Fibular Osteomyocutaneous Flap Research Articles

Functional Chimeric Double-barrel Fibula and Reinnervated Peroneus Brevis Osteomyocutaneous Flap for One-stage Forearm Reconstruction.

Reconstructing a mangled limb is complex and requires expertise in both bone and soft-tissue reconstruction, particularly when there is significant muscle loss. Typically, multistage surgery is necessary, starting with soft-tissue coverage, followed by bone grafting and tendon transfers. Sometimes, microsurgical techniques such as vascularized bone grafts and free functional muscle transfers are necessary, especially when there is a bone defect of over 6 cm; the soft-tissue environment is infected, scarred, or poorly vascularized; or there are extensive musculotendinous injuries. We treated a 34-year-old man who had a crushed left forearm resulting in an 18 × 8 cm open wound, 5-cm radius and 7-cm ulna bone defects, loss of the extensor pollicis longus and brevis muscles, and extensive injuries to the other musculotendinous structures of the forearm. To accomplish a one-stage reconstruction, we used a chimeric fibula osteomyocutaneous flap that included a 20 × 10 cm skin flap, peroneus brevis muscle with its motor nerve, and two segments of fibula. The proximal and distal fibula segments were used for ulnar and radial bone reconstruction, respectively, preserving forearm supination and pronation. The peroneus brevis tendon was sutured to the extensor pollicis longus tendon, and its motor nerve was coaptated with the posterior interosseous nerve to restore thumb extension. The skin flap provided complete coverage of all exposed bone and tendon structures. At the 12-month follow-up, the patient regained full extension of the thumb, and there were no difficulties with forearm supination and pronation or with foot eversion and plantar flexion at the donor leg.

Reconstruction of complex oro-mandibular defects by four different modifications of free fibula osteomyocutaneous flap: A prudent alternative to multiple flaps

Resection of advanced oral squamous cell carcinoma results in complex oro-mandibular defects involving external skin, oral mucosa, and bone. Reconstruction of such defects by a single free fibula flap (FFF) is limited by the lack of soft tissue bulk and adequate skin paddle for both intra- and extra-oral coverage. In this study, the reconstruction of large defects was achieved by four modifications of free fibula osteomyocutaneous flap as an alternative to multiple flaps. In this prospective study, 29 patients with complex oro-mandibular defects were reconstructed by FFF from December 2018 to October 2020. Reconstruction was done with any one of the four FFF modifications involving large proximal skin paddle from lateral leg: Strip de-epithelialization (De-Ep), chimeric bipaddle (Ch-Bp), muscle orally and skin extra-orally (Mo-Se), and double microvascular (Db-Mi). Outcome variables assessed were functional and esthetic results, early/late complications, donor site morbidity, and operative time. An algorithm based on Cordeiro's classification is proposed to assist in the selection of appropriate FFF modification. Among 29 patients, De-Ep was used in 13, Ch-Bp in 8, Mo-Se in 7, and Db-Mi in 1 case. None of the flaps underwent total loss. Two cases required re-exploration. The median operative time was 775min. Wound dehiscence and oro-cutaneous fistula were common early and late complications, respectively. Partial split skin graft loss (SSG) was the most common donor site morbidity. Functional and facial aesthetics were acceptable at the end of follow-up. Specific FFF modifications can be recommended in selected scenarios. It is reliable for single-stage reconstruction with satisfactory esthetic and functional outcomes. When used for reconstruction in first primary tumors, the second donor site is preserved, which can prove valuable in the event of a recurrence or second primary.

Free fibula osteomyocutaneous flap with lateral supramalleolar and soleus muscle flap—a novel chimeric flap combination

Free fibula osteomyocutaneous flap with lateral supramalleolar and soleus muscle flap—a novel chimeric flap combination

Osteomyocutaneous Free Fibula Flap Prevents Osteoradionecrosis and Osteomyelitis in Head and Neck Cancer Reconstruction.

