Latissimus Dorsi-Rib Pedicle Flap for Mandibular Reconstruction As a Salvage Procedure for Failed Free Fibula Flap

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*‡

The present paper describes the use of latissimus dorsi + rib Background: Mandibular reconstruction is usually performed by (LD + rib)5–7 flap for mandibular reconstruction in a patient who un- using free vascular flaps. However, there are instances in which it derwent an unsuccessful reconstruction with free fibula flaps and who must be carried out with pedicle flaps. Insofar, the main option refused a PM + rib pedicle reconstruction with the contralateral fibula recommended is the pectoralis major (PM) + rib pedicle flap. while he accepted to undergo a pedicle rib reconstruction. Methods: A 45-year-old patient affected by a primitive mandibular tumor presented after an unsuccessful reconstruction with free fib- CLINICAL REPORT ula flaps. He refused a PM + rib pedicle reconstruction, while he ac- A 45-year-old male patient affected by a primitive mandibu- cepted to undergo a latissimus dorsi (LD) + rib flap reconstruction. lar tumor (ameloblastoma of the left mandibular branch) was admit- Results: The postoperative course was uneventful. Also, the range ted to our department after the failure of both left and right free fibula of movements of the upper limb involved in the operation showed reconstruction performed in a different hospital. Due to his general no significant changes after surgery. conditions, the option of reconstructing the mandible by means of a free flap was rejected. The patient was advised a pedicle flap recon- Conclusions: The LD + rib flap proved to be a useful alternative struction with the PM + rib flap, which he refused. Our medical team procedure for mandibular reconstruction after cancer ablation in suggested then to perform a latissimus dorsi + rib pedicle flap recon- patients who are not candidates for vascularized bone-containing struction. The patient was briefed about this procedure and finally free flaps and refuse the PM + rib flap reconstruction. gave consent to it. Preoperative antibiotics were administered. An elliptical-shaped skin island was designed along the me- Key Words: Latissimus dorsi-rib pedicle flap, mandibular dial border of the latissimus dorsi muscle. The inferior border of the reconstruction, salvage procedure, free fibula flap, pectoralis flap was identified and the dissection was carried out following an major-rib pedicle flap inferior-to-superior direction until the 11th rib was reached. The (J Craniofac Surg 2014;25: 961–963) only rib that serves our purpose was the 11th as the length of the pedicle suffices to fully cover the mandible. The desired segment andibular reconstruction is a well-known and widely written of the rib was then osteotomized first laterally and then medially, Mtopic. Flaps such as the free fibula, free iliac crest, and free leaving 3–4 cm of rib at each side so as not to cause respiratory rib are among the most commonly performed techniques for man- problems. The perforating vessel that goes from the rib to the LD mus- dibular reconstruction.1–3 However, there are instances in which, cle was identified without dissection to provide a periosteal blood sup- due to the failure of free flaps or patients’ general conditions, the re- ply to the 11th rib. Once the rib was elevated, the remaining portion of construction of the mandible after the removal of tumors in the oral the flap was harvested along with its vascular pedicle as far as the ax- cavity must be carried out by employing pedicle flaps. Insofar, the illary artery (Fig. 1). The circumflex scapular artery was ligated. In main option recommended and described in literature is the this way, the pedicle can reach up to 11 cm in length, compared to the pectoralis major + rib (PM + rib) pedicle flap.4 The PM + rib flap thoracodorsal artery in normal condition that can only reach 4–5cm. rapidly and easily allows the covering of mandibular defects. How- The flap is tunneled under the humeral insertion of the pectoralis ma- ever, the donor site needs to be closed with skin grafts leading to a jor muscle. After placing 2 drainage tubes, the donor site was closed poor aesthetic appearance of the anterior chest wall. 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 be- From the *Department of Plastic and Reconstructive Surgery, China Medical cause of insufficient tissue in theÂ neck area (Fig. 2). Polyurethane University Hospital, Taichung, Taiwan; †Department of Plastic and dressings with ibuprofen (Biatain-Ibu) were used in the manage- Reconstructive Surgery, “Sapienza” University of Rome, Rome, Italy; ment of the skin graft recipient site; this expedient helps reducing and ‡ Department of Plastic and Reconstructive Surgery, University of 8 Sassari, Sassari, Italy. pain and keeping the wound clean. The patient was discharged Received December 22, 2013. 9 days later without complications, and 6 weeks afterwards, he began Accepted for publication January 7, 2014. radiation therapy (Fig. 3). The range of movements (ROM) of the up- Address correspondence and reprint requests to Nefer Fallico, MD, per limb involved in the operation was carefully measured before and Department of Plastic and Reconstructive Surgery, “Sapienza” after 6 weeks from the operation. The ROM of the left arm showed no University of Rome, Via Val Savio 3, 00141, Rome, Italy; significant changes before and after the operation (Fig. 4). E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD DISCUSSION ISSN: 1049-2275 Segmental continuity defects of the mandible are effectively re- DOI: 10.1097/SCS.0000000000000744 constructed using different vascularized bone flaps. The use of such

