A comparison between fibula and iliac crest in mandibular reconstruction

Nowadays the vascularized free fibula flap and the free iliac crest flap are the methods most frequently used to reconstruct the mandible. This is also the case in our clinic. A retrospective nonrandomized study was performed to compare both flaps. The vascularized fibula free flap and the iliac crest free flap were compared in terms of logistics, flap failure, revisionary surgery, donor site morbidity, and recipient site morbidity. No significant differences in flap failure and revision surgery were found between the fibula group and the iliac crest group. Recipient site and donor site complications (major and minor) were significantly less in the fibula group compared to the iliac crest group. In mandibular reconstruction, the free vascularized fibula flap appears to be superior to the free vascularized iliac crest flap in terms of both recipient site and donor site morbidity.     

Twelve-year experience in mandibular reconstruction using osteo-muscular dorsal scapular pedicled flaps

Primary mandibular reconstruction after tumor removal or osteoradionecrosis treatment is a standard procedure. The most common reconstruction techniques are fibula, scapula, and iliac crest free flaps. Nevertheless, all patients are not eligible for microsurgery.In this study, we assess 12 years of mandibular reconstruction using an osteo-muscular dorsal scapular pedicled flap (OMDS). We included 40 patients operated on using an OMDS flap. We collected parameters such as length of hospital stay, recurrence risk, and need for secondary flap for oral cutaneous fistula (OCF) treatment. Flap bone volume was assessed by segmenting the scapula on postoperative CT-scans using dedicated software.Forty patients were included. Indications for OMDS flaps were severe cardiovascular history (27%), preoperative radiotherapy with a radiation neck and potentially unreliable blood vessel sutures (20%), previous fibula free flap failure (15%), and patient refusing free tissue transfer (8%). Aside from these medical indications, OMDS flaps were performed in 30% of cases due to organizational concerns. The mean flap length was 73±16 mm, with a maximum of 109 mm. Flap bone volume was stable over time, with negligible resorption (p = 0.761). Secondary pedicled flaps were used to treat OCF in 5 patients (12%). Secondary esthetic procedures were performed in 9 patients (22%). None of the 40 flaps were removed. None of the patients had long-term scarring complications in donor sites.OMDS flaps merit consideration for mandibular reconstruction when free tissue transfer is contraindicated or impossible due to organizational issues.     

Current role of the iliac crest flap in mandibular reconstruction

The purpose of this study was to examine the current role of the iliac crest osteocutaneous flap in mandibular reconstruction, with a focus on the reliability of its skin island. We reviewed outcomes in 18 cases of immediate mandibular reconstruction with the iliac crest flap. Intraoral mucosal defects were closed with the skin island of the iliac crest flap in 13 patients (iliac crest flap group) and were closed with another free flap, because of poor circulation of the iliac crest skin island, in five patients (double-flap group). Postoperative results were poor in the iliac crest flap group. The rate of partial or total loss of the skin island was 46.2% in the iliac crest flap group and 20.0% in the double-flap group. The presence of a dominant perforator did not reduce the overall rate of recipient-site complications or reoperation. Combined use of another skin flap for intraoral lining provided better results. These results suggest that the skin island of the iliac crest flap should not be used for intraoral lining, unless adequate circulation of the skin island can be confirmed. If the circulation is questionable, combined use of another skin flap is strongly recommended.     

The optimum method for reconstruction of complex lateral oromandibular-cutaneous defects

BACKGROUND: Ablation of large intraoral cancers can create extensive through-and-through defects of the lateral face, resulting in loss of external facial skin, the lateral and anterior mandible, and the lateral mouth. Repair requires reconstruction of the lips, mandible, and full-thickness cheek defects. Ideal reconstruction with vascularized composite free flaps requires adequate bone and sufficiently large, yet versatile, skin flaps capable of resurfacing extensive intraoral and external defects. METHODS: A series of 12 patients with large lateral facial-mandibular defects is reviewed. All patients were treated for squamous cell carcinoma except for 1 patient with osteoblastic sarcoma of the mandible. All patients underwent primary reconstruction with various free flap techniques, including 6 scapular free flaps, 2 iliac crest free flaps, 3 free fibula flaps, and 1 radial forearm flap. Attainment of reconstructive goals, free flap survival, and complication rates were assessed. RESULTS: All defects were successfully reconstructed in the primary setting. No flap failures occurred. One venous occlusion was successfully salvaged. No orocutaneous fistulas or postoperative hematomas were noted. CONCLUSION: The reconstructive options for extensive defects of the lateral face and jaw are reviewed with attention to the complex three-dimensional soft tissue requirements. The superiority of the scapular composite flap is emphasized because this single free flap provides two independent and versatile skin paddles of optimal thickness in addition to adequate bone stock.     

