Abstract
Purpose
Fibula free flaps (FFF) are the gold standard tissue for reconstruction of segmental mandibular defects. A comparison of mini-plate (MP) and reconstruction bar (RB)-based fixation of FFFs has been previously described in a systematic review; however, long-term, single center studies comparing the two plating methods are lacking. The authors aim to examine the complication profile between MPs and RBs at a single tertiary cancer center. We hypothesized that increased components and a lack of rigid fixation inherent to MPs would lead to higher rates of hardware exposure/failure.
Methods
A retrospective review was carried out from a prospectively maintained database at Memorial Sloan Kettering Cancer Center. All patients who underwent FFF-based reconstruction of mandibular defects between 2015–2021 were included. Data on patient demographics, medical risk factors, operative indications, and chemoradiation was collected. The primary outcomes of interest were perioperative flap-related complications, long-term union rates, osteoradionecrosis (ORN), return to the operating room (OR), and hardware exposure/failure. Recipient site complications were further stratified into two groups: early (<90 days) and late (>90 days).
Results
96 patients met inclusion criteria (RB=63, MP=33). Patients in both groups were similar with respect to age, presence of comorbidities, smoking history, and operative characteristics. The mean follow-up period was 17.24 months. 60.6% and 54.0% of patients in the MP and RB cohorts received adjuvant radiation, respectively. There were no differences in rates of hardware failure overall; however, in patients with an initial complication after 90 days, MPs had significantly higher rates of hardware exposure (3 vs. 0, p=0.046).
Conclusions
MPs were found to have a higher risk of exposed hardware in patients with a late initial recipient site complication. It is possible that improved fixation with highly adaptive RBs designed by computer-aided design/manufacturing (CAD/CAM) technology explains these results. Future studies are needed to assess the effects of rigid mandibular fixation on patient reported outcome measures in this unique population.
Keywords: Reconstruction bar, mini plate, fibula free flap, mandibulectomy, mandible reconstruction
Introduction:
Oncologic resection for cancer of the head and neck often results in large composite defects that include both soft tissue and bony components. These defects can impair patients’ functional status in several ways. For example, large tissue loss may lead to compromised deglutition, mastication, speech articulation, facial nerve function, oral competence, and dentition. The goals of mandibular reconstruction include achieving tissue coverage, precise contour and occlusion, adequate articulation between the condyle and mandibular fossa, restoration of dentition, and reestablishment of the aforementioned functions of the lower jaw.1 The use of the fibula free flap (FFF) for repair of segmental mandibular defects was first described by Hidalgo in 1989,2 and since then has evolved into the workhorse flap for reconstruction of the jaw. The FFF is based on the peroneal artery and is an ideal tissue given its long vascular pedicle, dual blood supply (both periosteal and endosteal), reliable skin paddle, and the length of dense cortical bone available for harvest (up to ~25 cm in males). Additionally, the flap can be harvested with a component of muscle, thus creating additional soft tissue available for coverage and inset into complex defects. This enables reconstruction of large defects with a predictable rate of donor site morbidity.3,4 An additional advantage is that the FFF can be harvested simultaneously with the ablative procedure at the head, thus reducing operative time and cost.5,6
Segmental defects of the mandible are most commonly reconstructed with the FFF due to its ability to undergo multiple osteotomies, allowing for complex neo-mandibular shaping. Rigid fixation of the FFF bony segments to each other and the native mandible has evolved through the years, and includes interosseous wiring, Kirchner wires, lag screws, and metallic plates.7,8 Currently, the most common method of fixation is the application of metallic plates. This is performed with either mini plates (MPs), which allow points of rigid fixation at multiple sites of osteotomies, or reconstruction bars (RB) which span the length of the mandibular defect to include the intervening FFF. MP-based fixation of FFFs in the setting of mandibular reconstruction was described by Hidalgo and Pusic.9 They noted that the benefits of MPs include lower profiles, improved malleability, and ease of application to the osseous construct. Additionally, less periosteal stripping is required for application of MPs. In the event of hardware failure/infection, MPs can be removed individually via a minimally invasive approach, thus sparing the rest of the reconstruction and hardware. The benefits of MPs are offset by an increase in the amount of hardware components (i.e., need for multiple plates, higher number of screws). Also, with smaller plates, the force of mastication is distributed over a decreased surface area, which increases the risk of plate loosening and subsequent fracture/failure, especially if placed in areas