Maxillary Reconstruction with the Free Fibula Flap

Transcription

1 Maxillary Reconstruction with the Free Fibula Flap Xin Peng, D.D.S., Ph.D., Chi Mao, D.D.S., Ph.D., Guang-yan Yu, D.D.S., Ph.D., Chuan-bin Guo, D.D.S., Ph.D., Min-xian Huang, D.D.S., and Yi Zhang, D.D.S., Ph.D. Beijing, People s Republic of China Background: The objective of this study was to evaluate the outcomes of using the free fibula flap in the reconstruction of maxillary defects. Methods: Thirty-four consecutive cases of maxillary reconstruction with the free fibula flap were reviewed. All clinical data were analyzed, including primary diseases, types of maxillary defect, free fibula flap design, perioperative complications, and follow-up results. The main postoperative functional indices, including oral diet, speech, type of dental restoration, and aesthetic results, were evaluated. Results: Of the 34 patients who underwent maxillary reconstruction with the free fibula flap, the primary diseases were malignant tumor in 20 patients, benign tumor in 11 patients, and trauma in three patients. Free fibula flap transfer was successful in all cases. Postoperative complications occurred in five patients. Recipient-site wound infection occurred in two patients and donor-site wound dehiscence occurred in three patients. One patient with donor-site wound dehiscence had postoperative lameness. The oral and nasal cavities were separated well by the flap in all patients. The patients were able to take food orally and had no problems with speech intelligibility. Osseointegrated implants were placed in four patients, and complete conventional prostheses were applied in 19 patients. Excellent cosmetic results were obtained in 22 patients. Conclusions: Alveolar arch defects can be reconstructed successfully using free fibula flaps. This procedure also allows for dental implant rehabilitation, which can improve the patient s appearance and oral function and enhance the overall quality of life. The fibula free flap transfer has a high success rate and low perioperative complication rate, making it an ideal choice for maxillary defect reconstruction. (Plast. Reconstr. Surg. 115: 1562, 2005.) Maxillary defects resulting from tumor resection or trauma can cause severe functional and cosmetic deformities. Traditionally, maxillary defect is obturated with bulky dental prostheses. Although acceptable results can eventually be achieved in many cases, patients may become dissatisfied for several reasons. The removable prosthesis must be retentive enough for adequate speech, swallowing, and cosmetic appearance. Poor retention resulting from denture bulkiness and poor residual dentition can create leakage and oronasal regurgitation. The patients must maintain adequate hygiene at the surgical site and around the prosthesis. Functional maxillary reconstruction with vascularized composite bone flap and osseointegrated implants is one of the most important improvements in head and neck reconstructive surgery. In 1989, Hidalgo et al. 1 used a free fibula flap to reconstruct a mandibular defect. In 1993, Sadove et al. 2 described simultaneous From the Department of Oral and Maxillofacial Surgery, Peking University School of Stomatology. Received for publication December 31, 2003; revised July 6, DOI: /01.PRS

2 Vol. 115, No. 6 / FREE FIBULA FLAP 1563 maxillary and mandibular reconstruction with a free osteocutaneous fibula flap; although no dental prosthesis was accomplished, oral function was restored to some extent. Schusterman et al. 3 reported successful orbit and midface reconstruction with a free fibula flap. Multiple case reports have described the use of this flap to reconstruct a variety of maxillary defects. The fibula flap with osseointegrated implants can lead to satisfactory results both functionally and aesthetically over a long follow-up period. 4 7 At present, the free fibula flap is not only the best choice for mandibular reconstruction but is also an ideal approach for maxillary reconstruction. In this article, we present 34 cases of various maxillary defects reconstructed using the free fibula flap and their outcomes. PATIENTS AND METHODS TABLE I Patient Characteristics No. of Patients Sex (M:F) 17:17 Primary disease Benign tumor 11 Malignant tumor 20 Trauma 3 Defect type Class I 4 Class II 24 Class III 6 Complication Flap failure 0 Return to operating room for flap salvage 1 Recipient-site wound infection 2 Donor-site wound dehiscence 3 Prognosis Died as a result of local recurrence 1 Distant metastasis 1 Patient ages ranged from 21 to 66 years (mean age, 38 years). Patient Population and Assessment Tools Thirty-four consecutive patients (17 men and 17 women) with maxillary defects