Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in postoperative infection and healing.

CLINICAL ARTICLE

Reconstruction for Osteoradionecrosis of the Mandible Superiority of Free Iliac Bone Flap to Fibula Flap in Postoperative Infection and Healing Shih-Heng Chen, MD,* Hung-Chi Chen, MD, PhD, FACS,Þ Shyue-Yih Horng, MD,þ Hao-Chih Tai, MD,þ Jung-Hsien Hsieh, MD,þ Eng-Kean Yeong, MD,þ Nai-Chen Cheng, MD,þ Thomas Mon-Hsian Hsieh, MD,þ Hsiung-Fei Chien, MD,þ and Yueh-Bih Tang, MD, PhDþ

Background: Osteoradionecrosis (ORN) of the mandible is not an uncommon complication after radiotherapy for head and neck cancers. Although definitive treatment has been confirmed as radical excision of the necrotic bone with simultaneous vascularized osteocutaneous f lap reconstruction, it remains a unique challenge. In this study, we compare our results of reconstruction with free iliac and fibula f laps in f lap survival, bony union, and postoperative complications. Patients and Methods: From 1986 to 2011, there were 153 mandibular ORN cases in our center that were treated with radical resection of the necrotic bone and reconstruction with either vascularized iliac (n = 108) or fibula f laps (n = 45). Data collected for analysis included patient demographics, f lap survival rate, postoperative infection rate, nonunion/malunion rate, mean hospital stay, and antibiotics use. Results: All patients healed eventually without recurrence of ORN. However, we observed difference in the complication rate between the iliac f lap group and fibula f lap group. In the group with iliac f lap reconstruction, patients required less days of hospital stay for intravenous antibiotics treatment postoperatively. The average days required for intravenous antibiotics in the iliac f lap group were 10.46 (2.28) versus 16.09 (3.88) days in the fibula group (P G 0.01). In the group with fibula f lap reconstruction, 9 (20.0%) patients had subsequent neck infection due to healing problem, compared to 8 (7.4%) patients in the iliac f lap group (P = 0.04). In the iliac f lap group, the nonunion and malunion rates were 4.6% and 2.8% respectively; whereas in the fibula group, the rates were 15.5% and 6.6%, respectively (P = 0.04 and 0.36, respectively). Conclusions: For ORN patients, vascularized iliac bone f lap provides more reliable results compared to fibula f lap. The merits of vascularized iliac f lap include the following: (1) its natural curve mimics the shape of mandible and does not need osteotomy; (2) it offers more volume of bone that matches better to the native mandible to allow later osteointegration as well as faster bony union, due to the nature of being a membranous bone; and (3) it carries more abundant soft tissue to obliterate possible dead space. The only disadvantages are short pedicle and requiring special management of skin paddle, which can be overcome by training in microsurgery.

Received April 14, 2014, and accepted for publication, after revision, April 24, 2014. From the *Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY; †Department of Plastic Surgery, China Medical University Hospital, Taichung City; and ‡Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Yueh-Bih Tang, MD, PhD, Department of Plastic Surgery, National Taiwan University Hospital, 13F, No. 122, Sec. 2, Zhongshan North Rd, Zhongshan District, Taipei City 10449, Taiwan, Republic of China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-S018 DOI: 10.1097/SAP.0000000000000270

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Key Words: osteoradionecrosis, mandible, iliac bone flap, fibula flap (Ann Plast Surg 2014;73: S18YS26)

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steoradionecrosis (ORN) of the mandible is not infrequently seen in patients who have undergone radiotherapy1 of headand-neck region and can cause progressive morbidities.2,3 In Chinese descendants, nasopharyngeal carcinomas have higher prevalence rate, and ORN after radiotherapy is not uncommon. Other diseases that may require radiotherapy in the head and neck region (Table 1) include tonsillar cancer, tongue cancer, gingival cancer, buccal cancer, and parotid malignancies.1,4

