Fibula Free Flap Reconstruction Research Articles

VIDEO: Preoperative CT Angiography for Fibular Free Flap Reconstructions.

The objective of this video article is to provide an introduction to the use of fibular free flaps. Normal and variant vascular anatomy of the fibular free flap is discussed, as are imaging acquisition and CT angiography interpretation, computer-assisted design and manufacturing, and the limitations of the fibular free flap. The fibular free flap is commonly used for head and neck reconstructive surgery. Variation exists between individuals regarding the origin of the peroneal artery and the perforating arteries. Our method of performing CT angiography and reporting its findings for patients undergoing a fibular free flap procedure provides a reproducible means of identifying important elements of the vasculature and effectively communicating their locations to surgeons. Accurate communication can maximize the success of the flap harvesting and the preoperative manufacture of custom fibular cutting guides.

Mandibular reconstruction with free fibula flaps in the elderly: a retrospective evaluation

The purpose of this study was to evaluate surgical outcomes in elderly patients who had undergone free fibula flap transfer for malignant head and neck tumours. A retrospective chart review was performed to identify patients who had undergone free fibula flap transfer for mandibular reconstruction after malignant tumour resection at Jichi Medical University Hospital between May 2009 and April 2015. Enrolled patients were divided into an elderly group (≥80years old) and a younger group (<80years old). Seventeen patients met the inclusion criteria and were included in the elderly group. Age at surgery ranged from 80 to 92years. Thirteen patients (76.5%) experienced postoperative complications. Surgical site complications occurred in seven patients. The success rate of free fibula flap transfer was 100%. Systemic complications occurred in nine patients, most commonly delirium (n=6). No perioperative mortality was encountered. The overall 1-year survival rate was 94.1% (16/17). No patient reported gait disturbance as a donor site complication or any other major complication. The incidence of postoperative complications did not differ significantly between the elderly and younger groups. Almost no difference in postoperative course was seen between the groups. Elderly patients appear to tolerate free fibula flap reconstruction just as well as younger patients.

Identification of Independent Risk Factors for Complications: A Retrospective Analysis of 163 Fibular Free Flaps for Mandibulofacial Reconstruction

Fibular free flap transfer is a powerful tool available to the reconstructive surgeon when treating oral and maxillofacial defects, but complications still occasionally occur and predictive analysis focusing on this specific flap is limited in terms of risk factors for complication. The purpose of this study was to identify key variables associated with complications in patients undergoing fibular free flap transfer. The data of 163 consecutive patients who underwent fibular free flap surgery at the Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, between 2012 and 2015 were reviewed retrospectively. Patient demographic data, laboratory data, surgical data, and fluid infusion-related data that may have an influence on free flap outcomes were recorded. Univariate and multivariate logistic regression analyses were used to identify relevant risk factors. A total of 163 fibular free flaps were transferred for mandibulofacial reconstruction in 163 patients with a mean age of 50.9years. Postoperative complications developed in 33 (20.2%). Multivariate analysis showed that free flap complications were significantly associated with radiotherapy history (odds ratio [OR], 5.12; P=.001), postoperative anemia (OR, 1.048; P=.041), postoperative hypoalbuminemia (OR, 0.844; P=.002), and prolonged operative time (OR, 1.005; P=.004). Radiotherapy history, decreased postoperative hemoglobin and albumin levels, and prolonged operative time are potential predictors of postoperative complications after fibular free flap reconstruction for mandibulofacial defects.

