Vascularized Osteocutaneous Flaps

The development of microsurgery and further refinement of techniques in mandible reconstruction have revolutionized our ability to reconstruct the defect from a resected mandible. Since we can transfer large quantities of highly vascularized bone, soft tissue and skin with a single flap, almost any defect of the mandible can be reconstructed with one operation. Although vascularized tissue transfers are highly complex and time-consuming, their advantages far outweigh their disadvantages. Immediate reconstruction with one operation is clearly the major advantage of free flaps. Vascularized bone will heal within a period of 2 to 3 months, even with preoperative or postoperative radiation. The high bone union rates (>98%) using this technique have made it the reconstructive option of choice.28 The ability to transfer healthy muscle, soft tissue, and large quantities of skin with the bone segment further supports the indications for its use. Well-vascularized bone serves as an excellent bed for placement of osteointegrated implants, which maximizes both functional and esthetic results. Thus a vast majority of patients with segmental mandibular defects will benefit from the use of a vascularized bone flap.

Choice of Osteocutaneous Free Flap

The 4 osteocutaneous flaps most commonly used are the (1) radial forearm, (2) iliac crest, (3) scapula and

(4) fibula (Figure 19-1). Each flap has its distinct advantages and disadvantages.28 Table 19-1 evaluates each flap with regard to ease of dissection, length of pedicle, amount of available bone, soft tissue and skin, potential for osseointegrated implants, as well as donor site morbidity. The choice of flap is dependent on a combination of these different factors but is most commonly dictated by the amount of bone and skin that is required to reconstruct a given defect.19 Other parameters such as donor site availability, patient choice, ease of dissection, and the patient's overall medical condition may, in a rare case, override the tissue requirements.

Radial Forearm Osteocutaneous Flap

The radial forearm osteocutaneous flap is based on the radial artery, its venae comitantes, and the cephalic vein. This flap has the best available donor site vessels, with excellent length as well as diameter.

Figure 19-1. Osteocutaneous donor sites for mandible reconstruction drawn to the same scale: A, scapula, B, radius, C, ilium, D, fibula. Note the differences in tissue characteristics, with regard to quantity and configuration of the available bone and soft tissue, as well as type of blood supply and the vascular pedicle.

Figure 19-1. Osteocutaneous donor sites for mandible reconstruction drawn to the same scale: A, scapula, B, radius, C, ilium, D, fibula. Note the differences in tissue characteristics, with regard to quantity and configuration of the available bone and soft tissue, as well as type of blood supply and the vascular pedicle.

Table 19-1. COMPARISON OF OSTEOCUTANEOUS FREE FLAP DONOR SITES

Tissue Characteristics

Donor Site Characteristics

Bone

Skin

Vessels

Two-teamable Donor Site Morbidity

Osseointegration

Radial forearm flap Iliac crest Scapula Fibula

Flap characteristics are rated excellent (+++) to poor (+) and negative (-).

It also provides a skin island which is highly reliable, well-vascularized, and that is thin and pliable. It is thus perfectly suited for repair of mucosal lining of intraoral defects.29 One can usually harvest up to 8 to 10 cm of unicortical bone that is thin and cannot be reliably osteotomized. It also provides only minimal soft-tissue bulk, although a segment of the brachio-radialis muscle can be harvested to yield a small amount of extra bulk. The major disadvantages of this flap are inadequate bone, and a significantly high morbidity of the donor site if the radius fractures. We have resorted to bone grafting the donor site primarily in order to increase the amount of bone that can be harvested. The radial forearm osteocuta-neous flap is best suited to reconstruct defects that require a large amount of intraoral skin and small amounts of bone in a lateral location (Figure 19-2). This area usually does not require osseointegration.

Figure 19-2. A, A 62-year-old man with an intraoral carcinoma involving the ascending ramus of the mandible, who underwent segmental mandibulectomy with large mucosal resection. B Radial forearm osteocutaneous flap with the patient's condyle autotransplanted and rigidly fixed to the flap . Note large, thin, pliable skin island and long vascular pedicle in this flap.

Figure 19-2. A, A 62-year-old man with an intraoral carcinoma involving the ascending ramus of the mandible, who underwent segmental mandibulectomy with large mucosal resection. B Radial forearm osteocutaneous flap with the patient's condyle autotransplanted and rigidly fixed to the flap . Note large, thin, pliable skin island and long vascular pedicle in this flap.

Figure 19-2. C, Flap inset. The skin island has been used to resurface the retromolar trigone and palate, and the radius fixed to the remaining mandible. D, and E Postoperative photos 4 months after surgery showing good lower face contour and esthetic result. F, Panoramic roentgenograph showing adequate bony healing and symmetry, when compared with the contralateral side.

Figure 19-2. C, Flap inset. The skin island has been used to resurface the retromolar trigone and palate, and the radius fixed to the remaining mandible. D, and E Postoperative photos 4 months after surgery showing good lower face contour and esthetic result. F, Panoramic roentgenograph showing adequate bony healing and symmetry, when compared with the contralateral side.

Thus patients with large intraoral tumors involving the lateral pharyngeal wall, tonsillar pillar, soft palate or retromolar trigone who require resection of the ascending ramus of the mandible should have reconstruction with the forearm flap.19,29 We do not advocate its use for the anterior arch or even a mid-body lateral segment defect of the mandible.

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