J Oral Maxlllofac
Surg
49:244-250,199l
The Vascularized Fibula Graft in Mandibular Reconstruction J.M. SERRA,* V. PALOMA,t
F. MESA,t
AND A. BALLESTEROSt
The use of a vascularized graft from the fibula for mandibular reconstruction is presented. The great strength, pliability, and long vascular pedicle that characterize such grafts make them particularly suitable for this type of repair. The results in six cases were highly satisfactory. Masticatory function was well restored, without alteration of the facial contour, and with minimal sequelae at the donor site.
There are numerous surgical techniques for the repair of mandibular defects. Among these, however, vascularized bone grafts are most advantageous for the repair of bone and soft-tissue defects. They withstand high doses of radiotherapy, and complete restoration of the masticatory function can be achieved by the additional placement of intraosseous implants.’ Vascularized bone grafts from the iliac crest, the radius, the rib, and the scapula have been used in mandibular reconstruction.*-5 In 1986, we began to use a vascularized bone graft from the fibula2,3 for repair of the mandible. When defects of the floor of the mouth as well as of the skin of face and neck were present, we used an osteocutaneous flap; its island of skin served to repair the defects of the soft tissues.
through various segmentary branches entering the periosteum through the muscular insertions. Both the nutrient artery and the segmentary periostealmuscle vessels are branches of the peroneal artery, the external branch of the tibioperoneal trunk. The caliber of the peroneal artery varies between 1.8 and 3 mm, and the pedicle is very long, somewhere between 8 and 12 cm.6 The vascularized fibular graft may be accompanied by an island of skin. The middle third of the lateral aspect of the leg is supplied by two vascular systems: I) direct cutaneous branches of the peroneal artery, which run down the fascia between the peroneal muscles and the soleus, and 2) by the perforating branches derived from the circulation of the soleus. By respecting these factors, an improvement in the vascularization of the island of skin, and a better graft, can be obtained.
Anatomy Materials and Methods
The fibula receives its vascularization at the diaphyseal level posteriorly through a nutrient artery that provides circulation to the endosteum and
Our treatment protocols are classified according to the type of reconstruction that is to be carried out: mandibular symphysis, mandibular body, body and symphysis, or hemimandibulectomy; all with or without island of skin.
Received from the Department of Plastic, Aesthetic, and Reconstructive Surgery, Cllnica Universitaria, Faculty of Medicine, University of Navarra, Pamplona, Spain. * Chief. t Resident. Address correspondence and reprint requests to Dr Serra: Department of Plastic, Aesthetic, kd Reconstructive Surgery, Clinica Universitaria, Faculty of Medicine, University of Navarra, Apartado 192, 31080 Pamplona, Spain. 0 1991 geons
American
Association
of Oral
and Maxillofacial
SURGICAL TECHNIQUE
The approach described by Gilbert in 19794 is used. An incision is made in the middle third of the lateral aspect of the leg, and blunt dissection down the intermuscular partition between the peroneal muscles and the soleus is used until the fibula is reached. It is important to leave 1 cm of peroneal
Sur-
0278-2391/91/4903-0005$3.00/O
244
SERRA ET AL
muscle inserted in the bone to conserve the circulation of the periosteum. The size of the fibular bone graft can vary, at maximum, between 20 to 25 cm in adults, always leaving 3 to 4 cm proximally and 10 cm distally
FIGURE 1. A, Illustration of osteotomies in the tibula. B, Demonstration of use of libula for mandibular reconstruction.
245 (external malleolus). In cases where soft-tissue defects are to be repaired, a 12 x 6-cm island of skin from the lateral aspect of the leg is used. When dissecting the skin flap, the superficial fascia of the peroneal muscles, the soleus, and the intermuscular partition is maintained to obtain the greatest possible number of vessels. When an osteocutaneous flap is used, the donor site is repaired using a free meshed skin graft. In cases where no island of skin is required, the area is closed primarily in layers. The libula is remodeled, making a wedge from the upper part for forming the angle of the mandible, and a second wedge from the internal face of the fibula to form the symphysis (Fig 1). Osteosynthesis is achieved by means of small, adjustable plates. The libular graft is always placed with its posterior aspect (through which the nutrient artery enters) orientated caudally so that the pedicle enters the lower aspect of the neomandible. While operating, we rely on two factors that allow us to obtain better results. First, we use a methyl methacrylate model (Fig 2) of the mandible, which serves as a guide for forming the new mandible. Second, cephalometric studies are carried out in advance to determine the measurements of the ramus, the body, and the angle of the mandible (120” to 130” in adults), which indicates the location of the osteotomies in the tibula necessary for forming a mandible of similar dimensions to the one removed. In follow-up, scintigraphy is used. We carry out dynamic and static studies with 99mT~ between the
FIGURE 2. Model of the mandible used intraoperatively serve as a guide for forming the new mandible.
