Flow through fibula and fasciocutaneous free flaps in oromandibular reconstruction

The osteocutaneous fibula is a workhorse flap for oromandibular reconstruction. Skin paddles not only perform soft tissue reconstruction but also serve as a monitor for the fibula. In cases where the skin paddle cannot be harvested as desired due to variations, two challenges arise, such as fibula follow-up and the need for a second free flap so recipient. Moreover, there may not be enough recipient vessels for the double flaps in the neck. This report aimed to address the difficulties mentioned above with the use of flow-through free flaps in composite oromandibular reconstructions.

Between 2019 and 2021, five (three Female, two Male) patients underwent flow-through technique as free fibula and fasciocutaneous flaps due to variations in fibular skin paddle or insufficiency of recipient vessels in the neck. Ages of patients were between 45 and 75 years. Four patients underwent surgery for tumor and one patient for the result of radionecrosis. ALT, chimeric ALT, and RFFF were selected as second free flaps.

The size of the fasciocutaneous flaps ranged from 6 × 4 cm to 14 × 11 cm. Mandibular defects ranged from 6 to 16 cm. 1 venous occlusion occurred post-op 1st day and was salvaged. One hematoma and one wound dehiscence occurred postoperatively and were salvaged successfully. One Partial tongue necrosis occurred due to previous radiotherapy and additional tumor surgery. No additional complication occurred. All flaps survived. Follow-up period was between 3 months and 2 years. Patient who had tongue necrosis experienced swallowing and speech difficulty and Percutaneous endoscopic gastrostomy tube was placed post-operative 2 months. Functional finale outcomes were successful for other patients.

Flow-through technique provides fibula monitoring with avoiding to find second recipient. Customizing free flaps under more favorable conditions as on the operation table before fixation of the bone can be a useful approach.