Free Fibula Osteoseptocutaneous Flap Research Articles

Microsurgical Enophthalmos Correction After Silent Sinus Syndrome

A 66-year-old man with silent sinus syndrome, resulting in progressive enophthalmos and subclinical chronic maxillary sinusitis, presented after several failed attempts at reconstruction with conventional methods. A free fibula osteoseptocutaneous flap was used to recreate the orbital floor, obliterate the maxillary sinus, and augment the periorbital contour deformity in a single stage. This is a novel approach for the treatment of Silent Sinus Syndrome in a single stage.

Evaluation of Donor Leg Morbidity and Function Following Bilateral Fibula Osteoseptocutaneous Free Tissue Transfer

The donor site morbidity from harvesting of a free fibular osteoseptocutaneous flap in one leg has been previously evaluated and considered minimal. The purpose of this reported study was to review the long-term donor site morbidity associated with the removal of the fibula from both legs.

Does Bone Scanning Predict Bone Union in Vascularized Bone Grafts

Using a free fibula osteoseptocutaneous flap for a segmental long defect is the standard technique in recent reconstructive surgery. For postoperative monitoring of vascular patency, an overlying skin flap is useful. However, does the skin paddle of a fibula osteoseptocutaneous flap really reveal the real state of vascularized bone grafts? Between 1993 and 2001, 27 segmental bony long defects were reconstructed with fibula osteoseptocutaneous flaps. The defects were 18 in the tibia, 7 in the femoral, and one in each of the radius and humerus. The defects ranged from 6- to 15-cm. All of the vascularized fibula grafts were inserted into the bone marrows of the recipient bones as inlayed grafts with rigid fixations. Technetium-99 methylene diphosphate (MDP) bone scans were used to assess the viability of the transplanted fibula. It was performed to the donor legs one week preoperatively in nine normal patients to serve as the baseline for comparison with bone scans performed one week postoperatively. Intensity of phase three (delayed bone image) was graded from 0 to 5. Plain X-rays of the recipient limbs were taken at two-month intervals for assessment of bone union. In this series, all 27 skin flaps were clinically judged viable. In Tc-99 bone scan studies, 4 patients were rated as grade 0, 3 patients were grade 1, one patient was grade 2, 8 patients were grade 3, 9 patients were grade 4, 2 patients were grade 5. The bone union time between grade 0 and grade 1, grade 0 and grade 3, grade 0 and grade 4, was statistically significant difference (Mann-Whitney Test) (p＜0.05). The grade zero group the average union time was around 17 months, longer than the expectation. In spite of outer viable skin flaps, phase three bone scan is valuable to predict bone union time, because it is the better way to estimate the viability of osteocytes of vascularized bone grafts.

Osteoradionecrosis with Combined Mandibulotomy and Marginal Mandibulectomy

To evaluate the outcome of simultaneous anterior mandibulotomy and marginal mandibulectomy for patients with oral cavity cancer. The medical charts of seven patients who underwent simultaneous anterior mandibulotomy and marginal mandibulectomy for oral cavity cancer between July 1994 and June 2004 in Chang Gung Memorial Hospital, Taiwan were retrospectively reviewed. These seven patients had no prior radiation therapy nor clinical or radiographic evidence of mandible bone invasion. Seven patients, between 34 to 62 years of age, were followed up in the clinics from 4.5 to 39 months with an average of 19.4 months. Five (71%) patients developed mandible osteoradionecrosis. Among them, two patients underwent radical sequestrectomy followed by reconstruction with a free fibular osteoseptocutaneous flap or soft tissue flap, and the other three patients either received removal of the mandible fixation miniplate, limited sequestrectomy of the mandible, or conservative antibiotic treatment individually. Simultaneous anterior mandibulotomy and marginal mandibulectomy results in a high morbidity rate of avascular necrosis of the mandible and therefore should be avoided. To avoid a disastrous complication, segmental mandibulectomy and a composite free fibular osteoseptocutaneous flap reconstruction would be a preferred surgical alternative.

Maxillary Reconstruction with a Fibula Osteoseptocutaneous Free Flap and Simultaneous Insertion of Osseointegrated Dental Implants

The fibula osteoseptocutaneous flap is a good option for reconstruction of three-dimensional composite maxillary defects. This flap provides both bone and soft-tissue reconstruction and allows osseointegrated dental implantation, either simultaneously or in a second-stage procedure. Simultaneous placement of osseointegrated dental implants reduces operative sessions and allows faster oral rehabilitation for properly selected patients. The defects may result from trauma or resection of benign tumors or low-grade malignancies. Between August of 1999 and July of 2001, three patients underwent maxillary reconstruction with the fibula osteoseptocutaneous flap and simultaneous osseointegrated dental implants. The cause of the defect was trauma in two cases and resection of an adenoid cystic carcinoma in the other. The mean length of the fibula used for bony reconstruction was 4.7 cm. One osteotomy was performed in one case and no osteotomy was necessary in the other two. Skin islands of 8 x 2.5 cm and 16 x 3.5 cm were used for two patients. For the other patient, a double skin island was used for both nasal (6 x 4 cm) and oral (6 x 5 cm) reconstructions. Two osseointegrated implants were inserted into the fibular bone for each patient. Six months after the first-stage procedure, palatal rotation flaps or mucosa grafts were used to cover the exposed implant necks and prepare the implants for prostheses. One month after the second-stage procedure, prostheses were placed. An implant-supported prosthesis was used for one patient and implant/tissue-supported prostheses were used for the others. At a mean follow-up time of 30 months (range, 16 to 38 months), all patients were able to use the dental prosthesis for chewing (beginning 6 weeks after the final procedure) and all patients were satisfied with the cosmetic results.

