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Mandibulectomy

A mandibulectomy is the removal of all or part of the mandible (jawbone). This is required when a tumor approaches or invades the jawbone.

Preparing for surgery

Your doctor and care team will let you know what you need to do to prepare for surgery. In general, you should not eat or drink anything (except essential medications) anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection. Your doctor will give you a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

On the day of surgery, you will need to arrive at the hospital or surgery center a few hours before the scheduled operation. This allows the nurses and anesthesiologist to confirm everything is in order for you to have as safe a surgery as possible. You will see your surgeon one last time before receiving the anesthesia and falling asleep, and you can ask any last-minute questions at that time.

What to expect

You will be put to asleep with general anesthesia. A tracheotomy may or may not be done at the start of the procedure, depending on the extent of the anticipated resection and reconstruction.

There are two main types of mandibulectomies:

  • Marginal mandibulectomy: In this case, a saw is used to remove a rim of the jawbone against where the tumor is sitting. The jawbone remains continuous in this case, and therefore an extensive reconstruction is not required. This type of mandibulectomy is done when a tumor in the mouth comes up to the jawbone, but is mobile over it, and therefore does not invade it. A marginal mandibulectomy should be performed only if your surgeon can confidently remove the entire tumor while preserving enough bone to maintain structural support during eating. This procedure should NOT typically be done for cancer that is clearly invading the bone for two reasons: 1) Frozen section analysis cannot be accurately performed on bone; therefore, it is very difficult to pathologically confirm during the operation itself that the margins of resection are clear of tumor; and 2) if cancer cells have invaded the bone, they could spread more easily to other parts of the bone and therefore a wider resection should be performed.In this procedure, the nerve that travels through the mandible and is responsible for sensation of the chin skin can be preserved.

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  • Segmental mandibulectomy: In this surgery, a cut is made through the full thickness of the mandible, which means that an entire segment of the mandible is removed. This makes the mandible discontinuous, and some sort of reconstruction is required to maintain jawbone function and maintain a relatively normal outward appearance.

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In this procedure, unless the mandible cuts are made near the midline because of a centrally located tumor, the nerve that travels through the mandible and is responsible for sensation of the skin of the chin is sacrificed. A nerve graft can sometimes be performed to attempt to restore some sensation in the long term.

Also, just as in marginal mandibulectomy, pathologists cannot assess the margins (edges) of the tumor resection on bone. So, if there is any concern that the margins might be close during the surgery, your surgeon might decide to delay the reconstruction until the final pathology results are in or use a frozen section analysis for a rapid assessment of the surgical margins (a pathologist rapidly freezes a bit of tissue and can check it in minutes). If the final pathology does show cancer at the margin of the resection, your surgeon will probably recommend re-resection of that area.

The approach used to perform a mandibulectomy will depend on the type and extent of the mandibulectomy. It can be performed via a transoral approach, a transcervical approach or both approaches combined (with or without splitting your lip).

Most commonly, cancers inside the mouth that are just approaching the jawbone and do not require a major reconstruction can be removed along with a marginal mandibulectomy all through the mouth without splitting your lip (transoral approach). However, you will still probably require a neck dissection via a neck incision along a natural skin crease.

For larger mandibulectomies, and most segmental mandibulectomies for cancer that require major reconstruction, a lip splitting/cervical approach is necessary.

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A mandibulectomy for cancer is done with removal of additional tissue. For example, a tongue cancer that has grown to involve the floor of mouth and then invaded the jawbone will require a partial tongue resection, floor of mouth resection and a segmental mandibulectomy; this type of surgery is called a composite resection and will require an advanced reconstruction.

Rarely, a cancer inside the mouth can invade through the entire mandible and involve the skin of the face. This type of composite resection, which involves removal of part of the inside of the mouth, the mandible and face skin, will require an advanced reconstruction as well.

A mandibulectomy is different from a mandibulotomy. A mandibulotomy is an incision through the jawbone to gain exposure inside the mouth/throat. After the tumor inside the mouth/throat is removed, the mandible is put back together with a plate and screws. No mandible bone is removed in a mandibulotomy.