The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014 961

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

The latissimus–serratus–rib free flap is an effective procedure; however, it presents an excessive bulk and its cortical bone FIGURE 1. Intraoperative view of the latissimus dorsi muscle with the does not tolerate the insertion of dental implants. As a consequence, 11th rib attached after the harvest. this flap is only used in patients who are not candidates for more commonly used vascularized bone-containing free flaps.11 Unlike flaps allows reconstruction of both irradiated and non-irradiated the description given by Blackwell and colleagues,11 the periosteal fields. The most commonly used flaps in mandibular reconstruction blood supply is given by the subscapular artery, which is longer, 1 2 9 are the fibula flap, the iliac crest flap, the radial forearm flap, and allowing to perform a pedicled reconstruction. Moreover, the choice 3,10 latissimus–serratus–rib free flap. not to harvest the SA muscle allows the flap to be less bulky and, as The free fibula flap is considered the most appropriate choice for a consequence, to obtain a first intention skin closure. Also, the dis- mandibular reconstruction. However, sometimes it is not available be- section is easier requiring a shorter operative time and avoiding the cause it has been previously used or because of severe vascular disease. risk of winging scapula. The iliac crest flap has been extensively used in mandibular The free flaps based on the circumflex scapular artery reconstruction, but it includes an unreliable and relatively immobile containing the lateral border of the scapula require a long duration skin paddle, and a high incidence of postoperative donor site pain as of surgery because of impossible simultaneous flap harvest and tu- well as hernia formation. Among its other downsides, we can men- mor resection in case of oral cancer (simultaneous 2-team surgery). tion that it just provides a limited quantity of bone and muscle and In cases where it is not possible to perform any of the afore- 10 its pedicle is short. mentioned free flaps,12 the main reconstructive option described in The radial forearm flap allows a good lining of the oral mucosa, literature is the pectoralis major + rib pedicle flap.4 Despite the ease but it provides a limited quantity of bone tissue and, in time, it is very of technique, it requires large skin grafts to close the donor site, 10 likely to undergo spontaneous fractures of the radius after flap harvest. 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 2. Patient at the end of operation. Visible sutures with a meshed graft on the neck region. FIGURE 4. The longitudinal scar unhidden by the arm.

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014 LD-Rib Pedicle Flap After Failed Free Flaps

An alternative technique could be the bone graft from the fibula, 2. Miyamoto S, Sakuraba M, Nagamatsu S, et al. Current role of the iliac iliac crest, or rib, but it has been demonstrated that nonvascularized crest flap in mandibular reconstruction. Microsurgery 2011;31: bone grafts undergo a faster atrophic process.13 The LD + rib ped- 616–619 icle flap instead allows a direct closure of the donor site, with a ver- 3. Harashina T, Nakajima H, Imai T. Reconstruction of mandibular defects tically oriented scar that is usually well hidden. A small skin graft with revascularized free rib grafts. Plast Reconstr Surg 1978;62: 514–522 may be needed on the recipient site in the neck region if the wound 4. Dieckmann J, Koch A. Primary reconstruction of the mandible with a cannot be closed by direct suture. pedicled muscle and bone transplant—the pectoralis major and rib Moreover, the pectoralis major flap can present myospasms flap. Fortschr Kiefer Gesichtschir 1994;39:87–89 as a complication caused by an incomplete denervation of the 5. Reychler H, Lejuste P, Peiffer A. Mandibular reconstruction using a pectoralis major muscle. However, these spasms can be effectively pedicled osteomyocutaneous flap of the latissimus dorsi. Rev Stomatol 14 managed with BTX-A injections. Chir Maxillofac 1990;91(suppl 1):11–14 In the reported case, the LD + rib pedicle flap has been used for 6. Schlenker JD. Incorporating vascularized ribs in a latissimus dorsi mandibular reconstruction with good functional and aesthetic results. myocutaneous flap. Plast Reconstr Surg 1991;88:920–921 Despite some disadvantages related to the curvature and 7. Yamamoto Y, Sugihara T, Kawashima K, et al. An anatomic study of the strength of the rib, the LD + rib pedicle flap proves to be a reliable latissimus dorsi-rib flap: an extension of the subscapular combined flap that offers many advantages. It is a very useful reconstructive flap. Plast Reconstr Surg 1996;98:811–816 technique for bone defects ranging from small to large. Its pedicle 8. Cigna E, Tarallo M, Bistoni G, et al. Evaluation of polyurethane is long and generally not involved in peripheral vascular diseases. dressing with ibuprofen in the management of split-thickness skin graft The LD + rib flap provides a large quantity of muscle so that it is donor sites. In Vivo 2009;23:983–986 a good choice in case of radiation therapy. The donor-site morbidity 9. Zenn MR, Hidalgo DA, Cordeiro PG, et al. Current role of the radial forearm free flap in mandibular reconstruction. Plast Reconstr Surg is limited and the donor-site defect can be closed primarily. In addi- 1997;99:1012–1017 tion, the scar is easily disguisable because of its location on the 10. Trignano E, Fallico N, Nitto A, et al. The treatment of composite defect axillary line and it can only be seen when the patient elevates the of bone and soft tissues with a combined latissimus dorsi and serratus arms. A 2-team approach is mostly possible and there is no need anterior and rib free flap. Microsurgery 2013;33:173–183 for intraoperative repositioning. 11. Kim PD, Blackwell KE. Latissimus–serratus–rib free flap for In conclusion, the LD + rib flap has proved to be a useful al- oromandibular and maxillary reconstruction. Arch Otolaryngol Head ternative procedure for mandibular reconstruction after cancer abla- Neck Surg 2007;133:791–795 tion in patients who are not candidates for more commonly used 12. van Gemert JT, van Es RJ, Rosenberg AJ, et al. Free vascularized flaps vascularized bone-containing free flaps and refuse the pectoralis for reconstruction of the mandible: complications, success, and major + rib flap reconstruction. 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 REFERENCES 14. Trignano E, Dessy LA, Fallico N, et al. Treatment of pectoralis major 1. Trignano E, Fallico N, Faenza M, et al. Free fibular flap with periosteal flap myospasms with botulinum toxin type A in head and neck excess for mandibular reconstruction. Microsurgery 2013 reconstruction. J Plast Reconstr Aesthet Surg 2012;65: Epub ahead of print e23–e28