LETTER TO THE EDITOR
MICROSURGERY 00:1–3 (2014)
CHEST TUBE TEMPLATE FOR FREE FIBULAR FLAP OSTEOTOMIES IN MANDIBULAR RECONSTRUCTION Dear Editor,
Free
osteocutaneous fibular flap has become the workhorse bone flap for mandibular reconstruction. However, the fibular osteotomy remains a challenge because it is responsible for the aesthetic and functional outcomes. In most circumstances, the number, location, and angle of the osteotomies were performed in a free-hand fashion through a try-and-error process to achieve the optimal shape. It was a struggled and time-consuming course if the operator sought the most-optimal result. We described our method by using the chest tube as a template and as a cutting guide to facilitate the fibular flap osteotomies in mandibular reconstruction. For the mandibular defects, we used the 32-french chest tube as a substitute of the fibular bone. The already printed mark and radiopaque stripe on the chest tube were used to define the lateral and posterior surfaces, respectively. The optimal number, location, and angle of the osteotomies were determined, marked, and created directly on the chest tube, taking care to leave a small bridge of tube at the apex of the wedge osteotomies for continuity. These osteotomies can be fine tuning with a Mayo scissor and temporarily assembled with silk sutures to recreate the curve (Figs. 1A and 1B). Once the optimal shape achieved, the silk sutures were removed allowing the chest tube return to its linear form (Fig. 1C). The
*Correspondence to: Yao-Chou Lee, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, 138 Sheng-Li Rd., Tainan 70403, Taiwan. E-mail: [email protected] Received 1 May 2014; Revision accepted 29 May 2014; Accepted 13 June 2014 Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22288 Ó 2014 Wiley Periodicals, Inc.
fashioned chest tube was re-sterilized with Hibitanealcohol, brought to donor site, and used to guide the osteotomies on the fibular bone (Fig. 1D). The osteomized fibular segments were fixed with each other by titanium miniplates before the pedicle division (Fig. 1E). After the preparation of recipient vessels, the fibular flap was transferred to reconstruct the mandibular defects (Fig. 1F). From November 2013 to April 2014, we used this technique to reconstruct six segmental mandibular defects after cancer ablation. Two patients received 1-segment fibular flap reconstruction, two patients received 2segment fibular flap reconstruction, and two patients received 3-segment fibular flap reconstruction. All the flaps survived and optimal bone-to-bone contacts were achieved. Studies regarding the devices for fibular osteotomies in mandibular reconstruction have been reported but most of them did not been widely applied in clinical practice. Kane and Olsen1 used the Aquaplast rolled, folded, and fashioned intraoperatively to simulate the threedimensional defects. However, its use needed 30–45 minutes chemical sterilization and near-boiling water (> 150 F) submersion. Strackee et al.2 developed a modeling and osteotomy jig system to improve the accuracy of mandibular reconstruction with the fibular flap. This device did not gain its popularity may be due to its complexity and not user-friendly. Fernandes3 introduced the use of scrub sponge to aid in the fibular osteotomies. However, the sponge is compressible that might make the estimation of the closing wedge angle inaccurate. Yap et al.4 used the tongue depressor as a template to guide the osteotomies. However, the two-dimensional structure of the tongue depressor limited the capture of closing wedge angle in more than one axis. Yadav et al.5 used the “K” wire template to simulate the mandibular
2
Letter to the Editor
Figure 1. (A, B) Chest tube in the form of neomandible as a template. (C, D) Chest tube in the linear form as a cutting guide. (E) Fibular osteotomies and shaping in accordance with the chest tube cutting guide were performed before the division of peroneal vessels. (F) Intraoperative photo showed the 3-segment fibular bone flap was inset and good bone-to-bone contact was achieved. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
defect. But the K-wire cannot be transformed back to a linear form to guide the fibular osteotomies. Computerassisted design/computer-assisted manufacturing (CAD/ CAM) cutting guide is a popular issue discussed within recent years. It was proved to improve the aesthetic and functional outcome, as well as reduce the ischemia time in flap transfer.6 However, high-tech demand and cost may limit the popularity of CAD/CAM use in flap transMicrosurgery DOI 10.1002/micr
