Free Fibula Osteoseptocutaneous Flap Research Articles

Reconstruction of mandibular defects involving the central segment with fibula osteoseptocutaneous free flap following ameloblastoma resection: Patient-reported outcomes

Mandibular defects involving the central segment are challenging. This study analyzes the impact of defect extent and reconstruction method on quality of life (QOL) and obstructive sleep apnea (OSA). Twenty-nine ameloblastoma patients received segmental mandibulectomy involving the C-segment and immediate fibula free flap reconstruction were recruited. Defects: (C: 2, LC: 11, LCL: 19). Mean defect length: 8.79 cm (± 2.34). Inset: Low-single-barrel (n: 19), with secondary distraction osteogenesis (n: 8/19), high-single-barrel (n: 7), double barrel (n: 3). Patients were surveyed using University of Washington Quality of Life (UW-QOL) and Berlin risk of postoperative sleep apnea questionnaires. Flap failure: None. Mean follow-up: 109.6 ± 92.8 months. Physical function 91.83 (± 14.92); social function 90.17 (± 17.19). No statistical difference between C, LC, and LCL was found, but C group which received low-single-barrel had the lowest score in appearance and chewing domains. In health-related QOL (HR-QOL) compared with 1 month before cancer, 69% reported best results. "Appearance" was the most important issue for the past 7 days, followed by "Chewing," prevailing in LC and C groups that predominately reconstructed by low-single-barrel. Berlin score: 7 patients (4 LCL, 3 LC≥8 cm) were at high risk for postoperative OSA. "Like-with-like" reconstruction with immediate endosteal dental implants yields the best results. Inset of fibula bone could affect outcomes, favoring double-barrel or single-high-barrel inset. Appearance and chewing remain the main concerns, largely, in those with low-single-barrel inset and no dental restoration. After long/extensive LCL and LC mandibulectomies, postoperative OSA warrants further investigation, and modification of resection/reconstruction techniques.

Thinned-out skin paddle versus collagen matrix as an optimized peri-implant soft tissue following fibula osteoseptocutaneous free flap: 3-year retrospective study

The objective of this study was to compare the implant longevity following two methods of peri-implant soft tissue optimization following free fibula flap (FFF): thinning of skin paddle (SP) and collagen matrix (CM). All patients who underwent rehabilitation with dental implants after mandibular reconstruction with FFF between June 2009 to May 2014 were retrospectively reviewed. Two methods of peri-implant soft tissue optimization were applied: (1) SP group, (2) CM group. Outcome measurements were: modified plaque index (mPI), modified sulcus bleeding index (mSBI), probing depth (PD), marginal bone loss (MBL), implant success rate and complication rates. A total of 24 patients with 69 implants were included in the study, with 8.7% (n = 6) of implants lost in 3 years. No statistically significant difference was found regarding the outcome measurements in both groups. Failed implants presented with statistically significant higher mPI, mSBI, PD and MBL scores during prosthesis delivery and subsequent follow-ups (P<0.03). In the SP group, one patient experienced SP necrosis which later underwent soft tissue optimization using CM. CM is an alternative peri-implant soft tissue, while thinning of SP is feasible if thickness is well controlled.

FIBULA OSTEOSEPTOCUTANEOUS FREE FLAP GRAFTING IN PATIENT WITH GUNSHOT DIAPHYSEAL DEFECTS OF FOREARM

The authors report a case of a gunshot complex combined skeletal and soft tissue defect of the upper extremity complicated by chronical wound infection successfully treated with fibula osteoseptocutaneous free flap. A military man had sustained a gunshot-comminuted fracture and diaphyseal defect of both bones in the middle third of the right forearm fixed by Ilizarov external fixator. There also was a soft tissue defect on the radial aspect of the right forearm and persisting chronic wound process. A free vascularized osteoseptocutaneous fibula graft was harvested from the right lower extremity, prepared and inserted between radius fragments. Fixation of the graft was made by locking intramedullary nail. All wounds and the donor site healed primarily. Postoperative x-rays at 5 months demonstrated healing at both ends of the fibular graft.

The anatomy of free fibula osteoseptocutaneous flap in neophalloplasty in transgender surgery.

