Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty

Abstract

Purpose of review Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF). Recent findings Although FFF is the current ‘gold standard’ for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes. Summary There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.

Innovations with the scapula and subscapular system for head and neck microvascular reconstruction

“…Activities of daily living are not significantly impacted in patients undergoing scapula free flap reconstruction [29,40] (with the exception of physical quality of life impairments as measured by the UW-QoL physical domain) [38] . Disabilities of the arm, shoulder, and hand (DASH) questionaries completed 10-14 months after surgery had a mean score of 21.74 ± 7.30, which is significantly higher than a normal population but still lies within the very mild to mild rating of donor site morbidity [41] . Patients mobilize earlier in the hospital, which may benefit elderly patients or those with baseline mobility issues [16,40,42] .…”

Reconstruction of Acquired Segmental Mandibular Defects Using Pedicled Mandibular Muscle Flap and Evaluation of Speech Function and Aesthetic Outcomes

“…When the vascularized free flap is contraindicated or unfavorable and/or the patient is too weak to tolerate prolonged anesthesia, other reconstruction options must be considered. 3 Reconstruction with soft tissue alone may lead to mandibular wobbling, malocclusion, and facial contracture. 8,9 Soft tissue reconstruction combined with titanium plate fixation has a high complication rate, including titanium plate exposure (up to 80%) and titanium plate fracture, increasing the incidence of secondary surgery and decreasing the patient's quality of life.…”

“…However, many clinical factors may prevent a patient from undergoing free flap reconstruction, including multiple treatments, poor vascularization of the recipient area, failure of multiple previous reconstructions, poor prognosis of the tumor, poor economic status of the patient, and limited medical technology of the surgical team. When the vascularized free flap is contraindicated or unfavorable and/or the patient is too weak to tolerate prolonged anesthesia, other reconstruction options must be considered 3. Reconstruction with soft tissue alone may lead to mandibular wobbling, malocclusion, and facial contracture 8,9.…”

“…Fibula-free flap is currently the first choice in mandibular segmental reconstruction 2. However, when fibula-free flap is contraindicated or unfavorable and/or the patient is too weak to tolerate prolonged anesthesia, other reconstructive options must be considered 3. In this study, we investigated the clinical application of pedicled mandibular osteomuscular flap in the secondary reconstruction of mandibular segmental defects so as to provide new ideas and methods for the clinical repairment of mandibular defects.…”

The fusiform skin paddle in fibula free flap: a fusiform-designed skin paddle for maxillofacial soft defect reconstruction and reducing leg wound tension

“…To date, FFF is the gold standard and the most reliable method for jaw reconstruction. Its primary benefit lies in its capacity to effectively restore both missing parts of the jaw and associated soft tissue (3). Despite many efforts, previous studies failed to decrease suture tension of leg wound (2,4,5).…”