Bilobed fibula flap for reconstruction of through-and-through oromandibular defects

Reconstruction of complex oro-mandibular defects by four different modifications of free fibula osteomyocutaneous flap: A prudent alternative to multiple flaps

INTRODUCTION

Resection of advanced oral squamous cell carcinoma results in complex oro-mandibular defects involving external skin, oral mucosa, and bone. Reconstruction of such defects by a single free fibula flap (FFF) is limited by the lack of soft tissue bulk and adequate skin paddle for both intra- and extra-oral coverage. In this study, the reconstruction of large defects was achieved by four modifications of free fibula osteomyocutaneous flap as an alternative to multiple flaps.

METHODS

In this prospective study, 29 patients with complex oro-mandibular defects were reconstructed by FFF from December 2018 to October 2020. Reconstruction was done with any one of the four FFF modifications involving large proximal skin paddle from lateral leg: Strip de-epithelialization (De-Ep), chimeric bipaddle (Ch-Bp), muscle orally and skin extra-orally (Mo-Se), and double microvascular (Db-Mi). Outcome variables assessed were functional and esthetic results, early/late complications, donor site morbidity, and operative time. An algorithm based on Cordeiro's classification is proposed to assist in the selection of appropriate FFF modification.

RESULTS

Among 29 patients, De-Ep was used in 13, Ch-Bp in 8, Mo-Se in 7, and Db-Mi in 1 case. None of the flaps underwent total loss. Two cases required re-exploration. The median operative time was 775 min. Wound dehiscence and oro-cutaneous fistula were common early and late complications, respectively. Partial split skin graft loss (SSG) was the most common donor site morbidity. Functional and facial aesthetics were acceptable at the end of follow-up.

CONCLUSIONS

Specific FFF modifications can be recommended in selected scenarios. It is reliable for single-stage reconstruction with satisfactory esthetic and functional outcomes. When used for reconstruction in first primary tumors, the second donor site is preserved, which can prove valuable in the event of a recurrence or second primary.

Strategy for preventing skin paddle necrosis in mandibular reconstruction with free fibula osteocutaneous flap

BACKGROUND

Non-thrombotic skin paddle necrosis occasionally occurs during mandibular reconstructions with free fibula osteocutaneous flaps. The number of perforators, size of the skin paddle, and ischemia time of the flap are considered as causes of skin paddle necrosis. The importance of donor side selection has also been highlighted. This study aimed to investigate the leading cause of skin paddle necrosis and the optimal reconstructive procedure.

METHODS

A total of 66 patients who underwent mandibular reconstruction using a free fibula osteocutaneous flap were retrospectively analyzed. Skin paddle necrosis, number of cutaneous perforators, size of the skin paddle, and ischemia time of the flap were investigated. An incorrect "laterality" was defined as a skin paddle (septum) covering the reconstruction plate. Donor-site morbidity was recorded.

RESULTS

Skin paddle necrosis occurred in 15.2% of patients. An incorrect laterality was associated with a higher incidence of skin paddle necrosis (odds ratio, 22.0; 95% confidence interval, 2.5-195; p = .005). Donor-site morbidity was noted in 18.8% of the patients, without any significant difference in terms of the donor side with and without skin graft (p = .592). The postoperative activities of daily living were not affected.

CONCLUSIONS

To prevent skin paddle necrosis, donor side selection is an important safety strategy during mandibular reconstruction with free fibula osteocutaneous flap. The postoperative activities of daily living were found to be little affected by differences in the donor side.

Applications of intraoperative angiography in head and neck reconstruction

Objective

Laser-assisted angiography with indocyanine green (LAIG) allows objective intraoperative evaluation of tissue vascularity. We endeavored to describe our experience with this technique in the head and neck region.

Methods

A retrospective review from February 2016 till October 2018 was conducted. We included patients who underwent head and neck procedures in which LAIG was employed. The main outcome was postoperative wound complications. We analysed the influence of LAIG results in intraoperative decision-making process.

Results

Nineteen patients were included, and follow-up was for at least 6 months. LAIG was employed in 11 local flaps, 9 free flaps and 6 cases of pharyngeal closure during total laryngectomies. Wound complications occurred in two cases with distal tip flap necrosis. LAIG findings resulted in changes in decision making intraoperatively in 84% of procedures, which consisted in trimming poorly perfused tissues. There were no pharyngocutaneous fistulas.

