Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 2026e2033

Contents lists available at ScienceDirect

Journal of Cranio-Maxillo-Facial Surgery

journal homepage: www.jcmfs.com

Outcomes of microvascular free ap reconstruction for mandibular

osteoradionecrosis: A systematic review
Migie Lee a, Ronald Y. Chin b, *, Guy D. Eslick c, Niranjan Sritharan a,
Suchitra Paramaesvaran b
a
b
c

Department of Otolaryngology, Head and Neck Surgery, Nepean Hospital, Sydney, Australia
University of Sydney, Australia
The Whiteley-Martin Research Centre, The University of Sydney, Nepean Hospital, Sydney, Australia

a r t i c l e i n f o

a b s t r a c t

Article history:
Paper received 12 December 2014
Accepted 3 March 2015
Available online 20 March 2015

Introduction: Osteoradionecrosis of the mandible is a devastating complication of radiotherapy in patients with head and neck cancer. Many cases present at a late stage, from months to years following
completion of radiation therapy. When medical treatment fails, surgery may be required with a variety of
free aps available for microvascular reconstructive techniques.
Objective: To conduct a systematic review of the literature investigating the outcomes of free ap
reconstruction of the jaw in mandibular osteoradionecrosis and determine the failure rates of different
ap tissue.
Methods: A systematic literature search was performed using Medline (Ovid) Pubmed and Embase databases and Google Scholar. Primary outcome measures were ap failures and complications, with donor
site complications representing the secondary outcome measure. Analysis of pooled outcomes was
undertaken for different aps.
Results: 333 articles were identied and 15 articles met the nal inclusion criteria, detailing 368 primary
free tissue ap transfers. There was a ap failure rate of 9.8%. There were 146 post-operative complications (39.7%), the most common being stula formation (8.4%), hardware plate exposure (7.1%) and ap
wound infections (6.5%).
Conclusion: The bula is the workhorse free ap for reconstruction in mandibular osteoradionecrosis.
Evidence to date is largely limited with the need for larger powered multi-institutional prospective
studies to determine the ideal ap donor tissue and evaluate patient and treatment predictors of free
ap outcomes in order to tailor the best patient-based surgical approach for mandibular
osteoradionecrosis.
Crown Copyright 2015 Published by Elsevier Ltd on behalf of European Association for Cranio-MaxilloFacial Surgery. All rights reserved.

Keywords:
Osteoradionecrosis
Mandible
Free Tissue Flaps
Surgical aps
Head and neck neoplasms

1. Introduction
Osteoradionecrosis (ORN) is one of the most debilitating complications of radiation therapy in patients undergoing treatment for
head and neck cancer. It is dened as exposed irradiated bone that
fails to heal over a three-month period in the absence of residual or
recurrent tumour (Epstein et al., 1987) and can affect any bony
component of the craniomaxillofacial skeleton (Teng and Futran,
2005).

* Corresponding author. Department of Otolaryngology, Head and Neck Surgery,

Nepean Hospital, Derby Street, Penrith, NSW 2750, Australia.
E-mail address: drronaldchin@gmail.com (R.Y. Chin).

The management of ORN comprises primarily on symptomatic

management and prevention of further disease progression.
Despite appropriate management, many patients will progress to
advanced ORN disease to a stage where tissue may become necrotic
and overwhelmed by infection, making it difcult to salvage
affected bone (Alam et al., 2009).
With advancements in reconstructive techniques, there is
increasing evidence for improved outcomes with microvascular
free ap (MVFF) transfer following segmental resection of nonviable bone in osteoradionecrosis. MVFF in reconstructing ORN
defects has an advantage over multi-stage reconstructions as it
allows simultaneous reconstruction of both hard and soft tissue
components of the defect with tissue from a separate site
(Buchbinder and St Hilaire, 2006).

http://dx.doi.org/10.1016/j.jcms.2015.03.006
1010-5182/Crown Copyright 2015 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery. All rights reserved.

M. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 2026e2033

Historically, it has been shown that higher complication rates

are experienced when reconstructing tissue previously exposed to
radiation treatment (Weaver and Smith, 1973; Margolis et al., 1976;
Salyer et al., 1977; Kudo and Fujioka, 1978; Adamo and Szal, 1979;
Seran et al., 1980) with the key challenge in the inherent poor
wound healing in irradiated tissue. Radiation exposure compromises the integrity of recipient vessels and negatively affects free
ap viability (Krag et al., 1982), with both pre-operative and postoperative radiotherapy associated with an increased ap complication rate (Deutsch et al., 1999).
With advancements in technology and surgical techniques, the
rates of ap success have increased to a reported rate of 86e100%
(Celik et al., 2002; Store et al., 2002; Ang et al., 2003; Militsakh
et al., 2005; Buchbinder and St Hilaire, 2006). Whilst free ap
outcome is arguably primarily due to surgical technique, a better
understanding of clinical predictors and contributing factors is
necessary to help optimise peri-operative and post-operative
management. The aim of this systematic review is to present collective evidence from up to date literature and further dene factors contributing the ap failure by exploring the outcomes of
microvascular free tissue transfer reconstructions in patients with
mandibular osteoradionecrosis.
2. Methods
2.1. Study protocol
We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009).
Relevant articles were identied through a systematic search of the
databases MEDLINE, PubMed, Embase, Cochrane databases and
Google Scholar through to September 1, 2014. The search used the
terms Free Tissue Flaps AND Osteoradionecrosis OR Osteoradionecrosis AND Mandibular Reconstruction, which were
searched as text word and as exploded medical subject headings
where possible. The reference lists of relevant articles were also
hand-searched for appropriate studies. Conference proceedings
were not examined. No language restrictions were used in either
the search or study selection. A search for unpublished literature
was not performed.
2.2. Study selection
We included all types of studies that met the following inclusion criteria: (1) Osteoradionecrosis was clearly described by
clinical examination and/or conrmed radiologically; (2) the total
sample size of the study exceeded 5 free aps; (3) results
examined the outcomes of microvascular free tissue transfer
reconstruction; (4) the point estimate was reported as an odds
ratio (OR), or the data was presented such that an OR could be
calculated; (5) the 95% condence interval (CI) was reported, or
the data was presented such that the CI could be calculated. Two
independent reviewers initially screened the titles and abstracts
of the search for possible inclusion and the full text of all
screened studies were obtained for assessment. Any uncertainty
or disagreement was resolved by discussion with a third independent reviewer. We excluded studies that did not meet the
inclusion criteria.
2.3. Data extraction
One reviewer (M.L.) performed the data extraction using a
standardized data extraction form. Information was extracted on
the publication year, study design, number of cases, population

2027

type, country, continent, mean age, gender, adjuvant treatment,

months of follow-up, ap failure rates and incidence of free ap
complications. Quality of the studies was not assessed as all studies
found were observational case series. In articles that provided a
contact email address, authors were contacted for missing data.
Fig. 1.
From the initial literature search, 333 titles were retrieved and
after removal of duplicates, screening and exclusion based on
criteria, a nal 15 articles met the nal inclusion criteria (Fig. 1)
(Ioannides et al., 1994; Nakatsuka et al., 1996; Curi and Dib, 1997;
Santamaria et al., 1998; Chang et al., 2001; Celik et al., 2002; Store
et al., 2002; Militsakh et al., 2005; Bozec et al., 2006; Suh et al.,
2010; Baumann et al., 2011; Cannady et al., 2011; Chandarana
et al., 2013; Sawhney and Ducic, 2013; Hillerup et al., 2014).

2.4. Statistical analysis

Pooled odds ratio estimates and 95% condence intervals were
calculated for risk factors of mandibular osteoradionecrosis using a
random effects model (DerSimonian and Laird, 1986). We tested
heterogeneity with Cochran's Q statistic, with P < 0.10 indicating
heterogeneity, and quantied the degree of heterogeneity using the
I2 statistic, which represents the percentage of the total variability
across studies which is due to heterogeneity that is not due to
chance (Higgins et al., 2003). All analyses were performed with
Comprehensive Meta-analysis (version 2.0).

3. Results
3.1. Study characteristics
Table 1 shows selected characteristics of the identied studies
(Ioannides et al., 1994; Nakatsuka et al., 1996; Curi and Dib, 1997;
Santamaria et al., 1998; Chang et al., 2001; Celik et al., 2002; Store
et al., 2002; Militsakh et al., 2005; Bozec et al., 2006; Suh et al.,
2010; Baumann et al., 2011; Cannady et al., 2011; Chandarana
et al., 2013; Sawhney and Ducic, 2013; Hillerup et al., 2014).
Eight studies examined populations from North America, one
from South America, four from Europe and two from Asia. Of the
11 studies that reported follow-up periods, the average duration
was 35.4 months. Mean age was 57.4 years, and the reported
percentage of males was 68% (58%e72%), I2 37.52, p 0.07 and
smokers 55% (18%e88%), I2 92.07, p < 0.001. Squamous cell
carcinoma comprised the majority of cases, 83% (77%e89%),
I2 0.00, p 0.61 and the mean radiotherapy dose 67.71 gray
(Gy).

3.2. Adjuvant treatment

Of those that reported adjuvant treatment, one quarter received
adjuvant chemotherapy (25% (17%e36%), I2 37.63, p 0.16) and
more than half underwent hyperbaric oxygen therapy (HBO) (53%
(40%e65%), I2 70.83, p < 0.01).
3.3. Free ap donor sites
A total of 368 primary free aps were performed in 15 different
studies. Used donor sites comprised of that from the bula (n 215),
iliac crest (n 43), radial (n 31), scapula (n 18), anterolateral
thigh (n 18), latissimus dorsi (n 16), rectus abdominis (n 12),
serratus anterior (n 10) and the humerus (n 5).

2028

M. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 2026e2033

Fig. 1. Study selection owchart.