Donor-Site Complications in Vascularized Bone Flap Surgery

Microvascular osteocutaneous free flaps have given reconstructive surgeons a powerful tool in the reconstruction of composite defects in head and neck surgery. Radial forearm, scapula, iliac crest, and fibula flaps have been used extensively in mandibular reconstruction. The inevitable donor-site morbidity of these osteocutaneous flaps has received less attention than the reconstructive advantages. We have reviewed the literature for each type of flap to determine the kind, incidence, and consequences of flap associated morbidity. In the future, tissue-engineered prefabricated free flaps might play an important role.     

Mandibular reconstruction: are two flaps better than one?

This study compared the combined iliac and ulnar forearm flaps with the osteomusculocutaneous fibular free flap for mandibular reconstruction. A retrospective study of 40 patients who had oromandibular reconstruction was performed, of whom 23 patients had a combined iliac crest without skin and ulnar forearm free flap. Seventeen patients had an osteomusculocutaneous free fibular flap. Ten women and 30 men with a mean age of 57.5 years comprised this study population. Ninety percent of the cases were squamous cell carcinoma (55%, T4), of which 11% were recurrent tumors. Anterolateral mandibular defects constituted 52.9% of the fibular reconstructions and 60.9% accounted for the iliac/ulnar reconstructions. The mean bone gaps were 8.79 cm and 8.95 cm respectively. Functional evaluation was based on the University of Washington Questionnaire through phone calls and personal communication. The mean hospital stay was 15.43 days and 10.09 days for the fibular and iliac/ulnar flaps respectively. The facial artery (64.7%) and facial vein (60%) were the main recipient vessels for the fibular reconstructions whereas the external carotid artery (95.6%) and the internal jugular vein (66.7%) were the main recipient vessels for the iliac/ulnar reconstruction. Overall flap survival was 96.8% (100% of fibular flaps and 95.65% of iliac/ulnar flaps). Two flaps were lost in the iliac/ulnar series because of unsalvageable venous thrombosis. Local complications for the iliac/ulnar flaps were 30.4% but were 5.9% for the fibular reconstructions. Function such as speech, swallowing, and chewing were notably better in the fibular than the iliac/ulnar group in 23 of the patients tested. The cosmetic acceptance of 77.8% of the fibular flaps was judged to be excellent and good, whereas 71.4% of the iliac/ulnar flaps were rated good. It appears that within this study population the free osteomusculocutaneous fibular flap had fewer local complications and a higher flap survival rate than the combined iliac/ulnar forearm flaps. Overall functional outcome was also improved. The use of the double flap may be appropriate in massive oromandibular defects, but may be less appropriate in more modest functional reconstructions of mandibular defects.     

Donor-site complications in vascularized bone flap surgery.

Microvascular osteocutaneous free flaps have given reconstructive surgeons a powerful tool in the reconstruction of composite defects in head and neck surgery. Radial forearm, scapula, iliac crest, and fibula flaps have been used extensively in mandibular reconstruction. The inevitable donor-site morbidity of these osteocutaneous flaps has received less attention than the reconstructive advantages. We have reviewed the literature for each type of flap to determine the kind, incidence, and consequences of flap associated morbidity. In the future, tissue-engineered prefabricated free flaps might play an important role.     

The iliac crest and the radial forearm flap in vascularized oromandibular reconstruction

Sixty cases (59 patients) of oromandibular reconstruction using vascularized iliac crests were compared with 13 in which radial osteocutaneous flaps were used. These patients were reviewed from the standpoint of cosmetic results and function as well as their operative and postoperative courses. In both groups, the results were generally good. However, revisionary surgery was more frequent in those receiving the iliac crest. This group also had a higher incidence of intraoral wound breakdown and bone exposure. Nevertheless, the sheer size of the iliac crest made it ideal for massive oromandibular defects, just as its natural curvature lent itself to precise replication of the mandible in bone-only reconstructions. Its bulk proved a major obstacle in small composite defects. The radial forearm flap carried thin, pliable, well-vascularized skin that was superior to groin skin for oral lining. Bone gaps of up to 9 cm could be handled with ease, thus making it complementary to the iliac crest over the wide spectrum of mandibular reconstruction.     

Reconstructive indications of simultaneous double free flaps in the head and neck: A case series and literature review

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo‐radiotherapy. Forty‐two free flaps were used in these patients. The predominant combination was that of free fibula osteo‐cutaneous flap with free anterolateral thigh (ALT) fascio‐cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro‐mandibular bone and soft tissue defects (n = 13), (b) large oro‐mandibular soft tissue defects (n = 4), (c) complex skull‐base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow‐up period was 11 months. Twelve patients were alive and free of disease at the end of the follow‐up. Eighteen of 19 patients with oro‐mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro‐mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

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.     

