University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 39

University J Dent Scie 2015; No. 1, Vol. 3

ABSTRACT: Aim and Objectives: To determine the results of using the free vascularized fibular flap for comprehensive reconstruction of mandibular continuity defects. Materials and Methods: The study group consisted of patients who reported to the Department of Oral and Maxillofacial Surgery, Army Dental Centre (R&R) from the year May 2010 to Mar 2014. underwent reconstruction of continuity defects of the mandible using a fibular vascularized free flap Indication for mandibular resection were squamous cell carcinoma of the floor of the mouth and alveolar ridge in 4 cases, ameloblastoma of the mandible in 8 cases, odontogenic keratocyst in 2 cases and 1 case of osteosarcoma of the mandible and 3 cases of patients with post traumatic mandibular defects sustained due to Gunshot wound (GSW) . The type of reconstruction performed was primary reconstruction in 12 patients and secondary in 6 patients. Results: There were 18 patients including 13 males and 5 females with mean age of 40 years. Of those, 2 completely failed, due to venous thrombosis. Donor site morbidity was low; there was some compromise in the ankle function but none of the patient complaint of foot drop. Simple problems with wound healing such as dehiscence and delayed wound healing developed in 3 patients, which usually required only local antiseptic treatment. After the operation patient began oral feeding and walking with some aid in fourth week and became completely ambulant in 8 weeks. Conclusion: In this small series the free fibula flap was a versatile and reliable option for microvascular reconstruction of large mandibular defects. It provided a large quantity of bone, which could be easily shaped and passively adapt to the remaining mandible and for an implant-based prosthetic restoration.

1S.K. Roy, Professor & Head, Dept of Oral and Maxillofacial Surgery Army Dental Centre (R&R), 2Delhi Cantt-110010, Ajay P Desai, Assistant Professor, Dept of Oral and Maxillofacial Surgery

3Army Dental Centre (R&R), Delhi Cantt-110010, P.K. Chattopadhyay, Associate Professor, Dept of Oral and Maxillofacial Surgery Army Dental Centre (R&R), Delhi Cantt-110010 4V. Langer, Associate Professor, Dept of Plastic & Reconstructive Surgery, AH (R&R),

5Delhi Cantt-110010, I.D. Roy, Associate Professor, Dept of Oral and Maxillofacial Surgery Army 6Dental Centre (R&R), Delhi Cantt-110010, Col. Ravinder S. Semi, Assistant Professor, Dept of Oral and

Maxillofacial Surgery Army Dental Centre (R&R), Delhi Cantt-1100107Col. Serat Rehman, Assistant Professor, Dept of Oral and Maxillofacial SurgeryArmy Dental Centre (R&R), Delhi Cantt-110010

INTRODUCTION : Mandibular reconstruction continues to

be one of the most common surgical challenges faced by oral

and maxillofacial surgeons. The advent of microvascular

surgery has made it possible to reconstruct complex

maxillofacial region in a single stage. This technique allows

for larger resections and reconstruction, which allows patients

to return to normal function in a much shorter period when

compared with multistage local, regional pedicled flaps and

nonvascularized free bone flaps [1]. Multiple studies have

shown the clear superiority of microvascular reconstruction

of the mandible when compared with ''traditional'' methods.

