Early and late complications in the reconstructed mandible with free fibula flaps

Salvage of Intraoral Dehiscence With a Superficial Temporal Artery Islandized Flap (STAIF)

Intraoral dehiscence compromises free fibula flaps following mandibular reconstruction. Salivary contamination risks thrombosis of microvascular anastomosis and hardware infection. The superficial temporal artery islandized flap (STAIF) provides a non-microsurgical reconstructive option for regaining intraoral competency for a time-sensitive complication. The STAIF is based on the superficial temporal artery coursing along the anterior hairline. The flap is mapped with the assistance of the Doppler probe. The width of the skin paddle is dependent upon the ability to close the donor site. The flap is taken down to the level of the zygomatic arch and tunneled into the mouth. We present a case of a patient who underwent mandibular reconstruction with a free fibula flap after a traumatic shotgun wound. The patient developed repeated intraoral dehiscence following failed local buccal and floor of mouth flaps leading to salivary contamination of the flap and hardware. The intraoral dehiscence was successfully salvaged on the third attempt with a STAIF. Intraoral dehiscence requires urgent attention to prevent loss of the free fibula flap after mandibular reconstruction. The STAIF is a non-microsurgical option for restoring intraoral competency. This robust, axially vascularized skin paddle may be split for intra- and extraoral coverage, as was performed in this case, and is an essential tool in the reconstructive armamentarium.

Miniplate Versus Reconstruction Bar Fixation for Oncologic Mandibular Reconstruction with Free Fibula Flaps

BACKGROUND

 Fibula free flaps (FFF) are the gold standard tissue for the reconstruction of segmental mandibular defects. A comparison of miniplate (MP) and reconstruction bar (RB)-based fixation of FFFs has been previously described in a systematic review; however, long-term, single-center studies comparing the two plating methods are lacking. The authors aim to examine the complication profile between MPs and RBs at a single tertiary cancer center. We hypothesized that increased components and a lack of rigid fixation inherent to MPs would lead to higher rates of hardware exposure/failure.

METHODS

 A retrospective review was performed from a prospectively maintained database at Memorial Sloan Kettering Cancer Center. All patients who underwent FFF-based reconstruction of mandibular defects between 2015 and 2021 were included. Data on patient demographics, medical risk factors, operative indications, and chemoradiation were collected. The primary outcomes of interest were perioperative flap-related complications, long-term union rates, osteoradionecrosis (ORN), return to the operating room (OR), and hardware exposure/failure. Recipient site complications were further stratified into two groups: early (<90 days) and late (>90 days).

RESULTS

 In total, 96 patients met the inclusion criteria (RB = 63, MP = 33). Patients in both groups were similar with respect to age, presence of comorbidities, smoking history, and operative characteristics. The mean follow-up period was 17.24 months. In total, 60.6 and 54.0% of patients in the MP and RB cohorts received adjuvant radiation, respectively. There were no differences in rates of hardware failure overall; however, in patients with an initial complication after 90 days, MPs had significantly higher rates of hardware exposure (3 vs. 0, p = 0.046).

CONCLUSION

 MPs were found to have a higher risk of exposed hardware in patients with a late initial recipient site complication. It is possible that improved fixation with highly adaptive RBs designed by computer-aided design/manufacturing technology explains these results. Future studies are needed to assess the effects of rigid mandibular fixation on patient-reported outcome measures in this unique population.

Mandible Reconstruction in a Rural Population: Comparison of Radial Forearm and Free Fibula Flap Outcomes

Comparison of microsurgical reconstructive options after mandible resection is limited in the literature. Fibula free flaps (FFFs) can be costly and have timing limitations, but dental restoration can be performed, with varied reported rates of completion. The radial forearm free flap (RFFF) with mandible plating may be an alternative in select populations. The purpose of this study was to determine if the RFFF has similar outcomes to the FFF for mandible reconstruction in a rural population. A retrospective review of patients who underwent mandibulectomy from 2017 to 2021 at a single tertiary-care academic institution was performed. Those with FFF or RFFF reconstruction were included. Mandible defects were classified using the Jewer-Boyd H-C-L system. Sixty-eight patients were included with 53 undergoing FFF and 15 undergoing RFFF. Immediate reconstruction was significantly more common with RFFF than FFF (100% versus 64.2%; P =0.01). Lateral mandible defects were most common among both groups (52.9% FFF versus 73.3% RFFF; P =0.04). Osseous defect length was similar (9.5 cm FFF versus 7.7 cm RFFF; P =0.07), but soft tissue defect size was significantly larger in the RFFF group (28.6 cm 2 versus 15.3 cm 2 ; P =0.01). Complication rates (47.1% FFF versus 46.7% RFFF; P =0.98) and disease-free status at last follow-up (96.2% FFF versus 80.0% RFFF; P =0.06) were similar. Dental restoration occurred in 21.3% of patients undergoing FFF. Patients undergoing RFFF or FFF reconstruction after mandibulectomy had similar surgical and disease outcomes, with a low rate of completed dental restoration after FFF. Our findings suggest RFFF is a reasonable alternative to FFF for mandible reconstruction in select patients.

Management after fibula free flap necrosis in maxillofacial reconstruction

INTRODUCTION

Few articles discuss the management of a free fibula flap (FFF) necrosis in maxillofacial reconstruction.

MATERIAL & METHODS

Between 2005 and 2020, 170 FFF were used for maxillofacial reconstruction at the University Hospital of Caen, among which 16 cases suffered total necrosis and flap removal. The authors categorized these 16 cases into three groups based on the proposed salvage treatment and analyzed the post-operative follow-up, including complications, length of hospital stay and delay in radiotherapy.

RESULTS

In Group A, two patients underwent immediate reconstruction with a new free flap. There were no postoperative complications, and the average hospitalization duration after removal of the first flap was 10 days. In Group B, eleven patients underwent reconstruction with a pedicled musculocutaneous pectoralis major flap. These patients experienced numerous complications, with 73% of them requiring at least one additional surgery, and all of them had an indication for later FFF reconstruction. The average hospitalization duration in this group was 37 days. In Group C, three patients underwent conservative management with debridement and mucosal closure. Two of them experienced complications, and all of them underwent later FFF reconstruction. The average hospitalization duration in this group was 15 days.

DISCUSSION

Based on our experience and the literature review, the use of an immediate new free flap appears to be the best approach after the removal of a FFF. This generates shorter healing times and shorter hospitalization stays, and this allows better results in terms of function and aesthetics. At least, this is the approach that causes the least delay for radiation therapy if indicated. The other approaches should only be proposed in case of patient's poor general condition or in case of refuse of the patient.

Postoperative facial appearance of patients with extensive oral squamous cell carcinoma can be adequately preserved with in‑house virtually planned mandibular reconstruction

The present study aimed to assess the concordance of preoperative and postoperative hard and soft tissues in patients with advanced oral squamous cell carcinoma (OSCC) following virtual surgical planning (VSP) mandibular reconstruction. In the present study, a cohort of 32 patients with OSCC underwent in-house VSP, followed by guided mandibular reconstruction utilizing vascularized free tissue grafts sourced from the fibula or scapula. A morphometric analysis was conducted comparing preoperative and postoperative three-dimensional virtual models to evaluate discrepancies and identify potential risk factors associated with poor reconstruction outcomes. The outcome variables were the differences in root mean square (RMS) and mean surface distance (MSD) resulting from the application of an iterative closest point algorithm to the virtual data. The validity of soft tissue comparison data is limited due to its susceptibility to various confounding variables. The present study conducted a comprehensive re-evaluation of these variables. High tumor stage, positive N status and the use of adjuvant therapy contributed to more noticeable differences in preoperative and postoperative facial soft tissue appearance. The accuracy of postoperative bone reconstruction results was higher in patients who underwent neomandibular formation using a fibular graft compared with those who received a scapular graft. Preoperative and postoperative soft tissue analyses were conducted for comparison. The MSD showed a deviation of 3.2 mm (± 2.0 mm SD; range 1.3-9.5 mm), whereas the RMS was 5.3 (± 2.9 SD; range 2.1-14). In conclusion, in-house VSP and guided mandibular reconstructions can yield clinically accurate results, preserving patient appearance and offering the advantage of rapid feasibility.