fer. Xu et al.7 developed a novel fibula osteotomy guide for mandibular reconstruction according to the analysis of images of the jaw. However, it is used for the reconstruction of the anterior mandibular defects only. Adachi et al.8 used the bent template as a guide. Again, it cannot be used as a cutting guide to direct the angle of the closing wedge osteotomies. Wang et al.9 developed a mechanic device for fibular osteotomies in mandibular
Letter to the Editor
reconstruction. However, the fibular segment cannot be created shorter than 3.7 cm. In addition, its application needs the use of prebent reconstruction plate and an extra space for the placement of multiple devices. Our method by using the chest tube as a template and as a cutting guide for the fibular flap osteotomies is an inexpensive and easy-manipulated technique, even in inexperienced hand, to facilitate the contouring of neomandible. This three-dimensional plastic material is readily available in the operation room and allows for intraoperative effortless fine-tuning in more than one axis to recreate the parabolic shape of the mandible. It is also able to transform back to the linear form to demonstrate the angles of the closing wedge osteotomies. Using the chest tube as a cutting guide, shaping of the fibualr flap can be accomplished in a high degree of accuracy. YOU-CHENG LIN, M.D. AND YAO-CHOU LEE, M.D.* Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
3
REFERENCES 1. Kane WJ, Olsen KD. Enhanced bone graft contouring for mandibular reconstruction using intraoperatively fashioned templates. Ann Plast Surg 1996;37:30–33. 2. Strackee SD, Kroon FH, Spierings PT, Jaspers JE. Development of a modeling and osteotomy jig system for reconstruction of the mandible with a free vascularied fibula flap. Plast Reconstr Surg 2004;114: 1851–1858. 3. Fernandes R. An easy method for predictable osteotomies in the vascularized fibula flap for mandibular reconstruction. J Oral Maxillofac Surg 2007;65:1874–1875. 4. Yap LH, Constantinides J, Butler CE. Tongue depressor template for free fibular flap osteotomies in mandibular reconstruction. Plast Reconstr Surg 2008;122:209e–210e. 5. Yadav PS, Gazwan QA, Shankhdhar VK, Nambi GI. A simple and cost effectie template for central segment reconstruction of mandible with free fibula flap. J Maxillofac Oral Surg 2010;9:256–260. 6. Antony AK, Chen WF, Kolokythas A, Weimer KA, Cohen MN. Use of virtual surgery and stereolithography-guided osteotomy for mandibular reconstruction with the free fibula. Plast Reconstr Surg 2011; 128:1080–1084. 7. Xu LQ, Zhang CP, Poh EH, Yin XL, Shen SK. A novel fibula osteotomy guide for mandibular reconstruction. Plast Reconstr Surg 2012; 129:861e–863e. 8. Adachi M, Hyodo I, Hasegwa Y. Mandibular reconstruction with fibula flap using a simple and cost-effective template. J Maxillofac Oral Surg 2013;12:240–242. 9. Wang TH, Ma H, Tseng CS, Chou YH, Wu SH, Shin YC, Huang CP. A new device for fibular osteotomy in mandibular reconstruction. Microsurgery 2014;34:249–252.
Microsurgery DOI 10.1002/micr
MICROSURGERY 00:1–3 (2014)
CHEST TUBE TEMPLATE FOR FREE FIBULAR FLAP OSTEOTOMIES IN MANDIBULAR RECONSTRUCTION Dear Editor,
Free
osteocutaneous fibular flap has become the workhorse bone flap for mandibular reconstruction. However, the fibular osteotomy remains a challenge because it is responsible for the aesthetic and functional outcomes. In most circumstances, the number, location, and angle of the osteotomies were performed in a free-hand fashion through a try-and-error process to achieve the optimal shape. It was a struggled and time-consuming course if the operator sought the most-optimal result. We described our method by using the chest tube as a template and as a cutting guide to facilitate the fibular flap osteotomies in mandibular reconstruction. For the mandibular defects, we used the 32-french chest tube as a substitute of the fibular bone. The already printed mark and radiopaque stripe on the chest tube were used to define the lateral and posterior surfaces, respectively. The optimal number, location, and angle of the osteotomies were determined, marked, and created directly on the chest tube, taking care to leave a small bridge of tube at the apex of the wedge osteotomies for continuity. These osteotomies can be fine tuning with a Mayo scissor and temporarily assembled with silk sutures to recreate the curve (Figs. 1A and 1B). Once the optimal shape achieved, the silk sutures were removed allowing the chest tube return to its linear form (Fig. 1C). The
*Correspondence to: Yao-Chou Lee, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, 138 Sheng-Li Rd., Tainan 70403, Taiwan. E-mail: [email protected] Received 1 May 2014; Revision accepted 29 May 2014; Accepted 13 June 2014 Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22288 Ó 2014 Wiley Periodicals, Inc.
