Long-Term Plate Complications in Patient-Specific Plates Utilizing Computer-Aided Design

OBJECTIVE

Assess the long-term plate complications with patient-specific plates (PSPs) created with computer-aided design (CAD) and computer-aided manufacturing (CAM) for fibula free flap reconstructions for mandibular defects.

METHODS

Retrospective chart review from January 2010 to July 2022 of patients who underwent mandibular reconstruction with a fibula free flap and PSP. Primary outcome was plating-related complications, defined as plate exposure, fracture, loose screws, and plate removal.

RESULTS

A total of 221 patients underwent PSP fibula reconstruction. Average age was 59.8 + 14.3 years old with male to female ratio of 2:1. Squamous cell carcinoma of the mandible was the most common reason for resection, 47.5%, n = 105. Plate removal occurred in 11% of patients (n = 25) about 17.4 months after the initial surgery. Plates were removed due to exposure (76%, n = 19) or screw loosening (24%, n = 6). Malignancy was associated with an increased risk of plate complications when compared to benign tumor (odds ratio [OR] 9.04, confidence interval [CI] 1.36-3.85), osteonecrosis (OR 1.38, CI 0.59-3.48), and trauma (OR 1.26, CI 0.23-12.8). Postoperative radiation therapy (OR 2.27, CI 1.07-4.82, p = 0.026) and surgical site infection (OR 9.22, CI 4.11-21.88, p = 0.001) were associated with more plate complications.

CONCLUSIONS

CAD creates PSPs that remain stable in the majority of patients over the long term. Plate removal is less compared to non-PSP reconstruction. Consideration of the soft tissue envelope over the plate and management of perioperative infection at the time of surgery should be entertained.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 2024.

Is hardware colonization associated with latent hardware complications and removal in maxillomandibular free flap reconstruction?

BACKGROUND

The relationship between hardware colonization, latent hardware complications, and hardware removal remains unclear following osteocutaneous free flap reconstruction of the jaws.

METHODS

Retrospective cohort study of all patients undergoing free flap reconstruction of the maxilla or mandible from 2016 to 2021.

RESULTS

A total of 240 subjects were included. Hardware colonization was associated with latent hardware complication in bivariate (p ≤ 0.001) and multivariate analysis (p ≤ 0.001). Time to latent hardware complication was 6.87 months earlier in colonized subjects (p ≤ 0.001). Of the 35 subjects undergoing hardware removal, 25 initiated but failed conservative therapy, and resolution of symptoms was achieved in 24 subjects after one operative intervention and 33 subjects after repeat intervention if indicated.

CONCLUSIONS

Hardware colonization increases the risk and onset of latent hardware complication. Prompt hardware removal may improve outcomes by leading to faster resolution of symptoms without the burden and cost of conservative therapies.

Osseointegration and Bone Resorption of Scapula Tip Free Flaps in Mandibular Reconstruction

OBJECTIVES

Bone resorption of more conventional vascularized bone grafts have been well described showing minimal resorption over time. Few studies have evaluated osseous union and bone resorption in scapula tip free flaps (STFF) in the reconstruction of mandibulectomy defects. We aimed to describe our series on STFF with respect to osseous union and bone resorption over time.

METHODS

Retrospective chart review of patients receiving STFF from January 2014-January 2017 (n = 25). A neuroradiologist analyzed follow-up CT scans to assess (1) STFF complete, partial, or no osseous union with native mandible and (2) STFF volume change over time in a subset with multiple follow-up scans (n = 18).

RESULTS

Twenty-three of 25 patients (92%) showed complete or partial STFF osseous union with native mandible either distally or proximally. STFF volume change ranged from +4.8 to -54% (median -0.5%) over median follow-up interval of 23 months. History of chemoradiation therapy, bisphophonate use, sex, age, or smoking history did not correlate with bone resorption.

CONCLUSIONS

STFFs shows high rates of osseous union and limited bone resorption that is equivalent to, or less than, vascularized fibular and iliac crest flaps. Clinically, this translates into both optimal healing and functional and cosmetic outcomes, especially in the setting of prior therapies.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2597-2602, 2023.

