Vascularized Fibula Flap Research Articles

A pilot study of masticatory function after maxillectomy comparing rehabilitation with an obturator prosthesis and reconstruction with a digitally planned, prefabricated, free, vascularized fibula flap

Statement of problemOral rehabilitation after maxillectomy can be performed by prosthetic obturation or with a free fibula flap. Successful prosthetic obturation of large maxillectomy defects can be difficult, and masticatory function is at risk in these patients. Surgical reconstruction might provide adequate masticatory function, but the literature is lacking evidence regarding this topic. PurposeThe purpose of this pilot clinical study was to assess masticatory functions and health-related quality of life (HR-QoL) outcomes in patients after maxillectomy reconstructed by using the Rohner or the Alberta Reconstructive Technique and to compare outcomes with patients rehabilitated with an obturator prosthesis. Material and methodsMixing ability, maximum occlusal force, maximum mouth opening, and HR-QoL were assessed. Differences between the 2 groups were analyzed by using the Kruskal-Wallis tests for continuous variables and chi-squared tests for categorical variables. ResultsThe reconstructed patients (n=11) showed better mixing ability, occlusal force (nonoperated side), and overall mean HR-QoL. The nonreconstructed group (n=13) did not differ from the reconstructed groups in terms of maximum mouth opening, overall mean occlusal force, occlusal force on the operated side, and most HR-QoL questionnaire domains. ConclusionsMaxillary reconstruction might be beneficial for masticatory performance in patients undergoing maxillectomy. A larger study is justified to support the possible benefit of the reconstruction of maxillary defects regarding mixing ability, occlusal force (nonoperated side), and HR-QoL.

Mandibular Vertical Height Augmentation in Segmental Defects Using Combined Vascularized and Non-Vascularized Fibula Flap

Mandibular Vertical Height Augmentation in Segmental Defects Using Combined Vascularized and Non-Vascularized Fibula Flap

Fibula Free Flap in Reconstruction of Mandibular Defects

Purpose: To study a series of cases where vascularised fibula flap was used in mandibular defect. Patients and Method: The investigators designed a retrospective study composed of patients with any pathology or defect who underwent reconstruction of mandible with vascularised fibula free flap from 2014 to 2018. All patients were evaluated for age, gender, location and type of defect, incorporation of adjoining skin paddle and muscle, number of fibula osteotomies, ischaemia time, anticoagulant regimen, length of hospital stay, flap failure rate, dental implant rehabilitation. All patients with a minimum follow-up of 6 months post-operatively, were included in this study. Results: The study sample composed of 8 patients with average age of 40 years. Immediate reconstruction done in all patients. In two patients, the fibula was double barrelled. Skin island was included with the fibula in all patients. Two patients underwent dental rehabilitation using implantswith double barrel reconstructions. Hematoma at the recipient site was the commonest post-operative complication, although itsfrequency was low. A low donor site morbidity was seen. Average stay in hospital was about 10 days. Post-operatively all patients ambulated normally and none used assisted devices. A reconstruction plate was used to achieve the ideal contour of the jaw in most cases. Aesthetic results were usually good, especially in young patients. The overall success rate was good. Conclusion: The fibula has many assets which make it the ideal choice for bony reconstruction of mandible skeleton and adjoining soft tissue with predictable results.

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.

Development and validation of a nomogram incorporating selected systemic inflammation-based prognostic marker for complication prediction after vascularized fibula flap reconstruction

