Vascularized Bone vs. Fasciocutaneous Free Flaps for Mandibular Reconstruction: A Comparison of Outcomes and Complications
Patrick A. Gerety, MD, Marten N. Basta, BA, Gregory Epps, BA, John P. Fischer, MD, Jonas Nelson, MD, Suhail K. Kanchwala, MD, David W. Low, MD, Liza C. Wu, MD.
University of Pennsylvania, Philadelphia, PA, USA.
Mandibular reconstruction has been revolutionized by the use of free tissue transfer, but controversy remains concerning the algorithm for bony versus soft tissue reconstruction.
A retrospective review identified all patients undergoing free flaps for mandibular defects from 1/1/2005 - 6/1/2013. Univariate analysis of patient and operative factors identified significant associations with major surgical complications. Subsequent multivariate regression was performed to determine if there were independent predictors of complications by flap selection.
111 patients were identified (59 fibula, 52 soft tissue). Fibula patients were younger (<45 years=22.0% vs. 4%, p=0005), had more post-traumatic defects (9% vs. 0%, p=0.059), and underwent delayed reconstruction more commonly (14% vs. 2%, p=0.034). Soft tissue patients had higher rates of cardiovascular disease (69% vs. 37%, p=0.001) and squamous cell carcinoma (89% vs. 43%, p<0.0001). Fibula reconstructions were for larger defects (hemimandibulectomy=27% vs. 21%, p=0.034) and involved anterior/central defects (42.3% vs 33.4%, p=0.065)
Major surgical complication rate was 41% for fibula and 6% for soft tissue (p<0.0001). Flap complication rate was higher for fibula (36% vs 4%, p<0.0001). Soft tissue patients were more likely to be discharged with a PEG (61% vs. 48%, p=0.01) and a tracheostomy (94% vs. 77%, p=0.02). Multivariate regression demonstrated that use of fibula was an independent risk factor for major surgical complications (OR=5.96, p=0.04).
Fibula flaps were used in younger, healthier patients but were independently associated with worse outcomes. Soft tissue flaps have a favorable safety profile which reinforces their use in older, comorbid oncologic patients.
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