underwent reconstruction of the maxilla using the free fibula flap at Peking University School of Stomatology from September of 1999 to April of Patient ages ranged from 21 to 66 years, with a median age of 38 years. Thirty patients underwent primary reconstruction at the time of maxillectomy. Four patients were operated on secondarily. The primary diseases in the 34 patients were benign tumors in 11 patients, malignant tumors in 20 patients, and trauma in three patients (Table I). Brown et al. 8 suggested a modified classification for maxillectomy defects. The surgical defect was classified according to the vertical and horizontal dimension of the maxillectomy (Fig. 1). Vertical component Class I: Maxillectomy with no oro-antral fistula Class II: Low maxillectomy Class III: High maxillectomy Class IV: Radical maxillectomy Horizontal component a) Unilateral alveolar maxilla and hard palate resected; less than or equal to half of the alveolar and hard palate resection not involving the nasal septum or crossing the midline b) Bilateral alveolar maxilla and hard palate resected; includes a smaller resection that crosses the midline of the alveolar bone including the nasal septum c) Entire alveolar maxilla and hard palate removed According to Brown s modified classification, in the present study there were four, 24, and six patients in classes I, II, and III, and 18, 10, and six patients in groups a, b, and c, respectively. All clinical data from the 34 patients were reviewed. Follow-up period ranged from 7 to 50 months, with a mean of 23 months. The follow-up rate was 100 percent. The follow-up included examination for local recurrence and distant metastasis of primary diseases, postoperative oral diet, speech intelligibility, type of dental restoration, and cosmetic outcome. The patients were evaluated postoperatively for their diet type, defined as regular or soft. Speech intelligibility was measured by speech pathologists with a Chinese language speech intelligibility test. Cosmetic outcome was judged individually by each patient, a significant other person, and a physician as being poor, fair, good, or excellent. Surgical Technique The donor leg graft was usually selected from the same side as the maxillary defect. The free fibula composite flap contained fibula bone, skin paddle, and muscle. The fibula bone was applied to recreate the missing alveolar process. The skin paddle was used to seal the mucosal defect and the muscle was used to fill up the maxillary cavity. Plaster models of the maxillary and mandibular arches were cast before surgery. A resin surgical plate was made on the model according to the operation program; this could be used to keep the normal

3 1564 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2005 FIG. 1. The Brown classification system for maxillary defects. distance between the maxilla and mandible according to the occlusal relationship of the residual teeth and locate the fibula bone at the adequate three-dimensional position for future dental restoration during surgery. The surgical technique to harvest vascularized fibula flap has been previously described by Hidalgo, 1 Hidalgo and Rekow, 9 and Wei et al. 10 In our series, the fibula flap was harvested in standard fashion as described by Hidalgo. 1 All bony buttresses available for contact with the fibula flap in the midface were exposed. The upper neck vessels must be isolated. Often, the submandibular gland was removed to improve access of the vascular pedicle to the maxillary defect. A medial-mandibular tunnel from the upper neck to the maxillary defect was thus made with a two-finger width for the passage of the vascular pedicle. Osteotomies were performed in the fibula bone and contoured to recreate the missing alveolar arch according to the surgical plate. The osteotomies were made distally to proximally so that any excess proximal bone could be discarded, thus increasing the pedicle length. The bone segments were fixed with titanium miniplates. The fibula flap was then transferred to the recipient site with the pedicle through the tunnel into the neck. The surgical plate was placed into oral cavity with normal occluding relation between the residual teeth, which was a guide for the location of the recreated alveolar arch. Titanium miniplates were used to fix the fibula bone to the residual bony buttresses. Microvascular anastomoses were performed afterward. The flexor hallucis muscle was used to fill the maxillary cavity and the skin paddle was sutured to the oral mucosas (Figs. 2 through 7). RESULTS The length of the fibula bone for alveolar reconstruction ranged from 4.0 to 11.0 cm, FIG. 2. Preoperative view of the patient with palatal adenocarcinoma.