3.4. Flap failures

There were 36 ap failures (9.8% (9%e16%), I2 0.00, p 0.56)
requiring revision operations (Fig. 2). These aps originated from
donor sites bula (n 10), iliac crest (n 7), scapula (n 2) and
anterolateral thigh (n 1) and latissimus dorsi (n 1). In the 15
failures unaccounted for (from 4 studies), donor sites were not
stated. Of those that failed, 5 had stula formation, 3 became
otherwise infected, 10 had vessel thromboses and 2 had skin paddle
necrosis. One case had carotid artery rupture in which the ap that
was connected to the vessels in the contralateral neck was lost
during resuscitation. This patient subsequently died from multiorgan failure Fig. 2.
The pooled event rate for patients who underwent free ap
reconstruction for mandibular osteoradionecrosis is 0.12 (95%CI
0.09e0.16).
Failure rates according to tissue type were: iliac crest (n 7,
16.3%), scapula (n 2, 11.1%) and anterolateral thigh (n 1, 5.6%)
and bula (n 10, 4.7%).
3.5. Other ap complications
There were 146 post-operative complications (39.7%) that
otherwise did not result in ap failure. The most common complications stula formation (n 31), hardware plate exposure

(n 26) and ap wound infections (n 24). Vessel complications

were noted in a total 5 patients; thromboses were seen in 16 free
aps (4.3%), haematoma formation in 5 (1.4%) and 2 patients (0.5%)
had carotid artery rupture following ap reconstruction.
A total of 20 (5.4%) donor site complications were reported.
4. Discussion
Osteonecrosis is a serious complication not limited to the effects
of radiotherapy but also medication-induced side effects e.g.
bisphosphonates (Vercruysse et al., 2014). When it does arise, it can
cause signicant morbidity particularly that is devastating to the
patient. The focus of this review is mandibular osteoradionecrosis
in head and neck cancer patients, which has variable incidence
rates reported in the literature, ranging from as low as 0.4% to as
high as 56% (Jereczek-Fossa and Orecchia, 2002). In advanced disease, paradigm shifts in the management of mandibular osteoradionecrosis have seen surgical resection and immediate free tissue
transfer performed for stage 3 disease (Jacobson et al., 2010). Free
ap reconstruction in the irradiated jaw is difcult. Choosing the
right donor site and harvesting an appropriate ap requires great
precision and skill. Identication and dissection of recipient vessels
can be arduous and necessitates selection of vessels arising from
outside the irradiated eld, often from the contralateral neck
(Cordeiro et al., 1999; Ang et al., 2003).

M. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 2026e2033

2029

Fig. 2. Forest plot for ap failure event rate per study.

Surgical reconstruction of the mandible in patients with

osteoradionecrosis is reserved for advanced disease. In the treatment of early disease, the authors recommend oral hygiene, optimization of nutritional status and multidisciplinary management
including dental, head and neck surgery and plastics surgery review. In cases that are more severe, debridement of necrotic tissue
and appropriate use of antibiotics with involvement of infectious
diseases are necessary.
In treatment early stage disease, management is conservative
comprising of debridement of necrotic tissue, antibiotics and in
some institutions, hyperbaric oxygen therapy (HBO). From the
1960s, HBO had been utilised as an additional treatment modality
in the management of osteoradionecrosis, popularized by Marx
(Marx and Ames, 1982) as an adjunct to soft tissue aps in
managing irradiated tissue. It continues to be utilized by
some institutions and although in the days of its inception, HBO
did show promising results in the treatment of ORN (Mainous
et al., 1975; Hart and Mainous, 1976; Davis et al., 1979), current
literature demonstrates no benet. Recent evidence has
questioned any signicant benet (Mounsey et al., 1993; Maier
et al., 2000) with a multicenter randomized, double-blinded,
placebo-controlled trial in 2004 showing no benet of HBO
treatment in patients for osteoradionecrosis of the jaw (Annane
et al., 2004).
Reconstructive procedures should be reserved for difcult and
severe cases where conservative management has been unsuccessful in achieving adequate healing. Surgical repair of osteoradionecrotic tissue is a challenge both peri-operatively and postoperatively. Previous surgery obliterates tissue planes and
radiation-induced tissue breakdown leads to problems with wound
healing (Ang et al., 2003). Local wound healing problems may
manifest as infection, dehiscence, stula formation and/or plate
exposure and rates of such complications range from 8 to 43% (Celik
et al., 2002; Coskunrat et al., 2005), the upper limit close to that of
this review (42.7%). Progression of local wound complications, or
other microvascular events e.g. thrombosis, can lead to partial or
total free ap loss requiring further surgery for a second free ap or
regional myocutaneous ap (Ang et al., 2003).

The overall ap failure rate was 9.8% (n 36). Flap tissue type
was identied in 21 aps across 11 studies. 4 of the 15 studies did
not identify the types of aps that failed, leaving 15 ap failures
unaccounted for.
In mandibular reconstruction, restoration of bone continuity is
not the only key to success. The surgery needs to achieve adequate
bone height and width and supporting of overlying soft tissue
structures to restore jaw motion (McAllister and Haghighat, 2007).
The masseter muscle is the strongest muscle in the body and does
not stretch uniformly for major jaw movement thus a good supportive bone and soft tissue structural graft is crucial to maintain
the functional integrity of the jaw. The soft tissue needs to be
forgiving in both size as quality thus when considering the use of
non-vascularised bone grafts, the ideal tissue should have enough
bulk, vascularity and cellularity to achieve good graft application
(Arotiba et al., 2012).
Four osteocutaneous aps are commonly used for mandible
reconstruction: bula ap, iliac crest ap, scapula ap and the
radial ap. Li et al. (Li et al., 2012) conducted a cohort study in
which 116 patients underwent latissimus dorsi free ap and plate
reconstruction following advanced oro-mandibular tumour resection. The series demonstrated a very good survival rate (99.1%).
Despite favourable results, the use of latissimus dorsi along with
serratus anterior and upper arm (humerus) aps is becomingling
increasingly less common, largely due to the limited available bone
to repair mandible defects, and the short pedicle available, which
make the aps difcult to anastomose.
The iliac crest ap is usually considered when there is a
contraindication to the bula ap. Patients with signs of lower limb
vascular insufciency or a history of lower limb fracture are
deemed unsuitable for the bula ap. It does offer certain unique
advantages over the bula ap in the quality and quantity of bone
available, whereby the resting shape of the iliac crest bone resembles the mandible anatomically, requiring minimal osteotomy.
The major drawback is that whilst it has robust blood supply to the
bone and internal oblique muscle, issues can arise in the blood
supply to the skin, whereby the supplying perforators of the deep
circumex iliac artery can tear easily as they pass through the layers