Symptoms and Signs Symptoms of ORN2,3 may commence with toothache where the teeth were not removed and properly treated before radiotherapy. With the progression of the disease, redness and pain at the affected area may bother the patient with variable time interval after radiotherapy. The symptoms usually lead the patients to dentists or ENT physicians. Once the diseased teeth are loosened and need to be removed, the teeth extraction wound would never heal and would enlarge gradually, rendering infection of the mandible. If not contraindicated, the patients were often referred to hyperbaric oxygen (HBO) therapy.2Y5 However, HBO rarely cures the disease. Therefore, it is not uncommon that the patients are finally referred to plastic surgeons in a later stage of the ORN, with exposed bone (either intraorally or extraorally), purulent discharge with foul odor, or even orocutaneous fistulae (Fig. 1). Sometimes, ORN can present as a pathologic fracture (Fig. 2) with intractable pain.

Pathophysiology Irradiation causes inf lammation and endarteritis of the affected tissue, including the mandible, periosteum, and overlying soft tissue, and leads to thrombosis, hypovascularity, and tissue hypoxia. Both irradiation and hypoxia can further cause cellular death progressively. Eventually, the radiated bed is hypocellular and devoid of fibroblasts, osteoblasts, and undifferentiated osteocompetent cells. Clinically, the irradiated skin becomes atrophic, edematous, hypopigmented or sometimes hyperpigmented, and dry. The oral mucosa is fibrotic with decreased mucus production. Wound healing is affected because of hypocellularity of the wound bed and local hypoxia due to endarteritis of the inferior alveolar vessels, the marrow vessels, and the periosteal vessels.

Inherent Difficulties in Treating ORN With the aforementioned irradiation effect, progressive trismus would occur with mucositis, decreased mucus production, and mucosal fibrosis. These factors lead to poor oral hygiene and infection, with difficulty in oral examination and debridement. Due to Annals of Plastic Surgery

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Volume 73, Supplement 1, September 2014

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Annals of Plastic Surgery

& Volume 73, Supplement 1, September 2014

Free Iliac vs Free Fibula Flap for Mandibular ORN

TABLE 1. Diseases Requiring Radiotherapy and Resulted in ORN of Mandible in Our Patient Population Disease

No. Cases

Nasopharyngeal cancer Tonsillar cancer Tongue cancer Oral cancer Submandibular malignancy Parotid gland malignancy Minor salivary gland malignancy Mandibular osteosarcoma Total

97 19 15 13 3 2 2 2 153

poor wound healing with leakage of the intraoral content, orocutaneous fistula may form. Even worse, necrotizing fasciitis of the neck can occur and become lethal.

PATIENTS AND METHODS Since our first successful free iliac bone f lap for mandibular reconstruction done by the corresponding author in 1983, treatment of recalcitrant ORN of the mandible with vascularized bone f lap after radical resection of the diseased segment have become a standardized procedure. Although there are different recommendations of removing the diseased segment5,6 (Table 2), we prefer segmental resection for ORN of mandibular body and hemimandibulectomy for ORN of mandibular angle or above. Coronoidectomy is usually performed simultaneously to release trismus. The ORN cases that have undergone mandibular reconstruction from 1986 to 2011 in our center were reviewed. Data collected for analysis include patient demographics (sex, age, underlying disease, and reason for radiation), time interval between radiation and ORN, flap type, recipient vessel, flap survival rate, postoperative infection rate, nonunion/malunion rate, mean hospital stay, and antibiotics use.

Postoperative Care All patients were admitted to intensive care unit for monitoring of microvascular patency, vital signs, and infection status. Infection is usually a preexisting scenario, due to poor oral hygiene and necrotic tissue of the wound before the surgery. Intravenous antibiotics covering both aerobic and anaerobic bacteria are mandatory. Feeding from nasogastric tube or even duodenal tube has to be started as soon as the patients’ condition allows. Attention should be put on the change of white blood cell count, C-reactive protein, and hemoglobin level

FIGURE 2. An intraoperative photograph showing ORN of the right side mandible with pathologic fracture.

along with the nutritional status including serum albumin and prealbumin levels. Hyperglycemia usually accompanied infection with systemic dehydration.

