Donor-Site Morbidity after Fibula Transplantation in Head and Neck Tumor Patients: A Split-Leg Retrospective Study with Focus on Leg Stability and Quality of Life

Neuropathic pain at the donor-site following free fibula flap harvest: A multicenter study

BACKGROUND

The free fibula flap (FFF) is widely used and considered the workhorse flap for osteocutaneous head and neck reconstruction. Donor-site morbidity is considered to be low and mild, and has therefore received little attention. Although sensory deficits and chronic pain have been reported in the donor-site, the incidence of neuropathic pain remains unclear. This study aimed to identify the incidence and prognostic factors associated with neuropathic pain at the donor-site following FFF harvest and investigate its impact on leg function and quality of life.

METHODS

In this multicenter, cross-sectional study, 150 patients who underwent FFF surgery between 2010-2020 were included. Baseline characteristics were collected. All patients received questionnaires to measure self-reported pain (Doleur Neuropathique 4 and visual analog scale Pain), leg function (Lower Extremity Functional Scale), and quality of life (EuroQol-5D). Multivariable regression analysis was used to identify prognostic factors associated with the outcomes.

RESULTS

A total of 82 patients completed the questionnaires. Neuropathic pain was present in 21% of the patients. Multivariable analysis revealed that donor-site complications (p=0.025) and younger age (p=0.003) were independently associated with neuropathic pain. No difference in neuropathic pain incidence was found between primary and skin graft closure (p=0.54). Patients with neuropathic pain showed a significantly poorer quality of life (p=0.01).

CONCLUSION

One-fifth of all patients experienced neuropathic pain at the donor-site following FFF harvest. Younger patients and patients with donor-site complications are more prone to developing neuropathic pain. Future research should focus on analyses of surgical factors and optimalization of wound care to reduce the incidence of neuropathic pain.

Total Anatomical Nasal Skeletal Reconstruction Using a New Autologous Graft: The Tent Shaped Fibular Contoured Bone Graft

BACKGROUND

Reconstruction of the bony nasal dorsum is a challenge due to the unique anatomy of the nasal bones. The nasal bones by virtue of their shape, angulation and size provide an aesthetic and pleasing contour of the upper nose. The anatomy of the nasal bones can get deformed in many situations like congenital anomalies, iatrogenic and post-traumatic situations leading to nasal deformity. Many options for reconstruction of nasal dorsum are available including soft tissue and bony material. It is always desirable to reconstruct like tissue with like tissue. This paper describes the use of a cored out tent shaped fibular graft for total reconstruction of the bony nose dorsum.

METHODS

A bony defect-appropriate full thickness segment of the fibula was harvested. This was contoured and cored out to mimic the appearance and angulation of the bilateral articulated nasal bones. The bone graft extends from the radix to the upper part of the lateral cartilage. This graft was inserted into a pocket created under the nasal dorsum to recreate the normal appearance and slope of the nose. The graft if needed may be fixed to the underlying bone using a screw.

RESULTS

A total of 20 patients with total destruction of the bony nasal vault were operated using this technique from 2017 to 2021. The average dimensions of a fibular graft are a length of 4.5 cm, a width of 12 mm and a thickness of 3 mm. Only 4 out of 20 patients required fixation with a screw. All patients reported significant improvement in the appearance and profile of their nose after surgery. The visual analogue scale revealed a Gaussian normal distribution curve (range, 0.5 to 10) with a significant improvement and p value <0.05. There has been an improvement in the mean nasofrontal and nasofacial angles postoperatively. The complications have been minimal and temporary.

CONCLUSION

The specially contoured fibular bone graft most closely mimics the natural shape and contour of the nasal bones and hence gives satisfactory results with minimal intraoperative manoeuvring and sculpturing and has natural stability owing to the unique shape that often obviates the need of fixation to the underlying skeleton. This type of graft is suitable in cases where total nasal reconstruction of the bony dorsum is desired.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Vascularized Bone Reconstruction for Recalcitrant Clavicular Nonunion: A Systematic Review of the Literature

PURPOSE

Clavicular nonunion is an uncommon complication with a significant impact on quality of life and can be difficult to manage. In recalcitrant cases, or situations unfavorable for take of nonvascularized grafts, vascularized osseous reconstruction may be utilized. Several donor sites for such flaps have been described, with each associated with unique benefits and drawbacks.

