Mandibular and palatal reconstruction in patients with head and neck cancer
- Barry L Wenig, MD, MPH
Barry L Wenig, MD, MPH
- Francis L. Lederer Professor of Otolaryngology
- Director of Head and Neck and Robotic Surgery
- University of Illinois College of Medicine at Chicago
- Michael R Zenn, MD, FACS
Michael R Zenn, MD, FACS
- Adjunct Professor – Clinical Professor of Plastic Surgery
- Duke University Medical Center
- Section Editors
- Bruce E Brockstein, MD
Bruce E Brockstein, MD
- Section Editor — Cancer of the Head and Neck
- Clinical Professor of Medicine
- University of Chicago Pritzker School of Medicine
- Marvin P Fried, MD, FACS
Marvin P Fried, MD, FACS
- Section Editor — Head and Neck Surgery
- Professor and University Chairman, Department of Otorhinolaryngology - Head and Neck Surgery
- Montefiore Medical Center, Albert Einstein College of Medicine
Carcinoma of the head and neck can be treated and potentially cured by surgery, radiation therapy (RT), or a combined modality approach, which may also incorporate chemotherapy. The defects caused by surgical excision can cause significant problems in airway management, mastication, deglutition, speech, and cosmesis. In addition, RT has significant adverse effects upon wound healing that can complicate surgical management. (See "Management of late complications of head and neck cancer and its treatment".)
The goal of surgical reconstruction is to restore presurgical function and cosmesis. Optimization of the outcome of surgical reconstruction requires a team approach and should include speech pathology, physical therapy, and psychosocial support as appropriate.
The basic elements of mandibular reconstruction and palatal reconstruction will be reviewed here. The management of maxillary defects are discussed separately, as is rehabilitation for speech and swallowing defects. (See "Management of acquired maxillary and hard palate defects" and "Speech and swallowing rehabilitation of the patient with head and neck cancer".)
TIMING OF RECONSTRUCTION
Reconstruction may be primary (performed at the time of resection of the tumor) or secondary (performed as a separate procedure after resection, or to repair a defect left by an ulcerative tumor treated by primary radiation). Primary reconstruction has become the standard of care for most patients .
●Primary reconstruction can rapidly restore anatomy and function and decrease the number of operations and duration of hospitalization . Because the head and neck patient may have a limited life span and significant premorbid conditions, rapid recovery and decreased hospital stay are important considerations. However, the possibility of infection with intraoral contamination of the graft is always of concern.
Subscribers log in hereLiterature review current through: Jul 2017. | This topic last updated: Apr 06, 2017.References
- Wong CH, Wei FC. Microsurgical free flap in head and neck reconstruction. Head Neck 2010; 32:1236.
- Urken ML, Buchbinder D, Costantino PD, et al. Oromandibular reconstruction using microvascular composite flaps: report of 210 cases. Arch Otolaryngol Head Neck Surg 1998; 124:46.
- Bourget A, Chang JT, Wu DB, et al. Free flap reconstruction in the head and neck region following radiotherapy: a cohort study identifying negative outcome predictors. Plast Reconstr Surg 2011; 127:1901.
- Deutsch M, Kroll SS, Ainsle N, Wang B. Influence of radiation on late complications in patients with free fibular flaps for mandibular reconstruction. Ann Plast Surg 1999; 42:662.
- Kuriloff D, Sullivan M. Mandibular reconstruction. In: Head and Neck Surgery: Otolaryngology, Bailey B (Ed), JB Lippincott, Philadelphia 1993. p.1980.
- Burkey BB, Coleman JR Jr. Current concepts in oromandibular reconstruction. Otolaryngol Clin North Am 1997; 30:607.
- Becker ST, Menzebach M, Küchler T, et al. Quality of life in oral cancer patients--effects of mandible resection and socio-cultural aspects. J Craniomaxillofac Surg 2012; 40:24.
- Schultz BD, Sosin M, Nam A, et al. Classification of mandible defects and algorithm for microvascular reconstruction. Plast Reconstr Surg 2015; 135:743e.
- Haller JR, Sullivan MJ. Contemporary techniques of mandibular reconstruction. Am J Otolaryngol 1995; 16:19.
- Garvey PB, Selber JC, Madewell JE, et al. A prospective study of preoperative computed tomographic angiography for head and neck reconstruction with anterolateral thigh flaps. Plast Reconstr Surg 2011; 127:1505.
- Hanasono MM, Jacob RF, Bidaut L, et al. Midfacial reconstruction using virtual planning, rapid prototype modeling, and stereotactic navigation. Plast Reconstr Surg 2010; 126:2002.
