Free Flap Mandibular Reconstruction Research Articles

Deep Circumflex Iliac Artery (DCIA) Free-Flap Mandibular Reconstruction Using Patient-Specific Surgical Guides and Customized Plates: A Preliminary Study

Background: Mandibular reconstruction remains challenging in oral and maxillofacial surgery due to its complex anatomy and functional requirements. While Deep Circumflex Iliac Artery (DCIA) flaps offer advantages in bone height and natural contour, their application with computer-aided surgical planning remains limited. Aim: This preliminary study aimed to evaluate the accuracy and clinical outcomes of mandibular reconstruction using DCIA free flaps with patient-specific surgical guides and customized plates. Materials and Methods: A pilot study of five patients who underwent mandibular reconstruction using DCIA free flaps was conducted. Virtual surgical planning was performed using Cone-Beam Computed Tomography (CBCT) and pelvic Computed Tomography (CT) data to design patient-specific cutting guides and reconstruction plates. All surgeries were performed by a single experienced surgeon using standardized techniques. Results: The mean deviation between the virtual planning and actual surgical outcomes was 0.73 ± 0.23 mm, with maximum deviations ranging from 3.87 to 7.83 mm. All flaps achieved 100% survival, with one case (20%) experiencing screw loosening that required plate removal. This complication led to the modification of the plate design to include six or more holes in subsequent cases. Conclusions: Despite limitations including the small sample size and short follow-up period, our preliminary results demonstrate that computer-aided surgical planning with patient-specific devices can significantly improve the accuracy and predictability of DCIA flap mandibular reconstruction, even in challenging revision cases. Further studies with larger patient cohorts are needed to validate these findings.

Volumetric Bone Changes in Double Barrel Vascularized Fibula Flap Used for Mandibular Reconstruction: A Randomized Clinical Trial.

To assess the volumetric bone changes in double barrel vascularized fibular flap used for mandibular reconstruction using 3D miniplate versus 3D titanium mesh tray. Twenty patients seeking mandibular reconstruction were selected for this 2-arm parallel randomized clinical trial with a 1:1 allocation ratio. Both groups underwent double-barrel fibula free flap for mandibular reconstruction with fixation of the superior barrel to the inferior barrel using a Titanium mesh (Group A) or a 3D plate (Group B). The primary outcome was volumetric bone changes (immediate to 6 months postoperatively). Eleven participants (55%) were females, and 9 participants (45%) were males. The mean age of patients in group A was (28.8±8.9) years, while group B was (30.7±11.4) years. There was a statistically significant difference within each group in the volumetric bone changes with means of -7942.1±1804.8mm 3 and -6288.8±2607.3 for groups A and B, respectively. The difference between both groups was statistically insignificant with the mean of -1653.3±1002.8mm 3 . The percentage of mean volumetric change relative to immediate postoperatively for group A was -14.15%, while in group B was -11.01%. Both the titanium mesh tray and the 3D plate were effective in the fixation of the superior barrel of the vascularized fibular flap for mandibular reconstruction. There was no difference between both modalities regarding volumetric bone changes.

Implementation of In-house Computer-aided Design and Manufacturing for Accelerated Free Fibula Flap Reconstruction of Mandibular Defects in Cancer Patients.

Computer-aided design and manufacturing (CAD/CAM) is widely adopted for optimizing microsurgical reconstruction of mandibular defects. However, commercial solutions are hampered by costs and lengthy lead times, with the latter being problematic in cancer surgery. This study aimed to investigate the efficiency of an in-house CAD/CAM service for expeditious planning and execution of free fibula mandibular reconstruction in head and neck cancer patients. This retrospective cohort study compared cancer patients undergoing segmental mandibulectomy and immediate free fibula flap reconstruction treated before and after implementation of in-house CAD/CAM. The primary endpoint was treatment delay from preoperative consultation to surgery. Cases in the two groups were matched on the number of fibula segments required for mandibular reconstruction. The control group underwent segmental mandibulectomy and fibula flap reconstruction by "freehand." The CAD/CAM group underwent preoperative virtual surgical planning and CAD/CAM of intraoperative cutting guides for the mandibulectomy and fibula osteotomies. Outcomes were compared with the unpaired t test or Wilcoxon rank-sum test. Sixteen patients were included in both groups. Treatment delay did not increase after implementation of in-house CAD/CAM with a median 6 (range 6-20) days wait in the CAD/CAM group and 8 (6-20) days wait in the control group (P = 0.48). Utilization of CAD/CAM significantly reduced fibula flap ischemia time with a mean of 18.4 [95% confidence interval 2.8; 33.9] minutes (P = 0.022). In-house CAD/CAM was implemented for free fibula flap mandibular reconstruction in head and neck cancer patients without causing treatment delay. Furthermore, CAD/CAM reduced fibula flap ischemia time.

