Free Fibula Osteocutaneous Flap Research Articles

Surgical Anatomy for Fibular Free Flap Focusing on the Inferior Tibiofibular Syndesmotic System: A Cadaveric Study and Case Series of 3-Dimensional Prefabricate Cutting Guided Fibular Free Flap

Even though there are many options for mandibular reconstruction, a free fibula osteocutaneous flap is regarded as the most frequently used flap. Despite having some previous anatomical studies pertaining to syndesmotic ligaments, there is no study pointing out that surgical landmarks can be used while free fibula osteocutaneous flaps are performed and used for surgical landmarks in order to avoid syndesmotic ligament injuries. Therefore, this study investigates the characteristics and relationship between inferior syndesmotic ligaments and fibula in cadavers. A total of 140 legs were obtained from 83 embalmed cadavers as well as other soft ones, which were donated for the inferior tibiofibular syndes- motic system's study. Detailed dissection and measurement of each ligament's distance to the end of the fibula and lateral malleolus were performed. Distances from the distal end of the fibula to anterior inferior tibiofibular ligament, posterior inferior tibiofibular, and inferior transverse ligament, and the lower border of the interosseous membrane are 3.5 ± 0.4 cm, 3.4 ± 0.5 cm, 1.9 ± 0.4 cm, and 5 ± 1 cm (mean ± SD), respectively. Distance from the most distal part of the fibula to lateral malleolus is 1.6 ± 0.4 cm (mean ± SD). Thus, the remaining distance of the fibular should be left at least 4 cm without disrupting the syndesmotic ligament complex. It is argued that the lateral malleolus can be applied as a surgical landmark while harvesting fibula.

Osteoradionecrosis After Radiation to Reconstructed Mandible With Titanium Plate and Osseointegrated Dental Implants

A 68-year-old man with no history of smoking and no notable comorbidities presented to the hospital with a newly diagnosed T4aN2aM0 oral mucosal squamous cell carcinoma (SCC) invading the periosteum and body of the left mandible. He subsequently underwent tracheostomy, radical resection, segmental mandibulectomy, selective neck dissection, and reconstruction with a 3-segment, double-barrel osteocutaneous free fibula flap with immediate placement of 3 osseointegrated dental implants for ease of future dental reconstructions (Fig 1A).

Metastatic Malignant Phosphaturic Mesenchymal Tumor of Mandibular Alveolus: a Rare Case Report and Review of Literature.

Malignant phosphaturic mesenchymal tumors (PMT) of the head and neck region are extremely rare, which cause paraneoplastic syndrome characterized by hypophosphatemia and osteomalacia. We report a 48-year-old gentleman who had persistent knee and calf pain associated with weakness in lower limbs on presentation. He had hypophosphatemia and elevated FGF-23 and 68Ga-DOTANOC PET scan showed soft tissue density mass with increased peripheral radiotracer uptake in the left mandibular alveolus and adjoining floor of the mouth, revealing the primary tumor. It also showed a non-avid, histological inconclusive nodule of 17 × 12mm in size in the lower lobe of the right lung. The patient was treated with composite resection and bilateral level I-III neck dissection with microvascular free fibula osteocutaneous flap mandibular reconstruction. Histopathological examination showed malignant PMT with positive soft tissue margins and bilateral metastatic cervical lymphadenopathy. The patient received adjuvant radiation therapy and sequential post therapy scans showed no evidence of locoregional disease, however showed progressive functional pulmonary metastatic disease which did not respond to chemotherapy. We also made a brief review of literature of head and neck malignant PMT focusing on presentation, primary and adjuvant treatment, and response to treatment.

