Management of an exposed mandibular plate after fibula free flap with vacuum-assisted closure system.

Introduction: In 1997, Morykwas et al introduced negative pressure dressings to manage complicated wounds; since its introduction, the vacuum-assisted closure (VAC) system has been successfully used in the fields of general surgery, orthopedic surgery, plastic surgery, and gynecology. Recently, some authors described this technique to manage complex wounds in the craniomaxillofacial region; we introduce the case of exposed peroneal bone and mandibular reconstruction plate after a fibula osteomyocutaneous free flap managed with this method.

Clinical Report: A 41-year-old man presented an advanced mandibular osteoradionecrosis with an extensive composite three-dimensional defect of the lower jaw involving the oral mucosa, the mandibular bone, the external skin, and the soft tissue, with a clear communication between the oral cavity and the exterior. A subtotal mandibulectomy and a fibula osteomyocutaneous free flap to reconstruct the defect was performed; 1 month after surgery, the patient presented an exposition of a segment of the fibula and reconstruction plate. The patient was put on VAC for 20 days before a pedicle pectoralis major musculocutaneous flap was performed as definitive reconstruction.

Discussion: The advantages of the VAC device in the management of complicated craniofacial wounds have been discussed by a multitude of experimental and clinical studies. This method removes fluids and infectious materials and helps draw together wound edges, increasing blood flow and promoting wound healing. Of the 2 proposed mechanisms (fluid-based and mechanical), it seems that the latter is of greater importance in the production of new tissue. Up-to-date adequate surgical debridement, wet-to-dry dressing changes, and appropriate antibiotic treatment remain the mainstay in treating complex craniofacial wounds; however, in selected cases, the VAC system can be used to achieve a primary closure or to provide a transitory coverage preparing the wound bed until a definitive reconstruction is planned and/or performed.

Conclusions: This therapy is a safe, innovative, and useful tool and can be of great assistance especially in complex craniofacial wounds, but it poses some problems such as intricate contours and orifices of the head and neck region, painful dressing changes, and remarkable costs.