Free Fibula Flap Research Articles

Training of Oral and Maxillofacial Surgery Residents in Virtual Surgical Planning: A Feasibility Study Comparing Open-Source Freeware and Commercially Available Software for Mandibular Reconstruction with Fibula Free Flap

Study Design: This is an experimental feasibility study. Objective: The objective was to analyze the potential of open-source freeware (OSF) to train residents in virtual surgical planning (VSP) and compare this workflow with commercially available software (CAS). Methods: A workflow for mandibular reconstruction with a fibular free flap (FFF) was developed in 3D-Slicer® and Blender® and compared to our clinical workflow in Materialise Mimics Innovation Suite version 25 (Materialise InPrint®, ProPlan CMF® and 3-Matic®). Five CMF residents, inexperienced in VSP, were trained to use both the OSF and CAS workflows and then performed four planning sessions on OSF and CAS. The duration (minutes) and the amount of mouse clicks (MCs) of every step in the workflow were recorded. Afterwards, the experience with VSP was investigated with the System Usability Scale (SUS) and a self-developed questionnaire. Results: The total VSP time with CAS took 91 ± 15 min and needed 2325 ± 86 MCs compared to 111 ± 26 min and 1876 ± 632 MCs for OSF, respectively. The questionnaire had an 80% response rate. The SUS for CAS was 67.5 compared to 50 for OSF. The participants believe it is extremely valuable to learn VSP during their training and to be able to perform VSP as a surgeon. Conclusion: We believe OSF can be a cost-effective alternative compared to CAS for the training of surgical residents to gain insight in complex surgeries and to better understand CAD limitations and possibilities.

Neuropathic Pain at the Donor-site Following Free Fibula Flap Harvest: A Multicenter Study

Neuropathic Pain at the Donor-site Following Free Fibula Flap Harvest: A Multicenter Study

Paradigm Shift from Conventional to Virtual Surgery Using Three-dimensional Model of Fibula as Preoperative Planning and Guide Technique in Mandibular Reconstruction in Oral Carcinoma: A Prospective Multicentric Comparative Study

Abstract Background: Mandibular reconstruction using a free fibula osseocutaneous flap is a commonly performed and well-established technique accepted worldwide, as the postoperative restoration of form and function of the oral cavity and facial features is superior compared to pedicled flaps. However, this requires precise preoperative planning, followed by execution to correctly restore the loss caused by the complex defect created after the surgical extirpation. With the incorporation of virtual surgical planning (VSP) and computer-assisted design and manufacturing (CAD/CAM) techniques in medical science, their incorporation as preoperative tools holds a lot of promise for a better surgical outcome. Aim: The aim of study was to assess the utility and benefits of VSP using CAD/CAM techniques over preexisting preoperative planning methods for mandibular reconstruction using a free fibular flap. Materials and Methods: A multicentric prospective comparative study was carried out at two tertiary care hospitals of the Armed Forces. Two-year data were collected from October 2020 to October 2022. A total of 39 consecutive cases of oral carcinoma requiring mandibular reconstruction using a free fibular flap were included in the study. Nineteen cases underwent free fibula flap reconstruction using already established preoperative planning in one center, whereas 20 cases underwent VSP as a preoperative tool in another center. The primary objectives assessed were the operative time and intraoperative blood loss in each arm. The secondary objectives assessed were the incidence of flap loss, the presence of oral incompetence postsurgery, the total hospital stay, and the presence of facial symmetry. Results: The total flap harvest time in the VSP group (68 min ± 13 standard deviation [SD]) was lower than that in the control group (88 min ± 14 SD), which was statistically significant (P < 0.001). There was no statistical difference in total operative time (P = 0.06), although in the VSP group, the mean was 10.6 h ± 1.5 SD as opposed to 11.5 h ± 1.6 SD in the control group. Nearly 26.3% of cases in the control group, as compared to 10.5% in the VSP group, had flap-related complications. In the early postoperative period, oral competence was achieved in 94.7% of cases (18/20) in the VSP group as opposed to 68.4% (13/19) in the conventional arm, which was statistically significant (P = 0.04). The mean overall hospital stay was higher in the VSP group (7.1 weeks ± SD) compared to the conventional group (4.4 weeks ± 0.9 SD), which was statistically significant (P < 0.001). Nearly 73.7% (14/20) of cases in the VSP group were satisfied with their facial symmetry, compared to 63.2% (12/19) in the conventional group in the postoperative rehabilitation phase. However, this was not statistically significant (P < 0.48). Conclusions: This index multicentric study carried out in two tertiary care hospitals of the Armed Forces Medical Services, where this emerging technology was adopted as its test arm to prove a better postoperative outcome, may have exhibited equivocal results so far, but it is encouraging results, although not proven statistically significant, hold lots of promises for the future.

