A Novel and Simple Technique of Reconstructing the Central Arch Mandibular Defects-a Solution During the Resource-Constrained Setting of COVID Crisis

Abstract

The current COVID 19 pandemic has a major impact on healthcare delivery globally. Oral cancer involving anterior arch of mandible is difficult to reconstruct and ideally, requires free fibular osteomyocutaneous flap. During this time of resource constraint situation, these free flaps are not a great choice, as it increases exposure of both patient and surgical team to the deadly virus. We are describing a novel method of reconstruction after resection of oral cancer involving anterior arch of mandible. In this new technique, we have reconstructed central arch defect by hanging bipaddle pectoralis major myocutaneous flap with orbicularis oris muscle using ethylene terephthalate suture. Operative time, early postoperative complications and early cosmetic and functional outcome were assessed. We have used this novel technique in eight patients of T4a oral cancer involving anterior arch of mandible and skin over chin. Mean operative time was 180 min. One patient had minor flap loss with surgical site infection (Clavien-Dindo grade I). In all patients, we were able to discharge all patients on eighth postoperative day. Cosmetic outcome and functional outcomes were mostly satisfactory. All patients were able to oppose their lips without any oral incompetence and drooling. Tongue mobility was good. There was no incidence of 'Andy Gump deformity'. This is a feasible option for reconstructing anterior arch defect in resource- and time-limited setting of COVID 19 pandemic. This technique can also be used in comorbid conditions where it is not advisable to do very long surgery.

Keywords: Andy Gump deformity; Anterior arch mandible; COVID 19; Ethylene terephthalate; Free fibular osteomyocutaneous flap; Pectoralis major myocutaneous flap.

Fig. 1

Operative technique. a Primary tumour with chin involvement. b Mucosal cuts. c Defect after resection. d Marking of bipaddle pectoralis major flap. e Flap brought to the defect. f Inner paddle of the flap sutured to mucosa. g Flap underlying the lower lip de-epithelized. h Inner epidermal edge of the flap (inner paddle) sutured with inner mucosal edge of the lip. i Ethylene terephthalate suture passed through the orbicularis oris muscle all along lower lip. j Same suture passed through the exposed dermis of the flap to tie the knot at the end. k Edge of epidermis towards outer paddle was sutured to skin of lower lip. l Resected specimen

Fig. 2

Final outcome. a–c Closed mouth appearance. A–C Open mouth appearance of same patients