Fibula Free Flap Reconstruction Research Articles

Clinical Evaluation of Endosseous Implants in Radiated Fibula Bone Grafts

Purpose: Fibula free flap reconstruction with following placement of endosseous implants became a gold standard of reconstruction after mandible resection. Many patients had radiation to the area and there is little available data in the literature about the success of osteointegration in the irradiated fibula. The goal of this study is to evaluate implant success in radiated fibula flaps and mandibles after oral cancer resection.

Fibula free flap reconstruction of the mandible in cancer patients: Evaluation of a combined surgical and prosthodontic treatment concept

The final goal of mandibular reconstruction following ablative surgery for oral cancer is often considered to be dental implant-supported oral rehabilitation, for which bone grafts should ideally be placed in a suitable position taking subsequent prosthetic restoration into account. The aim of this study was to evaluate the efficacy of a standardized treatment strategy for mandibular reconstruction according to the size of the bony defect and planned subsequent dental prosthetic rehabilitation. Data of 56 patients, who had undergone such a systematic mandibular fibula free flap reconstruction, were retrospectively analyzed. Early complications were observed in 41.5% of the patients but only in those who had been irradiated. Late complications were found in 38.2%. Dental implant survival rate was 92%, and dental prosthetic treatment has been completed in all classes of bony defects with an overall success rate of 42.9%. The main reasons for failure of the complete dental reconstruction were patients' poor cooperation (30.4%) and tumour recurrence (14.3%) followed by surgery-related factors (10.8%) such as implant failure and an unfavourable intermaxillary relationship between the maxilla and the mandible. A comparison of our results with the literature findings revealed no marked differences in the complication rates and implant survival rates. However, a systematic concept for the reconstructive treatment like the method presented here, plays an important role in the successful completion of dental reconstruction. The success rate could still be improved by some technical progress in implant and bone graft positioning.

Latissimus-Serratus-Rib Free Flap for Oromandibular and Maxillary Reconstruction

To review complications and outcomes associated with latissimus-serratus-rib free flap oromandibular and midface reconstruction. Retrospective medical record review. Two academic tertiary care medical centers. Twenty-eight patients with segmental resection of the mandible and 1 patient with combined resection of the mandible and maxilla after excision of neoplasms of the oral cavity, who were believed to be poor candidates for fibula free flap reconstruction, were identified. Twenty-seven latissimus-serratus-rib osteomusculocutaneous free flap reconstructions and 2 serratus-rib osteomuscular free flap reconstructions were performed. The outcome of microvascular free tissue transfer as well as short- and long-term complications were recorded. There were no perioperative free flap failures. Delayed partial rib graft resorption occurred in 1 patient 33 months after free flap transfer for maxillary reconstruction. Among 28 cases of mandibular reconstruction, 1 case of bone graft nonunion was noted after a postoperative period of 57 months. All other cases achieved successful restoration of mandibular continuity. Donor site morbidity was well-tolerated in all patients. Latissimus-serratus-rib osteomusculocutaneous free flaps are effective for reconstruction of composite defects of the mandible in patients who are not candidates for more commonly used vascularized bone-containing free flaps.

Lambeau libre de péroné en double barre : intérêt du montage dans les reconstructions mandibulaires pour une réhabilitation prothétique sur implants (5 cas)

As major loss of mandibular bone stock requires a vascularized transfer, fibula free flap reconstruction is considered to be the best free flap for its length and reliability. Its main advantage is to accept dental implants. Single or double-barrel reconstruction can be performed. Double-barrel reconstruction is generally preferred because the bone superposition offers enough height to allow dental implants. We reviewed five selected cases of double-barrel fibula free flap adaptive mandibular reconstruction performed among a series of 11 oral rehabilitations with planned dental implants, focusing on the technical aspects. Today, dental rehabilitation has been achieved in three double-barrel fibula flaps. Details are reported concerning the implant step. In this perspective, we discuss the choice of the reconstructive technique in order to obtain adequate bone height. Early in our experience and for different reasons discussed in the text, we used a single barrel fibula flap. This technique provided sufficient height in some cases, but had to be completed by bone grafts in few patients. Our experience illustrates the usefulness of the double barrel technique which provide definitive bone height sufficient for dental implants. The double-barreled technique should be considered as the best solution.

