Osteocutaneous Free Flap Research Articles

Calcaneal Reconstruction with Free Fibular Osteocutaneous Flap

Due to the role of the calcaneus in weight bearing, soft tissue coverage along with proper reduction of the fracture is the treatment following open calcaneal injury. Intra-articular calcaneal fractures present a very difficult management problem, as the lack of soft tissue and the intricate vascularity in this area pose a risk of complications. Coverage with local and free muscle flaps following excision of infected structures is a common approach for the treatment of chronic osteomyelitis. However, it is unknown which type of flap is optimal for the treatment of lateral foot wounds, especially when complicated by calcaneal osteomyelitis. A patient presented with an open wound over the lateral aspect of the heel with exposed hardware and chronic osteomyelitis of the calcaneus. Following multiple debridements, an ipsilateral osteocutaneous free fibular flap was transferred to the bony defect. Weight bearing was initiated at 2 months postoperatively, and he now ambulates with a normal gait, has normal plantar sensation, and has no difficulty maneuvering stairs. The patient has done well postoperatively and has recovered full range of motion and complete mobility. In this case report, an osteocutaneous free flap provided an excellent outcome for an active patient with a very complex and complicated condition.

Microvascular Free Flaps for Mandibular Reconstruction in Goldenhar Syndrome

Although Goldenhar syndrome is a relatively common craniofacial malformation, there is some debate regarding the ideal treatment of severe mandibular hypoplasia. Traditionally, patients with severe mandibular deficits have been treated with iliac or costochondral bone grafts followed by distraction osteogenesis, with mixed results. The authors present their experience with the use of the osteocutaneous fibula and scapula free flap for mandibular reconstruction in patients with severe mandibular hypoplasia. The cases of 4 patients who underwent free-flap reconstruction of a severely hypoplastic mandible due to Goldenhar syndrome are presented. Microvascular reconstruction of the severely hypoplastic mandible is possible with the osteocutaneous scapula and the fibula flap. Minimal donor-site morbidity is elicited. Furthermore, the vertical relationship can be restored adequately, and breathing is facilitated. The microvascular fibula and scapula flap are a viable option for reconstruction of the severely hypoplastic mandible in patients with Goldenhar syndrome.

Treatment of Segmental Bone and Soft-Tissue Defects of the Forearm With the Free Osteocutaneous Lateral Arm Flap

Complex defects of the forearm often require microvascular reconstruction with osteocutaneous free flaps to salvage the limb. In this review, we report our experience with the use of the free osteocutaneous lateral arm flap to reconstruct such defects in four patients. Three male patients with osseous defects of the ulna and one defect of the radius with associated soft-tissue defects were treated with a free osteocutaneous lateral arm flap between 2004 and 2007. The indications for the procedure included posttraumatic osteitis (3) and bone with soft-tissue defects after trauma (1). We evaluated the patients with respect to postoperative results by evaluating the range of motion, pain, strength, and score on the disabilities of the arm, shoulder, and hand questionnaire. Donor-site morbidity was also documented. The average length of segmental bone defects was 5.75 cm. The average dimension of the skin paddle was 99.5 cm. The average duration of follow-up was 43.3 months. All bone flaps healed without nonunion; the fasciocutaneous flaps healed without complications. No problems related to microanastomoses were found. Functional results were very satisfactory; disabilities of the arm, shoulder, and hand questionnaire scores showed a median of 5.8 (0-10.8). All patients had returned to their preinjury occupations. This analysis demonstrates that the free osteocutaneous lateral arm flap is an effective treatment for combined segmental osseous and soft-tissue defects of the forearm that are caused by osteitis and trauma.

Reconstruction of a maxillectomy patient with an osteocutaneous flap and implant-retained fixed dental prosthesis: A clinical report

This clinical report describes a multidisciplinary approach in the implant rehabilitation of a 53-year-old white male diagnosed with chondrosarcoma. Following a maxillectomy and insertion of a surgical obturator, the patient was unable to adapt physically and psychologically to the removable prosthesis. The patient underwent a microvascular free tissue transfer using an osteocutaneous free fibula flap to reconstruct a right/left infrastructure maxillectomy defect, a soft tissue modification of the skin component using an implant retained stent, and placement of maxillary dental implants to retain a fixed prosthesis. Prosthodontic planning and treatment considerations are discussed.

