Aesthetic improvements in free-flap mandible reconstruction.

Mandible reconstruction with free flaps has become a well-established technique. Efforts are now focused on obtaining superior functional and aesthetic results. Improvements in the quality of the latter are possible with a systematic approach to shaping the bone graft. Important elements in this approach have been defined based on experience in 50 consecutive cases. Preoperative studies include the lateral cephalogram and a transverse plane CT scan from which mandible templates are constructed. These templates are models of the mandible in two planes and are used to shape the bone with a high degree of precision. They allow the bone to be completely shaped while still attached by the pedicle at the donor site. The surgical specimen serves as an additional key visual reference and as a source of measurements to determine overall bone-graft length. Miniplates alone provide sufficient fixation to stabilize the bone as it is shaped segment by segment. Intermaxillary fixation is used only to prevent errors in total bone-graft length. Hemimandible and anterior defects represent two completely different bone-shaping problems. Although the bone-shaping methods described have been developed primarily with the fibula, they have been successfully applied to the scapula and radius donor sites as well.