Operative Technique in Plastic Surgery – Kevin C.Chung

craniofacial skeleton and maxillary defect, allowing the
surgical team to verify that size and shape of the flap
conform to the operative plan.
■ Anticipated Secondary Surgeries
■ Phase 2+ goals: contour bone and/or soft tissues, and address position of
adjacent subunits when applicable (eyelids, nose, etc.) using reconstructive
surgery armamentarium.
■ Neomaxilla may require distraction or stabilization.
■ Flap soft tissues may require debulking procedures.
■ Cheek soft tissues may require augmentation via fat grafting or additional
free tissue transfer.
■ Maxillary defects involving the dentoalveolus and the inferior orbital rim
(Class II and IV) may require additional soft tissue augmentation in the
periorbital and malar regions.
PEARLS AND PITFALLS
Indications
■ Anticipate the need for multiple stages and incorporate
secondary surgeries into reconstructive plan
■ The full extent of the defect and precise composite tissue
requirements must be defined before initiating flap elevation
■ Early intervention is essential in high-energy traumatic defects
Flap design
■ The ample bone can be osteotomized and reshaped to
reconstruct a variety of composite midfacial defects
■ Focus on functional structural support, not exact replication of
absent bone
■ Muscle can be included to obliterate dead space
■ Generous skin paddle can be elevated based on septal
perforators
Approach
■ Employ efficient two-team approach
■ Protect the common peroneal nerve proximally
■ Exclude proximal and distal fibular segments to prevent knee
and ankle instability

Computerized
surgical
planning
■ Facilitates precise design of the bone segment
■ Predicts corrective osteotomies at recipient site for snap fit
■ Streamlines bone inset and fixation
■ Reduces ischemia time
Watertight soft
tissue closure
■ Avoid communication with oral cavity
Postoperative
management
■ Avoid restrictive dressings in head and neck
■ Administer DVT prophylaxis if not otherwise contraindicated
■ Close monitoring of hemodynamic stability and flap viability
■ Open communication with postanesthesia and/or ICU team to
avoid vasopressor therapy or compression whenever possible
POSTOPERATIVE CARE
■ Patients often remain intubated up to 48 hours after surgery to prevent early
respiratory complications due to airway secretions or edema.
■ This expedites emergent returns to the operating room.
■ Strict monitoring of hemodynamic status, urine output, and fluid balance is
mandatory.
■ Vasopressors are avoided unless other interventions such as fluid boluses, etc.
have failed to stabilize the blood pressure.
■ Deep venous prophylaxis is useful in most patients. However, concomitant
injuries or intracranial surgery may be a relative contraindication and should be
coordinated with anesthesia and the other surgical teams.
■ Dressings and other restrictive materials are preferably avoided in the head
and neck.
■ Assessment of the flap’s skin island must be aggressive to increase the
likelihood of salvage in the case of vascular compromise, particularly in the
first 24 to 48 hours.
■ Clinical monitoring of color, temperature, and capillary refill.
■ Doppler pencil probe monitoring at the site of anastomosis or available
exposed surfaces.
■ First 24 hours: every 30 to 60 minutes.
■ Postoperative day 2 to 3: every 60 minutes.
■ Subsequent days until discharge: every 6 hours.
■ Donor site:
■ The donor leg is placed in a boot or posterior splint with the ankle at 90

degrees, a monitor for signs of vascular insufficiency or compartment
syndrome.
■ Suction drains are evaluated daily and removed once less than 30 mL of
serum is collected in 24 hours.
■ There will be no ambulation initially, and the leg will remain elevated until
the skin graft is fully healed.
■ Upon ambulation, partial weight bearing will gradually transition to full
weight bearing.
■ Bone union and position can be assessed with serial CT scans (FIG 6).
FIG 6 • Postoperative CT and photograph of the patient
in FIG 5. CT image shows that the operation has been
performed according to the virtual plan, resulting in
successful restoration of midface contour.
OUTCOMES
■ In Chang et al.’s series of 116 free fibula flaps, increased rates of partial flap
loss and total complications were recorded for ischemia times exceeding 5
hours (tourniquet plus microvascular clamp).6
■ Marre found a higher risk of vascular compromise after 1.5 to 2 hours of
ischemia time in a series of 182 deep inferior epigastric perforator flaps.7

■ Seruya et al. compared CSP-assisted (10) vs conventional (58) free fibula flap
craniofacial reconstruction.8
■ Short- and long-term outcomes were comparable.
■ Total ischemia time was significantly shorter in CSP group; total operative
time was shorter but not significant.
■ Avraham et al. reported high rates of dental rehabilitation, increased
reconstructive complexity, and decreased total operative time in a series of 54
CSP mandibular reconstructions.9
■ Ch’ng and colleagues described a series of 54 patients receiving a free fibula
flap to reconstruct the maxilla or mandible and subsequent osseointegrated
implant dental rehabilitation after oncologic resection.10
■ Of 243 implants, 91.8% were retained at median 3-year follow-up.
■ Risk of implant failure without radiation was 5.1%.
■ Failure when implants were placed after radiation was 13%.
■ Failure when implants were placed before radiation was 18.6%.
COMPLICATIONS
■ Up to 30% overall donor site morbidity has been reported.
■ Infection
■ Wound dehiscence
■ Skin graft failure
■ Paresthesias distal to donor site
■ Great toe flexion contracture
■ Tibial curvature/valgus deformity in children
■ Recipient site complications:
■ Infection
■ Hematoma
■ Lower eyelid ectropion (delayed reconstruction)
■ Nonunion of the neomaxilla
■ Arterial or venous thrombosis requiring return to the operating room
■ Partial or total free flap failure
REFERENCES
1. Rodriguez ED, Bluebond-Langner R, Park JE, Manson PN. Preservation of
contour in periorbital and midfacial craniofacial microsurgery: reconstruction
of the soft-tissue elements and skeletal buttresses. Plast Reconstr Surg.
2008;121(5):1738-1747.

2. Rodriguez ED, Martin M, Bluebond-Langner R, et al. Microsurgical
reconstruction of posttraumatic high-energy maxillary defects: establishing the
effectiveness of early reconstruction. Plast Reconstr Surg. 2007;120(7 suppl
2):103S-117S.
3. Bluebond-Langner R, Rodriguez ED. Application of skeletal buttress analogy
in composite facial reconstruction. Craniomaxillofac Trauma Reconstr.
2009;2(1):19-25.
4. Golas AR, Levine JP, Ream J, Rodriguez ED. Aberrant lower extremity
arterial anatomy in microvascular free fibula flap candidates: management
algorithm and case presentations. J Craniofac Surg. 2016;27:2134-2137.
5. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft: a clinical
extension of microvascular techniques. Plast Reconstr Surg. 1975;55(5):533-
544.
6. Chang SY, Huang JJ, Tsao CK, et al. Does ischemia time affect the outcome
of free fibula flaps for head and neck reconstruction? A review of 116 cases.
Plast Reconstr Surg. 2010;126(6):1988-1995.
7. Marre D, Hontanilla B. Increments in ischaemia time induces microvascular
complications in the DIEP flap for breast reconstruction. J Plast Reconstr
Aesthet Surg. 2013;66(1):80-86.
8. Seruya M, Fisher M, Rodriguez ED. Computer-assisted versus conventional
free fibula flap technique for craniofacial reconstruction: an outcomes
comparison. Plast Reconstr Surg. 2013;132(5):1219-1228.
9. Avraham T, Franco P, Brecht LE, et al. Functional outcomes of virtually
planned free fibula flap reconstruction of the mandible. Plast Reconstr Surg.
2014;134(4):628e-634e.
10. Ch’ng S, Skoracki RJ, Selber JC, et al. Osseointegrated implant-based dental
rehabilitation in head and neck reconstruction patients. Head Neck.
2016;38(suppl 1):E321-E327.

