PubMed2004
OBJECTIVES: Microvascular mandibular reconstruction should be considered the procedure of choice for bone replacement in radiated tissue beds, orocutaneous fistulae with segmental bone loss, osteoradionecrotic mandibles, and for immediate composite tissue reconstruction. The free vascularized fibula has significant potential for the reconstruction of the mandible. We evaluated our clinical experience in 21 cases of mandible reconstruction with fibular flaps. PATIENTS AND METHODS: Between 1997 and 2002, we performed 7 free osseous fibula flaps and 14 osteocutaneous fibula flaps for a total of 21 mandible reconstructions in 21 patients (8 females, 13 males; mean age 41 years; range 22-58 years). Indications for mandibular resection were squamous cell carcinoma of the floor of the mouth, tongue, oropharynx, and/or alveolar ridge in 13 cases, ameloblastoma of the mandible in 4 cases, leiomyosarcoma of the mandible in 2 cases, and chondrosarcoma of the mandible in one case. There was a traumatic loss in one case. Of 21 patients, 17 were reconstructed primarily, and 4 patients had secondary reconstruction. RESULTS: All flaps, except one, survived and their viability was confirmed by scintigraphy when available. The skin defect in this patient was repaired by local lip flap which needed commissurotomy later, but the patient refused bone reconstruction. In two cases, because of long-lasting orocutaneous fistula and saliva drainage without flap loss, we used a pectoralis major pedicled flap as a secondary procedure. In three cases, donor side skin healing problems were managed well by secondary intention or split-thickness regrafting. Two patients had temporary foot drop which recovered in an average of three months. Simple problems with wound healing such as dehiscence and delayed healing developed in five patients, which usually required only local antiseptic treatment. After the operation, patients began oral feeding and walking with crutches in the third week, adjuvant radiotherapy began in the 6th week, and walking without crutches in the eighth week. CONCLUSION: 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. Among other alternatives like scapular and crista ilaca flaps, fibular flap has many advantages for mandible reconstruction and represents the first choice for the head and neck surgeon.