Free Flap Surgery Viable Choice for Mandible Reconstruction

What are the current indications and demographics for the use of free-flap reconstruction of the jaws?

Background: Free vascularized bone grafts were initially used to repair compound leg defects. Since then, there has been an exponential increase in the application of vascularized free tissue transfer to facilitate reconstruction of post-ablative head and neck defects. Today, surgical technique advances allow for mandible resection and reconstruction with osseous free flaps for elective, nonmalignant, quality-of-life indications as well.

Study design: Retrospective chart review of 620 osseous free flaps on patients who underwent free-flap reconstruction of the jaws between December 1995 and December 2012 using vascularized bone-containing free tissue transfer.

Setting: Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles.

Synopsis: A total of 620 osseous free flaps were performed for 603 patients. The most common surgery indications were squamous cell carcinoma and osteoradionecrosis (ORN) of the mandible. Other indications included malignant tumors (80.8%), benign tumors (5%), and trauma/iatrogenic (14.2%). Seventeen patients required a second osseous free-flap reconstructive surgery. The incidence of surgeries being performed for nonmalignancy indications increased over the review span. There were no significant differences in flap failure, partial necrosis, length of hospital stay, peri-operative complications, or mortality between any surgery indications. The overall incidence of free-flap failure was 1.2%; all were fibula flaps. Fibula free flap was significantly associated with decreased incidence of minor and major perioperative complications. Patients 60 years and older had a significantly higher rate of major perioperative complications and required longer hospital stays. Only 80.8% of osseous free flaps were performed for the malignant tumor treatment; the number of osseous free flaps being performed for nonmalignancy indications in general, and for ORN in particular, increased.

Bottom line: Patients who undergo free-flap surgery for ORN do not have greater risks of 90-day peri-operative complications or differences in free-flap viability compared with patients who undergo free-flap reconstruction for other indications.

Citation: Zaghi S, Danesh J, Hendizadeh L, Nabili V, Blackwell KE. Changing indications for maxillomandibular reconstruction with osseous free flaps: a 17-year experience with 620 consecutive cases at UCLA and the impact of osteoradionecrosis. Laryngoscope. 2014;124:1329-1335.