All procedures were performed by 3 senior surgeons with more than 10 years. Virtual planning and guided surgery in fibular freeflap mandibular. Full text of stepbystep mandibular reconstruction with. 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 fibula itself bears approximately 10% of the weight placed on the foot. Innervation of the flap is possible, and the flap has ample bone stock for the placement. Drawing on 25 years of experience, this book atlas on the standard technique used for reconstructing the mandible and the maxilla. A senior surgeon did the planning, flap harvesting. Mandibular defects may result from tumor ablations, trauma, or radiation necrosis.
Furthermore, the vascular anatomy of the flap simplifies the technical aspects of free tissue transfer. Stepbystep surgical technique for mandibular reconstruction with fibular free flap. Free vascularised fibular flap harvesting in children. So, back into surgery he went five days later using the. Stepbystep surgical technique for mandibular reconstruction. It is inserted into the bone through a minimal incision and acts like an internal splint to stabilize the fracture during healing. With great interest, we have read the special topic article by al deek et al. The free fibula flap was used in three types of approaches. 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. Dental rehabilitation for free fibula flapreconstructed. A textbook of advanced oral and maxillofacial surgery.
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. The biaxial doublebarrel fibula flap technique achieves the goals of providing adequate facial support and an alveolar segment amenable to implant dentistry. Basics of microvascular reconstruction of maxillomandibular. In order to reduce overall operation time, surgery was performed using two teams. 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. 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. 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. Successful management of free osteocutaneous fibula flap with. 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 skin paddle has proven to be dependable if care is taken to preserve the fasciocutaneous perforators.
It is critical that fibular length, alignment and rotation are accurately restored. 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. The biaxial doublebarrel fibula flapa simplified technique. Minimally invasive surgical approach to distal fibula fractures. It allows for intelligible speech, deglutition, orbital support, and separation of the oronasal, orbital, and sinus. Surgery went well, except that his arteries were severely damaged from radiation, and the surgeons had difficulty getting good blood flow to the flap. In comparison with other osteocutaneous flaps, the fibula flap offers many advantages and is associated with. 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.
Atlas of mandibular and maxillary reconstruction with the fibula. About book this atlas deals with the standard technique used for reconstructing the mandible and the maxilla the fibula flap. 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. 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. The latter team harvested the flap according to the principles described by hidalgo. They lost blood flow two days later and tried to salvage the flap. Based on individual preference, cost, and familiarity with monitoring techniques, various monitors are available. 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. This atlas deals with the standard technique used for reconstructing the mandible and the maxilla the fibula flap.
The primary blood supply to the harvested fibula flap is derived from periosteal perforators traveling circumferentially around the fibula. Primary disease, type of reconstruction, defect area, fibula segment length and number of osteotomies. 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. Extremity free fillet flap for reconstruction of massive oncologic resectionsurgical technique and outcomes. The fibular free flap is especially suited for mandibular reconstruction. The fibula head lies 3 cm below the lateral femoral condyle. All patients who underwent fibula freeflap mandibular reconstruction between. Conveys information on all important issues in the surgical procedure. The fibulock nail is a cuttingedge, minimally invasive treatment for ankle fractures. The average postoperative hospital stay was 18 3 days. Pmc, all databases, assembly, biocollections, bioproject, biosample, biosystems, books.
Our first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle. However, this may bring about mandibular implant failure in longterm followup. 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. 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 free flap approach allows the possibility of using bone withwithout skin for restoring the defect. The layered fibula osteocutaneous flap sets new standard for. 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. Fibula flaps with osteotomies have been associated with an increasing. A technique tip abstract wound complications following ankle fracture surgery are a major concern.
Once the bone is raised it is transferred to the head and neck and secured in position with small plates and screws. 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. The iliac crest and fibula flaps had bone dimensions consistently. The surgical technique is discussed in a stepbystep fashion. Free fibula flow through osteocutaneous flap in the upper. 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. 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. About your mandibulectomy and fibula free flap reconstruction. This study assessed the outcomes and tumor recurrence after immediate mandibular reconstruction using a free fibula osteocutaneous flap. Using a layered fibula freeflap design, we have developed a technique that addresses both form and function in total maxillary and orbital reconstruction.
