ATLFL Rescue Flap Surgery Is Highly Successful at Halting Mandibular Osteoradionecrosis Progression With Low Associated Morbidity

Patients with mandibular osteoradionecrosis (ORN) may finally have a highly effective, low-morbidity alternative to end-stage reconstruction, according to recently published research in JAMA Otolaryngology – Head & Neck Surgery. The retrospective chart review — the largest to date —tracked long-term outcomes of more than 40 patients who were treated with anterolateral thigh fascia lata (ATLFL) rescue flap. The technique was found it to be safe and highly effective in arresting mandibular ORN over the long term in nearly all patients with partial thickness disease.

“Traditionally there hasn’t been a good solution for patients with ORN other than at the end stage of the disease where we do full thickness resection of the jaw and reconstruction with a bone flap from the fibula,” says Michael Fritz, MD, Section Head, Facial Plastic and Microvascular Surgery at Cleveland Clinic and the senior author of the paper. “That procedure works well, but it’s a huge operation fraught with morbidity to the patient, and it usually takes them about a year to fully recover. About ten years ago, we began doing these smaller rescue flap operations and saw a good response in our patients.”

The ATLFL rescue flap technique

The procedure involves taking the fascia lata from the thigh with blood supply, and vascular access is obtained through small (3-4cm) incisions at the inferior mandible border, preauricular crease or nasolabial fold. The necrotic bone is filed down leaving just the healthy bone. In more extensive debridements, to ensure long-term mandibular stability, and iliac crest bone graft (also obtained through a small incision) is added. The free flap pedicle is passed from the intra-oral defect to the vessel access site, and microvascular anastomosis is performed. The ATLFL is then trimmed, inset into the healthy mucosa, and folded and imbricated into the defect to obliterate the space with vascularized tissue. The fascia mucosalizes over time.

Learn more about the procedure: Anterolateral Thigh Fascia Lata Rescue Flap for Osteoradionecrosis – Changing Paradigms of Treatment

“The average stay after the procedure is just a couple of days in the hospital,” says Dr. Fritz. “A lot of patients leave on post-op day one, and the surgery is about four to five hours long. Patients are walking the next day. It’s a whole different animal compared to the segmental resection and fibula reconstruction option. Although we have them on a soft diet for several weeks, patients can eat right away.”

The findings

The new research includes data from patients who were appropriate candidates to undergo the ATLFL for mandibular ORN between 2011 and 2022. A total of 43 patients comprising 51 cases of mandibular ORN were identified. The mean age of patients was 66 years (47-80 years), and the majority of patients were male (55.8% [n = 24] and 44.2% female [n = 19]). Eight patients had either simultaneous or asynchronous bilateral disease, requiring separate subsite reconstructions.

All of the included patients had preoperative imaging work-up, including a CT scan of the face, mandible, or neck (74.5%) or panoramic x-ray (80.8%). Preoperative Notani staging for the included patients was Stage I (23.9%), Stage II (45.7%) and Stage III (30.4%). Iliac crest bone grafting was performed during anterolateral thigh fascia lata rescue flap in 9 cases where nearly full-thickness resection was required (17.3%), and the mean mandibular defect area was 20.9 cm2. Of the 43 patients, just two of them required future fibular free flap reconstruction. Successful arrest was noted both clinically and radiographically in 96.2% of cases.

“We defined success by stabilization of the process clinically and radiographically,” explains Dr. Fritz. “So, we looked at imaging and reported lack of symptoms, i.e., no infection, no pain or anything that brought a patient back into the hospital or the clinic. We had 96% control with this technique.”

He continues, “What was interesting is that this success was independent of the depth of the bone that was involved. People who were candidates for this procedure did not have full-thickness disease, meaning their mandible wasn’t broken all the way through. But even if it was almost to the bottom and there was just a little rim of good bone left, we used an iliac crest bone graft and supplemented it, and the area just grew new bone and stabilized the mandible. This can be seen in our data – regardless of Notani stage, we still saw that 96% success rate. It’s also important to note that the use of rescue flaps in this surgery does not preclude or at all impair a patient’s candidacy for future fibula free flap reconstruction should further steps be necessary.”

Implications

Prior to the ATLFL technique, patients with mandibular osteoradionecrosis had few treatment options. Segmental resection and reconstruction is such an invasive, morbid and expensive operation that it is often prolonged until absolutely necessary. The rescue flap provides an effective early intervention for those individuals who present with extensive disease or who fail conservative management. Current medical management includes debridement, antibiotics and pentoxyphylline/tocopherol (PENTO). Over the last decade, PENTO has gained favor as an early ORN treatment that can help heal superficial diseases. Prior to pentoxifylline, hyperbaric oxygen therapy (HBO) was used, but its efficacy has come into question in recent years.

“The biggest downside to HBO is there are no studies that have shown that it works,” says Dr. Fritz. “I don’t know what other disease we treat in medicine with a technique that’s not established as being effective, let alone something that costs as much as HBO. It’s very expensive, both from a cost perspective and from a time perspective. It’s 30 days out of peoples’ lives, and it can cause several unpleasant side effects including vision and balance problems.”

Dr. Fritz also anticipates that the traditional watch-and-wait method for ORN will soon become a thing of the past. In those failing conservative measures with symptoms and disease progression, early surgical intervention will become commonplace. “When you talk to patients about, ‘We can just stop this for you with a 95+% chance with a small operation you go home in a day and you don’t have to think about this for the rest of your life,’ a lot of them just want to go ahead so don’t have to worry about it anymore. We believe that this surgical technique is a true game-changer for patients with ORN. Not only have we had an extremely high success rate, but the associated morbidity is also low. We expect that this will become the new standard of care for ORN.”