Fibula Free Flap Reconstruction Research Articles

Quality of Life Assessment in Patients after Mandibular Resection and Free Fibula Flap Reconstruction

Over the past decades, different interventions have been developed to treat patients requiring mandibular resection and reconstruction. Most have presented themselves as viable options, however, not without significant morbidity. There is little information regarding the patient's quality of life after such interventions. In this study we hope to gain better insight into the patient's quality of life after reconstruction of segmental mandibular defects with Free Fibula Flap (FFF).

Rehabilitation with endosseous implants in fibula free-flap mandibular reconstruction: A case series of up to 10 years

PurposeTo evaluate the clinical outcome and the aesthetic and functional results of implant rehabilitation of fibula free-flap reconstructed mandibles. Materials and methodsThe charts of patients who underwent mandibular reconstruction with fibula free flap and implant prosthodontic rehabilitation between 1998 and 2008 at the Operative Unit of Maxillofacial Surgery of Parma, Italy, were reviewed. In the study the estimated survival rates of implants placed in reconstructed mandibles we identified the prognostic factors and evaluated the functional outcomes. ResultsFourteen patients with a mean age of 50 years (range 15–63 years), were included in the study. A total of 62 implants were positioned. Complications occurred in 7 cases, an improvement in function and aesthetics was reported by the majority of patients. ConclusionsA high survival rate for implants placed in fibula free-flap reconstructed mandibles was observed. Although different factors were believed to be associated with a poorer prognosis (radiotherapy, composite defects, etc.) no statistically significance was found, showing no absolute contraindications to implant placement.

Analysis of the compatibility of dental implant systems in fibula free flap reconstruction

As a result of major ablative surgery, head and neck oncology patients can be left with significant defects in the orofacial region. The resultant defect raises the need for advanced reconstruction techniques. The reconstruction in this region is aimed at restoring function and facial contour. The use of vascularised free flaps has revolutionised the reconstruction in the head and neck. Advances in reconstruction techniques have resulted in continuous improvement of oral rehabilitation. For example, endosteal implants are being used to restore the masticatory function by the way of prosthetic replacement of the dentition. Implant rehabilitation usually leads to improved facial appearance, function, restoration of speech and mastication. Suitable dental implant placement’s site requires satisfactory width, height and quality of bone. Reconstruction of hard tissue defects therefore will need to be tailored to meet the needs for implant placement.The aim of this feasibility study was to assess the compatibility of five standard commercially available dental implant systems (Biomet 3i, Nobel Biocare, Astra tech, Straumann and Ankylos) for placement into vascularised fibula graft during the reconstruction of oromandibular region.Radiographs (2D) of the lower extremities from 142 patients in the archives of the Department of Radiology in University College London Hospitals (UCLH) were analysed in this study. These radiographs were from 61 females and 81 males. Additionally, 60 unsexed dry fibular bones, 30 right sided, acquired from the collection of the Department of Anatomy, University College London (UCL) were also measured to account for the 3D factor.In the right fibula (dry bone), 90% of the samples measured had a width of 13.1 mm. While in the left fibula (dry bone), 90% of the samples measured had a width of 13.3 mm. Fibulas measured on radiographs had a width of 14.3 mm in 90% of the samples. The length ranges of the dental implants used in this study were: 7-13 mm (Biomet 3i), 10-13 mm (Nobel biocare), 8-13 mm (Astra Tech), 8-12 mm (Straumann ) and 8-11 mm (Ankylos).This study reached a conclusion that the width of fibula is sufficient for placement of most frequently used dental implants for oral rehabilitation after mandibular reconstructive procedures.

