radiotherapy-related orocutaneous fistula or
osteoradionecrosis
90. hypovascularity,
hypocellularity, and
local tissue hypoxia
Radiation-related osteoradionecrosis, neck contractures, and
wound-healing problems with subsequent plate exposure are
frequent in patients undergoing fibula osteocutaneous flap
for mandibular reconstruction
preventing osteoradionecrosis :
› Enough soft tissue and bone coverage in the irradiated
field
91. MAR28,2013PI
A 23 year old female underwent
right hemi-mandibulectomy and a
neck dissection for a primary
sarcoma of the mandible 2 years
ago. She had a post-operative
radiation but no reconstruction
was done. She now wants a
correction of her deformity.
a) what problems do you
anticipate in the procedure and
how can you avoid them?