Microvascular reconstruction in oral and maxillofacial surgery: a Europe-wide data collection.

This study aims to analyze microvascular reconstruction in Oral and Maxillofacial Surgery (OMFS) in Europe. Based on previous studies, a dynamic online questionnaire was developed and subjected to internal and external evaluation. The questionnaire comprised multiple-choice, rating, and open-ended questions, addressing general and specific aspects and the impacts of the COVID-19 pandemic on microvascular reconstruction in OMFS in Europe. It was implemented into SurveyMonkey's® online survey software and emailed to OMFS departments registered with the European Association for Cranio-Maxillofacial Surgery (EACMFS). Seventy-five participants from 23 European countries participated. Among them, 89% perform between 1 and 70 microvascular free flaps (MFF) annually. 38% of the participants reported a reduction in MFF due to the COVID-19 pandemic. The radial forearm (41% of participants) and fibula free flap (31%) are the most reported MFF. In most cases (59%), MFF procedures are exclusively performed by OMFS for OMFS patients, while 43% of participants reported cooperations with plastic surgeons to perform MFF for OMFS patients. Many participants prefer arterial end-to-end anastomoses (54%) using the facial artery (54%) and, if available, two venous anastomoses (68%). Low molecular weight heparin is the most used postoperative anticoagulant, reported by 67% of participants. For flap monitoring, clinical assessment and Doppler ultrasound are preferred by most participants (95% and 78%, respectively). Many participants (66%) indicated that tracheotomy is only performed when necessary. Differences were observed in relation to CAD/CAM (Computer-Aided Design/Computer-Aided Manufacturing) techniques, types of osteosynthesis, and dental implant treatment. This study highlighted variability in microvascular reconstruction in OMFS in Europe. Further studies are needed to assess these aspects in detail.

Clinical Comparison of CAD/CAM vs. KLS L1® Mandible ReconGuide in Fibula Free Flap Mandible Reconstruction: A Retrospective Clinical Study

Clinical Comparison of CAD/CAM vs. KLS L1® Mandible ReconGuide in Fibula Free Flap Mandible Reconstruction: A Retrospective Clinical Study

Morbidity of the Free Fibular Flap in Reconstructive Surgery.

Our study evaluated long-term morbidities in patients and compared subjective morbidities to those measurable objectively. Patients completed a questionnaire regarding long-term morbidity, filled out the Pain Sensitivity Questionnaire by Ruscheweyh etal. and were examined physically. Eighty-two patients were included in the study, 31 patients returned to the clinic for further evaluation and testing. The most common morbidities were weakened dorsiflexion of the great toe (34 patients), reduced ambulatory status (33), and muscle weakness (31). A significant correlation (p < 0.01) was found between higher pain intensity and high pain sensitivity scores. However, donor-site morbidities were not significantly associated with pre-existing comorbidities like smoking, diabetes, or age over 70. Subjective morbidities were reported 2.3 times more frequently than objectively measured ones. Our findings suggest a notable discrepancy between subjective and objective morbidities, highlighting the importance of considering patients' subjective experiences when assessing postoperative outcomes and rehabilitation progress.

