• Archives of Plastic Surgery
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• v.48 no.6
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• pp.699-702
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• 2021

Extensive bone loss associated with severe vascular injury remains a challenge for lower extremity reconstruction. The fibular free flap has been utilized for many decades to reconstruct long-segment tibial defects. We present an unusual scenario of unilateral weight-bearing, wherein we salvaged the sole lower extremity by transfer of the fractured ipsilateral fibula and a bipedicled skin flap. A 38-year-old man sustained a severe crush injury in the right leg with loss of circulation. His left lower leg had a soft tissue defect measuring 20×15 cm with an exposed comminuted fracture and a 17-cm tibial defect, along with a segmental fracture of the fibula. Subsequently, we reconstructed the tibial defect by transferring a 17-cm-long section of the ipsilateral fibula. We covered the soft tissue defect with a bipedicled skin flap. The patient eventually began to ambulate independently after surgery.

• Archives of Reconstructive Microsurgery
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• v.2 no.1
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• pp.29-41
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• 1993

Recent advances in microsurgery have made it possible to provide a continued circulation of blood to the grafted bone so as to ensure viability. With the nutrient blood supply preserved, healing of the graft to the recipient bone is facilitated without the usual replacement of the graft by creeping substitution. We reviewed 34 cases of vascularized osteocutaneous fibular transfers to the infected tibial defect complicated with skin defect, which were performed from May, 1982 to January, 1992, and the following results were obtained: 1. Despite of uncontrolled bone infection with skin defect, the vascularized osteocutaneous fibular flap transfer could be performed. 2. In the vascularized osteocutaneous fibula transfer, the patency of anastomoses could be indirectly monitored by observing the color of the skin flap. 3. The vascularized fibula had been hypertrophied with bony union during the follow-up period of 13 months to 6 years and 4 months(average, 30 months) and there was no resorption of the grafted fibula. 4. There was no fracture of the grafted fibula in parti resection of involved tibia. 5. The hypertrophic potentiality of grafted fibula could be inhibited by the infection status as operation site.

• Journal of International Society for Simulation Surgery
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• v.2 no.2
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• pp.90-93
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• 2015

The fibula free flap has now become the most reliable and frequently used option for mandible reconstruction. Recently, three dimensional images and printing technologies are applied to mandibular reconstruction. We introduce our recent experience of mandibular reconstruction using three dimensionally planned fibula free flap in a patient with gunshot injury. The defect was virtually reconstructed with three-dimensional image. Because bone fragments are dislocated from original position, relocation was necessary. Fragments are virtually relocated to original position using mirror image of unaffected right side of the mandible. A medical rapid prototyping (MRP) model and cutting guide was made with 3D printer. Titanium reconstruction plate was adapted to the MRP model manually. 7 cm-sized fibula bone flap was designed on left lower leg. After dissection, proximal and distal margin of fibula flap was osteotomized by using three dimensional cutting guide. Segmentation was also done as planned. The fibula bone flap was attached to the inner side of the prebent reconstruction plate and fixed with screws. Postoperative evaluation was done by comparison between preoperative planning and surgical outcome. Although dislocated condyle is still not in ideal position, we can see that reconstruction was done as planned.

• Archives of Plastic Surgery
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• v.46 no.5
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• pp.426-432
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• 2019

