Alignment of the Double-Barrel Fibula Free Flap for Better Cosmesis and Bone Height for Osseointegrated Dental Implants

Sir: As microsurgery becomes progressively more reliable, the bar is continually raised on aesthetic and functional outcomes from free tissue transfer. In no other region is a balance between the two facets more important than in the head and neck, and reconstruction of the mandible with the fibula free flap is an excellent example. Direction of the vascular pedicle, design of the skin paddle, and number and orientation of the osteotomies are some of the basic considerations when reconstructing the mandible with the fibula free flap. Greater attention to detail, however, is required for optimal cosmetic and functional outcomes. One aspect pertains to positioning of the fibula strut in relation to the remaining native mandible. If the fibula strut is aligned to the inferior border of the native mandible, the height discrepancy and malposition of the bone relative to the alveolus makes wearing of conventional dentures and fabrication of osseointegrated implant–supported dentures difficult. If, however, the fibula strut is aligned with the alveolar process, the aesthetics are compromised by an irregular jawline. The double-barrel fibula provides a solution to the conundrum, but this technique requires greater finesse in planning and execution.1 We describe a novel technique of alignment of the struts in a double-barrel fibula free flap. Design of the skin paddle (for an osteocutaneous flap) and harvest of the fibula free flap is carried out as described.2–5 The fibula strut is usually orientated with its lateral surface facing externally (i.e., with its anteroposterior dimension equating with the height of the neomandible). However, placement of adjacent struts in a top/bottom configuration with the lateral surface of both segments facing externally often creates a neomandible that is taller than the native mandible. We have successfully reconstructed the mandible in seven patients (five men and two women; median age, 63 years; median follow-up, 16 months) for whom the inferior segment was rotated so that the lateral surface of the fibula faced the superior bone segment, and the posterior surface of the fibula became the external contour fixed to the reconstruction plate. This provides a broader lower border more akin to the native mandible. The superior segment is positioned first with its lateral surface facing externally, and is fixed with miniplates in a more lingual position as for the native alveolus. The superior segment uses proximal fibula bone with perforators for the skin paddle so that there is no compression following rotation of the vascular pedicle. A 1- to 1.5-cm gap is fashioned between the osseous struts to allow a gentle curve in the vascular pedicle (Fig. 1). In addition to creating a neomandible that is much closer in shape to the original mandible, this technique has the added bonus of a broader shelf at the floor of the mouth for anterior mandible reconstruction, which is beneficial for support of the tongue when a large amount of floor-of-mouth musculature has been sacrificed.Fig. 1: (Left) Anterolateral mandibular reconstruction with a double-barrel fibula free flap where the inferior segment had been rotated 90 degrees lingually, creating a segment of neomandible that was very close in height to the remaining native mandible. (Right) Schematic illustration of the orientation of the fibula struts relative to the skin paddle and vascular pedicle. The lateral surface of the inferior fibula segment is rotated so that it abuts the superior segment.There were no total or partial flap losses. One patient died as a result of recurrence at 6 months and another developed recurrence at 9 months postoperatively. One patient experienced wound breakdown following radiotherapy that warranted removal of the reconstruction plate. Of the remaining five patients who were disease-free at last follow-up, two had undergone complete dental rehabilitation using osseointegrated implants and a third was waiting for implant integration following radiotherapy (Fig. 2).Fig. 2: An orthopantomogram showing dental osseointegrated implants placed into the superior fibula strut in a double-barrel fibula free flap.DISCLOSURE The authors have no financial disclosures. This work was not supported by any funding sources. Sydney Ch’ng, Ph.D., F.R.A.C.S. Department of Plastic Surgery M. D. Anderson Cancer Center Houston, Texas, and Sydney Head & Neck Cancer Institute Royal Prince Alfred Hospital Sydney, New South Wales, Australia Bruce G. Ashford, F.R.A.C.S. Department of Head and Neck Surgery Liverpool Hospital Sydney, New South Wales, Australia Jonathan R. Clark, M.Biostat., F.R.A.C.S.