Microvascular Reconstruction in Benign Maxillofacial Disease: a Preliminary Report

The reconstruction of defects involving the stomatognathic system takes into consideration the restoration of lost structures with the balance of cosmesis and function.  The advent of microvascular free tissue transfer provides a reliable treatment option in large, complex defects secondary to trauma, oncologic surgery or vascular compromise due to radiation therapy. New reconstructive paradigms emphasize the use of techniques that restore form and function with the least amount of morbidity and match the reconstruction goals with those of the patient. The purpose of this retrospective analysis is to review the outcomes of patients with maxillofacial defects secondary to benign disease who underwent microvascular reconstruction.

The records of patients who underwent microvascular reconstruction from 2011-2013 were reviewed. Demographic variables were collected in addition to diagnosis, flap donor and recipient site, postoperative complications, endossseous implant reconstruction, type of prosthesis and overall flap survival. The primary study group consisted of patients with a benign condition/disease with the exclusion of those patients afflicted by osteoradionecrosis, bisphosphonate-related osteonecrosis of the jaws or avulsive traumatic injuries.

Descriptive statistics were computed for continuous variables and categorical variables utilizing Excel.

Sixteen patients were identified who met the inclusion criteria.  There were 10 females and 6 males, with a mean age of 49 years old (range 19-77 yrs).  There were 11 mandibular and 5 maxillary defects, with the donor site for microvascular reconstruction consisting of the fibula (13), radial forearm (2) and a scapula and serratus osteocutaneous flap. There were 8 patients with odontogenic tumors, 4 with chronic osteomyelitis, 2 with post-surgical infections that led to non-union and 2 with continuity defects from previous ablative surgery. The overall flap success rate was 100% and only 1 patient required admission to the intensive care unit post-operatively. There were 3 postoperative complications (1 recipient site hematoma, 1 myocardial infarction, 1 pneumonia).  A total of 13 patients had defects that involved the dentition, of which 9 patients (69%) underwent immediate implant placement at the time of the microvascular reconstruction, 1 (8%) patient underwent delayed implant reconstruction and 3 patients (23%) did not undergo implant placement.  Of the three patients that did not have endosseous implant reconstruction for replacement of lost dentition, 2 had defects that involved a total of 2 missing teeth. A total of 44 implants were placed, of which 29 implants (66%) were placed primarily, with 1 implant being a zygomatic implant. Fifteen implants (34%) were placed secondarily, with 1 implant being a zygomatic implant. A total of 33 implants have undergone second stage surgery, with 1 implant failure (3%) within 6 months of initial placement. A total of 7 patients have had their fixed prosthesis inserted and in a functional occlusion.

Microvascular reconstruction is at the top of the reconstructive ladder and its use in the management of benign maxillofacial conditions should also be considered when the restoration of form and function is better served by a more complex approach. It provides a reliable, immediate and delayed reconstructive technique that restores oral competence and allows for the placement of immediate implants for the fabrication of an implant-supported prosthesis. While dependable, the disease process, type of defect, available resources, morbidity, patient comorbidities and expectations need to be considered when determining the best reconstructive techniques.

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