Atlas of Mandibular and Maxillary Reconstruction with the
Fibula Flap A step by step approach
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To all my head and neck cancer patients who have inspired, challenged, and
motivated me to strive to provide them with the best possible outcomes in
reconstruction. I remain constantly amazed by their courage, fortitude,
optimism, humor, and grace even under the most challenging and difficult
circumstances. To my mentors, colleagues, fellows, residents, and medical
students who have contributed in myriad ways to my own education over the
past three decades. To my parents who fostered my diverse interests and
always encouraged me to make a difference. Finally, to my wife Carolyn and
children Christina, Catherine, and Andrew who have provided me with
unrelenting love and support; they have graciously sacrificed their time spent
with me so that I could follow my career path and passion as an academic
surgeon, in the field of reconstructive surgery.
Peter G. Cordeiro, MD, FACS
Preface
The advent of microsurgery in the 1980s dramatically expanded the options for reconstructing
defects of the lower and upper jaws, providing the reconstructive surgeon with a wider choice
of flaps of skin, soft tissue, and bone. Osteocutaneous free flaps to restore segmental bony
defects include the iliac crest, scapula, radius, and fibula, which have radically improved aes-
thetic and functional outcomes in the ensuing decades. Advantages and disadvantages of each
donor site relate to the quality and extent of bone and its ability to be osteotomized and shaped,
as well as the amount of soft tissue and skin.
The fibula flap has emerged as the most versatile and most commonly used in jaw
reconstruction due to the excellent quantity and quality of bone. The fibula provides
30–35 cm of straight bone that is well vascularized due to intraosseous and periosteal
blood supply. The segmental blood supply from the peroneal artery allows for multiple
osteotomies without devascularizing individual segments, which permits the reconstruc-
tive surgeon to create three-dimensional contours of the missing mandibular and maxillary
segments. The thickness of the bone, the bicortical nature, and width (1–2 cm) also allow
for the use of osseointegrated implants that maximize functional outcomes, primarily
mastication.
The fibula flap has other excellent advantages. The donor site is well removed from the
head and neck, which allows for simultaneous dissection of the flap during resection. A
single- or double-skin island can be harvested with the bone to include a large portion of the
lateral surface area of the leg. This skin can be used to resurface the external skin of the face
and neck, provide intraoral lining, close palatal defects, and maximize mobility of the
tongue. The skin has a moderate amount of soft tissue that can provide volume in large
defects. The flexor hallucis longus muscle can be harvested with the flap and used to fill in
dead space in the submental region, cheek, and maxillary sinus. The peroneal artery with its
venae comitantes can reliably provide a long pedicle with a large diameter, which maxi-
mizes microsurgical success. The pedicle can be lengthened by moving the design of the flap
more distally on the leg.
We have focused this book on the use of the fibula flap in reconstruction of the upper and
lower jaws because of its great utility and its overwhelming popularity as the first choice for
reconstructing a majority of the segmental defects. As the book is an atlas, we have used high-
quality photos of illustrative cases to demonstrate technical details and applications of the flap
to a variety of defects. We have used the Cordeiro classification systems for defects of the
mandible and maxilla because we felt these to be the simplest but most comprehensive clas-
sification of the most commonly seen defects after resection. We have included chapters that
address dissection of the fibula and reconstruction of the neomandible and neomaxilla, both
with traditional templates and virtual surgical planning, as well as sections on indications for
reconstruction, preoperative imaging, methods of fixation, osseointegration, postoperative
functional assessments, and secondary procedures.
vii
viii Preface
As reconstructive surgeons, we are dedicated to improving the lives of our patients by pro-
viding the best care and maximal aesthetic and functional restoration. We hope that this book
will help the reader gain a better understanding of how to conceptually and technically
approach the challenges of mandibular and maxillary reconstruction.
