Three salvage strategies in microvascular fibula osteocutaneous flap for mandible reconstruction with vascular compromise and establishment of an algorithm

Abstract

Background Fibula osteocutaneous flap is associated with a higher rate of reexploration in mandible reconstruction due to limited space for the fixation of various tissue components on multiple segments of the fibula flap. To maintain optimal circulation to the flap and to prevent negative outcomes because of partial or total flap loss, we shared our experiences on salvaging the free fibula flap with vascular compromise in the first reexploration and we developed an algorithm. Methods From 1992 to 2018, 12 patients between the ages of 48 to 63 (mean: 52.5) who had presented with oral squamous cell carcinoma (n = 10) followed by osteoradionecrosis of the mandible (n = 2) were explored. The operative findings were; (1) occlusions of vein (3 cases); (2) occlusions of artery (4 cases); and (3) occlusions of both artery and vein (5 cases). After correcting the kinking or evacuating the hematoma, the arterial inflow was initially reestablished by anterograde flow. If this was nonfunctional, retrograde flow from the distal end of the peroneal artery was provided. For the vein, anterograde venous drainage was reestablished. If the thrombus extended deep into the peroneal vein, regular venous return was blocked on the anterograde side, and the flap remained congested therefore retrograde venous drainage was performed regardless of the valves in the vein. However, the two ends of the peroneal artery were anastomosed to prevent thrombosis of the artery. Results The success rate of revised cases was 75% (9/12). All failed cases had presented with both artery and vein occlusion (three cases). Pectoralis major musculocutaneous flap and anterolateral thigh flap were needed for the external surface in two cases. Skin graft was required for seven cases to restore intraoral lining. Six patients underwent dental rehabilitation with prosthetic implants. Conclusion Immediate reexploration is mandatory to salvage the flap.

Multiple Free Flap Reconstruction of a Complex Intraoral Defect after Squamous Cell Carcinoma Excision: A Case Report

“…The main advantage of this technique precisely lies in the anatomy of the bone itself, as a triangular-shaped bone which allows greater primary stability of the implants themselves, being a bicortical bone [25,26]. Moreover, one of the greatest strengths of the fibula free flap is that it can be manipulated without difficulty to fill defects on the inner and outer sides [27].…”

Comparison of Hyperspectral Imaging and Microvascular Doppler for Perfusion Monitoring of Free Flaps in an In Vivo Rodent Model

“…If bony reconstruction is required, osteomyocutaneous fibula free flap, scapula flap, or deep circumflex iliac artery (DCIA) flap can be used. Depending on the type of flap, there is a flap survival rate of over 95% [ 1 , 2 , 3 , 4 , 5 ]. In addition to the type of MFF and the surgeon’s experience, several factors influencing the success rate of free tissue transfer have been identified.…”

Perforator-based Adipofascial Flaps and ADM: A Novel Combined Approach to Distal Lower Extremity Defects

“…6,7 On the other hand, microsurgery has its drawbacks: it is expensive, time-consuming, and requires high surgical skills, adequate instruments, and a trained team; moreover, a minimal possibility of a free flap failure is reported with all the problems related to a re-exploration and secondary reconstructive procedure. [8][9][10][11] To date, due to the wide spectrum of lower extremity defect presentations, no universal algorithm exists for their reconstruction; moreover, several studies showed no significant difference in terms of flap survival and complication rates between free and local flaps. 4,7,12 The introduction of angiosome and perforasome theories have allowed plastic surgeons to reevaluate the role of local flaps in light of the perforator concept.…”