Fibular Osteomyocutaneous Flap Research Articles

OP037: Special considerations in virtual surgical planning for secondary accurate maxillary reconstruction with vascularized fibula osteomyocutaneous flap

This paper describes our special considerations in virtual surgical planning for secondary maxillary reconstruction with vascularized fibular osteomyocutaneous flap and our revised surgical design for maxillary reconstruction. Eleven patients with different maxillary defects according to Brown’s revised classification underwent virtual surgical planning for secondary accurate reconstruction. For different horizontal class defects, the fibular was osteomized to match maxillary alveolar arch by using the mirror image of the contralateral alveolar ridge or the curve of mandibular arch and dentition. Maxillary reconstruction was performed with the guidance of preoperative virtual planning and using fibular osteotomy and reposition guide templates to replicate the virtual planning intraoperatively. Virtual surgical planning was replicated intraoperatively in all patients. The fibulae were osteotomized into four segments in three patients with the horizontal class d2 defect and three segments in eight patients with the horizontal class b ∼ d1 defects, respectively. Overall success rate for 11 flaps was 100%. Good bony unions and wound closure were observed and intelligible speech was achieved in 11 patients. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. Postoperative mid-facial appearance was good in all patients. We recommend that the horizontal class d defect in Brown’s revised classification of maxilla and mid-face be divided into two subtypes according to whether it involves the contralateral canine or not. Special considerations in virtual surgical planning are helpful to perform accurate secondary maxillary reconstruction with vascularized fibular osteomyocutaneous flap.

Reconstruction of metatarsal bone defects with a free fibular osteomyocutaneous flap incorporating soleus muscle

Severe traumatic bone and soft-tissue defects are often treated by lower leg amputation. The amputation level becomes a very important factor with respect to the patient's basic daily activities. We report the case of a 51-year-old man who was referred to us with severe traumatic metatarsal bone and dorsum pedis skin and soft-tissue defects. To avoid amputation, a free fibular osteomyocutaneous flap incorporating the soleus muscle was used to reconstruct the second and third metatarsal bones and the soft-tissue defect, respectively. Now, 2 years after the procedure, the patient is able to walk independently. To the best of our knowledge, this is the first report of use of such a composite transfer for a complex midfoot defect.

Application of CAD/CAM-assisted technique with surgical treatment in reconstruction of the mandible

ObjectiveThe purpose of this clinical study was to explore the optimal method of reconstruct mandible defects individually and immediately. Study designThree-dimensional model simulation technique and vascularized fibular osteomyocutaneous flap were used to repair 15 cases of mandible defects, which were caused by ameloblastoma. A three-dimensional computed tomography (CT) images were converted to a virtual model using CAD software and the 3-dimensional (3D) simulated resin models of skeleton and fibula were used to design the osteotomies, bone segment replacement and titanium mesh shaping preoperatively. ResultsFibula flaps were alive and no complication occurred. The patients were satisfied with the results both esthetically and functionally. ConclusionsThis preliminarily clinical study and case demonstrated that CAD/CAM-assisted technique with surgical treatment offers an individual anatomical reconstruction of the mandible in ameloblastoma patients. The procedures guarantee intraoperatively an exact placement of the preformed mesh even for precise reconstruction of extensive mandible defects.

Special considerations in virtual surgical planning for secondary accurate maxillary reconstruction with vascularised fibula osteomyocutaneous flap

This article describes our special considerations in virtual surgical planning for secondary maxillary reconstruction with vascularised fibular osteomyocutaneous flap and our revised surgical design for maxillary reconstruction. Eleven patients with different maxillary defects according to Brown's revised classification underwent virtual surgical planning for secondary accurate reconstruction. For different horizontal class defects, the fibular was osteomised to match the maxillary alveolar arch by using the mirror image of the contralateral alveolar ridge or the curve of the mandibular arch and dentition. Maxillary reconstruction was performed with the guidance of preoperative virtual planning and using fibular osteotomy and reposition guide templates to replicate the virtual planning intra-operatively. Virtual surgical planning was replicated intra-operatively in all patients. The fibulae were osteotomised into four segments in three patients with the horizontal class d2 defect and three segments in eight patients with the horizontal class b-d1 defects, respectively. The overall success rate for 11 flaps was 100%. Good bony unions and wound closure were observed and intelligible speech was achieved in 11 patients. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. Postoperative midfacial appearance was good in all patients. We recommend that the horizontal class d defect in Brown's revised classification of maxilla and midface be divided into two sub-types according to whether it involves the contralateral canine or not. Special considerations in virtual surgical planning are helpful to perform accurate secondary maxillary reconstruction with a vascularised fibular osteomyocutaneous flap.