Managing Oromandibular Hardware Failure after Free Flap Surgery

Hardware failure after oromandibular reconstruction using free tissue transfer can delay additional therapies directed at cancer treatment and prevent patients from returning to normal oral function. Understanding and strict adherence to principles of rigid fixation is critical in preventing complications. Early surgical intervention for hardware exposure as well as utilization of locoregional flaps may prevent the need for more extensive revision surgery.

Mini-plate versus reconstruction bar fixation for oncologic mandibular reconstruction with free fibula flaps: A systematic review and meta-analysis

Introduction There is currently no consensus as to the comparative complication profiles of mini-plate (MP) and reconstruction bar (RB) osseous fixation in fibula flap mandibular reconstruction. The aim of this study is to compare complication rates associated with the use of MP versus RB fixation for vascularized fibula free flap (FFF) reconstruction of oncologic mandibular defects in an effort to better guide hardware utilization and pre-operative virtual surgical planning methods. Methods A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, and Cochrane Library databases were queried to identify studies related to FFF-based mandibular reconstruction with either MP or RB fixation. Primary endpoints of interest were plate complications, wound infection, mal- or non-union, and total flap loss. Complication rates were calculated as weighted proportions and compared via Fisher's exact testing. Results Sixteen studies met inclusion criteria, which examined 1,513 patients. Only three studies directly compared MP fixation with RB fixation. MP fixation was used in 828 (54.7%) cases and RB fixation in 685 (45.3%) cases. MP fixation demonstrated greater rates of plate-related complications (32.5% versus 18.8%, p < 0.01, respectively), fistula formation (15.8% versus 4.7%, p = 0.04), total flap loss (9.4% versus 4.7%, p = 0.02), partial flap loss (20.6% versus 6.1%, p < 0.01), and re-operation for vascular compromise (13.3% versus 4.0%, p < 0.01). Rates of infection, mal-union/non-union, and wound dehiscence were similar across both groups. Conclusion Our results suggest that MP use may be associated with higher rates of plate-related complications. Though limited by outcome reporting heterogeneity, this review can serve as a template for future investigations evaluating the safety profiles of MP and RB fixation in head and neck surgery.

Association of Plate Contouring With Hardware Complications Following Mandibular Reconstruction

OBJECTIVES/HYPOTHESIS

Despite considerable effort being dedicated to contouring reconstruction plates, there remains limited evidence demonstrating an association between contour and reconstructive outcomes. We sought to evaluate whether optimizing mandibular reconstruction plate contouring is associated with reduced postoperative hardware complications.

STUDY DESIGN

Retrospective cohort study.

METHODS

A cohort study was performed with adult patients (age ≥18 years) who underwent mandibulectomy and osseous free flap reconstruction following oncologic ablation at the University Health Network in Toronto, Canada, between January 1, 2003 and December 31, 2014. Patients with computed tomography scans performed within 1 year of reconstruction were included. Computer-based three-dimensional models were generated and used to calculate the mean plate-to-bone gap (mm). The primary outcome was plate exposure. Secondary outcome included a composite of plate exposure or intraoral dehiscence. Logistic regression models were fitted for each outcome accounting for other patient and surgical characteristics associated with the primary outcome.

RESULTS

Ninety-four patients met inclusion criteria, with a mean age of 60.4 (standard deviation [SD] 14.9). The mean follow-up time was 31.4 months (range 3-94). Reconstruction was performed with fibular (57%) and scapular free flaps (43%). In the multivariable model, small mean plate-to-bone gap (<1 mm) was independently associated with 86% reduced odds of plate exposure (odds ratio [OR] 0.12; 95% confidence interval [CI] 0.02-0.55). Mean plate-to-bone gap less than 1 mm was also independently associated with reduced odds of developing a composite of plate exposure or intraoral dehiscence (OR, 0.29; 95%CI, 0.11-0.75).

CONCLUSION

Optimizing plate contouring during mandibular reconstruction may decrease the development of postoperative hardware complications.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

Removal of patient-specific reconstruction plates after mandible reconstruction with a fibula free flap: is the plate the problem?

