Mandibular Reconstruction Using the Free

Review Article
Vascularized Fibula Graft: An Overview of
Different Modifications
George Kokosis1, Robin Schmitz2, David B. Powers1, Detlev Erdmann1
1
Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, NC, USA; 2Department of
General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany

The reconstruction of the mandible is a complex procedure because various cosmetic as well Correspondence: George Kokosis
as functional challenges must be addressed, including mastication and oral competence. Division of Plastic, Reconstructive,
Maxillofacial and Oral Surgery, Duke
Many surgical techniques have been described to address these challenges, including non- University Medical Center, Box 3181,
vascularized bone grafts, vascularized bone grafts, and approaches related to tissue engineer Durham, NC 27710, USA
ing. This review summarizes different modifications of the free vascularized fibula graft, which, Tel: +1-919-684-3320
Fax: +1-919-681-2670
since its introduction by Hidalgo in 1989, has become the first option for mandibular recons E-mail: [email protected]
truction. The fibula free flap can undergo various modifications according to the individual
requirements of a particular reconstruction. Osteocutaneous flaps can be harvested for re
construction of composite defects. Double-barreling of the fibula can, for instance, enable
enhanced aesthetic and functional results, as well as immediate one-stage osseointegrated
dental implantation. Recently described preoperative virtual surgery planning to facilitate
neomandible remodeling could guarantee good results. To conclude, the free fibula bone
graft can currently be regarded as the gold standard for mandibular reconstruction in case of
composite (inside and outside) oral cavity defects as well as a way of enabling the perfor
mance of one-stage dental implantation.
No potential conflict of interest relevant
Keywords Mandibular reconstruction / Fibula / Microsurgery to this article was reported.

Received: 20 Nov 2015 Revised: 22 Dec 2015 Accepted: 31 Dec 2015

pISSN: 2234-6163 eISSN: 2234-6171 http://dx.doi.org/10.5999/aps.2016.43.1.3 Arch Plast Surg 2016;43:3-9

INTRODUCTION petence. This can be achieved through a variety of surgical tech-

niques, mainly non-vascularized and vascularized grafts. Non-
The reconstruction of the mandible is a complex procedure and vascularized bone grafts (NVBGs) may be suitable in specific
continues to be a challenge in reconstructive craniomaxillofacial circumstances, like delayed reconstructions of small traumatic
plastic surgery. Indications for mandibular reconstruction are bony defects. They provide a framework for creeping substitu-
versatile, and include oncologic resections, traumatic injuries, tion. Yet the lack of blood supply results in slow and incomplete
and osteoradionecrosis [1,2]. The mandible serves several im- healing, as well as increased rates of infection, non-union, and
portant functions in the head and neck. The ultimate goal is res- fracture [3,4]. They are also prone to osteoradionecrosis in con-
toration of both form and function, necessitating the evaluation junction with radiation therapy [5].
of appearance, mastication, deglutition, speech, and oral com- The advent of microvascular surgery has revolutionized man-

Copyright 2016 The Korean Society of Plastic and Reconstructive Surgeons

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
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Kokosis G et al. Review of mandibular reconstruction

dibular reconstruction, especially after cancer treatment utiliz- Fig. 1. In-situ osteoseptocutaneous fibula flap
ing radiation. Vascularized bone grafts (VBGs) contain an in-
Osteoseptocutaneous fibula flap immediately after harvest, includ-
trinsic blood supply that adds the biological advantage of short- ing the skin paddle. The skin island is located between the middle
ened union time. Outcomes from free VBGs, most notably free and distal third of the fibula (markings).
fibula grafts, have proved markedly superior to non-vascularized
options, including reconstruction plates and bone grafts, with
defects of the mandible exceeding 6 cm in length and traversing
the parasymphyseal and/or anterior border regions [3,4].
Direct comparisons of NVBGs and vascularized bone flaps
(VBFs) have shown superiority of the latter in terms of bony
union (69% for NVBGs vs. 96% of VBFs) [3] as well as superior
functional and aesthetic scores for diet, speech, and midline sym-
metry [6]. Superiority of VBGs compared to NVBGs increases
significantly in case of mandibular defects greater than 6 cm or
previously irradiated tissue [3]. Available options for VBGs are
the fibula, radial forearm, scapula, and iliac crest [7-10], with the
fibula flap being the most popular for mandibular reconstruction.
In this review, the authors present different variations of the
free vascularized fibula graft, which could serve as the treatment
of choice for mandibular reconstruction.

