SURGICAL ONCOLOGY AND RECONSTRUCTION
Use of Extended Vertical Lower Trapezius Island Myocutaneous Flaps to Cover Exposed Reconstructive Plates Si-Lian Fang, DDS, MD, PhD,* You-yuan Wang, DDS, PhD,y Wei-liang Chen, DDS, MD, MBA,z and Da-ming Zhang, MSx Purpose:
Plate exposure is the most common complication after reconstruction of oncologic resection using a titanium plate. The outcomes of covering exposed reconstructive plates with extended vertical lower trapezius island myocutaneous flaps (TIMFs) were evaluated.
Patients and Methods:
Twelve instances of exposure of reconstructive plates occurred in patients after segmental mandibulectomy to treat cancer of the oral cavity and oropharynx. The plates were covered with extended vertical lower TIMFs. The site of the primary tumor was the gingiva or mandible in 5 cases, the buccal mucosa in 3, the floor of the mouth in 2, and the base of the tongue in 2. The types of bone defect were hemimandibular in 1 case, central in 2, and lateral in 9. Intraoral, extraoral, and intra- and extraoral exposures occurred in 1, 7, and 4 instances, respectively. Intraorally and extraorally exposed plates were re-covered with skin paddles measuring 6 7 to 6 23 cm (average, 6.0 13.5 cm). Four folded extended vertical lower TIMFs were constructed to cover plates exhibiting intra- and extraoral exposure. Results:
All flaps survived. Patients were followed for 12 to 36 months (median duration, 22.8 months). One patient (8.3%) exhibited external plate exposure at 20 months. Nine patients (75.0%) were alive with no evidence of disease at 12 to 36 months, and 2 (16.7%) were alive with disease at 20 to 28 months. One patient (8.3%) died of local recurrence at 23 months.
Conclusions: The use of extended vertical lower TIMFs to cover intraorally, extraorally, or intra- and extraorally exposed plates is reliable. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:2092.e1-2092.e7, 2014
The most common indication for mandibular resection remains ablative surgery to treat cancer of the oral cavity and oropharynx. Microvascular bone grafts have become the preferred option for mandibular reconstruction. However, reconstruction after oncologic resection using a dynamic titanium bridging plate is a safe and rapid option for patients with poor prognoses or who are in poor general health; it also preserves the possibility for secondary reconstruction.1 A retrospective analysis of 660 patients who underwent primary reconstruction of the mandible showed that the total
complication rate was 14.7%; complications included screw loosening, plate fracture, plate exposure, infection, and poor plate union or union failure.2 Plate exposure was the most common complication, evident in 38% of all patients.3 In a previous study, 334 patients with segmental mandibular defects after ablative surgery for oral cancer were treated using titanium bridging plates, and 136 (40.7%) plates were removed because of intra- or extraoral exposure.4 Alloplastic reconstructive surgery has received surprisingly little attention. The relatively high complication and failure rates are
Received from Sun Yat-Sen University, Guangzhou, China.
Address correspondence and reprint requests to Dr Chen:
*Assistant Professor, Department of Oral and Maxillofacial
Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial
Surgery, The Sixth Affiliated Hospital.
Hospital, Sun Yat-sen University, 107 Yan-jiang Road, Guangzhou,
yAttending Physician, Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital.
China; e-mail: [email protected] Received March 26 2014
zProfessor and Director, Department of Oral and Maxillofacial xAttending Physician, Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital.
Accepted June 5 2014 Ó 2014 American Association of Oral and Maxillofacial Surgeons
Surgery, Sun Yat-sen Memorial Hospital.
0278-2391/14/01037-4$36.00/0 http://dx.doi.org/10.1016/j.joms.2014.06.420
Drs Fang and Wang contributed equally to this work.
2092.e1
FANG ET AL
of concern.5 The authors previously described reconstruction of large defects using (principally) extended vertical lower trapezius island myocutaneous flaps (TIMFs) after salvage surgery in patients with recurrent head and neck cancers. Such flaps are large, simple, and reliable.6-8 In the present retrospective study, the authors evaluated the outcomes of covering exposed reconstructive plates (of patients who had undergone ablative surgery to treat cancer of the oral cavity and oropharynx) with extended vertical lower TIMFs.
