Mandibular Reconstruction Using Free Microvascularized Fibula Flap and Virtual Surgical Planning in Resection of Desmoplastic Fibroma of the Jaw: Literature Review and a Rare Case Report

Statement of the problem: Craniofacial tumor resection is one of the procedures in maxillofacial surgery that demands skill to achieve stability, function and esthetics. Taylor et al first described the microsurgical fibula flap in 1975. Hidalgo was the first to use this flap for mandibular reconstruction in 1988. The fibula provides approximately 25 cm of bone, which is sufficient to reconstruct any mandibular defect, both a bone flap and an osteocutaneous flap can be obtained. However, reconstruction of the mandible and associated soft tissue can be performed during the ablation procedure (primary reconstruction) or during a subsequent procedure (secondary reconstruction). Desmoplastic fibroma is a very rare local, benign and aggressive tumor that occurs before the age of 40, with male predominance. The mandible is the principle site of occurrence, followed by the femur, tibia. The most important differential diagnosis is the low-grade fibrosarcoma. Curettage does not eradicate all tumor tissue; therefore, an enbloc resection of the lesion with wide margins is suggested in the literature. We believe this case represents one of the few cases reported in the literature with the subsequent maxillofacial reconstruction.

 Materials and methods: A female Caucasian patient, 40 years old, presented to the office, with the chief complaint of slowly growing painless swelling in the right lower back tooth region since 2 years. The swelling was hard and nontender on palpation. The patient's past medical history was noncontributory. Clinical extraoral examination revealed expansion of the rigth inferior border of the mandible and intraoral examination revealed a solitary bony hard swelling measuring about 4.0 cm × 5.0 cm in size with obliteration of the left buccal vestibule in relation to 47 and 48. An incisional biopsy revealed a desmoplastic fibroma, then the patient was taken to hemimandibulectomy procedure for resection of the tumor with the subsequent mandibular reconstruction using free microvascularized fibula flap, using previous 3D virtual surgical planning for design a custom-made plate with its cutting guides.

Methods of data analysis: Comparison with other maxillofacial tumors that need reconstruction to improve lifestyle, feeding, speech, function and esthetics.

Results: the patient has been evaluated for 3 times since her last intervention, the occlusion was the same planned before the surgery, the esthetic was measured by concern of the patient who referred she was satisfied with the results. CT scan was taken for assure good contact between the native and the bone graft, also it was made a ultrasonography for analyze the good irrigation of the microvascularized fibula flap

Outcomes Data: The microvascularized fibula flap was assessed for devitalized zones, the facial symmetry was optimum, also the occlusion is stable since the intervention until nowadays.

Conclusions: It is quite probable that the desmoplastic fibroma does occur with a much higher frequency than the present case report seems to indicate. The increasing number of cases being re- ported within the last few years lends support to this assumption. It is hoped that this report will stimulate the publication of cases of this highly interesting tumor.

References: 

1. Schneider M, Zimmermann AC, Depprich RA, Kübler NR, Engers R, Naujoks CD, et al: Desmoplastic fibroma of the mandible – Review of the literature and presentation of a rare case. Head Face Med. 5:25, 2009

2. Ghassan D, Satir AA, Sharif S: Desmoplastic fibroma of the mandible: A 5-year follow-up. Bahrain Med Bull. 30(4):1–10, 2008