Successful Salvage of Venous Thrombosis of a Free Flap by Creation of a Venocutaneous Fistula

This report describes the creation of a venocutaneous fistula to salvage a free fibular osteocutaneous flap compromised by extensive venous thrombosis. This technique has previously been described for salvage of digital replants, but this is the first report of a venocutaneous fistula being used to salvage a free flap. A 21-year-old woman underwent a 9-cm resection of the distal left tibia for an aneurysmal bone cyst. A contralateral right fibular osteocutaneous free flap was used for reconstruction. On postoperative day 2, the skin paddle showed evidence of venous congestion. Reexploration demonstrated extensive thrombosis throughout the entire venous system of the flap. The venae comitantes were transected as far back as possible and brought to the surface of the skin through two small stab wounds to allow venous egress. After a short course of heparin and dextran, the skin flap healed uneventfully and both osteosynthesis sites consolidated. A venocutaneous fistula provides a path of relatively low resistance for venous outflow, improving the arterial inflow-venous outflow balance for a short time until neovascularization and collateral venous channels develop. The venocutaneous fistula technique may be considered for salvage of free flaps compromised by extensive venous thrombosis.

Biomechanical study of a unilocking T-plate system for prophylactic internal fixation of the radial osteocutaneous donor site using the sheep tibia model

Prophylactic internal fixation (PIF), with a bone plate in either the anterior (over the section defect) or posterior (on intact cortex) position, has substantially reduced the incidence of fracture at the donor site of the radial osteocutaneous free flap. This study uses the sheep tibia model to compare the effectiveness of new T-shaped titanium plates utilising a unilocking screw system with a 3.5 mm steel plate and bicortical screw fixation system commonly applied for PIF. Forty matched pairs of adult sheep tibias were tested in torsion and 4-point bending. An osteotomised bone was significantly weaker (p<0.001) than an intact bone in both bending and torsion with a mean loss of 77% and 64% of strength respectively. The tibia withstood much greater bending loads. All of the constructs significantly strengthened an osteotomised bone by a factor of 1.73-2.43 times in bending and 1.54-2.63 in torsion. The 2.4 mm T-plate in an anterior position (section) was the baseline against which other plates in differing positions were compared. The 3.5 mm T-plate section, DCP section and DCP cortex constructs had 41%, 30% and 2% greater mean bending strengths respectively but only the 3.5 mm T-plate section result approached statistical significance (p=0.06). In torsion the DCP section, 3.5 mm T-plate section and DCP cortex constructs had 56% (p=0.01), 27% (p=0.06) and 25% greater mean strengths respectively. When compared to an intact bone the mean bending strength restored by the DCP section (84%) and 3.5 mm T-plate section (87%) constructs was greatest and effectively restored the strength to that of an intact bone (100%). In torsion the mean strength restored by the DCP section (62%), DCP cortex (44%), 3.5 mm T-plate section (40%) and 2.4 mm T-plate (36%) remained significantly less than an intact bone. All of the plate constructs significantly strengthened an osteotomised bone but overall the 3.5 mm T-plate section and DCP section were the strongest constructs and most suitable for PIF. The lighter 2.4 mm T-shaped titanium plate was least effective. The strongest reinforcement in bending and torsion was the 3.5 mm T-plate section and DCP section respectively. The 3.5 mm DCP section plate was significantly stronger (p=0.01) than the 3.5 mm T-plate in torsion and remains the most effective construct for resisting torsional stresses, which are probably the commonest cause of fracture in clinical practice.