The Free Fibula Osteoseptocutaneous flap is a reliable option when used in neophalloplastic procedures. It possesses intrinsic rigidity that is sufficient for penetrative intercourse, and satisfactory sensation. We review the pros and cons of this procedure, as well the anatomy and surgical steps involved. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites, as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The free fibula osteoseptocutaneous flap provides the neophallus with many desirable characteristics. Its thick subcutaneous and fascial layer, along with the thicker fibula (compared to the radius), allows for a neophallus of greater diameter. Skin marking, flap lifting, and transfer to the perineum with all relevant neurovascular anastomosis; fibular artery is anastomosed with the femoral artery, while the fibular veins are anastomosed to branches of the saphenous vein, as well as neurorrhaphy of the dorsal nerves of the clitoris and the LSCN are demonstrated. The osteomatized fibula is fixed to the periosteum of the pubic symphysis as shown. Anatomical traits of the Free Fibula Osteoseptocutaneous flap allow intercourse without prosthesis. The donor-site scar in this procedure can be covered by a long sock, and donor site morbidity is acceptable. Clin. Anat. 31:169-174, 2018. © 2018 Wiley Periodicals, Inc.

Porcine Urinary Bladder Extracellular Matrix for the Salvage of Fibula Free Flap Skin Paddle: Technical Note and Description of a Case.

This report establishes a novel application of a commercially available porcine urinary bladder extracellular matrix, MatriStem (ACell, Inc., Columbia, MD), in the salvage of partial loss of the skin paddle of a fibula osteoseptocutaneous free flap that was utilized for mandibular reconstruction.

Effect of concurrent mental nerve reconstruction at the same time as mandibular reconstruction using a fibula osteoseptocutaneous flap

The damage of inferior alveolar nerve causes some functional problem including numbness of lower lip and drooling. During segmental mandibulectomy, inferior alveolar nerve commonly resected, therefore, it is ideal to reconstruct the nerve to get better functional result. Sensory recovery was assessed after mandibular reconstruction using free fibula osteoseptocutaneous flap in thirteen cases. In six cases, the mental nerve reconstruction was performed simultaneously, and in seven cases, the mental nerve reconstruction was not performed. In the case that the mental nerve was reconstructed simultaneously, unilateral mental nerve reconstruction was performed in five cases, and bilateral mental nerve reconstruction was performed in one cases. More than one year after the reconstruction, sensory recovery was assessed and compared between the group that the mental nerve was reconstructed and the group that was not reconstructed. Our results showed almost a normal sensory recovery of the lips on the reconstructed side more than one year after the reconstruction in reconstructed group. In contrast, sensory recovery was poor in non-reconstructed group and non-reconstructed side. These results showed that mental nerve reconstruction at the same time as mandibular reconstruction affects the postoperative mandibular function. The sural nerve can be harvested from the same donor site of the free fibula osteoseptocutaneous flap and such mental nerve reconstruction with nerve grafting can be completed within an hour. Most cases of mandibular reconstruction using a free fibula osteoseptocutaneous flap transfer can therefore be candidates for mental nerve reconstruction at the time of mandibular reconstruction.

A computer-based comparative quantitative analysis of surgical outcome of mandibular reconstructions with free fibula microvascular flaps

The free fibula osteoseptocutaneous flap is the standard for reconstruction of extensive mandibular defects. The procedure must be precise to achieve the required functional and aesthetic results. The aim of the present study was to calculate retrospectively the exact differences in surgical outcome based on preoperative and postoperative Computed Tomography data sets. Ten patients with unilateral reconstructions of the mandible with a fibula based on conventional planning were analyzed quantitatively, applying mirroring techniques with direct comparison of the theoretically optimum with the actual reconstruction. The results showed that there is a significant discrepancy between what is actually achieved and the theoretical optimum. The result of the present retrospective analysis shows that there is room for further improvement of the outcome in complex mandible reconstruction cases.

Priority of fibular reconstruction in patients with oral cavity cancer undergoing segmental mandibulectomy.

