Research Article| Volume 50, SUPPLEMENT 5, S117-S122, December 2019

Download started.


Microsurgical reconstruction of complex oromandibular defects: An update

Published:October 23, 2019DOI:


      Free flaps are the gold standard for reconstruction of the mandible, tongue and floor of the mouth. Free fibular flaps are the most preferable option for reconstruction of complex mandibular defects, as well as for tongue and mouth floor reconstruction, since they are harvested easily, present excellent sculptability and good functional outcomes. Alternative options for bone reconstruction include the fibular and iliac crest free flap, and for soft tissue reconstruction include the anterolateral thigh, the radial forearm free flap, and the nasolabial island flap. The principles of the surgical approach include resection of the mandibular segment, intraoperative evaluation of the defect, and various surgical manipulations of the flap on site to reconstruct the defect. Advances in computerized preoperative planning have allowed virtual simulation of the defect and fabrication of an individualized stereolithic mandibular model. This short review discusses the current trends of bone and soft tissue flaps for complex oromandibular reconstructions aiming to present a comprehensive review that the readers would find interesting and informative.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Taylor G.I.
        • Miller G.D.
        • Ham F.J.
        The free vascularized bone graft. a clinical extension of microvascular techniques.
        Plast Reconstr Surg. 1975; 55: 533-544
        • Bumbasirevic M.
        • Stevanovic M.
        • Bumbasirevic V.
        • Lesic A.
        • Atkinson H.D.
        Free vascularised fibular grafts in orthopaedics.
        Int Orthop. 2014; 38: 1277-1282
        • Chacha P.B.
        Vascularised pedicular bone grafts.
        Int Orthop. 1984; 8: 117-138
        • Judet H.
        • Judet J.
        • Gilbert A.
        Vascular microsurgery in orthopaedics.
        Int Orthop. 1981; 5: 61-68
        • Korompilias AV
        • Paschos NK
        • Lykissas MG
        • Kostas-Agnantis I
        • Vekris MD
        • Beris AE
        Recent updates of surgical techniques and applications of free vascularized fibular graft in extremity and trunk reconstruction.
        Microsurgery. 2011; 31: 171-175
        • Panagopoulos G.N.
        • Mavrogenis A.F.
        • Mauffrey C.
        • Lesensky J.
        • Angelini A.
        • Megaloikonomos P.D.
        • Igoumenou V.G.
        • Papanastassiou J.
        • Savvidou O.
        • Ruggieri P.
        • Papagelopoulos P.J.
        Intercalary reconstructions after bone tumor resections: a review of treatments.
        Eur J Orthop Surg Traumatol. 2017; 27: 737-746
      1. Soucacos PN, Kokkalis ZT, Piagkou M, Johnson EO. Vascularized bone grafts for the management of skeletal defects in orthopaedic trauma and reconstructive surgery. 2013; Injury 44 Suppl 1:S70–75. doi:10.1016/S0020-1383(13)70016-0.

