Fibula Free Flap Reconstruction Research Articles

Impact of the adjacent bone on pseudarthrosis in mandibular reconstruction with fibula free flaps

BackgroundMechanical and morphological factors have both been described to influence the rate of pseudarthrosis in mandibular reconstruction. By minimizing mechanical confounders, the present study aims to evaluate the impact of bone origin at the intersegmental gap on osseous union.MethodsPatients were screened retrospectively for undergoing multi-segment fibula free flap reconstruction of the mandible including the anterior part of the mandible and osteosynthesis using patient-specific 3D-printed titanium reconstruction plates. Percentage changes in bone volume and width at the bone interface between the fibula/fibula and fibula/mandible at the anterior intersegmental gaps within the same patient were determined using cone-beam computed tomography (CBCT). Additionally, representative samples of the intersegmental zones were assessed histologically and using micro-computed tomography (µCT).ResultsThe bone interface (p = 0.223) did not significantly impact the change in bone volume at the intersegmental gap. Radiotherapy (p < 0.001), time between CBCT scans (p = 0.006) and wound healing disorders (p = 0.005) were independent risk factors for osseous non-union. Preliminary analysis of the microstructure of the intersegmental bone did not indicate morphological differences between fibula–fibula and fibula–mandible intersegmental bones.ConclusionsThe bone interface at the intersegmental gap in mandibular reconstruction did not influence long-term bone healing significantly. Mechanical and clinical properties seem to be more relevant for surgical success.

235 Late Start Times Do Not Disproportionately Prolong Operating Times in Major Head and Neck Reconstruction

Abstract Introduction Operating start time delays are deemed as having a detrimental effect on theatre efficiency, subsequent delays, costs, and potentially outcomes. This study assessed the significance of delayed operating start times on major head and neck reconstruction cases and whether later starts led to disproportionately later finishes. Focus was placed on free osteocutaneous fibula flap reconstruction due to long operating times, difficult anaesthesia, frequently overrun and the perception of increased morning efficiency. Method Single centre identification of 26 patients using coding informatics that were diagnosed with an intra oral malignancy or osteoradionecrosis requiring reconstruction with a free osteocutaneous fibula flap. Data was manually retrieved between 2015 to 2020 from electronic patient records and statistical analysis was completed using Microsoft Excel. Results Total number of patients collated was 27, however 1 was excluded due to insufficient electronic logging of patient data. The total mean age was 64.8 (40-79), 50% were male (13) and 50% were female (13). The mean start time was 9:57, end time was 18:52 and duration was 10:50 (4:46 to 13:42). For surgery start times before 10:00 a.m. the mean start time was 9:31, end time was 20:16 and duration was 10:46 (8:30 to 22:56). For surgery start times after 10:00 a.m. the mean start time was 10:22, end time was 19:25 and duration was 10:54 (10:01 to 00:51). Conclusions Delayed operating start times have minimal significance on theatre efficiency and don’t disproportionally prolong operating times in major head and neck reconstruction cases.

Management after fibula free flap necrosis in maxillofacial reconstruction

IntroductionFew articles discuss the management of a free fibula flap (FFF) necrosis in maxillofacial reconstruction. Material & methodsBetween 2005 and 2020, 170 FFF were used for maxillofacial reconstruction at the University Hospital of Caen, among which 16 cases suffered total necrosis and flap removal. The authors categorized these 16 cases into three groups based on the proposed salvage treatment and analyzed the post-operative follow-up, including complications, length of hospital stay and delay in radiotherapy. ResultsIn Group A, two patients underwent immediate reconstruction with a new free flap. There were no postoperative complications, and the average hospitalization duration after removal of the first flap was 10 days. In Group B, eleven patients underwent reconstruction with a pedicled musculocutaneous pectoralis major flap. These patients experienced numerous complications, with 73% of them requiring at least one additional surgery, and all of them had an indication for later FFF reconstruction. The average hospitalization duration in this group was 37 days. In Group C, three patients underwent conservative management with debridement and mucosal closure. Two of them experienced complications, and all of them underwent later FFF reconstruction. The average hospitalization duration in this group was 15 days. DiscussionBased on our experience and the literature review, the use of an immediate new free flap appears to be the best approach after the removal of a FFF. This generates shorter healing times and shorter hospitalization stays, and this allows better results in terms of function and aesthetics. At least, this is the approach that causes the least delay for radiation therapy if indicated. The other approaches should only be proposed in case of patient's poor general condition or in case of refuse of the patient.