Masticatory and swallowing threshold performances with conventional and implant-supported prostheses after mandibular fibula free-flap reconstruction

Significant strides in microvascular surgical techniques allow predictable restoration of bony and soft tissue orofacial defects. In combination with prosthetic rehabilitation, varying degrees of improvement in esthetics, speech intelligibility, and swallowing have been noted; however, the relative impact of conventional and implant-supported prostheses on restoration of masticatory function are not known. The purpose of this study was to determine whether conventional or implant-supported dental prostheses and current surgical reconstructive procedures restore patients' masticatory function to presurgical levels. Of the 46 subjects enrolled in this study, 23 (7 edentulous and 16 partially dentate) completed conventional prosthesis (CP) treatment and masticatory evaluation, and of these, 15 (3 edentulous and 12 partially dentate) completed treatment and evaluation with an implant-supported prosthesis (IP). Standardized masticatory performance tests with peanuts and carrots as the test food were made on the defect and nondefect sides. Tests of swallowing threshold performance were made with carrots as the test food. Statistical analysis included repeated-measures analysis of variance (ANOVA) with post hoc Tukey HSD tests (alpha=.05). Masticatory function at entry was markedly compromised. Further performance declines were noted following surgery (PS) on both the defect and nondefect sides. Restoration with CP and IP produced improvements (significant for defect side only, P<.05) in performance over the PS interval and were not significantly different from performances at entry prior to surgery. In addition, the performance on the defect side with the IP was significantly greater than the performance with the CP (P<.001). Impairment in masticatory ability remains following free-flap reconstruction prior to prosthetic rehabilitation. Both CP and IP may provide improved masticatory ability, permitting patients to regain the functional level they possessed prior to surgical intervention. The IP may contribute to greater support and stability of the prosthesis, resulting in increased use for mastication and superior performance on the defect side compared to the CP.

P.340 In situ performance and gap-ossification in the double-barrel technique for vascularized free fibular flap reconstruction of the mandible

This paper presents a meshless numerical scheme for recovering the time-dependent heat source in general three-dimensional (3D) heat conduction problems. The problem considered is ill-posed and the determination of the unknown heat source is achieved here by using the boundary condition, initial condition and the extra measured data from a fixed point placed inside the domain. The extra measured data are used to guarantee the uniqueness of the solution. The generalized finite difference method (GFDM), a recently-developed meshless method, is then adopted to solve the resulting time-dependent boundary-value problem. In our computations, the second-order Crank–Nicolson scheme is employed for the temporal discretization and the proposed GFDM for the spatial discretization. Several benchmark test problems with both smooth and piecewise smooth geometries have been studied to verify the accuracy and efficiency of the proposed method. No need to apply any well-known regularization strategy, the accurate and stable solution could be obtained with a comparatively large level of noise.

Efficacy of conventional and implant-supported mandibular resection prostheses: Study overview and treatment outcomes