Primary Versus Secondary Reconstruction Of all 153 cases, 137 received mandibular reconstructions primarily at the time of mandibular resection, whereas 16 had the reconstructions done secondarily because of severe infections (deep neck infection or abscess formation) that had to be treated with serial debridements before the reconstructive procedures.

RESULTS A total of 153 cases were reviewed (Table 3), and 108 were reconstructed with vascularized iliac bone f lap, whereas 45 were reconstructed with vascularized fibula f lap. The most commonly used recipient artery was superior thyroid artery, followed by transverse TABLE 2. Different Methods of Excision of Osteoradionecrotic Mandible6 Type of Mandible Resection

Description of the Technique

Sequestrectomy

FIGURE 1. Typical presentation of mandibular ORN with local skin atrophy and draining sinus. * 2014 Lippincott Williams & Wilkins

Usually cannot completely remove the diseased bone Coronoidectomy Coronoidectomy should be done to release the trismus and also for surgical debridement Marginal mandibulectomy Usually cannot completely remove the diseased bone Segmental mandibulectomy For mandibular body ORN Hemimandibulectomy For mandibular angle, ramus, coronoid process ORN



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TABLE 3. Demographic Data of the 2 Groups No. cases Male/female Average age, y Preoperative infection*

TABLE 5. Postoperative Comparison

Free Iliac Bone Flap

Free Fibular Flap

108 94:14 52.1 108 (100%)

45 39:6 50.8 45 (100%)

*Preoperative infection includes unhealing ulcer of skin or mucosa with local erythema or discharge, caries with gingival inf lammation or abscess, and exposure of implants.

cervical artery (Table 4). None of these cases had total failure of free flap. All patients finally got cured of ORN. Broad-spectrum antibiotics had been given preoperatively and postoperatively. The average days requiring intravenous antibiotics in the group with iliac f lap were 10.46 (2.28) versus 16.09 (3.88) days in the fibula group (P G 0.01). The average hospital stay were 15.23 (3.11) days in the iliac bone flap group versus 17.47 (5.97) days in the fibula group (P = 0.02) (Table 5). Of the 45 cases that were reconstructed with vascularized fibula f lap, 9 (20%) cases encountered neck infection postoperatively, including 6 cases of local fasciitis. All of the 9 cases had delayed healing of the intraoral wound that was complicated with leakage of saliva into the neck. These cases were treated with serial debridements and open drainage, followed by later closure or coverage. However, significant neck infection only happened in 8 (7.4%) cases of the iliac flap group, which is significantly fewer than the fibula f lap group (P = 0.04) (Table 5). In the iliac f lap group, the nonunion and malunion rates were 4.6% and 2.8%, respectively; whereas in the fibula group, the rates were 15.5% and 6.6%, respectively (Table 5). There was a significant difference as for the nonunion rate in these 2 groups (P = 0.04).

Case 1. Primary Reconstruction of Mandibular ORN With Free Iliac Osteocutaneous Flap This 35-year-old lady experienced mucoepidermoid carcinoma of the left submandibular gland. Radiotherapy was done after surgery.

TABLE 4. Recipient Vessels Used for Reconstruction Vascularized Vascularized Iliac Bone Fibular Graft Graft Total

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Free Iliac Bone Flap (n = 108)

Free Fibular Flap (n = 45)

P

Flap survival rate 108 (100%) 45 (100%) Bone healingYrelated issues Nonunion 5 (4.6%) 7 (15.5%) 0.0417 Malunion 3 (2.8%) 3 (6.6%) 0.3602 Infection-related issues Neck infection 8 (7.4%) 9 (20.0%) 0.0441 Average days of antibiotics use 10.46 (2.28) 16.09 (3.88) G0.01 Average length of stay, d 15.23 (3.11) 17.47 (5.97) 0.021 Average times of debridement 0.20 (0.76) 0.64 (1.37) 0.0466 required postoperatively

Unfortunately, long-term draining of oro-osteocutaneous fistula with a foul-odored discharge due to ORN of the left side mandible bothered her after extraction of a necrotic tooth 18 years after radiotherapy (Fig. 3A). She then received 80 courses of HBO therapy without significant improvement before she was referred to our service. Panoramic x-ray revealed extensive ORN at left mandibular body (Fig. 3B). Segmental resection of the osteoradionecrotic bone and thorough debridement of the intraoral and extraoral wound was performed (Fig. 3C), followed by reconstruction with iliac osteocutaneous flap (Fig. 3D). The wound healed and the drainage never recurred. Figure 3E-H shows good functional and aesthetic results at 10-year follow-up.

