Bony Free Flaps Research Articles

Early and Late Complications of Mandibulectomy Free Flap Reconstruction: Does the Selective Use of Soft Tissue Only Flaps Reduce Complications?

This study aims to evaluate the factors most associated with early and late complications following microvascular free tissue transfer (MVFTT) after mandibulectomy. A retrospective review of patients undergoing MVFTT after segmental mandibulectomy from September 2016 to February 2021 was performed across a single academic institution. Surgical variables were collected, including the location of the resultant mandibular defect (anterior vs posterior) and flap type (osseous or non-osseous). The primary outcome variables included postoperative complications (early, <90 days; and late, >90 days) and the patients' functional status (return to oral intake). Descriptive statistics, chi-square test, Fischer's exact test, and 2-sample t tests were used to analyze differences among variables. We analyzed a cohort of 114 consecutive patients with mandibular defects, comprising 57 anterior and 57 posterior defects. Bony free flaps with hardware were used to reconstruct 98% of anterior defects compared to 58% of posterior defects (P < .001). All soft tissue only flaps did not utilize any hardware during the reconstruction. Anterior defects demonstrated more late complications requiring additional surgery (30% vs 9%, P = .04). A secondary analysis of posterior mandibular reconstructions compared soft tissue only flaps and bony free flaps with hardware and showed equivalent rates of early (12% vs 13%, P > .99) and late (9% vs 8%, P > .99) complications requiring additional surgery while demonstrating a similar return to full oral competence (55% vs 46%, P = .52) and recovery of a 100% oral diet (67% vs 54%, P = .53). Osseous free tissue transfer for segmental mandibular defects remains the gold standard in reconstruction. In our patient cohort, anterior mandibular defects are associated with greater late (>90 day) complications requiring additional surgery. Comparable outcomes may be achieved with soft tissue only versus osseous free flap reconstruction of posterior mandibular defects.

The Perfect Timing-Immediate versus Delayed Microvascular Reconstruction of the Mandible.

In this retrospective study, the clinical and economic implications of microvascular reconstruction of the mandible were assessed, comparing immediate versus delayed surgical approaches. Utilizing data from two German university departments for oral and maxillofacial surgery, the study included patients who underwent mandibular reconstruction following continuity resection. The data assessed included demographic information, reconstruction details, medical history, dental rehabilitation status, and flap survival rates. In total, 177 cases (131 male and 46 females; mean age: 59 years) of bony free flap reconstruction (72 immediate and 105 delayed) were included. Most patients received adjuvant treatment (81% with radiotherapy and 51% combined radiochemotherapy), primarily for tumor resection. Flap survival was not significantly influenced by the timing of reconstruction, radiotherapy status, or the mean interval (14.5 months) between resection and reconstruction. However, immediate reconstruction had consumed significantly fewer resources. The rate of implant-supported masticatory rehabilitation was only 18% overall. This study suggests that immediate jaw reconstruction is economically advantageous without impacting flap survival rates. It emphasizes patient welfare as paramount over financial aspects in clinical decisions. Furthermore, this study highlights the need for improved pathways for masticatory rehabilitation, as evidenced by only 18% of patients with implant-supported dentures, to enhance quality of life and social integration.

A preliminary analysis of patient reported outcomes following posterolateral mandible reconstruction: The role of flap type.

The choice of tissue type for free flap reconstruction of posterolateral mandible resections is dependent on patient and defect characteristics. We compared clinical and patient-reported outcomes following reconstruction of these defects with a soft tissue or bony free flap. A retrospective review was performed on patients who underwent posterolateral segmental mandibulectomy with immediate free flap reconstruction at MSKCC from 2006 to 2021. Outcomes of interest were patient-reported outcome measures (PROMs) assessed by FACE-Q surveys and complications at the flap recipient site. Ninety patients received a bony flap and 24 patients received a soft tissue flap. Patients reconstructed with soft tissue flaps had greater rates of composite soft tissue defects (p < 0.0001), condyle resection (p = 0.001), and peripheral vascular disease (p = 0.035). Complication rates were similar between the cohorts (p > 0.05). Bony flaps scored higher on multiple FACE-Q scales: Facial Appearance (p = 0.023) Eating/Drinking (p = 0.029), Smiling (p = 0.012), Speaking (p < 0.001), Swallowing (p = 0.012), Smiling Distress (p = 0.037), and Speaking Distress (p = 0.001). Reconstruction of posterolateral mandibular defects has a similar complication profile when utilizing a bony or soft tissue free flap. Bony flaps may perform better with respect to PROMs. Reconstructive surgeons should consider using bony flap reconstruction to achieve higher patient satisfaction and quality of life.

