Osteocutaneous Free Flap Research Articles

Simultaneous Two Free Flaps for Head and Neck Reconstruction

The use of the free tissue transfers Improves the functional and cosmetic results of the head and neck reconstruction. Because a large composite defect or bilateral defects can not be reconstructed with a single free flap in one-staged operation, simultaneous double free flaps are used to achieve the reconstructive goals. Iii 1999, five patients of head and neck defects were reconstructed immediately with two free flaps. Four patients of primary buccal cancer and one recurrent tongue cancer were all squamous cell carcinoma The combined free anterolateral thigh flap and free fibular osteocutaneous flap were used for the large through-and- through oromandibular defects after the buccal cancei resection as well as for the oropharyngeal-mandibular defect after the ablation of the recurrent tongue cancer One patient of synchronous bilateral buccal cancers underwent the reconstruction with bilateral free anterolateral thigh flaps. Nine of the 10 flaps survived. One anterolateral thigh flap in the patient of bilateral buccal cancers suffered from venous thrombosis, which had been explored but failed. The radial forearm flap was salvaged and survived well later, Minor complications including one wound infection and one skin graft loss of donor site were noted and healed after debridement and skin graft. The combined anterolateral thigh flap and fibular flap have played an important role in the reconstruction of the oromandibular composite defects.

Microvascular composite tissue transfer for the management of type IIIB and IIIC fractures of the distal leg and compound foot fractures.

Patients who sustain high-energy, compound fractures with severe contamination and soft tissue loss, face high rates of delayed union, nonunion, infection and, in some instances, amputation. The authors reviewed 18 patients with compound foot fractures and IIIB and IIIC tibial fractures. All patients were treated by early free-flap coverage and simultaneous bone reconstruction. Corticocancellous bone grafting, composite osteocutaneous free flaps, or bone transport techniques were utilized, as required. Bony union was achieved in all cases; rehabilitation and return to work occurred within 12 to 18 months, with no major complications. The authors believe that the reconstruction ladder usually followed should be altered in certain cases in which severe periosteal stripping and soft-tissue contamination necessitate distant free composite tissue transfer, particularly those cases involving the distal third of the leg and foot. Simultaneous reconstruction is superior to other methods of wound management in providing early coverage of extensive wounds, a barrier against bacterial contamination, prevention of osteomyelitis, and enhanced union of the fractures.

Phalloplasty with free osteocutaneous fibular flap in a transsexual case. (Turkish)

Phalloplasty with free osteocutaneous fibular flap in a transsexual case. (Turkish)

Total Mandibular and Lower Lip Reconstruction with a Prefabricated Osteocutaneous Free Flap

Total Mandibular and Lower Lip Reconstruction with a Prefabricated Osteocutaneous Free Flap

Treatment of mandibular osteoradionecrosis by cancellous bone grafting

Purpose: This study was undertaken to evaluate a new method in the treatment of mandibular Osteoradionecrosis. Patients and Methods: Eight patients, seven male and one female, with a mean age of 64 years (range, 43 to 67 years), suffering from Osteoradionecrosis of the mandible, two bilaterally and six unilaterally, were treated. Five initially had hyperbaric oxygen (HBO) followed by sequestrectomy, and three had sequestrectomy alone. Because healing failed to occur, all patients were treated by removal of the necrotic bone in the affected part of the mandible and filling the defect with compressed particulated cancellous bone and marrow from the tibia. The patients were observed for an average period of 39 months (range, 20 to 93 months). Results: Primary healing was achieved in two patients with unilateral Osteoradionecrosis and HBO treatment. In another patient treated with HBO primary healing occurred on one side while the other healed secondarily. In the remaining five patients, complete secondary healing took place, but it was complicated in three patients by fistulas, two of which were associated with fractures of the mandibular body. The fistulas were excised, and complete healing of the soft tissues occurred, but the fractures resulted in pseudarthrosis. Conclusions: The technique presented in this study can be useful in the treatment of Osteoradionecrosis as an alternative to continuity resection and reconstruction with free osteocutaneous flaps, but, whenever possible, it should be proceeded by HBO treatment.