- Head C, Alam D, Sercarz JA, et al. Microvascular flap reconstruction of the mandible: a comparison of bone grafts and bridging plates for restoration of mandibular continuity. Otolaryngol Head Neck Surg 2003; 129:48.
- Modabber A, Gerressen M, Stiller MB, et al. Computer-assisted mandibular reconstruction with vascularized iliac crest bone graft. Aesthetic Plast Surg 2012; 36:653.
- Urken ML. Composite free flaps in oromandibular reconstruction. Review of the literature. Arch Otolaryngol Head Neck Surg 1991; 117:724.
- Urken ML, Weinberg H, Buchbinder D, et al. Microvascular free flaps in head and neck reconstruction. Report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg 1994; 120:633.
- López-Arcas JM, Arias J, Del Castillo JL, et al. The fibula osteomyocutaneous flap for mandible reconstruction: a 15-year experience. J Oral Maxillofac Surg 2010; 68:2377.
- Chang YM, Tsai CY, Wei FC. One-stage, double-barrel fibula osteoseptocutaneous flap and immediate dental implants for functional and aesthetic reconstruction of segmental mandibular defects. Plast Reconstr Surg 2008; 122:143.
- Momoh AO, Yu P, Skoracki RJ, et al. A prospective cohort study of fibula free flap donor-site morbidity in 157 consecutive patients. Plast Reconstr Surg 2011; 128:714.
- Urken ML, Buchbinder D, Weinberg H, et al. Functional evaluation following microvascular oromandibular reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients. Laryngoscope 1991; 101:935.
- Foster RD, Anthony JP, Sharma A, Pogrel MA. Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: an outcome analysis of primary bony union and endosseous implant success. Head Neck 1999; 21:66.
- Donald PJ, Ness JA. Trays with bone grafts. In: Mandibular Reconstruction, Komisar A (Ed), Thieme, New York 1997. p.15.
- Komisar A. Mandibular reconstruction: History and review of the literature. In: Mandibular Reconstruction, Komisar A (Ed), Thieme, New York 1997. p.1.
- Irish JC, Gullane PJ. Reconstruction plates without grafts. In: Mandibular reconstruction, Komisar A (Ed), Thieme, New York 1997. p.33.
- Moscoso JF, Keller J, Genden E, et al. Vascularized bone flaps in oromandibular reconstruction. A comparative anatomic study of bone stock from various donor sites to assess suitability for enosseous dental implants. Arch Otolaryngol Head Neck Surg 1994; 120:36.
- 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.
- Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: a 10-year follow-up study. Plast Reconstr Surg 2002; 110:438.
- Disa JJ, Hidalgo DA, Cordeiro PG, et al. Evaluation of bone height in osseous free flap mandible reconstruction: an indirect measure of bone mass. Plast Reconstr Surg 1999; 103:1371.
- Moscoso JF, Urken ML. The iliac crest flap. In: Mandibular Reconstruction, Komisar A (Ed), Thieme, New York 1997. p.77.
- Vinzenz K, Holle J, Würinger E. Reconstruction of the maxilla with prefabricated scapular flaps in noma patients. Plast Reconstr Surg 2008; 121:1964.
- Masden DL, Iorio ML, Higgins JP. Comparison of the osseous characteristics of medial femoral condyle and fibula flaps. J Hand Surg Eur Vol 2013; 38:437.
- Jones DB Jr, Moran SL, Bishop AT, Shin AY. Free-vascularized medial femoral condyle bone transfer in the treatment of scaphoid nonunions. Plast Reconstr Surg 2010; 125:1176.
- Brown JS, Zuydam AC, Jones DC, et al. Functional outcome in soft palate reconstruction using a radial forearm free flap in conjunction with a superiorly based pharyngeal flap. Head Neck 1997; 19:524.
- Futran ND, Urken ML, Buchbinder D, et al. Rigid fixation of vascularized bone grafts in mandibular reconstruction. Arch Otolaryngol Head Neck Surg 1995; 121:70.
- Lavertu P, Wanamaker JR, Bold EL, Yetman RJ. The AO system for primary mandibular reconstruction. Am J Surg 1994; 168:503.
- Saunders JR Jr, Hirata RM, Jaques DA. Definitive mandibular replacement using reconstruction plates. Am J Surg 1990; 160:387.
- Gullane PJ. Primary mandibular reconstruction: analysis of 64 cases and evaluation of interface radiation dosimetry on bridging plates. Laryngoscope 1991; 101:1.
