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A Prospective Cohort Study of Fibula Free Flap Donor-Site Morbidity in 157 Consecutive Patients
Adeyiza O. Momoh, M.D. Peirong Yu, M.D. Roman J. Skoracki, M.D. Suyu Liu, M.S. Lei Feng, M.S. Matthew M. Hanasono, M.D.
Houston, Texas
Background: Although the fibula free flap is preferred for bony head and neck reconstruction, donor-site morbidity remains a concern. The authors goal was to evaluate potential risk factors for complications and whether the type of wound closure and timing of postoperative ambulation had an effect on the development of short- and long-term morbidities. Methods: A prospective cohort study of donor-site morbidity was performed in 157 consecutive patients who underwent fibula free flap reconstruction for head and neck defects. Results: Perioperative donor-site complications occurred in 31.2 percent of patients, including skin graft loss (15 percent), cellulitis (10 percent), wound dehiscence (8 percent), and abscess (1 percent). Preoperative chemotherapy (p 0.02) was associated with increased complications. No significant difference in complication rates was observed between primary and skin graft wound closure (p 0.59). The timing of ambulation was not related to the development of complications (p 0.41). Long-term morbidities occurred in 17 percent of patients and included leg weakness (8 percent), ankle instability (4 percent), great toe contracture (9 percent), and decreased ankle mobility (12 percent). The occurrence of perioperative complications, flap type, and closure technique were not significantly associated with long-term morbidities. Functionally, 96 percent of patients returned to their preoperative level of ambulatory activity. Decreases in ambulatory status could all be ascribed to causes other than donor-site morbidity. Conclusion: Fibula free flap harvest is associated with a high rate of complications, but the majority of patients have no long-term functional limitations. (Plast. Reconstr. Surg. 128: 714, 2011.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.
lthough the fibula free flap is the preferred flap for bony head and neck reconstruction in most centers, donor-site morbidity remains a concern.1,2 The perioperative donor-site complication rate associated with the fibula free flap has been reported to be as little as 2 percent and as much as 38 percent.37 Reported long-term donor-site morbidity has also been variable, with some studies reporting no long-term morbidity and others suggesting that the majority of patients experience long-term problems with joint stiffness and instability, muscular weakness, or gait
From the Departments of Plastic Surgery and Biostatistics, University of Texas M. D. Anderson Cancer Center. Received for publication December 2, 2010; accepted March 18, 2011. Presented at the 89th Annual Meeting of the American Association of Plastic Surgeons, in San Antonio, Texas, March 20 through 23, 2010. Copyright 2011 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e318221dc2a
abnormalities.4,6 13 Given the prominent role of the fibula free flap in contemporary head and neck reconstruction, we felt that it was important to prospectively identify short- and long-term morbidities associated with this flap. In addition, we sought to identify predictive factors for complications and poor functional outcomes and to evaluate various options in how the donor site is managed operatively and postoperatively, which have rarely been studied before. Subjects of debate we address include the effect of method of donor-site closure (i.e., primary versus skin graft closure) and
Disclosure: The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for the work presented in this article.
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Table 2. Association of Donor-Site Complications with Medical Comorbidities and Other Potential Risk Factors in Patients Undergoing Fibula Free Flap Reconstruction (n 157)
No. of Patients (%) 15 (10) 12 (8) 18 (11) 6 (4) 3 (2) 19 (12) 46 (29) 39 (25) 16 (10) No. of Patients with Complication (%) 4 (27) 3 (25) 7 (39) 1 (17) 2 (67) 9 (47) 15 (32) 6 (15) 4 (25)
Comorbidity/ Risk Factor Cardiac disease Pulmonary disease Diabetes mellitus Peripheral vascular disease Morbid obesity Age 70 years Current tobacco use Preoperative chemotherapy Angiography*
*Patients for whom angiography was ordered because of a history suggesting vascular insufficiency or an abnormal lower extremity physical examination.
