Pedicle ossification after fibular flap reconstruction of maxillary defects: A case report and literature review

Key Clinical Message

The phenomenon of vessel pedicle ossification is a noteworthy aspect of the repair and reconstruction of maxillofacial defects. Imaging findings typically reveal high-density shadows within the vascular pedicle pathway, which may be managed through conservative observation or surgical intervention as deemed appropriate.

Abstract

Vessel pedicle ossification is a relatively uncommon complication associated with the reconstruction of oral and maxillofacial tissue defects using free tissue flap repair. In this paper, we report a case of pedicle ossification and conduct a comprehensive review of previous literature. A 39-year-old man presented with a limited ability to open his mouth 6 months after fibular flap reconstruction of the mandible. Plain film X-ray and computed tomography (CT) indicated pedicle ossification. Two years after the initial operation, the restriction in the patient's ability to open his mouth had not worsened, although there were more pronounced radiographic abnormalities.

Accuracy Evaluation of an Alternative Approach for a CAD-AM Mandibular Reconstruction with a Fibular Free Flap via a Novel Hybrid Roto-Translational and Surface Comparison Analysis

Although the fibula free flap represents the gold standard for mandibular reconstructions, when implanted as a single barrel, this flap does not have the cross-sectional requisites to restore the native mandibular height, which is in turn required for the implant-supported dental rehabilitation of the patient. Our team has developed a design workflow that already considers the predicted dental rehabilitation, positioning the fibular free flap in the correct craniocaudal position to restore the native alveolar crest. The remaining height gap along the inferior mandibular margin is then filled by a patient-specific implant. The aim of this study is to evaluate the accuracy in transferring the planned mandibular anatomy resulting from said workflow on 10 patients by means of a new rigid body analysis method, derived from the evaluation of orthognathic surgery procedures. The analysis method has proved to be reliable and reproducible, and the results obtained show that the procedure already has satisfactory accuracy (4.6° mean total angular discrepancy, 2.7 mm total translational discrepancy, 1.04 mm mean neo-alveolar crest surface deviation), while also pointing out possible improvements to the virtual planning workflow.

Dyskeratosis Congenita and Squamous Cell Cancer of the Head and Neck: A Case Report and Systematic Review

Objectives:

Dyskeratosis congenita (DC) is a progressive congenital disorder that predisposes patients to squamous cell cancers (SCC) of the head and neck. We report a case of a patient who underwent primary osteocutaneous free flap for mandibular SCC followed by additional treatments for positive margins and discuss a systematic review on therapeutic management for this patient population.

Methods:

Case report of a 39-year-old male with DC who underwent resection and reconstruction with a fibular free flap for mandible SCC, followed by revision surgery and adjuvant radiotherapy for positive margins. A systematic review was completed afterward with the following terms: “dyskeratosis congenita” AND “oral cancer” OR “head and neck” OR “otolaryngology” on Medline and Web of Science for articles between 1980 and 2021. In total, 12 articles were included that reported on DC and SCC in the head and neck.

Results:

Of the case reports that were included in this review, half the patients had recurrence within 1 year of primary treatments. Only 2 patients did not require revision surgery, adjuvant, or salvage therapy. Half of patients that received radiation therapy had severe side effects.

Conclusions:

This is the largest review of DC and SCC in the head and neck. Based off our case report and review, these patients have aggressive disease that often requires multi-modality treatment. Consideration should be taken in regards to reports of side effects with radiation therapy.

Fibula osteal flap with proximal peroneal perforator skin paddle for composite oromandibular reconstruction: A case report

RATIONALE

Cutaneous perforators of peroneal vessels are divided into proximal and distal perforators on the basis of perforator distributions and musculocutaneous or septocutaneous properties. The traditional fibular osteocutaneous free flap is raised over the distal two-thirds of the fibula with a skin paddle based on distal perforators, which is affixed to the posterior crural septum. However, the skin pedicle may not be available due to anatomic variations or intraoperative injuries. Herein, because of the absence of distal perforators, we reserved and expropriated proximal perforators originating from the musculocutaneous branch of the superior part of the peroneal artery before it divided into nutrient and arcuate arteries and successfully harvested a separate osteal fibula and proximal perforator skin paddle with a single vascular pedicle-peroneal vessel.

