0007~ 1216 900043~ (WliSIO
firms/l Jvurnolof Plasfic Surgery (1990). 43,403409 ,? l99Q The Trusteesof British Assoaation of Plastic Surgeon?
Mandibular
reconstruction
A.F.S.FLEMMING, M. LAWLOR
M. D. BROUGH, and I. M. LAWS
Departments of Plastic and Reconstructive Hospital and Ro yal Free Hospital, London
using vascularised fibula
N. D. EVANS, H. R. GRANT, M. HARRIS, Surgery
(ItI
and Oral and Maxillofacial
Surgery,
D. R. JAMES,
University
College
Summary-The osteocutaneous fibula flap has been used to reconstruct large segments of mandible in cases following ablation for cancer or radionecrosis. The bone can be cut to the appropriate shape and the fasciocutaneous flap may be used simultaneously to provide oral cavity lining or skin cover. The technique is described and its successful use in seven patients is reported with details of the complications encountered.
The fibula flap was first described by Taylor et al. (1975). They used a posterior approach to the flap and the lateral approach was described later by Gilbert (1979). The osteocutaneous fibula flap was subsequently described by Chen and Yan (1983). The anatomy has been clarified by Wei et al. (1986) and Carr et al. (1988). We have found many advantages of this flap over others when used for mandibular reconstruction. There is easy access to the donor site, allowing simultaneous elevation of the flap and resection in the head and neck region. A strong segment of bone up to 22 cm in length can be harvested and contoured. The flap can be raised with a relatively hairless, thin paddle of skin on a mobile septum and this can be used either inside or outside the oral cavity. If several perforating vessels are identified in the septum the skin paddle can be split and used on both surfaces of the bone. The principal disadvantage is the variable blood supply to the skin paddle. The donor site morbidity is low (Goodacre et al., 1990). Surgical technique Two teams can work simultaneously, one on the leg and one in the head and neck region with the patient lying supine. The fibula flap is raised under tourniquet using the lateral approach. The skin paddle to be used is marked over the posterolateral aspect of the fibula centred near its midpoint. The anterior margin is reflected to expose the posterior intermuscular septum (Fig. 1). If vessels are not identified in this, branches derived from the peroneal artery and perforating soleus must be 403
included when raising the posterior part of the flap. The fibula is exposed above and below and divided with a Gigli saw. Dissection is continued around the bone, retaining a cuff of muscle to protect the periosteal blood supply to the bone. The peroneal artery and venae comitantes are identified and preserved (Fig. 2). As the vascular pedicle of the flap is short. a vein graft is used routinely to link the flap to the contralateral vessels in the neck. This avoids kinking of the vessels as the vascular pedicle usually lies parallel with the bone and the contralateral neck vessel will not normally have been compromised by previous surgery or radiotherapy. A length of long saphenous vein is harvested from the contralateral thigh. The vein graft is divided at the sapheno-femoral bulb above the junction of the lateral and medial femoral veins, one of which is also harvested (Fig. 3). This allows both flap veins to be anastomosed end-to-end to the vein graft later. The vein graft is inserted into the neck, anastomosing it to a branch of the contralatera1 external carotid or end-to-side onto the external carotid itself. The venous end is anastomosed endto-side onto the contralateral internal jugular vein. A temporary arteriovenous fistula or vein graft loop is created (Taylor, 1983; Meyer and Largiader, 1988) and good flow is established before transfer of the flap (Fig. 4). A malleable template is fashioned. initially using an orthopantogram of the patient’s mandible. This must be carefully trimmed and adjusted at operation to match the excised bone (Fig. 5). Discrepancies arising at this stage can lead to unnecessary problems with both fixation and contour. The
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 1 Figure l-Reflection of the skin paddle demonstrating Route of dissection around the fibula.