The clinical application and anatomical analysis of proximal peroneal artery perforator in free fibula flap based on CTA

BackgroundThe vascularized free fibular flap is increasingly recognized as the standard technique for the repair of complex soft tissue and hard tissue defects in oral and maxillofacial surgery. Conventionally, the vascular supply to the skin island is derived from the distal perforators of the peroneal artery. However, complications may arise if these distal perforators are either absent or damaged during surgical procedures, highlighting the necessity to employ the proximal peroneal perforators as an alternative. This study aims to investigate the anatomical characteristics—including the presence, distribution, and origin—of proximal peroneal perforators through computed tomography angiography (CTA) prior to surgical intervention. A secondary objective is to confirm their viability when distal perforators are unavailable or when dual-skin paddles are needed.MethodsA comprehensive review was conducted involving 50 patients who underwent CTA examinations. Three-dimensional reconstruction of DICOM data was utilized to document the presence, quantity, location, and variations of proximal perforators. Relative positions of the origin points were measured, and the distances from these points to the fibula were calculated. Additionally, 11 studies were included in which a proximal perforator was successfully used to prepare a free fibula chimeric myocutaneous flap for the reconstruction of maxillofacial defects.ResultsAmong the 100 lower limbs evaluated, a successful identification rate of 98% for proximal perforators was achieved via CTA. Of those identified, 70% were found to originate from the fibular artery, 22% branched concurrently with it, and 8% emerged prior to the point of emergence of the fibular artery. Analysis through curve fitting indicated that the origin points of proximal perforators were predominantly located approximately 13.17 mm below the origin of the fibular artery, with their endpoints projecting about 123.9 mm below the fibular head.ConclusionsThe high prevalence of proximal peroneal perforators identified in this population, along with their relatively stable anatomical positions, suggests their significant surgical potential. In scenarios where the distal peroneal perforator is absent or suffers intraoperative injury, the proximal peroneal perforator can serve as a reliable alternative for preparing a free fibula osteal flap combined with a proximal peroneal perforator skin paddle.

Temporomandibular joint’s and mandible reconstruction after segmental mandibulectomy in oncological practice

Introduction. Segmental mandibulectomy with exarticulation and single-step reconstruction is an important problem of craniomaxillofacial surgery. Revascularized autotransplants (iliac crest, fibula free flaps) are used to reconstruct defects of the mandible and restore joint function.Aim. To evaluate functional, esthetic and oncological results of fragmental mandibular resection with exarticulation and single-step reconstruction using bone flaps.Materials and methods. The study included 52 patients who underwent segmental mandibular resection with exarticulation and single-step reconstruction using bone flaps. For defects of the ramus and head of the mandible, reconstruction was performed using iliac crest free flap (5 cases); defects of the ramus and body of the mandible, fibula free flap was used (47 cases).Results. Total necrosis of the flap was observed in 1 (4.7 %) case. Iliac crest free flap was modelled taking into account the size of mandibular ramus defect (usually to the angle of the mandible), mandibular head was formed from the distal part. At least one osteotomy was preformed on the autotrasplant near the angle, on the distal part the head was formed. Follow-up period varied between 1 and 5 years. Disease progression in the form of recurrence was observed in 15 (34.9 %) cases, in the form of distant metastases in 6 (13.9 %) cases.Conclusion. For small defects of the ramus of the mandible, revascularized iliac crest free flap should be used, for large defects the method of choice is fibula free flap. Temporomandibular joint can be formed from the distal end of a bone autotransplant with its subsequent adaptation during functional load.

Combination of Vascularized and Non-vascularized Fibula Free Flap With Dermofat Graft for Maxilla and Mandibula Reconstruction After Malignant Spindle Cell Tumor Resection.