Tissue loss resulting from cancer ablation, debridement of

infected tissues or secondary to trauma provides the surgeon

with various reconstructive challenges. Although

reconstruction of soft tissue defects of head and neck requires

a fasciocutaneous or musculocutaneous flap, composite

tissue loss that includes bone should be managed with a flap

that contains vascularized bone. The goal of reconstructive

surgery in tissue loss is to repair the defect, early return to

function with least complications [2]. Until the advent of free

tissue transfer, reconstruction of the defects of mandible and

midface was sub optimal. Plating across the defects with or

without nonvascularized bone flaps usually results in plate

exposure, particularly in irradiated patients. The fibula free

flap provides a strong long segment of bone and can include a

large fasciocutaneous component as well. As such this

versatile flap may be harvested as an osteocutaneous flap or a

purely osseous flap. It is now the most popular method of

mandibular reconstruction. The free fibula flap provides a

successful bone flap with an acceptably low complication rate

[1, 2]. Fibular bone allows to plan osteotomies in relation to

the orientation of the bone and its vascular pedicle. Thick

cortical bone readily accepts plates and screws for a secure

interosseous fixation and osteointegrated implants may be

placed in this bone safely. Another advantage of the free

fibular flap is that in case of the insufficient bone height for the

prosthetic rehabilitation either a double barrel or distraction

osteogenesis (DO) can be carried out [3]. Optimization of the

height di? erential between the native mandible and the ?bula

in selected patients may be achieved by placing the ?bula

approximately 1 cm superior to the inferior border of the

mandible [4]. Moreover, the free vascularized flaps are not

MICROVASCULAR RECONSTRUCTION OF MANDIBLE BY FREE FIBULAR FLAP

Journal of Dental Sciences

University

Key words: Fibula Flap. Autogenous flap. Reconstruction. Mandible.

Source of support : NillConflict of interest : None

Maxillofacial Reconstruction and Technics

expensive as compared to other methods and may provide

cost saving for selected patients. Among other alternatives

like scapular and iliac crest flaps, fibular flap has many

advantages for mandibular reconstruction and represents the

first choice for the head and neck surgeon [5]. In the field of

contemporary head and neck reconstructive surgery, free

vascularized tissue transfer is becoming a gold standard. The

current study was designed to determine the results of using

the free vascularized fibular flap for comprehensive

reconstruction of mandibular defects.

METHODOLOGY : This case series was conducted at

Department of Oral and Maxillofacial Surgery in association

with Department of Plastic and Reconstructive Surgery for

over a period of more than 4 years from May 2010 to Mar

2014.

The patients having mandibular defects or those needing

mandibular resection were selected. Medically fit patients of

either gender with an age range of 21-60 years were the

subjects of this study.

Patients, with abnormalities of the lower leg vascular

anatomy i.e. impaired circulation of the leg, with extensive

leg trauma and those who were diabetic and had significant

venous stasis or peripherial oedema, poor circulation or

healing, or cutaneous ulcers were excluded from the study.

An informed consent was obtained from them or their

parents/guardians for including their data in research. The

procedure, purpose with risks and benefits and treatment

alternatives were discussed with them. Baseline

investigations were carried out. Laboratory studies based on

patient history, coagulation status were done. Chest

radiography and CT scan was done to assess the presence of

chronic obstructive pulmonary disease and metastasis in case

of malignant lesions. Pre-operative Doppler examination or

MR angiography was done to assess the patency of the

peronneal vessels (Fig-1). Likewise routine examination of

patients with trauma or those who required secondary

reconstruction was carried out.

Ablative surgery of the tumor was done in the case of primary

reconstruction, while a recipient site was prepared for

secondary reconstruction especially for the vascular

anastomosis (Fig-2). Depending upon the case either the

facial artery or lingual artery was used for the anastomosis.

For better pedicle orientation contralateral fibula was selected

as the donor tissue. To reduce the operative time,

simultaneous harvesting of the free fibular flap was done by

the reconstructive surgeon keeping in mind the dimension of

the defect present or produced. Depending on the requirement

either osseous or osteomycutaneous free fibular flap was

harvested to reconstruct either the bone or composite defect

(Fig-3).

A tourniquet inflated to 350mm was used during harvesting.

As per requirement approx. 16 cms long incision was placed

on the lateral surface through the skin, superficial fascia to

expose the soleous and peroneous longus muscle. Skin

pedicle when required was marked as per the requirement.

Dissection was carried to expose the lateral surface of the

peroneous muscle. Peroneous muscle was traced to expose

the fibula, peroneal vessel was identified at lower 1/3rd of the

fibula. Proximally 6 cms of bone was preserved to avoid

injury to the peroneal nerve. Distally 8 cms of bone was left to

support the ankle. Hemostasis was achieved, suction drain

placed closure was done in layers by 3-0 vicryl sutures.

Fibular flap was contoured to the shape of mandible by

performing multiple closing osteotomies as per indication.

