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89th Annual Meeting Abstracts


Free Flap Reconstruction of Osteoradionecrosis of the Mandible: A 10-Year Review
Donald P. Baumann, MD, Matthew M. Hanasono, MD, Roman J. Skoracki, MD, Peirong Yu, MD.
MD Anderson Cancer Center, Houston, TX, USA.

Free Flap Reconstruction of Osteoradionecrosis of the Mandible: A 10-Year Review
Donald P. Baumann, MD, Matthew M. Hanasono, MD, Roman J. Skoracki, MD, Peirong Yu, MD.
Purpose: Osteoradionecrosis (ORN) of the mandible represents one of the most formidable challenges in head and neck reconstructive surgery, often requiring reconstruction of bone, mucosal lining and external skin. The purpose of this study was to evaluate the feasibility and outcomes of bone and soft tissue flap reconstructions of advanced ORN defects.
Methods: All cases involving free flap reconstruction for ORN of the mandible between 1998 and 2008 at the University of Texas M. D. Anderson Cancer Center were reviewed. Mandibular defects were classified as Type I- segmental bone loss with mucosal defect, Type II- segmental bone loss with combined mucosal/external skin defect, Type IIIa-posterior mandibular bone loss with mucosal defect, Type IIIb posterior mandibular bone loss with combined mucosal/external skin defect. Flap selection and outcomes were analyzed and evaluated by defect type.
Results: Seventy-four free flaps and 9 pedicle flaps were performed in 63 patients. The distribution of osteoradionecrotic wound defects included 13 Type I defects, 14 Type II defects, 12 Type IIIa defects, and 24 Type IIIb defects. The mean patient age was 61 years (range 29-88 years), mean radiation dose 66.5 Gy (range 59-76), and the mean interval from completion of radiation therapy to surgery was 4 years (range 1-14 years). All Type I defects underwent reconstruction with a single fibular osteocutaneous free flap (FFF). Type II defects were reconstructed with a chimeric FFF (n=5), a FFF with Pectoralis flap (n=4), a FFF with Anterolateral thigh flap (ALT) (n=4) or FFF with Radial forearm flap (RFF) (n=1). Type IIIa defects were reconstructed with a FFF (n=5), ALT flap (n=4) and VRAM flap (n=3). Type IIIb defects underwent reconstruction with a FFF (n=5), ALT (n=8), VRAM (n=3), FFF+ALT (n=4) and ALT with Pectoralis flap (n=3).
The overall complication rate was 19%, including 4 flap losses (5.8%) 2 peri-operative mortalities, 3 cervical infections, 2 orocutaneous fistulas and 1 cervical hematoma. Three secondary free flaps and one pedicled flap were required for salvage of the total flap losses. Complications were more commonly seen in patients with bone vs. soft tissue reconstruction (22% vs. 9%) and in through and through vs. mucosal defects (34% vs. 19%). The mean length of stay was 9 days (range 4-23 days). Overall, Thirty-five patients (55%) tolerated an oral diet without the need for tube feeding, 17 patents (27%) were required TF supplementation, and 12 patients 19% were TF dependent at the time of last follow-up.
Conclusions: Free flap reconstruction of advanced ORN defects can be safely performed in a variety of flap configurations. This simple classification may help guide the choice of flaps. In through and through posterior defects involving the condyle, a soft tissue flap may be preferable to a bone flap in an attempt to restore function and reduce postoperative complications.


 

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