CLINICAL STUDY

Latissimus Dorsi-Rib Pedicle Flap for Mandibular Reconstruction as a Salvage Procedure for Failed Free Fibula Flap Hung-Chi Chen, MD, FACS,* Nefer Fallico, MD,† Pedro Ciudad, MD,* and Emilio Trignano, MD, PhD*‡ Background: Mandibular reconstruction is usually performed by using free vascular flaps. However, there are instances in which it must be carried out with pedicle flaps. Insofar, the main option recommended is the pectoralis major (PM) + rib pedicle flap. Methods: A 45-year-old patient affected by a primitive mandibular tumor presented after an unsuccessful reconstruction with free fibula flaps. He refused a PM + rib pedicle reconstruction, while he accepted to undergo a latissimus dorsi (LD) + rib flap reconstruction. Results: The postoperative course was uneventful. Also, the range of movements of the upper limb involved in the operation showed no significant changes after surgery. Conclusions: The LD + rib flap proved to be a useful alternative procedure for mandibular reconstruction after cancer ablation in patients who are not candidates for vascularized bone-containing free flaps and refuse the PM + rib flap reconstruction. Key Words: Latissimus dorsi-rib pedicle flap, mandibular reconstruction, salvage procedure, free fibula flap, pectoralis major-rib pedicle flap (J Craniofac Surg 2014;25: 961–963)

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andibular reconstruction is a well-known and widely written topic. Flaps such as the free fibula, free iliac crest, and free rib are among the most commonly performed techniques for mandibular reconstruction.1–3 However, there are instances in which, due to the failure of free flaps or patients’ general conditions, the reconstruction of the mandible after the removal of tumors in the oral cavity must be carried out by employing pedicle flaps. Insofar, the main option recommended and described in literature is the pectoralis major + rib (PM + rib) pedicle flap.4 The PM + rib flap rapidly and easily allows the covering of mandibular defects. However, the donor site needs to be closed with skin grafts leading to a poor aesthetic appearance of the anterior chest wall.

From the *Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan; †Department of Plastic and Reconstructive Surgery, “Sapienza” University of Rome, Rome, Italy; and ‡Department of Plastic and Reconstructive Surgery, University of Sassari, Sassari, Italy. Received December 22, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Nefer Fallico, MD, Department of Plastic and Reconstructive Surgery, “Sapienza” University of Rome, Via Val Savio 3, 00141, Rome, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000744

The present paper describes the use of latissimus dorsi + rib (LD + rib)5–7 flap for mandibular reconstruction in a patient who underwent an unsuccessful reconstruction with free fibula flaps and who refused a PM + rib pedicle reconstruction with the contralateral fibula while he accepted to undergo a pedicle rib reconstruction.

CLINICAL REPORT A 45-year-old male patient affected by a primitive mandibular tumor (ameloblastoma of the left mandibular branch) was admitted to our department after the failure of both left and right free fibula reconstruction performed in a different hospital. Due to his general conditions, the option of reconstructing the mandible by means of a free flap was rejected. The patient was advised a pedicle flap reconstruction with the PM + rib flap, which he refused. Our medical team suggested then to perform a latissimus dorsi + rib pedicle flap reconstruction. The patient was briefed about this procedure and finally gave consent to it. Preoperative antibiotics were administered. An elliptical-shaped skin island was designed along the medial border of the latissimus dorsi muscle. The inferior border of the flap was identified and the dissection was carried out following an inferior-to-superior direction until the 11th rib was reached. The only rib that serves our purpose was the 11th as the length of the pedicle suffices to fully cover the mandible. The desired segment of the rib was then osteotomized first laterally and then medially, leaving 3–4 cm of rib at each side so as not to cause respiratory problems. The perforating vessel that goes from the rib to the LD muscle was identified without dissection to provide a periosteal blood supply to the 11th rib. Once the rib was elevated, the remaining portion of the flap was harvested along with its vascular pedicle as far as the axillary artery (Fig. 1). The circumflex scapular artery was ligated. In this way, the pedicle can reach up to 11 cm in length, compared to the thoracodorsal artery in normal condition that can only reach 4–5 cm. The flap is tunneled under the humeral insertion of the pectoralis major muscle. After placing 2 drainage tubes, the donor site was closed by direct suture. To avoid seroma formation in the donor site, the lateral part of the fascia was sutured with Vicryl 2/0. During the operation, a 3  3 cm graft was performed because of insufficient tissue in the neck area (Fig. 2). Polyurethane dressings with ibuprofen (Biatain-Ibu) were used in the management of the skin graft recipient site; this expedient helps reducing pain and keeping the wound clean.8 The patient was discharged 9 days later without complications, and 6 weeks afterwards, he began radiation therapy (Fig. 3). The range of movements (ROM) of the upper limb involved in the operation was carefully measured before and after 6 weeks from the operation. The ROM of the left arm showed no significant changes before and after the operation (Fig. 4).