New York, USA Peter G. Cordeiro
Modena, Italy Giorgio De Santis
Modena, Italy Luigi Chiarini
Contents
Part I Classification System
Classification System for Mandibulectomy Defects��������������������������������������������������������� 3
Peter G. Cordeiro
Classification System for Maxillectomy Defects�������������������������������������������������������������� 7
Peter G. Cordeiro
Part II Technique and Examples
The Fibula Osteocutaneous Free Flap: Surgical Approach ������������������������������������������� 13
Peter G. Cordeiro
Part III Mandibular and Maxilla Reconstruction
Use of Templates to Perform Osteotomies of the Fibula and to Shape
the Neo-mandible or Neomaxilla��������������������������������������������������������������������������������������� 21
Peter G. Cordeiro and Evan Matros
Mandible: Lateral, Hemimandibular, Anterior��������������������������������������������������������������� 27
Luigi Chiarini, Alexandre Anesi, and Sara Negrello
Maxilla: Types I–IV ����������������������������������������������������������������������������������������������������������� 39
Giorgio De Santis, Pier Francesco Nocini, and Luigi Chiarini
Bone Augmentation������������������������������������������������������������������������������������������������������������� 53
Pier Francesco Nocini, Alexandre Anesi, and Andrea Fior
Part IV Evolution in Concepts
Evolution in Indication������������������������������������������������������������������������������������������������������� 69
Alexandre Anesi, Sara Negrello, and Luigi Chiarini
Evolution in Preoperative Imaging����������������������������������������������������������������������������������� 81
Massimo Pinelli, Alberto Puglisi, and Giorgio De Santis
Evolution in Bone Synthesis����������������������������������������������������������������������������������������������� 85
Andrea Fior, Alexandre Anesi, and Pier Francesco Nocini
Part V Endosseous Dental Implants
Technique����������������������������������������������������������������������������������������������������������������������������� 95
Luigi Chiarini, Alexandre Anesi, and Sara Negrello
ix
x Contents
Assessment��������������������������������������������������������������������������������������������������������������������������� 101
Alexandre Anesi, Sara Negrello, and Luigi Chiarini
Part VI Adjunct Procedures
Second Vascularized Fibula Flap and Osteotomy to Correct Malocclusion����������������� 107
Pier Francesco Nocini, Alexandre Anesi, and Luigi Chiarini
Secondary Procedures and Refinements��������������������������������������������������������������������������� 115
Alessio Baccarani, Marta Starnoni, and Giorgio De Santis
Part I
Classification System
Classification System
for Mandibulectomy Defects
Peter G. Cordeiro
The mandible, a U-shaped bony structure with posterior ver-
tical extensions, establishes the height, width, and projection
of the lower face. The arch of the mandible and the body are
the primary teeth-bearing portions, while the ascending
ramus with condyles articulates with the skull base posteri-
orly, which allows for critical functions such as speech and
mastication. The bone of the mandible abuts multiple soft-
tissue structures that are equally essential to both function
and form: anteriorly, the chin, lips, and oral commissures;
laterally, the external cheek and intraoral lining; posteriorly,
the pharyngeal pillars; and medially, the floor of the mouth
and the tongue. Resection of cancers that occur in this region
can create not just bony defects but also loss of the surround-
ing soft-tissue components. Thus, a classification system for
mandibular defects must also address the soft-tissue defects.
The Cordeiro classification system consists of 13 primary
types of defects; the algorithms to approach reconstruction
of these defects can vary in the hands of different surgeons,
but the reconstructive options generally need to address the
specific defect.
andibulectomy Defect Classification
M
System
The mandibulectomy defect classification system consists of Fig. 1 Type I bony defect, anterior
a Roman numeral, a subdividing letter, and, in subcases, a
subcategory number.
The Roman numeral (I, II, III) describes the bony defect. Type II defects involve the hemimandible and always
Type I defects involve the anterior arch, which always include a portion of the body, the angle, and the ascending
includes the symphysis but may also include one or both ramus (with or without the condyle) (Fig. 2).
parasymphyses (Fig. 1). Type III defects are lateral defects that involve one or two
out of three of the following components: the ascending
ramus, angle, or body (Fig. 3).
A letter (A, B, C, D) describes the quality of the soft-tissue
P. G. Cordeiro (*)
Plastic and Reconstructive Surgery Service, Memorial Sloan defect and involvement of any combination of the skin, sub-
Kettering Cancer Center, Weill Medical College of Cornell cutaneous tissue, muscle, intraoral structures, and mucosal
University, New York, NY, USA lining.
e-mail: [email protected]
© Springer Nature Switzerland AG 2019 3
G. De Santis et al. (eds.), Atlas of Mandibular and Maxillary Reconstruction with the Fibula Flap,
https://doi.org/10.1007/978-3-030-10684-3_1
4 P. G. Cordeiro
Fig. 2 Type II bony defect, hemimandible Fig. 3 Type III bony defect, lateral
• A denotes no soft-tissue defect. • Excision of two or fewer intraoral zones is designated B1.