Patients and Methods The authors reviewed 12 instances of the use of extended vertical lower TIMFs to cover exposed reconstructive plates of patients who had undergone segmental mandibulectomy to treat cancer of the oral cavity and oropharynx from January 2009 to March 2013 at the Hospital of Sun Yat-sen and The Sixth Affiliated Hospital of Sun Yat-Sen University (Guangzhou, China). The institutional review board of Sun Yat-sen University approved the study. The patients included 9 men and 3 women 54 to 78 years old (median age, 67.2 yr). The pathologic diagnosis was squamous cell carcinoma in all instances. The site of the primary tumor was the gingiva or mandible in 5 cases, the buccal mucosa in 3, the floor of the mouth in 2, and the base of the tongue in 2. Tumors were classified as stage III in 5 patients and as stage IV in 7. The patients were surgically treated using tumor resection, ipsilateral radical neck dissection (10 cases), and bilateral radical neck dissection (2 cases). Reconstruction featured construction of submental flaps (3 cases), pectoralis major myocutaneous flaps (3 cases), a supraclavicular fasciocutaneous island flap (1 case), and a forearm free flap (1 case). Seven patients received adjuvant radiotherapy. The extent of each mandibular bone defect after segmental mandibulectomy was classified using the hemimandibular (H), central (C), and lateral (L) grading system of Jewer et al.9 The types of bone defect were H in 1 case, C in 2, and L in 9. Inferior 2.4-mm-thick locking reconstruction plates (Synthes, Paoli, PA) were used for mandibular reconstruction. Intraoral, extraoral, and intra- and extraoral plate exposures were evident in 1, 7, and 4 cases, respectively. The mean time to plate exposure was 6.8 months (range, 4 to 11 months). Intraorally and extraorally exposed plates were re-covered with skin paddles measuring 6 7 to 6 23 cm (average, 6.0 13.5 cm). Four folded extended vertical lower TIMFs were constructed to cover the plates exhibiting intra- and extraoral exposure (Table 1). SURGICAL TECHNIQUE
The principal blood supply to the trapezius muscle and the overlying skin is provided by the superficial
2092.e2 and deep descending branches of the transverse cervical artery (TCA). Preoperative 3-dimensional computed tomographic angiography is required for all patients to identify TCA patency and the branches of the TCA. Under general anesthesia, each patient was placed on his or her side at an angle of approximately 45 , with the head and neck moderately extended. Tumor resection and neck dissection were performed in this position. Then, the patient was placed in the lateral prone position. The extended vertical lower TIMF was elevated with the patient in this position. The skin paddle of the flap, created principally from the fasciocutaneous extension beyond the trapezius muscle (at right angles to the lateral margin of the trapezius muscle), was designed to follow the course of the TCA by centering the long axis of the flap between the vertebral column and the medial border of the scapula. The medial border of the flap was marked in the region of the spinal processes and then the lateral border was marked accordingly. The pivot point of each flap was at the level of the thyrocervical trunk in the lower neck region. Pedicle length was determined by reference to the distance from the pivot point to the defect. Extended vertical lower TIMFs, with skin paddles, measured 6 7 to 6 23 cm. Flap elevation began from the midpoint of the flap and proceeded laterally from the medial position. After identification of the trapezius muscle, medial vertebral insertions were created. Caudal cranial dissection of the trapezius muscle and the overlying dorsal skin was easily performed, beneath the trapezius muscle. Care was taken to identify the TCA and the vein, which were readily visualized on the deep fascia on the undersurface of the trapezius muscle. These vessels were incorporated within the flap. After such inclusion, the lateral border of the flap was incised. When the flap was elevated, the underlying latissimus dorsi and rhomboid muscles could readily be seen. At the line of transition between the rhomboid major and minor muscles, the dorsal scapular artery, which is lateral to the TCA, was ligated. This released the flap, allowing the flap to be dissected cranially. The cranial dissection ended at the level of the scapular spine (at the level of thoracic vertebrae 11 to 12), preserving the upper region of the trapezius muscle and the lateral attachment of the trapezius to the scapular spine and acromion. This prevented shoulder droop and weakness. A tunnel was made in the upper region of the trapezius muscle, allowing the flap to be dissected farther, to the point of entrance of the TCA (depending on the position of the thyrocervical trunk), to increase the length of the flap. The caudal end of the flap could extend 10 to 13 cm beyond the caudal end of the trapezius muscle, rendering the (distal) lateral half of the flap optional in form,
2092.e3
Table 1. USE OF EXTENDED VERTICAL LOWER TRAPEZIUS ISLAND MYOCUTANEOUS FLAPS TO COVER EXPOSED RECONSTRUCTIVE PLATES OF 12 PATIENTS WHO HAD UNDERGONE ABLATIVE SURGERY TO TREAT CANCER OF THE ORAL CAVITY AND OROPHARYNX
Patient Number/ Age (yr)/Gender
Tumor site/ Clinical Stage
Surgery/Classification of Mandibular Defect/RT (Gy)
Site of Exposure
Time of Exposure (mo)
SPF (cm)
Complications none none none wound dehiscence at donor site
gingiva/III gingiva/IV floor of mouth/IV floor of mouth/IV
TR, IND/L/y TR, IND, SFIF/L/64 TR/BND, SF/Cy TR, IND/C/60
EOE IEOE IEOE IEOE
4 6 6 8
6 11 6 (8 + 15)* 6 (6 + 12)* 6 (7 + 14)*
5/58/M 6/78/F 7/64/M 8/76/F 9/66/M 10/68/M 11/72/M 12/58/M
buccal mucosa/IV base of tongue/IV gingiva/III base of tongue/IV buccal mucosa/III buccal mucosa/III gingiva/III gingiva/IV
TR, IND, FFF/L/64 TR, IND/L/60 TR, IND/L/y TR, IND, PMP/H/60 TR, BND, SF/L/y TR, IND, PMP/L/64 TR, IND, SF/L/y TR, IND, PMP/L/60
EOE IOE EOE EOE EOE IEOE EOE EOE
5 10 6 7 11 4 8 6
68 68 69 68 6 19 6 (7 + 13)* 6 10 67
none none none none none none none
Plate Exposure/ Status
32 36 26 20
/AND /AND /AND +/AWD
23 18 16 23 18 28 22 12
/AND /AND /AND /DOD /AND /AWD /AND /AND
Abbreviations: AND, alive with no disease; AWD, alive with disease; BND, bilateral radical neck dissection; C, central segment including the 2 canines; DOD, died of disease; EOE, extraoral exposure; F, female; FFF, forearm free flap; H, lateral segment with a condyle; IEOE, intra- and extraoral exposure; IND, ipsilateral radical neck dissection; IOE, intraoral exposure; L, lateral segment without a condyle; M, male; PMP, pectoralis major myocutaneous flap; RT, radiotherapy; SF, submental flap; SFIF, supraclavicular fasciocutaneous island flap; SPF, skin paddle of the flap; TR, tumor resection. * Folded extended vertical lower trapezius island myocutaneous flap. y Patient refused radiotherapy. Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
COVERING EXPOSED RECONSTRUCTIVE PLATES
1/64/F 2/54/M 3/70/M 4/78/M
Follow-Up (mo)
2092.e4
FANG ET AL
producing a well-vascularized, thin, long island flap. The flap was passed through the tunnel formed in the upper region of the trapezius muscle and the neck. The flap was used to cover intraorally or extraorally exposed reconstruction plates. The flap can be rendered foldable by removing a 1.0-cm-wide band of skin, to allow intra- and extraorally exposed reconstruction plates to be covered.