Uso do retalho osteocutâneo microcirúrgico de fíbula na reconstrução dos defeitos complexos de mandíbula

BACKGROUND: Free fibular osteocutaneous flap is the first choice for segmental mandible and contiguous soft-tissue defect reconstructions in most situations. OBJECTIVE: This study presents a four-year experience with free fibular osteocutaneous flap for mandibular reconstruction. METHODS: An analysis of 15 patients underwent to microsurgical reconstruction of the mandible and oral floor, with a fibular osteocutaneous flap was performed. The mean follow-up after surgery was 2 years. We studied the histopathological classification of primary tumor, location of the resected mandibular portion, vessels used for the anastomosis, associated flap, exposition to radiation, results and complications. RESULTS: The most common histological type was squamous cell carcinoma (81%) followed by osteosarcoma (13%). The mandibular portion resected with greater frequency was the central arc in 81% of patients; 87% of patients were exposed to radiation in the preoperative or postoperative. Reconstruction was immediate in 81% of cases. Pedicled or free flaps associated were used in 46%. Immediate complications were observed in 25% of patients and late complications, in 31%, with a success rate of 100%. CONCLUSIONS: The osteocutaneous free fibula flap is indicated in reconstruction of large mandibular defects, especially of its central portion. The procedure indications must be individualized, taking into account risks and benefits, as well as its impact on quality of life of patients.

Invited Commentary

HomeRadioGraphicsVol. 31, No. 2 PreviousNext Neurologic/Head and Neck ImagingInvited CommentarySundeep NayakSundeep NayakSundeep NayakPublished Online:Mar 7 2011https://doi.org/10.1148/Radiographics.31.2.312374MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1 King KG, Kositwattanarerk A, Genden E, Kao J, Som PM, Kostakoglu L. Cancers of the oral cavity and oropharynx: FDG PET with contrast-enhanced CT in the posttreatment setting. RadioGraphics 2011;31(2):355–373. Link, Google Scholar2 Schwartz DL, Macapinlac HA, Weber RS. FDG-PET staging of head and neck cancer—can improved imaging lead to improved treatment? J Natl Cancer Inst 2008;100(10):688–689. Crossref, Medline, Google Scholar3 Oliver C, Muthukrishnan A, Mountz J, Deeb E, Johnson J, Deleyiannis F. Interpretability of PET/CT imaging in head and neck cancer patients following composite mandibular resection and osteocutaneous free flap reconstruction. Head Neck 2008;30(2):187–193. Crossref, Medline, Google Scholar4 Goerres GW, Von Schulthess GK, Hany TF. Positron emission tomography and PET CT of the head and neck: FDG uptake in normal anatomy, in benign lesions, and in changes resulting from treatment. AJR Am J Roentgenol 2002;179(5):1337–1343. Crossref, Medline, Google Scholar5 Yamamoto Y, Wong TZ, Turkington TG, Hawk TC, Coleman RE. Head and neck cancer: dedicated FDG PET/CT protocol for detection–phantom and initial clinical studies. Radiology 2007;244(1):263–272. Link, Google Scholar6 Uyl-de Groot CA, Senft A, de Bree R, Leemans CR, Hoekstra OS. Chest CT and whole-body 18F-FDG PET are cost-effective in screening for distant metastases in