Fig. 2
two arteries and veins in the posterior intermuscular septum. Figure 2-
template is then transferred to the leg and multiple subtotal osteotomies are made in the fibula with a fine burr or oscillating saw. These sections are carefully extended to the inner periosteal surface which is left intact. A fine osteotome can be used for the actual separation. Sufficient cuts are estimated and made and the bone is bent to the appropriate shape. The central osteotomies are fixed with miniature bone plates (Champy er al., 1978) (Fig. 6). The fibula is irrigated with saline and the vessels carefully protected throughout this process. The flap is transferred to the mandibular defect and rigidly fixed in place using further miniature bone plates. This eliminates the need for intermaxillary fixation. In order to reduce the ischaemic transfer time these plates should be contoured and fitted to the recipient bone ends prior to transfer. The flap artery and one flap vein are then anastomosed to the vein graft loop after division of this at an appropriate level. The second flap vein is
anastomosed to the tributary vein if this is available.
of the long saphenous
Results Seven patients underwent reconstruction following resection of a major part of the mandible (Fig. 7). Details of the age, sex, pathology and previous treatment of the patients are illustrated in Table 1. Case 6 was the only patient in our series in which reconstruction was performed as part of the primary treatment. Details of the flaps raised in the seven patients and the fate of the skin paddles are shown in Table 2. The average length of fibula segment harvested was 19 cm with a range of 15-22 cm. The bone was subsequently shortened to provide the required length. In six flaps a skin paddle was used to provide either skin cover or lining or both and this acted as a monitor for the flap. The average length of this skin paddle was 12 cm with a range of 5-
MANDIBULAR
RECONSTRUCTION
USING VASCULARISED
405
FIBULA
Femoral vein
Anterior, femoral cutaneous vein
Fig. 3 Figure %The
upper end of the long saphenous
vein
Fig. 5 Figure %The
20 cm. The average width was 4.5 cm with a range of 3-7 cm. Figure 8 A-D show pre- and postoperative views of Case 2. The postoperative orthopantogram of Case 4 (Fig. 9) demonstrates the bone contour that can be achieved.
malleable
template.
Complications developed in two of the flaps (Cases 3 and 6). When the skin and fascia were divided transversely, to provide oral lining and skin cover in Case 3, the external skin paddle suffered venous congestion in spite of the presence of two vessels in the intermuscular septum. The veins from this flap had a large diameter and venous stasis
Fig. 4 Figure 4-The vein graft loop anastomosed on the right side and passing through the left neck wound, perfusing before transfer of the flap.
Fig. 6 Figure &The bone segments in the leg before transfer.
fixed with miniature
bone plates
406
BRITISH JOURNAL
Case 1
Case 3
Case
cuff of muscle which survived. This patient was the oldest in the series. The whole bone segment survived in all other cases. In all cases there was some minor identifiable weakness of the extensor hallucis longus but this was only noticed by one patient. There has been no evidence of any adverse effect on the ankle joint. The leg scars have not been a significant problem although in two cases the defect required a split skin graft for repair.
2
:. ::::: :::::. ;;::;. w Case 4
‘.-::_‘.-. ~_‘,‘,~_‘.‘.‘.‘.~, ‘~.‘_‘.‘.‘.‘.‘.‘.~_‘. ~.‘.~.~.~,~_‘.‘. ‘...‘_
Case
5
Case 6
Case 7 Fig. 7
Figure 7-The stippled the seven cases.
areas illustrate
the mandibular
defect in
may have contributed to thrombosis. The venous anastomoses were revised three times but the external skin paddle died although the inner skin paddle and the bone both survived. In Case 6 the whole skin paddle necrosed. This was the smallest skin paddle used and there was a prolonged ischaemic time for the flap. In this patient a small sequestrum of bone from one end of the fibula was lost but the remaining bone healed uneventfully as it was protected from exposure by the surrounding Table 1
OF PLASTIC SURGERY
Discussion Many different bones have been used either as free grafts or attached to a muscular pedicle to reconstruct the mandible in the past. The blood supply in the latter is contentious but in the last decade free vascularised bone transfers have gained popularity because of their reliable blood supply. This not only promotes rapid healing and bone union but also reduces the risk of infection, particularly when local tissue has been irradiated. The most commonly used free flap for intraoral reconstruction is the forearm flap (Yang et al., 1981; Soutar er al., 1983). It can provide up to a half of the thickness of a length of radius to reconstruct the mandible as well as a paddle of thin, relatively hairless skin to reconstruct the defect in the oral cavity lining. Several authors (Soutar et al., 1983; Timmons et al., 1986) have documented the problems that may be encountered using this flap. These include fracture of the radius with limited pronation and supination, loss of sensation on the dorsum of the hand and a significant cosmetic defect on the forearm. Jones and O’Brien (1985) recorded a case with acute ischaemia of the hand which required immediate reconstruction of the radial artery with vein grafts. Other vascularised bones used include rib, iliac crest and clavicle but these have proved less satisfactory than the radius. The two main advantages of the fibula flap are
Details of cases
case
Age
Sex
Pathology
Preuious surgery
Previous chemotherapy
Radionecrosis of mandible
1 2 3 4 5 6 7
23 19 56 38 60 70 43
M F F M M F F
Osteosarcoma Ameloblastoma Squamous cell ca. Ameloblastoma Squamous cell ca. Squamous cell ca. Osteosarcoma
Yes Yes Yes Yes Yes No Yes
Yes No Yes No Yes No No
Yes No Yes No Yes No Yes
MANDIBULAR
RECONSTRUCTION
USING VASCULARISED
FIBULA
Fig. 8
Figure S-Cost
2. (A.B) Preoperative
views. (C,D) Postoperative
appearance.
