Major mandibular reconstruction with vascularized bone grafts: indications and selection of donor tissue.
Free vascularized bones have been shown by many specialists to exhibit specific capabilities of reconstructing a major mandibular defect and can solve problems that may be insoluble by other methods. Nevertheless, absolute indications for using vascularized bone for major mandibular reconstructions have not been sufficiently well delineated to convince people of always considering vascularized bone for major mandibular reconstructions as a first option. Based on our experience with 55 major mandibular reconstructions, we might delineate the absolute indications for using free vascularized bone for major mandibular reconstructions explicitly: 1) osteoradionecrosis of mandible or on irradiated tissue bed; 2) hemimandibular reconstruction with a free end facing the glenoid fossa; 3) long segment mandibular defect, especially across the symphysis; 4) inadequate skin or mucosal lining; 5) defects demanding sandwich reconstruction; 6) inability to obtain secure immobilization on the reconstructed unit; 7) failure of reconstruction by other methods; 8) near total mandibular reconstruction. Selection of donor tissue should be according to 1) the amount of tissue deficiencies, 2) composition of the defect, 3) design and placement of the flap, 4) irradiation on the recipient site or not, 5) which vessels to be used, 6) which flap has the appropriate vessel length 7) skin color and texture of the donor tissue, 8) how many osteotomies required to stimulate the curvature of the resected mandible 9) speed of bony union, 10) feasibility of future osseointegration. We have used three kinds of vascularized bones (iliac bone, fibula, scapula). Iliac bone was most frequently used, and has always been our first choice, since it can carry good quality bone, a large skin flap, and ample soft tissue. The fibula has the merit of being less bulky and good for simultaneous intraoral lining, but the contour is more rigid and the bony height is insufficient. The scapula bone is rarely used at present because of its relative inconvenience.