While surgical restoration of mandibular resections has advanced dramatically with free-flap techniques, oral function and patient perceptions of function, as well as treatment outcomes, often indicate significant impairment. This longitudinal prospective study was designed to determine whether conventional prostheses (CP) or implant-supported prostheses (IP) and current surgical reconstructive procedures restore patients' oral functions and quality of life to their status prior to segmental mandibulectomy with immediate fibula free-flap reconstruction. Study design and implementation, characteristics of the study sample, treatment completion rates, and selected presurgical and postsurgical functional and perceptual outcomes are presented. Forty-six subjects were enrolled. Longitudinal evaluations of medical and dental histories, oromaxillofacial examinations, questionnaires, and sensory and functional tests were planned before and after surgery and after CP and IP treatment. Sample characteristics are described with descriptive statistics and comparisons of subject responses to questionnaire items at entry and postsurgical intervals were made with Fisher exact tests (alpha=.05). Conventional prostheses were completed in 33 of 46 subjects, and 16 of 33 CP subjects were treated with IP. Reasons for noncompletion of IP were recurrent/metastatic disease (16), refusal of implant therapy (7), lost to follow-up (4), treatment with a reconstruction plate (1), excessive radiation at implant sites (1), and death (1). All 16 recurrences/metastases occurred within 13 months of surgery. Only 3 of the 58 implants placed in 17 participants were considered failures. One failed due to lack of integration 31 weeks following placement, and 2 were buried due to unacceptable positioning for prosthetic restoration during denture fabrication. The remaining 55 implants were successful at final evaluation, ranging from 58 to 123 weeks following implant placement (mean duration=78.9 +/- 16.0 weeks). While 72% (33/46) of the subjects enrolled were able and willing to complete treatment with CP, only 35% (16/46) completed IP treatment. Careful consideration must be given to selection of the type of prosthetic rehabilitation and the timing of implant placement if an IP is planned.

Lambeau libre de fibula pour la reconstruction des ostéoradionécroses mandibulaires évoluées

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. 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. 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. 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. Fibula free flap is the method of choice for mandible reconstruction after radical treatment of osteoradionecrosis.

Functional Outcomes after Primary Mandibular Resection and Reconstruction with the Fibular Free Flap

This study examined prospectively the functional outcomes of a cohort of patients who have undergone mandibulectomy and primary fibular free flap reconstruction, with particular emphasis on longitudinal comparison of the preoperative function with that in the postoperative and post-radiation therapy time periods. Speech and swallowing data were gathered at three evaluation times (preoperatively, pre-radiation therapy, and post-radiation therapy) for patients treated for oral cavity cancer with mandibular resection and reconstruction with a fibular free flap. Single words and sentences were recorded and analyzed for speech intelligibility. Modified barium swallows of liquid, pudding, and cookie consistencies were analyzed and graded for problems in the oral preparatory and oral phase according to the University of Chicago Center for Speech and Swallowing Disorders Oropharyngeal Mobility Data Form. There was no significant difference across any of the evaluation times for single-word or sentence intelligibility. The swallowing data showed no instances of post-treatment aspiration or laryngeal penetration. There were also no significant differences in any of the swallowing parameters across treatment times. Osteocutaneous fibular free flaps are an excellent reconstructive option for mandibular and floor of the mouth defects.

Radiation Therapy Does Not Impact Local Complication Rates After Free Flap Reconstruction for Head and Neck Cancer

To determine whether external beam radiation therapy (XRT), administered either before or after surgery, increases the rate and/or severity of local postoperative complications in patients with head and neck cancer who undergo microvascular free flap reconstruction. Retrospective cohort study. University of Washington Medical Center, Seattle, a tertiary care hospital. A total of 100 consecutive patients underwent fibular free flap reconstruction of the mandible. The study cohort was divided according to radiation treatment status: (1) no XRT (28 patients), (2) preoperative XRT (37 patients), and (3) postoperative XRT (35 patients). The median follow-up after surgery was 11 months (range, 1-89 months). Rate and severity of local postoperative complications. Fifty-four patients (54%) had at least 1 postoperative complication. There were no differences among the 3 XRT subgroups in the overall proportion of patients with complications of any severity (15 [54%] of 28 patients in the no XRT group, 24 [65%] of 37 patients in the preoperative XRT group, and 16 [46%] of 35 patients in the postoperative XRT group; P = .26, chi(2) analysis). There were also no differences seen when mild and severe complication rates were specifically examined (P = .58 and P = .10, respectively). No case of complete flap loss was observed. We noted no significant correlations between the rate of postoperative complications and the following covariates: total radiation dose, size of radiation field, disease stage, exposure to chemotherapy, presence of serious medical comorbidities, patient age, or history of tobacco use. Our experience suggests that XRT can be safely administered before or after surgery to patients undergoing head and neck free flap reconstruction at an experienced surgical referral center. Postoperative complication rates were not significantly affected by administration, timing, dose, or extent of XRT.

