Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions

OBJECTIVES/HYPOTHESIS: The radial forearm osteocutaneous free flap is an excellent reconstructive modality for oromandibular and maxillofacial reconstruction in certain well-defined circumstances. The initial concern over donor site morbidity and the ability of the bone to reconstruct mandibular defects have led to only a few published series. STUDY DESIGN: Retrospective study of the experience of two tertiary medical centers with radial forearm osteocutaneous free flap. METHODS: Retrospectively, 52 patients were studied who underwent radial forearm osteocutaneous free flap reconstruction for cancer (49 cases) and trauma (3 cases). Bone length and skin paddle harvested, general morbidity (hematoma, wound infection, and dehiscence), recipient site morbidity (nonunion of neomandible, flap failure, and bone or plate exposure), and donor site morbidity (radius bone fracture, plate exposure, and skin graft failure) were reviewed. RESULTS: The average skin paddle size was 55.1 cm (range, 15-112 cm). The average radius bone harvest length was 6.3 cm (range, 2.5-11 cm). Donor site complications included tendon exposure (3 cases), radius bone fracture (1 case), and exposure of the plate (0). Recipient site complications included nonunion of the mandible (4), exposed mandible (1), exposed mandibular plates (2), exposed maxillary plates or bone (0), venous compromise (1), and flap failure (1). Two patients had perioperative deaths. CONCLUSION: Radial forearm osteocutaneous free flap is a valuable and viable option for oromandibular and maxillofacial reconstruction.     

Comparison of radial forearm with fibula and scapula osteocutaneous free flaps for oromandibular reconstruction

OBJECTIVE: To compare our experience with the osteocutaneous radial forearm free flap (group 1) (n = 108) with other commonly used osteocutaneous free flaps (group 2) (n = 56) such as the fibula and scapula in single-stage oromandibular reconstruction. DESIGN: Retrospective case review. SETTING: Tertiary-care academic medical center. PATIENTS: One hundred sixty-three consecutive patients who underwent 164 mandibular reconstructions with osteocutaneous free flaps. MAIN OUTCOME MEASURES: Assessment of preoperative and intraoperative variables for both groups. We compared recipient-site complication rate, intensive care unit stay, total hospital stay, and postoperative function. RESULTS: The most common donor site used was the radius (n = 108 [66%]), followed by the fibula (n = 36 [22%]) and scapula (n = 20 [12%]). Mean follow-up was 29 months (range, 1-116 months). Group 2 patients had larger soft tissue and/or bony defects. Surgical and medical complication rates and major donor site morbidity in group 1 were similar or better when compared with those in group 2. The lengths of the intensive care unit (4 vs 7 days; P = .009) and hospital stays (13 vs 15 days; P = .06) were shorter in group 1. Although the microvascular success rate was similar in both groups, the local wound complication rate was significantly better for group 1. The difference for the length of intensive care unit stay was statistically significant and potentially amounts to more than 6000 dollars of savings. Functional outcomes, including the ability to tolerate oral diet, tracheostomy presence, and dental rehabilitation, were similar between the groups. CONCLUSIONS: The primary site long-term morbidity, donor site morbidity, and postoperative function of osteocutaneous radial forearm free flaps are comparable to those of other commonly used osteocutaneous free flaps such as the fibula and scapula when used in single-stage oromandibular reconstruction.     

Reconstruction of isolated mandibular bone defects with non-vascularized corticocancellous bone autograft and graft viability

Objective

The aim of this study is to discuss the use of non-vascularized bone grafts in mandibular reconstruction and their viability.

Methods

In this study, 11 patients with mandibular defect treated by surgery using non-vascularized bone grafts between 2011 and 2012 were reviewed. All patients underwent preoperative and postoperative 3-dimensional computerized tomography scan for surgical planning and evaluation of success after surgery. Grafts were used for defects caused by mandible tumors in 2 patients and firearm injuries in 9 patients. Reconstruction was achieved by using various non-vascularized bones, including iliac crest, fibula and scapula. To improve graft supply, periosteum of the grafts was spared and multiple bores were created on the graft during surgery by drilling. At the postoperative period, Dextran 70 and Bencyclane Hydrogen Fumarate was given in order to enhance micro-circulation. On the postoperative day 5, 15 and 30, Tc-99 m methylenediphosphonate scintigraph, blood-pool single photon emission computed tomography and it's bone phase were performed in order to assess viability of bone grafts greater than 3 cm.

