Facelift approach for mandibular resection and reconstruction
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1 ORIGINAL ARTICLE Facelift approach for mandibular resection and reconstruction Bernardo Bianchi, MD, Andrea Ferri, MD, * Silvano Ferrari, MD, Chiara Copelli, MD, Enrico Sesenna, MD Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy. Accepted 23 August 2013 Published online 18 December 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI /hed ABSTRACT: Background. Mandibular resection is the mainstay in the treatment of several pathologies involving the jaw. When benign lesions are approached, a limited exposure and less invasive access considering the cosmetic outcome is desirable to reduce morbidity and increase patient s quality of life after surgery. The facelift approach is widely used for rhytidectomy, parotidectomy, and facial animation procedures, whereas its use for mandibular resection and reconstruction is not described yet. Methods. Six patients underwent mandibular resection and reconstruction with free flaps or bone grafts via the facelift approach were retrospectively evaluated with regard to function and cosmesis. Results. No impairment of occlusion or facial nerve occurred; mouth opening was normal in 4 patient and partially limited in 2. Cosmesis was assessed as excellent by 3 patients and good in 3. Conclusion. The facelift approach is a valid option for resecting and reconstructing benign lesions involving the mandibular ramus, angle, and posterior body. VC 2013 Wiley Periodicals, Inc. Head Neck 36: , 2014 KEY WORDS: face lift, mandibular reconstruction, mandibular resections, facial reconstruction, mandibular tumor INTRODUCTION Mandibular resection is the mainstay in the treatment of several pathologies involving the jaw, including both malignant and benign lesions. The indications for mandibular resection are well established, and different approaches have been proposed over the years. 1 In the treatment of malignant neoplasms, a wide surgical field is mandatory to allow neck dissection, ensure adequate oncological safety, and control both the hard and soft tissues in the mandibular area. Conversely, when benign lesions are approached, a limited exposure and less invasive access considering the cosmetic outcome is desirable in order to reduce morbidity and increase the patient s quality of life after surgery, especially when the patients are children or young adults. 2 An ideal access should allow resection and reconstruction, whether performed with bone grafts or a bone-containing free flap, avoid visible scars, and provide access to vessels that are suitable for microvascular anastomosis in the case of free flap reconstruction. The facelift approach is widely used for different purposes, including rhytidectomy, parotidectomy, and facial animation procedures. 3,4 Its scar is hidden and comfortable access to facial vessels is provided if needed. The mandible can be reached after dissecting the terminal inferior branches of the facial nerve and the ramus, angle, and body can be exposed, resected, and reconstructed, *Corresponding author: A. Ferri, Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, via Gramsci 14, Parma, Italy. a.ferri@libero.it ultimately in association with an intraoral approach, thereby avoiding a visible incision in the neck. In this study, we propose the use of the facelift access for resecting benign tumors involving the mandibular ramus, angle, and body, discuss its indications and advantages, and present results obtained with this technique, which, as far as we know, has not been reported in the international literature. Surgical technique The skin incision is started in the pretragal area, continues around the ear lobe, curves up behind the ear, and finally proceeds straight down to the end of the hairbearing area (Figure 1). Dissection is performed in the subcutaneous plane, taking care to preserve the great auricular nerve branches, and then over the underlying parotid fascia and up to the posterior margin of the masseter muscle. The neck area requires subplatysmal dissection. The parotid gland is released from the surrounding tissues to allow, if needed, its elevation to expose the inferior mandibular margin, submandibular gland, and neck vessels. At this level, the terminal inferior branches of the facial nerve must be identified and dissected carefully, using magnification and an electrostimulator (Figure 2). The terminal branches are easily identified without also identifying the main trunk or main branches in the parotid gland, just as they emerge from the parotid gland at the posterior margin of the masseter muscle. In addition, the middle zygomaticbuccal and zygomatic main branches should be identified and dissected if condylar or subcondylar resection is planned. In these cases, the upper portion of the ramus HEAD & NECK DOI /HED OCTOBER
