|89th Annual Meeting Abstracts
A Prospective Analysis of Free Fibula Flap Donor Site Morbidity and Postoperative Function in 165 Consecutive Patients
Adeyiza O. Momoh, M.D.1, Peirong Yu, M.D.2, Roman J. Skoracki, M.D.2, Suyu Liu, M.S.2, Lei Feng, M.S.2, Matthew M. Hanasono, M.D.2.
1Baylor College of Medicine, Houston, TX, USA, 2The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA.
Donor site morbidity and function after fibula free flap harvest are concerns and have been previously reviewed only in small groups of patients. Our objectives were to prospectively determine the true rate of complications and the postoperative function associated with this procedure as well as to identify patient-related risk factors for complications and poor functional outcomes. Additionally, we wished to clarify whether the occurrence of complications or the functional outcome are related to the type of donor site closure, or the timing of postoperative mobilization.
Between 2005 and 2009, we performed 165 consecutive fibula free flap reconstructions for head and neck reconstruction. Osteocutaneous flaps were used in 145 (87.9%) patients and osseous flaps were performed in 20 (12.1%) patients. One hundred and seven (64.8%) donor sites were closed primarily and 58 (35.2%) required skin grafts. Ultimately, 157 (95.1%) patients were available for follow-up an average of 318.5 days after surgery. Potential risk factors, donor site complications, and postoperative function were evaluated, taking into account the type of wound closure (primary vs. skin graft) and two different mobilization protocols: early (beginning the second postoperative day) and late (beginning the sixth postoperative day).
Donor site complications occurred in 49 (30.6%) patients, including: skin graft loss (22.9%), cellulitis (9.6%), abscess (0.6%), and wound dehiscence (8.3%). There was an increased incidence of wound dehiscence in patients with rheumatologic disease (37.5%, p=0.02) and peripheral vascular disease (22.2%, p=0.054). Furthermore, the need for preoperative vascular studies was found to be a significant predictor for wound dehiscence (25.0%, p= 0.03). Donor sites closed primarily were more likely to result in wound dehiscence compared to skin grafted donor sites (p=0.055). Not surprisingly, larger skin-grafted donor wounds (≥100 cm2) were more likely to exhibit skin graft loss (p=0.04) and tendon exposure (p=0.007) than smaller donor wounds. However, complications were not more likely to occur with either primary or skin graft wound closure (p=0.59). Complications also did not appear to be related to early or late mobilization (p=0.95).
Functionally, a few patients complained of leg weakness (7.6%), and ankle instability (3.8%). Limitations in ankle (1.9%) and great toe (8.9%) range of motion were elicited in some patients. However, all patients were able to walk (27.8%), or run/climb stairs (72.2%) without difficulty by the time of last follow-up. Long-term, 94.3% of patients returned to their preoperative level of activity. Of the patients that did not regain their prior level of activity, 55.6% had restricted activity due to the effects of further treatment or disease recurrence. No significant difference in function was observed with primary or skin graft closure or the early or late mobilization protocols.
Fibula free flap reconstruction is associated with a significant 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 ambulation following fibula surgery is recommended given that it does not increase donor site complications.