Reconstruction of oncological oro-mandibular defects with double skin paddled-free fibula flap: A prudent alternative to double flaps in resource-constrained centres

The free fibula flap is the choice flap for mandibular reconstruction following extensive tumor resections. While large defects are managed with a second flap [free or pedicle] in advanced centres, a free fibula flap with a large skin paddle that can be de-epithelised to provide outer skin and inner lining is the best alternative in resource- constrained centres. From January 2005 to December 2009 a total of 386 free fibula flaps were used of which 307 flaps had de-epithelised double skin paddle in reconstructing complex oral and mandibular defects after tumor ablative surgeries. Complete flap survival was seen in 282/307 patients. Complete flap loss was seen in 9/307 patients. Partial flap loss was seen in 16 patients. Re - exploration was done in 30 patients and the flap was salvaged in 21 patients. The vascular supply of the free fibula osteo myocutaneous flap is reliable and a flap with a large skin paddle can be used to provide both inner lining and outer cover in resource-constrained centres.

Evaluation of oro-mandibular-facial reconstruction using vascularized free fibular osteomyocutaneous flap

Evaluation of oro-mandibular-facial reconstruction using vascularized free fibular osteomyocutaneous flap

Sequential Second Free Flap for Head and Neck Reconstruction in a Patient with Fanconi Anemia and Metachronous Squamous Cell Carcinoma

Sir: Fanconi anemia is a rare genetic disease characterized by chromosomal instability, bone marrow failure, congenital malformations, and increased susceptibility to both solid and leukemic malignancies. The incidence of solid malignancies approaches 28 percent by 40 years of age, with a high proportion of these being head and neck tumors.1 In a series of 754 patients with Fanconi anemia, Kutler et al. reported that 3 percent developed head and neck squamous cell carcinoma, with a 50 percent relapse rate by the age of 40.2 Although Fanconi anemia patients may develop multiple tumors over a lifetime, repeated operations/ reconstructions are rarely seen because of their shortened life expectancies. Furthermore, surgeons may be hesitant to treat patients with Fanconi anemia because of an increased risk of complications, particularly if treatment involves extensive resection or possible free tissue transfer. We have previously described a successful mandibular reconstruction with a free fibula free flap in a patient with Fanconi anemia and squamous cell carcinoma of the mandible.3 Unfortunately, the patient developed squamous cell carcinoma of the pharynx 18 months later. We now report subsequent pharyngeal reconstruction with a metachronous free flap. Initially, a 43-year-old woman with Fanconi anemia was referred to our institution with an erosive floor-of-mouth mass ultimately diagnosed as squamous cell carcinoma. She underwent hemimandibulectomy and bilateral neck dissection followed by immediate reconstruction with a right fibular osteomyocutaneous flap. The patient recovered from surgery without complications and underwent adjuvant radiation therapy. Her postoperative result was satisfactory. Eighteen months later, she was found to have squamous cell carcinoma of the hypopharynx. She then underwent total laryngopharyngectomy and construction of a neopharynx using a tubed anterolateral thigh flap. The soft tissues of the right neck were resurfaced with a separate skin paddle based off of a second perforator; the left lateral neck received a split-thickness skin graft. The patient recovered without any hematologic complications but did suffer partial skin graft loss and a small pharyngocutaneous fistula. A modified barium swallow performed 6 weeks postoperatively demonstrated a small leak that resolved 1 month later, resulting in satisfactory cosmetic and functional outcomes. As recommended by our hematologists, during both hospitalizations, the patient's perioperative hemoglobin level and platelet count were maintained above 7 g/dl and 50,000 cells/ml, respectively, by means of hematopoiesis-stimulating agents and blood product transfusions. A total of 42 units of single-donor platelets and 13 units of packed red blood cells were administered while the patient was hospitalized after the second free flap. In conclusion, patients with Fanconi anemia are at increased risk for perioperative hematologic complications. There are two published reports that describe successful free tissue transfer in Fanconi anemia patients.3,4 To our knowledge, this is the first reported case of a patient with Fanconi anemia to undergo a second sequential free flap operation for metachronous head and neck cancer reconstruction. As this case demonstrates, such large-scale reconstructions can be successfully undertaken with careful perioperative management of patients with this disease. Karly A. Kaplan, M.D. Alyssa J. Reiffel, M.D. David I. Kutler, M.D. Christine H. Rohde, M.D. Jason A. Spector, M.D.