ObjectiveTo develop and validate a nomogram incorporating systemic inflammatory markers (the Albumin/NLR Score [ANS]) to predict postoperative complications after vascularized fibula flap reconstruction. Patients and methodsA total of 238 patients who underwent vascularized fibula flap reconstruction between March 2012 and December 2016 were collected as the primary cohort. Univariable and multivariable analysis were performed to identify independent risk factors for postoperative complications. Backward stepwise logistic regression analysis was then applied with and without the ANS; and nomograms were established based on these criteria. Independent validation of these nomograms was carried out in an independent validation cohort including 106 consecutive patients from December 2016 and January 2018. ResultsRadiotherapy history (odds ratio [OR] = 0.336; 95% CI, 0.157–0.717; P = 0.005), the ANS (OR = 0.248; 95% CI, 0.093–0.661; P = 0.005) and fluid infusion rate over 24 h (OR = 0.671; 95% CI, 0.479–0.94; P = 0.02) were identified as independent risk factors for postoperative complications. A higher C-index was found in both the primary (0.759; 95% CI, 0.719–0.739) and validation cohort (0.704; 95% CI, 0.613–0.659) for the nomogram incorporating the ANS, and NRI was 0.496 (95% CI, 0.072–0.920; P = 0.022) comparing of these nomograms. Furthermore, a wider threshold probability (0.2–0.9) and superior clinical value were observed in the nomogram incorporating the ANS on the decision curve. ConclusionThe ANS was an independent risk factor for postoperative complications associated with vascularized fibula flap reconstruction. The nomogram incorporating the ANS was established with better accuracy and showed more potential clinical benefit for the estimation of postoperative complications.

Pediatric extremity bone sarcoma reconstruction with the vascularized fibula flap: Observational study assessing long-term functional outcomes, complications, and survival

BackgroundLimb salvage is important in pediatric patients with bone sarcomas. The vascularized fibula flap is a versatile option, combined or not with a bone allograft. The authors evaluated the functional long-term outcomes, complications, and survival of using this technique in pediatric patients. MethodsA retrospective review of 27 pediatric patients reconstructed between 2011 and 2018 with the fibula flap after bone sarcoma resection was conducted. Long-term functional outcomes, complications, and survival were assessed. Variables analyzed were age, sex, Capanna technique, follow-up, complications, additional surgeries, time to weight bearing, length discrepancy, and sport practice. ResultsTwenty-seven patients with a mean age of 9.3 years were included. The mean follow-up was 44.33 months. The Capanna technique was performed in 15 patients. All extremities but one were salvaged. The overall complication rate was 74.07%. Fibula fracture and nonunion rates were 34.04% and 11.11%, respectively. Partial weight bearing was resumed at a mean of 9.07 months. About 79.17% of patients with a 12-month follow-up achieved full weight bearing.An age below 8 years was significantly associated with a lower major complication rate and a shorter time to weight bearing and full weight bearing. Major complications and additional surgeries were significantly associated with longer periods until weight bearing and full weight bearing. ConclusionsThe fibula flap allows the majority of extremities to be reconstructed. However, a high rate of complications and additional surgeries should be anticipated. Full weight bearing is usually achieved within the first year, with modest functional increase afterward. Less complications and a faster functional recovery are expected in patients below the age of 8 years.

Combined Massive Allograft and Intramedullary Vascularized Fibula as the Primary Reconstruction Method for Segmental Bone Loss in the Lower Extremity: A Systematic Review and Meta-Analysis.

Reconstruction of segmental bone loss due to malignancy, infection, or trauma is a challenge for the reconstructive surgeon. The combination of a vascularized fibular flap with a cortical allograft provides a reliable reconstructive option in the lower extremity. In this systematic review, we describe the outcome of this technique for the treatment of segmental bone loss. A systematic review was performed on the use of a combined massive allograft and intramedullary vascularized fibula as a reconstruction method for large bone defects. We used PubMed, Embase, and the Wiley Cochrane Library. Seventeen clinical articles were included between 1997 and 2017, reporting 329 cases of lower-extremity reconstructions. A meta-analysis was performed on primary union rates. The main outcome measures were primary union rate, complication rate, reintervention rate, and function after reconstruction. All publications showed relatively high complication (5.9% to 85.7%) and reintervention rates (10% to 91.7%) with good primary union rates (66.7% to 100%) and functional outcome (range of mean Musculoskeletal Tumor Society [MSTS] scores, 24 to 29 points). The combination of a massive allograft with intramedullary vascularized fibula provides a single-step reconstruction method for large bone defects (>6 cm) in the lower extremity, with good long-term outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term behavior of the vascularized fibular free flap for reconstruction of bony defects in children