‘Black Bone’ MRI planning for fibula free flap reconstruction; a preliminary study

‘Black Bone’ MRI planning for fibula free flap reconstruction; a preliminary study

Free Flap Reconstruction of Lateral Mandibular Defects

To compare outcomes following osteocutaneous radial forearm and fibula free flap reconstruction of lateral mandibular defects. Retrospective case-controlled study. Historical cohort study. All patients who underwent free flap reconstruction of lateral mandibular defects from 1999 to 2010 were included in this study. Patients were classified into 2 groups based on type of reconstruction: (1) osteocutaneous radial forearm (n = 73) and (2) fibula free flap reconstruction (n = 51). Patient characteristics, length of hospital stay, recipient and donor site complications, and long-term outcomes including postoperative diet were evaluated. Most patients were male (68%) and presented with advanced T-stage (71%) squamous cell carcinoma (94%) involving the alveolus (21%), retromolar trigone (23%), or oral tongue (21%). Median length of hospital stay was 8 days (range, 4-22 days). The recipient site complication rate approached 27% and included infection (n = 11), mandibular malunion (n = 9), exposed bone or mandibular plates (n = 9), and flap failure (n = 5). Most patients demonstrated little to no trismus following reconstruction (94%) and were able to resume a regular or edentulous diet (73%). No difference in complication rates or postoperative outcomes was seen between osteocutaneous radial forearm and fibula free flap groups (P > .05). One patient underwent dental implantation following osteocutaneous radial forearm free flap reconstruction. No patients from the fibula free flap group underwent dental implantation. The osteocutaneous radial forearm and fibula free flap provide equivalent wound healing and functional outcomes in patients undergoing lateral mandibular defect reconstruction.

Follicular Thyroid Carcinoma Presenting as Bilateral Cheek Masses

Mandibular metastasis of thyroid carcinoma is extremely rare. We present the case of a 46-year-old woman who had bilateral huge cheek masses that had grown rapidly over several years. Intra-oral mucosal tissue biopsy and imaging work-up including computed tomography scan and magnetic resonance imaging were performed and the initial diagnosis was presumed to be central giant cell granuloma. Incidentally detected thyroid lesions were studied with ultra-sonography guided fine needle aspiration and diagnosed as simple benign nodules. Due to continuous oral bleeding and the locally destructive feature of the lesions, we decided to excise the mass surgically. To avoid functional deficit, a stepwise approach was performed: Firstly, the larger left mass was excised and the mandible was reconstructed with a fibular free flap. The final pathologic diagnosis was follicular thyroid cancer. Postoperative I-131 thyroid scan and whole body positron-emissions-tomography were performed. Right side mass was revealed as a thyroid malignancy. Multiple bony metastases were detected. Since further radioactive iodine therapy was required, additional total thyroidectomy and right side mandibulectomy with fibular free flap reconstruction was performed. The patient also underwent high dose radioactive iodine therapy and palliative extra-beam radiotherapy for the metastatic lumbar lesion. Follicular thyroid carcinoma should be considered as a differential diagnosis for mandibular mass lesions.

An Alternative Method of Preoperative Planning for Fibula Free Flap in Mandibular Reconstruction

The most frequent cause of defect in the mandible is tumor-related surgery. Larger defects cause severe morbidity due to disturbances in function and esthetics. A fibular free flap is one way of filling a bony hole in either the upper or lower jaw. It is one of the common ways of replacing bone that has been removed for cancer treatment. Doctors use a free fibular flap which is grafted from the patient who needs a transplant operation to fit the defect. In this study, a new method combining preoperative planning and rapid prototyping for mandibular fibula free flap reconstruction after tumor surgery was made based on Mimics software simulating surgery on a workstation. The preparatory work of surgery is divided into two parts: software simulation and model building. During software simulation the authors were able to choose the best site for the osteotomies regarding circulation and the model building can increase the precision and speed of treatment. A description of our surgical approach is presented and is supplemented by an illustrative case.