METHODS

A systematic review utilizing MEDLINE and Embase databases was performed for cases of vascularized bone reconstruction for clavicle nonunion.

RESULTS

Twenty-six papers met inclusion, comprising 67 patients. Mean age was 43.1 years, across 32 male and 35 female patients. Mean period of nonunion was 43.2 months in the fibular group, 42.0 months in the medial femoral condyle (MFC), and 12 months in the rib flap group. Patients had undergone a mean of 2.67 prior operations at the time of vascularized osseous flap; a proportion of patients had undergone prior locoregional radiotherapy (9/26) or been complicated by infection (12/22). Radiological union was achieved in 95.2% (20/21) of fibular flaps, 95.6% (25/27) of MFC flaps, and 66.7% (2/3) of rib flaps. Mean time to union was 10.6 months for the fibular group, 7.8 months for the MFCs, and 4.0 months for the rib flaps. Complications occurred in 55.6% (20/36) of patients having fibular flaps, 26.1% (6/23) of MFC flaps, and 50% (2/4) of rib flaps.

CONCLUSIONS

All osseous flaps yielded similar and consistent rates of union when used to reconstruct defects of the clavicle. Higher complication rates, particularly donor site morbidity, were noted with fibula and rib flaps when compared to the MFC.

Morbidity of the Free Fibular Flap in Reconstructive Surgery

BACKGROUND

Our study evaluated long-term morbidities in patients and compared subjective morbidities to those measurable objectively.

METHODS

Patients completed a questionnaire regarding long-term morbidity, filled out the Pain Sensitivity Questionnaire by Ruscheweyh et al. and were examined physically.

RESULTS

Eighty-two patients were included in the study, 31 patients returned to the clinic for further evaluation and testing. The most common morbidities were weakened dorsiflexion of the great toe (34 patients), reduced ambulatory status (33), and muscle weakness (31). A significant correlation (p < 0.01) was found between higher pain intensity and high pain sensitivity scores. However, donor-site morbidities were not significantly associated with pre-existing comorbidities like smoking, diabetes, or age over 70. Subjective morbidities were reported 2.3 times more frequently than objectively measured ones.

CONCLUSIONS

Our findings suggest a notable discrepancy between subjective and objective morbidities, highlighting the importance of considering patients' subjective experiences when assessing postoperative outcomes and rehabilitation progress.

Long-Term Postoperative Donor Site Musculoskeletal Morbidity after Osseous Free Flap Harvest

Objective

Complex ablative maxillary and mandibular defects often require osseous free flap reconstruction. Workhorse options include the fibula, scapula, and osteocutaneous radial forearm flap (OCRFF). The choice of donor site for harvest should be driven not only by reconstructive goals but also by donor site morbidity. The goal of this study is to evaluate the long-term postoperative musculoskeletal morbidity at the donor site after osseous free flap harvest.

Study Design

Cohort study and cross-sectional analysis.

Methods

A retrospective review of patients who underwent free flap harvest at 1 of the 3 donor sites from 2015 through 2021 was performed. An additional cross-sectional analysis at ≥1 year postoperatively was performed from 2021 to 2022 using validated patient-reported orthopedic surveys: Disabilities of the Arm, Shoulder, and Hand for scapula or OCRFF harvest, and Foot and Ankle Ability Measure for fibula harvest.

Setting

Single, high-volume tertiary care institution.

Results

Among 731 eligible patients, 162 (22.1%) answered the telephone surveys and were included. Functional differences between operated and nonoperated sides were 18.5% (scapula, n = 33), 13.5% (OCRFF, n = 29), and 10% (fibula, n = 98). Postoperative physical therapy (for all donor sites), ipsilateral neck dissection (for scapula and OCRFF), and extent of bony resection (for OCRFF) were not factors associated with long-term morbidity. Acute donor site complications were most common in fibula patients and were associated with worse long-term functional outcomes (7.5% difference; 95% confidence interval, -14.0 to -1; P = .03).

Conclusion

There is acceptable long-term musculoskeletal morbidity at the donor site after osseous free flap harvest, and patients should be counseled appropriately.

