Armamentarium

History of the Procedure

The restoration of form and function to the maxillofacial complex has always been a challenge. This region is the most complex regarding function in the human body, with the airway and gastrointestinal system traversing its structures, and the skeleton providing the framework for the dentition and oral cavity; this area is critical for esthetics, speech, breathing, and nutritional intake. Failure to reconstruct maxillofacial defects after trauma or oncologic resection results in unopposed muscle action leading to collapse to the ipsilateral side, cosmetic asymmetry, loss of function, and decreased quality of life.

The need for immediate reconstruction of head and neck defects resulted in the development of the deltopectoral flap and pectoralis major flap, but immediate bony reconstruction for complex oncologic defects was not performed in the head and neck. The reconstruction of complex head and neck oncologic defects was revolutionized with microvascular free tissue transfer and the ability to immediately reconstruct mandibular defects.

In 1971, Strauch and coworkers were isolating a rib on a vascular pedicle and transposing this to the mandible in dogs as an island flap, and in 1974 Östrup and Fredrickson described microvascular rib transfer to the mandible in dogs. In 1973, Daniel and Taylor introduced the clinical reality of a free flap with an iliofemoral island flap transposed to the distal extremity. Taylor, in 1975, described the first free fibula flap transfer in humans, explaining the repair of traumatic injuries to the tibia in two patients. In 1977, the first free flap reconstruction of the mandible using a vascularized rib occurred, and Chen and Yan, in 1979, described the first osteocutaneous free fibula flap transferred to treat the traumatic loss of the radius. In the same year, Gilbert introduced the lateral approach to the fibula, which was more efficient compared to Taylor’s posterior approach, which required the patient to be in a prone position. Ten years would pass until Hidalgo, in 1989, introduced the osteocutaneous fibula free flap for use in mandibular reconstruction when he presented 12 cases of segmental mandibular defects averaging 13.5 cm.

Since then, the fibula free flap has become the gold standard for reconstruction of a large variety of mandibular defects due to its consistency in size, vascular pedicle length, vessel diameter, as well as the ability to incorporate a reliable skin paddle with the bone flap. Wei and colleagues, in 1986, published an anatomic and clinical study showing the reliability of the osteocutaneous fibula free flap. The perforator anatomy has been revisited numerous times, confirming four to eight perforators along the fibula, most commonly located along the junction of the middle third and distal third of the fibula. These are more commonly septocutaneous, with the proximal perforators more likely to be musculocutaneous, traversing through the soleus or flexor hallucis longus muscle. The diameter of the peroneal artery ranges from 1 to 2.5 mm and the width of the venae comitantes ranges from 2 to 4 mm with a total pedicle length of up to 15 cm. The bone dimensions may range from a width of 1 to 3 cm, averaging 2 cm, with a length up to 26 cm. The skin paddle can be made up to a length of 32 cm and a width of 14 cm.

Many authors have described the reliability and viability of the fibula free flap with a success rate greater than 95%. Hidalgo showed the reliability more than a decade after surgery with 70% of patients tolerating a regular diet with maintenance of good esthetic outcomes.

Alternatives to the fibula free flap are also available, including nonvascularized corticocancellous bone grafts, vascularized scapula free flaps, osteocutaneous radial forearm free flaps, as well as the vascularized iliac crest free flap. Many contend that nonvascularized bone grafts offer better anatomic reconstructions with superior alveolar bone height, symmetric arch form, and graft width, whereas others state that the risk of infection, failure rates approaching 50%, and overall complication rates nearing 70% with nonvascularized corticocancellous bone grafts all make the approach too risky.

Frodel and coworkers and Moscoso and coworkers both compared the bone thickness and stock from four free flap donor sites—the iliac crest, scapula, fibula, and radius—and found that the iliac crest proved to be the most reliable implant donor site followed by the scapula, fibula, and radius; however, the difference between the iliac crest and scapula and between the scapula and fibula did not achieve statistical significance. The iliac crest has several disadvantages, such as having a bulky soft tissue cuff, difficult to inset, short vascular pedicle, the risk of postoperative hernia, and an inherent shape that sometimes makes contouring to the anterior mandible difficult. The disadvantages of the scapula include the lack of segmental blood supply, which does not tolerate osteotomies, the inability to use a two-team approach, and the risk of weakness and loss of range of motion associated with harvesting this flap. The radius provides a thin monocortical bone segment that does not tolerate osteotomies well, and the radius bone at the donor site is at risk for postoperative fractures.

Given its advantages, in many cases, the fibula free flap provides the best option for mandibular reconstruction. Its long bicortical bone, which is consistently uniform in terms of width and length, allowing reconstruction of extensive mandibular defects including the condyle, its consistent pedicle length and diameter with dual medullary and periosteal blood supply, the ability to incorporate a skin and muscular component, and the ability to use a two-team approach all make this the free flap of choice for most extensive mandibular reconstructions.

History of the Procedure

The restoration of form and function to the maxillofacial complex has always been a challenge. This region is the most complex regarding function in the human body, with the airway and gastrointestinal system traversing its structures, and the skeleton providing the framework for the dentition and oral cavity; this area is critical for esthetics, speech, breathing, and nutritional intake. Failure to reconstruct maxillofacial defects after trauma or oncologic resection results in unopposed muscle action leading to collapse to the ipsilateral side, cosmetic asymmetry, loss of function, and decreased quality of life.

