Iliac Crest Bone Graft and Fascia Lata Free Flap for Rescue of Mandibular Osteoradionecrosis

Abstract

Objective: Describe the use, indications, and outcomes of iliac crest bone graft (ICBG) with concomitant anterolateral thigh fascia lata (ALTFL) rescue flap for the management of mandibular osteoradionecrosis (ORN).

Study design: Retrospective chart review.

Setting: Single institution.

Methods: Retrospective chart review of patients who underwent ICBG with ALTFL rescue flap for mandibular ORN between 2011 and 2023.

Results: Twenty-three patients (mean age 66.5 years, 73.9% male) with mandibular ORN underwent ICBG at the time of ATLFL. Patients failed prior antibiotic therapy (78.3%), hyperbaric oxygen therapy (39.1%), and/or pentoxifylline/tocopherol (34.8%). The most common mandibular subsites included the body (91.3%) and the angle (60.9%). All patients underwent concurrent ICBG with ALTFL to augment cortical height of retained mandible (<1 cm following debridement of ORN to healthy, bleeding bone). Following the ALTFL rescue flap with ICBG, the median length of stay was 3 days. There was 1 episode of flap failure noted at follow-up, requiring additional ALTFL procedure. No other major complications were reported at the reconstructed site. There were no complications associated with ICBG harvest, with all patients ambulating at the time of discharge. The mean clinical follow-up length was 20 months. Mandibular stability, based on radiographic features and clinical symptoms, was maintained in the majority of patients. Mandibular height was restored to an average of 1.9 cm, with a mean radiographic follow-up length of 16.8 months. A subset of patients (n = 4, 17.4%) experienced a flare in ORN symptoms following this procedure and required additional mandibular debridement with antibiotic therapy. One such patient required segmental mandibulectomy with osteocutaneous free flap reconstruction; however, all other patients exhibited radiographic and clinical arrest of symptoms for the follow-up period of 6.5 to 61.7 months.

Conclusion: In patients undergoing ALTFL rescue flap for mandibular ORN, ICBG appears to supplement mandibular height and strength in patients with limited remaining mandibular bone height following debridement, with successful arrest of clinical and radiographic disease progression, low morbidity, and abbreviated hospital stays.

Level of evidence: Level 4.

Keywords: iliac crest bone graft; mandibular reconstruction; microvascular reconstruction; osteoradionecrosis.