ISSN No: 2582-0559

Volume No: 8, Issue No: 2

SYTSTEMATIC REVIEW

A SYSTEMATIC REVIEW TO EVALUATE THE POST-

OPERATIVE COMPLICATIONS FOLLOWING FREE FIBULA

FLAP FOR MANDIBULAR RECONSTRUCTION IN AN ADULT

POPULATION

Dr. Manasi Bavaskar, Dr. Aashish Deshmukh, Dr. Thomson Mariadasan Dcruz

Department of Oral and Maxillofacial Surgery, Y.M.T. Dental College, and Hospital, Institutional Area, Sector 4,

Kharghar, Navi Mumbai – 410210, Maharashtra, India

DOI:

1.37841/jidam_2021_V8_I2_02

Address for Correspondence

Dr. Manasi Bavaskar,

Postgraduate Student,

302, Abhiyanta CHS, Plot Number 4,

Sector 42, Nerul (W), Navi Mumbai – 400706,

Maharashtra, India

Email id: drmanasi05@gmail.com

Received:

04.05.2021 First Published

03.06.2021

Accepted:

28.05.2021

Published:

27.06.2021

ABSTRACT

The

objective

evaluate the

basic

complications such  as  necrosis,  infection,  fistula,
dehiscence, and hematoma at recipient site and the donor
site; as well as the incidence in failure of the Free Fibula
Flap  when  used  in  mandibular  reconstruction.  After
thorough  electronic  search  on  different  databases,
applying  the  inclusion  and  exclusion  criteria,  following
the PRISMA guidelines and assessing the risk of bias; 6
articles  were deemed eligible  for this analysis. The total
number  of  recipient  site  complications  was  the  highest,
i.e., 30.49% followed by the donor site complications with
9.75% and flap loss with 9.34%.  The authors emphasize
that success of the Free Fibula Flap depends not only on
the  major  post-operative  complications  but  also  on  the
avoidance  of  the  basic  complications  that  occur  at  the
recipient site as well as the donor site.

KEYWORDS:

Free

Fibula

Flap,

Mandibular

Reconstruction, Complications.

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Manasi et al: Post-op Complications after free fibula flap for mandibular reconstructions in Adults

Volume No: 8, Issue No: 2

INTRODUCTION:

Mandible plays a pivotal role in mastication,

articulation, deglutition, and respiration; as well as defines
the contour of the lower third of the face

. Interruption in the

continuity of mandible, therefore, produces both a cosmetic
as well as a functional deformity

. It results in deviation,

malocclusion, temporomandibular joint pain, soft tissue
contracture and scar formation

. Hence, reconstruction of

mandibular defects after trauma or tumor resection is one of
the most challenging problems faced by the reconstructive
surgeons.

The free fibula flap (FFF) was introduced to

reconstructive surgical practice for traumatic tibial defects
by Taylor et al

in 1975. Later in 1989, Hidalgo

reported

the successful use of the flap in 12 patients with post-
resective segmental mandibular defects. Wei & Seah et al

saw 96.3% success rate of FFF in composite mandibular
defects. The adaptability of the flap is further extended by
the incorporation of osteotomy of the fibula. Jones et al

performed  a  single  transverse  osteotomy,  forming  two
struts,  which  created  the  versatile  ‘double  barrel’  fibula.
Bahr  et  al

subsequently adapted and popularized this

technique.  More  recently,  oromandibular  reconstruction
with  osteocutaneous  fibula  free  flap  and  endosseous
implants  became  the  treatment  of  choice  for  patients  who
underwent  enbloc  resection.  Zlotolow  et  al

successfully

demonstrated  functional  prosthetic  rehabilitation  in
microvascular  fibula  free  flap  reconstructed  mandibles  by
placing osseointegrated implants.