The rigid fixation of the flap to the native bone was achieved

using miniplates (Fig-4). The protocol followed was a 6 holed

miniplate at the wedge osteotomy in body region and a curved

4-holed orbital miniplate with gap at the angle osteotomy as

per requirement. Anastomosis was carried out using

operating microscope with the recipient vessel either the

facial or lingual vessels. Venous filling and arterial pulsation

was found proximal to the anastomosis following the

procedure. As per the institutional protocol a three drug

antibiotic regimen was followed i.e. Inj cefotaxime1 gm 8

hrly, Inj amikacin 500mg 12 hrly, Inj clindamycin 600mg iv 8

hrly, Inj LMWH 2500IU 12 hourly, Inj Morphine 1mg/ hrly

after 3 hours (stopped 2 days postoperatively), Inj ketorolac

30 mg IV 8 hourly, Inj ranitidine (50mg) IV 8 hrly, Tab

Chymoral forte 2 TDS 6 hourly, Tab Paracetamol 6 hourly.

Postoperatively, patients' recovery was uneventful. Patients

were placed on nasogastric tube feed in the early

postoperative period. The patients were allowed to ambulate

in a non-weight bearing fashion on the second postoperative

day. The first postoperative visit was generally scheduled 1-2

weeks after release from the hospital. Flap and skin flap

viability were assessed. Postoperatively the patency of the

anastomosed vessel was confirmed with Doppler

examination (Fig-6). The recipient site was closely

monitored for early identification of any vascular

compromise. After healing of the donor site physical therapy

was instituted to restore ankle function. Adequate measures

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 40

University J Dent Scie 2015; No. 1, Vol. 3

were taken to avoid complications at donor and recipient sites.

Early operative intervention was considered for flap salvage

due to venous or arterial thrombosis or if twisting of the

pedicle had occurred.

Operative time, hospitalization period, donor site morbidity,

duration of NG tube feeding, postoperative complications

such as infection dehiscence, skin necrosis were noted. The

collected data was analyzed by SPSS statistical version 11.

The variables under study were age, sex, diagnosis, operative

time, donor site morbidity, and flap survival, duration of NG

tube feeding and postoperative complications (infection,

dehiscence, skin necrosis, and delayed wound healing or

fistula formation). Simple descriptive statistics were used.

Numerical variables like age, operative time, duration NG

tube feeding were analyzed using mean and standard

deviation and for qualitative variables like diagnosis, donor

site morbidity, flap survival and postoperative complications,

frequency distribution tables were made for them.

RESULTS : This study was carried out on 18 patients who

underwent reconstruction with fibula free flap for mandibular

defects (Table-1). Among these, 13 patients were males

(72.2%) and 5 were females (27.8%) with the male female

ratio was 2.6:1. The age of the patients presented with some

lesion or defect ranged between 24-55 years with the mean

age of 38.72 years.

Resection followed by primary reconstruction was done in 12

patients (70%) and secondary reconstruction was done in 6

patients (30%). Out of the 6 patients who were secondarily

reconstructed one had odontogenic keratocystic, one had

squamous cell carcinoma of the alveolar ridge one had

ameloblastoma and three cases of GSW. Out of the 12 patients

where primary reconstruction was done 7 had

ameloblastoma, 1 had OKC. 1 had osteosarcoma and 3 cases

had Ca-alveolus.

The range of operation time was 6-8 hours with average time

of 6.4 ±0.4 hours. The range of hospital stay was 14-29 days

and average stay was 18.8 ±.4.77 days. The range of duration

of NG tube was 12-25 days and average duration was 15.6 +

4.2 days.

Donor site morbidity included wound scarring in 3 patients

(16.7%). All patients were ambulated within 5 weeks. Major

donor site complications were uncommon. Skin flaps, when

used, were survived well. Range of motion of the foot was a

little limited due to scarring and muscle resection but none of

the patients complained of ankle instability. Prolonged pain

was rare at donor site. Recipient site complications included

vascular complication in 2 flaps (11.76%).100% salvaged

following venous thrombosis by an urgent operative

intervention. Thrombectomy and revision of the thrombosed

vessels were performed. Wound infection occurred in 1

patient (5.5%), which were managed by local antiseptic

measures. Dehiscence of the wound occurred in 3 patients

(16.6%) and was resutured after the control of infection.