Results

Mean age was 32. 27 ± 13.33 (min = 10–max = 56). Of the 11 patients, 10 (90. 9%) were men and 1 (9. 1%) was woman. Mandibular defects were at right corpus in 3 patients; at right ramus and angulus in 1 patient; at left corpus in 1 patient; at left ramus and angulus in 1 patient; at left ramus, angulus and corpus in 1 patient; left parasymphysis in 1 patient; at bilateral corpus in 1 patient; at symphysis in 1 patient and at whole segment from right corpus to left one in 1 patient. The following grafts were used: iliac crest grafts in 9 cases, scapula graft in 1 case and fibula graft in 1 case. The smallest graft used was 1 × 2 cm in size, while the greatest, single piece graft was 7 cm in size. The greatest multi-piece graft was a fibula graft of 14 cm in length. All grafts with a size of 3 and 7 cm had been supplied at the end of first month. No bone resorption or donor site morbidity was observed in any patient.

Conclusion

Non-vascular bone grafts can be successfully used in isolated bone defects of mandible in case of appropriate graft selection for fitting anatomical region. A single piece iliac crest grafts up to 7 cm can be revascularized in long-term.     

Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction

OBJECTIVE: To determine the incidence and causes of perioperative complications in patients who undergo microvascular free flap procedures for reconstruction of the head and neck. SETTING: Academic tertiary care medical center.Patients and METHODS: A total of 400 consecutive microvascular free flap procedures were performed for reconstruction of the head and neck, with 95% of the defects arising after the treatment of malignancies. Flap donor sites included radial forearm (n = 183), fibula (n = 145), rectus abdominis (n = 38), subscapular system (n = 28), iliac crest (n = 5), and a jejunal flap. Patient-related characteristics (age; sex; diagnosis; comorbidity level; tumor stage; defect site; primary vs secondary reconstruction; and history of surgery, radiation therapy, or chemotherapy) and the incidence of perioperative complications were recorded prospectively over a 7-year period. RESULTS: The perioperative mortality was 1.3%. Overall, perioperative complications occurred in 36.1% of all cases. Free flaps proved to be extremely reliable, with a 0.8% incidence of free flap failure and a 3% incidence of partial flap necrosis. Perioperative medical complications occurred in 20.5% of cases, with pulmonary, cardiac, and infectious complications predominating. Multivariate statistical analysis showed significant relationships between the incidence of perioperative complications and preoperative comorbidity level as indicated by American Society of Anesthesiologists (ASA) status (P =.02). CONCLUSIONS: The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck. The incidence of perioperative complications is related to preoperative comorbidity level.     

Rekonstruktion von Oberkieferdefekten mit einem freien Skapula-angle-Lappen

Background

In addition to prosthetic rehabilitation, maxillary defects can also be surgically reconstructed. Soft-tissue reconstruction employs a radial forearm or latissimus dorsi muscle flap, while bony reconstruction can be achieved using a fibula, iliac crest, or scapular flap. Reconstruction using a scapular flap is further divided into two subgroups: the traditional scapular flap with the circumflex scapular artery as the donor vessel and the scapular angle flap with the angular artery originating from the thoracodorsal artery as the donor vessel.

Materials and methods

We report on four patients who underwent successful reconstruction with a free scapular angle flap between 2009 and 2011, following maxillary resection due to malignancy.

Results

Vertical positioning of the scapular angle flap enables reconstruction of the facial contour, whereas its horizontal alignment and microvascular anastomosis makes a bony reconstruction of the hard palate possible.

Conclusions

The versatility, low rate of donor site morbidity and shape of the scapular angle flap—which resembles that of the hard palate—render it ideal for plastic reconstruction. The suitability of bone quality for dental rehabilitation with implants is a topic of controversial discussion. The scapular angle flap represents an alternative to obturator prosthesis for the reconstruction of maxillary defects ≥ grade I according to Okay et al.     

