Mandibular reconstruction with the tip of scapula free flap

Presentation: AHNS012
Topic: Reconstruction and Rehabilitation
Type: Oral
Date: Wednesday, April 18, 2018
Session: 10:30 AM - 11:20 AM Reconstruction and Rehabilitation
Authors: Jeffrey Blumberg, MD1, Paul Walker, MD2, Stephanie Johnson-Obaseki, MD3, Christopher Yao, MD4, Eugene Yu, MD4, Marie-Constance Lacasse, MD4, Stephanie Johnson-Obaseki, MD3, David Lam, MD, DDS, PHD4, Brian Rittenberg, DDS5, Douglas Chepeha, MD4, John de Almeida, MD4, David Goldstein, MD4, Ralph Gilbert, MD4
Institution(s): 1University of North Carolina at Chapel Hill, 2Loma Linda University, 3University of Ottawa, 4University of Toronto, 5Mount Sinai Hospital, Toronto, ON

Objective: Free tissue transfer with a bony flap after segmental mandibulectomy to restore mandibular continuity has become the reconstructive option of choice.  This approach optimizes function and anesthetics often in a single operation.  Traditionally, options for reconstruction included free fibula, iliac crest, lateral border of the scapula and, now, scapular tip based on the angular artery.  The aim of this study was to describe the utility and versatility of the scapular tip osteomyogenous flap (with or without a chimeric skin paddle from the subscapular system) in a series of mandibulectomy patients, analyze the potential for dental rehabilitation, and examine donor site morbidity.

Methods: Retrospective case series of consecutive patients (2005-2016) undergoing mandibulectomy and microvascular reconstruction with the scapular tip osteomyogenous flap.  Patient demographics, indication of surgery and characteristics of the bone harvested and inset were investigated.  Outcome measures included flap survival, bony union, perioperative complications, and potential for dental rehabilitation.  Donor site morbidity was evaluated using the validated Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.  Suitability for dental rehabilitation was independently evaluated by two oral surgeons based on post-operative CT scans. 

Results: 121 patients were identified (42 females with a mean age of 64y) with the majority undergoing reconstruction after mandibulectomy for malignant disease (75%) followed by osteoradionecrosis of the mandible (18%). The majority of the defects were lateral (body) and often included a portion of the symphysis or ramus.  55% underwent at least one osteotomy and 84% had a chimeric flap with an additional soft tissue component.  90 patients had postoperative imaging available for review at a minimum of six weeks after surgery.   Radiographically, the average inset bone length was 7.1cm (5 – 13cm). Complete or partial bony union was observed at the proximal and distal osteotomy in 77.9% and 82.6% of patients, respectively.  Of the 82 post-operative CT scans available to our oral surgeons, 97.5% met criteria for dental rehabilitation with implants. Mean/median shoulder disability as measured by the Disabilities of the Arm, Shoulder, and Hand questionnaire and time elapsed since surgery was 20.7/15.8 and 24.3/12.5mo, respectively.

Conclusions: To our knowledge, this is largest series of patients undergoing tip of scapula free tissue transfer for mandibular reconstruction reported in the literature. Here, we demonstrated the scapular tip is an excellent option for reconstruction of most segmental mandibular defects with the option of osteotomy, excellent bony union rates, low donor site morbidity and potential for dental rehabilitation.  Furthermore, it provides an excellent alternative to a fibular free flap in patients with peripheral vascular disease, need for early ambulation post-operatively (such as the elderly), active patients reliant on their lower extremities or those who need extensive soft tissue reconstruction in addition to bone.