Mandibular Reconstruction: Are Two Flaps Better Than One?

Abstract

This study compared the combined iliac and ulnar forearm flaps with the osteomusculocutaneous fibular free flap for mandibular reconstruction. A retrospective study of 40 patients who had oromandibular reconstruction was performed, of whom 23 patients had a combined iliac crest without skin and ulnar forearm free flap. Seventeen patients had an osteomusculocutaneous free fibular flap. Ten women and 30 men with a mean age of 57.5 years comprised this study population. Ninety percent of the cases were squamous cell carcinoma (55%, T4), of which 11% were recurrent tumors. Anterolateral mandibular defects constituted 52.9% of the fibular reconstructions and 60.9% accounted for the iliac/ulnar reconstructions. The mean bone gaps were 8.79 cm and 8.95 cm respectively. Functional evaluation was based on the University of Washington Questionnaire through phone calls and personal communication. The mean hospital stay was 15.43 days and 10.09 days for the fibular and iliac/ulnar flaps respectively. The facial artery (64.7%) and facial vein (60%) were the main recipient vessels for the fibular reconstructions whereas the external carotid artery (95.6%) and the internal jugular vein (66.7%) were the main recipient vessels for the iliac/ulnar reconstruction. Overall flap survival was 96.8% (100% of fibular flaps and 95.65% of iliac/ulnar flaps). Two flaps were lost in the iliac/ulnar series because of unsalvageable venous thrombosis. Local complications for the iliac/ulnar flaps were 30.4% but were 5.9% for the fibular reconstructions. Function such as speech, swallowing, and chewing were notably better in the fibular than the iliac/ulnar group in 23 of the patients tested. The cosmetic acceptance of 77.8% of the fibular flaps was judged to be excellent and good, whereas 71.4% of the iliac/ulnar flaps were rated good. It appears that within this study population the free osteomusculocutaneous fibular flap had fewer local complications and a higher flap survival rate than the combined iliac/ulnar forearm flaps. Overall functional outcome was also improved. The use of the double flap may be appropriate in massive oromandibular defects, but may be less appropriate in more modest functional reconstructions of mandibular defects.

Chimeric vs composite flaps for mandible reconstruction

“…In later large series of patients undergoing head and neck reconstruction with 2 free flaps, an unacceptably high rate of flap loss was noted in flaps connected in series, and the authors advised against this technique, opting instead to anastomose each flap to a separate recipient vessel or a side branch of the other flap pedicle, in a “fabricated” chimeric fashion . Although these later studies showed success with 2 free flaps, others have still suggested caution against the routine application of this technique by showing a higher rate of complications and flap loss in defects of similar size reconstructed with 2 flaps vs 1 flap …”

Surgical Modalities in Gunshot Wounds of the Face

“…17,18 The free osteocutaneous fibula flap has advantages such as its ease of application to the oral region due to its thin and flexible structure, its high flap survival rate, and its potential for multiple osteotomies because it can include about 25 cm of bony tissue to the flap. 19 In 5 cases, we were able to successfully reconstruct the 13-cm length of mandibular bony and accompanying soft tissue defects caused by a GSW using the free osteocutaneous fibular flap. Circulation insufficiency-induced necrosis occurred in 1 case on a large skin island of the fibula flap that was intended for soft tissue repair including the left oral commissure.…”

Outcomes after free tissue transfer for composite oral cavity resections involving skin

“…Alternatively, it can be used either with a second free flap or with a local or regional pedicled flap. Although there has been reported success of the use of double free flaps in these advanced cases, one study by Gabr et al showed that single flap use had a lower complication rate when compared with cases utilizing 2 free flaps. Furthermore, these patients have a return to only modest functional outcomes .…”