DISCUSSION Segmental continuity defects of the mandible are effectively reconstructed using different vascularized bone flaps. The use of such

The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014

Chen et al

FIGURE 3. Front (A) and lateral (B) view of patient 1 month after the operation.

FIGURE 1. Intraoperative view of the latissimus dorsi muscle with the 11th rib attached after the harvest.

flaps allows reconstruction of both irradiated and non-irradiated fields. The most commonly used flaps in mandibular reconstruction are the fibula flap,1 the iliac crest flap,2 the radial forearm flap,9 and latissimus–serratus–rib free flap.3,10 The free fibula flap is considered the most appropriate choice for mandibular reconstruction. However, sometimes it is not available because it has been previously used or because of severe vascular disease. The iliac crest flap has been extensively used in mandibular reconstruction, but it includes an unreliable and relatively immobile skin paddle, and a high incidence of postoperative donor site pain as well as hernia formation. Among its other downsides, we can mention that it just provides a limited quantity of bone and muscle and its pedicle is short.10 The radial forearm flap allows a good lining of the oral mucosa, but it provides a limited quantity of bone tissue and, in time, it is very likely to undergo spontaneous fractures of the radius after flap harvest.10

FIGURE 2. Patient at the end of operation. Visible sutures with a meshed graft on the neck region.

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The latissimus–serratus–rib free flap is an effective procedure; however, it presents an excessive bulk and its cortical bone does not tolerate the insertion of dental implants. As a consequence, this flap is only used in patients who are not candidates for more commonly used vascularized bone-containing free flaps.11 Unlike the description given by Blackwell and colleagues,11 the periosteal blood supply is given by the subscapular artery, which is longer, allowing to perform a pedicled reconstruction. Moreover, the choice not to harvest the SA muscle allows the flap to be less bulky and, as a consequence, to obtain a first intention skin closure. Also, the dissection is easier requiring a shorter operative time and avoiding the risk of winging scapula. The free flaps based on the circumflex scapular artery containing the lateral border of the scapula require a long duration of surgery because of impossible simultaneous flap harvest and tumor resection in case of oral cancer (simultaneous 2-team surgery). In cases where it is not possible to perform any of the aforementioned free flaps,12 the main reconstructive option described in literature is the pectoralis major + rib pedicle flap.4 Despite the ease of technique, it requires large skin grafts to close the donor site, which results in a poor aesthetic appearance of the anterior chest wall. Moreover, the furthest rib that can be used is the seventh rib, which causes respiratory discomfort and more pain to the patient.

FIGURE 4. The longitudinal scar unhidden by the arm.