Functional and aesthetic outcome with free fibula osteocutaneous flap in reconstruction of anterior mandibular defects in oral malignancies: our experience

<p class="abstract"><strong>Background:</strong> For anterior mandibular defects, vascularized bone flap reconstructions are the best for providing a solid arch necessary to restore form and function, especially in patients receiving tumour excision surgery in head and neck region. Our aim was to study aesthetic and functional outcome of free fibula osteocutaneous flap (FFOCF) in anterior mandibular defects in case of anterior floor of the mouth malignancies with mandibular infiltration.</p><p class="abstract"><strong>Methods:</strong> The clinical data of 15 oral cavity carcinoma patients with involvement of anterior floor of mouth with mandiblular infiltration that underwent FFOCF reconstruction at our institute, government medical college, Jammu, was prospectively collected from January 2018 till January 2020. In this study, the aesthetic and functional outcome of these patients was evaluated at 6 months and 1 year post surgery.</p><p class="abstract"><strong>Results:</strong> The aesthetic result of reconstruction was excellent in most patients. Also, there was no long-term donor-site morbidity. There was no peri-operative death. Flaps survived in all patients. Functional outcomes including the ability to tolerate oral diet and speech outcome were good in all cases.</p><p class="abstract"><strong>Conclusions:</strong> The FFOCF, in reconstruction surgery of advanced oral cavity carcinoma permits more radical resection of tumour with good functional as well aesthetic outcome.</p>

Experience of Saving Limbs With Free Fibula Osteocutaneous Flaps.

BackgroundComplex wounds of hands and feet have always been a challenge for reconstructive surgeon. We aim to share our experience of reconstruction of such defects using free fibula osteocutaneous flaps.Materials and methodsThis is a retrospective study over a period of six years which was conducted at a tertiary care teaching hospital in Karachi. All patients, who were included and had reconstruction with this flap, agreed to participate in this study. Hospital records were retrieved for patient’s demographic details, mode of injury, size of the defect, number of bone loss in the defect, dimensions of flap, size and number of bony segments in each flap. Outcomes were recorded in terms of flap survival and secondary procedures, with post-operative radiographs.ResultsIn 14 patients, 25 (80.5%) metacarpals and 6 (19.5%) metatarsals defects were reconstructed. K-wires were used for bony stabilization and were removed at 8 weeks post-operatively. Only two flaps were re-explored due to venous congestion. Minor wound dehiscence was noted in two flaps which were managed conservatively.ConclusionProper planning and meticulous flap dissection and inset using free fibula flap can save many hand and foot from amputations

Patient-Reported Aesthetic and Psychosocial Outcomes After Microvascular Reconstruction for Head and Neck Cancer

Aesthetic outcomes are key determinants of psychosocial functioning among surgically treated patients with head and neck cancer (HNC); however, long-term aesthetic outcomes after microvascular free tissue transfer (MFTT) are not well described. To examine risk factors for impaired long-term aesthetic satisfaction and appearance-related psychosocial functioning after HNC ablation with MFTT. A cross-sectional, web-based survey was conducted at an academic tertiary care center. A total of 228 individuals who underwent MFTT between January 1, 2015, and December 31, 2019, for treatment of HNC were included. The study was conducted from November 1, 2020, through January 15, 2021. Head and neck cancer ablation with MFTT. Patient-reported outcomes were assessed via Aesthetic FACE-Q scales. The primary objective was aesthetic satisfaction determined by the Satisfaction With Facial Appearance scale. Secondarily, the Appearance-Related Psychosocial Distress, Psychological Function, and Social Function scales were used to assess appearance-related psychosocial functioning. Patients were stratified by demographic, disease, surgical, and postoperative characteristics. Survey scores on a 100-point scale were compared and subjected to univariable and multivariable linear regression. A total of 124 of 228 patients (54.4%) completed surveys a median of 34.4 months after MFTT (interquartile range, 22.6-48.8). Most responders (79 [63.7%]) were men with advanced cancer of the oral cavity or skin, reconstructed with anterolateral thigh or osteocutaneous fibula free flaps. Nonresponders had no significant differences in baseline characteristics. The Satisfaction With Facial Appearance score was independently lower among patients who received osteocutaneous flaps (regression coefficient, -10.6 points, 95% CI, -20.4 to -0.8 points) and/or adjuvant (chemo)radiotherapy (regression coefficient, -6.9 points; 95% CI, -13.8 to -0.1 points). Impaired appearance-related psychosocial functioning was independently associated with female sex, a history of anxiety or depression, osteocutaneous flaps, prolonged tube feeding requirements, and any recurrent or persistent disease. After adjustment for covariates, each 1-point increase in the Satisfaction With Facial Appearance score independently estimated improved appearance-related psychosocial functioning as determined by the Appearance-Related Psychosocial Distress scale (regression coefficient, -0.5 points; 95% CI, -0.7 to -0.4 points), Psychological Function scale (regression coefficient, 0.4 points; 95% CI, 0.3 to 0.5 points), and Social Function scale (regression coefficient, 0.4 points; 95% CI, 0.3 to 0.6 points). The findings of this cross-sectional, web-based survey study suggest that osteocutaneous reconstruction and adjuvant therapy independently increase the risk of poor patient-reported long-term aesthetic satisfaction, which correlated with impaired appearance-related psychosocial functioning. Aesthetic outcomes appear to be a priority to address in patients with HNC undergoing MFTT.