Literature reveals an increased risk of post-operative

complications  while  using  the  FFF.  Several  studies  have
tried  to  elucidate  risk  factors  such  as  age,  tobacco  use,
comorbidities  and  operating  time  for  early  and  late  post-
operative complications

. Early complications encountered

are flap necrosis, infections, fistulas, dehiscence or
hematoma formation

. Late post-operative complications

warrant  interventions  that  involve  removal  of  the  fixation
plating  due  to  loosening  of  screws,  plate  fracture,  plate
exposure,  and  infection  if  sufficient  soft  tissue  is  not
available for watertight primary closure

On the basis of the data available on the use and

complications  of  FFF’s  in  head  and  neck  reconstructions,
most  studies  are  found  to  be  descriptive  and  also  lack
statistical  analysis

. Therefore, the purpose of this

systematic review was to analyze the incidence of flap
failure, and also the basic post-operative complications such
as necrosis, infection, fistula, dehiscence and hematoma at
the recipient and donor site when employing free fibula flap
for mandibular reconstruction.

MATERIALS AND METHODS:

A comprehensive systematic review search in

accordance  with  the  PRISMA  guidelines  was  made  of
relevant  publications  in  databases  from  1995  to  2019.
Search engines used were PubMed and Google Scholar. An
initial  search  was  conducted  with  a  combination  of
keywords;

‘Free

Fibula

Flap’,

‘Mandibular

reconstruction’, ‘outcomes’,  and  ‘complications’.  These
results were combined with the Boolean operators ‘AND’,
‘OR’,  ‘NOT’.   ‘Free  fibula  flap  for  mandibular
reconstruction’  AND  ‘outcomes’  AND  ‘complications’
NOT  ‘virtual  planning’  NOT  ‘prostheses  were  used
eventually.  All abstracts were reviewed, and articles written
in  English  language  and  described  as  prospective  clinical
trials,  retrospective  cohorts,  case  series,  and  randomized
controlled trials were selected for the study (Figure 1).

Fig 1: Study Flow Diagram

The focus question for this review was 'What is the

incidence  of  post-operative  complications  associated  with
Free Fibula Flap when used for mandibular reconstruction?'
in  which  the  PICOS  criteria  was  considered.  Included
studies  comprised  of  those  with  adult  population  having
mandibular  defect  caused  by  trauma,  tumor,  malignancy,
osteoradionecrosis  or  osteomyelitis,  with  only  Free  Fibula
Flap  used  for  reconstruction.  Only  retrospective  or
prospective  cohort  studies,  randomized  controlled  trials,
case series and reports  were  considered appropriate. Also,

JIDAM “An Official Journal of IDA - Madras Branch” ©2021. Available
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ISSN No: 2582-0559

Manasi et al: Post-op Complications after free fibula flap for mandibular reconstructions in Adults

Volume No: 8, Issue No: 2

the  articles  which  reported  the  incidence  of  flap  failure,
recipient site (RS) and donor site (DS) complications were
included. Studies involving adjunctive use of any other flap
for  reconstruction,  treatment  done  with  virtual  surgical
planning,  animal  studies,  literature  reviews,  studies  with
only  abstract  and  studies  not  written  in  English  were
excluded from the review.

The review aimed in evaluating the basic post-

operative complications using the following parameters: a)
incidence of failure of the free fibula flap used in

mandibular  reconstruction,  b) recipient site  complications
(necrosis, infection, fistula, dehiscence and hematoma), and
c)  donor site  complications  (necrosis,  infection,  fistula,
dehiscence  and  hematoma).  Two  reviewers  independently
scanned each title and abstract of the studies to narrow down
and  subsequently  read  the  full  articles  of  those  that  were
potentially  eligible.  Only  those  studies  that  met  the
predefined inclusion criteria were considered eligible for the
systematic review (Table 1). A detailed study design of each
included study was then tabulated (Table 2).

TABLE 1: ARTICLES REVIEWED.

Article

No.

Title

Year

Type of Study

Duration of

Study

Yamamoto N, Morikawa T, Yakushiji T, Shibahara T.