with high mechanical stress.10 With RBs, the load bearing status of functional jaw movements (i.e., speaking, chewing) is spread over the entire plate, thus decreasing mechanical force on the hardware. Additionally, RBs are often designed preoperatively using computer aided design/manufacturing (CAD/CAM) technology, facilitating extremely precise contour between the plate, native mandible, and donor fibula.11–13 CAD/CAM has allowed for the advent of RBs with much lower profiles compared to earlier plating systems. These advantages are offset by the fact that RBs require wider surgical exposure for their removal should the plates fail or become infected/exposed.14 Another potential downside of RBs is that their rigidity introduces a component of “stress shielding”, a factor which may increase the risk of osteoporosis of the graft and native mandible.15
We have previously performed a systematic review comparing the surgical outcomes between the two methods of fixation, where it was noted that MPs had a higher incidence of plate-related complications, including fistula formation, hardware malfunction/exposure, and partial/total flap loss.16 However, long-term single center studies are lacking and there is no clear consensus in the literature on the optimal method of mandibular fixation.13,14,17 The aim of this study is to assess long-term outcomes between MP and RB-based fixation of segmental mandibular defects reconstructed with FFFs at a large comprehensive cancer. Based on our previous systematic review and clinical experience, we hypothesized that RBs would have a lower rate of long-term hardware malfunction.
Methods:
Dataset
This is a retrospective case series. A prospectively maintained database was used to identify patients. Inclusion criteria were patients who underwent reconstruction of segmental mandibular defects with a FFF between January 2015 and June 2021. Patients reconstructed with other osseous flaps (i.e., iliac crest, scapula) were not examined. Permission was obtained from the institutional review board at Memorial Sloan Kettering Cancer Center. Demographic details were collected for all patients, including, age, gender, race, ethnicity, body mass index (BMI), medical comorbidities, chemoradiation history, and indication for surgery. Primary outcomes of interest included postoperative wound infection/abscess, fistula formation, malunion/nonunion, wound dehiscence, partial/total flap loss, primary plate-related complications (loosening, fracture, etc.), osteoradionecrosis (ORN), chyle leak, hardware exposure, and a return to the operating room (OR) for any reason. Operative details were collected, and included defect type/size, number of osteotomies, and number of osseointegrated implants.
Mandibular defects were characterized by laterality and type: right/left and anterior, lateral (defined as segmental mandibular defects that did not involve the ramus and left the condyle in situ), bilateral (segmental defects on either side of the symphysis), or hemimandibular (defined as defects spanning the entire length of the lateral mandible with concomitant resection of the ramus and/or condyle with/without auto-transplantation of the condyle). Defects were further characterized by the classification system previously described by Cordeiro et al.18 In this classification system, bony defects were divided into anterior (Type I), hemimandible (Type II), and lateral mandible (Type III), with further designation of the extent of external skin and intraoral soft tissue defects. Anterior defects were those that spanned the mental foramina with minimal involvement of the mandibular body. Patients under the age of 18 were excluded from this study.
Statistical Analysis
Categorical demographic, operative, and complication variables were presented as counts and percentages while continuous demographic variables were presented as means and standard deviations as well as medians and interquartile ranges. Demographics were compared using Fisher’s Exact Test (categorical variables), student t-test for age and BMI, and Mann-Whitney U test for follow-up days (data not normally distributed). Operative and complication comparisons were conducted using Fisher’s Exact Test. All analyses were done in R Studio (v. 1.4.1717).
Results:
A total of 96 patients met inclusion criteria and underwent FFF-based reconstruction of mandibular defects at our comprehensive cancer center. Table 1 provides a summary of patient demographics and comparison between MP and RB patients. Patients were not significantly different with respect to age (p=0.78), BMI (p=0.22), gender (p=0.49), diabetes mellitus (p=1.0), hypertension (p=1.0), cardiovascular disease (p=0.38), and smoking history (p=0.17). 66 patients were male and 30 were female, with an average age at surgery of 63.3 years. The most common indications for surgery were cancer (n=85) and ORN (n=10). Adjuvant radiation was administered to 60.6% and 54.0% of patients in the MP and RB cohorts respectively, while 18.2% and 28.6% of the MP and RB patients respectively had received radiation prior to surgery. Current or previous smokers comprised 61.4% of the total patients. Previous head and neck surgery for management of oral cavity cancer was performed in 10 MP and 22 RB patients. The mean follow-up duration was 17.24 months.
