Double-paddle peroneal tissue transfer for oromandibular reconstruction

Management of Through-and-Through Oromandibular Defects after Segmental Mandibulectomy with Fibula Osteocutaneous Flap

BACKGROUND

 Oromandibular defects involving the external skin are a reconstructive challenge. This study aimed to evaluate the use of the fibula osteocutaneous free flap (FOCFF) for through-and-through oromandibular defects by comparing the surgical outcomes and complications of different techniques to close the external skin defect.

METHODS

 A retrospective analysis was conducted of patients who underwent reconstruction of through-and-through oromandibular defects after oncologic segmental mandibulectomy between January 2011 and December 2014. Five groups were analyzed according to the method of external skin coverage: primary closure, locoregional flaps, deepithelialized double-skin paddle FOCFF (deEpi-FOCFF), division of the skin paddle for double-skin paddle FOCFF (div-FOCFF), and a simultaneous second free flap. Intraoperative and postoperative outcomes along with complications were analyzed between groups.

RESULTS

 A total of 323 patients were included. The mean total defect area requiring a simultaneous second free flap was larger in comparison to other groups (p < 0.001). Reconstructions performed with div-FOCFF had a higher number of perforators per flap when compared with deEpi-FOCFF (p < 0.001). External defects closed with another free flap exhibited higher intraoperative time for the reconstructive segment in comparison to other groups (p < 0.05). The overall rate of complications was comparable between groups (24%, p = 0.129).

CONCLUSION

 The FFOCF is a reliable alternative to harvesting multiple simultaneous free flaps for through-and-through oromandibular defects. The authors recommend appropriate curation of the surgical plan based on individual patient characteristics and reconstructive requirements.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Oromandibular reconstruction with double-skin paddle fibular free flap: A systematic review and meta-analysis

BACKGROUND

Reconstruction of complex head and neck defects is challenging, especially when more than one soft-tissue subunit is involved. The osteocutaneous fibular flap underwent continual evolution to improve its soft-tissue characteristics, such as including a second skin island. The purpose of this study was to evaluate outcomes regarding oromandibular reconstruction with a double-skin paddle fibular free flap (DSPFFF) using three different techniques: central de-epithelialized skin paddle, distally-based double-skin paddle (DSP), or proximally and distally-based DSP.

METHODS

A systematic review was performed in December 2020 using Pubmed and MedLine Ovid databases according to the PRISMA guidelines. A meta-analysis of functional outcome and complications was performed to estimate single incidence rates.

RESULTS

A total of 449 patients were included, with a follow-up of 1-84 months, where 330 patients underwent reconstruction with the first technique, 23 patients with the second technique, and 96 patients with the third technique. The meta-analysis showed an overall good functional outcome and a low-complication rate for oromandibular reconstruction with DSPFFF. A better functional outcome and a lower complication rate were found when a distally-based DSPFFF was harvested compared to a proximally and distally-based DSPFFF.

CONCLUSION

The DSPFFF was found to be useful and reliable for reconstructing composite and extensive head and neck defects, with an overall good functional outcome and a low-complication rate. The meta-analysis showed a better positive outcome on distally-based DSPFFF rather than proximally and distally-based DSPFFF. In addition, distally-based DSPFFF showed a lower complications rate when compared with proximally and distally-based DSPFFF.

A retrospective study on mandibular reconstruction using iliac crest free flap

PURPOSE

To assess the availability, success rate and complications of microvascular iliac crest free flap for reconstruction of mandibular segmental defects.

METHODS

In this retrospective-descriptive study, we report patients who had undergone segmental mandibular resection for pathologic lesions and received reconstruction with iliac crest microvascular free flap between 2016 and 2019. Clinical and demographic data of all the cases were collected. Success was regarded as complete consolidation of the bone graft in panoramic radiograph. Postoperative complications were defined as major or minor based on the need for intervention. T-test, Kolomogorov_Smirnov, and multivariate analysis were used and the p-value<0.05 was considered to be statistically significant.

RESULTS

Of all 30 patients, 16 were women and 14 were men with an average age of 27.2 years (range 14-40). Patients were followed for 12-60 month (mean: 38.4). One flap was lost due to unsalvageable venous thrombosis. Six other cases had post-op complications while smoking and diabetes were associated with more complications (P = 0.036). Twenty-three patients received primary reconstruction which was more successful than secondary ones (P = 0.003). Osteogenic sarcoma was associated with greater risk of complications (P < 0.01).