Figure 9-Case
4. Postoperative
orthopantogrdm.
408
BRITISH JOURNAL
Table 2
Details
of flaps used
in the seven cases
Case
Length offibula harvested (cm)
Size of skin paddle (cm)
Fate of skin paddle
1
20
None
2
20
18x5
Paddle divided both portions survived
3
18
20 x 7
Paddle divided and external portion lost
4
22
15x3
Survived
5
20
6x5
Survived
6
15
5x3
Lost
I
18
8x4
Survived
and
the great length of vascularised bone available and the low donor site morbidity. At least 22 cm of strong bone can be used torec&struct the mandible, 8 cm more than that available from the radius. The rich periosteal blood supply to the bone, with its protective cuff of muscle, allows it to be divided safely with formal osteotomies, and after contouring it can be rigidly fixed with miniature bone plates (Champy et al., 1978). The advantages of this method of fixation previously described by Frame et al. (1987) are simplicity and rigidity without intermaxillary fixation. The skin paddle may be used either as a visible monitor for the underlying bone graft or to provide lining or cover in the reconstruction. The ladder pattern type D vascular supply to the fasciocutaneous portion allows the flap to be split into two halves although caution must be exercised in dividing the fascia itself. Preoperative mapping of the vascular supply to the skin paddle can be performed using a Doppler probe (Yoshimura et al., 1984). Barclay et al. (1982) suggest that two to five perforators run up through the septum to join an axial vessel that forms the main supply to the fasciocutaneous flap first described by PontCn (198 1). A detailed description of the anatomy of the flap by Wei et al. (1986) confirms Barclay’s work but there have been reports of absence of perforating vessels in the septum. For this reason it is safer to raise the anterior part of the cutaneous portion first so that perforating vessels may be seen in the septum when this is reached. If these are not present the musculocutaneous branches perforating the soleus are included to sustain the skin paddle. The recent reports of Carr et al. (1988) suggest that the longer the flap is made the greater the likelihood of survival. Septal perforators most commonly
OF PLASTIC SURGERY
occur in the middle third of the leg, and these vessels give a better supply to the skin posterior to the septum. The long vein graft loop ensures the flap can be anastomosed to large dependable vessels away from the site of previous surgery or radiotherapy. Establishment of the vein graft as an arteriovenous fistula prior to flap transfer reduces the ischaemic transfer time. Unlike the radius, almost the whole of the fibula may be taken without significant detriment to the patient. A recent study by Goodacre et al. (1990), which includes our patients, showed that only one patient in ten was aware of functional loss following resection of the fibula and this was the inability to plantarflex the hallux. Acknowledgements We wish to thank Mr Derek Ellis and staff of the Photographic and Illustration centres of the Middlesex and University College Hospital Units of University College London for their help with the photographs and drawings.