The spindle cell tumor is a variant of sarcomatoid carcinoma that mostly affects the oral cavity. Bone involvement in this tumor leads to a wide excision, which sometimes requires resection of both the maxilla and mandible. The maxilla and mandible are important bones that function to form the 3-dimensional dimensions of the facial bones. The fibular bone can be selected to replace the facial bone because of its strong structure with a skin paddle, long pedicle, and proper bone shape. The authors present the case of a 24-year-old female who underwent maxillectomy and total hemimandibulectomy after a spindle cell tumor resection. The free fibular flap was harvested and divided into several segments to close the mandible and maxilla. However, the vascularized bone was insufficient; thus, non-vascularized bone was used in combination to reconstruct the maxilla. Six months after bone reconstruction, a dermofat graft was placed to fill the cheek structure. During the 6 months of follow-up, the vascularized and non-vascularized fibular bones were well arranged. Intraoral placement of a skin paddle covering the maxilla and mandible was viable. Both functional and esthetic outcomes were attained in patients with high satisfaction rates. Although there are many reconstruction options for patients with post-wide tumor excision, the fibula free flap remains the main choice as a replacement for facial bones because it has a strong and firm bone structure that can resemble facial bones; thus, a non-vascularized bone graft can be used in combination to cover the defects.

Single-Double-Single Barrel (1-2-1) Fibula Free Flap Design for Functional and Esthetic Brown Class III Mandibular Reconstruction.

This novel hybrid single-double-single barrel (1-2-1) design for fibula free flap reconstruction addresses the unique challenges presented by Brown Class III mandibular defects, which involve long-span defects at both bodies of the mandible and the chin. The importance of this design lies in its ability to overcome the limitations of traditional approaches in terms of mandible height and pedicle length, while optimizing both functional and esthetic outcomes.The technique utilizes a combination of single-double-single barrel fibula segments to achieve ideal esthetics and support for dental prosthesis across different areas of the mandible. At the chin, a double barrel design provides proper chin and lower lip projection and supports dental prosthesis at the alveolus, while single barrel segments are used for the mandibular bodies to allow adequate restorative space for dental rehabilitation and save the pedicle length.Favorable outcomes were demonstrated in terms of flap survival, dental implant osseointegration, bony healing, facial aesthetics, and occlusal rehabilitation. By addressing both functional and aesthetic requirements, this technique represents an important advancement in mandibular reconstruction for complex Brown Class III defects. The approach showcases the potential of computer-assisted surgery and innovative flap designs to improve patient outcomes in challenging reconstructive scenarios.

Double-Barreled Vascularized Fibula Free Flap in Pediatric Tibial Bone Defect Reconstruction: A 20-Year Monocentric Experience.

Reconstructing large bone defects for lower limb salvage in the pediatric population remains challenging due to complex oncological or septic issues, limited surgical options, and lengthy procedures prone to complications. The vascularized double-barreled fibula free flap is pivotal for reconstructing large bones. In this article, we report our experience with this technique in the surgical management of pediatric tibial bone defects. We conducted a retrospective analysis of patients under 18 years of age who underwent tibial reconstruction using a double-barreled fibula free flap at our center between 2004 and 2023. Collected data included demographic information, operative details, time to bone consolidation and full weight-bearing, and functional outcomes using the Musculoskeletal Tumor Society (MSTS) score. Eight patients (5 females, 3 males) with a mean age of 12.5 years (range 5-17) were included. The average tibial defect length was 11.2 cm (range 7-14 cm), affecting the proximal tibia in 4 cases (50%), the middle third in 3 cases (37.5%), and the distal third in 1 case (12.5%). Reconstruction followed oncologic resection in 7 patients (87.5%) and addressed congenital pseudarthrosis in 1 patient (12.5%). One patient died of sarcoma. Six patients (75%) achieved full weight-bearing within a median of 7 months (range 6-16) and a bone consolidation at 9 months in median (range 6-18). One reconstruction (12.5%) failed due to septic pseudarthrosis leading to a below-knee amputation. The mean MSTS score was 81.65 (range 63.3-100). This study is the first to focus on pediatric tibial reconstructions using the double-barreled vascularized fibula free flap. It highlights the technique's reliability for reconstructing tibial defects, particularly in intermediate-sized cases (7-14 cm). This single-stage procedure minimizes stress fracture risk, enables earlier weight-bearing, and is an alternative to the Capanna technique without requiring an allograft.

