Gi Nambi

Reconstruction of oncological oro-mandibular defects with double skin paddled-free fibula flap: A prudent alternative to double flaps in resource-constrained centres

OBJECTIVE The free fibula flap is the choice flap for mandibular reconstruction following extensive tumor resections. While large defects are managed with a second flap [free or pedicle] in advanced centres, a free fibula flap with a large skin paddle that can be de-epithelised to provide outer skin and inner lining is the best alternative in resource- constrained centres. MATERIALS AND METHODS From January 2005 to December 2009 a total of 386 free fibula flaps were used of which 307 flaps had de-epithelised double skin paddle in reconstructing complex oral and mandibular defects after tumor ablative surgeries. RESULTS Complete flap survival was seen in 282/307 patients. Complete flap loss was seen in 9/307 patients. Partial flap loss was seen in 16 patients. Re - exploration was done in 30 patients and the flap was salvaged in 21 patients. CONCLUSION The vascular supply of the free fibula osteo myocutaneous flap is reliable and a flap with a large skin paddle can be used to provide both inner lining and outer cover in resource-constrained centres.

Successful management of free osteocutaneous fibula flap with anomalous vascularity of the skin paddle

The free osteocutaneous fibula flap is an established method of reconstruction of maxillary and mandibular defects. The vascularity of the skeletal and the cutaneous components is provided by the peroneal artery via the nutrient artery and the septo- and musculocutaneous perforators. In rare situations, these perforators may arise from other major leg arteries. In such circumstances, the procedure has to be either abandoned or modified so that neither the vascularity of the flap nor the donor limb is compromised. We present a case of an anomalous musculocutaneous perforator, which originated from the proximal part of the posterior tibial artery, passed through the soleus muscle and supplied the skin paddle. The flap was elevated as a single composite unit and was managed by two separate vascular anastomosis at the recipient site, one for the peroneal vessels and the other for the anomalous perforator.

Reconstruction of complex thoraco-abdominal defects with extended anterolateral thigh flap

Background: The reconstruction of complex thoraco-abdominal defects following tumour ablative procedures has evolved over the years from the use of pedicle flaps to free flaps. The free extended anterolateral thigh flap is a good choice to cover large defects in one stage. Materials and Methods: From 2004 to 2009, five patients with complex defects of the thoracic and abdominal wall following tumour ablation were reconstructed in one stage and were studied. The commonest tumour was chondrosarcoma. The skeletal component was reconstructed with methylmethacrylate bone cement and polypropylene mesh and the soft tissue with free extended anterolateral thigh flap. The flaps were anastomosed with internal mammary vessels. The donor sites of the flaps were covered with split-skin graft. Result: All the flaps survived well. One flap required re-exploration for venous congestion and was successfully salvaged. Two flaps had post operative wound infection and were managed conservatively. All flap donor sites developed hyper-pigmentation, contour deformity and cobble stone appearance. Conclusion: Single-stage reconstruction of the complex defects of the thoraco-abdominal region is feasible with extended anterolateral thigh flap and can be adopted as the first procedure of choice.

Skin paddle vascularity of free fibula flap - A study of 386 cases and a classification based on contribution from axial vessels of the leg.

Objective: The skin paddle of the free fibula flap receives its vascular supply from septocutaneous perforators, musculocutaneous perforators or from both, and these perforators might originate from the peroneal or posterior tibial vessels or from both. The objective of this study was to classify the skin paddles based on the dominance of vascular contribution by these axial vessels through their different perforator systems. Materials and Methods: A retrospective analysis of 5-year data of 386 free fibula flaps used in oro-mandibular reconstruction was done and the skin paddle vascularity was studied. While majority of the skin paddles received their blood supply from the peroneal septocutaneous perforators, a few had their dominant supply from the soleus musculocutaneous perforators in addition to peroneal septocutaneous perforators. In few cases, the soleus musculocutaneous perforators were the sole source of blood supply to the skin paddle. The limitation in this study was the inability to augment the clinical observation with cadaveric study. Results: The skin paddle of the free fibula flap was classified into four different types (a–d) based on the dominance of vascular contribution by axial vessels of the leg. Conclusion: The skin paddle of the free fibula flap has reliable blood supply, but a thorough knowledge of the variations in vascular pattern of the skin paddle is required especially to salvage the larger paddles used in the reconstruction complex oro-mandibular defects.

Anterolateral Thigh Twin Free Flaps from a Single Donor Site—a Modification Based on the Oblique Branch of the Lateral Circumflex Femoral Artery

The pedicle of the anterolateral thigh flap is formed by the descending branch of the lateral circumflex femoral artery. Recently, an oblique branch of lateral circumflex femoral artery was described by Wei et al., which can also be used as an alternative to the descending branch. We describe a case in which both the pedicles were used to create two free flaps (twin flaps) from the same thigh for post tumour reconstruction of breast.

Pedicle transfer in oral cavity reconstruction.

In head and neck reconstructions when a free flap is used intra orally to provide the lining its vascular pedicle has to be transferred to the neck for anastomosis. This has to be performed in such a way that the pedicle does not get kinked or twisted. The pedicle is enrolled in a split open glove from its point of entry into the flap till its proximal most part. In order to prevent twisting of the vessels and to maintain orientation, the glove is wrapped in such a way that the imprint on the glove is on the visualized surface. The glove wrapped pedicle is passed from inside the oral cavity while an artery clamp passed from the neck wound through the submandibular or subcutaneous tunnel holds the tip of the glove component and guides it safely to the neck without exerting any traction on the flap or the pedicle vessels.

There is no donor side specificity of fibula free flap for complex oromandibular reconstruction

Background: The objective of this study was to prove that there is no significance to the donor side (right or left) of the free fibula osteocutaneous flap (FFOCF) in the reconstruction of complex oromandibular defects (COMD) and proper flap planning, designing and tailoring are important in reconstructing different types of COMD after tumour-ablative surgery. Materials and Methods: Three hundred and eighty-six consecutive patients who where reconstructed with FFOCF for COMD from Jan 2005 to Dec 2009 over a period of 5 years were studied. Except in seven patients, all fibula flaps were harvested from the left leg as per convenience and to facilitate a simultaneous, two-team approach. Depending on the condition of the neck vessels, vascular anastomosis was performed on the right or the left side, irrespective of the side of the defect. Results: Complete flap survival was seen in 334 patients (86.52%). Superficial skin necrosis was seen in 20 patients, and was managed conservatively (5.18%). Partial flap loss was seen in 20 patients (5.18%). There were 39 re-explorations. Complete flap loss was seen in 12 patients (3.10%). Conclusion: We found no significance in terms of the results as far as the side of flap donor leg or primary defect were concerned. Flap tailoring in terms of meeting the tissue requirement and vessel orientation were rather more important.