case report oncology & reconstruction · tensive reconstruction of the defects from oral...

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Case report

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For citation purposes: He Y, Jin SF, Zhu HG, Zhang YX, Zhang ZY. Reconstruction of composite oromandibular defects with rib-major pectoralis myocutaneous flap carrying costal parietal pleura: a forgotten option? Annals of Oral & Maxillofacial Surgery 2013 Aug 01;1(3):24. Co

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Reconstruction of composite oromandibular defects with a rib-major pectoralis myocutaneous flap carrying costal

parietal pleura: a forgotten option?Y He1, SF Jin1, HG Zhu1, YX Zhang2, ZY Zhang1*

AbstractIntroductionReconstruction of composite oro-mandibular defects of oral malig-nancy is a challenging problem for oromaxillofacial and plastic sur-geons. Revolutionary microvascular surgical techniques permit surgeons to use two free flaps in one stage—one for the bone and inner lining and one for the skin or soft tissue. But in some cases with poor quality of recip-ient vessel site and heavily irradiated neck condition, these flaps also have some problems, especially in ablative surgical cases with large soft-tissue loss. The aim of this article was to re-port a case of reconstruction of com-posite oromandibular defects with a rib-major pectoralis myocutaneous flap carrying costal parietal pleura.Case reportIn this article, a rib-major pecto-ralis myocutaneous flap was used to reconstruct a composite oro-mandibular defect with excellent cosmetic and functional outcome. It provided a suitable and cost-effective reconstruction with low microsurgical risk, relatively short operative time, sufficient soft-tissue replacement and minimum donor site morbidity.

ConclusionThis reconstructive method of the compound osteomyocutaneous flap should not be forgotten when two free flaps in one reconstructive stage are gaining in popularity.

IntroductionReconstruction of composite defects of oral malignancy is a challenging problem, and large composite oro-mandibular defects resulting from excision of T3 and T4 cancer are the most challenging reconstructions for oromaxillofacial and plastic surgeons. Numerous flaps have been described in the literatures to reconstruct these defects, including (1) pedicled flaps with or without reconstructive plate: pectoralis myocutaneous flap1, latis-simus dorsi flap and trapezius flap2; (2) free flaps with or without recon-structive plate: radial forearm flap3 and rectus abdominis flap4; (3) dou-ble flaps or flow-through flaps: radial forearm or rectus abdominis com-bined fibula flap5 and anterolateral thigh combined fibula flap6; (4) com-posite vascularized osteomyocutane-ous flaps: fibula flap7,8 and scapular flap9; (5) composite myocutaneous flap with bone: latissimus with scap-ular10 and pectoralis major-rib flap11.

The many and varied flaps so far used to reconstruct the composite oromandibular defects demonstrate not only the multiple choice of trans-ferable tissue, but also the complex-ity of the defects that require recon-struction. However, with increased experience, it was recognized that the large composite defects of the oromandibular area need not only a bone but also a large amount of

soft tissue for total reconstruction. Although the composite vascular-ized osteocutaneous flap can provide bone, intraoral and external face re-construction, it usually is inadequate for soft-tissue volume replacement. Pectoralis major and latissimus dorsi flaps are the most versatile compos-ite flaps for major reconstruction with sufficient soft-tissue transfer after extensive ablation of oral can-cer. Since ribs can be incorporated as a stable vascularized bone graft on the pectoralis major composite flap, and Bell in 198111 successfully uti-lized the rib-pectoralis major flap in 14 patients’ composite defect recon-struction after oral cancer surgery, this article prefers the rib-major pectoralis flap as a useful composite myocutaneous flap with bone in ex-tensive reconstruction of the defects from oral cancer.

Case reportA Chinese 26-year-old female pa-tient underwent extensive resec-tion of an osteosarcoma of the right ramus invaded by the surrounding soft tissue and received 7000 cGy radiation therapy 5 years earlier. The oral and maxillofacial team performed wide resection of the involved areas of masseter mus-cle, parotid gland, facial soft tissue and right segmental mandibulec-tomy with a simultaneous bridge of a reconstructive plate (Stryker, Freiburg, Germany) in that sur-gery. Follow-up result, up to now, was negative in the operative area and neck region by clinic exami-nation and panoramic radiograph (Figure 1). The patient has a severe

* Corresponding Author E-mail: [email protected] Department of Oral Maxillofacial-Head Neck

Oncology, Faculty of Oral and Maxillofacial Surgery, Shanghai Jiao-tong University School of Stomatology, Shanghai Ninth People’s Hos-pital, Shanghai, PR China

2 Department of Plastic Surgery, Medical School of Shanghai Jiao-tong University, Shanghai Ninth People’s Hospital, Shanghai, PR China

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Figure 1: Panoramic radiograph of mandible before reconstructive operation. Figure 2: Lateral views of facial de-fects preoperatively.