        • Hidalgo D.A.
        Fibula free flap: a new method of mandible reconstruction.
        Plast Reconstr Surg. 1989; 84: 71-79
        • Monaco C
        • Stranix JT
        • Avraham T
        • Brecht L
        • Saadeh PB
        • Hirsch D
        • et al.
        Evolution of surgical techniques for mandibular reconstruction using free fibula flaps: the next generation.
        Head Neck. 2016; 38: E2066-E2073
        • Ferreira JJ
        • Zagalo CM
        • Oliveira ML
        • Correia AM
        • Reis AR
        Mandible reconstruction: history, state of the art and persistent problems.
        Prosthet Orthot Int. 2015; 39: 182-189
        • Moubayed S.P.
        • L'Heureux-Lebeau B.
        • Christopoulos A.
        • Sampalis J.S.
        • Letourneau-Guillon L.
        • Bissada E.
        • Guertin L.
        • Harris P.G.
        • Danino A.M.
        • Ayad T.
        Osteocutaneous free flaps for mandibular reconstruction: systematic review of their frequency of use and a preliminary quality of life comparison.
        J Laryngol Otol. 2014; 128: 1034-1043
        • Toto J.M.
        • Chang E.I.
        • Agag R.
        • Devarajan K.
        • Patel S.A.
        • Topham N.S.
        Improved operative efficiency of free fibula flap mandible reconstruction with patient-specific, computer-guided preoperative planning.
        Head Neck. 2015; 37: 1660-1664
        • Wallace C.G.
        • Chang Y.M.
        • Tsai C.Y.
        • Wei F.C.
        Harnessing the potential of the free fibula osteoseptocutaneous flap in mandible reconstruction.
        Plast Reconstr Surg. 2010; 125: 305-314
        • Hanasono M.M.
        • Matros E.
        • Disa J.J.
        Important aspects of head and neck reconstruction.
        Plast Reconstr Surg. 2014; 134: 968e-980e
        • Schultz B.D.
        • Sosin M.
        • Nam A.
        • Mohan R.
        • Zhang P.
        • Khalifian S.
        • Vranis N.
        • Manson P.N.
        • Bojovic B.
        • Rodriguez E.D.
        Classification of mandible defects and algorithm for microvascular reconstruction.
        Plast Reconstr Surg. 2015; 135: 743e-754e
        • Kildal M.
        • Wei F.C.
        • Chang Y.M.
        Free vascularized bone grafts for reconstruction of traumatic bony defects of mandible and maxilla.
        World J Surg. 2001; 25: 1067-1074
        • Kokosis G
        • Schmitz R
        • Powers DB
        • Erdmann D
        Mandibular reconstruction using the free vascularized fibula graft: an overview of different modifications.
        Arch Plast Surg. 2016; 43: 3-9
        • David D.J.
        • Tan E.
        • Katsaros J.
        • Sheen R.
        Mandibular reconstruction with vascularized iliac crest: a 10-year experience.
        Plast Reconstr Surg. 1988; 82: 792-803
        • He Y.
        • Zhang Z.Y.
        • Zhu H.G.
        • Wu Y.Q.
        • Fu H.H.
        Double-barrel fibula vascularized free flap with dental rehabilitation for mandibular reconstruction.
        J Oral Maxillofac Surg. 2011; 69: 2663-2669
        • Wong R.C.
        • Tideman H.
        • Merkx M.A.
        • Jansen J.
        • Goh S.M.
        • Liao K.
        Review of biomechanical models used in studying the biomechanics of reconstructed mandibles.
        Int J Oral Maxillofac Surg. 2011; 40: 393-400
        • Wong R.C.
        • Tideman H.
        • Kin L.
        • Merkx M.A.
        Biomechanics of mandibular reconstruction: a review.
        Int J Oral Maxillofac Surg. 2010; 39: 313-319
        • Hayden R.E.
        • Mullin D.P.
        • Patel A.K.
        Reconstruction of the segmental mandibular defect: current state of the art.
        Curr Opin Otolaryngol Head Neck Surg. 2012; 20: 231-236
        • Genden E.M.
        Reconstruction of the mandible and the maxilla: the evolution of surgical technique.
        Archives Facial Plast Surg. 2010; 12: 87-90
        • Wijbenga J.G.
        • Schepers R.H.
        • Werker P.M.
        • Witjes M.J.
        • Dijkstra P.U.
        A systematic review of functional outcome and quality of life following reconstruction of maxillofacial defects using vascularized free fibula flaps and dental rehabilitation reveals poor data quality.
        J Plast Reconstr Aesthet Surg. 2016; 69: 1024-1036
        • Jones N.F.
        • Swartz W.M.
        • Mears D.C.
        • Jupiter J.B.
        • Grossman A.
        The "double barrel" free vascularized fibular bone graft.
        Plast Reconstr Surg. 1988; 81: 378-385
        • Horiuchi K
        • Hattori A
        • Inada I
        • Kamibayashi T
        • Sugimura M
        • Yajima H
        • et al.
        Mandibular reconstruction using the double barrel fibular graft.
        Microsurgery. 1995; 16: 450-454
        • Hidalgo D.
        • Disa J.
