Ocular Protection
Many nonsurgical modalities are used for eye protection, including:
Exogenous lubrication (drops and ointments)
Closure assistance (eyelid taping, especially at night)
External protective devices (protective chambers, eye patches)
Soft contact lenses
These serve as temporizing measures for patients who recover function as well as adjuncts to surgery
when operative intervention is indicated.
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Synkinesis
Management of synkinesis requires denervating the muscle that activates inappropriately or retraining it
to inhibit unwanted movement. The former is accomplished through the use of botulinum toxin, and the
latter through specialized physical therapy. Therapeutic techniques generally focus on the use of
biofeedback through tools such as mirror training and electromyographic feedback.
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Surgical Management
Surgical intervention may be pursued when facial paralysis is congenital, secondary to trauma or
iatrogenic injury, or when conservative/medical management of potentially recoverable cases fails to
generate satisfactory facial movement or tone. The choice of procedure depends on specific functional
deficits, patient desires, and suitability of the patient to undergo various surgeries.
Procedures can be classified as static or dynamic. Static procedures do not produce new motion, but
through suspension or repositioning of tissues, improve symmetry, appearance, and sometimes function.
Dynamic procedures generate new movement under emotional and/or volitional control.
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Static Procedures (Table 42.6)
Static procedures around the eye aim to improve lid closure and protect the cornea. Procedures can target
either the upper lid (enhance downward excursion) or the lower lid (ectropion repair to better appose lid
to globe). Placement of gold weights 17 (Figure 42.3) or platinum chain weights overlying the tarsus
within the upper lid is a popular procedure to enhance closure. Implants are available in a range of
weights such that the most appropriate one may be selected for each patient depending on their
functional deficiency.
TABLE 42.6
Commonly Used Static Procedures Throughout the Face
Focus
Static Options
Eye (lagophthalmos)
Upper lid
Gold weights/platinum chain weights
Palpebral springs
Lower lid
Canthoplasty/canthopexy (mild to moderate deformity)
Fascial slings (severe deformity)
Tarsorrhaphy (when other techniques fail to protect the cornea)
Ptosis
Brow lift
Nasal airway collapse
Alar base fixation and periosteal anchoring (mild to moderate deformity)
Alar base elevation and support via tendon sling (severe deformity)
Resting tone of mouth/lower face,
oral incompetence
Dermal or fascial slings for suspension of oral commissure (often use tensor fascia latae or tendon—
palmaris, plantaris, extensor digitorum longus)
Facelift
FIGURE 42.3 An appropriately sized gold weight is selected based on the weight needed to achieve lid closure and size of the
eyelid (A). It is centered over midline and affixed over the superior portion of the tarsus (B).
Both the upper and lower eyelids may be operated on simultaneously. When done, the upper lid should
be corrected first to assist in determination of the appropriate degree of lower lid tightening.
Although static procedures in the lower face cannot generate smile, they improve appearance and oral
competence. These techniques are avoided in the pediatric population because of the success of dynamic
procedures in children, and in whom the ability to emote is particularly important for social integration.
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Contralateral Defunctioning
When asymmetry between the normal and paralyzed sides is the primary aesthetic concern,
defunctioning of the normal side, through neurectomy/myectomy or chemodenervation (botox), may be
considered. These techniques are commonly used with good results in CULLP and in adult patients with
acquired unilateral lip depressor dysfunction. 18,19
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Dynamic Procedures
Multiple procedures offer restoration of function. The most appropriate procedure for a given patient
depends on the circumstances of paralysis as well as patient desires and suitability for surgery.
The state of both nerves and musculature dictates reconstructive options (Table 42.7). When paralysis
results from trauma or iatrogenic nerve injury, with relative sparing of muscle, reinnervation (via nerve
repair or transfer) of affected musculature may be an option when performed in a timely fashion. When
viable muscle is not present because of prolonged denervation (after approximately 24 months of
denervation, the muscles undergo irreversible atrophy and fibrosis), traumatic destruction, or agenesis,
dynamic reconstructive options include free or local muscle transfer.
TABLE 42.7
Reconstructive Options for Reanimation Based on Nerve and Muscle Viability
Proximal Stump Present
Proximal Stump Absent
Muscle viable with usable distal nerve
stump (i.e., early traumatic/iatrogenic
paralysis)
Nerve repair
Primary (if no tension between
nerve ends)
Interpositional
graft
(if
tension
between ends or if they do not
approximate)
Paralysis of <18 months duration
Cross-facial nerve graft (transfer from
contralateral facial nerve)
Nerve transfer from alternate donor (see
Table 42.8)
Paralysis of 18–24 months’ duration
Nerve grafting from alternate donor, without
need for interpositional graft
Nerve to masseter
Hypoglossal nerve
Muscle not viable (or no distal nerve stump,
i.e., late paralysis; agenesis)
Free functional muscle transfer,
innervated by proximal stump
Local muscle transfer
Free functional muscle powered by cross-facial
nerve graft or alternate donor (see Table 42.9)
Local muscle transfer
Following traumatic/iatrogenic damage to the facial nerve in which both proximal and distal stumps are
identified, nerve repair may be possible. If the ends can be approximated without tension, primary repair
is favored. Otherwise, interpositional grafting (usually sural) is required. Although results are reliable
following repair up to 12 to 18 months following injury, ideally, nerves are repaired within 72 hours. This
allows for intraoperative stimulation of distal stumps to assist in identification. After 72 hours following
injury, neurotransmitter reserves in the distal stumps become too depleted to reliably generate muscular
activity.
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Nerve Transfer
When injury leaves viable distal nerve stumps/musculature but no proximal nerve stumps, nerve transfer
is an option. 20 As with nerve repair, transfer should be performed as early as possible. Multiple donor
nerves exist (Table 42.8). In unilateral palsy with normal contralateral facial nerve function, cross-facial
nerve grafting from the corresponding contralateral facial nerve branch (Figure 42.4) is favored (when
performed within 6–12 months of injury). Twelve to eighteen months following injury, direct transfer
from physically closer nerves (i.e., nerve to masseter) is favored to shorten time to reinnervation.
TABLE 42.8
Donor Nerves for Nerve Transfer and Innervation of Free Functional Muscle Transfers
Nerve
Advantages
Disadvantages
Contralateral
facial nerve (via
cross-facial
nerve graft)
The
only
donor
capable
of
generating emotional control of
smile
Capable
of
generating
good
excursion in smile
Can
use
corresponding
contralateral branches for blink
No significant donor deficit
Not available in bilateral cases
Requires two-stage procedure when used in innervation of free
muscle transfers
In the setting of reinnervation of native mimetic musculature through
nerve transfer, the need for long nerve graft may preclude use in
paralysis of greater than 12 months duration owing to time for neural
regeneration through graft
Nerve to
masseter
Reliable donor (even in patients
with Mobius syndrome)
Capable
of
generating
good
excursion in smile (can show
greater
excursion
than
that
achieved via cross-facial nerve
grafting)
Consistent anatomy
No significant donor deficits
Generally close enough to recipient
nerve to avoid an intervening
nerve graft
Volitional rather than emotional control
Hypoglossal
Capable of producing powerful
smile
Third most commonly affected cranial nerve in Mobius syndrome—
unreliable source of innervation in these patients and use may impair
speech and ability to swallow
Volitional rather than emotional control
Spinal
accessory
Often available when other cranial
nerves may not be
Distance from target often necessitates use of intervening nerve graft
Volitional rather than emotional control
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FIGURE 42.4 Cross-facial nerve graft for reinnervation of contralateral facial nerve. When distal facial nerve stumps are
available for reinnervation on the injured side, contralateral (functional) facial nerve stumps can be transferred (via cross-facial
nerve graft) to the corresponding viable nerve stumps for neural input. Here, cross-facial nerve grafting for both blink and smile
are shown.
When cross-facial nerve grafting is unavailable (i.e., bilateral palsy), other donor nerves may be used.
Selection depends on donor availability, proximity to target (with the goal of decreasing the length or
need for interpositional grafts), and surgeon preference. Cranial nerve V (specifically, nerve to masseter)
is often a favorable choice because of proximity to targets and reliable anatomy. If a single donor nerve is
used to reinnervate multiple functions (i.e., smile and blink), synkinesis results.
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Muscle Transfer
When viable mimetic musculature is not available for reinnervation, animation can be achieved by
transfer of a functioning muscle, either local or free.
Local muscle transfer most commonly reroutes all or part of the temporalis and/or masseter for
generation of smile and/or blink. This can be a good option for patients who are not suitable candidates
for (or who do not wish to undergo) free muscle transfer.
Multiple techniques exist for transfer of all or part of the masseter to generate smile and/or blink. 21 For
smile, transfer may be performed through an intraoral approach, sparing the patient external scars. In the
lower face, masseter transfers reliably improve static tone, but results for animation are less consistent.
Functional smile may be achieved, but the vector of pull through many techniques of transfer leads to a
smile of unnatural appearance.
The temporalis transfer (Figure 42.5), as described by Labbe, 22 disinserts the temporalis from the
coronoid and transfer of the insertion to the commissure (for smile) or, in other descriptions, to the
periorbital region (for blink). As with masseteric transfers, temporalis transfer reliably provides static
support, although excursion is variable. 23 Additionally, depending on technique, temporal hollowing can
occur.