The need for immediate reconstruction of head and neck defects resulted in the development of the deltopectoral flap and pectoralis major flap, but immediate bony reconstruction for complex oncologic defects was not performed in the head and neck. The reconstruction of complex head and neck oncologic defects was revolutionized with microvascular free tissue transfer and the ability to immediately reconstruct mandibular defects.

In 1971, Strauch and coworkers were isolating a rib on a vascular pedicle and transposing this to the mandible in dogs as an island flap, and in 1974 Östrup and Fredrickson described microvascular rib transfer to the mandible in dogs. In 1973, Daniel and Taylor introduced the clinical reality of a free flap with an iliofemoral island flap transposed to the distal extremity. Taylor, in 1975, described the first free fibula flap transfer in humans, explaining the repair of traumatic injuries to the tibia in two patients. In 1977, the first free flap reconstruction of the mandible using a vascularized rib occurred, and Chen and Yan, in 1979, described the first osteocutaneous free fibula flap transferred to treat the traumatic loss of the radius. In the same year, Gilbert introduced the lateral approach to the fibula, which was more efficient compared to Taylor’s posterior approach, which required the patient to be in a prone position. Ten years would pass until Hidalgo, in 1989, introduced the osteocutaneous fibula free flap for use in mandibular reconstruction when he presented 12 cases of segmental mandibular defects averaging 13.5 cm.

Since then, the fibula free flap has become the gold standard for reconstruction of a large variety of mandibular defects due to its consistency in size, vascular pedicle length, vessel diameter, as well as the ability to incorporate a reliable skin paddle with the bone flap. Wei and colleagues, in 1986, published an anatomic and clinical study showing the reliability of the osteocutaneous fibula free flap. The perforator anatomy has been revisited numerous times, confirming four to eight perforators along the fibula, most commonly located along the junction of the middle third and distal third of the fibula. These are more commonly septocutaneous, with the proximal perforators more likely to be musculocutaneous, traversing through the soleus or flexor hallucis longus muscle. The diameter of the peroneal artery ranges from 1 to 2.5 mm and the width of the venae comitantes ranges from 2 to 4 mm with a total pedicle length of up to 15 cm. The bone dimensions may range from a width of 1 to 3 cm, averaging 2 cm, with a length up to 26 cm. The skin paddle can be made up to a length of 32 cm and a width of 14 cm.

Many authors have described the reliability and viability of the fibula free flap with a success rate greater than 95%. Hidalgo showed the reliability more than a decade after surgery with 70% of patients tolerating a regular diet with maintenance of good esthetic outcomes.

Alternatives to the fibula free flap are also available, including nonvascularized corticocancellous bone grafts, vascularized scapula free flaps, osteocutaneous radial forearm free flaps, as well as the vascularized iliac crest free flap. Many contend that nonvascularized bone grafts offer better anatomic reconstructions with superior alveolar bone height, symmetric arch form, and graft width, whereas others state that the risk of infection, failure rates approaching 50%, and overall complication rates nearing 70% with nonvascularized corticocancellous bone grafts all make the approach too risky.

Frodel and coworkers and Moscoso and coworkers both compared the bone thickness and stock from four free flap donor sites—the iliac crest, scapula, fibula, and radius—and found that the iliac crest proved to be the most reliable implant donor site followed by the scapula, fibula, and radius; however, the difference between the iliac crest and scapula and between the scapula and fibula did not achieve statistical significance. The iliac crest has several disadvantages, such as having a bulky soft tissue cuff, difficult to inset, short vascular pedicle, the risk of postoperative hernia, and an inherent shape that sometimes makes contouring to the anterior mandible difficult. The disadvantages of the scapula include the lack of segmental blood supply, which does not tolerate osteotomies, the inability to use a two-team approach, and the risk of weakness and loss of range of motion associated with harvesting this flap. The radius provides a thin monocortical bone segment that does not tolerate osteotomies well, and the radius bone at the donor site is at risk for postoperative fractures.

Given its advantages, in many cases, the fibula free flap provides the best option for mandibular reconstruction. Its long bicortical bone, which is consistently uniform in terms of width and length, allowing reconstruction of extensive mandibular defects including the condyle, its consistent pedicle length and diameter with dual medullary and periosteal blood supply, the ability to incorporate a skin and muscular component, and the ability to use a two-team approach all make this the free flap of choice for most extensive mandibular reconstructions.

Indications for the Use of the Procedure

The goal of maxillofacial reconstruction using the fibula free flap is to not only restore continuity to the mandible or maxilla but also to restore form and function, allowing a return to normal speech, chewing, and swallowing. There are several indications for fibula reconstruction, such as oncologic surgery, allowing for aggressive resection and reliable reconstruction of previously unreconstructable defects. In these cases the fibula or other free tissue transfer has the significant advantage of withstanding postsurgical radiotherapy. Other indications include posttraumatic defects, such as the definitive management of gunshot wounds, osteoradionecrosis, osteomyelitis, and congenital deformities. Mandibular defects larger than 4 to 6 cm are typically used for a fibula flap, and this osseous flap surpasses all others when the anterior mandibular segment is involved, or for those requiring condylar reconstruction.

Technique: Osteocutaneous Fibula Harvest