Qualitative and Quantitative Analyses of Donor-Site Morbidity following Suprafascial versus Subfascial Free Fibula Flap Harvesting:

Planning of physiotherapeutic procedure in patients after mandible reconstruction taking into account donor site: a literature review

BACKGROUND

Mandible tumors are very rare. One of the main methods of the treatments is resection of the tumor and then reconstruction of the mandible. The donor site is often distant tissue-fibula or ilium. Following this, it is necessary to improve the patient in two ways, on one hand restoring the function of the mandible, and on the other hand, improving the donor site area. For that reason, physiotherapy after tumor resection and reconstruction of the mandible is very complicated. The aim of this bibliographic review was to find the methods of the reconstruction of the mandible in the context of patients' functional assessment after surgeries to create effective physiotherapeutic procedures in the feature.

METHODS

PEDro, Medline (PubMed), Cochrane Clinical Trials were searched.

RESULTS

767 articles were found. 40 articles were included to this literature review.

CONCLUSIONS

Authors showed different kinds of surgeries strategy for patients with tumors of the mandible. They also showed manners of patients' functional assessment in the localization of transplantation and donor site. It could be useful for physiotherapists during planning of comprehensive physiotherapy.

Planes for Perforator/Skin Flap Elevation-Definition, Classification, and Techniques

BACKGROUND

 Elevation in different layers achieving thin flaps are becoming relatively common practice for perforator flaps. Although postreconstruction debulking achieves pleasing aesthetic results and is widely practiced, customized approach during elevation to achieve the ideal thickness will increase efficiency while achieving the best possible aesthetic outcome. Multiple planes for elevation have been reported along with different techniques but it is quite confusing and may lack correspondence to the innate anatomy of the skin and subcutaneous tissue.

METHODS

 This article reviews the different planes of elevation and aims to clarify the definition and classification in accordance to anatomy and present the pros and cons of elevation based on the different layers and provide technical tips for elevation.

RESULTS

 Five different planes of elevation for perforator flaps are identified: subfascial, suprafacial, superthin, ultrathin, and subdermal (pure skin) layers based on experience, literature, and anatomy.

CONCLUSION

 These planes all have their unique properties and challenges. Understanding the benefits and limits along with the technical aspect will allow the surgeon to better apply the perforator flaps.

An objective analysis of composite free flap donor site morbidity in head and neck surgery: Prospective series

BACKGROUND

A poor evidence basis exists regarding the objective donor site morbidity associated with osseous free flap harvest. This study prospectively assessed the objective donor site morbidity associated with osseous free flap harvest for the fibula, scapula, and iliac crest (DCIA) donor sites.

METHODS

A single-site, prospective cohort clinical research study was conducted. Sixty-four patients were recruited between 2017 and 2021. Patients were assessed using a donor site specific assessment tool pre-operatively, and again >12 months post-operatively.

RESULTS

There was a significant reduction post-operatively in assessment tool scores compared to the pre-operative period for the fibula, scapula and DCIA. Females were more likely to report a greater reduction in Harris Hip Score post-operatively compared to males.

CONCLUSIONS

The fibula, scapula, and DCIA donor sites are associated with reduced objective function post-operatively compared to patient's pre-operative baseline. The implications are least pronounced for the fibula.

Myofascial iliac crest flap for reconstruction of combined oral mucosa-mandibular defects: A single-centre experience

BACKGROUND

Deep circumflex iliac artery (DCIA) myofascial iliac crest flap has been used for combined oral mucosa-mandibular defects reconstruction. The bone component of this composite flap can reconstruct the mandible with superior contour match, and the muscle fascia which used for repairing the oral mucosa defect will transform into an oral mucosa-like appearance. To explore its scope of clinical application and how the fascia transformed into oral mucosa will give surgeons flexibility to reconstruct the combined oral mucosa-mandibular defects.

METHODS

A retrospective review of 18 patients who received combined oral mucosa-mandibular defects reconstruction with DCIA myofascial iliac crest flaps from Dec 2016 to Dec 2020 was performed. The characteristics of the mandibular defects and the flaps were recorded. The postoperative dynamic changes of one graft's fascia were observed from serial photographs.

RESULTS

All myofascial iliac crest flaps survived successfully. The bone grafts were from 4.0 to 9.5 cm (mean 7.6 ± 1.5 cm) in length and from 2.0 to 3.5 cm (mean 2.7 ± 0.4 cm) in height. The sizes of fascia were from 13.5 to 48.0 cm² (mean 27.2 ± 9.4 cm²). The grafted fascia firstly changed into a yellow pseudomembrane-like appearance, and then experienced muscle oedema before finally transformed into an oral mucosa-like appearance at about 60 days after operation.

CONCLUSION

Myofascial iliac crest flap is a good option for reconstruction of combined oral mucosa-mandibular defects because of its excellent bone and oral mucosa matches.

