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FFF Utilizing an Arteriovenous Vascular Loop of Two Peroneal Venae Comitantes for a PAM. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3790. [PMID: 34522567 PMCID: PMC8432636 DOI: 10.1097/gox.0000000000003790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/30/2021] [Indexed: 11/29/2022]
Abstract
Vascularized bone grafting is widely used for reconstruction of osseous defects of the forearm. Fibular free flap (FFF) is one option, which relies on harvesting the peroneal artery. This procedure is subject to lower extremity anatomic variants; therefore, some recommend preoperative angiography. However, high quality evidence for this approach and its cost-effectiveness are lacking and instead one can diligently assess the vascular anatomy intraoperatively. Here, we describe a case of a 73-year-old man who was found to have a peronea arteria magna intraoperatively during an FFF for a left radius reconstruction secondary to an infectious nonunion. We describe an approach to performing an FFF using an arteriovenous vascular loop through the fibula employing the two accompanying peroneal venae comitantes. The patient had no complications and was found to have appropriate healing of the upper extremity without lower extremity compromise at 3-month follow-up. This report illustrates an alternative to using an interpositional venous graft for peronea arteria magna found intraoperatively during FFFs.
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Ahmed ZU, Huryn JM, Petrovic I, Rosen EB. Oral rehabilitation following fasciocutaneous free-flap reconstruction: A retrospective study. J Indian Prosthodont Soc 2019; 19:221-224. [PMID: 31462860 PMCID: PMC6685344 DOI: 10.4103/jips.jips_97_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/29/2019] [Indexed: 11/04/2022] Open
Abstract
Aim: The aim of this study is to retrospectively, observe a consecutive series of patients with segmental mandibulectomy defects reconstructed with fasciocutaneous free flaps and mandibular resection prostheses, and to review treatment concepts for the management of such patients. Settings and Design: Observational study done at Memorial Sloan Kettering Cancer Center, New York, NY, USA. Materials and Methods: Records were reviewed of all patients who had fasciocutaneous free-flap reconstruction and fabrication of mandibular resection prostheses following segmental mandibulectomy between 2000 and 2017 at a tertiary cancer center. Mandibular resection prosthesis fabrication interval data, as well as follow-up interval data, were recorded. Statistical Analysis Used: Descriptive statistics. Results: Twenty-one consecutive patients had mandibular resection prostheses fabricated following segmental mandibulectomy and fasciocutaneous free-flap reconstruction during the study. The median time for mandibular resection prosthesis delivery following surgery was 9 months (range 4–41 months). There was a median of two-follow-up visits (range 0–4) within the first 90 days of mandibular resection prosthesis delivery. Conclusions: Oral rehabilitation with mandibular resection prosthesis following segmental mandibulectomy and fasciocutaneous free-flap reconstruction is an attainable treatment goal for the oncologic patient. Reviewing the proposed course of care is helpful for patient management.
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Affiliation(s)
- Zain Uddin Ahmed
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph M Huryn
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ivana Petrovic
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan B Rosen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Trojanowski P, Andrzejczak A, Trojanowska A, Olszański W, Klatka J. [Importance of donor site vascular imaging in free fibula flap reconstruction]. Otolaryngol Pol 2013; 66:40-4. [PMID: 23164106 DOI: 10.1016/s0030-6657(12)70784-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 07/20/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Free fibula flap is widely used in head and neck reconstruction. Imaging studies of the donor site can reveal vascular abnormalities and therefore prevent acute leg ischemia. AIM Evaluation of the role of donor site vascular imaging studies for free fibula flap planing. MATERIAL AND METHODS Out of 35 free flap reconstructions performed in Otolaryngology Head and Neck Surgery Department in Medical University in Lublin in 2011-2012, there were 10 fibula flaps. Each patient had preoperative lower leg subtraction angiography performed. RESULTS Lower leg angiography revealed vascular abnormalities in two out of 10 patients scheduled for free fibula flap transfer. One had dominant peroneal artery and second occlusion of anterior tibial artery. In both cases fibula was harvested from the other leg. CONCLUSIONS Imaging studies reveal lower leg vascular abnormalities in 20% of cases thus facilitate surgical plans alternations and prevent serious complications in free fibula flap patients.
