Jan 01, 2016 our first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle. Here, we aimed to establish the preplating technique for oromandibular reconstruction in a stepbystep fashion, based on 41 patients. The technique for implantation in fibula flap is very similar to the technique in native mandible but access to the bone is the most difficult step of the surgery. Free fibula flap technique dr jameel kifayatullah oral and maxillofacial surgeon peshawar,pakistan. Sep 19, 2018 unlike several other free flaps used for head and neck reconstruction, the fibula flap can be harvested simultaneously with the extirpation of the tumor by a second surgical team. A vestibuloplasty technique with application of a polyglycolic acid pga sheet is. A 20year experience of immediate mandibular reconstruction using.
We herein report dental rehabilitation of a free fibulareconstructed mandible with scar contracture. Singleincision technique for internal fixation of distal. The objective of this study was to evaluate a surgical technique and to present the results of delayed reconstruction of palatomaxillary defects using fibula free flap fff. The biaxial doublebarrel fibula flap technique achieves the goals of providing adequate facial support and an alveolar segment amenable to implant dentistry.
Based on individual preference, cost, and familiarity with monitoring techniques, various monitors are available. Before the surgery, a ct angiography is performed to study the vascularization of the distal femur. Fibula flaps with osteotomies have been associated with an increasing. Osteocutaneous fibula free flap iowa head and neck protocols. Free vascularised fibular flap harvesting in children. Conveys information on all important issues in the surgical procedure, including the use of cadcam technology, bone synthesis and flap modelling.
In comparison with other osteocutaneous flaps, the fibula flap offers many advantages and is associated with. Longitudinally the flap should be harvested long enough to complete the reconstruction. The free fibula flap was used in three types of approaches. Watch surgeons perform procedures in real time with an unparalleled twohour video collection that demonstrates harvest of the fibula flap for use in mandible reconstruction, the jejunum for esophagus reconstruction, and the siea, diep and igap flaps for breast reconstruction functioning muscle transfers for a variety of defects, including the gracilis muscle for facial reanimation and the gracilis musculocutaneous flap for finger flexion reconstruction with innervation using the. However, this may bring about mandibular implant failure in longterm followup. A textbook of advanced oral and maxillofacial surgery.
Over the years, there are literature reports of various modifications in the surgical technique and so do the reports of variations of normal anatomy of the leg and that of the flap. Application of digital technology in virtual surgical planning. Preplating, plate removal, resection, replating, template. Stepbystep surgical technique for mandibular reconstruction with fibular free flap. The reader will find useful information on all issues that are important in the surgical procedure, including the use of cadcam technology computer assisted technology, bone synthesis and flap modelling. European archives of otorhinolaryngology, 272 6, 14911501. The technique involves the use of a zygomatic oncology implant perforated microvascular soft tissue flap zip flap for the primary management of maxillary malignancy with surgical closure of the resultant maxillary defect and the installation of osseointegrated support for a zygomatic implantsupported maxillary fixed dental prosthesis. The ideal technique by which a flap can be assessed is only theoretical and practically varies depending on the flap, the patient, the available equipment, and other factors. Guides that direct the trajectory of the drill right into the plate. Evaluation of foot perfusion after fibula flap surgery. Mandibular reconstruction using vascularised fibula journal of. Minimally invasive surgical approach to distal fibula.
The fibula head lies 3 cm below the lateral femoral condyle. The fff has several advantages including sufficient bone length for mandibular reconstruction, a high survival rate, and performability at the time of skin grafting 3,4,5. A senior surgeon did the planning, flap harvesting. Virtual planning and guided surgery in fibular freeflap mandibular. Basics of microvascular reconstruction of maxillomandibular. The surgical technique is discussed in a stepbystep fashion. So, back into surgery he went five days later using the. Eckardt surgical management of soft tissue sarcomas semin oncol, 24.
It is inserted into the bone through a minimal incision and acts like an internal splint to stabilize the fracture during healing. Through the use of minimally invasive surgical techniques some of these complications can be mitigated. Proper preoperative planning and calculation is needed to ensure adequate fibula length without compromising ankle stability as well as a properly seated skin flap for mouth floor reconstruction. Primary disease, type of reconstruction, defect area, fibula segment length and number of osteotomies. The biaxial doublebarrel fibula flapa simplified technique. Whereas he believed that the skin paddle should be designed at the junction of the middle and distal third of the fibula, other authors proposed to center the flap 2 cm superior to the midpoint between the fibula head and ankle 88, 333, 479, 518 and subfascial. Extremity free fillet flap for reconstruction of massive oncologic resectionsurgical technique and outcomes. Dental rehabilitation with osseointegrated implants in reconstructed mandibles is a common procedure, but the technique still requires improvement, especially in its reliability and technical simplification.