Osteoradionecrosis (ORN) is one of the most severe complications of free fibula reconstruction after radiotherapy. The gold standard treatment of osteomyelitis involves extensive debridement, antibiotics, and sufficiently vascularized muscle flap coverage for better circulation. Therefore, we hypothesized that free fibula flap with muscle could decrease the risk of ORN. This study consisted of 85 patients who underwent reconstruction with free fibula flap in head and neck cancer by a single reconstructive surgeon at Kaohsiung Veterans General Hospital over a period of 19 years (1998-2016). Patients with postoperative adjuvant radiotherapy were included in the study and were grouped by either free fibula osteocutaneous flap or free fibula osteomyocutaneous flap (with flexor hallucis longus muscle), and the incidence of ORN was compared. Of the 85 patients, 15 were reconstructed with osteocutaneous fibula flap and 70 were with osteomyocutaneous fibula flap. The rate of ORN or osteomyelitis was significantly lower in the muscle group (18.6%, n = 13/70 vs. 46.7%, n = 7/15, p = 0.020, Chi-square test). Vascularized muscle transfer increases perfusion of surrounding tissues and the bone flap, thereby decreasing the incidence of osteomyelitis or osteonecrosis.

A Novel and Simple Technique of Reconstructing the Central Arch Mandibular Defects-a Solution During the Resource-Constrained Setting of COVID Crisis.

The current COVID 19 pandemic has a major impact on healthcare delivery globally. Oral cancer involving anterior arch of mandible is difficult to reconstruct and ideally, requires free fibular osteomyocutaneous flap. During this time of resource constraint situation, these free flaps are not a great choice, as it increases exposure of both patient and surgical team to the deadly virus. We are describing a novel method of reconstruction after resection of oral cancer involving anterior arch of mandible. In this new technique, we have reconstructed central arch defect by hanging bipaddle pectoralis major myocutaneous flap with orbicularis oris muscle using ethylene terephthalate suture. Operative time, early postoperative complications and early cosmetic and functional outcome were assessed. We have used this novel technique in eight patients of T4a oral cancer involving anterior arch of mandible and skin over chin. Mean operative time was 180 min. One patient had minor flap loss with surgical site infection (Clavien-Dindo grade I). In all patients, we were able to discharge all patients on eighth postoperative day. Cosmetic outcome and functional outcomes were mostly satisfactory. All patients were able to oppose their lips without any oral incompetence and drooling. Tongue mobility was good. There was no incidence of ‘Andy Gump deformity’. This is a feasible option for reconstructing anterior arch defect in resource- and time-limited setting of COVID 19 pandemic. This technique can also be used in comorbid conditions where it is not advisable to do very long surgery.

Jaw reconstruction with vascularized fibular flap: The 11-year experience among 104 patients

BackgroundA vascularized fibular osteomyocutaneous flap with severe vascular crisis often results in serious consequences. This study aims to examine the clinical effect of non-vascularized fibular graft on patients with severe vascular crisis after reconstruction of the defect jaw with vascularized fibular osteomyocutaneous flap.Materials and methodsFrom December 2007 to December 2018, a total of 104 patients with jaw neoplasms that underwent reconstruction with free vascularized fibular flap were retrospectively analyzed; seven of these cases had postoperative vascular crisis during mandibular reconstruction.ResultsOf the seven cases with postoperative vascular crisis, the vascularized fibular flaps in three patients survived completely, thanks to early detection; two cases were completely necrotic and removed in the end, and the remaining two cases had severe vascular crisis after the removal of the soft tissue attached to the fibular flap. The non-vascular fibular grafts were retained regardless of the severe absorption after follow-ups for 25 and 69 months, respectively.ConclusionsIf vascular crisis occurs following jaw reconstruction with a vascularized fibular osteomyocutaneous flap, early re-surgical exploration effectively improves the salvage rate. In addition, when a severe vascular crisis occurs, the vascularized fibular flap can be changed to a non-vascular fibular graft to reconstruct the mandibular defect, thus avoiding the serious consequences resulting from the complete failure of fibular graft.

Reconstruction of mandibular defects using vascularized fibular osteomyocutaneous flap combined with nonvascularized fibular flap.