Use of Ultrasonic Shears in the Harvest of the Free Osteocutaneous Fibula Flap

Traditionally, the fibula free flap has been raised by electrocautery and sharp dissection with clipping and tying of vessels. Use of the ultrasonic scalpel has been proposed to be a faster, more hemostatic, and less traumatic method of harvest. We performed a retrospective chart review of 58 patients who underwent fibula free flap reconstruction between 2007 and 2010. The main outcome measures were blood loss, operative time, and flap harvest time. Use of the ultrasonic shears was not associated with a statistically significant reduction in intraoperative blood loss, operative time, or flap harvest time. However, the flap harvest time did trend toward statistical significance (p = 0.073). Use of distribution-based effect sizes demonstrated a moderate clinically important difference in favor of the ultrasonic shears for both operative time and flap harvest time. The use of ultrasonic shears is comparable to traditional methods of fibula free flap harvest and can be considered an alternative method of harvest.

Free Flap Reconstruction of Lateral Mandibular Defects: Indications and Outcomes

Objective: To evaluate outcomes following lateral mandibular defect free flap reconstruction. Method: Patients undergoing lateral mandibular defect free flap reconstruction from 1999 to 2010 at 2 tertiary care centers were classified into 4 groups based on type of reconstruction: 1) radial forearm swing (n = 8), 2) radial forearm with bar (n = 5), 3) osteocutaneous radial forearm (n = 73) and 4) fibula free flap reconstruction (n = 51). Results: The majority of patients were male (67%) and presented with advanced T-stage (59%) squamous cell carcinoma (93%) involving the alveolus (26%) retromolar trigone (21%) or oral tongue (25%). The recipient site complication rate approached 35% and included infection and mandibular malunion (n = 9), exposed bone or mandibular plates (n = 7), venous congestion (n = 2), and flap failure (n = 6). Most patients demonstrated little to no trismus following reconstruction (81%) and were able to resume a regular or soft diet (61%). No difference in complication rates, hospital stay or postoperative outcomes was seen between osteocutaneous radial forearm and fibula free flap groups ( P > .05). Conclusion: Free flap reconstruction of lateral mandibular defects results in acceptable functional outcomes for the majority of patients including those who undergo osteocutaneous radial forearm free tissue transfer.

Design of a Reliable Skin Paddle for the Fibula Osteocutaneous Flap: Perforator Anatomy Revisited

Designing a reliable fibula flap skin paddle can be challenging because of the lack of information on precise perforator locations. The purpose of this study was to precisely map the perforators and provide a simple and reliable method for skin paddle design. Eighty consecutive patients undergoing free fibula flap reconstruction were included in this prospectively designed study. The location, size, and type of perforators were recorded intraoperatively and mapped on the line connecting the fibular head and lateral malleolus. There were 46 male and 34 female patients with a total of 202 perforators. The average length of the fibular head and lateral malleolus line was 36.1 ± 3.4 cm (male patients, 38.2 ± 2.2 cm; female patients, 34.1 ± 2.7 cm). Two discrete groups of perforators could be identified. The proximal perforator was consistently found one-third the length and 1.5 cm posterior to the line. The majority of these perforators (84 percent) were musculocutaneous. The more clinically useful perforators to support a skin paddle are the distal ones over the third quarter of the fibula. One to three distal perforators were consistently present, grouped as perforators A, B, and C at points 0.51, 0.62, and 0.73 along the line, respectively. Perforators were approximately 3.5 cm apart and 2 cm posterior to the line, and the majority (96 percent) were septocutaneous. Using common anatomical landmarks, a reliable skin paddle can be designed with simplicity and confidence over the third quarter of the fibula. The proximal perforator can be useful as a second skin paddle for through-and-through reconstruction.

Employing Rapid Prototyping to Assist Free Fibular Flap Reconstructive Surgery of Mandibular Defects

Patients suffering from mandible tumors often require a reconstructive surgery to repair the defects caused by large tumors. The particular type of reconstructive surgery studied in this paper is called free fibular flap reconstruction, which uses fibular segments to replace removed sections of the mandible and a titanium plate to provide strength. In order to decrease the dependence on design experience, decrease surgery time, and enhance the participation of surgeons in the design process, Rapid Prototyping (RP) biomedical models were employed to enable good visualization of the original and reconstructed geometry and for use as forming guides for the customized titanium plates. This study reports on one male and one female patients who underwent mandibular reconstruction. In one case, the operation time was reduced 2 hours and the other one was reduced 1.8 hours. The customized titanium plate shapes conformed to the patients’ mandible anatomy and were thick enough to provide the strength and stiffness needed to fix the mandible until the bone grafts and soft tissues heal.

