The fate of the osteotomized free radial forearm osteocutaneous flap in mandible reconstruction

Rates of bone reabsorption and union in mandibular reconstruction using the osteocutaneous radial forearm free flap

BACKGROUND

Historical concerns over bone resorption and malunion of the osteocutaneous radial forearm free flap (OCRFFF) limited its widespread adoption for head and neck reconstruction, despite lack of outcomes data evaluating this notion.

METHODS

A retrospective cohort study was performed including patients 18 years or older who underwent reconstruction of the mandible using an OCRFFF. Linear modeling and logistic regression were used to evaluate the change in bone volume and union over time.

RESULTS

One hundred and twenty-one patients were included in the study. A mixed effects linear model incorporating age, sex, treatment type, and number of bone segments did not demonstrate a significant loss of bone volume over time. A logistic regression model identified lack of adjuvant treatment and time to be significantly associated with complete union.

CONCLUSION

This study supports that the OCRFFF is a stable form of osseus reconstruction for defects of the head and neck.

Osteocutaneous free flaps for mandibular reconstruction: systematic review of their frequency of use and a preliminary quality of life comparison

OBJECTIVES

To determine whether the fibula free flap is the most frequently used osteocutaneous flap for mandible reconstruction, and whether it provides quality of life, depression and anxiety advantages.

METHODS

A systematic review of the public Medline database was conducted. Thirteen patients who underwent mandibular reconstruction at our hospital centre completed questionnaires to evaluate quality of life, depression and anxiety outcomes.

RESULTS

The most frequently used free flaps are those of the fibula (n = 982), radial forearm (n = 201), iliac crest (n = 113), subscapular system (n = 50) and rib-serratus (n = 7). In our patient population, there was a trend towards a better quality of life in those with a fibula free flap. However, patients in this group were significantly younger than patients with other flap types (p = 0.025). Patients with a subscapular system free flap were more depressed (p = 0.031); however, they had large through-and-through defects.

CONCLUSION

The flap used most frequently in the literature is the fibula free flap. Comparative quality of life data are lacking, and homogeneous populations should be used to reach significant conclusions.

Reconstruction of mandibular defects

Defects requiring reconstruction in the mandible are commonly encountered and may result from resection of benign or malignant lesions, trauma, or osteoradionecrosis. Mandibular defects can be classified according to location and extent, as well as involvement of mucosa, skin, and tongue. Vascularized bone flaps, in general, provide the best functional and aesthetic outcome, with the fibula flap remaining the gold standard for mandible reconstruction. In this review, we discuss classification and approach to reconstruction of mandibular defects. We also elaborate upon four commonly used free osteocutaneous flaps, inclusive of fibula, iliac crest, scapula, and radial forearm. Finally, we discuss indications and use of osseointegrated implants as well as recent advances in mandibular reconstruction.

Single osteotomized iliac crest free flap in anterior mandible reconstruction

While the iliac crest flap provides a natural contour for the lateral segment of the mandible, for the anterior segment en bloc, the use of the iliac graft, even harvested in a V shape, fails to yield a three-dimensional natural-shaped reconstruction. In this report, we present our experience with reconstruction of the anterior segment of the mandible using a single osteotomized free iliac crest flap in 5 patients. The study comprised 4 male patients and 1 female patient, their ages ranging between 34-82 years. In all patients, composite iliac osteomusculocutaneous flaps were harvested based on the deep circumflex iliac artery in the standard manner, and the bony segment of the flap was divided into two segments, performing a single osteotomy. The fixation of bone segments was performed in new positions, sliding the segments in different planes to provide the original shape of the resected mandible segment, and in a manner appropriate to the defect. The overall flap success rate was 100%. In no cases were wound infections or hematomas observed. X-rays showed bone healing without resorption. In conclusion, the use of a single osteotomy for an iliac crest flap in the reconstruction of the anterior segment of the mandible is a simple and safe procedure, and provides a natural and acceptable jaw appearance. The risk of devascularization is quite low when compared with the multiple osteotomy procedure, and it does not need to be fixed with complex devices such as reconstruction plates or external fixators.