to
246
VASCULARIZED
4th and the 10th postoperative after the operation. This allows accurate check on the viability when no island of skin is used. In the treatment of tumors, it postoperative radiotherapy.
day, and 1 month us to keep a more of the bone grafts is usual to employ
Results
FIBULA
the vascularized bone graft occurred in every case, as was shown by conventional radiography; the junction between the graft and the host bone was eliminated; and the trabeculation typical of healthy bone was established (Table 1). Report of Cases Case 1: Symphysis
The patients in this series of six cases were observed for a period of between 4 months and 2 years. During this period, the osteointegration of
GRAFT FOR REPAIR OF MANDIBLE
With Island of Skin
A 40-year-old man had been diagnosed as having an epidermoid carcinoma of the retromolar trigone. Mandibulectomy and radical bilateral cervical dissection had
247
SERRA ET AL
been performed. The first reconstruction had been carried out in another hospital using two rotation flaps of pectoral muscle and a titanium mesh for the mandible. The patient came to our center after problems began with extrusion of the mesh in the region of the symphysis. The titanium mesh was removed and the jaw reconstructed using a vascularized tibular flap with an island of skin to cover a large cutaneous defect in the anterior aspect of the neck (Fig 3).
Case 2: Body of Mandible Without Cutaneous Island A 20-year-old woman was diagnosed as having an ameloblastoma in the body of the mandible, and excision
was performed.
Because it produced a great facial contour deformity and there was pain with masticatory function, reconstruction was carried out using a vascularized bone graft from the tibula; neither an island of skin nor radiotherapy were necessary (Fig 4).
Discussion At present, there are three chief methods for reconstructing mandibular defects: synthetic materials (silicone, titanium),’ nonvascularized bone grafts, and vascularized bone grafts.‘.4.57738 Synthetic materials are beset with the problems of fre-
FIGURE 3. Case 1. A, Preoperative view of a patient who had undergone a complete mandibulectomy and reconstruction using a titanium mesh. B, Outline of the tibular graft with an island of skin. C, Dissection of island of skin over a supramuscular plane.
including the fascia of the peroneal muscles and the soleus. D. View vascular branches of the soleus to the skin. E. Dissected osteocutaneous graft. F, Osteocutaneous graft from the fibula shaped for reconstruction of the symphysis. G, Pedicle of the flap once it had been sutured to the facial vessels using microsurgical techniques. H. Postoperative result at 6 months. I, Photograph showing the minimal esthetic and functional sequela in the donor area when the gap left by removal the island of skin was covered by a free mesh skin graft.
248
VASCULARIZED
FIBULA GRAFT FOR REPAIR OF MANDIBLE
Table 1. Data Relating to Patients Whose Mandible was Reconstructed Using a Vascularired Graft From the Fibula, and Who Underwent Intraoperative Radiotherapy
Case 1
40
Epidermoid carcinoma
Retromolar trigone
2
20
Ameloblastoma
Body of mandible
3
45
Epidermoid carcinoma
Retromolar trigone
4
60
Floor of mouth
5
36
6
49
Epidermoid carcinoma Recurrence of carcinoma, epidermoid Recurrence of carcinoma, epidermoid
Diagnosis
Abbreviations:
Reconstruction With Vascular Fibular Graft
IORT
Mandibulectomy and excision, mouth floor Excision of body of mandible Excision of body and ascending names Excision of body and mouth floor Hemimandibulectomy, hemiglossectomy
With skin island
Hemimandibulectomy and excision of mouth floor
Surgical Treatment
Age (Yrl
Site
Floor of mouth
Floor of mouth
IORT, intraoperative
radiotherapy;
PRT, postoperative
quent infection, rejection, and breakage, which impede satisfactory recovery of masticatory function. Nonvascularized bone grafts can be unsuccessful because of bone resorption and necrosis, which may appear after radiotherapy. Vascularized bone grafts are the only type that can withstand radiotherapy and chemotherapy (Table 2). The appropriate characteristics for a vascularized bone graft to be used in the repair of a mandibular defect are as follows:
PRT
Follow-
WY)
UP (mo)
1,500
-
13
Without skin island
1,500
-
24
Without skin island
1,500
-
18
With skin island
1,500
5,ooa
6
With skin island
1,500
5,ooo
17
With skin island
1,500
4,ooa
4
radiotherapy.
