Journal of Plastic Surgery and Hand Surgery

ISSN: 2000-656X (Print) 2000-6764 (Online) Journal homepage: http://www.tandfonline.com/loi/iphs20

Functional outcome in 17 patients whose

mandibles were reconstructed with free fibular
flaps

Erik Jarefors & Thomas Hansson

To cite this article: Erik Jarefors & Thomas Hansson (2016): Functional outcome in 17 patients
whose mandibles were reconstructed with free fibular flaps, Journal of Plastic Surgery and
Hand Surgery, DOI: 10.1080/2000656X.2016.1213172

To link to this article: http://dx.doi.org/10.1080/2000656X.2016.1213172

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Published online: 15 Aug 2016.

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Download by: [La Trobe University] Date: 02 October 2016, At: 17:02
JOURNAL OF PLASTIC SURGERY AND HAND SURGERY, 2016
http://dx.doi.org/10.1080/2000656X.2016.1213172

ORIGINAL ARTICLE

Functional outcome in 17 patients whose mandibles were reconstructed with

free fibular flaps
Erik Jareforsa and Thomas Hanssonb,a
a
Department of Plastic Surgery, Hand Surgery and Burns, University Hospital of Link
oping, Linkoping, Sweden; bDepartment of Clinical and
Experimental Medicine, University Hospital of Linkoping, Link
oping, Sweden

ABSTRACT ARTICLE HISTORY

Objective: The vascularised free fibular flap is considered to be a reliable choice for reconstruction of Received 19 December 2015
oromandibular defects, especially after resection of malignant tumours in the area. This study evaluates Revised 2 May 2016
the functional outcome of this method. Accepted 1 June 2016
Method: From January 2001 - May 2014, 37 patients were treated at the University Hospital of Published online 12 August
2016
ping using the free fibular flap. The authors present the results from 17. This study reviewed their
Linko
records and used the University of Washington Quality-of-Life questionnaire (UW-QoL), the Head and KEYWORDS
Neck Performance Status Scale (PSS), and interviews to assess their outcome. Free fibular flap; functional
Results and conclusions: Functional evaluation showed a significant decrease in chewing (16 out of outcome; mandible
17 patients), appearance (n 10), salivation (n 6), sensitivity in the mouth and skin (n 16), occlusive reconstruction
problems in the mouth (n 13), and range of mouth opening (n 12). The remaining domains showed
acceptable results, although most of them probably could not compare with the preoperative function.
Out of 17 patients, six had to adjust their eating in public significantly, three thought their activity to
be considerably restricted and two their recreation to be notably diminished. Common postoperative
complications were infections or fistula in the mandible (n 6), partial or complete rejection of the
cutaneous flap (n 4), and rupture of some of the sutures (n 3). Nine patients required at least one
more operation to repair defects, and six required a new soft tissue flap.