Figure 3: Lateral views of facial defects preoperatively and incision designed.

cosmetic problem in the right fa-cial region due to the loss of soft tissue and mandibular hard tissue (Figures 2 and 3). The subcutane-ous reconstructive plate that looks likely to be exposed also has a great psychological impression on the patient. Because of the cosmetic and psychological reasons, the pa-tient was most inquiring of any

procedure that could improve her appearance.

Operative techniqueThe standard pectoralis major com-posite flap design was used with a vertical extension of the medial in-cision to expose the second to sixth chondrosternal junctions. The skin island of 3.5 cm × 7.5 cm used to

replace the intraoral lining was cen-tred on the fifth rib transversely (Fig-ure 4). After surgical access to the entire clavicular origin of the muscle and musculotendinous junction in the axilla, which is subsequently di-vided, the sternal origin of the pec-toralis major muscle was gained by raising a laterally based flap of about 10 cm width at the level of the anteri-or axillary line to the medial sternum (Figure 5). The pectoralis major mus-cle was raised from the chest wall along its lateral and bottom margin. The right fifth rib was approached through the fifth interspace and di-vided lateral to the margin of the pectoralis major muscle. Periosteum attached to the rib was preserved to ensure maximum blood supply, and the rib was elevated from the under-lying periosteum and pleura, dissect-ing lateral to medial according to the 10-cm bone length required (Figures 6 and 7). The rib-major pectoralis osteomyocutaneous flap was then raised on its neurovascular bundle and tunnelled beneath the skin in the supraclavicular area into the neck and head (Figure 8). Bleeding would be observed from the perichondri-um and periosteum of the rib. After surgical exposure of oromandibular

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defect, ipsilaterally residual mandi-ble and condyle, the rib was tailored to the appropriate length and fixed with stainless steel wire to the man-dibular remnants in the desired con-tour of the new mandible. The muscle of the major pectoralis flap was filled into the soft-tissue defect in the pa-torid and ramus region, and the distal part of the muscle was folded to cov-er the reconstructive plate. The skin island of the flap that was in the right position when turned over the clavi-cle was used to relax the intraoral lin-ing and as an observe window of the myocutaneous flap. The chest wall donor area was closed primarily after mobilization of the skin flaps.

ResultsThe patient got a significant cosmetic improvement from the reconstruc-tive surgery (Figures 9 and 10). The rib-major pectoralis myocutaneous flap survived without any evidence of flap crisis and partial necrosis. The vascularized rib bone had no obvious absorption in postoperative panoramic radiograph (Figure 11). Pneumothorax was not observed postoperatively, and there was a rapid return of oral competence and function 5 days after surgery. This re-constructive procedure needed only 3 to 4 h of time, and the patient’s re-covery from general anaesthesia was safe and quick.

DiscussionAdvanced malignancies of the oral cavity often require extensive abla-tive procedures as part of combined therapy. Surgical resection can leave composite defects with loss of facial soft tissue, mandible and oral mu-cosa, posing a difficult reconstructive challenge cost-effectively. The option of reconstruction of the composite oromandibular defect not only in soft tissue but also in hard tissue simulta-neously is gaining in popularity, since the relatively simple reconstruc-tion with plate and soft-tissue flap

Figure 4: Incision designed of the rib-major pectoralis myocutaneous flap in-traoperatively.

Figure 5: Intraoperative view of the rib-major pectoralis myocutaneous flap raising: the skin island, the sternal and anterior axillary border of the major pectoralis muscle.

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has plate-related problems, such as common exposure and loosening12. Revolutionary microvascular surgi-cal techniques, now, permit surgeons to use two free flaps in one stage—one for the bone and inner lining and one for the skin or soft tissue13,14, although a single osteocutaneous flap such as fibula flap15 or iliac crest flap16 is available for some composite oromandibular defects with less soft-tissue loss, the skin island of which may be adequate for the coverage of both the inner and the outer lining in extensive defects but inadequate to replace the soft-tissue loss. Wei FC5 described the successful use of fibula osteoseptocutaneous-radial forearm fasciocutaneous flap and fib-ula osteoseptocutaneous-rectus ab-dominis myocutaneous flap in the re-construction of extensive composite mandibular defects in head and neck cancer, and Ceulemans P6 applied flow-through anterolateral thigh flap for a free osteocutaneous fibula flap in secondary composite mandible reconstruction. The disadvantages of two microvascularized flap combina-tion reconstruction often quoted are the high risk of the microsurgery, re-ceipt vessel problem in radiation pa-tients, relatively long-time operation, more surgical injury and two flaps’ donor site morbidity.