Reconstruction of Complex Midfacial Defects

Modern treatment of complex midfacial defects has evolved over the past 5 years, primarily with the advent of reliable vascularized bone flaps and osseointegrated implants. To determine the effectiveness of these advances, 26 consecutive patients with complex midfacial defects treated from 1991 through 1995 with immediate muscle-flap coverage were evaluated. The etiology of the defect included neoplasm (n = 23) and trauma (n = 3). Seventy-eight percent of the patients received adjuvant radiation therapy. Follow-up ranged from 3 months to 4 years, with a mean of 18 months. Twenty-three patients (88 percent) were reconstructed with a single major procedure. All patients had free-flap reconstruction, and 100 percent of the flaps survived. Late tumor recurrence was seen in 5 of 23 patients (22 percent) and was detected promptly. Aesthetic and functional results were rated good or excellent in 77 and 88 percent of the patients, respectively, as determined by patient questionnaires and physical examinations. Fourteen of 18 patients (78 percent) undergoing partial or complete alveolar ridge resection received dental rehabilitation, 43 percent of whom received osseointegrated implants into either a bone flap or remaining native bone. Osseointegrated implants were inset during the initial reconstruction 50 percent of the time. A treatment algorithm for free-flap selection based on the size of the defect and the bony requirement for reconstruction is presented. Bony restoration is only required in those areas where osseointegrated implants need to be placed. In such cases, the fibula osteocutaneous free flap is the flap of choice. Otherwise, soft-tissue flaps are selected based on wound size. Immediate free-flap coverage provides effective, single-stage treatment, both aesthetically and functionally, for complex midfacial defects.

One-stage reconstruction of war wounds with free osteocutaneous flaps

Thirty-one patients with traumatic osteocutaneous defects of the extremities sustained during the war in Croatia and Bosnia and Herzegovina were treated at the Institute of Plastic-Reconstructive and Breast Surgery in Zagreb. Injuries were categorised using the Mangled Extremity Syndrome Index (MESI). The average length of bone defect was 5.9 cm (range 4–12 cm). Patients were divided in two groups according to the time they had reconstruction with a free osteocutaneous flap: group 1, within 6 days after injury, and group 2, after more than 6 days. The mean time to reconstruction in group 2 was 5.2 weeks. Average time to solid bone union was 13.3 weeks in group I and 16.6 weeks in group 2. Functional outcome was better in group 1 with fewer complications, smaller number of operations and shorter hospital stay. One-stage reconstruction of osteocutaneous defects with free composite flaps provides reliable treatment solution with good functional outcome.

Mandibular Reconstruction Using A Vascularized Osteocutaneous Scapular FLap

Mandibular reconstructive surgery is an indispensable operative procedure for a patient who received a radical surgery for oropharyngeal cancer to maintain their speech, swallowing, respiratory and masticating function. Serious cosmetic problem appearance would also arise after the craniofacial operation that associate with major mandibular defects. Primary mandibular reconstruction frequently require provision for interoral lining, tongue and as well as lateral wall of oropharynx.Scapular osteocuntaneous free flap is preferred for reconstruction of mandible. Because scapular osteocutaneous free flap has great flexibility in three-dimensional reconstruction and can be combined with other flaps based on the circumflex scapular artery. In this study, masticating function among 20 cases of mandibular reconstruction by scapular osteocutaneous flap were quantitated using dental prescale occluzer system.The postoperative mandibular mastication was dependent on the number of remaining natural teeth, the presence of adhesion between denture and the mobility of remaining tongue. Good mastication are expected in the case of good adherence of denture and remaining natural teeth were obtained. Osteointegrated implants are adequate for total mandibular reconstruction.

Mandibular reconstruction with the fibula osteocutaneous free flap

The fibula osteocutaneous free flap is effective for managing most mandibular defects. Debate over several technical aspects of the flap dissection continues to take place in the literature, specifically with regard to skin island viability and donor leg morbidity. In our experience, the fibula flap is harvested based solely on the septal perforators without incorporating portions of the soleus muscle. Flap bulk is minimized whereas donor leg function is maximized. Therefore, the overall dissection can proceed expeditiously, with extreme care necessary only in the deep posterior compartment at the level of the peroneal vessels. Optimal skin island viability can be ensured by harvesting a long segment of skin along the same axis as the underlying fibula to include the maximum number of perforators. This provides enough soft tissue and pedicle length to reconstruct virtually any size defect. Subsequently, a subperiosteal bone dissection to remove unneeded proximal fibula preserves the vascularity of the remaining skin and bone. Adherence to these and other principles outlined in this article should consistently ensure flap success with minimal morbidity.

Microsurgical reconstruction of the midface.