FIGURE 42.5 The temporalis transfer as described by Labbe involves a coronoid osteotomy for ease of repositioning of the
temporalis tendon (A), zygomatic arch osteotomy for enhanced accessibility to the temporalis (B), elevation and repositioning of
the entire temporalis muscle, and insertion of the temporalis tendon (stripped from the coronoid) to the oral commissure (C).
(Reproduced with permission from Panossian, A. Temporalis flap and lengthening temporalis myoplasty for facial paralysis. In: Chung, KC , ed. Operative
Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. Part 3, Figure 50-2.)
Temporalis transfer may not be possible for some patients who have undergone neurosurgical
procedures that require access through the temporal region because of potential disruption of the
neurovascular pedicle.
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Free Functional Muscle Transfer
Free functional muscle transfer is often considered the standard for smile reanimation, particularly in
children. Generally, these transfers produce superior commissure excursion (in terms of magnitude and
direction) compared with local muscle transfer. In children, these are nearly always the procedure of
choice for reanimation because of reliability in the younger population.
Options exist for both upper and lower facial reanimation. Many muscles have been utilized for smile
(Table 42.9). 24-29 Similarly, options exist for blink reinnervation 30 – most commonly either a segment of
gracilis or a slip of platysma.
TABLE 42.9
Commonly Used Muscles Used for Free Functional Transfers
Muscles Free Functional
Transfers
Advantages
Disadvantages
Gracilis
Consistent, reliable anatomy/pedicle
Can harvest with two-team approach in facial
reanimation
Can be transferred with minimal bulk
Minimal donor morbidity
Pectoralis minor
Can be transferred with minimal bulk
Minimal donor morbidity
Pedicle variable
Two-team approach difficult in facial
reanimation
Latissimus dorsi
Reliable donor
Often bulky
Two-team approach difficult in facial
reanimation
Extensor carpi radialis brevis
Can be transferred with minimal bulk
Minimal donor morbidity
Results often inferior to use of other
muscles
As with selection for muscle transfer, there are choices for neural input. Options are the same as those for
nerve transfer above 31 (see Table 42.8). Two of the most commonly used nerves are the contralateral facial
nerve (via cross-facial nerve graft) and the ipsilateral nerve to masseter. Both have been proven to
generate reliable, satisfactory smile excursion when powering free functional muscles. Each technique has
advantages and disadvantages.
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Cross-Facial Nerve Grafting
As with nerve transfers to reinnervate native mimetic musculature, emotional control of a free muscle can
be achieved only through use of the contralateral facial nerve as donor. This method of reconstruction is
performed in two stages (Figure 42.6). In the first stage, a cross-facial nerve graft (generally sural) is
coapted to the donor facial nerve and tunneled toward the affected side. The specific donor nerve
branches are selected through intraoperative nerve stimulation to identify those that produce commissure
and upper lip movement—most consistent with the smile to be reconstructed on the affected side. These
branches are then transected and coapted to the nerve graft, which is tunneled through the upper buccal
sulcus for later coaptation to the nerve to the transferred muscle.
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FIGURE 42.6 Free gracilis transfer powered by cross-facial nerve graft. The gracilis has been inset in the vector required to
produce a smile in the desired vector. The obturator nerve has been coapted to a cross-facial nerve graft, and the vascular
pedicle is receiving supply from the facial vessels.
(Reproduced with permission from Sugg, KB. Facial paralysis. In: Brown, DL , Borschel, GH , Levi, B , eds. Michigan Manual of Plastic Surgery. 2nd ed.
Philadelphia, PA: Wolters Kluwer Health; 2014:239. Figure 24-3.)
The technique for generation of eye closure is similar. Instead of selecting donor branches that generate
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smile, donors are selected on their ability to produce desired blink. Rather than tunneling through the
upper buccal sulcus, the graft is tunneled supraorbitally, across the nasal bridge, into the region of the
affected orbicularis oculi muscle.
In the second stage, performed approximately 12 months following the first (adequate time between
procedures is dictated by the presence of an advancing Tinel sign along the nerve graft, indicating the
distal extent of neural regeneration), free muscle transfer is performed and neurotized by the cross-facial
nerve graft that was previously placed.
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Nerve to Masseter
Unlike with cross-facial nerve grafting, reanimation is accomplished in a single stage, 32 making it a good
choice for patients who wish to avoid two procedures. Additionally, it can be used in patients with
bilateral paralysis, in whom the contralateral facial nerve is not available. The nerve to masseter is almost
always unaffected in patients with Mobius syndrome, making it a reliable choice in this population 26 (its
function can be verified by asking the patient to clench their masseter muscle). The nerve to masseter is
large and can donate more axons to the recipient free muscle than can a cross-facial nerve graft. This may
manifest functionally as greater commissure excursion resulting from use of nerve to masseter as
compared with cross-facial nerve grafting. 33
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Reanimation in Children
Ideally, smile reanimation should be completed by school age. In the setting of bilateral paralysis, this
ideally the first muscle transfer is not performed prior to the age of 4 years. This allows sufficient growth
of anatomic structures (i.e., neurovascular pedicles) and increases the likelihood of sufficient maturity on
the part of the patient for them to actively participate in postoperative rehabilitation and flap care.
Reanimation can be performed either simultaneously or staged (one side at a time, spaced 3 months
apart).
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Summary
Facial paralysis is a complex problem that can have significant functional as well as psychosocial effects.
Multiple etiologies exist, and proper diagnosis is essential to multidisciplinary care to ensure appropriate
treatment is offered. For those patients who will not regain adequate function with conservative
management, surgical intervention for improvement of static symmetry or restoration of function may be
indicated. All patients, regardless of surgical status, should undergo physical therapy. Retraining of
musculature can be laborious and slow, and targeted therapy directed to trained therapists is essential for
optimizing function.
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Questions
1. A 4-year-old girl with congenital bilateral facial paralysis and palsy of bilateral abducens nerves
presents for smile reanimation. She was told that she would undergo reanimation for the right and
left sides at separate surgeries. What is the most appropriate surgical method of smile reanimation in
this patient?
a. Bilateral gracilis free muscle transfers powered by cross-facial nerve grafts
b. Bilateral gracilis free muscle transfers powered by nerve to masseter
c. Bilateral gracilis free muscle transfers powered by the hypoglossal nerve
d. Bilateral temporalis transfers
e. She is not a candidate for smile reanimation.
2. A 22-year-old woman was stabbed in the cheek during an altercation and brought immediately to
the emergency room. She has unilateral difficulty with smiling. You suspect that she has suffered
sharp laceration to zygomaticobuccal branches of the facial nerve on that side. She has no other
obvious injuries. Ideally, the longest you should wait before bringing her to the operating room for
exploration and repair is:
a. 24 hours
b. 72 hours
c. 1 week
d. 6 months
e. 36 months
3. A 6-year-old girl with hemifacial microsomia presents for smile reanimation. She and her parents
wish for whatever procedure will produce the most favorable, natural appearing results. The
procedure that you will recommend to her is:
a. Temporalis transfer
b. Free gracilis transfer powered by the ipsilateral nerve to masseter
c. Free gracilis transfer powered by a cross-facial nerve graft
d. Chemodenervation of the contralateral zygomaticus major
e. Cross-facial nerve graft (nerve transfer) directly to a native zygomaticobuccal branch on the
paralyzed side
f. Nerve transfer from ipsilateral nerve to masseter directly to zygomaticobuccal branch on the
paralyzed side
4. A 56-year-old woman presents with lower lip dysfunction following a facelift. You wish to
determine which facial nerve branches may have been injured. You ask her first to perform a full-
denture smile and notice greater lower tooth show on the left. You then ask her to pout and notice
significant asymmetry, with no eversion on the right. Based on these findings, you can conclude:
a. The right marginal mandibular branch has been injured
b. The right cervical branch has been injured
c. The left marginal mandibular branch has been injured
d. The left cervical branch has been injured
e. Both the marginal mandibular and cervical branches have been injured
5. A 32-year-old male presents to clinic 1 week after a deep laceration to the midcheek that was
initially quickly irrigated and closed without exploration. You notice significant swelling on that side
consistent with a sialocele and suspect that a parotid duct injury may have gone undetected. Which
branch of the facial nerve is most likely to have also suffered injury in this patient?
a. Temporal
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b. Zygomaticobuccal
c. Marginal mandibular
d. Cervical
e. All equal likelihood
1. Answer: b. Based on the description of the patient, she most likely has Mobius syndrome. There is
no reason to expect that she would not be a candidate for smile reconstruction. In the pediatric
population, local muscle transfers are not generally used as first-line strategies for reanimation
because of the success of free functional muscle transfers. In patients with Mobius (or indeed
bilateral paralysis in general), the contralateral facial nerve is not available as a donor. The
hypoglossal nerve is the third most commonly affected cranial nerve in these patients and is not a
reliable donor, such that use may lead to poor reanimation outcomes and may also generate
significant donor deficits (i.e., impaired speech and eating). The best choice for these patients is
bilateral free functional gracilis transfer powered by the nerve to masseter, which is nearly always
sufficient in this patient population.