Since Medgyesi17 in 1973 dem-onstrated an extensive vascular network connecting muscle, perios-teum and bone in a variety of osteo-myocutaneous flaps, including ribs, the pectoralis major myocutaneous flap incorporating the underlying vascularized rib was spreading in the 1980s18 and 1990s19. Vascular anatomy by Freeman20 highlighted the possibility of a composite tissue transfer to the head and neck region. Bhathena and Kavarana19 described the utilization of rib-major pectora-lis myocutaneous flap as a safe and quick method of reconstruction to re-habilitate the patient with composite oromandibular defect. Therefore, the

Figure 6: Intraoperative view of the rib-major pectoralis myocutaneous flap raising: the pectoralis major muscle was raised from the chest wall attached, with fifth rib carrying costal parietal pleura.

Figure 7: Intraoperative view of the rib-major pectoralis myocutaneous flap raising: the attached fifth rib with periosteal blood supply from intercostal.

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compound rib-major myocutaneous flap should not be a forgotten choice in reconstructive surgery, since the advantages are distinct which are as follows: (1) stable vascular anatomy of the pectoralis major myocutane-ous flap and the vascularized rib bone where periosteal blood supply has been proved by viability stud-ies21 of the flurochrome markers; (2) free of high risk of two free flaps simultaneously used in one oroman-dibular defect reconstructive sur-gery and the shorter operative time gains relatively quickly recovery of the local and general functions; (3) the musculofasical nutrient pedicle lying in the neck provides good pro-tective coverage for the bared carotid system especially for some cases had radical neck dissection and needed postoperative radiotherapy; (4) provides the available reconstruc-tive opportunity for cases with poor head and neck recipient vessel con-dition including the transverse cervi-cal vessel system from the ablative surgery and radiotherapy; (5) pro-vides sufficient soft-tissue replace-ment and filling of dead space which is needed after ablative surgery of oral cancer; (6) the minimum func-tional loss at the donor site; (7) re-duces the microsurgical risk due to radiation patients’ bad receipt vessel situation22,23.

ConclusionIn the current case, the rib-major pectoralis myocutaneous flap pro-vided a suitable and cost-effective reconstruction to a composite oro-mandibular defect with low surgical risk, relatively short operative time, excellent cosmetic and functional outcome of patient and minimum donor site morbidity. This recon-structive method of the compound osteomyocutaneous flap should not be forgotten in case of poor receipt vessel condition when two free flaps in one reconstructive stage are gaining in popularity.

Figure 8: Intraoperative view: the rib-major pectoralis osteomyocutaneous flap was tunnelled over supraclavicular area into the neck and head, the vascular-ized rib was fixed with the residual mandible and muscle was filled into the soft-tissue defect.

Figure 9: Lateral view of the reconstruction intraoperatively.

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ConsentWritten informed consent was ob-tained from the patient for publica-tion of this case report and accompa-nying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

AcknowledgementThis work was supported by grants of the National Natural Science Foun-dation of China (NSFC: 30600714, 30973341) and Shanghai Rising-Star Program (07QA14039).

References1. Ord RA. The pectoralis major myocu-taneous flap in oral and maxillofacial reconstruction: a retrospective analysis of 50 cases. J Oral Maxillofac Surg. 1996 Nov;54(11):1292–5.2. Shapiro MJ. Composite myocutaneous flaps. Otolaryngol Head Neck Surg. 1981 Nov–Dec;89(6):969–73.3. Santamaria E, Granados M, Barrera-Franco JL. Radial forearm free tissue transfer for head and neck reconstruction: versatility and reliability of a single donor site. Microsurgery. 2000;20(4):195–201.4. Charles EB, Jan SL. Reconstruction of large composite oromandibulomax-illary defects with free vertical rectus abdominis myocutaneous flaps. Plast Re-constr Surg. 2004 Feb;113(2):499–507.5. Wei FC, Demirkan F, Chen HC, Chen IH. Double free flaps in reconstruction of extensive composite mandibular defects in head and neck cancer. Plast Reconstr Surg. 1999 Jan;103(1):39–47.6. Ceulemans P, Hofer SO. Flow-through anterolateral thigh flap for a free oste-ocutaneous fibula flap in secondary com-posite mandible reconstruction. Br J Plast Surg. 2004 Jun;57(4):358–61.7. Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibu-lar defects. Plast Reconstr Surg. 1994 Feb;93(2):294–304.8. Yuen JC, Zhou AT, Shewmake K. Double skin paddle fibular flap for a through-and –through oromandibular defect. Ann Plast Surg. 1996 Jul;37(1):111–5.9. Niitsuma K, Hatoko M, Kuwahara M, Tanaka A, Iioka H, Fukuda T, et al.

Figure 10: Lateral views of appearance 4 years postoperatively.

Figure 11: Panoramic radiograph of mandible 2 weeks postoperatively.

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