Table 1:
Patient Demographics
| Total Patients | Mini-Plates, n (%) | Reconstruction Bars, n (%) | p value | |
|---|---|---|---|---|
| 96 | 33 | 63 | ||
| Age | 0.78 | |||
| Mean (SD) | 63.3 (13.2) | 62.7 (16.3) | 63.6 (11.4) | |
| Median (IQR) | 66 (57, 71) | 66 (55, 71) | 66 (57.5, 70) | |
| Gender, n (%) | 0.49 | |||
| Male | 66 (68.8) | 21 (63.6) | 45 (71.4) | |
| Female | 30 (31.3) | 12 (36.4) | 18 (28.6) | |
| Race, n (%) | 0.85 | |||
| White | 62 (64.6) | 21 (63.6) | 41 (65.1) | |
| Black | 6 (6.3) | 2 (6.1) | 4 (6.3) | |
| Asian | 25 (26) | 9 (27.3) | 16 (25.4) | |
| Native American | 1 (1) | 0 (0) | 1 (1.6) | |
| Other | 1 (1) | 1 (3) | 0 (0) | |
| Refused to Answer | 1 (1) | 0 (0) | 1 (1.6) | |
| Ethnicity, n (%) | 0.6 | |||
| Hispanic or Latino | 2 (2.1) | 1 (3) | 1 (1.6) | |
| Not Hispanic or Latino | 91 (94.8) | 32 (97) | 59 (93.7) | |
| Unknown | 3 (3.1) | 0 (0) | 3 (4.8) | |
| Smoking, n (%) | 0.17 | |||
| Never Smoker | 36 (37.5) | 15 (45.5) | 21 (33.3) | |
| Previous | 46 (47.9) | 15 (45.5) | 31 (49.2) | |
| Current | 13 (13.5) | 2 (6.1) | 11 (17.5) | |
| Unknown | 1 (1) | 1 (3) | 0 (0) | |
| Hypertension, n (%) | 57 (59.4) | 20 (60.6) | 37 (58.7) | 1 |
| CVD, n (%) | 60 (62.5) | 23 (69.7) | 37 (58.7) | 0.38 |
| Diabetes, n (%) | 24 (25) | 6 (18.2) | 18 (28.6) | 1 |
| Immune, n (%) | 52 (54.2) | 22 (66.7) | 30 (47.6) | 0.09 |
| BMI, | 0.22 | |||
| mean kg/m2 (SD) | 27.03 (4.9) | 27.9 (5.6) | 26.6 (4.4) | |
| Median (IQR) | 26.2 (24.2, 29.4) | 27.1 (24.5, 30.7) | 26.1 (24.2, 28.6) | |
| Prior Surgery, n (%) | 0.78 | |||
| Yes | 32 (33.3) | 10 (30.3) | 22 (34.9) | |
| No | 63 (65.6) | 23 (69.7) | 40 (63.5) | |
| Unknown | 1 (1) | 0 (0) | 1 (1.6) | |
| Indication for Surgery | 0.16 | |||
| Cancer | 85 (88.5) | 32 (97) | 53 (84.1) | |
| ORN | 10 (10.4) | 1 (3) | 9 (14.3) | |
| Unknown | 1 (1) | 0 (0) | 1 (1.6) | |
| Chemotherapy, n (%) | 47 (49) | 14 (42.4) | 33 (52.4) | 0.4 |
| Radiation, n (%) | 0.56 | |||
| History of Previous Radiation | 24 (25) | 6 (18.2) | 18 (28.6) | |
| Adjuvant | 54 (56.3) | 20 (60.6) | 34 (54) | |
| None | 18 (18.8) | 7 (21.2) | 11 (17.5) | |
| Follow Up (days) | 0.17 | |||
| Mean (SD) | 524.5 (366.9) | 594.8 (360) | 488.2 (368) | |
| Median (IQR) | 483 (203.8, 783.8) | 556.5 (403.3) | 354 (828.5) |
SD: Standard Deviation; IQR: Interquartile Range.; CVD: cardiovascular disease; ORN: osteoradionecrosis; Immune: immunocompromised state
Table 2 outlines the operative characteristics between the two cohorts. A total of 63 RBs and 33 MPs were placed at the time of reconstruction. Patients in both cohorts were similar with respect to defect type (p=0.14), laterality (p=0.16), and length (p=0.56). Most patients in both cohorts had a hemimandibular defect (MP=78.8%, RB=66.7%), with the majority having a defect length in the range of 5–10 cm. There was no difference in the number of immediate dental implants (IDIPs) placed between the cohorts, with a total of two implants being the most frequent in both MP and RB patients (p=0.08). Patients in both cohorts most commonly had 2 or 3 fibular osteotomies, with no statistical difference between MP and RB patients (p=0.278). Extensive defects required a second soft tissue free flap, in addition to a fibula flap, in 8 patients (8.3%).