4 Vol. 115, No. 6 / FREE FIBULA FLAP 1565 FIG. 3. Intraoperative view of the maxillary defect after maxillectomy. FIG. 5. Six-month postoperative view. FIG. 6. Postoperative three-dimensional computed tomography scan shows the relationship between the fibula and the maxilla. FIG. 4.(Above) Intraoperative view of the harvested fibula composite flap; osteotomies are made to shape the fibula into the maxillary alveolar shape. (Below) The fibula bones were fixed by titanium miniplates with remainder maxilla. with a mean length of 6.94 cm. The height of fibula bone ranged from 1.1 to 1.8 cm, with a mean height of 1.52 cm. The alveolar process of the opposite side, lateral border of the piriform aperture, and zygomaticoalveolar crest were frequently used as the fixation sites. The length of vascular pedicles ranged from 8.0 to 12.0 cm, with a mean length of 10.1 cm. One patient required a vein graft because the peroneal vein to be anastomosed was not long enough to contact vessels in the neck. In one patient, the vein was obliterated and urgent

5 1566 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2005 TABLE II Results of Function Evaluations Items No. of Patients Diet Regular 26 Soft 7 Speech Normal 33 Mean intelligibility 98.4% Dental restoration Implant-borne prosthesis 4 Conventional prosthesis 19 No dental restoration 10 Aesthetics Excellent 22 Good 7 Fair 4 Poor 0 One patient died as a result of tumor recurrence; 33 patients received complete functional evaluations. FIG. 7. Six-month postoperative intraoral views without (above) and with (below) the prosthesis. reanastomosis was performed on the first day after surgery to save the fibula flap. Free fibula flap transfer was successful in all cases. Postoperative complications occurred in five patients. Recipient-site wound infection occurred in two patients and was treated successfully by local wound care. Donor-site wound dehiscence occurred in three patients; they were treated with local wound care and delayed wound closure. All wounds eventually healed completely. Only one patient with donor-site wound dehiscence had postoperative lameness; all other patients had no obvious dysfunction of the foot. One patient with squamous cell carcinoma died as a result of local recurrence 16 months after surgery. One case with adenoid cystic carcinoma showed metastasis to the right lung on the 28th month after surgery. No local recurrence or distant metastases were found in the other patients. The results of the functional evaluation are shown in Table II. Complete closure of the wound and successful separation between the oral and nasal cavities was found in all 34 patients. Of the 33 surviving patients, 23 received complete dental rehabilitation. Osseointegrated implants with implant-borne prostheses were applied in four patients. Conventional partial prostheses were applied in the other 19 patients. Among the 10 patients without dental rehabilitation, six patients were waiting for dental restoration because they wished to have a longer follow-up period and four patients refused dental restoration by itself. All 33 patients resumed their chewing function. At a minimum of 7-month follow-up, 26 patients resumed a regular diet and seven patients were on a soft diet. The speech intelligibility of each patient was measured by using a Chinese language speech intelligibility test after 6 months postoperatively. The Chinese language contains 396 syllables comprising a consonant and vowel combination. All 396 syllables were arranged at random in this test. Each patient was instructed to pronounce each syllable. Their pronunciation was recorded and then played back to 10 untrained listeners who described the Chinese syllables that they thought they heard. Speech intelligibility scores were determined as the mean percentages of correct responses to the 10 listeners. Speech intelligibility scores ranged from 93.8 percent to 100 percent, with a mean value of 98.4 percent. All patients reached normal levels of speech. The aesthetic outcome was judged as being excellent, good, and fair in 22, seven, and four patients, respectively. The excellent proportion was 66.7 percent.

