Clinical Scorecard: Complex Mandibular Reconstruction: A Sentara Specialty

At a Glance

Key Highlights

• Pre-operative planning uses fine-cut CT scans and 3D printing to create patient-specific reconstruction plates.
• Fibula free flap harvesting includes bone, skin paddle, blood vessels, and muscle with tourniquet use to limit blood loss.
• Revascularization achieved by anastomosing peroneal vessels to recipient neck vessels, typically the facial artery.

Guideline-Based Recommendations

Diagnosis

• Diagnose jawbone cancers based on tumor-related swelling, bleeding, or severe pain.

Management

• Perform surgical resection of affected mandible portions.
• Use fibula free flap with skin paddle for mandibular reconstruction.
• Employ patient-specific titanium reconstruction plates designed via 3D printing.
• Ensure water-tight seal when attaching soft tissue to prevent saliva leakage and infection.
• Manage concurrent therapies such as tracheostomies during recovery.

Monitoring & Follow-up

• Monitor blood flow to fibula graft intraoperatively after vascular anastomosis.
• Observe patients in ICU for minimum three days postoperatively.
• Continue monitoring on surgical floor for at least three additional days.
• Assess surgical wound healing before discharge, typically after one week.

Risks

• Risk of saliva leakage causing plate contamination and infection if water-tight seal is not achieved.
• Potential damage to tooth roots and inferior alveolar nerve during surgery.
• Risk of graft failure if revascularization is inadequate.

Patient & Prescribing Data

Patients undergoing complex mandibular reconstruction after cancer resection

Postoperative care includes ICU monitoring, nil per os status initially, and management of tracheostomies until healing permits removal.

Clinical Best Practices

• Use rapid prototyping and 3D printing for precise surgical planning and plate design.
• Collaborate with a multidisciplinary surgical team for complex reconstruction steps.
• Apply tourniquet during fibula harvest to minimize blood loss and allow revascularization.
• Secure titanium plate with surgical screws to integrate with native mandible.
• Ensure meticulous soft tissue closure to prevent saliva leakage and infection.
• Perform vascular anastomosis to ensure graft viability before surgical closure.
• Provide intensive postoperative monitoring in ICU and surgical floor settings.

References

• Sentara EVMS Comprehensive Head and Neck Center
• BroadcastMed: Complex mandible reconstruction surgical video
• Merck Manual Professional Version: Jaw Tumors