Report of Cases CASE 1
A 64-year-old woman presented after treatment of squamous cell carcinoma of the left mandibular gingiva (case 1). Five months previously, excision of
the gingival tumor, radical neck dissection, and L-type mandibular defect reconstruction using 2 locking reconstruction plates had been performed in another institution. Postoperatively, no adjuvant treatment had been prescribed, and extraoral exposure of the reconstruction plate was evident (Fig 1). An extended vertical lower TIMF with a skin paddle 6 11 cm in dimension was created to cover the exposed plates (Fig 2). The granular tissue around the plates was removed, creating a skin defect in the cheek, and the flap was transferred to cover the defect and the plates (Fig 3). The morphologic results were satisfactory (Fig 4). At the 32month follow-up, no recurrence or exposure of the plates was evident (Fig 5).
FIGURE 1. A 64-year-old woman presented with exposure of plates placed after treatment of left mandibular gingival cancer (case 1). A, Five months postoperatively, the reconstruction plates became extraorally exposed. B, Panorex radiograph showed that no screws were loose and neither plate was fractured. Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
2092.e5
COVERING EXPOSED RECONSTRUCTIVE PLATES
FIGURE 2. An extended vertical lower trapezius island myocutaneous flap with a skin paddle measuring 6 11 cm was designed.
FIGURE 4. The flap was transferred to the defect and covered the plates.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
CASE 2
A 54-year-old man presented after treatment of squamous cell carcinoma of the left mandibular gingiva (case 2). Six months previously, excision of the gingival tumor, radical neck dissection, L-type mandibular defect reconstruction using a locking reconstruction plate, and gingival mucosa reconstruction using a supraclavicular fasciocutaneous island flap had been performed at the authors’ institution. Postoperatively, the patient had received radiation (total dose, 64 Gy) and intra- and extraoral exposure of the reconstruction plate was evident (Fig 6). The patient underwent resection of the full-thickness cheek scar associated with the plate, creating a residual through-andthrough cheek defect. A foldable extended vertical lower TIMF with a skin paddle measuring 6 (8 + 15) cm was created to reconstruct the through-and-
through oral cavity defect (Fig 7). The distal portion of the flap served as the inner lining or mucosa of the mouth, and the medial portion served as the outer lining (the skin; Fig 8). At the 36-month follow-up, the morphologic results were satisfactory and the patient was able to elevate his shoulders (Fig 9). No further treatment was required, and no recurrence of plate exposure was observed.
Results All flaps survived. Wound dehiscence at the donor site occurred in 1 patient, but no major complication was evident in any patient. The appearance of the face and neck was acceptable. The patients were followed for 12 to 36 months (median duration, 22.8 months). One patient (8.3%) developed external plate
FIGURE 3. Development of a cheek skin defect around the plates.
FIGURE 5. The appearance of the face and neck after treatment.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
FANG ET AL
FIGURE 6. A 54-year-old man treated for left mandibular gingival cancer presented with intra- and extraoral exposure of the reconstruction plate (case 2).
2092.e6
FIGURE 8. The distal portion of the flap was turned to serve as the inner lining, or mucosa, of the mouth, and the medial portion was used for the outer lining (the skin). Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
exposure at 20 months. Nine patients (75.0%) were living with no evidence of disease at 12 to 36 months, 2 (16.7%) were living with disease at 20 to 28 months, and 1 (8.3%) died of local recurrence at 23 months (Table 1).
