Copyright restrictions may apply JAMA Facial Plastic Surgery Journal Club Slides: Reconstruction of the Lateral Mandibular Defect Shnayder Y, Lin D, Desai SC, Nussenbaum B, Sand JP, Wax MK. Reconstruction of the lateral mandibular defect: a review and treatment algorithm. JAMA Facial Plast Surg. Published online July 23, doi: /jamafacial

Copyright restrictions may apply Introduction Segmental defects of the mandible resulting from malignant neoplasm, trauma, or osteoradionecrosis present complex clinical challenges for the reconstructive surgeon. Restoration of function, including speech and swallow, while limiting long-term morbidity, are primary objectives. Defects of the lateral mandible are defined as those that extend posteriorly from the mental foramen and can include the ramus or condyle. These defects are associated with different aesthetic and functional consequences compared with anterior defects. The muscles of mastication insert on the posterior mandible; therefore, their detachment can create an imbalance of the mastication forces. The lateral mandible also provides the contour to the posterior lower third of the face. Nonetheless, compared with the anterior mandible, the lateral mandible has less projection and is surrounded by a greater amount of soft tissue.

Copyright restrictions may apply Purpose This review examines the current literature on functional outcomes of lateral mandibular reconstruction and presents an algorithm on selecting an optimal reconstructive choice for patients with lateral mandibular defects resulting from oncologic ablative surgery or trauma.

Copyright restrictions may apply Relevance to Clinical Practice When reconstructing the mandible in a patient following tumor extirpation, the patient’s overall prognosis, medical comorbidities, and need for adjuvant therapy should be considered. In the patient with aggressive malignant disease and a poor prognosis, a less complex reconstruction, such as soft- tissue flap with or without a reconstruction plate, may be adequate. In a dentate patient with favorable prognosis, a durable reconstruction, such as osseocutaneous microvascular free flap, is often preferred. Various reconstructive options are available for patients with lateral mandibular defects. Depending on the predominance of the soft-tissue or bony components of the defect, with consideration of the patient’s characteristics and functional and aesthetic goals, the surgeon can wisely select from these reconstructive possibilities.

Copyright restrictions may apply Description of Evidence PubMed and Medline searches on reconstructing lateral mandibular defect were performed of the English literature. Search terms included lateral mandibular defect, outcomes of mandibular reconstruction, and free flap reconstruction of mandible. Although most of the articles presented are retrospective reviews, priority was given to the articles with high-quality level of evidence for this narrative review.

Copyright restrictions may apply Description of Evidence Consideration for Donor Site and Technique Selection for Lateral Defect Mandibular Reconstruction Age of patient Medical comorbidities and functional status of the patient Patient and surgeon preferences Radiation history and need for adjuvant therapy Components of soft-tissue defect Amount of bone and soft tissue resected Prior surgical procedures and previous incision placements Resection of the temporomandibular joint Cancer prognosis (if applicable) Dental restoration plan Patient anatomy, including body habitus Technical expertise of the surgeon Vessel-depleted neck

Copyright restrictions may apply Controversies and Consensus Reconstruction with a plate and a bone-containing free tissue is commonly used for patients with lateral mandibular defects. It preserves the continuity of the bone, with its associated strength; allows the possibility of dental restoration; and provides the most stable long-term reconstruction. Other possible reconstructive options include the use of a soft-tissue flap with a reconstructive plate, or letting the mandible “swing” by using a soft- tissue flap without the reconstructive plate. The disadvantage of soft-tissue– only reconstruction is that it does not allow for dental restoration and may be associated with hardware complications, although at a rate much lower than that with anterior defect repair. When reconstructing a mandible in a patient following tumor extirpation, the patient’s prognosis and need for adjuvant therapy should be considered. In the patient with aggressive malignant disease and a poor prognosis, a less complex reconstruction may be adequate, particularly if the defect is of the lateral mandible. If the patient has a favorable prognosis, a durable reconstruction is often preferred.

Copyright restrictions may apply Algorithm for Lateral Mandibular Defect Reconstruction

Copyright restrictions may apply Comment There are only a few articles in the reconstructive literature that specifically address functional outcomes of various reconstructive options used for patients with lateral mandibular defects. Future studies will focus on comparing functional and cosmetic outcomes of patients with similar lateral mandibular defects reconstructed by osteocutaneous (bone-containing) free flaps, soft-tissue flaps and plate, and soft-tissue–only flaps.

Copyright restrictions may apply Conclusions Various reconstructive options are available for patients with lateral mandibular defects. Depending on the predominance of the soft-tissue or bony components of the defect, with consideration of the patient’s characteristics and functional and aesthetic goals, the surgeon can wisely select from these reconstructive possibilities.

Copyright restrictions may apply Contact Information If you have questions, please contact the corresponding author: –Yelizaveta Shnayder, MD, Department of Otolaryngology–Head and Neck Surgery, University of Kansas School of Medicine, 3901 Rainbow Blvd, Kansas City, KS Conflict of Interest Disclosures None reported.