Changing Indications for Maxillomandibular Reconstruction With Osseous Free Flaps: A 17-Year Experience With 620 Consecutive Cases at UCLA and the Impact of Osteoradionecrosis

Objectives/Hypothesis: To characterize the changing indications for osseous free flaps in maxillomandibular reconstruction at our institution. Study Design: Retrospective chart review. Methods: Database review of patients who underwent free-flap reconstruction of the jaws using vascularized bone-containing free tissue transfer from 1995 to 2012 at the University of California Los Angeles (UCLA). Results: A total of 620 osseous free flaps were performed. The most common indications for surgery were squamous cell carcinoma (n = 442) and osteoradionecrosis (ORN)) of the mandible (n = 73). There were no significant differences in 90-day perioperative complication, flap viability, or mortality rates between any of the indications for surgery. Patients older than 60 years had a higher rate of major perioperative complication (P = 0.0028). ORN cases represented 1.3% 61.2% of surgical volume from 1995 to 2000, 8.7% 61.8% from 2001 to 2006, and 17.5% 62.2% from 2007 to 2012 (P < 0.0001). Among cases of ORN, 95.8% of patients had radiation therapy completed at centers outside of our hospital system. For patients with ORN, there was an average interval of 8.7 +/- 8.0 years from initiation of radiotherapy to the date of mandibulectomy (range 1-37 years). Conclusion: The incidence of ORN as an indication for free-flap reconstruction has increased at our institution in recent years. This may reflect an increasing need for the surgical management of medically refractory ORN, a rising awareness or prevalence of ORN overall, and/or increasing comfort with free flaps as a treatment for ORN. Patients who undergo free-flap surgery for ORN do not have greater risks of 90-day perioperative complications or differences in free-flap viability as compared to patients who undergo free-flap reconstruction for other indications.