Aesthetic and Functional Outcomes Using Osseous or Soft-Tissue Free Flaps

ABSTRACT

The authors compared functional and aesthetic outcomes following reconstruction of the posterior mandible (i.e., unilateral defects distal to the mental foramen) with free flaps containing vascularized bone (VBFs) or only soft-tissue (STFs). Fifty-eight reconstructions of the posterior mandible were performed with STFs (n=32) or VBFs (n=26) and were available for review. All patients (n=58) completed a functional outcome questionnaire containing questions about diet, oral competence, pain, trismus, speech, cosmesis, social reintegration, and return to work. Computer-assisted image analysis was performed comparing facial proportions of patients with STFs (n=10), VBFs (n=11), or unoperated controls (n=10).

VBFs yielded statistically significantly superior functional scores compared to STFs in 5/12 categories. Normal scores were found for diet in 31 percent (10/32) vs. 21 percent (3/26) (p=0.006); oral competence in 56 percent (18/32) vs. 35 percent (9/26) (p=0.05); and speech in 47 percent (15/32) vs. 30 percent (7/26) (p=0.026). VBF patients returned to public dining (72 percent, 23/32) more frequently than STF patients (35 percent, 9/26), (p=0.003). VBFs yielded superior results for midline symmetry with a mean mandible deviation of 3.3±2.3 mm vs. 5.8±3.6 mm (STFs), and 1.2±0.7 mm (controls, p=0.001).

An objective method for the evaluation of aesthetic and functional outcomes in posterior mandible reconstruction was developed. This method demonstrated that posterior mandible reconstruction with VBFs is associated with superior results in speech, diet, and midline symmetry. However, rigorous analyses of oropharyngeal soft-tissue defects and the radiation therapy protocols utilized, were not performed in this study. Without these additional analyses, one cannot definitively conclude that VBFs are superior to STFs.

KEYWORDS

Posterior mandible reconstruction - functional and aesthetic outcomes - osseous and soft-tissue free flaps

REFERENCES

• 1 Kroll S S, Robb G L, Miller M J. Reconstruction of posterior mandibular defects with soft tissue using the rectus abdominis free flap.  Br J Plast Surg . 1998;  51 503
• 2 Anthony J P, Rawnsley J D, Benhaim P. Donor leg morbidity and function after fibula free flap mandible reconstruction.  Plast Reconstr Surg . 1995;  96 146
• 3 Sanger J R, Yousif N J, Matloub H S. Reconstruction of lower third of face with three simultaneous free flaps.  Plast Reconstr Surg . 1994;  94 709
• 4 Urken M L, Buchbinder D, Costantino P D. Oromandibular reconstruction using microvascular composite flaps: report of 210 cases.  Arch Otolaryngol Head Neck Surg . 1998;  124 46
• 5 Blackwell K E, Buchbinder D, Biller H F, Urken M L. Reconstruction of massive defects in the head and neck: the role of simultaneous distant and regional flaps.  Head Neck . 1997;  19 620
• 6 Talesnik A, Markowitz B, Calcaterra T. Cost and outcome of osteocutaneous free-tissue transfer versus pedicled soft-tissue reconstruction for composite mandibular defects.  Plast Reconstr Surg . 1996;  97 1167
• 7 Hassan S J, Weymuller Jr A E. Assessment of quality of life in head and neck cancer patients.  Head Neck . 1993;  15 485
• 8 Holdaway R A. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part I.  Am J Orthodont . 1983;  84 1
• 9 Wilson K M, Rizk N M, Armstrong S L, Gluckman J L. Effects of hemimandibulectomy on quality of life.  Laryngoscope . 1998;  108 1574
• 10 Urken M L, Buchbinder D, Weinberg H. Functional evaluation following microvascular oromandibular reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients.  Laryngoscope . 1991;  101 935
• 11 Komisar A. The functional result of mandibular reconstruction.  Laryngoscope . 1990;  100 364