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The free fibular flap is the flap of choice for reconstruction of complex mandibular defects, although two or more osteotomies may be required to recreate the normal mandibular contour. The effect of these surgical manipulations on the fibula has not been adequately investigated. This study was designed to study the effect of multiple segmental osteotomies and internal fixation techniques on blood flow in the vascularized pig fibula bone flap model. The hindlimbs of 15 Yorkshire pigs were randomized into 1 of 5 groups (n = 6 fibulae per group) consisting of: (1) a nonoperated, in situ fibula; (2) an elevated fibula flap; (3) an elevated fibula flap with two segmental osteotomies; (4) an elevated fibula with two segmental closing osteotomies rigidly fixed with 2-mm miniplates; (5) an elevated fibula with two segmental closing osteotomies rigidly fixed with 2-mm lag screws. Total and gradient blood flow was measured in the bone and soft-tissue components of these flaps using the 15-microm radioactive microsphere technique. The creation of two segmental osteotomies in the vascularized pig fibula bone flap model resulted in a significant decrease (p<0.05) in the gradient blood flow in the segment of bone distal to the second osteotomy. Application of miniplates or lag screws across closing osteotomies resulted in a significant decrease (p<0.05) in total and gradient blood flow to the bone component of the fibulae, as compared with the elevated and osteotomized fibulae groups. An increase in blood flow suggesting a hyperemic response was noted in the bone and soft tissue in the elevated and osteotomized flap groups as compared with the in situ, nonoperated controls. This study established the validity of the pig fibula as a suitable model for investigating the pathophysiology of blood flow changes in the face of standard surgical maneuvers necessary for the restoration of mandibular form and function. The results demonstrated that the creation of multiple segmental osteotomies and the application of internal fixation significantly decreases (p<0.05) blood flow to the distal portion of the flap. The effects of segmental osteotomies and internal fixation on healing and growth of the pig fibula bone flap model are investigated in a separate study.

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Five young adults between the ages of 16 and 27 years underwent mandibular reconstruction with free vascularized iliac crest bone grafts based on the deep circumflex iliac artery. These were the only patients under age 30 years in a series of over 60 patients undergoing this procedure. In all cases, the ipsilateral crest was employed, and special efforts were made to minimize bony bulk by removing the outer cortex and carefully shaping the graft. The bone graft underwent final trimming in situ, the exact dimensions being reproduced from measurements taken from the excised specimen. When bone alone requires replacement, as in the majority of young patients, an excellent functional result can be anticipated. Occlusion can be maintained or even restored, and the normal facial contour can be re-established. Osteointegrated implants hold out the possibility of providing full dental rehabilitation in an age group in which anything less is considered failure. Furthermore, the donor site scar can be hidden by a bathing suit. It is concluded that this form of reconstruction is particularly suitable for the young adult, in whom cosmesis, function, donor site, and freedom from long-term complications are of supreme importance.