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Background: Vascularized bone grafting (VBG) is preferred for mandibular reconstruction post-tumor ablation. Although various bone-free flaps are used, their application is compromised by limitations including insufficient bone volume and poor shape. Here, we report mandibular reconstruction using axial split-step osteotomy with an iliac crest-free flap., Methods: Over December 2018-November 2020, 12 patients underwent mandibular reconstruction via axial split osteotomy using a free iliac-crest flap., Results: The preoperative iliac-crest length was 5.7-9.5 mm (median, 7.5 cm); the mean post-axial split-osteotomy iliac-crest length increased to 9.59 mm (range, 6.34-15.15 mm). All patients presented with initial healing 2 weeks postoperation; good bone healing was achieved in all grafted flaps by the third month of follow-up., Conclusions: We propose a new axial split-step osteotomy technique using free iliac-crest flaps for mandibular reconstruction. We demonstrated this novel technique's reliability for safe and effective bone lengthening and establishing a reliable occlusal relationship., (© 2024 Wiley Periodicals LLC.)

Background: Reconstruction of continuity defects following osteonecrosis in multimorbid patients is challenging. In all cases of the predescribed palliative treatment method for alloplastic mandible reconstruction, plate fractures were detected in follow-up. We hypothesized that a modification could avoid these fractures, leading to stable long-term results., Methods: This retrospective study compares the original method with a modification using single, laser-sintered CAD-CAM plates instead of manually bent miniplates. The predescribed shuttering technique was used to reconstruct the mandible in its original shape with bone cement., Results: Uneventful wound healing was observed in 86% of the cases after modification of the method. No implant or plate fracture occurred., Conclusions: The presented method should be considered as a treatment option for mandible reconstruction in elderly, multimorbid patients in palliative situations. The results of this study suggest that the modification of the method leads to significantly improved long-term stability. Donor site morbidity is avoided with this method of palliative surgery., (© 2023 The Authors. Head & Neck published by Wiley Periodicals LLC.)

Background: This study aimed to introduce a novel loop neurorrhaphy technique using an innervated vascularized iliac bone flap (VIBF) with vascularized ilioinguinal nerve (IIN) to reconstruct the inferior alveolar nerve (IAN) and preserve lower lip sensation simultaneously with mandibular reconstruction., Methods: This study prospectively included patients who underwent mandibular reconstruction using VIBF from May 2018 to April 2020. Subjects were allocated into two groups: (1) Group I; innervated VIBF with loop neurorrhaphy (IIN doubly anastomosed with IAN and mental nerve), (2) Group II (control); conventional VIBF. Evaluation was done with operative time, intraoperative indocyanine green (ICG), lower lip sensory assessment (two-point discrimination [TPD] test and current perception threshold [CPT]), and drooling., Results: Twelve patients were included; 6 in each group, (7 males and 5 females), age ranging from 18 to 57 years (average: 36.75 years). In all cases, intraoperative perfusion of IIN was confirmed by ICG. Group I showed a statistically significant more flap harvesting time compared with group II (mean difference, 5.67 min; P = 0.0091). There was a significant difference in sensory recovery favoring group I (P < 0.05). The TPD results in group I showed an average of 9.8 ± 6.9 mm and 6.2 ± 5.7 mm on operated and non-operated sides, while Group II showed a poor sensory recovery, and the TPD showed an average of 24.6 ± 6.7 mm and 8.4 ± 2.3 mm on operated and non-operated sides. The CPT results showed a significant difference between both groups. In Group I, the extent of drooling was 3.16 ± 0.75, while in Group II, the score was 1.6 ± 0.81, revealing a significant difference favoring Group I., Conclusions: Concurrent mandibular reconstruction using VIBF and loop neurorrhaphy with vascularized IIN to reconstruct IAN successfully restore lower jaw form and preserve lip sensation., (© 2021 Wiley Periodicals LLC.)

Background: To determine whether virtual surgical planning and three-dimensional printed cutting guides (3D/VSP) improved radiographic bone union compared to conventional methods (CM) in fibula free flap (FFF) reconstruction of the mandibles., Methods: Retrospective study from the years 2000-2018 at a tertiary hospital. Osseous union was evaluated by a radiologist blinded to each patient's treatment., Results: Two hundred sixty patients who underwent FFF tissue transfer, 28 with VSP and 3D cutting guides. Bony union was not achieved in 46 (20%) patients who underwent CM compared to 1 (4%) of patients with VSP and guides (p = 0.036). FFF complication was significantly higher in CM with 87 patients (38%) compared to three patients (11%) in 3D/VSP (p = 0.005). Median time to bony union for patients who underwent CM was 1.4 years compared to 0.8 years in 3D/VSP., Conclusions: 3D/VSP reduced the rate of radiographic nonunion and flap-related complications in FFF reconstruction for mandibular defects., (© 2021 Wiley Periodicals LLC.)