Considerations for the Use of Alloplastic Temporomandibular Joint Replacement in Irradiated Patients: Report of an Off-Label Indication

BACKGROUND

Custom-made alloplastic temporomandibular joint replacement (ATMJR) is not validated in irradiated patients. However, in specific situations, after previous reconstructive surgical failures, the authors hypothesized the role of a customized ATMJR after radiotherapy.

METHODS

A 65-year-old male patient was referred to Instituto Português da Face-Lisbon, Portugal-after failed attempts of mandibular reconstruction secondary to oral carcinoma resection and partial hemi-mandibulectomy plus radiotherapy of 60 total Grays. Primary reconstruction was performed with fibula free flap. Due to failure, secondary reconstructions were performed with osteosynthesis plate without success. The patient was unable to have adequate mastication and deglutition due to a severe crossbite. The authors treated the patient with an extended customized alloplastic temporomandibular joint replacement (F0M2).

RESULTS

With 3 years of follow-up, the patient showed an improvement in masticatory function, mandibular motion, pain levels, and overall quality of life. No complications were observed related to ATMJR.

CONCLUSIONS

The presented case described how ATMJR, although not a validated option after radiotherapy, can be considered to restore functionality in complex cases with bone and soft tissues problems.

From bench to bedside - current clinical and translational challenges in fibula free flap reconstruction

Fibula free flaps (FFF) represent a working horse for different reconstructive scenarios in facial surgery. While FFF were initially established for mandible reconstruction, advancements in planning for microsurgical techniques have paved the way toward a broader spectrum of indications, including maxillary defects. Essential factors to improve patient outcomes following FFF include minimal donor site morbidity, adequate bone length, and dual blood supply. Yet, persisting clinical and translational challenges hamper the effectiveness of FFF. In the preoperative phase, virtual surgical planning and artificial intelligence tools carry untapped potential, while the intraoperative role of individualized surgical templates and bioprinted prostheses remains to be summarized. Further, the integration of novel flap monitoring technologies into postoperative patient management has been subject to translational and clinical research efforts. Overall, there is a paucity of studies condensing the body of knowledge on emerging technologies and techniques in FFF surgery. Herein, we aim to review current challenges and solution possibilities in FFF. This line of research may serve as a pocket guide on cutting-edge developments and facilitate future targeted research in FFF.

Osseointegration and Bone Resorption of Scapula Tip Free Flaps in Mandibular Reconstruction

OBJECTIVES

Bone resorption of more conventional vascularized bone grafts have been well described showing minimal resorption over time. Few studies have evaluated osseous union and bone resorption in scapula tip free flaps (STFF) in the reconstruction of mandibulectomy defects. We aimed to describe our series on STFF with respect to osseous union and bone resorption over time.

METHODS

Retrospective chart review of patients receiving STFF from January 2014-January 2017 (n = 25). A neuroradiologist analyzed follow-up CT scans to assess (1) STFF complete, partial, or no osseous union with native mandible and (2) STFF volume change over time in a subset with multiple follow-up scans (n = 18).

RESULTS

Twenty-three of 25 patients (92%) showed complete or partial STFF osseous union with native mandible either distally or proximally. STFF volume change ranged from +4.8 to -54% (median -0.5%) over median follow-up interval of 23 months. History of chemoradiation therapy, bisphophonate use, sex, age, or smoking history did not correlate with bone resorption.

CONCLUSIONS

STFFs shows high rates of osseous union and limited bone resorption that is equivalent to, or less than, vascularized fibular and iliac crest flaps. Clinically, this translates into both optimal healing and functional and cosmetic outcomes, especially in the setting of prior therapies.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2597-2602, 2023.

Outcome of Mandibular Reconstruction with Fibula free Flaps: Retrospective Analysis of Complications

Rationale: Fibula free flap has become the workhorse for head and neck reconstruction. In this retrospective study we aimed at determining the outcomes of mandibular reconstruction with fibula free flaps. Methods: Any patient who underwent a mandibulectomy and reconstructed with vascularised fibula flap was included in the study. The predictor variables were age, sex, type of lesion, tobacco and alcohol use, tracheostomy, neck dissection, post operative radio and chemotherapy. Flap failure, fistulas, dehiscence, bone exposure and hardware complications were the outcomes. A P value of < 0.05 was considered statistically significant. Results: 242 patient records were selected for evaluation. PORT, CRT, neck dissection, no. of segments were the factors significantly associated with every complication. Malignant lesion was significantly associated with every complication except for plate fracture. Plate fracture although occurred more frequently with malignant diseases, the association was insignificant. Tobacco consumption was significantly associated with increased incidence of post -operative complications. Alcohol consumption was significantly associated with plate fracture, screw loosening, fistulas, bone exposure and flap failure. Conclusion: Overall the fibula free flap has a success rate of 90.0% with fistulas being the most significant complication.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03344-2.

Quality of Life with the Rehabilitation After Partial Mandibulectomy: a Systematic Review

To evaluate the QoL before and after prosthetic rehabilitation of partial mandibulectomy patients based on the type of surgery, effects of radiation, the type of prosthesis, and to enlist their outcome on the rehabilitation. Literature search as per PICO format was carried out within a time range from January 2000 to June 2021. The review followed PRISMA guidelines and registered with the PROSPERO(CRD42021258472). The focus question was established as per the PICO format (Population, Intervention, Comparison, Outcome). The population involved partial mandibulectomy individuals with prosthetic rehabilitation as an intervention. The outcome, quality of life (QoL), was compared with the pre and post partial mandibulectomy patients rehabilitated with a prosthesis. The search yielded 367 articles and based on the search criteria only 7 articles were suitable for qualitative analysis. Marginal resection of the mandible is less aggressive than segmental resection which provided function, phonation, and esthetics at acceptable levels but the food mixing ability was reduced when resection is accompanied by glossectomy. However, the perceived chewing ability and OHRQoL were not accountable to the extent of surgical excision. An overall increase in the QoL on rehabilitation with acrylic prosthesis depicting satisfactory functionality with a considerable improvement in mastication, speech, and social life. QoL and Denture Satisfaction Index did not differ based on the number of implants in an implant overdenture prosthesis, but the chewing ability was improved. An increase in the number of remaining occlusal units improved the overall QoL. Restoration of the function, psychological comfort, and improvement in esthetics was significant in patients who underwent prosthetic rehabilitation. The QoL between conventional and implant prostheses was observed to be more similar, and the effect of remaining hard and soft tissue structures has a major influence on patient comfort signifying the influence of the extent of surgical excision.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01664-x.

Tenants of Mandibular Reconstruction in Segmental Defects

The premises of mandibular reconstruction are the restoration of occlusion and mandibular contour for the purpose of preserving the facial identity, oral airway, and effective speech and mastication. Establishing functional occlusion is the primary tenant in all mandibular reconstruction. In cases of segmental defects, particularly in dentate regions of the mandible, there has been a paradigm shift over the past two decades in how surgeons are approaching the restoration of load-bearing mandibular continuity with capacity for dental implantation. Here we discuss considerations for deciding the most effective method of reconstruction in segmental defects.

Rates of osteoradionecrosis in resected oral cavity cancer reconstructed with free tissue transfer in the intensity-modulated radiotherapy era

BACKGROUND

Resected oral cavity carcinoma defects are often reconstructed with osteocutaneous or soft-tissue free flaps, but risk of osteoradionecrosis (ORN) is unknown.

METHODS

This retrospective study included oral cavity carcinoma treated with free-tissue reconstruction and postoperative IMRT between 2000 and 2019. Risk-regression assessed risk factors for grade ≥2 ORN.

RESULTS

One hundred fifty-five patients (51% male, 28% current smokers, mean age 62 ± 11 years) were included. Median follow-up was 32.6 months (range, 1.0-190.6). Thirty-eight (25%) patients had fibular free flap for mandibular reconstruction, whereas 117 (76%) had soft-tissue reconstruction. Grade ≥2 ORN occurred in 14 (9.0%) patients, at a median 9.8 months (range, 2.4-61.5) after IMRT. Post-radiation teeth extraction was significantly associated with ORN. One-year and 10-year ORN rates were 5.2% and 10%, respectively.