Introduction a vascularised fibular osteocutaneous flap (n 33) or a free

Among many causes for mandible deformation are cancer of
the oral cavity, congenital deformities, osteoradionecrosis
after radiotherapy, and trauma to the head [1,2]. Although
the vascularised free fibular flap has some disadvantages, it
is thought to be the best choice for reconstruction of anter-
ior and lateral defects, as it has a long, strong, bicortical
bone, a large pedicle, and a reliable cutaneous flap [14].
Reconstruction of the lower jaw is time-consuming and
delicate. Repair of the mandible not only upholds function of
the jaw, but also contributes to cosmesis and self-confidence,
thereby enabling the patient to return to a reasonable
quality-of-life (QoL) [1,2,5].
Our aim was to measure different variables of functional
outcome in patients who had been operated on at the
Department of Plastic Surgery, Hand Surgery and Burns,
University Hospital of Linko ping from January 2001May 2014.
Method
From January 2001May 2014, 37 patients with oromandibu-
lar defects were operated on at the Department of Plastic
Surgery, Hand Surgery and Burns, University Hospital of
ping; using the free fibular flap. The patients had either
Linko
fibular bone flap (n 4). We used the standard microvascular
operative technique preserving the periosteal blood supply,
which is critical to vascularity of the bone, especially when
the fibula is formed to fit into the bone defect of the man-
dible. Care was taken to preserve as much periosteum as
possible, as well as a cuff of muscle close to the fibula.
Approved by the Regional Ethics Review Board in
Linkoping, the study was done in two parts; it started in 2010
for patients from 20012009, but, due to the small population
size it was resumed in 2015 for patients from 20102014. We
excluded patients operated on after May 2014 to guarantee at
least a 1-year follow-up, at which point 25 patients were still
alive. Five were excluded because the flap failed, resulting in
complete or partial extraction of the transplanted bone. Three
patients could not be reached. We, therefore, sent the ques-
tionnaire to 17 patients (four of whom were women); mean
age 67 years (range 4379). The overall duration of follow-
up was 4 years, 6 months (range 1 year 2 months8 years 6
months). Fifteen had a free fibular osteocutaneous flap and
two a free fibular bone flap.
We reviewed patients casenotes, and used questionnaires,
interviews, and measurement of mouth opening to evaluate
the impact of the operation on the patients daily life and
the function of the lower jaw. The questionnaires were:

CONTACT Erik Jarefors erik.richter86@gmail.com c/o Thomas Hansson; University Hospital of Linkoping, Department of Plastic Surgery, Hand Surgery and
Burns, 58185, Link
oping, Sweden
Supplemental data for this article can be accessed here.
2016 Acta Chirurgica Scandinavica Society
2 E. JAREFORS AND T. HANSSON
The University of Washington Quality-of-Life (QoL) question-
naire and the Head and Neck Performance Status Scale. We
also measured the range of mouth opening (palatepalate in
teeth 1141).
Questionnaires
The University of Washington Quality-of-Life (UW-QoL) is
described in more detail by Rogers et al. [6]. The variables
we used were: pain, appearance, activity, recreation, swallow-
ing, chewing, speech, shoulder, taste, and saliva. We kept the
rating of importance used in the UW-QoL, and omitted the
emotional and social aspects, because these refer specifically
to patients with cancer. Each domain consisted of 35 state-
ments about the patients function with a score system of
0100 points [7,8]. The highest total score in our UW-QoL
was 1000 points.
The Head and Neck Performance Status Scale (PSS) meas-
ures normality of diet, speech, and eating in public. Each of patients scoring at or below 50 points were: n 2, n 6,
domain consisted of 511 statements with a score ranging
from 0100 points. Patients with normal function got the
highest score of 100 points. It is reliable, has been validated,
and is short, concise, and easy to use [9,10]. These two ques-
tionnaires have been used together successfully before [11].
Although validated in multiple languages, we could find
