Sequential second free bone flaps for reconstruction of metachronous mandibular defects

Background: The purpose of this study was to identify patients who had previously undergone composite resection of a primary carcinoma of the oral cavity and immediate mandibular reconstruction with an osteocutaneous free flap and subsequently developed a local recurrence or a second metachronous tumor that required a second composite resection and immediate mandibular reconstruction with a second osteocutaneous free flap, in order to evaluate bone-to-bone healing of the two vascularized bone grafts and the long-term survival of these patients. Methods: Five patients who had undergone composite resection of a primary carcinoma of the oral cavity subsequently developed a local recurrence or a second metachronous tumor and therefore underwent mandibular reconstruction with two sequential osteocutaneous free flaps. Two sequential fibular osteocutaneous flaps were performed in three patients, two sequential radial forearm osteoeutaneous flaps in one patient, and a scapular osteocutaneous flap followed by a radial forearm osteocutaneous flap in one patient. End-to-end osteosynthesis of the second free vascularized bone graft to the first free vascularized bone graft was achieved using mandibular reconstruction plates, miniplates, or compression screws. Results: All five patients achieved solid bone-to-bone healing of the second free vascularized bone graft to the first free vascularized graft. Despite two patients only surviving 4 months after the second mandibular reconstruction, one patient survived for 1 year and 8 months and two patients remain disease-free after more than 3 years. Conclusion: Stable bone-to-bone union of a second osteocutaneous free flap to a previous osteocutaneous free flap mandibular reconstruction improves the quality of life of those patients who require a second composite mandibular resection for the treatment of a local recurrence or a metachronous tumor, but it is probably only palliative.