Examples of flaps include the forearm radial and ul nar, latissimus dorsi, and rectus abdominis 6. Impervious drape under the leg may use sandbags for positioning. Pdf stepbystep mandibular reconstruction with free fibula. The fibular free flap is especially suited for mandibular reconstruction. Indian dental academy leader in continuing dental education 2. It is one of the common ways of replacing bone that has been removed for cancer treatment. Both lower extremities must be evaluated to determine the presence or extent of any disease and to ascertain the pulse status of the patient. Its use in mandibular reconstruction was first described in 1989, by hidalgo, with fibular reconstruction now being the criterion standard for the reconstruction of mandibular and maxillary bony defects. It affects more the mandible than the maxilla, and has a predilection for the posterior region. Following a group teaching session, all healthcare providers provided input to create a flap monitoring chart. Mandibulectomy and free flap reconstruction a mandibulectomy is a surgery to remove all or part of your jaw mandible. Fibula osteocutaneous flap for mandible reconstruction after ameloblastoma resection 41 septal branch can be challenging. Vascularised free fibula flap fff technique in head and neck. Although fibula free flap reconstruction allows for immediate bony reconstruction, the process of dental rehabilitation can be very lengthy.
The free fibula flap was the preferred graft for oromandibular reconstruction because of its rich blood supply and the consistency in the size of the fibula bone and stability. Microvascular freeflap transfer for head and neck reconstruction in. Treatment of a mandibular discontinuity defect by using a. The study reports five consecutive patients with benign or malignant disease requiring. Proper preoperative planning and calculation is needed to ensure adequate fibula length without compromising ankle stability as well as a. The fibula free flap seems to be the best free flap to apply in this type of reconstruction, partial maxillectomy, in particular, can benefit from reconstruction with the double barrelled fibula.
Free flap transfer to preserve main arterial flow in early. The results of this metaanalysis confirm that there is no significant difference in total flap loss between fibula and iliacfree flap reconstruction of mandibular defects. You will have a breathing tube and will be on a ventilator for 24 48 hours. Acceptable dental rehabilitation was almost nonexistent. Alternative techniques for pedicle transfer of an island flap. Stepbystep mandibular reconstruction with free fibula.
Our experience suggests that mandibulectomy and free flap reconstruction is an effective treatment for patients with stage 3 and recalcitrant stage 2 disease. Fibula free flap the leg is the donor site that is most often used for jaw reconstructions. This study indicates that freeflap technique for head and neck reconstruction could be considered a safe option in elderly patients when a. Its use in mandibular reconstruction was first described in 1989, by hidalgo, with fibular reconstruction now being the criterion standard for the reconstruction of mandibular and. Sep 19, 2018 the fibula free flap was introduced in the mid1970s for the reconstruction of tibial defects. Oct 29, 20 micro vascular free flaps used in head and neck reconstruction certified fixed orthodontic courses by indian dental academy 1. An original technique used, in this series, to harvest the monitor skin paddle of the free radial forearm flap is described. Distally based sural fasciocutaneous flap was used for coverage in all cases and its survival, successful coverage of the defect and donor site morbidity studied.
This article explores the general complications, including free flap failure, carotid. Case example anterior mandibular reconstruction with. Reconstruction of oncological oromandibular defects with. During this entire protocol, your leg should not bear any of your body weight. Donor site morbidity of the fibula free flap has been evaluated in a large series of orthopedic patients. In conclusion, mandibular reconstruction using a free fibula flap can achieve good functional and cosmetic outcomes. Wang et al 41 studied a comparison of virtual planning surgery and conventional surgery for mandibular reconstruction with a vascularized fibular free flap and found that virtual surgical planning produced a more accurate mandibular reconstruction than conventional surgery. Fibula free flap in mandibular reconstruction request pdf. Autologous breast reconstruction means reconstruction using tissue skin, fat and sometimes muscle from another place on the body. The skin of the arm is pinched to judge the maximum with of the flap is a large paddle is needed. The fibula free flap has been considered the treatment of choice for patients with mandibular discontinuity defects to correct both functional difficulties and esthetic impairments. Tracheotomy, lip split, segmental mandibulectomy, bilateral neck dissection, fibular free flap, split thickness skin graft. Osteocutaneous free flaps for mandibular reconstruction. Radial forearm free flap this leaflet has been designed to improve your understanding of your forthcoming treatment and contains answers to many of the common questions.