CONCLUSIONS

ORN risk was comparable between osteocutaneous and soft-tissue reconstruction for resected oral cavity carcinoma. Osteocutaneous flaps can be safely performed with no excess concern for mandibular ORN.

Patient Specific Alloplastic Implant Reconstruction of Mandibular Defects-Safe Practice Recommendations and Guidelines

Mandibular continuity defects are commonly seen after tumor resection, osteomyelitis or maxillofacial trauma. Three-dimensional reconstruction of these mandibular segmental defects is critical for proper mandibular functioning and esthetics. Various methods used to reconstruct such defects include bridging reconstruction plates, modular endoprosthesis, non-vascularized and vascularized bone grafting with stock reconstruction plate or patient specific implants (PSI) and tissue engineering bone transfer. But in the recent years, literature documents use of PSI only alloplastic reconstruction as an alternate to microvascular bone flap reconstruction. Representative cases enumerate current practice of 'patient specific implant only' mandibular reconstruction and its pitfalls. This article discusses current status of literature on PSI's, choice of indications for 'PSI only' mandibular reconstruction and also proposes guidelines for safe practice of patient specific implant reconstruction of mandible.

An Analysis of Volume, Length and Segmentation of Free Fibula Flap in Reconstruction of the Jaws: Investigation of Their Role on Flap Failure

Reconstruction of defects of the jaws is mainly performed via free fibula flap. An incidence of 2–21% of overall flap failure is still described. We investigated the roles of volume, length and number of fibula flap segments on flap survival using novel three-dimensional segmentation tools. We also analyzed the role of other possible risk factors. Seventy-one consecutive patients with a follow up of at least three months and who underwent free fibula flap reconstruction in a single center between 2002 and 2022 have been evaluated. A total of 166 fibula segments were analyzed. Malignancies were the main reason of resection (45.1%). In 69% of the cases a reconstruction of the mandible was performed. The flaps were mainly divided in two segments (39%) (range 1–4), with a mean length of 2.52 cm and a mean volume was 3.37 cm3. Total flap failure (TFF) occurred in 12 cases, (16.9%), while partial flap failure (PFF) appeared in 3 patients (4.2%). Volume, length and number of fibula flap segments did not seem to influence flap failure incidence in uni- and multivariate analysis. Reconstruction of the maxilla and use of a recipient vessel different from the facial artery seemed to significantly impact on flap failure. Smoking and previous surgeries showed a higher trend to flap failure, but they did not reach statistical significance. Prospective and multicentric analysis on a wider population should be assessed.

Outcome Assessment after Reconstruction of Tumor-Related Mandibular Defects Using Free Vascularized Fibular Flap-A Clinical Study

The objective of this study was to analyze the outcomes of the free vascularized fibular flap in the reconstruction of mandibular defects, and to assess the oral health impact profile of these patients before surgery and after oral rehabilitation. Patients requiring reconstruction of defects greater than 6 cm were selected for this study. The defect size and type, the size of the required skin paddle, the need for second flaps, the intraoperative complications, and the type of closure were documented. Patients were evaluated postoperatively for function, aesthetics, and donor- or reconstruction-site complications. The validated oral health impact profile (OHIP-14) questionnaires were filled before and after surgery and after dental rehabilitation. This study included 11 cases of squamous-cell carcinomas, 2 cases of malignant nerve sheath tumors, and 1 case each of malignant melanoma, ameloblastoma, giant-cell tumor, osteosarcoma, and chondrosarcoma. The analysis revealed a significant association (p = 0.030) of gender with free vascular flap complications, while no significant association (p > 0.05) was found when donor- and recipient- site complications, as well as the type of resection (Brown’s classification), were compared with free vascular flaps. Moreover, the total OHIP-14 scores for patients before surgery, after surgery, and after dental rehabilitation were 12.03 ± 1.34, 10.66 ± 1.41, and 08.33 ± 0.62, respectively. The oral health-related quality of life was markedly improved after the reconstruction of the mandibular defects with free vascularized fibular flap and dental rehabilitation. The overall success rate of fibular flap in our study was 72.2%, which is lower than that reported in the literature. This may be attributed to the fact that almost all of our cases included large segmental defects that extended across the midline of the mandible.

Risk factors associated with fixation-related complications in microsurgical free flap reconstruction of the mandible

BACKGROUND

Hardware complications (loosening of screws, infection, or exposure of the plate) in mandibular reconstruction with vascularized osseous free flaps impose significant morbidity, and frequently require revision surgery. Purpose of this study was to identify possible contributing factors for hardware complications.

METHODS

This is a retrospective cohort study involving case series of patients who underwent microvascular mandible reconstructions between 2000 and 2020. Patient demographics, pathological, clinical, and treatment-related factors were analyzed in univariate and multivariate analyses.

RESULTS

Ninety-one patients were enrolled, encompassing 63 reconstructions with fibular free flaps, 26 reconstructions with scapular, and 2 reconstructions with iliac flaps. Rate of hardware complications and plate exposure was 14.3% and 7.7%, respectively, with a median follow-up time for extrusion of 29 months. In univariate analysis, preoperative radiotherapy (odds ratio [OR] = 6.57, p = .01), and secondary mandible reconstruction (OR = 4.3, p = .04) were significant predictors of hardware complications, and plate exposure was most frequently found in secondary reconstruction (37.5%, OR = 11.8, p = .04). Hypertension was the most commonly found comorbidity (24%), and it trended toward significance regarding plate exposure (p = .05). Only secondary mandible reconstruction was associated with osteosynthesis complications (OR = 12.53, p = .01) and plate exposure (OR = 23.86, p = .005) on multivariate analysis, while preoperative radiation therapy did not retain its relevance on plate exposure.

CONCLUSION

Secondary mandible reconstructions with vascularized osseous free flaps have a higher risk of osteosynthesis complications than primary reconstructions.

Three-dimensional evaluation of condylar position after mandibular reconstruction with a fibula free flap—comparison of different surgical techniques

Three-dimensional positional changes of the temporomandibular joint after mandible reconstruction using microvascular fibula flaps were investigated in 58 patients. The results of preoperative virtually planned surgery, intraoperative resection- and cutting-guided surgery, and non-guided surgery were compared. Pre- and postoperative computed tomography data of each patient were processed and superimposed digitally. The condyle deviations and rotations along the axes and planes of the skull, as well as Euclidean distances, were determined. Reliability analyses, descriptive statistics, and non-parametric tests were performed with the alpha level set at P = 0.05. Reliability proved to be excellent for all variables. The median Euclidean distance was 2.07 mm for the left condyle and 2.11 mm for the right condyle. Deviations of ≥ 10 mm occurred in nine (16%) cases. The maximum deviation occurred in the horizontal plane and the least deviation in the sagittal plane. Median rotation was ≤ 1.4° around all axes. The condylar displacements did not differ significantly between the different surgical techniques investigated. The three-dimensional measurement method applied is highly reliable for evaluating the three-dimensional condylar position after mandibular reconstruction.

Mini-plate versus reconstruction bar fixation for oncologic mandibular reconstruction with free fibula flaps: A systematic review and meta-analysis

Introduction There is currently no consensus as to the comparative complication profiles of mini-plate (MP) and reconstruction bar (RB) osseous fixation in fibula flap mandibular reconstruction. The aim of this study is to compare complication rates associated with the use of MP versus RB fixation for vascularized fibula free flap (FFF) reconstruction of oncologic mandibular defects in an effort to better guide hardware utilization and pre-operative virtual surgical planning methods. Methods A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, and Cochrane Library databases were queried to identify studies related to FFF-based mandibular reconstruction with either MP or RB fixation. Primary endpoints of interest were plate complications, wound infection, mal- or non-union, and total flap loss. Complication rates were calculated as weighted proportions and compared via Fisher's exact testing. Results Sixteen studies met inclusion criteria, which examined 1,513 patients. Only three studies directly compared MP fixation with RB fixation. MP fixation was used in 828 (54.7%) cases and RB fixation in 685 (45.3%) cases. MP fixation demonstrated greater rates of plate-related complications (32.5% versus 18.8%, p < 0.01, respectively), fistula formation (15.8% versus 4.7%, p = 0.04), total flap loss (9.4% versus 4.7%, p = 0.02), partial flap loss (20.6% versus 6.1%, p < 0.01), and re-operation for vascular compromise (13.3% versus 4.0%, p < 0.01). Rates of infection, mal-union/non-union, and wound dehiscence were similar across both groups. Conclusion Our results suggest that MP use may be associated with higher rates of plate-related complications. Though limited by outcome reporting heterogeneity, this review can serve as a template for future investigations evaluating the safety profiles of MP and RB fixation in head and neck surgery.