Safety and efficacy of secondary mandibular reconstruction using a free osteo-cutaneous fibula flap after segmental mandibular resection: a retrospective case\u2013control study

BackgroundFree osteocutaneous fibula flap (FFF) is currently considered the best option for segmental mandibular reconstruction; however, there are only a few reports comparing secondary with primary reconstructions using FFF. This study aimed to evaluate the safety and efficacy of secondary mandibular reconstruction using FFF when compared with primary mandibular reconstruction.MethodsFrom October 2018 to February 2020, patients who underwent mandibular reconstruction using FFF after segmental mandibulectomy were retrospectively reviewed. The size and location of the mandibular defect, the segment length and number of osteotomies in the fibula, types of the mandibular plating system, kinds and laterality of the recipient vessels were recorded from the surgical notes. Flap survival, duration of nasogastric tube use, and implant installation after reconstruction were recorded as postoperative evaluation indices.ResultsTwelve patients underwent mandibular reconstruction using FFF during the study period. There were no significant differences in demographic characteristics other than body mass index between the primary (n = 8) and secondary (n = 4) reconstruction groups. No significant differences were observed in the size and location of defects, the segment length and number of osteotomies in the fibula, and the types of mandibular plating system. There was no significant difference in the kinds of recipient vessels; however, the laterality of recipient vessels was ipsilateral in all cases of primary reconstructions and contralateral in all cases of secondary reconstructions. Three out of eight patients with primary FFF reconstruction developed partial flap necrosis. Four patients in the secondary FFF reconstruction group achieved complete flap survival. The duration of use of the nasogastric tube and implant installation after reconstruction was comparable between the two groups.ConclusionSafe and effective secondary mandibular reconstruction can be performed in this clinical case study using FFF.

Occurrence and Treatment Outcome of Late Complications After Free Fibula Flap Reconstruction for Mandibular Osteoradionecrosis.

Purpose: This study aimed to evaluate the occurrence and treatment outcome of late complications after free fibula osteocutaneous flap reconstruction for mandibular osteoradionecrosis (ORN).Methods: We enrolled 15 consecutive patients (14 men, one woman; median age 65 years, range 57-80 years) who underwent free fibula reconstruction for advanced mandibular ORN during 2013-2017 with two or more years of follow-up. Late complications included infection, plate exposure, and recurrence at the resection margin. The effect of perioperative antibiotic administration on late complications was also assessed.Results: Late complications occurred in 33.3% (5/15) of patients, including two infections (local and distant), two plate exposures, and two recurrences (plate exposure and recurrence occurred in one patient). Perioperative antibiotic administration duration did not significantly affect the occurrence of postoperative late complications. All late complications were treated without problems.Conclusions: Late complications after ORN reconstructive surgery are not uncommon, but can be treated properly.

Osteomyocutaneous Free Fibula Flap Prevents Osteoradionecrosis and Osteomyelitis in Head and Neck Cancer Reconstruction.

Osteoradionecrosis (ORN) is one of the most severe complications of free fibula reconstruction after radiotherapy. The gold standard treatment of osteomyelitis involves extensive debridement, antibiotics, and sufficiently vascularized muscle flap coverage for better circulation. Therefore, we hypothesized that free fibula flap with muscle could decrease the risk of ORN. This study consisted of 85 patients who underwent reconstruction with free fibula flap in head and neck cancer by a single reconstructive surgeon at Kaohsiung Veterans General Hospital over a period of 19 years (1998-2016). Patients with postoperative adjuvant radiotherapy were included in the study and were grouped by either free fibula osteocutaneous flap or free fibula osteomyocutaneous flap (with flexor hallucis longus muscle), and the incidence of ORN was compared. Of the 85 patients, 15 were reconstructed with osteocutaneous fibula flap and 70 were with osteomyocutaneous fibula flap. The rate of ORN or osteomyelitis was significantly lower in the muscle group (18.6%, n = 13/70 vs. 46.7%, n = 7/15, p = 0.020, Chi-square test). Vascularized muscle transfer increases perfusion of surrounding tissues and the bone flap, thereby decreasing the incidence of osteomyelitis or osteonecrosis.