Comparison of speech and resonance outcomes across three methods of treatment for maxillary defects

Purpose: Treatment of maxillary defects, whether by prosthetic rehabilitation or surgical reconstruction, should aim to restore speech function and resonance balance. With the advent of technology and changing clinical practices related to maxillary defect management, speech outcomes need to be evaluated and compared in order to determine efficacy of differing approaches. Materials and Methods: One hundred and four patients across three treatment groups for maxillary defects were included: 38 patients who were treated with maxillary obturators (OBT group), 39 patients who were treated with a standard fibular free flap reconstruction that did not involve digital planning of the reconstruction (Standard group) and 27 patients who were reconstructed using a digitally planned surgical design and simulation fibular free flap reconstruction (SDS group). Speech assessments were completed to assess word and sentence intelligibility, resonance balance, and aeromechanical orifice estimation among these three groups. Assessments included the Computerized Assessment of Intelligibility of Dysarthric Speech (C-AIDS), nasalance scores via the Nasometer and palatopharyngeal orifice area via the PERCI-SARS. Results: Significant differences were found in word intelligibility between the SDS and the Standard groups (p=.035) and on nasalance scores between the SDS and the OBT groups (p=.027). Conclusions: Patients treated with digital reconstruction (SDS) had better speech outcomes than the other two treatment groups, whose mean scores on certain speech variables were not within normal limits. Speech outcomes in the SDS group were consistently within the normal range across all measured speech variables. (Int J Maxillofac Prosthetics 2017;1:2-8)

Functional and Radiographic Changes Associated with Fibular Free Flap Reconstruction of the Condyle.

Functional and Radiographic Changes Associated with Fibular Free Flap Reconstruction of the Condyle.

Non-Union Rates in Fibula Free-Flap Reconstruction of Head and Neck Oncologic Defects

The microvascular free tissue transfer of the fibula is a well-established and predictable method of providing reconstruction for mandibular and maxillary defects that arise from the resection of benign and malignant disease or traumatic injury. The purpose of this study is to evaluate our experience with the fibula free flap in 20 cases and describe the rate of non-union after reconstruction.

Quality of Life after Free Fibula Flap Reconstruction of Segmental Mandibular Defects.

Free fibula flap (FFF) is considered gold standard in the reconstruction of mandibular defects. Despite the frequent use, patients' quality of life (QoL) after reconstruction has been sparsely investigated. This study aims to evaluate QoL and outcomes in patients who have undergone FFF reconstruction of segmental mandibular defects. A retrospective cohort study of consecutive patients (n = 73) operated at a single center during the years 2000 to 2014 was performed. Charts were reviewed and all living patients (n = 41) were invited to fill out three quality of life questionnaires (QLQ): SF-36, EORTC QLQ-C30, and QLQ-H&N35. Factors associated with poor outcome were derived from regression models and the results of the QLQs were compared with Swedish reference populations. Subgroup analysis was performed for two groups depending on reconstructive indication: cancer and osteoradionecrosis (ORN). The response rate of the QLQs was 93%. General QoL did not differ from reference populations, but the study group had significantly larger proportions of poor functioning patients in three domains in EORTC QLQ-C30: global health status, role functioning, and social functioning. Patients also reported a high incidence of poor functioning/high symptom burden in EORTC QLQ-H&N35, with a significantly higher frequency in the ORN group compared with the cancer group for the domains "swallowing" and "social eating." The overall flap success rate was 92% and complication rate was 48%. Previous surgery had a significant association with reoperation due to bleeding, and longer duration of surgery was significantly associated with local infection. When evaluated with validated QLQs, most patients experienced persistent functional loss in one or several domains, but still perceived a general QoL that is close to that of reference populations. Patients having ORN as the indication for surgery, as compared with cancer, reported a higher frequency of poor functioning patients in disease-specific QoL domains.

Comparison of speech and resonance outcomes across three methods of treatment for maxillary defects