Case 2. Primary Reconstruction of Extensive Mandibular Defect With Free Fibula Osteocutaneous Flap

CASE PRESENTATIONS

Artery Superior thyroid artery Superficial temporal artery Lingual artery Facial artery Transverse cervical artery External carotid artery Vein Only 1 vein Concomitant veins of recipient artery End-to-side internal jugular vein External jugular vein, contralateral External jugular vein, ipsilateral Cephalic vein Two or more veins


91 8 1 2 6 0

16 0 0 0 28 1

107 8 1 2 34 1

4 5 31 4 9 55

5 2 1 1 6 30

9 7 32 5 15 85

This 53-year-old lady received radiotherapy for nasopharyngeal carcinoma. One year after radiotherapy, she began to experience pain at the left mandible, intraoral discharge, and subsequently draining sinus at left mandibular angle (Fig. 4A). She underwent 30 courses of HBO therapy without improvement. Because the ORN was located around the mandibular angle, a hemimandibulectomy was carried out, followed by reconstruction with free fibula osteocutaneous f lap. The resected specimen showed severely infected and osteoradionecrotic mandible extending from left mandibular body, ramus to condyle with previous coronoidectomy (Fig. 4B). Free fibula osteocutaneous flap was harvested with 1 wedge osteotomy and plate osteosynthesis to replace the mandibular defect (Fig. 4C). Her postoperative course was uneventful and infection subsided under antibiotics treatment. There was no recurrence of ORN at 8-year follow-up (Fig. 4D).

Case 3. Secondary Reconstruction of Hemimandibular Defect With Free Iliac Osteocutaneous Flap This 28-year-old lady experienced an osteogenic sarcoma at left mandibular ramus. She underwent tumor resection and ramus excision, which was complicated with left complete facial palsy. Later, left hemimandibulectomy was performed for ORN of the mandible as a complication of postoperative irradiation despite HBO therapy. The severely deformed face lasted for 6 years before she was referred for further reconstruction (Fig. 5A). A free iliac osteocutaneous f lap was used to reconstruct her hemimandibular defect (Fig. 5B) followed by a temporalis muscle transfer later to correct her left facial palsy (Fig. 5C). * 2014 Lippincott Williams & Wilkins





FIGURE 3. A, ORN of left mandible with a foul-odored discharge from an orocutaneous fistula with local infection. B, Panoramic view revealed extensive ORN at left mandibular body. C, Segmental resection of the osteoradionecrotic bone and radical excision of the intraoral and extraoral tissue. D, Iliac bone osteocutaneous flap was harvested based on deep circumflex iliac vessels. E, Postoperative photograph showing acceptable symmetry of facial appearance, as well as abundant soft tissue of left lower face. F, Postoperative panoramic view. G, Satisfactory occlusion. H, Postoperative mouth opening was adequate for oral intake and hygiene care.

Case 4. Sandwich Reconstruction of Composite Mandibular and Chin Defect With Platysma Myocutaneous Flap and Free Iliac Bone Flap A 70-year-old gentleman experienced oral cancer at the mandibular symphyseal area. He refused surgery and only received * 2014 Lippincott Williams & Wilkins

radiotherapy as the primary treatment, which was carried out with 19,000 cGy. He later developed ORN of the mandible and necrosis of the oral f loor, and there was residual cancer around the wound. In addition to extensive radiation-related necrosis of the mandible (Fig. 6A) and oral f loor, there was also saliva leakage from the www.annalsplasticsurgery.com