Surgical management of mandibular and maxillary central giant cell granuloma

BackgroundCentral giant cell granuloma is a benign intraosseous lesion of bone. It frequently affects the head and neck region, particularly the maxillary and mandibular bones. Despite the availability of various nonsurgical treatment options, surgery is still the most effective treatment option for granulomas that do not respond to medical treatment, cause significant bone deformities, or result in extensive bleeding. In this article, we aimed to show the importance of surgery in certain patients by sharing our experience with five patients who were operated on in our clinic.Case presentationIn this case series, five patients who attended our clinic with central giant cell granuloma disease and underwent surgical treatments were retrospectively evaluated utilizing the hospital database records. Demographic and medical information, symptoms at admission, the results of CT and MRI imaging, pathologic results, previous treatments, and the surgical therapy performed at our clinic were all considered. Surgical procedures were performed in five patients; marginal mandibulectomy in two, segmental mandibulectomy in one, and partial maxillectomy in the other two. The granulation tissues in the cavity were removed using curettage and a diamond burr. Primary suture, secondary healing, palatal obturator repair, and free fibula flap reconstruction techniques were performed.ConclusionsThe objective of surgical therapy for central giant cell granuloma is to remove the mass with appropriate surgery and repair it properly with the least amount of morbidity and risk of recurrence possible.

Diagnostic and Prognostic Value of Indicators of Bone Metabolism Markers in Patients Following Mandibulectomy and Free Fibula Flap Reconstruction with Endosteal Implants.

To evaluate and assess the indicators of bone metabolism markers osteocalcin and β-Cross-Laps in blood serum as a tool for monitoring bone regeneration and determining the time of implantation in patients after mandibulectomy and reconstruction of a free fibular flap with subsequent endosteal implants. Forty-eight patients in a 6-year period participated in this study, due to resection for tumors. All patients underwent reconstruction with fibula free flap after tumor resection, 4-6months after osteoectomy, dental implants were installed with further orthopedic rehabilitation. To assess the rate of bone remodeling after transplantation, the content biochemical markers of bone remodeling osteocalcin and β-Cross-Laps serum were determined by enzyme immunoassay. All 46 fibular free flaps were healed without complications and were survived. A total 326 implants installed, 8 implants failed to osseointegrate, and 6 implants failed after 5years of loading (peri-implantitis). Success rate of implants after 5years was 95,7%. In patients before surgery, the mean of osteocalcin levels was 8.5ng/ml, two months later, there was a sharp increase in the content of osteocalcin by 15.4ng/ml, after four months reached 24.7ng/ml, after six months of 28.6ng/ml, then the indicator began to decrease and after 12months it was approaching the norm of 14.7ng/ml. In patients before surgery, the mean level of β-Cross-Laps was 0.76ng/ml, after two months bone transplantation the mean level of β-Cross-Laps decreased to - 0.65ng/ml, after four months the indicator increased and reached of 0.98ng/ml, after six months the indicator was - 1.56ng/ml, then these indicators began to decrease and after 12months, approaching normal values of - 0.87ng/ml. There is a correlation between different concentrations of osteocalcin or β-Cross- Laps and the success rate of implants. Implants were shown to be unsuccessful low concentrations of osteocalcin and high concentrations of β-Cross-Laps in serum. Studies have shown that the long-term survival and success rates of implants placed in the reconstructed areas may guarantee an excellent prognosis of implant-supported prostheses. Bone markers in blood serum osteocalcin and β-Cross-Laps can be used to evaluate the rate of bone remodeling, which allows you to determine the time of implantation.

Development and validation of a novel craniofacial statistical shape model for the virtual reconstruction of bilateral maxillary defects