Assessing Donor Site Morbidity and Impact on Quality of Life in Free Flap Microsurgery: An Overview

Donor site morbidity remains a significant concern in free flap microsurgery, with implications that extend beyond immediate postoperative outcomes to affect patients' long-term quality of life. This review explores the multi-faceted impact of donor site morbidity on physical, psychological, social, and occupational well-being, synthesizing findings from the existing literature. Particular attention is given to the functional limitations, sensory deficits, aesthetic outcomes, and chronic pain associated with commonly utilized free flaps. Advancements in surgical techniques, including nerve-sparing and muscle-sparing methods, as well as innovations, like perforator flaps, have demonstrated the potential to mitigate these morbidities. Furthermore, the integration of regenerative medicine strategies, such as stem cell therapy and fat grafting, and technological innovations, including virtual reality rehabilitation and biofeedback devices, has shown promise in enhancing recovery and minimizing long-term complications. Despite these advances, challenges persist in standardizing QoL assessments and optimizing donor site management. This review emphasizes the need for a holistic, patient-centered approach in reconstructive microsurgery, advocating for further research to refine current strategies, improve long-term outcomes, and develop robust tools for QoL evaluation. By addressing these gaps, reconstructive surgeons can better align surgical objectives with the comprehensive well-being of their patients.

A comparative analysis of free fibula flap donor leg and recipient vessel selection in composite oromandibular defect reconstructions

BACKGROUND

The free fibula flap (FFF) is acknowledged as the primary choice for reconstructing composite oromandibular defects (COMDs), yet the impact of donor leg selection remains inadequately explored. This study aims to investigate the correlation between flap failure and the choice of donor leg and recipient vessel side.

MATERIALS AND METHODS

In a retrospective analysis spanning 2011 to 2020, FFFs for COMD were examined using electronic records. Patient data, comorbidities, radiation history, FFF details, and intraoperative variables were considered. Laterality was categorized into "Cis" and "Trans" groups, further subclassified based on blood supply. Analyses involved logistic regression, bivariate analysis, and propensity score matching.

RESULTS

A total of 155 subjects with intraoral mucosal defects repaired only by the skin paddle of FFF were included. Cases were categorized into "Cis" (n = 65; 42%) and "Trans" (n = 90; 58%) groups based on COMD side and donor leg selection. No significant baseline differences emerged. Logistic regression found no laterality impact on total FFF failure. Initially, gender correlated with flap failure, but adjustment diminished the association. Partial skin paddle necrosis correlated with diabetes, not laterality. Propensity score matching revealed no significant differences between right and left legs in laterality or total flap failure risk. Subgroup analysis found no differences in parameters or flap failure rates within "Cis" and "Trans" groups.

CONCLUSION

Donor leg selection in COMD reconstruction with FFFs does not exhibit specificity. Furthermore, despite potential limitations in vessel anastomosis due to pedicle length or trauma history, recipient vessel side selection does not evidently affect flap failure.

A Treatment Algorithm for Free Vascularized Bone Reconstruction in Rare Large Osseous Defects Involving the Wrist

Large bone defects of the distal radius and/or carpus following tumor resection, trauma, or infection are extremely rare. There are few case reports and series in the literature on the reconstruction approaches required in such cases. Therefore, large studies cannot be used to guide the therapeutic decisions of reconstructive plastic and hand surgeons. The objective of this study is to propose a treatment algorithm to predict the functional outcome and quality of life for the different techniques of free vascularized bone reconstruction in the interval between the distal radius, the carpus, and/or the proximal metacarpal. The algorithm was developed based on our own case studies and the few treatment approaches described in the literature. It can be applied to rare cases of massive bone defects in the wrist. The flowchart enables surgeons to develop an individualized reconstruction concept for various intervals of bone defects in the area of the distal radius and proximal metacarpal bones. Ultimately, the treatment algorithm aims to maximize future quality of life (QoL) and function of the distal upper extremity in rare cases of massive wrist-bone defects.