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Affiliation(s)
- Piotr Trojanowski
- Katedra i Klinika Otolaryngologii i Onkologii Laryngologicznej Uniwersytetu Medycznego w Lublinie, Poland.
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Garvey PB, Chang EI, Selber JC, Skoracki RJ, Madewell JE, Liu J, Yu P, Hanasono MM. A prospective study of preoperative computed tomographic angiographic mapping of free fibula osteocutaneous flaps for head and neck reconstruction. Plast Reconstr Surg 2012; 130:541e-549e. [PMID: 23018715 PMCID: PMC3749731 DOI: 10.1097/prs.0b013e318262f115] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In designing an osteocutaneous fibula flap, poor planning, aberrant anatomy, or inadequate perforators may necessitate modification of the flap design, exploration of the contralateral leg, or additional flap harvest. The authors studied the predictive power of computed tomographic angiography in osteocutaneous fibula flap planning and execution. METHODS The authors studied a prospective cohort of 40 consecutive patients who underwent preoperative computed tomographic angiography mapping of the peroneal artery and its perforators and subsequent free fibula flap reconstruction of mandibular or maxillary defects. The authors compared their analysis of perforator anatomy, peroneal artery origin, and fibula length with intraoperative clinical findings. RESULTS Overall, computed tomographic angiography identified 94.9 percent of the cutaneous perforators found intraoperatively. Clinically, perforators were located an average of 8.7 mm from their predicted locations. The peroneal artery origin from the tibioperoneal trunk averaged 6.0 mm from its predicted location. The average length of the fibula differed from the predicted length by 8.0 mm. Computed tomographic angiography accurately predicted perforators as either septocutaneous or musculocutaneous 93.0 percent of the time. Perforator size was accurately predicted 66.7 percent of the time. Skin islands and osteotomies were modified in 25.0 percent of the cases on the basis of computed tomographic angiography findings. Two patients had hypoplastic posterior tibial arteries, prompting selection of the contralateral leg. There were no total flap or skin paddle losses. CONCLUSIONS Computed tomographic angiography accurately predicted the course and location of the peroneal artery and perforators; perforator size was less accurately estimated. Computed tomographic angiography provides valuable information to facilitate osteocutaneous fibula flap harvest.
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Affiliation(s)
- Patrick B. Garvey
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Edward I. Chang
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jesse C. Selber
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roman J. Skoracki
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John E. Madewell
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jun Liu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew M. Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Catalá-Lehnen P, Rendenbach C, Heiland M, Khakpour P, Rueger JM, Schmelzle R, Blake F. Long-Term Donor-Site Morbidity After Microsurgical Fibular Graft: Is There a Difference Between the Medial Approach and the Lateral Approach? J Oral Maxillofac Surg 2012; 70:2198-204. [DOI: 10.1016/j.joms.2011.09.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 09/29/2011] [Accepted: 09/29/2011] [Indexed: 10/14/2022]
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Evaluation of the vessels of the lower leg before microsurgical fibular transfer. Part I: anatomical variations in the arteries of the lower leg. Br J Oral Maxillofac Surg 2011; 49:270-4. [DOI: 10.1016/j.bjoms.2010.05.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 05/01/2010] [Indexed: 11/30/2022]
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Lubek J, Shihabi A, Salama A. Tibiofibular synostosis--an unusual case during vascularized fibula flap harvest. J Oral Maxillofac Surg 2010; 68:2629-31. [PMID: 20580144 DOI: 10.1016/j.joms.2009.09.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Accepted: 09/23/2009] [Indexed: 11/24/2022]
Affiliation(s)
- Joshua Lubek
- Head and Neck Surgical Associates, Legacy Emanuel Hospital and Health Center, Portland, OR, USA.
