Salvage Secondary Reconstruction of the Mandible with Vascularized Fibula Flap

Abstract

Primary restoration of the mandibular continuity remains the standard of care for defects, and yet several constraints preclude this objective. Interim reconstructions with plate and nonvascular bone grafts have high failure rates. The secondary reconstruction, when becomes inevitable, remains a formidable task. This retrospective study evaluates various issues to address secondary reconstruction. Twenty-one patients following mandibulectomy presented with various complications between 2012 and 2016 were included in the study. The profile of primary reconstruction includes reconstruction plate ( n = 9), reconstruction plate with rib graft ( n = 3), soft tissue only reconstruction ( n = 4), free fibula ( n = 2), inadequate growth of reconstructed free fibula during adolescence ( n = 1), nonvascular bone graft alone ( n = 1), and no reconstruction ( n = 1). All had problems or complications related to unsatisfactory primary reconstruction such as plate fracture, recurrent infection, plate exposure, deformity, malocclusion, and failed fibula reconstruction. All were reconstructed with osteocutaneous free fibula flap with repair of soft-tissue loss. All flaps survived and had satisfactory outcome functionally and aesthetically. Dental rehabilitation was done in four patients. One flap was reexplored for thrombosis and salvaged. The challenges in secondary reconstruction include difficulty in recreating true defects, extensive fibrosis and loss of planes, unanticipated soft-tissue and skeletal defects, reestablishing the contour and occlusion, insufficient bone strength, dearth of suitable recipient vessels, nonpliable skin, tissue contraction to accommodate new mandible, need of additional flap for defect closure, and postirradiation effects. Notwithstanding them, the reasonable successful outcome can be attainable.