2 BIANCHI ET AL. FIGURE 1. Intraoperative photograph showing the incision line drawing. [Color figure can be viewed in the online issue, which is available at FIGURE 3. The upper portion of the ramus can be approached passing through the masseter muscle between the middle and inferior branches of the facial nerve (retracted). [Color figure can be viewed in the online issue, which is available at and condyle neck are exposed through an additional transmasseter approach that passes between the middle and inferior facial nerve branches (Figure 3). In this way, the zygomatic branches are protected by the cuff of the masseter muscle, which can be elevated to allow an approach to the upper portion of the mandibular ramus and condyle. During this step, extreme care must be taken to avoid damaging the nerve branches during soft tissue retraction. The facial artery and vein are usually encountered and preserved, depending on the reconstruction needed. Next, the masseter muscle is elevated at its inferior portion on the angle, protecting the facial nerve branches, and the mandibular periosteum is incised (Figure 4). If needed, a cuff of masseter muscle can be added to the specimen. Bone dissection proceeds up to the planned site of the mandibular osteotomies; to facilitate their exposure, an assistant should gently move the mandible while the soft tissues are retracted. Intraoral access is obtained depending on the need of the resection: if it must be performed without including soft tissues and rib graft reconstruction is planned, we usually make small incisions in the area of the osteotomies, to release the mucosa and enable the control of instruments during resection and reconstruction. If a free flap is planned or soft tissues must be resected, we prefer a complete intraoral access, as it is very useful during the reconstructive procedure. Once the mandible is resected, reconstruction is performed; if a free flap is required, previously identified facial vessels are dissected and prepared for anastomosis. The free flap is inset and fixed using miniplates or a FIGURE 2. Identification and dissection of the inferior branch of the facial nerve. [Color figure can be viewed in the online issue, which is available at FIGURE 4. Mandibular angle and body are exposed. [Color figure can be viewed in the online issue, which is available at 1498 HEAD & NECK DOI /HED OCTOBER 2014
3 FACELIFT APPROACH FOR MANDIBULAR RESECTION AND RECONSTRUCTION FIGURE 5. Insetting and fixation of the free flap are controlled through the facial pocket. [Color figure can be viewed in the online issue, which is available at reconstructive plate under double control: externally from the facial pocket and internally from the intraoral access (Figure 5). If bone grafts are used, they are inset through the facial pocket and fixed with miniplates, using an angled screwdriver (Figure 6). Finally, the intraoral accesses are sutured carefully, a drain is placed inside the facial pocket, and the skin is closed with standard sutures. In the early postoperative period, the flap can be monitored with a Doppler probe. Patients We retrospectively evaluated 6 patients (4 women and 2 men; mean age, 34; range, 8 55 years) who underwent mandibular resection and reconstruction for benign lesions using this technique between January 1, 2008, and December 31, Because of the retrospective nature of the study, institutional review board approval was not required. Table 1 summarizes the patient data. The diagnosis was a recurrent keratocyst and recurrence of multicystic ameloblastoma in 2 cases each, a myxoma in 1 patient, and a benign fibro-osseous lesion in the remaining patient. The ramus was affected in all patients, the FIGURE 6. If free bone grafts are used for reconstruction, miniplates are placed for fixation through the facelift approach. [Color figure can be viewed in the online issue, which is available at angle was also involved in 5 patients, and the lesion was extended to the posterior body in 3 patients. All patients underwent a CT or MRI scan preoperatively. In 