The study reports five consecutive patients with benign or malignant disease requiring mandibular reconstruction using a microvascular fibular free flap, preoperative virtual planning, construction of cutting guides and customized laser prebent titanium plates. With great interest, we have read the special topic article by al deek et al. Several authors have described the surgical technique of free fibula harvest in detail. Full text of stepbystep mandibular reconstruction with. Ischemia time was recorded in all five cases, with an average of 75 8 min. Minimally invasive surgical approach to distal fibula fractures. The defects secondary to surgical ablation of the mandible have far. The fibulock nail is a cuttingedge, minimally invasive treatment for ankle fractures. Atlas of mandibular and maxillary reconstruction with the fibula. The fibular bone is removed the flap along with two blood vessels, one of which supplies blood to the flap the artery and one of which drains blood from the flap the vein.
The fibula free flap fff is one of the most widely used flaps for the reconstruction of mandibular defects caused by trauma or lesions such as tumors 1, 2. The fibula flap has been used extensively for oromandibular reconstruction. May 10, 2014 the study reports five consecutive patients with benign or malignant disease requiring mandibular reconstruction using a microvascular fibular free flap, preoperative virtual planning, construction of cutting guides and customized laser prebent titanium plates. The fibula free flap approach allows the possibility of using bone withwithout skin for restoring the defect. Drawing on 25 years of experience, this book atlas on the standard technique used for reconstructing the mandible and the maxilla. In addition, it minimizes the need for vein grafting. Our first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle.
Delayed reconstruction of palatomaxillary defect using fibula. Unlike several other free flaps used for head and neck reconstruction, the fibula flap can be harvested simultaneously with the extirpation of the tumor by a second surgical team. Dental rehabilitation for free fibula flapreconstructed. Free fibula flow through osteocutaneous flap in the upper. They lost blood flow two days later and tried to salvage the flap. Alternatively, the lateral decubitus position can be used, with the harvest leg placed up and the patient held in position with a beanbag. The average postoperative hospital stay was 18 3 days.
Fibula flap harvest the patient is placed in the supine position with a bump under the ipsilateral hip to lessen the need for excessive internal rotation of the lower leg. Its indicational spectrum, therefore, reaches from bony reconstruction at the extremities to replacement of the whole mandible, including closure of large perforating defects of the oral cavity. This atlas deals with the standard technique used for reconstructing the mandible and the maxilla the fibula flap. We describe a unique situation involving the perforators supplying the skin paddle of the flap which is significant in terms of flap survival and management. Innervation of the flap is possible, and the flap has ample bone stock for the placement.
Significant segmental mandibular loss or hemimandibular loss may sometimes be replaced with mandibular implants by ent surgeonsoral surgeonshead and neck surgeons. Conclusions according to our experience, the posterior approach for the harvest of the osteoseptocutaneous fibula flap is a safe technique and offers many advantages, such as a better visualization of the perforators, beneficial for chimeric flap elevation, preservation of the muscular fascia in the donor site, and an earlier diagnosis of any. The skin paddle has proven to be dependable if care is taken to preserve the fasciocutaneous perforators. The fibular free flap is especially suited for mandibular reconstruction.
In order to reduce overall operation time, surgery was performed using two teams. Fibula osteocutaneous flap for mandible reconstruction after ameloblastoma resection 41 septal branch can be challenging. The primary blood supply to the harvested fibula flap is derived from periosteal perforators traveling circumferentially around the fibula. Recent investigations have reported on percutaneous fixation. All patients who underwent fibula freeflap mandibular reconstruction between. The fibula osteocutaneous free flap is arguably the workhorse bone flap for both maxillary and mandibular reconstruction. Atlas of mandibular and maxillary reconstruction with the fibula flap a. The fibulas vascular pedicle is based on the peroneal artery with its venae comitantes, providing both an endosteal nutrient artery to the medullary canal of the fibula as well as periosteal branches along its course that supply the cortical surface. All procedures were performed by 3 senior surgeons with more than 10 years.