2030

M. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 2026e2033

of the abdominal wall (Chepeha and Teknos, 2001). The iliac crest
ap had a success rate of 76.6%, with the most common failure
reason attributed to venous thrombosis (Ioannides et al., 1994).
The scapula ap is a reasonable option with its main feature
being that of its abundant soft tissue and its two discrete skin
paddles, which allows for greater exibility in repairing complex
facial defects. A recent retrospective institutional study found the
free scapula/parascapular ap to be a versatile and reliable ap for
head and neck reconstructions with a good success rate (96%) and a
low complication rate (2.3%) (Mitsimponas et al., 2014). One limitation of this ap is its limited length, and the thin and ne nature
of the bone. Another disadvantage is the need for patient repositioning during the surgery in order to harvest the ap, precluding
simultaneous harvesting at the time of tumour resection and prolonging the operating time (Miles et al., 2010).
The radial forearm free ap is a reasonable alternative in its key
property of superior blood supply compared to other tissue options. It offers a large, thin and pliable skin segment that is widely
favored for soft tissue reconstruction of pharyngoesophageal defects as a fasciocutaneous ap. Additional bulk can be included
with use of the brachioradialis muscle and it has good nerve
supply for optimal recovery of sensory function (Disa and
Cordeiro, 2000). As an osteocutaneous ap however, the radius
in limited in the lack of bone available for osteotomy (Abdel-Kader
et al., 2013). There is approximately 10 cm of bone available to be
taken and although it is cortical bone, only one third of the crosssectional area can be taken without increasing the risk of mechanical stress fracture (Clark et al., 2004). This compromises the
thickness of the bone and thus only a small bony defect can be
repaired using the radial ap, unless combined with other donor
sites (Rinaldo et al., 2002). Of the total 31 radial free aps, no ap
failures were reported. However, it is unclear whether those undertaken in the studies included osteotomy or if they were fasciocutaneous aps only.
The bula microvascular free ap for head and neck reconstruction was rst introduced by Hidalgo in 1989 (Hidalgo, 1989)
and is now considered as the workhorse for mandible reconstruction (George and Krishnamurthy, 2013; Succo et al., 2014) (Ang
et al., 2003). The bula osteocutaneous free ap has quickly
gained popularity over other vascularized bone aps in recent years
for several reasons. The bula benets from its quality of bone, with
good cortical thickness, and the generous length of bone available
(up to 25e30 cm), which permits multiple osteotomies even whilst
the pedicle is still attached (Urken et al., 1991) (Hao et al., 1999). The
vasculature is also ideal. The ap's dominant arterial supply is from
the peroneal artery and venous drainage via the 2 venae comitantes, which have an average caliber of 1.5 mm and 3 mm
respectively. These vessel diameters closely match that of most
recipient vessels in the neck facilitating effective anastomoses. Its
long and reliable vascular pedicle (up to 12e15 cm) is useful when
confronted with recipient vessels that are difcult to locate in
heavily irradiated tissue (Wallace et al., 2010). Furthermore, the
bula provides the bony platform for eventual prosthetic rehabilitation, allowing the placement of intraosseous dental implants. The
bula free ap offers considerable advantages over its counterparts
as the ideal ap of choice for mandibular reconstruction and it was
by far the most common free ap tissue used (n 215) and, from
the free ap failure data reported, had a good success rate (95.3%).
With the great variations across the studies, and the small
numbers of some e.g. humerus (n 5) sufciently powered subset
analyses to determine the best donor ap site were unable to be
conducted.
The purpose of this systematic review was to summarize the
reported literature to date in the variety of free ap reconstructions

