An interesting case of autografting

December 17, 2007 § 7 Comments

This autumn I had the privilege of documenting several operations for head and neck cancer. Some of the most fascinating operations involved the use of an autograft to replace the resected cancerous structures.

One of these operations was performed on a patient with cancer of the gingiva (gums). The tumor had infiltrated the mandibular bone and the surgeons had decided to remove the tumor and a part of the mandible.

In order to make a functional jaw, they were going to cut out a segment of the patient’s fibula (calf bone) and reconstruct the mandible.

Resected mandibular bone segment

The resected segment of the mandible with a tooth. The missing teeth are replaced with a dental prosthesis.

The operation would involve both head and neck- , hand- and oral and maxillofacial surgeons.

Mandibulectomy and reconstruction with fibular graft
The operation proceeded like this:

  1. The skin and subcutaneous tissue of the chin was incised in the mid-line by a head and neck surgeon. The tissue was then stripped from the part of the mandibular bone that was going to be removed.
  2. The oral and maxillofacial surgeon fixed the patient’s jaw with steel wire so the bite would remain the same after the bone graft reconstruction.
  3. The mandible was then divided with an oscillating bone saw. Approximately 5 cm of bone was removed. Bone marrow samples from the remaining edges was sent for pathological analysis.
  4. When the bone was removed, the underlying tumor was resected.
  5. Meanwhile, the hand surgeons had started to work on the patient’s leg. His left calf was emptied of blood with a pressure bandage. The blood was kept out with a tourniquet, so the surgeons could work in a non-circulated environment. A 10 cm long segment of the fibula was cut out with an identified artery and vein. When the fibula segment is taken more than 20 cm from the ankle, this will in fact not affect the function of the patient’s leg at all!
  6. The oral and maxillofacial surgeon adapted the fibula segment to fit into the mandible. It was then fixed to the mandible using titanium plates and screws.
  7. Finally the hand surgeons anastomosed the graft vessels to vessels of the neck. The artery was anastomosed with the superior thyroid artery and the vein with the facial vein.
  8. The operation was finished by closing the wounds in the leg and the chin.
X-ray of fibulagraft in place in mandibel

An x-ray of a jaw with fibular graft in place. The titanium plates are clearly visible on the right.

If there was no complications with the blood circulation of the graft, the patient would have a fully functional jaw and would not have any problems with the divided calf bone.

Surgical video
Watch my video of the operation here. Commentary in Norwegian, but if you’ve read this post you’ll hopefully be able to follow the procedure.

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§ 7 Responses to An interesting case of autografting

  • Bongi says:

    nice blog. i found it through surgexperiences. can i suggest that you make yourself available to host a future edition of surgexperiences?

  • dokidok says:

    Very interesting, descriptive post about the surgery and video
    showing the steps of the operation. I haven’t seen that type of surgery
    and that video was really helpful. Actually we had a patient who was admitted
    in the hospital after a car accident, who had multiple fractures of his extremities
    and face. During the time we were fixing the femur, the colleagues
    from the other team were fixing the broken jaw. I wasn’t able to pay attention at the jaw surgery though. We were too busy!

  • sterileeye says:

    Thanks!

    Watching the video again now I realise some parts of it are not exactly optimal, but it’s nice you found it useful!

    A strict time schedule only gave me the opportunity to be present at one of these operations. Hopefully I’ll find the time to get som better footage of the fibula osteotomy later.

  • I am a Cardiothoracic Surgeon who will be undergoing this surgery for a local recurrent poratid tumor I had. I will have the surgery at MD Anderson Cancer Center. I found the video most helpful. Thank you for placing on the web.

  • Denise Silveira says:

    Hello, I’ve just found your blog looking for information about mandible reconstruction. I’ve found some cases where the reconstruction was made just after removing the bone infected with cancer, like in this case you show us.
    My mother recently had part of her mandible removed, but her doctor said to wait for about 4 years to try a reconstruction.
    Do you know where I can find more information about it?
    Thank you

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