head and neck cancer patients. J Nucl Med 2010;51(2):176–182. Crossref, Medline, Google Scholar7 Wahl RL, Jacene H, Kasamon Y, Lodge MA. From RECIST to PERCIST: evolving considerations for PET response criteria in solid tumors. J Nucl Med 2009;50(suppl 1):122S–150S. Crossref, Medline, Google Scholar8 Pfister DG, Ang KK, Brazel Det al.. Head and neck cancers. In: NCCN clinical practice guidelines in oncology. Fort Washington, Pa: National Comprehensive Cancer Network, 2010. Google Scholar9 Patel SG, Shah JP. TNM staging of cancers of the head and neck: striving for uniformity among diversity. CA Cancer J Clin 2005;55(4):242–258. Crossref, Medline, Google Scholar10 Coleman RE, Hillner BE, Shields AFet al.. PET and PET/CT reports: observations from the National Oncologic PET Registry. J Nucl Med 2010;51(1):158–163. Crossref, Medline, Google Scholar11 Ong SC, Schöder H, Lee NYet al.. Clinical utility of 18F-FDG PET/CT in assessing the neck after concurrent chemoradiotherapy for locoregional advanced head and neck cancer. J Nucl Med 2008;49(4):532–540. Crossref, Medline, Google Scholar12 Isles MG, McConkey C, Mehanna HM. A systematic review and meta-analysis of the role of positron emission tomography in the follow up of head and neck squamous cell carcinoma following radiotherapy or chemoradiotherapy. Clin Otolaryngol 2008;33(3):210–222. Crossref, Medline, Google Scholar13 Abgral R, Querellou S, Potard Get al.. Does 18F-FDG PET/CT improve the detection of posttreatment recurrence of head and neck squamous cell carcinoma in patients negative for disease on clinical follow-up? J Nucl Med 2009;50(1):24–29. Crossref, Medline, Google ScholarArticle HistoryPublished online: Mar 7 2011Published in print: Mar 2011 FiguresReferencesRelatedDetailsRecommended Articles Advances in Diagnosis and Multidisciplinary Management of Oropharyngeal Squamous Cell Carcinoma: State of the ArtRadioGraphics2019Volume: 39Issue: 7pp. 2055-2068Interrater Reliability of NI-RADS on Posttreatment PET/Contrast-enhanced CT Scans in Head and Neck Squamous Cell CarcinomaRadiology: Imaging Cancer2021Volume: 3Issue: 3Adverse Radiation Therapy Effects in the Treatment of Head and Neck TumorsRadioGraphics2022Volume: 42Issue: 3pp. 806-821CT-based Radiomic Signatures for Predicting Histopathologic Features in Head and Neck Squamous Cell CarcinomaRadiology: Imaging Cancer2020Volume: 2Issue: 3Critical Changes in the Staging of Head and Neck CancerRadiology: Imaging Cancer2020Volume: 2Issue: 1See More RSNA Education Exhibits AJCC 2018 Head and Neck Cancer Staging Manual: Get Prepared for the ENT Tumor BoardDigital Posters2018Depth of Invasion as a New Parameter in Oral Cavity TNM. Is It Just an Anatomopathological Measurement?Digital Posters2018How the Radiologist Can Help: Important Anatomic Landmarks in the Treatment of Oral Cavity, Oropharyngeal and Laryngeal Carcinoma and Their Impact on Surgical Options, Esthetic, Functional and Psychological ChallengesDigital Posters2019 RSNA Case Collection "Cold" Sentinel Lymph Node in Cutaneous Melanoma RSNA Case Collection2020Dedifferentiated Thyroid CancerRSNA Case Collection2020 Post vaccination axillary adenopathyRSNA Case Collection2021 Vol. 31, No. 2 Metrics Altmetric Score PDF download

