Prognosis as a determinant of free flap utilization for reconstruction of the lateral mandibular defect

ORIGINAL ARTICLE

PROGNOSIS AS A DETERMINANT OF FREE FLAPUTILIZATION FOR RECONSTRUCTION OFTHE LATERAL MANDIBULAR DEFECT

Frederic W.-B. Deleyiannis, MD, MPhil, MPH,1,2 Edward Lee, MD,1 Brian Gastman, MD,1,2

David Nguyen, MD,1 James Russavage, MD, DDS,1 Ernest K. Manders, MD,1

Robert L. Ferris, MD, PhD,2 Eugene N. Myers, MD,2 Jonas Johnson, MD2

1 University of Pittsburgh, Division of Plastic and Reconstructive Surgery, Suite 6B Scaife Hall,3550 Terrace Ave., Pittsburgh, PA 15261. E-mail: [email protected] University of Pittsburgh, Department of Otolaryngology and Head and Neck Surgery,Pittsburgh, Pennsylvania

Accepted 16 March 2006Published online 5 July 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.20463

Abstract: Background. The purpose of this study was to

determine whether patients with a poor prognosis for survival

were more likely to undergo reconstruction with a pectoralis

flap versus a free flap and whether the use of a pectoralis flap

offered any perioperative advantage, such as a reduction in

medical complications.

Methods. Fifty-five consecutive patients who underwent im-

mediate reconstruction after a lateral mandibulectomy were ret-

rospectively reviewed.

Results. Age �70 years (p ¼ .03), moderate or severe

comorbidity (p ¼ .02), and involvement of the base of tongue by

tumor (p ¼ .04) were significantly associated with decreased uti-

lization of a free flap (n ¼ 36). Comorbidity was the main deter-

minant of medical complications (p ¼ .001) and length of hospi-

tal stay (p ¼ .03).

Conclusions. Expectations of prognosis bias the surgeon’s

decision regarding flap selection. Reconstruction with a pectoralis

flap does not necessarily contribute toward the desired outcome

of reduced medical complications. Any functional comparison

between reconstructive groups needs to account for those dif-

ferences in health status and prognosis that might explain any

observed postoperative differences. VVC 2006 Wiley Periodicals,

Inc. Head Neck 28: 1061–1068, 2006

Keywords: prognosis; reconstruction; lateral mandibular defect

The indications for mandibular reconstructionremain a subject of legitimate controversy.1,2 Thefact that major mandibular resection carries withit significant functional and cosmetic sequelae isundisputed, but the morbidity of mandibularresection on function is highly variable. The levelof postoperative disability depends on the follow-ing: (1) the extent of mandible to be included inthe resection, (2) the site of the tumor (anterior vslateral), (3) the soft tissues to be resected, and (4)existing dentition. When the mandible is resectedwith an accompanying large soft tissue defect, themandibular defect is sometimes ‘‘incidental’’ tothe rest of the wound. Closure of the soft tissuedefect with restoration of function, as well as cov-erage of the planned mandibular reconstruction,become the primary goals.

Correspondence to: F. W.-B. Deleyiannis

VVC 2006 Wiley Periodicals, Inc.

Prognosis as a Determinant of Free Flap Utilization HEAD & NECK—DOI 10.1002/hed December 2006 1061

After a segmental lateral mandibulectomy,some patients function well without restoration ofmandibular continuity. For this reason, someinvestigators have advocated simply resurfacingthe mucosal defect with a skin graft and notrestoring mandibular continuity.1 However, a con-tour deformity of the lower third of the face willdevelop in patients who have not undergonereconstruction, and the pull of the contralateralmuscles of mastication displaces the remainingmandible toward the side of the defect. In patientswith dentition, this results in malocclusion. Forthese reasons, most surgeons offer patients pri-mary reconstruction of lateral mandibular defects.