of complications in patients who received preoperative chemotherapy (p 0.02). Each complication was also analyzed individually to determine whether any comorbidity or risk factor was associated with the occurrence of that complication (data not shown). The need for preoperative angiography, based on a history suggesting vascular insufficiency or an abnormal physical examination, was found to be associated with wound dehiscence (p 0.03), and the association with a prior diagnosis of peripheral vascular disease approached but did not reach statistical significance (p 0.05). The comorbidities and risk factors examined were not associated with the occurrence of any other complications. The association between the occurrence of complications and the type of flap and the management of the donor site is shown in Table 3. An analysis of complications occurring relative to the area of the donor-site wound that needed to be skin grafted showed that larger skin-grafted donor wounds ( 100 cm2) were more likely to exhibit skin graft loss
Table 3. Association of Donor-Site Complications with Flap Type and Donor-Site Management in Patients Undergoing Fibula Free Flap Reconstruction (n 157)
Flap Type/ Donor-Site Management Flap type Osseous Osteocutaneous Type of closure Primary Skin graft No. of Patients (%) 19 (12) 138 (88) 56 (36) 101 (64) No. of Patients with Complication (%) 2 (11) 47 (35) 0.60 16 (29) 33 (33)
p 0.06
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level of ambulatory function was observed in seven patients (4 percent). However, all decreases in ambulatory status were attributable to causes other than donor-site morbidity: five patients experienced a decrease in ambulatory status caused by debilitation associated with treatment for recurrent disease, one patient underwent a partial lung resection for a second primary lung cancer limiting pulmonary function, and one patient had trauma to the knee requiring a knee replacement. Table 6 shows the number of patients who returned to their preoperative ambulatory status as a function of the number of months after surgery, based on their status at the time of their follow-up appointments at 1, 3, 6, 9, and 12 months. Besides the seven patients who experienced a decline in ambulatory status, 18 patients were excluded from this analysis because they missed one or more follow-up appointments. By 12 months after surgery, all but the seven patients who experienced a decline in ambulatory status had returned to their preoperative level of activity.
DISCUSSION
The overall rate of perioperative complications following fibula free flap harvest was 31 percent in the present study. Only 3 percent of the complications required operative intervention to resolve. However, healing for some complications took a prolonged period, up to 32 weeks. Our perioperative complication rate was consistent with the complication rates reported in some studies but not others, which reported much lower rates. Studies of fibula free flap donor-site morbidity following head and neck reconstruction are summarized in Table 7. In contrast to the present study, prior studies have been retrospective in nature and limited to smaller numbers of patients. Similar to the present study, the most common perioperative comTable 6. Return to Preoperative Ambulatory Status as a Function of Time in Patients Undergoing Fibula Free Flap Reconstruction (n 132)*
Months after Surgery 1 3 6 9 12 No. of Patients Who Returned to Preoperative Status (%) 32 (24) 53 (40) 33 (25) 11 (8) 2 (2) Cumulative No. of Patients Who Returned to Preoperative Status (%) 32 (24) 85 (64) 118 (89) 129 (98) 132 (100)
Table 5. Comparison of Preoperative and Postoperative Ambulatory Status in Patients Undergoing Fibula Free Flap Reconstruction (n
Ambulatory Status Nonambulatory Ambulatory with cane or walker Ambulatory without assistance but abnormal gait Normal ambulation Running or athletics Preoperative (%) 0 (0) 3 (2) 0 (0) 93 (59) 61 (39)
157)
*Seven patients experienced a decline in ambulatory status; however, all of these changes could be ascribed to causes other than donor-site morbidity.
*Seven patients who experienced a decline in ambulatory status for recurrent cancer, lung surgery, or knee surgery were excluded from this analysis. An additional 18 patients who missed one or more follow-up appointments were also excluded.
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NA, not available or cannot be determined from the data presented. *Present study.
