|Year : 2012 | Volume
| Issue : 1 | Page : 91-95
Reconstruction of oncological oro-mandibular defects with double skin paddled-free fibula flap: A prudent alternative to double flaps in resource-constrained centres
Prabha S Yadav, Quazi G Ahmad, Vinay K Shankhdhar, GI Nambi
Plastic and Reconstructive Services, TATA Memorial Hospital, Mumbai, India
|Date of Web Publication||19-Apr-2012|
G I Nambi
Plastic and Reconstructive Microvascular Services, Comprehensive Cancer Center, K.M.C.H., Coimbatore, Tamilnadu - 641014
Source of Support: None, Conflict of Interest: None
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.
Keywords: Composite oral defects, oro-mandibular reconstruction, free fibula flap, de-epithelised double skin paddle, resource-constrained centre
|How to cite this article:|
Yadav PS, Ahmad QG, Shankhdhar VK, Nambi G I. Reconstruction of oncological oro-mandibular defects with double skin paddled-free fibula flap: A prudent alternative to double flaps in resource-constrained centres. J Can Res Ther 2012;8:91-5
|How to cite this URL:|
Yadav PS, Ahmad QG, Shankhdhar VK, Nambi G I. Reconstruction of oncological oro-mandibular defects with double skin paddled-free fibula flap: A prudent alternative to double flaps in resource-constrained centres. J Can Res Ther [serial online] 2012 [cited 2019 Nov 12];8:91-5. Available from: http://www.cancerjournal.net/text.asp?2012/8/1/91/95181
| > Introduction|| |
The reconstruction of complex defects of the oro-mandibular region has evolved over the years from pedicle flaps to free flaps. Among the available free flaps, the free fibula osteocutaneous flap ,,,,,, has become the first choice for majority of reconstructive surgeons because of the following advantages:
- A long thick bicortical bone - with segmental blood supplies enabling multiple osteotomies and provides for integration of dental implants at a later date.
- Large area of skin from the lateral leg - which can be de-epithelised and used to provide intra and extra oral lining.
- A less bulky flexor hallucis longus [FHL] muscle.
- Good blood supply from one of the major lower limb vessels.
- Minimal donor site morbidity.
- Two team approach simultaneously - reducing operative time.
In this study, extensive use of the lateral leg skin with segmental de-epithelisation was done in reconstructing central [Figure 1]a-f and lateral [Figure 2]a-f defects of the oro-mandibular region proving the reliability and efficacy of large skin paddles of free fibula flap.
|Figure 1: (a) Carcinoma of the lower alveolus involving the central segment of the mandible. (b) Post excision defect. (c) Free fibula flap. (d) After intra oral inset of the skin paddle a segment of skin paddle is de-epithelised before giving extra oral cover. (e) The de-epithelised segment is inserted to the lower lip and the outer paddle inserted to the chin region. (f) Late post-op view|
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|Figure 2: (a) Carcinoma of the left lower alveolus with involvement of the external skin – Anterior view. (b) Post-excision defect. (c) A segment of skin between the outer and inner paddles is de-epithelised after intra oral inset. (d) After fi nal inset. (e) Late post-op – Anterior view. (f) Late post-op – Lateral view|
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| > Materials and Methods|| |
Over a period of five years from 2005 to 2009, a total of 386 free fibula flaps were used for the reconstruction of complex oro mandibular defects of which 307 flaps had de-epithelised double skin paddle. The number of perforators distal to the de-epithelised segment varied from 0 to 3. The length of the de-epithelised segment varied from 1 to 4 cm and the width from 5 to 12 cm as per the width of the skin paddle. There were 214 males and 93 females. The oldest patient was aged 73 years and the youngest was 8 years. The most common pathology was squamous cell carcinoma. There were 208 central segment defects and 24 right lateral segment defects and 75 left lateral segment defects. The largest bone defect was 15 cm. Depending upon the size and location of the bone defect, 1 to 3 osteotomies were performed. Mandibular plates were used in 10 patients. Mini plates with screws were used in the rest. The longest of the skin paddle was 30 cm and the widest of the flap was 12 cm [Average size of a flap was 20 cm × 8.5 cm]. Tracheostomy was done in all the patients. Among the operated patients, 22 received pre operative radiotherapy and chemotherapy and rest of the patients received post-operative radiotherapy and chemotherapy. Dental rehabilitation with implants was done in willing patients  one year after radiotherapy. The follow-up period was ranging between 3 months and 2 years.
