Double free flaps in oral cavity and oropharynx reconstruction: Systematic review, indications and limits

Mannelli, Giuditta; Gazzini, Luca; Comini, Lara Valentina; Parrinello, Giampiero; Nocini, Riccardo; Marchioni, Daniele; Molteni, Gabriele

doi:10.1016/j.oraloncology.2020.104637

Cited by 11 publications

(10 citation statements)

References 57 publications

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“…23 Although the decision of single or double flaps for reconstruction should consequently aim for better outcomes and quality of life, both bony defect (<13 cm) and the large soft tissue volume requirement (<135 cm 2 ) were the remarkable considerations of a chimeric flap, unless there is contraindication of flap harvesting. 22,24 The presented algorithm was partially consistent with our results. 21 Apart from the surgeon's experience, the total surface area >159 cm 2 in through-and-through COMDs revealed a higher risk of thromboembolic event and finally caused prolonged ICU stay in our analysis.…”

Section: Discussionsupporting

confidence: 89%

Total Surface Area of a Through-and-Through Oromandibular Defect Is Associated With Thromboembolic Events for Reconstruction With a Single Fibula Free Flap

Chen

Wang

et al. 2023

Ann Plast Surg

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Background: Reconstruction of through-and-through composite oromandibular defects (COMDs) has been a challenge to plastic surgeons for decades. When using a free osteoseptocutaneous fibular flap, the skin paddle is restricted by the orientation of the peroneal vessels and the inset of bone segment(s). Although the combination of double flaps for extensive COMDs is viable and reliable, the decision of single-or double-flap reconstruction is still debated, and the risk factors leading to complications and flap failure of single-flap reconstruction are less discussed. Aim and Objectives: The aim of this study was to determine objectively predictive factors for postoperative vascular complications in through-and-through COMDs reconstructed with a single fibula flap. Methods: This was a retrospective cohort study in patients who underwent single free fibular flap reconstruction for through-and-through COMDs in a tertiary medical center from 2011 to 2020. The enrolled patients' characteristics, surgical methods, thromboembolic event, flap outcomes, intensive care unit care, and total hospital length of stay were analyzed. Results: A total of 43 consecutive patients were included in this study. Patients were categorized into a group without thromboembolic events (n = 35) and a group with thromboembolic events (n = 8). The 8 subjects with thromboembolic events were failed to be salvaged. There was no significant difference in age, body mass index, smoking, hypertension, diabetes mellitus, and history of radiotherapy. The length of bony defect (6.70 ± 1.95 vs 9.04 ± 2.96, P = 0.004) and the total surface area (105.99 ± 60.33 vs 169.38 ± 41.21, P = 0.004) were the 2 factors that showed a significant difference between the groups. Total surface area was the only significant factor in univariate logistic regression for thromboembolic event ( P = 0.020; odds ratio, 1.02; 95% confidence interval [CI], 1.003-1.033) and also in multivariate logistic regression analysis after adjusting confounding factors ( P = 0.033; odds ratio, 1.026; 95% CI, 1.002-1.051).The cutoff level of total surface area in determining thromboembolic event development was 159 cm 2 ( P = 0.005; sensitivity of 75% and specificity of 82.9%; 95% CI, 0.684-0.952). Conclusions: Free fibula flap has its advantages and drawbacks on mandible restoration. Because there is a lack of indicators before, a large total surface area may be an objective reference for single-flap reconstruction of through-and-through COMDs due to an elevated risk of thromboembolic event.