9
CHAPTER
Soft Tissue Flaps for
Maxillary Reconstruction
Ahmed M. Hashem and Brian R. Gastman
DEFINITION
■ Maxillary reconstruction is the process of rebuilding and coverage of midface
and cheek defects.
■ Tissue loss often results from oncologic resections but can also occur
secondary to blunt or penetrating trauma and, less commonly, from necrotizing
infections.
■ The loss of critical soft tissue components such as the lower eyelid, the nose,
the upper lip, and oral commissure adds significant complexity to the
reconstruction.
■ The functional implications involve speech, mastication, and deglutition.
ANATOMY
■ The maxilla is a complex structure occupying the midface.
■ Conceptually, it is a six-walled construct (hexahedron) bounded by the orbit
superiorly, the palate and oral cavity inferiorly, the nasal airway medially, and
the infratemporal fossa and cranial base posteriorly.
■ Anteriorly and laterally, it forms the contour of the cheek (FIG 1A,B).1
■ The maxillary sinus is a mucosa-lined air cavity in the maxillary process that
drains into the middle meatus of the nose.
■ The sinus is rudimentary at birth but undergoes rapid expansion 6 to 7 years
after puberty.
■ The skeletal framework consists mainly of the maxillary and zygomatic bones,
which articulate with parts of the pterygoid, palatine, lacrimal, ethmoid, and
sphenoid bones (see FIG 1A).
■ The vertical maxillary buttresses and the horizontally oriented alveolar process

define the contour of the midface, contribute to vertical facial height, carry the
dental elements of the upper jaw, and support the upper lip.1
■ The soft tissues comprising the skin, lining mucosa, and intervening facial
musculature constitute the lower eyelid, the cheek, the upper lip, and oral
commissure.1
■ From a reconstructive standpoint, it is critical to appreciate that the maxilla
forms the floor of the orbit, the roof of the mouth (the palate), and the lateral
nasal wall including the lacrimal system.1
■ From a functional perspective, its integrity is critical for normal speech,
mastication, and deglutition.1

FIG 1 • A. Left maxilla (frontal view). Bony articulations
of the maxilla. The maxilla shares in the formation of the
orbital floor and forms the lateral nasal wall. B. Right
maxilla (inferior view). The maxilla forms the roof of the
mouth (the palate) and is related posteriorly to the
infratemporal fossa and cranial base. C. Right maxilla.
The maxilla is related to the critical facial muscles
(orbicularis oculi, orbicularis oris, levators of the upper
lip) and the frontal, zygomatic, and buccal rami of the
facial nerve.
■ Anteriorly, it is related to the facial and angular arteries, whereas posteriorly, it

is in close proximity to the internal maxillary artery, the pterygoid venous
plexus, and the last four cranial nerves.
■ The zygomatic and buccal branches of the facial nerve ramify in the sub-
SMAS plane of the cheek to supply the orbicularis oculi, the orbicularis oris,
and the levators of the upper lip (FIG 1C).
■ The infraorbital nerve travels in the floor of the orbit to emerge on the cheek
through the infraorbital foramen and provide sensation to the midface. The
zygomaticofacial nerve also appears anteriorly through a foramen inferior to
the lateral part of the inferior orbital rim.
PATHOGENESIS
■ Maxillary defects occur in many cases secondary to tumor extirpation of
malignancies originating in the paranasal sinuses, the nasal cavity, the palate,
or the orbit.
■ In other cases, aggressive malignancies arising from the intraoral mucosa, the
cheek skin, or the salivary glands may invade the maxilla and require extensive
composite tissue excisions.1
■ High-energy traumatic injuries (eg, gunshot wounds) constitute another cause
of challenging maxillary defects.2
■ Necrotizing inflammations like noma (cancrum oris)3 and malignant pyoderma
in association with granulomatosis with polyangiitis have also been described.4
■ Composite resections where lining, support, and external skin are missing can
pose a significant reconstructive challenge.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A complete history should be obtained to identify comorbid conditions that
may be optimized preoperatively.
■ A personal or family history of clotting/bleeding abnormalities should be
elicited.
■ History of prior surgery, neck dissection, or radiation therapy of the head and
neck should be noted.
■ Physical examination of the head and neck should evaluate dentition, speech
and swallowing, facial nerve function, and sensory innervation.
■ Changes in skin texture and quality, eyelid function and support, and mouth
opening should be assessed.
■ The expected resection should be envisioned and soft tissue and bony
requirements estimated. Close collaboration with the ablative surgeon is crucial

in this regard.
■ Assessment of potential local and distant tissue donor sites should be
undertaken (eg, temporalis, pectoralis major, radial forearm, rectus abdominis,
anterolateral thigh [ALT] flap).
■ Allen test is useful for evaluation of the palmar arch in patients who may
require a radial forearm flap.
■ Assessment of soft tissue thickness and previous scars/surgery is important to
identify first-line and second-line choices for reconstruction.
IMAGING
■ Imaging modalities like CT scan and MRI are useful preoperatively to
determine the size and extent of the tumor and understand the potential
resulting defect. These studies are also useful in patients with acquired defects
of the maxilla resulting from trauma or infections.
■ A 3D CT scan helps with preoperative virtual surgical planning and
manufacturing of custom-designed models, templates, osteotomy guides, and
prebent plates and selection of optimum screw size and site especially if
dentoalveolar reconstruction and functional occlusion are contemplated.
However, these options are most useful for osseous reconstruction of maxillary
defects.
■ Duplex examination or CT angiography with 3D reconstruction is occasionally
required to evaluate the neck vessels in difficult cases with prior neck
dissection or radiotherapy.
■ Postoperatively, positron emission tomography (PET) and CT scan will be of
benefit to assess the operative bed for tumor recurrence if a free flap was
employed.
NONOPERATIVE MANAGEMENT
■ Custom-made obturators can be used to manage maxillary defects and can
provide support for facial structures and separate the oral cavity from the
maxillary sinus.
■ Obturators restore intelligible speech, prevent nasal regurge, and provide
aesthetic contours.
■ Obturators maybe useful in patients at high risk for complex reconstructive
procedures or, on occasion, as salvage of a failed reconstruction.
■ They may also be useful for small defects of the palate (<50% of the hard
palate), providing rapid rehabilitation with no donor-site morbidity.

■ In general, obturators are best for small defects in the hard palate and are
more difficult to secure in larger defects that involve the hard and soft palate.
■ Larger defects are more easily managed with free flaps resulting in superior
restoration of speech and swallowing5,6
■ The use of an obturator requires close preoperative, intraoperative, and
postoperative collaboration between the oncologic surgeon, reconstructive
team, and a prosthodontist. The steps necessary for obturator creation include:
■ Fabrication of dental casts, analysis of occlusion, and preoperative modeling
■ Creation of a temporary obturator manufactured from heat-processed
polymethylmethacrylate, which is strong enough to provide a stable and
functioning construct but is still adjustable intraoperatively using a bur or drill
to fit the surgical defect
■ Split-thickness skin grafting of the buccal surface of the cheek flap and
bolstering with the temporary obturator, which is fixed with screws or wires
■ Postoperative evaluation and adjustments
■ Fabrication of a permanent prosthesis fashioned from durable cast metal base
(eg, titanium) after maturation of the surgical cavity and conclusion of
radiotherapy
■ Use of obturators carries the advantage of visual inspection of the surgical site
for tumor recurrence. This benefit, however, remains theoretical because
reoperation is infrequent and modern imaging enables early detection.
Nevertheless, many patients have been successfully served with these devices.
■ Disadvantages of obturators include leakage and nasal regurgitation due to
imperfect fitting, the need for frequent cleaning and successive refinements as
the tissues remodel.
SURGICAL MANAGEMENT
■ The development of microsurgical techniques enabled successful autogenous
tissue reconstruction of complex maxillary and midface defects.
■ The approach is largely dictated by the extent of the defect and the functional
requirements.
■ Simple defects can be closed with local soft tissue flaps and bone grafts when
necessary and rarely pose a problem.
■ Complex composite defects involving external skin cover, structural support,
and lining require planning for restoration of orbital floor support, lining of the
nasal airway, palatal reconstruction, and resurfacing of surface defects that may
include the upper lips, eyelids, and nose. In addition, dental restoration is

necessary in most maxillary resections that involve the hard palate.
■ In this context, the classification system described by Cordeiro and
Santamaria1 is useful to stratify maxillary/midface defects and evaluate their
functional requirements. The resultant analysis is able to guide appropriate
treatment strategies.1 Based on this schema, maxillectomy/midface defects can
be categorized as follows:
■ Type I defect (limited maxillectomy): Only one or two walls—excluding the
palate—of the hexahedron are missing. Usually, there is an absence of the
anterior wall in conjunction with either the medial wall or the floor of the
orbit (FIG 2).1
■ Type II defect (subtotal maxillectomy): The whole lower maxilla is absent
(the dentoalveolar arch, the anterior, medial, and lateral walls, in addition to
the palate), while the orbital floor is intact.
• These are further subdivided into type II-A when less than half of the
transverse hard palate is missing and type II-B when more than half of the
transverse hard palate is resected (FIG 3).
■ Type III defect (total maxillectomy): The whole maxilla including the orbital
floor is deficient. Type III defects are additionally split into type III-A if the
orbital contents are preserved and type III-B if they are exenterated (extended
maxillectomy) (FIG 4).1
■ Type IV defect (orbitomaxillectomy): The orbit and maxilla are removed
while sparing the palate. This may include resection of the anterior cranial
fossa leaving the dura or brain exposed (FIG 5).1
■ The advent of vascularized composite allotransplantation (ie, facial
transplantation) refined midface and maxillary reconstruction by replacing
“like” with “exact like,” thus achieving a closer aesthetic match in terms of soft
tissue and skeletal components.
■ The risks of lifelong immunosuppression nevertheless limit the use of this
modality, which is still considered experimental, to a highly select group of
patients (eg, trauma).
■ Gastman et al. published an extension of Cordeiro and Santamaria
classification system1 to address the added specific needs in evaluating patients
presenting for facial vascularized composite allotransplantation.7

FIG 2 • In a type I (limited maxillectomy) defect, the
anterior and medial walls are missing and occasionally
the orbital floor; the palate is intact.

