Simultaneous vascularized bony reconstruction of the maxilla and mandible using a single fibula: A case report

Abstract

Simultaneous maxillary and mandibular reconstruction is exceedingly rare. These are complicated cases, requiring consideration of multiple variables: defect components, donor site morbidity, recipient vessels, and so forth. We describe a unique case of secondary maxillary/mandibular reconstruction in a 59-year-old male. The original defect was created after removal of a buccal squamous cell carcinoma, involving the external cheek skin, buccal mucosa, right mandibular body, and right inferior maxilla; a free vertical rectus abdominis musculocutaneous flap was used for the initial reconstruction. At the time of presentation to our clinic, the patient was tube-feed-dependent, unable to speak, and distressed regarding his appearance. We revised his reconstruction, rebuilding his maxilla and hemimandible using two free fibula flaps from a single fibula. The fibulae were vascularized via vein grafts and an ALT flap was used for external cheek resurfacing. All flaps survived and there were no complications at seven months since his surgery (when this report was written). The patient had intelligible speech and maintained adequate nutrition with a soft diet. Simultaneous vascularized bony reconstruction of the maxilla and mandible using a single fibula flap may be performed safely and with good outcomes.

Simultaneous maxillary and mandibular reconstruction with a single Osteocutaneous fibula free flap: A description of three cases

“…Defects similar to those discussed herein historically have been addressed either with multiple free flaps placed simultaneously(Ozkan et al, 2004; Punpale et al, 2006) or a single free tissue transfer split into two separate bony segments(Coleman 3rd & Sultan, 1991; Laure et al, 2008; Mericli et al, 2017; Punpale et al, 2006; Sadove & Powell, 1993). Utilizing a single free flap has multiple advantages, including reducing donor site morbidity and operative time, while preserving other donor sites as potential reconstructive options should initial efforts fail (Laure et al, 2008; Nguyen et al, 2013; Punpale et al, 2006).…”

“…Nguyen et al detailed the use of a single fibula to reconstruct a simultaneous maxillary and mandibular defect by splitting the pedicle and using two different anastomoses(Laure et al, 2008), which is similar to the reconstruction detailed by Mericli et al, who reported the use of a single fibula to create two free flaps(Mericli et al, 2017). Important aspects to consider is the location of the defect detailed by Nguyen et al, which was contralateral and relatively posterior, requiring a shorter individual pedicle for each flap; and the need for an anterolateral thigh free tissue transfer to accompany the fibula free flaps in order to reconstruct the soft tissue and external skin defects in the report by Mericli et al In contrast, our case series expands upon the use of the single fibula free flap with a single pedicle to reconstruct a defect that spans to the maxillary midline and does not require a separate accompanying soft tissue free flap.…”

“…The use of a single free tissue transfer, either the scapula(Coleman 3rd & Sultan, 1991) or the fibula(Laure, Sury, Martin, Chabut, & Goga, 2008; Nguyen, Wu, Huang, Chang, & Cheng, 2013; Punpale, Rajendra Prasad, Shetty, Kadam, & Udupa, 2006), has been previously described in case reports to simultaneously reconstruct two separate bony defects. Additional reports discuss the simultaneous reconstruction of the maxilla and mandible, however, these detail the use of more than one free flap for reconstruction(Mericli, Friedstat, Chang, & Hanasono, 2017; Nisanci, Turegun, Er, & Sengezer, 2003; Ozkan, Ozgentas, & Dikici, 2004). The fibula is ideal for primary insertion of osseointegrated dental implants and can be contoured to differing defect shapes by creating multiple osteotomies secondary to its corticocancellous bone and rich periosteal blood supply(Kildal, Wei, & Chang, 2001).…”

Simultaneous mandible and zygomatic arch reconstruction with a single free fibula flap

“…mandible defects with good outcomes (Krane et al, 2021;Laure et al, 2008;Mericli et al, 2017). On the other hand, new technologies and preoperative virtual planning provide help to surgeons with the number and placement of the osteotomies, optimizing the possibilities for complex bone reconstruction with a single flap (Kääriäinen et al, 2016;Powcharoen et al, 2019).…”