Optimized design for using of double-barrel vascularized fibular flap in various types of mandibular defects

Abstract

Background/purpose: The functional and aesthetic reconstruction of the mandible can be achieved by using the double-barrel vascularized free fibula flap. The purpose of this study was to use multiple integrated techniques to more effectively reconstruct the mandible, some contains of our unique ideas.

Materials and methods: 21 patients were included in this study. Computed tomography (CT) data of the patient's mandible and fibula were acquired preoperatively. Individualized surgical simulation was performed by using computer-aided surgical simulation (CASS) technology, about 6 kinds of integrated 3D design ideas were simultaneously perfectly transferred to real surgery. The accuracy of reconstruction was evaluated by superimposing the postoperative and preoperative image of mandible, measuring the linear and angular deviation of landmarks between the planned and actual outcomes.

Results: The mandibular reconstruction was effectively performed on all patients, and the result analysis showed that the surgical plan was precisely performed. The facial contours of the postoperative patients were harmonized and the largest mean linear and angular differences were 1.47 ± 0.31 mm and 3.97 ± 0.63°, respectively.

Conclusion: This study system illustrates how to select and position the fibula for reconstruction of various types of segmental mandibular defects by using double-barrel vascularized free fibula flap. It will provide valuable guidance and enhance the accessibility and efficiency of mandibular defects treatment.

Keywords: Computer-aided surgical simulation; Double-barreled; Fibula flap; Mandibular defects; Surgical guides.

Figure 1

Computer assisted design and virtual planning. (A) Class Ic of mandibular defects (From Brown et al.). (B) Simulation of fibular osteotomies (exclusion of about 6 mm segment of bone between 2 and 3) and shaping and placement of fibular bone. Cutting guide and repositioning guide design.

Figure 2

Computer assisted design and virtual planning. (A) Class II of mandibular defects (From Brown et al.). (B) Simulation of fibular osteotomies (exclusion of about 6 mm segment of bone between 3 and 4) and shaping and placement of fibular bone. Cutting guide and repositioning guide design.

Figure 3

Computer assisted design and virtual planning. (A) Class IIc of mandibular defects (From Brown et al.). (B) Simulation of fibular osteotomies (exclusion of about 6 mm segment of bone between 3 and 4) and shaping and placement of fibular bone. Cutting guide and repositioning guide design.

Figure 4

Computer assisted design and virtual planning. (A) Class III of mandibular defects (From Brown et al.). (B) Simulation of fibular osteotomies (exclusion of about 6 mm segment of bone between 2 and 3) and shaping and placement of fibular bone. Cutting guide and repositioning guide design.

Figure 5

Surgical procedure. (A) The titanium reconstruction plate was pre-bent along the contours of the 3D printed reconstruction mandible model. (B) (C) The cutting guide was positioned as planned and attached firmly to the mandible and the osteotomy had completed. The fibular segment was shaped according to the cutting guide. (D) The positioning guide was used to align the osteotomized fibular segments and the pre-bent reconstruction plate was fixed with the fibular segments to form a composite structure. (E) The composite structure were transferred into the mandibular space, and the repositioning guide screw holes were aligned with the mandible. The reconstruction plate was fixed to the mandible by the screws. (F) The repositioning guide were removed and the lower barrel was fixed by mini titanium, vascular anastomosis were performed as usual.

Figure 6

Example of class Ic-III reconstruction after ablation. (A) The proper fibular segments were transferred to reconstruct the defect. (B) Postoperative orthopantomograms for class Ic–III mandibular defects. (C) Color-coded discrepancy map of reconstruction mandible with the double-barrel vascularized free fibula flap. (D) Frontal images of the patient after surgery.

Figure 7

Computer assisted design and virtual planning. (A) The lingual aspect of the mandible. (B) The shape of the fibula bone and the vessel pedicle position. (C) The superior aspect of the mandible. (D) Illustration of the fibular osteotomy.