2 cases, a stereolithographic model was prepared before surgery allowing more detailed resection planning and a premodeled reconstructive plate. In 4 cases, a subperiosteal resection was performed, whereas in the remaining 2 cases, a small cuff of perimandibular soft tissues including the masseter muscle and alveolar crest mucosa was added. In the 5 patients requiring free flap reconstruction, a standard intraoral approach was also used, whereas the remaining patient underwent tooth and mucosal release in association with the external approach and rib graft reconstruction. The lengths of the mandibular defects ranged from 4.5 to 7.5 cm (mean, 6.18 cm). The coronoid process was included in the specimen in 4 cases, and in the remaining 2 cases it was resected via the intraoral access to prevent impaired mouth opening. In 5 cases, reconstruction was performed with a bonecontaining free flap: 3 fibula osseous flaps, 1 scapular TABLE 1. Patients. Sex/age Histology Location Plane of resection Approach Defect length Reconstruction F/42 y Multicystic ameloblastoma recurrence M/8 y Fibro-osseous benign lesion Mandibular ramus angle and body Mandibular ramus and angle F/35 y Keratocyst recurrence Mandibular ramus and angle and body M/28 y Multicystic Mandibular ramus ameloblastoma recurrence F/55 y Myxoma Mandibular ramus, angle and body F/36 y Keratocyst Mandibular ramus recurrence and angle Perimandibular soft tissues included Subperiosteal resection Subperiosteal resection Subperiosteal resection Facelift 1 endo-oral 7.5 Fibula free flap Facelift 1 small endo-oral release incisions 6.4 Rib grafts Facelift 1 endo-oral 6.5 Scapular angle free flap Facelift 1 endo-oral 5.0 Fibula free flap Perimandibular soft Facelift 1 endo-oral 7.2 Fibula free flap tissues included Subperiosteal resection Facelift 1 endo-oral 4.5 Iliac crest free flap HEAD & NECK DOI /HED OCTOBER
4 BIANCHI ET AL. TABLE 2. Results. Sex/age Follow-up, mo Complications Occlusion Facial nerve outcome Mouth opening Aesthetic results F/42 y 56 Facial nerve weakness (6 wk) Preserved Normal Normal Excellent M/8 y 38 Facial nerve weakness (3 wk) Preserved Normal Normal Excellent F/35 y 26 Facial nerve weakness (5 wk)sialocele Preserved Normal Partially limited Good M/28 y 18 None Preserved Normal Normal Good F/55 y 41 Intraoral wound dehiscence Preserved Normal Partially limited Good F/36 y 44 Sialocele Preserved Normal Normal Excellent angle flap, and 1 iliac crest flap. In all cases, the facial artery and vein were used for microvascular anastomosis. In the other patient, 2 free bone grafts harvested from ribs were used. RESULTS Follow-up ranged from 56 to 18 months (mean, 37.2 months); Table 2 summarizes the results. Safe margins were achieved at the final histopathological examination in all cases and to date no recurrence has been observed. All of the transplanted flaps survived and no major complications occurred. Minor complications included temporary weakness of the inferior branch of the facial nerve in 3 patients (lasting 3, 5, and 6 weeks, respectively), sialoceles in 2 patients, and dehiscence of the intraoral wound in 1 patient. No case of alopecia or skin edge necrosis was encountered and partial greater auricular nerve numbness was seen in only 1 case. The patients were evaluated functionally and cosmetically. Functional outcome was assessed based on occlusion (preserved or not), mouth opening (normal, partially limited, or severely limited), and facial nerve outcome (impaired or normal). Cosmetic results were assessed by the patients as poor, good, or excellent, considering the scar and facial contour restoration. With regard to functional results, both occlusion and facial nerve function were preserved in all patients. Mouth opening was normal in 4 patients and partially limited in 2, as a result of wide dissection of the masticatory muscles and subsequent scarring. The aesthetic results were rated as excellent by 3 patients and good by the other 3, basically because of minor facial contour asymmetry related to free flap reconstruction, 5 independently of the use of the facelift approach. Case 1 An 8-year-old boy was referred to our department with a 5-month history of a nonpainful, but rapidly expanding, mass in the right mandible. MRI and orthopantomography revealed a mandibular lesion involving the ramus and angle (Figure 7). Biopsy findings were consistent with a benign fibro-osseous lesion. Two weeks later, the patient underwent a partial right