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014

An alternative technique could be the bone graft from the fibula, iliac crest, or rib, but it has been demonstrated that nonvascularized bone grafts undergo a faster atrophic process.13 The LD + rib pedicle flap instead allows a direct closure of the donor site, with a vertically oriented scar that is usually well hidden. A small skin graft may be needed on the recipient site in the neck region if the wound cannot be closed by direct suture. Moreover, the pectoralis major flap can present myospasms as a complication caused by an incomplete denervation of the pectoralis major muscle. However, these spasms can be effectively managed with BTX-A injections.14 In the reported case, the LD + rib pedicle flap has been used for mandibular reconstruction with good functional and aesthetic results. Despite some disadvantages related to the curvature and strength of the rib, the LD + rib pedicle flap proves to be a reliable flap that offers many advantages. It is a very useful reconstructive technique for bone defects ranging from small to large. Its pedicle is long and generally not involved in peripheral vascular diseases. The LD + rib flap provides a large quantity of muscle so that it is a good choice in case of radiation therapy. The donor-site morbidity is limited and the donor-site defect can be closed primarily. In addition, the scar is easily disguisable because of its location on the axillary line and it can only be seen when the patient elevates the arms. A 2-team approach is mostly possible and there is no need for intraoperative repositioning. In conclusion, the LD + rib flap has proved to be a useful alternative procedure for mandibular reconstruction after cancer ablation in patients who are not candidates for more commonly used vascularized bone-containing free flaps and refuse the pectoralis major + rib flap reconstruction.

REFERENCES 1. Trignano E, Fallico N, Faenza M, et al. Free fibular flap with periosteal excess for mandibular reconstruction. Microsurgery 2013 Epub ahead of print

LD-Rib Pedicle Flap After Failed Free Flaps

2. Miyamoto S, Sakuraba M, Nagamatsu S, et al. Current role of the iliac crest flap in mandibular reconstruction. Microsurgery 2011;31: 616–619 3. Harashina T, Nakajima H, Imai T. Reconstruction of mandibular defects with revascularized free rib grafts. Plast Reconstr Surg 1978;62: 514–522 4. Dieckmann J, Koch A. Primary reconstruction of the mandible with a pedicled muscle and bone transplant—the pectoralis major and rib flap. Fortschr Kiefer Gesichtschir 1994;39:87–89 5. Reychler H, Lejuste P, Peiffer A. Mandibular reconstruction using a pedicled osteomyocutaneous flap of the latissimus dorsi. Rev Stomatol Chir Maxillofac 1990;91(suppl 1):11–14 6. Schlenker JD. Incorporating vascularized ribs in a latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1991;88:920–921 7. Yamamoto Y, Sugihara T, Kawashima K, et al. An anatomic study of the latissimus dorsi-rib flap: an extension of the subscapular combined flap. Plast Reconstr Surg 1996;98:811–816 8. Cigna E, Tarallo M, Bistoni G, et al. Evaluation of polyurethane dressing with ibuprofen in the management of split-thickness skin graft donor sites. In Vivo 2009;23:983–986 9. Zenn MR, Hidalgo DA, Cordeiro PG, et al. Current role of the radial forearm free flap in mandibular reconstruction. Plast Reconstr Surg 1997;99:1012–1017 10. Trignano E, Fallico N, Nitto A, et al. The treatment of composite defect of bone and soft tissues with a combined latissimus dorsi and serratus anterior and rib free flap. Microsurgery 2013;33:173–183 11. Kim PD, Blackwell KE. Latissimus–serratus–rib free flap for oromandibular and maxillary reconstruction. Arch Otolaryngol Head Neck Surg 2007;133:791–795 12. van Gemert JT, van Es RJ, Rosenberg AJ, et al. Free vascularized flaps for reconstruction of the mandible: complications, success, and dental rehabilitation. J Oral Maxillofac Surg 2012;70:1692–1698 13. Fujimaki A, Suda H. Experimental study and clinical observations on hypertrophy of vascularized bone grafts. Microsurgery 1994;15:726–732 14. Trignano E, Dessy LA, Fallico N, et al. Treatment of pectoralis major flap myospasms with botulinum toxin type A in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2012;65: e23–e28

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Latissimus dorsi-rib pedicle flap for mandibular reconstruction as a salvage procedure for failed free fibula flap.

Mandibular reconstruction is usually performed by using free vascular flaps. However, there are instances in which it must be carried out with pedicle...
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