used and the outcomes of different practice across different institutions. We appreciate that this review is a retrospective pooling
of case series predisposed to the drawbacks associated with such
studies. We also acknowledge the assumed limitations in the
outdated nature of some articles, particularly those predating the
new millennium (Ioannides et al., 1994; Curi and Dib, 1997;
Santamaria et al., 1998), with which current practice may now
vastly differ to that carried out in the older studies. In the 15 studies
included in this review, all retrospective case series, there were a
total 368 primary microvascular free aps studied with a 9.8%
failure rate. Flap failure requires a revision operation and in most
instances, necessitates a secondary free ap from another donor
site. This leads to further morbidity and a longer hospital stay,
which calls for measures in acquiring a better understanding of the
factors associated with ap loss. Direct associations between clinical and patient factors with ap loss overall were not explored in
the included articles in this systematic review, thus pooled outcomes of such could not be reported. In the literature, important
factors that have been associated with graft survival include the
length of mandibular defect, timing of the reconstruction (immediate or delayed), cancer diagnosis, intraoral communication, estimated blood loss and the duration of post-operative antibiotics
(August et al., 2000). Furthermore, longer close follow-up periods
are needed. All of the 11 studies that reported follow-up period
durations reported outcomes within a 5 year post-operative period.
Long-term outcomes and potential adverse consequences are not
known.
This is the rst systematic review looking at the surgical outcomes of reconstruction with microvascular free aps used in patients with mandibular osteoradionecrosis. The results show the
challenges inherent in successful microvascular free ap reconstruction in patients with mandibular osteoradionecrosis, however
the systematic review is limited in the retrospective nature of all
studies and the inherent selection bias in the patient populations.
The lack of randomized trials, variability in the donor ap site used
and the potential for confounding factors e.g. adjuvant medical
treatment and surgical technique, limit an objective analysis. As
institutional practices in relation to ap choice and surgical technique and consistencies in follow-up reporting of outcomes are
likely to vary, future prospective studies with in-depth analyses of
the predictors of ap survival are needed. Recommendations for
future research directions include the investigation of predictive
patient and clinical factors and determination of the ideal donor
ap site associated with the best outcomes.

5. Conclusions
Osteoradionecrosis of the mandible is an uncommon but signicant complication of radiotherapy, where surgical treatment
for advanced disease can carry great morbidity with postoperative complications. Whilst a number of free ap tissue
types can be used, the bula free ap continues to be the gold
standard and workhorse ap in the reconstruction of mandibular
defects with a good success rate. Higher-powered prospective
studies that closely examine patient and clinical factors associated
with ap outcomes will lead to greater understanding of predictors of ap survival and help guide individualized patient approaches to appropriate microvascular reconstruction in
mandibular osteoradionecrosis.

Conicts of interest
None.

M. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 2026e2033

2031

Appendices

Table 1
Study characteristics.
Author and date

Study type

Continent

Total no.
primary aps

Flap type

Mean follow-up (months)

Baumann et al. (2011)

Retrospective case series

North America

63

18.2

Bozec et al. (2006)

Cannady et al. (2011)

Retrospective case series

Retrospective case series

Europe
North America

6
53

Celik et al. (2002)

Retrospective case series

Asia

27

Chandarana et al. (2013)

Retrospective case series

North America

12

Chang et al. (2001)

Retrospective case series

North America

30

Curi et al. (2007)

Hillerup et al. (2014)
Ioannides et al. (1994)

Retrospective case series

Retrospective case series
Retrospective case series

South America
Europe
Europe

5
15
33

Militsakh et al. (2005)

Nakatsuka et al. (1996)

Retrospective case series

Retrospective case series

North America
Asia

9
9

Santamaria et al. (1998)

Sawhney and Ducic, 2013

Retrospective case series

Retrospective case series

North America
North America

12
37

Store et al. (2002)

Retrospective case series

Europe

17

Suh et al. (2010)

Retrospective case series

North America

40

Fibula n 38 (5 with pectoralis major,

6 with ALT, 1 with radial)
Scapula n 1
Radial n 1
Rectus abdominis n 7
Anterolateral thigh n 12 (2 with
pectoralis major)
Iliac crest n 63 (1 with ALT)
Fibula n 6
Fibula n 36
Radial n 14
Rectus abdominis n 1
Anterolateral thigh n 1
Iliac crest n 1
Fibula n 22
Anterolateral thigh n 5
Fibula n 4
Radial n 1
Scapula n 5
Iliac crest n 2
Fibula n 17
Radial n 1
Scapula n 2
Rectus abdominis n 4
Iliac crest n 5
Fibula n 5
Latissimus dorsi n 15
Serratus anterior n 8
Iliac crest n 25
Radial n 9
Radial n 1
Scapula n 8
Fibula n 12
Fibula n 32
Radial n 3
Scapula n 2
Fibula n 7
Radial n 1
Humerus n 5
Iliac crest n 4
Fibula n 36
Latissimus dorsi n 1
Serratus anterior n 2
Iliac crest n 1

31.0
Not reported

Not reported
41.0

33.0

25.0
Not reported
32.0
36.0
Not reported
45.0
54.0

57.0

17

Table 2
Free ap failures.
Study

Total free aps (n)

Total no. of free

ap failures (%)

Type of ap

Reason for failure

Baumann et al. (2011)

63

4 (6.3)

Not stated

Vessel thrombosis (n 3)
Carotid artery rupture (n 1)

Bozec et al. (2006)

Cannady et al. (2011)
Celik et al. (2002)

6
53
27

0 (0)
7 (13.2)
3 (11.1)

Chandarana et al. (2013)

Chang et al. (2001)

13
30

4 (3.1)
4 (1.4)

Curi et al. (2007)

Hillerup et al. (2014)
Ioannides et al. (1994)

5
15
33

1 (20.0)
1 (6.7)
5 (15.2)

N/A
Not stated
Fibula n 2
Anterolateral thigh n 1
Not stated
Fibula n 1
Iliac n 2
Scapula n 1
Fibula n 1
Latissimus dorsi n 1
Iliac n 5

Militsakh et al. (2005)

