Caso Clínico

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Complex reconstruction of the oral cavity by means of the combination
of two simultaneous free fibula and radial flaps
Reconstrucción compleja de la cavidad oral mediante dos colgajos simultáneos de peroné y radial

 

A. Dean Ferrer¹, F.J. Alamillos Granados², A. Redondo Camacho², J. Torres Corpas², J.J. Ruiz Masera²,
F. Zafra Camacho⁴, G. Barrios Sánchez⁴

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Abstract: The aim of this paper is to evaluate the functional and aesthetic results of complex orofacial reconstructions by means of the combination of two simultaneous free flaps (fibula osteocutaneous and radial forearm flaps). Three patients who have undergone this kind of reconstruction are presented with good functional and aesthetics results. Reconstruction with two free flaps is indicated in complex defects in which reconstruction with a single flap would not obtain adequate aesthetic and functional results. The choice of each particular flap depends on its specific characteristics that make it ideal for the reconstruction of each particular type of defect, osseous defects and soft tissue defects, with the aim of obtaining a better result than that obtained with the use of a single flap. Key words: Free flaps; Complex oromandibular defects; Oromandibular reconstruction; Fibula free flap; Radial free flap; Simultaneous free flaps.

Resumen: El objetivo del presente trabajo es valorar los resultados funcionales y estéticos de reconstrucciones complejas orofaciales, realizadas mediante la asociación de dos colgajos libres simultáneos de peroné y radial. Se ha realizado este tipo de reconstrucción en tres pacientes con buenos resultados funcionales y estéticos. La reconstrucción con dos colgajos libres está indicada en defectos complejos en los que la reconstrucción con un solo colgajo no obtendría resultados estéticos y funcionales adecuados. Cada colgajo se selecciona por sus características que lo hacen ideal para cada tipo de defecto, óseo y de partes blandas con la finalidad de conseguir un resultado estético y funcional superior al que se obtendría con un solo colgajo. Palabras clave: Colgajos libres; Defectos oromandibulares complejos; Reconstrucción oromandibular; Colgajo libre de peroné; Colgajo libre radial; Colgajos libres simultáneos.

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1 Médico Adjunto.
Profesor asociado de la Facultad de Medicina. Universidad de Córdoba. España.
2 Médico Adjunto.
3 Médico Especialista en Cirugía Oral y Maxilofacial. Práctica privada. Córdoba. España.
4 Médico Residente.
Servicio de Cirugía Oral y Maxilofacial.
Unidad de Reconstrucción Autotrasplante Microquirúrgico.
Hospital Universitario "Reina Sofía", Córdoba. España.

Correspondencia:
Dra. Alicia Dean
C/ José Mª Martorell 4, 2º-2
14005 Córdoba, España
E-mail: ADF10101@teleline.es

 

Introduction

The use of microsurgical flaps has permitted a great improvement in the reconstruction of patients with head and neck cancer following ablative surgery^1,2 and they are regularly used in the reconstruction of cancer of the oral cavity and oropharynx. However, complex oromandibular defects continue being a challenge for surgeons and an important problem from the functional as well as aesthetic point of view.

Various composite flaps for oromandibular reconstruction^3,4 have been described, but in complex oromandibular defects, no flap can simultaneously provide the ideal bone texture for mandibular reconstruction and soft-tissue for covering a mucosal surface.¹ There is no single flap that has a sufficient amount of bone together with soft-tissue for covering a mucosal area which is thin, pliable and which adapts to the oral environment. There are more and more articles in bibliographies in which two flaps are used to solve the problems arising from complex oromandibular reconstructions. ^1,2,5-11

The combination of various flaps is aimed at compensating the defects that may arise when reconstruction with a single [flap] is carried out for complex defects. Each flap is chosen independently for its characteristics, which make it ideal for each type of bone or soft-tissue defect with the aim of achieving an aesthetic and functional result that is superior to the use of a single flap.

We present our experience in complex reconstruction of oromandibular defects using two microvascularized free fibula and radial flaps simultaneously.

Clinical cases

The reconstruction of complex oromandibular defects was carried out in three patients using the combination of the fibula osteocutaneous flap for mandibular reconstruction and the radial forearm fasciocutaneous flap for soft-tissue reconstruction, either for mucosal surface or for cutaneous resurfacing.