Donor side selection in mandibular reconstruction using a free fibular osteocutaneous flap

While the free fibular osteocutaneous flap is indispensable for mandibular reconstruction, reliable setting is often difficult because relative positions of the bone, skin island, and vascular pedicle are critical. We have an algorithm for donor-side selection of free fibular osteocutaneous flap.From July 2002 to March 2004, we performed 15 mandibular reconstructions using free fibular osteocutaneous flaps. We retrospectively classified these procedures as follows. In type I (flap harvested ipsilaterally to defect, n = 5), the skin island was fixed to the oral cavity, and the vascular pedicle emerged from the anterior aspect of the fibula. In type II (flap contralateral to defect, n = 5), the skin island was fixed to the oral cavity, and the vascular pedicle arose from the posterior aspect. In type III (flap contralateral to defect, n = 4), the skin island was fixed to the facial skin and the vascular pedicle arose from the anterior aspect. In type IV (flap ipsilateral to defect, n = 1), the skin island was fixed to the facial skin and the vascular pedicle arose from the posterior aspect. Flaps took completely except in 1 group II case with partial necrosis. Close attention to geometric characteristics of a free fibular osteocutaneous flap facilitates reconstruction of mandibular defects and selection of donor side.     

头颈部肿瘤术后缺损游离组织瓣的供区选择

目的应用游离组织瓣修复头颈部肿瘤术后缺损,探讨较简便合适的方法。方法回顾并分析1999年1月~2002年1月,采用游离组织瓣修复头颈部肿瘤术后缺损86例。缺损部位:口腔32例,下咽27例,下颌骨12例,颅底5例,中面部4例和头皮/皮肤6例。供区:腹直肌皮瓣32例,股前外侧皮瓣10例,空肠瓣25例,腓骨瓣11例,背阔肌皮瓣4例,前臂皮瓣3例和肩胛皮瓣1例。其中皮瓣或肌皮瓣大小4 cm×5 cm~14 cm×24 cm,腓骨瓣长度4~16 cm,空肠瓣长度9~20 cm。结果游离组织瓣术后成活79例,成活率为92%。其中口腔缺损采用腹直肌肌皮瓣22例(69%)和股前外侧皮瓣10例(31%)修复;下咽缺损主要用空肠瓣修复25例(93%),下颌骨缺损则用腓骨瓣修复11例(92%),颅底缺损由腹直肌皮瓣修复4例(80%)。腹直肌、股前外侧、空肠和腓骨4种组织瓣修复头颈部缺损78例,占同期游离组织瓣的91%。结论头颈部肿瘤术后缺损复杂,利用腹直肌肌皮瓣、股前外侧皮瓣、空肠瓣和腓骨瓣可解决大多数修复重建的难题。     

The application of 3-D biomodeling technology in complex mandibular reconstruction��experience of 47 clinical cases

3-D biomodeling technology associated with stereolithography has become a fundamental tool in reconstructive surgery in recent years as it enables a highly accurate definition of the defect to be reconstructed. In complex mandibular reconstruction using free flaps, the exact 3-D characteristics of the flap are decisive to restore symmetry and structural integrity, which enables a good functional and aesthetic result. This paper reports the application of an innovative 3-D biomodeling approach for the calculation of the exact contours, angles, length, and general morphology of iliac crest and fibula free flaps for mandibular reconstruction. Between 2003 and 2009, we managed 47 complex mandibular reconstruction cases using this technology. The free flaps used were fibula (n = 29) and iliac crest (n = 18) transferred as osseous or osteocutaneous flaps. From computer tomography scans, virtual 3-D images of the patient's anatomy were converted into 3-D physical models using first Freeform Modeling? software and then selective laser stereolithography technology. Intra-operative bone osteotomies and modeling were guided by these biomodels. Functional and aesthetic end results were at least considered satisfactory in 95.7% of the patients. The majority (80.8%) were in the good and very good end-result categories. This personalized designing of free flaps enabled optimization of pre-operative planning, reduced operative time, and significantly improved the aesthetic and bio-functional outcome. We found it to be particularly useful in major secondary defects (oncological, osteoradionecrosis, trauma) with important distortion of craniofacial structure, congenital malformations, and primary tumor surgery when the dimensions of the tumor have altered normal anatomy considerably.     

Maxillary tumours and bilateral reconstruction of the maxilla

Reconstruction of maxillectomy defects following intraoral tumour excision presents a challenge to the plastic surgeon. The defect left after maxillectomy requires a formal reconstruction in order to minimize problems associated with speech and swallowing. A multidimensional approach is required to achieve a structural and functional restoration. The maxillectomy defects are complex, which often requires composite tissue replacement. A variety of reconstructive techniques have been used for the repair of the maxillary and palatal defects, including prosthetics, skin grafts, local and free flaps using the iliac crest, scapula, fibula, latissimus dorsi, radial forearm and abdominis rectus free flaps. We have used a lateral-arm osteocutaneous free flap for reconstruction of a bilateral maxillary defect, with excellent aesthetic, functional and structural support results. This type of reconstruction for this defect has never been reported previously.     