The fact that the mandible is a bone that has to withstand great pressure means that it must be strong. The fibula, being a tubular bone with a thick layer of cortex, is the strongest of all the vascularized grafts described in the literature, and is thus suitable for withstanding the positioning of intraosseous implants. ’ The implants must not be put into place during the same surgical procedure, however, so as to avoid excessive damage to the circulation of the bone graft. Another advantage of using vascularized fibula rather than the rib is that the removal does not carry the risk of causing a pneumothorax. Reconstruction of function is not the only important factor; the cosmetic result must also be considered. By making small wedges in the tibula, it can be shaped as necessary for esthetic adjustment. This requires meticulous preoperative cephalometric study and the preparation of a model of the mandible so that better results can be obtained, and the length of time needed for the operation and the period of ischemia can be reduced.
1. the bone must be strong; 2. there must be potential for shaping to form the symphysis; 3. it must be long enough to repair a complete hemimandible; 4. it must have a lengthy vascular pedicle; 5. it should be easy to obtain, to shorten the time of operation; 6. there should be no sequelae at the donor site; 7. it must have a potential island of skin, should a soft-tissue defect need to be repaired. Table 2.
WY)
Characteristics of Vascularired Bone Grafts Iliac Crest
Pedicle length Strength Island of skin Sequelae Conservation of facial contour Pneumothorax
Superficial Vessels
Deep Vessels
Rib
Radius
Scapula
Fibula
10 cm ++ + ++ -
10 cm ++ _ _
12 cm +++ -
IO-15 cm + + _
+ _
+ +
+ _
3-6 cm + + + + _
8-12 cm +++ + + + _
SERRA ET AL
249
FIGURE 4. Case 2. A, Preoperative computed tomography scan of a tumor affecting the left side of the mandible. B, Approach to the tibula via an incision in the lateral aspect of the middle third of the leg. C. Fibula dissected without incision of the soleus and peroneal muscles. D, Donor area is closed in layers with minimal esthetic and functional sequelae. E. Anteroposterior radiograph showing graft. F, Postoperative view of patient showing good opening to the mouth. G, Postoperative view of patient demonstrating an effective bite.
250
VASCULARIZED
If a defect in the soft tissues of the floor of the mouth or the cutaneous covering is present, it can be repaired by using a combined osteocutaneous flap from the fibula, which provides a thin cutaneous area that does not deform the facial contour, as is the case when an osteomyocutaneous flap of the iliac crest is used. David’ proposes a double free flap (bone from the iliac crest and skin from the forearm) to avoid this problem, but this is a complex procedure that increases the risk and may cause sequelae in both donor areas. References 1. Riediger D: Restoration of masticatory function by microsurgically revascularized iliac crest bone grafts using endosseous implants. Plast Reconst Surg 81:861, 1988
FIBULA GRAFT FOR REPAIR OF MANDIBLE
2. Taylor GI: The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconst Surg 55:533, 1975 3. Taylor GI, Daniel RV: The anatomy of several free flap donor sites. Plast Reconst Surg 56:243, 1975 4. Gilbert A: Vascularized transfer of the libula graft. Int J Microsurg 1: 100, 1979 5. Achilleas T: The free vascularized Reconst Surg 82:291, 1988
anterior rib graft. Plast
6. Serra JM, Vila Rovira R: Microcirugia reparadora. lona, Salvat, 1985, p 145
Barce-
7. Vuillemin T: Mandibular reconstruction with the titanium hollow screw reconstruction plate (Thorp) system: Evaluation of 62 cases. Plast Reconst Surg 82:804, 1988 8. David DJ, Tan E, Katsaros J, et al: Mandibular reconstruction with vascularized iliac crest: A 10 year experience. Plast Reconst Surg 82:792, 1978 9. Hidalgo DA: Flbula free flap: A new method of mandible reconstruction. Plast Reconst Surg 884:71, 1988
Surg
49:244-250,199l
The Vascularized Fibula Graft in Mandibular Reconstruction J.M. SERRA,* V. PALOMA,t
F. MESA,t
AND A. BALLESTEROSt
The use of a vascularized graft from the fibula for mandibular reconstruction is presented. The great strength, pliability, and long vascular pedicle that characterize such grafts make them particularly suitable for this type of repair. The results in six cases were highly satisfactory. Masticatory function was well restored, without alteration of the facial contour, and with minimal sequelae at the donor site.