Table 2:
Operative Characteristics
| Total Patients, n (%) | Mini-Plates, n (%) | Reconstruction Bars, n (%) | p value | |
|---|---|---|---|---|
| Total Patients | 96 | 33 | 63 | |
| Defect Type | 0.14 | |||
| Anterior Mandible | 5 (5.2) | 1 (3) | 4 (6.3) | |
| Bilateral | 12 (12.5) | 1 (3) | 11 (17.5) | |
| Hemimandible | 68 (70.8) | 26 (78.8) | 42 (66.7) | |
| Lateral Mandible | 11 (11.5) | 5 (15.2) | 6 (9.5) | |
| Defect Laterality | 0.16 | |||
| Bilateral | 12 (12.5) | 1 (3) | 11 (17.5) | |
| Central | 5 (5.2) | 1 (3) | 4 (6.3) | |
| Left | 36 (37.5) | 15 (45.5) | 21 (33.3) | |
| Right | 43 (44.8) | 16 (48.5) | 27 (42.9) | |
| Length of Defect | 0.56 | |||
| (0–5] | 3 (3.1) | 1 (3) | 2 (3.2) | |
| (5–10] | 66 (68.8) | 21 (63.6) | 45 (71.4) | |
| [10–15) | 26 (27.1) | 10 (30.3) | 16 (25.4) | |
| >15 | 1 (1) | 1 (3) | 0 (0) | |
| Number of IDIPs | 0.08 | |||
| 0 | 4 (4.2) | 2 (6.1) | 2 (3.2) | |
| 1 | 6 (6.3) | 4 (12.1) | 2 (3.2) | |
| 2 | 50 (52.1) | 20 (60.6) | 30 (47.6) | |
| 3 | 28 (29.2) | 7 (21.2) | 21 (33.3) | |
| 4 | 6 (6.3) | 0 (0) | 6 (9.5) | |
| 5 | 2 (2.1) | 0 (0) | 2 (3.2) | |
| Number of Fibula Osteotomies | 0.278 | |||
| 1 | 14 (14.6) | 7 (21.2) | 7 (11.1) | |
| 2 | 33 (34.4) | 13 (39.4) | 20 (31.7) | |
| 3 | 28 (29.2) | 10 (30.3) | 18 (28.6) | |
| 4 | 19 (19.8) | 3 (9.1) | 16 (25.4) | |
| 5 | 1 (1) | 0 (0) | 1 (1.6) | |
| 6 | 1 (1) | 0 (0) | 1 (1.6) | |
| Number of Donor Sites | 0.71 | |||
| 1 | 88 (91.7) | 31 (93.9) | 57 (90.5) | |
| 2 | 8 (8.3) | 2 (6.1) | 6 (9.5) |
IDIP: immediate dental implants
Table 3 provides a review of the overall complication rate as well as comparison of the MP and RB cohorts. There was no statistical difference in the rate of overall recipient site complications between MP and RB patients (p=0.665). In total, 54 of the 96 (56.25%) patients had a recipient site complication. Perioperative flap congestion/ischemia occurred in 4 patients (MP=2, RB=2). Cellulitis occurred in 16 patients (MP=9, RB=7, p=0.072), while 27 patients (MP=7, RB=20) had an abscess at the recipient site (p=0.158). There were 7 instances (MP=1, RB=6) of neck hematomas (p=0.239). There were no total flap losses. Partial flap loss occurred in 2 patients (MP=1, RB=1, p=1.0). Only one RB patient had issues with hardware failure, while 13 patients (MP=7, RB=6) developed exposed hardware (p=0.194). A higher percentage of MP patients developed cellulitis, orocutaneous fistula(s), wound dehiscence, delayed wound healing, exposed hardware, and ORN as compared to RB patients, although this was not statistically significant. Contrastingly, a higher percentage of RB patients developed abscesses and hematomas, which was also found to lack statistical significance.