Numerous reports have supported the use of areconstruction plate with soft tissue coverage toreconstruct pure lateral mandibular defects.3,4

Soft tissue coverage has generally been providedby a pectoralis myocutaneous flap or a soft tissuefree flap. Delayed reconstructive failure second-ary to plate exposure or plate fracture has beenreported to be between 5% and 46%.2,4–7 The useof an osteocutaneous free flap, in particular theosteocutaneous radial forearm free flap, likelyreduces the risk of plate complication and offersthe advantage of a large skin paddle that can beused to reconstruct nearly any accompanying mu-cosal defect.8 The fibular osteocutaneous free flapoffers the advantage that the cross-sectional areaof the fibula approximates the cross-sectional areaof the midbody of the mandible and is ideallysuited for placement of osseointegrated implantsfor dental rehabilitation.9 In addition, the seg-mental periosteal perforators of the fibula fromthe peroneal artery allow multiple osteotomies ofthe fibula, so that the fibula can be shaped into aneomandible.

Success rates of >95% are routinely reportedwith free tissue transfer to the head and neck.Numerous reports indicate that advanced age isnot a contraindication to free tissue transfer. How-ever, given that reconstruction with a pectoralisflap requires less time in the operating room, hasless chance of complete failure, and is less techni-cally demanding, it is likely that older patientsmay be reconstructed with this technique insteadof with a free flap.10 Patients would then beexposed to less potential perioperative risk andfewer complications and would be less at risk ofdays of life lost secondary to these complications.11

Similar justification for a simpler reconstructivetechnique could be extended to patients withgreater comorbidity and a worse overall prognosisbased on tumor extension.

The purpose of this study was to identify thosepatient and tumor variables that influence the uti-lization of free tissue transfer for reconstruction ofthe lateral mandibular defect. In particular, ourgoal was determine whether patients with apoorer prognosis of long-term survival, as indi-cated by advanced age, comorbidity, and/or tumorinvolvement of the base of tongue, were morelikely to undergo reconstruction with a pectoralisflap instead of a free flap, and if the use of a pector-alis flap offered any perioperative advantage,such as a reduction in medical complications orlength of hospital stay.

METHODS AND MATERIALS

Study Population. This study was conducted undera protocol approved by the Biomedical Institu-tional Review Board of the University of Pitts-burgh. All patients who underwent a compositesegmental mandibular resection between January1, 1998 and December 31, 2004 at the Universityof Pittsburgh Medical Center were retrospectivelyreviewed (n ¼ 103). Exclusion criteria included thefollowing: anterior defects involving the entiremandibular symphysis, reconstruction by primaryclosure, a skin graft, or with both a pectoralis flapand free flap, and a history of a previous free flap,benign pathology, or osteoradionecrosis (n ¼ 48).With these exclusion criteria, the remaining studypopulation consisted of 55 patients with lateralmandibular defects reconstructed with either apectoralis flap (n ¼ 19) or a free flap (n ¼ 36). Thetumor pathology was squamous cell carcinoma (52patients), adenocarcinoma (1 patient), and sar-coma (2 patients).

Classification of Comorbidity. Comorbidity is anydisease, illness, or condition other than the indexdisease under treatment or evaluation. Prognosticcomorbidity refers to any comorbidity that mightbe expected to impact on the patient’s outcome in-dependently of the index disease. In this study,the term prognostic comorbidity was used for con-comitant ailments that would be classified as‘‘moderate’’ or ‘‘severe’’ according to the Kaplan–Feinstein classification system.12,13 The Kaplan–Feinstein grade is based on severity of illness in anumber of categories, including hypertension,cardiac, cerebral or psychic, respiratory, renal, he-patic, gastrointestinal, peripheral vascular, ma-lignancy, locomotor illnesses, and alcoholism.Four overall Kaplan–Feinstein grades are possi-