Comparing donor site morbidity in osteocutaneous radial forearm versus fibula free flap for mandibular reconstruction

PurposeThe osteocutaneous radial forearm free flap has gained popularity as a less morbid option for oromandibular reconstruction compared to the fibular free flap. However, there is a paucity of data regarding direct outcome comparison between these techniques. MethodsRetrospective chart review of 94 patients who underwent maxillomandibular reconstruction intervened from July 2012–October 2020 at the University of Arkansas for Medical Sciences. All other bony free flaps were excluded. Endpoints retrieved encompassed demographics, surgical outcomes, perioperative data, and donor site morbidity. Continuous data points were analyzed using independent sample t-Tests. Qualitative data was analyzed using Chi-Square tests to determine significance. Ordinal variables were tested using the Mann-Whitney U test. ResultsThe cohort was equally male and female, with a mean age of 62.6 years. There were 21 and 73 patients in the osteocutaneous radial forearm free flap and fibular free flap cohorts, respectively. Excluding age, the groups were otherwise comparable, including tobacco use, and ASA classification. Bony defect (OC-RFFF = 7.9 cm, FFF = 9.4 cm, p = 0.021) and skin paddle (OC-RFFF = 54.6 cm2, FFF = 72.21 cm2, p = 0.045) size were larger in the fibular free flap group. However, no significant difference was found between cohorts with respect to skin graft. There was no statistically significant difference between cohorts regarding the rate of donor site infection, tourniquet time, ischemia time, total operative time, blood transfusion, or length of hospital stay. ConclusionsNo significant difference in perioperative donor site morbidity was found between patients undergoing fibular forearm free flap and osteocutaneous radial forearm flap for maxillomandibular reconstruction. Osteocutaneous radial forearm flap performance was associated with significantly older age, which may represent a selection bias.

188. Patient Reported Outcomes Following Soft Tissue Vs. Bony Free Flap Reconstruction Of Mandible Defects

188. Patient Reported Outcomes Following Soft Tissue Vs. Bony Free Flap Reconstruction Of Mandible Defects

D115. Patient Reported Outcomes after Soft Tissue Vs. Bony Free Flap Reconstruction of Mandible Defects

PURPOSE: Patient reported outcome measures in oncologic head and neck reconstruction have yet to be fully evaluated. Complex oncologic mandibulectomy reconstructions include bony and/or soft tissue elements. While previous studies evaluated complications and functional results, this study compares FACE-Q scores in patients reconstructed with bony vs. soft tissue free flaps for mandibulectomy defects. METHODS: Patients who underwent mandibulectomy reconstruction with a soft tissue or bony free flap between 2000-2022 and completed at least one postoperative FACE-Q were retrospectively reviewed. FACE-Q responses were divided into functional and stress domains scored from 0-100 (higher scores represent better outcomes). FACE-Q scores were compared by postoperative period (0-1 year and >1 year), and by mandibulectomy type (lateral and hemi-mandibulectomy). RESULTS: 179 patients underwent mandible reconstruction with a bony flap, and 135 patients received a soft tissue flap. 74 bony and 23 soft tissue flap patients filled out at least one postoperative FACE-Q. Bony flap patients reported significantly greater overall and >1 year satisfaction with their swallowing (p=0.031, p=0.005, respectively) and speaking (p=0.016; p=0.016) function. When reconstructing hemi-mandibulectomy defects, bony flaps also performed significantly better with swallowing (p=0.027) and speaking (p=0.035) function. There was no difference in FACE-Q scores for lateral mandibulectomy defects. CONCLUSION: A preliminary analysis of FACE-Q outcomes for mandibulectomy reconstruction found that bony free flaps may perform better than soft tissue flaps in the speaking and swallowing domains. Expanded cohort studies with longer follow-up could yield valuable information for surgeons considering flap tissue types based on size and location for mandible reconstruction.