PATIENT CONCERNS

A 62-year-old man with a 6-month history of mandibular swelling and soft tissue invasion was referred to us.

DIAGNOSIS

Panoramic radiography and computed tomography showed an irregular radiolucent lesion of the mandibular body, and histopathological analysis confirmed a follicular-pattern ameloblastoma.

INTERVENTIONS

The diseased mandible and soft tissue were resected and reconstructed with a vascularized fibular osteal flap with the proximal perforator skin paddle.

OUTCOMES

The mandibular contour was successfully restored; the skin paddle in the mouth was in good condition after 8 months of follow-up.

LESSONS

The proximal perforator is reliable and practical for supplying a skin paddle and has significant potential for future applications. We recommend reserving the proximal perforator skin paddle as a backup flap when planning to raise a fibula flap, since unavailability or injury of the traditional fibular skin island based on distal perforators occurs frequently. This approach can avoid the exploration for a second donor site, save surgical time, and reduce surgical complexity. Moreover, we anticipate more frequent use of the proximal perforator flap in the future because of its flexibility and large volume, and since it can be combined with the osteal fibula or fibular osteocutaneous flap. However, an understanding of the traits of the proximal perforator and determination of its peroneal origin by computed tomography angiography is crucial for predesigning fibular osteal flaps with a proximal perforator skin paddle.

Printed titanium implants in UK craniomaxillofacial surgery. Part I: access to digital planning and perceived scope for use in common procedures

This first part of a two-part study examines perceived applications for and barriers to using printed titanium in light of current caseloads, funding pathways, and use of digital planning. It aims to demonstrate the scope for printed titanium in modern practice and to guide industry about the needs of UK surgeons. A cross-sectional study over 14 weeks was performed electronically with support from the British Association of Oral and Maxillofacial Surgeons (BAOMS) and a national trainee-led recruitment team. Ethics approval was obtained at the lead centre. A total of 132 participants joined the study (70% consultants, 25% specialty registrars, and 5% other), approximating a 29% response rate from consultant/registrar BAOMS members throughout mainland UK. Eighty-eight per cent used CAD-CAM design, with highly variable funding/access, design/manufacturing workflows (in-house/outsourced). Eighty-eight per cent were involved with trauma, 61% with orthognathic, and 52% with oncology-reconstruction surgery. Favourite applications for printed titanium were orbital floor repair (89%) and free-flap jaw reconstruction (87%). Most participants also cited maxillary/zygomatic osteotomies and cranioplasty (range 61%-73%). Although a popular application (78%), the evidence base in temporomandibular joint surgery is limited. Those performing orthognathic surgery perceived more indications than those who did not (p=0.013). Key barriers included cost, turnaround time and logistics, and the need to be trained in traditional techniques. Printed titanium was useful for both common and niche procedures, but was specifically limited in emergency trauma. Most surgeons had experience in CAD-CAM surgery but technical understanding appeared unclear. Limiting factors included variable funding and production pathways, perceived costs, and logistics, but in-house design can minimise them. In part II, we quantify perceived benefits and limitations and whether surgeons' understanding and knowledge are sufficient to rationalise them.

Reconstruction of the Weightbearing Area of the Foot with Vascularized Chimeric Osteocutaneous Fibular Flap: A Case Report

