The Evolution of the Free Fibula Flap for Head and Neck Reconstruction: 21 Years of Experience with 128 Flaps.

BACKGROUND: The free fibula flap is commonly referred to as a "workhorse" for head and neck reconstruction. During our 21-year experience with this flap, we have performed several changes in preoperative planning, operative technique, and postoperative follow-up. PATIENTS AND METHODS: A retrospective cohort study designed to analyze the cohort of patients who underwent free fibula transfer for head and neck reconstruction. Demographics, medical background, operative data, and postoperative outcome were collected. The changes we performed in preoperative planning, operative technique, and postoperative follow-up were assessed and their impact on outcome discussed. RESULTS: During 1998 to 2019 a total of 128 free fibula flaps were transferred for head and neck reconstruction. When comparing the patients treated in the early years to those who were treated in recent years we found no statistically significant difference in minor or major nonmicrosurgical complications in the recipient and donor site and in the rate of take backs due to microsurgical reasons. However total flap failure rate improved from 28% in early years to 8% in recent years (p = 0.012). CONCLUSION: During this 21-year period, we performed several changes in our practice. This included the use of a three-dimensional (3D) prefabricated model of the mandible, a shift toward side-table osteotomies, increasing the rate of osteofascial flaps in contrast to osteocutaneous flaps and the use of an implantable Doppler. These changes, together with a learning curve of the surgical team, significantly improved our overall success rates.

The "Origami" Composite Free Fibula Flap for Complex Defects of the Mandible, Floor of the Mouth, and Tongue.

PURPOSE: The fibula flap serves as the workhorse for many mandibular defect types. For massive defects that include the mandible, floor of the mouth, and tongue, reconstruction might mandate a 2-flap approach. This report describes a systematic yet flexible design of a single composite osseocutaneous fibula flap for such cases. PATIENTS AND METHODS: From 2003 through 2011, 5 patients underwent surgery for T4 squamous cell carcinoma and adenoid cystic carcinoma. They underwent wide resection of the mandible and floor of the mouth with hemi- to subtotal glossectomy. A large skin paddle was designed on the leg using a customized template consisting of 3 components matching the alveolar, floor-of-mouth, and tongue segments. The round tongue component was folded using its thickness to provide 3-dimensional volume and form in place of the missing tongue. The other 2 components had a crescent shape and were adjusted intraoperatively to match the resected defect. RESULTS: All 5 flaps survived, with 1 case of flap loss that was successfully replaced. Delayed healing of the leg donor site was encountered in 4 patients. CONCLUSION: The proposed single 3-dimensionally folded flap design provides ample tissue to replace bony and soft tissue elements for major anterior or lateral segment defects. There was morbidity owing to donor-site complications but these were treatable, with recorded functional restoration.

V-stand--a versatile surgical platform for oromandibular reconstruction using a 3-dimensional virtual modeling system.

PURPOSE: The challenge of oromandibular reconstruction (OMR) after oncologic resections has been repeatedly addressed in the literature. Although final oncologic margins can be decided only during surgery, various attempts have been made to create an ideal and accurate platform for OMR. The purpose of this article is to present the V-stand, a versatile surgical platform for OMR using a 3-dimensional (3D) virtual modeling system. MATERIALS AND METHODS: Seventeen patients requiring an OMR were included in the study. A presurgical computed tomogram was obtained and virtual resection and reconstruction with a free fibular flap were planned using 3D virtual surgery software. The mandible was reconstructed intraoperatively using the V-stand, which served as a template for the lower border of the mandible and the lateral aspects of the stand were fixed to the proximal mandibular segments using 2-mm titanium screws. RESULTS: Patients' average age was 53 years (5 to 72 yr). Median follow-up was 19 months (2 to 35 months). All reconstructed mandibles resulted in good function and esthetics. CONCLUSIONS: The V-stand offers a safe and time-efficient method for OMR. It provides an excellent means for accurate spatial positioning of a fibular free flap. The V-stand preserves the original dimensions of the reconstructed mandible and can overcome surgical ablation modifications because it is not dependent on the precision of the resection, but rather provides a mold for the entire mandible.

[TURNOVER CAPSULAR FLAPS FOR THE TREATMENT OF IMPENDING EXTRUSION OF SILICONE PROSTHESIS IN RECONSTRUCTED BREASTS].

Pressure necrosis which might be followed by skin necrosis and implant extrusion is a dreaded complication of breast reconstructive surgery. Over the years, several techniques have been introduced to address this challenging problem. We offer a novel surgical technique to confront this perplexing complication. By using the capsule of the implant as a turnover flap, the soft tissue coverage is enhanced thereby decreasing the pressure between the breast prosthesis and the over-laying skin. The technique is simply reproduced, requires no new incisions, and avoids further morbidity to the involved breast reconstructed patient.