Bony resection in children presents a unique reconstructive challenge because of future growth potential. To achieve limb salvage and provide the patient with a functional extremity, vascularized free fibula transfer has become the workhorse for bony reconstruction. The authors present their reconstructive experience using vascularized fibula flaps in a group of pediatric patients. This is a monocentric, retrospective study of 25 pediatric patients who underwent reconstruction of bony defects with a vascularized fibula flap from 2004 to 2017. Perioperative and long-term complications were noted. Functional outcomes were analyzed. Twenty-five patients with a mean age of 10 years were included. The etiology was tumor for 21 of them and 4 had neurofibromatosis. Median follow-up was 86 months. Overall, survival was 92 percent and flap survival was 100 percent. Perioperative surgical complication rate was 32 percent. The overall union rate was 87 percent following supplemental bone grafting. 67 percent of the lower limb fibula presented hypertrophy, with a mean hypertrophy of 154 percent. Median time to union was 15 months. Leg-length discrepancy was present in 5 patients. Mean Musculoskeletal Tumor Score was 23. Vascularized fibula free flap is the ideal material for long bone reconstruction with a definitive result. It allows children with early ambulation, provides good functional outcomes and improve their quality of life.

Free Fibular Flap in Mandibular Defect Reconstruction in Perspective of a Tertiary Care Hospital of Bangladesh

Introduction:The principal objectives of reconstruction after mandible resection are to restore physiological articulation, chewing, swallowing functions and esthetics of the patient. Metal plate and bone graft are usually used to achieve this purpose.From the point of view of bone resorption and augmented exposure to infection, free vascularized fibular flap (FFF), comprising alive bone, have shown a lower infection rate and high rate of success.
 Materials and Methods: The study population of this clinical report included undertaking mandibular reconstruction by transplantation of a free vascularized fibular flap at the Department of Oral and Maxillofacial Surgery at the Dhaka Dental College between May 2014 to November 2014. The factors consider for studying were as following- age, sex, primary disease , period of reconstruction, mandibular defect classification, mandible resection range, height of reconstructed mandibular bone, number of locations of mandible osteotomy, vascular anastomosis and complication.
 Results: Primary disease comprised one was ameloblastoma, one was recurrent ameloblastoma, and another was post-surgical facial deformity. According to the CAT classification body was the most commonly observed defect. All mandibular bones were left as single barrel. There were 2 cases of primary reconstruction and 1 of secondary reconstruction. Free fibular flap ranges from 12-18 cm. No postoperative complications were seen in any case.
 Conclusion: Vascularized fibular flap is good choice in wide-range faults hard to fill with an iliac block graft. Further studies including greater samples of patients undertaking fibular bone transplantation are needed to comparatively investigate its merits in more detail.
 Medicine Today 2019 Vol.31(2): 80-84

3D virtual planning for vascularized fibula flap for mandibular reconstruction after ressection of ameloblastoma

3D virtual planning for vascularized fibula flap for mandibular reconstruction after ressection of ameloblastoma

IS OBESITY A RISK FACTOR FOR FREE VASCULARIZED FIBULAR FLAP COMPLICATIONS?