Nakatsuka et al. (1996)

9
9

0 (0)
1 (11.1)

N/A
Scapula n 1

Fistula (n 3)
Not stated
Venous thrombosis (n 2), infection (n 1), other (n 1)

Fistula (n 1)
Plate exposure (n 1)
Venous thrombosis (n 4)
Technical error (n 1)

(continued on next page)

2032

M. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 2026e2033

Table 2 (continued )
Study

Total free aps (n)

Total no. of free

ap failures (%)

Type of ap

Reason for failure

Santamaria et al. (1998)

12

2 (16.7)

Fibula n 2

Sawhney and Ducic (2013)

Store et al. (2002)
Suh et al. (2010)

37
17
40

2 (5.4)
2 (11.8)
0 (0)

Fibula n 2
Fibula n 2
N/A

Vessel thrombosis (n 1)
Fistula (n 1)
Skin paddle necrosis (n 2)
Infection (n 2)

Table 3
Free ap complications.
Study

Total ap complications (n)

Reason

Baumann et al. (2011) (Baumann et al., 2011)

20

Infection (n 8)
Fistula (n 6)
Haematoma (n 2)
Vessel thrombosis (n 3)
Vessel rupture (n 1)
Infection (n 1)
Fistula (n 1)
Skin paddle necrosis (n 1)
Fistula (n 2)
Vessel thrombosis (n 4)
Vessel rupture (n 1)
Other (n 5)
Fistula (n 3)
Infection (n 1)
Skin paddle necrosis (n 1)
Fistula (n 6)
Non-union (n 4)
Plate exposure (n 5)
Haematoma (n 1)
Other (n 3)
Infection (n 1)
Skin paddle necrosis (n 2)
Vessel thrombosis (n 2)
Fistula (n 1)
Vessel thrombosis (n 1)
N/A
Infection (n 3)
Fistula (n 2)
Haematoma (n 2)
Vessel thrombosis (n 4)
N/A
Skin paddle necrosis (n 1)
Fistula (n 1)
Non-union (n 1)
Skin paddle necrosis (n 1)
Fistula (n 2)
Vessel thrombosis (n 1)
Skin paddle necrosis (n 1)
Non-union (n 4)
Plate exposure (n 3)
Infection (n 3)
Plate exposure n 1
Infection n 7
Fistula n 6
Plate exposure n 17

Bozec et al. (2006) (Bozec et al., 2006)

Cannady et al. (2011)

13

Celik et al. (2002)

Chandarana et al. (2013)

3
20

Chang et al. (2001)

Curi et al. (2007)

Hillerup et al. (2014)

Ioannides et al. (1994)

0
13

Militsakh et al. (2005)

Nakatsuka et al. (1996)

0
3

Santamaria et al. (1998)

Sawhney and Ducic (2013)

Store et al. (2002)

Suh et al. (2010)

15

7
38

References
Abdel-Kader MS, Tamam AA, Elderwy AA, Gad M, El-Gamal MA, Kurkar A, et al:
Management of symptomatic ureteral calculi during pregnancy: experience of
23 cases. Urol Ann 5(4): 241e244, 2013
Adamo AK, Szal RL: Timing, results, and complications of mandibular reconstructive
surgery: report of 32 cases. J Oral Surg 37(10): 755e763, 1979
Alam DS, Nuara M, Christian J: Analysis of outcomes of vascularized ap reconstruction in patients with advanced mandibular osteoradionecrosis. Otolaryngol Head Neck Surg 141(2): 196e201, 2009
Ang E, Black C, Irish J, Brown DH, Gullane P, O'Sullivan B, et al: Reconstructive
options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton. Br J Plast Surg 56(2): 92e99, 2003
Annane D, Depondt J, Aubert P, Villart M, Gehanno P, Gajdos P, et al: Hyperbaric
oxygen therapy for radionecrosis of the jaw: a randomized, placebo-controlled,
double-blind trial from the ORN96 study group. J Clin Oncol 22(24):
4893e4900, 2004

Arotiba GT, Efom AO, Ayodele AS, Ogundana MO, Gbotolorun MO, Olasoji HO, et al:
A classication system for recurrent ameloblastoma of the jawsereview of 30
cases in Nigerians. Nig Q J Hosp Med 22(1): 44e51, 2012
August M, Tompach P, Chang Y, Kaban L: Factors inuencing the long-term outcome
of mandibular reconstruction. J Oral Maxillofac Surg 58(7): 731e737, 2000
discussion 738
Baumann DP, Yu P, Hanasono MM, Skoracki RJ: Free ap reconstruction of osteoradionecrosis of the mandible: a 10-year review and defect classication. Head
Neck 33(6): 800e807, 2011
Bozec A, Poissonnet G, Converset S, Vallicioni J, Demard F, Dassonville O: Fibula free
ap for reconstruction of extensive mandibular osteoradionecrosis. Ann Otolaryngol Chir Cervicofac 123(2): 98e106, 2006
Buchbinder D, St Hilaire H: The use of free tissue transfer in advanced osteoradionecrosis of the mandible. J Oral Maxillofac Surg 64(6): 961e964, 2006
Cannady SB, Dean N, Kroeker A, Albert TA, Rosenthal EL, Wax MK: Free ap
reconstruction for osteoradionecrosis of the jawseoutcomes and predictive
factors for success. Head Neck 33(3): 424e428, 2011

M. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 2026e2033

Celik N, Wei FC, Chen HC, Cheng MH, Huang WC, Tsai FC, et al: Osteoradionecrosis
of the mandible after oromandibular cancer surgery. Plast Reconstr Surg 109(6):
1875e1881, 2002
Chandarana SP, Chanowski EJ, Casper KA, Wolf GT, Bradford CR, Worden FP, et al:
Osteocutaneous free tissue transplantation for mandibular osteoradionecrosis.
J Reconstr Microsurg 29(1): 5e14, 2013
Chang DW, Oh HK, Robb GL, Miller MJ: Management of advanced mandibular
osteoradionecrosis with free ap reconstruction. Head Neck 23(10): 830e835,
2001
Chepeha DB, Teknos TN (eds), Microvascular free aps in head and neck reconstruction. Lippincott Williams & Wilkins, 2001
Clark S, Greenwood M, Banks RJ, Parker R: Fracture of the radial donor site
after composite free ap harvest: a ten-year review. Surgeon 2(5):
281e286, 2004
Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY: Reconstruction of the mandible with
osseous free aps: a 10-year experience with 150 consecutive patients. Plast
Reconstr Surg 104(5): 1314e1320, 1999
Coskunrat OK, Wei FC, Huang WC, Cheng MH, Yang WG, Chang YM: Microvascular
free tissue transfer for treatment of osteoradionecrosis of the maxilla. Plast
Reconstr Surg 115(1): 54e60, 2005
Curi MM, Dib LL: Osteoradionecrosis of the jaws: a retrospective study of the
background factors and treatment in 104 cases. J Oral Maxillofac Surg 55(6):
540e544, 1997 Discussion 545e546
Curi MM, Oliveira dos Santos M, Feher O, Faria JC, Rodrigues ML, Kowalski LP:
Management of extensive osteoradionecrosis of the mandible with radical
resection and immediate microvascular reconstruction. J Oral Maxillofac Surg
65(3): 434e438, 2007
Davis JC, Dunn JM, Gates GA, Heimbach RD: Hyperbaric oxygen. A new adjunct in
the management of radiation necrosis. Arch Otolaryngol 105(2): 58e61, 1979
DerSimonian R, Laird N: Meta-analysis in clinical trials. Control Clin Trials 7(3):
177e188, 1986
Deutsch M, Kroll SS, Ainsle N, Wang B: Inuence of radiation on late complications
in patients with free bular aps for mandibular reconstruction. Ann Plast Surg
42(6): 662e664, 1999
Disa JJ, Cordeiro PG: Mandible reconstruction with microvascular surgery. Semin
Surg Oncol 19(3): 226e234, 2000
Epstein JB, Wong FL, Stevenson-Moore P: Osteoradionecrosis: clinical experience
and a proposal for classication. J Oral Maxillofac Surg 45(2): 104e110, 1987
George RK, Krishnamurthy A: Microsurgical free aps: controversies in maxillofacial reconstruction. Ann Maxillofac Surg 3(1): 72e79, 2013
Hao SP, Chen HC, Wei FC, Chen CY, Yeh AR, Su JL: Systematic management of
osteoradionecrosis in the head and neck. Laryngoscope 109(8): 1324e1327,
1999 Discussion 1327e1328
Hart GB, Mainous EG: The treatment of radiation necrosis with hyperbaric oxygen
(OHP). Cancer 37(6): 2580e2585, 1976
Hidalgo DA: Fibula free ap: a new method of mandible reconstruction. Plast
Reconstr Surg 84(1): 71e79, 1989
Higgins JP, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in metaanalyses. BMJ 327(7414): 557e560, 2003
Hillerup S, Elberg JJ, Thorn JJ, Andersen M: Reconstruction of irradiated mandible
after segmental resection of osteoradionecrosis-a technique employing a
microvascular latissimus dorsi ap and subsequent particulate iliac bone
grafting. Craniomaxillofac Trauma Reconstr 7(3): 190e196, 2014
Ioannides C, Fossion E, Boeckx W, Hermans B, Jacobs D: Surgical management of the
osteoradionecrotic mandible with free vascularised composite aps.
J Craniomaxillofac Surg 22(6): 330e334, 1994
Jacobson AS, Buchbinder D, Hu K, Urken ML: Paradigm shifts in the management of
osteoradionecrosis of the mandible. Oral Oncol 46(11): 795e801, 2010
Jereczek-Fossa BA, Orecchia R: Radiotherapy-induced mandibular bone complications. Cancer Treat Rev 28(1): 65e74, 2002
Krag C, Holck S, DeRose G, Lyczakowski T, Freeman CR: Healing of microvascular
anastomoses. A comparative study using normal and irradiated recipient vessels for experimental free aps in rabbits. Scand J Plast Reconstr Surg 16(3):
267e274, 1982
Kudo K, Fujioka Y: Review of bone grafting for reconstruction of discontinuity defects of the mandible. J Oral Surg 36(10): 791e793, 1978
Li BH, Jung HJ, Choi SW, Kim SM, Kim MJ, Lee JH: Latissimus dorsi (LD) free ap and
reconstruction plate used for extensive maxillo-mandibular reconstruction after tumour ablation. J Craniomaxillofac Surg 40(8): e293e300, 2012