Before flap harvest, an assessment of skin paddle requirement for the intra and extra oral cover was made and the skin paddle was marked accordingly. The final design and inset were modified before beginning the flap inset. Pre operative marking of perforators to the skin was done after hand-held doppler examination. The number of skin paddle perforators varied from 1 to 7. The vertical extent of the skin paddle was limited within the line of osteotomy and the horizontal extent was from 1 cm lateral to the tibial shin to posterior midline. The superficial peroneal nerve was left behind and when the skin paddle extended posteriorly, the sural nerve was included in the flap to maintain the vascular plexus around it while care was taken not to bare the peroneal tendons. Irrespective of the bone requirement, the whole length of the fibula was harvested leaving behind the proximal and distal 6 cm to preserve the joint stability. The flexor hallucis longus [FHL] muscle was included in all the cases. The muscle was divided at its junction with the tendon. After the flap was isolated on its vascular pedicle, the tourniquet was released and the bleeding from the skin margins was checked. Once this was done, the flap was detached and the donor site was closed with split skin graft from the opposite thigh.
After the flap was harvested, the bone defect was analyzed and osteotomies were planned accordingly. The number of osteotomies varied from 1 to 3 depending up on the segments to be reconstructed. The osteotomised segments were fixed with miniplates and screws. Osteotomies extended from distal to proximal and excess length of bone was discarded from the proximal segment to increase the length of the vascular pedicle. The septo myocutaneous complex was sub-periosteally stripped from the excess bone before discarding so as to preserve the septocutaneous perforators. Once the neo mandible was constructed, it was fixed to the remnant mandible with miniplates and screws. The reconstruction plates were used in cantilever grafts  where the opposite mandible was totally removed. Once this was done, the intra oral inset of the flap was given and the anastomosis was completed. The most common recipient artery was facial followed by superior thyroid and transverse cervical. The most common recipient vein was tributary of the internal jugular vein followed by external jugular vein. Both veins were used whenever available. After the anastomosis was completed, bleeding from the edges of the skin paddle was assessed and the final inset was planned. The area in between inner and outer lining was de-epithelised and not divided. After this, the excess skin paddle was discarded and the final insetting was done. The number of perforators distal to the de-epithelised segment varied from none to three. Post operatively, the skin flaps were monitored with sterile needle prick test. Naso gastric tube feeding was started from first post operative day and was maintained till oral intake was adequate.
| > Case Reports|| |
Case 1 [Central defect]
A 65-year-old female with squamous cell carcinoma of the lower gingivo labial sulcus [Figure 1]a was planned for composite excision with bilateral neck node dissection followed by reconstruction with de-epithelised double paddle fibula free flap. Post excision defect [Figure 1]b had extensive loss of bone [central and right mandible] and soft tissue of the floor of the mouth, alveolus, and skin of the chin. The defect was reconstructed with free fibula composite flap from left leg [Figure 1]c with a skin paddle of size 18 cm × 9 cm. After intra oral inset, a segment of skin paddle measuring 3 cm × 9 cm was de-epithelised and the distal segment was used to provide skin cover to the chin [Figure 1]d-f. In this case, the skin paddle distal to the de-epithelised skin had no septocutaneous perforators. Right neck vessels [facial artery and a tributary of internal jugular vein] were used for anastomosis.
