Modelling Osteotomies with the FÍbula Free Flap for Reconstruction of the Mandible

The osteocutaneous fibula flap has been one of the most useful procedures for lower maxillary reconstruction, secondary to oncologic resection. Its advantages include the possibility for multiple osteotomies for modeling mandibular contour; its tolerance for tooth implant; the anatomic consistency of the flap; and the relatively few sequelae in the donor area. The circulation in the flap combines endosteal with periosteal circulation, allowing multiple osteotomies and bevel cutting at the margins for adequate consolidation of the bone. The goal of this study was to assess the aesthetic outcome and conservation of the mandibular contour with a limited number of osteotomies in the subtotal reconstruction of the lower maxilla with fibula flaps.

Eighteen cases of subtotal reconstruction with the fibula flap over the last 2 years were evaluated. Included were patients who required subtotal reconstruction of the lateral, anterolateral, or anterior sector of the mandible, in whom two or less modeling osteotomies were performed independent of the original pathology. Thirteen were males and five females (2:6). Their average age was 42.3 years, with a range from 12 to 72 years. Eight flaps were performed with a skin paddle and 10 without; the median length of the bone segment used was 16 cm (8 to 20 cm).

Good results were observed in 80% of the cases. Good mandibular contours were achieved, limiting the number of osteotomies to two in subtotal reconstruction, observing a decrease in surgical time and in osteosynthesis material. Successful perfusion was obtained in 16 patients; in one case, there was a failure of the venous anastomosis with flap loss at day 5; in the other case, there was observed failure of perfusion in a control scintigraphy, leaving the bone as a non-vascularized graft.

Bone consolidation was adequate in 15 patients with a stable condition in a 6-month follow-up. There were two cases of delay in consolidation without compromise of the distal segment, that required a second surgery with revision of the bone with osteosynthesis material withdrawal, followed by a new osteosynthesis using bone chips to close the gap. No osteointegrated dental implants were used owing to economic limitations. In a cosmetic assessment performed by the members of the surgical team, good results were obtained in 10 patients, fair in 5, and poor in 2.

In lateral radiographic analysis,a good anteroposterior projection was observed in 88.20% of the cases, being deficient in 11.76%. Results were stable in all patients at a 6-month follow-up. No distal segment necrosis was observed.

The authors consider that mandibular reconstruction with the fibula flap is a very adequate method, and that it is possible to reconstruct an aesthetically acceptable contour with no more than two osteotomies, without suffering the effects of bone devascularization. Limiting the number of osteotomies also diminishes total surgical time and the amount of osteosynthesis material needed for fragment fixation. The preferred use over other reconstructive methods derives from versatility, bone length, consistent anatomy, length and width of the artery, the possibility of using a skin paddle and above all, the capability of being modeled by multiple osteotomies with good response to osteointegrated dental implants.

The most significant advantage of this flap is the possibility of performing multiple modeling osteotomies to achieve a good mandibular contour, a main factor in keeping the aesthetical proportions of the face.