FIG 3 • Type II (subtotal maxillectomy) defect involves
the lower maxilla including the palate. In type II-A, less
than half of the transverse palate is missing. In type II-
B, more than half of the transverse palate is resected.
FIG 4 • Type III (total maxillectomy) defect. In type III-A,
orbital contents are preserved. Type III-B is associated
with orbital exenteration (extended maxillectomy).

FIG 5 • In a type IV (orbitomaxillectomy) defect, the
upper maxilla and orbit are missing, while the palate is
intact.
Preoperative Planning
■ Oncologic resections are by far the most common cause of maxillary defects.
Consequently, adequate tumor clearance and tumor-free margins assume the
highest priority in management. Close collaboration with the ablative surgeon
is thus critical.
■ Resections may involve functional impairment of speech and oral intake in
addition to loss of globe support and eyelid cover.
■ The reconstruction is best accomplished in a multidisciplinary setting with
input from surgical oncology, medical oncology, radiotherapy, speech,
nutrition, ophthalmology, and dentistry, in addition to reconstructive surgery.
■ Complex defects are often composite and require three-dimensional planning
to reconstruct lining, cover, and provide structural support. Accurate analysis
of the functional needs is hence crucial. Accordingly, precise assessment of the
extent of prospective resection based on clinical and imaging data should be
undertaken.
■ Adjacent critical soft tissue components including the eye, lip, oral
commissure, and nose are evaluated.
■ The neck is examined for previous scars and the availability of ipsilateral
suitable recipient vessels.
■ Supplementary Doppler examination can be helpful. In case of any doubt, a
CT angiogram with 3D reconstruction can clarify the vascular status in the
cervical region.
■ Occasionally, the superficial temporal vessels are spared and can serve as
recipient vessels near the defect, which facilitates the microsurgery.
■ Potential donor sites are evaluated for vascularity and adequacy, the pedicle
length is measured, the skin paddle is determined, and the potential for primary
donor-site closure is gauged.
■ Allen test is essential if a free radial forearm flap is contemplated.
■ CT angiography is occasionally necessary to assess donor vessels for other
soft tissue flaps such as the ALT or rectus flap.
■ In type II and III resections, the quality of dentition is assessed, the occlusion
is analyzed, and impressions of the maxillary dental arch and palate can be

taken to create stone casts.
■ Alternatively, computer-aided virtual surgical planning and 3D printing can
provide computer-generated templates. These guides are helpful for osseous
reconstruction of maxillary defects but are less useful in soft tissue
reconstruction.
Positioning
■ The resection is usually accomplished in supine position with the head rotated
to provide greater access.
■ A shoulder roll can be placed between the spine to extend the neck and
facilitate dissection of recipient vessels.
■ Flaps harvested in this position (eg, free radial forearm flap, free rectus
abdominis flap, free ALT flap) are advantageous for a two-team approach to
conserve operative time.
Approach
■ Ideally, donor-site dissection is started at the same time as the ablative
procedure. If there is uncertainty regarding the extent of the disease, it is wiser
to wait until the margins are clarified. The technical details for each flap donor
site are described elsewhere.
■ In dentoalveolar defects, simultaneous insertion of osseointegrated dental
implants at the time of osseous free flap reconstruction will optimize chewing,
speaking, and swallowing at an earlier date.8,9 Patient selection however is
crucial because subsequent radiotherapy can result in a high failure rate with
this approach.10
T E C H N I Q U E S
■ Limited Maxillectomy for Type I Defect
■ In these defects, the anterior and medial walls of the maxilla with or without
the orbital floor have been resected and require reconstruction (note that
palatal involvement converts the condition to either a type II or type III
maxillary defect) (see FIG 2).
■ Functionally, the lower eyelid and occasionally the upper lip and portions of

the lateral aspect of the nose are also missing and need reconstruction.
■ These are usually small-volume defects with large surface area requirements.
■ The bony needs are limited to orbital floor to provide globe support and
avoid dystopia. This does not necessitate vascularized bone nor a
biomechanically high load construct. Thus, a bone graft enveloped in the free
flap tissue is usually sufficient.
■ The free radial forearm fasciocutaneous flap is generally suitable in this
setting. It supplies relatively less bulky tissue and can harbor two skin islands
(one for external cover and the other for nasal lining). The flap can be de-
epithelialized to provide matching contour and envelope bone grafts for
orbital floor support.
■ Alternatively, an osteocutaneous design can be used to supply vascularized
bone and minimize bone resorption.
■ The reconstruction proceeds with analysis of the defect after oncologic
resection and planning of the flap taking care to estimate the length of the
pedicle necessary to reach recipient vessels as well as the size of the internal
and external skin paddles.
■ Recipient vessels in the neck or superficial temporal vessels are dissected
and made ready for microanastomosis.
■ If orbital floor reconstruction is required, a template of the defect is created
using a cardboard or foil material (the wrapper for chromic sutures is ideal).
■ This template is then used to harvest an iliac crest or split calvarial graft.
■ The inner table of the iliac crest is preferable in most cases due to its
increased thickness and natural curve.
■ However, if a calvarial bone flap has been raised by neurosurgery during
the resection, a bone graft can also be easily harvested from the inner table.
■ The bone graft is used to repair the orbital floor defect and fixed into place
using miniplates (preferably self-tapping) or wires.
■ A subcutaneous tunnel is created to pass the pedicle for the flap to the
recipient vessels.
■ The radial forearm flap is dissected as outlined in the flap harvest section
and allowed to reperfuse for 20 to 30 minutes once the tourniquet is taken
down.
■ The pedicle vessels are marked with blue dye to facilitate tunneling of the
vessels and prevent twisting or kinking in this process.
■ Once the pedicle length, suitability of recipient vessels, and hemostasis are

ensured, the flap is disconnected and brought up to the head and neck.
■ The pedicle vessels are carefully passed through the tunnel taking care to
avoid twisting.
■ The flap is then carefully inset into the defect (either completely or partially)
to set the length of the pedicle.
■ Microsurgical anastomosis is performed in the standard fashion.
■ Subtotal Maxillectomy for Type II Defect
■ This defect involves the lower maxilla, including the palate (see FIG 3).
■ Defects of the hemipalate in which the anterior projection of the maxilla is
maintained (ie, resection is posterior to the contralateral canine) can be
reconstructed with soft tissue flaps. These are moderate-volume defects
and, when using soft tissue flaps, in general require more tissues than a
radial forearm flap (although this is possible in obese patients).
■ Defects of the anterior palate that result in loss of facial projection are best
reconstructed with osteocutaneous flaps11 or an obturator.
■ The vertical rectus or ALT flaps are good options for soft tissue
reconstruction of type II maxillectomy defects.
■ The donor site should be selected based on the anatomic features of the
flap (thickness of the soft tissues) as well as volume requirements of the
defect.
■ The ALT flap can be harvested with a portion of the vastus lateralis muscle
that is used to obliterate the maxillary sinus. Similarly, a portion of the
rectus muscle can be used in the same manner.
■ In general, the use of adipose tissues for volume restoration is preferred
over muscle due to the loss of facial volume that will occur when the
muscle atrophies.
■ Similarly, the use of a muscle flap alone in obese patients should be
avoided if possible due to the expected atrophy of the muscle and loss of
facial volume. In these cases, a radial forearm flap may be a better option.
■ Passing the flap pedicle medial to the mandible (ie, behind the soft palate) is
the shortest route to the recipient vessels in the neck. The superficial
temporal vessels can also be used; however, this orientation can make the
inset of the flap more difficult.
■ It is easiest to pass the pedicle through the tunnel prior to insetting the flap.

■ The rectus or ALT flaps are usually oriented vertically to repair the palatal
defect.
■ Usually, a skin paddle measuring 4 to 5 cm in width is needed for
hemipalatal reconstruction.
■ The use of a very wide flap should be avoided as this results in a convex
palate that complicates postoperative eating and dental rehabilitation.
■ The goal is to recreate the concavity of the palate; however, this is not
always feasible with soft tissue flaps and may require secondary revision.
■ Total Maxillectomy for Type III Defect
Total Maxillectomy with Orbital Preservation for Type III-A
Defects
■ In this category of maxillary defects, the whole maxilla is missing including
both the palate and the orbital floor (see FIG 4). The orbital contents are
spared, however, and thus orbital floor reconstruction is necessary to avoid
orbital dystopia and diplopia and preserve binocular vision.
■ The reconstructive goals include orbital floor reconstruction, obliteration of
orbitonasal and orbito-oral communication, palatal resurfacing, and
restoration of malar contour and in some cases external skin cover.
■ The orbital floor can be reconstructed using split calvarium or iliac crest
grafts as outlined above.
■ These bone grafts are sandwiched between the preserved orbital contents
cranially and a free flap caudally.
■ Alternatively, an ipsilateral temporalis muscle flap can be used to cover the
inferior border of the bone graft and separate it from the maxillary sinus,
while an obturator is used to manage the oronasal communication.1,12 This
approach is probably best reserved for patients who are not suitable free
flap candidates and who will not require postoperative radiation therapy.
Total Maxillectomy with Orbital Exenteration or Extended
Maxillectomy for Type III-B Defects
■ This defect includes the whole of the orbit and the maxilla in continuity (see
FIG 4).
■ The anterior cranial fossa/roof of the orbit may be deficient with resultant
brain or dural exposure requiring urgent coverage.