Table 3:
Overall Recipient Site Complication Rates
| Total Patients, n (%) | Mini-Plates, n (%) | Reconstruction Bars, n (%) | p value | |
|---|---|---|---|---|
| Ever Complication* | 54 (56.25) | 20 (60.61) | 34 (53.97) | 0.665 |
| Abscess | 27 (50) | 7 (35) | 20 (58.82) | 0.158 |
| Aspiration Pneumonia | 2 (3.7) | 1 (5) | 1 (2.94) | 1 |
| Chyle Leak | 1 (1.85) | 0 (0) | 1 (2.94) | 1 |
| Delayed Wound Healing | 4 (7.41) | 2 (10) | 2 (5.88) | 0.622 |
| Exposed Hardware | 13 (24.07) | 7 (35) | 6 (17.65) | 0.194 |
| Flap Congestion | 1 (1.85) | 0 (0) | 1 (2.94) | 1 |
| Flap Ischemia | 3 (5.56) | 2 (10) | 1 (2.94) | 0.548 |
| Hardware Failure | 1 (1.85) | 0 (0) | 1 (2.94) | 1 |
| Hematoma | 7 (12.96) | 1 (5) | 6 (17.65) | 0.239 |
| Orocutaneous Fistula | 12 (22.22) | 7 (35) | 5 (14.71) | 0.101 |
| Osteoradionecrosis | 2 (3.7) | 1 (5) | 1 (2.94) | 1 |
| Partial Flap Loss | 2 (3.7) | 1 (5) | 1 (2.94) | 1 |
| Wound Dehiscence | 11 (20.37) | 7 (35) | 4 (11.76) | 0.077 |
| Wound Infection | 16 (29.63) | 9 (45) | 7 (20.59) | 0.072 |
Percentage out of total patients included in the study, all other percentages are out of those who had recipient site complications. MP: Mini-Plate; RB: Reconstruction Bar
To analyze the complication profiles between MPs and RBs, the two cohorts were divided into “early” and “late” groups. Patients in the early group had an initial recipient site complication within the first 90 days following surgery. Those in the late group had an initial recipient site complication after 90 days. The primary endpoint of infected or exposed hardware was then assessed within each cohort, with the hypothesis that prevention of early complications would have a protective effect against this outcome. Table 4 provides a comprehensive subgroup analysis and review of the complication rates between MP and RB patients after stratifying into early and late groups. There were 20 MP and 34 RB patients in the early group (p=1.0). The late group had 5 MP and 10 RB patients (p=0.55). RB patients had a statistically higher incidence of a return to the OR within the early group (p=0.02) Reasons for returning to the OR in the early period were most often for management of technical issues related to surgery itself rather than complications related to the implanted hardware. This included 3 patients who were explored for neck hematomas, 1 chyle leak and 2 abscesses drained in the OR, and 3 patients with flap ischemia that required operative exploration and assessment/revision of the microvascular anastomosis. Of note, within the early group, 20% of the MP patients (n=4) and 17.6% of the RB patients (n=6) eventually presented with hardware exposure. However, there was no statistical difference noted on analysis (p=1.0). Within the late group, there were no statistically significant differences in the occurrence of any of the recipient site complications, or their respective outcomes, between MP and RB patients. However, MP patients in the late cohort were found to be more likely to develop infected/exposed hardware (p=0.046) Should a patient be able to reach the 90-day mark after surgery without any recipient site complication, his/her chance of developing exposed hardware is thus significantly more likely if an MP was implanted at the time of surgery.