Comparison of condylar position after free fibular flap mandibular reconstruction using computer-assisted and traditional techniques

ObjectivesTo compare the changes in condylar position after mandibular reconstruction with free fibular flap(FFF) and the differences between computer-assisted techniques and traditional methods on CT images.MethodsThirty-four patients who underwent mandibular reconstruction with free fibular flap were selected according to the inclusion and exclusion criteria. In the 3D group, virtual surgical planning (VSP) with osteotomy cutting plate and placement guiding plate were used, while the traditional group underwent freehand reconstruction. The CT data of 68 temporomandibular joints (TMJs) were recorded before and immediately after surgery. The condylar position was evaluated by measuring the anterior space (AS), posterior space (PS) and superior space (SS), and the ln (PS/AS) was calculated according to the method proposed by Pullinger and Hollender.ResultsIn the patients included in the 3D group, the condyle on the ipsilateral side moved slightly backward; however, in the patients in the traditional group, the ipsilateral side moved considerably anteroinferior. No obvious changes on the contralateral side were noted. In the 3D group, 33% of ipsilateral condyles were in the posterior position postoperatively when compared with the preoperative position (13%). In the traditional group, the number of ipsilateral condyles in the anterior position increased from 4 to 10, accounting for 53% postoperatively. Contrary to the traditional group, the 3D group presented less condylar displacement on the ipsilateral side postoperatively.ConclusionsThis study showed a decreased percentage of change in condylar position postoperatively when VSP was used. Virtual surgical planning improved the accuracy of FFF mandibular reconstruction and made the condylar position more stable.

Early outcomes of osteofascial versus osteocutaneous fibula free flap mandibular reconstruction.

This study compares early outcomes of osteofascial fibula free flap (OF-FFF) with donor-site primary closure and osteocutaneous (OC) FFF with donor-site skin grafting in segmental mandibular reconstruction. A retrospective chart review of FFF mandibular reconstruction patients (2006-2022) divided into OF-FFF and OC-FFF groups. Clinical data, operative parameters, and early postoperative outcomes (≤ 90 days) were analyzed. The study included 67 patients (39 OF-FFF, 28 OC-FFF). OF-FFF had significantly lower donor-site complications (12.8% vs. 53.6%, p < 0.001) and revision surgeries (7.7% vs. 35.7%, p = 0.004) compared to OC-FFF. Recipient-site (28.2% vs. 25%, p = 0.77) and flap (15.4% vs. 17.9%, p > 0.99) complications were comparable. OF-FFF mandibular reconstruction with donor-site primary closure is a safe and reliable technique associated with superior donor-site and comparable flap and recipient-site outcomes to OC-FFF, thus may be considered as a viable alternative to OC-FFF for selected patients.

Fibula free flap for mandibular reconstruction following total en bloc resection in ameloblastoma: a case report and literature review

Background: The fibular free flap is considered the gold standard in mandibular bone reconstruction. It has a high survival rate, is well-vascularized, and fits seamlessly into long-bone defects. The purpose of this article is to describe the use of vascularized fibular free flap in mandibular reconstruction after total en bloc resection in case of ameloblastoma suspected of repeated trauma to the mandible. Case Presentation: A case report of a 26-year-old patient undergoing a mandibular reconstruction using fibula osteocutenous free flap following total en bloc resection due to ameloblastoma on mandibular symphisis region was monitored using Doppler ultrasound every 15 minutes for three to five days. Within four months of treatment, the patient had improved, and the graft was found to be viable. Conclusion: The severity and size of the affected tissue, the tumour's histological arrangement, and the consequences were the influence of whether or not ameloblastoma patients should require surgery. To determine the best course of treatment for each individual case of ameloblastoma, an accurate clinical examination and image evaluation are required.