BackgroundThe height of single-layer fibular flap is not long enough to return to the ideal height of the mandible. While the double-layer vascularized fibular osteomyocutaneous flap(VFF) is more complicated in shaping and fixation, along with a longer operation time. The aim of this study was to investigate the clinical effect of VFF combined with nonvascularized fibular flap(NVFF) in the reconstruction of mandibular defect.Material and MethodsFrom September 2016 to June 2018, 15 patients with benign mandibular tumors underwent reconstruction with VFF and NVFF. SimPlant Pro ™ software (version 11.04) was used to simulate reconstruction of the mandible preoperatively.ResultsAll patients were followed up for 8-23 month, with an average of 11.7 months. 15 VFFs survived well. Among the 15 NVFFs, one was almost completely absorbed, two with partial absorption, and the remaining survived regardless of the small amount of absorption. The postoperative absorption of the whole fibula was 7.53±6.362%, a favorable facial contour and speech function were attained.ConclusionsThe VFF combined with NVFF to reconstruct the mandibular defect can restore the vertical height of the mandible and achieve satisfactory clinical results. Key words:Vascularized fibular osteomyocutaneous flap(VFF), Nonvascularized fibular flap(NVFF), Mandibular defect.

Values of CAD/CAM technology and assistant reconstruction in mandible defect with fibular musculocutaneous flap

Objective To explore the role of computer-aided design and manufacturing technology (CAD/CAM technology) in the repair of mandibular defects using the fibular osteomyocutaneous free flap. Methods Eight patients with a portion of mandible defect due to various reasons were subjected to preoperative CT scan, obtaining CT data of the mandible and the fibular bone to be transplanted. The original and the reconstructed skull model, as well as the mandible and fibula osteotomy guide plates, was printed using CAD/CAM technology. The titanium plates were preformed using the reconstructed skull model, and the operation was performed with the help of guide plates and a preformed titanium plate. The patients were followed up for 6 to 24 months to evaluate the operation effect. Results Two in 8 cases had flap necrosis caused by immune rejection of the implant, and one case had flap necrosis due to poor postoperative blood glucose control. The other 5 patients healed at the primary site and the fibular myocutaneous flap survived well. There were no serious complications in the donor and recepient site. The patients' satisfaction was high. Conclusions The reconstruction of mandible with the aid of CAD/CAM technique has the advantages of accelerating the operation process, shortening the operation time, improving the accuracy of mandibular amputation and fibular shaping, promotlng postoperative function and morphology recovery. Key words: Mandibular reconstruction; Fibula; Myocutaneous flap; Reconstructive surgical procedures; Computer-aided design and manufacturing technology

Single stage reconstruction of post traumatic and post excisional composite perigenual defects using chimeric pedicled propelled osteomyocutaneous fibula flap

IntroductionComposite perigenual defects (CPGDs) are exacting the expertise of the reconstructive surgeons. Segmental skeletal defects continue to be a challenge for both orthopedic and plastic surgeons. There are many techniques available for the reconstruction of segmental skeletal defects in the perigenual region. This study explores the outcomes of pedicled chimeric propelled osteomyocutaneous fibula flap reconstruction of post traumatic and post excisional composite perigenual defects (CPGDs) Materials and methodsIt was a retrospective study conducted from 2011 to 2016 including 16 patients (5 post excisional defects and 11 post traumatic defects). 14 males and 2 females were included. Ages of the patients were ranging from 24 to 46 years. All had their CPGDs reconstructed with chimeric pedicled propelled fibula osteomyocutaneous flap ResultsAll 15 patients on an average of 26 months follow-up assumed pain free unrestrictive walking. Fracture of hardware and transferred fibula occurred in one case 2 1/2 years following the surgery. Other patients had good functional recovery in an average of 26 months follow up. The average MSTS score of 15 patients was 23.9. ConclusionThis anatomically construed procedure will be addendum to the armamentarium of reconstruction in both post excisional limb salvage milieu and secondary posttraumatic context for the perigenual composite defects. With high healing potential, infection culling capacity, high osteogenic potential and good supportive hardwares the pedicled osteomyocutaneous fibula flap may usher in better outcome in composite perigenual defects reconstruction.