Background: Computer-aided design/computer-aided manufacturing (CAD/CAM) surgical templates allow precise mandibular reconstructive surgery. However, their clinical accuracy is limited by manual plate bending. Digitally hydroformed plates maintain a digital workstream in virtual planning., Methods: Twelve patients with Brown's class IIc mandibular defects were randomized into two groups: group I (experimental), the reconstruction plate was digitally hydroformed, and group II (control), surgeries were performed CAD/CAM guided with the reconstruction plate manually prebent. The linear and angular deviations of reconstruction outcomes were compared to surgical simulation in both groups., Results: The mean linear and angular deviations of middle and posterior segments were 2.14 ± 0.79 mm, 3.71 ± 0.95 mm, 8.73° ± 1.91°, and 9.06° ± 0.96° in group I and 4.31 ± 0.78 mm, 6.74 ± 1.40 mm, 16.35° ± 0.72°, and 31.48° ± 3.38° in group II, respectively. Measurements in group I were significantly lower than group II (P < .005)., Conclusion: Digital hydroforming for plate prebent is a reliable method that helps improving the clinical accuracy of CAD/CAM-guided mandibular reconstruction surgery., (© 2019 Wiley Periodicals, Inc.)

Background: Composite mandibular reconstruction requires multiple tissue components inset in different planes. Intrinsic chimeric flap design provides this, and may be best suited for these reconstructions., Methods: A retrospective review of mandible reconstructions with composite, intrinsic chimeric, or 2 free flaps was performed. Patient and flap characteristics and complications were analyzed., Results: Seventy-five patients were reviewed. Defects reconstructed with intrinsic chimeric flaps had significantly more soft tissue needs than composite reconstructions. However, intrinsic chimeric bony defects were less complex. Despite significantly longer operative times for intrinsic chimeric flaps, there were no differences in complications or hospital stays. Intrinsic chimeric reconstruction resulted in significantly lower complication rates requiring an additional flap. This benefit was pronounced in through-and-through defects., Conclusion: Intrinsic chimeric flaps are a better option than composite flaps for reconstruction of mandibular defects with large soft tissue needs with no increased complication risk despite longer operative time., (© 2019 Wiley Periodicals, Inc.)

Background: Segmental mandibulectomy impairs health-related quality of life (QoL), by altering speech, mastication, swallowing, and facial aesthetics. Fibula free flap (FFF) used for mandible reconstruction is known to improve outcomes; however, minimal information exists in the literature regarding patient-reported outcomes. We aim to assess how current studies evaluate patient perception following segmental mandibulectomy and FFF mandible reconstruction., Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search was conducted for publications involving FFF mandible reconstruction from 2005 to 2017 using PubMed, Cochrane, EMBASE, Web of Science, and PsychInfo., Results: Of 2212 articles identified initially, only 7 studies were deemed suitable. Six studies used the University of Washington Quality of Life questionnaire, 3 Oral Health Impact Profile, and 1 used European Organization for Research and Treatment of Cancer Head and Neck (EORTC-H&N35)., Conclusions: There is a paucity of information in published reports on QoL outcomes following mandible reconstruction with FFF. In the era of patient-centered health care, observations warrant attention from researchers for physician-assessed patient-reported measures to factor in QoL expectation during surgical decision-making about the choice of reconstruction., (© 2018 Wiley Periodicals, Inc.)

Background: The principle reconstructive modality for segmental mandibulectomy defects is the osteocutaneous free fibula flap. Preoperative CT angiography has been recommended to assess the quality of arterial inflow to the flap and donor limb. However, the impact of the venous system on flap viability has not been explored., Methods: A retrospective review of all patients undergoing free fibula flap mandible reconstruction was performed at a single tertiary cancer center from 2002 to 2015. Overall complications, including operative reexploration and total flap losses, were evaluated., Results: One hundred seven patients underwent free fibula flap reconstruction of the mandible. Nine patients underwent multiple free flaps and were excluded from this study. Of the remaining 98 patients, 8 patients required operative exploration for microvascular compromise. All patients were found to have venous thrombosis. There were 3 total flaps losses with a salvage rate of 62.5% and overall flap survival of 96.9%. The size of the vena comitantes in the compromised flaps were significantly larger than those of the remaining patients (4.4 mm vs 3.1 mm; P < .0001). Although the total operative times were similar between the 2 groups (585.2 minutes vs 563.3 minutes), the ischemia time was significantly shorter in those cases that required operative takeback (76.5 minutes vs 104.0 minutes; P < .04)., Conclusion: Venous thrombosis of free fibula flaps is more common than arterial thrombosis. Venous stasis in larger vena comitantes may be a contributing factor to microvascular compromise. Anticoagulation and/or handsewn anastomosis may be beneficial if the veins are larger than 4.0 mm in size., (© 2017 Wiley Periodicals, Inc.)