Purpose: Treatment of maxillary defects, whether by prosthetic rehabilitation or surgical reconstruction, should aim to restore speech function and resonance balance. With the advent of technology and changing clinical practices related to maxillary defect management, speech outcomes need to be evaluated and compared in order to determine efficacy of differing approaches. Materials and Methods: One hundred and four patients across three treatment groups for maxillary defects were included: 38 patients who were treated with maxillary obturators (OBT group), 39 patients who were treated with a standard fibular free flap reconstruction that did not involve digital planning of the reconstruction (Standard group) and 27 patients who were reconstructed using a digitally planned surgical design and simulation fibular free flap reconstruction (SDS group). Speech assessments were completed to assess word and sentence intelligibility, resonance balance and aeromechanical orifice estimation among these three groups. Assessments included the Computerized Assessment of Intelligibility of Dysarthric Speech (C-AIDS), nasalance scores via the Nasometer and palatopharyngeal orifice area via the PERCI-SARS. Results: Significant differences were found in word intelligibility between the SDS and the Standard groups (p =.035) and on nasalance scores between the SDS and the OBT groups (p=.027). Conclusions: Patients treated with digital reconstruction (SDS) had better speech outcomes than the other two treatment groups, whose mean scores on certain speech variables were not within normal limits. Speech outcomes in the SDS group were consistently within the normal range across all measured speech variables.(Int J Maxillofac Prosthetics 2017;1:2-8)

Implant rehabilitation in fibula-free flap reconstruction: A retrospective study of cases at 1–18 years following surgery

PurposeTo determine the dental implant and prostheses success rate in a cohort of patients who underwent a vascularized fibula-free flap (FFF) for maxillary or mandibular reconstruction. MethodsThe investigators implemented a retrospective cohort study composed of patients who had undergone primary or secondary FFF reconstruction jaw surgery plus placement of 2–6 implants in the reconstructed arch, which were restored with an implant-supported prosthesis. The sample was composed of all patients who underwent FFF surgery between 1998 and 2012 and had either simultaneous or secondary dental implant placement. A total of 28 patients met inclusion criteria. Of these, 22 patients participated in the retrospective review. Patients were examined by an independent observer between January-December 2015. In addition, all patients completed a questionnaire to access satisfaction with the implant-supported prosthesis. ResultsThe patient cohort consisted of 12 males and 10 females, age 12–70 years. A total of 100 implants were placed, 92 implants in fibular bone and 8 implants in native bone. In the maxilla, 35 implants were placed into fibular bone and 4 into native bone (11 in irradiated patients and 28 in non-irradiated patients). In the mandible, 57 implants were placed into fibular bone and 4 into native bone (15 in irradiated patients and 46 in non-irradiated patients). The mean follow-up after implant loading was 7.8 years (range 1.3–17.5 years). The implant survival rate was 98% (95% CI: 92.2%–99.5%). No statistically significant difference was found in implant success between maxillary and mandibular implants, or between radiated and non-radiated bone. The prostheses success rate, determined by clinical exam and patient satisfaction, was 100%. ConclusionThe results of this study suggest that implant survival is high and implant-supported prostheses are a reliable rehabilitation option in patients whose jaws have been reconstruction with a FFF.

Ameloblastic carcinoma of the mandible: A case report and review of the literature

Aim: The purpose of this paper was to report an additional case of ameloblastic carcinoma of the left hemi-mandible and to review and analyze clinical, radiological and histopathologic features, treatment modalities and prognosis. Presentation of case: A 70 year old malepatient presented to Maxillofacial Department for a painful swelling of the left cheek. An ameloblastic carcinoma of the left hemi-mandible was diagnosed. He underwent radical surgical intervention comprising hemimandibulectomy, supraomohyoid neck dissection, and fibula free-flap reconstruction. Postoperative radiotherapy was employed. Discussion: Ameloblastic carcinoma of the mandible is a rare aggressive tumor with a poor prognosis. It can be seen in different ages. The most common symptom is a rapidly progressing painful swelling. It is defined as a malignant epithelial odontogenic tumor that retains the features of ameloblastic differentiation with cytologic features of malignancy. Non therapeutic consensus is established. However, wide surgical excision with radiotherapy is the most common treatment. Conclusion: Diagnosis of ameloblastic carcinoma at early stage and close periodic screening for metastasis are necessary to improve patient prognosis.