References Barclay, T. L., Cardoso, E., Sharpe, D. T. and Crockett, D. J. (1982). Repair of lower leg injuries with fascia-cutaneous flaps. British JournalofPIastic Surgery, 35, 121. Carr, A. J., MacDonald, D. A. and Waterhouse, N. (1988). The blood supply of the osteocutaneous free fibular graft. Journal of Bone and Joint Surgery, 70, 3 19. Champy, M., Lodde, J. P., Schmitt, R., Jaeger, J. H. and Muster, D. (1978). Mandibular osteosynthesis by miniature screwed plates via a buccal approach. Journal of Maxillo-Facial Surgery, 6, 14. Chen, Z. W. and Yan, W. (1983). The study and clinical applications of the osteocutaneous flap of fibula. Microsurgery, 4, 11. Frame, J. D., Bradley, N., James, D. R., Stearns, M. P. and Brough, M. D. (1987). Reconstruction of the middle third of the mandible. British JournalofPIastic Surgery, 40,274. Gilbert, A. (1979). Vascularised transfer of the fibular shaft. International Journal of Microsurgery, 1, 100. Goodacre, T. E. E., Walker, C. J., Jawad, A. S., Jackson, A. M. and Brough, M. D. (1990). Donor site morbidity following osteocutaneous free fibular transfer. British Journal of Plastic Surgery, 43,410. Jones, B. M. and O’Brien, C. J. (1985). Acute ischaemia of the hand resulting from elevation of the radial forearm flap. British Journal of Plastic Surgery, 38, 396. Meyer, V. and Largiader, J. (1988). The vein loop technique for connection of free tissue transfers. In Brunelli, G. (Ed.) Textbook of Microsurgery. Milan: Masson et Cie. Pootin, B. (1981). The fasciocutaneous flap: its use in soft tissue defects of the lower leg. British Journal of Plastic Surgery, 34, 215. Soutar, D. S., Scheker, L. R., Tanner, N. S. B. and McGregor, I. A. (1983). The radial forearm flap: a versatile method for F-oral reconstruction. British JournalofPlastic Surgery, 36,
MANDIBULAR
RECONSTRUCTION
USING VASCULARISED
Taylor, G. I. (1983). The current status of free vascularised bone grafts. Clinics in Plasiic Surgery, 10, 185. Taylor, G. I., Miller, G. D. H. and Ham, F. J. (1975). The free vascularised bone graft. Plastic and Reconsrruciive Surgery. 55,533. Timmons, M. J., Missotten, F. E. M., Poole, M. D. and Davies, D. M. (1986). Complications of radial forearm flap donor sites. Briiish Journal ojPlasGc Surgery, 39, 176. Wei, F.-C., Chen, H.-C., Chuang, C.-C. and NoordhoB, M. S. ( 1986). Fibular osteoseptocutaneous flap: anatomic study and clinical application. Plastic and Reconstructive Surgery, 78, 191. Yang, G., Chen, B., Cao, Y., Liu, X., Li, J., Jiang, S. and He, S. (1981). Forearm free skin flap transplantation. National Medical Journal of China, 61, 139. Yoshimura, M., Imura, S., Shimamura, K., Yamauchi, S. and Nomura, S. (1984). Peroneal flap for reconstruction in the extremity: preliminary report. Plastic and Reconstructice Surger?. 74,402.
The Authors A. F. S. Flemming, MB, FRCS, Senior Registrar in Plastic Surgery, Whiston Hospital, Liverpool; formerly Registrar in
FIBULA
409
Plastic Surgery, University College Hospital, London. M. D. Brough, MA, MB, FRCS, Consultant Plastic Surgeon, University College Hospital and Royal Free Hospital. London. N. D. Evans, MB, FRCS. FDS RCS, Consultant Oral and Maxillofacial Surgeon, Royal Free Hospital. H. R. Grant, MB, FRCS, Consultant ENT Surgeon. University College Hospital. M. Harris, MD, FDS RCS, FFD RCSI, Professor of Oral and Maxillofacial Surgery, Eastman Institute and University College Hospital. D. R. James, MB, FRCSEd, FDS RCS, Consultant Oral and Maxillofacial Surgeon, University College Hospital. M. Lawlor, MB, FDS RCS, FFD RCSI, Consultant Oral and Maxillofacial Surgeon, St Bartholomew’s Hospital, London. I. M. Laws, TD, MB, FDS RCS, Consultant Oral and Maxillofacial Surgeon, Royal Free Hospital. Requests for reprints to: Mr M. D. Brough. Plastic and Reconstructive Surgery Department, University College Hospital. Cower Street, London, WClE 6AU. Paper received 5 July 1989. Accepted 4 January 1990 after revision
firms/l Jvurnolof Plasfic Surgery (1990). 43,403409 ,? l99Q The Trusteesof British Assoaation of Plastic Surgeon?