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Wales CJ, Morrison J, Drummond R, Devine JC, McMahon J. Pre-operative evaluation of vascularised fibula donor sites: a UK maxillofacial e-survey. Br J Oral Maxillofac Surg 2010; 48:192-4. [DOI: 10.1016/j.bjoms.2009.10.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Accepted: 10/15/2009] [Indexed: 10/20/2022]
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Girish Rao S, Aditya TN, Gopinath KS, Anand K. Free fibula flap in the reconstruction of mandible: a report of six cases. J Maxillofac Oral Surg 2009; 8:275-8. [PMID: 23139525 DOI: 10.1007/s12663-009-0067-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2007] [Accepted: 04/11/2009] [Indexed: 11/26/2022] Open
Abstract
The defects secondary to surgical ablation of the mandible have far reaching consequences. Speech, respiration, mastication, deglutition and cosmesis are severely affected. Restoring these functions is a challenging task. Till the late eighties, myocutaneous flaps were the rule for mandibular reconstruction and free bone was used to restore bony continuity.In spite of the result being predictable the outcome left much to be desired. There was also a fairly regular crop of complications. Acceptable dental rehabilitation was almost non-existent. With the introduction of free flaps as a consequence of the development of the operating microscope, the field of reconstruction was revolutionized.The fibular free flap is especially suited for mandibular reconstruction. It provides adequate bone to re-establish bony continuity and also allows for the placement of osseointegrated implants.Here we present six of our cases, which underwent mandibular reconstruction with free fibula flaps and the current thoughts in literature on the reconstruction of the mandible with this technique.
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Affiliation(s)
- S Girish Rao
- Dept. of Oral and Maxillofacial Surgery, R.V. Dental College, Bangalore, India
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Blake F, Heiland M, Schmelzle R, Harms J, Werle H, Pohlenz P, Li L. The Medial Approach to the Fibula: A Feasible Alternative. J Oral Maxillofac Surg 2008; 66:319-23. [DOI: 10.1016/j.joms.2007.06.665] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Revised: 05/19/2007] [Accepted: 06/23/2007] [Indexed: 10/22/2022]
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Whitley SP, Sandhu S, Cardozo A. Preoperative vascular assessment of the lower limb for harvest of a fibular flap: the views of vascular surgeons in the United Kingdom. Br J Oral Maxillofac Surg 2004; 42:307-10. [PMID: 15225947 DOI: 10.1016/j.bjoms.2004.02.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2004] [Indexed: 11/30/2022]
Abstract
Adequate preoperative vascular assessment of the lower limb is essential before harvesting fibular free flaps to prevent ischaemic complications or failure of the flap. The best method of assessment remains controversial. Clinical examination, conventional angiography, colour flow Doppler, and magnetic resonance angiography have all been advocated. We asked 206 UK vascular surgeons for their opinions on preoperative assessment and potential issues of negligence and 85 (42%) completed the questionnaire. All respondents thought that further imaging should be done in addition to clinical examination, most of whom (n = 70) favoured colour flow Doppler (82%). In addition 75 (88%) considered that the surgeon would be judged to be negligent if clinical examination was the only preoperative assessment. In the light of these findings, we suggest that an objective assessment of the vasculature of the leg should be obtained before a fibular flap is harvested.
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Affiliation(s)
- S P Whitley
- Department of Oral and Maxillofacial Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.