Utility of Free Fibula Flap With an Extended Banana-shaped Skin Paddle for Oro-mandibular Reconstructions.

The free fibula flap is a common technique for mandibular bone defects. However, its limited skin paddle is disadvantageous in cases with significant soft-tissue defects. A free fibula dual-skin paddle flap is used for medium-sized soft-tissue defects. Just as the anterolateral thigh flap can be extended through linking vessels, so the peroneal skin flap can be extended to the adjacent proximal area through linking vessels. This has led to the development of the free fibula banana-shaped flap. From 2021 to 2023, 8 patients, with an average age of 68.1 years, underwent head and neck reconstructive surgery using the free fibula banana-shaped flap at the Saitama Cancer Center in Japan. Their primary disease, defect sites, flaps, bone size, and postoperative complications were analyzed retrospectively. The blood flow of the flap was examined using intraoperative indocyanine green imaging. All 8 patients had successful operations with only 1 partial necrosis of the flap tip. Four patients had buccal mucosa cancers, 3 had osteoradionecrosis of the jaw, and 1 had lower gingival cancer. The flap size averaged 25.0 ± 3.0 cm (long axis) and 4.1 ± 0.4 cm (short axis), with a transplanted bone length of 8.4 ± 1.9 cm. The number of perforators was 1-3 in the distal to the central area. All flaps' microcirculation was confirmed with intraoperative indocyanine green imaging; the average time was 3 minutes 59 seconds. Postoperative complications included 1 surgical site infection and 1 minor salivary leak. The free fibula banana-shaped flap is a good option for head and neck reconstructive surgery in medium-sized soft-tissue defects with mandibular bone defects.

Evaluation of the Accuracy of computer-assisted technique in Maxillary Reconstruction with Free Fibular flap

Evaluation of the Accuracy of computer-assisted technique in Maxillary Reconstruction with Free Fibular flap

Impact of segment length on bony changes following microvascular jaw reconstruction using virtually planned fibula flaps - A retrospective study.

Postoperative bone resorption within the first year after a free fibular flap is a common problem and poses major challenges for subsequent therapies. Due to the concerns of increased bone resorption, short segments in particular, i.e. ≤ 20mm long, are considered unfavorable despite insufficient data in the literature. Therefore, the aim of this retrospective study was to analyze the changes in bone volume (BV), cortical thickness (cTh) and cortical density of especially short fibula segments one year after microvascular jaw reconstruction. Eighty-six fibula segments were included in this study, of which 30 segments were ≤25mm and 16 segments were ≤20mm long. The longer fibula segments served as a comparison for bone remodeling. After 15.10±5.60 months, the changes in total bone volume (BV), cTh and cortical density of the fibula segments were determined from analyses of three-dimensional radiological images, and the percentage bone loss rates were assessed in relation to different segment lengths. All fibula segments showed loss of bone volume (BV) regardless of segment length, with no difference in the relative changes in BV as a function of segment length. While the volume changes were smaller in the shorter segments, the longer segments (average length: 26.50mm) showed a higher bone loss of up to 25%. Although the total BV of the small segments (≤20mm) did not change at follow-up, the loss of cortical density was substantial. Based on our findings that the largest bony changes were associated with segments of 25mm in length, the current clinical practice that fibula segments should not be smaller than 20mm should be critically reconsidered.

Long-Term Complications in Patient-Specific Plates for Maxillary Reconstruction.

