Microsurgical Jaw Reconstruction using Fibula Free Flap

Microsurgical techniques enable the utilization of distant bony flaps sourced from locations such as the iliac crest, scapula, or fibula, with a connection to recipient vessels in the face or neck. Among these options, the fibula osteocutaneous flap has emerged as the gold standard for jaw reconstruction. It offers ample corticocancellous bone volume capable of withstanding masticatory forces, restoring the lower facial contour, and facilitating the placement of osseointegrated implants for prosthetic rehabilitation when necessary.

Recreating the intricate 3D structure of the mandible involves performing multiple closing wedge osteotomies in the fibula, followed by the folding of bone segments, reminiscent of origami. Precision in designing and executing compound-angle osteotomies is crucial to ensure proper segment alignment and optimal bony apposition for successful bone healing. Utilizing 3D-printed osteotomy guides, positioning guides, and patient-specific osteosynthesis plates enhances accuracy and efficiency compared to earlier techniques involving balsa wood or silicone templates, freehand osteotomies, and time-consuming trial-and-error methods.

Preoperative CT scans of both the extremity donor site and the head/neck recipient site are obtained, including arterial phase CT angiography if vascular evaluation is required or following oncology protocols for planned cancer ablation. Planning typically involves collaboration between the ablative and reconstructive surgeons. Resection margins are first defined, followed by digital importation of the fibula or other donor-site bone into a 3D environment, overlaying it onto the defect, and adjusting its orientation. Multiple iterations may be performed to plan the segments, with osteotomy cutting guides generated accordingly.

Utilizing standard off-the-shelf plate fixation hardware is a viable option, although it is advantageous to complement this approach by printing a life-size 3D anatomic model of the reconstructed jaw. This model serves as a precise guide for manually bending the osteosynthesis plate to fit the patient’s unique anatomy accurately. Alternatively, a patient-specific fixation plate can be meticulously designed within the 3D planning environment. Here, the surgeon has the flexibility to determine the optimal number and spacing of hole placements on each segment, tailored to the specific needs of the reconstruction. Employing predictive holes in this scenario can significantly enhance the efficiency and accuracy of the fixation process.

An advantage of using osteotomy cutting guides in microvascular reconstructive procedures is the reduction of ischemia time. With resection margins confirmed intraoperatively, the reconstructive surgeon can proceed with fibula osteotomies using pre-printed guides, minimizing the time the flap is disconnected from its vascular supply until it is ready for transfer and fixation in the facial region.

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Presurgical planning and intraoperative guide use are widely accepted as the reference standard for mandible reconstruction, with reported benefits including **improved accuracy, higher rates of bony union, lower complication rates, and shorter ischemia and overall operative times.** Similarly, the use of patient-specific fixation plates has also been shown to result in fewer complications and shorter operative times when compared with traditional free-hand surgery.

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