1062 Prognosis as a Determinant of Free Flap Utilization HEAD & NECK—DOI 10.1002/hed December 2006

ble: no cogent comorbidity (grade 0), mild (grade1), moderate (grade 2), or severe (grade 3). Moder-ate or grade 2 comorbidity includes poorly con-trolled hypertension, former stroke with residua,and history of 1 episode of alcoholic seizure. Thefollowing are examples of ailments classified assevere comorbidity: congestive heart failure ormyocardial infarction within the past 6 months,recent stoke, marked pulmonary insufficiency (eg,cyanosis), uremia, hepatic failure (ascites, icte-rus), and severely decompensated alcoholism (>1episode of delirium tremens or alcoholic seizures).Patients’ preoperative functional status was alsoclassified according to the American Society ofAnesthesiologists (ASA) class.14 The ASA classwas included because it is a generic, universallyused, and easily obtained measure of health sta-tus in patients undergoing surgery that has beenshown to have an association with long-term out-come. According to a recent comparison of theavailable comordibity indexes,15 the Kaplan–Feinstein index more accurately predicts survivalin head and neck cancer patients compared withother comorbidity measures, such as the ASA sta-tus and the Charlson index.16

Preoperative vascular examinations (Allen’stest for a radial forearm free flap, and a color flowduplex or angiogram of the lower extremity for afibular free flap) for all 55 patients did not pre-clude any patient from a possible free flap.

Tumor Extension. At the time of initial anti-neo-plastic treatment, all patients were staged preop-eratively according to the TNM classification sys-tem.17 Tumor extension was noted by indicatingthose anatomic sites of the oral cavity and oro-pharynx that were involved by direct extension ofthe tumor. Mandibular resection was classifiedaccording to the system proposed by Urken et al18

All patients underwent a segmental lateral man-dibular resection (ie, complete resection of thebody of the mandible) with varying resections ofthe ascending ramus. Seventeen patients alsounderwent resection of some bone mesial to themental foramen but lateral to the ipsilateral cen-tral incisor (classified as a hemianterior resec-tion). None of the patients had a complete resec-tion of the symphysis and, without restoration ofmandibular continuity, all patients would havemaintained the projection of their chin point.

Thirty-six patients were treated initially witha mandibulectomy as part of their first definitiveanti-neoplastic therapy. Disease in these 36patients was clinically classified as T4 carcinoma.

Nineteen patients presented with persistent orrecurrent cancer after being treated previouslywith either local resection or definitive radiationtherapy, or both. Because of the concern of possi-ble invasion of the mandible and the goal ofachieving clear margins, these 19 patients under-went a segmental lateral mandibulectomy. Onreview of the surgical pathology, disease in 14 ofthese 19 was pathologically classified as T4; dis-ease in the remaining 5 patients (all with a historyof previous radiation therapy) was pathologicallyclassified as T2.

Outcomes. The primary outcomewas the utiliza-tion of a pedicled pectoralis flap versus a free flapfor reconstruction of the lateral mandibulardefect. A postoperative myocardial infarction,cerebrovascular accident, episode of pneumonia,delirium tremens, or a non–head and neck infec-tion requiring intravenous antibiotics (colitis, uri-nary tract infection) was classified as a majormedical complication. Operating time calculatedthe total time for both extirpation and reconstruc-tion. Mandibular plate fracture or exposure re-quiring removal was classified as a plate failure.Patients were followed for a mean of 18.6 months(SD¼ 14months).

Statistical Analysis. The data were entered intoa database and analyzed using SPSS version 10(SPSS, Chicago, IL). Univariate analyses wereperformed using the Mann-Whitney U, Fisher’sexact, and Pearson chi-square tests. Multivariateanalyses were performed using logistic regres-sion. The association of type of reconstructionwith age, comorbidity, and base of tongue involve-ment was quantified by odds ratio. The logisticmodels included terms for age, Kaplan–Feinsteingrade (or ASA class), and base of tongue involve-ment. Other patient and tumor variables were notincluded because they were not statistically asso-ciated with either the type of reconstruction or theconfounders of the main covariates in the logisticmodels. Cross-product 2-way interaction termswere entered into the logistic models, but theywere not included because they were not found tobe significant. Nonparametric data are given asmedians with the range of values. The Kaplan–Meier method was used to calculate survivalcurves and estimates from the date of reconstruc-tion. The log-rank test was used to test for statisti-cal significance of differences in survival curves.