Fibula free flap for mandibular reconstruction following total en bloc resection in ameloblastoma: a case report and literature review

Background: The fibular free flap is considered the gold standard in mandibular bone reconstruction. It has a high survival rate, is well-vascularized, and fits seamlessly into long-bone defects. The purpose of this article is to describe the use of vascularized fibular free flap in mandibular reconstruction after total en bloc resection in case of ameloblastoma suspected of repeated trauma to the mandible. Method: A case report of a 26-year-old patient undergoing a mandibular reconstruction using fibula osteocutenous free flap following total en bloc resection due to ameloblastoma on mandibular symphisis region was monitored using Doppler ultrasound every 15 minutes for three to five days. Result: Within four months of treatment, the patient had improved, and the graft was found to be viable. Conclusion: The severity and size of the affected tissue, the tumour's histological arrangement, and the consequences were the influence of whether or not ameloblastoma patients should require surgery. To determine the best course of treatment for each individual case of ameloblastoma, an accurate clinical examination and image evaluation are required.

Robot-guided osteotomy in fibula free flap mandibular reconstruction: a preclinical study

Various methods currently exist to guide fibular osteotomy positioning in fibula free flap mandibular reconstruction, but patient-specific navigation methods and cutting guides require experience, and may be time-consuming and/or expensive. This study describes a robot-guided osteotomy technique for mandible reconstruction using a fibula free flap according to virtual preoperative planning. The method was assessed on five 3D-printed models and a cadaveric model. The precision of the robot-guided osteotomy was evaluated by measuring the deviations between the lengths and angles of the fragments obtained and those of the virtual planning. The average deviation of the anterior and posterior crest lengths was 0.42±0.29mm for the 3D-printed models and 1.00±0.53mm for the cadaveric model. The average angle deviation was 1.90±1.22° and 1.94±0.69° for the 3D-printed and cadaveric models, respectively. The results of this preclinical study revealed that fibular osteotomy positioning guidance using a robot-positioned cutting guide may be a precise, easy-to-use technique that could be tailored for fibula free flap mandibular reconstruction.

Factors Affecting Complete Oral Rehabilitation in Patients With Vascularized Free Fibula Flap Mandibular Reconstruction: A 10-Year Retrospective Study.

The fibula is the preferred bone flap for mandibular reconstructions due to its many advantages, including the possibility to insert dental implants. All patients who received a mandibular reconstruction with a vascularized free fibula flap at the Uppsala University Hospital between 2009 and 2019 were retrospectively examined regarding the proportion of implant insertion and factors that affected implant outcome. Forty-one patients had 42 fibula flap reconstructions. Eleven patients (27%) received dental implants and 8 (20%) completed dental rehabilitation. Patient death and cancer recurrence were the main reasons for not receiving implants. The survival rates of implants placed in irradiated and nonirradiated fibulas were 15% and 76%, respectively. Less than 20% of reconstructed patients received an implant-supported prosthesis. Implants placed in an irradiated fibula should be considered at high risk for implant loss.

Double Arterialized Scapular Tip Free Flap for Mandibular Reconstruction.