Computer-aided microvascular mandible reconstruction is an increasingly common procedure in oral and maxillofacial surgery. The aim of this retrospective single-centre study was to evaluate the rate and specifics of hardware removal after fibula free flap (FFF) fixation with a patient-specific reconstruction plate. The study included patients who underwent hardware removal between April 2017 and October 2019. Statistical analyses were performed regarding the different indications for plate removal (dental implantation versus complication) and the surgical approach (intraoral versus extraoral). Plate removal was performed in 29 of 98 patients (29.6%) after FFF fixation with a patient-specific reconstruction plate. Plate removal was done prior to dental implantation in 58.6% of cases and due to complications in 41.4%. Complications seen between reconstructive surgery and plate removal were less frequent in the dental rehabilitation group (8/17 vs 12/12; P=0.002). Within this group, 35.3% of plates were removed intraorally, and the majority of partial plate removals were performed in the patients with plate removal for dental rehabilitation (72.7% vs 27.3%). Hospitalization was shorter with an intraoral approach (1.7 days vs 4.0 days, P=0.052). The removal of patient-specific reconstruction plates prior to dental implantation is often partial and can be performed intraorally. The use of patient-specific miniplates for fixation of FFF might facilitate later dental rehabilitation.

Risk Factors for Plate Extrusion After Mandibular Reconstruction With Vascularized Free Flap

PURPOSE

Plate extrusion after mandibular reconstruction is a complication that imposes significant morbidity on the patient. The goal of this study is to estimate the incidence of plate extrusion after mandible reconstruction with a vascularized free flap and to identify the factors associated with plate extrusion.

METHODS

This was a retrospective cohort study involving patients who underwent mandibular reconstruction from October 2008 to July 2019 at LAC + USC or Keck Hospital of USC. Inclusion criteria were age ≥ 18 years, single-stage mandibular reconstruction with vascularized free flap, and follow-up of at least 12 months. Relevant demographic, intraoperative, and postoperative data were collected. The primary outcome was postoperative plate extrusion within the 12-month follow-up. Descriptive, univariate, and multivariate analyses were performed. Statistical significance was set at P ≤ .05.

RESULTS

A total of 102 patients were included in this study. The majority received a fibula free flap (90%) for a malignant neoplasm (76%). All patients had at least 12 months of follow-up. The rate of plate extrusion was 16%, with the majority of those patients undergoing plate removal (69%). After adjusting for postoperative fistula, soft tissue, and length of hospitalization, we found that any history of smoking (odds ratio = 12.8; confidence interval, 1.57 to 104.2), number of osteotomies (odds ratio 3.07; confidence interval, 1.09 to 8.6), flap nonviability (odds ratio = 18.2; confidence interval, 2.22 to 148.8) were associated with plate extrusion on multivariate analysis. Postoperative soft tissue infection approached significance.

CONCLUSIONS

This study demonstrates that smoking history, number of osteotomies, and flap nonviability are associated with plate extrusion after mandible reconstruction. Performing fewer osteotomies when possible to avoid excessively small flap bone segments and minimizing postoperative complications may improve long-term outcomes after mandibular reconstruction.

Rapid prototyping: applications in oral and maxillofacial surgery

This article documents four mandibular reconstructions performed using free fibula flaps. CT scan DICOM (Digital Imaging and COmmunication in Medicine) files were obtained in order to print stereolithographic models of the mandible, and in one case cutting guides for fibular osteotomies. One case study details the treatment a cancer recurrence on a right emimandibulectomy. Because of a lack of access to previous CT scans, the left part of the mandible was mirrored to obtain an accurate 3D model. In one case, due to the young age of the woman, a double barrel fibula flap was used. All cases resulted in satisfactory chewing function and aesthetic outcome, with no flap failures. The report concludes that Virtual Planning and Rapid Prototyping are helpful as they reduce costs and intraoperative times while simultaneously improving surgical precision.

Complications After Soft Tissue With Plate vs Bony Mandibular Reconstruction: A Systematic Review and Meta-analysis

OBJECTIVE

Mandibular reconstruction for segmental defects is a well-studied topic. However, there are conflicting data on the risks of delayed plate-related complications. The objective of this systematic review and meta-analysis was to assess long-term plate-related complications following reconstruction of the mandible with soft tissue and a plate as compared with immediate vascularized bony reconstruction.

DATA SOURCES

A medical librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946-), Embase (1947-), Scopus (1960-), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov.