■ The external soft tissue loss is often extensive and may encompass the
eyelids, lateral nose, upper lip, and oral commissure.
■ The reconstructive goals comprise restoration of nasal and palatal lining,
coverage of brain or dura, and external skin cover if necessary.
■ In type III defects, the malar projection will be maintained if the malar
eminence is spared.
■ Otherwise, the soft tissue of the flap can be used to provide projection;
however, this may atrophy with radiation and require revision surgery.1
■ To reconstruct the through-and-through defects and seal the orbit, single free
flaps can be folded onto themselves to provide both external cover and
internal lining.
■ The selected free flap should fill the cavity of the maxillary antrum,
obliterate any dead space, and possess multiple skin islands to provide nasal
and palatal lining in addition to external skin cover.
■ The free rectus abdominis myocutaneous flap has a robust and dependable
blood supply.
■ The abundance of skin perforators permits versatility and yet reliability in
designing multiple skin islands to address palatal and nasal lining in
addition to external skin cover.12 The pedicle length is usually sufficient to
reach the ipsilateral neck and can be extended in select cases with more
cranial defects to reach the neck without the need for vein grafts.13
■ The main drawback of this flap is the excess bulk in some patients that
requires secondary debulking procedures.
■ Moreover, the flap does not provide vascularized bone to restore orbital
floor support or allow dental implants (TECH FIG 1). Nevertheless,
nonvascularized bone can be used for orbital floor reconstruction, and
dental prostheses (eg, dentures) can be designed to optimize function.14,15
■ Lateral circumflex femoral artery–based flaps can also provide ample soft
tissue and a long pedicle.
■ Multiple skin islands and muscle can be harvested on a single vessel using
the transverse and descending branches.
■ Excess adipose tissue can create a bulky reconstruction, however.16
■ Like the rectus abdominis myocutaneous flap, this is a soft tissue flap, and
nonvascularized bone grafts will need to be used (TECH FIG 2).
■ The ALT flap based on the descending branch of the lateral circumflex
femoral artery is particularly versatile in midface/maxillary reconstruction.

■ To achieve sufficient pedicle length, it is necessary to dissect the vessel up
to its takeoff from the lateral circumflex femoral artery.
TECH FIG 1 • A. Type III-A right maxillary defect
following total maxillectomy with orbital preservation.
The orbital floor (black arrow) and the palate (blue
arrow) are missing and will need to be reconstructed.
B. Elevation of a vertical rectus abdominis
myocutaneous flap based on the inferior epigastric
vessels (black arrow). The skin island (red arrow) is
designed to fit the palatal defect. C. Showing the flap
inset. The skin paddle was used to reconstruct the
palate (blue arrow). The orbital floor was restored with

a titanium mesh (black arrow) that is sandwiched
between the orbital tissue cranially and the free flap
caudally. The muscle was used to fill in the dead
space. D. Postoperative picture after closure of the
skin incision.
TECH FIG 2 • A. Central face high-energy avulsive
injury involving the mandible, the alveolar process,
and the palate, in addition to the nose and cranial
base. The black arrows point to the remnants of the
mandibular arch, the red arrows point to the remaining

part of the posterior palate, and the blue arrows point
to the cranial base. B. Harvesting of a free ALT flap
designed to be tubed and folded to reconstruct the
lateral nasal wall, the nasal floor, and the palate. The
black arrow points to the vascular pedicle. The red
dotted line denotes the axis where the flap will be
folded to form the nasal floor on one side and the
palate on the other. The red ellipse indicates the
border that will be tubed to create a nasal passage. C.
Early postoperative appearance after reconstruction.
The lower lip and lower jaw were restored with a free
osteocutaneous fibula flap.
■ With a perforator design, it is usually possible to achieve enough length to
reach the facial artery in the neck.
■ If the superficial temporal vessels are intact and preserved, they constitute
a reasonable alternative recipient. This simplifies the microsurgery.
■ Prior to surgery, it is prudent to evaluate the thickness of the subcutaneous
tissue of the lateral thigh, which is variable in different age groups, among
both sexes, and according to body habitus and fat deposition.
■ This is critical in maxillary/midface reconstruction, which frequently
requires folding of the flap to accommodate the complex multiwalled nature
of the maxilla (hexahedron).
■ The design of the flap should consider the location of the pedicle in relation
to the recipient vessels. Errors in design can render the reconstruction more
challenging.
■ The flap can be easily folded upon itself to provide cover and lining of
multiple surfaces (TECH FIG 2B).
■ A suprafascial dissection can result in less bulk and is not much more
challenging in harvesting the flap.
■ The advantage is a better thigh contour at the donor site especially if
grafting is necessary.
■ On the other hand, inclusion of the deep fascia can be useful to substitute
for absent dura in respective defects.
■ The reconstruction with the ALT is often bulky and requires secondary

revisions to optimize appearance.
■ The donor site rarely causes a problem even if a complex design is used.
■ Free iliac crest with internal oblique muscle based on the deep circumflex
iliac artery can provide vascularized bone to reconstruct the orbital floor and
simultaneously provide sufficient bone stock for dental implants.
■ The internal oblique muscle tissue can obliterate the dead space and seal
the oral and nasal communication.
■ Subsequent epithelialization of the muscle surface restores a near-normal
lining.
■ Harvesting can be more difficult than other flaps, however, and the pedicle
length is limited.5
■ Flaps based on the subscapular/thoracodorsal axis constitute another
alternative.
■ The latissimus dorsi, the serratus anterior, and the teres major can be
harvested in conjunction with parts of the scapula nourished by the
circumflex or angular branch, thus supplying plenty of muscle in addition
to vascularized bone.
■ The skin can be included as a musculocutaneous or perforator-based flap.
■ Bone stock is less robust compared to the iliac crest free flap, but the
pedicle is longer.
■ Although dissection is less challenging than the iliac crest free flap, the
main drawback is that a two-team approach is not feasible. Furthermore,
shoulder motion can be problematic in the early postoperative period.5,17,18
■ Orbitomaxillectomy for Type IV Defects
■ In these defects, the upper maxilla and orbit are missing while the palate is
intact (see FIG 5).
■ Again, the brain or dura may be exposed and may need urgent coverage.
■ The reconstructive goals include sealing of the anterior cranial fossa (to
manage oronasocranial communication), restoring the nasal airway,
reconstruction of the palate, obliteration of the maxillary sinus, and, in some
cases, external skin cover.
■ A multi-island free flap with large volume is needed to achieve these goals
and fill the resultant dead space.
■ The free rectus abdominis myocutaneous flap has several advantages as

described above.
■ Most relevant is the potential to extend the pedicle length to reach the neck
vessels in these more cranial defects.
■ Lateral circumflex femoral-based flaps (eg, free anterolateral thigh flap)
constitute a reasonable alternative since they possess a long pedicle, can
include additional muscle and fascia, allow versatility in design, and supply
plenty of soft tissue with limited donor-site morbidity.
■ The rectus flap is oriented in the vertical fashion as described for type II
defects, and the pedicle is passed medial to the mandibular border to the neck
vessels.
■ Critical Soft Tissue Component of the Face
Upper Lip and Oral Commissure
■ The upper lip and oral commissure can be involved in all types of maxillary
defects.
■ Reconstruction of the oral sphincter is extremely important from a functional
standpoint to preserve oral competence and avoid drooling, which can be
extremely disturbing.
■ Currently, there is no satisfactory method to recreate the oral sphincter
mechanism using tissues other than the lip itself.
■ Use of the remaining tissue to reconstruct the oral sphincter in form of a lip
switch procedure (Estlander flap or the Karapandzic flap) is therefore
indicated in all these defects unless the defect involves greater than 80% of
the lip.1,14,14
■ Incorporating the free flap tissue into the oral aperture will lead to oral
incompetence, drooling, and worse functional outcomes.1
■ Microstomia is generally less disturbing than the sequelae of oral
incompetence.1
Eyelids
■ The eyelids can be involved in type I, type III, or type IV defects.
■ In type III-B and type IV defects, this will be part of the orbital exenteration
procedure. Eyelid reconstruction in these cases would only serve to cover a
prosthesis and generally yields poor results.
■ A glue-on type of prosthesis can provide a reasonable alternative.1