Application of Combined Osteotomy and Reconstruction Pre-Bent Plate Position (CORPPP) Technology to Assist in the Precise Reconstruction of Segmental Mandibular Defects

To introduce and evaluate the clinical effects of digital surgical guide plate technology in the combined osteotomy and reconstruction pre-bent plate position (CORPPP) technique during mandibular segmental resections. Seven cases of mandibular segmental resection with simultaneous vascularized free fibula flap reconstruction by oral and maxillofacial surgery were selected (Xiangya Hospital, Changsha, China; June 2015 through December 2015). Cone-beam computed tomographic (CBCT) and spiral CT scans of mandibles and fibular donor sites, respectively, were collected. Surgical simulations were conducted after data collection. Pre-bent titanium plates were placed within the predicted mandibular models. The samples were scanned by CBCT to obtain the positional relations. Then, CORPPP surgical guide plates with location holes were designed and fabricated on pre-bent titanium plates. The CORPPP surgical guide plates were applied in osteotomy and the placement of pre-bent titanium plates during surgery. CBCT scans were obtained 2weeks after surgery to examine the reconstructed composite models composed of mandibles and titanium plates. Then, the scans were compared with the preoperatively designed models. In addition, the deviation of the integral and characteristic structure loci was analyzed. The 7 cases with placed pre-bent titanium plates exhibited good recovery in occlusal relations and the contour of the reconstructed mandibles. The absolute deviations in the integral analysis were 0.89±0.96mm (mandibles) and 0.33±0.36mm (titanium plates). The absolute deviations on the diseased side were 1.78±0.35mm (condylar head), 2.43±0.29mm (gonion), 2.22±0.22mm (gnathion), and 2.66±0.36mm (mesial inferior margin of the fibula). The results of this study suggest that mandibular segmental resections and the precise orientation of pre-bent titanium plates could be simultaneously assisted by CORPPP digital surgical guide plates. The use of these guide plates should be expanded.

Impact of venous outflow tract on survival of osteocutaneous free fibula flaps for mandibular reconstruction: A 14-year review.

The principle reconstructive modality for segmental mandibulectomy defects is the osteocutaneous free fibula flap. Preoperative CT angiography has been recommended to assess the quality of arterial inflow to the flap and donor limb. However, the impact of the venous system on flap viability has not been explored. A retrospective review of all patients undergoing free fibula flap mandible reconstruction was performed at a single tertiary cancer center from 2002 to 2015. Overall complications, including operative reexploration and total flap losses, were evaluated. One hundred seven patients underwent free fibula flap reconstruction of the mandible. Nine patients underwent multiple free flaps and were excluded from this study. Of the remaining 98 patients, 8 patients required operative exploration for microvascular compromise. All patients were found to have venous thrombosis. There were 3 total flaps losses with a salvage rate of 62.5% and overall flap survival of 96.9%. The size of the vena comitantes in the compromised flaps were significantly larger than those of the remaining patients (4.4 mm vs 3.1 mm; P < .0001). Although the total operative times were similar between the 2 groups (585.2 minutes vs 563.3 minutes), the ischemia time was significantly shorter in those cases that required operative takeback (76.5 minutes vs 104.0 minutes; P < .04). Venous thrombosis of free fibula flaps is more common than arterial thrombosis. Venous stasis in larger vena comitantes may be a contributing factor to microvascular compromise. Anticoagulation and/or handsewn anastomosis may be beneficial if the veins are larger than 4.0 mm in size.

Implant Utilization and Time to Prosthetic Rehabilitation in Conventional and Advanced Fibular Free Flap Reconstruction of the Maxilla and Mandible.