Osteomyocutaneous fibular flap harvesting: Computer-assisted planning of perforator vessels using Computed Tomographic Angiography scan and cutting guide

IntroductionMandibular reconstruction performed after virtual planning has become more common during recent years. The gold standard for extensive mandibular reconstruction is of course a fibular free flap. In designing an osteomyocutaneous fibula flap, poor planning, aberrant anatomy and/or inadequate perforator vessels are the most frequent causes of complications and may force the surgeon to modify the flap design, explore the contralateral leg or harvest an additional microvascular flap. The goal of our study was to pre-operatively evaluate the vascular anatomy of the fibula and localize the cutaneous perforator vessels, so to create the fibular cutting guide based on the position of the cutaneous perforator and safely harvest the reconstructive flap. Materials and methodsTwenty consecutive patients who were candidates for mandibular reconstruction using a fibular microvascular free flap were enrolled in this study between January 2016 and August 2016. The patients were preoperatively assessed with a Computed Tomographic scan of head and neck and with a Computed Tomographic Angiography (CTA) scan of the lower limbs to evaluate the vascular anatomy of the fibula. Virtual planning was carried out for all patients. The fibular cutting guide was based on the position of the perforator cutaneous vessels, which were used to harvest the cutaneous part of the flap. Preoperative CT measurements were performed in order to identify the cutaneous perforators on the patients’ skin. Intraoperative checking was performed to evaluate the accuracy of the perforators’ position and the reproducibility of the virtual planning. ResultsIn 5 patients out of 20 (25%), anatomical anomalies were discovered, without clinical evidence. The perforator vessels were localized in all patients. The average difference between the CTA and the intraoperative perforator localization was 1 mm (range 0–2 mm). Fibular cutting guide was positioned and fitted the anatomy of the patients in all treated patients. This allowed us to perform the planned segmentation of the fibula, obtaining the correct number of segments. In all cases, flap insetting was carried out and skin paddle was positioned as preoperatively planned. Neither donor site complications nor flap complications occurred. ConclusionsPreoperative evaluation of the legs using CTA, in patients who undergo an osteomyocutaneous fibular free flap for mandibular reconstruction, is a valuable approach to reduce altered-anatomy related complications and to improve the accuracy and outcomes of the reconstruction, especially in reconstructions of complex defects. In these cases, a soft tissue-based cutting guide can be planned based on the perforator vessels of the skin paddle, minimizing the harvesting risks of vascular lesions. Further studies and longer follow-ups are needed to evaluate the long-term outcomes and advantages of this procedure.

Acceptable clinical outcomes and recommended reconstructive strategies for secondary maxillary reconstruction with vascularized fibula osteomyocutaneous flap: A retrospective analysis

We conducted a retrospective analysis of the clinical outcomes and evaluated the reconstructive strategies in patients who underwent secondary maxillary reconstruction with a vascularized fibula osteomyocutaneous flap (VFOF). From May of 2001 to June of 2014, 34 patients who underwent secondary maxillary reconstruction with VFOF, with or without titanium mesh, were reviewed. The patients were divided into two groups of maxillary reconstruction, according to different planning and treatment strategies. In Group 1, presurgical planning was achieved using three-dimensional stereomodeling (n=12). In Group 2, virtual surgical planning was performed and guided templates were produced (n=22). The differences in the preoperative planning, intraoperative technique, postoperative complications, and long-term results between the two groups were analyzed. Statistical analysis was performed to determine the differences between the two groups and the risk factors for prognosis. Similar and accurate secondary maxillary reconstructions were successfully performed in Group 1 and 2. Postoperative complications were reported in 8 patients in Group 1 and 11 patients in Group 2. Complications were reported in patients who underwent radiotherapy. The incidence of postoperative complications in Group 2 were lower than that in Group 1 with the exception of midfacial collapse (P>0.05). The long-term results of some patients with class 3 defects were not satisfactory because of midfacial collapse and lower eyelid ectropion. Stepwise regression analysis showed radiotherapy to be a risk factor for prognosis. The long-term results of secondary maxillary reconstruction were reported to be acceptable in our study. Radiotherapy was the risk factor for prognosis in secondary maxillary reconstruction. On the basis of these results, we highly recommend our strategy for secondary maxillary reconstruction. Good functional results could be achieved after the accurate restoration of maxillary alveolar ridge with several fibular segments using virtual surgical planning and dental restoration.