■ In other categories of maxillary defects, the eyelids are usually preserved,
but ectropion is a common complication following free flap reconstruction.
In these cases, a secondary tarsal strip, skin grafting, and canthopexy are
required.
Nose
■ Loss of nasal tissue to different degrees can be encountered in a variety of
maxillary defects.
■ Functional restoration of the airway is independent of aesthetic
reconstruction of the external nose.
■ Ipsilateral local tissues (eg, nasolabial flap, mucoperichondrial septal flaps)
may not be available.
■ Concomitant nasal reconstruction at the time of maxillary coverage may lead
to poor outcomes.
■ Either a prosthesis or alternative surgical procedures, such as contralateral
forehead flaps or even a second free flap, can be employed in a delayed
fashion.
PEARLS AND PITFALLS
Oral
competence
■ Maxillary defects that involve a significant excision of the lips or
oral commissure risk the development of oral incompetence with
poor function and constant drooling. If less than 80% of the upper
or lower lip is missing, it is better to restore the oral sphincter by
way of a lip switch procedure (Estlander flap or the Karapandzic
flap) rather than simply incorporating the free flap into the lip,
which will result in oral incompetence and worse functional
outcomes. Microstomia is a risk though following a lip switch
procedure especially if a large portion of the lip was excised and
postoperative radiotherapy is administered. Nevertheless,
microstomia is less problematic than constant drooling.19
Intraoral
lining
■ In composite defects extending to the oral cavity, restoring the
intraoral lining is essential to a successful maxillary reconstruction.
Using the more proximal tissue that is nearest to the vascular
pedicle and has the most reliable blood supply for this purpose is
advisable.12 First, it sets the length of the pedicle for microvascular

anastomosis, and second, it lowers the risk of major oral leakage.
This permits early oral intake and avoids contamination near the
microsurgical anastomosis with attendant risks of secondary
hemorrhage. It is easier to manage loss of external coverage and
employ a secondary flap than to treat a situation of major oral leak
due to necrosis of intraoral lining with obligatory cessation of oral
feeding, infection, and pending risks of secondary hemorrhage.
Dental
rehabilitation
■ Preservation of the ipsilateral canine and at least one molar can be
extremely useful for dental rehabilitation to allow the alignment
and fixation of dentures.
■ Reconstruction of the palate to provide a concave surface facilitates
dental rehabilitation and preparation of a denture in patients who
undergo soft tissue reconstruction of the palate. Secondary revision
with liposuction and skin excision is sometimes necessary to
facilitate this process.
Ectropion
■ Providing sufficient skin for cheek reconstruction and anchoring
the flaps to bone can help minimize this complication. A
concomitant canthopexy or canthoplasty may also be helpful.
■ Secondary procedures such as skin grafting, a tarsal strip, or
canthopexy/canthoplasty can ameliorate cases of postoperative
established ectropion.
Orbital
dystopia
■ Accurate reconstruction of the orbital floor at an appropriate
clinical level and for optimum depth is mandatory to support the
globe and avoid this complication. The inner table of the iliac crest
and outer table of the calvarium have matching curvature and are
sufficiently strong to avoid dislodgement during mastication.
Fixation to the remaining bone can be challenging, and a tongue in
groove technique can be helpful in this regard.14
Palatal lining
■ It is crucial to accurately measure the skin inset into the palate. The
palatal skin should be smaller or equal to the defect to avoid
prolapse of skin into the oral cavity and speech impairment.
Suspending the flap to the cranial base can be a useful adjunct to
avoid this complication.
POSTOPERATIVE CARE
■ Free flap monitoring using clinical examination, Doppler, and infrared
spectroscopy is mandatory since early intervention will maximize flap salvage.
■ Care must be taken to avoid compression of the pedicle in the neck or in the
preauricular area. Pillows should be used carefully (or not at all) to avoid
wrapping around the neck and compressing the pedicle vessels. Similarly,

tracheostomy ties and other circumferential neck dressings should be avoided.
■ Patients should be kept in a head-up posture and hemodynamic stability
monitored.
■ General tracheostomy care if applicable and nutritional support are essential.
■ Speech, dental, and nutritional evaluation should ideally commence in the
preoperative phase and rehabilitation started immediately postoperatively to
optimize patient outcomes.
OUTCOMES
■ Cordeiro and Chen retrospectively reviewed 100 flaps used for midface
reconstruction following oncologic resections performed at the Memorial Sloan
Kettering Cancer Center.14
■ Generally satisfactory outcomes were achieved in most patients with
autogenous free flaps.
■ Intelligible speech was restored in most patients who required palatal resection
(43 of 44), especially when less than half of the palate was lost. They noted
that preservation of the soft palate maximized speech outcomes and prevented
velopharyngeal dysfunction.
■ When more than half of the palate was sacrificed, they recommended the
substituting skin island to be accurately measured equal to or smaller than the
defect to avoid intraoral prolapse. If needed, it can be anchored to the cranial
base.1,14
■ Most patients (47 of 50) resumed an unrestricted or soft diet postoperatively.
■ Oral competence was preserved or restored in most maxillary defects
requiring lip resection (11 of 12 patients) using a lip switch procedure.
■ Microstomia was encountered in 3 of 12 patients.14
■ Mild vertical and horizontal diplopia was observed in 1 and 4 of 12 patients,
respectively, following orbital floor reconstruction but led to minimal
functional disturbances.1,14
■ Ectropion occurred in 10 of 21 patients but was usually mild or moderate
(70% of cases).
■ Severe cases (30%) were improved with skin grafting, a tarsal strip
procedure, or a canthopexy/canthoplasty.14
■ Of 70 patients evaluated for aesthetic outcome, 41 were rated excellent
(58.6%), 25 were judged as good (35.7%), and 4 were evaluated as fair (5.7%).
■ Aesthetic outcomes were largely dependent on the extent of outer skin

resection and whether eyelid, lip, or globe removal was necessary.14
COMPLICATIONS
■ Free flap loss will usually require a secondary free flap.
■ Ectropion
■ Ocular dystopia
■ Enophthalmos
■ Velopharyngeal dysfunction
■ Unintelligible speech
■ Nasal regurgitation of fluid
■ Drooling
■ Microstomia
■ Color and texture mismatch of external skin
■ Bulky reconstruction
REFERENCES
1. Cordeiro PG, Santamaria E. A classification system and algorithm for
reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg.
2000;105(7):2331-2346.
2. Rodriguez ED, Martin M, Bluebond-Langner R, et al. Microsurgical
reconstruction of posttraumatic high-energy maxillary defects: establishing the
effectiveness of early reconstruction. Plast Reconstr Surg. 2007;120(7 suppl
2):103S-117S.
3. Danino AM, Servant JM. Reconstruction of the maxilla with prefabricated
scapular flaps in noma patients. Plast Reconstr Surg. 2009;123(6):1879-1880.
4. Gastman B, Hashem AM, Djohan R, et al. Malignant pyoderma associated
with granulomatosis with polyangiitis (Wegener granulomatosis) as a unique
indication for facial vascularized composite allotransplantation. Plast Reconstr
Surg. 2016;137(6):1007e-1015e.
5. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: Introducing a
new classification. Lancet Oncol. 2010;11(10):1001-1008.
6. Moreno MA, Skoracki RJ, Hanna EY, Hanasono MM. Microvascular free flap
reconstruction versus palatal obturation for maxillectomy defects. Head Neck.
2010;32:860-868.
7. Gastman B, Djohan R, Siemionow M. Extending the Cordeiro maxillofacial
defect classification system for use in the era of vascularized composite
transplantation. Plast Reconstr Surg. 2012;130(2):419-422.

8. Levine JP, Bae JS, Soares M, et al. Jaw in a day. Plast Reconstr Surg.
2013;131(6):1386-1391.
9. Chang Y-M, Coskunfirat OK, Wei F-C, et al. Maxillary reconstruction with a
fibula osteoseptocutaneous free flap and simultaneous insertion of
osseointegrated dental implants. Plast Reconstr Surg. 2004;113(4):1140-1145.
10. Roumanas ED, Markowitz BL, Lorant JA, et al. Reconstructed mandibular
defects: fibula free flaps and osseointegrated implants. Plast Reconstr Surg.
1997;99(2):356-365.
11. Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm
osteocutaneous “sandwich” free flap for reconstruction of the bilateral subtotal
maxillectomy defect. Ann Plast Surg. 1998;40(4):397-402.
12. Patel NP, Matros E, Cordeiro PG. The use of the multi-island vertical rectus
abdominis myocutaneous flap in head and neck reconstruction. Ann Plast Surg.
2012;69(4):403-407.
13. Cordeiro PG, Santamaria E. The extended, pedicled rectus abdominis free
tissue transfer for head and neck reconstruction. Ann Plast Surg.
1997;39(1):53-59.
14. Cordeiro PG, Chen CM. A 15-year review of midface reconstruction after
total and subtotal maxillectomy. Plast Reconstr Surg. 2012;129(1):124-136.
15. Cordeiro PG, Sanatamaria E, Kraus DH, Strong EW. Reconstruction of total
maxillectomy defects with preservation of the orbital contents. Plast Reconstr
Surg. 1998;102:1874-1884.
16. Broyles JM, Abt NB, Shridharani SM, et al. The fusion of craniofacial
reconstruction and microsurgery. Plast Reconstr Surg. 2014;134(4):760-769.
17. Uglesić V, Virag M, Varga S, et al. Reconstruction following radical
maxillectomy with flaps supplied by the subscapular artery. J
Craniomaxillofac Surg. 2000;28(3):153-160.
18. Clark JR, Vesely M, Gilbert R. Scapular angle osteomyogenous flap in
postmaxillectomy reconstruction: defect, reconstruction, shoulder function,
and harvest technique. Head Neck. 2008;30(1):10-20.
19. Cordeiro PG, Santamaria E. Primary reconstruction of complex midfacial
defects with combined lip-switch procedures and free flaps. Plast Reconstr
Surg. 1999;103(7):1850-1856.

