Title : Evolution of facial reconstruction techniques with microvascularized fibula flap: Accumulated experience since 1995
Abstract:
Introduction: Resection of facial tumors involving the maxilla and mandible frequently results in significant functional and aesthetic sequelae, compromising speech, chewing, swallowing, and patients' self-esteem. These repercussions directly impact quality of life, affecting vital functions, facial identity, and social interaction. Factors such as advanced disease staging, aggressive biological behavior, complex anatomical location, and failures in prevention and early diagnosis programs contribute to the need for extensive, often mutilating, resections. These procedures represent significant multidisciplinary challenges, requiring integration between surgical, oncological, and rehabilitation teams, especially when anatomical defects exceed the possibility of local repairs. The magnitude of tissue loss, involving bone and soft tissue structures, demands more elaborate reconstructive approaches. Reconstructions with microvascularized fibular flaps have been routinely performed at our institution since 1995, establishing themselves as a versatile and reliable alternative. This experience has allowed the development and improvement of technical variations that broaden reconstructive possibilities, focusing on functional and aesthetic restoration, promoting better quality of life and social reintegration of patients.
Objective: To present and systematize technical variations of facial reconstruction using the microvascularized fibula flap developed at our institution.
Method: These techniques are indicated for patients who require reconstruction of orofacial defects resulting from tumor resection, necrosis, or trauma. Fibular bone osteotomy is performed in multiple segments, according to the anatomical defect resulting from tumor resection or traumatic lesions with loss of orofacial substance. For fixation of the bone segments, miniplates and screws of the 2.0 system are used, allowing stabilization between the segments and their integration into the maxillofacial complex. The choice of reconstructive technique is individualized, being defined according to the specific characteristics of each defect presented by the patients. Different technical variations were employed, including: Maxillary reconstruction with a microvascularized fibular flap in a “U” shape for Le Fort I/II type defects with five-year follow-up; Maxillary and orbital floor reconstruction with parallel fibular flap segments; Bilateral maxillary reconstruction (variation IX); Mandibular reconstruction with increased contact area through fenestration of the stumps on the posterior surface of the fibula (variation VI); Microvascular fibula flap sandwiched between the fibula and mandible segments: variant VII; Mandibular reconstruction with a double segment in edentulous patients (variation I) and in dentate patients (variation II); “Fit-in” technique with a vascularized fibular flap (variation III); and Mandibular reconstruction with a vascularized fibular graft – variation IV. All these techniques were developed and applied at our institution and are duly described in the corresponding references.
Conclusion: The described approach, based on different variations of the microvascularized fibula flap, demonstrated satisfactory results from a functional and aesthetic point of view, in addition to overcoming technical challenges frequently encountered in maxillomandibular reconstructions. It is believed that these techniques contribute significantly to the restoration of the anatomy of the midface and mandible, favoring the rehabilitation of speech, mastication, and facial expression. Furthermore, they promote adequate bone neoformation, structural stability, and a consistent improvement in the quality of life of patients undergoing these procedures.
