Defects of the mandible affect dental and oral closure as well as eating. It requires a bony reconstruction with adequate strength to allow—if necessary— for subsequent dental reconstruction with osseointegrated implants. Furthermore, an associated mucosal or skin defect needs to be covered. Vascularized bone grafts are the method of choice.

Fibula Flap

The vascularized fibula based on the peroneal artery was described by Taylor in 1975,16 and the reliability of skin further characterized by Yoshimira, Beppu, and Wei. The osteocutaneous fibula flap has become the mainstay of the mandibular reconstruction providing both oral lining as well as bony structure to the resected mandible (Figs. 17-6 and 17-7). Large segments of up to

Figure 17-6 (A) A 70-year-old male patient status posthemimandibulectomy and radiation for cancer; (B) secondary reconstruction with osteoseptocutaneous fibula for contour cosmesis and restoration of mandibular balance; (C and D) postoperative results.
Figure 17-7 (A) Patient with SCC; (B) excision of tumor with hemi-mandibulectomy; (C) harvest of osteoseptocutaneous fibula free flap; (D) inset of free flap. A skin paddle was required for the extraoral soft tissue defect; (E) postoperative result.
Figure 17-7 (Continued)

25 cm can be obtained. One of the major disadvantages is the limited availability of the skin and soft tissue necessary for reconstructing mucosal defects. In the elderly, one has to be aware of associated vascular and atherosclerotic disease.

The free circumflex iliac osteocutaneous flap is an alternative bone flap based on the deep circumflex iliac vessels (Fig. 17-8). Associated soft tissue can be bulky. Furthermore, the radial forearm flap can be harvested with radial bone, the scapula flap can include scapular bone if needed, and the free serratus anterior flap can be harvested with ribs.

A pedicled alternative is the pectoralis major flap which can include a rib segment.

Craniofacial Defects

Craniofacial reconstruction includes restoration of

1. The base of the skull

2. The scalp and cranial area

3. The midface

Defects affecting the base of the skull need adequate coverage to protect and seal off the neurocranium. Muscular flaps provide better vascularization in infected, radiated, or scarred tissue.

Figure 17-8 A 45-year-old male patient with mandibulectomy and bilateral radical neck dissection for SCC. (A) Reconstruction with plate to recreate the mandibular contour; (B) donor site showing the hip region. An osteocutaneious deep circumflex iliac artery (DCIA) flap is marked containing part of the iliac crest; (C) flap in place.

The latissimus dorsi muscular or musculocutaneous flap is the largest muscular free flap. It is supplied by the large calibered thoracodorsal artery, a branch of the subscapular vessels. The harvest is uncomplicated and the donor site can be closed primarily. However, as with a scapula flap, turning the patient is necessary prolonging operative time.

Defects of the scalp and osseocranium cranium affect stability and protection of the neurocranium. It requires adequate and stable coverage either with soft tissue alone or combined with vascularized bone. For soft tissue defects, muscular flaps such as the latissimus, rectus abdominis, or gracilis are favorable options. Large defects can be covered with the free omental flap. The free omentum provides a pliable and well-vascularized tissue which needs an additional split-thickness skin graft (Figs. 17-9 and 17-10).

For a combined osteocutaneious coverage, the serratus anterior muscle flap with the anterior half of several ribs provides an elegant way to reconstruct calvarium.

Defects affecting the midface may impair sight, nasal breathing or respiration, eating, oral continence, and—importantly—esthetics. Cutaneous flaps and in particular local flaps provide best cosmesis, because skin characteristics are similar. If the defect is larger, the radial forearm flap again is the method

Figure 17-9 (A) Osteomyelitis of the skull following radiation for brain tumor; (B) insetting of an omental free flap; (C) result after 1 year. Patient wears a wig.

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