10
CHAPTER
Section V: Mandible
Mandible Reconstruction
With Fibula Free Flap Using
CAD/CAM Techniques
Jamie Levine, David Hirsch, and Lawrence Brecht
DEFINITION
■ Recent advances in imaging, computer-aided design/computer-aided modeling
(CAD/CAM) software, and 3D printing technology have enabled virtual
planning of complex 3D osseous reconstruction of head and neck defects.1-5
■ Using these methods, we can now prepare exact models and customized
surgical devices that facilitate and simplify reconstruction. Virtual surgical
planning and customized surgical templates decrease the learning curve for
osseous reconstruction of head and neck defects while simultaneously
improving the precision of reconstruction.6
■ This is important because traditional methods for surgical planning of these
reconstructions have a steep learning curve and even small errors can lead to
poor outcomes.
■ CAD/CAM virtual surgical planning also increases collaboration with
oncologic and dental colleagues leading to a more unified plan. This approach
allows development of more creative solutions for complex defects that
ordinarily would be difficult to visualize preoperatively.7,8
■ This chapter will provide step-by-step planning for mandible reconstruction
using the fibula flap with CAD/CAM planning. This approach can easily be
modified for use with other osseous sources (eg, iliac crest, scapula, etc.) or for
reconstruction of other osseous defects of the head and neck (eg, maxilla).

ANATOMY
■ Mandible
■ The mandible is a complex 3D structure with two symmetric points of
articulation at the skull base forming the temporomandibular joint (FIG 1A).
■ The mandibular body and the curved mental protuberance contain 16 sockets
to hold the lower teeth. The ramus and condyle form the articulation points
with the skull base.
■ The mandible has two foramina.
• The mandibular foramen is located on the internal surface of the ramus and
serves as the entry point for the inferior alveolar nerve.
• The mental foramen is on the external surface of the mandibular body,
below the second premolar. The inferior alveolar nerve exits the mandibular
canal at this location and then becomes the mental nerve.
■ The mandible serves as the attachment point for multiple muscles, including
the muscles of mastication that help coordinate movement of the mandible
with chewing.
■ The blood supply of the central mandible is derived from multiple sources
including the inferior alveolar artery and periosteal branches from the
surrounding musculature.
FIG 1 • A. Anatomy of the mandible. B. Anatomy of
fibula flap.
■ Fibula flap
■ The fibula is the preferred choice for mandible reconstruction in most

patients7,9 because of the following characteristics: the bone has a dual blood
supply (periosteal and axial) enabling complex shaping of the bone; there is a
large amount of bone available (20–25 cm) enabling reconstruction of
subtotal mandibulectomy defects; the vascular supply is consistent and large
caliber; the bone stock is sufficient for dental rehabilitation; and finally,
because the fibula can be harvested simultaneously with the oncologic
resection.
■ The dual blood supply of the fibula enables surgeons to perform multiple
osteotomies to achieve the complex shape of the mandible. However, in
general, segments are planned.
■ The blood supply for the fibula is derived from the peroneal artery and vein
(FIG 1B).
• The pedicle length is variable and depends primarily on the amount of bone
that is needed and anatomic variability in the take off of the peroneal
artery/vein from the tibioperoneal trunk. In general, the length of the pedicle
can be planned preoperatively using virtual surgical planning and
angiography.
PATHOGENESIS
■ CAD/CAM virtual surgical planning can be used for acquired and congenital
defects of the mandible. The most common cause of mandibular defects
necessitating vascularized bone transfer is oncologic resection of the mandible
for malignant tumors (FIG 2).
■ These tumors include primary bone tumors (eg, osteogenic sarcoma) or more
commonly, metastatic spread from squamous cell cancer of the soft tissues of
the head and neck (eg, floor of mouth or tongue).
■ Osteoradionecrosis is a common complication of radiation therapy of the head
and neck and in some cases results in late defects of the mandible. These
patients present with nonhealing wounds or pathologic fractures of the
mandible and in some cases, benefit from resection of the necrotic bone and
reconstruction with free flaps.
■ Benign lesions such as ameloblastoma, giant cell tumors, odontogenic
mandibular cysts, and odontogenic tumors (ie, ameloblastoma) also require
resection and reconstruction. These lesions do not metastasize but can be
locally aggressive and have a high risk of recurrence if not resected with
appropriate margins.
■ Traumatic injuries, and less commonly infectious etiologies (eg, refractory

osteomyelitis), resulting in bone loss or complex lesions with nonunions also
require osseous reconstruction in select cases.
■ Congenital defects of the mandible in rare cases require free tissue transfer
with bone flaps. More commonly, these defects are treated with bone grafting
or distraction osteogenesis.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The history and findings will depend mainly on the cause of disease process.
■ For all patients, bone donor sites should be carefully assessed for blood supply,
quality of soft tissues, and bone stock.
■ Similarly, the anticipated defect in the mandible should be assessed for
osseous and soft tissue needs and recipient vessels for microsurgery. Mouth
opening, mastication, and swallowing should be examined.
■ The quality and quantity of the teeth should be assessed and dental
consultation should be obtained as needed.
■ Dental rehabilitation (bone implants at the time of surgery or in a delayed
fashion versus dentures) should be considered if feasible and discussed with
the dental team.
■ Medical comorbidities, prior treatments, planned treatments postoperatively,
and prognosis should be assessed and noted whenever feasible.
■ Patients with osteoradionecrosis or osteomyelitis may need to be optimized for
treatment preoperatively using hyperbaric oxygen treatment, debridement, and
antibiotic treatment as needed.
IMAGING
■ Fine cut (1-mm-thick sections) CT scans of the mandible and fibula with 3D
reconstruction is the best option for examining the bone and for planning of the
reconstruction. MR imaging may also be useful in some cases to evaluate the
surrounding soft tissues but is not useful for developing 3D bone models (FIG
3).1,2
■ The mandibular CT scan is usually performed as a noncontrast study because
the primary need is to evaluate the bone anatomy and anticipated defects.

FIG 2 • Common causes of mandibular defects. A.
Right mandibular osteoradionecrosis with surrounding
infection. B. Squamous cell carcinoma of the right
hemimandible. C. Left mandibular ameloblastoma. D.
Treacher Collins syndrome with resorbing left
mandibular rib graft.
FIG 3 • A. Three-dimensional model of the mandible
derived from thin cut CT scans demonstrating area to
be resected (red bars). B. CT angiogram of the lower
extremity and fibula anatomy.
■ Imaging of the fibula flap is typically done with a CT angiogram to evaluate
the osseous anatomy as well as the vascular blood supply. The angiogram is
used to evaluate the vascular anatomy of the lower extremity (three vessel
runoff, abnormal vascular anatomy), and the perforator anatomy of the skin
paddle. This imaging helps with planning the placement of the osteotomies and

skin paddles.
■ Although standard models of the fibula are available and may be used for
planning, in our hands, CT scans of the patient’s own fibula is more accurate
since because is some variability in the shape of the bone that may alter the
angles needed for shaping of the fibula.
SURGICAL MANAGEMENT
Preoperative Planning
■ The CT scans of the mandible and fibula are used for preoperative virtual
surgical planning with the oncologic surgeons, dentists (if necessary), and the
reconstructive team.
■ It is important for the ablative surgeon to be involved in the planning session
to accurately plan surgical margins. In cases where there is doubt about the
surgical margins, two separate plans can be prepared. This approach enables
intraoperative modification of the virtual surgical plan depending on anatomic
or oncologic findings. Thus, a “narrow” margin resection plan may be created
as the initial plan; however, if intraoperative findings dictate larger resection,
then the backup “wider” resection plan can be executed instead. This approach
creates two separate cutting guides for the head and neck and fibula harvest
plans (FIG 4A).
FIG 4 • A. Virtual surgical planning and design of