neither of these questionnaires a validated Swedish version,
so we had to translate them.
Results
Ten of our patients were operated on for malignant tumours
and seven for osteoradionecrosis or osteomyelitis after pri-
mary radiotherapy for cancers of the head and neck region.
Of the malignant tumours, seven were staged T4, and three
had N12 involvement; there were no distant metastases.
The causes were squamous cell carcinoma (n 8), clear cell
tumour (n 1), and relapse of salivary gland cancer of the
gingiva (n 1). Nine of the 10 were given radiotherapy pre-
operatively and none postoperatively.
Preoperatively, six patients already had some degree of
salivary impairment, of which five also had some range of
mouth opening deficiency. Three had involvement of their
throat and decreased deglutition, and two needed a feeding
tube. In each case the cause was the large amount of radi-
ation needed to cure the cancer, which resulted in most
cases in osteoradionecrosis (n 5). All reported at least some
worsening of their symptoms postoperatively.
Postoperative complications were infections or fistula in
the mandible (n 6), partial or complete rejection of the
cutaneous flap (n 4), and rupture of some of the sutures
(n 3). Nine patients required at least one more operation to
repair defects, and six required a new soft tissue flap. One
patient had a relapse of squamous cell carcinoma, but was
completely cured with chemotherapy and radiation. Fourteen
out of 15 patients with osteocutaneous flaps reported
decreased or no feeling in their flaps or skin, which led to
occlusive problems in the mouth in 13 patients.
Both patients with free fibular bone flaps had decreased sen-
sitivity in their operation-site.
At follow-up, only three patients had dentition throughout
the mouth. The remaining part had no teeth at all (n 1),
gaps at the site of resection (n 9), or anterior dentition for
cosmetic reasons (n 5). Six had some degree of rehabilita-
tion, such as a speech therapist or a mouth clamp. None
were given rehabilitation that focused on all the mouths
functions. The range of mouth opening was 29.5 cm
(mean 4.6). Twelve patients had a considerable reduction
when compared with the normal range of mouth opening in
elderly people [12].
Performance status scale
As seen in Supplementary Appendix Table 1, mean scores
for understandability of speech, eating in public, and
normality of diet were: 74, 71, and 49 points; and numbers
and n 11, respectively. One hundred points was the highest
and best score to achieve in each domain, whereas 0 points
was the lowest and worst.
Six patients chose the highest score of 100 points for
eating in public, whereas two chose highest for normality
of diet and two for understandability of speech. The total
mean score was 194 points (range 25280). None achieved
the highest total score of 300 points (Supplementary
Appendix Table 1).
University of Washington QoL questionnaire
At follow-up the patients achieved an overall mean of 701
points (range 150870). Supplementary Appendix Table 2
shows that the domains pain, activity, recreation, and
shoulder got means above 80 points. The lowest results
were achieved by appearance, saliva, and chewing, with
57, 56, and 41 points, respectively. Most patients chose the
highest score of 100 points for shoulder (n 12), and pain
(n 12). In the remaining domains, the highest score was
chosen by fewer than half the patients. Again, appearance
(n 1) and chewing (n 1) had the lowest results, followed
by speech (n 2) and saliva (n 4).
The patients were asked to choose up to three domains
that had concerned them particularly during the past 7 days.
Some chose more and some fewer. The mean was 2.6
domains/patient. All choices were included in a ranking sys-
tem (Supplementary Appendix Table 2). The foremost con-
cern, and most often chosen by patients, was chewing
(n 11), followed by saliva (n 10), speech (n 8),
swallowing (n 6), and appearance (n 5).
Discussion
In this study, functional evaluation after reconstruction of the
mandible showed a significant impact on chewing, saliva,
appearance, reduced range of mouth opening, occlusive
problems, and sensitivity decrease in at least six out of
17 patients. Further, those changes significantly influenced

