Research Article| Volume 72, ISSUE 4, P572-580, April 2019

Navigation-guided fibula free flap for mandibular reconstruction: A proof of concept study

Published:February 08, 2019DOI:



      To analyze a novel technique of supporting fibula free flap harvest and fabrication with intraoperative navigation technology.

      Materials and methods

      In the first phase of the study, navigation accuracy achieved with two registration methods, namely, point-pair and hybrid technique utilizing point-pair with surface matching, were evaluated in the form of the fiducial (FRE) and target registration error (TRE). Next, a series of 42 simulated navigated fibular osteotomies were conducted on specially manufactured lower leg phantom. Postoperative results were analyzed in the form of the angular and position deviations between the virtually planned and the obtained osteotomies.


      Mean FRE values obtained with point-pair and hybrid registration methods were 1.82 ± 0.96 mm and 1.41 ± 0.44 mm, respectively. Mean TRE value in the fibula region was 2.00 ± 0.67 mm for the first method and 1.51 ± 0.72 mm for the second. For all performed surgeries, the total mean angular deviation between the planned and actual osteotomy trajectory equaled 3.66° ± 3.60°. The total mean position disparity of osteotomy control points was 1.85 ± 0.99 mm.


      Navigation-guided free fibula flap harvest and fabrication, due to encouraging study results and its superiority over currently popular cutting guides in many clinical aspects, may become a routine operative procedure for the reconstruction of complex mandibular defects. The presented method is especially well suited for plastic and maxillofacial surgery.