Mandibular reconstruction with free vascularized fibular graft.

The Bulletin of Tokyo Dental College. 2018:2017-0025.

[11]

2018

Clinical report Jan 03 – Jan

Camuzard O, Dassonville O, Ettaiche M, Chamorey E,

Poissonnet G, Berguiga R, Leysalle A, Benezery K, Peyrade F,

Saada E, Hechema R. Primary radical ablative surgery and fibula

free-flap reconstruction for T4 oral cavity squamous cell

carcinoma with mandibular invasion: oncologic and functional

results and their predictive factors. European Archives of Oto-

Rhino-Laryngology. 2017 Jan 1;274(1):441-9.

[12]

2016

Retrospective

Jan 2001- July

2013

Lodders JN, Schulten EA, De Visscher JG, Forouzanfar T,
Karagozoglu KH. Complications and risk after mandibular

reconstruction with fibular free flaps in patients with oral

squamous cell carcinoma: a retrospective cohort study. Journal of

reconstructive microsurgery. 2016 Jul;32(06):455-63.

[8]

2015

Retrospective

April 95 to Sep

Hoffman GR, Islam S, Eisenberg RL. Microvascular

reconstruction of the mouth, face and jaws. Oromandibular

reconstruction–free fibula flap. Australian dental journal. 2012

Sep;57(3):379-87.

[13]

2012

Retrospective

Sep 05 to June

González-García R, Naval-Gías L, Rodríguez-Campo FJ,

Muñoz-Guerra MF, Sastre-Pérez J. Vascularized free fibular flap

for the reconstruction of mandibular defects: clinical experience

in 42 cases. Oral Surgery, Oral Medicine, Oral Pathology, Oral

Radiology, and Endodontology. 2008 Aug 1;106(2):191-202.

[9]

2008

Prospective

1996 to 2001

Peled M, El-Naaj IA, Lipin Y, Ardekian L. The use of free

fibular flap for functional mandibular reconstruction. Journal of

oral and maxillofacial surgery. 2005 Feb 1;63(2):220-4.

[14]

2005

Retrospective

1997-2002

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ISSN No: 2582-0559

Manasi et al: Post-op Complications after free fibula flap for mandibular reconstructions in Adults

Volume No: 8, Issue No: 2

TABLE 2: DETAILS OF DESIGN OF INCLUDED STUDIES.

Abbreviations: N (Necrosis), I (Infection), F (Fistula), D (Dehiscence), H (Hematoma), N (Total)

Two review authors independently assessed the risk of

bias of each included study using the Cochrane Handbook
for Systematic Reviews of Interventions. The graphical
representation of the same is depicted in Figure B.

Fig 2: Risk of Bias Summary

RESULTS:

According to the data achieved from the 6 suitable

articles,  Graph  1  gives  the  comprehensive  distribution  of
complications  in  a  total  of  246  patients.  The  Graph  2
indicates that a total of 49.97% showed no complications in
the RS nor the DS; offering a success rate close to 50% for
FFF in mandibular reconstruction.

Graph 1: The Distribution of Patients and its Complications

Article

No.

Author

Total number of

Patients who

underwent FFF

Flap

Failure

Recipient Site (RS)

Complications

Donor Site (DS)

Complications

I F

Nobuharu

Yamamoto

[11]

Olivier Camuzard

[12]

J. N. Lodders

[8]

GR Hoffman

[13]

González

[9]

Micha Peled

[14]

N=246

N=23

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Manasi et al: Post-op Complications after free fibula flap for mandibular reconstructions in Adults

Volume No: 8, Issue No: 2

Graph 2: Percentage Distribution of Patients and its

Complications

It was also observed that the highest complication rate

was seen at the recipient site i.e., in 75 of 246 patients, which
accounted to 30.49% of the total distribution. The donor site
complications and the rate of flap failure were nearly the
same i.e., 9.75% and 9.34% respectively.