Donor site morbidity of composite free flaps in head and neck surgery: a systematic review of the prospective literature

Composite free flaps represent the cornerstone for the repair of osseous defects in the head and neck. For many patients, there are often multiple defect-suitable donor sites that may be utilised as part of the reconstructive process. Therefore, to optimise patient outcomes, an evidence-based approach to donor site selection is required to maximise quality of life and long-term functionality. A systematic review of the literature was conducted in accordance with PRISMA guidelines to evaluate the evidence for donor site selection based on minimising the associated donor site morbidity and optimising patient functionality postoperative. The fibula is associated with the greatest potential risk for wound healing complications. Fibula and scapula harvest has the potential to have a significant impact on physical performance. The iliac crest is most favourable in terms of aesthetic scar healing outcomes. Overall, however, the quality and quantity of evidence for all donor sites is limited. Each site is associated with specific complications and morbidity, of which the surgeon and patient must both be aware. Whilst a cross-sectional informed opinion of the likely advantages/disadvantages of one donor site over another can thus be made, there are few head-to-head studies available that directly compare donor sites.

Long-term donor site morbidity in head and neck cancer patients and its impact on quality of life: a cross-sectional study

Modern head and neck reconstructive surgery offers a multitude of different reconstructive options. In such cases, donor site morbidity is an important factor in the affected patient's decision-making. The aim of this study was to perform an objective comparison of donor site morbidity for the five most frequent microvascular donor sites in head and neck reconstructive surgery (radial forearm, anterolateral thigh, fibula, iliac crest, and scapula) using a uniform testing system. In this cross-sectional study, 117 donor sites were analyzed (106 for malignant disease and 11 for non-malignant disease): 73 radial forearm, 14 scapula, 12 anterolateral thigh, 10 fibula, and eight iliac crest. Testing consisted of range of motion, muscle strength, and sensation. The non-affected side served as the control. Quality of life was assessed using the Washington Quality of Life Questionnaire version 4 in its German translation. Range of motion was restricted in 15 cases (12.8%). Muscle strength was decreased in 58 cases (49.6%). Sensation was reduced in 70 cases (60%). Concerning quality of life, 31.2% of patients were limited in their daily activities. The scapula flap showed the highest incidence of overall donor site morbidity. However, correlation between objective and subjective donor site impairment was weak and the majority of patients experienced only minor limitations.

Osteocutaneous flaps for head and neck reconstruction: A focused evaluation of donor site morbidity and patient reported outcome measures in different reconstruction options

With significant improvements in success rates for free flap reconstruction of the head and neck, attention has turned to donor site morbidity associated with osteocutaneous free flaps. In this review, we address the morbidity associated with harvest of the four most commonly used osteocutaneous flaps; the free fibula flap, the scapula flap, the iliac crest flap and the radial forearm flap. A comprehensive literature search was performed to identify articles relevant to donor site morbidity for these flaps. We assessed morbidity in terms of incidence of delayed healing, chronic pain, aesthetic outcomes, site specific complications and patient satisfaction/quality of life. Weighted means were calculated when sufficient studies were available for review. The radial forearm and free fibula flaps are associated with high rates of delayed healing of approximately 20% compared to the scapular (<10%) and iliac flaps (5%). The radial forearm flap has higher rates of chronic pain (16.7%) and dissatisfaction with scar appearance (33%). For the majority of these patients harvest of one of these four osteocutaneous does not limit daily function at long-term follow-up. The scapular osteocutaneous flap is associated with the lowest relative morbidity and should be strongly considered when the recipient defect allows. The radial forearm is associated with higher morbidity in terms of scarring, fractures, chronic pain and wrist function and should not be considered as first choice when other flap options are available.

Subjective morbidity following fibular free flap reconstruction in head and neck cancer patients

OBJECTIVE

This study aimed to evaluate the presence of subjective post-operative donor site morbidity after fibula free flap reconstruction in head and neck cancer patients, utilising three validated instruments: the 36-item Short Form Health Survey, the Short Musculoskeletal Function Assessment questionnaire and the Lower Limb Core Scale.

METHODS

In this retrospective study, all head and neck cancer patients who underwent fibula free flap reconstruction between January 2009 and July 2014 were identified. All questionnaires and their respective subcomponents were scored.

RESULTS

Twenty-one cases were included. Patients were found to have a higher Short Musculoskeletal Function Assessment bothersome index (22.42 vs 13.77, p = 0.03), a lower Short Form 36 Health Survey Physical Component Summary score (42.44 vs 50, p < 0.01) and a decreased Lower Limb Core Scale score (47.08 vs 90.52, p < 0.01), compared to US population norms. The Short Form 36 Health Survey Mental Component Summary scores and Short Musculoskeletal Function Assessment function index failed to demonstrate significant differences. Gender affected overall disability.

CONCLUSION

In this study, significant long-term disability was demonstrated after fibular flap reconstruction, as measured by the Lower Limb Core Scale.

Star excursion balance test for assessment of dynamic instability of the ankle in patients after harvest of a fibular free flap: a two-centre study

We aimed to show that the star excursion balance test can identify instability in the ankle of patients who have had harvest of a fibular free flap. We compared the reach distance of the operated leg against that of the non-operated leg in 26 patients who had had harvest of the flap over a period of three years from August 2009 at two different centres. The goal of the test is to reach as far as possible with one leg in eight directions while balancing on the other. We also assessed the overall function of the operated leg using the Foot and Ankle Disability Index (FADI) and the American Orthopaedic Foot and Ankle Score (AOFAS). The star excursion balance test is simple and cheap, and is quick and easy to do in the outpatient department.

