Department of Plastic Reconstructive and Aesthetic Surgery, China Medical University Hospital, Taichung, Taiwan.
Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
Microsurgery. 2021 Mar;41(3):223-232. doi: 10.1002/micr.30720. Epub 2021 Feb 24.
Fibula osteocutaneous flap is associated with a higher rate of reexploration in mandible reconstruction due to limited space for the fixation of various tissue components on multiple segments of the fibula flap. To maintain optimal circulation to the flap and to prevent negative outcomes because of partial or total flap loss, we shared our experiences on salvaging the free fibula flap with vascular compromise in the first reexploration and we developed an algorithm.
From 1992 to 2018, 12 patients between the ages of 48 to 63 (mean: 52.5) who had presented with oral squamous cell carcinoma (n = 10) followed by osteoradionecrosis of the mandible (n = 2) were explored. The operative findings were; (1) occlusions of vein (3 cases); (2) occlusions of artery (4 cases); and (3) occlusions of both artery and vein (5 cases). After correcting the kinking or evacuating the hematoma, the arterial inflow was initially reestablished by anterograde flow. If this was nonfunctional, retrograde flow from the distal end of the peroneal artery was provided. For the vein, anterograde venous drainage was reestablished. If the thrombus extended deep into the peroneal vein, regular venous return was blocked on the anterograde side, and the flap remained congested therefore retrograde venous drainage was performed regardless of the valves in the vein. However, the two ends of the peroneal artery were anastomosed to prevent thrombosis of the artery.
The success rate of revised cases was 75% (9/12). All failed cases had presented with both artery and vein occlusion (three cases). Pectoralis major musculocutaneous flap and anterolateral thigh flap were needed for the external surface in two cases. Skin graft was required for seven cases to restore intraoral lining. Six patients underwent dental rehabilitation with prosthetic implants.
Immediate reexploration is mandatory to salvage the flap.
由于腓骨皮瓣的多个节段上有多种组织成分需要固定，因此空间有限，导致下颌骨重建后再探查的发生率较高。为了保持皮瓣的最佳循环，防止因部分或全部皮瓣丢失而导致不良后果，我们在第一次再探查时分享了处理游离腓骨皮瓣血管受压的经验，并制定了一个算法。
1992 年至 2018 年，我们共对 12 名年龄在 48 岁至 63 岁（平均 52.5 岁）的患者进行了探查，这些患者患有口腔鳞状细胞癌（n=10）或下颌骨放射性骨坏死（n=2）。手术发现：（1）静脉阻塞（3 例）；（2）动脉阻塞（4 例）；（3）动静脉均阻塞（5 例）。纠正扭曲或清除血肿后，通过顺行血流首先重新建立动脉入流。如果这不起作用，则提供来自腓动脉远端的逆行血流。对于静脉，重新建立顺行静脉引流。如果血栓延伸至腓静脉深部，顺行侧的静脉回流受阻，皮瓣仍充血，因此即使静脉内有瓣膜，也进行逆行静脉引流。然而，腓动脉的两端吻合以防止动脉血栓形成。
修订病例的成功率为 75%（9/12）。所有失败的病例均存在动静脉阻塞（3 例）。有两例需要胸大肌皮瓣和股前外侧皮瓣修复外部表面。有 7 例需要皮片移植修复口腔内衬。6 例患者接受了牙种植体修复。
立即再次探查是挽救皮瓣的必要条件。