FIBULA FLAP
The use of free vascularized fibula has become the gold stan-
dard for mandibular reconstruction since its introduction by
Hidalgo [11] in 1989, due to various advantages over other
VBGs. First, the fibula graft offers a good length of dense corti-
cal bone, up to 25 cm in adults, as well as a long pedicle based
on the peroneal artery for the reconstruction of long bony de- developed that include parts of the soleus or peroneus longus.
fects. Since the fibula graft was first described, many surgeons Most recently, a second skin island based on proximal perfora-
have adopted and ultimately optimized the technique. Today, tors off the peroneal artery present in 90% of the cases was de-
multiple modifications exist, each one developed to fit in a spe- scribed [16]. Thus, this graft provides convenient tissue for si-
cific individualized defect scenario. multaneous reconstruction of bony and soft tissue defects inside
as well as outside the oral cavity, bringing viable tissue to a most-
Bone-only and osteoseptocutaneous flap ly irradiated and contaminated field, with the lowest complica-
A few circumstances exist in which there is no associated soft tion rate among osteocutaneous flaps [17]. Limitations of the
tissue damage and an osseous flap only is sufficient to bridge the extent of the skin paddle harvested with the fibula graft have
defect. Composite tissue loss is usually more extensive, and the been overcome with the previously described double-skin pad-
versatility of the fibula flap comes into play. dle fibula free flaps based on septocutaneous, intramuscular, and
The fibula graft may provide skin islands, up to 25 cm long soleus perforators (Fig. 2) [18,19].
and 14 cm wide, suitable for reconstruction of associated soft
tissue defects (Fig. 1). Chen and Yan [12] were the first to de- Double barreling
scribe the osteocutaneous fibula flap in 1983. Multiple skin is- The height discrepancy between the native mandible and the
lands can be harvested with the fibula graft, including those based transplanted fibula can be a disadvantage of this approach, espe-
on septocutaneous as well as on musculocutaneous peroneal cially at the anterior segment, which significantly complicates
perforators supplying an osteomyocutaneous flap [13,14]. The prosthodontic reconstruction of the mandible. The average hei
most reliable septocutaneous perforators are located in the mid- ght of the native mandible, including the dentition, is generally
dle and distal third of the fibula [15]. Modifications have been in excess of 34 cm. The average height of the fibula is usually

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Fig. 2. Double-skin island osteoseptoctaneous fibula free flap

In this patient after major mandibular resection for osteosarcoma, the double-
skin island osteoseptocutaneous fibula free flap is used for simultaneous recon-
struction of a soft tissue defect externally (A) and intraorally (B). The photograph
depicts the immediate reconstructive result at the end of the procedure.

A B

1012 mm, which presents a reconstructive dilemma, as this Fig. 3. Radiographic appearance of double-barrel fibula
height is inadequate to allow for placement of dental implants free flap
that can be restored in a functional setting. Double-barreling of Postoperative panorex depicts the typical configuration of a dou-
the fibula, a technique that involves osteotomies and folding ble-barrel fibula free flap. The flap is well aligned and held stable by
the plate.
over the fibula graft to create equal struts, while preserving the
blood supply throughout the graft, was first recommended by
Horiuchi et al. [20] in 1995. A double-barrel fibula flap conve-
niently matches the height of the mandible of 34 cm, leading
to better aesthetic and functional results and enabling a one-
stage procedure with immediate osseointegrated dental implan-
tation (Fig. 3) [21,22]. In terms of dental implantation, the ver-
tical distraction technique has been described to expand the
neomandible up to 15 mm to allow a delayed osseointegrated
dental implantation after 46 months in a three-stage procedure
[2]. Most recently published data have shown a increased com- Pre-plating and osteotomies
plexity and frequency of complications with the vertical distrac- To recreate the anatomic form of the mandible, especially the
tion technique compared to double-barreled fibula grafts and contour of the anterior portion, the fibula has to be divided into
therefore recommend the use of double-barreled fibula grafts several segments using a closed wedge osteotomy technique
for osseointegrated dental implants [23]. Depending on the re- with potentially multiple osteotomies. The number of osteoto-
constructive purpose, the fibula can also be partially double-bar- mies should be kept to a minimum to preserve reliable segmen-
reled [2]. A 98% flap survival and good aesthetic and functional tal periosteal circulation [25]. The accurate restoration of the
outcomes have been reported [24]. neomandible is crucial due to sufficient occlusion and accept-
able aesthetic results. The contour of the neomandible will be
defined principally by the curve of a reconstruction plate formed