Fibula Grafting for Oromandibular Reconstruction and its Effect on Patient Quality of Life - A Scoping Review

Fibula osteoseptocutaneous flap has been widely used for oncologic bony reconstruction of both the mandible and maxilla. Early and late morbidities of the donor side such as leg weakness, ankle instability, limited ankle mobility, tibial stress fractures or incision area pain are well documented; however, there is a lack of information about the effects of fibula grafting on patient quality of life. To address this issue, a scoping literature search in the PubMed electronic database was performed to identify all relevant studies and reviews in the period between 2010 and 2022. The potential discomforts after free fibula grafting and their impact on different domains of everyday living were identified and evaluated. The present literature review indicates that donor site morbidity can negatively impact patients' quality of life, albeit generally classified as minor. However, the functional and aesthetic benefits of oromandibular reconstruction clearly outweigh the associated sequelae. Nevertheless, the authors of this review highlight the importance of a comprehensive clinical evaluation of the donor site besides the recipient site during follow-up examinations. This would help to subjectively evaluate the functional and esthetical limitations of a patient's site and promptly detect morbidities that could lead to long-term complications.

Reduced length of intensive care unit stay and early mechanical ventilator weaning with enhanced recovery after surgery (ERAS) in free fibula flap surgery

This study aimed to evaluate the effects of the enhanced recovery after surgery (ERAS) program on postoperative recovery of patients who underwent free fibula flap surgery for mandibular reconstruction. This retrospective study included 188 patients who underwent free fibula flap surgery for complex mandibular and soft tissue defects between January 2011 and December 2022. We divided them into two groups: the ERAS group, consisting of 36 patients who were treated according to the ERAS program introduced from 2021 to 2022. Propensity score matching was used for the non-ERAS group, which comprised 36 cases selected from 152 patients between 2011 and 2020, based on age, sex, and smoking history. After propensity score matching, the ERAS and non-ERAS groups included 36 patients each. The primary outcome was the length of intensive care unit (ICU) stay; the secondary outcomes were flap complications, unplanned reoperation, 30-day readmission, postoperative ventilator use length, surgical site infections, incidence of delirium within ICU, lower-limb comorbidities, and morbidity parameters. There were no significant differences in the demographic characteristics of the patients. However, the ERAS group showed the lower length of intensive care unit stay (ERAS vs non-ERAS: 8.66 ± 3.90 days vs. 11.64 ± 5.42 days, P = 0.003) and post-operative ventilator use days (ERAS vs non-ERAS: 1.08 ± 0.28 days vs. 2.03 ± 1.05 days, P < 0.001). Other secondary outcomes were not significantly different between the two groups. Additionally, patients in the ERAS group had lower postoperative morbidity parameters, such as postoperative nausea, vomiting, urinary tract infections, and pulmonary complications (P = 0.042). The ERAS program could be beneficial and safe for patients undergoing free fibula flap surgery for mandibular reconstruction, thereby improving their recovery and not increasing flap complications and 30-day readmission.

Assessment of lower limb proprioception after fibula free flap harvest: A pilot study

BACKGROUND

After undergoing fibula-free flap harvest, patients may experience complications such as ankle instability. It remains unclear whether these patients have deficits of proprioception, and the recovery process is also uncertain.

OBJECTIVE

This study aimed to objectively evaluate proprioception on the donor and normal side of surgical patients during long-term follow-up using the Pro-kin system.

METHODS

This study enrolled 36 patients who underwent reconstruction of the head and neck using osseous free flaps harvested from the fibula. Each patient underwent pre-operative evaluations and was subsequently evaluated at postoperative months 1, 3, 6, and 12. The study assessed the proprioceptive evaluation of the lower limbs, muscle function, range of motion of the ankle, and donor side complications.

RESULTS

On the donor side, the average trace error (ATE) at postoperative month 1 was significantly higher than pre-operation, postoperative months 6 and 12 (P< 0.05). The test execution time (TTE) at postoperative month 1 was significantly increased by 9.875s compared to the pre-operative levels (P= 0.012, 95% confidence interval [CI] 4: 1.877-17.873) and by 11.583s compared to postoperative month 12 (P= 0.007, 95% CI: 2.858-20.309). The reduction in range of motion of ankle dorsiflexion was most pronounced at postoperative month 1, exhibiting an 11.25∘ decrease compared to pre-operative levels (P< 0.001, 95% CI: 6.304-16.16). Although the range of motion of ankle dorsiflexion gradually improved over time at postoperative months 3, 6, and 12, it remained lower than pre-operative levels (P< 0.05).