Prefabricated Free Fibula Flap for Reconstruction of a Maxillary Defect: A Case Report

The present article describes a case of prosthetic rehabilitation with the new technique of prefabricated osteo-cutaneous free fibula flap for reconstructing a maxillary defect which had resulted from ameloblastoma. The fibula and a cuff of 6-8 mm were prepared with its pedicle intact. The bone flap was left in place with its pedicle intact for 2 to 3 months; the skin graft and the flap were free of inflammation. The fibula flap was then transferred to the maxilla. Implant placement was performed 4 to 6 months after transfer of the flap to the oral cavity. Three titanium implants, with a width of 4 mm and a length of 13 mm, were placed using a conventional two-stage protocol. A cement-retained 5-unit metal-ceramic fixed partial denture was fabricated.

Osteocutaneous free flaps: A critical analysis of quantitative evaluation of bone microcirculation with contrast-enhanced high resolution ultrasound (hrCEUS) and TIC analysis

Osteocutaneous free flaps (OFF) are widely used to reconstruct large bone defects in trauma and cancer surgery. Currently no monitoring method is available to detect blood circulation around and inside the bone after transplantation. Therefore we used for the first time contrast-enhanced high-resolution ultrasound (hrCEUS) to gain evidence for the microcirculation of the transplanted bone. 15 patients transplanted with OFF because of large bone defects at different sites were examined postoperatively with hrCEUS with a high resolution linear probe (6-9 MHz, LOGIQ E9/GE) and a bolus injection of 2.4 ml of contrast agent (SonoVue®, Bracco, Italy). Operation and examination were performed by either an experienced plastic surgeon or an experienced ultrasound examiner. Microcirculation of the periost and bone was analyzed in different regions of interest (ROIs) and quantitative microcirculation analysis was performed using time intension curve analysis (TIC). We further analyzed clinical outcome of the patients in respect to revision-surgery, necrosis of the OFF and flap survival as well as viability on standard x-rays 2 months after surgery. The most representative parameter by TIC analysis of hrCEUS were the area under the curve (AUC) and the time to peak (Ttop). The AUC of the periost and central part of the bone showed a high correlation (Pearson's r = 0.831). Mean AUC for the periost was 163.92 dB ± 49.44 and for the central part of the bone 70.42 dB ± 25.33. The Ttop of the periosteal ROI was 33.04 sec. ± 6.71 and the bone ROI 41.01 sec. ± 9.24. There was a high correlation of the Ttop of the periost and bone (Pearson's r = 0.937). One revision had to be performed due to haematoma and microcirculation defect of the distal part of the transplanted bone graft which was detected early by hrCEUS and the distal part of the avital bone could be removed timely. For the first time we could show that hrCEUS is a reliable method to evaluate the viability of OFF. The AUC and Ttop seem to be a valuable parameter to detect the microcirculation around and inside the bone transplant.

Malignant Immature Teratoma of the Larynx and Trachea with Functional Osteocutaneous Free Flap Reconstruction

Malignant Immature Teratoma of the Larynx and Trachea with Functional Osteocutaneous Free Flap Reconstruction

OSTEOCUTANEOUS RADIAL FOREARM FREE FLAPS: PROPHYLACTIC FIXATION OF DONOR SITE USING LOCKING PLATE AUGMENTED WITH MINERAL CEMENT

Prophylactic plating of donor site in osteocutaneous radial forearm free flaps have demonstrated improvement in fracture rates. Previous series used conventional plating systems which rely on plate-bone friction forces to generate stability and can result in iatrogenic fractures if not accurately contoured. Locking plates have superior stability and do not require contouring. This retrospective series reports our experience using locking plate fixation augmented with calcium phosphate mineral cement. Twenty patients' records were reviewed; 13 were alive and reviewed clinically. Mean radiological follow-up was 28.2 months. Two deceased patients had donor site fractures diagnosed on the first postoperative radiograph. These fractures were related to technical fixation errors and failure to apply correct locking fixation principles. None of the other patients with proper locking fixation had fractures or metalwork related complications. We believe that locking fixation augmented with mineral cement can provide more biological stability and enhance restoration of bone structural strength.

Lip and Perioral Trauma

The management of perioral injuries is a complex topic that must take into consideration the unique anatomy, histology, and function of the lips to best restore form and function of the mouth after injury. Basic reconstructive principles include three-layered closure for full-thickness lip lacerations. Additionally, special care is needed to ensure an aesthetic repair of the cosmetically complex and important vermillion border, philtrum, and Cupid's bow. Infraorbital and mental nerve blocks provide lip anesthesia for laceration repair without distorting crucial aesthetic landmarks. Prophylactic antibiotics are usually indicated in perioral injuries due to wound contamination with saliva. Perioral burn management is controversial; however, most lip burns can first be managed conservatively. Splinting, plasties, and other reconstructive options are available after secondary healing of perioral burns. Hypertrophic scars are common in the perioral area after trauma. The mainstays of treatment for hypertrophic scars on the lips are silicone elastomer sheeting and intralesional steroid injections. For large perioral defects, a myriad of reconstructive options are available, ranging from primary closure, cross-lip flaps, and local tissue transfer, to free tissue transfers such as radial forearm free flaps, innervated gracilis free flaps, anterolateral thigh free flaps, and osteocutaneous free flaps.

Prophylactic fixation of donor site in radial forearm osteocutaneous free flaps using locking reconstruction plate augmented with mineral cement

Prophylactic fixation of donor site in radial forearm osteocutaneous free flaps using locking reconstruction plate augmented with mineral cement

