Challenging the Orthodoxy of Mandibular Reconstructions Comparing Functional Outcomes in Osseous versus Soft Tissue Reconstructions of the Posterolateral Mandible

We read with interest the study by Dimovska et al¹ and congratulate the authors on the publication of their work. The study design and results merit further scientific discussion for the benefit of junior surgeons involved in oromandibular reconstruction.

In the study, posterolateral defects were divided into limited versus extensive based on masticatory muscles attachment, excluding mandibulectomies with condyle resection. This was useful for the message the study delivered. However, our concern is that such classification might not cover all lateral defects. Hemi-mandibulectomies and para-hemi-mandibulectomies are obvious example. And next is defects with masticatory space resection with/without skin, then trigone cancers requiring posterolateral mandibulectomy with inferior maxillectomy, etc. A segmental through-and-through defect posterior to the mandibular body does not fit the illustration, for example. Our explanation is that the classification was based on their defects in retrospective manner. Other institutes have their own resections and could deal with different etiologies. Careful interpretation is warranted.

With the classification in place, the authors compared the demographic data between both cohorts, no statistical significance was noted, and meaningful comparison regarding functional quality of life (QoL) was then conducted. Based on QoL results, soft tissue flaps only were recommended for limited resections. Though it appeared convincing, we had hard time accepting the conclusion. The demographic data lacked essential pre- and intraoperative information needed for decision making, and interpretation of QoL results, such as trismus, dentition, diet, tracheostomy, oral subsites involved, size and volume of soft tissue defects, and bone defects length. And, since there was no plate reconstruction, information on patients' postoperative changes in occlusion, airways, diet, mouth opening, speech, and swallowing, and whether patients received secondary osseous mandibular reconstruction become important to report on before advocating soft tissue flaps. Especially, the soft tissue flap patients in the limited resections group had shorter follow-up, and scored less than osseous patients, which was not statistically significant. So, can we surely say if follow-up was longer, complications might still not arise?

Authors' utilization of statistically significant findings laid strong foundation for their message. Statistics, however, are double-edge sword, which could confuse sometimes. For example, in the extended group, the osseous flaps did only significantly better in chewing, swallowing, and appearance but not in speech and overall QoL. What if we advocate soft tissue flaps since there were no statistically significant findings in overall?

Finally, the Washington questionnaire is comprised of 12 domains and global questions.[2] As the decision not to reconstruct the bone could have implications beyond swallowing, chewing, and speech, full assessment and documentation of changes in all domains over several time points could have provided a real picture of those patients for a more reasonable message.

Where we practice, one of the largest and last plastic surgery strongholds for head and neck reconstruction, an “orthodoxy” mandating specific reconstruction does not exist. The decision is multifactorial, individually based, and favors “like-with-like” when suitable. One should always remember that the decision we make in operating room could affect some of our patients for eternity.

Publication History

Received: 26 April 2020

Accepted: 16 June 2020

Article published online:
13 August 2020

• References

• 1 Dimovska EOF, Clibbon J, Heaton M, Viswanathan N, Ridha H, James R. Challenging the orthodoxy of mandibular reconstructions comparing functional outcomes in osseous versus soft tissue reconstructions of the posterolateral mandible. J Reconstr Microsurg 2020; 36 (01) 21-27
• 2 Rogers SN, Travers A, Lowe D, Levy AR, Midgely AW. Importance of activity and recreation for the quality of life of patients treated for cancer of the head and neck. Br J Oral Maxillofac Surg 2019; 57 (02) 125-134 . doi:10.1016/j.bjoms.2018.10.001