Use of soleus musculocutaneous perforator-based propeller flap for lower extremity wound coverage after osteocutaneous fibula free flap harvest.

Osteocutaneous fibula free flap (OCFFF) donor sites are often covered with skin grafts, with an additional donor site, more postoperative care, and increased cost. The authors examine posterior tibial artery (PTA) based pedicled propeller flaps (PPF) as an alternative for OCFFF donor site coverage. Retrospective review of 16 consecutive patients from 30 to 79 years old, who underwent OCFFF reconstruction of head and neck defects (11 mandibular, 5 maxillary), with the closure of donor site with PPF based on a perforator from PTA. Mean donor site defect measured 12.9 × 5.1 cm, PPF was an elliptical design, and rotated 180 degrees in a propeller fashion, to cover donor site defect. Visual analog scale (VAS) was used to assess esthetic results, functional outcomes assessed using mobility and range of motion (ROM), and secondary complications including infections, hematomas, and seromas were recorded. Follow-up period was noted in months postoperatively. Other information collected included underlying head and neck pathology. Average dimension of PPF measured 13.9 × 4.1 cm. Successful closure of donor site defects in 14 of 16 patients, with two flaps having partial necrosis, one requiring a secondary skin graft. Follow-up was 6 to 10 months, esthetic results with mean VAS 8.8 of 10, full ROM, and mobility noted. No secondary complications were observed. The most common pathology noted was squamous cell carcinoma (6 of 16 patients). PPFs based on the soleus branch of the PTA represent an excellent alternative to skin grafts for the closure of OCFFF donor site defects.

Superficial peroneal nerve accessory artery (SPNAA) flap for head and neck reconstruction: A cadaveric anatomical study and retrospective case series review

Several different flaps can reconstruct intraoral defects or lower limb deficits after free fibula osteo-cutaneous flap harvesting for jaw reconstructions. However, commonly used options may not be available for various reasons and can be associated with significant morbidity. We hypothesized that flaps supplied by the superficial peroneal nerve accessory artery (SPNAA) could be a viable alternative reconstructive option. We describe the SPNAA's anatomy using 20 human cadaveric leg dissections and report eight cases involving SPNAA-based perforator flap reconstructions (six propeller flaps and two free flaps) in a retrospective case series. Patient-specific baseline variables and intraoperative and postoperative outcomes are described. Cadaveric dissection suggests that the location of the SPNAA is reliable but its origin varies, with 40% (N = 8) of SPNAAs being of type I origin, 20% type II (N = 4), and 40% (N = 8) type III in our series. All reconstructions were successful. No intraoperative complications occurred during propeller or free-flap reconstructions. No flap failures occurred. One propeller reconstruction showed distal superficial skin necrosis and one donor site wound dehisced; both were successfully managed conservatively. No other short-term or long-term complications occurred. Flaps based on SPNAA perforators appear effective, reliable, and safe reconstructive methods for covering fibula osteocutaneous donor site defects and for intraoral reconstructions. Controlled trials are required to compare its effectiveness and safety with other reconstructive methods.

Evaluation of Peri-Implant Soft Tissue after Osteocutaneous Free Flap Reconstruction of Mandibular Defects: A Case Series