Surgical technique: In all three cases primary reconstruction was carried out. Two surgical teams were used. The patient is placed in a supine position. The elevation of the flaps and ablation is done simultaneously. The flaps are elevated until they are pedicled, but the attachment of the pedicle is left in tact, while the ablation is performed. First bone reconstruction is carried out with fibula. Anastomosis is carried out on the receptor vessels that have been selected. Later the radial forearm flap is positioned so that soft-tissues are resurfaced and anastomosis is carried out on the receptor vessels. Lastly, suturing of soft-tissues is completed in the oral cavity or outer surface together with soft-tissue fixation.

Case 1: Male patient, 52 years old with squamous cell carcinoma of the anterior floor of the mouth T4, N2a, M0. The oral lesion was affecting the anterior floor of the mouth, anterior half of the tongue, lateral floor of the mouth and mandibular bone from 37 to 47. Bilateral modified radical neck resection was carried out. The intraoral lesion was resected using a "Visor-type" approach. The intraoral resection included a segmental mandibulectomy from the right mandibular angle to the left mandibular angle, a subtotal glossectomy (4/5) and resection of the anterior and lateral floor of the mouth including the suprahyoid muscle group. The defect was reconstructed with a fibula osteocutaneous flap for mandible reconstruction and osteosynthesis was carried out with a mandibular reconstruction plate. The fibula was adapted to the shape of the mandible by means of three osteotomies so that four bone fragments were left that were secured to the reconstruction plate using screws. The radial forearm fasciocutaneous flap was used for reconstructing the lingual defect. Microvascular end-toend anastomosis was carried out, first on the fibula [flap] and then on the radial [flap]. The vessels of the fibula flap were connected to the vessels on the left side (facial artery and external jugular vein) and the radial flap to the vessels on the right side (facial artery, thyro-lingual-facial vein trunk and external jugular vein). The skin of the fibula flap was used to resurface of the mandibular alveolar border, the back of the vestibule, and mandibular lingual surface. The radial flap was used to resurface the lingual area. The posterior border of the skin of the fibula flap was sutured with the anterior border of the skin of the radial flap to form a concave shape for the new floor of the mouth. Flaps in the oral cavity normally tend to acquire a convex form. In order to achieve this concavity, which will facilitate the formation of the "neotongue", fixation sutures should be placed on the floor of the mouth. The suprahyoid muscles and the mandible depressors were sutured to the lower border of the neomandible, using the holes in the mandibular reconstruction plate. It is important to reposition and suspend the skin of the chin from the mandibular reconstruction plate in the area of the neosymphysis in order to avoid the low lower lip and chin drooping, which would cause and labial incompetence. The histopathological result was reported as moderately differentiated squamous cell carcinoma that did not extend to the surgical margins of the resection. Later he underwent radiotherapy. Figures 1 to 7 illustrate the case.

Case 2: Male patient, 55 years old, with squamous cell carcinoma on the anterior floor of the mouth T4 N2c M0. The lesion affected the anterior floor of the mouth, the anterior two thirds of the tongue, lateral floor of the mouth and mandibular bone from the premolars on the right side to the premolars on the left. Resection and reconstruction were done in a similar way to case 1. The defect was reconstructed with a fibula osteocutaneous flap in order to reconstruct the mandible and carry out osteosynthesis with a mandibular reconstruction plate, leaving the fibula skin for reconstructing the alveolar border and anterior floor of the mouth. The fibula was adapted to the mandibular form. Two osteotomies were carried out in order to leave three bone fragments, which were fixed to the reconstruction plate using screws. The fibula fasciocutaneous flap was used for reconstructing the lingual defect (Fig. 8). The histopathological result was reported as being moderately differentiated squamous cell carcinoma that did not reach the resection margins. Later radiotherapy treatment was started.

Case 3: Male patient 54 years old with a schizophrenic background. He had squamous cell carcinoma on his lower lip, which extended to the commissures, cheek and mandibular symphysis. Reconstruction was carried out with two simultaneous flaps: fibula osteocutaneous flap for mandibular symphysis, alveolar border and part of the floor of the mouth and radial forearm fasciocutaneous flap with a palmaris longus tendon for the internal and external surface of the lower lip, commissures, part of the cheek and chin. A bilateral supraomohyoid neck dissection was carried out. The resection included all the lower lip, both commissures, part of the right cheek, skin of the chin and part of the cervical skin under the chin, and the mandible from the premolar area on the right to the left premolar area. In this case, given the vestibular extension of the tumor, a resection of the mandible was carried out and later a mandibular reconstruction plate was adapted, taking as a reference the maxillomandibular relationship in occlusion. Two osteotomies were carried out in order to place the fibula bone in the defect. Osteosynthesis of the fragments using the plate was carried out with screws. Anastomosis is then carried out of the peroneal vessels to the receptor vessels on the left side of the neck (lingual artery, external jugular artery and thyro-lingualfacial trunk vein). Anastomoses of the vessels of the radial flap were carried out to the receptor vessels on the right side of the neck (superior thyroid artery, external jugular vein and thyro-lingual-facial trunk vein). Following this the softtissue were sutured and the skin of the radial flap folded to form the lower lip. The palmaris longus tendon was used to suspend the soft-tissue of the new lip so as to avoid labial incompetence. He later underwent radiotherapy (Figs. 9 to 12).