There was some delayed wound healing in 2 patients

(11.76%). One patient with osteosarcoma (5.5%) had plate

exposure was subsequently managed with local flap

advancement and primary closure. Due to the unfavorable

condition of the recipient bed and the formation of the fistula

two flaps failed one in patient with Ca alveolus and one

patient with GSW (Table-2). Out of 18 patients, 16 patients

(88%) had successful flap survival. Follow-up ranged from 8-

24 months. Six patients complained of trismus which might

be due to surgical manipulation and/or resection of the

masticatory muscles and disturbance in mandibular integrity.

Patients were counseled regarding jaw opening exercises to

minimize the impact of this complication. Patients were also

referred for the prosthodontic rehabilitation or for the

radiation therapy if indicated. DISCUSSION

Mandibular reconstruction continues to be one of the most

difficult challenges in reconstructive surgery. It plays a major

role in airway protection, support for the tongue, muscles of

the floor of the mouth, lower jaw dentition, articulation,

deglutition and respiration [6].

The goals of mandibular reconstruction are:

i) Establishment of mandibular continuity with

acceptable cosmetic result.

ii) Early return to function either by providing a stable

denture base or providing dental implants.

iii) Correction of soft tissue defect.

Therefore, a surgeon has to balance his procedure to achieve

best possible cosmetic appearance with reliable function. The

functions of chewing, swallowing, speech articulation and

oral competence must be addressed. In order to achieve it, one

must restore bony continuity, facial contour, tongue mobility

and speech. Dental rehabilitation must also be kept in mind.

Mandibular reconstruction represents a challenge to the oral

and maxillofacial surgeon and has been revolutionized by the

modern microvascular techniques. Non vascularized bone

flaps from various donor sites including the iliac crest, rib

and calvarial bones have been used for mandibular

reconstruction, either alone or in conjunction with pedicled

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 41

University J Dent Scie 2015; No. 1, Vol. 3

soft tissue flaps [7, 8, 9]. It is worth to mention that the flap

healing is significantly dependent on the quality of the

vascularity of the recipient bed.

The majority of patients requiring mandibular

reconstruction present with unfavorable recipient bed either

at the time of resection with contamination from the oral

cavity or subsequently because of adjuvant radiation

therapy. All these factors contribute significantly to failure

of conventional bone flaps [10,11]

The use of free bone flaps for mandibular reconstruction has

the obvious advantage of being a well-vascularized tissue that

can withstand the hostile environment of the oral cavity. The

donor site complication is a serious problem when planning a

free tissue transfer. Given the above condition in our case

series we still carried out secondary reconstruction in 06 of the

cases. Most of the cases where secondary reconstruction was

done were in early part of the study, where 3 patients one

ameloblastoma, one case of OKC and one case of Ca-alveolus

did not agree for harvesting of free fibular flap and in 3 cases

of GSW where there was gross contamination of the wound

with multiple splinters which could have compromised the

survival of the flap. In these cases the primary reconstruction

was done using a reconstruction plate, this acted as a guide

during our subsequent secondary reconstruction. The

problems faced during the secondary reconstruction was

severe scarring caused in the previously operated site leading

to difficulty in locating the vascular pedicle for anastomosis.

So care should be taken to preserve the vascular bed at the

time of primary reconstruction in those cases.

In this study the fibula free flap harvest appears to be

associated with acceptable donor site morbidity and

preservation of good foot and ankle function in most

individuals.

The average operative time was 6 hours and 40 minutes. It

also depends upon that whether the defect was primarily

reconstructed or it was done as a second stage procedure. This

is consistent with those in larger series [12]. The advantages

of revascularized free flap are achieved at the cost of the

procedure that is longer than other conventional

reconstructive procedures. Foster and co-workers also

concluded that additional operative time is required for a free

flap reconstruction [13].

