Mandibular reconstruction using microvascular free flaps: A statistical analysis of 178 cases

For this article, 178 consecutive cases of mandibular reconstruction using microvascular free flaps and performed from 1979 to 1997 were studied. The purpose of this report is to compare flap success rates, complications, and aesthetic and functional results. The ages of the 131 men and 47 women ran ged from 13 to 85 years, with an average of 55 years. Donor sites included the rib (11 cases), radius (one case), ilium (36 cases), scapula (51 cases) , fibula (34 cases), and soft-tissue flaps with implant (45 cases). Complic ations included total flap necrosis, partial flap necrosis, major fistula f ormation, and minor fistula formation. The rate of total flap necrosis invo lving the ilium and fibula was significantly higher than that of all other materials combined (P < 0.05). The overall rate of implant plate removal, w hich resulted from the exposure or fracture of the plate, was 35.6 percent (16 of 45 cases). Each mandibular defect was classified by the extent of the bony defect and by the extent of the soft-tissue defect. The extent of the mandibular bony defect was classified according to the HCL method of Jewer et al. The exten t of the soft-tissue defect was classified into four groups: none, skin, mu cosal, and through-and-through. According to these classifications, functio nal and aesthetic assessments of deglutition and contour were performed on 115 subjects, and speech was evaluated in 110. To evaluate the postoperativ e results, points were assigned to each assessment of deglutition, speech, and mandibular contour. Statistical analysis between pairs of bone-defect g roups revealed that there was no significant difference in each category. R egarding deglutition, statistical analysis between pairs of soft-tissue-def ect groups revealed there were significant differences (P < 0.05) between t he none and the mucosal groups and also between the none and the through-an d-through groups. Regarding speech, there was a significant difference (p < 0.05) between the none and the through-and-through groups. Regarding ontou r, there were significant differences (p < 0.01) between the none and the t hrough-and-through groups and between the mucosal and the through-and-throu gh groups. The points given for each function, depending on the reconstruct ion material, revealed that there was no significant difference between pai rs of material groups. From this prospective study, the authors have developed an algorithm for or omandibular reconstruction. When the bony defect is lateral, the ilium, fib ula, or scapula should be chosen as the donor site, depending on the extent of the soft-tissue defect. When the bony defect is anterior, the fibula is always the best choice. When the soft-tissue defect is extensive or throug h-and-th rough with an anterior bony defect, the fibula should be used with other soft-tissue flaps.