mandibular (left) and fibula (right) cutting guides. B.
Top-down plan for mandible reconstruction. Double
barrel fibula flap reconstruction is planned with
positioning of the mandibular segment along the upper
border of the mandible to facilitate dental implant
placement. C. Fibula cutting guide with predictive holes
for placement of prebent plates and positioning of
double barrel segment. D. Final placement of dental
implants with double barrel fibula flap reconstruction.
■ We used to be concerned only with the position of the bone reconstruction,
now we plan from the top down. We start with the jaws in occlusion during the
virtual meeting, then the noninvolved jaw is removed, and we plan the surgical
cuts (FIG 4B).
■ Finally, if dental implants are planned, we position them with the dental team
at this point. In general, we try to place our implants under opposing teeth. If
creating a bridge, then we evenly spread out the implants to equilibrate forces
(FIG 4C,D).
Positioning
■ The patient is positioned supine with the neck extended using a shoulder roll.
■ A roll (bump) is affixed on the OR table to position the lower leg at a 90-
degree angle at the knee (FIG 5). A hip roll may be needed to shift the patient
slightly away from the surgeon and facilitate positioning of the lower leg.
■ Bony prominences and soft tissues are padded appropriately.
■ The OR table may be rotated to facilitate positioning of the surgical,
anesthesia, and nursing teams.
Approach
■ In most cases, the fibula flap is harvested simultaneously with the head and
neck resection. This approach decreases the surgical time and improves
outcomes. However, in some cases, this is not feasible (eg, complex
reconstructions, or cases in which it is not clear if the tumor is resectable). In
these cases, fibula flap harvest is performed after the resection is completed.

FIG 5 • Placement of the bump on the OR table to help
position the fibula intraoperatively.
■ In general, it is possible to use the fibula flap from either side (ie, the flap that
is ipsilateral or contralateral to the anticipated mandibular defect).
■ The ipsilateral fibula flap will position the flap vessels laterally in the neck by
simplifying the microsurgical anastomosis. In addition, because the septum is
under the bone (ie, posterior to the fibula) in this flap orientation, the skin
paddle may be easily used for extraoral reconstruction. The skin paddle in an
ipsilateral flap can also be placed intraorally; however, because the septum
needs to go up and over the mandible, the amount of skin available for intraoral
reconstruction is more limited.
■ The contralateral fibula flap (in relation to the mandible defect area) places the
flap vessels medially in the neck by facilitating crossing over to the
contralateral neck if necessary. In addition, in this flap orientation, the septum
is above the bone thus facilitating intraoral placement of the skin paddle.
■ With the right planning, either leg can be utilized for most cases.
T E C H N I Q U E S
■ Fibula Flap Harvest
Design

■ The bone and posterior septum are marked and a Doppler is used to localize
skin perforators in the middle and distal thirds of the bone.
■ The position of these skin perforators can be checked with the preoperative
CT angiogram.
■ The size and shape of the skin paddle is marked to plan for intra- or extraoral
reconstruction.
■ Orient the skin paddle to incorporate the signal and the area designed for
coverage either intraorally or otherwise. This should be done carefully
because the fibula skin paddle has limited mobility in relation to the bone.
■ Although not necessary in all cases, we almost always design and harvest a
skin paddle. This can be used as a backup in case additional soft tissues are
resected or the quality of the remaining soft tissues is questionable. In
addition, the skin paddle can be used for postoperative monitoring.
■ In some cases, the vascularized fascia and de-epithelized skin paddle may
be used to augment soft tissue defects to improve contour or to cover the
fixation hardware and decrease the potential for erosion/exposure.
■ A tourniquet is applied to the upper thigh and padded with Webril or gauze.
We usually use a sterile tourniquet that is applied once the patient is prepped
and draped.
■ The tourniquet is set to a pressure that is about 100 mm Hg higher than the
systolic blood pressure.
■ The leg is elevated and partially exsanguinated using an Esmarch bandage
(personal preference) or without a full exsanguination.
■ Generally, 2 hours of ischemia are well tolerated. If longer periods are
needed for flap harvest, the circulation can be re-established for 20 to 30
minutes and the tourniquet can be reapplied.
Incisions and Flap Elevation
■ The lateral approach to the fibula is used. The anterior skin incision is
performed, and the fascia is incised. The skin is elevated off of the
underlying musculature taking care to avoid injury to the superficial peroneal
nerve.
■ The peroneus longus and brevis muscles are cut while applying tension on
the muscles leaving a 5-mm cuff of muscle on the anterior surface of the
fibula. Care should be taken in the upper part of the leg to avoid injury to the
anterior tibial vessels and tibial nerve.
■ The intermuscular septum is then incised.

■ The posterior skin incision is performed, and the skin and fascia are elevated
off of the musculature.
■ The septum is identified and perforating vessels in the septum are
preserved.
■ Branches to the soleus muscle are ligated.
■ The fibula is carefully separated from the soleus muscle and the perforating
branches from the peroneal artery/vein to the soleus muscle are identified and
divided.
■ The flexor hallucis longus muscle (FHL) is identified and divided.
■ The amount of FHL that is harvested with the flap can be modified
depending on the reconstructive needs. In some cases, very little FHL is
needed (eg, anterior defects) and therefore the FHL muscle is carefully
dissected away from the fibula.
■ In other situations, vascularized muscle can be used to obliterate soft tissue
defects (eg, posterior defects of the mandible or patients with
osteomyelitis). In these cases, the majority of the FHL muscle is harvested
with the flap.
■ The fibula is then osteotomized inferiorly and superiorly using an oscillating
electric saw, taking care to avoid injury to the tibioperoneal trunk proximally.
■ This can be done by passing a right angle from below the fibula while
directly visualizing the vascular trunk.
■ A malleable retractor or army-navy type retractor can then be placed
around the bone to avoid inadvertent injury to the vessels.
■ Leave about 6 cm of fibula bone proximally and distally, and take slightly
more if needed but leaving less than 4 cm of bone proximally or distally,
may result in instability and require screw fixation.
■ Bone clamps placed distally are used to pull the muscle out, and the distal
peroneal vessels are identified and ligated.
■ The posterior tibialis muscle is then carefully incised taking care to avoid
injury to the peroneal vessels that run deep to the muscle.
■ The peroneal vessels are then dissected away from the tibial nerve and
posterior tibial vessels.
■ At this point, the tourniquet is deflated, and hemostasis is ensured.
■ Mandibular Osteotomy

■ The ablative surgeons perform their exposure of the mandible, and the
custom mandible cutting guides are applied and fixed in place.
■ The resection is then performed using the cutting guides.
■ Frozen section margins are evaluated if necessary.
■ Recipient vessels in the neck are exposed. Commonly, we use branches of
the external carotid artery (facial, lingual, superior thyroid) and branches of
the internal or external jugular veins.
■ Fibula Flap Osteotomy
■ Place the personalized fibula cutting guide to the preplanned location on the
fibula and mark the area of the osteotomies and dental implants (if planned).
■ The cutting guide is attached to the fibula with two monocortical screws in
each segment to avoid movement/rotation. This is very important,
particularly if simultaneous dental implant placement is planned (TECH
FIG 1).
■ If dental implants are planned, clear a landing point on the fibula with a freer
elevator or cautery through the periosteum below the implant drilling guide.
■ All the holes and implant positioning should have been meticulously
planned in the online sessions and printed into the guide.
■ We place the implants before any osteotomies are made because precise
orientation and positioning of the implants is critical for their long-term
success.
■ Once the dental portion of the procedure is completed, a subperiosteal
dissection is performed at the area where the fibula osteotomy is planned to
protect the pedicle.
■ Wedge osteotomies are then performed using an oscillating saw. The
osteotomies may be fixated at this point using miniplates.
■ Alternatively, the flap may be transferred to the head and neck area and the
osteotomies fixated with a reconstructive bar.
■ We prefer to do all of this preparatory work while the flap still attached to
the vascular pedicle in situ in order to minimize flap ischemia time. For less
complex defects, however, osteotomies can also be performed on the back
table after pedicle ligation.
Insetting the Fibula Flap Into the Mandibular Defect

■ The flap pedicle is divided and the flap is transferred to the head and neck
area.
TECH FIG 1 • Positioning of the cutting guide on the
fibula and placement of dental implants prior to fibula
osteotomies.
TECH FIG 2 • Submental view of customized
reconstruction plate and fixation of the fibula flap to
the mandible.