Impact of intraoperative ischemia time on acute complications of head and neck microvascular free tissue transfer: A systematic review and meta-analysis

BACKGROUND

To evaluate the relationship between intraoperative ischemia time with acute microvascular free tissue transfer (MFTT) complications in head and neck reconstruction.

METHODS

A systematic review using PRISMA guidelines was performed. Inclusion encompassed all available studies published and indexed using PubMed, Medline, and Embase. Meta-analyses were performed using the Cochrane Review Manager tool. Methodological Index for Non-Randomized Studies (MINORS), the Revised Cochrane risk-of-bias tool for randomized trials, and the NIH Study Quality Assessment Tool for non-randomized prospective studies.

RESULTS

A total of 430 citations were reviewed. 25 were included in our overall qualitative analysis, and 14 for meta-analysis. When comparing ischemia times for flaps with and without complications, no significant difference was observed (p = 0.98). Additionally, in a separate cohort, no significant effect was realized when correlating ischemia time to overall rates and total complications.

CONCLUSION

Ischemia time was not significantly different between those with and without acute flap complications.

Outcomes in Pediatric Maxillofacial Reconstruction With Vascularized Fibular Flaps: A Systematic Review

BACKGROUND

The purpose of this study was to examine the complications and outcomes after maxillofacial reconstruction using the free fibular flap in the pediatric population.

METHODS

A systematic review and descriptive analysis were conducted using data variables, including study characteristics; patient characteristics; postoperative complications (major and minor); surgical revision; and dental rehabilitation.

RESULTS

The systematic review resulted in 1622 articles, 55 of which met inclusion criteria for this study. The 55 articles consisted of 17 case series and 38 case reports with level III/IV and level V of evidence, respectively. Of the 155 identified pediatric patients, the rate of major complications was 13.5% and minor complications was 24.5%. The most common complication was mild growth distortion (n = 7) at the recipient site. Complications at the donor site were less common. During follow-up, 29 patients (18.7%) underwent or awaited surgical revision, and 43 patients (27.7%) underwent or awaited dental rehabilitation.

CONCLUSIONS

Our study suggests that the free fibular flap for pediatric maxillofacial reconstruction is safe and reliable. Additionally, surgical revision to correct the functional impairments resulting from primary reconstruction using the free fibular flap is relatively common.

Bone Union of Osseous Microvascular Free Tissue Transfer in Mandibular Reconstruction

Objectives

Osseous microvascular free tissue transfer (MFTT) is the gold standard for reconstruction for most segmental mandibulectomy defects. The most common osseous MFTT utilized in reconstruction is the fibular, scapular, and osteocutaneous radial forearm (OCRF) free flap. We evaluated postoperative bone union as well as clinical complications following MFTT and the impact of various patient and reconstructive characteristics, including type of osseous MFTT.

Study Design

Retrospective cohort study.

Setting

Tertiary care academic hospital.

Methods

This study examined patients who underwent osseous MFTT for mandibular defects from January 2017 to January 2019.

Results

An overall 144 osteotomies in 58 patients were evaluated. Of the 144 junctions, 28 (19.4%) showed radiographic nonunion. Patients who underwent preoperative (odds ratio [OR] = 0.30, P = .027) and postoperative (OR = 0.28, P = .003) radiation had a significantly lower bone union score. Time from surgery to postoperative imaging was associated with higher bone union scores (OR = 1.07, P = .024). When bone union scores were compared among types of MFTT, fibular (OR = 5.62, P = .008) and scapular (OR = 4.69, P = .043) MFTT had significantly higher scores than OCRF MFTT. Twelve (20.7%) patients had postoperative complications. There was no statistically significant correlation between clinical complications and various variables, including type of osseous MFTT.

Conclusion

Pre- and postoperative radiation and time from surgery have an impact on bone union. Regarding the type of MFTT, fibular and scapular MFTT appeared to have higher bone union when compared with OCRF. There was no impact of bone union or type of osseous MFTT on clinical complications.

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.

Post-operative Complication at the Donor Site of Fibular Free Flap in a Pediatric Patient

The fibular free flap is most frequently used for reconstructing the mandible owing to the adequate length of the bone with a reliable blood supply. It has a long vascular pedicle with adequate vessel diameter for anastomosis and also a good amount of skin paddle for coverage. However, the reports of post-operative complications at the donor site among pediatric patients are scarce in the literature. We present a pediatric case of ankle valgus deformity following vascularized fibular harvest.

Implant-based dental rehabilitation in head and neck cancer patients after maxillofacial reconstruction with a free vascularized fibula flap: the effect on health-related quality of life

PURPOSE

To evaluate the effect of implant-based dental rehabilitation (IDR) on health-related quality of life (HRQoL) in head and neck cancer (HNC) patients after reconstruction with a free vascularized fibula flap (FFF).

METHODS

Eligible patients were identified by retrospectively reviewing the medical records of patients treated in Amsterdam UMC-VUmc. HRQoL data were used from OncoQuest, a hospital-based system to collect patient-reported outcome measures in routine care. Data were used of the EORTC QLQ-C30 and QLQ-H&N 35 before FFF reconstruction (T₀) and after completing IDR (T₁). Data were statistically analysed with the chi-square test, independent samples t test and linear mixed models.

RESULTS

Out of 96 patients with maxillofacial FFF reconstruction between January 2006 and October 2017, 57 patients (19 with and 38 without IDR) had HRQoL data at T₀ and T₁. In the cross-sectional analysis, patients with IDR scored significantly better at T₀ and T₁ on several EORTC domains compared to the patients without IDR. Weight loss was significantly different in the within-subject analysis between T₀ and T₁ for patients with IDR (p = 0.011). However, there were no significant differences in the mean changes of all the EORTC QLQ-C30 and EORTC QLQ-H&N35 scores between the defined timepoints for patients with IDR compared to those without.

CONCLUSIONS

In this study, no differences were found in the course of HRQoL in HNC patients who had undergone IDR after maxillofacial FFF reconstruction, compared to those who had not. Patients should be preoperatively informed to have realistic expectations regarding the outcome of IDR.

The combined anterolateral thigh-Partial iliac crest minihybrid free flap for mandibular reconstruction

BACKGROUND AND AIMS

Tumors of the oral cavity often require extensive resections leading to significant hard and soft tissue defects. Microvascular free flaps, consisting of both hard and soft tissue, are often required in reconstructions. Hybrid flaps, composed of two different joint free flaps, offer potential alternatives for head and neck reconstruction. This report presents our results with a modified hybrid ALT/DCIA, that is, minihybrid free flap (MH-flap) composed of the anterolateral thigh (ALT) and a partial inner lamina iliac crest only (partial DCIA) for reconstruction of the mandibular region.

PATIENTS AND METHODS

Eight patients underwent oral cancer reconstruction of the mandible with the MH-flap. The MH-flap was harvested sparing the outer crest and lamina of crista, and its pedicle was combined to the distal pedicle of ALT. Clinical data and postoperative complications were analyzed.

RESULTS

The mean length of the osseous graft was 64 mm (range 54-78 mm). None of the patients had complications requiring surgical intervention. No donor site complications were observed. The overall survival rate was 100%. The mean length of follow-up was 16 months (range 7-30 months).

CONCLUSIONS

According to our results, the ALT-partial DCIA MH-flap has postoperative outcomes comparable to those of the fibular flap. The flap is a good option with excellent bone properties for reconstruction of limited mandibular defects not suitable for fibular or scapular reconstruction.

Thirty-eight-year follow-up of the first patient of mandibular reconstruction with free vascularized fibula flap

Background

The mandible is responsible for vital functions of the stomatognathic system, and its loss results in functional and aesthetic impairment. Mandibular reconstruction with free fibula flap is considered the gold standard for mandibular reconstruction.

