Sternal defect reconstruction using a double-barrel vascularized free fibula flap: a case report.
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ABSTRACT:
SUBMITTER: Gravina PR
PROVIDER: S-EPMC8490120 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Reconstructing a mangled limb is complex and requires expertise in both bone and soft-tissue reconstruction, particularly when there is significant muscle loss. Typically, multistage surgery is necessary, starting with soft-tissue coverage, followed by bone grafting and tendon transfers. Sometimes, microsurgical techniques such as vascularized bone grafts and free functional muscle transfers are necessary, especially when there is a bone defect of over 6 cm; the soft-tissue environment is infected, scarred, or poorly vascularized; or there are extensive musculotendinous injuries. We treated a 34-year-old man who had a crushed left forearm resulting in an 18 × 8 cm open wound, 5-cm radius and 7-cm ulna bone defects, loss of the extensor pollicis longus and brevis muscles, and extensive injuries to the other musculotendinous structures of the forearm. To accomplish a one-stage reconstruction, we used a chimeric fibula osteomyocutaneous flap that included a 20 × 10 cm skin flap, peroneus brevis muscle with its motor nerve, and two segments of fibula. The proximal and distal fibula segments were used for ulnar and radial bone reconstruction, respectively, preserving forearm supination and pronation. The peroneus brevis tendon was sutured to the extensor pollicis longus tendon, and its motor nerve was coaptated with the posterior interosseous nerve to restore thumb extension. The skin flap provided complete coverage of all exposed bone and tendon structures. At the 12-month follow-up, the patient regained full extension of the thumb, and there were no difficulties with forearm supination and pronation or with foot eversion and plantar flexion at the donor leg.
| S-EPMC10412423 | biostudies-literature
Project description:Several different methods exist for reconstructing the mandibular body and ramus defect with the use of a free vascularized fibula flap, but none have adequately addressed the long-term mechanical stability and osseointegration. The aim of this study is to compare the biomechanics of different surgical methods and to investigate the best approach for reconstructing the mandibular body and ramus defect. Five finite element models based on different reconstructive methods were simulated. Stress, strain, and displacement of connective bone sections were calculated for five models and compared. The models were printed using a 3D printer, and stiffness was measured using an electromechanical universal testing machine. The postoperative follow-up cone beam computed tomography (CBCT) was taken at different time points to analyze bone mineral density of connective bone sections. The results showed that the "double up" (DU) model was the most efficient for reconstructing a mandibular body and ramus defect by comparing the mechanical distribution of three sections under vertical and inclined loading conditions of 100?N. The stiffness detection showed that stiffness in the DU and "double down" (DD) models was higher compared with the "single up" (SU), "single down" (SD), and "distraction osteogenesis" (DO) models. We used the DU model for the surgery, and postoperative follow-up CBCT showed that bone mineral density of each fibular connective section increased gradually with time, plateauing at 12 weeks. We conclude that a free vascularized fibula flap of the DU type was the best approach for the reconstruction of the mandibular body and ramus defect. Preoperative finite element analysis and stiffness testing were shown to be very useful for maxillofacial reconstruction.
| S-EPMC7094202 | biostudies-literature
Project description:BackgroundExtensive through-and-through oromandibular defects after advanced oral carcinoma excision pose a reconstructive challenge for the head and neck surgeon. These complex oromandibular wounds often involve the mandible, oral and/or aerodigestive mucosa, and the external skin. As a result, these defects are often not amenable to reconstruction with a single flap due to the volume of soft tissue needed and the three-dimensional reconstructive requirement. The use of two free flaps has often been suggested to overcome this reconstructive challenge. A simpler and less technically demanding way to deal with this may involve the use of a free flap in combination with a pedicled regional flap. We present our experience of the use of a simultaneous microvascular fibula free flap (FFF) with a pectoralis major myocutaneous flap (PMMC) for addressing these defects.MethodsA retrospective chart review was performed of patients treated with a FFF and PMMC combination for the reconstruction of oromandibular defects at the University of Mississippi Medical Center (Jackson, MS) between October 2013 and February 2016. A minimum follow-up of 12 months was required. Data collected included the extent and location of tumor involvement, size of the postablative defect, tumor histology, clinical and pathological staging, length of follow-up, functional outcomes, and associated complications.ResultsA total of three patients were identified to have been treated with the above technique. Defects repaired involved through-and-through mandibular defects with associated oral mucosa and external skin defects. In all cases, the FFF was used for restoring bony continuity with the skin paddle used to reconstruct the intraoral lining. The PMMC was used for reconstruction of the external skin defect and for providing soft tissue bulk. The average size of the fibula skin paddle used for intraoral reconstruction was 7.7 cm × 11.7 cm. The average size of the PMMC paddle was 7.3 × 9 cm. The mean follow-up was 21.7 months. Both the FFF and PMMC survived in all cases, although postoperative wound healing complications occurred in two of the three patients. There was one partial flap loss. Two patients regained good oral intake while one patient tolerated oral intake but was PEG tube-dependent.ConclusionsThe combination of pectoralis major myocutaneous flap and a vascularized free fibular flap is a viable option for the reconstruction of complex through-and-through oromandibular defects. This technique may be useful when a single microvascular free flap is not sufficient for reconstruction of such defects.