        Mandible reconstruction.
        in: Mathes S. Hentz V. Plastic surgery, vol 3. Saunders, Philadelphia2005: 957-991
        • Nocini P.F.
        • Wangerin K.
        • Albanese M.
        • Kretschmer W.
        • Cortelazzi R.
        Vertical distraction of a free vascularized fibula flap in a reconstructed hemimandible: case report.
        J Craniomaxillofac Surg. 2000; 28: 20-24
        • Deleyiannis F.W.
        • Rogers C.
        • Ferris R.L.
        • Lai S.Y.
        • Kim S.
        Johnson J reconstruction of the through-and-through anterior mandibulectomy defect: indications and limitations of the double-skin paddle fibular free flap.
        Laryngoscope. 2008; 118: 1329-1334
        • Hirsch D.L.
        • Garfein E.S.
        • Christensen A.M.
        • Weimer K.A.
        • Saddeh P.B.
        • Levine J.P.
        Use of computer-aided design and computer-aided manufacturing to produce orthognathically ideal surgical outcomes: a paradigm shift in head and neck reconstruction.
        J Oral Maxillofac Surg. 2009; 67: 2115-2122
        • Foley B.D.
        • Thayer W.P.
        • Honeybrook A.
        • McKenna S.
        • Press S.
        Mandibular reconstruction using computer-aided design and computer-aided manufacturing: an analysis of surgical results.
        J Oral Maxillofac Surg. 2013; 71: e111-e119
        • Salgueiro M.I.
        • Stevens M.R.
        Experience with the use of prebent plates for the reconstruction of mandibular defects.
        Craniomaxillofac Trauma Reconstr. 2010; 3: 201-208
        • Roddy E.
        • DeBaun M.R.
        • Daoud-Gray A.
        • Yang Y.P.
        • Gardner M.J.
        Treatment of critical-sized bone defects: clinical and tissue engineering perspectives.
        Eur J Orthop Surg Traumatol. 2017; (Epub ahead of print)
        • Chen H.
        • Zhou N.
        • Huang X.
        • Song S.
        Comparison of morbidity after reconstruction of tongue defects with an anterolateral thigh cutaneous flap compared with a radial forearm free-flap: a meta-analysis.
        Br J Oral Maxillofac Surg. 2016; 54: 1095-1101
        • Li X.
        • Sun Q.
        • Guo S.
        Functional assessments in patients undergoing radial forearm flap following hemiglossectomy.
        J Craniofac Surg. 2016; 27: e172-e175
        • Henry A.
        • McCaul J.A.
        Osseocutaneous radial forearm flap with beavertail modification; a case report of a novel, single, reconstructive free flap for the tongue, floor of mouth and mandible.
        Int J Surg Case Rep. 2016; 28: 270-273
        • Mo K.W.
        • Vlantis A.
        • Wong E.W.
        • Chiu T.W.
        Double free flaps for reconstruction of complex/composite defects in head and neck surgery.
        Hong Kong Med J. 2014; 20: 279-284
        • Wei F.C.
        • Demirkan F.
        • Chen H.C.
        • Chen I.H.
        Double free flaps in reconstruction of extensive composite mandibular defects in head and neck cancer.
        Plast Reconstr Surg. 1999; 103: 39-47
        • Zhu L.
        • Zhang J.
        • Song X.
        • Hou W.
        • Wu S.
        • Chen W.
        • Svensson P.
        • Wang K.
        Sensory recovery of non-innervated free flaps and nasolabial island flaps used for tongue reconstruction of oncological defects.
        J Oral Rehabil. 2017; 44: 736-748
        • Engel H.
        • Huang J.J.
        • Lin C.Y.
        • Lam W.
        • Kao H.K.
        • Gazyakan E.
        • Cheng M.H.
        A strategic approach for tongue reconstruction to achieve predictable and improved functional and aesthetic outcomes.
        Plast Reconstr Surg. 2010; 126: 1967-1977
        • Yu P.
        Reinnervated anterolateral thigh flap for tongue reconstruction.
        Head Neck. 2004; 26: 1038-1044
        • Lin Y.S.
        • Liu W.C.
        • Lin Y.S.
        • Chen L.W.
        • Yang K.C.
        Peroneal flap for tongue reconstruction.
        J Reconstr Microsurg. 2017; 33: 389-394
        • Yang G.F.
        • Chen P.J.
        • Gao Y.Z.
        • Liu X.Y.
        • Li J.
        • Jiang S.X.
        • He S.P.
        Forearm free skin flap transplantation: a report of 56 cases. 1981.
        Br J Plast Surg. 1997; 50: 162-165
        • de Vicente J.C.
        • de Villalain L.
        • Torre A.
        • Pena I.
        Microvascular free tissue transfer for tongue reconstruction after hemiglossectomy: a functional assessment of radial forearm versus anterolateral thigh flap.
        J Oral Maxillofac Surg. 2008; 66: 2270-2275
        • Fang Q.G.
        • Shi S.
        • Li M.
        • Zhang X.
        • Liu F.Y.
        • Sun C.F.
        Free flap reconstruction versus non-free flap reconstruction in treating elderly patients with advanced oral cancer.
        J Oral Maxillofac Surg. 2014; 72: 1420-1424