Case report
The rare phenomenon of vascular pedicle ossification of free fibular flap in mandibular reconstruction

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Abstract

Ossification of the vascular pedicle in the vascularized free fibular flap (VFFF) has been only previously described twice for jaw reconstruction. A case of severe trismus secondary to periosteal osteogenesis following VFFF for maxillary reconstruction, and four cases of ossification of the vascular pedicle in VFFF for maxillary and mandibular reconstruction have been respectively described. Etiology remains unclear, although presence of periosteum in continuity with bone seems to play a major role. Hormonal stimuli, stress over the bone, and corticosteroid therapy have been proposed as determinant factors, although no clear correlation has been already established. No histologic studies concerning the generation of new bone around the vascular pedicle in VFFF are nowadays present. We report a new case of vascular pedicle ossification of VFFF following mandibular reconstruction, this being the third report in the literature, and focus on histologic examination of the specimen.

Introduction

Several classical benefits have been reported for vascularized free fibular flap (VFFF) in relation to jaw reconstruction, being low donor site, greatest bone height, suitability for osseointegrated dental implants, display of a two-team approach, and possibility of combination with skin flaps for composite reconstruction, between its most valuable advantages. Its periosteal blood supply allows the performance of multiple osteotomies, which ultimately leads to an almost perfect mismatch of the native mandibular or maxillary contour.

In harvesting the VFFF, the excess of bone is removed at the proximal part of the fibula, while a cuff of muscle layer on a strip of periosteum is preserved along the vascular pedicle. In previous experimental studies (Finley et al., 1978, Sakata et al., 2006) osteogenic potential of periosteum was demonstrated following transposition. Others have suggested a possible role for periosteum–polymer complex in the reconstruction of orbital floor fractures (Asamura et al., 2010) or even the ectopic bone formation from cultured human osteoblasts (Mai et al., 2006). This condition is further increased if the transposed tissue is also vascularized. Some authors (Aurelitano et al., 2008) have suggested the importance of mechanical stress in the development of a proliferative stimulus over the vascular pedicle, leading to generation of new bone from a remnant periosteum layer. It has also been stressed the relevance of continuity between the reconstructed bone and periosteum in the development of osteogenesis, although scarce clinical data are available concerning pathogenesis of this otherwise considerably rare effect. In fact, ossification of vascular pedicle in free fibular flaps has only been previously described in two papers, which described a case of severe trismus secondary to periosteal osteogenesis after fibula free flap maxillary reconstruction (Smith and Funk, 2003), and four cases of ossification of vascular pedicle in VFFF for two cases each of maxillary and mandibular reconstruction (Aurelitano et al., 2008).

We report a new case of vascular pedicle ossification of VFFF following mandibular reconstruction, this being the third report in the literature, and focus on histologic examination (HE) of the specimen.

Section snippets

Case report

A 33-year-old man with a history of Fanconi’s anemia presented with swelling and a painless mass in the upper right maxilla for 2 months. Examination showed a 1-cm infiltrating ulcer in the attached gingiva of the upper maxilla. A biopsy was performed with the result of squamous cell carcinoma (SCC) of the maxillary alveolus. The Panorex-X- ray showed erosion of the maxillary vestibular cortex. Partial right hemi-maxillectomy was performed without the need for further reconstruction, except for

Discussion

Ossification of the vascular pedicle in vascularized osseous free grafts has been rarely reported. Smith and Funk (2003) first reported on a 12-year-old girl with a previous medical history significant for SCC of the maxillary alveolus who underwent secondary reconstruction of the generated orosinusal fistula several years after inferior maxillectomy. Reconstruction consisted on a VFFF over the maxillary defect, but 3 months later the patient presented severe trismus secondary to neoformation

Conclusion

A new case of ossification of the vascular pedicle in the VFFF for jaw reconstruction is presented. Maxillofacial surgeons must keep in mind this process in patients that undergo reconstruction of the maxilla or the mandible and later develop trismus and/or hard swelling of the buccal space or the submandibular region, respectively. A careful scrutiny of routinely post-operative Panorex-X rays and CT-scans may be the best help in the diagnosis of asymptomatic patients. Further serial

Competing interests

None declared.

Funding

None.

Ethical approval

Not required.

Acknowledgement

We want to thank Dr. Saenz de Santamaría, from the Department of Pathology of the University Hospital Infanta Cristina, Badajoz, Spain, for histological analysis and microphotographs.

References (10)

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Cited by (19)

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    The images show an ossification of the vascular pedicle of the fibula free flap. It is generally considered an uncommon finding [1–3]. The incidence reported in the literature varies between 2.6 and 65% [1].

  • Periosteal ossification of the vascular pedicle after reconstruction of continuity defects of the mandible and the maxilla with fibular free flaps: A retrospective study

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    In the present study periosteal ossification was more common on postoperative panoramic radiographs in younger patients and in patients who were not given high doses of radiotherapy (>60 Gy). Treatment is recommended only if patients have functional symptoms, and consists of meticulous removal of the excess bone along the vascular pedicle or resection of the area of ossification (Fig. 2).2–4,6 Obviously resection is possible only when neovascularisation of the flap has been completed.

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