Mandibular Reconstruction with Fibula Osteoseptocutaneous Free Flap and Osseointegrated Dental Implants

The fibula osteoseptocutaneous free flap is ideal for reconstruction of composite mandible defects. Osseointegration is possible and advantageous. Primary osseointegration of dental implants is a safe and reliable procedure in selected groups of patients, promoting early total oral rehabilitation with restoration of both function and cosmesis. Further studies are necessary to assess the specific indications for osseointegration teeth in patients with malignant tumors and in those patients who have received radiation therapy.

Routine donor leg angiography before vascularized free fibula transplantation is not necessary: a prospective study in 120 clinical cases.

To evaluate the value of routine preoperative angiographies of donor sites, 120 patients with free fibula osteoseptocutaneous flap transplantations were included in this prospective study, which consisted of preoperative evaluation of dorsalis pedis and tibial posterior artery pulsation and angiographies of the donor legs (120 patients) and contralateral legs (111 patients). Both pedal pulses were palpable in 114 patients, and only one pulse was palpable in six patients. The respective nonpalpable foot pulses were detectable with pencil Doppler in five patients, but they were not detectable in one patient. Intraoperatively, the latter patient had a relatively hypertrophied peroneal artery as compared with both the tibial posterior and tibial anterior arteries. The angiographic result was arteria peronea magna. The other five patients showed intraoperatively and angiographically normal-sized major arteries of the lower leg. In three patients with normal pedal pulses, hypoplasias of either the tibial anterior or tibial posterior arteries were found intraoperatively. These findings corresponded with the angiographical results. In all patients (n = 119), except one with peroneal artery hemangioma, free osteoseptocutaneous fibula flap was harvested from the originally planned leg without subsequent sequelae to the respective donor leg. In 231 leg angiographies, only 7 cases (3 percent) with abnormalsized major lower leg arteries were described. The diagnoses in these cases were hypoplasia of either the tibial posterior or tibial anterior artery (4 cases), arteria peronea magna (2 cases, one of which was a false positive), absence of peroneal artery combined with hypoplastic tibial posterior artery (1 case), and hemangioma of the peroneal artery (1 case). From this prospective study, it was determined that routine preoperative angiography of the donor leg before fibula transplantation is not justified. It does not add relevant new information about donor leg vascularity, provided that the clinical evaluation of the pedal pulses is well conducted. The only two conditions that may require a preoperative donor leg angiography are abnormal pedal pulses or significant previous lower leg trauma.

Primary Insertion of Osseointegrated Dental Implants into Fibula Osteoseptocutaneous Free Flap for Mandible Reconstruction

Twelve patients with segmental mandibular defects were reconstructed with fibula osteoseptocutaneous flaps and simultaneous placement of osseointegrated implants. Decision to perform this procedure was based on the facts that all patients had benign diseases, did not require postoperative radiotherapy, were in good general and oral conditions, and were psychologically motivated. A total of 34 fixtures was inserted in the first stage. Eight patients underwent second stage surgery, which consisted of connection of the implant abutments to the fixtures and the use of palatal mucosal grafts around the implants. Final dental prostheses were fixed 1 month later in seven patients, at this time. All flaps survived after surgery, and no implant failure was observed after a mean follow-up period of 25 months. Only one fixture was not used during the subsequent stage and was left as a sleeper. Fixed dental prostheses were used in five patients and removable overlay prostheses in the other two. Chewing function was recovered between 4 and 6 weeks after the start using the definitive dental prosthesis. In contrast to previous results, we conclude that excellent results can be achieved when this combined procedure is used in carefully selected patients. In addition, it is confirmed that the fibula osteoseptocutaneous flap is a versatile, reliable composite tissue that facilitates primary placement of osseointegrated dental implants during mandible reconstruction, thus allowing full oral rehabilitation in a shorter period of time. (Plast. Reconstr. Surg. 102: 680, 1998.)

Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction.

Twelve patients with segmental mandibular defects were reconstructed with fibula osteoseptocutaneous flaps and simultaneous placement of osseointegrated implants. Decision to perform this procedure was based on the facts that all patients had benign diseases, did not require postoperative radiotherapy, were in good general and oral conditions, and were psychologically motivated. A total of 34 fixtures was inserted in the first stage. Eight patients underwent second stage surgery, which consisted of connection of the implant abutments to the fixtures and the use of palatal mucosal grafts around the implants. Final dental prostheses were fixed 1 month later in seven patients, at this time. All flaps survived after surgery, and no implant failure was observed after a mean follow-up period of 25 months. Only one fixture was not used during the subsequent stage and was left as a sleeper. Fixed dental prostheses were used in five patients and removable overlay prostheses in the other two. Chewing function was recovered between 4 and 6 weeks after the start using the definitive dental prosthesis. In contrast to previous results, we conclude that excellent results can be achieved when this combined procedure is used in carefully selected patients. In addition, it is confirmed that the fibula osteoseptocutaneous flap is a versatile, reliable composite tissue that facilitates primary placement of osseointegrated dental implants during mandible reconstruction, thus allowing full oral rehabilitation in a shorter period of time.