plications include partial or total skin graft loss, wound dehiscence, and infection. There have been few prior analyses of risk factors for donor-site morbidity associated with the fibula free flap. In the present study, preoperative chemotherapy was found to be a significant predisposing factor for perioperative complications. Peripheral vascular disease may also be a risk factor for wound dehiscence but not statistically significantly so. Notably, two of six patients with a prior diagnosis of peripheral vascular disease had unremarkable lower extremity physical examinations, and four of six patients with a prior diagnosis of peripheral vascular disease underwent angiography that showed patent three-vessel flow to the distal leg. One reason that the diagnosis of peripheral vascular disease and other conditions associated with compromised tissue vascularity, such as diabetes and smoking, may not have been found to be strongly associated with complications is that symptoms and signs of advanced vascular insufficiency may have eliminated patients from undergoing fibula free flap reconstruction entirely. Consistent with this is that the need for angiography, based on abnormal findings during the history and physical examination, was itself found to be predictive of donor-site wound dehiscence. Looked at another way, the findings of this study suggest that patients without signs or symptoms of peripheral vascular compromise, either by prior diagnosis or by preoperative evaluation, can undergo fibula free flap harvest without elevated risks for donor-site morbidity (with the exception of those who have undergone neoadjuvant chemotherapy). Some authors have suggested that skin grafting may result in higher complication rates because of poor graft take of the donor-site wound bed.4,8 Others have hypothesized that moderately tight primary closures result in increased tissue ischemia and injury and therefore advocate skin graft closure of all but the smallest of donor-site wounds to avoid wound dehiscence or late morbidities related to tissue fibrosis.5 Only one prior
study has specifically examined the relationship of wound closure technique to the occurrence of donor-site morbidity: Shindo et al.5 found an 18 percent complication rate in donor sites closed with a skin graft compared with a 38 percent complication rate in those closed primarily, and ascribed the difference to the possible development of a pseudocompartment syndrome in donor sites closed primarily, although the difference in complication rates was not significant (p 0.10). Overall, 33 percent of patients in the present study who had their donor sites skin grafted experienced perioperative complications compared with 29 percent of patients who had primary wound closure (p 0.59). Our data therefore do not support prophylactically skin grafting donor-site wounds that can be closed under modest tension, using proper surgical judgment and common sense. The timing of ambulation following fibula harvest has never previously been studied. The few published protocols for ambulation following fibula free flap harvest vary considerably and are not evidence-based. For example, Zimmermann et al.7 allow crutch walking on postoperative day 1 and allow the patient to progress as tolerated to unassisted full-weight-bearing ambulation. Babovic et al.6 allow ambulation on postoperative day 2 in patients who undergo primary closure, but require bed rest until postoperative day 5 in patients who undergo skin graft closure, at which time the skin graft dressings are removed and weight-bearing ambulation is allowed. Papadopulos et al.19 mobilize their patients on the fifth postoperative day, allowing weight bearing as tolerated, although a splint is kept on for 6 weeks after surgery. Because we did not observe a significant association between the incidence of complications and timing of first ambulation, we now encourage early mobilization of our patients, beginning on postoperative day 1 or 2, if possible, because this may theoretically minimize the risks associated with prolonged bed rest, such as atelectasis, pneumonia, venous thromboembolism, and pressure ulcers.
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CONCLUSIONS
Fibula free flap harvest is associated with a high rate of complications. However, complications requiring surgical intervention are rare, and the vast majority of patients have no long-term functional limitations. Neither primary closure nor skin grafting is associated with an increased level of complications. Early weight-bearing ambulation is encouraged following fibula surgery because an association between the development of complications and the timing of postoperative ambulation was not observed.
Matthew M. Hanasono, M.D. Department of Plastic Surgery, Unit 443 University of Texas M. D. Anderson Cancer Center 1515 Holcombe Boulevard Houston, Texas 77030 mhanasono@mdanderson.org
REFERENCES
1. Wallace CG, Chang YM, Tsai CY, Wei FC. Harnessing the potential of the free fibula osteoseptocutaneous flap in mandible reconstruction. Plast Reconstr Surg. 2010;125:305313. 2. Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Reconstruction of the mandible with osseous free flaps: A 10-year experience with 150 consecutive patients. Plast Reconstr Surg. 1999;104: 13141320. 3. Anthony JP, Rawnsley JD, Benhaim P, Ritter EF, Sadowsky SH, Singer MI. Donor leg morbidity and function after fibula free flap mandible reconstruction. Plast Reconstr Surg. 1995; 96:146152. 4. Shpitzer T, Neligan P, Boyd B, Gullane P, Gur E, Freeman J. Leg morbidity and function following fibula free flap harvest. Ann Plast Surg. 1997;38:460464. 5. Shindo M, Fong BP, Funk GF, Karnell LH. The fibula osteocutaneous flap in head and neck reconstruction: A critical evaluation of donor site morbidity. Arch Otolaryngol Head Neck Surg. 2000;126:14671472. 6. Babovic S, Johnson CH, Finical SJ. Free fibula donor-site morbidity: The Mayo experience with 100 consecutive harvests. J Reconstr Microsurg. 2000;16:107110. 7. Zimmermann CE, Borner BI, Hasse A, Sieg P. Donor site morbidity after microvascular fibula transfer. Clin Oral Investig. 2001;5:214219. 8. Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg. 1995;96: 585596; discussion 597602. 9. Vail TP, Urbaniak JR. Donor-site morbidity with use of vascularized autogenous fibular grafts. J Bone Joint Surg Am. 1996;78:204211.
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