Table 4:
Subgroup Analysis
| Total Patients | MPs | RBs | p value | |
|---|---|---|---|---|
| Total Recipient Site Complications | 54 | 20 | 34 | |
| Early Complication (<90 days), n(%) | 39 (72.2) | 15 (75) | 24 (70.6) | 1 |
| Type, n (%) | ||||
| Abscess | 20 (37) | 7 (35) | 13 (38.2) | 0.77 |
| Chyle Leak | 1 (1.9) | 0 (0) | 1 (2.9) | 1 |
| Flap Congestion | 1 (1.9) | 0 (0) | 1 (2.9) | 1 |
| Flap Ischemia | 2 (3.7) | 1 (5) | 1 (2.9) | 1 |
| Hematoma | 3 (5.6) | 0 (0) | 3 (8.8) | 0.29 |
| Orocutaneous Fistula | 2 (3.7) | 0 (0) | 2 (5.9) | 0.52 |
| Wound Dehiscence | 7 (13) | 5 (25) | 2 (5.9) | 0.09 |
| Wound Infection/Cellulitis | 3 (5.6) | 2 (10) | 1 (2.9) | 0.55 |
| Outcome, n (%) | ||||
| Inpatient Antibiotics | 3 (5.6) | 2 (10) | 1 (2.9) | 0.55 |
| Bedside I&D | 12 (22.2) | 5 (25) | 7 (20.6) | 0.74 |
| Conservative Management | 11 (20.4) | 7 (35) | 4 (11.8) | 0.08 |
| IR Drainage | 2 (3.7) | 0 (0) | 2 (5.9) | 0.52 |
| Return to OR | 9 (16.7) | 0 (0) | 9 (26.5) | 0.02 |
| Outpatient Antibiotics | 2 (3.7) | 1 (5) | 1 (2.9) | 1 |
| Readmission | 0 (0) | 0 (0) | 0 (0) | -- |
| Later Exposed Hardware, n (%) | 10 (18.5) | 4 (20) | 6 (17.6) | 1 |
| Late Complication (> 90 days), n (%) | 15 (27.8) | 5 (25) | 10 (29.4) | 0.55 |
| Type, n (%) | ||||
| Abscess | 4 (7.4) | 0 (0) | 4 (11.8) | 0.28 |
| Cancer Recurrence | 1 (1.9) | 0 (0) | 1 (2.9) | 1 |
| Contour Irregularities | 2 (3.7) | 1 (5) | 1 (2.9) | 1 |
| Exposed Hardware | 1 (1.9) | 0 (0) | 1 (2.9) | 1 |
| Malunion | 1 (1.9) | 0 (0) | 1 (2.9) | 1 |
| Wound Dehiscence | 1 (1.9) | 0 (0) | 1 (2.9) | 1 |
| Wound Infection/Cellulitis | 5 (9.3) | 4 (20) | 1 (2.9) | 0.06 |
| Outcome, n (%) | ||||
| Inpatient Antibiotics | 6 (11.1) | 4 (20) | 2 (5.9) | 0.18 |
| Bedside I&D | 2 (3.7) | 0 (0) | 2 (5.9) | 0.52 |
| Conservative Management | 1 (1.9) | 0 (0) | 1 (2.9) | 1 |
| Fat Grafting | 1 (1.9) | 1 (5) | 0 (0) | 0.37 |
| IR Drainage | 1 (1.9) | 0 (0) | 1 (2.9) | 1 |
| Return to OR | 2 (3.7) | 0 (0) | 2 (5.9) | 0.52 |
| Outpatient Antibiotics | 1 (1.9) | 0 (0) | 1 (2.9) | 1 |
| Readmission | 1 (1.9) | 0 (0) | 1 (2.9) | 1 |
| Later Exposed Hardware, n (%) | 3 (5.6) | 3 (15) | 0 (0) | 0.046 |
MP: Mini-Plate; RB: Reconstruction Bar; IR: Interventional Radiology; OR: Operating Room; I&D: Incision and Drainage
Discussion:
The fibula free flap has become the workhorse tissue source for reconstruction of segmental mandibular defects. The fibula is relatively uniform in shape and size along its length, and when paired with a fixation plate, allows for excellent contouring to the native mandible. Additionally, flap harvest and the ablative surgery may be performed simultaneously, allowing for a two-team approach, and reduced operating time. The excellent cortical bone stock provided by the FFF permits placement of osseointegrated dental implants, either in an immediate or delayed setting. Fixation of the FFF to the native mandible requires the use of metallic plates, usually either MPs or RBs, with each type having its own set of advantages. MPs have lower profiles, excellent malleability, and are easily contoured to the osseous construct. Additionally, MPs require a decreased amount of periosteal stripping prior to application to the bony flap/mandible, a factor that may be critical for preserving the vascularity of the FFF. The removal of MPs is technically easier in the setting of plate exposure/infection. However, with MP fixation, the stress of mastication is distributed over a smaller area, thus increasing the risk of micromovement of hardware components and subsequent plate fracture/failure. RBs span the entire length of the defect from either end of the remaining native mandible, to include the intervening FFF. This allows for improved recreation of the gonial angle. With RBs, the forces of mastication are spread over a larger area, theoretically preventing stress on the metallic components, a factor which may protect against hardware failure.18 Previously, osseous fixation plates had to be bent to shape by the operating surgeon, a time-consuming and imprecise practice. Additionally, the bending process creates points of weakness in the metallic plate, increasing the risk of future hardware malfunction and/or bony nonunion. CAD/CAM technology has allowed for detailed and highly accurate preoperative planning of both the donor and recipient sites. With this technology, prefabricated