Bilateral maxillary defects are a challenge for fibula free flap reconstruction (FFFR) surgery due to limitations in virtual surgical planning (VSP) workflows. While meshes of unilateral defects can be mirrored to virtually reconstruct missing anatomy, Brown class c and d defects lack a contralateral reference and associated anatomical landmarks. This often results in poor placement of osteotomized fibula segments. This study was performed to improve the VSP workflow for FFFR using statistical shape modeling (SSM) – a form of unsupervised machine learning – to virtually reconstruct premorbid anatomy in an automated, reproducible, and patient-specific manner. A training set of 112 computed tomography scans was sourced from an imaging database by stratified random sampling. The craniofacial skeletons were segmented, aligned, and processed via principal component analysis. Reconstruction performance was validated on a set of 45 unseen skulls containing various digitally generated defects (Brown class IIa–d). Validation metrics demonstrated promising accuracy: mean 95th percentile Hausdorff distance of 5.47 ± 2.39 mm, mean volumetric Dice coefficient of 48.8 ± 14.5%, compactness of 7.28 × 105 mm2, specificity of 1.18 mm, and generality of 8.12 × 10−6 mm. SSM-guided VSP will allow surgeons to create patient-centric treatment plans, increasing FFFR accuracy, reducing complications, and improving postoperative outcomes.

Outcomes in Fibula Free Flap Reconstruction for Treatment of Mandibular Osteonecrosis

Background: Osteoradionecrosis (ORN) of the mandible is an unfortunate possible sequela of radiotherapy for head and neck cancer. In advanced cases of ORN, mandibulectomy and free fibula flap reconstruction is required. We hypothesized that patients undergoing fibula free flap reconstruction of ORN mandibulectomy pose unique challenges and experience more complications than patients undergoing fibula free flaps after oncologic mandibulectomy. Methods: After IRB approval, we created a database of all free fibula flaps for mandible reconstruction from April 2005 through October 2019. Medical records were retrospectively reviewed for patient and surgical characteristics and post-operative outcomes. Results: 549 patients met inclusion criteria (173 ORN versus 376 non-ORN patients). Average age was 61.8±13.7 years. Mean follow-up was 35.0±29.5 months. ORN patients received more double-skin-island fibula flaps compared to non-OR patients (21.4% vs. 5.9%, p<0.001). Recipient artery other than the facial artery was utilized more commonly in ORN patients (41.0% vs. 19.1%, p <0.001). ORN patients had higher rates of delayed wound healing (27.2% vs. 17.3%, p=0.006) and surgical site infections (22.0% vs. 16.0%, p=0.058). Rates of flap loss, return to operating room, hematoma, operative time, and length of stay were similar between the groups. Conclusion: Mandibular reconstruction with fibula flaps for osteoradionecrosis is a more complicated procedure, often requiring two skin islands for both intraoral and extraoral resurfacing as well as utilization of unconventional recipient vessels due to previous history of neck dissection and radiotherapy. ORN patients also experience more complications such as delayed wound healing and infection compared to non-ORN patients.

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis

Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique's safety, effectiveness, and long-term outcomes is needed. To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN. This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023. Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals. The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months. The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.

33. Long-term Clinical Outcomes Following Free Fibula Flap Reconstruction of Maxillomandibular Defects with Immediate Dental Implant Placement

PURPOSE: Immediate dental implant placement (IDIP) at the time of ablative/reconstructive surgery for maxillomandibular cancer is a novel technique that has yet to be evaluated for its long-term clinical outcomes. This study describes long-term clinical outcomes with IDIP in free fibula flaps (FFF) for oncologic head and neck reconstruction. METHODS: A retrospective review for patients who underwent oncologic FFF reconstruction of mandibular or maxillary defects with and without IDIP was performed. Average length of follow-up and complication rates over two time periods (1-2 years and 2+ years) were analyzed. Patients who were lost to follow-up, died, or have not reached the 1 year postoperative timepoint were excluded. The number of patients who achieved dental rehabilitation in the IDIP cohort was also examined. RESULTS: 99 patients received FFF reconstruction with IDIP, and 120 historical patients received FFF reconstruction alone. The average length of follow-up was significantly longer in the historical group (1498.9±1700.6 days vs. 565.4±397.9 days, p=0.0005). 63/99 IDIP patients achieved dental rehabilitation. There was no significant difference in the complication rates between the IDIP and historical cohorts in either 1-2 year or 2+ year time period. CONCLUSION: IDIP is an effective method for rapidly achieving dental rehabilitation in patients undergoing maxillomandibular reconstruction with FFF. Long-term complications in IDIP patients were not significantly different from the historical cohort. Further studies investigating patient satisfaction and quality of life scores with IDIP are warranted to elucidate the full benefits of this treatment.