Case 2 [Lateral defect]
A 55-year-old male with squamous cell carcinoma of the left lower alveolus involving the external skin [Figure 2]a was planned for composite resection and reconstruction with de-epithelised double paddle fibula flap. Post excision defect [Figure 2]b had extensive loss of bone and soft tissue over the lateral aspect of the oral cavity and cheek. The defect was reconstructed with a composite free fibula flap with a skin paddle measuring 27 cm × 12 cm. In this case, 1 cm × 12 cm [Figure 2]c was de-epithelised after intra oral inset of the flap and the cheek skin cover was given [Figure 2]d-f. The skin paddle distal to the de-epithelised segment had two septo cutaneous perforators. Left neck vessels were used for anastomosis [left facial artery, a tributary of the internal jugular vein and external jugular vein]
| > Results|| |
Complete flap survival was seen in 282 patients and complete flap loss was seen in 9 patients [3.10%]. Partial flap loss [outer skin paddle loss] was seen in 16 patients [5.18%] and superficial skin necrosis was seen in 20 patients and was managed conservatively. We found no correlation between the number of perforators and skin paddle survival. Re-exploration was done in 30 cases and flap was salvaged in 21 cases. Among the lost flaps, 3 flaps were re-explored twice. The lost flaps were replaced with pectoralis major myocutaneous flap, nasolabial flap, forehead flap, or delto pectoral flap. The forehead flap  was used when the outer paddle was lost over the lateral segment and the deltopectoral flap  was used when the loss was over the central segment while nasolabial and pectoralis major flaps used for oral lining. All the free fibula flap donor sites were covered with split skin graft and 12 patients required secondary skin grafting due to infection and partial graft loss. Disorders of the toe movements due to the harvest of the flexor hallucis longus muscle was noted in 7 patients [Figure 3]. Mouth opening, jaw occlusion, and oral competence were used clinically to assess the functional results and patients were found to have satisfactory results. Dental rehabilitation with osseointegrated implants was done in willing patients one year after radiotherapy and was done in 10 patients [Figure 4].
|Figure 3: Lateral view showing the fibula harvest site and inability to flex the big toe|
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| > Discussion|| |
The complex oro mandibular defects also known as en bloc defects  or through and through defects  arise as a result of resection of T3 or T4 tumors of the oral cavity. Reconstruction of these defects with restoration of form and function require a combined team approach. In this era of micro surgery, the options  available for the reconstructive surgeons are free fibula, free iliac, free radial, and free scapula flaps with their associated soft tissues. The free fibula flap first described by Ian Taylor,  pioneered by Wei et al., and later popularized by Hidalgo ,, has emerged as the ideal flap in the reconstruction of complex oro-mandibular defects because of its versatile characters. 
The addition of skin from the lateral leg was first done by Yoshimura et al. in order to monitor the viability of the underlying bone and later modified by Wei et al. to evolve as osteo septocutaneous flap and further as osteo septo myocutaneous flap to reconstruct complex defects in various regions of the body. The muscles that were included in the flap were flexor hallucis longus, gastrocnemius and soleus. Because of its less bulk and minimal side effects, the flexor hallucis longus has become the commonly used muscle along with this flap.  Addition of this muscle does not produce limitations of the skin paddle movement because of the pliability of the septum. Therefore, the skin paddle overlying the osteo myocutaneous flap receives its vascular supply from the musculo cutaneous and septocutaneous perforators. The number of septo cutaneous perforators varies from 1 to 7. Based on these perforators, Yang et al. introduced the concept of two skin paddles from the same flap based on two perforators or two branches of one perforator to line intra and extra oral defects. However, there were contrasting reports about the reliability of the skin paddle. Hidalgo 1 first reported that the skin overlying the fibula flap is unreliable and later modified after extensive studies. Wei et al., pioneered the concept of using double free flaps in reconstructing the extensive soft tissue defects associated with mandibular defects owing to the unreliability of the skin paddle. The commonly used second free flaps were radial artery flaps, rectus abdominis myocutaneous flaps and the antero lateral thigh flaps. , Jones et al. made extensive study of the vasculature of the lateral leg both in cadavers and in clinical applications and reported that the vascularity of the lateral leg skin is reliable and large skin paddles can be used to line intra and extra oral defects with a segment of de-epithelised skin in between so as not to disturb the sub dermal vascular plexus. In their clinical study, Jones et al. used de-epithelised skin paddle in 16 cases and was 100% successful in reconstructing complex oro mandibular defects. They used skin paddles transverse to the long axis of the bone but was not clearly mentioned whether simultaneous two team approach was adopted.