Treatment and Rehabilitation of Repetitively Recurrent Langerhans Cell Histiocytosis: A Case Report

Langerhans cell histiocytosis (LCH) is characterized by proliferation of histiocyte-like cells (Langerhans cell histiocytes) with characteristic Birbeck granules, accompanied by other inflammatory cells. Treatments of LCH include surgery, chemotherapy, and radiotherapy. One of the representative forms of chemotherapy is intralesional injection of steroids. Surgical treatment in the form of simple excision, curettage, or even ostectomy can be performed depending on the extent of involvement. Radiotherapy is suggested in case of local recurrence, or a widespread lesion. This article shows the case of repetitively recurrent LCH of a 56-year-old man who had been through surgical excision and had to have marginal mandibulectomy and radiotherapy when the disease recurred. After the first recurrence occurred, lesions involved the extensive part of the mandible causing pathologic fracture, so partial mandibular bone resection was performed from the right molar area to the left molar area followed by the excision of the surrounding infected soft tissues. The resected mandibular bone was reconstructed with a segment of fibula osteomyocutaneous free flap and overdenture prosthesis supported by osseointegrated implants.

Misdiagnosis of osteosarcoma as cementoblastoma from an atypical mandibular swelling: A case report.

Cementoblastoma is a form of benign odontogenic tumor, with the preferred treatment consisting of tooth extraction and follow-up examinations, while in certain cases, follow-up examinations without surgery are performed. Osteosarcoma of the jaw is a rare, malignant, mesenchymal tumor, associated with a high mortality rate and low incidence of metastasis. Cementoblastoma and osteosarcoma of the jaw are dissimilar in terms of their histological type and prognosis; however, there are a number of covert associations between them. The present study describes the case of a 20-year-old female with an unusual swelling in the left mandible that had been present for 2 years. The patient was initially clinically diagnosed with cementoblastoma; however, following pathological examination, a diagnosis of osteosarcoma was confirmed. A total mandibulectomy was performed on the left mandible, with a fibular osteomyocutaneous flap used for reconstruction. At the 6-month post-operative examination, the patient demonstrated normal occlusion and oral commissure, and no recurrence or metastasis was observed over 2 years of follow-up.

Intraoral lining with the fibular osteomyofascial flap without a skin paddle during maxillary and mandibular reconstruction.

To achieve an ideal intraoral lining, we harvest the fibular osteomyofascial flap to avoid the common embarrassment caused by the fibular osteomyocutaneous flap, and we report on our experience with this technique in this article. Twenty-eight patients underwent reconstruction of the maxilla and mandible using an osteomyofascial free fibula flap after oncologic ablation. Data, including the size of the fascial flaps, the number of debulking operations, the complications at both the donor and recipient sites, and the dental rehabilitation, were collected. All fascial flaps survived and were remucosalized, except one with partial necrosis. None of the patients in the osteomyofascial group required an additional debulking operation, and 82% of the patients (23 of 28) had conventional dentures and showed good chewing function and cosmetic results. The fibular osteomyofascial flap yielded a more anatomic solution for oral mucosal defects, obviating the need for additional debulking and potentially reducing donor-site wound problems. © 2015 Wiley Periodicals, Inc. Head Neck 38: E832-E836, 2016.