Results

The results have been analyzed by assessing the duration of the surgery, the survival of the flaps, complications, the need for secondary surgery, swallowing function, oral competence, diet, need for a permanent tracheotomy, phonatory function, morbidity at the donor site, aesthetic [results] and evolution of the disease. The average length of all the surgery was 11.5 hours. Postoperative evolution was favorable as none of the flaps were lost. Patient 1 developed an infection of the surgical bed on the left side of the neck that was resolved with conservative treatment.

No secondary surgery was carried out. Swallowing function was adapted with no need for intubation. Oral diet was begun 10-15 days following surgery. Extubation was carried out 10 days after surgery. Oral competence, which was evaluated using drooling (absent, mild, moderate or severe) was adequate, with the absence of drooling in the fist two patients, and mild drooling in the third patient. Speech, which was evaluated as excellent (normal), good (easily intelligible), regular (understood with difficulty) and bad (unintelligible), was good in patient 2 and 3, and regular in patient 1. There were no complications in the donor sites. The radial and fibula bed were resurfaced in all cases with cutaneous grafts of partial thickness.

The aesthetic results were evaluated by surgeons and by the patients themselves, according to the following scale: excellent, good, regular and bad. The aesthetic results of the first two patients were considered excellent by the surgeons as well as by the patients. The aesthetic result of the third patient was considered between good and regular by the surgeons and good by the patient himself.

The first patient developed lung metastasis four years after surgery. The second patient is free of disease six years after surgery and the residence of the third patient changed and he did not attend later check-ups.

Discussion

Many of the defects created after ablative surgery of the head and neck can be reconstructed adequately using a single flap. However, there are patients in which the combination of a large mandibular defect with a tridimensional defect of soft-tissue, or covering a considerable area in the oral cavity or with composite intra-extraoral defects, leads to reconstruction with a single flap not being satisfactory.

For intraoral reconstruction a fine, pliable, adaptable surface is needed, which is adaptable to the oral cavity environment and that does not hinder the movement of the tongue, nor interfere with possible dental rehabilitation. For osseous reconstruction of the mandible a bone with sufficient thickness and width is required so that dental rehabilitation can later be carried out.

For bone reconstruction of oromandibular defects fibula, iliac crest and scapula flaps are available. They supply a sufficient amount of bone for dental rehabilitation,⁸ even though their soft tissue characteristics are all different. The scapula flap provides a bone segment between 10 and 12 cm in adult males and 10 cm in women with a thickness that varies between 1 and 3 cm. With the iliac crest 12-14 cm in length can be transferred. The fibula provides the longest bone for mandibular reconstruction (up to 20-25 cm), and the mandible can be reconstructed completely with it. In oromandibular reconstruction, the skin surface of the osteocutaneous flaps of fibula and iliac crest have a restricted arc of rotation with regard to bone component, and their use is limited to certain complex defects.⁸ The flaps of the scapular system are more pliable with regard to the soft-tissue they provide, but the patient needs to be repositioned intraoperatively and using both surgical sites simultaneously is not possible thus surgical time is extended.⁸ In addition to this, the scapula bone is worse with regard to implantability rates compared with the fibula and iliac crest (the iliac crest provides the highest rate of implantability). In order to reconstruct defects of the mucosal surface the ideal tissue should be a fine tissue which is pliable and which adapts to the contours and surfaces of the oral cavity. This can be achieved with the radial forearm fasciocutaneous flap, lateral arm and lateral thigh flaps.⁸

