Download PDF
J Reconstr Microsurg
DOI: 10.1055/a-2555-2169
Original Article

Risk Factors for Flap Loss in Midface Reconstruction with Vascularized Fibular Flap

Katsuhiro Ishida 
1   Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
,
Yohjiro Makino
1   Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
,
Keita Kishi
1   Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
,
Hiroki Kodama
1   Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
,
Haruyuki Hirayama
1   Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
,
Doruk Orgun
1   Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
,
Masaki Nukami
1   Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
,
Taisuke Akutsu
2   Department of Otolaryngology, Head and Neck Surgery, Jikei University School of Medicine, Tokyo, Japan
,
Takeshi Miyawaki
1   Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background

Midface reconstruction should address both functional and cosmetic aspects. The vascularized fibular osteomyocutaneous flap (VFOF) is a promising first choice because of its numerous advantages in this type of reconstruction.

Methods

This study aimed to investigate the causes of VFOF failure during midface reconstruction. We retrospectively reviewed patients who underwent midface defect reconstruction using VFOF from August 2011 to May 2022 at a single center. The primary outcome variable was VFOF loss within 30 days, and secondary outcomes included late complications related to VFOF occurring at least 6 months postoperatively.

Results

A total of 62 patients underwent VFOF reconstruction for midface defects. The VFOF technique was primarily used in 56 (90.3%) patients for initial reconstruction. according to the Brown and Shaw classification, most reconstructions were performed for Class III (77.4%) and Class b (83.6%) defects. Skin paddles of the VFOF were used in 51 (82.3%) patients, and a double flap technique utilizing the fibular was employed in 24 (38.7%) patients. VFOF failure occurred in 10 (16.1%) patients. Prognostic factors associated with VFOF failure included sex (p = 0.01) and maxillary Brown and Shaw classification (horizontal; p = 0.01). Long-term follow-up of 47 patients revealed late complications in 11 (23.4%) patients, and diabetes mellitus was identified as a significant risk factor (p < 0.01).

Conclusion

The VFOF is suitable for midface defect reconstruction; however, proper placement of the fibular bone, avoiding pedicle vessel kinking, ensuring tension-free vascular anastomosis during surgery, considering the use of an additional flap in addition to the fibula flap for large defects, and diligent postoperative nasal care are essential.

Keywords

fibular flap - maxillectomy - midface defect

Registry Information

Registry name: A retrospective study of early and late complications of fibula flap reconstruction after midface defects; registration identification number: UMIN000054486; and registry URL: https://center6.umin.ac.jp/cgi-bin/ctr/ctr_view_reg.cgi?recptno=R000062238.


Ethical Approval

This study was conducted in accordance with the Declaration of Helsinki and was approved by the independent ethics committee and institutional review board of our university (IRB number 35-251 [118800]). All authors have read and agreed to the submitted version of the manuscript.




