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PubMed2003

A comparison of the long-term morbidity following deep circumflex iliac and fibula free flaps for reconstruction following head and neck cancer.

Composite free tissue transfer has an established role in head and neck oncology for the reconstruction of the bony defect following tumor ablation, and while donor-site morbidity is variably reported, there is little consensus on the most favorable donor site. The fibula and deep circumflex iliac artery have distinct advantages in terms of the volume and length of bone in mandibular reconstruction. Few studies have compared their donor-site morbidity. The aim of this study was to compare the fibula and deep circumflex iliac artery flaps using a review of the case notes and cross-sectional review of patients attending a research clinic for validated orthopedic examination and completion of health-related quality-of-life questionnaires. Between February of 1993 and May of 2001, 44 fibula free flaps and 73 deep circumflex iliac artery free flaps were performed. Ninety-nine case notes and 36 patients were available for review of donor-site morbidity. Sixteen patients with fibula flaps and 20 patients with deep circumflex iliac artery flaps took part in the clinical examination component of the study, which was composed of a clinical examination by an orthopedic surgeon using the American Orthopedic Foot and Ankle Society ankle scoring system and the Harris hip scoring system, and two patient-completed questionnaires, the University of Washington Questionnaire and the Hospital Anxiety and Depression Scale. Subjective and objective markers of morbidity related to both flaps were similar in most parameters. However, fibula flaps were associated with more problems with donor-site healing, reduced power, and sensation. Poor orthopedic scores for both flaps were associated with notably poor scores on the University of Washington Questionnaire and the Hospital Anxiety and Depression Scale. The study would suggest that both deep circumflex iliac artery and fibula donor sites result in an acceptable and comparable morbidity for most patients, but in cases in which significant donor-site morbidity is encountered, health-related quality of life is significantly compromised.

Activities of Daily Living↗
PubMed2004

[Repair of extensive bone defect of distal femur with free vascularized two fibulae transplantation in adults].

OBJECTIVE: To investigate the treatment of extensive bone defect of distal femur caused by various diseases in adults. METHODS: From February 1998 to December 2002, 6 cases(aged from 19 to 37) of extensive bone defects of distal femur were treated with two free vascularized fibulae, whose defects were caused by resection of bone tumor, osteomyelitis and trauma. After the resection of distal femur and articular surface of tibia, the fibulae were transplanted and fixed with screws. And the periosteum of the two fibulae was dissected and sutured with each other. RESULTS: The average follow-up time was 3.3 years. Two free vascularized fibulae could give more support to the body and the bone union of the fibulae was possible when the periosteum was incised and sutured with each other. As time went on, both of the medullary canal reunioned to form a new canal as a whole, which would make the grafts stronger. CONCLUSION: Autograft with two free vascularized fibulae can increase the stability in treating extensive bone defect of distal femur, but the union of knee joint will make flexion and extension impossible.

Adult↗
PubMed2005

Tibialization of the fibula: a viable option to salvage limbs with extensive scarring and gap nonunions of the tibia.

I retrospectively reviewed 21 patients who had tibialization of the fibula for infected nonunions with scarring of soft tissues. Most of the patients had unsuccessfully had other operations to restore continuity of the tibia before this treatment. The prerequisites were adequate vascularity, an intact sensate sole, and intact fibula. Proximal site tibiofibular synostosis was done in all patients. Three patients required a supplementary procedure at the proximal tibiofibular junction because of screws cutting out. Distal tibiofibular synostosis was done as a second-stage procedure in a majority of the patients 3 to 6 weeks after the proximal procedure. Protected weightbearing was recommended for 4 to 8 months. The transplanted fibula hypertrophied and approached the diameter of the tibia (or double the size of original fibula) in 2-3 years. Tibialization of the fibula is a safe, nondestructive, salvage procedure for treating difficult infected nonunions of the tibia. It is a simple technique that can be done in hospitals with a moderate infrastructure. Despite scarring, shortening, and limitation of knee and ankle motion, the patients were satisfied to be able to take part in normal daily activities on their own. After the success of synostosis, all patients engaged in activities of daily living and during the followup of 4-14 years none developed stress fracture of the tibialized fibula.

Adolescent↗
PubMed1990

[Role of the fibula in distal tibial fracture].