CONCLUSION

The study revealed that the patients exhibited proprioceptive disturbances in both lower limbs at postoperative month 1. The proprioceptive function gradually improved over time, with a gradual decrease in donor site complications.

A retrospective study on application of fibula/iliac flap surgical techniques to mandibular defects

This study group consists of a total of 61 patients who underwent fibula flap and iliac flap surgeries to repair mandibular defects. Patients' Quality Of life (QOL) at 6 and 24 months after surgery is investigated and compared by the EORTC-QLQ-H&N and OHIP-14. The base data of the two groups of patients are collected and analysed by the SPSS 20.0 statistical software. Independent sample t test was conducted for EORTC-QLQ-H&N and OHIP-14 scores at two time points in each group. The 61 cases of free flap all survived and the difference in the location of the primary tumor between the two groups is statistically significant. The EORTC-QLQ-H&N showed that the score of speech, diet, social contact, and teeth all went up at 6 months after surgery, but went down dramatically at 24 months after surgery. The OHIP-14 showed that there was significant reduction in functional limitation at 24 months after surgery, with statistical significance (p < 0.05) between the groups of iliac flap (19.16 ± 5.33) and fibula flap (33.77 ± 7.71). Therefore, it is suggested that patients suffering from mandibular defects receive surgery utilizing the iliac flap, while those with a larger range of defects or lesions involving the condyle and chin should receive corrective surgery utilizing the fibular flap.

Safety of free fibula flap harvest in IIIA and IIIB tibio-peroneal trunk variations

INTRODUCTION

In head and neck cancer malignancies, free fibula flap is the gold standard for reconstruction of segmental bone defects owing to its predictable anatomy, long bone length, and feasibility for multiple osteotomies. However, sometimes because of variations in anatomy of tibio-peroneal trunk, it is a dilemma for the surgeons to use free fibula flap for reconstruction. This case series aimed to evaluate the safety of harvest of fibula in such cases in terms of acute and chronic donor-site complications.

MATERIAL AND METHODS

A retrospective study was conducted from January 2018 to May 2021. All the patients with tibio-peroneal trunk anomaly, diagnosed during surgery, who underwent successful harvest of the free fibula were included in the study and analyzed for the early major and minor donor wound complications, long-term donor complications, and late functional deficit using the Foot and Ankle Disability Index (FADI).

RESULTS

Out of 714 free fibulae operated, 26 patients (3.6%) had such tibio-peroneal trunk variations: 22 (2.9%) cases of type III A and B anomalies and 4 (0.56%) cases of type III C anomalies. The average FADI score was 95.3%. No one had any difficulty in personal care and activity of daily living.

CONCLUSIONS

The free fibula flap can be safely harvested in patients with type III A and B anomalies if vascularity of foot after clamping of peroneal vessels is good and anterior tibial vessels are normal.

Reconstructing avascular necrotic femoral head through a bioactive β-TCP system: From design to application

A variety of techniques have been used for treating avascular necrosis of the femoral head (ANFH), but have frequently failed. In this study, we proposed a β-TCP system for the treatment of ANFH by boosting revascularization and bone regeneration. The angio-conductive properties and concurrent osteogenesis of the highly interconnected porous β-TCP scaffold were revealed and quantified through an in vivo model that simulated the ischemic environment of ANFH. Mechanical test and finite element analysis showed that the mechanical loss caused by tissue necrosis and surgery was immediately partially compensated after implantation, and the strength of the operated femoral head was adaptively increased and eventually returned to normal bone, along with continuous material degradation and bone regeneration. For translational application, we further conducted a multi-center open-label clinical trial to assess the efficacy of the β-TCP system in treating ANFH. Two hundred fourteen patients with 246 hips were enrolled for evaluation, and 82.1% of the operated hips survived at a 42.79-month median follow-up. The imaging results, hip function, and pain scores were dramatically improved compared to preoperative levels. ARCO stage Ⅱ disease outperformed stage Ⅲ in terms of clinical effectiveness. Thus, bio-adaptive reconstruction using the β-TCP system is a promising hip-preserving strategy for the treatment of ANFH.