The use of osteocutaneous free flaps has been a long-standing, predictable method of reconstruction for mandibular defects that has allowed patients to regain form and function. Placement of dental implants into the osteocutaneous free flap has been a significant advancement that has improved mastication, retention, and stability of dental prostheses. However, several challenges have been noted, such as peri-implant mucositis and gingival tissue overgrowth, that have limited implant longevity due to lack of adequate peri-implant hygiene. Other contributors to this problem may be inherent to skin itself as a peri-implant tissue, flap thickness, and skin mobility. The aim of our study was to analyze soft tissue challenges and their effect on implant success after dental implant placement into osteocutaneous free flaps. A case series identified 6 patients who underwent dental implant placement in microvascular mandibular reconstructions between 2012-2019 in an academic institution. Patient-specific information, such as indication for osteocutaneous fibula free flap reconstruction and history of radiation to the head and neck region, were evaluated. Furthermore, implant-specific information, such as implant longevity, radiographic changes of surrounding peri-implant bone, and implant success as defined by the Albrektsson criteria, were examined. Tissue-specific factors, such as type and number of tissue modification procedures performed, were collected. We also analyzed the type of dental restoration each patient obtained. A total of 20 (16 BioHorizons Laser-Lok and 4 NobelActive TiUnite) dental implants were placed into osteocutaneous fibula free flaps. One patient in the cohort received radiation therapy to the head and neck. Based on the Albrektsson criteria, 3 of the 20 (15%) implants failed due to severe peri-implant bone loss and implant mobility. Secondary gingival debridement, flap debulking, and vestibuloplasty procedures were performed in 4 patients. Two patients underwent simultaneous implant placement and flap debulking; however, both required additional flap debulking prior to dental rehabilitation. Two patients obtained soft tissue debulking, vestibuloplasty, or gingival debridement after implant placement. Of the patients with post-implant placement soft tissue modifications, 1 patient required serial gingival debridements. Of the 5 patients with restorative data, 1 patient had implants restored with a fixed partial denture, and 4 patients are being restored with an implant retained mandibular partial overdenture (3 loaded and 1 awaiting final restoration). Endosseous dental implant placement into osteocutaneous fibula free flaps continues to be an acceptable treatment option for dental reconstruction. Even though dental implants allowed for a stable dental rehabilitation, significant soft tissue challenges exist that require multiple pre-prosthetic and maintenance surgeries to maintain implant function.

Dynamic Oromandibular Reconstructions Using Chimeric Fibular and Gracilis or Vastus Lateralis Free Flaps

Abstract Background Despite efforts of head and neck functional reconstruction, anatomic restoration has been used until now. This article describes our experience of using a chimeric free fibular osteocutaneous flap conjoined with a functional muscle free flap, defined as dynamic oromandibular reconstruction. Methods Through a retrospective chart review, four consecutive patients who underwent reconstruction with a total fibular free flap were included. The former two patients underwent reconstruction using a conventional osteocutaneous free fibular flap. The latter two patients had an oromandibular defect after cancer resection and underwent dynamic oromandibular reconstruction with a chimeric free fibular flap conjoined with a gracilis free flap or vastus lateralis muscle free flap. Results In the speech analysis, the dynamic group revealed a satisfactory tongue movement. Protrusion and lateralization were the most different movement changes. The tongue range of motion score was 62.5 in the dynamic group and 25.0 in the control group. On the dynamic magnetic resonance imaging, the contact of the soft palate with the tongue was excellent, and the epiglottis closure during deglutition was complete. In the three-dimensional volumetric analysis of mandibular aesthetic contouring, the dynamic group showed a much smaller difference in hemifacial volume, with a difference of 73.7 mL in the dynamic group and 101.76 mL in the control group. Conclusion This study is a preliminary trial of dynamic oromandibular reconstruction using chimeric free fibular flaps with functional muscle transfer. We demonstrated the possibility of dynamic oromandibular reconstruction, which enhanced more functional aspects in the patients in this study.

Experience on primary closure of fibular flap donor sites and development of an algorithm for closure based on different flap designs.

Most skin paddles of the fibula flap are harvested from the distal third of the lower leg, skin grafting for the donor-site is necessary. A retrospective review was done on patients with large bony defects using free fibula osteocutaneous flaps (FOSCFF) for head and neck reconstruction. We focus on the techniques for closure of donor sites were skin grafting, primary closure with tear drop design and propeller flap technique on the donor site closure using skin graft, primary closure and local propeller flap based on the different location of perforators of FOSCFF. Postoperative follow up include incidence of wound complications, postoperative days to ambulation and cosmetic outcome. A total of 48 patients were included. Twenty five patients had skin graft (Group A), and 23 patients had primary closure (Group B); in 16 patients tear-drop design was used, 6 had propeller flap, and the remaining 1 patient received a chimeric flap. Group A had more wound complication rates compared to Group B; 20% versus 4.3%, respectively (p = .19). The average postoperative days to ambulation for Group A were 15.1 days versus 7.3 days for Group B (p < .001). The cosmetic score in the B group (2.71) versus A group (4.89) was also statistically significant (p = .007). All the patients ambulated well at follow up. Primary closure using the tear drop technique and propeller flap is superior to skin grafting in terms of better cosmetic appearance, earlier postoperative ambulation, and no need for another donor site for skin graft.

