Donor Side Selection in Mandibular Reconstruction Using a Free Fibular Osteocutaneous Flap

Abstract

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.

Surgical Modalities in Gunshot Wounds of the Face

“…It has been stated that this flap has important disadvantages such as insufficient soft tissue reconstruction due to the thin skin island in a large defect, which increases the risk of fistula formation and may cause necrosis by bending the septal perforators between the mandible and the oral cavity. 6 Matros et al 5 applied the bilateral free fibular flap on 10 patients with secondary oral neoplasm and stated that fibular flap prevents Andy Gump deformity and allows sufficient soft tissue reconstruction. For anterior and anterolateral mandibular defects with partial bony defects and accompanying oral cavity soft tissue defects, various osteocutaneous free flaps can be used as an alternative method.…”

“…6 The flap method selection is directly related to the skin and mucosa defect and to the bony tissue. 5,6 Numerous methods such as the free radial forearm osteocutaneous flap, free dorsal scapular osteomuscular flap, free fibula osteocutaneous flap, deep circumflex iliac artery perforator flap including iliac crest, and dorsalis pedis free flap have been used for repairing composite mandible defects with respect to the patient's clinical status. 3Y10 Hidalgo and Pusic, 11 in their 10-year study, stated that the bone graft consistently saved except for minimal bone erosions.…”

Fibula Osteoseptocutaneous Flap

“…In the past, Yagi's classification regarding the donor site selection in mandibular reconstruction was helpful for choosing the donor side based on the direction of the vascular pedicle. 25 However, our harvest technique allows for nearly 360 degrees of freedom for the skin paddle, and thus, the donor leg side and the recipient vessel direction are no longer limiting factors for flap choice. This is especially important in endemic betel nut-chewing areas, such as Taiwan and South Asia, where patients commonly have oncologic recurrences and multiple reconstructions, depleting the donor tissue available on the lower extremities.…”

Multiple Free Flap Reconstructions of Head and Neck Defects Due to Oral Cancer

“…1 Thus, multiple free flap reconstructions in the head and neck present a distinct technical challenge. 2 Difficulties can occur because of prior surgical scarring, postsurgical alteration of anatomy, intraoral or extraoral soft-tissue defects, 3 and complications such as infection, draining fistulae, and poor vascularity of local tissue. 1 Also, in multiple reconstructive cancer surgeries, limitation of selective recipient vessels by previous neck dissection or radiotherapy hampers successful reconstruction.…”