Survival assessment regarding vascularized osseous flaps on reconstruction for mandibular defect: a Bayesian network meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

WANG Li ¹ ,  LI Chenxi ^2,3 , WANG Zhengye ⁴ , GONG Zhongcheng ² , DING Mingchao ⁵ , LIU Hui ⁶ , SUN Jialin ⁷

1. Department of Periodontics, the First Affiliated Hospital / Affiliated Stomatology Hospital of Xinjiang Medical University, Urumqi 830054, P.R. China;
2. Department of Oral and Maxillofacial Oncology & Surgery, the First Affiliated Hospital / Affiliated Stomatology Hospital of Xinjiang Medical University, Stomatological Research Institute of Xinjiang Uygur Autonomous Region, Urumqi 830054, P.R. China;
3. Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, School of Stomatology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan 430022, P.R. China;
4. Center for Disease Control and Prevention, Xinjiang Production and Construction Corps, Urumqi 830092, P.R. China;
5. State Key Laboratory of Military Stomatology, National Clinical Research Center for Oral Diseases, Shaanxi Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Traumatology & Orthognathic Surgery, the Third Affiliated Hospital of Air Force Medical University, Xi'an 710032, P.R. China;
6. Department of Oral and Maxillofacial Surgery, Shanghai Stomatological Hospital & School of Stomatology; Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai 200031, P.R. China;
7. School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, P.R. China;

Corresponding author：

LI Chenxi, Email: lichenximed@163.com

Keywords：

Mandible; Plastic surgery and reconstructive techniques; Network meta-analysis; Clinical prognosis; Evidence-based evaluation

DOI：

10.7507/1672-2531.202404020

Video：

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Objective To systematically review the survival rate of different vascularized bone flaps in mandibular defect repair and reconstruction by Bayesian network meta-analysis. Methods The PubMed, EBSCO, Scopus, Web of Science, Cochrane Library, WanFang Data and CNKI databases were electronically searched to collect clinical studies related to the objects from inception to February 2024. Two reviewers independently screened literature, extracted data and assessed the risk of bias of the included studies. The Bayesian network meta-analysis was carried out applying R software. Results A total of 24 studies involving 1 615 patients were included. The results of meta-analysis showed that the respective survival rates of fibula free flap (FFF), deep circumferential iliac artery flap (DCIA), scapula flap, and osteocutaneous radial forearm flap (ORFF) were 95.62%, 94.09%, 98.16%, and 93.75%. Moreover, the network meta-analysis failed to show a statistically significant difference between all comparators. Conclusion Current evidence shows that different vascularized bone flaps have similar survival rates in mandibular defect repair and reconstruction. Due to the limited quality and quantity of the included studies, more high quality studies are needed to verify the above conclusion.