Oral rehabilitation after mandibular reconstruction using an osteocutaneous fibula free flap with endosseous implants

The development of endosseous implants and free vascularized bone grafting has permitted increased possibilities of oromandibular reconstruction in patients with oral cancer. In this study, a concept combining surgical and prosthodontic treatments for mandibular fibula free flap reconstruction after tumor surgery was made based on a classification of bone defects. A follow-up study was performed to evaluate the treatment concept for oral rehabilitation in order to identify possible factors which may influence the functional result. A follow-up examination included 28 patients who underwent the ablative tumor surgery and mandibular reconstruction during a 4-year period. The follow-up protocol included clinical examination, radiological evaluation, and an interview using a standardized questionnaire. The timing of the study was set to allow for a minimum 2-year follow-up (mean 45 months). At the time of examination, prosthesis-based oral rehabilitation was completed in six patients (21%), and the prosthodontic work was still unfinished in four other patients. The other 18 had no dental prosthetic rehabilitation. Thirteen patients received a total of 37 oral implants, and 23 implants were functionally loaded. No implant loss was recorded. Oral functions such as speech, diet tolerance and oral competence were not directly affected by the presence of dentures. A decisive factor affecting the oral function was the extent of soft-tissue loss. According to the classification described here, the extent of the mandibular defect did not correlate with oral functions. The application of oral implants seemed to be advantageous for the oral rehabilitation of patients who had undergone intraoral resections.

Aeromonas Infection After Medicinal Leech Therapy: Case Reports and Review of the Literature

Aeromonas Infection After Medicinal Leech Therapy: Case Reports and Review of the Literature

Radial forearm and fibula free flap reconstruction after radical resection of head and neck malignancies

The incidence of head and neck cancer has been rapidly increasing in Hungary during the last decade. Most of these tumors are discovered in advanced stage, consequently, surgical removal of the tumor results in large complex defects in the soft tisses and bone elements of the face and neck. For optimal anatomical and functional reconstruction we perform free flap transfer in increasing number of cases. Between December 1993 and March 2001 in the Head and Neck Surgery Department of the National Institute of Oncology the defects after resection of head and neck tumors were reconstructed with free flaps in 85 cases. Radial forearm flap in 64 cases, fibula osteoseptocutaneous flap in 14 cases were used. In 87% of the patients the postoperative period was uneventful, the surgical complications were not more numerous than following traditional reconstructions. The average duration of operations became shorter by 2.5 hours during the last two years than before. In most of the cases we achieved good functional and esthetic results. The quality of life of the patients was excellent in 14%, almost normal in 73% and bad with serious problems of social life in 13%. It is surprising that there was no significant difference between the survival of neck node positive and negative patients. In our practice the replacement of large defects in the head and neck region with free flaps is a reliable and useful method for reconstruction.

A retrospective analysis of temporomandibular joint reconstruction with free fibula microvascular flap.

