|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
When the bone is used for mandibular reconstruction, it is generally not as wide as an edentulous mandible. The bone should be inset so that it is nearly flush with the alveolar bone of the mandible; otherwise a step occurs intraorally and denture fitting is more difficult. Bony fixation is usually accomplished with A-O screws at each osteosynthesis site. Stability of the reconstructed mandible is augmented by bridging the defect along the lower mandibular border with a mandibular plate.
DONOR SITE CLOSURE
The defect in the radial artery is usually reconstructed with a reversed cephalic or saphenous vein graft. The cephalic vein is in the field and is usually easily removed. Although the literature reports approximately 50% patency rates in such reconstructions,16 we have had 100% patency in our first 20 cases as assessed clinically by Doppler and occlusion of the ulnar artery. It may be possible to close the flap defect primarily, but this is not always possible with flaps more than 3 or 4 cm wide. Split-thickness skin grafts are placed over the forearm muscles and paratenon. The fingers and wrist must be completely immobilized for 5 to 7 days to allow graft take, and some surgeons advocate even longer immobilization.17
| Protection of the radius after removal of a segment of bone is mandatory for at least 6 weeks, and, perhaps as long as 12 weeks, to prevent fracture at the donor site.15 Occasionally, suction drains are placed in the defect, particularly when bone has been removed.
1. A major concern with this flap is the risk of producing an unsightly donor site scar. This can be a problem when large skin paddles are used, particularly in young patients and overweight patients.7 This problem must be considered preoperatively when discussing flap alternatives with the patient.
2. In using the radial artery, the possibility of ischemic compromise of the hand arises.19 This risk is minimized by a preoperative Allen's test and reconstruction of the artery with a vein graft when indicated. We have not seen cold intolerance or significantly altered hand perfusion in any of our patients.
3. Injury to the radial nerve can occur during dissection of the radial artery or flap elevation.18,20 One patient in a series of 20 had paresthesia lasting approximately 9 months postoperatively.
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