1.	中华口腔医学会口腔颌面修复专业委员会. 下颌骨缺损修复重建治疗专家共识. 中华口腔医学杂志, 2019, 54(7): 433-439.
2.	Molteni G, Gazzini L, Sacchetto A, et al. Mandibular reconstruction in head and neck cancer: which is the gold standard. Eur Arch Otorhinolaryngol, 2023, 280(9): 3953-3965.
3.	Ross DA, Chow JY, Shin J, et al. Arterial coupling for microvascular free tissue transfer in head and neck reconstruction. Arch Otolaryngol Head Neck Surg, 2005, 131(10): 891-895.
4.	Li C, Shi W, Gong Z, et al. Anterolateral thigh perforator flap made by customized 3D-printing fabrication of fixed positioning guide for oromaxillofacial reconstruction: a preliminary study. Med Oral Patol Oral Cir Bucal, 2023, 28(1): e41-e47.
5.	Wilde F, Hanken H, Probst F, et al. Multicenter study on the use of patient-specific CAD/CAM reconstruction plates for mandibular reconstruction. Int J Comput Assist Radiol Surg, 2015, 10(12): 2035-2051.
6.	单小峰, 蔡志刚. 颌骨缺损血管化游离骨瓣重建后的种植修复治疗. 华西口腔医学杂志, 2023, 41(2): 123-128.
7.	Takushima A, Harii K, Asato H, et al. Choice of osseous and osteocutaneous flaps for mandibular reconstruction. Int J Clin Oncol, 2005, 10(4): 234-242.
8.	Tomioka H, Nishii N, Oikawa Y, et al. Clinicopathological analysis of 134 patients with squamous cell carcinoma of the mandibular gingiva. Heliyon, 2023, 10(1): e23120.
9.	Cumpston M, Li T, Page MJ, et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane handbook for systematic reviews of interventions. Cochrane Database Syst Rev, 2019, 10(10): ED000142.
10.	李兴红, 李晨曦, 王正业, 等. 妊娠期脑动静脉畸形出血风险的系统评价和Meta分析. 中国循证医学杂志, 2024, 录用待发表.
11.	Li C, Matthies L, Hou X, et al. A meta-analysis of the pros and cons of partial superficial parotidectomy versus superficial parotidectomy for the treatment of benign parotid neoplasms. J Craniomaxillofac Surg, 2020, 48(6): 590-598.
12.	Zhang WW, Li CX, Cao SJ, et al. A network meta-analysis of risk factors of infection among close contacts of COVID-19. Heliyon, 2023, 9(10): e20861.
13.	邓永强, 郑苍尚, 朱耀旻, 等. 腓骨及髂骨组织瓣在修复下颌骨缺损的应用比较研究. 口腔医学研究, 2013, 29(6): 569-571.
14.	Takushima A, Harii K, Asato H, et al. Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases. Plast Reconstr Surg, 2001, 108(6): 1555-1563.
15.	Haughey BH, Fredrickson JM, Lerrick AJ, et al. Fibular and iliac crest osteomuscular free flap reconstruction of the oral cavity. Laryngoscope, 1994, 104(11 Pt 1): 1305-1313.
16.	Fujiki M, Miyamoto S, Sakuraba M, et al. A comparison of perioperative complications following transfer of fibular and scapular flaps for immediate mandibular reconstruction. J Plast Reconstr Aesthet Surg, 2013, 66(3): 372-375.
17.	Hanken H, Schablowsky C, Smeets R, et al. Virtual planning of complex head and neck reconstruction results in satisfactory match between real outcomes and virtual models. Clin Oral Investig, 2015, 19(3): 647-656.
18.	Chen SH, Chen HC, Horng SY, et al. Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in postoperative infection and healing. Ann Plast Surg, 2014, 73(Suppl 1): S18-S26.
19.	Wilkman T, Husso A, Lassus P. Clinical comparison of scapular, fibular, and iliac crest osseal free flaps in maxillofacial reconstructions. Scand J Surg, 2019, 108(1): 76-82.
20.	Politi M, Toro C. Iliac flap versus fibula flap in mandibular reconstruction. J Craniofac Surg, 2012, 23(3): 774-779.
21.	Chen YB, Chen HC, Hahn LH. Major mandibular reconstruction with vascularized bone grafts: indications and selection of donor tissue. Microsurgery, 1994, 15(4): 227-237.
22.	Schultz BD, Sosin M, Nam A, et al. Classification of mandible defects and algorithm for microvascular reconstruction. Plast Reconstr Surg, 2015, 135(4): 743e-754e.
23.	Ritschl LM, Fichter AM, Grill FD, et al. Bone volume change following vascularized free bone flap reconstruction of the mandible. J Craniomaxillofac Surg, 2020, 48(9): 859-867.