Myxofibrosarcoma of the mandible: a case report and review of the literature

BackgroundMyxofibrosarcoma (MFS) is a soft tissue sarcoma that commonly occurs in late adult life. It is mainly located in the subcutaneous soft tissues of extremities characterized by a high recurrence rate at the original site. MFS of the head and neck is rare, while it occurs in the maxilla and mandible is extremely rare.Case presentationWe report a case of MFS of the mandible in a 51-year-old female who presented with a painless gingival swelling and mobile, super-erupted right mandibular second and third molars. Panoramic x-ray and maxillofacial CT revealed an ill-defined radiolucent lesion surrounding the mandibular molars giving a teeth-floating-in-air appearance. Histopathological examination showed scattered spindle and stellate cells with mild atypia distributed in the myxoid stroma. Only a few mitotic figures were identified and no area of tissue necrosis was found. The characteristic thin-walled and curvilinear vasculature were prominent. Immunohistochemistry analysis revealed the tumor cells being positive for vimentin and vascular CD31. CK, S-100, P63, HHF-35 stains were negative. The labeling index of Ki-67 was about 30%. Based on the histopathological and immunohistochemical examinations, the diagnosis of a low-grade MFS was established. This patient underwent a radical segmental excision with a 2-cm margin, supraomohyoid neck dissection and immediate reconstruction of the mandibular continuity defect with a fibular osteocutaneous free flap. This patient has been followed for 20 months to date and has remained disease free.ConclusionsThis report describes a rare case of MFS of the mandible. Recognizing the histopathological features of MFS and applying the appropriate immunohistochemical examinations are crucial in establishing the correct diagnosis. Our case may provide diagnosis and treatment experiences of MFS occurs in the mandible.

Airway, Voice, and Swallowing Functions after Surgical Management of Multilevel Chordoma of the Cervical Spine Using Fibula Osteocutaneous Free Flap

Airway, Voice, and Swallowing Functions after Surgical Management of Multilevel Chordoma of the Cervical Spine Using Fibula Osteocutaneous Free Flap

Combining free tissue transfer with pedicled flap in reconstruction of extensive oromandibular malignancy defects: a clinical study

Background: Extensive composite defects of the oromandibular site involve skin, mandible, soft tissue and oral mucosa. Though many opine that with the coming on of free flap surgery, the pedicled flap is an outdated surgical option, the latter still has its uses. Free flaps are criticized as being medically risky, expensive, and time-consuming. Combining both these flaps in a single surgery would bring in the baggage of all negatives along with the benefits of these flaps.Methods: Over a period of 3 years, 13 patients with expected large composite oral defects after ablative surgery for malignancy were included in the study requiring both skin cover and mucosal lining. A one-stage reconstructive procedure employing combination of free and pedicled flaps was used. Data was abstracted pertaining to cancer demography and surgical outcome.Results: The free fibula osteocutaneous flap (FFOCF)- deltopectoral fasciocutaneous flap (DPF) combination was most commonly used (n=5), secondly by free radial forearm flap (FRAFF)-DPF combination (n=4), FRAFF- pectoralis major myocutaneous flap (PMMF) amalgamation and FFOCF-PMMF (n=2). The complete flap survival rate was 88.5 percent with 3.8% percent total (1 of 26 flaps) and 7.7% partial (2 of 26 flaps) flap failures. Minimum follow-up period was 6 months with 2 (7.7%) recurrences and 2 (7.7%) mortalities.Conclusions: We believe that in combined use of free-flap and pedicled flap procedure for one-stage reconstruction of massive mandibular defects with through-and-through cheek defects is justified because it is safe and effective and improves the quality of life for these patients albeit a bit prolonged surgery which can effectively be shortened with 2 reconstructive team approach as in our study.

