Novel Technique for Autologous Mandibular and Condylar Component Reconstruction Utilizing a Bicomposite Flow-Through Osteochondral Joint Salvage Therapy (BOOST) Free Flap

Document Type

Conference Proceeding

Publication Date

8-2024

Publication Title

Plastic and Reconstructive Surgery - Global Open

Abstract

INTRODUCTION/OBJECTIVE: A 16-year-old male presented with a rapidly growing 6 cm lytic lesion of the right mandible which was biopsy proven as odontogenic myxoma. He was scheduled for right hemi-mandibulectomy sparing the ipsilateral condyle by the oral and maxillofacial surgery team. Plastic surgery concurrently evaluated the patient and recommended BOOST (Bi-composite flOw through Osteochondral joint Salvage Therapy) free tissue transfer. This modality combined use of a fibula free flap with peroneal vessel-based flow-through to a medial femoral condyle periosteal flap for sub-condylar reconstruction, with the goal of minimizing temporomandibular joint ankylosis in this young patient.

METHODS: A thorough preoperative consultation was performed with the patient and his parents. Virtual surgical planning with computer-aided design was utilized for bony reconstruction. The patient underwent right hemi-mandibulectomy with the ablative team. The uninvolved condyle was preserved. We then harvested a left free fibula flap utilizing a prefabricated osteotomy template. A right medial femoral condyle periosteal free flap was harvested and revascularized in flow through fashion after wrapping the complex around native condyle, which was then fixated to the fibular construct with a miniplate. The composite structure was fixated to the remaining native mandible with a rigid plate using predrilled predicted sites. Microvascular anastomoses were created between the peroneal and facial arteries, and the peroneal vein and retromandibular vein. The patient tolerated the procedure well and was transferred to the pediatric intensive care unit for hourly flap monitoring and airway management.

RESULTS: The patient was evaluated 1 week after discharge where his diet was advanced to a soft diet. Oral exam was limited at that time secondary to MMF which was scheduled to come off the following week. At the 1 month post op visit, he continued to do well and was tolerating a diet without any issues. His MMF had been removed, and a 3D recon CT scan was ordered. He was reevaluated at 3 months where he was able to open his mouth partially secondary to soreness. He returned at 6 months post op where he was now able to fully open his mouth without any pain or limitations. The 3D CT scan showed the reconstruction was healing well with radiographic evidence of condylar remodeling.

CONCLUSION: Complex mandibular reconstruction often carries high morbidity and requires extensive preoperative surgical planning with multiple surgical teams involved. The vascularized free fibula flap is often labeled as the “Gold Standard” for mandibular reconstruction given reliable anatomy, length, durability, and feasibility of future dental reconstruction. Double free flaps for complex mandibular defects have been described in the literature, most commonly as a fibula free flap with either a radial forearm flap or an anterolateral thigh flap. To our knowledge, the flap we performed (flow through free fibula flap to medial femoral condyle periosteal flap) has not been previously described for mandibular reconstruction. Our experience suggests a role for BOOST flap utilization in mandibular reconstruction, when the native condyle is spared.

Volume

12

Issue

S7

First Page

5

Comments

Michigan Academy of Plastic Surgeons Biennial Scientific Meeting, August 1-4, 2024, Mackinac Island, MI

DOI

10.1097/01.GOX.0001028208.65128.13

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