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Page 6 of 10 Mayland et al. Plast Aesthet Res 2021;8:62 https://dx.doi.org/10.20517/2347-9264.2021.38

Figure 2. (A) Fibula free flap reconstruction of osteonecrosis defect extending from mandibular symphysis to ramus. (B) Example of the
fasciocutaneous paddle of the fibula being to provide intraoral coverage for a mucosal defect.

Another variation in surgical design includes orientation and placement of the soft tissue component.
Orientation of the fasciocutaneous paddle, in particular when a fibula donor site is used, can either be
medial to the reconstructed bone segment or lateral to the reconstructed segment. When the soft tissue is
oriented lateral to the hardware, it may provide an additional layer of soft tissue coverage over the
reconstruction hardware. An example of a fasciocutaneous paddle that was brought medially into the floor
of the mouth is depicted in Figure 2B. Interestingly, the medial orientation of the fasciocutaneous paddle
was found to result in a lower incidence of postoperative bone exposure and required fewer postoperative
[40]
tissue debridement and local flaps procedures . The authors hypothesize that the medial orientation for
the fasciocutaneous paddle reduces tension on the perforating vessels and provides protection from vascular
[40]
insufficiency to the soft tissues .
Dental implantation can significantly improve a patient’s quality of life. Dental implantation success in
[41]
ORN reconstruction has been cited around 95% . The literature cites similar complications rates with
primary vs. secondary implantation in the setting of ORN. Secondary implantation has been found to
correlate with higher fixed costs , while primary implantation leads to a faster return of oral intake .
[41]
[41]
Implant success rates were found to be similar for fibula vs. scapula free flaps .
[42]
QUALITY OF LIFE
Pain is thought to be a large contributor to poor quality of life for patients with advanced ORN [23,43] . Exposed
nerve endings are subjected to infection and inflammation within a non-healing ORN wound. Free flaps are
advantageous in their ability to provide coverage of exposed nerves and improve the blood flow to the area.
One prospective study found a consistent reduction in pain-related domains following surgical resection
and immediate free flap reconstruction of ORN, leading the authors to conclude that free flap
reconstruction of advanced ORN improves QOL .
[43]

In addition to pain, other QOL variables of concern for patients included speech, chewing, swallowing, and
appearance [24,44-46] . The University of Washington Quality of Life (UW-QOL) survey is commonly utilized
for the assessment of QOL following head and neck reconstruction with a free flap [23,24,43,46-48] . It was
previously found that UW-QOL domain scores following free flap reconstruction for advanced ORN were
higher for those patients who received dental implants, did not have a history of prior head and neck
[22]
[22]
surgery, and did not develop a cancer recurrence . In contrast, Sweeny et al. found UW-QOL domain
scores were not impacted by ORN recurrence, anatomic subsite of the ORN, or donor tissue used for the
reconstruction. A summary of QOL outcomes can be found in Table 3.