Lower limb reconstruction with bone free flaps: experience of 25 cases

Bone structure is fundamental for the function of the lower limbs—orthostatism and locomotion. Before the technical evolution observed in the last two decades, many extremities that are saved now were amputated in the past. Lower limb bone defects are generally associated with complex traumatic lesions and constitute a permanent reconstructive challenge. The management of this kind of defect requires a multidisciplinary approach involving plastic and orthopedic surgeons. The bone free flaps are a very important and technically exacting tool for lower limb bone reconstruction. We present and analyze our experience in 25 traumatic cases where we used 17 fibula free flaps and 2 iliac crest free flaps for tibia and talus reconstruction; 5 fibula free flaps for femur reconstruction; and 1 antebrachial radial osteocutaneous free flap for first metatarsal reconstruction. We registered 88% of success (three flap necroses—12%) with good bone integration and good functional recovery. Lower limb bone reconstruction is a long and tortuous stair whose success depends not only on the multidisciplinary surgical team but also on the patient's cooperation and determination     

The place of the iliac crest in vascularized oromandibular reconstruction

The iliac crest is reevaluated with respect to the rapid evolution of vascularized mandibular reconstruction. With more flaps to choose from, indications for the crest have become more specific—playing to the strengths of this particular transfer. Ideally, defects should exclude soft tissue and occupy lateral segments of the mandibular arch—up to and including a complete hemimandible. The composite flap is capable of reconstructing external skin with ease, but the color match leaves something to be desired. Mucosal defects are less well handled. The flap can replace soft tissue bulk as well as mandibular height following through-and-through excisions in the region of the chin. Where donor site cosmesis is of paramount importance, the iliac crest is simply the best flap available. © 1994 Wiley-Liss, Inc.     

Practically: differential indications of mandibular reconstruction in maxillofacial cancerology]

This study, based on the authors' experience, intends to determine the specific indications of mandibular reconstruction after oncological maxillofacial resections. Mandibular defects without osseous interruption do not necessarily need an osseous reconstruction: the esthetic and functional problems can be resolved using dental osseointegrated implants. On the contrary, mandibular defects with osseous interruption need imperatively an osseous and/or composite reconstruction: the best esthetic and functional results are obtained with an immediate reconstruction by an osseous or osteocutaneous free flap, either from the fibula or the iliac crest. The advantages and the disadvantages of all these reconstruction technics are detailed and largely illustrated.     

Iliac crest free flap and submental island flap for maxillary reconstruction

Abstract

The iliac crest free flap is one of the most reliable flaps for maxillary reconstruction because of the large amount of bone provided and the chance to harvest both muscle and skin. However, reconstruction of maxillary through-and-through defects requires special skills to be managed. Simultaneous replacement of oral lining and external tissue with the same features as the resected skin is difficult to achieve with conventional techniques and the use of flaps association is often necessary to ensure acceptable cosmetic and functional results. In the case presented the submental island flap was a good choice to overcome these difficulties.     

Oromandibular reconstruction with vascularized free flaps: a review of 50 cases

Fifty cases of oromandibular reconstruction using vascularized free flaps to evaluate functional parameters of results were evaluated. There were 23 iliac crest flaps, 17 fibula flaps, 30 ulnar forearm flaps, and 3 radial forearm flaps with bone. Thirteen female and 37 male patients comprised the study, with a mean age of 57.66 years. Squamous-cell carcinoma (SCC) constituted 86% of cases, of which 60% were T4 lesions and 13.9% were recurrent. Anterolateral mandibular defects constituted 48.7%, and the mean bone gap was 8.13 cm. Functional evaluation was based on the University of Washington Questionnaire (UWQ) through phone calls and personal communication. The mean hospital stay was 12.42 days. The external carotid (75%) and facial (18.3%) were the main recipient arteries. The internal jugular (47.05%) was the main recipient vein. Overall flap survival was 95.9%. Three flaps were lost due to unsalvageable venous thrombosis. Major local complications such as partial flap loss, hematoma, and orocervical fistula constituted 10% of cases. Speech was classified as "excellent" and "good" in 43.3% of cases. Swallowing was identified as "excellent" and "good" in 53.3% of cases. Cosmetic acceptance was rated "good" in 63.3% of cases. Vascularized free flap reconstruction of oromandibular defects provides excellent functional and aesthetic results. The majority of patients are able to tolerate a regular diet. Intelligible speech and acceptable appearance are restored, providing patient satisfaction.