- Blackwell KE, Buchbinder D, Urken ML. Lateral mandibular reconstruction using soft-tissue free flaps and plates. Arch Otolaryngol Head Neck Surg 1996; 122:672.
- Ueyama Y, Naitoh R, Yamagata A, Matsumura T. Analysis of reconstruction of mandibular defects using single stainless steel A-O reconstruction plates. J Oral Maxillofac Surg 1996; 54:858.
- Zohar Y, Buler N, Shvilli Y, Sabo R. Reconstruction of the soft palate by uvulopalatal flap. Laryngoscope 1998; 108:47.
- Logemann JA. Upper digestive tract anatomy and physiology. In: Head and Neck Surgery: Otolaryngology, Bailey B (Ed), JB Lippencott, Philadelphia 1993. p.485.
- Panje WR, Morris MR. The oropharynx. In: Excision and reconstruction in Head and Neck Surgery, Soutar DS, Tiwari R (Eds), Churchill Livingstone, New York 1994. p.141.
- Maldonado AR, Baker BM, Judson WF. Palatal insufficiency: a surgical technique for reconstruction. South Med J 1985; 78:954.
- Curtis TA, Beumer J III. Speech, palatopharyngeal function and restoration of soft palate defects. In: Maxillofacial Rehabilitation; Prosthodontic and Surgical Considerations, Beumer J, Curtis T, Firtell DN (Eds), Mosby, St. Louis 1979. p.244.
- Michiwaki Y, Schmelzeisen R, Hacki T, Michi K. Functional effects of a free jejunum flap used for reconstruction in the oropharyngeal region. J Craniomaxillofac Surg 1993; 21:153.
- Finlay PM. Prosthodontics. In: Excision and Reconstruction in Head and Neck Surgery, Soutar DS, Tiwari R (Eds), Churchill Livingstone, New York 1994. p.103.
- Curtis TA, Beumer J III. Restoration of acquired hard palate defects: Etiology, disability and rehabilitation. In: Maxillofacial Rehabilitation: Prosthodontic and Surgical Considerations, Mosby, St. Louis 1979. p.188.
- Shapiro BM, Komisar A, Silver C, Strauch B. Primary reconstruction of palatal defects. Otolaryngol Head Neck Surg 1986; 95:581.
- Zeitels SM, Kim J. Soft-palate reconstruction with a "SCARF" superior-constrictor advancement-rotation flap. Laryngoscope 1998; 108:1136.
- Thomson CJ, Allison RS. The temporalis muscle flap in intraoral reconstruction. Aust N Z J Surg 1997; 67:878.
- Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral flap: facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg 1992; 90:421.
- Truelson JM, Close LG. Regional flaps in head and neck surgery. In: Head and Neck Surgery: Otolaryngology, Bailey B (Ed), JB Lippencott, Philadelphia 1993. p.1937.
- Panje WR, Morris MR. Oral cavity and oropharyngeal reconstruction. In: Otolaryngology-Head and Neck Surgery, 2nd, Cummings C (Ed), Mosby, St. Louis 1993. p.1479.
- Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109:2219.
- Chang YM, Coskunfirat OK, Wei FC, et al. Maxillary reconstruction with a fibula osteoseptocutaneous free flap and simultaneous insertion of osseointegrated dental implants. Plast Reconstr Surg 2004; 113:1140.
- Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986; 77:530.
- Shen Y, Sun J, Li J, et al. Special considerations in virtual surgical planning for secondary accurate maxillary reconstruction with vascularised fibula osteomyocutaneous flap. J Plast Reconstr Aesthet Surg 2012; 65:893.
- Matros E, Stranix JT. Long-Term Operative Outcomes of Preoperative Computed Tomography-Guided Virtual Surgical Planning for Osteocutaneous Free Flap Mandible Reconstruction. Plast Reconstr Surg 2016; 138:774e.
- Chang EI. Long-Term Operative Outcomes of Preoperative Computed Tomography-Guided Virtual Surgical Planning for Osteocutaneous Free Flap Mandible Reconstruction. Plast Reconstr Surg 2016; 138:559e.
- TIMING OF RECONSTRUCTION
- MANDIBULAR RECONSTRUCTION
- Free tissue transfer
- Pedicled vascularized grafts
- Nonvascularized autogenous bone grafts
- Donor sites
- Reconstruction plates
- SOFT PALATE RECONSTRUCTION
- Function of the palate
- Treatment of palatal defects
- - Obturators
- - Reconstructive flaps