A specific evaluation of complications for both RS and

DS  was  also  studied  (Graph  3).  Wherein,  the  RS
complication  revealed  that,  fistula  had  the  highest  rate  of
presentation which accounted to 30.6%. This was followed
by infection with a rate of 20%, necrosis and dehiscence had
the  same  prevalence  of  about  18.6%  each  and  hematoma
was the least seen complication, with a rate of 4% only.

Graph 3: Comparison of Complication Rate at Recipient Site

and Donor Site

In the DS complications, necrosis presented with an

exceptionally high rate of 37.5%, followed by infection and
dehiscence with a rate of 25% and 20.8% respectively,
hematoma in 12.5% and fistula with a rate of 4.1% only. A
stark difference was noted in fistula formation between the
RS and DS.

DISCUSSION:

Among the many causes, malignancy of the oral cavity,

osteoradionecrosis

after

radiotherapy,

congenital

deformities, trauma and ballistic injuries are few of the
leading reasons for mandible deformation

. Historically,

the results of oromandibular reconstruction were
unfortunately disastrous, notably at a time when surgery was
restricted to direct closure, or at best, locoregional flap
repair

. The patient’s appearance following such surgeries

was epitomized by the ‘Andy Gump’ cartoon figure of the
1930s

. Over the previous 15 years, reconstruction of large

mandibular defects has essentially been transformed by the
use of osseous microsurgical free flaps, such as the fibula,
iliac crest, and scapula

. The advent of these numerous

bone grafts with its versatility have now become the
preferred treatment modality for mandibular reconstruction.
However, each of these options have their own merits and
demerits.

The vascularized fibula flap is considered as the first

choice for reconstruction of mandibular continuity defects
in oral cavity cancer patients

. The success rates of FFF vary

between 92.9% and 100%.

8.9

Fibula bone has a thicker

cortex than the scapula, radius, or ilium and therefore,
resembles more closely to the mandible than any other
graft

. The possibility of several osteotomies because of the

periosteal blood supply allows for its better contour and
adaptation

9,18

. The added benefit of its ability to be

combined with other skin flaps for reconstruction of
composite defects, suitability for osseointegrated dental
implant and display of a 2-team approach makes it a reliable
flap in maxillofacial reconstruction

9,18

Even though, FFF presents with certain disadvantages;

various modifications are available to overcome the same.
One of the disadvantages being the inadequate height of
bone obtained; was attenuated by the introduction of double
barrel fibular graft

. The use of double-barrel FFF was first

described by Bahr et al.

in 1998, which allowed to obviate

the disadvantage of limited graft height relative to the
original mandible in dentate patients

. Another issue

observed with FFF was the variability of cutaneous
perforators and the limited size of skin island

. A

controversy exists in the literature, regarding the viability of
the skin paddle as an oral seal for which, it is recommended
to make use of a larger paddle by incorporating a cuff of
soleus to help ensure adequate blood supply by means of

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Manasi et al: Post-op Complications after free fibula flap for mandibular reconstructions in Adults

Volume No: 8, Issue No: 2

including as many septo-cutaneous vessels as possible to the
skin flap

17,9

. Moreover, the distal third of the lower leg

seems to be the most dependable region for obtaining the
skin

island,

ensuring

additional

reliability

9,17

Comprehending the above numerous assets and a handful
liabilities of FFF, it is crucial to have a thorough surgical
plan when incorporating it for mandibular reconstruction.