| S-EPMC6458920 | biostudies-literature
Project description:BackgroundMandibular defects involving the condyle represent a complex reconstructive challenge for restoring proper function of the temporomandibular joint because it requires precise bone graft alignment, or alloplastic materials, for complete restoration of joint function. The use of computerized patient-specific surgical planning (CPSSP) technology can aid in the anatomic reconstruction of mandibular condyle defects with a vascularized free fibula flap without the need for additional adjuncts. The purpose of this study was to analyze clinical and functional outcomes after reconstruction of mandibular condyle defects using only a free fibula graft with the assistance of virtual surgery techniques.MethodsA retrospective review was performed to identify all patients who underwent mandibular reconstruction utilizing CPSSP with only a free fibula flap without any temporomandibular joint adjuncts after a hemimandibulectomy with total condylectomy.ResultsFrom 2018 to 2021, five patients underwent reconstruction of mandibular defects involving the condyle with CPSSP technology and preservation of the native temporomandibular articulating disk. The average age was 62 years (range, 44-73 years). The average follow-up period was 29.2 months (range, 9-46 months). Flap survival was 100% (N = 5). The maximal interincisal opening range for all patients was 22-45 mm with no lateral deviation or subjective joint pain. No patients experienced progressive joint hypomobility or condylar migration.ConclusionThe use of CPSSP technology can aid in the anatomic reconstruction of mandibular condyle defects with a vascularized free fibula flap through precise planning and intraoperative manipulation with optimal functional outcomes.
| S-EPMC9390826 | biostudies-literature
Project description:BACKGROUND:Gingival tissue enlargement is a common side effect of antiepileptic medications (e.g. phenytoin and sodium valproate), immunosuppressing drugs (e.g. cyclosporine) and calcium channel blockers (e.g. nifedipine, verapamil, amlodipine) (Murakami et al. 2018, Clin Periodontol 45:S17-S27, 2018). The clinical and histological appearances of lesions caused by these drugs are indistinguishable from one another (Murakami et al. 2018, Clin Periodontol 45:S17-S27, 2018). Drug-induced gingival enlargement is rarely seen in edentulous patients. CASE PRESENTATION:This case presents a 72-year-old female with a history of squamous cell carcinoma of the floor of the mouth treated with surgical excision and fibula-free flap reconstruction. Following the uncovering of osseointegrated implants placed in the fibular-free flap, the patient developed gingival enlargement of the floor of the mouth. Cessation of amlodipine and switching to an alternative medication lead to a resolution of the enlarged tissue. CONCLUSIONS:This case illustrates that gingival enlargement can occur around dental implants, most notably in rehabilitation cases in patients who have had head and neck cancer. Clinicians should be aware of the risk of gingival enlargement in hypertensive patients taking calcium channel blockers prior to implant placement.
| S-EPMC7431483 | biostudies-literature
Project description:BackgroundSurgical design and simulation (SDS) is a useful tool to help surgeons visualize the anatomy of the patient and perform operative maneuvers on the computer before implementation in the operating room. While these technologies have many advantages, further evidence of their potential to improve outcomes is required. The present benchtop study was intended to identify if there is a difference in surgical outcome between free-hand surgery completed without virtual surgical planning (VSP) software and preoperatively planned surgery completed with the use of VSP software.MethodsFive surgeons participated in the study. In Session A, participants were asked to do a free-hand reconstruction of a 3d printed mandible with a defect using a 3d printed fibula. Four weeks later, in Session B, the participants were asked to do the same reconstruction, but in this case using a preoperatively digitally designed surgical plan. Digital registration computer software, hard tissue measures and duration of the task were used to compare the outcome of the benchtop reconstructions.ResultsThe study revealed that: (1) superimposed images produced in a computer aided design (CAD) software were effective in comparing pre and post-surgical outcomes, (2) there was a difference, based on hard tissue measures, in surgical outcome between the two scenarios and (3) there was no difference in the time it took to complete the sessions.ConclusionThe study revealed that the participants were more consistent in the preoperatively digitally planned surgery than they were in the free hand surgery.