The plastic surgery term for a piece of tissue like this is a flap. The patient can touchdown their body weight as tolerated. Download as an information leaflet pdf fibular free flap. Defect of the floor of the mouth was filled using a pectoralis major muscle myocutaneous flap and lower lip reconstruction was achieved with a deltopectoral fasciocutaneous flap. When the dorsalis pedis artery andor posterior tibial artery cannot be palpated, we utilize computed tomography angiography to verify the site of vascular injury prior to performing free flap transfer. Stepbystep mandibular reconstruction with free fibula flap.
Adequate mandibular angle shape is achieved by performing this type of osteotomy with a minimal use of titanium hardware for flap insetting. They lost blood flow two days later and tried to salvage the flap. Reconstruction of five similar nasal defects using different flaps elbert h. The radial forearm free flap is a viable reconstructive option for tongue defects. The free flap technique represented a revolution in reconstructive surgery as it enabled the harvesting of a large amount of revascularized tissue, and it could be. Surgical anatomy of the medial sural artery perforator flap. The role of free fibula flap in the reconstruction of a mandibular ameloblastoma.
Anatomical studies and clinical experience mtm rebot bsc md frcsc, mf stranc frcsc frcseng facs, bm abdulrauf mb chb queensway general hospital, etobicoke, ontario and section of plastic surgery, university of manitoba, winnipeg, manitoba the vasculature of the forearm allows for the. Even though each step in modelling the flap is important, fibula preplating and templating should be considered to be crucial steps for facilitating the procedure and guaranteeing a satisfactory result. The microvascular technique of free flap and its artery. Radial free forearm flap rfff surgical technique vula. The flap can be quite long however, from the deltoid insertion to.
After four years of tumorfree followup we decided secondary mandible reconstruction using the free osteofasciocutaneous fibula flap. The microvascular fibula free flap, popularized by hidalgo, 1 has been one of the greatest advances in reconstruction of the maxillofacial region. The feet are examined for signs of peripheral vascular disease and the anterior and posterior tibial pulses are palpated. At present, mandibular reconstruction with a fibular free flap is the gold standard for functional and esthetic rehabilitation after oncological surgery. Alternative techniques for pedicle transfer of an island flap and a free flap. For vascular anastomosis, we fundamentally perform endtoside anastomosis or. Importance bisphosphonaterelated osteonecrosis of the jaws is an increasingly recognized complication of intravenous and oral bisphosphonate therapy. It is a vascularised free composite flap containing bone. Surgery went well, except that his arteries were severely damaged from radiation, and the surgeons had difficulty getting good blood flow to the flap.
A splint should be placed to keep the foot flexed when in bed. Microvascular free tissue transfer allows one to transfer wellvascularised, bone containing flaps for oromandibular and midface reconstruction. Micro vascular free flaps used in head and neck reconstruction certified fixed orthodontic courses by indian dental academy 1. The ameloblastoma is a rare odontogenic tumor of the oral cavity. Can j plast surg vol no 2 summer 2005 77 alternative techniques for pedicle transfer of an island flap and a free flap dale a classen md frcsc division of plastic surgery, department of surgery, university of saskatchewan, royal university hospital, saskatoon, saskatchewan. Fibula free flap is now the attitude of choice for most authors,,, but other flaps iliac crest, scapula still have a role to play in selected cases. The patient did not complain about the appearance and function of the left forearm. Ulnar artery free flap and the need for concern in its use. Surgical anatomy of the medial sural artery perforator flap wong et al. Micro vascular free flaps used in head and neck reconstruction. We created and delivered a teaching session to junior nursing staff with regard the basic principles of flaps and their postoperative care and generated a universal postoperative flap monitoring protocol to help improve and standardize care provision.