Oral Cavity Reconstruction over a 30-Year Period at a Dedicated Tertiary Head and Neck Cancer Centre

There are around 2,500 new cases of oral cavity squamous cell carcinoma (OSCC) reported yearly within Australia. Resection often leads to substantial defects, requiring complex reconstruction. The aim of this study was to examine how reconstruction at a dedicated head and neck cancer unit has evolved over a 30-year period. A retrospective review was conducted of all OSCC carcinoma cases performed from 1988 to 2017. Data was analysed in six-time periods; pre-1995, 1995–1999, 2000–2004, 2005–2009, 2010–2014, and 2015 and above. A total of 903 patients were identified, of which 56.1% (n = 507) underwent free flap reconstruction including 426 (84.0%) soft tissue free flaps (STFF) and 81 (16.0%) bony free flaps (BFF). STFF usage remained stable over time. The radial forearm was the most common free flap but declined over time with increasing use of the anterolateral thigh flap. The number of BFF increased from 5.0% before 1995 to 20.4% in 1995–2015. The tongue was the most common subsite, followed by the floor of mouth. Free flaps were utilised in more than 50% of OSCC reconstructions at each time period. Over time, the proportion of different STFF evolved towards increased use of the ALT flap and BFF within our institution. Level of evidence: Level four.

Classification of pedicle ossification after maxillofacial reconstruction with bony free flap: An observational study

IntroductionMaxillofacial reconstruction with bony free flap is a classical technique. However, pedicle ossification after such reconstruction is a misunderstood complication that is rarely reported in the literature. It is usually manifested as trismus, neck pain, and hard swelling, but it is predominantly asymptomatic and, thus, mainly incidentally discovered at a later stage. The aim of our study is to propose a classification for pedicle ossification based on both radiological features and vascular calcification progression. We also describe a case of metachronous ossification after two fibula free flap procedures. Material & MethodsOur observational study includes all patients from our unit who underwent maxillofacial reconstruction with bony free flap from 2003 to 2018. We collected all cases of pedicle ossifications identified during the follow-up and described the radiological status of each one to categorise them in different groups and propose a classification scheme for the same. ResultsRadiological and histological analysis showed a progressive three-step evolution of pedicle ossification, starting from the media, progressing into the lumen, and then reaching completion in the extravascular region. The final stage was observed in all symptomatic patients. ConclusionPedicle ossification is a progressive process that passes through three successive histological stages that may be associated with factors such as smooth muscle cell phenotype modification [1]. This complication may lead to more severe clinical symptoms and may require surgery for removal of the calcification.

Distraction osteogenesis; an option following failed bony free flaps in head and neck reconstruction

Introduction: Primary reconstruction of the mandible with bony free flaps is a predictable technique with high success rates. However, failure of composite flaps do occur, and can pose a difficult situation for patient and surgeon. Options may include further flap procedures, alloplastic replacement and opting for non-bony reconstructions. These all have limitations. Challenges of reconstruction in salvage cases include an irradiated field, sequalae from primary procedures, and development of adequate bone and quality soft tissue for dental rehabilitation. Distraction osteogenesis (DO), has been long utilised in maxillofacial surgery and presents one further option to be considered in such cases.