To establish a treatment algorithm for reconstructing complex midfacial defects. Retrospective case series. University-based teaching hospital. Thirty-one consecutive patients were treated from 1991 through 1995. The 18 males and 13 females were aged 15 to 90 years (mean age, 58 years). The cause of the defect included neoplasm (n = 27) and trauma (n = 4). Reconstruction consisted of 1 of 4 free flaps: rectus abdominis, radial forearm, fibula, or latissimus dorsi. Aesthetic and functional results were determined by patient questionnaires and physical examinations. Length of stay, postoperative morbidity and mortality, degree of aesthetic and functional restoration, and detection of tumor recurrence. Twenty-seven (87%) of the 31 patients underwent reconstruction with a single major procedure. All of the flaps survived. Postoperative hospital stays averaged 14 days. Late tumor recurrence occurred in 7 (23%) of the 31 patients and was promptly detected. Aesthetic and functional results were rated good or excellent in 77% (24/31) and 87% (27/31) of patients, respectively. Of the 20 patients who underwent alveolar ridge resection, 16 (80%) received dental rehabilitation, 44% of whom received osseointegrated implants into either a bone flap or remaining native bone. Osseointegrated implants were inset during the initial reconstruction 57% (4/7 patients) of the time. For complex midfacial defects, free-flap transfer can be performed with a high degree of success, restoring both appearance and function in most patients. The only instance in which bone is necessary to reconstruct the midface involves those areas in which osseointegrated implants are needed, ie, alveolar ridge (dental implant) and/or orbit (ocular prosthesis). In such cases, the fibula osteocutaneous free flap is the flap of choice. Otherwise, soft-tissue flaps are selected based on wound size.

Skin Paddle Salvage in the Fibula Osteocutaneous Free Flap with Secondary Skin Paddle Vascular Anastomosis

The fibular osteocutaneous free flap has become a popular choice for the reconstruction of bone and skin defects. A potential drawback has been the reported unreliability of the skin paddle. Previous studies have emphasized total loss of the overlying skin paddle, if the expected perforating vessels are not present either in the intermuscular septum or in the soleus. Two cases are presented in which the skin paddle was found to be supplied by vessels arising from the proximal peroneal artery. there were no intraseptal or intramuscular vessels in the osteocutaneous septum which connected to the overlying skin paddle. The skin island was salvaged by performing independent microsurgical anastomoses of the fibular graft and the skin paddle. Both patients had complete survival of the fibula and overlying skin paddle.

The fate of the osteotomized free radial forearm osteocutaneous flap in mandible reconstruction.

The radial forearm osteocutaneous free flap has become a standard method of mandible reconstruction. In order to improve the contour of the reconstructed jaw in large resections, especially the anterior defect, the radial forearm bone graft needs to be osteotomized. The bone graft is nourished by small branches of the radial artery via the fascial connections between the skin flap and bone. The effect of the osteotomy, fixation devices, and the angulation of the bone segment on bone viability and eventual bone healing is not known. Forty-two radial forearm osteocutaneous flaps were used for composite mandible reconstruction. In 25 patients, the bone graft required osteotomy to achieve contour, of which 16 required single osteotomy and nine required double osteotomy. In a remaining 17 cases, no osteotomy was performed. Only those patients who had at least a 1-year follow-up were included in this study. The proportion of patients who achieved bone union was similar for both groups (i.e. osteotomy vs. nonosteotomy). Performing osteotomies on the segment of the radius in free osteocutaneous transfers is safe, and it allows for more flexibility in reconstruction, to achieve a natural-appearing jaw.

Fracture of radius 1 year after procurement of osteocutaneous flap

After radical excision of tumors of the oral cavity involving mucosa and bone, reconstruction with a free osteocutaneous flap gives a very satisfactory functional and cosmetic result. Donor morbidity from the forearm osteocutaneous flap has been well described 1 and includes sensory loss in the first web space (radial nerve), wrist stiffness and swelling, delayed healing and a cosmetic defect of a skin graft on the forearm, cold intolerance, and fracture of the radius. After reports of early postoperative fracture of the radius, it was recommended that the forearm be protected by an above-elbow cast, 2 and also that the osteotomy of the bone should leave a boat-shaped defect in the radius rather than a rectangular one, because cuts made at right angles at each end of the defect leave it more likely to fracture at this site. The following is a report of a case of fracture of a donor radius 1 year after surgery.

New reconstruction for total maxillectomy defect with a fibula osteocutaneous free flap

The osteocutaneous fibula free transfer with three segments of bone and the peroneal flap was used to reconstruct a total unilateral maxillectomy defect. Satisfactory restoration of three-dimensional facial structure, orbital support, and prosthesis wearing was achieved. The fibula osteocutaneous free flap is a very useful alternative for reconstructing a maxillectomy defect.