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FIGURE 4. A, Draining sinus at left mandibular angle 1 year after the radiotherapy for nasopharyngeal carcinoma. B, Specimen of hemimandibulectomy showing severely infected and osteoradionecrotic mandible extending from left mandibular body, ramus to condyle with previous coronoidectomy (viewing from the lingual side). C, Free fibula osteocutaneous f lap was harvested with 1 wedge osteotomy and plate fixation to replace the mandibular defect. D, Postoperative photograph showing acceptable appearance, with less ideal symmetry as well as hollowing of left lower face.

wound (Fig. 6B), which led to local infection. Thus, radical resection of the necrotic mandible and oral f loor was performed (Fig. 6C), and left side platysma myocutaneous f lap was used to restore

the intraoral lining of the oral f loor (Fig. 6D); then a free iliac osteocutaneous f lap was used to reconstruct the mandible as well as the skin (Fig. 6E). At 2-year follow-up, he had good

FIGURE 5. A, This 28-year-old lady experienced left facial palsy after tumor ablative surgery. Later, she developed ORN after radiotherapy and underwent left hemimandibulectomy. B, A postoperative panoramic x-ray showing an iliac osteocutaneous free f lap was used to reconstruct the hemi-mandibular defect. C, One year after reconstruction of the mandible, a temporalis muscle transfer was performed to correct her left facial palsy. S22


* 2014 Lippincott Williams & Wilkins





FIGURE 6. A, Extensive radiation-related necrosis of the mandible and oral f loor with mucositis. B, Atrophy of the chin with erythema, crusting and orocutaneous fistula, causing local infection. C, Radical resection of the necrotic mandible, chin, and oral f loor. D, Left platysma myocutaneous f lap was used to reconstruct the defect at oral f loor. E, Iliac osteocutaneous f lap was harvested based on deep circumf lex iliac vessels for mandibular reconstruction. F, Postoperative photograph showing both the platysma myocutaneous f lap and iliac osteocutaneous f lap healed well.

Complications

site complications include exposure of the peroneus longus tendon. Healing of the iliac bone f lap donor site is usually less problematic. The most undesirable donor-site complication of iliac bone flap is hernia, which can be prevented with strong and secure donor-site repair and proper postoperative immobilization with hip in f lexed position.

In our series, the most common complication was postoperative infection, followed by nonunion (Table 5). As for the postoperative infection, we observed neck infection in 8 (7.4%) cases of the iliac f lap group and 9 (20.0%) cases of the fibula f lap group, and neck fasciitis in none of the iliac f lap group and 6 (13.3%) cases in the fibula group (Fig. 7). In contrast to iliac crest, fibula f lap usually requires multiple osteotomies to mimic the natural contour of the mandible. However, we observe higher rates of nonunion and malunion in the fibula f lap group (Table 5). In addition, poor healing ability in these wounds may sometimes end up with plate extrusion and bone exposure (Fig. 8). Although the wound may heal eventually, subsequent contracture may lead to malunion in a multiple osteotomized fibula (Fig. 9). The donor site of the fibula sometimes may have the problems of healing due to tight closure or venous congestion which is not infrequently seen in the aged (Fig. 10). Harvesting of the fibula f lap may result in clawing of the great toe due to contracture of f lexor hallucis longus and/or flexor digitorum longus (Fig. 11). Other donor-

Mandibular ORN is a serious and common complication in patients with head and neck malignancies who were treated with radiotherapy. Despite the improvement in the techniques of irradiation and dental care, the reported incidence is around 37%.7 Risk factors for mandibular ORN include poor oral hygiene, total irradiation dose, tooth extraction, and fixation method after mandibulotomy.8 Management of mandibular ORN has been a formidable task, and timing of surgical intervention is still debatable. Hyperbaric oxygen therapy has been reported useful and has become the mainstay of the conservative treatment in cases with minimal amount of necrotic bone radiographically.9,10 We agree that increasing local oxygen concentration may create a better healing environment with increased vascular proliferation; however, in advanced conditions with moderate amount of necrotic bone on x-rays, HBO can only be an adjuvant,4,11 and aggressive surgical management should be planned. In our service since 1983, definitive treatment of mandibular ORN has

intraoral lining without contracture and the mandible healed well with the free iliac f lap, and there was no recurrence of ORN or cancer (Fig. 6F).


