Preoperative Vascular Interventions to Improve Donor Leg Perfusion: A Report of Two Fibula Free Flaps Used in Head and Neck Reconstruction

Kim, Roderick Y.; Burkes, Jason N.; Broker, Harshal; Williams, Fayette C.

doi:10.1016/j.joms.2018.10.017

Cited by 5 publications

(4 citation statements)

References 15 publications

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“…Despite vascular calcifications impacting the flap vascular pedicle, successful microvascular FFF has been described, with a 0 % complete flap failure rate and a 7 % partial flap failure rate ( 87 ). Preoperative optimizing of leg perfusion by endovascular interventions has also been reported as a therapeutic option in possible critical limb perfusion ( 88 ).…”

Section: Discussionmentioning

confidence: 99%

Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning

et al. 2022

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BackgroundVirtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success.MethodThis retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply.ResultA total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs’ vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP.ConclusionIn general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome.

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Section: Discussionmentioning

confidence: 99%

Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning

et al. 2022

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“…Alternative reconstructions should be considered in the presence of PAD, borderline PAD, symptomatic claudication or severe atherosclerosis at or distal to the branchpoint of the ipsilateral popliteal artery. Kim et al [33] reported two patients with severe lower extremity PAD who underwent preoperative multivessel endovascular intervention on the donor leg prior to successful mandibular reconstruction with FFF, suggesting the ability to 'rescue' the FFF site in the presence of otherwise prohibitive PAD.…”

Section: Fibula Free Flap: the 'Gold Standard' And Its Limitationsmentioning

confidence: 99%

“…However, head and neck cancer patients frequently have multiple, potentially severe comorbidities complicating the use of FFF, including severe peripheral arterial disease (PAD), difficulty with ambulation, chronic anticoagulation or coagulopathic disorders, mandibular ORN or osteomyelitis, diabetes, chronic smoking [32], and/or severely vessel-limited necks. Poor FFF candidacy commonly results from insufficient lower extremity vascularity, often detected by computed tomography arteriogram (CTA) showing dominant peroneal artery or inadequate three-vessel runoff due to terminal atherosclerosis [33]. Alternatively, obtaining the ankle-brachial index (ABI) of the proposed limb may be helpful to evaluate PAD if three-vessel run-off or doppler evaluation is equivocal (ABI > 1 = no obstruction, ABI 0.91–0.99 = borderline PAD and ABI 0.9 or less = PAD) [34].…”

Section: Introductionmentioning

confidence: 99%

Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty

Rubin

Sayre

Kovatch

et al. 2021

Current Opinion in Otolaryngology &Amp; Head &Amp; Neck Surgery

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Purpose of review Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF). Recent findings Although FFF is the current ‘gold standard’ for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes. Summary There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.

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“…Efforts to elucidate relationships between blood flow and functional ability after atraumatic amputation continue. 2,[9][10][11] Below-knee vessel run-off (VRO) is often considered a surrogate of limb perfusion but has limited clinical reliability. For example, for below-knee amputation (BKA) closure, while the soleus flap relies on segmental perfusion from the posterior tibial and peroneal arteries, the conventional posterior gastrocnemius muscle flap relies on the medial and lateral sural arteries.…”

Section: Introductionmentioning

confidence: 99%

Popliteal artery patency is an indicator of ambulation and healing after below-knee amputation in vasculopaths

et al. 2021

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Background The posterior flap is a conventional technique for closing a below-knee amputation (BKA) that uses the gastrocnemius and soleus muscle and relies on the popliteal and posterior compartment arteries. If the prior mentioned arterial blood supply is compromised, this flap likely relies on collateral flow. The purpose of this study is to identify and differentiate any significant associations between preoperative popliteal and tibial arterial flow and BKA outcomes and patient-reported function. Methods A retrospective review identified patients from a single tertiary wound care center who received BKAs and angiogram between 2010 and 2017 by a single surgeon. BKA complications, wound healing, and amputee ambulatory status at latest follow-up were all stratified for differences according to baseline tibial vessel run-off (VRO) status, popliteal artery patency, and popliteal angioplasty outcome. Chi-square, Fisher’s exact, and Wilcoxon rank sum tests were used with significance defined as p ≤ 0.05 . Results BKAs were performed on 313 patients, of which, 167 underwent preoperative angiography. Thirty-two were excluded due to lack of adequate follow-up leaving a total of 135 patients in the studied population. Diabetes was present in 87%, and 36% had end-stage renal disease. By the study’s conclusion, 92% of BKAs had fully healed, with median time-to-healing of 79 days (range 19–1314 days). 60% of patients were ambulatory at 9.5 months. Higher VRO was associated with higher healing rates and lower complications and time-to-healing. The conversion rate of BKA to above-knee amputation (AKA) was 4%. Preoperative popliteal patency was associated with higher postoperative ambulation rates when compared to patients without popliteal flow preoperatively (patent: 71/109, 65%; occluded: 10/26, 40%; p = 0.02) and independently increased the likelihood of postoperative ambulation. Conclusions The posterior flap design for BKA works even in the setting of popliteal occlusion. Complication rates are higher in patients with more compromised blood flow, which may ultimately lead to AKA. Given poor ambulation rates in patients who undergo AKA, the results of this study should encourage surgeons to consider a more functional BKA, even in instances when the popliteal artery is occluded.

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Preoperative Vascular Interventions to Improve Donor Leg Perfusion: A Report of Two Fibula Free Flaps Used in Head and Neck Reconstruction

Cited by 5 publications

References 15 publications

Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning

Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning

Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty

Popliteal artery patency is an indicator of ambulation and healing after below-knee amputation in vasculopaths

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