CONCLUSIONS

The results of this study suggest that iliac crest microvascular free flap serves as a promising option for the reconstruction of mandibular defects, providing excellent contour and acceptable success rate with low donor site morbidity. Future studies will focus on the role of systemic diseases in post-op complications and flap failures.

Osteomyocutaneous Free Fibula Flap Prevents Osteoradionecrosis and Osteomyelitis in Head and Neck Cancer Reconstruction

BACKGROUND

 Osteoradionecrosis (ORN) is one of the most severe complications of free fibula reconstruction after radiotherapy. The gold standard treatment of osteomyelitis involves extensive debridement, antibiotics, and sufficiently vascularized muscle flap coverage for better circulation. Therefore, we hypothesized that free fibula flap with muscle could decrease the risk of ORN.

METHODS

 This study consisted of 85 patients who underwent reconstruction with free fibula flap in head and neck cancer by a single reconstructive surgeon at Kaohsiung Veterans General Hospital over a period of 19 years (1998-2016). Patients with postoperative adjuvant radiotherapy were included in the study and were grouped by either free fibula osteocutaneous flap or free fibula osteomyocutaneous flap (with flexor hallucis longus muscle), and the incidence of ORN was compared.

RESULTS

 Of the 85 patients, 15 were reconstructed with osteocutaneous fibula flap and 70 were with osteomyocutaneous fibula flap. The rate of ORN or osteomyelitis was significantly lower in the muscle group (18.6%, n = 13/70 vs. 46.7%, n = 7/15, p = 0.020, Chi-square test).

CONCLUSION

 Vascularized muscle transfer increases perfusion of surrounding tissues and the bone flap, thereby decreasing the incidence of osteomyelitis or osteonecrosis.

Peroneal flap: How to harvest and clinical appraisal for head and neck reconstruction

BACKGROUND

A peroneal flap, the boneless version of fibula flap, is considered as the equivalent of radial forearm flap of the lower leg. Because it is thinner than an anterolateral thigh (ALT) flap, the use of a peroneal flap is a viable option for the repair of soft tissue defects when a thin flap could bring about better functional and cosmetic outcomes. In this article, we describe the details of peroneal flap harvest and present our experience with the use of peroneal flaps for head and neck reconstruction.

MATERIALS AND METHODS

Between 1996 and 2017, a total of 265 peroneal flaps were used to reconstruct a variety of head and neck defects. With the same vascular anatomy and slight modifications to the harvesting technique of a fibula flap, a peroneal flap can be harvested within 1-2 h. All medical records were retrospectively reviewed.

RESULTS

A peroneal flap can be harvested as different types of chimeric flaps to fit a variety of head and neck defects. The peroneal flap failure rate was 3.4% and the postoperative complication rate was 12.8%.

CONCLUSION

A peroneal flap might be an alternative option for the reconstruction of head and neck defects.

A Novel Application of Double-Paddle Peroneal Chimeric Flap as External Sentinel Monitor in Hypopharyngeal Reconstruction

OBJECTIVES

Monitoring the viability of buried free flaps in hypopharyngeal reconstruction is difficult. Various methods have been proposed to monitor these buried flaps, but limitations remain.

METHOD

We present a method of using double-paddle chimeric peroneal flaps that permanently externalizes a flap skin paddle as a monitoring paddle in hypopharyngeal reconstructions. This study was performed in a medical center in southern Taiwan; between 2013 and 2015, 10 patients underwent double-paddle chimeric peroneal flap reconstruction in advanced stages of hypopharyngeal cancer. We retrospectively reviewed the medical records from these surgeries, searching for either short-term postoperative complications or long-term follow-up morbidity and researched relevant articles for comparisons with other monitoring methods.

RESULTS

None of the 10 flaps underwent total loss. The rate of stenosis and that of fistula formation was 10%. The average postoperative hospital stay was 39 days. Six of 10 patients were able to resume at least a soft diet after reconstruction, and none of the patients experienced significant complications.

CONCLUSIONS

The peroneal flap is a useful flap because it is thin and pliable, has minimal donor site morbidity in patients without peripheral vascular disease, and has the potential of multiple skin paddles so that one skin paddle can be used for monitoring the buried flap. Using this method, direct clinical monitoring is feasible, and early detection of vascular complications is possible. Furthermore, the drawbacks of using a monitoring paddle produced by a deepithelialized bridge can be avoided.

Oromandibular reconstruction with chimeric double-skin paddle flap based on peroneal vessel axis for synchronous opposite double oral cancer

BACKGROUND

Synchronous double oral cancer represents the minority of cases of head and neck cancer. After tumor ablation, 2 separate oromandibular defects, even combined with a through-and-through oral defect, pose a serious reconstructive challenge. The ideal method for reconstruction remains controversial.