Background: Virtual surgical planning (VSP) has contributed to a number of technical innovations in mandible reconstruction. We report on these innovations and the overall evolution of mandible reconstruction using free fibula flaps at our institution., Methods: We performed a retrospective chart review of all patients who underwent virtually planned free fibula flap reconstruction of the mandible. Comparisons were made between cohorts based on distinct eras related to the virtual planning approach., Results: Seventy-six patients underwent a total of 78 VSP-assisted mandible reconstructions with free fibula flaps. Significant differences were noted among the groups with regard to mean number of segments, percentage of flaps that had at least 3 segments, percentage of flaps that had double-barrel components, and innovations per flap., Conclusion: VSP-assisted mandible reconstruction has contributed to more complex surgeries at our institution. The technology ensures functional restoration, permitting an optimized aesthetic reconstruction that has not increased operative times or complications. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2066-E2073, 2016., (© 2016 Wiley Periodicals, Inc.)

Background: The purpose of this study was to assess the impact of bone harvest length and multiple osteotomies on osteocutaneous radial forearm free flap (RFFF) complication rates., Methods: A retrospective chart review was conducted for patients undergoing osteocutaneous RFFF reconstruction during an 8-year period., Results: One hundred fifty-five osteocutaneous RFFF procedures were performed. Recipient-site flap complications were 18 of 55 (32.7%) when bone harvest length was less than 7 cm and 40 of 100 (40.0%) when it was ≥7 cm. No osteotomies were performed in 69 of 155 cases with a corresponding complication rate of 30.4% (21 of 69). One osteotomy was utilized in 69 of 155 flaps, whereas 17 of 155 required more than 1 osteotomy; complications were experienced in 42% (29 of 69) and 47% (8 of 17) of these cases, respectively., Conclusion: Osteocutaneous RFFF complication rates were only slightly higher when the bone length was ≥7 cm or when multiple osteotomies were required., (© 2015 Wiley Periodicals, Inc.)

Background: Free fibula osteocutaneous flaps are the primary option for reconstruction after segmental mandibulectomies. This study evaluates the impact of CT-guided preoperative planning on operative outcomes after free fibula mandible reconstruction., Methods: We conducted a retrospective review of all patients undergoing free fibula reconstruction of the mandible from 2002 to 2011., Results: Fifty-seven patients underwent free fibula osteocutaneous flap reconstruction for head and neck cancers involving the mandible. Twelve patients had shaping of the neomandible performed on the back table while 20 patients underwent shaping in situ without the use of any adjunctive technology. The remaining 25 patients underwent preoperative CT imaging, which significantly decreased operative time (707 minutes vs 534 minutes; p < .0003) as well as overall costs ($24,532.50 vs $20,950.48). There were no significant differences in outcomes or complications., Conclusion: Preoperative, patient-specific CT modeling, and cutting guide fabrication outweigh the costs associated with the additional technology without jeopardizing overall outcomes or increasing complication rates., (© 2014 Wiley Periodicals, Inc.)

Background: The purpose of this study was to evaluate the efficacy of preoperative versus intraoperative mandibular contouring using rapid prototyping technology., Methods: Ten patients requiring mandibular reconstruction had a preoperative mandibular plate contoured to a fabricated 3D mandibular model based on preoperative imaging. A traditional intraoperative plate was also contoured. Two surgeons blinded to the study compared the plates with respect to conformance, surface-area contact, and best overall match. A cost-benefit analysis was then performed., Results: The average time to contour was 867 ± 243 seconds and 833 ± 289 seconds for the preoperative and intraoperative plates, respectively (p = .83). Interobserver analysis revealed no statistically significant differences in conformance (p = .38) or surface area contact (p = .14). In 7 of 9 cases, the preoperative plate was selected for the final reconstruction. In 1 case, an intraoperative plate was not contoured because of the lateral extent of the tumor., Conclusion: In cases of mandibular distortion secondary to disease, pathologic fracture or defects involving multiple mandibular subsites this method is particularly advantageous., (© 2013 Wiley Periodicals, Inc.)

Background: The free fibular osteocutaneous flap is a commonly used flap for mandible and buccal mucosa reconstruction in head and neck cancer surgery. However, the skin paddle restriction from the intermuscular septum often limits the soft tissue reconstruction., Methods: We have proposed a new modified chimeric fibular osteocutaneous flap design based on the combination of a traditional fibular flap and a peroneal artery perforator fasciocutaneous flap to overcome the restriction from intermuscular septum., Results: We successfully applied this modified chimeric free fibular osteocutaneous flap design to 2 patients after buccal cancer wide excision surgery., Conclusion: The modified free chimeric fibular flap can be easily applied to a segmental defect over the mandible and adjacent soft tissue without restrictions between the bone and the skin paddle. Furthermore, this skin paddle design can also serve as an extra skin paddle to reconstruct an outer cheek skin defect., (Copyright © 2012 Wiley Periodicals, Inc.)