Radical resection of giant ameloblastoma mandible with free fibula reconstruction: a case report and review of literature

The ameloblastoma is a rare odontogenic tumor of the oral cavity. It is slow growing, locally invasive benign tumor affecting mandible more than maxilla mostly in age group 30-60 years. It grows in bone and soft tissue causing facial disfigurement. Treatment is surgical taking wide margins. This case report describes the treatment of a 30-year-old female having right side jaw swelling since two years, fine needle aspiration cytology was suggestive of ameloblastoma. Right hemi mandibulectomy was done by head and neck surgery team and reconstruction was done by plastic surgery team using free fibula flap. The free fibula osteocutaneous flap is the most versatile and reliable option for microsurgical reconstruction of large mandibular defects.

Salvage Secondary Reconstruction of the Mandible with Vascularized Fibula Flap.

Primary restoration of the mandibular continuity remains the standard of care for defects, and yet several constraints preclude this objective. Interim reconstructions with plate and nonvascular bone grafts have high failure rates. The secondary reconstruction, when becomes inevitable, remains a formidable task. This retrospective study evaluates various issues to address secondary reconstruction. Twenty-one patients following mandibulectomy presented with various complications between 2012 and 2016 were included in the study. The profile of primary reconstruction includes reconstruction plate ( n = 9), reconstruction plate with rib graft ( n = 3), soft tissue only reconstruction ( n = 4), free fibula ( n = 2), inadequate growth of reconstructed free fibula during adolescence ( n = 1), nonvascular bone graft alone ( n = 1), and no reconstruction ( n = 1). All had problems or complications related to unsatisfactory primary reconstruction such as plate fracture, recurrent infection, plate exposure, deformity, malocclusion, and failed fibula reconstruction. All were reconstructed with osteocutaneous free fibula flap with repair of soft-tissue loss. All flaps survived and had satisfactory outcome functionally and aesthetically. Dental rehabilitation was done in four patients. One flap was reexplored for thrombosis and salvaged. The challenges in secondary reconstruction include difficulty in recreating true defects, extensive fibrosis and loss of planes, unanticipated soft-tissue and skeletal defects, reestablishing the contour and occlusion, insufficient bone strength, dearth of suitable recipient vessels, nonpliable skin, tissue contraction to accommodate new mandible, need of additional flap for defect closure, and postirradiation effects. Notwithstanding them, the reasonable successful outcome can be attainable.

Efficacy of free fibula flap for reconstruction of post traumatic long bone defect: retrospective study of eighteen cases

&lt;p class="abstract"&gt;&lt;strong&gt;Background: &lt;/strong&gt;Complex and segmental bone defects are common after resection of tumors and trauma involving long bones of the extremities. Free fibula flap is commonly practiced for complex oromandibular defects and bone reconstruction after sarcoma and bone tumor excision. But post traumatic bone reconstruction of extremities with free fubula is less commonly practiced and only reserved for long segmental reconstruction or as an alternative to distraction osteogenesis. We are presenting a retrospective analysis of surgical details and outcome of 18 cases with post traumatic long bone defect reconstructed with free fibula osteocutaneous flap.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 18 patients with post traumatic composite or segmental long bone defect which were reconstructed with free fibula osteocutaneous flap (FFOCF) between 2014 to 2018 are included in this study. Operative details, success rate, bone healing, functional outcome and complications are reviewed retrospectively.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Success rate of flap surgery was 17/18 (94.44%). Bone gap was 6-17 cm and Skin paddle ranged from 10 cm × 8 cm to 15 cm × 10 cm. Bone healing, weight bearing outside cast and return to daily activity period were 8-16 weeks, 10-15 months and 12-18 months respectively. Non-union, malunion and stress fracture were noted in one,one and three patients respectively.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Free fibula flap is a reliable method for reconstruction of post traumatic complex and segmental long bone defects. Quality of bone healing is good enabling resuming to early weight bearing and daily activities and high success rate. Free fibula flap may be procedure of choice for reconstruction of such bony injuries with the microvascular surgical facilities.&lt;/p&gt;