JAMA Facial Plastic Surgery
Journal Club Slides:
Reconstruction of the Lateral
Mandibular Defect
Shnayder Y, Lin D, Desai SC, Nussenbaum B, Sand JP, Wax MK.
Reconstruction of the lateral mandibular defect: a review and treatment
algorithm. JAMA Facial Plast Surg. Published online July 23, 2015.
doi:10.1001/jamafacial.2015.0825.
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Introduction
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Segmental defects of the mandible resulting from malignant neoplasm,
trauma, or osteoradionecrosis present complex clinical challenges for the
reconstructive surgeon. Restoration of function, including speech and
swallow, while limiting long-term morbidity, are primary objectives.
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Defects of the lateral mandible are defined as those that extend posteriorly
from the mental foramen and can include the ramus or condyle. These
defects are associated with different aesthetic and functional consequences
compared with anterior defects. The muscles of mastication insert on the
posterior mandible; therefore, their detachment can create an imbalance of
the mastication forces. The lateral mandible also provides the contour to the
posterior lower third of the face. Nonetheless, compared with the anterior
mandible, the lateral mandible has less projection and is surrounded by a
greater amount of soft tissue.
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Purpose
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This review examines the current literature on functional outcomes of lateral
mandibular reconstruction and presents an algorithm on selecting an
optimal reconstructive choice for patients with lateral mandibular defects
resulting from oncologic ablative surgery or trauma.
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Relevance to Clinical Practice
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When reconstructing the mandible in a patient following tumor extirpation,
the patient’s overall prognosis, medical comorbidities, and need for adjuvant
therapy should be considered. In the patient with aggressive malignant
disease and a poor prognosis, a less complex reconstruction, such as softtissue flap with or without a reconstruction plate, may be adequate. In a
dentate patient with favorable prognosis, a durable reconstruction, such as
osseocutaneous microvascular free flap, is often preferred.
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Various reconstructive options are available for patients with lateral
mandibular defects. Depending on the predominance of the soft-tissue or
bony components of the defect, with consideration of the patient’s
characteristics and functional and aesthetic goals, the surgeon can wisely
select from these reconstructive possibilities.
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Description of Evidence
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PubMed and Medline searches on reconstructing lateral mandibular defect
were performed of the English literature. Search terms included lateral
mandibular defect, outcomes of mandibular reconstruction, and free flap
reconstruction of mandible. Although most of the articles presented are
retrospective reviews, priority was given to the articles with high-quality level
of evidence for this narrative review.
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Description of Evidence
Consideration for Donor Site and Technique Selection for
Lateral Defect Mandibular Reconstruction
Age of patient
Medical comorbidities and functional status of the patient
Patient and surgeon preferences
Radiation history and need for adjuvant therapy
Components of soft-tissue defect
Amount of bone and soft tissue resected
Prior surgical procedures and previous incision placements
Resection of the temporomandibular joint
Cancer prognosis (if applicable)
Dental restoration plan
Patient anatomy, including body habitus
Technical expertise of the surgeon
Vessel-depleted neck
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Controversies and Consensus
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Reconstruction with a plate and a bone-containing free tissue is commonly
used for patients with lateral mandibular defects. It preserves the continuity
of the bone, with its associated strength; allows the possibility of dental
restoration; and provides the most stable long-term reconstruction.
Other possible reconstructive options include the use of a soft-tissue flap
with a reconstructive plate, or letting the mandible “swing” by using a softtissue flap without the reconstructive plate. The disadvantage of soft-tissue–
only reconstruction is that it does not allow for dental restoration and may
be associated with hardware complications, although at a rate much lower
than that with anterior defect repair.
When reconstructing a mandible in a patient following tumor extirpation, the
patient’s prognosis and need for adjuvant therapy should be considered. In
the patient with aggressive malignant disease and a poor prognosis, a less
complex reconstruction may be adequate, particularly if the defect is of the
lateral mandible. If the patient has a favorable prognosis, a durable
reconstruction is often preferred.
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Algorithm for
Lateral
Mandibular
Defect
Reconstruction
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Comment
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There are only a few articles in the reconstructive literature that specifically
address functional outcomes of various reconstructive options used for
patients with lateral mandibular defects.
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Future studies will focus on comparing functional and cosmetic outcomes of
patients with similar lateral mandibular defects reconstructed by
osteocutaneous (bone-containing) free flaps, soft-tissue flaps and plate, and
soft-tissue–only flaps.
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Conclusions
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Various reconstructive options are available for patients with lateral
mandibular defects. Depending on the predominance of the soft-tissue or
bony components of the defect, with consideration of the patient’s
characteristics and functional and aesthetic goals, the surgeon can wisely
select from these reconstructive possibilities.
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Contact Information
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If you have questions, please contact the corresponding author:
– Yelizaveta Shnayder, MD, Department of Otolaryngology–Head and Neck
Surgery, University of Kansas School of Medicine, 3901 Rainbow Blvd,
Kansas City, KS 66160 (yshnayder@kumc.edu).
Conflict of Interest Disclosures
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None reported.
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