Osteocutaneous free fibular flap for anatomical reconstruction of the mandible following tumor resection

Abstract EN

Purpose : the development of micro vascular free tissue transfer has revolutionized the current approaches for mandible reconstruction.

It allowed one stage reconstruction of complex bony and soft tissue defects with high reliability.

This study presents our experience using vascularized free fibular graft for reconstruction of different anatomical mandibular defects following tumor ablation.

Methods : this study involves a total of 16 patients who were treated over 3-year period at the National Cancer Institute, Cairo University.

All patients underwent man-fibular resection and immediate reconstruction using free fibula osteocutaneous flap.

Mandibular resections were performed due to either primary mandibular tumors, or tumors directly invading the mandible from adjacent areas.

The extent of mandibular involvement by tumor was preoperatively assessed by X-ray panoramic view and CT scan.

Mandibular defects were classified according to HCL system where H defects are lateral defect of any length including the condyle, L defects are the same without condyle and C defects represent the central segment between the mental foramina.

The success rate, recipient vessels used, complications and functional as well as cosmetic outcome will be discussed.

Results : of sixteen patients, ten were males and 6 were females.

The age ranged from 4 to 68 years.

Five patients had preoperative chemotherapy ; two had radiation therapy, while six patients received postoperative radiation therapy.

All patients had preoperative histological diagnosis ; squamous cell carcinoma was the most common histology.

Mandibular defects consisted of central segment (3 C), lateral defect (9 L) and 4 patients with H defects.

The skin island was used to provide inner mucosal lining in 11 patients and as external monitor in 5 patients.

The free flap was successful in 13 patients.

There were 3 complete free flap necrosis; all were due to venous thrombosis.

Salvage surgery was attempted in all failing flaps, however, it was unsuccessful.

The most commonly recipient vessels were the facial vessels and external jugular vein.

There were 3 cases of or cutaneous fistulae that closed spontaneously.

Donor site was closed primarily except in two patients where split thickness skin graft was used.

The average length of the free fibula was 14 cm, while the average dimension of the skin island was 8.5 X 2.5 cm.

Osteotomy sites healed primarily in 12 patients, while non-union occurred in a 4-year old child who received postoperative chemotherapy.

The least follow up was 8 months ; two patients developed local tumor recurrences and underwent salvage surgery with excision of the flap.

Conclusion : Free fibula osteocutaneous flap is a versatile and reliable method of reconstruction of central, lateral and poster-lateral bony as well as composite mandibular defects.

However, it is a technically demanding surgery with high learning curve.