RESULTS

Thirty-six patients underwent reconstruction oftheir lateral mandibular defect with free tissuetransfer. Thirty-one patients were reconstructedwith an osteocutaneous free flap (24 osteocutane-ous radial forearm flaps [RFFF], 6 fibular osteocu-taneous free flaps, 1 osteocutaneous iliac crest freeflap); 3 patients were reconstructed with a myocu-taneous rectus free flap; and 2 patients were recon-structed with a fasciocutaneous radial forearmfree flap. One fibular free flap failed completely af-ter a postoperative myocardial infarction. Thedefect was then reconstructed with a pectoralisflap and reconstruction plate. One osteocutaneousradial forearm free flap suffered a partial loss ofthe cutaneous portion of the osteocutanaeous flapand required a subsequent pectoralis flap for oralcavity closure. The remaining 34 patients in thefree flap required no further reconstructive flapsurgery during their hospital stay. Microvascular2.4-mm reconstruction mandibular plates wereused in 32 patients. The reconstruction plates of 2patients (2/32, 6.3%) required removal. One platefractured 19 months postoperatively, and theother was removed 24 months postoperatively af-

ter it became exposed. Both patients had beenreconstructed with an osteocutaneous RFFF. Onepatient died on hospital day 60 after the develop-ment of respiratory failure.

Nineteen patients were reconstructed with apedicled myocutaneous pectoralis major flap; 2.4-mm reconstruction mandibular plates were usedin 11 of the 19 patients. Three of these plates (3/11, 27.3%) became exposed and were removed. Noadditional flap surgery was needed in the groupinitially reconstructed with a pectoralis flap.

Advancing age (p ¼ .03), moderate or severecomorbidity (p¼ .02), and involvement of the baseof tongue by tumor (p ¼ .04) were significantlyassociated with decreased utilization of a free flap(Table 1). Each of these variables remained signif-icantly or strongly associated with free flap utili-zation after controlling for each other (Table 1) ina multivariate logistic model. Three-year survivalestimates according to the presence of comorbiditywere 0% for patients with moderate or severecomorbidity (n¼ 13) versus 68.8% (SE¼ 0.08; p<.01) with mild or no comorbidity (n ¼ 42). Three-year survival estimates according to tumor inva-sion of the base of tongue were 37.9% (SE ¼ 0.15)for patients with base of tongue invasion versus55.0% (SE¼ 0.11; p¼ .08) for patients without baseof tongue invasion. Patients aged �70 years had a3-year survival estimate (37.3%, SE ¼ 0.15) lowerthan patients aged<70 (56.3%, SE¼ 0.11; p¼ .12).

Seventeen patients (31%, 17/55) suffered amajor non–head and neck medical complication.Age and comorbidity were significantly or stronglyassociated with medical complications before andafter controlling for each other (Table 2). Patientswith moderate or severe comorbidity had on aver-age a hospital stay 1 week longer than those withmild or no comorbidity (21 days vs 14 days, p ¼.03). Base of tongue involvement was not signifi-cantly associated with medical complications(35.7% vs 29.3%, p ¼ .65) or an increased lengthof stay (Table 2).

Patients who underwent reconstruction with apectoralis flap had amedian decrease in operatingtime of 2 hours and 22 minutes (p ¼ .001) and anincreased incidence of plate failure compared withthe free flap group (27.3% vs 6.3%, p ¼ .10).Length of stay was similar for both the free flapand pectoralis groups (Table 3). Medical complica-tions were more common (42.1% vs 25%) in thepatients reconstructed with a pectoralis flap thanin those reconstructed with a free flap. Whenstratified by comorbidity, in the group of patientswith moderate or severe comorbidity (n ¼ 13),

Table 1. Clinical and tumor variables associated

with free flap utilization.