Mandibular
reconstruction
A.F.S.FLEMMING, M. LAWLOR
M. D. BROUGH, and I. M. LAWS
Departments of Plastic and Reconstructive Hospital and Ro yal Free Hospital, London
using vascularised fibula
N. D. EVANS, H. R. GRANT, M. HARRIS, Surgery
(ItI
and Oral and Maxillofacial
Surgery,
D. R. JAMES,
University
College
Summary-The osteocutaneous fibula flap has been used to reconstruct large segments of mandible in cases following ablation for cancer or radionecrosis. The bone can be cut to the appropriate shape and the fasciocutaneous flap may be used simultaneously to provide oral cavity lining or skin cover. The technique is described and its successful use in seven patients is reported with details of the complications encountered.
The fibula flap was first described by Taylor et al. (1975). They used a posterior approach to the flap and the lateral approach was described later by Gilbert (1979). The osteocutaneous fibula flap was subsequently described by Chen and Yan (1983). The anatomy has been clarified by Wei et al. (1986) and Carr et al. (1988). We have found many advantages of this flap over others when used for mandibular reconstruction. There is easy access to the donor site, allowing simultaneous elevation of the flap and resection in the head and neck region. A strong segment of bone up to 22 cm in length can be harvested and contoured. The flap can be raised with a relatively hairless, thin paddle of skin on a mobile septum and this can be used either inside or outside the oral cavity. If several perforating vessels are identified in the septum the skin paddle can be split and used on both surfaces of the bone. The principal disadvantage is the variable blood supply to the skin paddle. The donor site morbidity is low (Goodacre et al., 1990). Surgical technique Two teams can work simultaneously, one on the leg and one in the head and neck region with the patient lying supine. The fibula flap is raised under tourniquet using the lateral approach. The skin paddle to be used is marked over the posterolateral aspect of the fibula centred near its midpoint. The anterior margin is reflected to expose the posterior intermuscular septum (Fig. 1). If vessels are not identified in this, branches derived from the peroneal artery and perforating soleus must be 403
included when raising the posterior part of the flap. The fibula is exposed above and below and divided with a Gigli saw. Dissection is continued around the bone, retaining a cuff of muscle to protect the periosteal blood supply to the bone. The peroneal artery and venae comitantes are identified and preserved (Fig. 2). As the vascular pedicle of the flap is short. a vein graft is used routinely to link the flap to the contralateral vessels in the neck. This avoids kinking of the vessels as the vascular pedicle usually lies parallel with the bone and the contralateral neck vessel will not normally have been compromised by previous surgery or radiotherapy. A length of long saphenous vein is harvested from the contralateral thigh. The vein graft is divided at the sapheno-femoral bulb above the junction of the lateral and medial femoral veins, one of which is also harvested (Fig. 3). This allows both flap veins to be anastomosed end-to-end to the vein graft later. The vein graft is inserted into the neck, anastomosing it to a branch of the contralatera1 external carotid or end-to-side onto the external carotid itself. The venous end is anastomosed endto-side onto the contralateral internal jugular vein. A temporary arteriovenous fistula or vein graft loop is created (Taylor, 1983; Meyer and Largiader, 1988) and good flow is established before transfer of the flap (Fig. 4). A malleable template is fashioned. initially using an orthopantogram of the patient’s mandible. This must be carefully trimmed and adjusted at operation to match the excised bone (Fig. 5). Discrepancies arising at this stage can lead to unnecessary problems with both fixation and contour. The
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 1 Figure l-Reflection of the skin paddle demonstrating Route of dissection around the fibula.