The temporomandibular joint is occasionally encountered in extirpative surgery of the head and neck. It presents a difficult management issue. Little has been reported on functional outcomes after resection and reconstruction of the temporomandibular joint. A retrospective analysis consisting of chart reviews and phone interviews was performed on 17 patients who underwent fibular free flap reconstruction of the temporomandibular joint from 1993 to 1998. Mean follow-up in surviving patients (10) was 41.3 months. Mean age of the group was 62; male-to-female ratio was 11:6. Average hospital stay was 11.6 days. Four patients had no radiation therapy, 2 had preoperative and 11 had postoperative treatment. Five patients had one osteotomy, seven had two, one had three, and one had four. Ten patients could chew, one could not, and none were recorded for the remaining. Diet consisted of regular food for two patients, soft food for seven, full liquids for four, and tube feeds for four. Cosmesis was judged as excellent by eight patients, acceptable by two, and unacceptable by two. Five patients did not describe cosmesis. Most patients stated that bony contour was excellent, but that the soft tissue defect was noticeable. Speech was judged as intelligible by seven and moderately understandable by one. Nine patients did not describe speech. Two patients had postoperative displacement of the fibular head out of the fossa. Primary reconstruction of the temporomandibular joint with microvascular fibular flaps is a viable and effective means of restoring function. The majority of patients are able to resume oral feeds, obtain excellent or pleasing cosmetic results, and maintain intelligible speech.

Traumatic medial malleolar fracture of a fibula flap donor leg

A 50-year-old male presented with a T4 N0 squamous cell carcinoma of the floor of the mouth and alveolus. Treatment included a partial mandibulectomy with a free osseocutaneous fibula flap reconstruction. He made a good postoperative recovery and was given adjuvant radiotherapy. No problems were reported with the donor site or ankle. Five months after harvesting the flap the patient sustained a fracture of the medial malleolus having jumped over a ditch playing golf. This was treated successfully with a below knee plaster of Paris cast. The interosseous membrane was not ruptured in the accident indicating that the distal fibula left in situ was adequate to maintain the integrity of the mortice. A degree of ankle instability may be present after fibula flap harvest which is only revealed by athletic activity. (c) 2000 Harcourt Publishers Ltd Copyright 2000 The British Association of Plastic Surgeons DOI: 10.1054/bjps.1999.3227.

IMMEDIATE FREE FLAP MANDIBULAR RECONSTRUCTION IN OSTEOSARCOMA OF THE MANDIBLE IN CHILDHOOD

Mandibular osteogenic sarcoma (OS) is a very rare entity in childhood. Adequate surgical rejection with a wide margin of normal tissue is the mainstay of treatment of this site, while the role of adjuvant chemotherapy remains uncertain. A case is presented of a 15 1/2-year-old male with a huge OS of the mandible. The boy underwent surgical resection of the mandible with immediate fibula free flap reconstruction and is alive and free of disease 6 1/2 years following unitial diagnosis. This case suggests that immediate bone reconstitution with vascularized grafts have good functional and morphological results for osteosarcoma of the lower jaw.

A combined approach to benign but advanced mandibular tumor

Mandibular tumors such as ameloblastoma or fibrous dysplasia frequently follow a relentless course despite the fact that they are pathologically benign. Patients suffered from multiple recurrences and repeated surgery, and might still lose their masticatory function. To solve the above problems, a new combined approach—segmental mandibulectomy, free fibular flap reconstruction and primary osseointegration—was applied to three cases of aggressive mandibular tumors. The pathology spectrum included an enormous ameloblastoma, a fibrous dysplasia and a multiple recurrent ameloblastoma. Fixed partial prosthesis were loaded 6 months after the procedure. There were no detectable recurrence after 30 months' follow-up. The patients regained their facial contour, dental occlusion and masticatory function in a relatively short period of time. Segmental mandibulectomy lessens the likelihood of recurrence, free fibular flap transfer restores the dental articulation function and facial contour, and immediate osseointegration has further enhanced the masticatory function. This combined approach thus improves the patients' satisfaction and ensure their social interactions. It is justified for some selected aggressive mandibular tumors.

The current role of preoperative arteriography in free fibula flaps.

