12663_2009_Article_4
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Fibula free flap splitting for mandible reconstruction: A technical note José María López-Arcas 1 · Burgueño M 2 · JL Del Castillo 3 1 Resident 2 Head of the Department 3 Faculty Dept. of Oral and Maxillofacial Surgery University Hospital, Spain Address for correspondence: Jose María Lopez-Arcas Dept. Oral and Maxillofacial Surgery University Hospital La Paz Pº de la Castellana 261 PO. 28046 Madrid, Spain Ph: +34639794252 E-mail: [email protected] Abstract Conformation of the fibula flap to passively adapt to the remaining mandible may be indeed challenging. A review of the ‘axial splitting’ technique for fibula free flaps is presented with a novel method of osteosynthesis. Adequate mandibular angle shape is achieved by performing this type of osteotomy with a minimal use of titanium hardware for flap insetting. Keywords Fibula free flap · Mandible reconstruction · Head and neck reconstruction · Microvascular reconstruction · Fibula osteotomies Received: 26 January 2009 / Accepted: 17 February 2009 © Association of Oral and Maxillofacial Surgeons of India 2009 Introduction Microsurgical techniques have improved functional and cosmetic outcomes following the reconstruction of extensive mandible defects. Taylor [1] and Gilbert [2] described a technique for harvesting a fibula free flap. Following the experience of Hidalgo [3], the flap came into widespread use for mandible microsurgical reconstruction. Subsequently, several refinements for flap harvesting and insetting have been described for better adjusting and contouring of the bone. Usually, the flap is tailored to adjust to the remaining mandible or to replace it by performing several ‘wedge’ osteotomies, which allow the angulation of the different segments. However, this technique has some disadvantages, which include bone loss of 1–3 cm, difficulty making an optimal wedge according to the formula of Kahler and Manders, [4] and increased risk of damaging the vascular pedicle of the flap. To overcome these drawbacks of the wedge osteotomy, Guyot et al. [5] published their initial experience with an axial splitting technique for the fibula flap to shape the angle of the neo- mandible in 2001. Since then, little attention [6] has been given to this elegant, useful technique in the literature. The axial splitting technique used at the Oral and Maxillofacial Department, University Hospital La Paz in Madrid (Spain), with an innovative modification in the method of fixation, is presented. Operative technique Once the flap has been harvested, the length of the defect in the body of the mandible is measured and the expected position of the new angle of the mandible is the determined with the aid of a template, three- dimensional model, or visually. Next, an axial osteotomy is performed, mimicking the mandible sagittal split procedure in orthognathic surgery. First, the periosteum at the osteotomy site is carefully stripped. Then, the osteotomy, as described by Guyot et al. [5], is performed with an oscillating saw, making three cuts: (1) First is on the external surface of the fibula, perpendicular to the main axis of the bone Fig. 1 Osteotomy designed for an axial splitting technique Fig. 3 Osteosynthesis with two bicortical compression screws Fig. 2 Osteotomy completed with adequate movement of both fragments J Maxillofac Oral Surg 8(1):17–18 123 TECHNICAL NOTE
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Transcript of 12663_2009_Article_4
Fibula free flap splitting for mandiblereconstruction: A technical note
José María López-Arcas1� ·Burgueño M2 · JL Del Castillo3
1 Resident2 Head of the Department3 Faculty
Dept. of Oral and Maxillofacial SurgeryUniversity Hospital, Spain
Address for correspondence:
Jose María Lopez-ArcasDept. Oral and Maxillofacial SurgeryUniversity Hospital La PazPº de la Castellana 261PO. 28046 Madrid, SpainPh: +34639794252E-mail: [email protected]
Abstract Conformation of the fibula flap to passively adapt to the remainingmandible may be indeed challenging. A review of the ‘axial splitting’ technique forfibula free flaps is presented with a novel method of osteosynthesis. Adequatemandibular angle shape is achieved by performing this type of osteotomy with aminimal use of titanium hardware for flap insetting.
Keywords Fibula free flap · Mandible reconstruction · Head and neckreconstruction · Microvascular reconstruction · Fibula osteotomies
Received: 26 January 2009 / Accepted: 17 February 2009© Association of Oral and Maxillofacial Surgeons of India 2009
Introduction
Microsurgical techniques have improvedfunctional and cosmetic outcomesfollowing the reconstruction of extensivemandible defects. Taylor [1] and Gilbert[2] described a technique for harvesting afibula free flap. Following the experienceof Hidalgo [3], the flap came intowidespread use for mandiblemicrosurgical reconstruction.Subsequently, several refinements for flapharvesting and insetting have beendescribed for better adjusting andcontouring of the bone.