Background The mandible is an important structure that is located in the lower third of the face. Large mandibular defects after tumor resection cause loss of its function. This study assessed the outcomes and tumor recurrence after immediate mandibular reconstruction using a free fibula osteocutaneous flap following radical resection of ameloblastoma. Methods This is a retrospective non-randomized study of outcomes and tumor recurrence of all patients diagnosed with mandibular ameloblastoma from August 1997 until August 2017 (20 years) requiring free fibula osteocutaneous flap reconstruction at a single institution. The patients were identified through an electronic operative database; subsequently, their medical records and photo documentation were retrieved. Results Twenty-seven patients were included in this study. Eighteen patients were male, while nine were female. The majority of the patients (48.1%) were in their third decade of life when they were diagnosed with ameloblastoma. All of them underwent radical resection of the tumor with a surgical margin of 2 cm (hemimandibulectomy in cases with a large tumor) and immediate mandibular reconstruction with a free fibula osteocutaneous flap. Two patients required revision of a vascular anastomosis due to venous thrombosis postoperatively, while one patient developed a flap recipient site infection. The flap success rate was 100%. There was no tumor recurrence during a mean follow-up period of 5.6 years. Conclusions Mandibular ameloblastoma should be treated with segmental mandibulectomy (with a surgical margin of 2 cm) to reduce the risk of recurrence. Subsequent mandibular and adjacent soft tissue defects should be reconstructed immediately with a free fibula osteocutaneous flap.

• Anatomy and Cell Biology
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• v.56 no.3
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• pp.334-341
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• 2023

Anterior talofibular ligament (ATFL) injuries are the most common cause of ankle sprains. To ensure anatomically accurate surgery and ultrasound imaging of the ATFL, anatomical knowledge of the bony landmarks around the ATFL attachment to the distal fibula is required. The purpose of the present study was to anatomically investigate the ATFL attachment to the fibula with respect to bone morphology and attachment structures. First, we analyzed 36 feet using micro-computed tomography. After excluding 9 feet for deformities, the remaining 27 feet were used for chemically debrided bone analysis and macroscopic and histological observations. Ten feet of living specimens were observed using ultrasonography. We found that a bony ridge was present at the boundary between the attachments of the ATFL and calcaneofibular ligament (CFL) to the fibula. These two attachments could be distinguished based on a difference in fiber orientation. Histologically, the ATFL was attached to the anterodistal part of the fibula via fibrocartilage anterior to the bony ridge indicating the border with the CFL attachment. Using ultrasonography in living specimens, the bony ridge and hyperechoic fibrillar pattern of the ATFL could be visualized. We established that the bony ridge corresponded to the posterior margin of the ATFL attachment itself. The ridge was obvious, and the superior fibers of the ATFL have directly attached anteriorly to it. This bony ridge could become a valuable and easy-to-use landmark for ultrasound imaging of the ATFL attachment if combined with the identification of the fibrillar pattern of the ATFL.

• Archives of Reconstructive Microsurgery
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• v.7 no.2
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• pp.88-94
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• 1998

Free vascularized fibular transplantation is one of the most useful living bone reconstructive procedure in microsurgical field. Concerning about donor site morbidity, the donor has minor problems of ankle stability and muscle power weakness and transient peroneal nerve symptoms. That problems can be minimized with longitudinal splitted osteotomy on the donor fibula if the bone defect in recipient site is not so large. Half splitted fibula with peroneal arterial pedicle which contains nutrient artery and periosteal vessels, grafted bone can survive with those vascular supplies. Authors underwent five cases of half splitted free vascularized fibular transplantation from 1985. There were no evidence of devascularization in all cases, we can minimized donor morbidity with leaving half fibula intact on donor site. The problem of that technique is technically demanding in longitudinal splitting of bone without damage to peroneal nutrient vessels and periosteal soft tissues which attached to the bone. Authors can propose longitudinal half fibular transplantation is one of modification in free vascularized bone transplantation that minimize donor defect.

• Journal of International Society for Simulation Surgery
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• v.3 no.1
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• pp.12-15
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• 2016

Functional and esthetic reconstruction after segmental mandibulectomy is one of the most challenging surgeries in microsurgical reconstruction field. Simulation surgery before free flap reconstruction has been performed for efficient surgery and successful results. Fibula free flap is the flap of the choice for reconstruction of the segmental mandibular defect. Straight nature of the fibula bone requires multiple segmentations to fit into mandible. 3D rapid prototype (RP) model gives a lot of information for mandibular reconstruction. The purpose of this study was to report mandibular reconstruction with free fibular flap using simulation surgery. A total of 30 consecutive patients were included for functional and esthetic evaluation. Among 30 patients, two flaps showed necrosis after radiotherapy. The other flaps were all survived and showed successful reconstruction in both function and esthetics.