AIM AND OBJECTIVES

Based on the peroneal vessel axis, a chimeric double-skin paddle peroneal fasciocutaneous or fibular osteomyocutaneous flap could be designed to accomplish the difficult reconstruction.

MATERIALS AND METHODS

Six male patients, each with 2 separate oromandibular defects after tumor ablation of synchronous double oral cancer, received double-skin paddle flap reconstruction with 3 peroneal fasciocutaneous and 3 fibular osteomyocutaneous flaps.

RESULT

All 6 flaps survived; however, complications included 1 skin paddle lost due to insufficient perfusion of a visible perforator, and 1 superficial necrosis occurring over the tip of a longer skin paddle. One postoperative intraoral infection and 1 donor site infection were also reported. During follow-up, 3 months later, 1 patient succumbed to local recurrence and bony metastasis. One patient developed a new cancer in the maxillary gingiva, and another had osteoradionecrosis 8 months later. Four patients gained acceptable cosmesis with good oral competence.

CONCLUSIONS

A chimeric flap based on the peroneal artery could provide a segment of fibular bone, 1 or 2 skin paddles, and a cuff of the flexor hallucis longus muscle simultaneously. For 1-stage reconstruction of separate oromandibular defects after tumor ablation of synchronous double oral cancer, this design could provide all components at 1 transfer.

Recurrent giant mandibular ameloblastoma in young adults

BACKGROUND

The purpose of the study was to define the most appropriate management of the giant mandibular ameloblastoma (GMA) in young adults.

METHODS

A retrospective study was performed on patients with GMA <30 years old. The data collected included initial treatment, tumor margins, reconstruction, and follow-up. Patients evaluated speech, chewing, swallowing, and facial appearance after definitive treatment.

RESULTS

Thirteen patients were identified with recurrent solid/multicystic disease requiring further treatment. Definitive treatment involved segmental mandibulectomy and reconstruction with free fibular flap in all patients. Seven patients had immediate reconstruction (group A) and 6 had secondary (group B). Mandibular resection was planned at least 2 cm beyond the radiological limit, free margins were achieved in all patients, and all flaps were transplanted successfully. In group A, functional score was 13.7 ± 0.45 and facial appearance score was 4.5 ± 0.49, whereas in group B were 11.16 ± 0.37 and 3.3 ± 0.5, respectively (both p < .05).

CONCLUSION

Aggressive resection of the GMA and immediate reconstruction is strongly advised. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1947-E1954, 2016.

[Harvesting technique of chimeric multiple paddles fibular flap for wide oromandibular defects]

Carcinological head and neck reconstruction still remains a challenge due to the volume and varied tissues needed. Large and wide oromandibular defects require, not just the bone but also soft tissues for the pelvilingual reconstruction and therefore, a second free flap may become necessary in addition to a fibular flap. The option of an unique chimeric flap based on the fibular artery and its branches is less known whereas it offers the advantage of a unique flap with bone, muscle and multiple skin paddles, independent of each other. The aim of this technical note is to present step by step the surgical procedure of this chimeric flap and share this method that avoids a second free flap.

Free Flaps in a Resource Constrained Environment: A Five-Year Experience-Outcomes and Lessons Learned

Introduction. Free flap surgery is a routine procedure in many developed countries with good surgical outcomes. In many developing countries, however, these services are not available. In this paper, we audit free flaps done in a resource constrained hospital in Kenya. Objective. This is a five-year audit of free flaps done in a tertiary hospital in Kenya, between 2009 and 2014. Materials and Methods. This was a prospective study of patients operated on with free flaps between 2009 and 2014. Results. A total of one hundred and thirty-two free flaps in one hundred and twenty patients were performed during the five-year duration. The age range was eight to seventy-two years with a mean of 47.2. All the flaps were done under loupe magnification. The overall flap success rate was eighty-nine percent. Conclusion. Despite the many limitations, free flaps in our setup were successful in the majority of patients operated on. Flap salvage was noted to be low due to infrequent flap monitoring as well as unavailability of theatre space. One therefore has to be meticulous during surgery to reduce any possibilities of reexploration.

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

BACKGROUND

The role of fibula free flaps for reconstruction of through-and-through oromandibular defects is examined.