Usually, the flap is tailored to adjustto the remaining mandible or to replace itby performing several ‘wedge’osteotomies, which allow the angulationof the different segments. However, thistechnique has some disadvantages, whichinclude bone loss of 1–3 cm, difficultymaking an optimal wedge according to theformula of Kahler and Manders, [4] andincreased risk of damaging the vascularpedicle of the flap. To overcome thesedrawbacks of the wedge osteotomy, Guyotet al. [5] published their initial experiencewith an axial splitting technique for thefibula flap to shape the angle of the neo-mandible in 2001. Since then, littleattention [6] has been given to this elegant,useful technique in the literature. The axialsplitting technique used at the Oral andMaxillofacial Department, UniversityHospital La Paz in Madrid (Spain), with
an innovative modification in the methodof fixation, is presented.
Operative technique
Once the flap has been harvested, the lengthof the defect in the body of the mandible ismeasured and the expected position of thenew angle of the mandible is the determinedwith the aid of a template, three-
dimensional model, or visually. Next, anaxial osteotomy is performed, mimickingthe mandible sagittal split procedure inorthognathic surgery.
First, the periosteum at the osteotomysite is carefully stripped. Then, theosteotomy, as described by Guyot et al.[5], is performed with an oscillating saw,making three cuts: (1) First is on theexternal surface of the fibula,perpendicular to the main axis of the bone
Fig. 1 Osteotomy designed for an axialsplitting technique
Fig. 3 Osteosynthesis with two bicorticalcompression screws
Fig. 2 Osteotomy completed with adequatemovement of both fragments
J Maxillofac Oral Surg 8(1):17–18
123
TECHNICAL NOTE
down to the level of the medullary canal;(2) the second is made along the main axisof the bone and is between 3 and 5 cmlong; and (3) the last is made perpendicularto the internal surface at the junction ofthe anterolateral and posteromedialsurfaces down to the medullary canal, aswas done for the first cut. The vascularpedicle is protected by placing a bluntdissector in the subperiosteal plane. Ifnecessary, the osteotomy can be finishedusing a chisel.
Next, the surgeon slides the twooverlapping bone segments, adjusting theirangulation to shape the new mandibularangle precisely.
Osteosynthesis can be performedusing a standard technique withminiplates or a reconstruction plate,although a simpler method with twocompression screws is preferred, onceagain, mimicking the fixation methods oforthognathic surgery, as two overlappingbony surfaces are available. In this sense,
the amount of titanium hardware insertedis reduced, lowering the risk ofcomplications related to osteosynthesisand reducing the cost.
In summary, the axial splittingtechnique for a free fibula flap is aneffective, safe and cost saving way to shapea new mandibular angle duringmicrosurgical reconstruction. We have usedthis technique in 4 cases, without problems.In two cases we used a reconstruction plateto fixate the segments and in the other twowe used the bicortical screws.
References
1. Taylor GI, Miller GD, Ham FJ (1975)The free vascularised bone graft: Aclinical extension of microvasculartechniques. Plast Reconstr Surg 55(5):533–544
2. Gilbert A (1979) Vascularised transferof the fibular shaft. Int J Microsurg1: 100–105
3. Hidalgo DA (1989) Fibula free flap: Anew method of mandible reconstruction.Plast Reconstr Surg 84(1): 71–79
4. Kahler SH, Manders EK (1991)Planned angle osteotomy. Plast.Reconstr Surg 87(5): 969–973
5. Guyot L, Richard O, Cheynet F, SauvantJ, Chossegros C, Layoun W, Blanc JL,Gola R (2001) ‘Axial Split Osteotomy’of free fibular flaps for mandiblereconstruction: Preliminary Results.Plast Reconstr Surg 108(2): 332–335
6. Li J, Sun J, He Y, Weng YQ, Jiang JD(2005) Axial split osteotomy of freefibular flap for mandibular anglereconstruction: A clinical study.Shanghai Kou Qiang Yi Xue 14(4):355–358, 369
Source of Support: Nil, Conflict of interest: None declared.
18 J Maxillofac Oral Surg 8(1):17–18
Fig. 4 The model of the axial split osteotomy. A) Design of the osteotomy, B) Osteotomycompleted, C) Contouring of the mandibular angle (Reproduced from (Li J, Sun J, He Y, WengYQ, Jiang JD (2005) Axial split osteotomy of free fibular flap for mandibular angle reconstruction:A clinical study. Shanghai Kou Qiang Yi Xue 14(4): 355–358, 369)
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