The Free Vascularized Flap and the Flap Plate Options: Comparative Results of Reconstruction of Lateral Mandibular Defects

Abstract

Objectives/Hypothesis: Reconstruction of the mandible and oral cavity after segmental resection is a challenging surgical problem. Although osteocutaneous free flaps are generally accepted to be optimal for reconstruction of anterior defects, the need for bony reconstruction for a pure lateral mandibular defect remains controversial. Study Design: A retrospective study. Methods: A retrospective comparative study of short-and long-term outcomes of three different reconstruction techniques for lateral defects was performed. In total, 57 patients were included, of whom 27 had a plate and pedicled pectoralis major myocutaneous flap (PMMF group), 16 had a plate and free radial forearm flap (FRFF group), and 14 had an osteocutaneous free flap. Functionality, flap failure, and complications were scored. Results: Plates had to be removed in 7 of the 27 patients in the PMMF group and 2 of the 16 in the FRFF group; none of the 14 osteocutaneous free flaps failed. The difference was of borderline statistical significance (P ‫؍‬ .055). Longterm functional outcome revealed no statistically significant difference in oral deglutition (P ‫؍‬ .76) or in facial contour (P ‫؍‬ .36). Oral continence was significantly better in patients in the FRFF group (88%) as compared with the PMMF group (52%) or the osteocutaneous free flap group (43%) (P ‫؍‬ .02). On the other hand, the results for speech favored the osteocutaneous free flap group; 13 of 14 patients (92.9%) had a normal score compared with 12 of 16 patients (75%) in the FRFF group and 17 of 27 (63%) in the PMMF group. However, this represented a borderline statistically significant result (P ‫؍‬ .06). Conclusions: For lateral mandibular defects, the osteocutaneous free flap is reliable and durable in the long term. However, in a selected group of patients either of the two flapplate options is a viable reconstructive option. Key Words: Lateral mandibular defect, osteocutaneous free flap, flap and plate.

Reconstruction of lateral through and through oro‐mandibular defects following oncological resections

“…The use of a titanium plate with a soft tissue flap has been widely discussed. 16,17 The high rate of exposure, especially with through-andthrough defects and after radiation therapy, limits its application to small lateral and posterior mandibular defects, and only when a free bone-containing flap cannot be used. 18 In these cases, in order to limit exposure, fractures, and other plate-related complications, it is crucial to surround the plate with a large amount of revascularized tissue, thereby obliterating any dead space and ensuring adequate separation between the oral cavity, plate, and skin.…”

Asymptomatic Deep Peroneal Vein Thrombosis During Free Fibula Flap Harvest

“…16 However, L and H defects reconstructed with soft tissue alone cause the mandible to drift toward the resected side, leading to restriction to a soft diet and change in appearance. 22 Ideal reconstruction follows the premise of replacing like with like; vascularized bone grafts provide the best functional and aesthetic results. However, in settings where the medical condition of the patient, the anatomy, or the intraoperative findings of peroneal thrombus prevent a free fibula f lap, an alternative method is needed.…”

Prognosis as a determinant of free flap utilization for reconstruction of the lateral mandibular defect

“…2,4,5,7,11 Comparing 3 different reconstruction techniques for lateral mandibular defects (plate and pectoralis flap, plate and RFFF, and osteocutaneous flap), Shpitzer et al 2 reported that plates had to be removed in 7 of the 27 patients in the pectoralis flap group and 2 of the 16 patients in the FRFF group. None of the 14 osteocutaneous free flaps failed.…”

“…Delayed reconstructive failure secondary to plate exposure or plate fracture has been reported to be between 5% and 46%. 2,[4][5][6][7] The use of an osteocutaneous free flap, in particular the osteocutaneous radial forearm free flap, likely reduces the risk of plate complication and offers the advantage of a large skin paddle that can be used to reconstruct nearly any accompanying mucosal defect. 8 The fibular osteocutaneous free flap offers the advantage that the cross-sectional area of the fibula approximates the cross-sectional area of the midbody of the mandible and is ideally suited for placement of osseointegrated implants for dental rehabilitation.…”