Free radial forearm flap after partial glossectomy for squamous cell carcinoma of the tongue chuah uc,kamarul t,sara t department of orthopaedic surgery,university of malaya medical centre,50603 kuala lumpur,malaysia abstract. Usually, four to five centimeters are the widest a flap can be. The fibula osteocutaneous flap in head and neck reconstruction. If your jaw is being rebuilt using bone from a different donor site or if bone will not be used in your reconstruction, your plastic surgeon will discuss this with you. The flap can be quite long however, from the deltoid insertion to distal to the lateral epicondyle. If the blood supply to the flap remains attached, it. Osteocutaneous fibula free flap iowa head and neck protocols. Pdf stepbystep mandibular reconstruction with free.
The free fibula flap allows skin palette to be obtained that is up to 25 cm long and 5 cm wide. The indications for free microvascular tissue transfer were traumatic injury in 49% n81, tumour. This fibula free flap fff has recently become a more and more popular. Standard prep, 10% providone iodine circumferential to leg, from foot to groin drape prep the head and neck separately from the leg. The fibula is a small, thin bone that runs along the outer part of the lower leg from the knee to the ankle. Conformation of the fibula flap to passively adapt to the remaining mandible may be indeed challenging. Lower legfoot free flap protocol in order to allow for proper healing and to prevent excess swelling following your leg surgery, you must follow a progressive leg dangle protocol before you can return to having your leg down and on the ground. Microvascular fibula free flap for mandibular reconstruction in a patient with bilateral knee replacements. Osteomyocutaneous fibula free flap failure complete 12,4%. The purposes of this study were to 1 compare the complications and functional outcome of primary closure vs splitthickness skin grafting of the fibula osteocutaneous flap donor site, 2 identify patientmix and treatment factors that may be related to the development of donor site complications, and 3 address early detection and. Mandibulectomy and freeflap reconstruction a mandibulectomy is a surgery to remove all or part of your jaw mandible. The role of free fibula flap in the mandibular reconstruction. If you have any other questions that the leaflet does not answer or would like further explanation please ask your surgeon. Abdominal pedicle flaps to the hand and forearm globalhelp publications.
Anterior mandibular reconstruction prep and drape osteocutaneous fibula free flap general considerations. The role of free fibula flap in the reconstruction of a. Anesthesia and surgical microvascular flaps scielo. Fibula osteocutaneous flap for mandible reconstructionafter. The purpose of this study was to describe the computerassisted mandibular reconstruction procedure adopting the customized solution synthes proplan cmf. Partial flap loss was found in 2 patients 8%, marginal flap necrosis in 2 patients 8% and complete loss in 1 patient 4%. The patient is placed in the supine position with a bump under the ipsilateral hip to lessen the need for excessive internal rotation of the lower leg. The fibula free flap was introduced in the mid1970s for the reconstruction of tibial defects. Free fibula flap in the reconstruction of mandible.
Patients will be in the icu for 24 days and are usually sedated asleep for 2448 hours. A mandibulectomy is a surgery to remove all or part of your jaw mandible. It has since become a workhorse for soft tissue replacement in head. According to us, fibula free flap satisfies many of these requirements and is the flap of choice in most cases of difficult mandibular reconstruction. Instructional video about submental flap for cheek reconstruction in noma case, noma, facing africa, surgery, incision, guideline, plastic surgery, flap, dis. Nursing monitoring and management of free and pedicled.
The selection of recipient vessels is crucial when reconstructing traumatized lower extremities using a free flap. Alternative techniques for pedicle transfer of a reverse radial forearm flap for hand coverage, and a latissimus dorsi myocutaneous free flap for pelvic wound coverage, are illustrated. Reconstruction of oncological oromandibular defects with double skin paddledfree fibula flap. Your jaw may be rebuilt using bone from another part of your body the donor site. The bone may be taken from your fibula, which is the smaller of. With the introduction of free flaps as a consequence of the development of the operating microscope, the field of reconstruction was revolutionized. Conclusion although the fibula free flap is the flap of choice, the iliac crest is an. Indications for pedicle flap coverage local flaps are preferable to distant flaps but are limited for use by area requirements, rotation limitations, and blood supply which may be. Reconstruction of oral cavity defects must maximize residual function of remaining tissue.