6 Vol. 115, No. 6 / FREE FIBULA FLAP 1567 DISCUSSION Maxillary defects resulting from tumor resection or trauma represent a challenging dilemma for the reconstructive surgeon. Every reconstructive technique must satisfy the following key objectives: (1) obliteration of the defect; (2) restoration of function, particularly speech and mastication; (3) structural support for reconstruction of external facial features; and (4) aesthetic reconstruction of these external facial features. With the development of microsurgery and reconstructive surgery of the head and neck, the basic functional and aesthetic goals of maxillary reconstruction can now be predictably and reliably achieved. Free composite bone flaps can simultaneously reconstruct the softand hard-tissue defect of the maxilla. Furthermore, osseointegrated implants can be placed in the vascularized graft bone to completely retain, support, and stabilize the prosthesis. Such outcomes represent truly functional maxillary reconstruction. The free composite bone flaps that were used in maxillary reconstruction include radial forearm osteocutaneous free flap, scapular osteocutaneous flap, iliac crest free flap, and fibula free flap. Cordeiro et al. 11 described using the sandwich radial forearm osteocutaneous free flap for the reconstruction of the subtotal maxillectomy defect. The bone stock is very limited, however, and the donor site shows obvious defects from this procedure. The radial forearm osteocutaneous free flap is now seldom used. The scapula osteocutaneous free flap is advantageous because the bone stock is larger than other composite flaps. It is particularly useful in defects when both the orbital floor/ zygoma and palate must be reconstructed, although it may not always be suitable for the placement of osseointegrated implants. Other disadvantages include the impossibility of immediate reconstruction, difficulty in the orientation of the bone to provide orbit, zygoma, and alveolar reconstruction, and the relatively short pedicle length. 12 The iliac crest free flap provides an excellent bone source for maxillary reconstruction but it also has obvious disadvantages. Excessive bulk, poor skin paddle mobility in relationship to bone, and short pedicle length are some of its disadvantages. The short pedicle usually requires a vein graft, which may increase the risk of complications during microsurgery. 13 In a comparative study of the dimensions of bone available for implant placement from the iliac crest, scapula, fibula, and radius osseous flaps, Frodel et al. 14 suggested that the iliac crest and fibula flaps had bone dimensions consistently adequate for implant placement. Fibulae have the further advantage of bicortical fixation for implant placement, providing greater stability and higher chances of osseointegration. The fibula flaps have a long pedicle. In our series, the mean pedicle length of the fibula flap was 10.1 cm and only one patient required a vein graft. The vertical height of the fibula is suitable for maxillary reconstruction. The fibula bone is used to restore alveolar defects and the surgical plate can locate the adequate position of the fibula bone for future prosthesis. Several studies showed the vertical height of the fibula bone was approximately 13.1 to 16.7 mm in the Asian population. 15,16 In our series, the mean vertical height was 15.2 mm. Moreover, the bone resorption rate of vascularized fibula bone was only 2 percent to 7 percent from long-term observation. 17 Frodel et al. 14 suggested that bone height for implantation should be no less than 1.0 cm. There is no doubt that maxillary reconstruction with a fibula flap can achieve the standard for implantation even after taking bone resorption into account. The following unique advantages make the fibula flap an ideal choice for maxillary reconstruction : (1) the long vascular pedicle; (2) the wide diameter of the peroneal vessels; (3) the provision of fibula bone, skin paddle, and muscle tissues by the composite fibula flap; (4) the relatively easier flap-harvesting procedure and low donor morbidity; (5) the distant donor site from the head and neck, which makes a two-team operation possible; (6) the relatively accurate three-dimensional contouring of the fibula to simulate the alveolar processes; and (7) the fibula bone, which is a good recipient of osseointegrated implants. Futran et al. 21 used the fibula free flap for maxillary reconstruction in a large series of 27 patients. Excellent results were obtained for speech, swallowing, and aesthetics in 20 patients with limited defects of the inferior maxilla. When the residual palate and dentition were insufficient to support a conventional prosthesis, the fibula was selected so that os-