Precisely designed jaw reconstruction rehabilitation (JRR) is important to the integrity of the jaw structure and oral functions. Advanced three-dimensional (3D) digital surgical design and simulation (SDS) techniques have the potential to reduce time to reconstructive and dental treatment completion, thereby promoting early functional oral rehabilitation. This study investigated the use of SDS in JRR procedures. A retrospective chart review was conducted on adult head and neck tumor (HNT) participants who completed JRR treatment with a fibular free flap (FFF) reconstruction. Two treatment approaches, advanced 3D SDS technique (with-SDS) and conventional, nondigitally planned technique (without-SDS), included the use of osseointegrated implants. Data were collected from adult patients treated between January 2000 and March 2014 at the Institute for Reconstructive Sciences in Medicine (iRSM). Participants were excluded if they underwent a bone-containing augmentation to the FFF reconstruction. The without-SDS group underwent a conventional, nonguided FFF reconstruction followed by nonguided implant placement. The with-SDS group underwent a guided FFF reconstruction with guided implant placement during the reconstructive surgery. The outcome measures included implant utilization (ratio of implants placed to connected) and time to prosthetic connection after FFF reconstruction. Mann-Whitney U test was used to analyze the data. The digital SDS technique (with-SDS) group completed prosthetic treatment with a significantly higher utilization of implants as well as a significantly shorter time to prosthetic delivery. SDS allows an interdisciplinary treatment team to work together to create a virtual plan that leads to greater efficiency in patient treatment time and utilization of dental implants.

Assessment of perfusion of free flaps used in head and neck reconstruction using pulsatility index.

Objective:To detect venous or arterial obstruction in the pedicle of a free flap we can monitor resistance in the flap bed which is reflected in Pulsatility Index (PI) Therefore if we detect change in the values of the PI in these flaps then we can detect complications in flap due to vascular insufficiency early.Materials and Methods:Seven patients of Free Fibular Flap Reconstruction and ten patients of Free Radial Forearm Flap reconstruction were evaluated over a period of 18 months. In the pre op we recorded PI of Radial and Peroneal artery using colour doppler study. In the Post Operative Period 2 readings of PI at the anastomotic site were taken on Day 1 and Day 7.Results:Both Free Radial Forearm and Free Fibula flaps which were healthy (n = 15) showed a significant decrease in PI values on first Post Op day as compared to Pre Op. Also there was a significant fall in PI on Post Op Day 7 as compared to post op Day 1 (P < 0.05) in these flaps. The flaps developing complications (n = 2) had significantly higher Day 1 Post op PI readings as compared to healthy flaps (P < 0.05).Conclusion:PI is an objective index which can indicate changes in perfusion of free flaps used in Head and Neck reconstruction based on which we can predict if a flap is susceptible to circulatory compromise.

Letter to the Editor: Morbidity of the Free Fibula Flap Reconstruction in Head and Neck Malignancies.

Letter to the Editor: Morbidity of the Free Fibula Flap Reconstruction in Head and Neck Malignancies.

Follicular thyroid carcinoma metastasis to the facial skeleton: a systematic review

BackgroundFollicular thyroid carcinoma (FTC) metastasis to the facial skeleton is exceedingly rare. A case of FTC metastasizing to the mandible is presented and a systematic review of the literature describing thyroid metastasis to the facial skeleton is performed.Case presentationA 73-year-old female presented with metastatic FTC to the mandible and underwent total thyroidectomy, segmental mandibulectomy, bone impacted fibular free flap reconstruction, and adjuvant radioactive iodine treatment. The PubMed database was searched for literature describing thyroid cancer with facial skeleton metastasis using the key words “thyroid,” “cancer,” “carcinoma,” “metastasis,” and “malignancy” with “oral cavity,” “maxilla,” “mandible,” “sinus,” “paranasal,” and “orbit.” Reports that only involved the soft tissues were excluded. Systematic review revealed 59 cases of well-differentiated thyroid cancer with facial skeleton metastasis: 35 mandibular metastases (21 = FTC), 6 maxilla metastases (2 = FTC), 9 orbital metastases (4 = FTC), and 11 paranasal sinus metastases (7 = FTC). Treatment included surgery, RAI, external beam radiotherapy (XRT), or a combination of these modalities. The one, two, and five-year survival rates were 100%, 79%, and 16%, respectively.ConclusionFacial skeleton metastasis of FTC is a rare clinical challenge. Optimal treatment appears to include total thyroidectomy and resection of involved structures with or without adjuvant treatment.