24.	Dean NR, Wax MK, Virgin FW, et al. Free flap reconstruction of lateral mandibular defects: indications and outcomes. Otolaryngol Head Neck Surg, 2012, 146(4): 547-552.
25.	van Gemert JT, van Es RJ, Rosenberg AJ, et al. Free vascularized flaps for reconstruction of the mandible: complications, success, and dental rehabilitation. J Oral Maxillofac Surg, 2012, 70(7): 1692-1698.
26.	Heller KS, Dubner S, Keller A. Long-term evaluation of patients undergoing immediate mandibular reconstruction. Am J Surg, 1995, 170(5): 517-520.
27.	Chang DW, Oh HK, Robb GL, et al. Management of advanced mandibular osteoradionecrosis with free flap reconstruction. Head Neck, 2001, 23(10): 830-835.
28.	Yu Y, Zhang WB, Liu XJ, et al. Double-barrel fibula flap versus vascularized iliac crest flap for mandibular reconstruction. J Oral Maxillofac Surg, 2020, 78(5): 844-850.
29.	Dowthwaite SA, Theurer J, Belzile M, et al. Comparison of fibular and scapular osseous free flaps for oromandibular reconstruction: a patient-centered approach to flap selection. JAMA Otolaryngol Head Neck Surg, 2013, 139(3): 285-292.
30.	Deleyiannis FW, Rogers C, Lee E, et al. Reconstruction of the lateral mandibulectomy defect: management based on prognosis and location and volume of soft tissue resection. Laryngoscope, 2006, 116(11): 2071-2080.
31.	Boyd JB, Rosen I, Rotstein L, et al. The iliac crest and the radial forearm flap in vascularized oromandibular reconstruction. Am J Surg, 1990, 159(3): 301-308.
32.	Shpitzer T, Neligan PC, Gullane PJ, et al. The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and long-term evaluation. Head Neck, 1999, 21(7): 639-647.
33.	Yilmaz M, Vayvada H, Menderes A, et al. A comparison of vascularized fibular flap and iliac crest flap for mandibular reconstruction. J Craniofac Surg, 2008, 19(1): 227-234.
34.	Virgin FW, Iseli TA, Iseli CE, et al. Functional outcomes of fibula and osteocutaneous forearm free flap reconstruction for segmental mandibular defects. Laryngoscope, 2010, 120(4): 663-667.
35.	Mertens C, Decker C, Engel M, et al. Early bone resorption of free microvascular reanastomized bone grafts for mandibular reconstruction--a comparison of iliac crest and fibula grafts. J Craniomaxillofac Surg, 2014, 42(5): e217-e223.
36.	Mertens C, Decker C, Engel M, et al. Early bone resorption of free microvascular reanastomized bone grafts for mandibular reconstruction--a comparison of iliac crest and fibula grafts. J Craniomaxillofac Surg, 2014, 42(5): e217-223.
37.	Brown JS, Barry C, Ho M, et al. A new classification for mandibular defects after oncological resection. Lancet Oncol, 2016, 17(1): e23-30.
38.	Boyd JB, Gullane PJ, Rotstein LE, et al. Classification of mandibular defects. Plast Reconstr Surg, 1993, 92(7): 1266-1275.
39.	Algra AM, Lindgren A, Vergouwen MDI, et al. Procedural clinical complications, case-fatality risks, and risk factors in endovascular and neurosurgical treatment of unruptured intracranial aneurysms: a systematic review and meta-analysis. JAMA Neurol, 2019, 76(3): 282-293.
40.	Jansen JP, Naci H. Is network meta-analysis as valid as standard pairwise meta-analysis. It all depends on the distribution of effect modifiers. BMC Med, 2013, 11: 159.
41.	Markiewicz MR, Bell RB, Bui TG, et al. Survival of microvascular free flaps in mandibular reconstruction: a systematic review and meta-analysis. Microsurgery, 2015, 35(7): 576-587.
42.	Lonie S, Herle P, Paddle A, et al. Mandibular reconstruction: meta-analysis of iliac- versus fibula-free flaps. ANZ J Surg, 2016, 86(5): 337-342.
43.	Laverty DP, Addison O, Wubie BA, et al. Outcomes of implant-based oral rehabilitation in head and neck oncology patients-a retrospective evaluation of a large, single regional service cohort. Int J Implant Dent, 2019, 5(1): 8.