• B denotes intraoral structure and/or mucosal lining • Excision of three or more intraoral zones is designated B2.
defect.
• C denotes a skin/external soft-tissue defect only. Thus, a classification system of 13 principal zones is
• D denotes a through-and-through or both intraoral struc- described (Fig. 4).
tures/lining and skin defect.
• 1A, 1B, 1C, 1D
The extent of the intraoral defect has been found to com- • IIA, IIB1, IIB2, IIC, IID
monly dictate the reconstruction algorithm for type II hemi- • IIIA, IIIB, IIIC, IIID
mandibular defects; therefore, a subclassification of B1 and
B2 is described. The algorithm to reconstruct each type of mandibular
Based on five zones of intraoral structures that include the defect must first consider the location of the resected bone
buccal mucosa, floor of mouth, palate, tongue, and pharynx. and then the required soft-tissue deficits.
Classification System for Mandibulectomy Defects 5
Fig. 4 Mandibulectomy
defect classification system
algorithm for flap selection and surgical outcomes. Plast Reconstr
Further Reading Surg. 2018;141(4):571e–81e.
Cordeiro PG, Hidalgo DA. Conceptual considerations in mandibular
Cordeiro PG, Henderson PW, Matros E. A 20-year experience with 202 reconstruction. Clin Plastic Surg. 1995;22:61–9.
segmental mandibulectomy defects: a defect classification system,
Classification System for Maxillectomy
Defects
Peter G. Cordeiro
The two maxillary bones contribute to creating a major por- Maxillectomy Defect Classification System
tion of the midfacial skeleton, which is critical to both form
and function in the midface. The maxilla is essentially a tet- The maxillectomy defect classification system follows the
rahedron, with the roof of the maxilla supporting the globe most common patterns of resection of the bony structure of
and orbital contents; the floor of the maxilla being the hard the maxilla plus/minus the contiguous soft tissues. There are
palate; the maxillary arch being the tooth-bearing compo- six principal types of maxillectomy defects: I, IIA, IIB, IIIA,
nent; and the four vertical walls of the maxilla contributing IIIB, and IV.
to maintaining the height and projection of the midface and
the medial wall forming the lateral walls of the nasal cavity
(Fig. 1). Type I: Limited Maxillectomy Defects
The maxilla is in close contiguity to multiple critical soft
tissue areas, and cancer resections will often include resec- These most commonly include one or two walls of the max-
tion of this soft tissue in conjunction with certain walls of the illa, usually the anterior and medial walls, often the skin/soft
maxilla. These areas include the external skin and soft tis- tissues of the cheek overlying the maxilla, and occasionally
sues, as well as muscles of the midface, the lips/oral com- critical structures such as the lips, nose, and eyelids (Fig. 2).
missure, nose/nasal lining, and orbital contents extending up
to the cranial base.
Fig. 1 The maxilla is conceptually a tetrahedron
P. G. Cordeiro (*)
Plastic and Reconstructive Surgery Service, Memorial Sloan
Kettering Cancer Center, Weill Medical College of Cornell
University, New York, NY, USA
e-mail: [email protected] Fig. 2 Type I maxillectomy or limited defects
© Springer Nature Switzerland AG 2019 7
G. De Santis et al. (eds.), Atlas of Mandibular and Maxillary Reconstruction with the Fibula Flap,
https://doi.org/10.1007/978-3-030-10684-3_2
8 P. G. Cordeiro
Type II: Subtotal Maxillectomy Defects Type III: Total Maxillectomy Defects
These defects include resection of the lower five walls of the These defects include resection of all six walls of the max-
maxilla, which include the palate and dentoalveolar arch but illa, including the floor of the orbit and palate/alveolar arch,
leave the orbital floor intact. and may or may not include resection of the orbital
Type IIA defects include less than 50% of the arch of the contents.
maxilla and do not extend past the midline (Fig. 3). Type IIIA defects involve resection of all six walls of the
Type IIB defects involve greater than 50% of the maxillary maxilla, including the floor of the orbit but sparing the orbital
arch and extend past the midline. Many of these defects can contents (Fig. 5).
include bilateral maxillae and involve the entire arch (Fig. 4). Type IIIB defects involve resection of all six walls of the
maxilla, including exenteration of the orbital contents (Fig. 6).