Sternocleidomastoid region restoration with lateral hemisoleus muscle incorporatied in free fibular flap for reconstruction of radical neck dissection and hemimandibulectomy

In the treatment of head and neck carcinoma, radical cervical lymphadenectomy leaves the affected side of the neck devoid of the sternocleidomastoid muscle, thus more vulnerable to the unwanted side effects of the adjuvant radiotherapy. It also causes asymmetry and cosmetically unpleasant appearance of the cervical region. In the reported case with widely ulcerated squamous-cell carcinoma over mandible, hemimandibulectomy and radical neck dissection was performed. Following the mandibular reconstruction, the lateral hemisoleus muscle of the harvested osteomyocutaneous fibula flap was utilized to restore the ipsilateral sternocleidomastoid region. This new application promises to be a useful method, which can aid in the restoration of the aesthetic contour of the neck and provide protection against unwanted effects of the adjuvant radiotherapy on the ipsilateral carotid artery.

Use of fibula pedicle as a composite interposition vascular graft to salvage large skin paddle with anomalous vascular supply

We report a case of free fibula osteomyocutaneous flap whose skin paddle had a dominant blood supply from a soleus musculocutaneous perforator which originated in the posterior tibial artery in addition to contribution from the peroneal septocutaneous perforators and was managed by two sets of anastomosis on either side of the neck, one for the peroneal vessels and the other for the dominant musculocutaneous perforator. The second anastomosis was achieved by using the excess length of the flap pedicle vessels (peroneal) as composite (both artery and vein) autologous interposition vascular graft to reach the opposite side of the neck.

Giant Cell-Rich Osteosarcoma or Giant Cell Reparative Granuloma of the Mandible?

Giant cell-rich osteosarcoma (GCRO) is a rare subtype of osteosarcoma, and no literature has reported occurrence in the mandible region up to now. In this article, we report a case of GCRO originating from the mandible in a 67-year-old woman who presented a history of painless mass located in the left side of the mandible after teeth extraction. The curettage biopsy histologic diagnosis is giant cell reparative granuloma before mandibulectomy surgery, but panoramic radiograph revealed an osteolytic lesion. The tumor was completely resected with segmental mandibulectomy and soft tissue with postoperative histologic diagnosis of GCRO. The free fibula osteomyocutaneous flap was performed to reconstruct the defect of the mandible and gingival mucosa. The patient received postoperative radiotherapy and chemotherapy. The 1-year follow-up situation is fine.

Immediate Reconstruction of Bilateral Mandible Defects: Management Based on Computer-Aided Design/Computer-Aided Manufacturing Rapid Prototyping Technology in Combination With Vascularized Fibular Osteomyocutaneous Flap

Since the last century, many researchers have attempted to improve the quality of treatment for facial defects.1 In recent years a computer scan information–aided surgical navigational system was used to accurately compare the intraoperative reduction profile with preoperative computer virtual simulation for exact reduction.2 Fan et al3 used computer-aided design (CAD)/computer-aided manufacturing (CAM) to treat complex periorbital fractures, deeming it a useful clinical tool to assist surgeons in accurate design of the surgical scheme and procedure and achieving improved surgical outcome.