Postoperative delirium in patients with head and neck oral cancer in the West of Scotland

Our aims were to determine the prevalence and association of postoperative delirium (POD) in head and neck (H&N) cancer patients undergoing free flap reconstruction at the oral and maxillofacial surgery (OMFS) unit, Queen Elizabeth University Hospital (QEUH) Glasgow, and to assess whether these determinants can be modified to optimise patient care and reduce the occurrence of POD. Delirium remains an important problem in the postoperative care of patients undergoing major H&N surgery, and early detection and management improve overall outcomes. The patient database containing details of the preoperative physical status (including alcohol misuse, chronic comorbidity, and physiological status) of 1006 patients who underwent major H&N surgery with free-flap repair at the QEUH from 2009-2019, was analysed. Factors associated with delirium were studied, identifying univariate associations as well as multivariate models to determine independent risk factors. The incidence of POD was 7.5% (75/1006; 53 male:22 female; mean (SD) age 65.41 (13.16) years). POD was strongly associated with pre-existing medical comorbidities, excess alcohol, smoking, a prolonged surgical operating time (more than 700 minutes), tracheostomy, blood transfusion, and bony free flaps. Those with POD were at an increased risk of postoperative wound and lung complications, and were more likely to require a hospital stay of more than 21 days. Presurgical assessment should identify risk factors to optimise the diagnosis and treatment of POD, and will enhance patient care by reducing further medical and surgical complications, and overall hospital stay.

Evaluation of a novel osteosynthesis plate system for mandibular defects

Continuity defects of the jaw can be reconstructed with titanium plates or microvascular bone flaps; osteosynthesis plates are necessary for both. In this study we performed a retrospective review of patients treated with Medartis MODUS® Mandible Trauma/Reco 2.0-2.5, TriLock bridging plates, mandibulectomy and soft tissue free flap or reconstruction with a bony free flap and TriLock mandibular plates from the same system from January 2015 to August 2019. The variables recorded were sex, age, diagnosis, radiotherapy, date of implantation, date of explantation or death of patient, size of mandibular defect, Jewer classification of defect, number of screws used, segments of bony reconstruction, screws per segment, plate exposure, plate breakage, and pseudarthrosis. The bridging plate group consisted of 41 patients, while the mandibular plate group consisted of 24 patients. The percentage of plate exposure was 17.07% for the bridging plate group and 4.17% for the mandibular plate group. Plate breakage was 0 in both groups. Pseudarthrosis was 4.17% in the mandibular plate group. In the bridging plate group, an anterolateral thigh flap covered all exposures. Of 7 plate exposures, 4 were found in a C defect. The complication rate of the investigated plates was lower than the complication rates of other plate systems.

Use of Kinesiography to Assess Mandibular Function Following Segmental Resection and Microvascular Reconstruction.

Mandibular reconstruction has attained adequate morphological outcomes. However, some patients encounter difficulties in oral function and limited mandibular movements. An objective: evaluation has seldom featured actual kinetic measurements after mandibular reconstruction.Thirty patients who underwent mandibular reconstruction using bony free flap were enrolled in the study. Twenty-two patients were recruited after surgery and compared to a control group of 8 healthy subjects; 8 patients underwent both pre and postoperative evaluations. For each patient, a kinesiographic scan was obtained, recording maximum mouth opening, maximal laterality, and maximal protrusion.All postoperative kinesiographic evaluations were performed at least 6 months after surgery to ensure complete healing. In the first group of 22 patients, all measured movements were less than those of healthy controls, in particular maximum mouth opening. In the second study group (pre and postoperative evaluation), the postsurgical values did not achieve the control ones, but were no less than the preoperative values, granting adequate functional outcomes.The kinesiograph appears useful for objectively recording the functional outcomes in patients who have undergone mandibular reconstruction. The postoperative jaw movements were acceptable, ensuring a sufficient functional recovery.

Comparative osteoradionecrosis rates in bony reconstructions for head and neck malignancy