• Archives of Plastic Surgery
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• v.48 no.5
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• pp.498-502
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• 2021

Total and subtotal sternectomy oncological defects can result in large deficits in the chest wall, disrupting the biomechanics of respiration. Reviewing the current literature involving respiratory function and rib motion after sternectomy, autologous rigid reconstruction was determined to provide the optimal reconstructive option. We describe a novel technique for sternal defect reconstruction utilizing a double-barrel, longitudinally oriented, vascularized free fibula flap associated with rib titanium plates fixation. Our reconstructive approach was able to deliver a physiological reconstruction, providing rigid support and protection while allowing articulation with adjacent ribs and preservation of chest wall mechanics.

• Archives of Plastic Surgery
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• v.49 no.2
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• pp.253-257
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• 2022

The free fibula flap (FFF) is based on the peroneal artery (PA) system, and it is well known that several anatomical variations of the lower limb vascular system exist, including peronea arteria magna (PAM). PAM is a rare congenital variation in which both anterior tibial artery and posterior tibial artery are either aplastic or hypoplastic, and as a result, PA will be the dominant blood supply to the foot. This variation was described as type III-C in Kim-Lippert's Classification of the Infra-Popliteal Arterial Branching Variations. The awareness of its existence is crucial as it often precludes FFF from being harvested due to the risk of significant limb ischemia and limb loss. Despite some literature reporting donor site complications and impending limb loss following FFF harvest in PAM, preoperative vascular mapping before FFF transfer remains controversial among the microsurgeons. We present a case with an incidental intraoperative finding of PAM that had a successful FFF harvest by luck, without preoperative vascular mapping.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.41
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• pp.30.1-30.8
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• 2019

Background: Advancements in the field of microvascular surgery and the widespread adoption of microvascular surgical techniques have made the use of osteocutaneous fibula free flaps the standard of care in the surgical management of segmental mandibular defects. Although the literature possesses abundant evidence to support the effectiveness of fibula free flaps as a reconstructive method, there are relatively few studies reporting on outcomes as objectively measured by videofluoroscopic swallowing studies (VFSS). The purpose of this study is to explore the potential correlation between early postoperative VFSS and the long-term swallowing outcomes in patients who underwent mandibular reconstruction with fibula free flaps. Methods: We performed a retrospective chart review of 36 patients who underwent mandibular reconstruction with osteocutaneous fibular free flaps between 2009 and 2012. Demographics, clinical variables, VFSS data, and diet information were retrieved. Penetration and aspiration findings on VFSS, long-term oral feeding ability, and the need for gastrostomy tube were statistical endpoints correlated with postoperative clinical outcomes. Results: Thirty-six patients were reviewed (15 females and 21 males) with a mean age of 54 years (7-81). Seventeen cases were treated for malignancy. The size of the bony defect ranged from 3 to 15 cm (mean = 9 cm). The cutaneous paddle, a surrogate for soft tissue defect, ranged from 10 to 125 ㎠ (mean = 52 ㎠). A gastrostomy tube was present in patients preoperatively (n = 8), and postoperatively (n = 14). Seventeen patients had neoadjuvant exposure to radiation. Postoperative VFSS showed penetration in 13 cases (36%) and aspiration in seven (19%). Overall, 29 patients (80.6%) achieved unrestricted diet, and this was statistically correlated with age (p = 0.037), radiation therapy (p = 0.002), and preoperative gastrostomy tube (p = 0.03). The presence of penetration or aspiration on VFSS was a strong predictor for long-term unrestricted oral diet (p < 0.001). Conclusion: Early postoperative VFSS is an excellent predictor for long-term swallowing outcomes in patients undergoing mandibular reconstruction with osteocutaneous fibula free flaps.