Fig. 5 Type IIIA total maxillectomy defect sparing the orbital contents
Fig. 3 Type IIA subtotal maxillectomy defect
Fig. 6 Type IIIB total maxillectomy defect including the orbital
Fig. 4 Type IIB subtotal maxillectomy defect contents
Classification System for Maxillectomy Defects 9
Type IV: Orbitomaxillectomy Defects
These defects involve resection of the upper maxilla/floor of
orbit and the orbital contents (Fig. 7).
The algorithms for reconstruction of the various types of
maxillectomy defects vary from surgeon to surgeon, but the
conceptual approach addresses the bony deficits as well as
the soft tissue, skin, and oral/nasal deficits.
Further Reading
Cordeiro PG, Chen CM. A 15-year review of midface reconstruction
after total and subtotal maxillectomy: part I. algorithm and out-
comes. Plast Reconstr Surg. 2012;129:124–36.
Cordeiro PG, Santamaria E. A classification system and algorithm
for reconstruction of maxillectomy and midfacial defects. Plast
Reconstr Surg. 2000;105:2331–46.
McCarthy CM, Cordeiro PG. Microvascular reconstruction of oncologic
defects of the midface. Plast Reconstr Surg. 2010;126(6):1947–59.
Fig. 7 Type IV orbitomaxillectomy defect
Part II
Technique and Examples
The Fibula Osteocutaneous Free Flap:
Surgical Approach
Peter G. Cordeiro
The fibula is the workhorse osseous flap for mandibular and ing this an excellent donor site. For wider dimensions, a skin
maxillary reconstruction. It provides a significant amount— graft is placed on the muscle after removal of the flap. It is
up to 30 cm in length—of good-quality cortical bone. The useful to draw the approximate course of the superficial
fibula flap may be harvested as a purely osseus flap or be peroneal nerve, which crosses the fibula 2–3 cm below the
combined with muscle, fascia, and skin to provide soft-tissue fibula head. It is also useful to draw the approximate location
elements that may be required for reconstruction. The flap of the pedicle connection to the bone (Fig. 1).
has an excellent pedicle based on the peroneal artery and
venae comitantes, with large-diameter vessels up to 3–4 mm.
A significantly sized skin paddle designed on the lateral leg nterior Dissection of the Skin, the Lateral
A
can be as large as 10–12 cm in the anteroposterior dimension Septum, and the Lateral/Anterior Muscle
and 20–25 cm in the longitudinal dimension. The flexor hal- Compartments
lucis longus muscle can be taken in its entirety to provide
excellent soft-tissue fill. The bone has both an intraosseous After partially exsanguinating the leg with a tourniquet, the
blood supply and a periosteal blood supply that allows for dissection is started anteriorly. The incision is carried
the ability to perform multiple osteotomies, which can be through the subcutaneous tissues, and the skin and fascia
shaped to create the various contours of the mandible or the are dissected off the lateral compartment muscles (Fig. 2).
maxilla. The highly reliable fibula flap can be dissected Great care is taken to avoid injuring the septum, which car-
simultaneously with the resection for trauma or disease in ries the blood supply to the skin. Sometimes, there are
the head and neck, significantly decreasing operating time. obvious, large septocutaneous perforators within the sep-
tum; if these are not visible, as long as the septum is not
injured by the cautery, there is usually adequate blood sup-
perative Technique: Surface Markings
O ply to the skin (Fig. 3).
and Skin Island Design
The skin island is always centered over the septum between
the lateral and posterior compartment muscles. This septum
can be identified by palpating the posterior border of the
fibula and drawing a line along the posterior border. As long
as the skin island is centered over this septum, there should
be an excellent blood supply, particularly in the distal two-
thirds of the leg, where the main septocutaneous perforators
lie. The transverse dimension of the skin island is relatively
small; if less than 3–4 cm, it is usually closed primarily, mak-
P. G. Cordeiro (*)
Plastic and Reconstructive Surgery Service, Memorial Sloan
Kettering Cancer Center, Weill Medical College of Cornell
University, New York, NY, USA Fig. 1 Design of skin island and incision on the left lower lateral
e-mail: [email protected] extremity
© Springer Nature Switzerland AG 2019 13
G. De Santis et al. (eds.), Atlas of Mandibular and Maxillary Reconstruction with the Fibula Flap,
https://doi.org/10.1007/978-3-030-10684-3_3