Role of the island deltopectoral flap in contemporary head and neck reconstruction

OBJECTIVES: The deltopectoral flap (DP) was originally described 40 years ago for head and neck reconstruction. Since that time, use of pedicled myocutaneous flaps and free tissue transfer has supplanted the DP flap as a first-line reconstructive tool. The island DP flap, a variation of the DP flap wherein the skin bridge is de-epithelialized, provides a source of thin and pliable tissue that can be useful for select head and neck reconstruction. The purpose of this review is to assess the utility of the island DP flap in contemporary head and neck reconstruction. METHODS: A retrospective review of 16 consecutive cases utilizing the island DP flap was performed. Indications, complications, and outcome were reviewed in an effort to determine the role of the island DP in contemporary head and neck reconstruction. RESULTS: Sixteen island DP flap procedures were successfully performed in 16 patients for a variety of reconstructions, including esophageal, laryngeal, cutaneous, and pharyngeal defects. The donor skin paddles averaged 22.4 cm2 (range, 14 to 40.8 cm2). There were no recipient site complications; however, there was 1 donor site hematoma that was managed with drainage. In all 16 cases, the island DP flap provided an appropriate source of donor tissue for reconstruction of limited defects of the pharynx, esophagus, and skin of the neck. CONCLUSIONS: The island DP flap is a reliable donor site that provides an excellent source of thin and pliable tissue for limited defects of the head and neck.     

Pursestring closure of radial forearm fasciocutaneous donor sites

BACKGROUND: The radial forearm fasciocutaneous free flap has become one of the most common methods of reconstructing defects after head and neck ablative surgery. The fasciocutaneous flap is an excellent replacement for the tissue that has been removed. Unfortunately, donor site morbidity remains a problem. Donor site morbidity is primarily related to poor skin graft take, cosmesis, and neural dysfunction. Decreasing the size of the donor site defect may allow for improved cosmesis with decreased morbidity. MATERIAL AND METHODS: Prospective evaluation of a pursestring closure of radial forearm fasciocutaneous donor sites over a 16-month period. RESULTS: Seventy-one radial forearm free flaps were used. Sixty-seven had a pursestring closure of the donor site. After flap elevation the mean size of the defect was 61 cm2 (range, 28-140 cm2). Pursestring closure decreased the mean of the defect to 34 cm2 (range, 10-104 cm2) (P <.0001). Defect size was decreased by a mean of 44.5% (range, 24.5%-66.7%) (P <.0001). COMPLICATIONS: The rate of skin graft loss (>25%) (9% of patients) was less than that reported in the literature. No patient required a second surgical procedure. Neural morbidity was equal in both groups. Cosmesis was much improved. CONCLUSIONS: Pursestring closure allowed for a significantly decreased donor defect, associated with better cosmesis and less skin graft loss.     

Second osteocutaneous fibular free flaps for head and neck defects

OBJECTIVE: To analyze the morbidity of a second fibular free tissue transfer when necessary in rare instances when the initial fibular flap fails. CASE DESIGN: Retrospective analysis of a case series. METHODS: A database of patients who underwent resection of head and neck malignancies with resultant free flap reconstruction was analyzed retrospectively. All patients undergoing fibular free flaps were studied, and those needing a second fibular osteocutaneous flap were identified. The morbidity from the second flap was evaluated by a standard questionnaire. RESULTS: Seven patients underwent a second fibular osteocutaneous flaps for reconstruction; data were available from six. The indications for the second flap were perioperative flap loss (5 patients), osteoradionecrosis (1), and recurrent tumor (1). Follow-up began at 3 months; mean follow-up was 44 (range 9-67) months. The morbidity of harvesting a second fibular flap was similar to that of a unilateral harvest. Four of six patients rated their overall morbidity as low; one patient indicated an intermediate morbidity, and one patient rated their morbidity from the procedure as major. The only donor site morbidities were episodes of mild cellulitis that resolved with outpatient antibiotics. CONCLUSION: Harvest of a second fibular osteocutaneous is a reasonable option for reconstruction when a second flap becomes needed. The morbidities are comparable with those encountered with a unilateral fibular flap harvest.     