Discussion Mandibular defects repaired using reconstructive plates exhibit higher complication rates than defects repaired using bone grafts, and radiation therapy significantly increases the incidence of plate exposure.2 If flaps are not transferred in patients exhibiting plate exposure, dead space can persist beneath the plates. To prevent plate exposure, titanium plates
covered with an anterolateral thigh flap or a pedicled pectoralis major myocutaneous flap can be used.10,11 In previous work, 9 plates became extraorally exposed at a mean postoperative time of 40 weeks, and the remaining 16 plates became intraorally exposed at a mean postoperative interval of 16 weeks.12 In the present series, 7 patients (58.3%) received adjuvant radiotherapy; and supraclavicular fasciocutaneous island flaps, submental flaps, forearm free flaps, or pectoralis major myocutaneous flaps were used to cover the plates in 8 cases (66.7%). Intraoral, extraoral, and intra- and extraoral exposures developed in 1 case (8.3%), 7 cases (59.4%), and 4 cases (33.3%), respectively. L-type bone defects were present in 9 cases (75.0%). The time of plate exposure ranged from 4 to 11 months (median duration, 6.8 months) after reconstruction. To date, no report has addressed the exposure of reconstructive plates
FIGURE 7. An extended vertical lower trapezius island myocutaneous flap with a skin paddle measuring 6 (8 + 15) cm was created.
FIGURE 9. The appearance of the face and neck 36 months postoperatively.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
2092.e7
covered with flaps placed after ablative surgery to treat cancer of the oral cavity and oropharynx. In the present study, 12 intraorally, extraorally, and intra- and extraorally exposed reconstructive plates (placed after segmental mandibulectomy to treat cancer of the oral cavity and oropharynx) were covered with extended vertical lower TIMFs with skin paddles measuring 6 7 to 6 23 cm (average, 6.0 13.5 cm). All flaps survived, and no major complication was noted in any patient. Only 1 instance (8.3%) of plate re-exposure developed, at 20 months. An extended vertical lower TIMF is a large flap that can be reliably used to cover intraorally, extraorally, or intra- and extraorally exposed plates, and any dead space beneath such plates is removed. The indications for use of this surgical technique are the absence of loose screws and no plate fracture. Tumors were classified as stage III in 5 patients (41.7%) and as stage IV in 7 (58.3%). Two patients (16.7%) were living with disease at 20 to 28 months, and 1 (8.3%) died of local recurrence at 23 months. Mandibular reconstruction using the dynamic titanium bridging plate system is safe and rapid when used to treat patients with poor prognoses or who are in poor general condition. The method also preserves the possibility for secondary reconstruction.1 An extended vertical lower TIMF is large and can be reliably used to cover intraorally, extraorally, or intraand extraorally exposed plates.
References 1. Lopez R, Dekeister C, Sleiman Z, et al: Mandibular reconstruction using the titanium functionally dynamic bridging plate
COVERING EXPOSED RECONSTRUCTIVE PLATES
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
system: A retrospective study of 34 cases. J Oral Maxillofac Surg 62:421, 2004 Liu SP, Cai ZG, Zhang J, et al: Plate related complication after mandibular reconstruction. Zhonghua Kou Qiang Yi Xue Za Zhi 48:586, 2013 Chepeha DB, Teknos TN, Fung K, et al: Lateral oromandibular defect: When is it appropriate to use a bridging reconstruction plate combined with a soft tissue revascularized flap? Head Neck 30:709, 2008 Ettl T, Driemel O, Dresp BV, et al: Feasibility of alloplastic mandibular reconstruction in patients following removal of oral squamous cell carcinoma. J Craniomaxillofac Surg 38:350, 2010 Sadr-Eshkevari P, Rashad A, Vahdati SA, et al: Alloplastic mandibular reconstruction: A systematic review and meta-analysis of the current century case series. Plast Reconstr Surg 132:413e, 2013 Chen WL, Li J, Yang Z, et al: Extended vertical lower trapezius island myocutaneous flap in reconstruction of oral and maxillofacial defects after salvage surgery for recurrent oral carcinoma. J Oral Maxillofac Surg 65:205, 2007 Chen WL, Zhang B, Wang JG, et al: Reconstruction of large defects of the neck using an extended vertical lower trapezius island myocutaneous flap following salvage surgery for neck recurrence of oral carcinoma. J Plast Reconstr Aesthet Surg 64: 319, 2011 Chen W, Yang Z, Zhang D, et al: Second salvage surgery with extended vertical lower trapezius island myocutaneous flap reconstruction for advanced re-recurrent oral and oropharyngeal squamous cell carcinoma. Int J Oral Maxillofac Surg 43: 531, 2014 Jewer DD, Boyd JB, Manktelow RT, et al: Orofacial and mandibular reconstruction with the iliac crest free flap: A review of 60 cases and a new method of classification. Plast Reconstr Surg 84: 391, 1989 Onoda S, Kimata Y, Yamada K, et al: Prevention points for plate exposure in the mandibular reconstruction. J Craniomaxillofac Surg 40:e310, 2012 El-Zohairy MA, Mostafa A, Amin A, et al: Mandibular reconstruction using pectoralis major myocutaneous flap and titanium plates after ablative surgery for locally advanced tumors of the oral cavity. J Egypt Natl Canc Inst 21:299, 2009 Nicholson RE, Schuller DE, Forrest LA, et al: Factors involved in long- and short-term mandibular plate exposure. Arch Otolaryngol Head Neck Surg 123:217, 1997
Use of Extended Vertical Lower Trapezius Island Myocutaneous Flaps to Cover Exposed Reconstructive Plates Si-Lian Fang, DDS, MD, PhD,* You-yuan Wang, DDS, PhD,y Wei-liang Chen, DDS, MD, MBA,z and Da-ming Zhang, MSx Purpose:
Plate exposure is the most common complication after reconstruction of oncologic resection using a titanium plate. The outcomes of covering exposed reconstructive plates with extended vertical lower trapezius island myocutaneous flaps (TIMFs) were evaluated.
