The Evolution of the Free Fibula Flap for Head and Neck Reconstruction: 21 Years of Experience with 128 FlapsFunding None.
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.
Keywordsmicrosurgery - head and neck - free fibula flap - mandibular reconstruction - maxillary reconstruction
This study was presented at annual American Society of Reconstructive Surgery (ASRM) meeting, January 13, 2020.
All authors have contributed to the study design, drafting and reviewing of the manuscript and have approved it submission.
Received: 09 May 2020
Accepted: 18 August 2020
30 September 2020 (online)
© 2020. Thieme. All rights reserved.
Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.
- 1 Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989; 84 (01) 71-79
- 2 Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients. Plast Reconstr Surg 1999; 104 (05) 1314-1320
- 3 Hidalgo DA. Aesthetic improvements in free-flap mandible reconstruction. Plast Reconstr Surg 1991; 88 (04) 574-585 , discussion 586–587
- 4 Mitchell SL, Seth AK, Matros E, Cordeiro PG. Maxillary reconstruction using a gullwing fibula osteofascial flap and flexor hallucis longus muscle. Plast Reconstr Surg Glob Open 2018; 6 (06) e1821
- 5 Smith ML, Clarke-Pearson E, Dayan JH. Fibula osteo-adipofascial flap for mandibular and maxillary reconstruction. Head Neck 2012; 34 (10) 1389-1394
- 6 Brinkman JN, Kambiz S, de Jong T, Mureau MAM. Long-term outcomes after double free flap reconstruction for locally advanced head and neck cancer. J Reconstr Microsurg 2019; 35 (01) 66-73
- 7 Chang EI, Jenkins MP, Patel SA, Topham NS. Long-term operative outcomes of preoperative computed tomography-guided virtual surgical planning for osteocutaneous free flap mandible reconstruction. Plast Reconstr Surg 2016; 137 (02) 619-623
- 8 Sugiura Y, Sarukawa S, Hayasaka J, Kamochi H, Noguchi T, Mori Y. Mandibular reconstruction with free fibula flaps in the elderly: a retrospective evaluation. Int J Oral Maxillofac Surg 2018; 47 (08) 983-989
- 9 Baron S, Salvan D, Cloutier L, Gharzouli I, Le Clerc N. Fibula free flap in the treatment of mandibular osteoradionecrosis. Eur Ann Otorhinolaryngol Head Neck Dis 2016; 133 (01) 7-11
- 10 Shpitzer T, Neligan PC, Gullane PJ. et al. Oromandibular reconstruction with the fibular free flap. Analysis of 50 consecutive flaps. Arch Otolaryngol Head Neck Surg 1997; 123 (09) 939-944
- 11 Inbal A, Gur E, Zaretski A, Barnea Y, Khafif A, Amir A. The “origami” composite free fibula flap for complex defects of the mandible, floor of the mouth, and tongue. J Oral Maxillofac Surg 2015; 73 (08) 1617-1626
- 12 Horowitz G, Warshavsky A, Fridman O. et al. Balsa wood for precise intra-operative bone contouring in fibula free-flap mandible reconstruction. Eur Arch Otorhinolaryngol 2019; 276 (08) 2339-2343
- 13 Barr ML, Haveles CS, Rezzadeh KS. et al. Virtual surgical planning for mandibular reconstruction with the fibula free flap: a systematic review and meta-analysis. Ann Plast Surg 2020; 84 (01) 117-122
- 14 Powcharoen W, Yang WF, Yan Li K, Zhu W, Su YX. Computer-assisted versus conventional freehand mandibular reconstruction with fibula free flap: a systematic review and meta-analysis. Plast Reconstr Surg 2019; 144 (06) 1417-1428
- 15 Momoh AO, Yu P, Skoracki RJ, Liu S, Feng L, Hanasono MM. A prospective cohort study of fibula free flap donor-site morbidity in 157 consecutive patients. Plast Reconstr Surg 2011; 128 (03) 714-720
- 16 van Gemert JTM, Abbink JH, van Es RJJ, Rosenberg AJWP, Koole R, Van Cann EM. Early and late complications in the reconstructed mandible with free fibula flaps. J Surg Oncol 2018; 117 (04) 773-780
- 17 Parise GK, Guebur MI, Ramos GHA, Groth AK, da Silva ABD, Sassi LM. Evaluation of complications and flap losses in mandibular reconstruction with microvascularized fibula flap. Oral Maxillofac Surg 2018; 22 (03) 281-284
- 18 Wu CC, Lin PY, Chew KY, Kuo YR. Free tissue transfers in head and neck reconstruction: complications, outcomes and strategies for management of flap failure: analysis of 2019 flaps in single institute. Microsurgery 2014; 34 (05) 339-344
- 19 Petrovic I, Baser R, Blackwell T. et al. Long-term functional and esthetic outcomes after fibula free flap reconstruction of the mandible. Head Neck 2019; 41 (07) 2123-2132
- 20 Löfstrand J, Nyberg M, Karlsson T. et al. Quality of life after free fibula flap reconstruction of segmental mandibular defects. J Reconstr Microsurg 2018; 34 (02) 108-120
- 21 Fichter AM, Ritschl LM, Georg R. et al. Effect of segment length and number of osteotomy sites on cancellous bone perfusion in free fibula flaps. J Reconstr Microsurg 2019; 35 (02) 108-116
- 22 Alolabi N, Dickson L, Coroneos CJ, Farrokhyar F, Levis C. Preoperative angiography for free fibula flap harvest: a meta-analysis. J Reconstr Microsurg 2019; 35 (05) 362-371
- 23 Ling XF, Peng X. What is the price to pay for a free fibula flap? A systematic review of donor-site morbidity following free fibula flap surgery. Plast Reconstr Surg 2012; 129 (03) 657-674
- 24 Akashi M, Hashikawa K, Takasu H. et al. Comparison between primary closure and skin grafts of the free fibula osteocutaneous flap donor site. Oral Maxillofac Surg 2016; 20 (03) 233-237
- 25 Li P, Fang Q, Qi J, Luo R, Sun C. Risk factors for early and late donor-site morbidity after free fibula flap harvest. J Oral Maxillofac Surg 2015; 73 (08) 1637-1640
- 26 Wood CB, Shinn JR, Amin SN, Rohde SL, Sinard RJ. Risk of plate removal in free flap reconstruction of the mandible. Oral Oncol 2018; 83: 91-95
- 27 Fan S, Wang YY, Wu DH. et al. Intraoral lining with the fibular osteomyofascial flap without a skin paddle during maxillary and mandibular reconstruction. Head Neck 2016; 38 (Suppl. 01) E832-E836
- 28 Mohindra A, Parmar S, Praveen P, Martin T. The fat-fascia paddle only with a composite fibula flap: marked reduction in donor site morbidity. Int J Oral Maxillofac Surg 2016; 45 (08) 964-968
- 29 Toto JM, Chang EI, Agag R, Devarajan K, Patel SA, Topham NS. Improved operative efficiency of free fibula flap mandible reconstruction with patient-specific, computer-guided preoperative planning. Head Neck 2015; 37 (11) 1660-1664
- 30 Pang JH, Brooke S, Kubik MW. et al. Staged reconstruction (delayed-immediate) of the maxillectomy defect using CAD/CAM technology. J Reconstr Microsurg 2018; 34 (03) 193-199
- 31 Schmulder A, Gur E, Zaretski A. Eight-year experience of the Cook-Swartz Doppler in free-flap operations: microsurgical and reexploration results with regard to a wide spectrum of surgeries. Microsurgery 2011; 31 (01) 1-6