No. of

patients

%

of patients

receiving

a free flap

Adjusted

OR (95% CI)y

Age, y

< 55 19 84.2 Reference

55–69 21 66.7 0.27 (0.05–1.55)

�70 15 40.0 0.09 (0.01–0.59)

p value* .03 .04

Kaplan–Feinstein comorbidity

None or mild 42 73.8 Reference

Moderate or severe 13 38.5 0.29 (0.06–1.28)

p value* .02 .10

ASA class

2 16 93.8 Reference

3 39 53.8 0.13 (0.01–1.28)

p value* .01 .07

Base of tongue involvement

No 41 73.2 Reference

Yes 14 42.9 0.16 (0.03–0.77)

p value* .04 .02

Abbreviations: OR, odds ratio; CI, confidence interval; ASA, AmericanSociety of Anesthesiologists.yOR (95% CI) ¼ odds ratio (95% confidence interval). Adjusted oddsratio was calculated by constructing a logistic regression model con-taining age, comorbidity (Kaplan–Feinstein index or ASA class), andbase of tongue involvement as independent variables.*p values for univariate analyses were performed using the Fisher’sexact and Pearson v2 tests.


75% (6/8) of those reconstructed with a pectoralisflap had amajor medical complication versus 60%(3/5) of those reconstructed with a free flap (p ¼1.00). In the group of patients with no or mildcomorbidity (n ¼ 42), 18.2% (2/11) of those recon-structed with a pectoralis flap had a major medi-cal complication versus 19.4% (6/31) of thosereconstructed with a free flap (p¼ 1.00). The over-all 3-year survival for patients reconstructed witha pectoralis flap was 14.0% (SE ¼ 0.13) versus63.6% (SE ¼ 0.11; p <0.01) for patients recon-structed with a free flap.

Additional patient, tumor, and treatment vari-ables that were examined were smoking history,alcohol consumption history, history of prior radi-ation therapy, N classification, neck dissection,extirpative surgeon, and reconstructive surgeon.None of these variables was found to be associatedwith flap selection, medical complications, orlength of stay. Rates of medical complications

were not associated with operating times (oper-ating time >10 hours: p ¼ .75). Rates of free flaputilization for patients with primary tumors andrecurrent tumors were 69.4% and 57.9%, respec-tively (p ¼ .39). Rates of free flap utilization fortumors that required hemianterior resections ver-sus resections lateral to the mental foramen were64.7% versus 65.8%, respectively (p¼ .94).

DISCUSSION

Clinical decision making in head and neck recon-struction is influenced by many factors. Patientvariables, such as age and comorbidity, and tumorvariables, such as the site and the size of thedefect, impact reconstructive decisions. Outcomedata concerning function and quality of life mustalso guide clinical decisions. This article was writ-ten to underscore the methodologic issues thatmust be accounted for when surgeons compare

Table 2. Medical complications and length of stay according to clinical and tumor variables.

No. of

patients

Medical complicationsLength of stay,

median (range)% of patients Adjusted OR (95% CI)y

Age, y

< 55 19 26.3 Reference 14.0 (6–54)

55–69 21 14.3 0.36 (0.06–2.12) 14.0 (8–31)

�70 15 60.0 3.18 (0.64–15.96) 15.0 (8–35)

p value* .01 .06 .68

Kaplan–Feinstein comorbidity

None or mild 42 19.0 Reference 14.0 (6–54)

Moderate or Severe 13 69.2 9.40 (1.96–45.13) 21.0 (10–35)

p value* .001 .005 .03

ASA class

2 16 6.3 Reference 12.0 (7–35)

3 39 41.0 7.26 (0.82–64.5) 15.0 (6–54)

p value* .01 .08 .20

Base of tongue involvement

No 41 29.3 Not calculated 14.0 (7–35)

Yes 14 35.7 15.0 (6–54)

p value* .65 .78

Abbreviations: OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists.yAdjusted odds ratio was calculated by constructing a logistic regression model containing age and comorbidity (Kaplan–Feinstein index or ASAclass). Base of tongue was not entered into the multivariate logistic model because it was not associated with medical complications.*Univariate analyses were performed using the Mann–Whitney U, Fisher’s exact, or Pearson v2 tests.

Table 3. Outcomes according to type of reconstruction.

