Non-vascularized Fibular Cortex Grafts with Osteocutaneous Free Fibula Transfer: A Novel Technique in Midface Reconstruction

Abstract

Objectives: To present a method to reconstruct the midface using the fibula as both a microvascular free flap and as a free cortex graft. Methods: 22-year-old male presented with bilateral maxillary odonotogenic myxoma. Bilateral total maxillectomy defects were reconstructed using an osteocutaneous fibula free flap. The nasomaxillary buttresses were augmented using free cortex grafts to provide additional soft tissue projection and lateral nasal support. Results: The patient received dental implants at 10 months postoperatively and resumed a normal diet. His midface height, nasal and maxillary projection were adequate. At 36 months post-treatment he has no evidence of disease recurrence or resorption of the free bone grafts. Conclusion: The fibula free flap can be used to provide additional support to a patient’s reconstruction by means of free cortex grafts. The patient has had successful restoration of pyriform aperture, nasal projection, mastication, and dental restoration using a single donor site.

Use of Banked Fibula for Improved Nasal Reconstruction Following Free Fibula Midface Reconstruction

“…The reported cases involve either mandibular reconstruction where the authors combine a fibular flap and the excess fibula as a graft to achieve greater vertical height or simultaneous mandibular and maxillary reconstruction, where the free fibula is used for the mandible and the excess is used as a bone graft for the maxilla. 3,[9][10][11] . Although Perez et al 3 were the first to describe a technique wherein fibular bone graft was used in conjunction with a free fibula flap to successfully reconstruct the piriform aperture and nasomaxillary buttress after maxillectomy, in the cases presented herein, a staged approach allowed for a reassessment of the defect after the resolution of most of the swelling, potentially leading to a more accurate reconstruction.…”

“…3,[9][10][11] . Although Perez et al 3 were the first to describe a technique wherein fibular bone graft was used in conjunction with a free fibula flap to successfully reconstruct the piriform aperture and nasomaxillary buttress after maxillectomy, in the cases presented herein, a staged approach allowed for a reassessment of the defect after the resolution of most of the swelling, potentially leading to a more accurate reconstruction.…”

“…Others have reported the use of the excess fibula as a bone graft in combination with a vascularized fibula flap. The reported cases involve either mandibular reconstruction where the authors combine a fibular flap and the excess fibula as a graft to achieve greater vertical height or simultaneous mandibular and maxillary reconstruction, where the free fibula is used for the mandible and the excess is used as a bone graft for the maxilla 3,9–11 …”

“…Therefore, an optimal reconstruction would provide enough bone stock for restoration of midface height and projection of the maxilla and the nose, as well as dental rehabilitation. 3 In 1989, Hidalgo 4 described the use of a fibula-free flap for mandible reconstruction, which was subsequently utilized for maxillary reconstruction given the capability to predictably shape multiple osteotomized segments. 5 Although the fibula flap has become the workhorse for the reconstruction of large maxillary defects, the use of extra fibula bone (harvested, but not included in the flap) to augment nasal reconstruction at a second stage, to our knowledge, has not been described in the literature.…”

“…The premaxilla, along with the frontonasal spine, is required to support the entire nasal structure, including the septum. Therefore, an optimal reconstruction would provide enough bone stock for restoration of midface height and projection of the maxilla and the nose, as well as dental rehabilitation 3 …”