Fig. 2
two arteries and veins in the posterior intermuscular septum. Figure 2-
template is then transferred to the leg and multiple subtotal osteotomies are made in the fibula with a fine burr or oscillating saw. These sections are carefully extended to the inner periosteal surface which is left intact. A fine osteotome can be used for the actual separation. Sufficient cuts are estimated and made and the bone is bent to the appropriate shape. The central osteotomies are fixed with miniature bone plates (Champy er al., 1978) (Fig. 6). The fibula is irrigated with saline and the vessels carefully protected throughout this process. The flap is transferred to the mandibular defect and rigidly fixed in place using further miniature bone plates. This eliminates the need for intermaxillary fixation. In order to reduce the ischaemic transfer time these plates should be contoured and fitted to the recipient bone ends prior to transfer. The flap artery and one flap vein are then anastomosed to the vein graft loop after division of this at an appropriate level. The second flap vein is
anastomosed to the tributary vein if this is available.
of the long saphenous
Results Seven patients underwent reconstruction following resection of a major part of the mandible (Fig. 7). Details of the age, sex, pathology and previous treatment of the patients are illustrated in Table 1. Case 6 was the only patient in our series in which reconstruction was performed as part of the primary treatment. Details of the flaps raised in the seven patients and the fate of the skin paddles are shown in Table 2. The average length of fibula segment harvested was 19 cm with a range of 15-22 cm. The bone was subsequently shortened to provide the required length. In six flaps a skin paddle was used to provide either skin cover or lining or both and this acted as a monitor for the flap. The average length of this skin paddle was 12 cm with a range of 5-
MANDIBULAR
RECONSTRUCTION
USING VASCULARISED
405
FIBULA
Femoral vein
Anterior, femoral cutaneous vein
Fig. 3 Figure %The
upper end of the long saphenous
vein
Fig. 5 Figure %The
20 cm. The average width was 4.5 cm with a range of 3-7 cm. Figure 8 A-D show pre- and postoperative views of Case 2. The postoperative orthopantogram of Case 4 (Fig. 9) demonstrates the bone contour that can be achieved.
malleable
template.
Complications developed in two of the flaps (Cases 3 and 6). When the skin and fascia were divided transversely, to provide oral lining and skin cover in Case 3, the external skin paddle suffered venous congestion in spite of the presence of two vessels in the intermuscular septum. The veins from this flap had a large diameter and venous stasis
Fig. 4 Figure 4-The vein graft loop anastomosed on the right side and passing through the left neck wound, perfusing before transfer of the flap.
Fig. 6 Figure &The bone segments in the leg before transfer.
fixed with miniature
bone plates
406
BRITISH JOURNAL
Case 1
Case 3
Case
cuff of muscle which survived. This patient was the oldest in the series. The whole bone segment survived in all other cases. In all cases there was some minor identifiable weakness of the extensor hallucis longus but this was only noticed by one patient. There has been no evidence of any adverse effect on the ankle joint. The leg scars have not been a significant problem although in two cases the defect required a split skin graft for repair.
2
:. ::::: :::::. ;;::;. w Case 4
‘.-::_‘.-. ~_‘,‘,~_‘.‘.‘.‘.~, ‘~.‘_‘.‘.‘.‘.‘.‘.~_‘. ~.‘.~.~.~,~_‘.‘. ‘...‘_
Case
5
Case 6
Case 7 Fig. 7
Figure 7-The stippled the seven cases.
areas illustrate
the mandibular
defect in
may have contributed to thrombosis. The venous anastomoses were revised three times but the external skin paddle died although the inner skin paddle and the bone both survived. In Case 6 the whole skin paddle necrosed. This was the smallest skin paddle used and there was a prolonged ischaemic time for the flap. In this patient a small sequestrum of bone from one end of the fibula was lost but the remaining bone healed uneventfully as it was protected from exposure by the surrounding Table 1
OF PLASTIC SURGERY
Discussion Many different bones have been used either as free grafts or attached to a muscular pedicle to reconstruct the mandible in the past. The blood supply in the latter is contentious but in the last decade free vascularised bone transfers have gained popularity because of their reliable blood supply. This not only promotes rapid healing and bone union but also reduces the risk of infection, particularly when local tissue has been irradiated. The most commonly used free flap for intraoral reconstruction is the forearm flap (Yang et al., 1981; Soutar er al., 1983). It can provide up to a half of the thickness of a length of radius to reconstruct the mandible as well as a paddle of thin, relatively hairless skin to reconstruct the defect in the oral cavity lining. Several authors (Soutar et al., 1983; Timmons et al., 1986) have documented the problems that may be encountered using this flap. These include fracture of the radius with limited pronation and supination, loss of sensation on the dorsum of the hand and a significant cosmetic defect on the forearm. Jones and O’Brien (1985) recorded a case with acute ischaemia of the hand which required immediate reconstruction of the radial artery with vein grafts. Other vascularised bones used include rib, iliac crest and clavicle but these have proved less satisfactory than the radius. The two main advantages of the fibula flap are
Details of cases
case
Age
Sex
Pathology
Preuious surgery
Previous chemotherapy
Radionecrosis of mandible
1 2 3 4 5 6 7
23 19 56 38 60 70 43
M F F M M F F
Osteosarcoma Ameloblastoma Squamous cell ca. Ameloblastoma Squamous cell ca. Squamous cell ca. Osteosarcoma
Yes Yes Yes Yes Yes No Yes
Yes No Yes No Yes No No
Yes No Yes No Yes No Yes
MANDIBULAR
RECONSTRUCTION
USING VASCULARISED
FIBULA
Fig. 8
Figure S-Cost
2. (A.B) Preoperative
views. (C,D) Postoperative
appearance.