Patients and Methods:
Twelve instances of exposure of reconstructive plates occurred in patients after segmental mandibulectomy to treat cancer of the oral cavity and oropharynx. The plates were covered with extended vertical lower TIMFs. The site of the primary tumor was the gingiva or mandible in 5 cases, the buccal mucosa in 3, the floor of the mouth in 2, and the base of the tongue in 2. The types of bone defect were hemimandibular in 1 case, central in 2, and lateral in 9. Intraoral, extraoral, and intra- and extraoral exposures occurred in 1, 7, and 4 instances, respectively. Intraorally and extraorally exposed plates were re-covered with skin paddles measuring 6 7 to 6 23 cm (average, 6.0 13.5 cm). Four folded extended vertical lower TIMFs were constructed to cover plates exhibiting intra- and extraoral exposure. Results:
All flaps survived. Patients were followed for 12 to 36 months (median duration, 22.8 months). One patient (8.3%) exhibited external plate exposure at 20 months. Nine patients (75.0%) were alive with no evidence of disease at 12 to 36 months, and 2 (16.7%) were alive with disease at 20 to 28 months. One patient (8.3%) died of local recurrence at 23 months.
Conclusions: The use of extended vertical lower TIMFs to cover intraorally, extraorally, or intra- and extraorally exposed plates is reliable. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:2092.e1-2092.e7, 2014
The most common indication for mandibular resection remains ablative surgery to treat cancer of the oral cavity and oropharynx. Microvascular bone grafts have become the preferred option for mandibular reconstruction. However, reconstruction after oncologic resection using a dynamic titanium bridging plate is a safe and rapid option for patients with poor prognoses or who are in poor general health; it also preserves the possibility for secondary reconstruction.1 A retrospective analysis of 660 patients who underwent primary reconstruction of the mandible showed that the total
complication rate was 14.7%; complications included screw loosening, plate fracture, plate exposure, infection, and poor plate union or union failure.2 Plate exposure was the most common complication, evident in 38% of all patients.3 In a previous study, 334 patients with segmental mandibular defects after ablative surgery for oral cancer were treated using titanium bridging plates, and 136 (40.7%) plates were removed because of intra- or extraoral exposure.4 Alloplastic reconstructive surgery has received surprisingly little attention. The relatively high complication and failure rates are
Received from Sun Yat-Sen University, Guangzhou, China.
Address correspondence and reprint requests to Dr Chen:
*Assistant Professor, Department of Oral and Maxillofacial
Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial
Surgery, The Sixth Affiliated Hospital.
Hospital, Sun Yat-sen University, 107 Yan-jiang Road, Guangzhou,
yAttending Physician, Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital.
China; e-mail: [email protected] Received March 26 2014
zProfessor and Director, Department of Oral and Maxillofacial xAttending Physician, Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital.
Accepted June 5 2014 Ó 2014 American Association of Oral and Maxillofacial Surgeons
Surgery, Sun Yat-sen Memorial Hospital.
0278-2391/14/01037-4$36.00/0 http://dx.doi.org/10.1016/j.joms.2014.06.420
Drs Fang and Wang contributed equally to this work.
2092.e1
FANG ET AL
of concern.5 The authors previously described reconstruction of large defects using (principally) extended vertical lower trapezius island myocutaneous flaps (TIMFs) after salvage surgery in patients with recurrent head and neck cancers. Such flaps are large, simple, and reliable.6-8 In the present retrospective study, the authors evaluated the outcomes of covering exposed reconstructive plates (of patients who had undergone ablative surgery to treat cancer of the oral cavity and oropharynx) with extended vertical lower TIMFs.