Associated procedures might include a neck dissection, nerve graft, tracheotomy and dental extractions.

Reconstructive procedures after a mandible procedure will depend on a number of factors, including how much mandible and associated soft tissue is removed and your general health status. If a segmental mandibulectomy is performed, bone from another part of the body (such as the leg, back, arm or hip) can be transferred as a free flap to recreate the contour of the mandible and provide structural support in order to eat. In most cases, a metallic reconstruction plate is used to secure the new bone in place. Regional flaps (such as a pectoralis major muscle flap) can also be used, but this does not provide bone. Either at the same time or at a later date, you can choose to have dental implants placed to restore any teeth that may be missing.

When you waken, you might have a tracheotomy, a feeding tube, either in your nose or directly into your stomach, and some drains to remove any accumulated fluid from the neck. In some cases, your jaw may be wired closed to help keep the upper and lower teeth aligned. Pain will be controlled with strong pain medication. You will probably be advised to not eat anything for a number of days to prevent food and liquids from leaking from your mouth into your neck and causing an infection.

Recovery and aftercare

The recovery course will depend on the extent of the surgery and reconstruction. With some surgeries you could go home after a few hours of observation in the recovery room; others might require a stay in the hospital for one to two weeks. A stay longer than two weeks is usually due to some sort of post-operative complication that your doctors are working to improve.

If you do stay in the hospital for recovery, the recovery course can happen in a few different parts of the hospital. Your pathway might include trips to the recovery room, intensive care unit, step-down unit and a shared or private “floor” bed. As soon as possible and when the time is right for each step, you will progress from having your tubes and drains removed to being disconnected from the lines, and eventually getting up and out of bed. Asking for assistance to get out of bed to move around will help your recovery.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital with or without visiting nurses or receiving home care, others might go to a rehabilitation or skilled nursing facility for a short while before going home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for the next steps.

Risks

As with any procedure, there are risks in undergoing a mandibulectomy that you need to be aware of:

  • Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.
  • Seroma: This is a collection of normal body fluid in the neck after removal of the drain. This can be treated with observation, as the body will eventually resorb it, or repeated needle aspirations. The risk of leaving seroma is that it could become infected.
  • Infection: Neck dissections are done under completely sterile conditions. Still, as with any surgical procedure, there is always risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection.
  • Salivary fistula: This means that saliva is leaking from the mouth into the neck. The chances of this increase if you have had previous treatment, including radiation and/or chemotherapy. This is because wound healing might be impaired in these cases. Typical treatment for this is to place a drain to divert the saliva away from critical structures in the neck and later to place packing into that diverted tract and let the body heal it up on its own. In some cases, an additional surgical procedure might be required to close the leak.
  • Blood clots: Patients who undergo major surgeries, especially patients who have cancer, are at an increased risk of developing blood clots in their legs (deep venous thrombosis). Sometimes these blood clots can travel through the veins and into the lungs, causing a pulmonary embolus. This can be a serious complication, causing problems with oxygenation of your blood. If such a problem occurs, you will likely require anticoagulation (blood-thinning medication) to prevent more clots from forming and ending up in your lungs. This blood-thinning medicine, though necessary to prevent more clots, might itself cause another complication, such as bleeding, especially immediately after surgery. This is why it is important for you to get out of bed early and move your legs. If you are not up and moving about, dynamic compression stockings should be used (these are like massage boots for your calves to keep the blood flowing). Also, you will probably be given a low dose of blood-thinning medication immediately after surgery to help prevent clots.
  • Persistent tumor: After the cancer is removed, the jawbone (and associated tissue) will be analyzed by a pathologist. This requires up to about a week to completely analyze the tissue. If there is evidence of cancer on the margins of the bone resection, your doctor might recommend you undergo an additional surgical resection to obtain clear margins.
  • Malocclusion: This means that your upper and lower teeth do not meet together normally. You should work with an oral surgeon to help with this. The best treatment for this is prevention at the time of the original mandible reconstruction. Malocclusion can be a complication of a failed reconstruction (for example, using a reconstruction plate without vascularized free bone to put together a large defect in the jawbone).