Figure 9-Case
4. Postoperative
orthopantogrdm.
408
BRITISH JOURNAL
Table 2
Details
of flaps used
in the seven cases
Case
Length offibula harvested (cm)
Size of skin paddle (cm)
Fate of skin paddle
1
20
None
2
20
18x5
Paddle divided both portions survived
3
18
20 x 7
Paddle divided and external portion lost
4
22
15x3
Survived
5
20
6x5
Survived
6
15
5x3
Lost
I
18
8x4
Survived
and
the great length of vascularised bone available and the low donor site morbidity. At least 22 cm of strong bone can be used torec&struct the mandible, 8 cm more than that available from the radius. The rich periosteal blood supply to the bone, with its protective cuff of muscle, allows it to be divided safely with formal osteotomies, and after contouring it can be rigidly fixed with miniature bone plates (Champy et al., 1978). The advantages of this method of fixation previously described by Frame et al. (1987) are simplicity and rigidity without intermaxillary fixation. The skin paddle may be used either as a visible monitor for the underlying bone graft or to provide lining or cover in the reconstruction. The ladder pattern type D vascular supply to the fasciocutaneous portion allows the flap to be split into two halves although caution must be exercised in dividing the fascia itself. Preoperative mapping of the vascular supply to the skin paddle can be performed using a Doppler probe (Yoshimura et al., 1984). Barclay et al. (1982) suggest that two to five perforators run up through the septum to join an axial vessel that forms the main supply to the fasciocutaneous flap first described by PontCn (198 1). A detailed description of the anatomy of the flap by Wei et al. (1986) confirms Barclay’s work but there have been reports of absence of perforating vessels in the septum. For this reason it is safer to raise the anterior part of the cutaneous portion first so that perforating vessels may be seen in the septum when this is reached. If these are not present the musculocutaneous branches perforating the soleus are included to sustain the skin paddle. The recent reports of Carr et al. (1988) suggest that the longer the flap is made the greater the likelihood of survival. Septal perforators most commonly
OF PLASTIC SURGERY
occur in the middle third of the leg, and these vessels give a better supply to the skin posterior to the septum. The long vein graft loop ensures the flap can be anastomosed to large dependable vessels away from the site of previous surgery or radiotherapy. Establishment of the vein graft as an arteriovenous fistula prior to flap transfer reduces the ischaemic transfer time. Unlike the radius, almost the whole of the fibula may be taken without significant detriment to the patient. A recent study by Goodacre et al. (1990), which includes our patients, showed that only one patient in ten was aware of functional loss following resection of the fibula and this was the inability to plantarflex the hallux. Acknowledgements We wish to thank Mr Derek Ellis and staff of the Photographic and Illustration centres of the Middlesex and University College Hospital Units of University College London for their help with the photographs and drawings.