REVIEW METHODS

Candidate articles were independently reviewed by 2 authors. Inclusion/exclusion criteria were uniformly applied. Articles were considered eligible if they included adequate reporting of plate extrusion and/or fracture and had follow-up ≥12 months.

RESULTS

A total of 2379 patients were included. The risk of plate fracture was low in cases of soft tissue with a plate (5%; 95% CI, 0.03-0.08) and osseous reconstruction (1%). The risk of extrusion following soft tissue and plate reconstruction was 20% (95% CI, 0.15-0.27). In the osseous reconstruction group, the risk of extrusion was 10% (95% CI, 0.06-0.18). Revision surgery was performed twice as often following soft tissue with a plate as compared with vascularized bony reconstruction (32% [95% CI, 0.25-0.40] vs 14% [95% CI, 0.09-0.21], respectively).

CONCLUSION

Delayed plate-related complications remain a significant problem following segmental defect reconstruction. Soft tissue and plate reconstruction techniques may increase the risk of plate removal and revision surgery.

Fibula free flap in maxillomandibular reconstruction. Factors related to osteosynthesis plates' complications

The aim of this paper is to identify risk factors associated with the development of osteosynthesis plates' related complications in fibula free flap reconstructions. This is a case series study of consecutive fibula free flaps. Clinical and radiological variables were recorded. Patient outcomes were evaluated with special attention to osteosynthesis plates' related complications; these included plate exposure, plate fracture, loosening of screws, non-union, bone resorption, oro-cutaneous fistulas, and bone exposure. We have done a descriptive analysis, univariate analysis, and multivariate logistic regression model to explore possible risk factors for osteosynthesis plates' related complications. Data analysis was performed using R software (version 3.5.0). 111 fibula free flaps were studied. 29 patients (26.1%) developed osteosynthesis plates' related complications. The mean time to osteosynthesis plates' related complications was 22 months; range (1-120); the median and mode were 12 months. Patients with preoperative radiotherapy (34% vs 14%, p = 0.021), and secondary reconstruction (31% vs 15%, p = 0.053) had a higher incidence of osteosynthesis plates' related complications. In the univariate analysis, "preoperative radiotherapy" (OR 3.07, 95%CI = 1.139-8.242, p = 0.025) and "extraoral soft-tissue defect" (OR 2.907, 95%CI = 1.032-8.088, p = 0.042) were risk factors for osteosynthesis plates' related complications. We have observed an interaction effect: patients with mandibular Brown's classes III + IV and "secondary reconstruction" have a higher risk for osteosynthesis plates' related complications; more than 47.30 times compared to Brown's class I and "primary reconstruction" (p = 0.026). Different factors may contribute to the development of osteosynthesis plates' related complications. Our study adds important information about these. Patients with higher risk of developing complications should be informed that a second intervention to remove the plates might be necessary.

Evaluation of a novel osteosynthesis plate system for mandibular defects

Continuity defects of the jaw can be reconstructed with titanium plates or microvascular bone flaps; osteosynthesis plates are necessary for both. In this study we performed a retrospective review of patients treated with Medartis MODUS® Mandible Trauma/Reco 2.0-2.5, TriLock bridging plates, mandibulectomy and soft tissue free flap or reconstruction with a bony free flap and TriLock mandibular plates from the same system from January 2015 to August 2019. The variables recorded were sex, age, diagnosis, radiotherapy, date of implantation, date of explantation or death of patient, size of mandibular defect, Jewer classification of defect, number of screws used, segments of bony reconstruction, screws per segment, plate exposure, plate breakage, and pseudarthrosis. The bridging plate group consisted of 41 patients, while the mandibular plate group consisted of 24 patients. The percentage of plate exposure was 17.07% for the bridging plate group and 4.17% for the mandibular plate group. Plate breakage was 0 in both groups. Pseudarthrosis was 4.17% in the mandibular plate group. In the bridging plate group, an anterolateral thigh flap covered all exposures. Of 7 plate exposures, 4 were found in a C defect. The complication rate of the investigated plates was lower than the complication rates of other plate systems.

Reconstruction plate-related complications in mandibular continuity defects

PURPOSE

The purpose of this study was to evaluate the complications associated with the use of reconstruction plates with or without non-vascularized bone graft in reconstruction of mandibular segmental defects caused by trauma and tumor resection and to analyze various factors that are associated with the development of complications.