■ The pedicle vessels can be dissected in a subperiosteal manner to position
the vessels optimally for microsurgical anastomosis.
■ Care should be taken to avoid devascularization of the fibula.
■ In most cases, we use a prebent reconstructive plate that has been
customized for the patient.
■ This plate is applied to the mandibular defect based on the cutting guide
(TECH FIG 2).
■ The fibula is then inset into the defect and fixated to the plate. Minor
burring of the bone may be necessary to achieve an optimal fit.
■ Monocortical screws are used on the fibula and each segment is usually
fixated with two screws to prevent movement. We generally avoid
bicortical screws since this may result in pedicle injury or weakening of the
bone.
■ If a prebent plate is not available, then a 2-mm-thick reconstructive plate can
be bent to the defect (ideally prior to mandibular resection) or based on 3D
model.
■ Guiding elastics may be needed in these cases to precisely fixate the
mandible and ensure proper alignment of the teeth.
■ If we are planning a double barrel segment to increase the vertical height of
the mandible, we resect a 2-cm periosteal sleeve between bone segments to
prevent kinking of the vascular pedicle.
■ Inset the skin flap (usually the posterior or deep portions) prior to
revascularization to stabilize the vascular pedicle because bleeding may
obscure visualization of this closure.
■ Microsurgical Anastomosis and Flap Inset
■ Microsurgical anastomosis is performed using a microscope or loupes, and
reperfusion is monitored.
■ The remainder of the flap skin paddle is performed and the flap is trimmed
as needed. Meticulous intraoral closure is critical to avoid complications like
salivary leaks and complex infections.
■ Skin monitoring sutures are placed for postoperative evaluation using a
Doppler. In cases where the flap is buried or no skin perforator is available,
an implantable Doppler may be used.

■ Dental Implants
■ If dental implants are placed at the time of reconstruction, we generally
unroof and expose these implants 4 to 6 months postoperatively, when the
bone has undergone appropriate osteosynthesis.3
■ In the rare case of a benign tumor in which most or all of the mucosa is
being spared, we can contemplate a single-stage reconstruction with fibula,
placing the implant, then direct prosthesis placement.10
■ These cases require good soft tissue so that we can cover around the
implant abutments and under the prosthesis to protect against salivary
leakage. If we are not able to do this with well-vascularized mucosa or
fascia, then prosthesis placement may not be possible and a well-
vascularized skin paddle should be put in place.
PEARLS AND PITFALLS
Imaging
timing
■ When planning a resection, the preoperative CT scan should be
obtained relatively close in time to the planning session and the
surgery to avoid changes in the resection plan.
Planning
session11
■ The tumor or disease process should be outlined by the modeling
team and generous margins should be planned. It is best to do this
with the ablative team involved during the online meeting so that
they agree with this plan. If there is a question about margin safety
and need for further intraoperative resection, an alternate guide can
be made to accommodate for these potential changes.
Soft tissue
planning
■ Take into account your soft tissue needs when planning these
procedures. Take as much skin as you need from your primary flap
or choose alternative flaps if a complex resection is planned and
there is a large intra- and extraoral soft tissue need. Do not leave
yourself short of tissue.
Planning
maneuvers to
minimize soft
tissue need
■ In cases with significant tissue loss or lack of tissue flexibility
such as in radiation injury, the bony reconstruction can be
deprojected slightly to minimize strain on the overlying soft tissue
and decrease the complexity of the reconstruction.
Plan approval
■ Each team should evaluate the plan that is created by the
engineers. This includes the ablative, dental, and reconstructive
teams if dental prosthetic is planned.

Customized
plates
■ As the reconstruction becomes more complex with multiple
segments, predesigned plates can play an important role in
obtaining very precise reconstruction results.
Primary
implant
consideration
■ Consider primary osteointegrated implants in benign cases and
isolated malignant cases where the intraoral soft tissues are healthy
and enable watertight closure around dental implants.
Bone size
■ Bone segments should remain at least 2 cm in length to maintain
appropriate periosteal circulation.
Perforator
location
■ Use the virtual planning to appropriately position your bone
segments. Imaging can note 3D variations in the bone and
perforator location, which can assist in the soft tissue design. Place
skin where needed intra- or extraorally.
Fibula
position and
side decision
■ As a guideline, if both fibulas are available, when we have a need
for an intraoral skin paddle and ipsilateral blood supply, we choose
the contralateral fibula for orientation purposes. When skin is
needed extraorally, with ipsilateral vessels, then the ipsilateral leg
is planned. This arrangement can be adjusted based on the need of
the situation. This is also the case with anterior defects, the
location of the cutaneous defect and side of vascular supply will
help determine which fibula will fit best.
Accuracy
strategies
■ When using multiple segments or have critical positional
requirements such as needed for primary implant placement, make
intermediary splint devices to help confirm the position of the
reconstruction as you advance through each step. Also, predictive
hole guides and customized plating can help with this accuracy
significantly.
Vessel
dissection
■ Maximize peroneal vessel length as needed up to the attachment to
the posterior tibial vessels.
Double barrel
■ When planning a double barrel segment, we find that a 2-cm (or
greater if needed) periosteal sleeve allows for appropriate rotation.
Implant
planning
■ Planning for implants should be performed from the top down.
Need to plan the position based off of the maxillary dentition. If
bone is not planned out appropriately, then implant position may
also not be appropriate.
Implant
placement
■ If placing primary implants, we place the guide and the implants
first prior to performing the osteotomies. This helps to maintain
accuracy.

POSTOPERATIVE CARE
■ Postoperative care monitoring depends on the underlying health of the patient.
In most cases, ICU observation is not necessary and may delay ambulation and
tracheostomy decannulation.
■ Head movement usually limited to less than 25 degrees first week
postoperatively. The head is maintained in the neutral position and external
compression of the vascular pedicle is avoided.
■ Monitoring is preferred with physical assessment of the skin paddle color and
pencil Doppler. The skin paddle may also be stuck with a needle and bleeding
evaluated directly. In patients with implantable Dopplers, the skin paddle (if
available) is still evaluated for color and refill. Monitoring protocol is in place
with q1h flap checks for the first few days postoperatively and then decreasing
to q2h and q4h thereafter.
■ The ankle is splinted at the conclusion of the procedure in neutral position
with a plaster or fiberglass splint.
■ Alternatively, a preordered walking type of ankle-foot orthotic (AFO) can be
obtained so the patient can ambulate early in the postoperative period.
Physical therapy consultation is useful in most cases to improve movement
and stabilize early ambulation.
■ If a skin graft is placed for the skin donor site, we usually use a VAC as a
bolster for 5 days. Patients may ambulate with the VAC in place. Once the
VAC is removed, ambulation is limited until the skin graft has completely
taken.
■ Compression wrapping with ACE bandage and elevation is usually needed for
1 to 2 months postoperatively.
■ Feeding tubes are placed transnasally in the operating room and the position is
confirmed radiologically. Tube feeds are usually started postoperative day one
on and can be maintained until healing has occurred. Long-term tube feeds
may require gastric tube placement.
■ Swallowing function may be assessed if necessary in patient who have
undergone floor of mouth resection. In these cases, speech/swallow evaluation
may also be necessary.
■ Once intraoral healing has been confirmed and the tracheostomy has been
removed, oral feeds can be started and advanced as necessary.
■ Most patients who undergo mandible reconstruction require tracheostomy. The
timing of decannulation is dependent on the patients’ recover. In most cases,

we downsize the tracheostomy by 3 to 4 days postoperatively once the intraoral
and tongue swelling is decreased. Then from there advance to decannulation
within another 1 to 2 days.
■ Care must be taken to avoid tracheostomy ties to prevent compression of the
pedicle. In these cases, tracheostomies are usually sutured or stapled into place.
■ Most patients are discharged home by 7 to 14 days postoperatively.
■ Some patients, depending on their preoperative condition, benefit from a short
stay in a subacute rehabilitation center.
OUTCOMES
■ Patients usually do very well postoperatively.4
■ By 6 to 8 weeks, ambulation is usually back to normal and the facial
aesthetics are stabilized.
■ If chemotherapy or radiation is necessary postoperatively, this can usually be
performed safely by 6 to 8 weeks postop.
■ Oral function should be normalized by 2 to 4 weeks postoperatively especially
if the tongue was left intact.
■ Bone healing between the osteotomy sites should be well integrated by 3 to 4
months.
■ If a patient is treated with radiation postoperatively, then dental implant
placement requires careful consideration because the bone is at high risk of
breakdown and implant failure.
■ The reconstruction plates can be left in place unless there is hardware failure,
exposure, pain, screw loosening, or palpability.
■ Dental implants result in an excellent reconstruction (FIG 6).
COMPLICATIONS
■ Typical complications include infections, bleeding, salivary leaks,
malocclusion, pain, and nerve complications (sensory impairment, or more
rarely, motor difficulties). Medical complications including pneumonia,
aspiration, and cardiovascular morbidity may also occur. Donor site
complications may include impaired healing, skin graft loss, pain, and
neurovascular injury. Vascular complications from the donor site are rare but
possible in patients with atherosclerotic disease.

FIG 6 • Postoperative view of the final reconstruction
with dental implants in place.
■ Long-term problems may include trismus, pain, and speech/swallowing
problems. In addition, patients may have nonunion or implant-related
complications.
■ Airway risks are particularly worrisome in the early postoperative period
especially if there is a large anterior or floor of mouth resection.
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