Reconstruction of High Maxillectomy Defects with the Fibula Osteomyocutaneous Flap in Combination with Titanium Mesh or a Zygomatic Implant

This retrospective review examined the authors' patients who underwent reconstruction of high maxillectomy defects with fibula osteomyocutaneous flaps in combination with titanium mesh or a zygomatic implant. Outcome assessments included aesthetic, speech, and masticatory function. Twenty patients who underwent reconstruction of high maxillectomy defects with fibula osteomyocutaneous flaps in combination with titanium mesh (n = 19) or a zygomatic implant (n = 1) were reviewed. The fibula was fashioned to recreate the alveolar ridge and pterygomaxillary buttress, and the skin paddle was applied to restore the palate and nasal airway. The anterior wall of the maxilla and the orbital floor were reconstructed with titanium mesh in 19 patients. In four patients with extensive soft-tissue defects, a radial forearm flap was combined to restore missing soft tissue. Aesthetics, speech, and masticatory function were evaluated postoperatively. Nine patients underwent immediate maxillary reconstruction and 11 patients underwent secondary reconstruction. The overall success rate of 24 flaps was 95.8 percent. The exposure rate for titanium mesh and the oronasal fistula rate were both 10.5 percent. The average length of follow-up was 34.7 months. Recurrence occurred in only one patient, who died as a result of the disease. Ten patients received implant-borne prostheses or removable partial dentures. Excellent or good cosmesis and intelligible speech were noted in 19 patients. All patients were ultimately able to tolerate a regular or soft diet. Reconstruction of high maxillectomy defects with the fibula osteomyocutaneous flap in combination with titanium mesh or a zygomatic implant is a feasible and acceptable option with a high success rate, a low complication rate, excellent postoperative cosmesis, and well-accepted function.

Functional Total Heel Reconstruction with a Fibular Osteomyocutaneous Flap

Functional Total Heel Reconstruction with a Fibular Osteomyocutaneous Flap

The Fibula Osteomyocutaneous Flap for Mandible Reconstruction: A 15-Year Experience

This report documents our experience over the previous 15 years using free vascularized fibular flaps for comprehensive reconstruction of large defects in the mandible, after combined resections of aggressive, malignant odontogenic tumors or for post-traumatic defects. Charts were reviewed retrospectively for 117 consecutive patients who underwent microsurgical reconstruction of the oromandibular complex with a fibula osteocutaneous or osteomyocutaneous free flap over a 15-year period, with an average follow-up of 4 years. All charts were reviewed retrospectively for tumor type, stage and location, surgical procedure performed (including type of plate used), dental restoration if done, the use of pre- or postoperative radiotherapy, length of follow-up, and evidence of complications. Fibula osteocutaneous free flaps were used for reconstruction in 117 patients, of whom 60% were men (mean age, 57.1 years) and 40% were women (mean age, 56.6 years). Most cases (61.1%) were secondary to oral malignancies (89.1% of these were squamous cell carcinoma). Thirty-one patients (26.5%) developed postoperative complications, including hardware failure or intolerance in 16 patients (13.7%), total or partial flap failure in 10 patients (8.5%), wound infection in 3 patients (2.6%), and peroneal nerve damage in 2 patients (1.7%). Regarding donor site morbidity, calf paresthesias were recorded in 21% of cases. Similar rates of claw-toe deformity were also observed. In our opinion, the free fibula osteocutaneous flap is the most versatile and reliable option for microsurgical reconstruction of large mandibular defects. It provides a large quantity of bone, which is easily shaped to passively adapt to the remaining mandible. The bone height is suitable for an implant-based prosthetic restoration. Preoperative mapping of the cutaneous perforators of the skin paddle improves the versatility of the flap design and decreases the morbidity at the donor site. In selected cases, other options (iliac crest or scapular free flap) may also be considered.

Functional Total Heel Reconstruction with a Fibular Osteomyocutaneous Flap

The fibular osteocutaneous flap is a versatile option for a range of reconstructive challenges. In this report, a novel osteocutaneous fibular flap in which a V-shaped strut of fibula was used to reconstruct the weight-bearing function of the calcaneus has been described. The case raised interesting questions about the vascularity of the fibular flap, which we addressed with an anatomic study of the lower leg. Eight cadavers were injected with the modified lead oxide-gelatin mixture. Two cadavers were selected for three-dimensional reconstructive modeling. Dissections of each layer were performed to outline the course of every perforator in the lateral leg and the region of the ankle. The peroneal artery originated from 5.0 +/- 1.0 cm inferior to the lateral fibular tuberosity (diameter of 2.0 +/- 0.4 mm). The artery gave off 7.6 +/- 1.8 branches and provided blood supply to the fibula bone and its adjacent soft tissue. Proximal perforators from the peroneal artery were large and consistent. Based on the success of this clinical case and the details of the vascular anatomy, the authors feel that distally based osteocutaneous fibular flaps with a V-shaped strut of fibula offer a novel option for reconstruction of complex defects in the heel area in which there are both bony and soft tissue defects.

