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Mandibulectomy with fibula graft


Medical editor Olav Jetlund MD
Head/Neck Surgeon
Oslo University Hospital

General

In patients where tumor has infiltrated the lower jaw, parts of the jaw may need to be removed. In such cases, it may be necessary to reconstruct with vascularized bone. The fibula is well suited for this. Hip bone is another alternative used at other centers. Lower jaw injured by irradiation (osteoradionecrosis) may also require this type of surgery.  

Indications

  • Primary tumor has infiltrated the mandible.
  • Primary tumor originating in the mandible.
  • Osteoradionecrosis

The patient's general health status, vessel status, age, and other diseases may be contraindications for reconstruction.

Goal

  • Remove tumor without great consequences for eating, drinking, speech, and appearance.

Equipment

  • General surgery tray
  • Equipment for
    • orthopedics
    • osteosynthesis
  • Microinstruments

Preparation

  • Antibiotic prophylaxis
  • Steroids (Decadron®, Fortecortin®)
  • The surgery is performed under general anesthesia while the patient lies supine. 
  • Two surgical fields are prepared.

Implementation

Neck/jaw

The extent of the surgery depends on the disease. Sometimes half of the jaw must be removed. A cervical dissection is always performed on the same side, where a donor vessel is also found.

  • The lip is split in the midline and the skin is placed to the side.
  • The bite is immobilized intramaxillarily.
  • The skin of the cheek is resected.
  • The resection will depend on the extent of the tumor. Soft tissue content is resected and the mandible is resected with adequate margins.
  • Frozen sections are made from bone marrow, among others.

Leg

  • Surgical tourniquet to reduce bleeding
  • The incision is drawn lateral to the fibula.
  • Resect fibula with blood supply and any possibly overlying skin which is used for the covering in the mouth. The length of the fibula graft will depend on the defect in the mandible to be replaced. 

Reconstruction

Jaw surgeon

  • The free transplant from the fibula is adapted for the mandible.
  • The specimen is attached with plates on each side.

Hand surgeons

  • Microvascular anastomosis is performed to cervical vessels, usually the facial artery or superior thyroid artery. 
  • On the venous side, the facial vein or other branches is used.

ENT surgeons

  • The soft tissue over the graft is closed either primarily with mucosa or covered with full-thickness skin from the graft, or possibly with partial skin on muscle/soft tissues. 
  • The incision is closed.

Follow-up

  • The graft is monitored, possibly with a laser probe (doppler of vessels).
  • Steroids
  • Thrombosis prophylaxis
  • Antibiotic prophylaxis
  • The foot should be elevated for a couple of days.
  • The patient may drink water and other liquids from the first postoperative day. The patient should not chew.
  • Rehabilitation of teeth status is a significant part of treatment. Implants may be inserted around one year after hyperbaric oxygen treatment in Bergen. 

Frequent follow-up visits will take place during the first year at ENT- and oral surgeons. 

The patient will have follow-up for three years.


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