Mandibular osteoradionecrosis: part I: severity factors

INTRODUCTION: The severe evolution for some patient presenting with osteoradionecrosis, even if classified in the same stages as other patients, suggests that there are aggravating factors. MATERIAL AND METHOD: A retrospective study was made between 1992 and 2002 on all patient operated for mandibular osteoradionecrosis. Fifty-nine patients were included and the mandibular defects were reconstructed with a bone or a composite free flap (fibula 21%, iliac crest 49%, scapula 6%, antebrachial 3%), and with a periosteal free flap (13%). RESULTS: The study included severe cases (87% of stage II or III) operated on several times without success. Free flap reconstruction was successful in 90% of the cases. However, complications were present in 60% of cases (24% minor complications, 48% major complications), and were more frequent with a higher stage. The analysis allowed identifying morbidity factors. DISCUSSION: Studying the morbidity allowed identifying severity factors of osteoradionecrosis; spontaneous onset, important irradiation (important dose, bone proximity of the tumor, bilateral damage), vascular damage (symphyseal localization, lack of sequestrum, facial artery ligature, active tobacco addiction), actinomycosis colonization, non-observance of medical treatment. Understanding aggravating factors should allow us to offer more efficient surgery on an early osteoradionecrosis stage, also decreasing the morbidity linked to reconstructive surgery.     

游离腓骨肌皮瓣及CT血管造影技术在颌面部软硬组织缺损功能性重建中的应用

目的：评估应用游离腓骨肌皮瓣功能性重建口腔颌面部软硬组织缺损及术前增强CT血管造影检查的临床价值。方法：口腔癌患者8例,应用游离腓骨肌皮瓣一期修复下颌骨及周围软组织缺损,血管吻合采用端端吻合法,分析腓骨肌皮瓣的设计、大小、修复部位和存活情况等。术前行供瓣区增强CT断层扫描血管造影（CTA）排查腓骨肌皮瓣血管变异。结果：1例牙龈癌患者存在腓动脉与胫后动脉共干,改用其他肌皮瓣修复;余7例游离腓骨肌皮瓣全部成活,均携带1块皮岛,皮岛6cm×2cm～10．0cm×3．5cm,用于口内软组织缺损修复。术后语音功能基本正常,面部外形、功能及咬合关系良好。下肢功能在术后2周～2个月恢复正常。结论：术前CTA检查对游离腓骨肌皮瓣的供区评价具有十分重要的应用价值。游离腓骨肌皮瓣的骨量充足,具有骨膜和骨髓双重血供,抗感染能力强。可根据需要做截骨塑形从而更加准确地恢复颌骨牙槽突形态,腓骨的高度和宽度以及皮质骨的厚度也十分适合牙种植体的植入。游离腓骨瓣的皮岛还可作为术后血供的观察窗,是能够同时兼顾颌骨缺损及周围软组织缺损功能修复重建的理想方法。     

Iliac crest internal oblique osteomusculocutaneous free flap reconstruction of the postablative palatomaxillary defect.

BACKGROUND: Traditionally, restoration of extensive palatomaxillary defects have been achieved by prosthetic restoration, often with suboptimal functional results. More recently, vascularized bone-containing free flaps have been used for this purpose. OBJECTIVE: To describe 6 patients who underwent palatomaxillary reconstruction using the composite iliac crest-internal oblique osteomusculocutaneous free flap. METHODS: Six cases of iliac crest osteomusculocutaneous free flap reconstruction of extensive postablative palatomaxillary defects were retrospectively reviewed with clinical follow-up. We reviewed these cases for pathologic findings, defect size, dental restoration, oral rehabilitation, and speech. RESULTS: Pathologic findings included squamous cell carcinoma (n = 4), osteogenic sarcoma (n = 1), and sinonasal hemangiopericytoma (n = 1). Mean follow-up was 14.5 months (range, 10-25 months). Four patients underwent resection and reconstruction primarily and 2 underwent reconstruction secondarily. Two patients required reconstruction of a cutaneous defect using the iliac skin paddle. The hard palate and lateral nasal wall were reconstructed in all 6 patients, and the orbital rim and zygomatic body were reconstructed in 4. One patient underwent reconstruction with an orbital prosthesis supported by osseointegrated implants. There was 1 donor site complication and 1 recipient site infection, which was treated successfully with oral antibiotics. Four patients were rehabilitated with osseointegrated implants, and all 6 patients maintain an unrestricted oral diet. All 6 patients have normal speech without velopharyngeal or oronasal insufficiency. CONCLUSION: For extensive palatomaxillary defects, the iliac crest-internal oblique osteomusculocutaneous free flap offers a reliable method of primary reconstruction, allowing for complete orodental rehabilitation without the use of a prosthetic obturator.     