Computer-Aided Surgical Simulation in Mandibular Reconstruction: Maximizing Outcomes in Single-Stage Fibula Free Flap Reconstruction with Immediate Dental Implants

Plastic and Reconstructive Surgery: October 2010 - Volume 126 - Issue - p 88-89 doi: 10.1097/01.prs.0000388811.12683.1f

Transport Osteogenesis in the Maxillofacial Skeleton

To report our clinical experience using bifocal distraction osteogenesis (BDO) with internal devices to treat patients having bony defects of the maxillofacial skeleton following tumor ablation and to focus on outcomes of dental implant placement in patients having maxillomandibular segmental defects. Retrospective case series. Academic research. Patients were selected according to the following inclusion criteria: a bony defect in the maxillofacial skeleton, moderate soft-tissue defect, local or general conditions that preclude more aggressive surgery, and adequate patient compliance. Types of BDO included horizontal mandibular or maxillar alveolar, bilateral alveolar, vertical mandibular or maxillar, ramus and body, mandibular angle, symphysis, the 2-step procedure, temporalis muscle flap reconstruction, vascularized free-fibular flap reconstruction, radial forearm free-flap reconstruction, and pectoralis muscle flap reconstruction. The latency period was 10 days, after which distraction was initiated at a rate of 0.5 mm/d. The distraction period continued until the transport disk reached the distal stump. The consolidation period ranged from 8 to 48 weeks. Seven patients required additional bone grafting to complete union with the residual bone. Twenty-eight patients having bony defects of the maxillofacial skeleton underwent BDO. The mean (SD) bony defect length was 47.0 (20.1) mm. The mean (SD) distracted bone lengthening was 36.5 (20.0) mm, with a mean (SD) consolidation period of 16.4 (8.0) weeks. The bony defect involved the hemimandibular body in 12 patients, with greater involvement of the body and symphysis in 4 patients and of the bilateral mandibular body in 2 patients. Complications after BDO included the following: discomfort in 8 patients, complete intraoral exposure and infection in 3 patients, partial cutaneous exposure in 1 patient, premature consolidation in 1 patient, and temporomandibular joint ankylosis in 1 patient. Overall, BDO for reconstruction of bony defects was successful in 22 patients and failed in 6 patients. At the end of the follow-up period, 11 patients had undergone endosseous dental implant placement. Bifocal distraction osteogenesis potentially benefits patients with bony defects following tumor ablation at various locations in the maxillofacial skeleton. Sufficient bone is gained to allow dental implant placement, an important functional outcome.

Free Fibular Flap Reconstruction of the Mandible in a Patient with Fanconi Anemia

Free Fibular Flap Reconstruction of the Mandible in a Patient with Fanconi Anemia

Fibula Free Flap Reconstruction of the Pelvisin Children after Limb-Sparing Internal Hemipelvectomy for Bone Sarcoma

