Mandibular Reconstruction After Hemimandibulectomy Huseyin Karagoz, MD, PhD,* Fikret Eren, MD,* Celalettin Sever, MD,* Ersin Ulkur, MD,* Cengiz Acikel, MD,Þ Bahattin Celikoz, MD,* and Bilge Kagan Aysal, MD* Abstract: Ameloblastoma is a benign tumor of the mandible, which is not commonly diagnosed in the early stages. The extensive mandible resection may be needed for treatment. In this report, we present 6-year follow-up results of a patient who had undergone hemimandibulectomy and mandible reconstruction with free vas- cularized fibular flap, costochondral rib graft to restoration of the temporomandibular joint, and iliac bone graft to enhance the vertical height of the mandible. The long-term results are very satisfactory. Key Words: Mandible, ameloblastoma, fibular flap, costochondral graft (J Craniofac Surg 2012;23: 1373Y1374) A meloblastoma is a benign tumor that develops from the epi- thelial cellular elements and dental tissues, localized in the mandible and the upper jaw. 1,2 In many cases, ameloblastoma is not diagnosed in the early stages because this benign tumor is often asymptomatic and has a slow grow pattern without evidence of swelling. Despite the benign nature of the tumor, ameloblastoma is a locally aggressive tumor and malignant transformation is pos- sible. 3 To avoid recurrence and possible malignant transforma- tion, the tumor should be resected totally with or without border preservation. 4 The mandible is a major component of the human facial ap- pearance and makes a great contribution to the orofacial function. For this reason, mandibular bone defects may result in oral function deficits, aesthetic disturbances, and psychologic problems. 5 Many mandibular reconstruction options are available. In this clinical report, we present 6-year outcomes of a pa- tient who had undergone mandible and temporomandibular joint (TMJ) reconstruction with combined free vascularized fibular flap, costochondral rib, and iliac bone graft for reconstruction of the hemimandibulectomy defect. CLINICAL REPORT A 21-year-old man was admitted to our clinic with a chief complaint of swelling in the lower jaw (Fig. 1). He has noticed a mass on the right side of his face, and the mass has grown slowly since childhood without known etiology. On the basis of physical exam- ination and radiography, the right ramus and the greater part of the right mandibular body were involved, and we performed incisional biopsy for a definite diagnosis and treatment (Fig. 2). The pathologic diagnosis of the biopsy specimen was reported as ameloblastic fi- broma, and the treatment was planned after careful analysis of each factor. We performed right hemimandibulectomy and removed the tumor and the right hemimandible (Fig. 3). For reconstruction, 15-cm-long free fibular flap with a 3 Â 10-cm skin island was planned and harvested. Osteotomies were performed to shape the flap as a potential ramus and corpus of the neomandible. To restore the TMJ, a 6-cm-long costochondral composite graft was harvested from the sixth rib and the chondral segment was shaped like a condyle of the mandible. In addition, the bony segment of the graft was sharpened to a cone to be embedded in the proximal edge of the flap that was planned as a connection with fibula flap (Figs. 4A, B). Subsequently, the bony segment of the costochondral graft had been implanted in a drilled hole at the proximal part of the fibula flap and a new mandible with a condyle was established (Fig. 5). The flap was placed to the defect, and rigid fixation was carried out. The artery and the veins of the flap were anastomosed to the facial artery and the jugular vein in an end-to-end and end-to-side fashion, re- spectively. The operation was successful. There were no major or moderate complications. After 6 months, the patient was reoperated on to prepare the neomandible for the dental osteoimplantation, and rigid internal fixation materials were removed and the iliac bone graft was placed FIGURE 1. Preoperative view of the patient. FIGURE 2. Preoperative panorex radiographic view of the patient. FIGURE 3. Right hemimandible with tumor that was resected en bloc. CLINICAL STUDY The Journal of Craniofacial Surgery & Volume 23, Number 5, September 2012 1373 From the *Department of Plastic and Reconstructive Surgery, Gulhane Mili- tary Medical Academy, Haydarpasa Training Hospital; and †Department of Plastic and Reconstructive Surgery, School of Medicine, Acibadem University, Istanbul, Turkey. Received November 1, 2011. Accepted for publication March 12, 2012. Address correspondence and reprint requests to Huseyin Karagoz, MD, PhD, Plastik Cerrahi Servisi, GATA Haydarpasa Egitim Hastanesi, 34668 Uskudar, Istanbul, Turkey; E-mail: hkaragozmd@hotmail.com The authors report no conflicts of interest. Copyright * 2012 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31825653ad Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.