There are several publications in which two free flaps are used simultaneously in oromandibular reconstruction. Iliac crest has been used with the radial [forearm] flap;^5,12 the scapular osteocutaneous flap with the radial [forearm flap];^6,12 the fibula with the radial [forearm] or the lateral arm [flaps]:^1,2,13,14 and the fibula with anterolateral thigh [flap]^9,10,15 Also described are combinations of two free flaps for the reconstruction of soft-tissues; bilateral radial [forearm flap] for the oral cavity;² for the esophagus;¹⁶ for defects of the mid-face following gunshot wounds¹⁷ and two TRAM flaps for restoring facial contour.¹⁸ And in this respect there are publications of three simultaneous microvascular flaps: fibula with two radial [forearm flaps]¹⁴ and even five free microvascular free flaps: bilateral radial, bilateral innervated gracilis and myocutaneous of abdominal rectus.¹⁹

Of all these possible combinations combining the fibula and radial [flaps] has a series of advantages. The patient can be operated on in the supine position and as positional changes are not required, surgical time is reduced. The elevation of the fibula [flap] leaves little morbidity in the donor site and provides adequate length for reconstructing extensive mandibular defects. With regard to soft-tissue, the radial [forearm] flap has a much longer pedicle of greater caliber than that of the lateral arm [flap]. Its skin is fine and pliable which makes it ideal for reconstructing intraoral defects as, in reconstructions of the floor of the mouth or tongue after a partial glossectomy, the mobility of the remaining tongue is preserved, and dental rehabilitation is later facilitated when the alveolar border is recontructed.²

There are variations according to the authors as to the way in which anastomosis to the two free flaps should be performed. Some authors prefer sequential anastomosis or "bridging", with the bone flap acting as a conductor of fluids for the skin flap, which then allows the skin flap to act as a "monitor" for the bone flap.¹ Other authors reserve this technique for situations in which the presence of previous surgery or radiotherapy has diminished the number disposable receptor vessels.^6,12 The inherent danger of the sequential [connection] of free flaps is that thrombosis in the first flap (conductor flap) puts into danger both flaps. Urken reports the loss of two flaps out of a total of 20 flaps used in 10 patients⁵ and Wells a loss of six flaps out of a total of 20 flaps (in 10 patients with double flaps).¹⁴ Like Urken and Serletti, we feel that the advantages that this technique provides are outweighed by the risks, and that it should only be used when receptor vessels are not available.^1,5 Recently a classification has been published with the form in which free flaps should be connected: bridge, chimeric, Siamese, mosaic and chain-circle flaps.²⁰

The total surgical time of ablation and reconstruction with two microsurgical flaps takes an average of 10 to 12 hours according to data in the literature⁵ and of the cases presented. This time is approximately two hours longer that when a single composite free microvascularized flap in used.

In order to achieve adequate functional results, suspending soft-tissue from the bone adequately is fundamental (suspending the perihyoid muscles from the mandibular base, suspending skin and subcutaneous [tissue] from the anterior mandibular surface, suspending the commissures using the palmaris longus tendon in order to achieve lip competence). Sensate re-innervation of the radial flap can improve functional results in extensive reconstructions. With this end, in complex defects of the mandible, tongue or lip, the iliac crest or fibular flap is connected with a sensate radial forearm free flap performing anastomosis to the lingual nerve or inferior dental [nerve] according to the requirements.^5,11 The other important factor to keep in mind is that, in order to achieve functional results, the mobility of the residual tongue should be maintained. This is achieved by transferring a pliable, flexible, fine and adaptable tissue to the surface of the oral cavity such as the radial, lateral arm, lateral thigh and dorsal foot flap.⁵

The simultaneous autotransplantation of the radial and fibula flaps has allowed complex oromandibular defects to be reconstructed where reconstruction with a single flap would have resulted in worse aesthetic and functional results. A single fibula flap could have been used to reconstruct the mandibular defect and the anterior part or the floor of the mouth but a severe lingual dysfunction would have remained. The considerable length of the mandibular defect rules out other options for microvascular bone reconstruction (iliac crest³ and scapula^21,22). Using two surgical teams means that surgical time is not prolonged excessively with two free flaps.

The most frequent indications for the reconstruction with two free flaps is for oromandibular defects in which the complexity of soft-tissue component requires the use of a thin, pliable tissue which adapts to the tridimensional anatomy of the oral cavity in addition to bone tissue for mandibular reconstruction.⁸

Conclusions

The reconstruction with two or even three simultaneous free flaps is indicated when reconstructive requirements are diverse, the defect affects different structures and there is no simple flap which encompasses the entire reconstructive requirement.

The connection of two free fibula and radial flaps is indicated for complex oromandibular defects, with very long mandibular and soft-tissue defects, in order to achieve adequate functional and aesthetic results.

 

References

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