Neoadjuvant chemotherapy has improved the treatment of bone sarcomas, making wide resection with limb salvage frequently possible. However, resection of iliac tumors without reconstruction causes pelvic instability and significant leg length discrepancy. Free vascularized bone autograft reconstruction represents a potentially optimal method for iliac reconstruction because of the faster healing time and rapid hypertrophy of the grafts. Furthermore, living incorporated autograft may be more durable in the setting of radiation therapy or chemotherapy. The purpose of this study was to characterize the successful reconstruction of the pelvis in children using a triangular double-barrel fibula free flap following limb-sparing internal hemipelvectomy for sarcoma. A retrospective review of the operative records and patient charts was performed with identification of patient characteristics, operative details, postoperative outcomes, complications, and need for additional procedures. Four patients were identified who underwent fibula free flap reconstruction of the hemipelvis following type I resection with preservation of the hip joint. The mean age of the patients was 13.4 years, with a mean follow-up of 7.2 years. Flap survival was 100 percent, no postoperative infections occurred, and there were no local recurrences. All four patients returned to independent ambulation. The female patient was ultimately able to bear two children. One patient required epiphysiodesis for leg length discrepancy. An "A-frame" double-barrel fibula free flap can be used effectively for reconstruction of the type I internal hemipelvectomy defect. It permits a return to ambulation and minimizes leg length discrepancy and other complications, which may be critical in the immature pediatric skeleton.

Fibula Free Flap Reconstruction of the Pelvis in Children after Limb-Sparing Internal Hemipelvectomy for Bone Sarcoma

Fibula Free Flap Reconstruction of the Pelvis in Children after Limb-Sparing Internal Hemipelvectomy for Bone Sarcoma

Analysis of the compatibility of dental implant systems in fibula free flap reconstruction

The use of vascularised free flaps has revolutionised the reconstruction in head and neck surgery. In addition to restoring structure, these flaps have reduced the adverse effects of ablative surgery on patients’ oral function when compared to other reconstructive means. Dental implants, placed into osseous free flap, are being increasingly used to restore the masticatory function and improve facial profile and speech. A suitable implant site requires satisfactory width, height and quality of bone.

Analysis of the compatibility of dental implant systems in fibula free flap reconstruction

Analysis of the compatibility of dental implant systems in fibula free flap reconstruction

Avoiding Secondary Skin Graft Donor Site Morbidity in the Fibula Free Flap Harvest

To compare donor site morbidity in patients who have undergone fibula free flap reconstruction in which the skin graft was taken from the expected cutaneous paddle of the fibula with the known complications of the popular technique of obtaining a split-thickness skin graft (STSG) from a secondary donor site. Cohort study. The tertiary care centers at Loma Linda University Medical Center and University of California, Los Angeles, Medical Center. From September 1, 2006, to March 30, 2007, 30 patients underwent fibula free flap harvest by 2 surgeons at separate tertiary care centers. Twenty-one of those procedures took place at the University of California, Los Angeles, and 9 at Loma Linda University. Patients included 15 men (50%) and 15 women (50%), with a mean age of 58 (range, 19-88) years. All 30 patients underwent fibula free flap harvest with a split-thickness skin graft (graft thickness, 0.04 cm), obtained from osteocutaneous paddle using a 5.1-cm-wide dermatome, as well as oral cavity and oropharyngeal reconstruction with the de-epithelialized skin paddle. Measures of donor site morbidity, including graft failure and wound breakdown, and measures of recipient site morbidity, including flap failure, hardware complications, intraoral complications, and the need for additional surgery. Of the 30 patients who underwent this procedure, 4 had partial skin graft failures, for a complete skin graft survival of 87%. There were no complete skin graft losses. Regarding the fibula osteocutaneous free flap, there were no complete flap losses, 1 skin paddle necrosis that required debridement, 2 postoperative orocutaneous fistulas, 1 case of infected/extruded hardware, and 1 adhesion formation that required additional surgery for lysis of adhesion and placement of the split-thickness skin graft. The outlined novel technique has similar rates of free flap survival and skin graft take compared with previously described methods. Harvesting the skin graft over the expected osteocutaneous paddle results in decreased lower extremity morbidity by providing equivalent graft tissue for donor site closure and eliminating the morbidity of a secondary donor site. As long as there will not be 2 large opposing grafted surfaces, this technique should be considered when harvesting fibula free flaps for reconstruction of oromandibular resection defects, especially in cancers of the alveolar ridge and floor of the mouth.

P.099 Distraction osteogenesis for mandibular reconstruction after partial mandibulectomy

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 (α=.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.