fashioned chest tube was re-sterilized with Hibitanealcohol, brought to donor site, and used to guide the osteotomies on the fibular bone (Fig. 1D). The osteomized fibular segments were fixed with each other by titanium miniplates before the pedicle division (Fig. 1E). After the preparation of recipient vessels, the fibular flap was transferred to reconstruct the mandibular defects (Fig. 1F). From November 2013 to April 2014, we used this technique to reconstruct six segmental mandibular defects after cancer ablation. Two patients received 1-segment fibular flap reconstruction, two patients received 2segment fibular flap reconstruction, and two patients received 3-segment fibular flap reconstruction. All the flaps survived and optimal bone-to-bone contacts were achieved. Studies regarding the devices for fibular osteotomies in mandibular reconstruction have been reported but most of them did not been widely applied in clinical practice. Kane and Olsen1 used the Aquaplast rolled, folded, and fashioned intraoperatively to simulate the threedimensional defects. However, its use needed 30–45 minutes chemical sterilization and near-boiling water (> 150 F) submersion. Strackee et al.2 developed a modeling and osteotomy jig system to improve the accuracy of mandibular reconstruction with the fibular flap. This device did not gain its popularity may be due to its complexity and not user-friendly. Fernandes3 introduced the use of scrub sponge to aid in the fibular osteotomies. However, the sponge is compressible that might make the estimation of the closing wedge angle inaccurate. Yap et al.4 used the tongue depressor as a template to guide the osteotomies. However, the two-dimensional structure of the tongue depressor limited the capture of closing wedge angle in more than one axis. Yadav et al.5 used the “K” wire template to simulate the mandibular
2
Letter to the Editor
Figure 1. (A, B) Chest tube in the form of neomandible as a template. (C, D) Chest tube in the linear form as a cutting guide. (E) Fibular osteotomies and shaping in accordance with the chest tube cutting guide were performed before the division of peroneal vessels. (F) Intraoperative photo showed the 3-segment fibular bone flap was inset and good bone-to-bone contact was achieved. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
defect. But the K-wire cannot be transformed back to a linear form to guide the fibular osteotomies. Computerassisted design/computer-assisted manufacturing (CAD/ CAM) cutting guide is a popular issue discussed within recent years. It was proved to improve the aesthetic and functional outcome, as well as reduce the ischemia time in flap transfer.6 However, high-tech demand and cost may limit the popularity of CAD/CAM use in flap transMicrosurgery DOI 10.1002/micr
fer. Xu et al.7 developed a novel fibula osteotomy guide for mandibular reconstruction according to the analysis of images of the jaw. However, it is used for the reconstruction of the anterior mandibular defects only. Adachi et al.8 used the bent template as a guide. Again, it cannot be used as a cutting guide to direct the angle of the closing wedge osteotomies. Wang et al.9 developed a mechanic device for fibular osteotomies in mandibular
Letter to the Editor
reconstruction. However, the fibular segment cannot be created shorter than 3.7 cm. In addition, its application needs the use of prebent reconstruction plate and an extra space for the placement of multiple devices. Our method by using the chest tube as a template and as a cutting guide for the fibular flap osteotomies is an inexpensive and easy-manipulated technique, even in inexperienced hand, to facilitate the contouring of neomandible. This three-dimensional plastic material is readily available in the operation room and allows for intraoperative effortless fine-tuning in more than one axis to recreate the parabolic shape of the mandible. It is also able to transform back to the linear form to demonstrate the angles of the closing wedge osteotomies. Using the chest tube as a cutting guide, shaping of the fibualr flap can be accomplished in a high degree of accuracy. YOU-CHENG LIN, M.D. AND YAO-CHOU LEE, M.D.* Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
3
REFERENCES 1. Kane WJ, Olsen KD. Enhanced bone graft contouring for mandibular reconstruction using intraoperatively fashioned templates. Ann Plast Surg 1996;37:30–33. 2. Strackee SD, Kroon FH, Spierings PT, Jaspers JE. Development of a modeling and osteotomy jig system for reconstruction of the mandible with a free vascularied fibula flap. Plast Reconstr Surg 2004;114: 1851–1858. 3. Fernandes R. An easy method for predictable osteotomies in the vascularized fibula flap for mandibular reconstruction. J Oral Maxillofac Surg 2007;65:1874–1875. 4. Yap LH, Constantinides J, Butler CE. Tongue depressor template for free fibular flap osteotomies in mandibular reconstruction. Plast Reconstr Surg 2008;122:209e–210e. 5. Yadav PS, Gazwan QA, Shankhdhar VK, Nambi GI. A simple and cost effectie template for central segment reconstruction of mandible with free fibula flap. J Maxillofac Oral Surg 2010;9:256–260. 6. Antony AK, Chen WF, Kolokythas A, Weimer KA, Cohen MN. Use of virtual surgery and stereolithography-guided osteotomy for mandibular reconstruction with the free fibula. Plast Reconstr Surg 2011; 128:1080–1084. 7. Xu LQ, Zhang CP, Poh EH, Yin XL, Shen SK. A novel fibula osteotomy guide for mandibular reconstruction. Plast Reconstr Surg 2012; 129:861e–863e. 8. Adachi M, Hyodo I, Hasegwa Y. Mandibular reconstruction with fibula flap using a simple and cost-effective template. J Maxillofac Oral Surg 2013;12:240–242. 9. Wang TH, Ma H, Tseng CS, Chou YH, Wu SH, Shin YC, Huang CP. A new device for fibular osteotomy in mandibular reconstruction. Microsurgery 2014;34:249–252.
Microsurgery DOI 10.1002/micr