PC18. FACE-Q Outcomes following Free Fibula Flap Reconstruction with Immediate Dental Implant Placement

PURPOSE: Immediate dental implant placement (IDIP) is a technique that places dental implants into the bony reconstructions of maxillomandibular defects at the time of oncologic surgery. FACE-Q is a patient reported outcome measure (PROM) that has two scales: function and distress. This study describes short- and long-term PROMs in patients undergoing IDIP during free fibula flap reconstruction of their maxillomandibular defects. METHODS: Postoperative FACE-Q scores for patients who underwent IDIP were prospectively collected between November 2017 and January 2022. Converted scores (0 to 100) were analyzed at three timepoints: perioperative (0-90 days), short-term (90-365 days), and long-term (1+ years). Patient demographics, surgical characteristics and complications were also assessed. RESULTS: 70 patients underwent IDIP and completed FACE-Q postoperatively. We found no significant difference in scores between timepoints, although many domains, including eating/drinking and speaking function as well as speaking and drooling distress, showed an upward trend over time points. IDIP patients with short-term complications reported significantly worse function in eating/drinking (p=0.002), oral competence (p=0.018) and swallowing (p=0.012) as well as distress in eating/drinking (p=0.005) and speaking (p=0.024) compared to those without complications. Patients with long-term complications reported worse function in eating/drinking (p=0.028), oral competence (p=0.015), and swallowing (p<0.001) than those without long-term complications. CONCLUSION: Patient satisfaction following IDIP placement is stable through one year. As expected, complications adversely affect PROMs in this complicated patient population. Future studies are needed to evaluate patients undergoing IDIP to those who do not as it relates to patient satisfaction and quality of life.

Total Surface Area of a Through-and-Through Oromandibular Defect Is Associated With Thromboembolic Events for Reconstruction With a Single Fibula Free Flap

Reconstruction of through-and-through composite oromandibular defects (COMDs) has been a challenge to plastic surgeons for decades. When using a free osteoseptocutaneous fibular flap, the skin paddle is restricted by the orientation of the peroneal vessels and the inset of bone segment(s). Although the combination of double flaps for extensive COMDs is viable and reliable, the decision of single- or double-flap reconstruction is still debated, and the risk factors leading to complications and flap failure of single-flap reconstruction are less discussed. The aim of this study was to determine objectively predictive factors for postoperative vascular complications in through-and-through COMDs reconstructed with a single fibula flap. This was a retrospective cohort study in patients who underwent single free fibular flap reconstruction for through-and-through COMDs in a tertiary medical center from 2011 to 2020. The enrolled patients' characteristics, surgical methods, thromboembolic event, flap outcomes, intensive care unit care, and total hospital length of stay were analyzed. A total of 43 consecutive patients were included in this study. Patients were categorized into a group without thromboembolic events (n = 35) and a group with thromboembolic events (n = 8). The 8 subjects with thromboembolic events were failed to be salvaged. There was no significant difference in age, body mass index, smoking, hypertension, diabetes mellitus, and history of radiotherapy. The length of bony defect (6.70 ± 1.95 vs 9.04 ± 2.96, P = 0.004) and the total surface area (105.99 ± 60.33 vs 169.38 ± 41.21, P = 0.004) were the 2 factors that showed a significant difference between the groups. Total surface area was the only significant factor in univariate logistic regression for thromboembolic event (P = 0.020; odds ratio, 1.02; 95% confidence interval [CI], 1.003-1.033) and also in multivariate logistic regression analysis after adjusting confounding factors (P = 0.033; odds ratio, 1.026; 95% CI, 1.002-1.051).The cutoff level of total surface area in determining thromboembolic event development was 159 cm2 (P = 0.005; sensitivity of 75% and specificity of 82.9%; 95% CI, 0.684-0.952). Free fibula flap has its advantages and drawbacks on mandible restoration. Because there is a lack of indicators before, a large total surface area may be an objective reference for single-flap reconstruction of through-and-through COMDs due to an elevated risk of thromboembolic event.

Challenges in managing an ossified free flap arterial pedicle: a case report

The authors describe a difficult case of symptomatic pedicle ossification in a fibular free flap reconstruction of the head and neck region.

Prosthetic Rehabilitation Options in Post-Ablative Maxillomandibular Microvascular Reconstructions.