DISCUSSION



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FIGURE 7. A, Panoramic view showing ORN at right mandibular body after radiotherapy for tonsillar cancer. B, Fibula f lap was harvested. C, Postoperative photograph after reconstruction with free fibula f lap. D, Local fasciitis happened 5 days after the surgery despite complete survival of the f lap. E, Follow-up panoramic view reveals healing of the fibula with the mandible. F, After intensive care unit care and thorough debridement, the neck defect was covered with ipsilateral latissimus dorsi myocutaneous f lap. The fibula f lap healed well with the mandible and oral mucosa.

been confirmed as radical resection of the dead bone and reconstruction with free vascularized iliac or fibula osteocutaneous f lap. Our treatment goal of mandibular ORN comprises of (1) radical excision of the necrotic bone and elimination of the infection

source, (2) reconstruction of the mandibular arch and intraoral lining, and (3) restoration of facial symmetry. Although number 3 is sometimes difficult to achieve, numbers 1 and 2 are always the priority during surgical planning to maintain the essential functions of

FIGURE 8. Reconstruction of mandible with fibula f lap with immediate osseointegration done at another hospital, complicated with orocutaneous fistula, extrusion of implant, intraoral bone exposure, and necrosis. S24






FIGURE 9. Angulation deformity of fibula bone f lap due to multiple wedge osteotomies.

the mandible including deglutination, mastication, speech, and retention of saliva.12Y15 In our practice, vascularized iliac osteocutaneous flap is the preferred reconstructive option for most of the mandibular ORN, whereas vascularized fibula osteocutaneous f lap is preferred for extremely large mandibular defects or anterior defects involving only the parasymphyseal region. Vascularized iliac osteocutaneous f lap has a natural curvature that simulates well with the mandibular body and does not require osteotomy. This flap can offer a well-vascularized and sizable bone stock that matches the width of the mandible. It contains large amount of cancellous bone that allows faster healing of the osteosynthesis. In addition, its abundant soft tissue provides the advantages of resistance against intraoral pathogens, tamponade of possible dead space, and restoration of facial symmetry.16Y19 The disadvantage of


FIGURE 11. Clawing of toes after harvesting of fibular f lap.

the iliac osteocutaneous f lap is mainly its shorter vascular pedicle, which can be overcome with vein grafts.16Y19 The reliability of its skin paddle can be ensured by connecting the superficial circumf lex iliac artery of the skin paddle to the terminal branch of deep circumf lex iliac artery with a vein graft.20 Vascularized fibula osteocutaneous f lap offers a straight, long, and cortical bone stock that is advantageous for a short and straight bony defect. It can be osteotomized to accommodate the contour of mandible, especially in an extremely long defect21Y25; however, multiple osteotomies are associated with a higher risk of compromising the blood supply to each bony segments. Its bony stock is usually half the width of the mandible; therefore, it can be used only to contour the outer cortex of the mandible unless it is double barreled. It offers a thin skin paddle that is ideal for intraoral lining, but suboptimal for the volume of lower face to restore facial symmetry. It offers long pedicle,21Y25 but in cases that superior thyroid artery or external carotid artery is not a recipient vessel and transverse cervical or ascending thyroid artery need to be used, a vein graft is still needed for a tensionless anastomosis. Infection with variable severity is very common in mandibular ORN. In our series, 100% of patients had local wound infection preoperatively, including caries, ulcer of oral mucosa, or skin (with or without exposure of hardware) (Table 3). This might be related to the postoperative infection rate in our series. Most of the postoperative infection are mild and can be treated with intravenous antibiotics, whereas 7.4% of the iliac f lap group and 20.0% of the fibula f lap group turned into neck infection that required surgical debridement and drainage. Six cases of the fibula flap group even developed fasciitis that required more extensive debridement and later soft tissue coverage. We observed that the fibula f lap group had a higher rate of deep infection postoperatively (P = 0.04) with longer hospital stay (P = 0.02) and antibiotics use (P G 0.01) (Table 5). This might result from the limited volume of soft tissue that a fibula f lap can provide as well as multiple osteotomies and more hardware required for contouring and bone fixation. We also observed a significant difference in the nonunion rate between the iliac f lap group (4.6%) and the fibula f lap group (15.5%) (P = 0.04) (Table 5). This can be explained by 2 factors as follows: (1) iliac f laps do not need osteotomy for contouring, whereas fibula flaps usually need multiple osteotomies and more hardware; and (2) iliac crest contains cancellous bone, which theoretically allows the osteosynthesis to heal faster than a cortical bone like fibula.