2. Answer: b. Facial nerve lacerations (as with motor nerve lacerations throughout the body) should
ideally be explored and repaired within 72 hours of injury. This allows the distal nerve stumps to be
stimulated to help in intraoperative identification. After 72 hours, neurotransmitter stores in the
distal stumps are generally too depleted to activate muscular contraction with stimulation.
3. Answer: c. In patients with hemifacial macrosomia, there is no viable recipient nerve or normal
musculature available for reinnervation (ruling out answers E and F). Local muscle transfers are not
considered first-line options for reanimation in children given success with free muscle transfers. A
free gracilis transfer is ideal for smile reanimation in patients who lack viable mimetic musculature,
especially children, with facial paralysis. Although both cross-facial nerve grafts and nerve to
masseter are both reliable donors for free functional muscle transfers, only use of cross-facial nerve
graft will permit emotional smile. Additionally, use of cross-facial nerve grafts will also generate
some resting tone, which does not occur with reinnervation using nerve to masseter.
4. Answer: a. Injury to cervical and marginal mandibular branches can look quite similar. Both may
result in weakness of lower lip depression (although it is possible to have intact depression with
isolated injury to cervical branches depending on the patient). Only injury to the marginal
mandibular branch, however, because of its innervation of the mentalis, will leave a patient unable to
evert their lower lip. It is possible that this patient has injured both branches. However, based on the
information given, the only absolute conclusion that may be drawn is that the right marginal
mandibular branch is not working.
5. Answer: b. Despite variations in branching patterns of the facial nerve, it is generally accepted that
the zygomaticobuccal branch runs in close approximation to the parotid duct. Although it is certainly
possible to injure multiple nerve branches with a laceration to the midcheek that also injures the
parotid duct, the proximity of the zygomaticobuccal branch makes it the most likely to be involved.
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References
Myckatyn, TM, Mackinnon, SE. A review of facial nerve anatomy. Semin Plast Surg. 2004;18(1):5-12.
Pitanguy, I, Ramos, AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg.
1966;38(4):352-356.
Gosain, AK, Sewall, SR, Yousif, NJ. The temporal branch of the facial nerve: how reliably can we predict its path? Plast Reconstr Surg.
1997;99(5):1224-1236.
Agarwal, CA, Mendenhall, SD, Foreman, KB, Owsley, JQ. The course of the frontal branch of the facial nerve in relation to fascial planes: an
anatomic study. Plast Reconstr Surg. 2010;125(2):532-537.
Saylam, C, Ucerler, H, Orhan, M, Ozek, C. Anatomic guides to precisely localize the zygomatic branches of the facial nerve. J Craniofac Surg.
2006;17(1):50-53.
Saylam, C, Ucerler, H, Orhan, M, Ozek, C. Anatomic landmarks of the buccal branches of the facial nerve. Surg Radiol Anat. 2006;28(5):462-
467.
Dorafshar, AH, Borsuk, DE, Bojovic, B, et al. Surface anatomy of the middle division of the facial nerve: Zukerês point. Plast Reconstr Surg.
2013;131(2):253-257.This study validates the use of Zuker’s point as an anatomic landmark for identification of the branches of the facial nerve that
generates smile (i.e., for use in cross-facial nerve grafting).
Davies, JC, Ravichandiran, M, Agur, AM, Fattah, A. Evaluation of clinically relevant landmarks of the marginal mandibular branch of the
facial nerve: a three-dimensional study with application to avoiding facial nerve palsy. Clin Anat. 2016;29(2):151-156.
Nelson, DW, Gingrass, RP. Anatomy of the mandibular branches of the facial nerve. Plast Reconstr Surg. 1979;64(4):479-482.
Chowdhry, S, Yoder, EM, Cooperman, RD, et al. Locating the cervical motor branch of the facial nerve: anatomy and clinical application.
Plast Reconstr Surg. 2010;126(3):875-879.
Terzis, JK, Kalantarian, B. Microsurgical strategies in 74 patients for restoration of dynamic depressor muscle mechanism: a neglected target
in facial reanimation. Plast Reconstr Surg. 2000;105(6):1917-1931.
Hohman, MH, Hadlock, T. Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center. Laryngoscope.
2014;124(7):E283-E293.
Gaudin, RA, Jowett, N, Banks, CA, et al. Bilateral facial paralysis: a 13-year experience. Plast Reconstr Surg. 2016;138(4):879-887.
Kadakia, S, Helman, SN, Schwedhelm, T, et al. Examining the genetics of congenital facial paralysis—a closer look at Moebius syndrome.
Oral Maxillofac Surg. 2015;19(2):109-116.
Pastuszak, AL, Schuler, L, Speck-Martins, CE, et al. Use of misoprostol during pregnancy and Mobius’ syndrome in infants. N Engl J Med.
1998;338(26):1881-1885.
House, JW, Brackmann, DE. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985;93(2):146-147.
Manktelow, RT. Use of the gold weight for lagophthalmos. Oper Tech Plast Reconstr Surg. 1999;6(3):157-158.
Lindsay, RW, Edwards, C, Smitson, C, et al. A systematic algorithm for the management of lower lip asymmetry. Am J Otolaryngol Head Neck
Med Surg. 2011;32(1):1-7.
Hussain, G, Manktelow, RT, Tomat, LR. Depressor labii inferioris resection: an effective treatment for marginal mandibular nerve paralysis.
Br J Plast Surg. 2004;57(6):502-510.This article describes deformity related to dysfunction of the marginal mandibular nerve and details myectomy for
treatment of asymmetry.
Conley, J, Baker, DC. Hypoglossal–facial nerve anastomosis for reinnervation of the paralyzed face. Plast Reconstr Surg. 1979;63(1):63-72.
Baker, DC, Conley, J. Regional muscle transposition for rehabilitation of the paralyzed face. Clin Plast Surg. 1979;6(3):317-331.
Labbé, D, Huault, M. Lengthening temporalis myoplasty and lip reanimation. Plast Reconstr Surg. 2000;105(4):1289-1297.
Bos, R, Reddy, SG, Mommaerts, MY. Lengthening temporalis myoplasty versus free muscle transfer with the gracilis flap for long-standing
facial paralysis: a systematic review of outcomes. J Craniomaxillofa Surg. 2016;44(8):940-951.
Terzis, JK. Pectoralis minor: a unique muscle for correction of facial palsy. Plast Reconstr Surg. 1989;83(5):767-776.
Dellon, AL, Mackinnon, SE. Segmentally innervated latissimus dorsi muscle. Microsurgical transfer for facial reanimation. J Reconstr
Microsurg. 1985;2(1):7-12.
Zuker, RM, Goldberg, CS, Manktelow, RT. Facial animation in children with Mobius syndrome after segmental gracilis muscle transplant.
Plast Reconstr Surg. 2000;106(1):1-8.This article describes techniques of reanimation in children with Mobius. It describes key considerations in this
patient population from a surgical standpoint and describes a technique for reanimation.
Yang, D, Morris, SF, Tang, M, Geddes, CR. A modified longitudinally split segmental rectus femoris muscle flap transfer for facial
reanimation: anatomic basis and clinical applications. J Plast Reconstr Aesthet Surg. 2006;59(8):807-814.
Liu, AT, Lin, Q, Jiang, H, et al. Facial reanimation by one-stage microneurovascular free abductor hallucis muscle transplantation: personal
experience and long-term outcomes. Plast Reconstr Surg. 2012;130(2):325-335.
Sugg, KB, Kim, JC. Dynamic reconstruction of the paralyzed face, part II: extensor digitorum brevis, serratus anterior, and anterolateral
thigh. Oper Tech Otolaryngol Head Neck Surg. 2012;23(4):275-281.
Terzis, JK, Karypidis, D. Blink restoration in adult facial paralysis. Plast Reconstr Surg. 2010;126(1):126-139.
Borschel, GH, Kawamura, DH, Kasukurthi, R, et al. The motor nerve to the masseter muscle: an anatomic and histomorphometric study to
facilitate its use in facial reanimation. J Plast Reconstr Aesthet Surg. 2012;65(3):363-366.This article describes the technique for identifying the
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nerve to masseter through the use of surface landmarking: 3 cm anterior to the tragus and 1 cm inferior to the zygomatic arch.
Klebuc, MJA. Facial reanimation using the masseter-to-facial nerve transfer. Plast Reconstr Surg. 2011;127(5):1909-1915.
Bae, YC, Zuker, RM, Manktelow, RT, Wade, S. A comparison of commissure excursion following gracilis muscle transplantation for facial
paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve. Plast Reconstr Surg. 2006;117(7):2407-2413.This study
compares results of innervation of free gracilis transfer for smile using nerve to masseter and cross-facial nerve grafting to power the transfer. It finds
that excursion is greater following transfer from nerve to masseter.
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C H A P T E R 4 3
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Mandible Reconstruction
Mark W. Stalder and Chad A. Perlyn
Key Points
The ideal donor site for nonvascularized bone grafts is from the ilium, whereas the free fibula flap
remains the standard for vascularized reconstruction of critical mandibular defects.
Rigid fixation of bone grafts, both vascularized and nonvascularized, is essential for optimum
healing and integration.