METHODS

A retrospective observational study was conducted, and the investigated variables included the age and gender of the patients, etiology of the defect, the site of the defect, the size of the defect, whether bone graft was used or not, type of plate used, and whether the reconstruction was immediate or delayed. The outcome variables were the postoperative complications and the success rate.

RESULTS

Fifty-one patients were enrolled in this study; the etiology of mandibular defect was trauma in 39 patients (76.5%) and resection of benign or malignant tumors in 12 patients (23.5%). The complication rate was (58.8%) and the success rate was (94.1%); the only factor that significantly increased the incidence of postoperative complications was the size of the defect.

CONCLUSION

Reconstruction plates demonstrated a high success rate despite the high complication rate. Segmental defects caused by trauma were smaller than those created after tumor resection and the only factor that increased complication rate was the size of the defect; other factors did not affect the complication rate.

The use of vascularized fibula flap in mandibular reconstruction; A comprehensive systematic review and meta-analysis of the observational studies

BACKGROUND

Vascularized fibular flaps are considered the gold standard for the reconstruction of segmental defects in the mandible. This review compares the complication and success rates of these techniques between primary and secondary reconstruction, as well as between lateral and antero-lateral defects.

TYPE OF STUDIES REVIEWED

A systematic review and meta-analysis were conducted according to PRISMA protocol and the Cochrane Handbook for Systematic Reviews of Interventions. The authors performed an independent comprehensive search using PubMed, Ovid MEDLINE, Web of Science, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and COS Conference Papers Index according to established inclusion and exclusion criteria. The methodological index for nonrandomized studies (MINORS) was used to assess the quality of the included studies. Meta-analysis was conducted to compare the type of reconstruction and location of the defect.

RESULTS

Seventy-eight studies, involving 2461 patients, were eligible. 83.7% of the included patient received primary reconstruction with vascularized fibular flap. The overall flap success rate was 93%. There was improvement in MINORS quality score over time with positive correlation with the publication year (r = 0.5549, P < 0.0001, CI 0.3693 to 0.6979). Meta-analysis indicated no significant association in flap success between primary and secondary reconstruction, or lateral and antero-lateral defects.

CONCLUSION

Based on the available studies, this review found no evidence of difference in success or complication rates between primary and secondary reconstruction or between lateral and anterolateral defects. High-quality clinical studies are required to analyze the outcome of these techniques, especially regarding the impact of chemotherapy, radiation therapy, implant-supported dental prostheses, and preoperative planning, on the outcome of reconstruction.

The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study

INTRODUCTION

The purpose of this retrospective clinical study was to evaluate the indications for and the utility of reconstruction plates in the management of benign mandibular pathological lesions. The complications associated with plate use were also assessed.

PATIENTS AND METHODS

The clinical and radiological data of 23 patients (16 males, 7 females) with large, benign mandibular pathologies were evaluated. During operations, reconstruction plates were used to prevent mandibular fracture or to allow for bone reconstruction after segmental or disarticulation resection. The mean follow-up time was 11.2months.

RESULTS

Condylar sag was observed in one patient who had undergone disarticulation resection. A reconstruction plate was removed from one patient because of pain. A plate became exposed in one patient who had undergone a disarticulation resection. Two patients reported slight paraesthesia. Screw-loosening was observed in one patient who had received a non-locking plate.

CONCLUSION

Reconstruction plates can be safely used to manage benign mandibular lesions. Preoperative bending of the plates on individualised models is useful for reducing the time required for plate adaptation during operation. Locking reconstruction plates are preferable for preventing screw-loosening. All complications can be managed with careful follow up.