A critical assessment of the fibula flap donor site

BACKGROUND

The free fibula flap has become popular for mandibular reconstruction. The purpose of this study was to propose comprehensive functional assessments of the donor site.

METHODS

Thirty free fibula flaps for mandible reconstruction were prospectively enrolled in the study. Objective assessments included isokinetic testing of the ankle joint, electromyographic examination of the superficial peroneal nerve (SPN), and preoperative and postoperative foot scans. The Patient and Observer Scar Assessment Scale (POSAS) was used to subjectively assess the donor site.

RESULTS

The isokinetic values of the donor side showed a significant decrease 1 year postoperatively. The results of the electromyographic test of the SPN were categorized as 3 types. The plantar center pressure shifted to the heel on the donor side 6 months postoperatively. The aesthetic outcome was satisfactory.

CONCLUSION

The functional parameters of the donor site indeed declined in our assessments. Further refinements in the surgical technique are needed to improve the donor site status. © 2016 Wiley Periodicals, Inc. Head Neck 39: 279-287, 2017.

Long-term donor-site morbidity after vascularized free fibula flap harvesting: Clinical and gait analysis

The aim of this study was to determine the clinical morbidity and changes in gait temporal spatial parameters after harvesting of a vascularized free fibula flap. This study included 11 patients (mean age: 52 ± 17 years) and 11 healthy controls (mean age: 50 ± 14 years). The patients were assessed between 5 and 104 months post surgery. The study consisted of a subjective functional evaluation with two validated clinical scores (Kitaoka Score and Point Evaluation System (PES) score), clinical and neurological examination of the legs, and evaluation of gait temporal spatial parameters while walking at a comfortable speed. The mean functional Kitaoka score was 78/100, and the mean PES score of 12.18 was considered average. At the time of the review, five patients had sensory disorders, two had toe deformities, and eight had pain at the donor site. The gait analysis showed that the patient's comfortable walking speed was significantly lower in comparison to that of the controls, and that stride length and cadence were reduced. In addition, most of the gait-specific parameters were significantly different. The donor leg displayed greater variability during walking. To reduce the risk of falling, this study revealed that the patients' gait pattern had changed as they took a more cautious approach during walking. Early rehabilitation is expected to help improve and/or restore the physical abilities of patients after harvesting of the vascularized free fibula flap.

Risk Factors for Early and Late Donor-Site Morbidity After Free Fibula Flap Harvest

PURPOSE

This article reports on the incidence of donor-site complications and identifies predictive factors for early and late donor-site complications.

MATERIALS AND METHODS

From January 2007 through December 2012, 45 patients underwent free fibula flap reconstruction and their medical records were reviewed. They were asked to complete a questionnaire on the operated leg and they were evaluated for ankle stability and ambulatory status.

RESULTS

One patient (2.2%) developed a complication owing to a hematoma, but no other patients had any complications. During the risk factor analysis, no domain was found to be statistically associated with early morbidity; late dysfunction was noted in 20 patients (57.1%), and of these cases, at least 2 symptoms were found in 10 patients (50%). The most common complication was numbness followed by toe contracture and abnormal ambulatory movement. During the risk analysis, the following domains affected late donor-site morbidity: harvested fibula length, operation time, and follow-up time. Furthermore, in cases with complications, patients with the osteocutaneous fibula flap complained more than patients with the osseous flap (P = .07).

CONCLUSION

Early donor-site morbidity was uncommon, but late morbidity occurred frequently. Harvested fibula length, operation time, and follow-up time were statistically linked to postoperative function.

Donor-site morbidity after fibula free flap transfer: a comparison of subjective evaluation using a visual analogue scale and point evaluation system

The aims of this study were: (1) to compare the visual analogue scale (VAS) with the point evaluation system (PES) in the subjective evaluation of donor-site morbidity after fibula free flap transfer; (2) to compare the functional outcomes of fibula free flap surgery between patients with a normal body mass index (BMI) and patients with a high BMI, and between skin paddle and non-skin paddle harvesting; and (3) to determine the correlation between functional outcomes and related factors. This study included 15 patients who underwent a vascularized fibula free flap transfer for oral and maxillofacial reconstruction. Demographic data, preoperative, intraoperative, and postoperative data were collected. Subjective self-evaluation of functional outcomes was done using a VAS followed by a PES. Comparison of the VAS and PES scores was assessed with Pearson's correlation coefficient. The statistical significance was set at P<0.05. The VAS score was significantly correlated with the PES score (r=0.63, P=0.01). The tourniquet times for the skin paddle group were longer than for the non-skin paddle group (P=0.02), while the satisfaction score of the non-skin paddle group was higher than that of the skin paddle group (P=0.03). The VAS is a potential option for the subjective evaluation of donor-site morbidity after fibula free flap transfer.