Donor-site Morbidity following Microvascular Fibular Transfer for Head and Neck Reconstruction

Abstract

BACKGROUND: Continuous refinement in head and neck reconstruction requires a thorough evaluation of donor-site morbidity of established workhorse flaps. Regardless of the favoritism bestowed on the free fibular flap (FFF) for head and neck reconstruction by most microsurgeons, the donor-site morbidity associated with harvesting remains a controversial and concerning issue. In fact, the perioperative donor-site complication rate following FFF harvest ranges between 2% to 38%. The objective of this study is to analyze surgical and postoperative factors that contribute to donor-site morbidity in patients undergoing FFF transfer for mandibular and/or maxillary reconstruction of oncologic defects. METHODS: We conducted a prospective single-institutional investigation to analyze complications and assess their effect on the postoperative status of the ankle, great toe, and gait in 53 patients who underwent reconstruction of maxillary and/or mandibular defects with the FFF. We used the American Academy of Orthopaedic Surgeons foot and ankle questionnaire (AAOS-FAOQ), X-ray of ankles, and clinical examination (pain, paresthesia, claw toe deformity, and range of motion) to evaluate postoperative outcomes one, three, and six months after surgery. RESULTS: Forty-six males (86.8%) and seven females (13.2%) were finally included. The mean age was 50.18 years (range, 22-75). The mean tourniquet time was 74.25 minutes. The mean length of the segment of fibula harvested was 12.85 ± 1.1 cm, while the residual mean distal and proximal fibula segment length were 6.6 cm (range, 6-8) and 6.7 cm (range, 6-8) respectively. The mean size of the skin paddle harvested was 53.2 cm2 (range, 36-64 cm2). Flap failure secondary to venous congestion was seen in 2 cases. The most common acute donor site complications recorded were edema of the ipsilateral foot (11.30%) and delayed wound healing (9.4%). Additional complications reported included partial graft loss (7.5%) and wound infection (7.5%). Three of the four grafts that were partially lost, had signs of infection (75%). Spontaneous recovery was observed in the 3 partial graft loss cases (75%) whereas 1 patient (25%) required an additional STSG. Long-term claw toe deformity was observed in 1 patient (1.8%) who had required excision of the flexus hallucis longus. Nerve alterations were present in the form of paresthesia (39.6%) and superficial peroneal nerve sensory loss (18.9%). The overall rate of perioperative donor site complications was 35.8%. Significant improvement in the average AAOS-FAOQ score was observed at 6-months when compared to 1-month results (p<.001). Dorsiflexion (p=0.923) and plantarflexion (p=0.913) did not significantly improve at different time points. Complications did not affect range of motion for dorsiflexion (p=0.759) or plantarflexion (p=0.254) at 6-months. A larger residual fibular stump (≥8cm) did not significantly affect postoperative ROM for dorsiflexion (p=0.232) or plantarflexion at 6-months. A large skin paddle area resulted in an increase in incidence of complications. (p <.001). CONCLUSION: Although FFF is associated with a high complication rate and postoperative reduction in lower limb performance, these findings do not challenge the reliability of this versatile flap. A larger flap’s skin paddle increases the rate of donor-site complications. Future studies focusing on refinement of harvest technique are anticipated.