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Twenty Years of Free Flap Mandible Reconstruction: Outcomes and Development of a Comprehensive Algorithm
Peter G. Cordeiro, Evan Matros.
Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Traditional mandible reconstruction algorithms have stressed the importance of osseus flaps; however a more comprehensive approach should account for location and extent of soft tissue structures resected. A rationale for osseus and non-osseus mandibular reconstruction is presented with analysis of functional and aesthetic outcomes.
Prospectively collected data of a single surgeon’s experience with mandible reconstruction over the past 20 years was reviewed. Demographic data, surgical indications, type of flap reconstruction, and outcomes were collected. The extent of the soft tissue defect was characterized by number of anatomic areas/zones removed. A classification system was derived based on both location and quantity of bone and soft tissues excised.
202 mandible defects were reconstructed using 211 free flaps from 1991-2010. Pathologic indications were squamous cell cancer 65%, sarcoma 13%, osteoradionecrosis 5%, ameloblastoma 4% and other 12%. 80% of cases underwent osseus reconstruction, 15% had soft tissue reconstruction only, and 4.5% required simultaneous soft tissue and osseus flaps. Osseus flaps included the fibula, radius, scapula, and iliac crest in 91%, 6.5%, 1.7% and .8% of cases respectively. The rectus abdominis flap was used in 87% of cases of a soft tissue flap alone. The radial forearm and fibula flaps were used together in 7/9 cases which required simultaneous osseus and soft tissue flaps. A reconstructive algorithm for flap selection based on bone defect location and quantity/location of soft tissue defect is presented (Table I). Osseus flaps had 1.66 osteotomies on average with autocondyle transplants in 31% of cases. 2% of flaps required re-explorations for flap salvage, with no complete flap losses. Partial/complete skin-island loss occurred in 5.9% of osteocutaneous fibula flaps requiring salvage with 3 radial forearm flaps and conservative management in 9 others. Compared to osteocutaneous flaps there was no complete or partial skin-island loss in any soft tissue flap (p<.05). A tight correlation was observed between use of soft tissue flaps and increased number of anatomic soft tissue zones resected (Figure 1). Rates of major and minor donor site complications were 3.5 and 7.5% respectively. Decreased results of speech, aesthetic and dietary outcomes were associated with anterior bony defects and an increased number of soft tissue zones excised. Median time to death for expired patients was 16.3 months. Median follow-up time for living patients is 6.7 years.
A novel algorithm for mandible reconstruction flap selection is proposed based on bone defect location and extent of soft tissue involvement. As a rule osseus reconstruction is preferred for all defects. For anterior defects rigidity provided by osseus flaps is mandatory. For posterior and lateral defects, increasing consideration should be given to soft tissue flaps, alone or in combination with osseus flaps, as the quantity of soft tissue excised increases.
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