Bony free flaps are used to reconstruct head and neck cancer defects. The most commonly used flaps are the free fibula flap and the deep circumflex iliac artery (DCIA) flap. Radiotherapy may be given post-operatively to prevent cancer recurrence. This radiotherapy can, however, destroy the bone; a complication termed osteoradionecrosis (ORN). Although there have been studies comparing free fibula and DCIA flaps in terms of success rates and complications, few have assessed the incidence of ORN in both groups. A retrospective cohort study was conducted involving patients from Royal Melbourne Hospital and St Vincent's Hospital Melbourne who had either a free fibula or DCIA flap for head and neck cancer reconstruction in the past 10 years. Data collected included demographic, operative, and postoperative data. Analysis was performed using Statistical Package for Social Sciences and Microsoft Excel, utilising t-tests, chi-square tests and logistic regression analyses. A total of 154 patients were identified. Of these patients, 127 had free fibula flaps and 27 had free DCIA flaps. Twelve patients had ORN post-op, 10 had free fibula flaps, and 2 had free DCIA flaps. No statistically significant difference was found between the ORN rates in free fibula flaps and free DCIA flaps. Rates of ORN incidence should not be a major consideration in preoperative planning of free flaps for mandibular reconstruction as both fibula and DCIA free flaps are comparable.

Advances in computer-aided design for bony free-flap reconstruction.

The current article reviews the most recent publications of computer-assisted reconstruction using bony free flaps, emphasizing on comparative reports using these novel techniques. Computer-aided reconstruction has shown some benefits in comparison with traditional techniques and some of the perceived limitations are currently being addressed in the latest reports. Still, there is a lack of appropriate comparative studies and unblinded measurements to establish solid conclusions. Despite the application of new technologies showed encouraging results, it is premature to state that the traditional technique should be replaced by the modern approaches.

3D printed models in mandibular reconstruction with bony free flaps

The aim of the study was to compare two types of mandible reconstructive operations with scapula and fibula free flaps: procedures with 3-D models from thermoplastic materials and conventional planning surgeries. 8 patients were treated due to an advanced oral cavity squamous cell carcinoma. In four patients with a mandibular defect, a physical 3-D model consisting of the reconstructed and unaffected sites was prepared for a reconstruction protocol. The 3-D models were designed based to high resolution CT scans. Assessment of comparative functionality (stability of junction, mobility, mastication ability) and cosmetics was examined in both groups, following a 8 weeks healing period with better results in group with 3D model. 3-D models for mandible and donor bones allow to obtain better functionality of restored mandible in comparison to the traditional method also significantly decreases time of the operation and allows to achieve the desired shape and esthetic effect within the 1/3 of the lower face.

Pre-programmed robotic osteotomies for fibula free flap mandible reconstruction: A preclinical investigation.

Bony free flap reconstruction of the facial skeleton remains a challenging area of reconstructive surgery. Despite technological advances that have aided planning and execution of these procedures, surgical inaccuracy is not insignificant. One source of error that has not been wholly addressed is that attributable to a human operator. In this study, we investigate the feasibility and accuracy of performing osteotomies robotically in pre-programmed fashion for fibula free flap mandible reconstruction as a method to reduce inaccuracies related to human error. A mandibular defect and corresponding free fibula flap reconstruction requiring six osteotomies were designed on a CAD platform. A methodology was developed to translate this virtual surgical plan data to a robot (KUKA, Augsburgs, Germany), which then executed osteotomies on three-dimensional (3D) printed fibula flaps with the aid of dynamic stereotactic navigation. Using high-resolution computed tomography, the osteotomized segments were compared to the virtually planned segments in order to measure linear and angular accuracy. A total of 18 robotic osteotomies were performed on three 3D printed fibulas. Compared to the virtual preoperative plan, the average linear variation of the osteotomized segments was 1.3 ± 0.4 mm, and the average angular variation was 4.2 ± 1.7°. This preclinical study demonstrates the feasibility of pre-programmed robotic osteotomies for free fibula flap mandible reconstruction. Preliminarily, this method exhibits high degrees of linear and angular accuracy, and may be of utility in the development of techniques to further improve surgical accuracy.