Open Anterior Skull Base Reconstruction: A Contemporary Review

Skull base extirpative and reconstructive surgery has undergone significant changes due to technological and operative advances. While endoscopic resection and reconstruction will continue to advance skull base surgery for the foreseeable future, traditional open surgical approaches and reconstructive techniques are still contemporarily employed as best practices in certain tumors or patient-specific anatomical cases. Skull base surgeons should strive to maintain a working knowledge and technical skill set to manage these challenging cases where endoscopic techniques have previously failed, are insufficient from anatomical constraints, or tumor biology with margin control supersedes the more minimally invasive approach. This review focuses on the reconstructive techniques available to the open skull base surgeon as an adjunct to the endoscopic reconstructive options. Anatomic considerations, factors relating to the defect or patient, reconstructive options of nonvascular grafts, local and regional flaps, and free tissue transfer are outlined using the literature and author's experience. Future directions in virtual surgical planning and emerging technologies will continue to enhance open and endoscopic skull base surgeon's preparation, performance, and outcomes in this continually developing interdisciplinary field.

Miniplates Versus Reconstruction Bars for Oncologic Free Fibula Flap Mandible Reconstruction

PURPOSE

The free fibula is the flap of choice for reconstructing most segmental mandibular defects resulting from head and neck resections. The use of miniplates or reconstruction bars for fixation has been described in the literature. We wanted to compare outcomes between the 2 methods of fixation in head and neck cancer patients.

PATIENTS AND METHODS

An IRB approved retrospective review of 25 consecutive patients undergoing free fibula flap reconstruction of the mandible for head and neck cancer over a period of 5 years was performed. Patient demographics, risk factors, number of fibula osteotomies, defect length, and clinical outcomes were noted. Fourteen patients were reconstructed with miniplates and 12 with reconstruction bars. The choice of plate fixation was determined by the individual reconstructive surgeon. Wound complications requiring surgery and hardware removal rate were recorded.

RESULTS

Average follow-up was 27 months. There was no significant difference with regard to age (P = 0.67), sex (P = 0.77), smoking (P = 0.63), neoadjuvant radiation (P = 0.47), number of osteotomies (P = 0.99), or defect length (P = 0.95) between the 2 groups. Of the 4 patients requiring hardware removal for infection or persistent symptoms, all were in the miniplate group (P = 0.05). Other clinical outcomes, such as hematoma, wound dehiscence, infection, fistula formation, and osteoradionecrosis were comparable between the 2 groups without significant differences. The overall complication rate was similar as well (P = 0.25).

DISCUSSION

Different from other reports in the literature, we show that miniplate use resulted in more hardware removal for infection or persistent symptoms, and this was statistically significant while controlling for patient demographics, risk factors, number of osteotomies, and defect length. Much like other reports in the literature, however, there is no statistically significant difference in overall complication rates, and all other specific complications, when using miniplates versus reconstruction bars. The decision to use miniplates versus reconstruction bars remains a clinical one. In our experience, for 0 to 1 osteotomy, a reconstruction bar suffices. For multiple osteotomies, however, miniplates allow for more customization.

Surgical site infections following oral cavity cancer resection and reconstruction is a risk factor for plate exposure

Background

Plate-related complications following head and neck cancer ablation and reconstruction remains a challenging problem often requiring further management and reconstructive surgeries. We aim to identify an association between surgical site infections (SSI) and plate exposure.

Methods

A retrospective study between 1997 and 2014 was performed to study the association between postoperative SSI and plate exposures. Eligible patients included those with a history of oral squamous cell carcinoma who underwent surgical resection, neck dissection, and free tissue reconstruction. Demographic and treatment related information was collected. SSI were classified based on CDC definition and previously published literature. Univariable analysis on demographic factors, smoking history, diabetes, radiation, surgical and hardware related factors; while multivariable analysis on SSI, plate height, segmental mandibulectomy defects and radiation were conducted such as using cox proportional hazard models.

Results

Three hundred sixty-five patients were identified and included in our study. The mean age of the study group was 59.2 (+/−13.8), with a predominance of male patients (61.9%). 10.7% of our patient cohort had diabetes, and another 63.8% had post-operative radiation therapy. Patients with SSI were more likely to have plate exposure (25 vs. 6.4%, p <0.001). Post-operative SSI, mandibulectomy defects, and plate profile/thickness were associated with plate exposure on univariable analysis (OR = 5.72, p < 0.001; OR = 2.56, p = 0.014; OR = 1.44, p = 0.003 respectively) and multivariable analysis (OR = 5.13, p < 0.001; OR = 1.36, p = 0.017; OR = 2.58, p = 0.02 respectively).

Conclusion

Surgical site infections are associated with higher rates of plate exposure. Plate exposure may require multiple procedures to manage and occasionally free flap reconstruction.