Patients and Methods The authors reviewed 12 instances of the use of extended vertical lower TIMFs to cover exposed reconstructive plates of patients who had undergone segmental mandibulectomy to treat cancer of the oral cavity and oropharynx from January 2009 to March 2013 at the Hospital of Sun Yat-sen and The Sixth Affiliated Hospital of Sun Yat-Sen University (Guangzhou, China). The institutional review board of Sun Yat-sen University approved the study. The patients included 9 men and 3 women 54 to 78 years old (median age, 67.2 yr). The pathologic diagnosis was squamous cell carcinoma in all instances. The site of the primary tumor was the gingiva or mandible in 5 cases, the buccal mucosa in 3, the floor of the mouth in 2, and the base of the tongue in 2. Tumors were classified as stage III in 5 patients and as stage IV in 7. The patients were surgically treated using tumor resection, ipsilateral radical neck dissection (10 cases), and bilateral radical neck dissection (2 cases). Reconstruction featured construction of submental flaps (3 cases), pectoralis major myocutaneous flaps (3 cases), a supraclavicular fasciocutaneous island flap (1 case), and a forearm free flap (1 case). Seven patients received adjuvant radiotherapy. The extent of each mandibular bone defect after segmental mandibulectomy was classified using the hemimandibular (H), central (C), and lateral (L) grading system of Jewer et al.9 The types of bone defect were H in 1 case, C in 2, and L in 9. Inferior 2.4-mm-thick locking reconstruction plates (Synthes, Paoli, PA) were used for mandibular reconstruction. Intraoral, extraoral, and intra- and extraoral plate exposures were evident in 1, 7, and 4 cases, respectively. The mean time to plate exposure was 6.8 months (range, 4 to 11 months). Intraorally and extraorally exposed plates were re-covered with skin paddles measuring 6 7 to 6 23 cm (average, 6.0 13.5 cm). Four folded extended vertical lower TIMFs were constructed to cover the plates exhibiting intra- and extraoral exposure (Table 1). SURGICAL TECHNIQUE
The principal blood supply to the trapezius muscle and the overlying skin is provided by the superficial
2092.e2 and deep descending branches of the transverse cervical artery (TCA). Preoperative 3-dimensional computed tomographic angiography is required for all patients to identify TCA patency and the branches of the TCA. Under general anesthesia, each patient was placed on his or her side at an angle of approximately 45 , with the head and neck moderately extended. Tumor resection and neck dissection were performed in this position. Then, the patient was placed in the lateral prone position. The extended vertical lower TIMF was elevated with the patient in this position. The skin paddle of the flap, created principally from the fasciocutaneous extension beyond the trapezius muscle (at right angles to the lateral margin of the trapezius muscle), was designed to follow the course of the TCA by centering the long axis of the flap between the vertebral column and the medial border of the scapula. The medial border of the flap was marked in the region of the spinal processes and then the lateral border was marked accordingly. The pivot point of each flap was at the level of the thyrocervical trunk in the lower neck region. Pedicle length was determined by reference to the distance from the pivot point to the defect. Extended vertical lower TIMFs, with skin paddles, measured 6 7 to 6 23 cm. Flap elevation began from the midpoint of the flap and proceeded laterally from the medial position. After identification of the trapezius muscle, medial vertebral insertions were created. Caudal cranial dissection of the trapezius muscle and the overlying dorsal skin was easily performed, beneath the trapezius muscle. Care was taken to identify the TCA and the vein, which were readily visualized on the deep fascia on the undersurface of the trapezius muscle. These vessels were incorporated within the flap. After such inclusion, the lateral border of the flap was incised. When the flap was elevated, the underlying latissimus dorsi and rhomboid muscles could readily be seen. At the line of transition between the rhomboid major and minor muscles, the dorsal scapular artery, which is lateral to the TCA, was ligated. This released the flap, allowing the flap to be dissected cranially. The cranial dissection ended at the level of the scapular spine (at the level of thoracic vertebrae 11 to 12), preserving the upper region of the trapezius muscle and the lateral attachment of the trapezius to the scapular spine and acromion. This prevented shoulder droop and weakness. A tunnel was made in the upper region of the trapezius muscle, allowing the flap to be dissected farther, to the point of entrance of the TCA (depending on the position of the thyrocervical trunk), to increase the length of the flap. The caudal end of the flap could extend 10 to 13 cm beyond the caudal end of the trapezius muscle, rendering the (distal) lateral half of the flap optional in form,
2092.e3
Table 1. USE OF EXTENDED VERTICAL LOWER TRAPEZIUS ISLAND MYOCUTANEOUS FLAPS TO COVER EXPOSED RECONSTRUCTIVE PLATES OF 12 PATIENTS WHO HAD UNDERGONE ABLATIVE SURGERY TO TREAT CANCER OF THE ORAL CAVITY AND OROPHARYNX
Patient Number/ Age (yr)/Gender
Tumor site/ Clinical Stage
Surgery/Classification of Mandibular Defect/RT (Gy)
Site of Exposure
Time of Exposure (mo)
SPF (cm)
Complications none none none wound dehiscence at donor site
gingiva/III gingiva/IV floor of mouth/IV floor of mouth/IV
TR, IND/L/y TR, IND, SFIF/L/64 TR/BND, SF/Cy TR, IND/C/60
EOE IEOE IEOE IEOE
4 6 6 8
6 11 6 (8 + 15)* 6 (6 + 12)* 6 (7 + 14)*
5/58/M 6/78/F 7/64/M 8/76/F 9/66/M 10/68/M 11/72/M 12/58/M
buccal mucosa/IV base of tongue/IV gingiva/III base of tongue/IV buccal mucosa/III buccal mucosa/III gingiva/III gingiva/IV
TR, IND, FFF/L/64 TR, IND/L/60 TR, IND/L/y TR, IND, PMP/H/60 TR, BND, SF/L/y TR, IND, PMP/L/64 TR, IND, SF/L/y TR, IND, PMP/L/60
EOE IOE EOE EOE EOE IEOE EOE EOE
5 10 6 7 11 4 8 6
68 68 69 68 6 19 6 (7 + 13)* 6 10 67
none none none none none none none
Plate Exposure/ Status
32 36 26 20
/AND /AND /AND +/AWD
23 18 16 23 18 28 22 12
/AND /AND /AND /DOD /AND /AWD /AND /AND
Abbreviations: AND, alive with no disease; AWD, alive with disease; BND, bilateral radical neck dissection; C, central segment including the 2 canines; DOD, died of disease; EOE, extraoral exposure; F, female; FFF, forearm free flap; H, lateral segment with a condyle; IEOE, intra- and extraoral exposure; IND, ipsilateral radical neck dissection; IOE, intraoral exposure; L, lateral segment without a condyle; M, male; PMP, pectoralis major myocutaneous flap; RT, radiotherapy; SF, submental flap; SFIF, supraclavicular fasciocutaneous island flap; SPF, skin paddle of the flap; TR, tumor resection. * Folded extended vertical lower trapezius island myocutaneous flap. y Patient refused radiotherapy. Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
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1/64/F 2/54/M 3/70/M 4/78/M
Follow-Up (mo)
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FANG ET AL
producing a well-vascularized, thin, long island flap. The flap was passed through the tunnel formed in the upper region of the trapezius muscle and the neck. The flap was used to cover intraorally or extraorally exposed reconstruction plates. The flap can be rendered foldable by removing a 1.0-cm-wide band of skin, to allow intra- and extraorally exposed reconstruction plates to be covered.