Type of

reconstruction

Operating time,

median

(range), h

Length of

stay, median

(range), days

Medical

complications,

% of patients

Plate failure,

% of patients

Pectoralis flap 8.88 (3.75–11.25) 15 (6–35) 42.1 27.3

Free flap 11.25 (7.0–16.25) 14 (7–54) 25.0 6.3

p value* .001 .68 .19 .10

*Univariate analyses were performed using the Mann–Whitney U, Fisher’s exact, or Pearson v2 tests; 19 and 36 patients, respectively, underwent recon-struction with a pectoralis flap and free flap.


different reconstructive techniques. In particular,we wished to document the selection bias thatguides the utilization of a free flap for reconstruc-tion of the lateral mandibular defect and to deter-mine whether our bias offers any demonstrableperioperative benefit.

A randomized clinical trial offers protectionagainst selection bias. However, despite themulti-tude of flaps available for comparison no compara-tive randomized clinical trial has been done inhead and neck reconstruction. Most clinical recon-structive studies are retrospective, observationalinvestigations. Because of selection bias, observa-tional studies tend to show greater differences intreatment groups than do randomized clinical tri-als.19,20 Multivariate analysis can theoreticallycontrol for prognostic factors that confound resu-lts, but only a properly designed randomized clini-cal trial can truly minimize selection bias. It isimperative that, in measuring outcomes, clini-cians recognize their own selection bias so thatclinical results are valid and can be generalized.

The results of this study indicate that patientswho were older and sicker (with worse comorbid-ity) and who had tumors involving the base oftongue were more likely to undergo reconstruc-tion of a lateral mandibular defect with a pectora-lis flap instead of a free flap. Age, comorbidity, andtumor involvement of the base of tongue eachindependently affect survival expectations. Pre-vious studies using the Kaplan–Feinstein index instudies of prognosis for head and neck cancerpatients have demonstrated significant survivalreductions of patients with severe comordi-bity.13,21–25 For example, in a study of 277 patientswith tumors of the oral cavity, Piccirillo and col-leagues25 reported a 5-year survival rate of 10%with severe comorbidity versus 49% withoutcomorbidity. The 5-year survival rates of patientswith advanced oral cavity and oropharyngeal can-cer are reported to be 49% and 40%, respec-tively.26,27 Tumors that involve the base of tonguehave an even worse overall prognosis, with overall5-year survival rates reported as low as 25% to30% for patients with stage IV tumors.28 Theseexpectations of overall prognosis likely bias thereconstructive and extirpative surgeons’ decisionmaking with regard to flap selection. Given thatreconstruction with a pectoralis flap requires lessoperating room time, has less chance of completefailure, and is less technically demanding, patientsmay be offered this type of reconstruction with thehope that these patients will suffer less periopera-tive morbidity, have a reduced hospital stay, and

be able to more quickly resume their previous life-styles in what may be a shortened life span.

Comorbidity was the main determinant of med-ical complications and the length of hospital stay.Previous case series of patients who have under-gone free tissue transfer have demonstrated simi-lar finding.29,30 Age was also independently associ-ated with the occurrence of systemic complications,probably because advanced age is a surrogatemarker for comorbidity that additionally indicatescomorbidity not captured by the Kaplan–Feinsteinindex. Compared with the free flap patients, thepatients who were reconstructed with a pectoralisflap had a reduction in operating time of approxi-mately 2 hours and 22 minutes. However, recon-struction with a pectoralis flap was not associatedwith a decreased length of stay or a reduction inmedical complications. To the contrary, medicalcomplications were more common (42.1% vs 25%)in the patients reconstructed with a pectoralis flapthan in those reconstructed with a free flap. Giventhat the patients who were reconstructed with apectoralis flap were more likely to be older and tohave moderate or severe comorbidity than wastrue of the free flap patients, the pectoralis groupwould be expected to have an increased complica-tion rate based solely on their advanced age andworse comorbidity. After stratifying patients bycomorbidity, the rates of medical complicationsbetween the 2 reconstructive groups were similar.In the group of patients with no or mild comorbid-ity (n ¼ 42), 18.2% (2/11) of those reconstructedwith a pectoralis flap had a major medical compli-cation versus 19.4% (6/31) of those reconstructedwith a free flap (p ¼ 1.00).

