Free Flap Surgery for Treating Osteoradionecrosis
What is osteoradionecrosis (ORN)?
Osteoradionecrosis (ORN) is a condition in which bone has died due to exposure to radiation. It is a side effect of radiation treatments for cancer in the head or neck. ORN can develop months or years after radiation treatment for cancer. Symptoms include pain, swelling, and sores.
How does radiation treatment affect bone health?
The radiation damages the blood supply to the bone and this makes it harder to heal from surgery (such as removal of a tooth), trauma or infection. Without a properly working blood supply, the bone and surrounding tissue:
- Cannot resist infection
- Cannot heal properly and an expanding area begins to die
The jaw is particularly at risk because of the unavoidable bone exposure to radiation when head and neck cancer is treated and also because of natural bacteria in the mouth. The radiation exposure makes it harder to maintain dental health and damage to teeth and gums can be a setup for infection which then triggers ORN.
In the mouth, the damage from radiation is commonly evident by:
- Bone that is exposed through the gums
- Repeated episodes of jaw swelling and discomfort
- An area of tissue that does not heal
ORN most commonly affects the lower jaw (mandible), but can also occur in the upper jaw (maxilla), the front of the spine or in any other bone exposed to significant radiation.
What are the non-surgical treatment options for osteoradionecrosis (ORN)?
Currently accepted management practices for moderate mandibular ORN are to:
- Give antibiotics if there is infection in the bone.
- Debride (remove) damaged and/or dead bone and surrounding tissue.
- Start hyperbaric oxygen (HBO) therapy. HBO involves breathing pure oxygen in a pressurized dive chamber. This specialized chamber promotes healing by allowing more oxygen to dissolve in the blood, which results in more oxygen being delivered to tissues. HBO is often used as a first line of treatment for ORN but there is debate about how effective it is. Treatment usually consists of daily "dives" for a total of 30 to 40 dive sessions over several consecutive weeks.
What is free flap reconstruction surgery?
“Free flap,” also known as “free tissue transfer,” is a term for a procedure in which tissue and its blood supply (artery and vein) are surgically removed from one part of the body and transferred to another area of the body for the purpose of reconstruction. It is the equivalent of transplant surgery, but because it comes from the patient’s own body, no long-term medications are required after surgery.
What areas of the body does the tissue for free flap reconstruction come from?
Free flaps can be taken from many areas of the body that have a good blood supply. The areas where flaps are taken are those where little long term effects are seen at the donor site. Surgeons essentially take “spare parts” from other parts of the body to perform reconstruction.
For mandibular jaw reconstruction, the typical donor tissue site has been the fibula (the long thin bone in the lower leg). More recently, the upper thigh area has become a donor site for appropriately selected patients.
What type of patient is best suited for free flap reconstruction using tissue from the fibula?
The fibula is usually considered as the tissue source for a typical flap when:
- Non-surgical methods, such as antibiotics and HBO, have not healed the jaw
- The jawbone is severely damaged or broken (fractured) and a full replacement of the jawbone is needed
Removal of the fibula is reserved for these patients because full replacement of the jaw (full removal and reconstructive surgery) is a very long (sometimes over 12 hours) and difficult surgery. This surgery typically requires a large neck incision to access the jaw for removal and reconstruction, a tracheotomy (due to swelling) and a feeding tube. The hospital stay averages at least 7 to 10 days.
What type of patient is best suited for free flap reconstruction using tissue from the upper thigh area?
Tissue from the thigh area is typically considered as the source for a free flap when:
- The osteoradionecrosis is moderate in severity
- Several courses of HBO and antibiotics have been tried and failed and the patient continues to have exposed jawbone, swelling and discomfort
- The osteoradionecrosis is more severe, the patient is unlikely to respond to HBO and he or she still has a good amount of healthy bone to maintain a stable jaw
The surgical process for harvesting tissue from the thigh area is called anterolateral thigh (ALT) fascia lata rescue flap procedure. Anterolateral thigh fascia flaps come from the front outside part of the upper thigh and include the strong lining over the muscle, called fascia lata, which has a very good blood supply. The purpose of ALT fascia flap surgery for osteoradionecrosis (also known as “mandibular rescue”) is to provide healthy coverage and strong blood supply to the remaining jawbone after the dead bone is removed and thus prevent any further loss.