some patients choice of food (n 11), whereas they were
comfortable with eating in public (n 6) and their speech
(n 2). We know of no other quality-of-life study that has
used similar methods in a comparable group of patients.
Either they did not differentiate between the different kinds
of flaps, excluded patients with osteoradionecrosis, or meas-
ured other domains [11,1316]. However, despite preopera-
tive radiotherapy and the relatively high complication rate in
our patients, our UW-QoL and PSS questionnaires showed
that good-to-excellent function was achieved in most
domains. Only chewing, saliva, and appearance showed [14,13,16,18]. Our data, however, indicates a considerable
low scores and, thus, indicate a considerable loss of function.
These results are to be expected in this kind of procedure
and have been reported before [5,11,1316]. Radiotherapy
clearly affects the functional outcome in oromandibular
reconstruction [15]. Each of our patients had preoperative
radiotherapy, which can explain some of the functional loss
in our patients.
The degree of disfigurement and dysfunction is thought
to depend on which segment of the mandible has been
removed and how much of the surrounding tissue was
excised [1,2]. In some part we confirmed this. One patient
had an almost complete resection of the entire lower jaw
and part of the floor of the mouth, which resulted only in
stiffness of the jaw postoperatively. Whether the patients
quality-of-life was affected by these changes was individual.
Patients with low eating in public scores (n 6) all said that
problems with chewing and malocclusion were the reason.
Only three also gave appearance as a major contributor. The
other patients had almost no reduction in activity, although
they had appreciable problems with chewing and cosmesis.
The UW-QoL ranking system showed that, despite a less
severe decrease in the functions of swallowing and speech,
they still were ranked higher than appearance, which indi-
cates that those variables are more affected by minor
changes and, therefore, more important to the patient. This
was also shown by Dropkin et al. [5], who concluded that
aphonia and impaired deglutition in particular were among
the hardest factors to cope for.
The functional decrease in mastication and normalcy of diet
are major factors in this study, yet only three of our patients
had dental implants or dentures at follow-up. It has been sug-
gested that dental rehabilitation and a prosthesis can almost
completely restore function in the mouth, if the damage is not
too great [1,2]. The ability to maintain oral hygiene should be
considered before osseointegration [1]. Twelve of our patients
had a considerable decrease of range of mouth opening and
six almost no saliva production at all. That explains why so
many of our patients were excluded from dental implantation.
Jacobsen et al. [17], on the other hand, achieved high implant
survival regardless of this fact (83% of 140 screw-retained
implants). They request a prioritisation of quality-of-life and
psychosocial comfort instead of unrealistic goals such as full
functionality, perfect cosmesis, and absence of peri-implantitis.
This should be taken into account considering our patients
low score in chewing and normalcy of diet.
Our patients rehabilitation comprised either a speech
therapist or a mouth clamp only when they had evident
restriction of movement of the tongue. However, most
JOURNAL OF PLASTIC SURGERY AND HAND SURGERY 3
patients had some kind of speech deficiency postoperatively.
Considering the high incidence of stiffness and range of
mouth opening decrease in our patients, it might be logical
to professionally rehabilitate all patients who have had oper-
ations on the lower jaw, with the function of the whole
mouth in mind. That could be the aim of further
investigations.
Other studies have indicated that the morbidity of recon-
struction of the mandible with a vascularised free fibular flap
is considered to be acceptable with good-to-excellent results
problem with the morbidity in our study group. Besides
having to exclude five patients because of total or partial
bone-flap failure; six (35%) had infections or fistula in the
mandible, and four (24%) had partial or complete rejection
of the cutaneous flap. This is a higher complication rate than
in other studies with similar patients (1.95% and 08.5%,
respectively) [4,13,16,18,19]. The number of patients that
these departments seem to operate on is at least 34-times
more compared to our department. A weakness of this study
is that it has been difficult to find reliable data about reasons
for the complication rate in our patients casenotes. As a con-
sequence, the complication rate in our department should
be investigated further.
The risk of changing the original design of the UW-QoL
and translated it into Swedish may have compromised the
reliability of the questionnaire. We had the choice between
decreasing the population size, which already is small, even
further or adjust the questionnaire so it would be able to fit