BackgroundThe fibula osteoseptocutaneous free flap is generally used for segmental mandibular reconstructions following resection of oral cavity squamous cell carcinoma (OSCC). However, less complex reconstructions may be feasible for patients with predicted poor survival. Herein, we sought to identify the main risk factors (RFs) associated with poor prognosis in OSCC patients undergoing segmental mandibulectomy to help decide between fibular and non-fibular reconstructions.MethodsBetween 1996 and 2011, we examined the 5-year control, distant metastases, and survival rates in 310 consecutive, previously untreated patients with primary OSCC who underwent segmental mandibulectomy.ResultsMargin status was the only independent RF for 5-year local control. Level IV/V metastases, extracapsular spread, and tumor depth ≥15 mm were independent RFs for poor 5-year survival. In the entire study cohort, 23% of the patients had 2 or 3 adverse RFs; such a high-risk group was characterized by a poor prognosis and may be suitable for non-fibular reconstructions. Overall, 70% of the study patients were cT1-4N0, cT1N2, cT2N1, or had tumor depth <15 mm; less than 5% of patients in this subgroup had 2 or 3 adverse RFs and were thus candidates for fibular reconstructions. Among the remaining 30% of patients who showed both advanced clinical stage (cT2N2, cT3-4N1-2) and tumor depth ≥15 mm, 70% exhibited 2 or 3 adverse RFs.ConclusionsLevel IV/V metastases, extracapsular spread, and tumor depth ≥15 mm were independent predictors of poor prognosis in OSCC patients undergoing segmental mandibulectomy. The preoperative or intraoperative identification of adverse RFs may help decide between fibular and non-fibular mandibular reconstruction. High-risk patients bearing 2 or 3 adverse RFs have poor prognosis and should not be considered as candidates for fibular reconstructions.

Asynchronous Osteoradionecrosis of the Mandible Treated With Sequential Fibula Osteoseptocutaneous Flaps

Osteroradionecrosis of the mandible is one of the most serious complications of radiotherapy in head and neck cancer. Once osteoradionecrosis of the mandible has been established, conservative therapy is often useless. Two cases of asynchronous bilateral osteoradionecrosis of the mandible are presented. In both cases, successful reconstruction was performed with 2 free fibula osteoseptocutaneous flap transfers from both legs. We believe that adequate debridement, with removal of dead or hypovascular bone and surrounding soft tissue, followed by vascularized composite bone grafts, is the key for a successful outcome. In our cases, the oral function after 2 reconstructive surgeries with the fibula osteoseptocutaneous flap was acceptable. Furthermore, the patient could walk without difficulty.

Reconstruction of hand injuries with multiple metacarpal defects using free fibular osteoseptocutaneous flap

Hand injuries with multiple metacarpal involvements often include midpalmar muscle, extensor tendon, and skin defects. Reconstruction method is decided according to the type and amount of structures to be restored. Bone reconstruction and resurfacing of the skin is regarded as priority, and restoration of tendon function and joint mobility can be left for further procedures. An ideal flap for such defects should provide bone for multiple metacarpal defects and a large enough skin paddle. Such flaps are few, and one of the most suitable of them all is the free fibular osteoseptocutaneous flap (free FOSCF). In this report, our experience with the use of free FOSCF for reconstruction of the mutilating hand injury in five patients with extensive skin integument and metacarpal involvement has been presented. Total lengths of fibular flaps were averagely 11 cm in length and were divided into averagely 2.4 segments. Average dimensions of the skin paddles were 7.75 × 8.75 cm. Although the nature of the devastating traumas limited the ultimate functional recovery; wound closure, stability, and various degrees of mobility were restored in all patients. In our experience, reconstruction with free FOSCF proved to be an effective tool in mutilating hand injuries with metacarpal involvement.

No adverse affect after harvesting of free fibula osteoseptocutaneous flaps on gait function

The aim of this study was to analyze gait function and muscular strength on donor site after harvesting of a vascularized fibula osteoseptocutaneous flap. Nine patients with a mean follow-up of 33 months (range, 7-59) and a mean resection length of the middle portion of the fibula of 18.0 cm (range, 14.0-23.0) underwent an instrumented three-dimensional gait analysis to evaluate gait function. Furthermore, CYBEX II extremity system was used for muscular strength measurements. Subjective muscle strength measurements were performed according to Kendall et al. and were classified according to the British Medical Research Council. Intraindividual comparison between the operated and the nonoperated leg revealed no significant differences for gait function parameters (cadence, velocity, and stride length, P > 1.00) and for muscular strength measurements for flexion (knee: P = 0.93, ankle: P = 0.54) and extension (knee: P = 0.97, ankle: P= 0.21), respectively. In conclusion, intraindividual comparison of the operated and nonoperated sides after harvesting of the middle portion of the fibula for gaining a free fibula osteoseptocutaneous flap has no adverse affect on gait function or muscular flexion and extension strength on donor site at a mean follow-up of 33 months.