Analysing 1077 fractures of the distal segment of the tibia the author found specific morphologies of the accompanying fibula fractures when axial dislocations exist. In valgus position compression and bending forces induce multifragmentary fractures of the diaphysis or impactions of the metaphysis. In varus position bending and traction forces create simple oblique or transverse fractures. The ligaments of the syndesmosis are rarely ruptured when the fibula is fractured. They may remain undamaged when the fibula is intact. Ruptures of the fibulotalar and fibulocalcanear ligaments are not uncommon. The internal fixation of the fibula remains the first step of the AO-tactics for the operative treatment of Pilon-tibial fractures. The initial axial position must be respected. In valgus cases there will be postoperative compression forces (pillar function), in varus cases traction forces (tension band function) acting on the repaired fibula. Indirect reduction techniques ought to be used for complex fibula fractures.

Ankle Injuries↗
PubMed1989

[Pseudarthroses of the fibula following fracture of the lower leg].

There are few reports in the literature on nonunion of the fibula following simultaneous fracture of the tibia and fibula. They apparently develop in cases where when only the tibia is stabilized and early functional treatment follows. Six patients suffering from painful nonunion of the fibula were treated in our trauma center from 1985 to 1987. Primary fixation was achieved with a plate in three cases, external fixation in two, and a Küntscher nail in one case. Because of infection, the nail was replaced by external fixation after 2 weeks. After healing of the tibia, the patients developed pain during normal use, and there was local tenderness, edema, and paresthesia. In all cases the X-ray films showed hypertrophic nonunion of the fibula. Four patients were treated with plate osteosynthesis of the fibula, which alleviated the problems. From our retrospective data we conclude that in primary therapy of lower leg fractures, plate fixation of the fibula should also be included in cases where the fractures are located in the distal half of the lower leg and show signs if instability due to displacement, oblique fracture forms, and multiple fragments.

Adult↗
PubMed1985

[Significance of the fibula in tibial fractures and pseudarthroses].

The importance of the shaft of the fibula in lower leg fractures is the greater, the more unfavourable the situation of the tibia together with the surrounding soft tissue. We consider the operative stabilisation of the fibula to be a good procedure in cases of distal lower leg fractures, comminuted fractures of the tibial shaft and intramedullary nailing of the tibia, to increase overall stability of the whole lower leg system. The fibula is of still greater importance in cases of non-unions with loss of bone, with or without infection. The reconstruction of the tibial bone defect can be achieved via the stable fibula by means of several modifications of the fibula-pro-tibia operation. It can be demonstrated by various examples that the fibula and its stability should be considered more often in the therapeutic management of lower leg fractures and non-unions of the tibia.

Adolescent↗
PubMed1983

Growth and morphogenesis of the fibula in the chick embryo.

The development of the avian fibula was studied both histologically and experimentally. It was found that from the onset of chondrogenesis, the fibula possessed a smaller diameter than the neighbouring tibia. The truncated growth of the fibula was a result of the loss of its distal epiphysis between stages 27-31. This epiphysis subsequently became fused to the tibia and formed the fibulare of the tibiotarsus. The experiment of Hampé (1960) was repeated by inserting tantalum barriers into the limb between stages 18 and 23: this sometimes prevented the separation of the fibula distal epiphysis, thus giving rise to an elongated element. A similar result was obtained from grafts of polarizing region into the leg bud at stages 18-20. It was concluded that there was no evidence for competitive interaction between the blastemata of the tibia and fibula. In addition, the differential growth in diameters between the tibia and fibula was largely a result of differential osteogenesis rather than chondrogenesis as previously thought.

Animals↗
PubMed1996

Anatomic and hemodynamic study of the vascularized pig fibula bone flap model.