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Kokosis G et al. Review of mandibular reconstruction

Fig. 4. Preparation of three-dimensional models of fibula grafts prior to surgery

(A) Prefabricated plate bend on a three-dimensional model of the neomandible. (B) Cutting guide for in situ donor-site osteotomies. (C) In situ
construct of prefabricated plate and osteotomized fibula.

A B C

prior to the surgery or during the surgery using a no-touch tech- late cellular bone and marrow (PCBM) and platelet-rich plasma
nique along the specimen. Another technique includes pre-plat- (PRP) has been shown to form microstructures of the cellular
ing of the mandible prior to the resection. Different variations of bone resembling those in normal mandibles [34]. Additionally,
pre-plating are described depending on the tumor spread [26]. an off-label use of bone morphogenetic protein-2 (rhBMP-2) in
The stereolithographic model completes this technique involv- a collagen carrier has been described as a new alternative to vari-
ing preplating, templating, and insetting of the mandible with ous types of autogenous bone grafting procedures [35,36]. Nev-
convincing results with regard to shape and function [27]. ertheless, none of these approaches can yet be considered estab-
lished as standard in craniomaxillofacial reconstructive surgery.
Prefabricated plates and cutting systemsthree-
dimensional approach DISCUSSION
As described before, sculpting the fibula graft is a critical step
during restoration of the mandibular shape. The evolution of The reconstruction of mandibular defects is complex due to the
technology has introduced three-dimensional (3D) approaches need to address both functional and aesthetic objectives. This
to virtual surgical planning by preparation of 3D models of fibu- review has noted that reconstruction with a free fibula bone graft
la grafts prior to surgery. Stereolithographic models of the man- has been shown to produce superior patient outcomes over
dible and the fibula can be obtained from computer tomogra- NVBGs [3,4]. Nevertheless, it is also one of the most challeng-
phy scan data preoperatively [28]. Subsequently, plates can be ing procedures from the standpoint of craniomaxillofacial sur-
bent according to the model to increase the accuracy and de- gery. For this reason, NVBGs may be a reasonable alternative in
crease the duration of surgery by preplanning each step of the selected cases, depending on the size of the bony and soft tissue
operation including the osteotomies on the mandible and the defect [37,38]. Additionally, soft tissue flaps alone such as an-
fibula by use of staged cutting guides (Fig. 4) [29]. Thus, com- terolateral thigh, gracilis, rectus, and latissimus dorsi have been
puter-assisted mandibular reconstruction (CAMR) has increas successfully used in reconstruction of posterolateral defects [39,
ed preoperative planning accuracy, resulting in greater surgical 40]. Tissue-engineered alternatives have also shown promise
precision and reduction of surgical duration [30]. However, these but still need more comprehensive clinical testing. In the case of
models are expensive, require a strict realization of the planned additional soft tissue defects, a fibula graft can be harvested with
intervention, and are not easily adaptable to an aberrant surgical various reliable skin paddles [1], which enable a one-stage re-
approach [31]. constructive procedure of composite mandibular defects [41-
43]. Several modifications of skin paddles have been described,
Future directions including a chimeric double-skin paddle [18] for simultaneous
Utilization of microsurgery in management of the mandibular reconstruction of intra- and extraoral defects [44]. Especially in
reconstruction, even though associated with adequate outcomes such complex defects, the free fibula graft has outstanding im-
and low donor-site morbidity [32], it remains challenging. Fu- portance. Another advantage of the free vascularized fibula graft
ture strategies include tissue engineering approaches utilizing is the ability to have two teams working simultaneously with the
collagen-based scaffolds combined with bone marrow-derived patient in the supine position by reducing operating time, which
stromal cells and growth factors [5,33]. Furthermore, particu- is associated with reduced blood loss and lower rates of infec-