Dental Implant Outcome after Primary Implantation into Double-Barreled Fibula Osteoseptocutaneous Free Flap–Reconstructed Mandible

Functional and aesthetic mandibular reconstruction can be achieved in a single operation by means of a double-barreled fibula osteoseptocutaneous free flap with dental implants loaded simultaneously into the upper barrel. The aim of this study was to evaluate the quality and result of such reconstruction. From 2005 to 2007, 10 patients underwent segmental mandibular defect reconstructions with double-barreled fibula osteoseptocutaneous flaps and simultaneous dental implantations. Implant marginal bone loss, clinical mucosal changes, marginal plaque indices, bleeding on probing, and pocket probe depth were evaluated at an average of 22.2 months after implant functional loading. Ten patients with a total of 25 osseointegrated implants were evaluated. The mean implant marginal bone loss was 0.18 ± 0.18 mm (range, 0 to 0.6 mm) at the mesial surfaces and 0.25 ± 0.2 mm (range, 0 to 0.6 mm) at the distal surfaces. Probing pocket depth was shallower for implants protected by palatal mucosal grafts (2.56 ± 0.54 mm) than by skin flaps (3.50 ± 0.90 mm) (p < 0.05). There was a significant difference in marginal bone loss between palatal mucosal grafts (0.11 ± 0.09 mm) and skin flaps (0.29 ± 0.23 mm) (p < 0.05). Bleeding on probing was more prominent when pocket depth exceeded 5 mm and occurred more frequently in skin flap-protected than in keratinized mucosa graft-protected implants. The one-stage combined surgical method is safe and reliable. Both oral function and mandible contour were good. Firmly attached gingiva-like palatal mucosal grafts prevent periimplant soft-tissue inflammation and facilitate maintenance of oral hygiene. Therapeutic, V.

Foot Salvage After Loss of the First and Second Metatarsal Rays with a Free Fibular Osteocutaneous Flap

Severely comminuted fractures of the metatarsal bones with significant bone and soft-tissue loss have commonly subjected patients to proximal amputation procedures. We describe two patients who experienced high-energy traumatic injuries to their limbs that resulted in significant destruction of their first and second metatarsal bones with overlying soft-tissue trauma not amenable to local coverage. In both cases, a vascularized free fibular osteocutaneous flap was used to reconstruct the metatarsal bone defect and traumatized soft tissues so that a proximal amputation was avoided. At an average of 14 months of follow-up, both patients had recovered well and regained independent ambulation, with one patient being able to play soccer. We show that the free fibular osteoseptocutaneous flap is useful in reconstructing significant metatarsal bone defects and in avoiding amputations in this patient population. The skin component of the flap may be used to fill soft-tissue losses, and the fibula bone may be osteotomized so that more than one ray may be reconstructed.

Harnessing the Potential of the Free Fibula Osteoseptocutaneous Flap in Mandible Reconstruction

The free fibula osteoseptocutaneous flap remains the first choice for segmental mandible and contiguous soft-tissue defect reconstructions in most situations. Several important principles are described that should be respected during skin paddle design: fibula contouring, insetting, and fixation, and dental implant osseointegration. Recent advancements that address difficulties in height contouring, particularly at the anterior segment, are highlighted. The presented methods can help provide an optimal mandibular reconstruction that restores mechanical functions, facial aesthetics, and complete dental competence. Efficient interdisciplinary communication and teamwork are necessary throughout the longitudinal care of the patient if optimal results are to be achieved.

Simultaneous Radius and Ulna Reconstruction With Folded Free Vascularized Fibula Transfer: Case Report

We report 1 case of successful treatment of radius and ulna nonunion by a folded vascularized fibular graft, in which 2 parallel fibular struts remained connected by the periosteum and peroneal vessels, and another case of infected nonunion of the ulna and radius with osseous and soft tissue defects treated by a free fibular osteoseptocutaneous flap with folded fibular graft in a 1-stage procedure.

Gunshot Upper Extremity Injury Reconstructed With a Fibula Osteoseptocutaneous Free Flap (Case Report)

The management of upper extremity gunshot wound with soft tissue and bone injuries remains a remarkable problem and often requires sophisticated reconstructive strategies.There are limited reconstructive options for the treatment of segmental bone defects of the upper extremity exceeding 6 cm in length, especially when associated with soft tissue loss. Among the limited treatment options, the osteoseptocutaneous fibular transplantation is well established. The vascularized fibula flap has become a major tool in upper limb reconstruction but still is an uncommon procedure and continues to challenge reconstructive surgeons.In this paper, we report a complex combined skeletal and soft tissue involvement of an upper extremity case successfully treated with fibula osteoseptocutaneous free flap. The bone defect measured 12 cm. In severe injuries of the upper extremity, free transfer of the fibula flap not only provides replacement of the resulting composite defect but may also offer salvage of the extremity.