Surgery remains the mainstay for managing most neoplasms arising in the head and neck area. Removable or fixed prostheses are commonly used for prosthetic rehabilitation of head and neck defects following surgical resection. Some major challenges in prosthetic rehabilitation after maxillomandibular microvascular reconstruction include excessive prosthetic space, soft tissue bulk, and occlusal disharmony in the remaining dentition. This review focuses on the challenges we have experienced in the real clinical scenario while rehabilitating reconstructed maxillomandibular defects and the effective prosthetic treatment options that could be considered in each situation. Digital revolution has changed all arenas of life, and it has created a significant impact on cancer treatment planning and the delivery of quality treatment to the needy. Creating adequate retention while ensuring stability and support for the prosthesis can be challenging with temporary acrylic and cast partial removable dentures. Endosseous dental implants are considered a stable, reliable, and esthetic option for reconstruction with advantages such as increased chewing efficiency, preservation of the remaining bone height and width, and improved quality of life. The FP3 to RP5 (Misch's classification) are some commonly followed prosthetic rehabilitation options after microvascular reconstruction. The prosthetic design should permit the usage of interdental aids that ensure the longevity of prostheses. Occlusion-driven/prosthetic-driven implant-assisted prostheses are considered a reliable option that ensures stable and functional oral rehabilitation among patients with free fibula flap reconstruction. Multidisciplinary teamwork is mandatory for an optimal outcome that improves patients' quality of life.

An Analysis of Volume, Length and Segmentation of Free Fibula Flap in Reconstruction of the Jaws: Investigation of Their Role on Flap Failure

Reconstruction of defects of the jaws is mainly performed via free fibula flap. An incidence of 2–21% of overall flap failure is still described. We investigated the roles of volume, length and number of fibula flap segments on flap survival using novel three-dimensional segmentation tools. We also analyzed the role of other possible risk factors. Seventy-one consecutive patients with a follow up of at least three months and who underwent free fibula flap reconstruction in a single center between 2002 and 2022 have been evaluated. A total of 166 fibula segments were analyzed. Malignancies were the main reason of resection (45.1%). In 69% of the cases a reconstruction of the mandible was performed. The flaps were mainly divided in two segments (39%) (range 1–4), with a mean length of 2.52 cm and a mean volume was 3.37 cm3. Total flap failure (TFF) occurred in 12 cases, (16.9%), while partial flap failure (PFF) appeared in 3 patients (4.2%). Volume, length and number of fibula flap segments did not seem to influence flap failure incidence in uni- and multivariate analysis. Reconstruction of the maxilla and use of a recipient vessel different from the facial artery seemed to significantly impact on flap failure. Smoking and previous surgeries showed a higher trend to flap failure, but they did not reach statistical significance. Prospective and multicentric analysis on a wider population should be assessed.

Patterns of Postoperative Trismus Following Mandibulectomy and Fibula Free Flap Reconstruction.

The factors that contribute to postoperative trismus after mandibulectomy and fibula free flap reconstruction (FFFR) are undefined. We retrospectively assessed postoperative trismus (defined as a maximum interincisal opening ≤35 mm) in 106 patients undergoing mandibulectomy with FFFR, employing logistic regression to identify risk factors associated with this sequela. The surgical indication was primary ablation in 64%, salvage for recurrence in 24%, and osteonecrosis in 12%. Forty-five percent of patients had existing preoperative trismus, and 58% of patients received adjuvant radiation/chemoradiation following surgery. The overall rates of postoperative trismus were 76% in the early postoperative period (≤3 months after surgery) and 67% in the late postoperative period (&gt;6 months after surgery). Late postoperative trismus occurred more frequently in patients with ramus-involving vs. ramus-preserving posterior mandibulotomies (82% vs. 46%, p = 0.004). A ramus-involving mandibulotomy was the only variable significantly associated with trismus &gt;6 months postoperatively on multivariable logistic regression (OR, 7.94; 95% CI, 1.85-33.97; p = 0.005). This work demonstrates that trismus is common after mandibulectomy and FFFR, and suggests that posterior mandibulotomies that involve or remove the ramus may predispose to a higher risk of persistent postoperative trismus.