Current Management of Diaphyseal Long Bone Defects-A Multidisciplinary and International Perspective

The treatment of defects of the long bones remains one of the biggest challenges in trauma and orthopedic surgery. The treatment path is usually very wearing for the patient, the patient's environment and the treating physician. The clinical or regional circumstances, the defect etiology and the patient´s condition and mental status define the treatment path chosen by the treating surgeon. Depending on the patient´s demands, the bony reconstruction has to be taken into consideration at a defect size of 2-3 cm, especially in the lower limbs. Below this defect size, acute shortening or bone grafting is usually preferred. A thorough assessment of the patient´s condition including comorbidities in a multidisciplinary manner and her or his personal demands must be taken into consideration. Several techniques are available to restore continuity of the long bone. In general, these techniques can be divided into repair techniques and reconstructive techniques. The aim of the repair techniques is anatomical restoration of the bone with differentiation of the cortex and marrow. Currently, classic, hybrid or all-internal distraction devices are technical options. However, they are all based on distraction osteogenesis. Reconstructive techniques restore long-bone continuity by replacing the defect zone with autologous bone, e.g., with a vascularized bone graft or with the technique described by Masquelet. Allografts for defect reconstruction in long bones might also be described as possible options. Due to limited access to allografts in many countries and the authors' opinion that allografts result in poorer outcomes, this review focuses on autologous techniques and gives an internationally aligned overview of the current concepts in repair or reconstruction techniques of segmental long-bone defects.

Donor-Site Complication of Severe Valgus Ankle Deformity in an Adult With Ehlers-Danlos Syndrome Following Free Vascularized Fibular Grafting

Valgus deformity of the ankle joint is a well-known and relatively common donor-site complication of free vascularized fibular graft harvest in children. Due to children having naturally greater ligamentous laxity than adults, the tibiofibular syndesmosis can be compromised with the loss of the fibular shaft, leading to valgus ankle deformity (VAD). Syndesmotic stabilization with screws is commonly recommended in subsets of pediatric patients at the greatest risk of this complication. In adults, the occurrence of VAD is seldom reported in the literature following fibular graft harvest. As such, no recommendation for syndesmotic stabilization exists in the adult population. We present a case of end-stage VAD in an adult patient with Ehlers-Danlos syndrome (EDS) following free vascularized fibular graft harvest. We hypothesize that other patients with generalized joint hypermobility may face the same complication and, thus, recommend the consideration of syndesmotic stabilization or primary syndesmotic fusion at the time of graft harvest in this patient population.

Donor-Site Morbidity after Osteocutaneous Free Fibula Transfer: Longitudinal Analysis of Stair Climbing Asymmetry and Functional Outcome

The autologous vascularised free fibula flap is currently considered the best option for facial reconstruction after oncological surgery, but its donor-site morbidity has not been fully examined. The purpose was to evaluate donor-site changes in temporal and spatial kinematic gait parameters during stair climbing, as well as the gait symmetry. Fourteen patients (48 ± 16 years) were evaluated before and six months after harvest of a vascularised free fibula flap. Temporal gait variables for both the ascent and descent phases did not change after surgery (2-way ANOVA, p > 0.05). During stair ascent, ankle flexion (healthy side, increased; donor side, reduced; low effect size) had a significant time × side interaction. During stair descent, hip flexion was significantly larger on the donor side (medium effect size). Significant time × side interactions were observed for ankle inversion (healthy side, reduced; donor side, increased; and low effect size) and knee flexion (healthy side, increased; donor side, unchanged; and low effect size). Medium effect sizes were found for hip flexion side differences (significant). No relevant spatio-temporal nor kinematic asymmetry emerged apart from ankle joint kinematics. Overall, only the side effect of hip flexion during descent was both statistically significant and practically meaningful. Considering the slight modifications of the gait variables, no major functional limitations were found following vascularised free fibula flap reconstruction during stair climbing and descent.

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.

Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning

BACKGROUND

Virtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success.

METHOD

This retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply.

RESULT

A total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs' vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP.

CONCLUSION

In general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome.

Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty

PURPOSE OF REVIEW

Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF).

RECENT FINDINGS

Although FFF is the current 'gold standard' for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes.

SUMMARY

There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.