Scapular tip free flap (STFF) has become today one of the workhorse flaps for maxillary reconstruction; recently, the possibility of extending the vascular supply by adding to the angular branch of the circumflex pedicle up to its periosteal entrance in the lateral border of the scapula has been proposed as a reliable technique to improve the length of perfused bone when STFF is used for mandibular reconstruction. The purpose of this study was to evaluate the patients who had received microvascular reconstruction of the mandible with STFF vascularized by both the circumflex scapular artery via the periosteal branch and the thoracodorsal artery via the angular artery. A retrospective chart review was conducted for all patients who underwent reconstruction with an STFF for mandibular defect between January 2016 and December 2020 at the University Hospital of Parma. The outcome was evaluated by assessing dietary intake (unrestricted, soft, liquid, and tube feed) and speech (normal, intelligible, partially intelligible, and unintelligible). The final study sample included 9 patients (5 men and 4 women). The average patient age was 68.9 years (range, 59.9-74.8 y) at the time of surgery. There was no flap loss. A 1-year postoperative computed tomography scan revealed full osteointegration of the flap. Our results show that the STFF is a valuable reconstructive option, especially in patients with complex head and neck defects requiring soft and hard tissues.

Rates of osteoradionecrosis in resected oral cavity cancer reconstructed with free tissue transfer in the intensity-modulated radiotherapy era.

Resected oral cavity carcinoma defects are often reconstructed with osteocutaneous or soft-tissue free flaps, but risk of osteoradionecrosis (ORN) is unknown. This retrospective study included oral cavity carcinoma treated with free-tissue reconstruction and postoperative IMRT between 2000 and 2019. Risk-regression assessed risk factors for grade ≥2 ORN. One hundred fifty-five patients (51% male, 28% current smokers, mean age 62 ± 11 years) were included. Median follow-up was 32.6months (range, 1.0-190.6). Thirty-eight (25%) patients had fibular free flap for mandibular reconstruction, whereas 117 (76%) had soft-tissue reconstruction. Grade ≥2 ORN occurred in 14 (9.0%) patients, at a median 9.8months (range, 2.4-61.5) after IMRT. Post-radiation teeth extraction was significantly associated with ORN. One-year and 10-year ORN rates were 5.2% and 10%, respectively. ORN risk was comparable between osteocutaneous and soft-tissue reconstruction for resected oral cavity carcinoma. Osteocutaneous flaps can be safely performed with no excess concern for mandibular ORN.

Use of a Fibula Free Flap for Mandibular Reconstruction in Severe Craniofacial Microsomia in Children with Obstructive Sleep Apnea.

This is a retrospective study describing a multi-stage protocol for the management of severe mandibular hypoplasia in craniofacial microsomia (CFM) with accompanying obstructive sleep apnea (OSA). Patients with severe mandibular hypoplasia require reconstruction functionality and esthetical features. In the cohort, reconstructions based on free fibular flaps (FFF) may be the most effective way. Patients aged 4-17 years with severe mandibular hypoplasia were treated with FFF, which initially improved the respiratory function assessed on polysomnography (AHI). In the next stages of treatment of cases with respiratory deterioration, it was indicated to perform distraction osteogenesis (DO) of the mandible and the structures reconstructed with FFF. All surgeries were planned in accordance with virtual surgery planning VSP. The aim of the study was to prospectively assess the effectiveness of multi-stage mandibular reconstruction in craniofacial microsomia with the use of a free fibula flap in terms of improving respiratory failure due to obstructive sleep apnea (OSA). The FFF reconstruction method, performed with virtual surgical planning (VSP), is proving to be an effective alternative to traditional methods of mandibular reconstruction in patients with severe CFM with OSA.

Osseointegration and Bone Resorption of Scapula Tip Free Flaps in Mandibular Reconstruction.

Bone resorption of more conventional vascularized bone grafts have been well described showing minimal resorption over time. Few studies have evaluated osseous union and bone resorption in scapula tip free flaps (STFF) in the reconstruction of mandibulectomy defects. We aimed to describe our series on STFF with respect to osseous union and bone resorption over time. Retrospective chart review of patients receiving STFF from January 2014-January 2017 (n=25). A neuroradiologist analyzed follow-up CT scans to assess (1) STFF complete, partial, or no osseous union with native mandible and (2) STFF volume change over time in a subset with multiple follow-up scans (n=18). Twenty-three of 25 patients (92%) showed complete or partial STFF osseous union with native mandible either distally or proximally. STFF volume change ranged from +4.8 to -54% (median -0.5%) over median follow-up interval of 23 months. History of chemoradiation therapy, bisphophonate use, sex, age, or smoking history did not correlate with bone resorption. STFFs shows high rates of osseous union and limited bone resorption that is equivalent to, or less than, vascularized fibular and iliac crest flaps. Clinically, this translates into both optimal healing andfunctional and cosmetic outcomes, especiallyin the setting of prior therapies. 4 Laryngoscope, 133:2597-2602, 2023.