Average hospital stay was 14-28 days with an average of

18.37 + 4.52 days. This time was a little longer than those,

which are mentioned, in recent patient series [13,14]

The range of NG tube dependencies was 14-36 days with an

average of 21.6 + 7.31 days. This wide range was due to the

fact that those patients who had failure of their flaps had

extended period of NG tube dependency. However, in

recently published studies the NG tube dependency is less in

patients who underwent revascularized free tissue transfer as

compared to the pedicle flaps [15].

Tosoco and co-workers evaluated 18 patients of free fibular

flap reconstruction of the mandible which were resected for

central giant cell granuloma. In this study they also

prosthodontically rehabilitated the patients via implants.

They had best functional and esthetic results [16].

In the present study, the functional results were assessed as

regards deglutition, oral competence, and speech. Regarding

deglutition, 56% of our patients resumed normal diet and

44% patients tolerated only soft diet. None of our patients

was feeding tube dependent.

Hidalgo and Rekow reported 51% normal diet, 42% soft

diet and 7% feeding tube dependent [17]. Rivas et al reported

78% normal diet and 22% soft diet. The causes of diet

limitations in our patients were malocclusion, restricted

tongue mobility and insufficient dentition [18]. Chana et al

recommended simultaneous placement of osseointegrated

implants for ideal function, however, none of our patients

had osseointegrated implants, but two patients had dental

rehabilitation in the form of removable denture [19].

Peled reconstructed 13 patients (9 males, 4 females) of

discontinuity defects of the mandible with free fibular flap

[1]. Wound healing disturbance at the donor site occurred in 4

cases. Two flaps were lost with the success rate of 84%. In this

study there were two complete flap failures, one due to

unfavorable recipient bed of the patient with GSW and other

due to venous thrombosis. There was an overall success rate

of 88%, which is comparable to previously published studies.

Our success rate is comparable to study by Kroll et al who

reported 90% success rate that included 93 patients [20].

Hidalgo and Rekow salvaged 3 of 4 failing flaps to improve

what would have otherwise been 93% success rate to 98%

[17]. We had 1 free flap failure due to venous thrombosis,

salvage surgery attempted was not successful. Frequent

clinical observation of the flap, Doppler examination of the

pedicle by a trained staff would help in improving our chances

of early detection of free flap compromiseCONCLUSION

Within the last three decades major advances have been

made in the field of microvascular and reconstructive

surgery. In mandibular reconstruction the challenge is to

restore airway support, oral incompetence, articulation,

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 42

University J Dent Scie 2015; No. 1, Vol. 3

mastication, deglutition and acceptable cosmesis; thus,

allowing the patient to resume role in the society.

In this series the free fibula flap was a versatile and reliable

option for microvascular reconstruction of large mandibular

defects.

It provided a large quantity of bone, which could easily be

shaped and passively adapt to the remaining mandible.

In conclusion, we believe that vascularized fibula flap is a

versatile and reliable method of reconstruction of lateral as

well as antero-lateral mandibular defects. However, it is a

technically demanding surgery with high learning curve.

REFERENCES :

1. Peled M, El-Naaj IA, Lipin Y, Ardekian L. The use of free

fibula flap for functional mandibular reconstruction. J

Oral Maxillofac Surg 2005; 63:220-4.

2. Fonseca RJ. Reconstruction of the maxillofacial cancer

patient. In: Quereshy FA, Powers MP, editors. Oral and

maxillofacial surgery. Philadelphia: WB Saunders;

2000: 361

3. Shen Y, , Li J, Shi J, Ow A. Long-term results of

partial double-barrel vascularized fibula flap in

symphysis for extensive mandibular reconstruction. J

Oral Maxillofac Surg 2012;70:983-91

4. Rui Fernandes. Fibula Free Flap in Mandibular

Reconstruction. Atlas Oral Maxillofacial Surg Clin N

Am 2006; 143–150

5. Genden E, Haughey BH. Mandibular reconstruction by

vascularised free tissue transfer. Am. J. Otolaryngol

1996;17:219-27.

6. Nath S, Joshi KD, Shakya S, Shrestha S, Koirala U

Mandibular reconstruction. Kathmandu University

Medical Journal 2006;16:497-500. .