Report of Cases CASE 1
A 64-year-old woman presented after treatment of squamous cell carcinoma of the left mandibular gingiva (case 1). Five months previously, excision of
the gingival tumor, radical neck dissection, and L-type mandibular defect reconstruction using 2 locking reconstruction plates had been performed in another institution. Postoperatively, no adjuvant treatment had been prescribed, and extraoral exposure of the reconstruction plate was evident (Fig 1). An extended vertical lower TIMF with a skin paddle 6 11 cm in dimension was created to cover the exposed plates (Fig 2). The granular tissue around the plates was removed, creating a skin defect in the cheek, and the flap was transferred to cover the defect and the plates (Fig 3). The morphologic results were satisfactory (Fig 4). At the 32month follow-up, no recurrence or exposure of the plates was evident (Fig 5).
FIGURE 1. A 64-year-old woman presented with exposure of plates placed after treatment of left mandibular gingival cancer (case 1). A, Five months postoperatively, the reconstruction plates became extraorally exposed. B, Panorex radiograph showed that no screws were loose and neither plate was fractured. Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
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COVERING EXPOSED RECONSTRUCTIVE PLATES
FIGURE 2. An extended vertical lower trapezius island myocutaneous flap with a skin paddle measuring 6 11 cm was designed.
FIGURE 4. The flap was transferred to the defect and covered the plates.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
CASE 2
A 54-year-old man presented after treatment of squamous cell carcinoma of the left mandibular gingiva (case 2). Six months previously, excision of the gingival tumor, radical neck dissection, L-type mandibular defect reconstruction using a locking reconstruction plate, and gingival mucosa reconstruction using a supraclavicular fasciocutaneous island flap had been performed at the authors’ institution. Postoperatively, the patient had received radiation (total dose, 64 Gy) and intra- and extraoral exposure of the reconstruction plate was evident (Fig 6). The patient underwent resection of the full-thickness cheek scar associated with the plate, creating a residual through-andthrough cheek defect. A foldable extended vertical lower TIMF with a skin paddle measuring 6 (8 + 15) cm was created to reconstruct the through-and-
through oral cavity defect (Fig 7). The distal portion of the flap served as the inner lining or mucosa of the mouth, and the medial portion served as the outer lining (the skin; Fig 8). At the 36-month follow-up, the morphologic results were satisfactory and the patient was able to elevate his shoulders (Fig 9). No further treatment was required, and no recurrence of plate exposure was observed.
Results All flaps survived. Wound dehiscence at the donor site occurred in 1 patient, but no major complication was evident in any patient. The appearance of the face and neck was acceptable. The patients were followed for 12 to 36 months (median duration, 22.8 months). One patient (8.3%) developed external plate
FIGURE 3. Development of a cheek skin defect around the plates.
FIGURE 5. The appearance of the face and neck after treatment.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
FANG ET AL
FIGURE 6. A 54-year-old man treated for left mandibular gingival cancer presented with intra- and extraoral exposure of the reconstruction plate (case 2).
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FIGURE 8. The distal portion of the flap was turned to serve as the inner lining, or mucosa, of the mouth, and the medial portion was used for the outer lining (the skin). Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
exposure at 20 months. Nine patients (75.0%) were living with no evidence of disease at 12 to 36 months, 2 (16.7%) were living with disease at 20 to 28 months, and 1 (8.3%) died of local recurrence at 23 months (Table 1).