An essential component of bony reconstruction of the mandible, particularly with nonvascularized
grafts, lies in having a healthy bed of soft tissue to receive the graft.
In reconstruction of major posttraumatic defects of the mandible, it is advisable to set the occlusion
temporarily and delay reconstruction until the soft tissue has had adequate time to heal.
In cases of postoncologic reconstruction, the surgeon must be cognizant of the likely need for
radiation, and thus vascularized bone is essential to maintain support of the soft tissue and viability
of bone.
In cases of osteoradionecrosis of the mandible, radical debridement of any involved tissue to that
which is obviously healthy and bleeding, and beyond—both soft tissue and bone—is essential to
prevent future complications and/or a failed reconstruction.
The surgeon must not hesitate to use multiple free flaps, if necessary, to attain the necessary volume
of healthy tissue in cases of massive tissue loss or resection.
Preoperative virtual surgical planning offers an ideal option for improving accuracy of bony
reconstruction, as well as the efficiency of intraoperative maneuvers.
The mandible is one of the primary structural components essential to mastication and maintenance of a
patent airway, as well as an essential component of the aesthetic balance and appearance of the lower
third of the face. As such, traumatic, ablative, and congenital defects of the bony mandible confer
significant physical and psychosocial impediments in the daily lives of affected patients. Restoration of
this structure is essential to providing a sense of normalcy to these patients, allowing them to eat, speak,
and interact socially without undue disruption and stigmata of deformity.
Objectives of mandibular reconstruction are clear: restoration of premorbid form and function. This
ideally includes an intact and functional bony construct capable of supporting normal dental occlusion,
through osseointegrated dental implants, dental bridge, or dentures. Optimally the patient should be
capable of eating a regular diet postoperatively. Additionally, the postoperative result should attempt to
restore or maintain the appearance of the soft tissue envelope of the lower face by providing appropriate
bony support.
Successful reconstruction is strongly contingent upon patient optimization, donor site selection, surgical
technique, and reconstructive timeline, as well as the surgeon’s experience and aptitude at evaluating
those factors and establishing the appropriate conditions that promote a successful surgical effort. The
mandible presents several challenges to the reconstructive surgeon that may affect outcomes. It is a
mobile, load-bearing structure that requires proper fixation to promote adequate healing. Additionally,
its adjacent position to the oral cavity increases the risk for bacterial contamination and salivary leakage
into the surgical site. If these factors can be properly mitigated, surgical outcomes can be suboptimal.
Prior to the rise of vascularized free tissue transfer techniques, the primary method of bony
reconstruction of the mandible used nonvascularized autologous bone grafting and often included
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nonrigid fixation that had high potential for failure or suboptimal outcomes. However, due to the
continued advancement of technological and surgical techniques, reconstructive surgeons currently can
treat mandibular defects with high reliability, achieving excellent short- and long-term functional and
aesthetic results.
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Indications for Reconstruction
Trauma
Traumatic injury with associated segmental bony loss represents a relatively smaller component of the
overall volume of reconstructive procedures of the mandible that are performed each year. There are
three main classifications of traumatic etiology affecting the mandible: low-energy blunt trauma, high-
energy blunt trauma, and ballistic trauma. Low-energy blunt trauma involves simple assault or falls from
standing height and typically results in simple fractures that are easily treated with closed reduction or
simple open reduction and fixation. Generally these injuries do not include soft tissue loss, comminution,
periosteal stripping, or devascularization of bony fragments. High-energy blunt trauma includes motor
vehicle collisions, motorcycle accidents, assault with a blunt object, or falls from significant height. These
are generally more serious injuries and frequently cause comminuted fractures that may result in small
segmental bony defects and damage to soft tissue that can impact both the viability of the bony fragments
as well as the techniques that must be considered for adequate coverage of any internal hardware or
efforts at bony reconstruction. Ballistic injury from gunshot wounds or explosive events can cause
devastating damage to the mandible and surrounding soft tissue. Fractures are commonly comminuted,
often with acute segmental loss of bone and frequently include significant soft tissue damage or loss.
These severe injuries require careful planning to achieve functional mandibular reconstruction and are
the most likely to require bony reconstruction.
Regardless of the nature of the injury, the approach for treating traumatic injuries of the mandible
remains the same, following established stepwise principles for optimum outcomes. Fractures should be
stabilized acutely—either by closed reduction and maxillomandibular fixation or open reduction with
internal fixation—to reestablish premorbid occlusion, or in the event of poor dentition, anatomic
alignment of the bony framework. For simple fractures without loss of bone, this is likely the definitive
treatment. For more serious injuries that include segmental loss of bone, acute reduction and fixation
achieve optimal healing of the larger fractured segments, while permitting interval healing of damaged
soft tissue so that there may be an adequate envelope of vascularized tissue to provide a healthy recipient
bed for nonvascularized bone grafts without undue contraction of the defect. Likewise, if possible,
delayed reconstruction using vascularized bone allows for demarcation of tissue injury and a healthy
recipient site, as well as resolution of edema and inflammatory processes. It also gives time for careful
preoperative planning using virtual surgical planning (VSP) techniques.
Stabilization under these circumstances is typically performed with a defect-spanning reconstruction
plate for load-bearing fixation for early mobilization and prevention of ankylosis of the
temporomandibular joint. If there is significant loss of soft tissue associated with a segmental loss of bone,
vascularized tissue transfer is required in addition to any bony reconstruction (vascularized or
nonvascularized) to provide adequate coverage and healing of the construct.
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Primary Oncologic Resection
Reconstruction of mandibular defects secondary to oncologic ablation represents a much larger
percentage of the overall volume of bony reconstructive cases involving the mandible. These patients also
present a very different set of circumstances that must be considered relative to the trauma patient. On
one hand, these cases are typically planned in advance with the ablative surgeon, to achieve patient’s
physical status and set expectation, as well as VSP for improved efficiency in the operating room (OR)
and accuracy of the reconstruction. There is also the advantage of controlling damage to the surrounding
soft tissue envelope (if the patient has not been radiated), so edema and inflammatory processes are
minimized. Having said that, these patients are typically older, have a long history of tobacco and
sometimes alcohol abuse, commonly do not have an optimized nutrition status, and most importantly are
often radiated either preoperatively or postoperatively. The significance of the damage to the
surrounding soft tissue envelope due to radiation cannot be overstated. The implications for healing can
result in an array of postoperative complications ranging from small wounds to total graft failure or even
life-threatening medical complications.
The vast majority of these patients (radiated or not) will require vascularized bone for optimum
functional and aesthetic reconstructive results. Under no circumstances should a nonvascularized bone
graft be placed either in a radiated soft tissue envelope or in a patient who will require postoperative
radiation therapy. Additionally, the impaired nutrition and continued tobacco use in many of these
patients can impede proper healing of nonvascularized grafts. If possible, advanced preoperative
placement of a feeding tube should be considered to ameliorate nutritional deficiencies with
supplementation of oral intake for improved healing.
As with trauma patients, fixation of the bony construct should be performed with load-bearing plates, as
early mobilization remains important. These patients will also require a temporary tracheostomy to
maintain an established airway postoperatively during the acute phase of edema, for unencumbered
access to the operative field during the procedure. If there are no significant postoperative concerns, the
patient can typically be decannulated prior to discharge.
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Osteoradionecrosis
Likely, the most complex patients undergoing bony reconstruction of the mandible are those who suffer
from osteoradionecrosis. These patients have the unfortunate circumstance of having suffered from an
oral malignancy as well as having been treated with radiation and experiencing all of the negative
sequelae inherent to that process. Mandibular bone death occurs due to the resulting localized
hypovascularity, hypocellularity, and hypoxia from radiation. In these patients, it is the treatment that
has caused their insidious and progressive pathology. The extent of disease is commonly not obvious on
imaging or examination and often involves the soft tissue. When the patient demonstrates pathologic
fracture or extensive segmental disease, the appropriate treatment is aggressive resection of the involved
mandible and reconstruction with vascularized bone. Use of nonvascularized bone grafts under these
circumstances is wholly unsuitable for the problem at hand, as the radiated tissue bed will not permit
appropriate healing. These patients will often require a soft tissue free flap in addition to vascularized
bone to achieve a proper result.
As these are very complicated patients, VSP is a key component for obtaining an accurate bony
reconstruction while improving the patient’s chances for a long-lasting result. Resection of the diseased
bone should be planned based on computed tomography (CT) imaging and extend at least 1 cm beyond
the edges of the lesion to assure the presence of healthy bone stock at the margins of the reconstruction.
Not only will this improve the chances of a successful bony union, but also diminishes the risk of leaving
behind occult disease that could cause failure of the reconstructive effort.
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Nonvascularized Bone Grafts
A long-standing technique for the reconstruction of noncritical bony defects of the mandible is the use of
nonvascularized bone grafts. This is an effective strategy for patients who have not suffered devastating
traumatic soft tissue injury, have not undergone prior radiation treatment for malignancy, or who will
not undergo postoperative radiation treatment following ablative surgery. These grafts are commonly
used after ablation of benign tumors of the mandible or localized malignancies with nonaggressive
features where the bony resection is less and there is minimal disruption of the surrounding tissue
envelope.