cutting guides are created to assist with intraoperative decision making and marking of predicted osteotomy sites. Additionally, this has allowed for production of prefabricated, pre-bent plates tailored to each patient, eliminating the factor of human error introduced with plate manipulation. This has minimized the difference in contour between the FFF and the reconstruction plates, thus reducing operating time, improving aesthetic outcomes, and decreasing plate and hardware-related complication rates.19,20 Despite the improved load-bearing status and superior rigid fixation with RBs, they have a set of disadvantages. RBs have higher profiles than MPs despite the improving and thinner design of newer constructs. Another drawback with RBs is the increased technical difficulty required for their removal. Lastly, RBs are associated with “stress shielding”, a factor that may decrease bone density in the osseous construct.8 Although the development of osteoporosis in the fibular graft was not quantified in our study, it can be assumed that loosening of hardware components is an indicator of this event. Given the higher number of metallic components and the less rigid fixation inherent to MPs, the potential for hardware loosening/malfunction may be higher with this plating system, a factor which may contribute to osteoporotic changes to the fibular graft.
A previous systematic review by our group showed that MPs were associated with higher rates of hardware related complications, orocutaneous fistula, and flap loss.16 To our knowledge, our study is the largest examination comparing long-term outcomes between MPs and RBs in patients who underwent FFF-based reconstruction of segmental mandibular defects. We found that the overall complication profile was similar with both fixation plates. When comparing complications in the early (<90 days) and late (>90 days) groups, the results show that MPs are associated with a higher risk of hardware infection/exposure in the long term. In theory, RBs may portend a higher risk of plate exposure given their larger size; however, advances in the design and production of RBs using CAD/CAM technology has led to the creation of low-profile plates with improved biocompatibility, a possible reason for the decreased complication rate seen in this study. Given the fact that all plating systems produced by CAD/CAM at our institution are RBs, we have found that this plating system has largely replaced MPs in the setting of FFF-based reconstruction following segmental mandibulectomy. The temporal nature of the utilization of MPs and RBs, with the latter being preferred in our institution, may have contributed to our findings. Additionally, it is theorized that MPs lack the inherent rigid fixation that is achieved with a plating system that spans longer lengths and defects. With MPs, mechanical stress associated with functional jaw movements would thus be distributed over a smaller area. This may lead to micromovement of hardware with time, and eventual loosening of the individual components. These patients are then prone to repeated bouts of infection and/or malfunction of the metallic implants (i.e., loosening, fracture, malunion, exposure). CAD/CAM technology has allowed the production of bars tailored to the individual patient. This process eliminates the need to bend plates intraoperatively, a technique which creates points of weakness, and likely contributes to the improved outcomes seen with patients who have preoperative CAD/CAM.20–23
In examining complications following FFF-based reconstruction of mandibular defects, the operating surgeon should ensure familiarity with patient-specific factors and comorbidities that may contribute to deleterious and undesirable results. For instance, certain medical comorbidities and environmental exposures, including diabetes mellitus, underlying cardiovascular disease, and smoking status should be considered in the preoperative workup. These patients may have an increased risk of delayed wound healing and infections, variables which may contribute to tissue edema and continued local inflammation. This, in turn, may compromise blood supply to the free flap.24–27 These factors may act in concert to increase the risk of flap failure or hardware-associated complications. Additionally, radiation therapy, whether in the adjuvant or historical