Osteomyocutaneous Rotational Flap Used to Reconstruct a Segmental Mandible Defect Due to Osteoradionecrosis: A Case Report and Review of the Literature

Radiation therapy (RT) is and essential treatment for many oral cavity and oropharynx tumors. However, radiation may cause significant long-term morbidity for survivors. A serious jaw complication from radiation includes osteoradionecrosis (ORN) requiring mandibulectomy and reconstruction, which has significant medical, economic, and quality of life implications for affected patients. Reconstructing ORN defects is challenging due to late effects of radiotherapy on bone and soft tissue tissues resulting in severe fibrosis and possibly infected wound environments. Microvascular free flaps (MVFF) are commonly used for mandibular reconstruction in ORN. When MVFF reconstructions are contraindicated, regional pedicle flaps combined with rigid fixation and autologous bone grafts are commonly reported options that can provide satisfactory functional and aesthetic outcomes. In the present case report we describe an osteomyocutaneous rotational flap using a rib to reconstruct a continuity defect due to ORN.

The patient is a 64-year-old female with a history of successful simple surgical treatment for ORN of the left body of the mandible that included hyperbaric oxygen (HBO) therapy who developed ORN and pathologic fracture of the right body of the mandible. Another long-term concern was the prognosis for the clinically healed left mandible. Treatment options were presented to the patient including a microvascular osteocutaneous fibula free flap. However, the patient’s ambulation and recovery time was a major concern and she preferred an osteomyocutaneous pectoralis major rib graft. The risks and benefits of both options were discussed. Three months postoperatively she developed an extraoral soft tissue dehiscence with exposure of the plate without infection. Computed tomography seven months postoperatively demonstrated a bone union of the rib at both the proximal and distal resection margins. She subsequently underwent examination of the graft which was found to be healed. The reconstruction plate was removed and the cutaneous defect was repaired using a full thickness skin graft to the right mandible.

Reports on vascularized osteocutaneous rib grafts to reconstruct the mandible for ORN have been brief.¹Reconstruction of the mandible using rib has been reported primarily as a free bone graft.^2,3 Additional considerations for our patient with a history of ORN of the left mandible include: the 25% failure rate associated with simple surgical treatment (i.e., sequestrectomy),⁴  the controversial efficacy of perioperative HBO therapy^5,6 and the increased risk of ORN over time.⁷An osteomyocutaneous pectoralis major rib graft was able to restore continuity of the right mandible and maintain the option for a microvascular fibula graft in the event of recurrent ORN in either or both sides of the mandible. The limitations for this option are the size of the defect and inability to place dental implants. The conclusion from this case report is that a rotational osteomyocutaneous rib graft may be an option for some patients with ORN.

References

1. Pearlman N, Albin R, O'Donnell R. Mandibular reconstruction in irradiated patients utilizing myosseous-cuatneous flaps. Am J Surg. 1983; 146: 474-477.

2. Torroni A, Marianetti T, Romandini M, Gasparini G, Cervelli D, Pelo S. Mandibular reconstruction with different techniques. J Craniofac Surg. 2015;26:885-890.

3. Banerjee A, Westmore G. Free rib graft reconstruction of the mandible: a forgotten option? Ann R Coll Surg Engl. 1995;77:278-281.

4. Wong J, Wood R, McLean M. Conservative management of osteoradionerosis. Oral Surg Oral Med Oral Path Oral Rad Endo. 1997;84:16-21.

5. Bessereau J, Annane D. Treatment of osteoradionerosis of the jaw: The case against the use of hyperbaric oxygen. J Oral Maxillofac Surg. 2010;68:1907-1910.

6. Freiberger J, Fedlmeter, JJ. Evidence supporting the use of hyperbaric oxygen in the treatment of osteoradionecrosis of the jaw. J Oral Maxillofac Surg. 2010;68:1903-1906.

7. Marx R, Johnson R. Studies in the radiobiology of osteoradionecrosis and their clinical significance. Oral Surg Oral Med Oral Path Oral Rad Endo. 1987;644:379-390.