To determine with statistical significancewhether the use of a pectoralis flap offers any peri-operative advantage, such as a reduction in com-plications or length of hospital stay, would requirea much larger retrospective sample size or arandomized clinical trial. However, given the gen-eral belief that reconstruction of a lateral mandib-ular defect with an osteocutaneous free flap pro-vides the optimal long-term outcome, in regard toplate failure, facial symmetry, and masticatoryfunction, it is unlikely that such a randomizedstudy would be offered to patients.

The results of this study did not demonstratean association between longer operating timesand increased medical complications. The rela-tionship between the duration of the procedureand risk has long been debated. Haljamae31

showed that the duration of anesthesia influencesthe incidence of postoperative complications but


suggests that this incidence might reflect the se-verity of the underlying disease and the extent ofthe surgery performed instead of some uniquecharacteristic of a prolonged exposure to anes-thetics. Comparable with our data, Schustermanand Horndeski32 as well as Shestak et al33 werenot able to identify anesthesia time as a signifi-cant risk factor for developing complications. Incontrast, Farwell et al34 identified an anesthesiatime of >8 hours as a significant factor for the de-velopment of medical and surgical complications,and Singh et al35 identified an anesthesia time of>10 hours as a significant risk factor for medicalcomplications. Simultaneous free flap harvest andtumor extirpation is one strategy to reduce operat-ing times.

The rate of plate failure in the group recon-structed with a pectoralis flap was 27.3% versus6.3% in the group reconstructed with a free flap.This rate of plate failure in the pectoralis group issimilar to previously published rates. If the goal ofreconstruction with a pectoralis flap is simply toclose the wound and allow a patient to avoid com-plications and return to home, one should considerusing a pectoralis flap only for soft tissue recon-struction without restoration of mandibular conti-nuity with a plate.

Numerous reports have documented the func-tional and cosmetic advantages of using an osteo-cutaneous free flap versus a soft tissue flap and aplate.2,4,5,7,11 Comparing 3 different reconstruc-tion techniques for lateral mandibular defects(plate and pectoralis flap, plate and RFFF, andosteocutaneous flap), Shpitzer et al2 reported thatplates had to be removed in 7 of the 27 patients inthe pectoralis flap group and 2 of the 16 patientsin the FRFF group. None of the 14 osteocutaneousfree flaps failed. Speech was also best in the osteo-cutaneous free flap group. In a recent study thatincluded all mandibular bony defects reconst-ructed with an osteocutaneous free flap (not justlateral defects), it was reported that the postoper-ative function (resumption of an oral diet and den-tal rehabilitation) and primary site long-termmorbidity of the osteocutaneous RFFF were com-parable to other osteocutaneous free flaps, such asthe fibula and scapula.36 Our study, because of itsretrospective design, did not collect detailed qual-ity of life outcomes, such as those in the Univer-sity of Washington Quality of Life Question-naire.37 However, given the recognized, superioroutcomes, in regard to a plate failure rate, facialsymmetry, and mastication, our preferred methodof reconstructing a pure lateral mandibular defect

remains an osteocutaneous free flap, preferablyan osteocutaneous RFFF.

Functional outcomes and success rates of freetissue transfer to the head and neck are generallyreported as excellent. The results of this studyunderscore that selection criteria for free flapreconstruction are used that likely bias outcomestoward success. A previous study from our institu-tion that examined head and neck free flaps inpatients>60 years of age concluded that free flapscan successfully be done in the elderly.33 Age isnot a contraindication to free tissue transfer, butit is likely that patients who do undergo free tissuetransfer are younger and healthier with a betteroverall prognosis than those patients with a simi-lar defect that do not receive a free flap. Any func-tional comparison between reconstructive groupsneeds to account for these baseline differences inhealth status and prognosis that may explain anyobserved postoperative differences.

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Prognosis as a determinant of free flap utilization for reconstruction of the lateral mandibular defect