There are numerous surgical techniques for the repair of mandibular defects. Among these, however, vascularized bone grafts are most advantageous for the repair of bone and soft-tissue defects. They withstand high doses of radiotherapy, and complete restoration of the masticatory function can be achieved by the additional placement of intraosseous implants.’ Vascularized bone grafts from the iliac crest, the radius, the rib, and the scapula have been used in mandibular reconstruction.*-5 In 1986, we began to use a vascularized bone graft from the fibula2,3 for repair of the mandible. When defects of the floor of the mouth as well as of the skin of face and neck were present, we used an osteocutaneous flap; its island of skin served to repair the defects of the soft tissues.
through various segmentary branches entering the periosteum through the muscular insertions. Both the nutrient artery and the segmentary periostealmuscle vessels are branches of the peroneal artery, the external branch of the tibioperoneal trunk. The caliber of the peroneal artery varies between 1.8 and 3 mm, and the pedicle is very long, somewhere between 8 and 12 cm.6 The vascularized fibular graft may be accompanied by an island of skin. The middle third of the lateral aspect of the leg is supplied by two vascular systems: I) direct cutaneous branches of the peroneal artery, which run down the fascia between the peroneal muscles and the soleus, and 2) by the perforating branches derived from the circulation of the soleus. By respecting these factors, an improvement in the vascularization of the island of skin, and a better graft, can be obtained.
Anatomy Materials and Methods
The fibula receives its vascularization at the diaphyseal level posteriorly through a nutrient artery that provides circulation to the endosteum and
Our treatment protocols are classified according to the type of reconstruction that is to be carried out: mandibular symphysis, mandibular body, body and symphysis, or hemimandibulectomy; all with or without island of skin.
Received from the Department of Plastic, Aesthetic, and Reconstructive Surgery, Cllnica Universitaria, Faculty of Medicine, University of Navarra, Pamplona, Spain. * Chief. t Resident. Address correspondence and reprint requests to Dr Serra: Department of Plastic, Aesthetic, kd Reconstructive Surgery, Clinica Universitaria, Faculty of Medicine, University of Navarra, Apartado 192, 31080 Pamplona, Spain. 0 1991 geons
American
Association
of Oral
and Maxillofacial
SURGICAL TECHNIQUE
The approach described by Gilbert in 19794 is used. An incision is made in the middle third of the lateral aspect of the leg, and blunt dissection down the intermuscular partition between the peroneal muscles and the soleus is used until the fibula is reached. It is important to leave 1 cm of peroneal
Sur-
0278-2391/91/4903-0005$3.00/O
244
SERRA ET AL
muscle inserted in the bone to conserve the circulation of the periosteum. The size of the fibular bone graft can vary, at maximum, between 20 to 25 cm in adults, always leaving 3 to 4 cm proximally and 10 cm distally
FIGURE 1. A, Illustration of osteotomies in the tibula. B, Demonstration of use of libula for mandibular reconstruction.
245 (external malleolus). In cases where soft-tissue defects are to be repaired, a 12 x 6-cm island of skin from the lateral aspect of the leg is used. When dissecting the skin flap, the superficial fascia of the peroneal muscles, the soleus, and the intermuscular partition is maintained to obtain the greatest possible number of vessels. When an osteocutaneous flap is used, the donor site is repaired using a free meshed skin graft. In cases where no island of skin is required, the area is closed primarily in layers. The libula is remodeled, making a wedge from the upper part for forming the angle of the mandible, and a second wedge from the internal face of the fibula to form the symphysis (Fig 1). Osteosynthesis is achieved by means of small, adjustable plates. The libular graft is always placed with its posterior aspect (through which the nutrient artery enters) orientated caudally so that the pedicle enters the lower aspect of the neomandible. While operating, we rely on two factors that allow us to obtain better results. First, we use a methyl methacrylate model (Fig 2) of the mandible, which serves as a guide for forming the new mandible. Second, cephalometric studies are carried out in advance to determine the measurements of the ramus, the body, and the angle of the mandible (120” to 130” in adults), which indicates the location of the osteotomies in the tibula necessary for forming a mandible of similar dimensions to the one removed. In follow-up, scintigraphy is used. We carry out dynamic and static studies with 99mT~ between the
FIGURE 2. Model of the mandible used intraoperatively serve as a guide for forming the new mandible.