2033

Maier A, Gaggl A, Klemen H, Santler G, Anegg U, Fell B, et al: Review of severe

osteoradionecrosis treated by surgery alone or surgery with postoperative hyperbaric oxygenation. Br J Oral Maxillofac Surg 38(3): 173e176, 2000
Mainous EG, Hart GB, Soffa DJ, Graham GA: Hyperbaric oxygen treatment of
mandibular osteomyelitis in osteopetrosis. J Oral Surg 33(4): 288e291, 1975
Margolis IB, Smith RL, Davis WC: Reconstruction of defects of the mandible. Surgery
79(6): 638e643, 1976
Marx RE, Ames JR: The use of hyperbaric oxygen therapy in bony reconstruction of
the irradiated and tissue-decient patient. J Oral Maxillofac Surg 40(7):
412e420, 1982
McAllister BS, Haghighat K: Bone augmentation techniques. J Periodontol 78(3):
377e396, 2007
Miles BA, Goldstein DP, Gilbert RW, Gullane PJ: Mandible reconstruction. Curr Opin
Otolaryngol Head Neck Surg 18(4): 317e322, 2010
Militsakh ON, Wallace DI, Kriet JD, Tsue TT, Girod DA: The role of the osteocutaneous radial forearm free ap in the treatment of mandibular osteoradionecrosis. Otolaryngol Head Neck Surg 133(1): 80e83, 2005
Mitsimponas KT, Iliopoulos C, Stockmann P, Bumiller L, Nkenke E, Neukam FW,
et al: The free scapular/parascapular ap as a reliable method of reconstruction
in the head and neck region: a retrospective analysis of 130 reconstructions
performed over a period of 5 years in a single department. J Craniomaxillofac
Surg 42(5): 536e543, 2014
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P: Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. BMJ 339: b2535,
2009
Mounsey RA, Brown DH, O'Dwyer TP, Gullane PJ, Koch GH: Role of hyperbaric oxygen therapy in the management of mandibular osteoradionecrosis. Laryngoscope 103(6): 605e608, 1993
Nakatsuka T, Harii K, Yamada A, Ueda K, Ebihara S, Takato T: Surgical treatment of
mandibular osteoradionecrosis: versatility of the scapular osteocutaneous ap.
Scand J Plast Reconstr Surg Hand Surg 30(4): 291e298, 1996
Rinaldo A, Shaha AR, Wei WI, Silver CE, Ferlito A: Microvascular free aps: a major
advance in head and neck reconstruction. Acta Otolaryngol 122(7): 779e784,
2002
Salyer KE, Newsom HT, Holmes R, Hahn G: Mandibular reconstruction. Am J Surg
134(4): 461e464, 1977
Santamaria E, Wei FC, Chen HC: Fibula osteoseptocutaneous ap for reconstruction
of osteoradionecrosis of the mandible. Plast Reconstr Surg 101(4): 921e929,
1998
Sawhney R, Ducic Y: Management of pathologic fractures of the mandible secondary to osteoradionecrosis. Otolaryngol Head Neck Surg 148(1): 54e58, 2013
Seran D, Riefkohl R, Thomas I, Georgiade NG: Vascularized rib-periosteal and
osteocutaneous reconstruction of the maxilla and mandible: an assessment.
Plast Reconstr Surg 66(5): 718e727, 1980
Store G, Boysen M, Skjelbred P: Mandibular osteoradionecrosis: reconstructive
surgery. Clin Otolaryngol Allied Sci 27(3): 197e203, 2002
Succo G, Berrone M, Battiston B, Tos P, Goia F, Appendino P, et al: Step-by-step
surgical technique for mandibular reconstruction with bular free ap: application of digital technology in virtual surgical planning. Eur Arch Otorhinolaryngol, 2014 . Published online ahead of print http://dx.doi.org/10.1007/s00405014-3078-3
Suh JD, Blackwell KE, Sercarz JA, Cohen M, Liu JH, Tang CG, et al: Disease relapse
after segmental resection and free ap reconstruction for mandibular osteoradionecrosis. Otolaryngol Head Neck Surg 142(4): 586e591, 2010
Teng MS, Futran ND: Osteoradionecrosis of the mandible. Curr Opin Otolaryngol
Head Neck Surg 13(4): 217e221, 2005
Urken ML, Buchbinder D, Weinberg H, Vickery C, Sheiner A, Parker R, et al: Functional evaluation following microvascular oromandibular reconstruction of the
oral cancer patient: a comparative study of reconstructed and nonreconstructed
patients. Laryngoscope 101(9): 935e950, 1991
Vercruysse Jr H, Backer T, Mommaerts MY: Outcomes of osseous free ap reconstruction in stage III bisphosphonate-related osteonecrosis of the jaw: systematic review and a new case series. J Craniomaxillofac Surg 42(5): 377e386,
2014
Wallace CG, Chang YM, Tsai CY, Wei FC: Harnessing the potential of the free bula
osteoseptocutaneous ap in mandible reconstruction. Plast Reconstr Surg
125(1): 305e314, 2010
Weaver AW, Smith DB: Frozen autogenous mandibular stent-graft for immediate
reconstruction in oral cancer surgery. Am J Surg 126(4): 505e506, 1973