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The NYU experience with free fibula reconstruction of the mandible utilizing virtual surgical planning
Tomer Avraham, MD, Peter Franco, DMD., Lawrence Brecht, DDs., David Hirsch, DDs, MD, Jamie Levine, MD.
NYU Langone Medical Center, New York, NY, USA.
Purpose: The use of free osseous flaps has become the gold standard for reconstruction of complex mandibular defects, with free fibula transfer commonly the flap of choice for these indications. While this operation has become routine, contouring of the flap using wedge osteotomies, as well as its inset remain operator dependent and imprecise. At our institution, we have attempted to make this process more uniform and reproducible through the use of virtual planning and pre-fabricated cutting jigs. The purpose of this study was to review our series free fibula mandibular reconstructions using these adjunctive technologies.
Methods: Prior to surgery all patients underwent CT scanning of the face and bilateral lower extremities. These images were then transmitted to an outside vendor. In consultation with both the ablative and reconstructive teams, a surgical plan was devised, cutting jigs for both creation of the mandibular defect and for fibular osteotomies were fabricated, and a streolithic model that allows for precise reconstruction plate bending was created. The rest of the surgical procedure was performed in standard fashion. Following IRB approval, all cases between 2009 and 2012 were identified and retrospectively reviewed.
Results: Fifty four reconstructions were performed in 52 patients. Patients were evenly divided between a private, university affiliated medical center and a large county hospital. The most common indications were malignancy (45%), ameloblastoma (24%), osteonecrosis/osteomyelitis (20%), and congenital defects (8%). Sixty-six percent of patients were male with an average age of 44 (range 10-77). Thirty percent of patients had irradiation of the recipient site and 38% had previous surgery . A skin paddle was utilized in 85% of cases, and additional osteotomies to create a “double barrel segment” were performed 25% of the time. Sixty-four percent of patients received dental implants into the fibula flap, with 49% achieving functional dentition with dentures. Postoperative imaging demonstrated excellent precision and accuracy of flap positioning.
Conclusions: Pre-operative virtual planning along with use of prefabricated cutting jigs allows for precise contouring and positioning of microvascular fibular free flaps in mandibular reconstruction. Employing this technique in over fifty patients we have been able to achieve excellent outcomes with dental rehabilitation rates that greatly exceed previously published reports. While we feel that this technology facilitates reconstruction, prospective trials are necessary to establish superiority to previously employed techniques.
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