There are numerous reports of the successful use of nonvascularized grafts for mandibular defects greater
than 6 cm; however, the risk for failure becomes significantly greater as defect size increases, and it is
generally recommended to avoid this technique beyond that length. 1-4 The main factors resulting in graft
failure include bony resorption, infection, and defect length. Above all else, the use of nonvascularized
grafts requires a healthy, well-vascularized recipient bed of surrounding soft tissue, and healthy adjacent
mandibular bone at the margins of the defect to achieve an osseous union and reestablish effective bony
structural support. As such, it can be advantageous to delay grafting for soft tissue healing to occur. 2,3,5
As with any procedure designed to reestablish the bony structure of the mandible, proper fixation
techniques are essential for a successful bony union, and an extraoral approach is often recommended to
avoid undue salivary contamination and mitigate the risk of infection.
There is an abundance of potential donor sites from which to harvest bone grafts that can be used for this
purpose, and most trained reconstructive surgeons can successfully perform these procedures. By far, the
most common site for graft harvest is the ilium. The iliac crest, both anterior and posterior, is an ideal
donor for intact corticocancellous grafts that immediately provide inherent structural support for the
reconstruction, as well as purely cancellous or particulate corticocancellous grafts that, while offering no
immediate structure, are able to be manipulated and molded to provide ideal aesthetic reconstructive
outcomes. 2,5,6 After adequate healing and ossification of these grafts, they can also serve as a base for
dental restoration using osseointegrated implants, though without the same degree of success seen with
vascularized bone grafts. 2,3,5 Additional possible nonvascularized bone grafts that can be used
successfully for mandibular defects are rib grafts, fibular grafts, tibial grafts, and split calvarial grafts.
These sites are used less frequently than the ilium but offer adequate alternatives should the need arise.
4,6,7
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Vascularized Free Tissue Transfer
As microsurgical techniques and surgical efficiency continue to improve over the last two decades, the
use of vascularized bone flaps has become the standard for reconstruction of critical segmental defects of
the mandible. Though these procedures have a big learning curve and require specialized training and
experience, there is simply no better substitute than living, vascularized bone in most complex
reconstructive cases. The time to bony union is significantly faster than with nonvascularized grafts, the
risk of infection is considerably lower. Because these flaps do not depend upon an optimized wound bed,
they can be transferred with the addition of healthy, vascularized soft tissue, and can achieve successful
reconstruction of the entire length of the mandible in a single procedure. More specifically, any defect
greater than 6 cm and any patient who has been radiated or will be radiated should be considered a
prime candidate for vascularized bone reconstruction.
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Deep Circumflex Iliac Artery Free Flap
The deep circumflex iliac artery (DCIA) flap offers vascularized iliac crest bone stock of moderate length
(though up to 16 cm has been reported) as a reconstructive option for shorter straight-segment bony
defects of the mandible. Its advantage over nonvascularized iliac crest grafts is quicker healing, improved
resistance to infection, and the possibility of simultaneous transfer of vascularized soft tissue if need be.
Because of its shape and relatively limited length, this flap is more suited for lateral segmental defects as
opposed to anterior or ramus/angle defects that might require multiple osteotomies for adequate
contouring. It can be harvested as an osteocutaneous flap if skin is required, or along with a segment of
internal oblique muscle based off of a perforating vessel from the main pedicle that can be used for
intraoral lining (Figure 43.1). The bone stock can provide good matching height to the native mandible
and is capable of accepting osseointegrated implants for dental restoration, with excellent long-term
retention of upwards of 96% reported. 8-11
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FIGURE 43.1 This patient suffered a self-inflicted gunshot wound to the face. A. Resultant injuries included a comminuted
fracture with segmental loss of the right mandibular body and loss of intraoral mucosal coverage of that area. He underwent
initial debridement and stabilization of the mandible with a defect-spanning reconstruction plate in preparation for a delayed
definitive reconstruction. Subsequent reconstruction was performed using a vascularized segment of the anterior iliac crest
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based off the deep circumflex iliac artery (DCIA). C. Dissection proceeded through an incision along the length of the vessel
and iliac crest as marked. D. A flap of internal oblique muscle based off an ascending perforator from the main vascular pedicle
was included in order to provide intraoral coverage with vascularized soft tissue. E. Ultimately the dissection yielded about 5 cm
of bone, along with the vascularized muscle on a short but adequate vascular pedicle. The flap was inset into the defect using a
custom-milled plate designed through the virtual surgical planning process, and the muscle flap was wrapped around the
construct intraorally (F) to provide an excellent reconstruction of the mandible with matching height and good contour of the
mandibular border (B).
Downsides of this vascularized option include a relatively short pedicle that may require the use of vein
grafts for anastomosis, an inability to effectively perform segmental osteotomies for purposes of
multisegment reconstruction of the mandible, and a general lack of available bony length. 10 Additionally,
donor site morbidity can include an increased risk for abdominal wall hernias, persistent pain, gait
disturbances, and sensory alteration. 12 Because of these factors and the advantages offered by the free
fibula flap, the DCIA flap is employed less frequently for purposes of mandibular reconstruction.
However, it can be useful for moderate length lateral segmental traumatic defects that also require soft
tissue coverage, or similar defects that occur in a radiated field. From a perspective of functional and
aesthetic restoration, the DCIA offers similar outcomes when compared to the fibula flap with regard to
appearance, speech, and oral continence. 11
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Scapula Free Flap
The free scapula bone flap is another less-frequently used vascularized option for reconstruction of
critical mandibular defects. Based off of the circumflex scapular (lateral border of the scapula) or angular
(scapular tip) arteries from the subscapular system, this flap offers a segment of bone of moderate length
—up to 13 cm long at the upper end of its range—though only 1 to 2 cm wide and somewhat thin (Figure
43.2). The scapular tip has been shown to be useful in the reconstruction of short-segment defects and
isolated angular defects, whereas the lateral border provides more length in cases of longer defects of the
body. This is also an excellent option in revision procedures and conveys the versatility inherent to its
root vascular supply, namely the opportunity to be harvested along with one of a number of other tissue
flap options as a chimera with a single common vascular pedicle of significant length. This facilitates the
transfer and inset of a variety of skin or muscle flaps if soft tissue is required for the reconstruction and
without the need for a second microvascular anastomosis. Additionally, when treating older patients, use
of this vascular system can mitigate the issues inherent to the lower extremity peripheral vascular disease
often present in this population. 13
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FIGURE 43.2 This patient underwent primary resection of an oral malignancy that involved segmental resection of the left
mandibular body and associated mucosa. Reconstruction of the mandibular defect was undertaken using a vascularized bone
flap from the lateral border of the scapula based off the circumflex scapular artery from the subscapular system. Additionally, a
skin paddle was planned for intraoral coverage based off perforators of the thoracodorsal artery leading back to the common
subscapular vascular pedicle. A. After the ablative procedure was complete, the flap harvest necessitated placing the patient in
the lateral decubitus position. Once the chimeric flap had been harvested (B), the patient was placed back into the supine
position, and a load-bearing reconstruction plate was shaped and fixed into position at the inferior border of the mandible (C).
D. The bone flap was subsequently inset into the defect, and the skin paddle positioned intraorally for coverage of the construct.
Microvascular anastomosis was performed using the facial artery and vein as recipient vessels.
Although the scapula flap does present a viable option for successful restoration of mandibular form and
function, including osseointegrated implant-based dental prostheses, there are disadvantages that
diminish its usefulness as a primary choice for these cases. Intraoperative logistics can sometimes be
difficult due to the required lateral positioning of the patient, which can prevent a simultaneous two-
surgeon approach to the case. The need to reposition after harvest of the flap can negatively influence
efficiency and increase surgical times. Reported complication rates associated with the scapula flap vary,
and in some cases are suggested to be more favorable relative to the free fibula flap with regard to donor
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site healing, but can cause some degree of long-term shoulder dysfunction. 14
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Fibula Free Flap
The free fibula flap, first described in the late 1980s by Hidalgo, has since become the standard for
vascularized bony reconstruction of critical defects of the mandible. 15 This flap offers numerous
advantages over all other vascularized options that make it the primary choice for almost all cases
including traumatic and primary ablative defects, as well as for reconstruction of osteoradionecrosis
(Figures 43.3–43.5). Its ample length of up to 26 cm (depending upon the patient) and consistent shape
make it incredibly versatile, capable of recreating any segment of the mandible, including defects of the
condyle, body, or anterior segment. This flap is also highly reliable, with numerous published reports
demonstrating up to 100% flap survival. 16,17 Morbidity of the donor site is also within acceptable limits.
At times there can be incisional wound breakdown when a large skin paddle is taken and there is too
much tension on the closure. Additionally, some patients can experience a slightly altered gait, or
reduced ability to participate in strenuous physical activity. 18 However, most patients do not experience
significant postoperative complications. 16
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FIGURE 43.3 This patient previously underwent radiation therapy to treat an oral malignancy but subsequently developed
osteoradionecrosis of the right mandibular body. Virtual surgical planning was used to design the appropriate resection of the
diseased bone and to plan for reconstruction using a vascularized free fibula flap with a perforator-based skin paddle for
intraoral coverage. These preoperative (A,B) and 3-month postoperative (C,D) images demonstrate the ability of this technique
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to restore bony structure and continuity to the mandible and maintain an aesthetic appearance of the lower third of the face with
almost no stigmata of surgery.