not only for head and neck cancer patients, but osteoradio-
necrosis patients as well. We did not change the specific con-
tent of each domains questions. Further, we hoped that it
was more likely to get a true answer if the patient received
the questionnaire in their own language instead of in
English. The questions are easy to understand and translate
and, thus, our alternations should not have changed the con-
tent of the questions.
As is the nature of retrospective studies, we could not com-
pare the patients preoperative and postoperative function.
Measurements before, directly after, and sometime later
would have been of value. Schrag et al. [1] and Villaret et al.
[11] conducted such a study and concluded that none of their
measured domains could achieve the preoperative state.
Conclusion
Free fibular flaps are commonly used for reconstruction of the
oromandibular defects. In this study, functional evaluation
after reconstruction of the mandible showed a significant
impact on chewing, saliva, appearance, reduced range of
mouth opening, occlusive problems, and sensitivity decrease
in at least six out of 17 patients. Further, those changes signifi-
cantly influenced some patients choice of food (n 11),
whereas they were comfortable eating in public (n 6) and
with their speech (n 2). Nevertheless, acceptable results
were achieved in the remaining domains, even if most of
them probably couldnt compare to the preoperative state.
Postoperative complications were more frequent in our
group of patients then in other comparable studies which
4 E. JAREFORS AND T. HANSSON
could explain the functional outcome in many of the
patients.
Disclosure statement
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the paper.
References
1. Schrag C, Chang YM, Tsai CY, Wei FC. Complete rehabilitation of
the mandible following segmental resection. J Surg Oncol
2006;94:53845.
2. Disa JJ, Cordeiro PG. Mandible reconstruction with microvascular
surgery. Semin Surg Oncol 2000;19:22634.
3. Frodel JL Jr, Funk GF, Capper DT, et al. Osseointegrated implants:
a comparative study of bone thickness in four vascularized bone
flaps. Plast Reconstr Surg 1993;92:44955. discussion 56-8.
4. Jones NF, Monstrey S, Gambier BA. Reliability of the fibular osteo-
cutaneous flap for mandibular reconstruction: anatomical and sur-
gical confirmation. Plast Reconstr Surg 1996;97:70716. discussion
17-8.
5. Dropkin MJ, Malgady RG, Scott DW, et al. Scaling of disfigurement
and dysfunction in postoperative head and neck patients. Head
Neck Surg 1983;6:55970.
6. Rogers SN, Lowe D, Yueh B, Weymuller EA. Jr., The physical func-
tion and social-emotional function subscales of the University of
Washington quality of life questionnaire. Arch Otolaryngol Head
Neck Surg 2010;136:3527.
7. Hassan SJ, Weymuller EA, Jr., Assessment of quality of life in head
and neck cancer patients. Head Neck 1993;15:48596.
8. Torres-Carranza E, Infante-Cossio P, Hernandez-Guisado JM, et al.
Assessment of quality of life in oral cancer. Med Oral Patol Oral Cir
Bucal 2008;13:E73541.
9. List MA, D'Antonio LL, Cella DF, et al. The performance status scale
for head and neck cancer patients and the functional assessment
of cancer therapy-head and neck scale. A study of utility and valid-
ity. Cancer 1996;77:2294301.
10. List MA, Ritter-Sterr C, Lansky SB. A performance status scale for
head and neck cancer patients. Cancer 1990;66:5649.
11. Villaret AB, Cappiello J, Piazza C, et al. Quality of life in patients
treated for cancer of the oral cavity requiring reconstruction:
a prospective study. Acta Otorhinolaryngol Ital 2008;28:1205.
12. Gallagher C, Gallagher V, Whelton H, Cronin M. The normal range
of mouth opening in an Irish population. J Oral Rehabil
2004;31:1106.
13. Holzle F, Kesting MR, Holzle G, et al. Clinical outcome and patient
satisfaction after mandibular reconstruction with free fibula flaps.
Int J Oral Maxillofac Surg 2007;36:8026.
14. Li X, Zhu K, Liu F, Li H. Assessment of quality of life in giant ame-
loblastoma adolescent patients who have had mandible defects
reconstructed with a free fibula flap. World J Surg Oncol
2014;12:201.
15. Rogers SN, Scott J, Chakrabati A, Lowe D. The patients' account of
outcome following primary surgery for oral and oropharyngeal
cancer using a 'quality of life' questionnaire. Eur J Cancer Care
(Engl) 2008;17:1828.
16. Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: a
10-year follow-up study. Plast Reconstr Surg 2002;110:43849.
discussion 50-1.
17. Jacobsen C, Kruse A, Lubbers HT, et al. Is mandibular reconstruc-
tion using vascularized fibula flaps and dental implants a reason-
able treatment? Clin Implant Dent Relat Res 2014;16:41928.
18. Lopez-Arcas JM, Arias J, Del Castillo JL, et al. The fibula osteomyo-
cutaneous flap for mandible reconstruction: a 15-year experience.
J Oral Maxillofac Surg 2010;68:237784.
19. Wu YQ, Huang W, Zhang ZY, et al. Clinical outcome of dental
implants placed in fibula-free flaps for orofacial reconstruction.
Chin Med J (Engl) 2008;121:18615.