Conclusions

This represents a descriptive report on the use of LAIG on diverse head and neck reconstruction cases, with important impact on the decision-making process. A low number of postoperative wound complications were observed.

Resuming Oral Feeding in Patients With Oral Squamous Cell Carcinoma With Free Anterolateral Thigh Flap Reconstruction

BACKGROUND

Quality of life and functional improvement have emerged as important goals for patients with oncologic disease. For patients with head and neck cancer, free anterolateral thigh (ALT) flaps serve as reliable reconstruction and provide functional restoration. Nevertheless, factors affecting the resumption of oral feeding are rarely described. This study aimed to evaluate and compare the functional outcomes of oral feeding for patients with different oncologic defect patterns and reconstructive ALT flap designs.

METHODS

We retrospectively reviewed patients with head and neck cancer undergoing oncologic ablation and free ALT reconstruction between January 2016 and April 2018 at National Taiwan University Hospital. Patients were categorized into 2 groups as through-and-through (T&T) and non-through-and-through (non-T&T) according to the defect pattern. We further subgrouped T&T patients into lip resection/lip sparing according to lip involvement. Reconstructive ALT flaps were of 2 designs, folded (F-ALT) and chimeric (C-ALT). Outcomes of oral feeding were analyzed using descriptive statistics, and differences between groups were compared using the Student t test.

RESULTS

We identified 233 patients who received oncologic ablation and free ALT flap reconstruction. There was no significant difference in functional recovery between the T&T and non-T&T groups (81.2% vs 73%, P = 0.137). However, among patients who succeeded in resuming oral feeding, lip-sparing patients had better functional recovery in terms of early oral feeding within 6 months and nasogastric tube removal compared with lip-resection patients (100% vs 83.3%, P = 0.001). Moreover, the F-ALT design resulted in a higher success rate in resuming oral feeding compared with the C-ALT design (90.5% vs 54.6%, P = 0.032).

CONCLUSIONS

Patients with head and neck cancer with T&T defects were associated with higher rates of secondary flap revision and a trend of delayed oral feeding. In the long term, improved oral feeding outcome with the F-ALT design was observed compared with the C-ALT design in the specific group with T&T defect.

Free fibula flap in the reconstruction of mandible: a report of six cases

The defects secondary to surgical ablation of the mandible have far reaching consequences. Speech, respiration, mastication, deglutition and cosmesis are severely affected. Restoring these functions is a challenging task. Till the late eighties, myocutaneous flaps were the rule for mandibular reconstruction and free bone was used to restore bony continuity.In spite of the result being predictable the outcome left much to be desired. There was also a fairly regular crop of complications. Acceptable dental rehabilitation was almost non-existent. With the introduction of free flaps as a consequence of the development of the operating microscope, the field of reconstruction was revolutionized.The fibular free flap is especially suited for mandibular reconstruction. It provides adequate bone to re-establish bony continuity and also allows for the placement of osseointegrated implants.Here we present six of our cases, which underwent mandibular reconstruction with free fibula flaps and the current thoughts in literature on the reconstruction of the mandible with this technique.

Reconstruction of the through-and-through oral cavity defect with the fibula free flap

Objective: To evaluate our experience with reconstruction of anterior and lateral through-and-through defects of the oral cavity using the fibula osteocutaneous flap.

Study Design: Case series with chart review.

Methods: Review of patients undergoing reconstruction of through-and-through oral cavity defects between August 2006 and July 2008. Defect size, complications, and need for additional reconstruction were examined.

Results: Twelve patients were identified with through-and-through oromandibular defects reconstructed with the fibula. Soft tissue defects were successfully closed using a de-epithelialized segment to create two skin paddles. Four patients required additional pectoralis major flap reconstruction for secondary fibula skin loss (1), neck skin breakdown (1), delayed flap loss (1), and need for additional tissue for closure (1).

Conclusion: The versatility of the fibula for through-and-through defects of the oral cavity is underestimated, and in most cases it is appropriate to reserve second flaps for salvage reconstruction.

Clinical research in head and neck reconstruction

Reconstructive head and neck surgery is not unlike other surgical fields in its paucity of clinical research. Difficulties exist in the design and execution of surgical studies, and there are many challenges and limitations that must be addressed. In this article, the types of studies that make up head and neck reconstructive literature are reviewed, as well as the evolution toward the use of quality-of-life scales, which measure patients' satisfaction with their state of health and function.