Bilateral Orbitozygomatic Reconstruction With Tissue-Engineered Bone

Critical defects of the craniomaxillofacial region and long bones are often treated with bone grafts and vascularized osteocutaneous free flaps. These lengthy operations may be associated with considerable donor site morbidity and often have suboptimal functional and aesthetic results. The allure of providing an exact replica of a missing bone that incorporates to become indistinguishable from self, has the capacity to heal and grow, is resistant to infection, and with minimal morbidity is a "holy grail" to all surgeons who work with bone. This is a report of a 14-year-old adolescent boy with Treacher Collins syndrome whose bilateral orbitozygomatic defects were treated with engineered bone made from a combination of human bone allograft, adipose-derived mesenchymal stem cells, bone morphogenic protein-2, and periosteal grafts. This single-stage reconstruction was followed by an exuberant amount of postoperative swelling that persisted for 3 weeks. He had slight lid malposition postoperatively as well but has had no long-term negative effects from the surgery. His reconstruction has remained stable during a 6-month follow-up, and a recent biopsy of the engineered bone demonstrated healthy, lamellar bone. These data are the first to demonstrate revitalization of large volume allograft bone in humans and have positive implications for craniofacial bone tissue engineering. The combination of adipose-derived stem cells, bone morphogenic protein-2, bone allograft, and periosteum may provide an alternative method to both osteocutaneous free flaps and large structural allografts with less morbidity and improved long-term results.

The Fibula Osteomyocutaneous Flap for Mandible Reconstruction: A 15-Year Experience

This report documents our experience over the previous 15 years using free vascularized fibular flaps for comprehensive reconstruction of large defects in the mandible, after combined resections of aggressive, malignant odontogenic tumors or for post-traumatic defects. Charts were reviewed retrospectively for 117 consecutive patients who underwent microsurgical reconstruction of the oromandibular complex with a fibula osteocutaneous or osteomyocutaneous free flap over a 15-year period, with an average follow-up of 4 years. All charts were reviewed retrospectively for tumor type, stage and location, surgical procedure performed (including type of plate used), dental restoration if done, the use of pre- or postoperative radiotherapy, length of follow-up, and evidence of complications. Fibula osteocutaneous free flaps were used for reconstruction in 117 patients, of whom 60% were men (mean age, 57.1 years) and 40% were women (mean age, 56.6 years). Most cases (61.1%) were secondary to oral malignancies (89.1% of these were squamous cell carcinoma). Thirty-one patients (26.5%) developed postoperative complications, including hardware failure or intolerance in 16 patients (13.7%), total or partial flap failure in 10 patients (8.5%), wound infection in 3 patients (2.6%), and peroneal nerve damage in 2 patients (1.7%). Regarding donor site morbidity, calf paresthesias were recorded in 21% of cases. Similar rates of claw-toe deformity were also observed. In our opinion, the free fibula osteocutaneous flap is the most versatile and reliable option for microsurgical reconstruction of large mandibular defects. It provides a large quantity of bone, which is easily shaped to passively adapt to the remaining mandible. The bone height is suitable for an implant-based prosthetic restoration. Preoperative mapping of the cutaneous perforators of the skin paddle improves the versatility of the flap design and decreases the morbidity at the donor site. In selected cases, other options (iliac crest or scapular free flap) may also be considered.

Dorsalis pedis free flap in oromandibular reconstruction

This paper reports the free dorsalis pedis flap as a fasciocutaneous and osteocutaneous flap in oromandibular reconstruction. The authors present a 7-year series of nine patients with squamous cell carcinoma of oral cavity with extensive soft tissue/soft tissue and bone defect in whom this flap was used for intraoral reconstruction. The free fasciocutaneous flap (two neurosensate) was used in eight patients, and in one patient, a free osteocutaneous flap was required. The follow-up period ranged from 2 and 7 years. No ischemic flap complications occurred and a good anatomical and functional reconstruction was achieved in the majority of patients. There was no significant donor area functional disability. One death occurred in the early post-operative period due to multi-organic failure and four deaths in the follow-up period due to recurrence of the oncological disease. The dorsalis pedis free flap was found to be a good alternative tool for reconstruction of the anterior floor of mouth defects (including marginal mandibular defects). This was also used for anterolateral intraoral soft tissue defects. The donor area morbidity is not problem-free, but with good planning and careful flap dissection, it is possible to minimize the sequelae to a very acceptable level.

