Letter to the Editor: Morbidity of the Free Fibula Flap Reconstruction in Head and Neck Malignancies

Reply to Letter to the Editor: Morbidity of the Free Fibula Flap Reconstruction in Head and Neck Malignancies

We read with great interest the article by Lodders et al[1] on free fibula reconstruction in patients suffering from oral squamous cell carcinoma. We welcome the authors' effort to critically analyze the complications of such a major reconstruction. The analysis has thrown up some results which merit deliberation.

The authors mention that a tracheostomy was performed for all patients. The mean anesthesia time was 100 minutes more than the mean operating time. However, they have not mentioned about the duration of postoperative mechanical ventilation. Do the authors not resort to a period of elective ventilation to counter any possibilities of undue neck movements or worse still, a stormy extubation? We follow a practice of overnight elective ventilation and weaning the support off the next day morning, after the patient and flap have been reassessed and found good. We began this protocol after one of our patients had a stormy extubation. The surgery finished late at night, and the patient was taken off the ventilator immediately. He struggled at the time of coming out of anesthesia, with undue movements of the entire upper half of the body. The flap in this patient was found to be congested the next day, and after a week of efforts at salvage, had to be removed on postoperative day 8.

Incidences of anatomic variations are also not mentioned by the authors. A recent article quoted that the percentage of finding a dominant peroneal artery is as high as 5.2%.[2] We too have not come across the arteria peronea magna,[3] similar to the experience of Lodders et al. However, in the last 4 years, we have encountered two instances of atheromatous calcification in the peroneal arterial wall. This comes as an intraoperative surprise ([Fig. 1]), more so because the peroneal artery is thought to be free of atherosclerosis in most patients.[4] Anastomosis could be performed uneventfully, with 8–0 nylon, and both the times the flaps did not cause any problem postoperatively.

Fig. 1 Picture showing the peroneal artery having a “lead-pipe appearance.” The inset shows a magnified view of the mouth of the artery, with calcification in the tunica media (black arrow).

The authors mention that 38.4% of their patients had a prior malignancy. A history of radiotherapy was documented in 8%. Were many of these reconstructions performed for recurrent disease, then? This in itself could be a very important reason for the high rate of complications reported.

The authors have found that the addition of a partial glossectomy resulted in a decreased complication rate. The explanation that increased tongue movements resulted in wound dehiscence, bleeding, and flap complications is debatable. A more convincing reason would be that partial glossectomy was performed in those patients who also had a lateral mandibulectomy, and in this subset of patients, the rate of complications is anyway less than those having a central mandibulectomy.

We would once again commend the authors in choosing to analyze in detail a reconstruction that could be time consuming and tricky at times.

• References

• 1 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. J Reconstr Microsurg 2016; 32 (6) 455-463
• 2 Abou-Foul AK, Borumandi F. Anatomical variants of lower limb vasculature and implications for free fibula flap: systematic review and critical analysis. Microsurgery 2016; 36 (2) 165-172
• 3 Rahmel BB, Snow TM, Batstone MD. Fibular free flap with arteria peronea magna: the role of preoperative balloon occlusion. J Reconstr Microsurg 2011; 27 (3) 169-172
• 4 Hansen T, Wikström J, Johansson LO, Lind L, Ahlström H. The prevalence and quantification of atherosclerosis in an elderly population assessed by whole-body magnetic resonance angiography. Arterioscler Thromb Vasc Biol 2007; 27 (3) 649-654