The fibula free flap for postresective reconstruction of the mandible. Alternative techniques for pedicle transfer of an island. Christopher le, arnaud bewley, d gregory farwell and quang luu department of head and neck surgery, university of california, usa. In terms of recipient site complication, there was a significantly higher risk of delayed healing and suture line breakdown in the iliac flap group p 0. The lateral arm flap is designed with its longitudinal axis on this marking. The results of this metaanalysis confirm that there is no significant difference in total flap loss between fibula and iliac free flap reconstruction of mandibular defects. The radial free forearm flap rfff was one of the first free tissue transfer flaps to be described.
Nursing monitoring and management of free and pedicled flaps. Proper preoperative planning and calculation is needed to ensure adequate fibula length without compromising ankle stability as well as a properly seated skin flap for mouth floor reconstruction. We concluded that fibular osteocutaneous free flap can be performed safely in patients with osteoradionecrosis and yields positive outcomes with significantly increased success rate. Reconstruction of a defect interrupting the mandible can use osteosynthesis plates, bone graft or pediculated or free flap. External monitor for buried free flaps in head and neck reconstructions. It has since become a work horse for soft tissue replacement in. Surgical technique ottie van zyl the radial free forearm flap rfff was one of the first free tissue transfer flaps to be described. A fibular free flap is one way of filling a bony hole in either the upper or lower jaw.
After the cast is removed they can ambulate and work with physical therapy to optimize leg function. However, oral deglutition was statistically significantly better in the fibula free flap group p 0. May 10, 2014 at present, mandibular reconstruction with a fibular free flap is the gold standard for functional and esthetic rehabilitation after oncological surgery. About your mandibulectomy and fibula free flap reconstruction. A prudent alternative to double flaps in resourceconstrained centres prabha s yadav, quazi g ahmad, vinay k shankhdhar, gi nambi plastic and reconstructive services, tata memorial hospital, mumbai, india. Stepbystep surgical technique for mandibular reconstruction. Departments of dermatology, otorhinolaryngology, and surgery, university of michigan medical. Aug 09, 2012 in conclusion, mandibular reconstruction using a free fibula flap can achieve good functional and cosmetic outcomes. There was also a fairly regular crop of complications. Anatomical studies and clinical experience mtm rebot bsc md frcsc, mf stranc frcsc frcseng facs, bm abdulrauf mb chb queensway general hospital, etobicoke, ontario and section of plastic surgery, university of. Foot web free flaps for singlestage reconstruction of. It is important because if the flap is not the exact same size and shape, there may be some oblique traction applied to the flap which may impede the arterial supply and venous return to the thinned abdominal pedicle flap. Fibula free flap after a fibula free flap, the donor lower leg should be cast with the ankle slightly dorsiflexed for 5 days. Indications the fibula flap has been used extensively for oromandibular reconstruction.
The fibular osteocutaneous free flap was our preferred choice for the mandibular reconstruction due to its versatility and predictability. Fibular free flap how is fibular free flap abbreviated. Squamous cell carcinoma of the tongue is a highly malignant condition. A fibular free flap is surgery that removes the fibula and uses it to reconstruct bone in the upper or lower jaw that has been damaged or removed due to cancer. Of all the flaps currently known, the fibula has become the technique of choice 1, 2. Mandible reconstruction using the free osteocutaneous. Alternatively, the lateral decubitus position can be used, with the harvest leg placed up and the patient held in position with a beanbag. Reconstruction with fibular osteocutaneous free flap in. You may have a mandibulectomy if you have a tumor involving your jaw. Two teams, one of maxillofacial surgery and another one for vascular surgery, collaborated to perform a hemimandibulectomy with a free fibula flap graft. It is very important that the donor flap be of the exact same size as the defect to be covered on the dorsum of the hand. Complications of head and neck reconstruction and their treatment.
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