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Mandible Reconstruction with Fibula Free Flap. Is this an option?
In cases of radiation to the jaw resulting in Osteoradionecrosis (radiation bone death) or Ameloblastoma or similar growths on the mandible, reconstruction surgery is sometimes recommended. The mandible (lower jaw bone) has become constantly infected, weak causing pain, teeth failing, habitually sore or troublesome, after radiation therapy often years in the past. Your doctors or dentists may be suggesting surgery. Ameloblastoma patients sometimes have little choice due to the tumor often embedded in the mandible itself. While there are options to mandible reconstruction, what works very well is replacement of the infected section with your own transplanted bone and tissue.
When replacing a mandible section with harvested bone, the bone section selected will have the blood supply attached (free flap) which will be reconnected to an existing artery to keep the bone alive. This allows for healing and complete attachment to the existing mandible. Mayo Clinic Rochester, one of only a few places in the world that perform this type of surgery, uses either a section of bone from the Fibula or from the hip or shoulder area. The Fibula is a flexible bone in the lower leg which is non-weight bearing and won’t be particularly missed.
Dr’s Arce and Ettinger among others in the Oral and Maxillofacial Surgery group removed a section of my left fibula and surrounding tissue and fit that precisely into my left mandible along with peg inserts to support prosthetic teeth. 3-D models of my jaw were worked up and used as templates prior to surgery so that everything fit as necessary. The entire procedure for my end was about six hours of happy sleep. Recovery was a bit longer of roughly a week before I was released from hospital.
I had a feeding tube installed for nutrition and medication as well as a CAM-boot on my leg to promote healing. The feeding tube was removed after three weeks whilst the CAM-boot was probably gone after two. The healing while not comfortable was certainly manageable and I returned to work (restricted mostly to a desk) about four weeks after surgery.
Healing continued with return visits to Mayo for teeth prosthesis and to have my trach closed, which it did not do on it’s own because things like that happen to me. Nine months out I was eating corn on the cob for the first time in many years and walking without issue, miles per day. Now two years out, other than meticulously cleaning my teeth thrice-daily, I really have no issues with eating, talking, or walking. The healing was certainly much faster than the cancer treatments that proceeded this adventure twenty years prior.
Has anyone else been troubled by teeth or jaw since radiation or surgery? Has Mandible Reconstruction been considered?
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So interesting, thanks for sharing. December 28, 2021, I had adenoid cystic carcinoma in my right sinus cavity surgery removal and reconstruction. Long story short, I also had reconstruction upper jaw with my fibula, tissue and blood vessels from my right leg., feeding tube and a tracheotomy. Also radiation for 6 weeks. But still have several after effects from surgery and radiation and upper teeth prosthetics are still on going procedures. Hopfully someday I'll feel just half of good as you. They were the best, Dr Arce and Dr. Ettinger and team.
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3 ReactionsBack in 1990-91 my father had this surgery at The Ohio State University James Cancer Center with his partial mandibulectomy for invasive oral SCC. It was an innovative surgery then and I imagine there have been many improvements since. It was successful in replacing the mandible with quick healing. Unfortunately there was a recurrence of the cancer under his tongue and he received only palliative care at that point. The surgeon was a recent transfer from U of Michigan Hospital, Dr. David Schuller.
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2 ReactionsHi @hrhw , nice sharing! i have one question. What about the total cost for surgery?
Cost of surgery would depend on not only where the surgery is performed but the extent of the surgery based upon the patient's specific requirement. In my case mine was done at Mayo / St. Mary's and roughly $250K, perhaps a bit more. My additional dental prosthetics was out of pocket cost roughly the price of a car. Hopefully it will last considerably longer. I don't have money to throw away. One must consider quality of life and priorities.
I am a bit reluctant to answer your question because cost can be significantly more at Sloan Kettering or Johns Hopkins and maybe less at the Cleveland Clinic. I do not know and as I say there are many factors. Having pegs installed for teeth prosthetics added to the cost.
There are not many hospitals that do this surgery. There are not a lot of doctors that have done this more than a handful of times however Mayo has done well over a thousand and has helped refine the techniques used by others today. If your doctor is using a manual to do this you might reconsider where you are going. Make sure to ask about experience prior to signing the surgery waiver. If the surgeon is offended then you are definitely in the wrong place.
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2 ReactionsThanks 👍🏻
<p>When should I have fibular free flap mandible reconnect surgery?</p><p>Just not sure what to do!</p>
Hello @brschultz33 and welcome to Connect.
It is so hard to make these medical decisions, especially for surgery. I assume you have researched and asked lots of questions about adverse effects, healing time, etc. With the bone involvement I would want to know the odds of removing all the cancer in this surgery. My dad had the free fibular graft mandibular replacement back in the early 90s when it was a new treatment for invasive oral cancer. It was done at Ohio State University James Cancer Hospital and he did well after a long recovery at age 71. He was able to resume eating softer foods and had a good quality of life. He did not have radiation or chemo prior to the surgery. Unfortunately his cancer recurred underneath his tongue and after that it was palliative radiation and chemo only. I would assume that your pretreatment with radiation is standard protocol and increases chances of a cure. I believe that 30 plus years of using this surgery has to have perfected the techniques. I also have had head and neck squamous cell carcinoma (originating from the ear, not oral) for the past 11 years, and have had all my treatment at Mayo Rochester. I cannot recommend enough having at least a second opinion at a large referral center. Good luck to you and I will try to answer any other questions that you may have.
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1 ReactionThanx!!!
@brschultz33, I add my welcome. I moved your question about mandible reconstruction timing to this existing discussion in the Head & Neck Cancer support group.
- Mandible Reconstruction with Fibula Free Flap. Is this an option? https://connect.mayoclinic.org/discussion/mandible-reconstruction-with-fibula-free-flap-is-this-an-option/
I did this so you can read the previous helpful posts and connect easily with members like @hrhwilliam @kjwilson23 @sepdvm @city and others.
@brschultz33, what surgery have you had and when is mandible reconstruction being suggested for you?
Hello @brschultz33 When should you have the surgery? Since the question isn't "if you should" rather "when", then it is clear this needs to happen. The short answer is when it fits your schedule and that of the surgical team. I know it is a hard decision to make, going under the knife, being in hospital for a week, not getting around well for a month, etc. Not sure if you are scheduling around work or retired. I returned to work limited rather quickly but that's me, perhaps not you.
The ability to talk well or function without facial issues such as drooling within weeks after surgery may also limit your functionality with work or living in general. These things are usually temporary.
I think the biggest obstacle is having the courage to get this done. In that you are not alone. But I can pretty much guarantee that within a year after you will wonder why you didn't do this sooner. Good luck and I am here for you.