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tion [45]. Additionally, the blood supply can be monitored post- tional outcomes using osseous or soft-tissue free flaps. J Re-
operatively with an implantable Cook-Swartz Doppler probe, constr Microsurg 2002;18:365-71.
since the peroneal artery remains sizeable, enabling the recogni- 7. Taylor GI, Townsend P, Corlett R. Superiority of the deep
tion of vascular compromise early, which in turn results in an circumflex iliac vessels as the supply for free groin flaps. Plast
overall flap success rate of 98.1% [46,47]. The donor site mor- Reconstr Surg 1979;64:595-604.
bidity of the free vascularized fibula graft is consistently accept- 8. Soutar DS, Scheker LR, Tanner NS, et al. The radial forearm
able among different studies, and is mostly avoidable with care- flap: a versatile method for intra-oral reconstruction. Br J
ful planning and appropriate technique [48-50]. Plast Surg 1983;36:1-8.
One disadvantage of the free fibula graft is the height discrep- 9. Swartz WM, Banis JC, Newton ED, et al. The osteocutane-
ancy between the native mandible and the transplanted fibula, ous scapular flap for mandibular and maxillary reconstruc-
especially at the anterior segment. The double-barreling of the tion. Plast Reconstr Surg 1986;77:530-45.
fibula to create equal struts is a useful modification with good 10. Taylor GI, Miller GD, Ham FJ. The free vascularized bone
aesthetic and functional outcomes [24]. Partially double-bar- graft: a clinical extension of microvascular techniques. Plast
reled grafts, as needed for aesthetic improvements, have also Reconstr Surg 1975;55:533-44.
been reported, and a commonly used modification [2]. The 11. Hidalgo DA. Fibula free flap: a new method of mandible re-
double-barreling of the fibula enables immediate osseointe- construction. Plast Reconstr Surg 1989;84:71-9.
grated dental implantation, obtaining better results and lower 12. Chen ZW, Yan W. The study and clinical application of the
complication rates compared to vertical distraction devices [23]. osteocutaneous flap of fibula. Microsurgery 1983;4:11-6.
Levine et al. [51] even published three cases of total mandibular 13. Daya M. Peroneal artery perforator chimeric flap: changing
reconstruction in a single stage procedure with immediate den- the perspective in free fibula flap use in complex oroman-
tal implantation. Preoperative virtual surgery planning using 3D dibular reconstruction. J Reconstr Microsurg 2008;24:413-8.
technology has shown convincing improvements in postopera- 14. Cheng MH, Saint-Cyr M, Ali RS, et al. Osteomyocutaneous
tive outcomes, including a reduced operation duration and in- peroneal artery-based combined flap for reconstruction of
creased functional as well as aesthetic results, and should be composite and en bloc mandibular defects. Head Neck 2009;
considered, especially in complex defects [52]. However, as dis- 31:361-70.
cussed before, these models are expensive and have not become 15. Heitmann C, Khan FN, Levin LS. Vasculature of the pero-
an integral part of the surgical approach [31]. neal artery: an anatomic study focused on the perforator
vessels. J Reconstr Microsurg 2003;19:157-62.
REFERENCES 16. Potter JK, Lee MR, Oxford L, et al. Proximal peroneal per-
forator in dual-skin paddle configuration of fibula free flap
1. Erdmann D, Giessler GA, Bergquist GE, et al. Free fibula for composite oral reconstruction. Plast Reconstr Surg 2014;
transfer: analysis of 76 consecutive microsurgical procedures 133:1485-92.
and review of the literature. Chirurg 2004;75:799-809. 17. Hayden RE, Mullin DP, Patel AK. Reconstruction of the
2. Wallace CG, Chang YM, Tsai CY, et al. Harnessing the po- segmental mandibular defect: current state of the art. Curr
tential of the free fibula osteoseptocutaneous flap in mandi- Opin Otolaryngol Head Neck Surg 2012;20:231-6.
ble reconstruction. Plast Reconstr Surg 2010;125:305-14. 18. Leclere FM, Bosc R, Temam S, et al. Reconstruction of large
3. Foster RD, Anthony JP, Sharma A, et al. Vascularized bone mandibulofacial defects with the composed double skin pad-
flaps versus nonvascularized bone grafts for mandibular re- dle fibula free flap: a review of 32 procedures. Laryngoscope
construction: an outcome analysis of primary bony union 2014;124:1336-43.
and endosseous implant success. Head Neck 1999;21:66- 19. Nakajima H, Fujino T, Adachi S. A new concept of vascular
71. supply to the skin and classification of skin flaps according
4. Pogrel MA, Podlesh S, Anthony JP, et al. A comparison of to their vascularization. Ann Plast Surg 1986;16:1-19.
vascularized and nonvascularized bone grafts for reconstruc- 20. Horiuchi K, Hattori A, Inada I, et al. Mandibular reconstruc-
tion of mandibular continuity defects. J Oral Maxillofac Surg tion using the double barrel fibular graft. Microsurgery 1995;
1997;55:1200-6. 16:450-4.
5. Chim H, Salgado CJ, Mardini S, et al. Reconstruction of man- 21. Chang YM, Tsai CY, Wei FC. One-stage, double-barrel fibu-
dibular defects. Semin Plast Surg 2010;24:188-97. la osteoseptocutaneous flap and immediate dental implants
6. King TW, Gallas MT, Robb GL, et al. Aesthetic and func- for functional and aesthetic reconstruction of segmental