Virtual surgical planning (VSP) allows for optimal reconstruction of maxillary defects with fibula free flaps. Current data are limited regarding long-term complications of patient-specific plates (PSPs) in this setting. Our objective was to determine long-term complications of PSPs in maxillary reconstruction using fibula free flaps. A retrospective chart review was performed on patients undergoing maxillary reconstruction with a fibula free flap and PSP between January 2010 to July 2022. The primary outcomes were plate-related complications, which were defined as plate exposure, fracture, removal or evidence of loose screws. Secondary outcomes were wound infection, nonunion, or flap failure. A total of 39 patients underwent fibular reconstruction of maxillary defects using PSP. The average age was 56 years, with 56% of patients being female. There were 14 (35.8%) patients with plate-related complications, 10 (25.6%) underwent plate removal, 12 (30.8%) developed exposed hardware, 2 (5.1%) had loose screws, and none had a plate fracture. The average time to plate removal was 2.76 ± 1.94 years. With regard to age, sex, tobacco or alcohol use, diabetes, hypothyroidism, preoperative radiation therapy, number of fibula segments, type of cancer, postoperative radiation therapy, or whether the patient underwent orodental rehabilitation, there were no significant differences between patients who did and did not experience plate complications. VSP allows for patient-specific reconstruction of maxillary defects with a fibula free flap that remains stable in the majority of patients. In the long term, up to 25% of patients may require plate removal, but the reconstruction remains stable. Level 4.

Association between microvascular free-flap arterial anastomosis caliber and risk for development of osteoradionecrosis.

Osteoradionecrosis (ORN) following radiation therapy (RT) is a serious complication for patients undergoing head and neck cancer treatment. Recent literature has found an association between ipsilateral external carotid artery (ECA) diameter and the development of ORN. This study evaluates microvascular free-flap arterial anastomosis diameter and the development of ORN. Sixty-six patients underwent fibular free-flap reconstruction followed by RT between 2012-2019 at the University of Florida. Anastomosis and ECA diameters pre- and post-RT were measured from computed tomography images. Multivariate regression analysis identified significant factors in the development of ORN. Incidence of ORN was 33.3% (N=22/66). Mean post-RT anastomosis diameters were 2.3 and 2.2 for the ORN group and no-ORN group, respectively (p=0.548). Mean post-RT ipsilateral ECA diameters were 4.7 and 4.2 for the ORN group and no-ORN groups, respectively (p=0.040). The change in pre-RT versus post-RT ipsilateral ECA diameters was different in patients with RT dose above and below 55Gy (p=0.041). Neither post-RT anastomosis (OR = 1.78, 95% CI: 0.43, 8.65, p=0.434), nor ECA (OR = 1.44, 95% CI: 0.78, 2.83, p=0.250) diameters were associated with development of ORN while controlling RT dose (OR = 1.15, 95% CI: 1.04, 1.28, p=0.006), post-operative fistula (OR = 9.11, 95% CI: 1.65, 93.7, p=0.010), and post-operative infection (OR = 3.48. 95% CI = 1.01, 12.7, p=0.048), and CCI (OR = 0.61, 95% CI: 0.36, 0.96, p=0.031). A higher degree of narrowing in ipsilateral ECA following RT may be linked to development of ORN. RT doses≥55Gy were associated with a high risk of ORN.

Evaluation of zirconia implants in fibula and deep circumflex iliac artery flaps: a prospective 1.5-year follow-up study.

Follow-up results of modern zirconia implants inserted in fibula free and deep circumflex iliac artery (DCIA) flaps with fixed dentures are scarce. This study aimed to evaluate crestal bone changes and the survival rate of zirconia implants for up to 1.5 years of prospective follow-up. Ten patients with six fibula and four DCIA flaps underwent reconstruction in the lower and upper jaws using vascularized composite flaps and were treated with zirconia implants. Peri-implant bone resorption was measured using radiographic images that were taken immediately after implant surgery (T1) and after three (T2), 12 (T3), and 18 months (T4). Between the day of operation and T3, a significant increase in distance was recorded for the fibula flaps. After occlusal loading (T2) of 41 zirconia implants for up to 1.5 years, no significant bone loss in each flap was observed overall. An overall survival rate of 96.56% was reported. When comparing both composite flaps, no significant difference in periimplant bone levels was measured between the same timepoints. For fixed dentures, modern zirconia implants can be used in the DCIA and fibula flaps, however further long-term data is necessary.

