Fibula free flap in mandibular reconstruction.

Mandibular reconstruction continues to be one of the most common surgical challenges faced by oral and maxillofacial surgeons. Coupled with the complex demands of mandibular reconstruction are the public expectations of an expeditious reconstruction, which often translates into a single stage resection and reconstruction. Gone are the days when patients tolerated resections without reconstruction and, to a degree, multiple stage reconstructions. The advent of microvascular surgery has catapulted the reconstruction of complex head and neck defects to a single stage reconstruction. This technique allows for larger resections and reconstruction, which allows patients to return to normal function in a much shorter period when compared with multistage local, regional pedicled flaps and nonvascularized free bone grafts. Multiple studies have shown the clear superiority of microvascular reconstruction of the mandible when compared with ‘‘traditional’’ methods. Although the use of microvascular techniques has been around for nearly 20 years, it still has struggled to gain acceptance by American oral and maxillofacial surgeons. This lack of acceptance may be caused primarily by a lack of training in microvascular surgery. The options for bony free-tissue transfer for mandibular reconstruction primary rest on the fibula, iliac, scapula, and to a much lesser degree, the radius bone. The radial osseocutaneous free flap is seldom used currently because of the lack of bone height and width of the radius and the accompanying morbidity of high rate of fracture of the forearm. The scapula flap is not commonly used for mandibular reconstruction because of the thin bone stock and the inability to tolerate multiple osteotomies. Another significant disadvantage of the scapula flap is the inability to have a two-team approach because of the proximity to the head and neck and the need to turn the patient. A significant advantage of the scapular flap is that it may be harvested as separate bone and skin/muscle paddles, which allows for its use in complex reconstructions. The iliac crest can provide a large bone stock and muscle and skin for tissue coverage. The main disadvantage of this flap is its short vascular pedicle, which often necessitates a vein graft to increase the pedicle length to carry out the anastomosis. The fibula free flap continues to be the gold standard and the workhorse flap in the reconstruction of mandibular defects. The advantages of the fibula free flap over other microvascular free tissue flaps include its consistency and uniformity in width and length, its pedicle length and vessel diameter, and the ability to incorporate a skin or muscle component with the flap. The location of the fibula away from the head and neck also allows for a simultaneous two-team approach, which shortens the operative time. The goals of mandibular reconstruction are not only to re-establish the continuity of the mandible but also to restore function. The return of function entails speech, swallowing, and chewing. To that end, the fibula provides the bony platform for eventual prosthetic rehabilitation of the patient, whether that involves the placement of intraosseous dental implants or conventional dentures.