| S-EPMC3729729 | biostudies-literature
Project description:BackgroundThe long-term outcome of mandible reconstruction when performed in children has not been well documented.MethodsThis is a retrospective case series of patients who underwent immediate oncologic mandible reconstruction with a fibula free flap at younger than 18 years of age over a 20-year period, by a single surgeon, who had long-term follow-up.ResultsA total of 10 patients met inclusion criteria. Patient age ranged from 3 years and 8 months to 17 years and 9 months (mean 11 years). The etiology was malignant tumors in seven patients and benign locally aggressive tumors in three patients. All fibula flaps survived. All donor sites were closed primarily. The mean follow-up duration was 10 years and 5 months (range 3-20 years). The mean patient age at follow-up was 21 years and 10 months (range 8 years and 9 months to 30 years and 9 months). All patients achieved a regular diet and normal speech. Final occlusion was normal in seven of 10 patients. The aesthetic outcome, as evaluated by clinical examination, was a symmetric mandible in eight patients (in the other two the aesthetic asymmetry and malocclusion was minor and did not require operative intervention). Dental implants were ultimately placed in three patients. Leg function was normal in eight patients. Achilles lengthening and tendon transfer was required in one patient, and one patient developed ankle pain associated with running.ConclusionMandible reconstruction in children with the fibula free flap provides excellent aesthetic and functional outcomes that are durable over time.
| S-EPMC9333495 | biostudies-literature
Project description:Introductionand importance: Large cutaneous defects may result from excision of skin malignancies. Typically, skin grafting is used to manage such defects, but the final result may be compromised by inadequate take and poor cosmesis. Accordingly, transposition flaps may be indicated.Case Presentation and clinical discussion: A 93-year-old female presented with a painful, necrotic 12 cm × 12 cm Squamous Cell Cancer of left upper back. She underwent wide excision followed by a rhomboid transposition fasciocutaneous flap. The flap was easily designed, quickly executed, and did not require any special instruments. The overall result was a good cosmetic outcome with no complications.ConclusionOur case outlines successful use of rhomboid flap instead of a more complicated option to reconstruct a very large cutaneous defect. The flap healed with excellent contour, texture, thickness, and color match.
| S-EPMC7848721 | biostudies-literature
Project description:Osteoradionecrosis is the most dreadful complication after head and neck irradiation. Orocutaneous fistula makes patients difficult to eat food. Fibular free flap is the choice of the flap for mandibular reconstruction. Osteocutaneous flap can reconstruct both hard and soft tissues simultaneously. This study was to investigate the success rate and results of the free fibular flap for osteoradionecrosis of the mandible and which side of the flap should be harvested for better reconstruction.A total of eight consecutive patients who underwent fibula reconstruction due to jaw necrosis from March 2008 to December 2015 were included in this study. Patients were classified according to stages, primary sites, radiation dose, survival, and quality of life.Five male and three female patients underwent operation. The mean age of the patients was 60.1 years old. Two male patients died of recurred disease of oral squamous cell carcinoma. The mean dose of radiation was 70.5 Gy. All fibular free flaps were survived. Five patients could eat normal diet after operation; however, three patients could eat only soft diet due to loss of teeth. Five patients reported no change of speech after operation, two reported worse speech ability, and one patient reported improved speech after operation. The ipsilateral side of the fibular flap was used when intraoral soft tissue defect with proximal side of the vascular pedicle is required. The contralateral side of the fibular flap was used when extraoral skin defect with proximal side of the vascular pedicle is required.Osteonecrosis of the jaw is hard to treat because of poor healing process and lack of vascularity. Free fibular flap is the choice of the surgery for jaw bone reconstruction and soft tissue fistula repair. The design and selection of the right or left fibular is dependent on the available vascular pedicle and soft tissue defect sites.
| S-EPMC5122601 | biostudies-literature
Project description:Metacarpal and phalanx defects with soft tissue loss were suggested to be reconstructed by vascularized bone flap. The fibular osteocutaneous flap is a preferred method. Three-dimensional virtual planning has successfully applied in mandibular reconstruction with fibular free flap. We applied three-dimensional virtual planning in precise fibula flap harvest to maintain the continuity of the fibula and to achieve accurate metacarpal and phalanx reconstruction.A 35-year-old male presented with extensive soft tissue defects and first metacarpal defect involving the first metacarpophalangeal joint.There were 4?cm of first metacarpal defect involving the first metacarpophalangeal joint and soft tissue defects of 5cm?×?3cm?+?3cm?×?2cm.By combining three-dimensional virtual planning, we harvested a chimeric fibular flap. The precise fibula partial osteotomies were performed with cutting guides designed in virtual planning.All the chimeric flaps survived and no significant donor-site morbidity was noted. Michigan Hand Outcome Questionnaire scores indicated acceptable functional results.Our preliminary experience with the approach of three-dimensional virtual planning in precise chimeric fibula free flap is practical and efficient. Although more cases and follow-up are needed to evaluate it, this approach is expected to benefit patients.
| S-EPMC5626122 | biostudies-literature