Choice of osseous and osteocutaneous flaps for mandibular reconstruction

Microvascular free flap transfer currently represents one of the most popular methods for mandibular reconstruction. With the various free flap options now available, there is a general consensus that no single kind of osseous or osteocutaneous flap can resolve the entire spectrum of mandibular defects. A suitable flap, therefore, should be selected according to the specific type of bone and soft tissue defect. We have developed an algorithm for mandibular reconstruction, in which the bony defect is termed as either "lateral" or "anterior" and the soft-tissue defect is classified as "none," "skin or mucosal," or "through-and-through." For proper flap selection, the bony defect condition should be considered first, followed by the soft-tissue defect condition. When the bony defect is "lateral" and the soft tissue is not defective, the ilium is the best choice. When the bony defect is "lateral" and a small "skin or mucosal" soft-tissue defect is present, the fibula represents the optimal choice. When the bony defect is "lateral" and an extensive "skin or mucosal" or "through-and-through" soft-tissue defect exists, the scapula should be selected. When the bony defect is "anterior," the fibula should always be selected. However, when an "anterior" bone defect also displays an "extensive" or "through-and-through" soft-tissue defect, the fibula should be used with other soft-tissue flaps. Flaps such as a forearm flap, anterior thigh flap, or rectus abdominis musculocutaneous flap are suitable, depending on the size of the soft-tissue defect.

Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions

OBJECTIVES/HYPOTHESIS

The radial forearm osteocutaneous free flap is an excellent reconstructive modality for oromandibular and maxillofacial reconstruction in certain well-defined circumstances. The initial concern over donor site morbidity and the ability of the bone to reconstruct mandibular defects have led to only a few published series.

STUDY DESIGN

Retrospective study of the experience of two tertiary medical centers with radial forearm osteocutaneous free flap.

METHODS

Retrospectively, 52 patients were studied who underwent radial forearm osteocutaneous free flap reconstruction for cancer (49 cases) and trauma (3 cases). Bone length and skin paddle harvested, general morbidity (hematoma, wound infection, and dehiscence), recipient site morbidity (nonunion of neomandible, flap failure, and bone or plate exposure), and donor site morbidity (radius bone fracture, plate exposure, and skin graft failure) were reviewed.

RESULTS

The average skin paddle size was 55.1 cm (range, 15-112 cm). The average radius bone harvest length was 6.3 cm (range, 2.5-11 cm). Donor site complications included tendon exposure (3 cases), radius bone fracture (1 case), and exposure of the plate (0). Recipient site complications included nonunion of the mandible (4), exposed mandible (1), exposed mandibular plates (2), exposed maxillary plates or bone (0), venous compromise (1), and flap failure (1). Two patients had perioperative deaths.

CONCLUSION

Radial forearm osteocutaneous free flap is a valuable and viable option for oromandibular and maxillofacial reconstruction.

Oromandibular reconstruction after cancer resection

The goals of this article are (1) to summarize the epidemiology of oromandibular cancer, (2) to describe the classification of defects after cancer extirpation, and (3) to discuss the principles of and state of the art in reconstruction of the oromandibular defect. The four commonly used flaps (fibula flap, radial forearm flap, scapula flap, and the iliac crest) and their key characteristics are summarized. Finally, some future speculations are entertained.

Free-flap mandibular reconstruction: a 10-year follow-up study

Free-flap reconstruction of oncologic mandibular defects has become the modern standard of care. However, no previous studies have established the long-term results of such reconstructions. The objective of this study was to review functional and aesthetic outcomes in patients a decade after free-flap mandibular reconstruction.A single surgeon's experience with free-flap reconstruction of the mandible was retrospectively reviewed. Eighty-two consecutive patients who underwent reconstruction from January of 1987 to December of 1990 were identified. Of the 34 patients still alive, 20 agreed to participate (response rate, 59 percent). To assess complications and functional outcome, patients were interviewed using validated questions and questions developed specifically for the study. Aesthetic outcome was judged by two independent observers. Panorex radiographs were obtained to assess bone resorption. Bone height was measured at standardized locations on the body, ramus, and symphysis and compared with the immediate postoperative Panorex radiographs. Differences in Panorex magnification were adjusted for by comparison of miniplate measurements. Mean length of follow-up was 11 years. Mean patient age at the time of the study was 48 years. Nineteen of 20 patients had malignant disease, one of whom had a local recurrence during the follow-up period. Two patients received radiation therapy preoperatively and 13 postoperatively. Mean length of mandible resection was 13 cm. Defect types were as follows (Jewer's classification): 12 L, 4 H, 3 LC, and 1 LCL. All flaps survived. At 10-year follow-up, aesthetic outcome was judged to be excellent in 55 percent of patients, good in 20 percent, fair in 15 percent, and poor in 10 percent. The aesthetic results were remarkably stable over time. Slight accentuation of subtle postoperative asymmetry became evident as facial aging progressed. Dental rehabilitation in the study group included five patients with osteointegrated implants and seven with conventional dentures. Seventy percent of patients reported a regular diet. The remainder required a soft diet. Food tolerance was good, as rated by the List Scale (mean score, 77 percent). Seventeen patients had easily intelligible speech, whereas three were intelligible with effort. At the midbody of the mandible, 92 percent of the postoperative bone height was preserved; at the midramus, 93 percent was maintained; and at the symphysis, 92 percent remained. In several patients, there was greater age-related bone loss from the residual native mandible compared with the reconstructed site. One patient developed an orocutaneous fistula following postoperative radiation therapy. Nine patients had miniplates removed, either because of plate problems or to allow implant placement. There were no cases of osteoradionecrosis, bone fracture, or miniplate fracture. There was no significant long-term disability related to the donor site.Free-flap reconstruction of the mandible provides excellent functional and aesthetic results that remain stable over time. Bone resorption is surprisingly minimal, even in the face of postoperative radiation therapy. The majority of patients are able to tolerate a regular diet and to either wear dentures or acquire osteointegrated implants. Acceptable speech and appearance are restored and continue to be a source of patient satisfaction at least a decade after surgery.

Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases

For this article, 178 consecutive cases of mandibular reconstruction using microvascular free flaps and performed from 1979 to 1997 were studied. The purpose of this report is to compare flap success rates, complications, and aesthetic and functional results. The ages of the 131 men and 47 women ranged from 13 to 85 years, with an average of 55 years. Donor sites included the rib (11 cases), radius (one case), ilium (36 cases), scapula (51 cases), fibula (34 cases), and soft-tissue flaps with implant (45 cases). Complications included total flap necrosis, partial flap necrosis, major fistula formation, and minor fistula formation. The rate of total flap necrosis involving the ilium and fibula was significantly higher than that of all other materials combined (p < 0.05). The overall rate of implant plate removal, which resulted from the exposure or fracture of the plate, was 35.6 percent (16 of 45 cases). Each mandibular defect was classified by the extent of the bony defect and by the extent of the soft-tissue defect. The extent of the mandibular bony defect was classified according to the HCL method of Jewer et al. The extent of the soft-tissue defect was classified into four groups: none, skin, mucosal, and through-and-through. According to these classifications, functional and aesthetic assessments of deglutition and contour were performed on 115 subjects, and speech was evaluated in 110. To evaluate the postoperative results, points were assigned to each assessment of deglutition, speech, and mandibular contour. Statistical analysis between pairs of bone-defect groups revealed that there was no significant difference in each category. Regarding deglutition, statistical analysis between pairs of soft-tissue-defect groups revealed there were significant differences (p < 0.05) between the none and the mucosal groups and also between the none and the through-and-through groups. Regarding speech, there was a significant difference (p < 0.05) between the none and the through-and-through groups. Regarding contour, there were significant differences (p < 0.01) between the none and the through-and-through groups and between the mucosal and the through-and-through groups. The points given for each function, depending on the reconstruction material, revealed that there was no significant difference between pairs of material groups. From this prospective study, the authors have developed an algorithm for oromandibular reconstruction. When the bony defect is lateral, the ilium, fibula, or scapula should be chosen as the donor site, depending on the extent of the soft-tissue defect. When the bony defect is anterior, the fibula is always the best choice. When the soft-tissue defect is extensive or through-and-through with an anterior bony defect, the fibula should be used with other soft-tissue flaps.

Oromandibular reconstruction with the radial-forearm osteocutaneous flap: experience with 60 consecutive cases

One of the more difficult problems in reconstructive surgery of the head and neck is replacement of bone and soft tissue lost because of injury, osteomyelitis, or malignancy. The radial-forearm osteocutaneous flap is an accepted choice for oromandibular reconstruction. This study was undertaken to review one center's experience with 60 consecutive cases of oromandibular reconstruction with the radial-forearm osteocutaneous flap. Records of the 38 men and 22 women (mean age, 60 years; range, 26 to 86 years) were reviewed for tumor location, defect and bone length, flap failure rate, recipient- and donor-site complications, length of surgery, and hospital stay. Cancer resection was the reason for 97 percent of reconstructions; 33 percent of flaps were used to reconstruct a lateral defect of the mandible, 40 percent a lateral-central defect, and 27 percent a lateral-central-lateral defect. Mean skin flap size was 55 cm2 (range, 15 to 117 cm2) and mean bone length, 9.4 cm (range, 5 to 14 cm). The microvascular success rate was 98.3 percent. Complications included fracture of the donor radius (15 percent), nonunion of the mandible (5 percent), and hematoma (8.3 percent). These results are comparable to results reported in the literature with other radial forearm flaps. The free radial osteocutaneous flap is a safe and reliable choice for mandibular reconstruction. It offers sufficient bone to reconstruct large defects and can provide adequate pedicle length for vessel anastomosis to the contralateral side of the neck. The above attributes make the radial forearm osteocutaneous flap one of the "first line" flap choices for oromandibular reconstruction.