Reconstruction of the mandible with osseous free flaps: A 10-year experience with 150 consecutive patients

Osseous free flaps have become the preferred method for reconstructing segm ental mandibular defects. Of 457 head and neck free flaps, 150 osseous mand ible reconstructions were performed over a 10-year period. This experience was retrospectively reviewed to establish an approach to osseous free flap mandible reconstruction. There were 94 male and 56 female patients (mean age, 50 years; range 3 to 7 9 years); 43 percent had hemimandibular defects, and the rest had central, lateral, or a combination defect. Donor sites included the fibula (90 perce nt), radius (4 percent), scapula (4 percent), and ilium (2 percent). Rigid fixation (up to five osteotomy sites) was used in 98 percent of patients. A esthetic and functional results were evaluated a minimum of 6 months postop eratively. The free flap success rate was 100 percent, and bony union was achieved in 97 percent of the osteotomy sites. Osseointegrated dental implants were pla ced in 20 patients. A return to an unrestricted diet was achieved in 45 per cent of patients; 45 percent returned to a soft diet, and 5 percent were on a liquid diet. Five percent of patients required enteral feeding to mainta in weight. Speech was assessed as normal (36 percent), near normal (27 perc ent), intelligible (28 percent), or unintelligible (9 percent). Aesthetic o utcome was judged as excellent (32 percent), good (27 percent), fair (27 pe rcent), or poor (14 percent). This study demonstrates a very high success rate, with good-to-excellent fu nctional and aesthetic results using osseous free flaps for primary mandibl e reconstruction. The fibula donor site should be the first choice for most cases, particularly those with anterior or large bony defects requiring mu ltiple osteotomies. Use of alternative donor sites (i.e., radius and scapul a) is best reserved for cases with large soft-tissue and minimal bone requi rements. The ilium is recommended only when other options are unavailable. Thoughtful flap selection and design should supplant the need for multiple, simultaneous free flaps and vein grafting in most cases.