7
Kokosis G et al. Review of mandibular reconstruction

mandibular defects. Plast Reconstr Surg 2008;122:143-5. row, and platelet-rich plasma. J Craniomaxillofac Surg 2011;
22. He Y, Zhang ZY, Zhu HG, et al. Double-barrel fibula vascu- 39:628-32.
larized free flap with dental rehabilitation for mandibular re- 35. Herford AS, Boyne PJ. Reconstruction of mandibular conti-
construction. J Oral Maxillofac Surg 2011;69:2663-9. nuity defects with bone morphogenetic protein-2 (rhBMP-2).
23. Chang YM, Wallace CG, Hsu YM, et al. Outcome of osseo- J Oral Maxillofac Surg 2008;66:616-24.
integrated dental implants in double-barrel and vertically 36. Carter TG, Brar PS, Tolas A, et al. Off-label use of recombi-
distracted fibula osteoseptocutaneous free flaps for segmen- nant human bone morphogenetic protein-2 (rhBMP-2) for
tal mandibular defect reconstruction. Plast Reconstr Surg reconstruction of mandibular bone defects in humans. J Oral
2014;134:1033-43. Maxillofac Surg 2008;66:1417-25.
24. Shen Y, Guo XH, Sun J, et al. Double-barrel vascularised fib- 37. van Gemert JT, van Es RJ, Van Cann EM, et al. Nonvascu-
ula graft in mandibular reconstruction: a 10-year experience larized bone grafts for segmental reconstruction of the man-
with an algorithm. J Plast Reconstr Aesthet Surg 2013;66: dible: a reappraisal. J Oral Maxillofac Surg 2009;67:1446-
364-71. 52.
25. Strackee SD, Kroon FH, Jaspers JE, et al. Modeling a fibula 38. Gadre PK, Ramanojam S, Patankar A, et al. Nonvascular-
transplant in mandibular reconstructions: evaluation of the ized bone grafting for mandibular reconstruction: myth or
effects of a minimal number of osteotomies on the contour reality? J Craniofac Surg 2011;22:1727-35.
of the jaw. Plast Reconstr Surg 2001;108:1915-21. 39. Hanasono MM, Zevallos JP, Skoracki RJ, et al. A prospective
26. Marchetti C, Bianchi A, Mazzoni S, et al. Oromandibular re- analysis of bony versus soft-tissue reconstruction for poste-
construction using a fibula osteocutaneous free flap: four rior mandibular defects. Plast Reconstr Surg 2010;125:1413-
different preplating techniques. Plast Reconstr Surg 2006; 21.
118:643-51. 40. Mosahebi A, Chaudhry A, McCarthy CM, et al. Reconstruc-
27. Pellini R, Mercante G, Spriano G. Step-by-step mandibular tion of extensive composite posterolateral mandibular de-
reconstruction with free fibula flap modelling. Acta Otorhi- fects using nonosseous free tissue transfer. Plast Reconstr
nolaryngol Ital 2012;32:405-9. Surg 2009;124:1571-7.
28. Yeung RW, Samman N, Cheung LK, et al. Stereomodel-as- 41. Wei FC, Seah CS, Tsai YC, et al. Fibula osteoseptocutaneous
sisted fibula flap harvest and mandibular reconstruction. J flap for reconstruction of composite mandibular defects.
Oral Maxillofac Surg 2007;65:1128-34. Plast Reconstr Surg 1994;93:294-304.
29. Hirsch DL, Garfein ES, Christensen AM, et al. Use of com- 42. Minami A, Usui M, Ogino T, et al. Simultaneous reconstruc-
puter-aided design and computer-aided manufacturing to tion of bone and skin defects by free fibular graft with a skin