Continuous Ropivacaine Peroneal Nerve Infiltration for Fibula Free Flap in Cervicofacial Cancer Surgery: A Randomized Controlled Study.

Introduction: Pain after cervicofacial cancer surgery with free flap reconstruction is both underestimated and undertreated. There is a rational for regional anesthesia at the flap harvest site, but few studies describe it. We assessed the influence of common peroneal nerve infiltration on pain and opioid consumption in patients having oropharyngeal cancer surgery with fibular free flap mandibular reconstruction. Methods: After institutional review board (IRB) approval and written informed consent, fifty-six patients were randomly allocated to perineural catheter with ropivacaine infiltration (ROPI) or systemic analgesia (CONTROL). In the ROPI group, an epidural catheter was placed by the surgeon before closure, and ropivacaine 0.2% 15 mL, followed by 4 mL/h during 48 h, was administered. The primary outcomes were pain scores and morphine consumption during the 48 h postoperative period. We also measured ropivacaine concentration at the end of infusion. Finally, we retrospectively assessed long-term pain up to 10 years using electronic medical charts. Results: Perineural infiltration of ropivacaine significantly reduced pain scores at the harvest site only at day 1, and did not influence overall postoperative opioid consumption. Ropivacaine assay showed a potentially toxic concentration in 50% of patients. Chronic pain was detected at the harvest site in only one patient (ROPI group), and was located in the cervical area in the case of disease progression. Discussion: Although the catheter was visually positioned by the surgeon, continuous ropivacaine infiltration of the common peroneal nerve did not significantly reduce postoperative pain, but induced a blood concentration close to the toxic threshold at day 2. Further studies considering other infiltration locations or other dosing schemes should be tested in this context, both to improve efficacy and reduce potential toxicity.

What Factors Influence the Bony Fusion of Vascularized Fibula Free Flaps for Mandibular Reconstruction?

The vascularized fibula free flap was implemented over 20 years ago for reconstruction of maxillofacial defects,1 however, little is known about healing and osseous fusion postoperatively. We sought to determine the factors influencing bony fusion of the vascularized fibula free flap. We performed a retrospective cohort analysis of patients treated at University of Illinois Chicago with free fibula flaps for mandibular reconstruction from August 2016 to August 2021 in order to analyze fusion at osteotomy sites (UIC IRB #2022-0351).

851 3D Printing Technology in Microsurgical Reconstruction of the Maxilla and Mandible at Great Ormond Street Hospital (GOSH)

Abstract Aim Since its development, three-dimensional (3D) printing has been used successfully in many industries, however its use in surgery is still in its infancy. We present two cases where 3D printing technology was used to aid surgical planning and guide free-flap microsurgical reconstruction. Method A free fibula flap was performed following a hemi-maxillectomy for a mucoepidermoid carcinoma of the palate. 3D-technology was used to design the position of the osteotomies, osteosynthesis and osseo-integrated dental implants by our in-house 3D technician. A 3D-printed cutting guide was created for the fibula and a custom-made titanium plate was designed for the maxillary reconstruction. Similar 3D-technology was used in a free DCIA flap mandibular reconstruction following resection of a mandibular ameoblastoma. Lower limb CTA showed bilateral peronea arteria magna. Thus, a DCIA flap was performed. A 3D computer-aided design-model for the surgical procedure was created allowing for precise measurement of iliac crest bone and cutting guides were created to aid mandibular resection and ensure accurate bone harvest. Results Both patients underwent successful reconstruction, the flaps maintained good perfusion with strong and consistent doppler signals with healthy skin paddles post-operatively. The patients recovered well; one remains in the immediate post-operative period and one-month follow-up of the DCIA flap showed good position of the bone flap with reasonable movement of the mandible. Conclusions 3D technology has the potential to improve the quality of craniofacial reconstructions. This technology allows the reconstructive surgeon to improve accuracy, demonstrate complex anatomy, plan and execute complex surgical plans with improved functional and aesthetic outcomes.