Despite much interest in studying the pathophysiology of experimental skin and muscle flaps to better understand the pathobiology of flap failure, relatively little has been published in the investigation of vascularized bone flaps. The aim of this study was to develop a suitable vascularized bone flap model in the pig in the hope that this model may prove useful in studying the pathophysiology of vascularized bone tissue transfer. Yorkshire pigs (17-26 kg) were used for all experiments. Anatomic studies revealed that the fibula in the hindlimb was the most suitable bone for investigation as a flap model. Anatomic dissections, radiologic investigations (plain x-rays, angiograms), and morphometric analyses of the fibulae in both hindlimbs of five animals were carried out. In a separate group of pigs (n = 6), the fibula was elevated as a vascularized flap and then blood flow was measured using the 15-microns radioactive microsphere technique. The fibula in the pig is supplied by a branch of the cranial tibial artery, running along an intermuscular septum between the posterior and anterior compartments of the hindlimb accompanied by one or two vena commitans. The bone flap is raised with a cuff of flexor hallucis longus with a length of 9.2 +/- 0.2 cm (mean +/- SEM). Blood flow measurement confirmed that the entire fibula was well vascularized when elevated on its pedicle. Gradient blood flow showed a bimodal distribution, with regions of highest blood flow noted at the proximal and distal ends of the bone flap, in areas where there were greater percentages of cancellous bone. The results of these experiments suggest that the pig fibula may be a suitable model for the study of vascularized bone flap pathophysiology.

Animals↗
PubMed2000

[Tibial fracture with intact fibula treated by reamed nailing].

PURPOSE OF THE STUDY: The main difficulties encountered in the orthopedic treatment of leg fractures with intact fibula are reduction of the tibial and an unusually high rate of varus unions and non-unions. The aim of this retrospective study was to assess the outcome after reamed nailing of tibial fractures with an intact fibula. MATERIAL AND METHOD: Between 1986 and 1997, 38 fractures of the tibia with an intact fibula were treated by first intention centromedullar nailing. There were 28 men and 10 women, mean age 28 years, with a single fracture in 25 cases. There were 25 motor vehicle accidents (17 two-wheel, 8 four-wheel), 5 sports accidents, 2 home falls, and 6 others. Fracture of the tibial diaphysis was associated with a homolateral femoral fracture in 7 cases, 7 fractures were open (7 type 1, 2 type 2, 1 type 3), 7 fractures were associated with abrasive skin lesions. Using the AO classification, the tibial fracture was type A in 26 cases, type B in 11, and type C in 1. The fracture was in the middle third of the tibia in 21 cases, the distal third in 15 and in the proximal third. Grosse and Kempf nails were used exclusively. Static nailing was used in 27 cases, dynamic nailing in 8, and the nail was not locked in 3 cases. Nails of diameter 9 to 13 were implanted after reaming 1 mm more. RESULTS: The fracture gap increased during the reaming in 5 patients; 2 patients had to undergo a secondary aponeurectomy due to a postoperative compartment syndrome and had no further sequela. Consolidation was achieved after the first intention treatment in 30 patients, after dynamization in 6. A non-union in 2 patients was also successfully managed with new nailing and dynamization. Delay to consolidation was a mean 175 days (range 60 - 480). Transverse fractures consolidated more rapidly (mean 122 days). At last follow-up (minimum 1 year), active knee and ankle mobility were normal in all patients. Nineteen patients complained of pain at the site of the nail insertion, evaluated at 1 on a 10-point analogie scale by 10 of them and at 2 by the 9 others. Eight out of 10 patients felt cure had been achieved 5 months postoperatively. DISCUSSION: These rapidly obtained clinical results and the relatively low rate of non-union (5 p. 100) should be attributed to the reamed nailing technique. We discuss the frequency of tibial fractures with intact fibula and the underlying circumstances. The lack of patent fibular fracture does not signify the fibula is intact. Trauma-induced tibio-fibular dislocation (1 case in our series) can occur. A review of the literature emphasizes the frequency of non unions and misalignment after orthopedic treatment. The most widely used surgical technique is reamed nailing. This technique has the inconvenience of possible pain at the insertion site which usually disappears after ablation of the nail and also a compartment syndrome where reaming is a possible aggravating factor. CONCLUSION: Nailing is a reliable technique for the treatment of tibial fractures with an intact fibula. Weight bearing should be encouraged as early as possible. The indication for a locked nail depends on the anatomic type of the tibial fracture and its localization. Immediate weight bearing should be recommended. Strict surveillance allows dynamization with fibulotomy in case of late consolidation. Prospective randomized studies comparing nailing with other therapeutic methods are needed to confirm these data.

Adult↗
PubMed1999

Tibia and fibula fractures in soccer players.