ABSTRACTObjective:Although our knowledge of bone reconstruction through microsurgery has increased, the vascularized fibula flap remains one of the most difficult free flap reconstructions to perform, and complications remain a challenge. The incidence of obesity is increasing and is associated with higher rates of free flap complications, which can lead to disastrous results. Since there is no consensus in literature regarding the influence of obesity on free flap outcomes in orthopedic surgeries that require segmental bone reconstruction, the objective of this study was to determine whether obesity increases the risk of post-operative complications (Clavien-Dindo grade III) after free vascularized fibular flap surgery.Methods:A cohort study was conducted in all patients undergoing free flap limb reconstructions between July 2014 and July 2018. Patients were separated in two groups based on their body mass index (BMI): non-obese and obese (BMI≥30 kg/m2).Results:Twenty-three free vascularized fibular flaps were studied. The indications included trauma in 13, tumors in 7, and congenital pseudarthrosis of the tibia in 3. Obese patients were associated with an increase in surgical complications (p=0.038). During the final follow-up, consolidation was obtained in 17 patients (74%).Conclusion:Obesity is a risk factor for complications in free vascularized fibular flap surgery. Level of evidence IV, original article.

Treatment of Complex Infected Non-union of Bone of the Upper Extremity by a Staged Approach: Debridement and Antibiotic Cement Followed by a Vascularized Free Fibula Flap

Background: Infected non-union of bone of the upper extremity remains a difficult problem to treat with limited options. Management must address chronic osteomyelitis and skeletal instability caused by the non-union. We present our experience with a staged approach in five patients. Methods: The study cohort consisted of five males with an average age of 38 years and 4 prior procedures for infected non-union of the humerus (1) radius(1), ulna(1), ulna and radius(1) and metacarpal(1). The first stage consisted of aggressive debridement of all infected devitalized bone, bone cultures, removal of hardware, placement of antibiotic impregnated cement and stabilization with an external fixator (4 of 5 patients) followed by culture specific antibiotics. This was followed by definitive reconstruction using a free vascularized fibular flap and a course of post-operative antibiotics. Results: The average bony defect measured 8.6 cm. All flaps survived, one required re-exploration for venous thrombosis 72 hrs post-operatively and was successfully salvaged with a re-do anastomosis using a vein graft. The average time to bony union was 14 weeks. There was one hypertrophic non-union from proximal hardware failure which required repeat surgical intervention. At an average of 5.1 years follow-up all patients remain infection free and were working. Conclusions: A stage approach to the treatment of infected non-union of bone consisting of aggressive debridement, antibiotic cement, culture specific antibiotic followed by a vascularized fibular transfer is an effective treatment to a complex problem with limited alternatives. Keywords: Infected non-union of bone, Osteomyelitis, Microsurgery, Antibiotic cement, Free vascularized fibula flap.

Vertical distraction osteogenesis of a reconstructed mandible with a free vascularized fibula flap: a report of two cases

BackgroundThe free vascularized fibula flap presents many advantages such as sufficient length of the bony segment, good vascularization, better quality of the bone, and a long vascular pedicle, but it is also associated with some disadvantages with regard to prosthetic rehabilitation because of its limited height. Improvement in bone height is necessary for ideal dental implant treatment of reconstructed mandibles.Case presentationFor two squamous cell carcinoma patients, mandibular bone reconstruction was performed secondarily with the peroneal flap after tumor resection. Since the bone height was insufficient at the time of implant treatment, occlusion reconstruction by dental implant was performed after vertical distraction osteogenesis.ConclusionsVertical distraction osteogenesis is a suitable treatment option for alveolar ridge deficiency resulting from fibula transplantation for mandibular reconstruction following tumor surgery.

Virtual planning and 3D printing modeling for mandibular reconstruction with fibula free flap