Discussion Mandibular defects repaired using reconstructive plates exhibit higher complication rates than defects repaired using bone grafts, and radiation therapy significantly increases the incidence of plate exposure.2 If flaps are not transferred in patients exhibiting plate exposure, dead space can persist beneath the plates. To prevent plate exposure, titanium plates
covered with an anterolateral thigh flap or a pedicled pectoralis major myocutaneous flap can be used.10,11 In previous work, 9 plates became extraorally exposed at a mean postoperative time of 40 weeks, and the remaining 16 plates became intraorally exposed at a mean postoperative interval of 16 weeks.12 In the present series, 7 patients (58.3%) received adjuvant radiotherapy; and supraclavicular fasciocutaneous island flaps, submental flaps, forearm free flaps, or pectoralis major myocutaneous flaps were used to cover the plates in 8 cases (66.7%). Intraoral, extraoral, and intra- and extraoral exposures developed in 1 case (8.3%), 7 cases (59.4%), and 4 cases (33.3%), respectively. L-type bone defects were present in 9 cases (75.0%). The time of plate exposure ranged from 4 to 11 months (median duration, 6.8 months) after reconstruction. To date, no report has addressed the exposure of reconstructive plates
FIGURE 7. An extended vertical lower trapezius island myocutaneous flap with a skin paddle measuring 6 (8 + 15) cm was created.
FIGURE 9. The appearance of the face and neck 36 months postoperatively.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
Fang et al. Covering Exposed Reconstructive Plates. J Oral Maxillofac Surg 2014.
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covered with flaps placed after ablative surgery to treat cancer of the oral cavity and oropharynx. In the present study, 12 intraorally, extraorally, and intra- and extraorally exposed reconstructive plates (placed after segmental mandibulectomy to treat cancer of the oral cavity and oropharynx) were covered with extended vertical lower TIMFs with skin paddles measuring 6 7 to 6 23 cm (average, 6.0 13.5 cm). All flaps survived, and no major complication was noted in any patient. Only 1 instance (8.3%) of plate re-exposure developed, at 20 months. An extended vertical lower TIMF is a large flap that can be reliably used to cover intraorally, extraorally, or intra- and extraorally exposed plates, and any dead space beneath such plates is removed. The indications for use of this surgical technique are the absence of loose screws and no plate fracture. Tumors were classified as stage III in 5 patients (41.7%) and as stage IV in 7 (58.3%). Two patients (16.7%) were living with disease at 20 to 28 months, and 1 (8.3%) died of local recurrence at 23 months. Mandibular reconstruction using the dynamic titanium bridging plate system is safe and rapid when used to treat patients with poor prognoses or who are in poor general condition. The method also preserves the possibility for secondary reconstruction.1 An extended vertical lower TIMF is large and can be reliably used to cover intraorally, extraorally, or intraand extraorally exposed plates.
References 1. Lopez R, Dekeister C, Sleiman Z, et al: Mandibular reconstruction using the titanium functionally dynamic bridging plate
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system: A retrospective study of 34 cases. J Oral Maxillofac Surg 62:421, 2004 Liu SP, Cai ZG, Zhang J, et al: Plate related complication after mandibular reconstruction. Zhonghua Kou Qiang Yi Xue Za Zhi 48:586, 2013 Chepeha DB, Teknos TN, Fung K, et al: Lateral oromandibular defect: When is it appropriate to use a bridging reconstruction plate combined with a soft tissue revascularized flap? Head Neck 30:709, 2008 Ettl T, Driemel O, Dresp BV, et al: Feasibility of alloplastic mandibular reconstruction in patients following removal of oral squamous cell carcinoma. J Craniomaxillofac Surg 38:350, 2010 Sadr-Eshkevari P, Rashad A, Vahdati SA, et al: Alloplastic mandibular reconstruction: A systematic review and meta-analysis of the current century case series. Plast Reconstr Surg 132:413e, 2013 Chen WL, Li J, Yang Z, et al: Extended vertical lower trapezius island myocutaneous flap in reconstruction of oral and maxillofacial defects after salvage surgery for recurrent oral carcinoma. J Oral Maxillofac Surg 65:205, 2007 Chen WL, Zhang B, Wang JG, et al: Reconstruction of large defects of the neck using an extended vertical lower trapezius island myocutaneous flap following salvage surgery for neck recurrence of oral carcinoma. J Plast Reconstr Aesthet Surg 64: 319, 2011 Chen W, Yang Z, Zhang D, et al: Second salvage surgery with extended vertical lower trapezius island myocutaneous flap reconstruction for advanced re-recurrent oral and oropharyngeal squamous cell carcinoma. Int J Oral Maxillofac Surg 43: 531, 2014 Jewer DD, Boyd JB, Manktelow RT, et al: Orofacial and mandibular reconstruction with the iliac crest free flap: A review of 60 cases and a new method of classification. Plast Reconstr Surg 84: 391, 1989 Onoda S, Kimata Y, Yamada K, et al: Prevention points for plate exposure in the mandibular reconstruction. J Craniomaxillofac Surg 40:e310, 2012 El-Zohairy MA, Mostafa A, Amin A, et al: Mandibular reconstruction using pectoralis major myocutaneous flap and titanium plates after ablative surgery for locally advanced tumors of the oral cavity. J Egypt Natl Canc Inst 21:299, 2009 Nicholson RE, Schuller DE, Forrest LA, et al: Factors involved in long- and short-term mandibular plate exposure. Arch Otolaryngol Head Neck Surg 123:217, 1997