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. Ischemia time was recorded in all five cases, with an average of 75 8 min. Extremity free fillet flap for reconstruction of massive oncologic resection surgical technique and outcomes. European archives of otorhinolaryngology, 272 6, 14911501. Recent investigations have reported on percutaneous fixation. Through the use of minimally invasive surgical techniques some of these complications can be mitigated. Atlas of mandibular and maxillary reconstruction with the fibula flap. Preplating, plate removal, resection, replating, template. Significant segmental mandibular loss or hemimandibular loss may sometimes be replaced with mandibular implants by ent surgeonsoral surgeonshead and neck surgeons.
Atlas of mandibular and maxillary reconstruction with the fibula flap a. Mandibular reconstruction using vascularised fibula journal of. Atlas of mandibular and maxillary reconstruction with the. The defects secondary to surgical ablation of the mandible have far.
The fvff technique was first developed by taylor et al. Fibula osteocutaneous flap for mandible reconstruction after ameloblastoma resection 41 septal branch can be challenging. 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. A 20year experience of immediate mandibular reconstruction using. Transfer of a free vascularised fibular flap fvff is an option for treating bone defects of 5 cm or more in children. 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. Application of digital technology in virtual surgical planning.
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. Minimally invasive surgical approach to distal fibula. Free fibula long bone reconstruction in orthopedic. Conveys information on all important issues in the surgical procedure, including the use of cadcam technology, bone synthesis and flap modelling. Osteocutaneous flap an overview sciencedirect topics. We herein report dental rehabilitation of a free fibulareconstructed mandible with scar contracture. Singleincision technique for internal fixation of distal.
Alternatively, the lateral decubitus position can be used, with the harvest leg placed up and the patient held in position with a beanbag. Here, we aimed to establish the preplating technique for oromandibular reconstruction in a stepbystep fashion, based on 41 patients. Fibula free flap the leg is the donor site that is most often used for jaw reconstructions. Osteocutaneous fibula free flap iowa head and neck protocols. In spiral or oblique fracture patterns, a clamp can be applied for reduction. Kreutzrodrigues l, mohan at, moran sl, carlsen bt, mardini s, houdek mt, rose ps, bakri k. Condyle dislocation following mandibular reconstruction using. Distally the fibula is subcutaneous and forms the lateral malleolus. A vestibuloplasty technique with application of a polyglycolic acid pga sheet is. Before the surgery, a ct angiography is performed to study the vascularization of the distal femur. 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. 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. 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.
Several authors have described the surgical technique of free fibula harvest in detail. Longitudinally the flap should be harvested long enough to complete the reconstruction. It allows for intelligible speech, deglutition, orbital support, and separation of the oronasal, orbital, and sinus cavities. 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. Stepbystep mandibular reconstruction with free fibula flap modelling. Proper preoperative planning and calculation is needed to ensure adequate fibula length without compromising ankle stability as well as a. 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. This atlas deals with the standard technique used for reconstructing the. The fibula osteocutaneous free flap is arguably the workhorse bone flap for both maxillary and mandibular reconstruction.
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. Evaluation of foot perfusion after fibula flap surgery. A long segment of bone up to approximately 22 cm is available for harvest. 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. 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. Free fibula flap technique dr jameel kifayatullah oral and maxillofacial surgeon peshawar,pakistan. The fibula flap has been used extensively for oromandibular reconstruction. Fibula, flap, technique, approach, safety, reliability, anatomy, surgical, surgery. Eckardt surgical management of soft tissue sarcomas semin oncol, 24 1997, pp. Guides that direct the trajectory of the drill right into the plate. Free fibula flap in the reconstruction of mandible. Fibula osteocutaneous flap for mandible reconstructionafter. 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.