Outcomes of free flap reconstruction for mandibular ORN: Systematic review and meta-analysis
Soroush Farsi, Anna Benafield, Jerry Dorman, James Reed Gardner, Hayden Hairston, Rohan S Rereddy, Hayato Nakanishi, Deanne King, Susan Steelman, Emre Vural, Mauricio A. Moreno, Jumin Sunde
Abstract
This study aims to evaluate the success rates and complications associated with different free flap donor sites used in surgical reconstruction for mandibular osteoradionecrosis, providing insights to aid clinical decision-making. MEDLINE, Embase, Cochrane, and Web of Science. Comprehensive database searches were conducted up to October 2023. Three independent reviewers screened articles per PRISMA guidelines. This review is registered with PROSPERO (CRD42023456929). Meta-analysis, using inverse variance statistical method and a random effects model, was performed with OpenMeta software (Version 10.12, Brown University, USA). Study quality was assessed via the methodological index for non-randomized studies (MINORS). Nineteen full-text articles met inclusion criteria, encompassing 397 patients and 424 free flap procedures. Patients averaged 54.8 years old; 27.5 % were female. Squamous cell carcinoma was the main radiation indication (83.1 %). Flap types included fibula (63 %), iliac crest (36 %), scapula (3.7 %), and radial forearm (3.5 %). Symptoms of osteoradionecrosis appeared on average four years post-radiation therapy, with a mean dose of 6346 cGy. Pooled postoperative complication rate was 22.5 % (95 % CI 0.165–0.284, I 2 :48%). Radial forearm flaps had the lowest complication rate (13.5 %, 95 % CI 0.026–0.295, I 2 :0%), while scapula flaps had the highest (34.9 %, 95 % CI 0.039–0.66, I 2 :40.3 %). Fibula flaps had the lowest failure rate (3.3 %, 95 % CI 0.003–0.025, I 2 :0%), while iliac crest flaps had the highest (11.9 %, 95 % CI 0.022–0.260, I 2 :60.4 %). The fibula is the preferred flap for mandibular reconstruction due to its low failure rate. Radial forearm flaps show the fewest complications. More robust, multi-institutional prospective studies are needed.