The accuracy of computer-assisted primary mandibular reconstruction with vascularized bone flaps: iliac crest bone flap versus osteomyocutaneous fibula flap

BackgroundThe intention of mandibular reconstruction is to restore the complex anatomy with maximum possible functionality and high accuracy. The aim of this study was to evaluate the accuracy of computer-assisted surgery in primary mandibular reconstruction with an iliac crest bone flap compared with an osteomyocutaneous fibula flap.Materials and methodsPreoperative computed tomography data of the mandible and the iliac crest or fibula donor site were imported into a specific surgical planning software program. Surgical guides were manufactured using a rapid prototyping technique for translating the virtual plan, including information on the transplant dimensions and shape, into real-time surgery. Using postoperative computed tomography scans and an automatic surface-comparison algorithm, the actual postoperative situation was compared with the preoperative virtual simulation.ResultsThe actual flap position showed a mean difference from the virtual plan of 2.43 mm (standard deviation [SD] ±1.26) and a surface deviation of 39% <2 mm and 15% <1 mm for the iliac crest bone flap, and a mean difference of 2.18 mm (SD ±1.93) and a surface deviation of 60% <2 mm and 37% <1 mm for the osteomyocutaneous fibula flap. The position of the neomandible reconstructed with an osteomyocutaneous fibula flap indicated a mean difference from the virtual plan of 1.25 mm (SD ±1.31) and a surface deviation of 82% <2 mm and 57% <1 mm, in contrast to a mean difference of 1.68 mm (SD ±1.25) and a surface deviation of 63% <2 mm and 38% <1 mm for the neomandible after reconstruction with an iliac crest bone flap. For shape analysis, a similarly high accuracy could be calculated for both flaps.ConclusionVirtual surgical planning is an effective method for mandibular reconstruction with vascularized bone flaps, and can help to restore the anatomy of the mandible with high accuracy in position and shape. It seems that primary mandibular reconstruction with the osteomyocutaneous fibula flap is more accurate compared with the vascularized iliac crest bone flap.

Special considerations in virtual surgical planning for accurate maxillary reconstruction with vascularized fibula osteomyocutaneous flap

Special considerations in virtual surgical planning for accurate maxillary reconstruction with vascularized fibula osteomyocutaneous flap

Maxillary Reconstruction Using Vascularized Fibular Osteomyocutaneous Flap and Iliac Bone Through Modified Lateral Lip-Submandibular Approach

The objective of this study was to demonstrate total maxillary reconstruction using 1 vascularized fibular osteomyocutaneous flap segment alone and nonvascularized iliac crest bone through the modified lateral lip-submandibular approach. At the same time, three-dimensional virtual technology was performed as well. Nine patients suffering from total maxillary defects, who had undergone maxillary reconstruction using 1 vascularized fibular osteomyocutaneous flap segment and nonvascularized iliac bone through the modified lateral lip-submandibular approach, were reviewed for this study. Before the surgery, patients' computed tomography scan data were virtually analyzed using SimPlant Pro software (version 11.04). Healing courses were uneventful in all patients; acceptable maxillomandibular relationship, mouth opening, and speech were assessed as normal in all. There were no long-term functional limitations of the lower limb, even though all complain of dysfunction of the first toe, which developed the deformity of the claw toe in the end. Other complications did not occur such as diplopia, ectropion, flap necrosis, facial paralysis, and sensory numbness in the lower lip. The maxillary reconstruction using 1 vascularized fibular osteomyocutaneous flap segment and nonvascularized iliac crest bone through the modified lateral lip-submandibular approach is a feasible and acceptable technique because of multiple advantages. Combined with the three-dimensional virtual technology, the technique can improve the postoperative outcomes.

OP032: What can fibula flap do in jaw reconstruction?

