Microsurgical reconstruction of the mandible part I: experience of 218 cases and surgical outcomes

Background Mandibular defects can be caused by a vast number of pathologies which may compromise both function and aesthetics of the lower face region. Over the years, a range of reconstructive techniques were developed, leading to the current gold standard—free-flap transfer. The aim of this study is to present the experience of the senior author (HC) over the last 25 years, based on 218 cases of mandibular reconstruction with vascularized free bone transfer. Methods This is a retrospective observational study that includes 218 patients submitted to segmental mandibular excision and immediate reconstruction with free flaps between 1996 and 2021. Collected data included gender, age, etiology, defect size and location, selected flaps, microsurgical recipient vessels, flap bone osteotomies, complications, and flap failure. Functional and aesthetic results were evaluated by a direct examination and also through a questionnaire. Functional outcomes were evaluated regarding diet type (unrestricted, soft, liquid) and speech (normal, perceptible, imperceptible). The Voice Handicap Index-10 Portuguese validated version was also used. Aesthetic outcomes related to symmetry and also oral rehabilitation (absence, presence: dental implants or removable dental prosthesis) were evaluated, as well. Results Aetiology for the oromandibular defect included malignant tumours ( n = 73), osteoradionecrosis ( n = 57), benign tumours ( n = 41) and defects related to previous tumour excision ( n = 23). A total of 225 reconstructive surgeries with 239 free flaps were performed in 218 patients. The most commonly selected flap was the fibula flap ( n = 125), followed by the iliac crest flap ( n = 69) and the radial forearm flap ( n = 26). The sequentially linked flow-through flap concept was used in 13 cases. Total flap necrosis occurred in 15 patients. Functional and aesthetic outcomes were evaluated in 23.9% (50 patients). In 71% of the interviewed, the diet is unrestricted, in 80% the speech is perceptible, and 44% of them had oral rehabilitation procedures. Conclusions Mandible reconstruction implies the restoration of form and function of the mandibular bone apparatus as well as aesthetics, and for that reason, the authors consider the free bone flaps as the paramount technique for complex oromandibular reconstruction. Level of evidence: Level IV, therapeutic study.