7. Soutar D, Scheker LR, Tanner NSB, MaGregor IA: the

radial forearm flap: A versatile method for intraoral

reconstruction. Br J Plas Surg. 1983; 36:1,

8. Serafin D, Villarrreal – Rios A, Feorgiade N: A rib

containing free flap to reconstruct mandibular defects.

Br J Plas Surg 1977;30: 263

9. Daniel RK: Mandibular reconstruction with free tissue

transfer. Ann Plas Surg 1978; 1: 346.

10. DeFries H.O., Marble H.B. and Sell K.W.:

Reconstruction of the mandible. Use of a homoflap

combined with autogenous bone and marrow. Arch.

Otolaryngol 1971; 93: 426-32.

11. Soutar D.S.: Mandibular reconstruction with

Sun J

vascularized bone. In Soutar D.S. and Tiwari R.

(editors): Excision and reconstruction in head and neck

cancer. Ediburgh Churchill Livingstone1994; 59

12. Rosenthal E, Carroll W, Dobbs M, Wax M, Peters G.

Simplifying head and neck micro-vascular

reconstruction. Head Neck 2004;26:930-6.

13. Foster RD, Anthony JP, Sharma A, Pogrel MA.

Vascularized bone flaps versus nonvascularized bone

flaps for mandibular reconstruction: an outcome

analysis of primary bony union and endosseous implant

success. Head Neck 1999; 21:66-71

14. Kroll SS, Evans GR, Goldberg D, Wang BG, Reece GP,

Miller MJ, et al. A comparison of resource cast and

reconstruction with free and pectoralis major flaps.

Plast Reconstr Surg 1997; 99:1282-6.

15. Chepeha DB, Annich G, Pynnonen MA, Beck J, Wolf

GT, Teknos TN, et al. Pectolaris major myocutaneous

flap vs. revascularized free tissue transfer:

complications, gastotomy tube dependency, and

hospitalization. Arch Otolaryngol Head and Neck Surg

2004;130:181-6.

16. Tosco P, Tanteri G, Iaquinta C, Fasolis M, Roccia F,

Berrone S, et al. Surgical treatment and reconstruction

for central giant cell granuloma of the jaws: a review of

18 cases. J Craniomaxillofac Surg 2009; 37:380-7

17. Hidalgo D.A. and Rekow A.: A series of 60 consecutive

fibula free flap mandible reconstruction. Plast. Reconstr.

Surg 1995;96: 585-96.

18. Rivas B., Carrillo J.F. and Granados M.: Oromandibular

reconstruction for oncological purposes. Ann. Plast.

Surg 2000; 44: 29-35.

19. Chana J.S., Chang Y.M., Wei F.C., Shen Y.F., Chan C.P.,

Lin H.N., Tsai C.Y. and Jeng S.F. Segmental

mandibulectomy and immediate free fibula

osteocutaneous flap reconstruction with endosteal

implant ideal treatment method for mandibular

ameloblastoma. Plast. Reconstr. Surg 2004; 113 : 80-87.

Kroll S.S., Schusterman M.A., Reece G.P., Miller M.J.,

Evans G.R., Robb G.L. and Baldwin B.J.: Choice of

flap and incidence of free flap success. Plast. Reconstr.

Surg 1996;98: 459-63.

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 43

University J Dent Scie 2015; No. 1, Vol. 3

Fig-1 Preoperative MR angiography.

Fig-2 Ablative surgery for the tumor and the resected specimen

Fig-3 Harvesting of the Free fibular Graft

Fig-4 Osteotomized Fibular graft

Fig-5 Reconstructed mandible with Fibular graft

Fig-6 Postoperative Doppler examination

Table 1 - Database of the patients.

Table 2 Relative percentage of the postoperative complications

Corresponding Author:

Dr. Ajay P. Desai

Dept of Oral & Maxillofacial Surgery, Army Dental

Centre (R&R), Delhi Cantt-110010

Email : drajaydesai@rediffmail.com

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 44

University J Dent Scie 2015; No. 1, Vol. 3