7 1568 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2005 seointegrated implants could be placed to support dental prostheses. When reconstruction of the zygomatic complex and infraorbital rim and floor was required, however, this flap was limited in its ability to restore the entire maxillary form. In our series, 34 patients were reported; this is perhaps the largest case number that has been examined in one series. Twentyeight patients with maxillary defects classified as I and II had received subtotal maxillectomy or low maxillectomy without subsequent development of oro-antral fistula. The bone provided bulk and skeletal support, and the soft tissue was easily rotated to resurface the palatal area when necessary. They are the major indications for maxillary reconstruction with a free fibula flap. For the patients with class III and class IV defects high and radical maxillectomy leading to huge soft- and hard-tissue defects the composite fibula flap was inadequate in restoring both the maxilla and infraorbital area. Meanwhile, it remains very difficult to fix the fibula with the residual bone. The soft-tissue flaps, such as the rectus abdominis flap, are the choice for maxillary reconstruction of class III and class IV defects. Our experience has shown that the ability to reach good speech function in all cases. In our series, speech intelligibility scores ranged from 93.8 percent to 100 percent, with a mean value of 98.4 percent. All patients reached normal levels of speech. In the most past literature, the speech function of the patients with maxillary reconstruction with fibula flap was judged as intelligible by over the telephone. 21,22 In this paper, the speech intelligibility of each patient was measured by using a Chinese language speech intelligibility test that is more objective and quantitative. In this study, postoperative complications occurred in five patients. Recipient-site wound infection occurred in two patients and donorsite wound dehiscence occurred in three patients. All wounds eventually healed completely. Only one patient with donor-site wound dehiscence had postoperative lameness. Compared with the report of Futran et al., 21 there was one patient with total flap failure, three patients with venous or arterial obstruction, four patients with wound dehiscence, and three patients with additional procedures. The proportion of the patients with complications in our series is lower. Generally, the complications of the procedure are acceptable and can be treated eventually. The maxillary reconstruction with free fibula flap procedure is complicated, and the treatment period for osseointegrated implant prostheses is long. Therefore, the indications for fibula flap reconstruction should be strictly controlled. 23 In our opinion, the indications for maxillary reconstruction with the free fibula flap are as follows: (1) the defect resulted from a benign tumor and trauma, (2) the defect resulted from a limited malignant tumor, (3) the defect affects the entire maxilla and hard palate, (4) secondary reconstruction is necessary, and (5) there are class I and class II maxillary defects. In general, reconstruction of head and neck defects with free flaps is reliable and safe. Recent statistics show that free flap survival rate in series of more than 100 cases of microvascular head and neck reconstructions performed by a single surgeon or institution ranged from 91.5 percent to 99.2 percent. 24 Large clinical series have firmly established the unsurpassed reliability of free flaps. In the current series, the success of the fibula flap was a remarkable 100 percent. The successful outcome depends not only on excellent microsurgery technique but also on careful management in the perioperative period. There are some key points related to the success of the operation. Before surgery the donor leg should be examined carefully. Normally, pulsation of the arteria dorsalis pedis and the posterior tibial artery can be felt clearly. There might be vascular variation. If no pulse can be felt, the donor leg should be switched to the other leg. Preoperative Doppler ultrasonography should be performed for accurate detection of cutaneous perforators from the peroneal artery, which enhance the reliability of the skin paddle for reconstructing the soft-tissue defect. During the harvesting of the fibula flap, the level of proximal osteotomy should be as high as possible. During contouring of the fibula bone, the osteotomies were made from distal end to proximal end so that any excess proximal bone could be discarded, thus increasing the pedicle length. The utmost effort must be made during surgery to avoid technical errors such as trauma to the vascular pedicle or recipient vessels, creation of an imperfect vascular anastomosis, or selection of poor geometry between the donor and recipient vessels. The head should be maintained strictly motionless for the first 3 days after the operation, as head and neck movement may result in

