Urology

Complex Mandibular Reconstruction: A Sentara Specialty

 

Doctors typically diagnose jawbone cancers when tumors cause swelling, bleeding or severe pain. In certain cases, jawbone cancers are resected surgically, a process that also removes portions of the mandible.

Surgeons at the Sentara EVMS Comprehensive Head and Neck Center specialize in complex mandibular reconstructive surgery. The procedure restores mandibular structure and function using free tissue transfer from the patient’s fibula and skin.

 

Mandibular reconstruction pre-operative planning

Approximately two weeks before the scheduled procedure, surgeons obtain a fine-cut CT Scan of the patient’s mandible. After importing the data into a computer program, surgeons use rapid prototyping followed by 3D printing to design a patient-specific reconstruction plate. These tools allow surgeons to best plan the most effective surgical approach while minimizing risk to surrounding tissues. The plan includes methods to minimize damage to the tooth root and inferior alveolar nerve when feasible.

 

Steps of mandible reconstruction surgery

Mandibular reconstruction is a complex process involving several steps. Multiple surgeons work collaboratively to perform this procedure as a surgical team. The steps involved are:

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Harvesting the fibula free flap

Cutting guides and a cutting jig direct the harvest of the fibula free flap to the exact specifications detailed in the computer model. During the harvest, surgeons collect the specified portion of the fibula together with a skin paddle along the lateral aspect, blood vessels and even some muscle.

In this period of the operation, a tourniquet surrounds the operative leg to limit blood loss. Surgeons release the tourniquet after the fibula free flap is harvested but still receiving blood, which allows for revascularization of the bone tissue.

 

Attaching the reconstructive plate and fibula free flap

While the fibula revascularizes, surgeons work to secure a molded titanium plate onto the patient’s remaining native mandible. The operating team uses surgical screws to attach the plate to the mandible. Eventually, the screws integrate into the mandible, providing additional support to the reconstruction.

When the titanium plate is secure, surgeons disconnect the fibula from the operative leg’s blood supply. The bone and soft tissues are prepared for reimplantation into the mandible. Surgeons insert the fibula — cut to exact specifications — snugly into the mandible. The titanium plate holds everything in place as this occurs.

Following insertion of the fibula, surgeons insert the soft tissue along the lateral aspect of the tongue and cheek tissue. The skin paddle is sewn in place, with careful attention to the creation of a water-tight seal when attaching this new tissue to existing structures. Failure to create a water-tight seal increases the likelihood saliva will leak into the neck, causing plate contamination and risk of a significant infection.

 

Reanastomosis of the vasculature

After the soft tissue is in place, surgeons anastomose the peroneal artery and vein to recipient blood vessels in the neck. The facial artery is an excellent choice for revascularization of the graft. After surgeons determine the fibula is receiving sufficient blood flow, they close the surgical incisions.

 

Recovery after mandible reconstructive surgery

The recovery period after mandible reconstruction surgery varies for each patient. However, each person undergoing this surgical procedure spends a minimum of three days in the ICU, followed by at least three days on a surgical floor. During this time, patients cannot ingest any food or drink by mouth.

Doctors usually discharge mandibular reconstruction patients after one week, when the surgical wounds have healed. In many cases, patients undergoing complex mandibular reconstructive surgery have other therapies that doctors manage concurrently, particularly tracheostomies. In most cases, surgeons remove trachs before discharge. When patients are fully healed and are completely free of recurrent cancer, the fibular bone can be implanted to create structure for restorative dental dentures.

 

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