Free rib graft mandibular reconstruction

The rib free graft mandibular reconstruction is used for the surgical treatment of mandibular tumors. Treatment of diseases: mandibular retraction Indication The rib free graft mandibular reconstruction is suitable for all cases of benign tumor resection. In low-grade cases, bone grafting can be performed immediately. Contraindications Jaw cancer with high degree of malignancy should not be implanted immediately after resection. Patients who are over-aged, have poor health, or have long-term surgery for heart and lung disease, can delay bone grafting. Preoperative preparation Slant guides or winged splints should be made before surgery to prevent postoperative bone graft displacement. Prepare the whole chest skin 1d before surgery, and wrap it with a chest strap after cleaning. Whole chest disinfection, the back of the operation side has to go through the midline, over the shoulder, down the umbilicus, including the armpit on the surgical side. Surgical procedure Rib cutting method The ribs are the main components of the chest wall, 12 on each side. The surface layer is covered by skin, subcutaneous tissue and muscle layer, and the deep surface is pleura. The upper and lower ribs are intercostal spaces containing vascular nerve tissue. The first to seventh ribs are directly connected to the sternum by cartilage, and the eighth to tenth costal cartilage is integrally attached to the upper costal cartilage at the front end, and is not directly connected to the sternum, and the front end of the 11th to 12th costal cartilage is floated. rib. The main muscle covering the ribs has a part of the pectoralis major, the pectoralis minor muscle and the external oblique muscle in front. The lateral side is the anterior serratus muscle, which is connected with the external oblique muscle, and the trapezius and latissimus dorsi are on the dorsal side. , rhomboid muscles and other muscles. Between the upper and lower intercostal spaces, the intercostal muscles are obliquely and downwardly inclined, and the intercostal muscles are obliquely attached to the lower and lower ribs. The intercostal muscles are posteriorly forward, ending at the proximal costal cartilage, and thus connected to the intercostal ligaments forward to the sternum. Between the intercostal inner and outer muscles, the intercostal veins, arteries and nerves pass from top to bottom. (1) Total rib cutting method: incision and exposed ribs: According to the needs of the bone graft, an arc-shaped incision is made in the chest, and the length should exceed about 2 to 3 cm. It is advisable to cut the ribs with the 7th rib, the 8th rib, and the 9th rib. If the mandible is to be reconstructed, the 8th rib is best. Taking the reconstruction of one mandible as an example, starting from the cartilage of the eighth rib, an incision of about 15 to 18 cm is made according to the curvature of the rib. Cut the skin, subcutaneous tissue and deep fascia. Use a retractor to retract the wound edges on both sides. Continue to cut the muscle layer covering the ribs, and a little separation can expose the periosteum. The periosteum is longitudinally cut in the middle portion of the rib, and after each end of the desired length, each has a transverse incision and is H-shaped. The periosteal stripper is placed against the surface of the rib and separated under the periosteum. Peeling should be performed in the direction of the intercostal muscles. When peeling off the upper edge of the rib, the stripper should be pushed forward and backward, and when the lower edge is peeled off, the stripper should be moved to the rear to avoid difficulty in peeling off the direction of the reverse muscle fibers, damage the muscle fibers and intercostal vascular bundles or tear the pleura. Avoid violent peeling, prevent the stripper from slipping and puncture the pleura, and damage the lung tissue. When the medial and lateral periosteum is peeled off, a stripper is placed on the inside to protect it, and then placed into the bone scissors, and the ribs are cut at the distal end of the hard rib. The soft rib can be cut off after cutting with the blade according to the required length and shape. The length of the ribs should be cut, which should be relaxed by 0.5 to 1 cm, which is convenient for dressing and application. Fully stop bleeding, carefully check for pleural penetration, or suture or transfer adjacent muscle tissue flaps to repair. The wound is washed, the drainage strip is placed, the periosteum is sutured first, and then the muscle layer, subcutaneous tissue and skin are layered. The surface of the wound is placed with an alcohol gauze and gauze, sealed with a wide tape, and the upper chest strap is fixed. (2) Half-rib rib cutting method: the advantage is that the upper periosteum rib is cut, leaving the lower ribs, no thoracic deformity occurs, pleural rupture is not easy, and the ribs with periosteum can continue to grow and increase thickness; Applicable fashion can take two half ribs to overlap the bone graft; in addition, due to the periosteum, its anti-infective ability is strong, suitable for one-time bone grafting after oral surgery. The skin and muscle layers were cut with the full rib method to expose the surface of the ribs. At this time, the intercostal muscles are separated, the upper and lower edges of the ribs are exposed, the periosteum is cut along the rib edges, and a cut is scored on the hard ribs to preserve the periosteum on the surface of the ribs. Cut into the shape of the ascending branch from the soft rib, the depth is half of the thickness of the cartilage. Use a wide-bone knife to wedge and slide to the hard rib junction. After hitting the hard rib, use a hammer to lightly cut it. Half of it. The ends of the wide bone knife should be above the rib space to avoid damage to the soft tissue during the bone cutting process. At this time, the bone is cut by hand, and the shape is as follows: the knife is used to cut the bamboo, that is, according to the knife indentation on the edge of both ends, the wide bone knife is used to move up and down and advance, and the rib can be smoothly cut into two halves. . If the rib piece is thinned, the blade should be pressed slightly downward; if the bone piece becomes thicker, the blade should be lifted slightly. Finally, the hard ribs are cut according to the required length. Bone wax on the bone surface to stop bleeding, rinse the wound, layered suture, pressure bandage. 