The Laryngoscope
C 2016 The American Laryngological,
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Rhinological and Otological Society, Inc.
How I Do It
Contour and Osteotomy of Free Fibula Transplant
Using a Ruler Template
Stephen Y. Kang, MD; Matthew O. Old, MD; Theodoros N. Teknos, MD
The fibula free tissue transplant has been used in mandibular reconstruction for several decades. Various techniques exist to
shape and contour the fibula to restore continuity to the segmental mandible defect. Recently, virtual surgical planning has
introduced the ability to use cutting guides to contour and create osteotomies for fibula free tissue reconstruction of the
mandible. In this article, we describe a practical and reproducible technique to perform template-based fibula free tissue
reconstruction of the mandible without the use of cutting guides.
Laryngoscope, 126:2288–2290, 2016
INTRODUCTION
Since its introduction by Hidalgo1 in 1989, the fibula free tissue transfer has remained a workhorse transplant in the reconstruction of segmental mandibular
defects. Traditionally, the contouring and creation of
wedge osteotomies was performed using a freehand technique. However, newer technology has introduced the
use of fibula cutting guides to facilitate the inset of the
transplant.2
The ideal technique for fibula contouring would be
accurate, reproducible, cost-efficient, and translatable
to residents and fellows in training. Regardless of the
technique used, the end result should be a fibula transplant that fits tightly into the defect, maximizing bone
contact while remaining in contact with the reconstruction plate. In this report, we describe a practical technique to contour and guide osteotomies in the fibula
transplant during mandibular reconstruction that can
be used to reconstruct nearly any segmental mandibular defect.
METHODS
A 61-year-old gentleman presented with previously
untreated T4a N2b M0 squamous cell carcinoma of the mandibular alveolus. Composite resection and bilateral selective neck
dissection of levels I–IV were performed (Fig. 1). Mandibular
reconstruction was performed with a fibula free tissue trans-
From the Department of Otolaryngology–Head and Neck Surgery,
The James Cancer Hospital and Solove Research Institute, The Ohio
State University Wexner Medical Center, Columbus, Ohio, U.S.A.
Editor’s Note: This Manuscript was accepted for publication
January 26, 2016.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Stephen Y. Kang, MD, 915 Olentangy
River Road, Suite 4000, Columbus, OH 43212. E-mail: stephen.kang@
osumc.edu
DOI: 10.1002/lary.25925
Laryngoscope 126: October 2016
2288
plant and a 2.5-mm titanium locking mandibular reconstruction
plate. In this article, we describe the technique used to contour
and create wedge osteotomies in the fibula to restore mandibular continuity.
Surgical Technique
The buccal surface of the mandible was exposed via a transoral and transcervical approach. A 2.5-mm titanium mandibular
reconstruction plate was bent to the shape of the mandible and
secured to the mandible. The plate was then removed and composite resection was completed (Fig. 1). The contoured plate was then
applied to the remaining segments of the mandible.
The ruler template technique was used to plan the osseous
reconstruction. Beginning with the posterior mandibular segment, the ruler was placed into the osseous defect, contacting
the mandibular segment and the mandibular reconstruction
plate. The distance was measured to the location where the curvature of the mandibular reconstruction plate necessitated the
first osteotomy. The ruler was partially cut at this distance so
that it remained in continuity but could bend and conform to
the plate. This process was repeated until the ruler template fit
into the mandibular defect (Fig. 2), and in this case two osteotomies were required. Once this was complete, the planned wedge
osteotomies were cut from the ruler template.
The fibula free tissue transplant was then harvested. Subperiosteal dissection was performed on the proximal fibula, and
the template was used to determine the amount of bone
required. The proximal fibula was then cut and discarded. The
template was then used to contour the bone segments and perform osteotomies (Fig. 3). It was critical to apply the template
in the correct orientation. For orientation, the surface of the fibula that was to receive the titanium screws to be plated represented the anterior surface of the fibula. Using this orientation,
the template was then applied to the inferior surface of the fibula (Fig. 3). A reciprocating saw was then used to contour the
posterior aspect of the transplant. Next, the periosteum was cut
along the anterior surface of the fibula with a no. 15 blade at
the location of the first osteotomy. A no. 9 elevator was then
used to elevate the pedicle off of the bone along the posterior
aspect of the bone, and a reciprocating saw was used to cut the
Kang et al.: Contour and Osteotomy of Fibula Transplant
Fig. 1. Composite resection of a T4a mandibular alveolus squamous cell carcinoma.
bone, using the ruler template as a guide for the wedge osteotomy (Fig. 3). The second osteotomy was made in similar fashion. Finally, the anterior edge of the fibula was contoured to
the template. The skin paddle was then passed into the oral
cavity and the bone was carefully positioned into the osseous
defect (Fig. 4). The bone was secured to the reconstruction
plate with monocortical titanium screws. The intraoral portion
of the inset was then performed, followed by microvascular
anastomosis.
