Mericli Alexander F, Schaverien Mark V, Hanasono Matthew M, Yu Peirong, Largo Rene D, Villa Mark T, Reece Greg, Butler Charles E, Garvey Patrick B
Houston, Texas.
From the Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center.
Plast Reconstr Surg. 2017 Aug;140(2):381-389. doi: 10.1097/PRS.0000000000003523.
A significant percentage of patients who undergo segmental mandibulectomy for head and neck cancer will develop a new or recurrent cancer or osteoradionecrosis, necessitating a second mandibulectomy and reconstruction. In this scenario, many surgeons are reluctant to perform a reconstruction with an osseous flap because of the presumed increased morbidity and complexity. The purpose of this study was to evaluate the safety and efficacy of performing a second free fibula flap reconstruction after repeated segmental mandibulectomy.
The authors retrospectively reviewed their prospectively maintained departmental database for mandible reconstructions performed between 1991 and 2016, identifying patients who had two sequential free fibula flap reconstructions. Patient, disease, and treatment characteristics were recorded and analyzed.
Twenty patients underwent a second free fibula flap reconstruction after a second mandibulectomy. The median follow-up was 72.5 months (range, 16 to 243 months). Preoperative virtual planning was used more often for the second fibula flap compared with the first (50 percent versus 10 percent; p = 0.004). The mean operative times were statistically similar for the first versus second fibula flap (673 minutes versus 586 minutes, respectively; p = 0.13). The postoperative complication rates (50 percent versus 30 percent, respectively; p = 0.19) and functional outcomes were similar between the first and second fibula flap reconstructions.
Despite the increased technical complexity, the use of a second free fibula flap after repeated segmental mandibulectomy appears to be safe and to confer no higher risk than that for the first fibula flap.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
因头颈癌接受节段性下颌骨切除术的患者中，有相当比例会发生新发或复发性癌症或放射性骨坏死，需要进行二次下颌骨切除术及重建。在这种情况下，由于预计会增加发病率和手术复杂性，许多外科医生不愿采用骨瓣进行重建。本研究的目的是评估在重复节段性下颌骨切除术后进行二次游离腓骨瓣重建的安全性和有效性。
作者回顾性分析了他们前瞻性维护的1991年至2016年间进行下颌骨重建的科室数据库，确定接受了两次连续游离腓骨瓣重建的患者。记录并分析患者、疾病和治疗特征。
20例患者在二次下颌骨切除术后接受了二次游离腓骨瓣重建。中位随访时间为72.5个月（范围16至243个月）。与第一次相比，第二次腓骨瓣更常使用术前虚拟规划（50%对10%；p = 0.004）。第一次与第二次腓骨瓣的平均手术时间在统计学上相似（分别为673分钟和586分钟；p = 0.13）。第一次和第二次腓骨瓣重建的术后并发症发生率（分别为50%和30%；p = 0.19）和功能结果相似。
尽管技术复杂性增加，但在重复节段性下颌骨切除术后使用二次游离腓骨瓣似乎是安全的，且风险并不高于第一次腓骨瓣。
临床问题/证据水平：治疗性，IV级。