Transplantation of the chimerical osteocutaneous perforator flap with superficial circumflex iliac artery for repair of bone and skin defect in limbs

Objective To investigate the applied methods and effects of the chimerical osteocuta-neous perforator flap with superficial circumflex iliac artery for reconstruction of bone and skin defect in limbs. Methods From February 2008 to April 2009, five patients in whom bone and skin defect in limbs were reconstructed with free chimerical osteocutaneous perforator flaps using superficial circumflex iliac vessel, in-cluding 4 males and 1 female with an average age of 31.2 years. Of 5 patients, 2 were used for the recon-struction of composite metacarpal bone and soft-tissue defects, 2 for foot reconstruction, and 1 for fibula re-construction. The area of cutaneous deficiency was about 5 cm×2 cm to 16 cm×5 cm. The size of osseous flaps ranged from 2 cm×1 cm×0.8 cm to 8 cm×2 cm×0.5 cm, and the size of cutaneous flaps ranged from 6 cm×3 cm to 18 cm×6 cm. All the arteries were reconstructed by end-to-end anastomoses between the donor iliac artery and the recipient artery, except one, which was performed using an end-to-side method. The bone flaps were fixed with the aid of plate and screw (4 cases), and Kirschner wire (1 case). Results One hap-pened arterial crisis during the 2-day postoperative period. The other flaps were fully survival by first intention, and all wounds of the donor site healed within 8 to 27 days. All the cases were followed up for 8 to 19 months, the appearance of flaps was satisfactory and no special protection was needed. All bone defects healed during a period time of 3 to 6 months. No patient complained of pain at the donor site. The function of hand prehension was completely recovered, and thumb opposition was partly recovered. Patients who re-ceived repairing of lower limb were able to ambulate with self-weight bearing. Conclusion The chimerical os-teocutaneous superficial circumflex iliac free perforator flap can minimize the donor site complication and is suit-able for the reconstruction of small area of bone defect, especially combined with a large area of soft tissue defect. Key words: Surgical flaps; Bone transplantation; Transplantation, autologous; Microsurgery

A New Method of Urethroplasty for Prevention of Fistula in Female-to-Male Gender Reassignment Surgery

One of the primary goals of the phalloplasty for female-to-male transsexuals is to gain the voiding ability in the standing position. However, achieving the competence of urethra, sensation and rigidity of the neophallus is still a significant challenge. Serious complications such as urethral fistula, obstruction and stricture were encountered in this surgery. In experienced hands, this seems to be associated with urethroplasty technique. The authors performed phalloplasty with radial forearm osteocutaneous free flap method in 70 patients of female-to-male transsexuals. In 38 cases which were enrolled before 2001, we had carried out the urethroplasty by our own method, but since 2001, we have applied the modified method of urethroplasty to reduce the incidence of urethrocutaneous fistula. Thirty-four cases have undergone a new modified method of ours. For construction of the urethra, an anteriorly based vaginal wall flap and labium minoral flaps were used in this technique. In our new method series, 1 case (1.4%) of flap loss occurred after phalloplasty. The incidence of urethrocutaneous fistula was 30%. Before the year 2001, of 38 patients, there were 14 cases (36.8%) who developed urethrocutaneous fistula. On the other hand, 7 of 32 patients (21.9%) who underwent urethroplasty by the modified labium minoral flap and anteriorly based vaginal flap had urethrocutaneous fistula after 2001. One-stage total phalloplasty and urethroplasty is associated with a significant increase of urethral fistula and obstruction. However, the urethrocutaneous fistula at the level of the female external urethral orifice can be successfully reduced using this new method.

Reconstruction of Mandibular Defects

Defects requiring reconstruction in the mandible are commonly encountered and may result from resection of benign or malignant lesions, trauma, or osteoradionecrosis. Mandibular defects can be classified according to location and extent, as well as involvement of mucosa, skin, and tongue. Vascularized bone flaps, in general, provide the best functional and aesthetic outcome, with the fibula flap remaining the gold standard for mandible reconstruction. In this review, we discuss classification and approach to reconstruction of mandibular defects. We also elaborate upon four commonly used free osteocutaneous flaps, inclusive of fibula, iliac crest, scapula, and radial forearm. Finally, we discuss indications and use of osseointegrated implants as well as recent advances in mandibular reconstruction.