mandibulectomy following the described technique using a facelift approach and small intraoral release incision. Mandibular reconstruction was performed simultaneously using 2 rib grafts (Figure 6). After 7 days of uneventful hospitalization, the patient was discharged with no major complication. A minor complication was temporary facial nerve weakness, which had resolved completely by 3 weeks after surgery. The final histological examination confirmed the biopsy diagnosis of benign fibro-osseous lesion. At the 38-month follow-up visit, the patient showed no clinical or radiological evidence of recurrence, with harmonious craniofacial development and good esthetic and functional outcomes (Figures 8 and 9). DISCUSSION Because it is necessary to consider the aesthetic outcome when approaching benign mandibular lesions, a more hidden, conservative approach is the best way to achieve this objective. A standard transcervical approach is widely used and is the classic approach to extended benign lesions that cannot be controlled via intraoral access alone. 6 Although this procedure is safe and FIGURE 7. MR images in axial (A) and coronal (B) planes showing the extension of the benign fibro-osseous mandibular lesion affecting patient 1. FIGURE 8. Postoperative orthopantomography showing the reconstruction HEAD & NECK DOI /HED OCTOBER 2014
5 FACELIFT APPROACH FOR MANDIBULAR RESECTION AND RECONSTRUCTION FIGURE 9. Preoperative (A) and postoperative (B, C) photographs of patient 1 showing cosmetic results. [Color figure can be viewed in the online issue, which is available at reliable, visible scars on the neck limit the cosmetic outcome; this is a major drawback, especially when pediatric patients or young adults are being treated. The major advantage of the facelift approach is that it avoids visible scars on the neck, with the exception of bald patients. However, the tumor histology and extent and the planned reconstruction must be considered before using this approach. With regard to histology, only benign lesions should be considered with this access because of the limited surgical field, which is sufficient for bone resection but very unsafe for malignancies with soft tissue involvement. Furthermore, the need for neck dissection in malignancies overcomes the utility of this approach. The extent and site of mandibular involvement must also be considered. Although the ramus, angle, and posterior body up to the first molar can be reached adequately, it is very difficult to control the anterior mandible. If this is the only part involved, another approach should be selected, especially because the intraoral approach is adequate in most cases. 7 The facelift approach can be used with no other access when the ramus and angle require resection, but a small intraoral incision can facilitate better control during the osteotomies and reconstruction, especially if free flaps are used. Conversely, when the mandibular body is involved or when some perimandibular soft tissue resection is planned, a combined intraoral approach is mandatory to ensure adequate control. The reconstructive procedure is a major issue that must be addressed to achieve satisfactory aesthetic results. The use of free bone grafts, locoregional flaps, 8 and free flaps 9 for such reconstructions has been widely described. When a facelift approach is used, we found no contraindications for either free flaps or bone-graft reconstruction. We usually reserve rib grafting for small reconstructions of edentulous areas, such as the ramus or posterior body, and for pediatric patients undergoing subperiosteal resections, 10 as the low morbidity and possibility of transferring cartilage growth centers for condylar resection improve the results in terms of mandibular development in growing patients. 11 In these cases, we try to reduce the intraoral wound as much as possible to prevent fistulas and infections, which are the main causes of graft failure. 12 When free flaps are used, the facelift approach provides comfortable access to the facial artery and vein, 13 which are easily dissected and used for the anastomosis, similar to the standard technique for neuromuscular transplantation for facial animation procedures. Furthermore, the positions of the pedicle and anastomosis avoid the need to limit head movement in the early postoperative period, which is usually the case when neck vessels are used for transplantation, thereby improving patient comfort after the surgery. Finally, if needed, the neck vessels are easily reached and can be used for anastomosis and the submandibular gland can be resected if an increased space is required to prevent flap pedicle compression. 