Statistical analysis of 133 cases of mandibular reconstruction using free osseous/osteocutaneous flaps

We studied 133 consecutive cases of mandibular reconstruction using free osseous/osteocutaneous flaps performed from 1979 to 1997. The ages of the 97 men and 36 women ranged from 13 to 79 years with an average age of 53.7 years. Donor sites included the rib (11 cases), radius (1 case), ilium (36 cases), scapula (51 cases), and fibula (34 cases). Complications included total flap necrosis, partial flap necrosis, major fistula formation, and minor fistula formation. The rate of total flap necrosis involving the ilium and fibula was significantly higher than that of all other donor materials combined. Mandibular defects were classified in two ways: by the extent of the bony defect according to the HCL method of Jewer and Boyd and by the extent of the soft tissue defect itself. The extent of the soft tissue defect was classified into four groups including "none", "skin", "mucosal", and "through-and-through". According to these classifications, functional and aesthetic assessments of deglutition and contour were performed on 95 cases, and speech was evaluated in 94 cases. To evaluate the postoperative results, points were assigned to each assessment of deglutition, speech, and mandibular contour. Statistical analysis between pairs of bone defect groups revealed there was no significant difference in each category. Regarding deglutition, statistical analysis between pairs of soft tissue defect groups revealed that there were significant differences between the "none" and "mucosal" groups and also between the "none" and "through-and-through" groups. Regarding the speech assessment, there was a significant difference between the "none" and the "through-and-through" groups. Regarding the contour assessment, there were significant differences between the "none" and the "through-and-through" groups, and between the "mucosal" and the "through-and-through" groups. Points given for each function depending on the reconstruction material were also analyzed statistically. Although there was no significant difference regarding deglutition, there were significant difference between the rib and other materials regarding speech and contour assessments. From this prospective study, we have developed an algorithm for oromandibular reconstruction. When the bony defect is lateral, the ileum, the fibula, or the scapula should be chosen, 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 through-and-through with an anterior bony defect, the fibula should be used with other soft tissue flaps.