1. 中华口腔医学会口腔颌面修复专业委员会. 下颌骨缺损修复重建治疗专家共识. 中华口腔医学杂志, 2019, 54(7): 433-439.
2. Molteni G, Gazzini L, Sacchetto A, et al. Mandibular reconstruction in head and neck cancer: which is the gold standard. Eur Arch Otorhinolaryngol, 2023, 280(9): 3953-3965.
3. Ross DA, Chow JY, Shin J, et al. Arterial coupling for microvascular free tissue transfer in head and neck reconstruction. Arch Otolaryngol Head Neck Surg, 2005, 131(10): 891-895.
4. Li C, Shi W, Gong Z, et al. Anterolateral thigh perforator flap made by customized 3D-printing fabrication of fixed positioning guide for oromaxillofacial reconstruction: a preliminary study. Med Oral Patol Oral Cir Bucal, 2023, 28(1): e41-e47.
5. Wilde F, Hanken H, Probst F, et al. Multicenter study on the use of patient-specific CAD/CAM reconstruction plates for mandibular reconstruction. Int J Comput Assist Radiol Surg, 2015, 10(12): 2035-2051.
6. 单小峰, 蔡志刚. 颌骨缺损血管化游离骨瓣重建后的种植修复治疗. 华西口腔医学杂志, 2023, 41(2): 123-128.
7. Takushima A, Harii K, Asato H, et al. Choice of osseous and osteocutaneous flaps for mandibular reconstruction. Int J Clin Oncol, 2005, 10(4): 234-242.
8. Tomioka H, Nishii N, Oikawa Y, et al. Clinicopathological analysis of 134 patients with squamous cell carcinoma of the mandibular gingiva. Heliyon, 2023, 10(1): e23120.
9. Cumpston M, Li T, Page MJ, et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane handbook for systematic reviews of interventions. Cochrane Database Syst Rev, 2019, 10(10): ED000142.
10. 李兴红, 李晨曦, 王正业, 等. 妊娠期脑动静脉畸形出血风险的系统评价和Meta分析. 中国循证医学杂志, 2024, 录用待发表.
11. Li C, Matthies L, Hou X, et al. A meta-analysis of the pros and cons of partial superficial parotidectomy versus superficial parotidectomy for the treatment of benign parotid neoplasms. J Craniomaxillofac Surg, 2020, 48(6): 590-598.
12. Zhang WW, Li CX, Cao SJ, et al. A network meta-analysis of risk factors of infection among close contacts of COVID-19. Heliyon, 2023, 9(10): e20861.
13. 邓永强, 郑苍尚, 朱耀旻, 等. 腓骨及髂骨组织瓣在修复下颌骨缺损的应用比较研究. 口腔医学研究, 2013, 29(6): 569-571.
14. Takushima A, Harii K, Asato H, et al. Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases. Plast Reconstr Surg, 2001, 108(6): 1555-1563.
15. Haughey BH, Fredrickson JM, Lerrick AJ, et al. Fibular and iliac crest osteomuscular free flap reconstruction of the oral cavity. Laryngoscope, 1994, 104(11 Pt 1): 1305-1313.
16. Fujiki M, Miyamoto S, Sakuraba M, et al. A comparison of perioperative complications following transfer of fibular and scapular flaps for immediate mandibular reconstruction. J Plast Reconstr Aesthet Surg, 2013, 66(3): 372-375.
17. Hanken H, Schablowsky C, Smeets R, et al. Virtual planning of complex head and neck reconstruction results in satisfactory match between real outcomes and virtual models. Clin Oral Investig, 2015, 19(3): 647-656.
18. Chen SH, Chen HC, Horng SY, et al. Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in postoperative infection and healing. Ann Plast Surg, 2014, 73(Suppl 1): S18-S26.
19. Wilkman T, Husso A, Lassus P. Clinical comparison of scapular, fibular, and iliac crest osseal free flaps in maxillofacial reconstructions. Scand J Surg, 2019, 108(1): 76-82.
20. Politi M, Toro C. Iliac flap versus fibula flap in mandibular reconstruction. J Craniofac Surg, 2012, 23(3): 774-779.
21. Chen YB, Chen HC, Hahn LH. Major mandibular reconstruction with vascularized bone grafts: indications and selection of donor tissue. Microsurgery, 1994, 15(4): 227-237.
22. Schultz BD, Sosin M, Nam A, et al. Classification of mandible defects and algorithm for microvascular reconstruction. Plast Reconstr Surg, 2015, 135(4): 743e-754e.
23. Ritschl LM, Fichter AM, Grill FD, et al. Bone volume change following vascularized free bone flap reconstruction of the mandible. J Craniomaxillofac Surg, 2020, 48(9): 859-867.
