Neoplastic, Inflammatory and Degenerative Conditions

Head and Neck Reconstruction

Maxillomandibular-Labial Reconstruction: An Autogenous Transplant as an Alternative to Allogenic Face Transplantation

Chepeha DB, Malloy KM, Moyer JS, et al (Univ of Pennsylvania, Philadelphia; Univ of Minnesota, Minneapolis) Plast Reconstr Surg 126:2007-2011, 2010^§

Abstract

Background

Large-volume maxillomandibular-labial defects are unusual and present reconstructive challenges. Such injuries impair oral sphincter function and cause debilitating and disfiguring soft tissue and bone loss that affect speech and swallowing. Limited local tissue is available, multiple autogenous transplants are needed, and few techniques permit reconstruction of near-total oral sphincter defects. Face transplantation is associated with functional challenges and chronic immunosuppression risks. An alternative technique was used in two patients with traumatic defects of the premaxilla, mandible, and oral sphincter.

Methods

One patient was age 3 years and the other age 26 years. The technique was accomplished in two steps. First, the intraoral mucosal defect was reconstructed using an independent skin paddle. The design is based on measurements obtained with the patient in “open-mouth” position to accommodate the labial sulcus, labial height, and labial width. A second independent skin paddle was used for the cutaneous defect. The template-based technique maintained the proportions of the oral sphincter and surrounding soft tissues. The remaining native lip and oral sphincter were tacked in place on the external cutaneous skin paddle to avoid contraction, and the maxilla and mandible were projected to correct position. The paddles were allowed to heal for at least 6 weeks, with a small port for suctioning secretions and monitoring mucosal restoration provided.

In the second step, the oral fissure was opened between the maxilla and mandible, carefully placing it midway between the two and in an anatomically proportional site for the individual’s face. The part of the flap that the native lip was to replace was resected, then the remnant of native lip inlayed into the oral fissure. It is important to avoid making the oral fissure too wide to control oral secretions. To ensure oral competence, the oral fissure can only exceed the width of the native lip tissue by a small amount. Twelve months or more after the procedure, patients underwent analysis of their speech and swallowing function, diet, oral competence, functional status, and quality of life.

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