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Talbot SG, Athanasian EA, Cordeiro PG, Mehrara BJ. Soft tissue reconstruction following tumor resection in the hand. Hand Clin 2004; 20:vi, 181-202. [PMID: 15201023 DOI: 10.1016/j.hcl.2004.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
With advances in diagnosis, staging, imaging, and adjuvant chemo- and radiotherapy,upper limb salvage surgery has become a realistic option for upper limb malignancies. Following an adequate and complete resection, reconstruction of ensuing defects consequently has become an area of increasing importance. Many options are available,including primary closure, skin grafting, local soft tissue flaps, regional pedicle and island flaps, free tissue transfer, composite free tissue transfer, allografts, endoprostheses,and tendon, nerve, or arterial grafting. Form, function, and cosmetic outcome influence surgical decision making, as do characteristics of the patient, tumor, and involved site.
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Affiliation(s)
- Simon G Talbot
- Plastic and Reconstructive Surgical Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Abstract
Salvage of the upper extremity following tumor resection may require reconstruction of massive bone defects. This more commonly results from malignant bone tumors, but defects requiring reconstruction also may occur following resection of locally aggressive benign tumors. Examples include osteosarcoma, chondrosarcoma, Ewing sarcoma, giant cell tumor, and certain soft tissue sarcomas invading bone. Obtaining satisfactory results using conventional bone grafting techniques is at best challenging when defects of substantial size are encountered. Free vascularized bone grafting procedures provide the appealing option of transferring living bone based on a vascular pedicle.
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Affiliation(s)
- Peter M Murray
- Department of Orthopaedic Surgery, Mayo Graduate School of Medicine, Rochester, MN 55905, USA.
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Klein MB, Karanas YL, Chow LC, Rubin GD, Chang J. Early experience with computed tomographic angiography in microsurgical reconstruction. Plast Reconstr Surg 2003; 112:498-503. [PMID: 12900607 DOI: 10.1097/01.prs.0000070990.97274.fa] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Preoperative angiography is frequently used in the planning of microsurgical reconstruction. However, several potentially devastating complications can result from angiography, including arterial occlusion and pseudoaneurysm. Computed tomographic angiography is a relatively new technique that can provide detailed information about vascular anatomy as well as soft and bony tissue without the risks of traditional angiography. In addition, three-dimensional image reconstruction uniquely demonstrates anatomical relationships among blood vessels, bones, and soft tissue. Fourteen computed tomographic angiograms were obtained in 10 patients undergoing microsurgical reconstruction of the head and neck, lower extremity, or upper extremity. The average patient age was 46.9 years (range, 22 to 67 years). Charges related to the computed tomographic procedure were compared with those of conventional preoperative imaging for microsurgical repair. At our institution, the average computed tomographic angiogram charge was 1140 US dollars, whereas the average charge for traditional arteriography was 3900 US dollars. When compared with intraoperative evaluation, computed tomographic angiograms demonstrated clinically relevant surgical anatomy. No complications were noted for the radiographic procedure or after free flap reconstruction. Computed tomographic angiography provides high-resolution, three-dimensional arterial, venous, and soft-tissue imaging without the risks of traditional angiogram and at a lower cost.
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Affiliation(s)
- Matthew B Klein
- Division of Plastic ansd Reconstructive Surgery, Stanford University Medical Center, and Section of Plastic Surgery, Veterans Affairs Palo Alto Health Care System, California 94305, USA
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Seres L, Csaszar J, Voros E, Borbely L. Donor site angiography before mandibular reconstruction with fibula free flap. J Craniofac Surg 2001; 12:608-13. [PMID: 11711831 DOI: 10.1097/00001665-200111000-00021] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The use of fibular free flaps has become established as a reliable and popular method for reconstruction of segmental mandibular defects. The role of routine preoperative angiography remains controversial. Sixty four digital subtraction angiograms were studied in a series of 39 consecutive patients clinically judged to be satisfactory candidates for fibula free transfer. Angiographic findings revealed vascular anomalies in 10 extremities (15.6%). Regarding the high potential for significant donor site morbidity authors consider vascular imaging essential part of preoperative evaluation.
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Affiliation(s)
- L Seres
- Department of Oral and Maxillofacial Surgery, University of Szeged, Szeged, Hungary.
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