Keywords jaw defect - fibula flap - bilateral harvesting - case report - three-team approach
Introduction
Around 41 to 45% of submandibular salivary gland tumors are malignant, the most common
of which are mucoepidermoid carcinoma, adenoid cystic carcinoma, and adenocarcinoma.[1 ] Radical surgical excision followed by adjuvant radiotherapy is the treatment of
choice for well-differentiated salivary gland tumors with higher T stage.[2 ]
The operation involves an extensive en bloc resection followed by a modified radical
lymph node dissection. Such resection leaves an extensive defect in soft and hard
tissues, which should be reconstructed with free revascularized flaps to restore the
structural and functional integrity of this anatomical region. Reconstruction of critical-size
jaw defects with a free revascularized bone autograft (in particular, a fibular flap)
is currently the gold standard in head and neck surgery.[3 ]
Here, we report a case of patient with malignant myoepithelioma, who underwent a radical
en bloc resection of both jaws with immediate reconstruction using two fibula bone
flaps. During reconstruction dental implant placement and immediate loading on prefabricated
flaps were made. In this case we applied a three-team approach for parallel performance
of the steps of operation.
Case
In 2014, a 37-year-old female patient was diagnosed with pleomorphic adenoma of right
submandibular gland. The extirpation of salivary gland was performed.
In 2015, the patient had a recurrence of tumor. A second surgical procedure was performed
to remove the tumor, after which the patient was put under follow-up.
On January, 2018, the patient discovered the presence of a tumor in the right carotid
triangle and in the right submandibular region. The patient went to the local oncological
hospital in March. A preliminary diagnosis was established: recurrence of pleomorphic
adenoma of the right submandibular salivary gland. On April 05, 2018, a biopsy was
performed from a tumor of the right submandibular salivary gland. The patient was
diagnosed with cancer of the submandibular salivary gland with spread to the right
half of the parapharyngeal space and destruction of the upper and lower jaws with
regional metastases to right cervical lymph nodes, Т4аcN1M0, stage IVа. The tumor
measured 76 × 46 × 63 mm. On the multidisciplinary consilium, the decision was made
to perform four courses of polychemotherapy - doxorubicin 100 mg (60 mg/m2 ) + cisplatin 60 mg (40 mg/m2 ). During chemotherapy, the patient showed no response with an increase in tumor size
(78 × 49 × 70 mm). Later, a course of radiation therapy (cumulative dose – 38 Gy)
was performed with concurrent chemotherapy with paclitaxel (100 mg daily for 3 weeks),
but no significant response was observed. In November, 2018, the patient visited our
surgical center complaining on a tumor in the right submandibular and retromandibular
regions, on the lateral surface of the neck and in the oral cavity, third-degree trismus,
pain, tissue disintegration, and periodic recurrent bleeding ([Figs. 1A ] and [2A ])
Fig. 1 Anthropophotometry. (A ) Tumor in the lower and upper jaws on the right, in the submandibular region, on
the lateral surface of the neck, a scar is visible from the previous surgical resection;
(B ) Anthropophotometry 6 months after the treatment.
Fig. 2 (A ) The tumor spread in the oral cavity. (B ) 1 year postoperatively.
The clinical examination included photo anthropometry, contrast-enhanced CT of the
maxillofacial region, contrast-enhanced maxillofacial MRI, PET/CT, and histological
examination ([Fig. 3A ]). The following diagnosis was made: malignant myoepithelioma of the right submandibular
salivary gland with invasion and destruction of the maxilla and mandible on the right
and with regional metastases to right cervical lymph nodes, Т4аcN1M0, stage IVа, grade
group II. Tumor size was 52 × 53 × 82 mm.
Fig. 3 CT and MRI reconstruction. (A ) The tumor of the right submandibular region, half of the floor of oral cavity, peripharyngeal
space, with destruction of the lower and upper jaw on the right. (B ) CT and MRI imaging 6 months postoperatively. CT, computed tomography; MRI, magnetic
resonance imaging.
The following surgery was considered for the patient: right-sided oropharyngeal en
bloc resection of the maxilla and mandible, bilateral-modified extended lymph node
dissection with simultaneous reconstruction with two free revascularized fibular osteomusculocutaneous
autotransplants and dental implantation with immediate loading.
The surgical procedure was performed under endotracheal anesthesia. The patient underwent
the lower tracheostomy (The Björk technique). The first team of surgeons made a collar-shaped
incision along the cervical fold, passing into the submental region and the lower
lip. Modified radical bilateral cervical type III lymphadenectomy was performed from
this approach. The external carotid artery, the facial arteries and veins, and the
external jugular vein were prepared. A vertical mandibulotomy between 3.1 and 4.1
teeth was performed, and a fragment of the right half of the lower jaw was isolated.