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FIGURE 43.4 The dissection shown in these images was undertaken to reconstruct the segmental mandibular defect for the
patient in Figure 43.3. This is performed under tourniquet to facilitate visualization and speed of the dissection in a bloodless
field. A. The fibula is marked preoperatively, taking care to preserve 6 cm of proximal and distal bony length in order to protect
joint integrity and important neurologic structures. Additionally, a handheld Doppler device is used to identify perforators along
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the posterior border of the fibula and the skin paddle designed based off one or more of these vessels. B. An incision is made
along the axis of the fibula contiguous with the anterior edge of the designed skin paddle, and dissection proceeds until the
appropriate perforating vascular bundle is identified and adequate length is obtained. Once the perforator dissection is
complete, the harvest then continues anteriorly along the length of the fibula, taking care to leave a couple of millimeters of
muscle attached to the bone so as not to disrupt the vascular supply from the periosteum. This is taken to the interosseous
membrane, and then proceeds along the posterior aspect of the fibula in a similar fashion. C. At this point, the periosteum is
dissected away from the bone circumferentially at the proximal and distal sites of the planned osteotomies. A retractor is placed
between the fibula and the peroneal vessels to protect them during the osteotomies. Once these have been made, the
interosseous membrane is divided, exposing the length of the vascular pedicle and giving freedom of movement so that the
vessels can be released from the surrounding tissue and its branches from distal to proximal. D. The tourniquet is then released
to allow perfusion of the flap while the printed osteotomy guide is positioned in situ along the fibula. E. Once the closing
osteotomies are made, the patient-specific plate can be applied, completing the planned construct. F,G. Meanwhile, the printed
osteotomy guides for the resection are positioned on the mandible, the diseased portion of bone is removed, and the flap
construct can be fully harvested. H. The flap is then fixed into place at the recipient site using preplanned screw holes for the
custom plate, and the skin paddle is inset intraorally to obtain a watertight closure. Microvascular anastomosis in this patient
was performed using the ipsilateral facial vessels.
FIGURE 43.5 Virtual surgical planning was performed preoperatively for the patient shown in Figures 43.3 and 43.4. This
process allows the surgeon to identify the segment of the mandible to be resected/reconstructed and design an exact-fitting
construct from the fibula. Patient-specific osteotomy guides can then be printed for precise cuts at both the mandible and at the
fibula. Additionally, custom-milled reconstruction plates can then be designed to the surgeon’s specifications and fitted to the
contour of the patient’s mandible.
Based off the peroneal artery, the vascular pedicle can provide excellent length often required in head
and neck reconstruction. Though the peroneal provides an endosteal blood supply through a large
nutrient artery, when transferred as a free flap, the bone stock is usually dependent on the robust
periosteal circulation, as this allows for multiple segmental wedge osteotomies for incredibly versatile
shaping and manipulation. This permits simultaneous reconstruction of straight segments as well as the
curved structures of the mandible at the angle and the parasymphysis anteriorly. Though the surgeon
must bear in mind that to optimize viability, it is generally accepted that each segment must maintain at
least 2 cm in length. Likewise, although the bone stock does not necessarily possess ideal height, it can be
cut for a stacked or double-barreled technique that can adequately recreate the shape of the native
mandible and provide for an optimum aesthetic restoration of the lower third of the face.
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Although not all cases of mandibular reconstruction require additional soft tissue coverage, it is often
necessary to achieve a watertight intraoral closure, which is essential to prevent salivary leakage onto the
vascular pedicle. The fibula flap, again, offers great versatility in this regard, as it can be harvested either
as an osteocutaneous flap, or more commonly, along with a skin paddle based off the perforating vessels
of the peroneal artery. Though there is not an ample volume of excess skin of the lower leg, flaps of up to
5 cm wide and traversing the entire length of the bone flap can be harvested based on these perforators
and still closed primarily. If a skin paddle of greater width is required, the donor site can be readily
closed with a skin graft. The advantage of the perforator-based skin paddle is that it offers flexibility of
inset, with the surgeon able to manipulate positioning with relative ease. These cutaneous flaps can also
be used to provide external coverage if needed. And if the patient requires a very large volume of soft
tissue, or both intraoral and external coverage, the distal end of the peroneal pedicle can provide excellent
flow through vessels for transferring a second fasciocutaneous free flap in series.
As restoration of function is of primary importance, dental restoration is an important consideration for
these patients. The fibula provides excellent bone stock for this purpose with the use of osseointegrated
implants and subsequent design and placement of a dental prosthesis. Numerous studies have confirmed
both the excellent success rates and quality of life measures when dental restoration is pursued in
conjunction with a free fibula reconstruction of the mandible. Additionally, when required, and with
proper contouring, the fibula provides the opportunity for condyle reconstruction, a relative limitation of
the other vascularized bone options.
From a technical perspective, though the basic dissection of the fibula flap is relatively straight forward
(Figure 43.4), the level of complexity can quickly become overwhelming for the inexperienced surgeon in
cases of composite tissue or multisegmental defects. This can become readily apparent when the need
arises for multiple osteotomies or the addition of perforator-based skin paddles or a simultaneous second
fasciocutaneous free flap. Keeping this in mind, the regular use of virtual surgical planning, three-
dimensional-printed osteotomy guides, and predesigned patient-specific reconstruction plates can
significantly reduce the risk of a poor outcome and greatly increase surgical efficiency in the OR. The
addition of a second surgeon to prepare simultaneously the recipient site and vessels is also highly
recommended.
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Virtual Surgical Planning
One of the more recent and useful technological developments that has helped to shape present day
reconstructive efforts is VSP. VSP offers the opportunity to precisely plan the bony mandibular
reconstruction well in advance of the actual procedure using computer-generated three-dimensional
reconstructions of the patient’s anatomy with imported CT imaging files (Figure 43.5). This allows the
surgeon to enter the OR with the details of the procedure having already been thought out and virtually
played out in a stepwise manner. Beyond that, the most practical aspect of this technology is the design
and production of three-dimensional-printed patient-specific guides for use when performing
osteotomies. These guides can be used both to guarantee an accurate bony resection at the recipient site,
as well as on the donor flap to permit accurate and efficient shaping of the bony construct to maximize
bony contact of the osteotomized segments. The potential benefits of regular utilization of VSP are
significant. Published reports demonstrate significantly diminished operative times, more accurate bony
reconstructions, and increased complexity of the cases that can be performed. 19-23
An even more recent addition to this technology is the advent of patient-specific reconstruction plates.
These plates are typically produced through a custom milling process. The surgeon is able to design the
length and screw-hole placement, as well as bends in the plate specific to the needs of the individual
reconstructive procedure. Based on the CT imaging, the plate is contoured precisely to fit the patient’s
native mandible and the designed bony construct to be used in reconstructing the segmental defect. This
additional tool further reduces operative time by preventing the need for intraoperative design and plate
contouring, and the accuracy is unmatched.
At the present time, VSP should be considered for essentially all but the simplest straight-segment cases
of mandible reconstruction employing free osseous flaps. The time saved in the OR as well as the
improvements in accuracy of the reconstruction and plating design justify and make up for the added
expense. Use of this technology is rapidly becoming the de facto standard of care for these procedures.
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Single-Stage Comprehensive Mandibular Restoration
The jaw-in-a-day procedure, as it is popularly known, is the penultimate technique for mandibular
reconstruction. This procedure fully implements currently available state-of-the-art technology and
surgical techniques by virtually planning vascularized fibula flap reconstruction of mandibular defects in
conjunction with simultaneous osseointegrated implant-based dental prosthetic restoration. Printed
osteotomy guides are used to create a precise bony defect, as well as to accurately shape the fibula bone
flap. Additionally, the virtual planning process allows for the preplanned placement of implants prior to
transfer of the flap, as well as prefabricated prosthetic dentition. The patient awakens from surgery and
has a fully functional lower jaw. This technique successfully omits the time gap between reconstruction
and dental rehabilitation under the presumption that early restoration of form and function is
psychologically beneficial for patients by allowing them to seamlessly maintain normal daily activities
and social interactions. 19,20,24,25
This is a highly complex and sophisticated procedure that, at present, is only available at relatively high-
volume centers of microsurgical head and neck reconstruction and requires the availability of several
different specialists to optimize outcomes. Of note, funding is often a significant barrier for obtaining the
implant-based dental prostheses for these patients, limiting the overall number of these cases that are
performed.