CONCLUSIONS FIGURE 10. Complication of fibula f lap harvesting with neighboring skin necrosis due to tight skin closure. * 2014 Lippincott Williams & Wilkins

In our experience with 153 patients for reconstruction of mandibular ORN, both vascularized iliac and fibula osteocutaneous flaps had equal survival rate. The merits of vascularized iliac f lap include its natural contour, its cancellous bone content, and abundant soft tissue. www.annalsplasticsurgery.com


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In our study, the iliac f lap has significantly lower rate of postoperative deep infection and nonunion compared to the fibula f lap. Therefore, we conclude that vascularized iliac osteocutaneous f lap is one of the superior options for reconstruction of mandibular ORN. However, when the available recipient vessels are distant or when the mandibular defect is extremely large, a fibular osteocutaneous f lap is still a reasonable option.

11. Mounsey RA, Brown DH, O’Dwyer TP, et al. Role of hyperbaric oxygen therapy in the management of mandibular osteoradionecrosis. Laryngoscope. 1993;103:605Y608.

ACKNOWLEDGMENT Informed consent was received for publication of the figures in this article.

14. Adamo AK, Szal RL. Timing, results, and complications of mandibular reconstructive surgery: report of 32 cases. J Oral Surg. 1979;37:755Y763.

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16. Taylor IG, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps: experimental work. Plast Reconstr Surg. 1979;64:595Y604.

1. Rubin P, Casarett GW. Clinical radiation pathology as applied to curative radiotherapy. Cancer. 1968;22:767Y778. 2. Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg. 1983;41:283Y288. 3. Marx RE, Johnson RP. Studies in the radiobiology of osteoradionecrosis and their clinical significance. Oral Surg Oral Med Oral Pathol. 1987;64: 379Y390. 4. Epstein J, van der Meij E, McKenzie M, et al. Postradiation osteonecrosis of the mandible: a long-term follow-up study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83:657Y662. 5. Sanger JR, Matloub HS, Yousif NJ, et al. Management of osteoradionecrosis of the mandible. Clin Plast Surg. 1993;20:517Y530. 6. Hao SP, Chen HC, Wei FC, et al. Systematic management of osteoradionecrosis in the head and neck. Laryngoscope. 1999;109:1324Y1327; discussion 1327Y1328. 7. Shaha AR, Cordeiro PG, Hidalgo DA, et al. Resection and immediate microvascular reconstruction in the management of osteoradionecrosis of the mandible. Head Neck. 1997;19:406Y411. 8. Moran WJ, Panje WR. The free greater omental flap for treatment of mandibular osteoradionecrosis. Arch Otolaryngol Head Neck Surg. 1987;113:425Y427. 9. Chang DW, Oh HK, Robb GL, et al. Management of advanced mandibular osteoradionecrosis with free flap reconstruction. Head Neck. 2001;23:830Y835. 10. Aitasalo K, Niinikoski J, Grenman R, et al. A modified protocol for early treatment of osteomyelitis and osteoradionecrosis of the mandible. Head Neck. 1998;20:411Y417.

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12. Chen YB, Chen HC, Hahn LH. Major mandibular reconstruction with vascularized bone grafts: indications and selection of donor tissue. Microsurgery. 1994;15:227Y237. 13. Pogrel MA, Podlesh S, Anthony JP, et al. A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects. J Oral Maxillofac Surg. 1997;55:1200Y1206.

15. Cordeiro PG, Disa JJ, Hidalgo DA, et al. Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients. Plast Reconstr Surg. 1999;104:1314Y1320.