14 As mentioned above, when free flaps are used, the combined use of an intraoral approach is strongly recommended to enable faster, safer, more precise flap insetting and fixation. Additionally, stereolithographic models can be used to model any required plates preoperatively. 15 The facial nerve is the most important consideration when using the facelift approach. It is mandatory to locate and dissect the inferior terminal branches during facial pocket harvesting in order to preserve them. Given the limited field, it is mandatory to use magnification with loops (3.53 is recommended) or a microscope. This lengthens the surgery by about 1 hour when compared with the standard transcervical approach, and is the most difficult aspect of the technique, requiring great experience in microsurgery and confidence with facial nerve dissection. Despite great care during the procedure, temporary (3 6 weeks in our series) facial nerve weakness related to soft-tissue traction during the procedure is a possible minor complication, and the patient should be informed adequately. CONCLUSION The facelift approach is a valid option for resecting and reconstructing benign lesions involving the mandibular ramus, angle, and posterior body. It provides adequate access for resection and reconstruction with either free flaps or bone grafts and enables excellent cosmetic results. Facial nerve management is the most difficult aspect of this procedure, so it should only be attempted by surgeons with experience in this area. REFERENCES 1. Bianchi B, Ferri A, Ferrari S, et al. Mandibular resection and reconstruction in the management of extensive ameloblastoma. J Oral Maxillofac Surg 2013;71: Bak M, Jacobson AS, Buchbinder D, Urken ML. Contemporary reconstruction of the mandible. Oral Oncol 2010;46: Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E. Improving esthetic results in benign parotid surgery: statistical evaluation of facelift approach, sternocleidomastoid flap, and superficial musculoaponeurotic system flap application. J Oral Maxillofac Surg 2011;69: Bianchi B, Copelli C, Ferrari S, Ferri A, Sesenna E. Facial animation in Moebius and Moebius-like syndromes. Int J Oral Maxillofac Surg 2010;39: Verhoeven TJ, Coppen C, Barkhuysen R, et al. Three dimensional evaluation of facial asymmetry after mandibular reconstruction: validation of a new method using stereophotogrammetry. Int J Oral Maxillofac Surg 2013;42: Landa LE, Tartan BF, Acartuk A, Skouteris CA, Gordon C, Sotereanos GC. The transcervical incision for use in oral and maxillofacial surgical procedures. J Oral Maxillofac Surg 2003;61: Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E. Subtotal mandibular reconstruction using an intraoral approach: report of 2 cases. J Oral Maxillofac Surg 2008;66: HEAD & NECK DOI /HED OCTOBER
6 BIANCHI ET AL. 8. Genden EM, Buchbinder D, Chaplin JM, Lueg E, Funk GF, Urken ML. Reconstruction of the pediatric maxilla and mandible. Arch Otolaryngol Head Neck Surg 2000;126: Hayden RE, Mullin DP, Patel AK. Reconstruction of the segmental mandibular defect: current state of the art. Curr Opin Otolaryngol Head Neck Surg 2012;20: Gadre PK, Ramanojam S, Patankar A, Gadre KS. Nonvascularized bone grafting for mandibular reconstruction: myth or reality? J Craniofac Surg 2011;22: Ferri T, Bacchi G, Bacciu A, Oretti G, Bottazzi D. The pectoralis major myocutaneous flap in head and neck reconstructive surgery: 16 years of experience. Acta Biomed Ateneo Parmense 1999;70: De Riu G, Meloni SM, Raho MT, Tullio A. Complications of mandibular reconstruction in childhood: report of a case of juvenile aggressive fibromatosis. J Craniomaxillofac Surg 2006;34: Park YM, Lee WJ, Yun IS, et al. Free flap reconstruction after robotassisted neck dissection via a modified face-lift or retroauricular approach. Ann Surg Oncol 2013;20: Bianchi B, Ferri A, Ferrari S, Copelli C, Leporati M, Sesenna E. Alternate approaches to recipient vessels in maxillary reconstruction. Microsurgery 2011;31: Marchetti C, Bianchi A, Mazzoni S, Cipriani R, Campobassi A. Oromandibular reconstruction using a fibula osteocutaneous free flap: four different preplating techniques. Plast Reconstr Surg 2006;118: HEAD & NECK DOI /HED OCTOBER 2014
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