Case presentation

We describe here the 38-year follow-up of the patient who was the first case of mandibular reconstruction with free fibula flap reported in the literature. The original report describes a 27-year-old woman who had undergone extensive mandibulectomy due to an osteosarcoma. A microvascularized fibula flap was used for mandibular reconstruction in 1983. Two years later, a vestibulo-lingual sulcoplasty with skin graft was performed to allow the construction of a total dental prosthesis. Fifteen years after the initial treatment, an autologous iliac crest graft was placed in the fibula flap, aimed at increasing bone thickness and height for rehabilitation with implant supported prosthesis. In 2015, a rib graft was positioned in the mental region, enhancing the support to the soft tissues of the face and improving the oral function. A recent review of the patient shows well-balanced facial morphology and optimal functional results of the procedure.

Conclusions

The fibula flap method, described in 1975 and first reported for mandibular reconstruction in 1985, continues to be applied as originally described, especially where soft tissue damage is not extensive. Its use in reconstructive surgery was expanded by advancements in surgery and techniques such as virtual surgical planning. However, there is still a lack of evidence related to the long-term evaluation of outcomes. The present work represents the longest-term follow-up of a patient undergoing mandibular reconstruction with free vascularized fibula flap, presenting results showing that, even after 38 years, the procedure continues to provide excellent results.

Prevention and Management of Complications of Tissue Flaps

In this article, we discuss 4 common free flaps performed in reconstructive surgery: the anterolateral thigh flap, the radial forearm flap, the fibula flap, and the transverse rectus abdominis myocutaneous/deep inferior epigastric perforator flap. Donor and recipient complications for each flap type and strategies on how to prevent and manage such complications are discussed.

The Effect of Smoking on the Postoperative Course After Head and Neck Reconstruction With a Vascularized Free Flap: A Retrospective Study

OBJECTIVES

The objective of the present study is to determine the impact of smoking on hospital and intensive care unit stay, need for surgical reintervention, Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, and surgical complications after head and neck reconstructions.

METHODS

All 153 patients who underwent head and neck reconstructions with free tissue transfer at the department of oral and maxillofacial surgery at the University Hospitals of Leuven between January 1, 2015 and December 31, 2018 were enrolled in this retrospective cohort study. Data from medical charts were extracted. Univariate and multiple regression analyses were performed. A level of significance of P < 0.05 (α = 0.05) was used.

RESULTS

Smoking was not associated with Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, hospital or ICU stay, the incidence of postoperative complications in both flap and donor site, or surgical reintervention.

CONCLUSIONS

Regarding the outcomes included in this study, smoking status should not be considered as a critical factor in patient selection for head and neck reconstructions with a vascularized free flap.

Intensive Care as an Independent Risk Factor for Infection after Reconstruction and Augmentation with Autologous Bone Grafts in Craniomaxillofacial Surgery: A Retrospective Cohort Study

Autologous bone grafts for reconstruction and augmentation are routinely used for maintaining functionality and facial aesthetics. Associated complications, however, have a significant impact on patients and health care systems. This study aims to investigate the possible risk factors associated with the occurrence of complications in order to provide evidence for the outcome of autologous bone graft reconstructive procedures. Patients from 2008 to 2018 who underwent autologous (mostly mandibular) reconstruction were included in the observational study. Clinical, pathological, and therapeutic factors were examined in univariate and multivariate analysis for significance with occurring complications. A multivariate model was used to create a prognostic model predicting the occurrence of complications. Graft complications requiring revision were exhibited by 33/128 patients. Infections were most frequent, with 4/22 patients affected by multi-resistant germs. Multivariate analysis showed radiotherapy (OR = 5.714; 95% CI: 1.839–17.752; p = 0.003), obstructive pulmonary disease (OPD) (OR = 4.329; 95% CI: 1.040–18.021; p = 0.044) and length of defect (in mm) (OR = 1.016; 95% CI: 1.004–1.028; p = 0.009) as independent risk factors associated with graft complications with high accuracy of prediction (AUC = 0.815). Intensive care (OR = 4.419; 95% CI: 1.576–12.388; p = 0.005) with a coefficient between intensive care and OPD (0.214) being low was identified as the most relevant risk factor for infection. Although intensive care is not a classic risk factor, but rather a summation of factors not reaching significance in the individual case, a stay in ICU (intensive care unit) needs to be considered for graft complications. As a clinical consequence, we recommend using the best possible hygienic measures during procedures e.g., while performing dressing and drainage changes in ICU.

Removal of patient-specific reconstruction plates after mandible reconstruction with a fibula free flap: is the plate the problem?

Computer-aided microvascular mandible reconstruction is an increasingly common procedure in oral and maxillofacial surgery. The aim of this retrospective single-centre study was to evaluate the rate and specifics of hardware removal after fibula free flap (FFF) fixation with a patient-specific reconstruction plate. The study included patients who underwent hardware removal between April 2017 and October 2019. Statistical analyses were performed regarding the different indications for plate removal (dental implantation versus complication) and the surgical approach (intraoral versus extraoral). Plate removal was performed in 29 of 98 patients (29.6%) after FFF fixation with a patient-specific reconstruction plate. Plate removal was done prior to dental implantation in 58.6% of cases and due to complications in 41.4%. Complications seen between reconstructive surgery and plate removal were less frequent in the dental rehabilitation group (8/17 vs 12/12; P=0.002). Within this group, 35.3% of plates were removed intraorally, and the majority of partial plate removals were performed in the patients with plate removal for dental rehabilitation (72.7% vs 27.3%). Hospitalization was shorter with an intraoral approach (1.7 days vs 4.0 days, P=0.052). The removal of patient-specific reconstruction plates prior to dental implantation is often partial and can be performed intraorally. The use of patient-specific miniplates for fixation of FFF might facilitate later dental rehabilitation.

Risk factors assessment in fibular free flap mandibular reconstruction

INTRODUCTION

The fibular free flap (FFF) is the best choice method for mandibular reconstruction. However, the failure and the complications risk factors (RF) are not yet fully identified. This study aims to analyze these RF in order to improve the success rate.

MATERIAL

This retrospective study includes all patients who benefited from a FFF mandibular reconstruction between the first of January, 2014 and the thirty-first of December, 2018 in the Department of Stomatology and Maxillofacial Surgery department of the CHU Saint-Pierre Hospital, Brussels, Belgium.

RESULTS

Thirty patients benefited from this intervention. The overall success rate was 90%. Majority of the patients were men (67%) (mean age: 52 years). The main associated co-morbidities were: alcohol (50%), tobacco consumption (67%) and previous radiotherapy (20%). The mean operative time was 9,5hours. The morbidities rates at the receiving site (RS) and the donor site (DS) were respectively 43% and 30%. Infection and dehiscence of the RS were the main complications. Statistical analysis identified RF for RS infections: atherosclerosis and operative time; RS dehiscence (previous cervical dissection and secondary reconstruction); flap necrosis (ischemia time, rate of infection at the recipient site, history of radiation therapy, alcohol consumption, National Nosocomial Infection Surveillance score (NNISS), and history of cervical dissection); and DS morbidities (NNISS and dehiscence rate at the DS in the early period).

CONCLUSION

The FFF mandibular reconstruction offers a significant success rate. Nevertheless, this study highlighted several failure and complications RF of the procedure. Previous neck dissection and radiotherapy, operative and the ischemia time, were RF associated with complication at the RS. Furthermore, the NNIS score and the dehiscence rate were also reported as RF for FFF necrosis.

Donor- and recipient-site morbidity of vascularized fibular and iliac flaps for mandibular reconstruction: A systematic review and meta-analysis

The aim of this article is to evaluate the early and late morbidities of the donor- and recipient-site in patients undergoing mandibular reconstruction using either vascularized fibular flap (VFF) or vascularized iliac flap (VIF). Electronic databases, including PubMed, Web of Science, Cochrane Central and Embase, were explored for literature published until October 2020. A total of twenty-four articles reporting complications following mandibular reconstruction surgery with follow-up periods ranging from six to 63 months were selected based on the exclusion criteria. For each research, the JBI Critical Assessment Tool and the ROBINS-I Tool were used to analyze the methodological quality and the risk of bias. A single-arm meta-analysis was performed to have a synthesized analysis of the donor- and recipient-site early and late morbidities. Results showed that the early morbidities in VFF group ranged from 3% to 12%, and the late morbidities in VFF group ranged from 5% to 67%. In VIF group, the early morbidities ranged from 3% to 16%, and the donor-site late morbidities ranged from 6% to 43%. Complications with the top three morbidities in the VFF group were: chronic sensory disturbances at the donor-site (67%), malocclusion (22%) and chronic lower limb weakness (20%); and in the VIF group were: chronic sensory disturbances at the donor-site (43%), chronic pain at the donor-site (26%), chronic gait disturbance (20%). Further controlled clinical trials are needed to assess the long-term outcome of VFF or VIF grafting.