24. Dean NR, Wax MK, Virgin FW, et al. Free flap reconstruction of lateral mandibular defects: indications and outcomes. Otolaryngol Head Neck Surg, 2012, 146(4): 547-552.
25. van Gemert JT, van Es RJ, Rosenberg AJ, et al. Free vascularized flaps for reconstruction of the mandible: complications, success, and dental rehabilitation. J Oral Maxillofac Surg, 2012, 70(7): 1692-1698.
26. Heller KS, Dubner S, Keller A. Long-term evaluation of patients undergoing immediate mandibular reconstruction. Am J Surg, 1995, 170(5): 517-520.
27. Chang DW, Oh HK, Robb GL, et al. Management of advanced mandibular osteoradionecrosis with free flap reconstruction. Head Neck, 2001, 23(10): 830-835.
28. Yu Y, Zhang WB, Liu XJ, et al. Double-barrel fibula flap versus vascularized iliac crest flap for mandibular reconstruction. J Oral Maxillofac Surg, 2020, 78(5): 844-850.
29. Dowthwaite SA, Theurer J, Belzile M, et al. Comparison of fibular and scapular osseous free flaps for oromandibular reconstruction: a patient-centered approach to flap selection. JAMA Otolaryngol Head Neck Surg, 2013, 139(3): 285-292.
30. Deleyiannis FW, Rogers C, Lee E, et al. Reconstruction of the lateral mandibulectomy defect: management based on prognosis and location and volume of soft tissue resection. Laryngoscope, 2006, 116(11): 2071-2080.
31. Boyd JB, Rosen I, Rotstein L, et al. The iliac crest and the radial forearm flap in vascularized oromandibular reconstruction. Am J Surg, 1990, 159(3): 301-308.
32. Shpitzer T, Neligan PC, Gullane PJ, et al. The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and long-term evaluation. Head Neck, 1999, 21(7): 639-647.
33. Yilmaz M, Vayvada H, Menderes A, et al. A comparison of vascularized fibular flap and iliac crest flap for mandibular reconstruction. J Craniofac Surg, 2008, 19(1): 227-234.
34. Virgin FW, Iseli TA, Iseli CE, et al. Functional outcomes of fibula and osteocutaneous forearm free flap reconstruction for segmental mandibular defects. Laryngoscope, 2010, 120(4): 663-667.
35. Mertens C, Decker C, Engel M, et al. Early bone resorption of free microvascular reanastomized bone grafts for mandibular reconstruction--a comparison of iliac crest and fibula grafts. J Craniomaxillofac Surg, 2014, 42(5): e217-e223.
36. Mertens C, Decker C, Engel M, et al. Early bone resorption of free microvascular reanastomized bone grafts for mandibular reconstruction--a comparison of iliac crest and fibula grafts. J Craniomaxillofac Surg, 2014, 42(5): e217-223.
37. Brown JS, Barry C, Ho M, et al. A new classification for mandibular defects after oncological resection. Lancet Oncol, 2016, 17(1): e23-30.
38. Boyd JB, Gullane PJ, Rotstein LE, et al. Classification of mandibular defects. Plast Reconstr Surg, 1993, 92(7): 1266-1275.
39. Algra AM, Lindgren A, Vergouwen MDI, et al. Procedural clinical complications, case-fatality risks, and risk factors in endovascular and neurosurgical treatment of unruptured intracranial aneurysms: a systematic review and meta-analysis. JAMA Neurol, 2019, 76(3): 282-293.
40. Jansen JP, Naci H. Is network meta-analysis as valid as standard pairwise meta-analysis. It all depends on the distribution of effect modifiers. BMC Med, 2013, 11: 159.
41. Markiewicz MR, Bell RB, Bui TG, et al. Survival of microvascular free flaps in mandibular reconstruction: a systematic review and meta-analysis. Microsurgery, 2015, 35(7): 576-587.
42. Lonie S, Herle P, Paddle A, et al. Mandibular reconstruction: meta-analysis of iliac- versus fibula-free flaps. ANZ J Surg, 2016, 86(5): 337-342.
43. Laverty DP, Addison O, Wubie BA, et al. Outcomes of implant-based oral rehabilitation in head and neck oncology patients-a retrospective evaluation of a large, single regional service cohort. Int J Implant Dent, 2019, 5(1): 8.

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