METHODS

Thirty-four patients underwent reconstruction of through-and-through oromandibular defects using fibula free flaps that contain large, bilobed skin paddles for simultaneous reconstruction of intraoral mucosa and external skin. We examined the incidence of wound healing complications, the need for revision reconstructive surgery, and factors affecting the incidence of complications.

RESULTS

Wound healing complications occurred in 50% of patients. There was a relatively high incidence of partial flap necrosis (26%) and revision surgery (41%). The area of the flap skin paddle was significantly associated with the risk of partial flap necrosis and the need for revision surgery.

CONCLUSIONS

Many through-and-through oromandibular defects can be successfully reconstructed using a fibula free flap that contains a large, bilobed skin paddle. However, wound healing complications are increased when the flap skin paddle area exceeds 300 cm2.

Double-skin paddle perforator flap from the lateral lower leg for reconstruction of through-and-through cheek defect - a report of two cases

Extensive defects after ablative surgery of oral cancer, involving exterior skin of the cheek, demand for complex reconstruction. It often requires two free flaps, or double-skin paddle scapular-, radial forearm- or fibular-flap to reconstruct through-and-through cheek defects. The outcome is mostly described as successful and functional. Nevertheless donor site morbidity and functional impairment should not be neglected. This report describes the use of double-skin paddle perforator flaps from the lateral lower leg for combined intra and extraoral reconstruction after tumour resection. This kind of flap first avoids the need of an additional free flap, secondly it produces minimal donor site morbidity because of consequent preservation of the peroneal artery and primary wound closure. Thirdly it enables a good aesthetic outcome possible because of the primarily thin, pliable and variable skin paddles.

Perforator flaps in head and neck surgery

A 'perforator flap' is a flap of skin or subcutaneous tissue that is based on the dissection of a 'perforating vessel'. Over the past few years a large number of 'perforator flaps' have been devised and described. By reducing any muscle harvest and trauma to a minimum, perforator flaps aim to minimize donor site morbidity whilst providing the reconstructive surgeon with more versatility than other flap types. The principal perforator flaps are discussed, particularly those employed in head and neck reconstruction including 'free style perforator flaps'. Methods of locating perforating vessels for the use of perforator flaps are described. The technique of perforator flap harvest is illustrated as exemplified in the anterolateral thigh perforator flap. Advantages in the use of this flap for head and neck reconstruction are discussed and are compared with that of non-perforator flaps, particularly the Radial Forearm Flap. The role of the primary thinning of perforator flaps is discussed. The versatility of the anterolateral flap is discussed, which may well supersede the Radial Forearm Flap as the principal soft tissue flap used in head and neck surgery.

Oromandibular reconstruction after cancer resection

The goals of this article are (1) to summarize the epidemiology of oromandibular cancer, (2) to describe the classification of defects after cancer extirpation, and (3) to discuss the principles of and state of the art in reconstruction of the oromandibular defect. The four commonly used flaps (fibula flap, radial forearm flap, scapula flap, and the iliac crest) and their key characteristics are summarized. Finally, some future speculations are entertained.

Combined free fibular osteocutaneous-lateral calcaneal fasciocutaneous flap for reconstruction of composite oromandibular defects

The free fibular osteocutaneous flap is often used in the reconstruction of composite oromandibular defects. In contrast, the lateral calcaneal flap has never been used in oromandibular reconstruction. On the basis of their anatomic continuity, the authors combined the free fibular osteocutaneous flap with the lateral calcaneal skin paddle to obtain 2 adjoining flaps in different anatomic areas with the same vascular axis. The authors report their experience in 3 patients with composite oromandibular defects. In 1 patient without an outer skin defect, only a sensory lateral calcaneal skin paddle with a fibular osseus flap was harvested. The lateral calcaneal flap carried the sural nerve as a sensory flap in 2 patients, and the result was passable. Only 1 patient encountered superficial flap tip necrosis at the lateral calcaneal skin paddle, and recovered well after wound care. In conclusion, a flap with many specific features is a feasible choice for reconstruction of composite oromandibular defects.

Defect-related variations in mandibular reconstruction using fibula grafts. A review of 96 cases

Despite the popularity of the donor region 'laterodorsal calf' with the fibula, the flexor muscles and the overlying skin for microsurgical bone and soft tissue transfer some limitations and possible pitfalls have to be considered. We report on 93 patients who had 96 reconstructions, 65 with and 31 without soft tissue transfer in 8 years using microvascular fibular grafts for mandibular replacement and oromandibular reconstruction. Six patients died within 4 weeks and eight flaps were lost. Necrosis of the skin paddle occurred in 7 (11%) of 61 cases with uncomplicated bony healing.