Hardware Removal after Osseous Free Flap Reconstruction

Abstract

Objective Identifying risk factors for hardware removal in patients undergoing mandibular reconstruction with vascularized osseous free flaps remains a challenge. The purpose of this study is to identify potential risk factors, including osteocutaneous radial forearm versus fibular flap, for need for removal and to describe the fate of implanted hardware. Study Design Case series with chart review. Setting Academic tertiary care medical center. Subjects and Methods Two hundred thirteen patients undergoing 227 vascularized osseous mandibular reconstructions between the years 2004 and 2012. Data were compiled through a manual chart review, and patients incurring hardware removals were identified. Results Thirty-four of 213 evaluable vascularized osseous free flaps (16%) underwent surgical removal of hardware. The average length of time to removal was 16.2 months (median 10 months), with the majority of removals occurring within the first year. Osteocutaneous radial forearm free flaps (OCRFFF) incurred a slightly higher percentage of hardware removals (9.9%) compared to fibula flaps (6.1%). Partial removal was performed in 8 of 34 cases, and approximately 38% of these required additional surgery for removal. Conclusion Hardware removal was associated with continued tobacco use after mandibular reconstruction (P = .03). Removal of the supporting hardware most commonly occurs from infection or exposure in the first year. In the majority of cases the bone is well healed and the problem resolves with removal.

The use of the Radial Styloid in the Extended Osteocutaneous Radial Forearm Free Flap

“…Donor site complications were similarly low, including a single radius fracture in each series (incidence 0.45% to 0.6%) (3,9). Notably, recipient site hardware exposure was 16% to 17%, a value that is higher than typically reported for the fibula flap (16,17), but consistently reported for the OC-RFFF (9,15). This complication occurred in one of the six patients (16.7%) in the present study.…”

Predictors of plate extrusion in oromandibular free flap reconstruction

“…In our series, the use of one osteotomy was a significant predictor of plate extrusion and osteotomies were more commonly utilized in FFF versus STFF. However, other studies have not found osteotomies to be predictors of plate extrusion (Day et al, ; Knott et al, ). In addition, anterior mandibular reconstructions were associated with a significantly increased rate of plate extrusion when compared to lateral mandibular reconstructions.…”

“…Deficiencies in soft tissue coverage may be an important factor in the development of plate extrusion. Several authors have noted that hardware exposure occurred at a higher rate in patients who underwent osseocutaneous radial forearm free flaps (OCRFFF) versus fibular free flaps (FFF), and concluded that this was likely due to the smaller amount of soft tissue incorporated in the OCRFFF (Day et al, ; Dean et al, ; Virgin et al, ). The subscapular system of free flaps makes available considerable soft tissue bulk with excellent mobility of the soft tissue relative to the bony component and generally provides abundant soft tissue coverage of the reconstruction plate (Gibber et al, ; Urken et al, ; Yoo et al, ).…”

“…Preoperative or postoperative radiation was not a significant predictor of plate extrusion in our series. Reports have varied in regards to radiotherapy with some reviews finding an association (Liu, Cai, Zhang, Zhang, & Zhang, ; Maurer et al, ), while others have found no significant effect of radiation on plate extrusion and complications (Day et al, ; Futran, Urken, Buchbinder, Moscoso, & Biller, ; Militsakh et al, ; Nicholson et al, ; van Gemert et al, ).…”

Minimally Invasive Removal of Mandibular Hardware after Free Flap Reconstruction

“…3,4 In patients who have a chronic infection and/or fistula, the social and economic impact of a draining wound, with repeated clinic visits and hospital admissions, can be significant. This technique forgoes a large skin flap elevation and dissection in a scarred operative bed without increasing risk to the facial nerve or causing cosmetic deformity.…”