The internal oblique-iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Report of 20 cases

Microvascular free tissue transfer techniques using composite flaps are the most reliable method for the combined bone and soft-tissue reconstitution of oromandibular defects. Functional oromandibular reconstruction requires that maximum tongue mobility be achieved along with dental prosthetic rehabilitation. The internal oblique-iliac crest osseomyocutaneous microvascular free flap was used in 20 patients for oromandibular reconstruction. The internal oblique muscle, based on the ascending branches of the deep circumflex iliac artery and vein, was used to resurface mucosal defects of the oral cavity and pharynx. The iliac bone, because of its length, width, and natural contour, is the best source of vascularized bone for mandibular reconstruction. The improved soft-tissue component of this composite flap markedly improved the functional results. Reconstruction failed in one patient. Eleven patients underwent dental rehabilitation with either a tissue-borne or osseointegrated implant-borne denture. Follow-up of longer than one year showed minimal donor site morbidity.     

The fibula osteocutaneous flap in head and neck reconstruction: a critical evaluation of donor site morbidity

OBJECTIVES: To (1) compare the complications and functional outcome of primary closure vs split-thickness skin grafting of the fibula osteocutaneous flap donor site, (2) identify patient-mix or treatment factors related to donor site complications, and (3) address early detection and management of donor site complications. DESIGN: Retrospective review and questionnaire study. SETTING: Two university tertiary referral centers. PATIENTS: Fifty-three patients (31 men and 22 women, ages 20 to 80 years) who underwent fibula osteocutaneous free tissue transfer between February 1992 and January 1997. MAIN OUTCOME MEASURES: Minor complications; major complications; and postoperative function, including sensory and motor deficits, pain, swelling, temperature intolerance, and activities of daily living. RESULTS: Four patients developed major wound complications (group 1), 11 patients developed minor wound complications (group 2), and 38 patients had no wound complications (group 3). The donor site was closed primarily in 26 patients and with a split-thickness skin graft in the remaining 27 patients. Major wound complications developed in 3 patients (12%) who underwent primary closure and 1 patient (4%) who underwent split-thickness skin grafting. Minor wound complications developed in 7 (27%) of the patients who underwent primary closure and 4 patients (15%) who underwent split-thickness skin grafting. Three patients who had major complications had residual sensory or motor deficits that resulted in impaired gait or alteration in their daily activities. Comparing all patients with complications (groups 1 and 2) to patients with no complications (group 3) demonstrated an increased incidence of donor site complications in heavy smokers (P<.05) and a strong trend toward higher donor site complications in patients who underwent primary closure (P =.10). Although trends were identified, no significant differences were found in age, comorbid illnesses, alcohol use, preoperative laboratory values, operating time, tourniquet time, or skin paddle width. CONCLUSIONS: A variety of patient-mix and operative factors are likely related to the development of donor site wound complications. Width of the skin paddle alone is not a reliable criterion for determining the need to skin graft the donor site. Primary closure tended to result in a higher rate of both major and minor wound complications compared with split-thickness skin grafting. Primary closure of fibula donor site defects should be undertaken if this can be accomplished with no tension along the suture line. If tension at the suture line is present, a skin graft should be strongly considered to minimize the possibility of a wound complication. Arch Otolaryngol Head Neck Surg. 2000;126:1467-1472     

The combined sensate radical forearm and iliac crest free flaps for reconstruction of significant glossectomy-mandibulectomy defects.

The loss of motor and sensory function of the tongue following ablative surgery has a devastating effect on oral function. At the present time, there is no way to restore lost tongue musculature following partial glossectomy. The use of sensate cutaneous flaps has been shown to restore sensory feedback to reconstructed areas of the oral cavity. No single composite flap supplies a sensate soft-tissue component together with an osseous component of sufficient bone stock for functional mastication. In this article, the combination of the radial forearm free flap with the iliac crest osteocutaneous or osteomyocutaneous free flap is reported. The radial forearm free flap was used to resurface the resected portion of the tongue to provide maximum mobility and sensation. The lingual nerve was the recipient nerve for anastomosis to the antebrachial cutaneous nerves in all but one case. The iliac bone was used to reconstruct the mandible, with the iliac skin paddle or the internal oblique muscle used to reconstruct the neoridge. This combination of flaps was used in 10 patients. There was one flap failure due to vascular kinking from "piggybacking" the iliac crest to the distal end of the radial forearm flap. As a result, the use of two separate sets of recipient vessels is now advocated. Although a single composite free flap offers an excellent form of oromandibular reconstruction in most cases, it has been shown that oral function deteriorates when large areas of anesthesia are present in the oral cavity. We believe that this combination of two free flaps offers an opportunity for superior function in select patients with significant glossectomy and/or large mucosal defects.     