The free fibula flap has become a "workhorse" flap for reconstructive surgeons, yet the indications for preoperative arteriography for the donor extremity remain unclear. Therefore, a retrospective review of all free fibula candidates over a 4-year period was conducted to clarify the need for preoperative arteriography. One hundred consecutive patients were evaluated as potential candidates for free fibula reconstruction. Twenty-one patients were deemed unsuitable because of associated comorbid conditions (15) or unusable limbs (6). The remaining 79 patients were candidates for fibula free flap reconstruction. Eight patients (10 percent) who had an abnormal lower extremity vascular physical examination (diminished or absent pedal pulses) underwent arteriography to evaluate the fibula donor site. Free fibula transfer was performed in 77 patients (mean age, 41; range, 3 to 80 years) to the following sites: mandible (65), upper limb (4), lower limb (6), and trunk (2). The overall free flap success rate was 99 percent. Results of arteriography included: normal three-vessel runoff (6), bilateral peroneal arteria magna (1), and bilateral posterior tibial artery occlusion with reconstitution via the peroneal artery (1). Two patients with unusable fibula donor sites (determination based on arteriographic findings) were reconstructed with ilium and radius. All others underwent uncomplicated free fibula transfer. Ischemic complications at the fibula donor site did not occur in any patient. This study supports the use of lower extremity vascular physical examination as the primary means of evaluating the fibula donor site. Routine preoperative arteriography is unnecessary and should be reserved for those patients with abnormal vascular examinations.

Preoperative Color Flow Doppler Imaging for Fibula Free Tissue Transfers

Fibula osteocutaneous free tissue transfer to reconstruct the oromandibular complex is a widely recommended technique following oncologic resection. Preoperative determination of adequate perfusion to the donor extremity is necessary to assure lower extremity viability after flap harvest. Vascular variations and/or peripheral arterial occlusive disease (PAOD) may exist whereby sacrifice of peroneal vessels can cause ischemia to the lower leg and foot. Additionally, variability of cutaneous perforators can make the fibula skin paddle viability unpredictable. Color flow Doppler (CFD) is a reliable modality to preoperatively assess the lower extremity in fibula osteocutaneous free tissue transfer patients. Prospective CFD examination of 38 consecutive patients (76 legs) considered for fibula free flap reconstruction was performed. A standard protocol was designed to evaluate the lower extremity vasculature and identify cutaneous perforators with CFD. Findings were studied with respect to flap choice, operative findings, and reconstruction outcomes. Number of cutaneous perforators and their impact on skin paddle design were also recorded. Color flow Doppler's ability to image peroneal vessels as well as determine collateral and distal perfusion were effective. CFD accurately identified bilateral vascular anomalies in one patient (2.6%), and significant arterial disease in three patients (7.9%). Cutaneous perforators were also accurately mapped and confirmed intraoperatively in 31 patients. In several instances, the information provided by the CFD examination altered flap selection, 4/38 patients (10.5%), or skin paddle design, 5/32 patients (15.6%). Color flow Doppler allowed successful fibula transfer in all the free flap candidates with normal exams. It has the advantages of low cost and no morbidity. CFD allows for accurate mapping of fibula cutaneous perforators which facilitates skin paddle design. We recommended the use of preoperative CFD in all patients being considered for fibular free flap surgery.

Bone spur presenting as a submandibular mass following free fibula reconstruction of the mandible

(Editorial Comment: The head and neck surgeon should be aware of this interesting sequela following free fibula reconstruction of the mandible.) Recent advances in free tissue transfer techniques have revolutionized efforts of the head and neck surgeon to reconstruct the mandible. Several osseocutaneous free flaps are available including the radial forearm flap, scapular flap, and iliac crest flap. Experience with the fibula osseocutaneous free flap for mandibular reconstruction has grown significantly through the last decade, and many authors favor this technique as a first-line approach.le3 The flap is versatile, dependable, affords soft tissue and supports osseointegrated dental implants4 The high success rate with the fibula free flap is well described in the literature and reflected by our experience with over forty such reconstructions. What is not well-described are variants that may occur with the free fibula flap reconstruction over time. We present three cases of bone spurs originating from the transferred fibula that presented as neck masses. The presentation and radiographic appearance of these spurs is reviewed. Possible etiology and treatment are also discussed.