We performed a retrospective review of 31 athletes who sustained a fracture of the lower leg from a direct blow while playing soccer. Fifteen fractures involved both the tibia and fibula 11 only the tibia, and 5 only the fibula. Information was collected using a standardized questionnaire. The mean follow-up from the time of injury was 30 months. Injuries typically occurred in young, competitive athletes during game situations. The mechanisms were broadly classified into several categories: contact during a slide tackle (13, 42%), a collision with the goalkeeper (8, 26%), two opposing players colliding while swinging for a loose ball (7, 23%), or a player being kicked by a standing opponent (3, 10%). The majority of fractures (26, 90%) occurred while the athletes were wearing shin guards. The point of impact was with the shin guard prior to the fracture in 16 cases (62%). Return to competitive soccer averaged 40 weeks for combined tibia and fibula fractures, 35 weeks for isolated tibia fractures, and 18 weeks for isolated fibula fractures. Injuries were associated with a high incidence of major complications (12 out of 31, 39%), especially in concurrent tibia and fibula fractures (8 out of 15, 50%). These findings suggest that lower leg fractures in soccer players are serious injuries, often necessitating a prolonged recovery time. In addition, this study questions the ability of shin guards to protect against fractures.

Adolescent↗
PubMed1988

The anterior tibial vessels and their role in epiphyseal and diaphyseal transfer of the fibula: experimental study and clinical applications.

The blood supply to the fibula from the anterior tibial and peroneal arteries was investigated in 66 fresh cadaver limbs by India ink injection and radiographic studies. These studies revealed a reliable blood supply to the proximal epiphysis and the proximal two-thirds of the diaphysis of the fibula from the anterior tibial artery. Although the peroneal artery provided the dominant supply to the shaft of the bone, its contribution to the head of the fibula was scanty. The cutaneous supply of each vessel was defined and correlated with the territories of the other vessels supplying the leg. The vascular anatomy of the leg was examined in 100 clinical angiograms, revealing 21 limbs with anomalies. This reinforces the case for preoperative angiogram studies where transfer of the fibula is contemplated. The technique of harvesting the proximal growth plate and the shaft of the fibula on the anterior tibial vessels alone is described and illustrated with two successful clinical cases, each followed for 4 years. The growth rate of the transferred epiphysis averaged 1 cm per year.

Blood Vessels↗
PubMed1997

Long-term evaluation of bone mass in free fibula flap mandible reconstruction.

BACKGROUND: Vascularized fibula transfer has become a preferred method of mandibular restoration after oncologic surgical ablation. In order to elucidate the long-term effect on fibular mass after mandibular reconstruction, change in fibular height was utilized as an indirect measure of change in bone mass over time. Other potentially influential factors in long-term bone mass preservation were evaluated; these included site of reconstruction (central, body, ramus), patient age, length of follow-up, adjuvant radiotherapy, and the delayed placement of osseointegrated dental implants. METHODS: A retrospective analysis of patients undergoing free fibula mandible reconstruction for oncologic surgical defects between 1987 and 1993 was performed. Postoperative panorex examinations were used to evaluate fibular height and bony union after osteotomy. Fixation hardware was used as a reference to eliminate magnification as a possible source of error in measurement. Only patients with at least 24 months follow-up were included in this study. RESULTS: There were 27 patients (15 males and 12 females) with a mean age of 43 years (range 14 to 65) included in this study. Mandibular defects were anterior (16) and lateral (11). There were between two and five segmental osteotomies per patient (excluding the ends of the graft). Thirty percent of patients had delayed placement of osseointegrated dental implants. Initial panorex examinations were taken between 1 and 9 months (mean 2) postoperatively. Follow-up panorex examinations were taken 24 to 104 months (mean 54) postoperatively. The bony union rate after osteotomy was 93%. Comparative measurements of fibular height revealed that central segments underwent a mean decrease in height by 4% (range 0% to 22%); body segments decreased in height by 7% (range 0% to 33%); ramus segments decreased in height by 5% (range 0% to 15%). In each anatomic segment, fibular height varied by 10% or less when compared with respect to patient age, length of follow-up, adjuvant radiation therapy, and the presence of osseointegrated dental implants. CONCLUSIONS: We conclude that the retention of fibula height seen in this study indicates that fibula bone mass is preserved after free flap mandible reconstruction. Furthermore, these findings are not affected by the site of reconstruction, patient age, length of follow-up, adjuvant radiation therapy, or presence of osseointegrated dental implants. This study further supports the efficacy of vascularized fibula grafts for mandible reconstruction.