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Pediatric Considerations
Pediatric mandibular reconstruction is performed for congenital anomalies of the lower jaw. Congenital
differences include micrognathia, retrognathia, asymmetries, or absence of the mandible or its
components. These issues are commonly associated with diagnoses, including hemifacial or craniofacial
microsomia, Treacher Collins syndrome, Pierre Robin sequence, and Nager syndrome. 26
Though most children with congenital mandibular issues do not require intervention in early infancy, the
exception is the infant with acute respiratory distress who does not respond to conservative measures
such as repositioning or nasal trumpet. Rather than directly proceeding to tracheostomy, mandibular
lengthening can be performed with distraction osteogenesis to improve the upper airway and airflow
resistance, thereby avoiding the need for a surgical airway. Upper airway volume expansion via
distraction has been shown to be able to decrease the flow resistance over the length of the airway,
presumably secondary to an increase in the average cross-sectional area. 26
Those patients with absence of the vertical ramus, condyle, and temporomandibular joint may require
costochondral grafting. Timing for this procedure is typically between 3 and 6 years of age, as this allows
for a more robust donor rib and improved postoperative cooperation. 27 The donor site harvest is not
technically demanding, and after the donor rib has been secured (along with a cartilaginous cap) the graft
is fixed in an overlap fashion to the native mandible using either a lag screw technique or conventional
screws with a piece of titanium plate cut to act as a washer to prevent fracture of the graft. The major goals
of reconstruction in these patients should be alignment of the maxillary and mandibular dental midlines
with the midsagittal plane, a correction/leveling of the mandibular cant, and restoration of facial
symmetry. Published reports have demonstrated the effectiveness of this technique at improving both
functional outcomes (chewing and better oral opening) and aesthetic facial appearance. 28,29 As an
additional consideration, though costochondral grafts can have excellent growth with time, occasionally
additional length is still necessary as the child grows. In these cases, distraction of the rib graft can
achieve the desired symmetry. 30
Mandibular reconstruction following ablative surgery is uncommon in the pediatric patient. When
necessary, the techniques described above, as well as those presented previously in this chapter, can be
applied. Autologous material is preferred and the amount of hardware should be limited and/or
subsequently explanted in the growing child. And consideration of the developing tooth root anatomy
must be considered when using plates on the mandible of a child. 31
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Acknowledgments
Hugo St. Hilaire, DDS, MD, assisted on the cases presented within this chapter, and also contributed
expert insight to the material of the text. Camille Rogers, PhD, contributed significantly in the collection
and organization of background information and bibliographical sources.
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Questions
1. A 57-year-old man with a history of oral squamous cell carcinoma treated initially with radiation
therapy is referred to your office with complaints of recent development of a draining wound to his
left cheek and difficulty chewing food. Examination shows poor dentition. Panorex imaging
demonstrates pathologic fracture at the angle of the left side of the mandible. What is the appropriate
course of treatment?
a. a. A 10-day course of oral amoxicillin/clavulanate
b. Debridement and closure of the cutaneous wound and open reduction/internal fixation (ORIF)
of the angle fracture via extraoral approach
c. Closed reduction of the angle fracture and placement in maxilla-mandibular fixation
d. Radical debridement of the fractured segment of the mandible and free tissue transfer to
reconstruct the angle and involved soft tissue
e. Open debridement of the involved bone and cutaneous tissue and reconstruction with iliac
bone graft
2. A 22-year-old male patient presents to the emergency department having suffered a gunshot
wound to the face. His airway is stable, and there is no active hemorrhage. On physical examination,
there is a contour deformity of the lower face with moderate-sized stellate soft tissue injury to the
lateral cheek. There is significant loss of mucosa on intraoral examination, with multiple mobile
segments of mandibular bone. CT scan shows severely comminuted fractures of the right body and
parasymphysis, with readily apparent loss of bone. What is the most appropriate sequence of events
in the treatment of this patient’s injury?
a. Operative washout and debridement with delayed ORIF of the fractures using load-bearing
fixation
b. Immediate load-bearing fixation of the mandible fractures with primary nonvascularized
bone graft from the iliac crest
c. Operative washout and debridement with immediate load-bearing fixation of the mandibular
segments, followed by delayed reconstruction using a vascularized fibula flap including a skin
paddle based off a peroneal artery perforator
d. Operative washout and debridement with immediate load-bearing fixation of the mandibular
segments, followed by delayed reconstruction using an osteocutaneous DCIA flap
e. Operative washout and debridement with maxillomandibular fixation
3. A 54-year-old woman presents to the emergency department having been involved in a motor
vehicle accident in which she was unrestrained and thrown from the vehicle. She has suffered
multiple injuries including multiple rib fractures, a fractured humerus, a subdural hematoma,
complex lacerations to the face, and multiple facial fractures. CT imaging demonstrates a severely
comminuted fracture of the mandible involving the left mandibular body and a displaced right
subcondylar fracture. On intraoral examination the mucosa is lacerated, but appears to be mostly
intact. After initial debridement and stabilization of the mandible with a load-bearing plate,
subsequent washouts demonstrate a 2-cm segmental defect due to removal of nonviable bone
fragments. The complex cutaneous lacerations have been repaired, but are located immediately
adjacent to the site of bone loss. What is the most appropriate course of treatment for this patient’s
mandible injury?
a. Immediate reconstruction with nonvascularized corticocancellous iliac crest bone graft
b. Delayed reconstruction with nonvascularized corticocancellous iliac crest bone graft
c. Delayed reconstruction with a vascularized free fibula flap, including a perforator-based skin
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paddle for intraoral coverage
d. Delayed reconstruction with nonvascularized split calvarial bone graft
e. Immediate reconstruction with a vascularized DCIA iliac crest bone flap
4. A newborn infant is born with severe micrognathia. There is significant respiratory distress and
conservative measures to improve the airway have not been tolerated. The jaw is symmetrical with
formed condyles, but extremely small. The baby is intubated by the neonatologist and the Plastic
Surgery team is consulted. There are no intrinsic airway anomalies. The next step in the management
of this infant should be:
a. bilateral costochondral grafts for mandibular lengthening
b. bilateral distraction osteogenesis for mandibular lengthening
c. tracheostomy
d. tracheostomy followed by immediate distraction osteogenesis
5. A 16-year-old female presents to the emergency department with a large mass in the mandible. It
has been growing slowly for several years. Imaging shows an expansile lesion with multilocular lytic
lesion and soap bubble appearance, and the diagnosis of ameloblastoma is made. Following segmental
resection, the patient has a mandibular defect of approximately 65%. What is the most appropriate
reconstructive option?
a. Reconstructive plate
b. Costochondral graft
c. Mandibular distraction
d. Free fibular flap
e. Iliac crest bone graft and bone morphogenic protein
1. Answer: d. This patient who has been previously treated with radiation for his oral cancer now
developed osteoradionecrosis of the mandible with loss of structural integrity and orocutaneous
fistula. At this stage of disease, the tissue exhibits severe radiation damage and no longer has the
ability to properly heal. The major principles in treating this patient require replacing the unhealthy,
radiation-damaged tissue (both bone and soft tissue), and reestablishing the structural and functional
integrity of the mandible. This can only be done with wide debridement of the involved bone and
soft tissue and free tissue transfer using the fibula, and quite possibly a second fasciocutaneous free
flap for adequate healthy soft tissue coverage. A course of antibiotics will not repair or replace the
radiation-damaged tissue. ORIF of this pathologic fracture is not an adequate plan for this patient, as
the bone will not have the localized blood supply/tissue oxygenation necessary to heal and is
essentially dead at this point. Likewise, placing the patient in maxilla-mandibular fixation may
reestablish premorbid occlusion, but adequate healing will not take place.
Nonvascularized bone graft will not be adequate to reconstruct what will likely be a large segmental
loss of the mandible, nor will the graft have an adequate recipient site with the healthy soft tissue
necessary to integrate and heal.
2. Answer: c. This patient has suffered a high-energy ballistic injury to the face with significant
intraoral soft tissue loss and segmental loss of the mandible, likely including the body and the
parasymphysis. Immediate washout and debridement of the site of injury is required, along with
stabilization of the fractured mandible. If he has adequate dentition remaining, maxillomandibular
fixation may be possible as a stabilization technique, but this is highly unlikely considering the
nature of the injury. A load-bearing, segment-spanning reconstruction plate is the best choice for
stabilizing this patient’s mandible based on the information at hand. This approach will temporize
the reconstruction by allowing additional debridements as the injured tissue declares itself and time
for adequate soft tissue healing and resolution of edema. The patient is most likely to require a free
fibula for bony reconstruction due to the multisegment involvement of the injury and will also need
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intraoral soft tissue coverage of the construct with a perforator-based skin paddle due to the loss of
mucosa. Immediate nonvascularized bone grafting would not be appropriate in this patient due to
the inadequate bed of soft tissue at the site of injury. Reconstruction with a DCIA iliac crest flap will
not provide adequate length or the ability to reliably perform osteotomies to reconstruct the involved
body and parasymphyseal segments. Maxillomandibular fixation is likely not possible in this patient
based on the description of his injury, as there will probably not be adequate dentition. Additionally,
the patient has segmental loss of bone and will require additional bone stock for a proper
reconstruction.
3. Answer: b. This patient has a noncritical segmental defect of the mandible with intact, but suspect
soft tissue coverage. After stabilization of the fractures with load-bearing fixation, the site of injury
should be permitted time to properly heal to receive a bone graft later. In this case, due to the small
size of segmental loss, a vascularized bone flap is not likely to be necessary, and a structurally sound
nonvascularized corticocancellous graft from the iliac crest should be adequate, and represents the
simplest option. Immediate reconstruction with a nonvascularized bone graft should not be
performed in this patient with questionable soft tissue at the recipient site. A free fibula flap is not
necessary in this patient with a 2-cm segmental defect.