In this study, 307 cases were reconstructed with de-epithelised double skin paddles to provide the outer and inner lining with good success. The skin paddle designed was parallel to the long axis of the bone and the extents were mentioned earlier. After giving the intra oral inset and completing the anastomosis, the amount of skin required for the outer lining was assessed and the intervening segment was de-epithelised to accommodate the remaining native tissues. The rotation of the skin paddle from inside to outside was possible because of the pliability of the septum and by preserving the skin, subcutaneous tissue, septum and its perforators by sub periosteally stripping them from the excess bone before discarding. By just de-epithelising the skin and preserving the dermis, the sub dermal plexus was maintained intact there by not compromising the vascularity of the skin used to provide the outer lining distal to the de-epithelised segment. The flexor hallucis longus muscle was included in all the flaps. The advantages of including this muscle were, the harvest of the flap became simpler and faster, the muscle provides additional blood supply to the overlying skin through its musculo septo cutaneous perforators thereby increasing its viability, fills up the soft tissue defect in the submandibular region there by providing a contour and covering the vital structures in the floor of the mouth and the neck, the muscle is less bulkier than the soleus or gastrocnemius and harvest of this muscle gives less deformity to the donor leg when compared to the soleus. The osteotomies were planned after assessment of the defect, the bone and skin requirement and availability of the recipient blood vessels in the neck. Miniplates and screws were used to fix the bone segments. The advantages of using miniplates are, they are malleable, need no periosteal dissection therefore not interfering with the blood supply of the bone, they need not be removed during future dental rehabilitation with implants contrary to the mandibular reconstruction plates. We used reconstruction plates only in very minimal numbers when there was no mandible left on the opposite side and free fibula was used as a cantilever graft. We did not encounter any incidence of plate fracture in the post op periods. Use of de- epithelised double skin paddle with free fibula flap is suitable for single axial defects and those in which either skin or the mucosal lining is less extensive, when there is a part or whole of orbicularis oris is remnant to maintain oral competence and in patients with decreased or doubtful expectancy. The drawback of using de-epithelised double skin paddle is that after irradiation, the paddle gets shrunk and thereby reduces the mouth opening. The application of two flaps is required in reconstruction of multi axial, composite and complex defects of the oro-mandibular reconstruction and for better cosmesis. While using a pedicle flap along with the free fibula flap may be required in selected cases,  use of two free flaps is not possible in resource constrained centers like ours, where there is a large patient population with limited resources of manpower, time and technical expertise where using a single free fibula flap with a large skin paddle from the lateral leg which can be de-epithelised serves as a prudent alternative. With increasing experience and refinement of techniques over the period of 5 years enabled us to reconstruct with less operative time and lesser rate of complications. The success rate associated with our series was better than the previous reports , and on par with those by Hidalgo and Jones. ,
| > Conclusion|| |
The free fibula osteo myocutaneous flap is ideal for reconstructing complex oro-mandibular defects. 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 outer skin cover and inner lining as first option in the reconstruction of complex oro-mandibular defects in resource-constrained centres with the following modifications;
- Inclusion of the flexor hallucis longus muscle in the flap
- Inclusion of the sural nerve in the flap whenever the posterior incision extends till the midline
- De-epithelising a segment of skin between the inner and outer lining rather than dividing in order to provide two skin paddles.
| > References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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