Adult↗
PubMed2006

[Fibula free flap for reconstruction of extensive mandibular osteoradionecrosis].

OBJECTIVE: Treatment of mandibular osteoradionecrosis is always a therapeutic challenge. The aim of this article is to evaluate the interest of fibula free flap for mandible reconstruction after radical excision of osteoradionecrotic lesions. MATERIAL AND METHODS: Six consecutives cases of extensive osteoradionecrosis of the mandible were treated with fibula free flap reconstruction. We report a meticulous analysis of the cosmetic and functional results. RESULTS: All vascularized fibula osteocutaneous flaps transplanted were successful. Median hospital stay was 32 days. At 6 months, functional results (swallowing, mouth opening and speech) were good. All patients had sufficient oral intake and a comprehensible speech with just two patients requiring a soft diet and 1 patient retaining a moderate trismus. DISCUSSION: Extensive mandibular osteoradionecrosis requires a radical surgical treatment. Fibula free flap is the best solution for mandible reconstruction in this situation. This technique allows good functional results. CONCLUSION: Fibula free flap is the method of choice for mandible reconstruction after radical treatment of osteoradionecrosis.

Aged↗
PubMed1998

Use of the "double barrel" free vascularized fibula in mandibular reconstruction.

PURPOSE: Microvascularized fibula transplants have become established in reconstruction of the mandible. However, because of the limited diameter of the fibula compared with the height of the mandible, the vertical distance between the reconstructed segment and the occlusal plane can be substantially large. This is a particular problem in nonatrophic or dentate mandibles, especially when rehabilitation with dental implants or an implant-borne denture is contemplated. The large leverage forces resulting from the high vertical dimension of the prosthetic construction can lead to overloading of the osseointegrated implants and endanger the longevity of the prosthetic restoration. This article describes experience with a new method of circumventing this problem. PATIENTS AND METHODS: This procedure was used in eight patients. A fibula graft corresponding to at least twice the length of the mandibular defect was harvested, halved perpendicular to its length, and the resulting struts folded on top of each other to form a "double barrel." The struts are then fixed to each other with screws and plates and stabilized in the defect using a reconstruction plate. RESULTS: Compared with the conventional one-strut fibula transplant, the "double-barrel" graft achieved more bone height and appreciably reduced the vertical distance to the occlusal plane. CONCLUSIONS: This technique creates better conditions for prosthetic rehabilitation. In comparison with the iliac graft, the fibula is easier to harvest, more reliable regarding anastomosis, and is associated with less postoperative morbidity.

Adult↗
PubMed2002

Ontogeny and occurrence of the corpus fibulae in the domesticated goat (Capra aegagrus f. hircus).

Osteological characteristics are often used to identify animal species in a cheap and rapid manner. In this context it is believed that the corpus fibulae of the goat is represented by a tight cord of connective tissue--the so-called ligamentum fibulare. The results of the present morphometric study indicate, however, that in nearly 60% of the 143 examined animals, the corpus fibulae is a pin-shaped flattened piece of bone which may additionally be accompanied by a pyramid-shaped bone lying closely to the caput fibulae. The length of the corpus fibulae increases with age and varies greatly between individuals but its centre is located close to the border between the proximal and the intermediate third of the tibia. The cartilaginous fetal anlage is either transformed to bone or catabolised during fetal live. Desmal ossification should play an important role in the growth of the corpus fibulae since no cartilage could be detected in kids and adult goats.

Aging↗
PubMed1996

Experience with the osteocutaneous fibula flap: an analysis of 24 consecutive reconstructions of composite mandibular defects.

Based on findings from anatomical dissections of the skin of the peroneal artery, we used the osteocutaneous fibula flap for combined replacement of the mandible and floor of the mouth in 24 patients, form November 1993 to December 1995. There were 22 primary and 2 secondary reconstructions; the mean age of the patients (2 women and 22 men) was 64 years. The length of the fibula segments ranged between 5.5 and 18 cm, the size of the skin component between 3 x 5 and 6 x 15 cm. Corresponding to the results of our anatomical studies, the skin island was exclusively raised form the distal third of the lower leg, and the donor sites were generally covered with split thickness skin grafts. The average length of the dissected vascular pedicle was 11 cm, so that a vein graft was only required in one case. Flap raising and tumour resection were always carried out simultaneously. Fibula osteosynthesis was done with titanium miniplates; the insertion of endosseous implants followed secondarily. The success rate was 95.8% with one transplant loss and pseudarthrosis in one case. Despite the limited width of the fibula, the shape of the mandible was satisfactorily reconstructed in all patients, and the thin, pliable component enabled intraoral coverage with only negligible surplus volume. Chronic wound-healing disturbances at the donor site of the skin island occurred in two cases; impairment of walking ability was not detected. According to our experience, the use of the osteocutaneous fibula flap is a valuable method for the reconstruction of composite mandibular defects.