Comprehensive Reconstruction of Mandibular Defects with Free Fibula Flaps and Endosseous Implants

Purpose: The goal of this paper is to review the use of fibula free flaps in reconstruction of various mandibular defects, as well as illustrate that placement of dental implants into free fibula flaps is a viable option ensuring a superior functional outcome. Patients and Methods: Nine of patients with mandibular fibula free flap reconstruction who underwent dental implant placement were included in this study to demonstrate the versatility of this reconstructive technique. Results: In all nine patients, fibula flaps provided adequate bone stock for implant placement. All 30 implants were placed in bicortical fashion and none had issues with primary stability at the time of placement. Conclusion: Fibula free flap reconstruction is the treatment of choice for patients with various disease processes resulting in significant mandibular defects and can ultimately be restored with fixed dental prostheses.

Heterogeneity of Necrotic Changes between Cortical and Cancellous Bone in Mandibular Osteoradionecrosis: A Histopathological Analysis of Resection Margin after Segmental Mandibulectomy.

Background This study aimed to analyze differences in necrotic changes between cortical and cancellous bone in resection margins after segmental mandibulectomy for advanced mandibular osteoradionecrosis. Methods Anteroposterior bone specimens from eleven patients who underwent segmental mandibulectomy with simultaneous free fibula flap reconstruction for advanced osteoradionecrosis were analyzed histopathologically for the presence of necrotic bone based on the presence of blood vessels within Haversian canals. Results Ten of eleven (91%) cortices near the inferior border of the mandible at the anterior margins were necrotic. All cancellous bones at the anterior margins were viable. Seven of eleven (64%) cortices near the inferior border of the mandible at the posterior margins were necrotic. Three of eleven (27%) cancellous bones at the posterior margins were necrotic. Conclusion Necrotic changes are more prevalent in cortices than in cancellous bones in mandibular osteoradionecrosis, probably due to a decrease of periosteal blood supply caused by radiotherapy.

Axiographic results of CAD/CAM-assisted microvascular, fibular free flap reconstruction of the mandible: A prospective study of 21 consecutive cases.

Virtual planning and guided reconstruction of the mandible following ablative surgery have become standard procedures in reconstructive surgery. Many advantages regarding operation time, morphology, bony fit, and consolidation have been described, but analyses of the functional outcome of virtually planned mandibular reconstructions are lacking. We prospectively analyzed 21 consecutive cases of mandibular reconstructions using CAD/CAM-assisted microvascular, fibular free flaps in operations between July 2014 and January 2016 at a single center. Axiographic measurements were performed preoperatively and at 10 days and 3 months postoperatively and were correlated with clinical findings. Uni- and multivariate regression analyses were performed to determine the association between possible predictor variables on functional outcomes. Overall, no statistical differences between the t1 and t3 measurements were seen in the analyzed variables. The univariate analysis showed a significant influence of indication and pre- and postoperative irradiation only on mouth opening (p=0.018, p=0.026, and p=0.049). Timing, the number of osteotomies, and the incidence of wound healing disturbances had no significant influence on postoperative function (p=0.753, p=0.69 and p=0.776). In particular, cases without malignancy or preoperative irradiation benefitted from the integration of the CAD/CAM technique and showed good functional outcomes.

Réhabilitation sensitive du nerf alvéolaire inférieur après mandibulectomie interruptrice

The sacrifice of inferior alveolar nerve (IAN) is usual in case of resection of mandibular tumors and is responsible for disabling sensory disorders, drooling and lip incompetence. We report the case of a reconstruction of the IAN by means of an autologous nerve graft after segmental resection of the mandible. A 27-year-old man presented with a recurrence of mandibular ameloblastoma. Treatment consisted in segmental mandibulectomy with resection of the IAN. Bone reconstruction was performed with a fibula free flap and IAN reconstruction was obtained by mean of a 7-cm nerve graft obtained from the greater auricular nerve (GAN). At the 6th postoperative month, the patient had recovered a normal sensitivity of his lower lip and chin. Latency of somatosensory evoked potentials was similar for both sides. The repair of the IAN by nerve autograft is a simple procedure that allows for good sensitive rehabilitation. The use of the GAN is well suited from its anatomy and from the moderate ear sensory sequelae.