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        • Hidalgo P.A.
        Fibula free flap: a new method of mandible reconstruction.
        Plast Reconstr Surg. 1989; 84: 71-79
        • Cordeiro P.G.
        • Disa J.J.
        • Hidalgo D.A.
        • Hu Q.Y.
        Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients.
        Plast Reconstr Surg. 1999; 104: 1314-1320
        • Hidalgo D.A.
        • Pusic A.L.
        Free-flap mandibular reconstruction: a 10-year follow-up study.
        Plast Reconstr Surg. 2002; 110: 438-449
        • Hölzle F.
        • Kesting M.R.
        • Hölzle G.
        • et al.
        Clinical outcome and patient satisfaction after mandibular reconstruction with free fibula flaps.
        Int J Oral Maxillofac Surg. 2007; 36: 802-806
        • López-Arcas J.M.
        • Arias J.
        • Del Castillo J.L.
        • et al.
        The fibula osteomyocutaneous flap for mandible reconstruction: a 15-year experience.
        J Oral Maxillofac Surg. 2010; 68: 2377-2384
        • 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
        • Thankappan K.
        • Trivedi N.P.
        • Subash P.
        • et al.
        Threedimensional computed tomography-based contouring of a free fibula bone graft for mandibular reconstruction.
        J Oral Maxillofac Surg. 2008; 66: 2185-2192
        • Roser S.M.
        • Ramachandra S.
        • Blair H.
        • et al.
        The accuracy of virtual surgical planning in free fibula mandibular reconstruction: comparison of planned and final results.
        J Oral Maxillofac Surg. 2010; 68: 2824-2832
        • Dong Z.
        • Li B.
        • Xie R.
        • Wu Q.
        • Zhang L.
        • Bai S.
        Comparative study of three kinds of fibula cutting guides in reshaping fibula for the reconstruction of mandible: an accuracy simulation study in vitro.
        J Craniomaxillofac Surg. 2017; 45: 1227-1235
        • 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
        • Avraham T.
        • Franco P.
        • Brecht L.E.
        • et al.
        Functional outcomes of virtually planned free fibula flap reconstruction of the mandible.
        Plast Reconstr Surg. 2014; 134: 628-634
        • Metzler P.
        • Geiger E.J.
        • Alcon A.
        • Ma X.
        • Steinbacher D.M.
        Three-dimensional virtual surgery accuracy for free fibula mandibular reconstruction: planned versus actual results.
        J Oral Maxillofac Surg. 2014; 72: 2601-2612
        • Chang E.I.
        • Jenkins M.P.
        • Patel S.A.
        • Topham N.S.
        Long-term operative outcomes of preoperative computed tomography-guided virtual surgical planning for osteocutaneous free flap mandible reconstruction.
        Plast Reconstr Surg. 2016; 137: 619-623
        • Weitz J.
        • Bauer F.J.
        • Hapfelmeier A.
        • Rohleder N.H.
        • Wolff K.D.
        • Kesting M.R.
        Accuracy of mandibular reconstruction by three-dimensional guided vascularised fibular free flap after segmental mandibulectomy.
        Br J Oral Maxillofac Surg. 2016; 54: 506-510
        • Eckardt A.
        • Swennen G.R.
        Virtual planning of composite mandibular reconstruction with free fibula bone graft.
        J Craniofac Surg. 2005; 16: 1137-1140
        • Hirsch D.L.
        • Garfein E.S.
        • Christensen A.M.
        • Weimer K.A.
        • Saddeh P.B.
        • Levine J.P.
        Use of computeraided 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
        • Antony A.K.
        • Chen W.F.
        • Kolokythas A.
        • Weimer K.A.
        • Cohen M.N.
        Use of virtual surgery and stereolithography-guided osteotomy for mandibular reconstruction with the free fibula.
        Plast Reconstr Surg. 2011; 128: 1080-1084
        • Valentini V.
        • Agrillo A.
        • Battisti A.
        • Gennaro P.
        • Calabrese L.
        • Iannetti G.
        Surgical planning in reconstruction of mandibular defect with fibula free flap: 15 patients.
        J Craniofac Surg. 2005; 16: 601-607
        • Chopra K.
        • Manson P.N.
        • Gastman B.R.
        Stereolithographic modeling in reconstructive surgery of the craniofacial skeleton after tumor resection.
        Plast Reconstr Surg. 2012; 129: 743-745
        • Sharaf B.
        • Levine J.P.
        • Hirsch D.L.
        • Bastidas J.A.
        • Schiff B.A.
        • Garfein E.S.
        Importance of computeraided design and manufacturing technology in the multidisciplinary approach to head and neck reconstruction.
        J Craniofac Surg. 2010; 21: 1277-1280
        • Stirling Craig E.
        • Yuhasz M.
        • Shah A.
        • et al.
        Simulated surgery and cutting guides enhance spatial positioning in free fibular mandibular reconstruction.
        Microsurgery. 2015; 35: 29-33
        • Lim S.H.
        • Kim Y.H.
        • Kim M.K.
        • Nam W.
        • Kang S.H.