2. Bone graft preparation (1) Thoroughly flush the wound: repeatedly wash the wound with saline, ligature the live bleeding point, and minimize the pollution in the mouth. (2) sutured oral mucosa: the oral mucosa of the buccal lingual side was tightly sutured with a No. 1 silk thread. When sewing to the frontal bone section, there is usually a triangular gap here, which is not easy to seal tightly, and it is easy to form cracks. Therefore, before suturing the mucosa, the bone surface of the broken end is removed by bone tongs or osteotome, and the bone is broken. The end is formed with a bevel, which is sutured after flattening, where the tension can be eliminated and the suture is flattened. (3) suture submucosa: in order to avoid the oral mucosa cracking through, so after suturing the oral mucosa, the suture or thin wire is used as the submucosal suture, so that after double suture, the oral mucosa is not easy to crack. Rinse the wound with saline again and stop bleeding properly. 3. Implanted ribs It can be implanted in two ways. (1) Insertion implantation: a bone chisel is inserted into the bone marrow cavity of the broken end by about 1 cm, and then the hard rib end of the rib block is bitten into a spear shape by a rongeur and inserted into the marrow cavity to be fixed. The hard rib becomes the mandibular body, the soft rib becomes the ascending branch, and the tip is placed in the joint concave to become a pseudo joint. (2) Embedded implantation: The bone of the buccal side of the bed was cut by a bone chisel to be about 1 cm × 1 cm, and the inner cortical bone of the hard rib was bitten 1 cm to make them adhere to each other. Then, two holes are drilled in the opposite direction of the bone bed and the hard rib by hand or electric drill. When drilling, saline should be instilled at the same time to prevent the heat generated from damaging the bone marrow. Finally, the stainless steel wire is ligated and fixed. For the convenience of threading, the wire can be threaded out from the hole above the side to the side of the tongue; then an injection needle is inserted into the hole above the side of the side, and the wire on the side of the tongue is introduced into the pinhole of the injection needle. The lingual wire can be threaded out of the opposite bone hole when the needle is pulled out. 4. suture the wound The intestine is firstly inserted into the needle from the lower edge of the implanted rib, through the soft tissue on the inside, through the upper edge of the implanted rib, and then wrapped around the implanted bone to strengthen the fixation. It can be ligated in 4 to 5 places with a needle spacing of about 1.5 cm. The periosteum is then sutured, and the muscle, subcutaneous tissue and skin are sutured, and the flow strip is placed as appropriate. 5. Wear a beveled guide or a winged splint for auxiliary fixation. complication Intraoperative pleural rupture, if not treated correctly in time, postoperative complications such as pneumothorax and empyema. Oral mucosal sutures are disengaged, local wound infections, and osteomyelitis, leading to partial or partial necrosis of the bone graft. Residual infection occurred in the wire portion of the bone in the bone, causing the local wound to form a fistula, which was unhealed for a long time. The rib free graft can be applied to the old bone trauma defect of the mandible, the congenital malformation of the jaw and craniofacial complex and the inflammatory bone defect. The surgical principles and bone grafting procedures are basically the same, but they are not exactly the same in preoperative preparation. For preoperative preparation of mandibular old bone trauma defects, attention must be paid to: 1 local soft tissue conditions. If there are too many local scars or soft tissue defects, and there is not enough soft tissue bed to affect blood supply, soft tissue should be repaired first. 2 The dislocation of the jaw is healed, and the bite should be cut off, the scar should be loosened, the residual teeth of the upper and lower jaws should be used for intermaxillary fixation, and the teeth on the residual mandible should be kept in the normal occlusion position. The defective oral mucosa should be restored first. . 3 If the residual mandible is not easily reset due to the pulling of the muscle fibers, the sacral or ascending branch leading edge can be cut off, the diaphragm is lost and the sustained intermaxillary traction is made, and the occlusion is gradually restored to normal occlusion. 4 When the bone stump is exposed, the hardened bone of the broken end or the pseudoarticular surface should be bitten to make a fresh bone wound. 5 Most of the bone grafting is embedded and sutured with metal wire, or fixed with micro steel plate.

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