The relative survival of composite free flaps in head and neck reconstruction

Various composite free flaps are available for reconstruction of bony head and neck defects. The aim of this study was to compare the relative success of four different bony free flaps. One hundred and seventy-three microvascular composite free flap reconstructions for bony defects of the head and neck region, performed over the period April 2008 to April 2015, were reviewed retrospectively. The type of free flap, indication for free flap reconstruction, age at harvesting of the free flap, use of pre- or postoperative radiotherapy, and free flap failure were examined. For the 173 reconstructions performed, 84 fibula free flaps, 43 iliac crest free flaps, 32 scapula free flaps, and 14 osteocutaneous radial forearm free flaps were harvested. The mean age at time of harvesting was 40.7 years for the iliac crest, 57.3 years for the fibula, 64.3 years for the scapula, and 73.9 years for the osteocutaneous radial forearm free flap. No complete free flap failure was documented, nor was there any failure of bony segments. Three fibula flap skin paddles did not survive. No returns to theatre for salvage were required. This study showed no difference in the survival rates of these four types of composite free flap.

Predictive factors for perioperative blood transfusion in neck dissection.

There is growing interest in reducing the exposure of patients to allogeneic blood transfusions by lowering preoperative cross-matched blood ordering and adopting alternative practices, such as autologous blood donations. Our aim was to investigate the predictors for perioperative blood transfusion (PBT) in head and neck cancer patients undergoing neck dissection (ND). Retrospective cohort study. Retrospective observational study. All patients who underwent ND between January 2011 and August 2014. The primary outcome measure was PBT. Predictors tested included: gender, age, American Society of Anesthesiologists comorbidity score, Charlson comorbidity index, preoperative hemoglobin level, head and neck primary tumor location, tumor and nodal staging, side and laterality of ND, central versus lateral ND, elective ND, preoperative chemotherapy/radiotherapy/I(131) therapy, history of previous ND, other surgical procedures in addition to the ND, bone resection, use and type of reconstruction, and the use of bony free flap reconstruction. Twenty-one preoperative and operative variables were tested for an association with PBT using univariate and multivariate analyses. Multivariate analysis found only the following three predictors to be significantly associated with PBT in patients undergoing ND: low preoperative hemoglobin level, advanced N stage, and concurrent reconstructive surgery. Evaluation of specific risk factors for predicting the need for PBT prior to neck dissection may be helpful in identifying the head and neck cancer patients in whom preoperative ordering of cross-matched blood is required or who could benefit from alternative means, such as preoperative autologous blood donation. 4.

Osseointegrated implant-based dental rehabilitation in head and neck reconstruction patients.

Dental restoration is an integral part of head and neck cancer reconstruction. We evaluated the success rate of osseointegrated implants in patients with head and neck cancer, comparing outcomes between implants placed in fibula free flaps to those placed in native mandibular and maxillary bone. A total of 1132 implants were placed in 246 patients. The overall implant loss rate was 3.7% and was higher in fibula flaps (8.2%) compared to the native mandible (2.6%) and maxilla (2.2%), although these differences did not reach statistical significance (p = .059 and p = .053, respectively). The failure rate was 8.0% for implants placed after radiation and 3.6% in patients who did not undergo radiation (p = .097). Osteoradionecrosis (ORN) occurred in 19 patients (7.7%) after implant placement, and tobacco use was found to be a risk factor (p = .027). Osseointegrated implants are reliable in patients with head and neck cancer, including those undergoing bony free flap reconstruction. © 2015 Wiley Periodicals, Inc. Head Neck 38: E321-E327, 2016.

Is immediate bony microsurgical reconstruction after head and neck tumor ablation associated with a higher rate of local recurrence?

The purpose of this retrospective study was to examine the possible effect of immediate bony microvascular free flap reconstruction of mandibular defects after radical tumor resection of oral squamous cell carcinoma (OSCC) on the rate of local relapse. Our own data regarding recurrence rates for 1-step immediate reconstruction were compared to the published recurrence rates of 2-step reconstructions. A total of 21 patients (aged 45–77 years) with OSCC who underwent a primary surgical therapy with subsequent immediate bony microvascular free flap reconstruction of mandibular defects were followed up for 18–38 months. Four local relapses (19%) were recorded, all in patients with initial tumor stage of T4. Although intraoperative histological findings were R0 in all 21 cases, definitive histology later detected R1 status in the resected bone in 2 cases (10%). Immediate bony free flap reconstruction of mandibular defects after radical surgical resection of OSCC does not seem to increase the risk of local recurrence nor affect patient survival when compared with the 2-step surgical approach.