Microvascular reconstruction of the mandible with medial femoral condylar flap for treatment of mandibular non-union

Mandibular non-union occurs in 2-9% after open reduction and internal fixation of a mandibular fracture (trauma surgery, orthognathic cases, access osteotomy for oncological purposes). The medial femoral condyle (MFC) has emerged more recently as one of the most versatile donor sites in the treatment of challenging bone reconstruction. This is the first description of MFC for treatment of mandibular non-union. A retrospective chart review was conducted for all patients who underwent reconstruction with a microvascular MFC flap for bone defects of the head and neck area between January 2015 and December 2018 at Careggi Hospital of Florence. Inclusion criteria were patients where the FMC was used for mandibular defects arising due to non-union. Seven patients presented mandibular defects reconstructed by MFC flap and were included in this investigation (two cases of segmental mandible defect due to post-traumatic non-union; two patients of pathological mandibular fracture after prolonged bisphosphonate therapy for osteoporosis; three patients with mandibular continuity loss after failed orthognathic surgeries). At one-year follow-up, all patients had satisfactory occlusion. One-year postoperative CTs revealed full osteointegration of the flaps. In conclusion, the MFC free flap is an attractive option for mandibular reconstruction. Small defects (3-5 cm) in poorly vascularized beds are the ideal target.

Partial and Total Flap Failure after Fibula Free Flap in Head and Neck Reconstructive Surgery: Retrospective Analysis of 180 Flaps over 19 Years

Fibula free flap (FFF) is widely used in head and neck reconstructive surgery and is considered as a standard and therapy of choice after ablative cancer surgery. The aim of this retrospective monocenter study was to determine the success rates of fibula free flaps for jaw reconstruction after ablative tumor surgery. The disease course of patients who underwent jaw reconstructive surgery with FFF from January 2002 to June 2020 was evaluated regarding the flap success rate. Flap failure was analyzed in detail and categorized into two groups: partial flap failure (PFF) and total flap failure (TFF). A total of 180 free fibular flaps were performed over the last 19 years and a total of 36 flap failures were recorded. TFF occurred in n = 20 (56.6%) and PFF in n = 16 cases (44.4%) cases. No statistically significant differences were found concerning patients' age at flap transfer, sex, BMI, ASA-Score, preoperative non-virtual or virtual surgical planning (non-VSP vs. VSP), and time of reconstruction (immediately vs. delayed). Duration of hospitalization shows statistically significant differences between both groups (p = 0.038), but no differences concerning operating time and duration on Intensive Care Unit (ICU). Partial flap failure appears to be underreported in literature. Sub- and complete failure of the skin paddle leads to clinical complaints like uncovered bone segments and plate exposure. Partial or complete FFF failure lead to infections on the recipient site and prolonged wound healing and therefore may cause a delay of the beginning of adjuvant radiation therapy (RT). PFF of hard tissue can be induced by RT.

Heterotopic Ossification of the Vascular Pedicle after Maxillofacial Reconstructive Surgery Using Fibular Free Flap: Introducing New Classification and Retrospective Analysis

Heterotopic ossification (HO) is one of the described phenomena after maxillofacial reconstructive surgery using fibular free flap (FFF) at the reception-site. The aim of this study was to determine the radiological incidence and form of HO along the fibular vascular pedicle as well as the rate of clinical symptoms if present. CT-scans of 102 patients who underwent jaw reconstructive surgery by using FFF from January 2005 to December 2019 were evaluated concerning the presence of HO. Subsequently, the patient files were evaluated to identify the cases with clinical signs and complications related to the presence of HO. A radiological classification of four different HO types was developed. Out of 102 patients, 29 (28.43%) presented radiological findings of HO. Clinical symptoms were recorded in 10 cases (9.8%) (dysphagia (n = 5), trismus (n = 3), bony masses (n = 2)) and from these only five (4.9%) needed surgical removal of calcified structures. HO occurs significantly in younger patients (mean 52.3 year). In maxillary reconstructions, HO was radiologically visible six months earlier than after mandibular reconstruction. Furthermore, HO is observed after every third maxilla and every fourth mandible reconstruction. This study developed for the first time a classification of four distinct HO patterns. HO types 1 and 2 were mostly observed after mandible reconstruction and type 4 predominantly after maxilla reconstruction.