Objective: To evaluate the use of virtual planning and 3D printing modeling in mandibular reconstruction and compare the operation time and surgical outcome of this technique with conventional method. Methods: Between June 2013 and June 2017, A total of 18 patients underwent the mandibular reconstruction with fibula free flap in the Affiliated Hospital of Qingdao University.Among 18 patients, there were 11 males and 7 females with an average age of 36.5 years (21-73 years). Nine patients underwent vascularized fibula flap mandibular reconstruction using virtual planning and 3D printing modeling.Titanium plates were pre-bent using the models and cutting guides which were used for osteotomies.Another 9 patients who underwent mandibular reconstruction using fibula flap without aid of virtual planning and 3D printing models were selected as control group. The operation time was recorded and compared in two groups. Accuracy of reconstruction was measured by superimposing the preoperative image onto the postoperative image of mandible. The selected bony landmark, distance and angle were measured. Results: The mean total operation time were 4.7-6.2(5.5±0.5) h in computer-assisted group and 5.6-7.5(6.6±0.7) h in conventional group, respectively. The operation time was shorter in computer-assisted group. The difference between the preoperative and postoperative intercondylar distances, intergonial angle distances, anteroposterior distances were(2.6±1.4)vs(4.4±1.6)mm, (2.9±1.2)vs(4.7±1.7)mm, (4.2±1.4) vs(5.9±1.8)mm in the computer-assisted and conventional group, respectively. The differences between the preoperative and postoperative mandible were smaller in the computer-assisted group. Conclusions: Virtual planning and 3D printing modeling have the potential to increase mandibular reconstruction accuracy and reduce operation time. We believe that this technology for mandibular reconstruction in selected patients can significantly improve the quality of reconstruction.

Virtual Planning and 3D printing modeling for mandibular reconstruction with fibula free flap.

BackgroundThis study was to evaluate the use of virtual planning and 3D printing modeling in mandibular reconstruction and compare the operation time and surgical outcome of this technique with conventional method.Material and MethodsBetween 2014 and 2017, 15 patients underwent vascularized fibula flap mandibular reconstruction using virtual planning and 3D printing modeling. Titanium plates were pre-bent using the models and cutting guides were used for osteotomies. 15 patients who underwent mandibular reconstruction using fibula flap without aid of virtual planning and 3D printing models were selected as control group. The operation time was recorded and compared in two groups. Accuracy of reconstruction was measured by superimposing the preoperative image onto the postoperative image of mandible. The selected bony landmark, distance and angle were measured.ResultsThe mean total operation time and reconstruction time were 1.60±0.37 and 5.54±0.50 hours in computer-assisted group, respectively; These were 2.58±0.45 and 6.54±0.70 hours in conventional group, respectively. Both operation time and reconstruction time were shorter in computer-assisted group. The difference between the preoperative and postoperative intercondylar distances, intergonial angle distances, anteroposterior distances and gonial angles were 2.92±1.15 and 4.48±1.41mm, 2.93±1.19 and 4.79±1.48mm, 4.31±1.24 and 5.61±1.41mm, 3.85±1.68° and 5.88±2.12° in the computer-assisted and conventional group, respectively. The differences between the preoperative and postoperative mandible is smaller in the computer-assisted group.ConclusionsVirtual planning and 3D printing modeling have the potential to increase mandibular reconstruction accuracy and reduce operation time. we believe that this technology for mandibular reconstruction in selected patients will become a used method and improve the quality of reconstruction. Key words:Mandibular reconstruction, fibula flap, virtual planning, computer-assisted design, 3D printing.

Stereolithographic model-assisted reconstruction of the mandibular condyle with a vascularized fibular flap following hemimandibulectomy: Evaluation of morphological and functional outcomes.

The vascularized fibular flap is one of the standard treatment choices for the reconstruction of the mandible; however, the consequences of condylar restoration have not previously been reported. The use of three-dimensional models allows for a more predictable reconstruction. The purpose of the present study was to assess the outcome of stereolithographic model-assisted reconstruction of the mandibular condyle with a vascularized fibular flap. A total of 5 patients underwent mandibular resection including the condyle and immediate reconstruction with a vascularized fibular flap. A stereolithographic model was used to determine the length and angle of the bony reconstruction. In all patients, the temporomandibular joint (TMJ) disc was preserved, and the contoured fibular end was placed directly into the glenoid fossa under the TMJ disc. To investigate the morphological and functional outcomes, radiographic and clinical examinations were performed, and a food scale questionnaire was administered. The mean period of follow-up was 23 months, and all the flaps were viable. Cosmetic results were generally satisfactory. Radiographic assessment revealed that the end of the fibular graft became round-shaped. None of the patients had abnormal bone resorption, dislocation or ankylosis. The mean value of maximum mouth opening was 31 mm. No patients exhibited difficulties with occlusion. All patients recovered their ability to ingest nearly the same foods that were ingested prior to surgery. The stereolithographic model-assisted reconstruction of mandibular condyle with a vascularized fibular flap is therefore useful for morphological and functional reconstructions of the hemimandible, including condylar defects.

