Indications and Outcomes for Mandibular Reconstruction Using Sequential Bilateral Fibula Flaps
Evan Matros, MD, MMSc, Graham Schwarz, MD, Babak Mehrara, MD, Peter G. Cordeiro, MD, Jospeh J. Disa, MD.
Memorial Sloan Kettering, NY, NY, USA.
A subset of patients with recurrent or second intraoral tumors will undergo both primary and secondary mandibular reconstruction using bilateral fibula flaps. The objective of this report is to describe indications and outcomes for these patients.
Retrospective analysis of a prospectively collected database was performed. Patient charts were reviewed to identify demographics, operative features, complications and functional outcomes.
Over the past 20 years 357 patients with head and neck cancers had fibula flap reconstructions performed for mandibular defects at our institution. Ten of these patients underwent a second mandibular reconstruction for recurrent or second oral tumors with a second fibula flap. The mean time between flaps was 20 months. Most patients were male with squamous cell pathology. Bone gap size was similar after both resections measuring 8 cm. Eighty percent of primary resections removed either lateral or hemi-mandible segments whereas 80% of secondary defects included the mandibular arch (p=.070). Compared to primary resections, secondary soft tissue defects were larger and more likely to require fibula flaps with extended skin paddles or a pectoralis muscle flap to achieve defect closure (p=.051). There were no flap failures and low complication rates after both reconstructions. Functional evaluation showed a significantly greater dependency on supplemental enteral nutrition via percutaneous tubes after the second resection (p=.033). Average survival time for expired patients was 15.7 (n=5) months after the second resection. The mean follow-up time for living patients is 25 months (n=5).
The principal indication for second fibular flaps in mandibular reconstruction is central segment defects where lack of rigid support leads to severe functional problems and cosmetic deformity. For lateral and hemi-mandible resections, the large soft tissue deficits associated with secondary extirpation may be better served by reconstruction with soft tissue free flaps which fill dead space and more reliably achieve defect closure. Although second osseous free flaps are technically feasible and can be performed safely, a significant decline in oropharyngeal function is seen afterwards. Goals of surgery and quality of life need to be addressed prior to considering mandibular reconstruction with a second fibula flap.