吻合血管的双游离瓣技术在大型头颈部缺损修复中的应用

目的　分析双游离瓣技术在大型头颈部缺损修复中的应用价值。方法　对 2 0 0 0年 3月～ 2 0 0 2年 1月期间完成的 33例利用双游离瓣行大型头颈部缺损修复的病例作回顾性研究 ,分析所采用游离瓣的类型、受区血管、游离瓣成活情况及术后并发症的发生情况 ,并分析有可能影响游离瓣成活的各种因素。结果　 33例患者中 2 3例采用腓骨瓣 +前臂瓣 ,6例采用腓骨瓣 +腹直肌皮瓣 ,4例采用前臂瓣 +腹直肌皮瓣 ;除 1例采用串联瓣的形式外 ,其余 32例患者的两块游离瓣均采用不同的受区血管 ,其中 14块游离瓣采用了对侧颈部的受区血管 ;6 6块游离瓣中 ,1块腓骨瓣和 1块腹直肌皮瓣因静脉栓塞而失败 ,其余的 6 4块瓣均成活 ;受区和供区总的并发症发生率为 39 4 % ( 13 33) ,但大多数并发症均不严重 ,没有造成严重的后果。结论　大型头颈部缺损的双游离瓣修复安全可靠 ,能较好地恢复患者的外形和功能 ,提高了患者的生存质量     

游离股前外侧皮瓣修复头颈肿瘤术后缺损

目的探索供区功能和外观损伤更小的游离股前外侧(anterolateralthigh,ALT)皮瓣修复技术,运用于头颈肿瘤术后缺损。方法2003年12月—2005年5月中国医科院肿瘤医院头颈外科用于头颈部手术缺损修复的游离股前外侧皮瓣8例。头颈部肿瘤手术缺损按受区部位分为口咽侧壁3例,舌活动部2例,颊黏膜、舌根和颅底各1例。结果8例游离ALT皮瓣手术均获成功。供区伤口一期愈合,未发现切口裂开,下肢运动和感觉功能障碍等手术并发症。8例皮瓣的穿支血管类型均为肌皮穿支,皮瓣应用面积为(4~8)cm×(5~10)cm。手术时间5~10h,平均7h。皮瓣切取制作时间65~115min,平均80min。结论游离股前外侧皮瓣具有修复技术可靠、供区部位隐蔽和并发症少等优点,是头颈部缺损修复的理想皮瓣之一。     

Reconstruction of the pediatric maxilla and mandible

BACKGROUND: The creation of osseous defects in the upper and lower jaws in children is an uncommon occurrence. It is therefore likely that a head and neck reconstructive surgeon will accumulate only limited experience in restoring such defects. We have reviewed 7 pediatric bone-containing microvascular free flap reconstructions in 6 patients for reconstruction of the upper or lower jaws. Three patients were available for long-term follow-up to evaluate the effect of osseous free flap reconstruction on function and growth and development of the donor site. DESIGN: Retrospective review. SETTING: Academic tertiary referral center for otolaryngology. PATIENTS AND METHODS: Six pediatric patients ranging in age from 8 to 16 years underwent 2 fibular, 4 scapular, and 1 iliac free flap procedure for restoration of 2 maxillary and 5 mandibular defects from 1992 to 1997. Three of the 6 patients were available for long-term follow-up to assess the postoperative donor site function in an effort to determine the effect of this surgery on long-term donor site morbidity and development. RESULTS: Two patients were lost to follow-up, and 1 died secondary to complications related to distant metastatic disease. Three of 6 patients were observed for 2 years 6 months, 4 years, and 4 years 2 months, respectively. Two of the 3 patients who were observed long term have undergone full dental rehabilitation and currently maintain a regular diet and deny pain with mastication or deglutition. One patient did not require dental rehabilitation. All 3 patients demonstrate gross facial symmetry and normal dental occlusion. Assessment of the fibular donor site demonstrated normal limb length and circumference. The patients denied pain or restriction to recreational activity. Scapular donor sites demonstrated normal range of motion, strength, and shoulder stability. CONCLUSIONS: Free flap reconstruction of the pediatric maxilla and mandible requires harvesting bone from actively growing donor sites. We have found no evidence of functional deficit after bone harvest from the fibular or scapular donor sites. Patients demonstrate normal growth at the donor sites, and symmetry of the mandible and maxilla is preserved.     

