M. Chamorro

The Fibula Osteomyocutaneous Flap for Mandible Reconstruction: A 15-Year Experience

PURPOSE This report documents our experience over the previous 15 years using free vascularized fibular flaps for comprehensive reconstruction of large defects in the mandible, after combined resections of aggressive, malignant odontogenic tumors or for post-traumatic defects. PATIENTS AND METHODS Charts were reviewed retrospectively for 117 consecutive patients who underwent microsurgical reconstruction of the oromandibular complex with a fibula osteocutaneous or osteomyocutaneous free flap over a 15-year period, with an average follow-up of 4 years. All charts were reviewed retrospectively for tumor type, stage and location, surgical procedure performed (including type of plate used), dental restoration if done, the use of pre- or postoperative radiotherapy, length of follow-up, and evidence of complications. RESULTS Fibula osteocutaneous free flaps were used for reconstruction in 117 patients, of whom 60% were men (mean age, 57.1 years) and 40% were women (mean age, 56.6 years). Most cases (61.1%) were secondary to oral malignancies (89.1% of these were squamous cell carcinoma). Thirty-one patients (26.5%) developed postoperative complications, including hardware failure or intolerance in 16 patients (13.7%), total or partial flap failure in 10 patients (8.5%), wound infection in 3 patients (2.6%), and peroneal nerve damage in 2 patients (1.7%). Regarding donor site morbidity, calf paresthesias were recorded in 21% of cases. Similar rates of claw-toe deformity were also observed. CONCLUSIONS In our opinion, the free fibula osteocutaneous flap is the most versatile and reliable option for microsurgical reconstruction of large mandibular defects. It provides a large quantity of bone, which is easily shaped to passively adapt to the remaining mandible. The bone height is suitable for an implant-based prosthetic restoration. Preoperative mapping of the cutaneous perforators of the skin paddle improves the versatility of the flap design and decreases the morbidity at the donor site. In selected cases, other options (iliac crest or scapular free flap) may also be considered.

The Deep Inferior Epigastric Artery Perforator (DIEAP) Flap for Total Glossectomy Reconstruction

PURPOSE Total or subtotal glossectomy following the resection of intraoral tumors causes significant morbidity. However, which reconstructive technique is the most successful remains controversial. PATIENTS AND METHODS After approval by the Ethics Committee, charts were reviewed retrospectively for patients treated at the Oral and Maxillofacial Surgery Department, University Hospital La Paz (Madrid, Spain), during a 3-year period (2005-2008). All were reconstructed with a deep inferior epigastric artery perforator (DIEAP) flap after total glossectomy. Data collected included affiliation data, extent of extirpation, type of reconstruction, and surgical outcome, including donor-site morbidity, complications, and functional results. RESULTS Seven patients (5 men, 71.4%; 2 women, 28.6%) with primary squamous cell carcinoma of the tongue underwent total glossectomy and simultaneous microsurgical reconstruction with a DIEAP flap. In all cases, the flap was harvested with a fusiform shape oriented craniocaudally and limited to zone 1. The average size of the flap was 16.7 × 7.2 cm. Functional outcome related to swallowing was poor; 57.1% of the patients required a permanent gastrostomy. Speech was considered intelligible in 85.7% of cases by 2 independent observers. The surgical outcome was uneventful in most of the cases, with only 1 case of local dehiscence at the mouth floor. None of the cases developed abdominal wall dehiscence or an abdominal hernia at mid- or long-term follow-up. CONCLUSIONS The DIEAP flap is a reliable alternative for tongue reconstruction. It provides a large volume of soft tissue for transfer and is predictable and stable over time with low donor-site morbidity.