Fibular osteocutaneous free flap reconstruction of the mandible after resection of ossifying fibroma in a seven-year old child

Ossifying fibromas (OSF) belong to a group of benign fibro-osseous neoplasms encountered almost exclusively in the craniofacial skeleton. The clinical course is typically asymptomatic. However, discomfort in the mouth begins to develop once the neoplasm progressively extends, causing an overgrowth of bone resulting in pain and facial asym­metry. The development of craniofacial bone tumors in children is quite a rare occurrence. In international medical literature, the described cases typically involve young adolescent patients, with very few case reports of craniofacial neoplasms in children under the age of seven [1, 2]. In the current case report, we present a seven-year-old patient with a biopsy-proven ossifying fibroma. The patient underwent a resection of the neoplasm with reconstruction. One of the major issues encountered in reconstruction of the mandible using a vascularized fibular flap in children is the growth potential of the fibula in comparison to the mandible, resulting in a symmetrical facial image. The use of a fibular osteocutaneous free flap in reconstruction of mandibular deficits in children is a favourable solution. The use of this type of flap permits functional restoration and significantly improved facial cosmesis. The union of the mandible with the integrated fibula is still a topic of ongoing discussion and one must be prepared for possible further orthognathic procedures after completing the growth of the craniofacial skeleton.

Computer-aided surgery technique in jaw reconstruction with vascularised fibula flap

Computer-aided surgery technique in jaw reconstruction with vascularised fibula flap

A Case of Implant Treatment by Guided Surgery with the Addition of Bone Graft to Post-Maxillectomy Vascularized Fibula Flap

A Case of Implant Treatment by Guided Surgery with the Addition of Bone Graft to Post-Maxillectomy Vascularized Fibula Flap

Non-vascularised iliac crest bone graft for immediate reconstruction of lateral mandibular defect.

Mandibular defect reconstruction is extremely important to achieving an improved quality of life of patients as this bony defect influences facial harmony and aesthetics. Reconstruction of mandibular defects at our centre comprises use of reconstruction plate, non-vascularised anterior iliac crest graft and vascularised fibula flap. Despite the large mandibular defect recorded in our developing environment, non-vascularised iliac crest graft continues to play a role in its exclusive use for lateral mandibular defects. The aim of this study was to analyse the role, complications and outcomes of the use of non-vascularised iliac crest graft for mandibular reconstruction in a free flap-enabled centre. This was a retrospective case cohort from study institution's records of mandibular reconstruction following mandibular surgery for benign tumours. Eligibility for study inclusion comprised case cohort with head and neck diseases requiring mandibular surgery and reconstruction with either reconstruction plate, non-vascularised iliac crest graft or vascularised fibula flap. A total of 18 subjects underwent iliac crest grafting. Of the 18 subjects with iliac crest graft, 7 (39%) were females while 11 (61%) were males. Ten of the 18 subjects with iliac crest grafting were diagnosed with ameloblastomas. Six (33.3%) subjects had class H (Jewer's classification) mandibular defect. The average graft length was 5.4cm and height was 2.3cm. Three cases experienced graft site complications of which two grafts were lost. All 18 cases experienced good to acceptable clinical outcomes. Predictors of graft outcome were not statistically significant. Despite our small sample size, it is suggestible that non-vascularised iliac crest graft be considered for lateral mandibular defect reconstruction, considering the reduced graft failure rate and satisfactory clinical outcomes from this study.