Adult↗
PubMedDate not supplied

Computed tomography validating bony ingrowth into fibula strut allograft: a criterion for fusion.

BACKGROUND CONTEXT: Static and dynamic X-ray studies routinely determine whether or not fusion of a fibula strut allograft has occurred after multilevel anterior corpectomy with fusion (ACF) combined with posterior wiring and fusion (PWF). PURPOSE: Two-dimensional (2D) computed tomography (CT) studies were assessed for documentation of bony ingrowth into fresh frozen fibula strut allograft to constitute an additional sign of fusion. STUDY DESIGN/SETTING: This was a prospective, nonrandomized study, which was conducted at a university medical center. PATIENT SAMPLE: Eighteen patients with moderate to severe myelopathy undergoing circumferential cervical surgery for ossification of the posterior longitudinal ligament and spondylostenosis were evaluated. OUTCOME MEASURES: Static and dynamic X-rays and 2D CT examinations were performed in 18 patients 3 and 6 months after circumferential cervical procedures. METHODS: Fusion was assessed on static and dynamic X-rays, and 2D CT studies performed in 18 patients following average 2.9 level anterior corpectomy with fusion (ACF) with posterior wiring and fusion (PWF) (C2-T1) with halo application. Routine fusion criteria on static radiographs included the documentation of bony trabeculation and absence of bony lucency at the graft/vertebral end plate interface. Routine dynamic X-ray criteria of fusion mandated that less than 3.5 mm of translation, less than 20 degrees of angulation, and less than 1 mm of motion be observed between adjacent spinous processes. Here, a potential additional 2D CT criterion for fusion, progressive bony ingrowth into the central shaft of a fibula strut allograft, was investigated on 3 and 6 month postoperative 2D CT examinations using direct measurement of Hounsfield units. Telescoping (mm) was also differentiated from ingrowth into the bony shaft based on a comparison of immediate, 3 and 6 month postoperative CT studies. RESULTS: Immediate postoperative baseline 2D CT studies revealed no bone within the central canal but an average of less than 1 mm of cephalad and 2.3 mm of caudad graft telescoping. Within 6 postoperative months, 2D CT studies demonstrated an average of 3.5 mm of superior and 4.6 mm of inferior bony ingrowth (confirmed by measuring 500 to 900 Hounsfield units) into the central fibula canal of 17 of 18 patients (94%). Seventeen had routine/dynamic X-ray and CT studies confirming fusion. CONCLUSIONS: Two-dimensional CT evidence of bony ingrowth into the central canal of fibula strut allografts after multilevel ACF/PWF provided an additional means of quantifying the extent of fusion.

Adult↗
PubMed2000

Comparisons of bone volumes and densities relating to osseointegrated implants in microvascularly reconstructed mandibles: a study of cadaveric radius and fibula bones.

The study was designed to compare the dimensions and densities of two frequently used bone donor sites with regard to placement of endosseous dental implants in microvascularly reconstructed mandibles. A total of 40 radii and of 40 fibulae were investigated. Fifty two percent of the fibulae had adequate bone volume for the positioning of four 10 mm implants, while this figure was 55% for the radii. After using the 'double barrel' technique the placement of four 10 mm implants succeeded in 87% of all the fibulae. Due to the lack of bone length required, this special technique was not possible in the radii investigated. Cortical thickness and density of bone were higher in the radii when compared with the fibulae. In each bone the central and distal parts presented the highest values of cortical thickness and density. Although the radius offers enough substantial bone for implant placement in some cases this cannot be used for clinical purpose, as only hemicortical grafts can be obtained. Otherwise the resulting donor site morbidity would be intolerable. In conclusion, our results support the clinical experience that the fibula is today's 'work horse' donor site for reconstruction of the mandible.

Aged↗