8 Vol. 115, No. 6 / FREE FIBULA FLAP 1569 thrombosis at the site of vascular anastomosis. Routine postoperative anticoagulant therapy should be performed with low-molecularweight dextran and aspirin. The timing of clinical observations of the fibula flap is also very important. Immediate exploration and salvage of the flap are essential when any signs of vascular thrombosis appear. CONCLUSIONS Excellent function and well-accepted aesthetics can be achieved in maxillary reconstruction with the fibula free flap. The criteria for fibula flap and long-term evaluation of postoperative function should be investigated thoroughly. Xin Peng, D.D.S., Ph.D. Department of Oral and Maxillofacial Surgery Peking University School of Stomatology Beijing, , People s Republic of China pxpengxin@263.net REFERENCES 1. Hidalgo, D. A. Fibula free flap: A new method of mandibular reconstruction. Plast. Reconstr. Surg. 84: 71, Sadove, R. C., and Powell, L. A. Simultaneous maxillary and mandibular reconstruction with one free osteocutaneous flap. Plast. Reconstr. Surg. 92: 141, Schusterman, M. A., Reece, G. P., and Miller, M. J. Osseous free flap for orbit and midface reconstruction. Am. J. Surg. 166: 341, Yim, K. K., and Wei, F. C. Fibula osteoseptocutaneous free flap in maxillary reconstruction. Microsurgery 15: 353, Nakayama, B., Matuura, H., Ishihara, O., Hasegawa, H., Mataga, I., and Torii, S. Functional reconstruction of a bilateral maxillectomy defect using a fibula osteocutaneous flap with osseointegrated implants. Plast. Reconstr. Surg. 96: 1201, Kazaoka, Y., Shinohara, A., Yokou, K., and Hasegawa, T. Functional reconstruction after a total maxillectomy using a fibula osteocutaneous flap with osseointegrated implants. Plast. Reconstr. Surg. 103: 1244, Ferri, J., Caprioli, F., Peuvrel, G., and Langlois, J. M. Use of the fibula free flap in maxillary reconstruction: A report of 3 cases. J. Oral Maxillofac. Surg. 60: 567, Brown, J. S., Rogers, S. N., McNally, D. N., and Boyle, M. A modified classification for the maxillectomy defect. Head Neck 22: 17, Hidalgo, D. A., and Rekow, A. A review of 60 consecutive fibula free flap mandibular reconstructions. Plast. Reconstr. Surg. 96: 585, Wei, F. C., Chen, H. C., Chung, C. C., and Noordhoff, M. S. Fibula osteoseptocutaneous flap: Anatomic study and clinical application. Plast. Reconstr. Surg. 78: 191, Cordeiro, P. G., Bacilious, N., Schantz, S., and Spiro, R. The radial forearm osteocutaneous sandwich free flap for reconstruction of the bilateral subtotal maxillectomy defect. Ann. Plast. Surg. 40: 397, Uglesic, V., Virag, M., Varga, S., Knezevic, P., and Milenovic, A. Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery. J. Craniomaxillofac. Surg. 28: 153, Brown, J. S. Deep circumflex iliac artery free flap with internal oblique muscles as a new method of immediate reconstruction of maxillectomy defect. Head Neck 18: 412, Frodel, J. L., Funk, G. F., Capper, D. T., et al. Osseointegrated implants: A comparative study of bone thickness in four vascularized bone flaps. Plast. Reconstr. Surg. 92: 449, Horiuchi, K., Hattori, A., Inada, I., et al. Mandibular reconstruction using the double barrel fibular graft. Microsurgery 16: 450, Matsuura, M., Ohno, K., Michi, K., Egawa, K., and Takiguchi, R. Clinicoanatomic examination of the fibula: Anatomic basis for dental implant placement. Int. J. Oral Maxillofac. Implants 14: 879, Disa, J. J., Hidalgo, D. A., Cordeiro, P. G., Winters, R. M., and Thaler, H. Evaluation of bone height in osseous free flap mandible reconstruction: An indirect measure of bone mass. Plast. Reconstr. Surg. 103: 1371, Mao, C., Yu, G., Peng, X., Guo, C., Huang, M., and Zhang, Y. A preliminary study of maxillary reconstruction using free flaps: A review of 20 consecutive cases [in Chinese]. J. Modern Stomatol. 15: 352, Mao, C., Yu, G., Peng, X., Guo, C., Huang, M., and Zhang, Y. Preliminary study on microsurgical reconstruction of maxillary and midfacial defect [in Chinese]. J. Oncolol. 7: 36, Futran, N. D., and Haller, J. R. Considerations for freeflap reconstruction of the hard palate. Arch. Otolaryngol. Head Neck Surg. 125: 665, Futran, N. D., Wadsworth, J. T., Villaret, D., and Farwell, D. G. Midface reconstruction with the fibula free flap. Arch. Otolaryngol. Head Neck Surg. 128: 161, Triana, R. J., Jr., Uglesic, V., Virag, M., et al. Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects. Arch. Facial Plast. Surg. 2: 91, Mao, C., Yu, G., Guo, C., Huang, M., and Peng, X. A preliminary study of maxillary reconstruction using free fibula composite flap [in Chinese]. J. Oral Maxillofac. Surg. 11: 11, Blackwell, K. E. Unsurpassed reliability of free flaps for head and neck reconstruction. Arch. Otolaryngol. Head Neck Surg. 125: 295, 1999.