A Brief Clinical Study: The Use of a Custom Guide for Scapula Free Flap Harvest and Mandibular Reconstruction.

Head and neck cancer can leave patients with significant defects requiring major reconstruction. The scapula free flap remains a relatively underused flap choice. This article examines the novel use of a custom guide for a scapula free flap in mandibular reconstruction following resection. A case file was created involving a consultant surgeon, KLS advisor, and technical team based in Belgium. A computed tomography scan of the mandible was sent electronically to render a 3-dimensional model. Custom cutting guides for resection and scapula graft harvest were fabricated. A custom plate for fixation was also developed. The scapula free flap was successfully placed using custom guides. In this case, the use of a custom guide enabled easier harvest, manipulation, and handling of the scapula free flap into the defect. The use of new technology and computer-generated guides represents a considerable shift forward into improving precision in complex surgical procedures and reducing intraoperative time. The use of a custom guide can provide an easier means to handle and manipulate one of the largest free flaps in surgery, the scapula free flap.

Free vascularized flap reconstruction for osteoradionecrosis of the mandible: a 25-year retrospective cohort study

BackgroundOsteoradionecrosis of the jaw is a severe complication of radiotherapy in head and neck cancer patients. If conservative treatment and surgical debridement have been unsuccessful, the preferred treatment for symptomatic mandibular osteoradionecrosis (mORN) is radical surgery and subsequent reconstruction with a free vascularized flap. This study aims to assess the outcomes of free vascularized flap reconstruction in mORN.MethodsA retrospective study was conducted on all patients who underwent a free vascularized flap reconstruction for mORN between 1995 and 2021 in Amsterdam UMC – VUmc, The Netherlands.ResultsIn our cohort study, three of the twenty-eight flap reconstructions failed (10.7%). No recurrences of mORN were observed during a mean follow-up of 8 years.ConclusionsThe success rate of free vascularized flap reconstruction for mORN is high. The fibula is the preferred free flap for mandibular reconstruction in mORN cases. However, this type of surgery is at risk for complications and patients need to be informed that these complications may require surgical re-intervention.Level of evidence: Level IV, Therapeutic; Risk/Prognostic.

Combination of surgical techniques and reconstructive devices as an alternative treatment after fibula free flap mandibular reconstruction failure: a case report

Combination of surgical techniques and reconstructive devices as an alternative treatment after fibula free flap mandibular reconstruction failure: a case report

The combined anterolateral thigh-Partial iliac crest minihybrid free flap for mandibular reconstruction.

Tumors of the oral cavity often require extensive resections leading to significant hard and soft tissue defects. Microvascular free flaps, consisting of both hard and soft tissue, are often required in reconstructions. Hybrid flaps, composed of two different joint free flaps, offer potential alternatives for head and neck reconstruction. This report presents our results with a modified hybrid ALT/DCIA, that is, minihybrid free flap (MH-flap) composed of the anterolateral thigh (ALT) and a partial inner lamina iliac crest only (partial DCIA) for reconstruction of the mandibular region. Eight patients underwent oral cancer reconstruction of the mandible with the MH-flap. The MH-flap was harvested sparing the outer crest and lamina of crista, and its pedicle was combined to the distal pedicle of ALT. Clinical data and postoperative complications were analyzed. The mean length of the osseous graft was 64 mm (range 54-78 mm). None of the patients had complications requiring surgical intervention. No donor site complications were observed. The overall survival rate was 100%. The mean length of follow-up was 16 months (range 7-30 months). According to our results, the ALT-partial DCIA MH-flap has postoperative outcomes comparable to those of the fibular flap. The flap is a good option with excellent bone properties for reconstruction of limited mandibular defects not suitable for fibular or scapular reconstruction.