Pre-implantation iliac graft in the sinus. Retrospective study of the complications encountered in 100 cases

MATERIAL AND METHODS: This series included 60 patients operated on between 1996 and 1998. Preoperative work-up included a x-ray study bone quality, preparation of the buccal cavity and assessment of the rhinosinus. We used the surgical technique described by Boynes and Tatum with modifications. The bone graft, mean 16 cm2 was fixed with a stud and clamp assemble or a long screw through the gingival crest, or with a microscrew on the lateral wall of the maxillary sinus. Minimal follow-up was two years. RESULTS: Mean age was 54 years (range 20-80). There were only two minor (hematoma) donor site problems. At the receiver site, there were 30 perforations of the mucosa that had no effect on the graft vitality. During the postoperative period, there were 2 hematomas that resolved spontaneously and 20 cases of dysesthesia in the V2 territory. Mid-term outcome (15 days to 6 months postoperatively) showed: 4 graft infections requiring removal in 3 cases and 6 partial resorptions requiring a new parietal bone graft in 3 cases. DISCUSSION: The iliac bone graft provided abundant cancellous tissue. The mid-term outcome was satisfactory although the postoperative problems resolved more slowly and were more painful than when harvesting a parietal graft. Mucosal perforations were frequent but reparable and did not increase postoperative morbidity. Infection was the most severe complication. Our incidence (3%) was slightly higher than reported in the literature. A possible explanation would be the mean height of the graft (18-20 mm) and the severity of the atrophies treated.     

Evaluation of fibula free flap donor site morbidity

OBJECTIVE: To evaluate foot and ankle function in a series of patients undergoing fibula microvascular free tissue transfer. STUDY DESIGN: A nonrandomized, nonblinded analysis was performed using the ankle-hindfoot scale as well as radiographic analysis to determine donor site morbidity. RESULTS: Overall, foot ankle function was deemed to be good in this series of patients. Average ankle-hindfoot score was 84.82 of a possible 100 (range, 55-100). Radiographic analysis of donor and contralateral ankles showed no difference in the syndesmotic space or medial clear space. Only 1 patient had increased talar tilt compared with the contralateral side, although this patient had preservation of stability. CONCLUSION: Fibula free flap harvest appears to be associated with acceptable donor site morbidity and preservation of good foot and ankle function in most individuals.     

Short-term functional donor site morbidity after radial forearm fasciocutaneous free flap harvest

OBJECTIVES/HYPOTHESIS: The existing literature on postoperative donor extremity function describes a spectrum of morbidity in the long term (>3 mo after surgery). However, the consensus is that there is minimal to no impact of flap harvest on patients' activities of daily living. No previous reports have examined functional donor site morbidity in the early postoperative period; such may affect patients' overall perioperative progress, especially with respect to donor extremity dominance. The authors' objective was to quantify functional morbidity of the donor site in radial forearm fasciocutaneous free flaps during the early postoperative period. STUDY DESIGN: Retrospective case series review. METHODS: Patient data were obtained from hospital records of 12 consecutive patients who underwent head and neck reconstruction with radial forearm fasciocutaneous free tissue transfer over a 6-month period at a tertiary academic medical center. Functional results of each patient's donor extremity obtained preoperatively and at 5 to 8 days after surgery were determined by quantifying forearm supination and pronation, wrist flexion and extension, and sharp and dull hand sensations in radial, median, and ulnar nerve distributions. RESULTS: Mean patient age was 57 years (age range, 42-71 y). The nondominant extremity was the donor site in 9 of 12 patients. Using the paired two-tailed t test, statistically significant differences were demonstrated in preoperative versus postoperative forearm supination (P <.032), pronation (P <.006), wrist flexion (P <.000), and wrist extension (P <.000). Three of 12 patients demonstrated diminished sharp sensation in the "anatomical snuffbox" distribution. CONCLUSION: The authors describe statistically significant functional forearm and wrist range-of-motion morbidity associated with the harvest of a radial forearm fasciocutaneous free flap in the early postoperative period.