Effectiveness of contemporary surgical approaches and prosthetic rehabilitation in the management of ameloblastoma: a narrative review of functional and aesthetic outcomes

Ameloblastoma, a benign yet aggressive odontogenic tumour poses significant challenges in management due to its potential for recurrence and impact on oral functionality and aesthetics. Effective treatment necessitates a combination of surgical resection, bone reconstruction, and prosthetic rehabilitation. This review aims to evaluate contemporary surgical approaches and prosthetic rehabilitation strategies for managing ameloblastoma, focusing on functional and aesthetic outcomes to enhance patient recovery and quality of life. A narrative review was conducted using scholarly databases, incorporating articles published in English from 2013 to 2023. Studies were selected based on their focus on surgical approaches and prosthetic rehabilitation outcomes. A systematic framework categorized surgical techniques (radical, conservative) and prosthetic methods (fixed, removable, or implant-supported). Radical segmental resection with sufficient safety margins emerged as the preferred surgical approach to minimize recurrence. Immediate reconstruction using autogenous bone grafts, particularly vascularized fibula free-flaps, demonstrated high success rates and improved quality of life. Implant-supported prosthetics showed enhanced functional and aesthetic recovery, with immediate implants yielding better survival rates. Technological advancements such as CAD/CAM and 3D printing improved surgical precision and patient outcomes. Contemporary surgical and prosthetic advancements significantly enhance the management of ameloblastoma. Integrating innovative techniques with long-term follow-up ensures optimal functional and aesthetic results, contributing to improved patient satisfaction and recovery.

The use of a vascularized fibular flap in the treatment and surgical rehabilitation of military trauma patients

Aim. The purpose of the work is to demonstrate the possibilities of using a vascularized fibular flap to replace bone defects in the treatment of acute military trauma and its consequences at the rehabilitation stage. Materials and methods. An anatomical feature description of the vascularized fibular flap with a cutaneous component. Clinical cases of the vascularized fibular flap use to reconstruct bone and soft tissue defects after military injuries. In the presented cases, vascularized fibula osteocutaneous flaps were used. Results. Two clinical cases of reconstruction using the fibula flap are presented. The first case presents a patient with a total mandibular defect resulting from a gunshot wound. The second case presents a patient with consequences of a mine-shrapnel injury of the left forearm and an ulnar defect of about 12 cm in length and the resultant inability to perform rotational movements. Vascularized fibula osteocutaneous flaps were used for reconstruction in both cases being transferred to the recipient site, and microvascular anastomoses were performed for flap reperfusion. Conclusions. Adding a free fibula flap to the reconstructive surgeon’s arsenal enables one-stage reconstructions of large wounds with bone defects after injuries or oncological resections without significant musculoskeletal functional loss to donor limbs.

Clinical impact of magnetic resonance angiography in patients undergoing free fibular flap transfer

AbstractObjectiveThis retrospective study was carried out to assess the impact of dynamic time‐resolved magnetic resonance angiography (DTR‐MRA) in detecting lower extremity vascular abnormalities and its impact on deciding the harvest site in patients undergoing free fibular transfer.MethodsConsecutive patients who underwent DTR‐MRA imaging of lower extremities prior to free fibular flap transfer (FFFT) during the period of 2008–2020 were retrospectively included in the study. Retrospective review of medical records was performed to include the patients who had provisional side of harvest decided prior to DTR‐MRA based on clinical findings. The criteria for change in management included changing the harvest site, either to the contralateral leg or a different site based on DTR‐MRA.ResultsImaging findings in 103 patients who underwent DTR‐MRA prior to FFFT were included in the study. Overall incidence of vascular abnormalities of clinical significance for FFFT was 30/103 (29%), and site of harvest was changed in 30/103 (29%) patients after DTR‐MRA study. Addition of delayed venous phase imaging detected additional venous pathologies of clinical significance in 7/103 (6.8%) patients.ConclusionsDTR‐MRA as a preoperative study before FFFT has an excellent accuracy in detecting vascular abnormalities of clinical significance. Addition of delayed phase images can also detect clinically significant venous abnormalities.