Publication History

Received: 02 October 2024

Accepted: 19 February 2025

Accepted Manuscript online:
11 March 2025

Article published online:
27 March 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Cordeiro PG, Chen CM. A 15-year review of midface reconstruction after total and subtotal maxillectomy: part I. Algorithm and outcomes. Plast Reconstr Surg 2012; 129 (01) 124-136
    CrossrefPubMedSearch in Google Scholar
  • 2 Chan TG, Nickel C, Solares C. et al. Stacked fibula flap for unilateral total maxillectomy reconstruction with orbital preservation. Head Neck 2024; 46 (01) 218-227
    CrossrefPubMedSearch in Google Scholar
  • 3 Shipchandler TZ, Waters HH, Knott PD, Fritz MA. Orbitomaxillary reconstruction using the layered fibula osteocutaneous flap. Arch Facial Plast Surg 2012; 14 (02) 110-115
    CrossrefPubMedSearch in Google Scholar
  • 4 Bini A, Derka S, Stavrianos S. Midface microvascular reconstruction after maxillary complex tumor resection: A retrospective study. J Craniomaxillofac Surg 2024; 52 (07) 803-808
    CrossrefPubMedSearch in Google Scholar
  • 5 Peng X, Mao C, Yu GY, Guo CB, Huang MX, Zhang Y. Maxillary reconstruction with the free fibula flap. Plast Reconstr Surg 2005; 115 (06) 1562-1569
    CrossrefPubMedSearch in Google Scholar
  • 6 Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol 2010; 11 (10) 1001-1008
    CrossrefPubMedSearch in Google Scholar
  • 7 Vass G, Bella Z, Tóbiás Z, Nagy A, Iván L, Rovó L. Esthetically favorable surgical alternative for the removal of sinonasal malignant tumors-the modified facial degloving technique. J Oral Maxillofac Surg 2017; 75 (10) 2272.e1-2272.e10
    CrossrefPubMedSearch in Google Scholar
  • 8 Amin MB, Greene FL, Edge SB. et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. CA Cancer J Clin 2017; 67 (02) 93-99
    CrossrefPubMedSearch in Google Scholar
  • 9 Futran ND, Wadsworth JT, Villaret D, Farwell DG. Midface reconstruction with the fibula free flap. Arch Otolaryngol Head Neck Surg 2002; 128 (02) 161-166
    CrossrefPubMedSearch in Google Scholar
  • 10 Nguyen S, Tran KL, Wang E, Britton H, Durham JS, Prisman E. Maxillectomy defects: Virtually comparing fibular and scapular free flap reconstructions. Head Neck 2021; 43 (09) 2623-2633
    CrossrefPubMedSearch in Google Scholar
  • 11 Yu P, Chang DW, Miller MJ, Reece G, Robb GL. Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head Neck 2009; 31 (01) 45-51
    CrossrefPubMedSearch in Google Scholar
  • 12 Stevens MN, Freeman MH, Shinn JR. et al. Preoperative predictors of free flap failure. Otolaryngol Head Neck Surg 2023; 168 (02) 180-187
    CrossrefPubMedSearch in Google Scholar
  • 13 Chang EI, Zhang H, Liu J, Yu P, Skoracki RJ, Hanasono MM. Analysis of risk factors for flap loss and salvage in free flap head and neck reconstruction. Head Neck 2016; 38 (Suppl. 01) E771-E775
    CrossrefPubMedSearch in Google Scholar
  • 14 Verhelst PJ, Dons F, Van Bever PJ, Schoenaers J, Nanhekhan L, Politis C. Fibula free flap in head and neck reconstruction: Identifying risk factors for flap failure and analysis of postoperative complications in a low volume setting. Craniomaxillofac Trauma Reconstr 2019; 12 (03) 183-192
    CrossrefPubMedSearch in Google Scholar
  • 15 Garfein E, Doscher M, Tepper O, Gill J, Gorlick R, Smith RV. Reconstruction of the pediatric midface following oncologic resection. J Reconstr Microsurg 2015; 31 (05) 336-342
    Thieme ConnectPubMedSearch in Google Scholar
  • 16 Pellegrino G, Tarsitano A, Ferri A, Corinaldesi G, Bianchi A, Marchetti C. Long-term results of osseointegrated implant-based dental rehabilitation in oncology patients reconstructed with a fibula free flap. Clin Implant Dent Relat Res 2018; 20 (05) 852-859
    CrossrefPubMedSearch in Google Scholar
  • 17 Urken ML, Roche AM, Kiplagat KJ. et al. Comprehensive approach to functional palatomaxillary reconstruction using regional and free tissue transfer: Report of reconstructive and prosthodontic outcomes of 140 patients. Head Neck 2018; 40 (08) 1639-1666
    CrossrefPubMedSearch in Google Scholar
  • 18 Moon JH, Kim EH, Kim SH. Various modifications of a vascularized nasoseptal flap for repair of extensive skull base dural defects. J Neurosurg 2019; 132 (02) 371-379
    CrossrefPubMedSearch in Google Scholar
  • 19 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 20 Li CQ, Xie S, LiuFu JF. et al. Retrospective study of the deep circumflex iliac artery flap and the vascularized fibula free flap for maxillary defect repair. Oral Oncol 2024; 154: 106860
    CrossrefPubMedSearch in Google Scholar
  • 21 Vranckx JJ, Desmet O, Bila M, Wittesaele W, Wilssens N, Poorten VV. Maxillomandibular reconstruction using insourced virtual surgical planning and homemade CAD/CAM: A single-center evolution in 75 patients. Plast Reconstr Surg 2023; 152 (01) 143e-154e
    PubMedSearch in Google Scholar