Biomaterial-based strategies for maxillofacial tumour therapy and bone defect regeneration

Issues caused by maxillofacial tumours involve not only dealing with tumours but also repairing jaw bone defects. In traditional tumour therapy, the systemic toxicity of chemotherapeutic drugs, invasive surgical resection, intractable tumour recurrence, and metastasis are major threats to the patients' lives in the clinic. Fortunately, biomaterial-based intervention can improve the efficiency of tumour treatment and decrease the possibility of recurrence and metastasis, suggesting new promising antitumour therapies. In addition, maxillofacial bone tissue defects caused by tumours and their treatment can negatively affect the physiological and psychological health of patients, and investment in treatment can result in a multitude of burdens to society. Biomaterials are promising options because they have good biocompatibility and bioactive properties for stimulation of bone regeneration. More interestingly, an integrated material regimen that combines tumour therapy with bone repair is a promising treatment option. Herein, we summarized traditional and biomaterial-mediated maxillofacial tumour treatments and analysed biomaterials for bone defect repair. Furthermore, we proposed a promising and superior design of dual-functional biomaterials for simultaneous tumour therapy and bone regeneration to provide a new strategy for managing maxillofacial tumours and improve the quality of life of patients in the future.

Three salvage strategies in microvascular fibula osteocutaneous flap for mandible reconstruction with vascular compromise and establishment of an algorithm

BACKGROUND

Fibula osteocutaneous flap is associated with a higher rate of reexploration in mandible reconstruction due to limited space for the fixation of various tissue components on multiple segments of the fibula flap. To maintain optimal circulation to the flap and to prevent negative outcomes because of partial or total flap loss, we shared our experiences on salvaging the free fibula flap with vascular compromise in the first reexploration and we developed an algorithm.

METHODS

From 1992 to 2018, 12 patients between the ages of 48 to 63 (mean: 52.5) who had presented with oral squamous cell carcinoma (n = 10) followed by osteoradionecrosis of the mandible (n = 2) were explored. The operative findings were; (1) occlusions of vein (3 cases); (2) occlusions of artery (4 cases); and (3) occlusions of both artery and vein (5 cases). After correcting the kinking or evacuating the hematoma, the arterial inflow was initially reestablished by anterograde flow. If this was nonfunctional, retrograde flow from the distal end of the peroneal artery was provided. For the vein, anterograde venous drainage was reestablished. If the thrombus extended deep into the peroneal vein, regular venous return was blocked on the anterograde side, and the flap remained congested therefore retrograde venous drainage was performed regardless of the valves in the vein. However, the two ends of the peroneal artery were anastomosed to prevent thrombosis of the artery.

RESULTS

The success rate of revised cases was 75% (9/12). All failed cases had presented with both artery and vein occlusion (three cases). Pectoralis major musculocutaneous flap and anterolateral thigh flap were needed for the external surface in two cases. Skin graft was required for seven cases to restore intraoral lining. Six patients underwent dental rehabilitation with prosthetic implants.

CONCLUSION

Immediate reexploration is mandatory to salvage the flap.

Risk Factors for Plate Extrusion After Mandibular Reconstruction With Vascularized Free Flap

PURPOSE

Plate extrusion after mandibular reconstruction is a complication that imposes significant morbidity on the patient. The goal of this study is to estimate the incidence of plate extrusion after mandible reconstruction with a vascularized free flap and to identify the factors associated with plate extrusion.

METHODS

This was a retrospective cohort study involving patients who underwent mandibular reconstruction from October 2008 to July 2019 at LAC + USC or Keck Hospital of USC. Inclusion criteria were age ≥ 18 years, single-stage mandibular reconstruction with vascularized free flap, and follow-up of at least 12 months. Relevant demographic, intraoperative, and postoperative data were collected. The primary outcome was postoperative plate extrusion within the 12-month follow-up. Descriptive, univariate, and multivariate analyses were performed. Statistical significance was set at P ≤ .05.

RESULTS

A total of 102 patients were included in this study. The majority received a fibula free flap (90%) for a malignant neoplasm (76%). All patients had at least 12 months of follow-up. The rate of plate extrusion was 16%, with the majority of those patients undergoing plate removal (69%). After adjusting for postoperative fistula, soft tissue, and length of hospitalization, we found that any history of smoking (odds ratio = 12.8; confidence interval, 1.57 to 104.2), number of osteotomies (odds ratio 3.07; confidence interval, 1.09 to 8.6), flap nonviability (odds ratio = 18.2; confidence interval, 2.22 to 148.8) were associated with plate extrusion on multivariate analysis. Postoperative soft tissue infection approached significance.

CONCLUSIONS

This study demonstrates that smoking history, number of osteotomies, and flap nonviability are associated with plate extrusion after mandible reconstruction. Performing fewer osteotomies when possible to avoid excessively small flap bone segments and minimizing postoperative complications may improve long-term outcomes after mandibular reconstruction.

A Comprehensive Analysis of Complications of Free Flaps for Oromandibular Reconstruction

OBJECTIVES/HYPOTHESIS

To determine the frequency and management of short- and long-term complications related to oromandibular free flap reconstruction and identify potentially predictive factors of hardware complications.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective database from chart review was formed consisting of 266 oromandibular free flap reconstructions performed at a single institution over a 15-year period. Data were collected on demographics, surgical treatment, complications, and management of complications. Subgroup univariate and multivariate analyses were performed to compare patients with hardware complications and those without.

RESULTS

Eighty-one of 266 patients (30.5%) that underwent oromandibular reconstruction had an early complication (<4 weeks after surgery), and the most common complications were cervical wound dehiscence (11.3%) and fistulas (9.40%). Eighty of 266 patients (30.1%) had a long-term complication (>4 weeks after surgery) and the most common complication was plate exposure (26.7%). Univariate and multivariate analyses showed no association between whether there was hardware extrusion and fibula versus scapula, smoking history, virtual surgical planning (VSP), and dental implantation (P > .05). Only early complications (OR, 3.59, 95% CI, 1.83-7.05, P < .01) and patients undergoing oromandibular reconstruction for osteoradionecrosis (OR, 2.26, 95% CI, 1.10-4.64, P = .03) were strongly and independently associated with subsequent hardware extrusion on univariate analysis.

CONCLUSIONS

Both short- and long-term complications are common after oromandibular reconstruction. The most important predictive factor for a late complication is an early complication and prior radiation. There was no difference of plate complications among the various free flap types. Dental implantation and use of VSP were not associated with hardware complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1997-2005, 2021.

Multicentre evaluation of the interest in planned surgery for mandibular reconstruction with fibula free flap: a retrospective cohort study

PURPOSE

The aim of this study was to determine the impact and cost-effectiveness of virtual surgical planning during fibula free flap mandibular reconstruction on peri- and postoperative data.

METHODS

We conducted a retrospective cohort study from January 2012 to December 2016 in four French university centres.

RESULTS

Three hundred fibula free flaps for mandibular reconstruction were performed in 294 patients. Surgeries were planned in 29.7% of cases (n = 89). There was no significant difference in the rate of negative-margins excision, median length of hospital stay, operative time, and early complications between planned and non-planned surgeries. Morphological analysis revealed a higher rate of centred occlusion in planned patients (satisfactory alignment of interincisal points: Planned 65.5% vs Non-Planned 33.3%, p = 0.006).

CONCLUSION

In mandibular reconstruction by fibula free flap, the additional cost generated by virtual surgical planning does not seem to be balanced by savings resulting from a shorter operative course, a reduced hospital stay, or a reduction in postoperative complications. However, virtual surgical planning may provide a higher rate of centred occlusion. Long-term benefits should be assessed by further studies.

Four Lessons Learned from Complications in Head and Neck Microvascular Reconstructions and Prevention Strategies

Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients.