References Barclay, T. L., Cardoso, E., Sharpe, D. T. and Crockett, D. J. (1982). Repair of lower leg injuries with fascia-cutaneous flaps. British JournalofPIastic Surgery, 35, 121. Carr, A. J., MacDonald, D. A. and Waterhouse, N. (1988). The blood supply of the osteocutaneous free fibular graft. Journal of Bone and Joint Surgery, 70, 3 19. Champy, M., Lodde, J. P., Schmitt, R., Jaeger, J. H. and Muster, D. (1978). Mandibular osteosynthesis by miniature screwed plates via a buccal approach. Journal of Maxillo-Facial Surgery, 6, 14. Chen, Z. W. and Yan, W. (1983). The study and clinical applications of the osteocutaneous flap of fibula. Microsurgery, 4, 11. Frame, J. D., Bradley, N., James, D. R., Stearns, M. P. and Brough, M. D. (1987). Reconstruction of the middle third of the mandible. British JournalofPIastic Surgery, 40,274. Gilbert, A. (1979). Vascularised transfer of the fibular shaft. International Journal of Microsurgery, 1, 100. Goodacre, T. E. E., Walker, C. J., Jawad, A. S., Jackson, A. M. and Brough, M. D. (1990). Donor site morbidity following osteocutaneous free fibular transfer. British Journal of Plastic Surgery, 43,410. Jones, B. M. and O’Brien, C. J. (1985). Acute ischaemia of the hand resulting from elevation of the radial forearm flap. British Journal of Plastic Surgery, 38, 396. Meyer, V. and Largiader, J. (1988). The vein loop technique for connection of free tissue transfers. In Brunelli, G. (Ed.) Textbook of Microsurgery. Milan: Masson et Cie. Pootin, B. (1981). The fasciocutaneous flap: its use in soft tissue defects of the lower leg. British Journal of Plastic Surgery, 34, 215. Soutar, D. S., Scheker, L. R., Tanner, N. S. B. and McGregor, I. A. (1983). The radial forearm flap: a versatile method for F-oral reconstruction. British JournalofPlastic Surgery, 36,
MANDIBULAR
RECONSTRUCTION
USING VASCULARISED
Taylor, G. I. (1983). The current status of free vascularised bone grafts. Clinics in Plasiic Surgery, 10, 185. Taylor, G. I., Miller, G. D. H. and Ham, F. J. (1975). The free vascularised bone graft. Plastic and Reconsrruciive Surgery. 55,533. Timmons, M. J., Missotten, F. E. M., Poole, M. D. and Davies, D. M. (1986). Complications of radial forearm flap donor sites. Briiish Journal ojPlasGc Surgery, 39, 176. Wei, F.-C., Chen, H.-C., Chuang, C.-C. and NoordhoB, M. S. ( 1986). Fibular osteoseptocutaneous flap: anatomic study and clinical application. Plastic and Reconstructive Surgery, 78, 191. Yang, G., Chen, B., Cao, Y., Liu, X., Li, J., Jiang, S. and He, S. (1981). Forearm free skin flap transplantation. National Medical Journal of China, 61, 139. Yoshimura, M., Imura, S., Shimamura, K., Yamauchi, S. and Nomura, S. (1984). Peroneal flap for reconstruction in the extremity: preliminary report. Plastic and Reconstructice Surger?. 74,402.
The Authors A. F. S. Flemming, MB, FRCS, Senior Registrar in Plastic Surgery, Whiston Hospital, Liverpool; formerly Registrar in
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Plastic Surgery, University College Hospital, London. M. D. Brough, MA, MB, FRCS, Consultant Plastic Surgeon, University College Hospital and Royal Free Hospital. London. N. D. Evans, MB, FRCS. FDS RCS, Consultant Oral and Maxillofacial Surgeon, Royal Free Hospital. H. R. Grant, MB, FRCS, Consultant ENT Surgeon. University College Hospital. M. Harris, MD, FDS RCS, FFD RCSI, Professor of Oral and Maxillofacial Surgery, Eastman Institute and University College Hospital. D. R. James, MB, FRCSEd, FDS RCS, Consultant Oral and Maxillofacial Surgeon, University College Hospital. M. Lawlor, MB, FDS RCS, FFD RCSI, Consultant Oral and Maxillofacial Surgeon, St Bartholomew’s Hospital, London. I. M. Laws, TD, MB, FDS RCS, Consultant Oral and Maxillofacial Surgeon, Royal Free Hospital. Requests for reprints to: Mr M. D. Brough. Plastic and Reconstructive Surgery Department, University College Hospital. Cower Street, London, WClE 6AU. Paper received 5 July 1989. Accepted 4 January 1990 after revision
