The Chimeric LFC and DCIA Flap in Combined Mandibular and Condylar Head and Neck Reconstruction-A Case Series

Abstract

Background: Defects of the ascending ramus of the mandible, including the condylar head and neck or the whole temporomandibular joint (TMJ), are difficult to reconstruct. Reconstruction is mainly based on the use of alloplastic joint prosthesis, costochondral grafting, distraction osteogenesis of the dorsal part of the mandibular ramus, or osseous microvascular flaps of various origin. With the objective of developing a method that overcomes the restrictions of these methods, we recently introduced a sequential chimeric flap consisting of a lateral femoral condyle flap (LFC) and deep circumflex iliac artery flap (DCIA) for reconstruction of up to half of the mandible and the condylar head and neck. Methods: The chimeric flap was used in four patients with the following diagnoses: therapy-refractory osteomyelitis, extended recurrent odontogenic keratozyst, Goldenhar syndrome, and adenocarcinoma of the parotid gland. After a diagnostic workup, LFC and DCIA flaps were harvested in all patients and used in a sequential chimeric design for the reconstruction of the mandibular body and condylar head and neck. Results: Follow-up from at least 24 months up to 70 month after surgery showed a successful reconstruction in all four patients. The LFC provided a cartilaginous joint surface, allowing for a satisfactory masticatory function with a stable occlusion and unrestricted mouth opening and preserved or regained lateral and medial excursions in all patients. The DCIA allowed for a bony reconstruction anatomically resembling a non-atrophied mandibular body. No flap-related complications were observed. Conclusions: The sequential chimeric LFC and DCIA flap is an appropriate method for reconstructing up to half of the mandible and the condylar head and neck. It is suitable in cases where alloplastic joint replacement cannot be used or where other methods have failed. Due to the necessity of harvesting two flaps, the burden of care is increased, and a careful indication is required. The technique is reserved for maxillofacial surgeons who have already gained significant experience in the field of microsurgery.

Keywords: DCIA flap; TMJ reconstruction; chimera flap; lateral femoral condyle flap; mandibular reconstruction; maxillofacial surgery; plastic and reconstructive surgery.

Figure 1

In-house printed 3D cutting guide for mandibular resection and template for the assembly of the sequential chimeric LFC and DCIA flap.

Figure 2

Harvesting the LFC.

Figure 3

The osteochondral LFC.

Figure 4

A skin perforator flap harvested together with the LFC for concomitant skin replacement after extended resections.

Figure 5

The sequential chimeric LFC and DCIA flap ready for transfer to the recipient site. Note the DCIA replacing the body and parts of the ramus of the mandible and the LFC replacing the condylar neck and head.

Figure 6

The sequential chimeric LFC and DCIA flap: an overview of the bony and vascular anatomy.

Figure 7

The 3D reconstruction of a CT scan showing an anatomically correct reconstruction of the right mandible up to the condylar head with the sequential chimeric LFC and DCIA flap.

Figure 8

Sagittal CT view of the LFC in relation to the articular fossa, showing a good position.