Prefabrication of a Free Fibula Flap by Distraction Osteogenesis for Mandibular Reconstruction

Free fibula reconstruction works well, but not perfectly, for constructing a neo-mandible. One of the main problems is the height of the reconstructed mandible for placement of osseointegrated implants. Post-reconstructive augmentation of the fibula flap by vertical distraction was presented first by Hellner et al. (1993). Alveolar distraction devices were applied to the flap after its transfer as preparation for long-term implant prosthetic rehabilitation. In this report, the authors presented their experience with distraction osteogenesis of the fibula before free transfer. This prefabricated flap allowed for the transfer of a 2.5-cm wide fibula to reconstruct a deficient mandible in a child with craniofacial microsomia (CFM).

The patient presented as a 10-year-old male with Pruzansky type 3 craniofacial microsomia. He had undergone a previous reconstructive effort with rib graft that failed. Preoperative imaging demonstrated a complete absence of the ramus, the angle, and a large portion of the body on the involved side. The contralateral fibula was approached through a standard lateral incision. A longitudinal osteotomy was performed parallel to the long axis of the bone to allow for transverse widening of the fibula. An external distraction device was applied and distraction osteogenesis was delivered to widen the fibula by 1.5 cm. The callus was allowed to consolidate for a period of 8 weeks.

A second procedure involved harvesting of the pre-expanded fibula flap using the same incision and a standard technique. The harvested bone segment was 14 cm in length and 2.5 cm in maximum width; the original width of the fibula was 1 cm. A near hemi-mandibular segment was easily shaped using two horizontal osteotomies and microplates. The recipient site was exposed through preauricular and mandibular border incisions. A 2 × 2-cm costal cartilage graft was wired to the zygoma for reconstruction of the joint surface. The fibula flap was inset and fixed with two microplates. There were no perioperative complications. The fibula incorporated well.

Prefabrication of the fibula offers additional advantages to the methods described previously. The authors presented a successful report of pre-transfer widening of the fibula for mandible reconstruction in a patient with CFM. This modality of treatment is a valid addition to the surgical armamentarium for reconstruction of these complex deformities.