COST AND OUTCOME OF OSTEOCUTANEOUS FREE-TISSUE TRANSFER VERSUS PEDICLED SOFT-TISSUE RECONSTRUCTION FOR COMPOSITE MANDIBULAR DEFECTS

Thirty-nine patients underwent reconstruction of composite mandibular defects following resection for squamous cell carcinoma. Thirty-four u nderwent immediate reconstruction, while 5 were reconstructed secondar ily. Twenty-one received soft-tissue reconstruction only with a pector alis major myocutaneous flap, 14 underwent osteocutaneous free-tissue transfer, and 4 received a reconstruction plate with free-tissue trans fer for soft-tissue coverage. The mandibular defects in the pectoralis major myocutaneous flap group tended to be posterolateral, while free -tissue transfer defects were more severe, usually involving the anter ior mandible. Length of surgery and duration of intensive care unit ca re were significantly longer for free-tissue transfer patients, while length of hospitalization was similar. Systemic complications were mor e frequent in the free-tissue transfer patients, while flap complicati ons were more common in the pectoralis major myocutaneous flap patient s. Facial appearance scores were higher for the free-tissue transfer g roup by both patient and physician assessment. Social function, speech , and oral function did not differ significantly. Patients reconstruct ed secondarily with free tissue transfer reported significant improvem ent in appearance, oral continence, and social function, with little c hange in speech intelligibility, deglutition, or diet tolerance. The c ost of the main hospitalization was significantly higher in the free-t issue transfer group than in the pectoralis major myocutaneous flap gr oup, although when the costs of subsequent hospitalizations are includ ed, the difference in total cost narrows. Despite more adverse defects , free-tissue transfer provided more predictable aesthetic results and expeditious return to normal social function than did pectoralis majo r myocutaneous flap reconstruction. The fiscal impact of these complex reconstructions is, however, significant. Cost-containment issues are presented and recommendations are made.