Resection and microvascular reconstruction of bisphosphonate-related osteonecrosis of the jaw: The role of microvascular reconstruction.

BACKGROUND: Current treatment guidelines caution against osseous reconstruction using free flap tissue to treat bisphosphonate-related osteonecrosis of the jaw (BRONJ). The primary rationale for this stance is the theoretical risk of nonunion and recurrence of disease within the reconstruction. Emerging evidence suggests that these theoretical risks may be overestimated. We performed a literature review of this procedure for the treatment of advanced BRONJ. We also present a new case report of resection and microvascular reconstruction in a 58-year-old man with stage III BRONJ. METHODS: A MEDLINE search was performed to gather all reports of maxillary and mandibular reconstruction using free tissue flap transfer for BRONJ. Inclusion criteria were confirmed stage II or III BRONJ, free tissue transfer and reconstruction, and reported complications. Articles were excluded if they contained only local flap reconstruction, wound closure without reconstruction, or osteoradionecrosis. Outcomes from our case report were added to the analysis. RESULTS: We identified 10 articles that met criteria. Adding our case, we identified 40 cases of free flap reconstruction. The rate of nonunion was 5% (2 of 40). Fistulas formed in 4 cases (10%). BRONJ recurred in 2 cases (5%). CONCLUSION: Complication rates after free flap microvascular reconstruction in BRONJ seem acceptable. Nonunion is relatively rare and should not be the sole reason to recommend against free flap reconstruction. A randomized clinical trial would help clarify the role of this procedure in refractory BRONJ; however, we believe that segmental resection and microvascular reconstruction is a viable option in select cases of BRONJ. (c) 2016 Wiley Periodicals, Inc. Head Neck 38:1278-1285, 2016.