produce orthognathically ideal surgical outcomes: a para- flap. Microsurgery 1986;7:38-45.
digm shift in head and neck reconstruction. J Oral Maxillo- 43. van Twisk R, Pavlov PW, Sonneveld J. Reconstruction of
fac Surg 2009;67:2115-22. bone and soft tissue defects with free fibula transfer. Ann
30. Succo G, Berrone M, Battiston B, et al. Step-by-step surgical Plast Surg 1988;21:555-8.
technique for mandibular reconstruction with fibular free 44. Loeffelbein DJ, Holzle F, Wolff KD. Double-skin paddle
flap: application of digital technology in virtual surgical plan- perforator flap from the lateral lower leg for reconstruction
ning. Eur Arch Otorhinolaryngol 2015;272:1491-501. of through-and-through cheek defect: a report of two cases.
31. Moro A, Cannas R, Boniello R, et al. Techniques on model- Int J Oral Maxillofac Surg 2006;35:1016-20.
ing the vascularized free fibula flap in mandibular reconstruc- 45. Rosenberg AJ, Van Cann EM, van der Bilt A, et al. A pro-
tion. J Craniofac Surg 2009;20:1571-3. spective study on prognostic factors for free-flap reconstruc-
32. Ling XF, Peng X. What is the price to pay for a free fibula tions of head and neck defects. Int J Oral Maxillofac Surg
flap? A systematic review of donor-site morbidity following 2009;38:666-70.
free fibula flap surgery. Plast Reconstr Surg 2012;129:657- 46. Guillemaud JP, Seikaly H, Cote D, et al. The implantable
74. Cook-Swartz Doppler probe for postoperative monitoring
33. Seto I, Marukawa E, Asahina I. Mandibular reconstruction in head and neck free flap reconstruction. Arch Otolaryngol
using a combination graft of rhBMP-2 with bone marrow Head Neck Surg 2008;134:729-34.
cells expanded in vitro. Plast Reconstr Surg 2006;117:902-8. 47. Kind GM, Buntic RF, Buncke GM, et al. The effect of an
34. Matsuo A, Chiba H, Takahashi H, et al. Bone quality of man- implantable Doppler probe on the salvage of microvascular
dibles reconstructed with particulate cellular bone and mar- tissue transplants. Plast Reconstr Surg 1998;101:1268-73.

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48. Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: 111:2237-42.

a 10-year follow-up study. Plast Reconstr Surg 2002;110: 51. Levine JP, Bae JS, Soares M, et al. Jaw in a day: total maxillo-
438-49. facial reconstruction using digital technology. Plast Reconstr
49. Anthony JP, Rawnsley JD, Benhaim P, et al. Donor leg mor- Surg 2013;131:1386-91.
bidity and function after fibula free flap mandible reconstruc- 52. Wang WH, Zhu J, Deng JY, et al. Three-dimensional virtual
tion. Plast Reconstr Surg 1995;96:146-52. technology in reconstruction of mandibular defect includ-
50. Bodde EW, de Visser E, Duysens JE, et al. Donor-site mor- ing condyle using double-barrel vascularized fibula flap. J
bidity after free vascularized autogenous fibular transfer: sub- Craniomaxillofac Surg 2013;41:417-22.
jective and quantitative analyses. Plast Reconstr Surg 2003;