Three-dimensional model simulation and reconstruction of composite total maxillectomy defects with fibula osteomyocutaneous flap flow-through from radial forearm flap

A total maxillectomy always causes composite defects of maxilla, zygomatic bone, orbital floor or rim, and palatal and nasal mucosa lining. This leads to significant functional and cosmetic consequences after ablative surgery. The purpose of this clinical study was to preliminarily 3-dimensionally reconstruct the defect of total maxillectomy with sufficient bone support and soft tissue lining. Three-dimensional model simulation technique and free fibula osteomyocutaneous flap flow-through from radial forearm flap were used to reconstruct a total maxillectomy defect for a 21-year-old female patient. Preoperatively, the 3-dimensional (3D) simulated resin models of skeleton and fibula were used to design the osteotomies and bone segment replacement. At surgery, a 22-cm-length free fibula was divided into 4 segments to make 1 maxilla skeletal framework in the schedule of the preoperative model surgical planning with a radial forearm flap flow-through for the free fibula flap with skin paddle to repair the palatal and nasal region. Free fibula and radial forearm flap were alive, and the patient was satisfied with the results both esthetically and functionally after dental rehabilitation which was carried out 6 months after surgery. This preliminarily clinical study and case demonstrated that: the fibula osteomyocutaneous flap is an ideal donor site in 3D total maxillectomy defect reconstruction, because of its thickness, length, and bone uniformity which makes ideal support for dental rehabilitation; the flow-through forearm radial flap not only serves as the vascular bridge to midface reconstruction, but also provides sufficient soft tissue cover for the intraoral defect; and the 3D model simulation and preoperative surgical planning are effective methods to refine reconstruction surgery, shorten the surgical time, and predict the outcome after operation.

Maxillary reconstruction after total maxillectomy with vascularised fibula osteomyocutaneous flap and titanium mesh

Maxillary reconstruction after total maxillectomy with vascularised fibula osteomyocutaneous flap and titanium mesh

Desmoid Tumors of the Pediatric Mandible

Desmoid tumors are benign fibrous neoplasms originating from the musculoaponeurotic structures throughout the body. These rare neoplasms have been shown to account in 0.03% of all cancers. Twenty-five percent of all desmoid tumors occur in children under 15 years of age. The infrequency of these tumors has limited studies to case reports and retrospective reviews dictating the authors recommended treatments and management. We present a case report of desmoid tumor involving the left mandible in a 14-month-old infant. His treatment course included 2 excisions, removal of the free rib graft secondary to persistence of the tumor, and wound dehiscence, and later a free fibular osteomyocutaneous flap for reconstruction. We then retrospectively reviewed all published data of desmoid tumor involving the pediatric mandible since 1950 to 2007 in the PubMed database. Forty cases have been reported, which had a M:F ratio of 1:1 with an average age of 5.3 (standard deviation [SD] +/- 4.5) years. There appeared to be left-sided predominance of desmoid tumors in the pediatric mandible with a ratio of 3:1. The mean size of the tumors was 4.6 cm (SD +/- 2.1) at the largest diameter. We have tabulated the relevant data of all the cases including the methods of treatment and recurrence. It is found that when compared with conservative management, radiation therapy, chemotherapy, and curettage or surgical local excisions as treatment options the most efficient treatment was partial mandiblectomy, which resulted in complete tumor dissipation with no tumor recurrence. In summary, this is the largest review of the pediatric desmoid tumor of the mandible to date where we provide for the first time an algorithm for the management and treatment of the pediatric desmoid tumor of the mandible.

O.242 Fibula osteomyocutaneous flap for mandible reconstruction

O.242 Fibula osteomyocutaneous flap for mandible reconstruction

Poster 038: The Use of the Fibula Osteomyocutaneous Flap for Mandible Reconstruction: A 15-Year Experience

Poster 038: The Use of the Fibula Osteomyocutaneous Flap for Mandible Reconstruction: A 15-Year Experience