Reconstruction plates used in the surgery for mandibular discontinuity defect

OBJECTIVES

The purpose of this study was to analyze the survival rate of reconstruction plates that were used to correct mandibular discontinuity defects.

MATERIALS AND METHODS

We analyzed clinical and radiological data of 36 patients. Only discontinuous mandibular defect cases were included in the study. Reconstruction plate survival rate was analyzed according to age, gender, location of defect, defect size, and whether the patient underwent a bone graft procedure, coronoidectomy, and/or postoperative radiation therapy (RT).

RESULTS

Plate-related complications developed in 8 patients, 7 of which underwent plate removal. No significant differences were found in plate survival rate according to age, gender, location of defect, defect size, or whether a bone graft procedure was performed. However, there were differences in the plate survival rate that depended on whether the patient underwent coronoidectomy or postoperative RT. In the early stages (9.25±5.10 months), plate fracture was the most common complication, but in the later stages (35.75±17.00 months), screw loosening was the most common complication.

CONCLUSION

It is important to establish the time-related risk of complications such as plate fracture or screw loosening. Coronoidectomy should be considered in most cases to prevent complications. Postoperative RT can affect the survival rate and hazard rate after a reconstruction plate is fitted.

Hardware removal after osseous free flap reconstruction

OBJECTIVE

Identifying risk factors for hardware removal in patients undergoing mandibular reconstruction with vascularized osseous free flaps remains a challenge. The purpose of this study is to identify potential risk factors, including osteocutaneous radial forearm versus fibular flap, for need for removal and to describe the fate of implanted hardware.

STUDY DESIGN

Case series with chart review Setting Academic tertiary care medical center.

SUBJECTS AND METHODS

Two hundred thirteen patients undergoing 227 vascularized osseous mandibular reconstructions between the years 2004 and 2012. Data were compiled through a manual chart review, and patients incurring hardware removals were identified.

RESULTS

Thirty-four of 213 evaluable vascularized osseous free flaps (16%) underwent surgical removal of hardware. The average length of time to removal was 16.2 months (median 10 months), with the majority of removals occurring within the first year. Osteocutaneous radial forearm free flaps (OCRFFF) incurred a slightly higher percentage of hardware removals (9.9%) compared to fibula flaps (6.1%). Partial removal was performed in 8 of 34 cases, and approximately 38% of these required additional surgery for removal.

CONCLUSION

Hardware removal was associated with continued tobacco use after mandibular reconstruction (P = .03). Removal of the supporting hardware most commonly occurs from infection or exposure in the first year. In the majority of cases the bone is well healed and the problem resolves with removal.

Disease relapse after segmental resection and free flap reconstruction for mandibular osteoradionecrosis

Objective: The objective of this study was to assess the outcomes, complications, and incidence of disease recurrence of mandibular osteoradionecrosis (ORN) after resection and microvascular free flap reconstruction.

Study Design: Case series with chart review.

Setting: Academic medical center.

Subjects And Methods: Retrospective patient data review of 40 patients with mandibular ORN who were treated by segmental mandibulectomy and microvascular reconstruction between 1995 and 2009. All patients received radiation therapy for previous head and neck cancer, and 12 of 40 patients received concurrent chemotherapy. All patients failed to respond to conservative management. There were 26 males and 14 females, with a median age of 62 years. Median follow-up was 17.4 months.

Results: There were no free flap failures. The incidence of wound-related complications was 55 percent. Median time to complication was 10.6 months. Ten (25%) patients developed symptoms of residual or recurrent ORN, with 70 percent of the recurrences arising in unresected condyles that were adjacent to the segmental mandibulectomy. Statistical analysis revealed that current smokers were at reduced risk to develop residual or recurrent ORN.

Conclusion: This present study confirms that microvascular free flaps are reliable for treatment of advanced mandibular ORN. Nevertheless, there remains a 55 percent incidence of wound-healing complications. The lack of objective clinical criteria to judge the appropriate amount of mandible resection in patients with ORN remains an unresolved issue that resulted in the development of recurrent ORN in 25 percent of patients. Further investigations are needed to better understand the pathophysiology of ORN to prevent postoperative wound complications and disease recurrence.