17. Taylor IG, Watson N. One-stage repair of compound leg defects with free, revascularized flaps of groin skin and iliac bone. Plast Reconstr Surg. 1978; 61:494Y506. 18. Gottlieb ME, Chandrasekhar B, Terzis JJ, et al. Clinical applications of the extended deep inferior epigastric flap. Plast Reconstr Surg. 1986;78:788Y792. 19. Boyd BJ, Taylor IG, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg. 1984;73:1Y14. 20. Koshima I, Nanba Y, Tsutsui T, et al. Sequential vascularized iliac bone graft and a superficial circumflex iliac artery perforator flap with a single source vessel for established mandibular defects. Plast Reconstr Surg. 2004;113: 101Y106. 21. Yoshimura M, Shimamura K, Iwai Y, et al. Free vascularized fibular transplant. A new method for monitoring circulation of the grafted fibula. J Bone Joint Surg Am. 1983;65:1295Y1301. 22. Yoshimura M, Shimada T, Matsuda M, et al. Double peroneal free flap for multiple skin defects of the hand. Br J Plast Surg. 1989;42:715Y718. 23. Saito H, Kimura Y, Tsuda G, et al. Free peroneal skin flap for oropharyngeal reconstruction. Scand J Plast Reconstr Surg Hand Surg. 1999;33:41Y46. 24. Ikeda K, Yoshimura M, Hashimoto F, et al. Fate of the vascularized fibular graft: report of two cases with 15-year follow-up. J Trauma. 1999;47:777Y779. 25. Saito H, Yoshimura M, Tsuda G, et al. Free peroneal and its composite flap: a distant donor for head and neck reconstruction. Auris Nasus Larynx. 1993; 20:63Y71.



Evaluation of bone height of the free fibula flap in mandible reconstruction.

The accuracy of computer-assisted primary mandibular reconstruction with vascularized bone flaps: iliac crest bone flap versus osteomyocutaneous fibula flap.

Functional outcomes of virtually planned free fibula flap reconstruction of the mandible.

Ossifying Fibroma of the Mandible: A Case Report Using Vascularized Free Fibula Flap Reconstruction.

Response to: standardized templates for shaping the fibula free flap in mandible reconstruction. J Reconstr Microsurg 2013;29:619-622.

[Condylar remodelling after temporomandibular joint reconstruction with fibula free flap].

Health-related quality of life after segmental resection of the lateral mandible: Free fibula flap versus plate reconstruction.

Resorption of fibula bone following mandibular reconstruction for osteoradionecrosis.

Reconstruction of irradiated mandible after segmental resection of osteoradionecrosis-a technique employing a microvascular latissimus dorsi flap and subsequent particulate iliac bone grafting.

Study of mandible reconstruction using a fibula flap with application of additive manufacturing technology.

Fibular free flap reconstruction for the management of advanced bilateral mandibular osteoradionecrosis.

Mandibular reconstruction with iliac crest free flap, nasolabial flap, and osseointegrated implants.

Latissimus dorsi-rib pedicle flap for mandibular reconstruction as a salvage procedure for failed free fibula flap.

Sagittal split osteotomy on the previously reconstructed mandible with fibula free flap.

Proximal peroneal perforator in dual-skin paddle configuration of fibula free flap for composite oral reconstruction.

The "Origami" Composite Free Fibula Flap for Complex Defects of the Mandible, Floor of the Mouth, and Tongue.

Evaluation of bone length and number of osteotomies utilizing the osteocutaneous radial forearm free flap for mandible reconstruction: An 8-year review of complications and flap survival.

Modifications of the deep circumflex iliac artery free flap for reconstruction of the maxilla.

Dual free flap transfer using forearm flap for mandibular reconstruction.

Quality of life assessment in patients after mandibular resection and free fibula flap reconstruction.

Versatility of Fibula Free Flap in Reconstruction of Facial Defects: A Center Study.

Pedicled Retrograde Fibula Flap for Ankle Reconstruction after Oncologic Resection of the Distal Fibula.

Discussion: computer-assisted versus conventional free fibula flap technique for craniofacial reconstruction: an outcomes comparison.

Synchronous reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular osteocutaneous flap in patients with nasopharyngeal carcinoma.