Functional outcomes following mandibulectomy and fibular free-flap reconstruction

There remains a paucity of evidence with regards to functional outcomes following the reconstruction of segmental defects in the mandible. It is, however, well recognised that oral rehabilitation following head and neck surgery is a driver of improved quality of life outcomes. We present a prospective service review of functional outcomes of a consecutive cohort of patients following segmental mandibulectomy and virtual surgical planning (VSP) composite fibular free-flap reconstruction. Twenty-five patients, who were identified as having a complete dataset with a minimum of 12 months’ follow up, ultimately met the inclusion criteria. Validated functional outcome measures were used primarily to assess speech, diet, and swallowing outcomes. The results demonstrate a decline in both speech and swallowing outcomes at three months postoperatively, with a decline of 37% in the Speech Handicap Index from the preoperative baseline, and a decline of 35% in the MD Anderson Dysphagia Inventory score over the same period. The MD Anderson Dysphagia Inventory score improved at 12 months, whereas the Speech Handicap Index did not. Fundamentally a collaborative approach is required between members of the multidisciplinary team (MDT) to enable optimal patient outcomes.

A comparative study of three-dimensional airway changes after fibula flap reconstruction for benign and malignant tumours in the anterior mandible

Surgical treatment of tumours in the anterior mandible and surrounding tissues may result in defects which can be restored by a fibula free flap. The upper airway may change during this process. The purpose of this retrospective study was to evaluate upper airway changes after fibula free flap reconstruction. A total of 37 patients who underwent anterior mandibulectomy and fibula free flap reconstruction between 2012 and 2020 were recruited. Patients with benign and malignant tumours involving the anterior mandible were included. Spiral computed tomography was performed 1 week preoperatively, 1 week postoperatively, and at> 1 year (range 12–23 months) after surgery. Cross-sectional areas and volumes of the upper airway were measured. Data were analysed by two-way analysis of variance. The upper airway in the malignant tumour group showed an increasing trend, especially at the soft palate and tongue base levels (P < 0.01). In the benign tumour group, the upper airway showed no significant changes. The location of the minimum cross-sectional area moved downwards in both groups, and the area increased in the malignant tumour group during long-term follow-up. Upper airway obstruction is less likely to occur in the long term after surgical resection of anterior mandible malignancies and fibula free flap reconstruction.

Reconstruction of mandibular defects in osteoradionecrosis and medication-related osteonecrosis of the jaw using fibula free flap and management of postoperative wound infections.

Complications from osteoradionecrosis (ORN) and medication-related osteonecrosis of the jaw (MRONJ) include oro-cutaneous fistulas, necrotic bone exposure, soft-tissue defects, and pathologic fractures. The fibula free flap (FFF) is a common free flap method used to reconstruct the mandible in severe cases. Recently, we have used the FFF successfully for the reconstruction of ORN and MRONJ mandibular defects. We report this method as a recommended technique for the treatment of ORN and MRONJ and the management method of postoperative infections. Four patients who were diagnosed with ORN of the mandible and 3 patients who were diagnosed with MRONJ of the mandible were included in the study. Among the 7 patients, 3 patients also had pathologic fractures. Partial mandibulectomy and FFF reconstruction were performed at the Department of Oral and Maxillofacial Surgery, Samsung Medical Center from April 2019 to March 2021. All 7 patients recovered following the reconstruction of the defect by FFF. Four patients experienced infections after surgery and pus cultures were performed. All were well healed without flap damage after changing the antibiotics by consultation with infectious medicine experts. FFF is a widely used method and can provide an extensive flap to reconstruct the mandible, especially those affected by ORN or MRONJ. If an infection occurs after surgery, appropriate antibiotic changes should be made through cooperation with the infectious medicine department. Therefore, FFF is a well-established and recommended method even in cases of challenging reconstruction.

29. A formal and multi-centre based protocol for rehabilitation post-fibular free flap surgery for patients undergoing major head and neck reconstruction

The fibular free flap (FFF) represents a workhorse in the reconstruction of major maxillofacial defects. This study was developed within a major UK head and neck unit with over 20 years’ high-volume experience in fibular free flap reconstruction (FFFR). The authors present a novel and formalised protocol for donor-site management and rehabilitation post-FFFR designed to optimise donor-site related outcomes.

24. Is it best to leave the fibular donor site dressing in place for 3 weeks? 9 years data audit of outcomes

The aim introduces an audit of outcomes in the Oral and Maxillofacial Head and Neck department over the last 9 years about fibular donor site morbidity (DSM) (n=86). DSM is a well-recognized complication of fibular free-flap reconstruction with 30% risk of complications, wound dehiscence, tendon exposure, graft failure. There is no consensus on how long to leave graft undisturbed. We aim to outline oxford experience leaving the bolster for 21 days, using the same type of dressing.