Microvascular Free Flap Reconstruction for Osteomyelitis/Osteoradionecrosis/Bisphosphanate Related Osteonecrosis of the Maxillofacial Region
The management of infectious and ischemic diseases of the maxillofacial region, such as osteomyelitis, osteoradionecrosis (ORN), and bisphosphanate related osteonecrosis of the jaw (BRONJ), typically require a step-wise approach including both medical and surgical intervention. If medical therapy, including antibiotic therapy, conservative marginal resection fail to eradicate disease, en-bloc resection with reconstruction plate is typically indicated with delayed bone grafting. The role of HBO treatment has been heavily debated in the treatment of refractory osteomyelitis,1 BRONJ, and ORN. Medical management, including antibiotic therapy and HBO treatment is expensive, time consuming, and disruptive to the patient’s life.2 The only proven definitive treatment for infectious and ischemic disease of the maxillofacial region is surgical resection with reconstruction. Here, we report our experience with osteomyelitis/ORN/BRONJ in the maxillofacial region who received microvascular free flap reconstruction.
Materials and methods:
This is a case series report of patients treated at Bellevue Hospital and Tisch Hospital during 2006-2012. Patients were diagnosed with ORN/BRONJ/Osteomyelitis that failed both conservative therapy and local debridement subsequently required extensive reconstruction with a vascularized free flap.
Method of data analysis,
Patients were identified as having osteomyelitis/ORN/BRONJ of the maxillofacial region and required microvascular free tissue transfer. These patients had failed initial therapy and required further reconstruction.
Statistical Methods: none, case series
Results of investigation:There were 20 patients identified requiring vascular free flaps of the maxillofacial region. 8 patients were identified as having complications related to ORN, 8 patients with complications related to osteomyelitis and 4 patients with BRONJ. 16 patients had a fibular microvascular free flap reconstruction of the maxilla/mandible and 2 patients had radial forearm free flaps for reconstruction of the maxilla. 19/20 patients had flap survival and have been followed for 3month-6 years post operatively. 1 patient who had flap failure, also expired 10 days post operatively from a massive pulmonary embolism.
Conclusions relevant to the problem
Refractory cases of ORN/BRONJ and osteomyelitis pose a treatment dilemma for physicians. Treatment options are vast depending on the size of the affected region and residual defect that will be. Free flaps have become the preferred method for reconstruction for large continuity defects with predictable outcome. Free flaps allow for a one stage surgical model with removal of the inflammatory tissue bed and a predictable model for bony reconsitution
Bibliography
- Freiberger, John J. Utility of Hyperbaric Oxygen in Treatment of Bisphosphonate-Related Osteonecrosis of the Jaws. J Oral Maxillofacial Surg 67:96-106, 2009, Suppl 1.
- Miloro, M. et al. Peterson’s Principles of Oral & Maxillofacial Surgery Third Edition. Peoples Medical Publishing Housing-USA 2012.