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Section: Discussionsupporting

confidence: 89%

Total Surface Area of a Through-and-Through Oromandibular Defect Is Associated With Thromboembolic Events for Reconstruction With a Single Fibula Free Flap

Chen

Wang

et al. 2023

Ann Plast Surg

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“…The FFOF and ALT flap is the most prevalent combination of simultaneous free flap transposition for complex head and neck defects. 3 Revision rate, flap failure rate, and recipient and donor site complications are not significantly different between double and single free flaps. [3][4] Using in-house CAD-CAM technology, we were able to optimise the restoration of the facial contour and function, simultaneously reducing the handling trauma of donor tissues, ischemia and operative time.…”

mentioning

confidence: 78%

“…3 Revision rate, flap failure rate, and recipient and donor site complications are not significantly different between double and single free flaps. [3][4] Using in-house CAD-CAM technology, we were able to optimise the restoration of the facial contour and function, simultaneously reducing the handling trauma of donor tissues, ischemia and operative time. 5 In conclusion, double free flap reconstruction of the paediatric mandible after extensive Ewing sarcoma resection is safe and offers excellent facial aesthetic and functional results.…”

mentioning

confidence: 78%

CAD-CAM planned double free flap reconstruction of the paediatric mandible after Ewing sarcoma resection

Busser

Kerckhoven

Vranckx

2021

Journal of Plastic, Reconstructive & Aesthetic Surgery

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“…Although chimeric flaps represented a significant improvement in microsurgery thanks to the possibility to use a single vascular supply to provide tissue to different anatomical areas, they have a limited indication for very large defects that simultaneously involve the middle and the inferior third of the maxillofacial skeleton. According to Mannelli and colleagues (11), intrinsic chimeric flaps are contraindicated for large soft tissue need (>350 cm 2 ) and large and complex bone defects (>13-14 cm). Moreover, chimeric flaps require a higher microsurgical training compared with simple flap harvesting, and require the ablative surgical time to be complete prior to harvesting the flap, thus precluding any dual-team surgery, with an increase in surgical time (12).…”

Section: Discussionmentioning

confidence: 99%

Double osseous flaps for simultaneous midfacial and mandible reconstruction: Automation in surgical complexity within an entirely computerized workflow

Tel

Bagatto²,

Sembronio³

et al. 2023

Front. Oncol.

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IntroductionBroad maxillofacial surgical resections involving both the midface and the mandible represent a challenge in terms of reconstruction. Although several papers have explored the possibility of simultaneously using two microsurgical flaps, reports on the implementation of a dual osseous flap strategy are limited, and mainly addressed to static anatomical reconstruction, regardless of functional implications. In particular, there is a lack in the literature of a unifying protocol which illustrates how technology including virtual planning, statistical shape modeling, virtual occlusion, 3D-printing and patient-specific implants can address the functional and accuracy needs required for an optimal reconstruction.Materials and methodsIn this paper, the Authors present their preliminary experience in a two-center study, showing how broad maxillofacial defects, requiring a simultaneous reconstruction in both the mandible and the midface, can be successfully reconstructed using the combination of two osseous flaps in an automated sequence in which all steps are anticipately defined in a virtual plan, accounting for the optimal alignment of temporomandibular joint, predicting the final occlusion and defining a mandibular shape according to a statistical shape model.ResultsAverage RMSE for the iliac bone crest flap was of 3.2 ± 0.36 mm; for the fibula flap, RMSE value was of 2.3 ± 0.65 mm, for patient-specific implants, for mandibular prostheses the average RMSE was 2.46 mm with 0.76 mm standard deviation. Temporomandibular joint function increased when a TMJ prosthesis was placed.ConclusionsDouble bone free flap is a valuable resource to reconstruct wide defects that simultaneously involve two thirds of the cranio-maxillo-facial skeleton, but a careful virtual planning study should be always performed before approaching this surgical option.

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Double free flaps in oral cavity and oropharynx reconstruction: Systematic review, indications and limits

Cited by 11 publications

References 57 publications

Total Surface Area of a Through-and-Through Oromandibular Defect Is Associated With Thromboembolic Events for Reconstruction With a Single Fibula Free Flap

Total Surface Area of a Through-and-Through Oromandibular Defect Is Associated With Thromboembolic Events for Reconstruction With a Single Fibula Free Flap

CAD-CAM planned double free flap reconstruction of the paediatric mandible after Ewing sarcoma resection

Double osseous flaps for simultaneous midfacial and mandible reconstruction: Automation in surgical complexity within an entirely computerized workflow

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