Preparation of Scapular Osteocutaneous Free Flap.

Free flap transfer has become a widely accepted method in head and neck reconstruction. Many kinds of free flaps are available today. A suitable flap can be selected according to the condition of the defect. The scapular osteocutaneous free flap is a method of choice for the simultaneous repair of the defect consists of both soft tissue and skeletal one, because 1) Both the skin flap and bone flap can be transplanted with a single pair of vascular pedicle, 2) blood supply to the bone flap is excellent, and 3) Osteotomies within the flap can be done safely due to the double pedicle of the bone flap. The operative procedure of harvesting scapular osteocutaneous free flap is presented. Our strategy is in brief as follows.1. Detection of triangular space by palpation.2. Marking of the courses of cutaneous branches.3. Elevation of skin flap at the deep fascial plane, from distal to proximal.4. Dissection of circumflex scapular vessels within the triangular space, and preservation of osteal branch.5. Severance of teres major and teres minor muscles.6. Identification and preservation of the angular branch.7. Cutting out the bone flap from lateral edge of the scapula.8. Dissection of the circumflex scapular vessels toward the subscapular vessels, further more to the axillary vessels.9. Pulling out of the flap through a counter incision made in the axilla.10. Closure of the donor wound and change of the patient's position from lateral to supine.

Enhancing Fibula Free Flap Skin Island Reliability and Versatility for Mandibular Reconstruction

Although the fibula osteocutaneous free flap has many advantages when used in mandibular reconstruction, many investigators have found the skin island is not always reliable. We present a technique that enhances skin island reliability by including a maximal number of skin perforators. This method has been used in 10 consecutive osteocutaneous free flaps without any skin loss. This technique also expands the usefulness of the fibula free flap, allowing it to be used for shorter bone defects or in cases when skin coverage is needed at a distance from the bone. In addition, this method provides additional vascularized soft tissue for neck contour restoration and coverage of fixation plates.

Hemimandibular reconstruction with bipedicled scapular osteocutaneous free flap

A case report is presented on the successful use of a bipedicled scapular osteocutaneous free flap in a young woman, whose hemimandible was resected because of sarcoma, 1 year prior to presentation. The postoperative course was uneventful and donor site morbidity minimal.

Osteocutaneous free flap reconstruction of a deformity of the cheek and orbit

PRESENTATION: The patient is a 66-year-old woman who is status post subtotal maxillectomy in 1985 for treatment of an osteogenic sarcoma of the left maxillary sinus. She then received 6,500 cGy of postoperative radiation therapy. She has been without evidence of disease since her treatment. In 1989, she underwent reconstruction of her left zygomatico-orbital deformity with split calvarial bone grafts. She was dissatisfied with her appearance after reconstruction and had significant diplopia requiring the use of prisms to prevent diplopia. She presented in 1991 for evaluation and treatment of her left cheek and orbital deformity (Fig 1).

Ewing's sarcoma of the mandible: A case report

The authors report the case of an 8-year-old boy with a Ewing's sarcoma localized to the mandible. The therapeutic modalites consisting of induction chemotherapy, surgical removal of the involved portion of the mandible with reconstruction using a parascapular osteo-cutaneous free flap, and maintenance chemotherapy are described. Emphasis is placed on the importance of performing a wide resection and the use of a multidisciplinary team approach in the treatment of these unusual tumours.

Use of the Osteocutaneous Free Scapular Flap on the Lower Extremities

Reports on the use of osteocutaneous free scapular flap transfers have focused primarily on mandible reconstruction. Yet the scapula is a nearly straight bone, and it is also useful in the reconstruction of long bones. We would like to report on 23 patients undergoing osteocutaneous free scapular flap transfers to the lower extremities in whom we obtained extremely satisfactory results. These 23 surgical patients included 10 with pseudoarthrosis with osteomyelitis, 3 with pseudoarthrosis due to trauma, and 5 with osteomyelitis of the lower extremities, as well as 5 with other miscellaneous problems. Surgery was successful in all patients. There was a recurrence of osteomyelitis in 2 patients. In 1 patient, the problem was minor and was treated on an outpatient basis. In the other patient, an infection arose in surgical dead space, and a second operation was required. The level of weight bearing achieved with the osteocutaneous free scapular flap is the same as obtained with a vascularized free fibular graft used for the treatment of pseudoarthrosis. We therefore believe that the osteocutaneous free scapular flap is extremely effective in the treatment of chronic and severe lower leg problems.