According to the preoperative planning model, an osteotomy was performed at the level
of right condylar process. The next step was the resection of the tumor of parapharyngeal
space and the right upper jaw. Oropharyngeal en bloc resection was performed. Adequacy
of the surgical resection is confirmed by frozen section of margins.
Simultaneously, two teams of surgeons harvested free fibular osteocutaneous flaps
and their subsequent modeling according to the intraoperative template with dental
implantation and placement of temporary crowns. According to preliminary marking,
skin islets were also isolated (10 × 5 cm on the right and 5.5 × 5 cm on the left
leg). Modeling, implantation, and placement of the prosthodontic construction were
performed without division of the vascular pedicle. The final osteosynthesis of the
bones of the «neomaxilla» and «neomandible» was performed under the control of occlusal
stability of implant-supported bridges.
To provide vascular supply of maxilla, the anastomoses were applied between the right
external carotid and peroneal arteries, the right external jugular vein and peroneal
veins. For the mandible vascularization, the anastomoses were made between the left
facial and peroneal arteries and the left external jugular and peroneal veins. The
lateral surface of the pharynx and the retromolar area were reconstructed using the
skin islets of both flaps.
The entire surgical procedure lasted 18 hours. During the procedure, the patient lost
1,500 mL of blood, and the urine output was 1300 mL. Over the period of the manipulation,
640 mL of donor blood was transfused to the patient.
A week later, the endoscopic revision of wounds was made. The wound healed without
signs of inflammation or swelling of the vestibule and vocal cords.
Six-month follow-up included CT and MRI of the maxillofacial region, CT of the chest,
PET CT, ultrasound scanning of the soft tissues of the neck, abdominal, and pelvic
organs ([Figs. 1B ], [2B ], and [3B ]).
On December 3rd , 2020, the patient complained of deformations of middle and low thirds of face. The
defect is repaired with inguinal fold autodermal and palatal mucous grafts. Dental
implantation (Renova 3.75 × 11.5 mm. Torque 50 N cm) of 21, 23 teeth was performed.
After surgical reconstruction, the chewing ability of the patient was changed significantly.
This is primarily due to the limitation of the function of masticatory muscles, as
well as restriction of tongue movements. The patient eats food predominantly with
liquid consistency. The patient is able to open her mouth up to 40 mm. The patient
has no difficulty with breathing and swallows freely. Bilateral harvesting of fibula
flaps slightly affected the movement of patient. The patient undergoes diagnostic
CT/MRI every 6 months. Three years after surgery the patient has no recurrence of
the tumor ([Fig. 4 ]).
Fig. 4 Panoramic X-ray 3 years postoperatively.
Discussion
Jaw reconstruction using two fibular autografts with simultaneous implantation in
patients with a defect in both jaws allows avoiding additional, delayed surgical procedures
that prolong treatment to more than a year.[4 ] Besides, one-stage implantation with temporary prosthetics allows the patient to
avoid psychological stress of feeling inferior due to the absence of dentition. The
temporary prosthetics ensures the patient's adaptation to new occlusion and contributes
to the fastest possible speech recovery.
After adequate rehabilitation, the patient was able to walk steadily and maintain
balance. The use of two fibula flaps in patients with extensive jaw defects is justified,
since it does not increase morbidity.[5 ]
Reconstructive operations of a similar complexity require the participation of various
specialists in maxillofacial surgery, reconstructive microsurgery, dentistry, and
prosthodontist. For the first time, the simultaneous work of several surgical teams
was demonstrated during an esophageal resection and reconstruction operation.[6 ] Freiberg and Bartlett pioneered this approach in head and neck reconstruction.[7 ] Today, the simultaneous work of several surgical teams is the standard for extensive
surgical interventions.[8 ]
Reconstructive operations in the head and neck region could be quite lengthy.[9 ] An increase in surgery time positively correlates with the incidence of postoperative
complications.[10 ] In particular, the probability of reoperations increases three times after surgical
interventions lasting more than 10 hours.[11 ]
The multidisciplinary team approach has undeniable benefits for both patient and medical
staff. It allows reducing the time spent by the patient on operating table and, accordingly,
decreasing the risk of anesthesia.[12 ]
[13 ] Also, reducing the duration of the operation through simultaneous work of several
surgical teams results in lower likelihood of flap loss.[9 ] It should be added that this method significantly reduces the load on each surgeon
and improves the efficiency of the entire surgical team ([Fig. 4 ]). This case report demonstrates that the simultaneous work of three surgical teams
together with an implantologist and a prosthodontist is an effective approach to the
reconstruction of extensive head and neck defects. This method expands the indications
and scope of surgical interventions, in particular, through the use of computer planning,
auxiliary surgical template printing, harvesting several revascularized flaps, and
a well-coordinated multiteam approach. Apart from prolonging the life of patients
who were previously doomed to palliative care, this surgery organization method ensures
efficient and safe functional and anatomical rehabilitation and socialization of patients.