to
246
VASCULARIZED
4th and the 10th postoperative after the operation. This allows accurate check on the viability when no island of skin is used. In the treatment of tumors, it postoperative radiotherapy.
day, and 1 month us to keep a more of the bone grafts is usual to employ
Results
FIBULA
the vascularized bone graft occurred in every case, as was shown by conventional radiography; the junction between the graft and the host bone was eliminated; and the trabeculation typical of healthy bone was established (Table 1). Report of Cases Case 1: Symphysis
The patients in this series of six cases were observed for a period of between 4 months and 2 years. During this period, the osteointegration of
GRAFT FOR REPAIR OF MANDIBLE
With Island of Skin
A 40-year-old man had been diagnosed as having an epidermoid carcinoma of the retromolar trigone. Mandibulectomy and radical bilateral cervical dissection had
247
SERRA ET AL
been performed. The first reconstruction had been carried out in another hospital using two rotation flaps of pectoral muscle and a titanium mesh for the mandible. The patient came to our center after problems began with extrusion of the mesh in the region of the symphysis. The titanium mesh was removed and the jaw reconstructed using a vascularized tibular flap with an island of skin to cover a large cutaneous defect in the anterior aspect of the neck (Fig 3).
Case 2: Body of Mandible Without Cutaneous Island A 20-year-old woman was diagnosed as having an ameloblastoma in the body of the mandible, and excision
was performed.
Because it produced a great facial contour deformity and there was pain with masticatory function, reconstruction was carried out using a vascularized bone graft from the tibula; neither an island of skin nor radiotherapy were necessary (Fig 4).
Discussion At present, there are three chief methods for reconstructing mandibular defects: synthetic materials (silicone, titanium),’ nonvascularized bone grafts, and vascularized bone grafts.‘.4.57738 Synthetic materials are beset with the problems of fre-
FIGURE 3. Case 1. A, Preoperative view of a patient who had undergone a complete mandibulectomy and reconstruction using a titanium mesh. B, Outline of the tibular graft with an island of skin. C, Dissection of island of skin over a supramuscular plane.
including the fascia of the peroneal muscles and the soleus. D. View vascular branches of the soleus to the skin. E. Dissected osteocutaneous graft. F, Osteocutaneous graft from the fibula shaped for reconstruction of the symphysis. G, Pedicle of the flap once it had been sutured to the facial vessels using microsurgical techniques. H. Postoperative result at 6 months. I, Photograph showing the minimal esthetic and functional sequela in the donor area when the gap left by removal the island of skin was covered by a free mesh skin graft.
248
VASCULARIZED
FIBULA GRAFT FOR REPAIR OF MANDIBLE
Table 1. Data Relating to Patients Whose Mandible was Reconstructed Using a Vascularired Graft From the Fibula, and Who Underwent Intraoperative Radiotherapy
Case 1
40
Epidermoid carcinoma
Retromolar trigone
2
20
Ameloblastoma
Body of mandible
3
45
Epidermoid carcinoma
Retromolar trigone
4
60
Floor of mouth
5
36
6
49
Epidermoid carcinoma Recurrence of carcinoma, epidermoid Recurrence of carcinoma, epidermoid
Diagnosis
Abbreviations:
Reconstruction With Vascular Fibular Graft
IORT
Mandibulectomy and excision, mouth floor Excision of body of mandible Excision of body and ascending names Excision of body and mouth floor Hemimandibulectomy, hemiglossectomy
With skin island
Hemimandibulectomy and excision of mouth floor
Surgical Treatment
Age (Yrl
Site
Floor of mouth
Floor of mouth
IORT, intraoperative
radiotherapy;
PRT, postoperative
quent infection, rejection, and breakage, which impede satisfactory recovery of masticatory function. Nonvascularized bone grafts can be unsuccessful because of bone resorption and necrosis, which may appear after radiotherapy. Vascularized bone grafts are the only type that can withstand radiotherapy and chemotherapy (Table 2). The appropriate characteristics for a vascularized bone graft to be used in the repair of a mandibular defect are as follows:
PRT
Follow-
WY)
UP (mo)
1,500
-
13
Without skin island
1,500
-
24
Without skin island
1,500
-
18
With skin island
1,500
5,ooa
6
With skin island
1,500
5,ooo
17
With skin island
1,500
4,ooa
4
radiotherapy.