Damage to the weightbearing surface of the foot is a challenge for the reconstructive surgeon. The aim is to reconstruct the skeletal tripod and soft tissue, allowing the patient to walk normally. We report the case of a patient admitted with an acute right foot open fracture of the second, third, fourth, and fifth metatarsal bones. After debridement of all nonvital tissues, the patient required reconstruction of the metatarsal heads (third, fourth, and fifth) plus soft tissue coverage. We then performed a reconstruction with a free osteocutaneous fibular flap, insetting the bone perpendicular to the long axis of the metatarsal bones. This configuration allowed the reconstruction of the foot skeletal tripod. A second free flap, a thin radial forearm flap, was added during the revision surgery to improve the venous drainage of the skin paddle of the fibular flap and avoid tension after skin closure. At 1-year follow-up, the patient was able to walk entirely weightbearing on the forefoot, returning to her previous employment with no limitation in physical and recreational activities. To our knowledge, this is the first description of the use of a chimeric osteocutaneous fibular flap, oriented transversely, to reconstruct a complex bone/soft tissue defect after a traumatic loss of multiple metatarsal heads.

Considering the Better Donor-side in Reconstruction of Composite Radius After Resection of Spindle Cell Sarcoma Using Free Fibular Osteocutaneous Flap: A Case Report

Reconstruction of bone and soft-tissue defects in the forearm is a surgery that often proves unsuccessful. Free fibular osteocutaneous flaps are a useful material for reconstruction that enable simultaneous reconstruction of bone, skin, and soft tissues. However, in free fibular osteocutaneous flaps, the fibula, skin, and vascular pedicle are tightly bound together by the posterior intermuscular septum and the perforators that pass through the septum, giving the disadvantage of a low degree of freedom when setting these structures in place. We take into account the 3-dimensional structure of the free skin flap when selecting which lower leg to use as the donor. We report here the case of a 61-year-old man with defects in the radius, skin, and soft tissues after resection of spindle cell carcinoma of the right forearm, which was reconstructed using a free fibular osteocutaneous flap harvested from the left lower leg. Two years postoperatively, recovery has been uneventful with no complications. Donor-side selection of free fibular osteocutaneous flap is an important factor for safely completing composite radius reconstruction.

Stereolithographic model-assisted reconstruction of the mandibular condyle with a vascularized fibular flap following hemimandibulectomy: Evaluation of morphological and functional outcomes

The vascularized fibular flap is one of the standard treatment choices for the reconstruction of the mandible; however, the consequences of condylar restoration have not previously been reported. The use of three-dimensional models allows for a more predictable reconstruction. The purpose of the present study was to assess the outcome of stereolithographic model-assisted reconstruction of the mandibular condyle with a vascularized fibular flap. A total of 5 patients underwent mandibular resection including the condyle and immediate reconstruction with a vascularized fibular flap. A stereolithographic model was used to determine the length and angle of the bony reconstruction. In all patients, the temporomandibular joint (TMJ) disc was preserved, and the contoured fibular end was placed directly into the glenoid fossa under the TMJ disc. To investigate the morphological and functional outcomes, radiographic and clinical examinations were performed, and a food scale questionnaire was administered. The mean period of follow-up was 23 months, and all the flaps were viable. Cosmetic results were generally satisfactory. Radiographic assessment revealed that the end of the fibular graft became round-shaped. None of the patients had abnormal bone resorption, dislocation or ankylosis. The mean value of maximum mouth opening was 31 mm. No patients exhibited difficulties with occlusion. All patients recovered their ability to ingest nearly the same foods that were ingested prior to surgery. The stereolithographic model-assisted reconstruction of mandibular condyle with a vascularized fibular flap is therefore useful for morphological and functional reconstructions of the hemimandible, including condylar defects.

Reconstruction of mandibular defects

Defects requiring reconstruction in the mandible are commonly encountered and may result from resection of benign or malignant lesions, trauma, or osteoradionecrosis. Mandibular defects can be classified according to location and extent, as well as involvement of mucosa, skin, and tongue. Vascularized bone flaps, in general, provide the best functional and aesthetic outcome, with the fibula flap remaining the gold standard for mandible reconstruction. In this review, we discuss classification and approach to reconstruction of mandibular defects. We also elaborate upon four commonly used free osteocutaneous flaps, inclusive of fibula, iliac crest, scapula, and radial forearm. Finally, we discuss indications and use of osseointegrated implants as well as recent advances in mandibular reconstruction.