Split calvarial bone graft is not the best option available for this patient compared to the iliac crest, as
it would not provide the same level of structural support. A vascularized DCIA iliac crest graft is not
necessary in this patient with a 2-cm segmental defect.
4. Answer: b. Bilateral distraction osteogenesis for mandibular lengthening. This technique has been
shown to be effective at lengthening the mandible, alleviating airway obstruction and preventing
tracheostomy. The infant should remain intubated during the distraction period and extubated once
the jaw has been brought to length. Bilateral costochondral grafts for mandibular lengthening is not
indicated in the newborn, nor is it necessary given that there are formed vertical rami and condyles.
Tracheostomy may be avoided if successful mandibular lengthening can be achieved with
distraction. While it may still be necessary, an attempt to avoid a tracheostomy would be of benefit to
the newborn given the associated comorbidities. If a tracheostomy is performed, it typically is left in
place until the child is at least 1 year of age before consideration is given to removing it. As such, it
would be prudent to wait until the child was older before performing the distraction.
5. Answer: d. A free fibula flap is the most appropriate choice for a defect of this size. In addition, a
free fibular flap can be designed to restore the normal contour of the mandible. It also will have the
viability and durability to accept osseointegrated implants. With proper planning, these implants can
be placed prior to flap elevation. The defect is too large for a costochondral graft or iliac crest bone
graft. In addition, bone morphogenic protein is not indicated in the pediatric patient population.
Mandibular distraction is a possibility, but it is difficult to obtain the natural contour of the mandible
and will likely not be effective for reconstruction of this type of defect. A free fibula would be a much
more appropriate choice.
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References
Akinbami, BO. Reconstruction of continuity defects of the mandible with non-vascularized bone grafts. Systematic literature review.
Craniomaxillofac Trauma Reconstr. 2016;9(3):195-205.
Pogrel, MA, Podlesh, S, Anthony, JP, Alexander, J. A comparison of vascularized and nonvascularized bone grafts for reconstruction of
mandibular continuity defects.
J Oral Maxillofac Surg. 1997;55(11):1200-1206.
Foster, RD, Anthony, JP, Sharma, A, Pogrel, MA. Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction:
an outcome analysis of primary bony union and endosseous implant success. Head Neck. 1999;21(1):66-71.This study elucidates the clear
superiority of vascularized bone grafts versus nonvascularized bone grafts for critical defects in mandible reconstruction, demonstrating a significantly
higher rate of bony union, fewer operations required, and significantly higher rate of endosseous implant success. These results were seen despite
reconstructing larger average bony defects, and often in radiated patients.
Moura, LB, Carvalho, PH, Xavier, CB, et al. Autogenous non-vascularized bone graft in segmental mandibular reconstruction: a systematic
review. Int J Oral Maxillofac Surg. 2016;45(11):1388-1394.
van Gemert, JT, van Es, RJ, Van Cann, EM, Koole, R. Nonvascularized bone grafts for segmental reconstruction of the mandible—a
reappraisal. J Oral Maxillofac Surg. 2009;67(7):1446-1452.
Ferretti, C, Muthray, E, Rikhotso, E, et al. Reconstruction of 56 mandibular defects with autologous compressed particulate corticocancellous
bone grafts. Br J Oral Maxillofac Surg. 2016;54(3):322-326.
Gadre, PK, Ramanojam, S, Patankar, A, Gadre, KS. Nonvascularized bone grafting for mandibular reconstruction: myth or reality? J Craniofac
Surg. 2011;22(5):1727-1735.
Kniha, K, Möhlhenrich, SC, Foldenauer, AC, et al. Evaluation of bone resorption in fibula and deep circumflex iliac artery flaps following
dental implantation: a three-year follow-up study. J Craniomaxillofac Surg. 2017;45(4):474-478.
Möhlhenrich, SC, Kniha, K, Elvers, D, et al. Intraosseous stability of dental implants in free revascularized fibula and iliac crest bone flaps. J
Craniomaxillofac Surg. 2016;44(12):1935-1939.
Chen, S, Chen, H, Horng, S, et al. Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in
postoperative infection and healing. Ann Plast Surg. 2014;73(suppl 1):S18-S26.
Shpitzer, T, Neligan, PC, Gullane, PJ, et al. The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and
long-term evaluation. Head Neck. 1999;21(7):639-647.
Schardt, C, Schmid, A, Bodem, J, et al. Donor site morbidity and quality of life after microvascular head and neck reconstruction with free
fibula and deep-circumflex iliac artery flaps. J Craniomaxillofac Surg. 2017;45(2):304-311.
Dowthwaite, SA, Theurer, J, Belzile, M, et al. Comparison of fibular and scapular osseous free flaps for oromandibular reconstruction: a
patient-centered approach to flap selection. JAMA Otolaryngol Head Neck Surg. 2013;139(3):285-292.
Fujiki, M, Miyamoto, S, Sakuraba, M, et al. A comparison of perioperative complications following transfer of fibular and scapular flaps for
immediate mandibular reconstruction. J Plast Reconstr Aesthet Surg. 2013;66(3):372-375.
Hidalgo, DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989;84(1):71-79.This is the landmark article that
first described the use of the vascularized fibula flap for mandibular reconstruction. Dr. Hidalgo performed 12 successful reconstructions of large bony
defects in this series, and also demonstrated the ability to perform segmental osteotomies on the fibula construct while still maintaining vascularity. The
fibula flap has since become the workhorse free flap for reconstruction of large segmental bony defects of the mandible.
Hidalgo, DA, Rekow, A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg. 1995;96(3):585-596.
Cordeiro, PG, Disa, JJ, Hidalgo, DA, Hu, QY. Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150
consecutive patients. Plast Reconstr Surg. 1999;104(5):1314-1320.
Feuvrier, D, Sagawa, Y Jr, Béliard, S, et al. Long-term donor-site morbidity after vascularized free fibula flap harvesting: clinical and gait
analysis. J Plast Reconstr Aesthet Surg. 2016;69(2):262-269.
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.This article describes the outcomes of mandible reconstruction with free fibula flaps performed with the
assistance of virtual surgical planning (VSP) and printed cutting guides in a high-volume center. While the accuracy of the reconstructions were
similar, cases performed with VSP were overall more complex (with more average osteotomies performed), and were performed significantly faster in the
operating room (163 minutes faster on average). These results demonstrate how VSP technology can be harnessed to enhance the surgeon’s ability to
improve upon reconstructive outcomes.
Monaco, C, Stranix, JT, Avraham, T, et al. Evolution of surgical techniques for mandibular reconstruction using free fibula flaps: the next
generation. Head Neck. 2016;38(suppl 1):E2066-E2073.
Metzler, P, Geiger, EJ, Alcon, A, et al. Three-dimensional virtual surgery accuracy for free fibula mandibular reconstruction: planned versus
actual results. J Oral Maxillofac Surg. 2014;72(12):2601-2612.
Craig, ES, Yuhasz, M, Shah, A, et al. Simulated surgery and cutting guides enhance spatial positioning in free fibular mandibular
reconstruction. Microsurgery. 2015;35(1):29-33.
Chang, EI, Jenkins, MP, Patel, SA, Topham, NS. Long-term operative outcomes of preoperative computed tomography-guided virtual
surgical planning for osteocutaneous free flap mandible reconstruction. Plast Reconstr Surg. 2016;137(2):619-623.
Levine, JP, Bae, JS, Soares, M, et al. Jaw in a day: total maxillofacial reconstruction using digital technology. Plast Reconstr Surg.
2013;131(6):1386-1391.The patient series described in this article demonstrates the penultimate example of mandible reconstruction—restoration of full
functional dentition performed simultaneously with vascularized free fibula reconstruction of a critical mandibular defect. This procedure would not be
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possible without the use of VSP, again demonstrating the power of this technology to enhance our outcomes as surgeons.
Qaisi, M, Kolodney, H, Swedenburg, G, et al. Fibula jaw in a day: state of the art in maxillofacial reconstruction. J Oral Maxillofac Surg.
2016;74(6):1284.e1-1284.e15.
Perlyn, CA, Schmelzer, RE, Sutera, SP, et al. Effect of distraction osteogenesis of the mandible on upper airway volume and resistance in
children with micrognathia. Plast Reconstr Surg. 2002;109:1809-1818.
Singhal, V, Hill, E. Craniofacial macrosomia and craniofacial distraction. In: Principles and Practice of Pediatric Plastic Surgery. St Louis, MO: Quality
Medical Publishing; 2008:755-800.
Goerke, D, Sampson, DE, Tibesar, RJ, Sidman, JD. Rib reconstruction of the absent mandibular condyle in children. Otolaryngol Head Neck
Surg. 2013;149(3):372-376.
Tahiri, Y, Chang, CS, Tuin, J, et al. Costochondral grafting in craniofacial microsomia. Plast Reconstr Surg. 2015;135(2):530-541.
Stelnicki, EJ, Hollier, L, Lee, C, et al. Distraction osteogenesis of costochondral bone grafts in the mandible. Plast Reconstr Surg.
2002;109(3):925-933.
Adolphs, N, Liu, W, Keeve, E, Hoffmeister, B. Craniomaxillofacial surgery planning based on 3D models derived from cone-beam CT data.
Comput Aided Surg. 2013;18:101-108.
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