Response to: Standardized Templates for Shaping the Fibula Free Flap in Mandible Reconstruction. J Reconstr Microsurg 2013;29:619–622

Having a special interest on mandibular reconstruction, we came across to the article by Matros et al.[1] We appreciated the creativity in establishing a custom-made acrylic template guides the straight fibula to fit the parabolic shape of mandible. We agree with heterogeneous of mandible size, however, a standardized template can somehow simplified osteotomy planning yet provide a promising result which is suitable for all strata of socioeconomic status.

Nevertheless, we would like to bring the readers' attentions on mandibular workout. Mandible framework was represented by condyle (Articulare, Ar), mandible angle (Gonion, Go), and symphysis (Pogonion, Pg) ([Fig. 1]) in respecting to functional muscular attachment[2] ([Fig. 2]). Therefore, a three, four, or five bone segments for mandibular arch reconstruction is optional as long as the main framework supporting points were rebuilt. Slight lateral discrepancy of fibula flap can always be camouflaged by overlying soft tissue, implant, and/or prosthesis.

Fig. 1 Mandible framework which was represented by condyle (Articulare, Ar), mandible angle (Gonion, Go) and symphysis (Pogonion, Pg).

Fig. 2 Muscles attachment of mandible (blue, digastrics muscles; red, medial pterygoid muscle; green, lateral pterygoid muscle; orange, masseter muscle; purple, temporalis muscle) to coordinate with mandibular movement.

However, an increasing number of osteotomy segment bear a risk of segmental ischemia. Thus, we felt that five segments osteotomy in which the anterior segment (symphysis region) is too short, fibula was wedged off to form a 1.8 to 2 cm short segment which the lingual surface make sense will be a lot shorter, it was illustrated though the length of lingual surface was not specifically stated. Meanwhile, we support the statement published by Matros et al[3] emphasized a potentiality of ischemic risk when a bone segment is smaller than 2 cm. Thus, it will be very challenging for beginner to preserve the attachment of lingual periosteum during wedging. A detached segment of free bone graft might delay the bone healing which might call for radiotherapy postponement especially in lower gingival or mandibular oriented cancer.

In addition, we suggest a golden triangle measurement ([Fig. 3])[4] in addition to standardized template formation as we belief final plate positioning greatly reflect the position of bone flap. The precision of manual bending and positioning a reconstruction plate significantly influenced the relationship of fibula to mandible subsequently the overall facial appearance especially when absent of original condyle as a guide. The reconstruction plate and fibula can then be accurately placed by referring to golden triangle measurement, this is significantly helpful for large mandibular defect (hemimandibulectomy and above) and also for beginner.

Fig. 3 Equilateral triangle (golden triangle measurement) referring to the measured distance between both mandibular angle (GoGo) and distance between symphysis and mandibular angle (PgGo). A 9 cm ± 0.5 cm for the variation between male and female subjects.

With the application of both standardized osteotomy template and positioning reference, an almost ideal reconstruction can be formed even without virtual surgical planning. It appears to be a cheaper, simplified preoperative planning, shorted the operating time yet leading to an acceptable result, and lesser perioperative comorbidity.

• References

• 1 Matros E, Santamaria E, Cordeiro PG. Standardized templates for shaping the fibula free flap in mandible reconstruction. J Reconstr Microsurg 2013; 29 (9) 619-622
• 2 Zhang CP, Samman N. Mandibular Reconstruction: Bases and Clinics. 1st ed. [in Chinese] Shanghai: Shanghai Educ. Pub; 2009
• 3 Matros E, Disa JJ. Discussion: computer-assisted versus conventional free fibula flap technique for craniofacial reconstruction: an outcomes comparison. Plast Reconstr Surg 2013; 132 (5) 1229-1230
• 4 Xu LQ, Zhang CP, Poh EH, Yin XL, Shen SK. A novel fibula osteotomy guide for mandibular reconstruction. Plast Reconstr Surg 2012; 129 (5) 861e-863e