Part A 3-D model simulation and reconstruction of composite total maxillectomy defects with fibula osteomyocutaneous flap flow-through from radial forearm flap 3-Dimensional model simulation technique and free fibula osteomyocutaneous flap flow-through from radial forearm flap were used to reconstruct a total maxillectomy defect for a 21-years-old female patient. Preoperatively, the 3-dimensional simulated resin models of skeleton and fibula were used to design. In surgery, a 22-cm length free fibula was divided into four segments to make skeletal framework as surgical planning with a radial forearm flap flow-through for the free fibula flap with the skin paddle to repair the palatal and nasal region. Free fibula and radial forearm flap were alive, and the patient was satisfied with the results both aesthetically and functionally due to dental rehabilitation which was carried out 6 months postoperatively. This preliminarily clinical study and case demonstrated the fibula osteomyocutaneous flap is an ideal donor site in total maxillectomy defect reconstruction; the flow-through forearm radial flap not only serves as the vascular bridge to midface reconstruction, but also provides sufficient soft tissue cover for the intra-oral defect. Part B Double barrel fibula free flap with second-staged dental implants for mandibular reconstruction. The aim of this study was to evaluate the method for segmental mandibular reconstruction using double-barrel fibular flap with second-staged dental implant-supported prosthetic rehabilitation. 5 patients (2 gingival carcinomas, 2 ameloblastomas and 1 keratocyst) had undergone segmental mandibulectomy with 6–9 cm defect length. After tumor resection, double barrel fibula osteomyocutaneous flaps were used to reconstruct the mandible. All the flaps were alive with no complications post-operatively. Follow-up at 6 months showed good osteo-integration in panoramic radiograph and esthetic facial appearance. The patients underwent second-stage implants 8 months after fibula transplantation and implant-supported prosthesis was installed 1–2 months later to complete teeth rehabilitation.

Computer-Assisted Orthognathic Surgery Combined With Fibular Osteomyocutaneous Flap Reconstruction to Correct Facial Asymmetry and Maxillary Defects Secondary to Maxillectomy in Childhood

Maxillectomy in childhood not only causes composite primary defects but also secondary malformation of the middle and lower face. In the case presented, we introduced computer-assisted planning and simulation of orthognathic surgery combined with fibular osteomyocutaneous flap reconstruction to correct complex craniofacial deformities. Virtual orthognathic surgery and maxillary reconstruction surgery were undertaken preoperatively. LeFort I osteotomy, with bilateral sagittal split ramus osteotomy and lower border ostectomy, was performed to correct malocclusion and facial asymmetry. Maxillary reconstruction was accomplished using a fibular osteomyocutaneous flap. The patient recovered uneventfully with an adequate aesthetic appearance on 3D computed tomography. Our experience indicates that orthognathic surgery combined with fibular osteomyocutaneous flap reconstruction can used to correct complex facial asymmetry and maxillary defects secondary to maxillectomy. Computer-assisted simulation enables precise execution of the reconstruction. It shortens the free flap ischemia time and reduces the risks associated with microsurgery.

OP037: Special considerations in virtual surgical planning for secondary accurate maxillary reconstruction with vascularized fibula osteomyocutaneous flap

This paper describes our special considerations in virtual surgical planning for secondary maxillary reconstruction with vascularized fibular osteomyocutaneous flap and our revised surgical design for maxillary reconstruction. Eleven patients with different maxillary defects according to Brown’s revised classification underwent virtual surgical planning for secondary accurate reconstruction. For different horizontal class defects, the fibular was osteomized to match maxillary alveolar arch by using the mirror image of the contralateral alveolar ridge or the curve of mandibular arch and dentition. Maxillary reconstruction was performed with the guidance of preoperative virtual planning and using fibular osteotomy and reposition guide templates to replicate the virtual planning intraoperatively. Virtual surgical planning was replicated intraoperatively in all patients. The fibulae were osteotomized into four segments in three patients with the horizontal class d2 defect and three segments in eight patients with the horizontal class b ∼ d1 defects, respectively. Overall success rate for 11 flaps was 100%. Good bony unions and wound closure were observed and intelligible speech was achieved in 11 patients. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. Postoperative mid-facial appearance was good in all patients. We recommend that the horizontal class d defect in Brown’s revised classification of maxilla and mid-face be divided into two subtypes according to whether it involves the contralateral canine or not. Special considerations in virtual surgical planning are helpful to perform accurate secondary maxillary reconstruction with vascularized fibular osteomyocutaneous flap.