Unique operations of the National Medical Research Radiological Centre: reconstruction of the lower jaw from the fibula
Patient Y.K. at the age of 73 entered P. Hertsen Moscow Oncology Research Institute – branch of National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation in 2023 with a diagnosis “Stage IV Small Salivary Gland Cancer”.
From the medical history it was known that in 2020 he had a cyst removed from the lower jaw and some of the lower anterior teeth. Of course, a morphological study was done, which showed no evidence of a malignant neoplasm. The patient was sent for observation at his place of residence, and two years later a focus of osteodestruction was identified in him in the frontal part of the lower jaw, for which a biopsy was performed, and again no evidence of the presence of malignant pathology was found. In August 2023, the tumor made itself felt again, it began to grow, and mucoepidermoid carcinoma of the minor salivary gland of the oral cavity was identified at A.I. Evdokimov Moscow State University of Medicine and Dentistry. The patient was referred to an oncologist.
In the department of head and neck microsurgery of P. Hertsen Moscow Oncology Research Institute they said that the patient had a tumor on the soft tissues of the floor of the mouth with the involvement of the frontal part of the lower jaw. In practice, if such a large area occupied by the tumor process was removed, a person could be disabled for life with all that it entails: disruption of the natural process of eating, swallowing and speech. At the interdisciplinary council of the Institute, a plan for surgical treatment was developed with simultaneous reconstruction of the lost part of the lower jaw and soft tissues of the oral cavity.
A feature of modern reconstructive microsurgery is the widespread use of IT technologies. Before the operation, the patient underwent virtual computer modeling using CAD/CAM technologies, the areas of tissue to be removed were determined, and a donor for reconstruction of the lower jaw was selected. Today it is the “gold standard” in reconstructive plastic surgery of head and neck tumors. In this case, it was planned to perform two operations at once in one stage: block resection of the lower jaw, floor of the mouth and microsurgical reconstruction with a fibular autograft.
– Two teams of our surgeons simultaneously performed an operation to treat and restore the vital functions of this patient, – says the head of the department of head and neck microsurgery of P. Hertsen Moscow Oncology Research Institute professor Andrey Polyakov. – First team headed by Irina Novikova, removed the tumor and prepared recipient vessels in the neck for autotransplantation of part of the fibula. The other, headed by Alexander Mordovsky, collected this autograft from the fibular vessels and gave it the desired configuration using pre-made 3D templates.
Almost all surgeons in the microsurgery department have several specializations: oncologist, surgeon, microsurgeon, plastic surgeon, maxillofacial surgeon and ENT doctor. And of course, they have knowledge of computer modeling. They have already accounted for hundreds of people with restored functions of the tongue, larynx, pharynx, jaw. The department does not simply remove the affected organ, but gives people the opportunity to eat, drink, communicate normally, take care of themselves, and do the work they love.
An operation to remove a tumor and restore a lost organ using autotransplantation is the coordinated work of a team whose actions are coordinated. Step by step, surgeons do their job: first, they remove the tumor on the lower jaw and prepare a place for “planting” the transplant.
To re-attach the transplanted fragment using an operating microscope, two surgeons immediately sew together vessels with a diameter of 3-4 mm with a thread thinner than a human hair.
At this time the second team, having isolated a fragment of the fibula along with the blood supply vessel, using pre-made templates, files it in the right places, bends it to form a part that repeats the shape of the lower jaw.
A bone autograft with an individual titanium plate is assembled as a constructor. Each screw that will connect the “metal structure” and the donor bone is “named” and lies in a special sealed box. Please note that these parts are made to order at one of the Russian enterprises.
And here is the moment of plastic surgery: when the transplant is fixed in the right place, you need to restore the blood supply in it by stitching the vessels under a microscope, returning the face to its previous shape and giving back full mobility of the lower jaw.
-Plastic surgery is the final apotheosis of all our work, – says Irina Valerievna. – And in our department there are a lot of real masters in this area.
-Even ten years ago, many patients with tumors of the larynx, tongue, jaws – more than 30 percent –refused surgery, – says Director General of the National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation, Academician of the Russian Academy of Sciences Andrey Kaprin. – They did not want to be disabled and become a burden to themselves and others. With the advent of new reconstructive plastic technologies, we are able to fully socialize such patients.