The fact that the mandible is a bone that has to withstand great pressure means that it must be strong. The fibula, being a tubular bone with a thick layer of cortex, is the strongest of all the vascularized grafts described in the literature, and is thus suitable for withstanding the positioning of intraosseous implants. ’ The implants must not be put into place during the same surgical procedure, however, so as to avoid excessive damage to the circulation of the bone graft. Another advantage of using vascularized fibula rather than the rib is that the removal does not carry the risk of causing a pneumothorax. Reconstruction of function is not the only important factor; the cosmetic result must also be considered. By making small wedges in the tibula, it can be shaped as necessary for esthetic adjustment. This requires meticulous preoperative cephalometric study and the preparation of a model of the mandible so that better results can be obtained, and the length of time needed for the operation and the period of ischemia can be reduced.
1. the bone must be strong; 2. there must be potential for shaping to form the symphysis; 3. it must be long enough to repair a complete hemimandible; 4. it must have a lengthy vascular pedicle; 5. it should be easy to obtain, to shorten the time of operation; 6. there should be no sequelae at the donor site; 7. it must have a potential island of skin, should a soft-tissue defect need to be repaired. Table 2.
WY)
Characteristics of Vascularired Bone Grafts Iliac Crest
Pedicle length Strength Island of skin Sequelae Conservation of facial contour Pneumothorax
Superficial Vessels
Deep Vessels
Rib
Radius
Scapula
Fibula
10 cm ++ + ++ -
10 cm ++ _ _
12 cm +++ -
IO-15 cm + + _
+ _
+ +
+ _
3-6 cm + + + + _
8-12 cm +++ + + + _
SERRA ET AL
249
FIGURE 4. Case 2. A, Preoperative computed tomography scan of a tumor affecting the left side of the mandible. B, Approach to the tibula via an incision in the lateral aspect of the middle third of the leg. C. Fibula dissected without incision of the soleus and peroneal muscles. D, Donor area is closed in layers with minimal esthetic and functional sequelae. E. Anteroposterior radiograph showing graft. F, Postoperative view of patient showing good opening to the mouth. G, Postoperative view of patient demonstrating an effective bite.
250
VASCULARIZED
If a defect in the soft tissues of the floor of the mouth or the cutaneous covering is present, it can be repaired by using a combined osteocutaneous flap from the fibula, which provides a thin cutaneous area that does not deform the facial contour, as is the case when an osteomyocutaneous flap of the iliac crest is used. David’ proposes a double free flap (bone from the iliac crest and skin from the forearm) to avoid this problem, but this is a complex procedure that increases the risk and may cause sequelae in both donor areas. References 1. Riediger D: Restoration of masticatory function by microsurgically revascularized iliac crest bone grafts using endosseous implants. Plast Reconst Surg 81:861, 1988
FIBULA GRAFT FOR REPAIR OF MANDIBLE
2. Taylor GI: The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconst Surg 55:533, 1975 3. Taylor GI, Daniel RV: The anatomy of several free flap donor sites. Plast Reconst Surg 56:243, 1975 4. Gilbert A: Vascularized transfer of the libula graft. Int J Microsurg 1: 100, 1979 5. Achilleas T: The free vascularized Reconst Surg 82:291, 1988
anterior rib graft. Plast
6. Serra JM, Vila Rovira R: Microcirugia reparadora. lona, Salvat, 1985, p 145
Barce-
7. Vuillemin T: Mandibular reconstruction with the titanium hollow screw reconstruction plate (Thorp) system: Evaluation of 62 cases. Plast Reconst Surg 82:804, 1988 8. David DJ, Tan E, Katsaros J, et al: Mandibular reconstruction with vascularized iliac crest: A 10 year experience. Plast Reconst Surg 82:792, 1978 9. Hidalgo DA: Flbula free flap: A new method of mandible reconstruction. Plast Reconst Surg 884:71, 1988