setting, is an important factor to consider. The effects of radiotherapy are well described and include both acute and chronic complications. In the acute setting, mucositis, xerostomia, and inflammation/edema of the skin may occur, all of which may perpetuate infections and impaired wound healing. In the long-term, radiation may lead to persistent xerostomia, diminished vascular supply and fibrosis of soft tissues, ORN, and fistula formation.27–29 Adjuvant therapy can cause direct damage to the soft tissue covering the flap, as well as to the flap itself. On the other hand, a history of radiation prior to surgery spares the FFF and its associated skin paddle but may affect the native oral mucosa. These may be significant contributing factors in the development of eventual hardware failure.
Our study shows that the overall complication profile for MPs and RBs are similar. However, for patients with an initial complication that occurs after 90 days, the rate of infected and/or exposed hardware is higher with MPs. This suggests that tailored and diligent postoperative care is essential to achieving desirable outcomes. The complication profile for reconstruction of the head and neck is well established;30 however, preventing early perioperative complications may have a protective effect on the flap and implanted hardware in the long term. Our study is limited by its retrospective nature as well as the relatively small sample size. Recently, CAD/CAM technology has been integrated into most patients’ preoperative workup at our institution. This may have contributed to our findings given the fact that all recent RBs are produced using CAD/CAM technology and have replaced MPs as the preferred method of fixation. It should be noted that recent advances have ushered in CAD/CAM MPs; however, our institution has just recently integrated this technology. Additionally, we typically us CAD/CAM designed MPs in the setting of maxillary reconstruction given the need for more acute angulation of the plates as well as the decreased weight-bearing status of the maxilla.Another potential advantage of CAD/CAM MPs is the avoidance of screw overlap with dental implant placement in the fibula. The use of CAD/CAM, however, makes this process quite seamless with RB fixation and immediate dental implant placement. Further studies are needed to examine the effects of rigid fixation on patient reported outcome measures (PROMs) in both the short and long-term.
Conclusions:
Fibula free flaps are largely considered the workhorse for reconstruction and restoration of mandibular continuity following ablative oncologic procedures. Rigid fixation of the fibula to the native mandible requires the use of metallic plates, typically with an MP or RB. Our results show that overall complications are similar with both plating methods. The type of plate used is a factor of both surgeon preference as well as intraoperative assessment of the defect. RBs may have lower rates of long-term hardware exposure as compared to MPs, likely reflecting advancements in CAD/CAM technology and microsurgical techniques. However, strong conclusions favoring one plating method over the other are limited by our small sample size. Further large scale and multi-institutional studies are required to definitively assess the optimal method of rigid fixation in this unique population.
Footnotes
Financial Disclosures: The authors have no conflicts of interest to disclose.
Contributor Information
Zack Cohen, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 166 Elizabeth St. #2A, New York, NY 10012.
Francis D. Graziano, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, New York, NY 10065
Meghana G. Shamsunder, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, New York, NY 10065
Farooq Shahzad, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, New York, NY 10065.
Jay O. Boyle, Head and Neck Surgical Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065
Marc A. Cohen, Head and Neck Surgical Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065
Evan Matros, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, New York, NY 10065.
Jonas A. Nelson, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, New York, NY 10065
Robert J. Allen, Jr., Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, New York, NY 10065
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