METHODS

Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient's reconstructive journey.

RESULTS

Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest.

CONCLUSION

The authors reflect on the causes and propose preventative strategies in each peri-operative stage.

[Possible applications of free microsurgical fibula transplantation in the reconstruction of complex bone defects in the extremities: review of the literature and case series]

BACKGROUND

 Extensive osseous defects of the extremities following trauma and tumour resection represent a major challenge for plasticreconstructive surgical teams. Defect reconstruction by free microsurgical fibula transplantation has become a standard method but is associated with a considerable rate of complications. The aim of the present work is to provide an up-to-date overview of the various reconstruction methods and to report our personal experiences with free fibula transplantation in a case series.

PATIENTS AND METHODS

 The literature search on the subject was performed on Pubmed and Web of Science, and a retrospective collection of data was conducted based on our own cases, including clinical and radiological data.

RESULTS

 From 2007 to 2018, free fibula transplantation was performed in 11 patients under the guidance of the senior author (MS). The defects were a result of pseudarthrosis in four cases, osteitis in three, and a tumour in two cases. Two patientssustained a primary defect due to a high-energy trauma. In nine cases the upper limb was affected; only two had the defect in the lower limb. No graft failure was observed. In eight cases, an osteoseptocutaneous graft was taken; in two cases there was a post-operative loss of the skin island. Fibula length ranged between 5 and 22 cm. In all cases, bony integration of the graft was complete. The range of motion in the affected limb after physiotherapy was very good to satisfactory.

CONCLUSION

 Extensive bone defect reconstruction using free fibula flaps is undoubtedly the gold standard method, but the high rate of complications described in the literature necessitates a strict indication in due consideration of possible alternatives. Close cooperation between the disciplines of plastic reconstructive surgery and trauma orthopaedics is indispensable.

Outcomes following Microvascular Mandibular Reconstruction in Pediatric Patients and Young Adults

Background:

The etiology and treatment of complex mandibular defects in children differ markedly from those of adults, although treatment with free bone flaps is historical in both groups. While adult outcomes and complication rates are well known, few pediatric data exist, especially for patients with congenital deficiencies. This study reports early and late outcomes from a cohort of young, primarily syndromic patients undergoing microvascular mandibular reconstruction.

Methods:

This is a retrospective case series of patients who underwent microvascular mandibular reconstruction between 1995 and 2016.

Results:

Thirteen patients received a total of 13 fibula transfers and 1 medial femoral condyle transfer. Most patients carried a congenital diagnosis (77%), and the average age during surgery was 11.7 ± 5.7 years. The median (interquartile range) [IQR] length of follow-up was 6.3 (5.7) years. There was a 100% flap survival rate, although 86% of all patients experienced at least one complication. Half of all procedures resulted in an early complication. Nine patients (69%) developed late complications, of which temporal mandibular joint ankylosis was the most common (n = 5; 38%).

Conclusions:

This study is one of few detailing outcomes following mandibular reconstruction by free flap transfer in pediatric patients. These patients were primarily syndromic with appreciable complication rates higher than in other adult and pediatric studies. Some complications are manageable or self-resolving, but others lead to functional problems that may require late operative interventions to correct. Microsurgical treatment should be reserved for children with large, complex mandibular defects when other options are unavailable or have been exhausted.

The Evolution of the Free Fibula Flap for Head and Neck Reconstruction: 21 Years of Experience with 128 Flaps

BACKGROUND

 The free fibula flap is commonly referred to as a "workhorse" for head and neck reconstruction. During our 21-year experience with this flap, we have performed several changes in preoperative planning, operative technique, and postoperative follow-up.

PATIENTS AND METHODS

 A retrospective cohort study designed to analyze the cohort of patients who underwent free fibula transfer for head and neck reconstruction. Demographics, medical background, operative data, and postoperative outcome were collected. The changes we performed in preoperative planning, operative technique, and postoperative follow-up were assessed and their impact on outcome discussed.

RESULTS

 During 1998 to 2019 a total of 128 free fibula flaps were transferred for head and neck reconstruction. When comparing the patients treated in the early years to those who were treated in recent years we found no statistically significant difference in minor or major nonmicrosurgical complications in the recipient and donor site and in the rate of take backs due to microsurgical reasons. However total flap failure rate improved from 28% in early years to 8% in recent years (p = 0.012).

CONCLUSION

 During this 21-year period, we performed several changes in our practice. This included the use of a three-dimensional (3D) prefabricated model of the mandible, a shift toward side-table osteotomies, increasing the rate of osteofascial flaps in contrast to osteocutaneous flaps and the use of an implantable Doppler. These changes, together with a learning curve of the surgical team, significantly improved our overall success rates.

Fibula free flap in maxillomandibular reconstruction. Factors related to osteosynthesis plates' complications

The aim of this paper is to identify risk factors associated with the development of osteosynthesis plates' related complications in fibula free flap reconstructions. This is a case series study of consecutive fibula free flaps. Clinical and radiological variables were recorded. Patient outcomes were evaluated with special attention to osteosynthesis plates' related complications; these included plate exposure, plate fracture, loosening of screws, non-union, bone resorption, oro-cutaneous fistulas, and bone exposure. We have done a descriptive analysis, univariate analysis, and multivariate logistic regression model to explore possible risk factors for osteosynthesis plates' related complications. Data analysis was performed using R software (version 3.5.0). 111 fibula free flaps were studied. 29 patients (26.1%) developed osteosynthesis plates' related complications. The mean time to osteosynthesis plates' related complications was 22 months; range (1-120); the median and mode were 12 months. Patients with preoperative radiotherapy (34% vs 14%, p = 0.021), and secondary reconstruction (31% vs 15%, p = 0.053) had a higher incidence of osteosynthesis plates' related complications. In the univariate analysis, "preoperative radiotherapy" (OR 3.07, 95%CI = 1.139-8.242, p = 0.025) and "extraoral soft-tissue defect" (OR 2.907, 95%CI = 1.032-8.088, p = 0.042) were risk factors for osteosynthesis plates' related complications. We have observed an interaction effect: patients with mandibular Brown's classes III + IV and "secondary reconstruction" have a higher risk for osteosynthesis plates' related complications; more than 47.30 times compared to Brown's class I and "primary reconstruction" (p = 0.026). Different factors may contribute to the development of osteosynthesis plates' related complications. Our study adds important information about these. Patients with higher risk of developing complications should be informed that a second intervention to remove the plates might be necessary.

Outcomes of microvascular bone flaps versus osteocutaneous flaps in head and neck reconstruction

BACKGROUND

Surgical resection of head and neck (H&N) neoplasms requiring osseous reconstruction have underdefined complication profiles. This study aimed to characterize postoperative outcomes of patients with H&N neoplasia undergoing osteocutaneous flap (OCF) or bare bone flap (BBF) reconstructions.

MATERIALS AND METHODS

Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) 2005-2017 databases. Queried for diagnosis and procedural codes extracted patients with H&N neoplasms undergoing BBF or OCF reconstruction. Postoperative complications were evaluated. Multivariable regression generated adjusted odds ratios.

RESULTS

A cohort of 746 patients were identified. Of reconstructions, 24.9% (n = 186/746) were BBFs while 75.1% (n = 560/746) were OCFs. 58.1% of the BBF cohort and 59.9% of the OCF cohort experienced an all-cause complication (p = .654). Sub-stratified, 24.2% of BBF and 17.5% of OCF patients experienced a wound complication (p = .045). Regression analysis demonstrated no difference in risk for medical complications between cohorts. However, patients receiving OCFs had a decreased likelihood of developing a wound complication (OR 0.652; 95%CI 0.430-0.989; p = .044) compared to patients receiving BBFs.

CONCLUSION

The incidence of complications following osseous reconstruction of the H&N is considerable. Although several complication outcomes do not seem to differ between BBF or OCF reconstructions, OCFs is associated with a decreased likelihood of wound complications.

The impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap: a systematic review and meta-analysis

Reconstructive surgery with a free vascularised tissue flap is indicated in large defects in the head and neck region, which arise mostly because of head and neck cancer. Tobacco smoking is a major risk factor for head and neck cancer, and many patients undergoing reconstructive surgery in the head and neck have a history of smoking. The objective of this meta-analysis was to determine the impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap. A systematic review was undertaken for articles reporting and comparing the incidence of overall surgical complications after reconstructive surgery with a free vascularised tissue flap between smokers and nonsmokers. Relevant articles were searched using PubMed, Cochrane, and Embase databases, and screened for eligibility according to the PRISMA guidelines. The risk of bias analysis was conducted using the Newcastle-Ottawa quality assessment scale. A meta-analysis was performed to quantitatively compare the incidence rate of overall surgical complications, flap failure, surgical site infection, fistula, and haematoma between smokers and nonsmokers using OpenMetaAnalyst (open source) software. Only qualitative analysis was performed for wound dehiscence, bleeding, nerve injury, and impaired wound healing. Forty-six articles were screened for eligibility; 30 full texts were reviewed, and 19 studies were included in the quantitative meta-analysis. From the 19 studies, 18 were retrospective and 1 was a prospective study. In total, 2155 smokers and 3124 nonsmokers were included in the meta-analysis. Smoking was associated with a significantly increased risk of 19.12% for haematoma (95% Confidence Interval (CI): 4.75-33.49; p<0.01), and of 4.57% for overall surgical complications (95% CI: 1.97-7.15; p<0.01). No significant difference in risk was found for flap failure (95% CI: -4.33-9.90; p=0.44), surgical site infection (95% CI: -0.88-2.60; p=0.33) and fistula formation (95% CI: -3.81-3.71; p=0.98) between smokers and nonsmokers. Only for flap failure was a significant heterogeneity found (I²=63.02%; p=0.03). Smoking tobacco was significantly associated with an increased risk of overall surgical complications and haematoma, but did not seem to affect other postoperative complications. Encouraging smoking cessation in patients who need reconstructive head and neck surgery remains important, but delaying surgery to create a non-smoking interval is not needed to prevent the investigated complications. More high-quality retrospective or prospective studies with a standardised protocol are needed to allow for definitive conclusions.

Biomechanical Analysis of Various Reconstructive Methods for the Mandibular Body and Ramus Defect Using a Free Vascularized Fibula Flap

Several different methods exist for reconstructing the mandibular body and ramus defect with the use of a free vascularized fibula flap, but none have adequately addressed the long-term mechanical stability and osseointegration. The aim of this study is to compare the biomechanics of different surgical methods and to investigate the best approach for reconstructing the mandibular body and ramus defect. Five finite element models based on different reconstructive methods were simulated. Stress, strain, and displacement of connective bone sections were calculated for five models and compared. The models were printed using a 3D printer, and stiffness was measured using an electromechanical universal testing machine. The postoperative follow-up cone beam computed tomography (CBCT) was taken at different time points to analyze bone mineral density of connective bone sections. The results showed that the “double up” (DU) model was the most efficient for reconstructing a mandibular body and ramus defect by comparing the mechanical distribution of three sections under vertical and inclined loading conditions of 100 N. The stiffness detection showed that stiffness in the DU and “double down” (DD) models was higher compared with the “single up” (SU), “single down” (SD), and “distraction osteogenesis” (DO) models. We used the DU model for the surgery, and postoperative follow-up CBCT showed that bone mineral density of each fibular connective section increased gradually with time, plateauing at 12 weeks. We conclude that a free vascularized fibula flap of the DU type was the best approach for the reconstruction of the mandibular body and ramus defect. Preoperative finite element analysis and stiffness testing were shown to be very useful for maxillofacial reconstruction.

Long-Term Complications of Osteocutaneous Free Flaps in Head and Neck Reconstruction

OBJECTIVE

To determine the frequency at which patients with osteocutaneous free flap reconstruction of the head and neck develop long-term complications and identify predisposing perioperative factors.

STUDY DESIGN

A prospectively maintained database of free flaps performed at a single institution over a 10-year period was queried.

SETTING

Single tertiary care referral center.

SUBJECTS AND METHODS

In total, 250 osseous or osteocutaneous free flaps (OCFFs) for mandibular or maxillary reconstruction were analyzed. Data were collected on demographics, preoperative therapy, resection location, adjuvant treatment, complications, and subsequent surgeries, and multivariate analysis was performed. Subgroup analysis based on perioperative factors was performed.

RESULTS

The median follow-up time was 23 months. In 185 patients with at least 6 months of follow-up, 17.3% had at least 1 long-term complication, most commonly wound breakdown, fistula or plate extrusion (13.5%), osteoradionecrosis or nonunion (6.5%), and infected hardware (5.9%). Prior chemoradiotherapy and cancer diagnosis predisposed patients to long-term complications. At the 5-year follow-up, 21.7% of patients had experienced a long-term complication.

CONCLUSIONS

Long-term complications after OCFF occurred in 17% of patients. In this series, a preoperative history of chemoradiation and those undergoing maxillary reconstruction were at high risk for the development of long-term complications and thus warrant diligent follow-up. However, OCFFs can often enjoy long-term viability and survival, even in the case of perioperative complications and salvage surgery.

Low skeletal muscle mass is a strong predictive factor for surgical complications and a prognostic factor in oral cancer patients undergoing mandibular reconstruction with a free fibula flap

BACKGROUND

Fibula free flaps (FFF) are effective in accomplishing successful reconstruction for segmental defects of the mandible. Potential risk factors for FFF complications have been described in previous research, e.g. age, comorbidity and smoking. Low skeletal muscle mass (SMM) has shown to be an emerging predictive factor for complications and prognostic factor for survival in head and neck cancer. This study aims to identify the predictive and prognostic value of low SMM for surgical FFF related complications, postoperative complications and survival in patients who underwent mandibular reconstruction with FFF after oral cavity cancer resection.

MATERIALS AND METHODS

A retrospective study was performed between 2002 and 2018. Pre-treatment SMM was measured at the level of the third cervical vertebra and converted to SMM at the level of the third lumbar vertebra (L3). SMM at the level of L3 was corrected for squared height. Low SMM was defined as a lumbar skeletal muscle index (LSMI) below 43.2 cm²/m².

RESULTS

78 patients were included, of which 48 (61.5%) had low SMM. Low SMM was associated with an increased risk of FFF related complications (HR 4.3; p = 0.02) and severe postoperative complications (Clavien-Dindo grade III-IV) (HR 4.0; p = 0.02). In addition low SMM was a prognosticator for overall survival (HR 2.4; p = 0.02) independent of age at time of operation, ACE-27 score and TNM stage.

CONCLUSION

Low SMM is a strong predictive factor for FFF reconstruction complications and other postoperative complications in patients undergoing FFF reconstruction of the mandible. Low SMM is also prognostic for decreased overall survival.

Effect of Coagulation Status and Co-Morbidity on Flap Success and Complications in Patients with Reconstructed Free Flap

Objective

Free flap surgeries constitute the basis of reconstruction surgery in patients with major defects. Prediction of complications that cause flap loss in such patients is important in terms of reducing the length of hospital stay and expenses. We aimed to retrospectively investigate the effect of co-morbidities and the coagulation status on flap loss and complications in patients with reconstructed free flap.

Methods

Demographic data, smoking, alcohol habits, co-morbidities, coagulation tests and thromboelastogram results from preoperative, intraoperative and postoperative anaesthesia and surgical records of patients undergoing free flap surgeries between January 2015 and June 2017 were retrospectively screened.

Results

Flap success rate was found to be 96.1% in total 77 patients with free flap. Coagulation related complication rate, such as thrombosis, haematoma and partial necrosis, were 22.1%. There was a significant relationship between age, chronic obstructive pulmonary disease and hypercholesterolaemia and flap loss (p=0.006, p=0.025 ve p=0.025, respectively). Flap complications were more frequent in patients with chronic obstructive pulmonary disease and hypertension. Laboratory test results revealed no statistical correlation between flap complications and flap loss with preoperative and postoperative TEG.

Conclusion

Advanced age, co-morbidities such as hypertension and chronic obstructive pulmonary disease are associated with complications and flap loss in free flap surgery. However, there were no clinically significant association of complications and flap loss with laboratory tests showing coagulation. We believe that standardised protocols should be established in terms of preparation, intraoperative management and postoperative follow-ups because the time between taking the coagulation tests and postoperative anticoagulant administration should be standardised in such surgeries.