A treatment algorithm for managing giant mandibular ameloblastoma: 5-year experiences in a Paris university hospital

Aims To review our experiences with giant mandibular ameloblastoma (GMA) over a 5-year period, and to formulate a treatment algorithm for managing this tumour. Methods We retrospectively reviewed all GMA patients who underwent segmental mandibulectomy and immediate free fibular osteoseptocutaneous flap reconstruction (SM-IFFOFR) by a single reconstructive team from 2002 to 2006. All treatment methods and outcomes were analysed. Findings Forty-four ameloblastoma patients were operated upon during this study period. Sixteen cases had GMA, of which 9 patients were included in this series (mean age: 35 years). The defects in the mandible ranged from 7 to 16 cm in length (mean: 12 cm). The average length of the harvested fibula was 11 cm, and the number of osteotomies ranged from 1 to 2. The mean ischemic time was 137 min (range: 90–180 min). Neck recipient vessels were used for flap perfusion in all cases. All but one flaps were viable without any complications, whilst partial skin-island necrosis occurred in 2 patients. Hospital stay was 2 weeks in most of the patients. No tumour recurrence was found during the follow-up period (range: 26–73 months). Dental implants were placed in 2 patients. Conclusions Despite several limitations of this study, we suggest that a radical approach with the SM-IFFOFR is an effective treatment for GMA. Further well-designed, larger series with longer follow-up periods are still encouraged.

Survival of the Fibula Osteoseptocutaneous Flap with Thrombosis of Peroneal Veins on Harvesting-Case Report

Management of bone loss that occurs after severe trauma of open lower extremity fractures remains a challenge to reconstructive surgeons. For patients with lower limb trauma, an osteocutaneous flap may be required when there are simultaneous defects of bone and soft tissue. We present a case where thrombosis in the peroneal veins of the fibula osteoseptocutaneous flap was encountered during the harvest. The mistake happened as the injury to the donor leg was inconspicuous and angiography was not routinely performed before harvesting. Here we describe a clinical situation in which bone marrow was used for drainage of venous blood in a free fibula osteoseptocutaneous flap. There were two important factors accounting for the survival of this large fibula osteoseptocutaneous flap. (1) In this flap, the arterial circuit was designed so that the two ends of the peroneal artery in the fibula flap were anastomosed to the anterior tibial artery and a branch of the great saphenous vein, to establish the flow-through mechanism. This constituted an uninterrupted arterial circulation. (2) The major venous drainage was through bone marrow. Although there was initial venous congestion and necrosis of the skin paddle, bone and most of the soft tissue survived. Roentgenogram and periosteal abundant vascularity demonstrated bone survival and gradual healing. After rehabilitation, the patient can stand up and walk with the traumatic leg tolerating partial weight bearing after 9 months.

Assessment of Donor-Site Morbidity Using Balance and Gait Tests After Bilateral Fibula Osteoseptocutaneous Free Flap Transfer

The donor-site morbidity from harvesting unilateral free fibular osteoseptocutaneous flaps has been previously evaluated and is considered minimal. The purpose of this study was to investigate functional deficits after bilateral fibular osteoseptocutaneous flap harvest. Between 1990 and 2004, 7 consecutive patients undergoing mandible reconstruction utilizing bilateral autogenous free fibular osteoseptocutaneous flaps were included in the study. They were evaluated for the following subjective symptoms on the donor leg: pain, paresthesia, walking ability, restriction in activity, gait alteration, and aesthetic result. In addition, balance test and gait analysis were used to quantitatively assess functional outcomes. The results of this objective assessment were compared with those of 8 age-matched control subjects. Most patients had few subjective symptoms. The most common complaints were pain after prolonged walking (14%), slight difficulty in squatting (28%), and minimal paresthesia on 1 of the donor legs (14%). There were no significant differences in reaction time and movement velocity on either the balance test or gait analysis between the study and control groups (P > 0.05). However, there were significant differences with regard to right backward directional control, maximum stability with eye closing, sway referenced support, and ankle strategy (P < 0.05). Long-term follow-up revealed minimal donor-site morbidity after bilateral fibular osteoseptocutaneous free flap harvests. The functional deficits could only be found under the most unfavorable sensory feedback conditions.

Seizure-Like Activity and Prolonged Central Nervous System Side Effects After Intravenous Sedation

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