As with any microsurgical flap, the complications

related  to  the  use  of  FFF  in  reconstruction  of  continuity
defects of the mandible have been extensively studied; and
are reported to occur at the recipient site as well as the donor
site.  The  incidence  of  post-operative  complications
following  reconstruction  using  FFF  published  in  the
literature  ranges  from  22%  to  33%

12,16,19

Whereas, in our

search  and  systematic  analysis,  we  observed  a  post-
operative  complication  rate  of  50.03%;  out  of  which,  the
highest  contribution  was  from  the  complications  that
occurred  at  the  RS,  that  accounted  for  30.49%.  The
complications at recipient site could be catastrophic and are
predominantly  associated

with primary thrombotic

occlusion at the anastomosis

. Novakovic et al

stated that

the majority of failures at RS are prone to occur within the
first 48 hours and can be managed effectively with
immediate revision surgery. The later surgical interventions
are predominantly caused by infection, wound dehiscence,
osteonecrosis and plate fracture

. The inference to be

marked  is  that  there  is  an  increased  predisposition  of
complications that could occur at the RS; fistula formation
being the most frequent, as analysed in this study. Followed
by  infection  as  another  cause,  along  with  necrosis  and
dehiscence  that  could  account  for  an  increased  rate  of
recipient site complication after FFF reconstruction.

In concordance with the included studies; appropriate

pre-operative evaluation of the donor site was done prior to
graft  harvesting.  The  donor  site  presented  relatively  with
fewer  complications  but,  FFF  may  result  in  other
morbidities such as compartment syndrome, distal ischemia,
edema,  ankle  instability,  restricted  range  of  motion,  foot
drop, pain and impaired ambulation at the DS

17,13

. Anthony

et al

investigated a cohort study of 27 patients and

identified that 17% of donor sites presented with immediate
complications such as wound infection and skin graft loss.
It  also  identified  ankle  stiffness  (41%),  ankle  instability
(10%),  and  transient  pereneal  motor  weakness  (7%),  as
donor  site  morbidity

. There is enormous literature that

focuses on the aforementioned morbidities at DS

22-24

; hence,

our systematic review only emphasized on the additional
complications such as necrosis, infection, fistula formation,
dehiscence, and hematoma; out of which we concluded that
necrosis had the highest rate of occurrence.

Furthermore, the rate of flap failure achieved from our

analysis was 9.34%, which is closely consistent with the
data reported in previous literature. Lodders et al

and Wu

et al

stated that FFFs have an increased risk for flap failure.

Gonzales et al

revealed that out of 38 patients, two patients

presented with partial loss of the flap, one patient with total
loss  of  the  flap  and  at  the  end  of  the  five-year  follow-up
period,  five  cases  (11.9%)  showed  partial/total  loss  of  the
flap although only two cases (4.76%) developed loss of the
bone.

Therefore, it is prudent to understand that the fibular

graft with its numerous advantages does present with post-
operative complications. This study highlighted the
noticeably higher rate of basic complications at the recipient
site as well as a considerable rate at the donor site; making
it essential for the surgeons to be aware of them as well as
stringently learn their management.

DRAWBACKS:

We appreciate that this review is a retrospective

pooling of case series, which has led to the heterogenicity in
the  data  collection.  Recommendations  for  future  research
include  the  investigation  of  predictive  patient  and  clinical
risk  factors  as  well  as  incorporation  of  the  functional
outcomes and quality of life of patients that contribute in the
overall success of this flap in mandibular reconstruction.

CONCLUSION:

The

pre-operative

evaluation,

intra-operative

procedure  and  the  post-operative  assessment,  all  the  three
play  a  vital  role  in  determining  the  success  of  a  surgical
procedure.  Our  systematic  review  highlighted  the
possibility  and  occurrence  of  basic  post-operative
complications  that  occur  after  the  reconstructive  surgery
using Free Fibula Flap both at the recipient as  well as the
donor  site.  With  an  acceptable  low  morbidity  rate  at  the
donor  site  and  considerable,  but  easily  manageable
complications  at  the  recipient  site;  this  review  makes  us
aware about the importance of basic complications that are
equally essential towards the success of Free Fibula Flap.

CONFLICT OF INTEREST:

There are no conflicts of interest related to this review.

FUNDING AND SPONSORSHIP:

This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
profit sectors.

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Volume No: 8, Issue No: 2

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Volume No: 8, Issue No: 2

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