The patient and the family were greeted in the preoperative area. All the risks and benefits of the procedure were once again explained to both the patient and the family and the risks of gait disturbances, paresthesias or the thigh, as well as lower chin and lip numbness were explained in detail all questions were answered. I also explained that there were risks of pain, bleeding, infection, swelling. Consent had already been signed. Care was then handed back to the anesthesia team.
The patient was brought into the operating room and anesthesia team the patient was placed in the supine position where the patient remained for the rest of the case. Anesthesia was able to establish an nasotracheal intubation without any complications. Care was then handed back to the OMFS team. Patient was prepped and draped in a sterile manner and a timeout was performed in which the patient was correctly identified by name medical record number as well as a site of the procedure to be performed. Patient had received preoperative Decadron as well as IV *** Antibiotics preop.
Attention was first directed to the left side of the mandible. Patient was given approximately *** cc of 1% lidocaine 1-100,000 epinephrine as local anesthesia at the site of the left mandible. A fifteen blade was used to make Approximately a 4 cm incision about 1.5 cm inferior to the inferior border of the left mandible. Next electrocautery was used to dissect through the subcutaneous fat, then through the platysma muscle, then through the superficial layer of the deep cervical fascia. Then dissection was carried out superiorly to the level of the inferior border of the mandible. A malleable retractor was used to retract the tissue on the lingual surface. Electrocautery was used to make an incision through the periosteum at the inferior border of the mandible. A subperiosteal flap was superiorly reflected. This flap was elevated until sufficient access was obtained. There was no communication into the intraoral cavity. A pocket was created in which the graft would be placed. Was found that there was a significant deficit in the height of the left mandible. Once the site was prepared, care was then directed to the site of the right iliac crest.
Patient was given approximately *** cc of 1% lidocaine 1-100,000 epinephrine the site of the right iliac crest. The anterior superior iliac spine as well as the right tubercle was marked. A 4 cm incision was made slightly medial to the iliac crest. Incision was made with electrocautery through the dermis through the subcutaneous fat. The incision was then reflected laterally. Electrocautery was used to incise through the aponeurosis of the tensor fascia lata and the external oblique muscles. An incision was then extended to the periosteum. The flap was medially reflected with the iliacus muscle reflected and the iliac crest was exposed. A reciprocating saw with copious irrigation was used to make a sagittal osteotomy (~3cm) as well as 2 vertical osteotomies. Then sequentially increasing osteotomes were used to separate the corticocancellous block bone. Bone curettes were used to harvest cancellus bone approximately 10 cc of bone was harvested total. At this point the surgical site was thoroughly irrigated with sterile saline. Bone wax was used to obtain hemostasis at the marrow. Then Gelfoam and Avitene was used to fill the defect.
These resorbable polyglactin synthes resorbable mesh was adapted to the defect of the graft. This was secured using 4 mm resorbable screws. The periosteal and aponeurosis layers were closed with 3-0 Vicryl sutures. Then 4-0 Vicryl sutures were used to close the deep dermis. A 5-0 Monocryl suture was used to close the skin and hemostasis was achieved. Steri-Strips followed by Telfa and Tegaderm dressing was placed. Care was then directed to the site of the left mandible.
The harvested block graft was adapted to the superior aspect of the left mandible distal to the remaining incisor teeth and the graft was secured with *** Synthes miniplate.The remaining cancellous bone from the graft was adapted to the buccal surface of the site. Surgical site was found to be hemostatic. Deep sutures were placed with 3-0 Vicryl sutures followed by closure of the platysma. The deep dermis was closed with 4-0 Vicryl suture. The skin was closed with Prolene sutures. With the bacitracin Telfa Tegaderm dressing placed hemostasis achieved.
Care was then handed back to anesthesia team of the patient was extubated in the operating room without any complications and transferred to the postanesthesia care unit.