This study assessed the outcomes and tumor recurrence after immediate mandibular reconstruction using a free fibula osteocutaneous flap. Atlas of mandibular and maxillary reconstruction with the. Although literature shows that a reconstruction plate or miniplates may be used with equal efficacy in the flap procedure, we prefer to use a 2. Transfer of a free vascularised fibular flap fvff is an option for treating bone defects of 5 cm or more in children. The layered fibula osteocutaneous flap sets new standard for. Successful management of free osteocutaneous fibula flap with. The fibula s vascular pedicle is based on the peroneal artery with its venae comitantes, providing both an endosteal nutrient artery to the medullary canal of the fibula as well as periosteal branches along its course that supply the cortical surface. A technique tip abstract wound complications following ankle fracture surgery are a major concern. Furthermore, the vascular anatomy of the flap simplifies the technical aspects of free tissue transfer.
If your jaw is being rebuilt using bone from a different donor site or if bone will not be used in your reconstruction, your plastic surgeon will discuss this with you. Free fibula long bone reconstruction in orthopedic. Reconstruction for mandibular implant failure intechopen. Osteocutaneous flap an overview sciencedirect topics. This singleincision technique is applicable to fractures of the distal third of the tibia and fibula best treated with open reduction and internal fixation of both fractures, eg, a type al, a2. Conveys information on all important issues in the surgical procedure. The iliac crest and fibula flaps had bone dimensions consistently. Using a layered fibula freeflap design, we have developed a technique that addresses both form and function in total maxillary and orbital reconstruction. It is critical that fibular length, alignment and rotation are accurately restored.
Mandibular defects may result from tumor ablations, trauma, or radiation necrosis. Stepbystep mandibular reconstruction with free fibula flap modelling. Extremity free fillet flap for reconstruction of massive oncologic resection surgical technique and outcomes. Proper preoperative planning and calculation is needed to ensure adequate fibula length without compromising ankle stability as well as a. The fibula itself bears approximately 10% of the weight placed on the foot. About your mandibulectomy and fibula free flap reconstruction. Condyle dislocation following mandibular reconstruction using. About book this atlas deals with the standard technique used for reconstructing the mandible and the maxilla the fibula flap. The fvff technique was first developed by taylor et al. Atlas of mandibular and maxillary reconstruction with the fibula flap. Distally the fibula is subcutaneous and forms the lateral malleolus. Sep 19, 2018 the ideal technique by which a flap can be assessed is only theoretical and practically varies depending on the flap, the patient, the available equipment, and other factors.
Once the bone is raised it is transferred to the head and neck and secured in position with small plates and screws. Fibula osteocutaneous flap for mandible reconstructionafter. Stepbystep mandibular reconstruction with free fibula flap. Kreutzrodrigues l, mohan at, moran sl, carlsen bt, mardini s, houdek mt, rose ps, bakri k. The fibula is the longest bone flap available and can be transferred as a bone flap or in combination with one or two skin paddles. Pmc, all databases, assembly, biocollections, bioproject, biosample, biosystems, books. Free fibula flap in the reconstruction of mandible.
This atlas deals with the standard technique used for reconstructing the. The reader will find useful information on all issues that are important in the surgical procedure, including the use of cadcam technology computer assisted technology, bone synthesis and flap. Its indicational spectrum, therefore, reaches from bony reconstruction at the extremities to replacement of the whole mandible, including closure. Fibula free flap the leg is the donor site that is most often used for jaw reconstructions. It allows for intelligible speech, deglutition, orbital support, and separation of the oronasal, orbital, and sinus. The skin flap can be harvested to a length varying from 1030 cm and a width of 414 cm depending on the size of the patient. Eckardt surgical management of soft tissue sarcomas semin oncol, 24 1997, pp.
By modifying the fibula to address orbitozygomatic defects superiorly and palatalalveolar absence inferiorly, we have adapted the fibula flap to 1 replace midface and orbital contour and. Distal fibula plating system 7 fast, accurate surgeries to facilitate surgical procedures even more, our anatomic and composite fibula plates come preloaded with fixed angle screw targeting f. In spiral or oblique fracture patterns, a clamp can be applied for reduction. It allows for intelligible speech, deglutition, orbital support, and separation of the oronasal, orbital, and sinus cavities. The latter team harvested the flap according to the principles described by hidalgo. Fibula, flap, technique, approach, safety, reliability, anatomy, surgical, surgery. Stepbystep surgical technique for mandibular reconstruction. Surgery went well, except that his arteries were severely damaged from radiation, and the surgeons had difficulty getting good blood flow to the flap. Aug 17, 2015 using a layered fibula free flap design, we have developed a technique that addresses both form and function in total maxillary and orbital reconstruction. A long segment of bone up to approximately 22 cm is available for harvest.
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