RESULTS
Ischemia time was 2 hours and 5 minutes. The
anterior and lateral mandibular defect required two
Fig. 3. The fibula transplant was then harvested and the template
was applied. The proximal fibula was dissected from the pedicle,
cut, and discarded. The plating surface of the fibula was referenced as the anterior surface of the fibula. In this orientation, the
ruler template was applied to the inferior surface of the fibula. The
edges of the fibula were contoured, and wedge osteotomies were
performed, guided by the ruler template.
wedge osteotomies, creating three bone segments. Surgical pathology revealed perineural invasion and two positive ipsilateral lymph nodes and was staged as
T4aN2bM0. The patient received adjuvant radiation
treatment. He was begun on a clear liquid diet on postoperative day 7 and advanced to a soft diet on postoperative day 10. He maintained all nutrition by mouth
during radiation treatment. Oral competence remained
intact with liquids and solids and the patient returned
to eating in public without restriction.
DISCUSSION
In recent years, medical modeling and virtual
three-dimensional surgical planning have advanced the
field of reconstructive microsurgery.3 Production of a
stereolithic mandibular model allows the mandibular
reconstruction plate to be bent prior to surgery,4 thus
saving valuable operating room time. Mandibular
Fig. 2. After the mandibular reconstruction plate was placed, the
ruler template was formed. First, the posterior edge of the template was contoured to the posterior edge of the mandible. Next,
the ruler was placed into the defect against the plate, and the
measurement (4.1 cm) was marked for the first osteotomy. The
ruler is partially cut so that it remains in continuity but can bend.
The next measurement (6.1 cm) was then marked for the second
osteotomy, and the ruler was cut at this location. Finally, the anterior edge of the template was contoured to the anterior edge of
the mandible. The wedge osteotomies were then designed in the
template at the 4.1 cm and 6.1 cm marks.
Laryngoscope 126: October 2016
Fig. 4. The three segments of the fibula were fit into the defect,
achieving maximal bone contact while adhering close to the
reconstruction plate.
Kang et al.: Contour and Osteotomy of Fibula Transplant
2289
models are also particularly useful where tumor has
extended beyond the cortical bone, preventing placement
of the reconstruction plate prior to composite resection.
Other advances, such as virtual surgical planning, utilize computed tomographic scans of the mandible and
lower extremity to produce customized reconstruction
plates and stereolithography-guided osteotomies in the
fibula for mandibular reconstruction.5 Although the
authors utilize medical models and customized reconstruction plates on a case-by-case basis, we have not
adopted the routine use of fibula cutting guides, as we
have found that the technique described in this article
can be applied to the great majority of segmental mandibular defects.
There are several advantages to the ruler template
presented in this article. First, this is a simple technique
that is easily reproducible and applicable to nearly any
segmental mandibular defect. The ruler used is a standard paper surgical ruler that is readily available. The
measurement markers on the ruler make measuring the
distance to each planned osteotomy straightforward.
Once the location of the osteotomy is determined, the
wedges are designed and cut into the template. This portion of the procedure requires the most finesse to obtain
the final template and requires that the template be
placed in and out of the defect until the angles are finalized. Once the template is completed, it can be interposed on the fibula, subperiosteal dissection can begin,
and the proximal portion of the fibula can be quickly cut
and discarded.
Second, this technique is a low-cost method compared to the additional $2,700 cost of the preoperative
planning session and creation of fibula cutting guides.6
Other low-cost methods for contouring the fibula transplant include the tongue depressor7 and the scrub
sponge technique.8
Finally, use of the ruler template technique
provides significant flexibility to the oncologic and reconstructive surgeon. Intraoperative inspection and palpation of the tumor, as well as frozen section analysis,
yield critical data that influence the resection, and
subsequently, the osseous defect. In contrast, virtual
three-dimensional surgical planning and use of fibula
cutting guides require that the exact defect be deter-
Laryngoscope 126: October 2016
2290
mined preoperatively. However, intraoperative findings,
such as unanticipated tumor extension to additional subsites, may dictate the need to change the location of the
mandibular osteotomies to achieve oncologic control.
Reconstructive surgeons who routinely use preoperative
surgical planning and fibula cutting guides should also
be adept at template techniques for contouring the mandible in the event that intraoperative findings dictate a
change in the surgical plan.
CONCLUSION
The ruler template technique is a practical, lowcost, accurate, and reproducible freehand method of
shaping the fibula free tissue transplant during mandibular reconstruction. A carefully designed template can
be used to accurately contour the fibula and create
wedge osteotomies. This technique also provides maximal flexibility, allowing surgeons to plan the resection
and reconstruction based upon intraoperative data that
may influence the extent of resection. This technique
serves as a viable alternative to fibula cutting guides
for most defects requiring segmental mandibular
reconstruction.
BIBLIOGRAPHY
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Kang et al.: Contour and Osteotomy of Fibula Transplant