Combined Flexor Hallucis Longus Muscle and Free Fibular Osteocutaneous Flap for Head and Neck Reconstruction

Background:

Reconstruction of head and neck defect after tumor ablation is challenging. The aim of reconstruction is not only repairing the defect, but maintaining functional demand and a pleasing facial contour. In some cases, the conventional fibular osteocutaneous flap may not provide sufficient soft tissue for obliterating dead space after tumor ablation. Increased incidence of fluid accumulation, poor wound healing and unsatisfactory cosmetic results perplex both patients and surgeons. In this study, we used a combination of a segment of fibular bone osteocutaneous flap and flexor hallucis longus muscle for reducing recipient site complication and achieving better cosmetic results in head and neck reconstruction after tumor ablation.

 

Materials and Methods

This retrospective study evaluated 212 consecutive patients (201 males and 11 females) with an average age of 52.75 years (range, 26-78 years) who required mandibular reconstruction for aggressive benign or malignant disease with a free fibula osteocutaneous flap at Kaohsiung Veterans General Hospital (Kaohsiung, Taiwan) between February 1998 and December 2017. In each case, a segment of fibular bone (range, 5 to 22 cm, mean 10 cm) was harvested with single or double skin paddle (5.5x3.5 to 13x10 plus 12x8 cm² in size) in combination of flexor hallucis longus muscle (7x4 to 13x5 cm in size) which was nourished by peroneal artery. The flexor hallucis longus muscle was used for obliterating the dead space in cheek, retromolar, mouth floor region or shaping the mandibular contour.  

 

Results

All flap survived except total flap failure occurred in 10 patients (4.7 percent of the flaps), partial failure occurred in 7 patients (3.3 percent of the flaps) and orocutaneous fistula occurred in 2 patients (0.9 percent of the flaps). Patients had achieved satisfactory contour without significant donor site morbidity at a mean 12-months of follow-up. The flap related complication (wound infection, poor healing and fistula) is reduced. However, the flap failure rate is slightly higher (no significance) than conventional osteocutaneous fibular flap (4.1 percent of 121 flaps) due to complexity of the chimeric flap harvest and inset. 

 

Conclusion

This refinement of free fibula flap for mandibular reconstruction can reduce surgical complication and achieve better aesthetic results when combined with flexor hallucis longus muscle.