        Validation of a fibula graft cutting guide for mandibular reconstruction: experiment with rapid prototyping mandible model.
        Comput Assist Surg. 2016; 21: 9-17
        • Liu X.J.
        • Gui L.
        • Mao C.
        • Peng X.
        • Yu G.Y.
        Applying computer techniques in maxillofacial reconstruction using a fibula flap: a messenger and an evaluation method.
        J Craniofac Surg. 2009; 20: 372-377
        • Haddock N.T.
        • Monaco C.
        • Weimer K.A.
        • Hirsch D.L.
        • Levine J.P.
        • Saadeh P.B.
        Increasing bony contact and overlap with computer-designed offset cuts in free fibula mandible reconstruction.
        J Craniofac Surg. 2012; 23: 1592-1595
        • Rodby K.A.
        • Turin S.
        • Jacobs R.J.
        • et al.
        Advances in oncologic head and neck reconstruction: systematic review and future considerations of virtual surgical planning and computer aided design/computer aided modeling.
        J Plast Reconstr Aesthet Surg. 2014; 67: 1171-1185
        • Rohner D.
        • Bucher P.
        • Hammer B.
        Prefabricated fibular flaps for reconstruction of defects of the maxillofacial skeleton: planning, technique, and long-term experience.
        Int J Oral Maxillofac Implant. 2013; 28: 221-229
        • Schramm A.
        • Gellrich N.C.
        • Gutwald R.
        • et al.
        Indications for computer-assisted treatment of cranio-maxillofacial tumors.
        Comput Aided Surg. 2000; 5: 343-352
        • Feichtinger M.
        • Pau M.
        • Zemann W.
        • Aigner R.M.
        • Karcher H.
        Intraoperative control of resection margins in advanced head and neck cancer using a 3D-navigation system based on PET/CT image fusion.
        J Craniomaxillofac Surg. 2010; 38: 589-594
        • Pietruski P.
        • Majak M.
        • Swiatek-Najwer E.
        • et al.
        Accuracy of experimental mandibular osteotomy using the image-guided sagittal saw.
        Int J Oral Maxillofac Surg. 2016; 45: 793-800
        • Wu J.
        • Sun J.
        • Shen S.G.
        • Xu B.
        • Li J.
        • Zhang S.
        Computer-assisted navigation: its role in intraoperatively accurate mandibular reconstruction.
        Oral Surg Oral Med Oral Pathol Oral Radiol. 2016; 122: 134-142
        • Gui H.
        • Yang H.
        • Shen S.G.
        • Xu B.
        • Zhang S.
        • Bautista J.S.
        Image-guided surgical navigation for removal of foreign bodies in the deep maxillofacial region.
        J Oral Maxillofac Surg. 2013; 71: 1563-1571
        • Ewers R.
        • Schicho K.
        • Truppe M.
        • et al.
        Computer aided navigation in dental implantology: 7 years of clinical experience.
        J Oral Maxillofac Surg. 2004; 62: 329-334
        • Li P.
        • Xuan M.
        • Liao C.
        • et al.
        Application of intraoperative navigation for the reconstruction of mandibular defects with microvascular fibular flaps-preliminary clinical experiences.
        J Craniofac Surg. 2016; 27: 751-755
        • Świątek-Najwer E.
        • Żuk M.
        • Majak M.
        • Popek M.
        The rigid registration of CT and scanner dataset for computer aided surgery.
        in: Proceedings of the VI ECCOMAS thematic conference on computational vision and medical image processing, VipIMAGE. 27. 2017: 345-353
        • Fitzpatrick J.M.
        • West J.B.
        The distribution of target registration error in rigid-body point-based registration.
        IEEE Trans Med Imaging. 2001; 20: 917-927
        • Rustemeyer J.
        • Melenberg A.
        • Sari-Rieger A.
        Costs incurred by applying computer-aided design/computer-aided manufacturing techniques for the reconstruction of maxillofacial defects.
        J Craniomaxillofac Surg. 2014; 42: 2049-2055
        • Pietruski P.
        • Majak M.
        • Światek-Najwer E.
        • et al.
        Image-guided bone resection as a prospective alternative to cutting templates – a preliminary study.
        J Craniomaxillofac Surg. 2015; 43: 1021-1027
        • Mazzoni S.
        • Marchetti C.
        • Sgarzani R.
        • Cipriani R.
        • Scotti R.
        • Ciocca L.
        Prosthetically guided maxillofacial surgery: evaluation of the accuracy of a surgical guide and custom-made bone plate in oncology patients after mandibular reconstruction.
        Plast Reconstr Surg. 2013; 131: 1376-1385
        • Zhao L.
        • Patel P.K.
        • Cohen M.
        Application of virtual surgical planning with computer assisted design and manufacturing technology to cranio-maxillofacial surgery.
        Arch Plast Surg. 2012; 39: 309-316
        • Wei F.C.
        • Santamaria E.
        • Chang Y.M.
        • Chen H.C.
        Mandibular reconstruction with fibular osteoseptocutaneous free flap and simultaneous placement of osseointegrated dental implants.
        J Craniofac Surg. 1997; 8: 512-521