What type of patient is not a good candidate for the anterolateral thigh (ALT) free flap procedure?
Patients who should not be considered candidates for the ALT free flap approach include:
- Patients who have severe trismus (lockjaw)
- Patients who have chronic nerve pain (not caused by infection) in the area needing treatment
- Patients who do not have enough healthy bone present to maintain jaw strength
In these patients, the larger fibula free flap reconstruction is required.
How is the anterolateral thigh (ALT) free flap surgical procedure done?
Because complete reconstruction of the jaw is not needed, the surgery can be performed mostly through the mouth with minimal or no neck incisions.
First, damaged tissue and bone is removed from the area to be treated. Next, a flap of fascia – connective tissue found under the skin along with its blood vessels (artery and vein) – is removed from the thigh and transferred to the affected area inside the mouth. The flap’s blood vessels are sewn to the blood vessels already in the area, to create a new blood supply. The flap is secured to the surrounding mucosa or is sometimes covered with a graft of skin taken from the same part of the thigh.
What happens after the anterolateral thigh (ALT) free flap procedure?
After surgery, you will need medication to control pain. You will usually stay in the hospital for one to three days after an ALT fascia free flap reconstruction. You will be placed on a liquid diet immediately afterward and a mechanical soft diet – meaning you’ll eat only soft things that require minimal chewing – for three or four weeks. Because you will begin to eat right away and there is minimal swelling with the procedure, no tracheotomy or feeding tube is required.
Before you leave the hospital you’ll be taught how to take care of your wounds and the drain in your thigh. The drain removes the buildup of excess fluids and blood from the area. It will stay in place for about a week.
You will be encouraged to walk while still in the hospital, usually beginning the day after surgery. You might need help at first. The distance of your walks should be increased slowly after you go home. The strength in your leg will return gradually. Long-term strength and function of the thigh is not affected by taking the free flap. You will have a scar on your leg at the site where the flap was removed.
Risks / Benefits
What are the advantages of free flap reconstruction?
Compared to the more traditional hyperbaric oxygen (HBO) treatment, free flap reconstruction saves time and creates less disruption for the patient. Hyperbaric oxygen treatment typically involves 40 sessions of up to three hours, called “dives,” over a period of several weeks.
In addition, controlled studies comparing HBO to placebo in patients with osteoradionecrosis have failed to demonstrate a significant difference in outcomes. As a result, there is much debate over the efficacy of this treatment for moderate osteoradionecrosis.
In contrast, early experience with ALT fascia flaps shows them to be highly effective in halting osteoradionecrosis in appropriately selected patients. Patients who undergo an ALT flap procedure usually return to their normal activities -- except for eating food that require chewing -- within a week.
What are the possible complications of the free flap reconstructive procedure?
Blood clots that develop in the first 48 hours after the procedure are the most common cause of flap failure. Sometimes, a second procedure to remove the clot is successful and the flap is saved. If blood flow cannot be re-established, the flap procedure would need to be repeated.
Another possible complication is infection. Infections can occur either in the thigh where the flap was removed or at the site where the tissue is transferred.
Recovery and Outlook
What’s the outcome (prognosis) for patients who undergo a free flap procedure?
The free flap reconstructive procedure has been very effective in establishing a new blood flow to the transferred tissue and halting osteoradionecrosis, with over 95 percent of patients avoiding further reconstructive surgery.
About radiation therapy and dental health
Dental procedures after radiation treatment increase the risk for osteoradionecrosis. You should consult your radiation oncologist if you’re going to have a tooth removed or another significant dental procedure. It’s good to get dental work taken care of before you have radiation therapy.
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