Immediate free flap mandibular reconstruction: Significance of adequate surgical margins

Abstract

The pathologic records of 182 consecutive patients who had mandible resections were reviewed to determine the incidence of positive margins in the bone specimens and the risk factors associated with positive margins. Of the 182 cases reviewed, 82 (45%) were found to have involvement of the mandible at the time of resection and four (2%) were found to have positive margins. The predominant tumor histology was squamous cell carcinoma, 148 of 182 (81%), followed in frequency by osteosarcoma 12 of 182 (7%), salivary gland tumors 13 of 182 (7%), and miscellaneous other tumors (nine of 182 (5%). Of the four tumors with positive margins, two (50%) were squamous cell carcinomas, one (25%) was an osteosarcoma, and one (25%) was a salivary gland tumor. All four tumors were large tumors that had failed to respond to previous therapy. All obviously involved the mandible at the time of presentation. This study demonstrates that the incidence of bone margin involvement after mandibulectomy is rare and predictable and that clinical selection of candidates for immediate reconstruction is reliable in preventing inappropriate use of free bone flaps in patients at risk for positive bone margins.

A new guide to mandibular resection for oral squamous cell carcinoma based on the Cawood and Howell classification of the mandible

“…In the early series of segmental resections, the percentage of invaded mandibles tended to be low 22% (23/104) 11 and 30% (3/111) 15 . More up to date series report a much higher rate of mandibular invasion for segmental resection of 65-100% 1,5,[16][17][18][19][20] more consistent with the present study. At present the only method to audit the accuracy of mandibular resection is the margin, and the presence and extent of mandibular invasion.…”

“…Previous papers have reported that it is the soft tissue resection, which is the main determinant of compromised margins with compromised bone margins much less likely 14,20,22 . The question of whether a segmental resection of the mandible will ensure a higher chance of a clear soft tissue margin in the presence of early or an uninvaded mandible has not been answered.…”

Complete rehabilitation of the mandible following segmental resection

“…The majority of mandible defects result from resection of advanced squamous cell carcinomas (SCC), which involve the mandible by extension from intraoral structures [6]. Several factors complicate the reconstruction of these mandibular defects:…”

“…Historically, segmental mandibular resection left patients significantly disabled, horribly disfigured, and socially isolated due to a lack of reliable reconstructive methods [1]. However, through advances made in reconstructive microsurgery over the last three decades not only have the boundaries of mandibular tumor respectability been extended, but surgeons can now also expect reasonable postoperative functional and aesthetic outcome [2,3].…”

Sagittal Split Osteotomy on the Previously Reconstructed Mandible With Fibula Free Flap

“…The most common reason for mandibular resection is ablative surgery for large neoplasms involving the mandible, such as ameloblastomas. 1,2 An extensive ameloblastoma sometimes requires segmental mandibular resection or hemimandibulectomy. 3 Reconstruction of these mandibular defects is challenging, and various reconstruction methods are required to achieve functional and esthetic rehabilitation.…”