Free fibula flap OMFS 2021 journal club presentation
1. FREE FIBULA FLAP
MODERATOR: PROF. GUTHUA
PRESENTER: DR ROBERT KYALO MBALUKA
PLASTIC SURGERY
PGY3
UNIVERSITY OF NAIROBI
3RD MAY 2021
ORAL AND MAXILLOFACIAL
SURGERY
2. OUTLINE
• Introduction
• History
• Anatomy
• Flap components
• Flap applications
• Advantages & Disadvantages
• Pre Op Evaluation
• Flap design and raising
• Complications
• References
3. INTRODUCTION
• The free fibula flap (FFF) is a free tissue transfer of the fibula (± overlying skin) with
its vascular pedicle to a recipient site
• Fibula is a long non-weight bearing bone with adequate cortical thickness rendering it
one of the strongest bones available for mandibular reconstruction
• Harvested as - Osseous flap
- Fasciocutaneous flap
• To date, no flap alternative is capable of providing a longer segment of bone
4. HISTORY
• 1975 - Taylor1 et al. first introduced the fibula flap
• 1989 - Popular for mandibular reconstruction after Hidalgo2 utilized this technique to
restore 12 mandibular defects
• 1992 - Zlotolow3 and colleagues incorporated secondary osseointegrated dental
implants for functional rehabilitation
1. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg. 1975 May;55(5):533-44. doi:
10.1097/00006534-197505000-00002. PMID: 1096183.
2. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989 Jul;84(1):71-9. PMID: 2734406.
3. Zlotolow IM, Huryn JM, Piro JD, Lenchewski E, Hidalgo DA. Osseointegrated implants and functional prosthetic rehabilitation in microvascular fibula free flap reconstructed
mandibles. Am J Surg. 1992 Dec;164(6):677-81. doi: 10.1016/s0002-9610(05)80733-0. PMID: 1463123.
5. HISTORY
• 1994 - Wei4 and colleagues described the use of osteoseptocutaneous fibula flap for
reconstructing composite mandibular defects
• 1994 - Wei et al. and O'Leary5 et al. independently sought to convert the fibula flap into
a neurosensory flap by incorporating the lateral sural cutaneous nerve
• 2010 - Kuo6 and colleagues combined partial soleus muscle with fibula
osteoseptocutaneous flap for dead space obliteration
4. Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg. 1994 Feb;93(2):294-304;
discussion 305-6. PMID: 8310021.
5. O'Leary MJ, Martin PJ, Hayden RE. The neurocutaneous free fibula flap in mandibular reconstruction. Otolaryngol Clin North Am. 1994 Dec;27(6):1081-96. PMID: 7885692.
6. Kuo YR, Shih HS, Chen CC, Boca R, Hsu YC, Su CY, Jeng SF, Wei FC. Free fibula osteocutaneous flap with soleus muscle as a chimeric flap for reconstructing mandibular
6. ANATOMY & PHYSIOLOGY
Bony Anatomy
• Long, straight, non-weight bearing bone
• Adequate cortical thickness
• Measures 3 cm x 40 cm
Length; M>F (male mean length is 387.4 ± 23.7 mm/ females 361.5 ± 12.3 mm)7
• Tricortical profile, or triangular cross-section due to muscle attachments thus its shape
• 3 Surfaces – Medial, Lateral, Posterior
7. Taqi M, Raju S. Fibula Free Flaps. [Updated 2021 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK564337/
11. ANATOMY
Vascular Anatomy
Pattern of Circulation
• Nutrient endosteal and periosteal septal and muscular pedicles
(Type 5)
Dominant: Nutrient artery from peroneal artery;
Length: 1–2 cm, Diameter: 1.0 mm
Minor: Periosteal and muscular branches from peroneal artery
Diameter: At their origin range from 0.8 mm to 1.7 mm
Image 4. Borrowed from the Clinical Atlas of Muscle and Musculocutaneous Flaps, January 9, 1979 by Stephen J. Mathes, Foad
Nahai
12. ANATOMY
Vascular Anatomy
• Periosteal and muscular branches – Derived from the peroneal artery
• Peroneal artery - Located along the fibular origin of musculature and posterolateral
septum
• Musculoperiosteal vessels - Course via flexor hallucis longus and tibialis posterior
muscles
• Averagely 4–8 cutaneous arteries arising from the peroneal artery
• Middle third of the fibula shaft – most number of the periosteal branches
• When there are no septocutaneous branches, musculocutaneous branches can supply
adequate circulation to the same skin area
13. Image 5. Borrowed from the Clinical Atlas of Muscle and Musculocutaneous Flaps, January 9, 1979 by Stephen J.
14. Image 6. Borrowed from https://thoracickey.com/duplex-scanning-prior-to-fibula-
15. ANATOMY
Vascular Anatomy
• Venous Drainage
Primary: Venae comitantes of the peroneal artery, often 2
Length: 2–6 cm; Diameters: 2–4 mm
Secondary: Superficial venous system
Length: 2–6 cm or longer; Diameter: 2–4 mm
Note: In the case of a fibular osteoseptocutaneous flap a superficial vein (commonly the lesser
saphenous) draining the skin paddle may sometimes be used as adjunctive drainage of the flap. This is
particularly useful when a large skin island is harvested.
16. ANATOMY
Vascular Anatomy Relevance
• Deciding which part of the fibula is needed for a particular case
• Length of the pedicle -Up to 15 cm if distal fibula is harvested
- Less if the more proximal bone is used
• Perforating vessels from the peroneal artery can support a skin paddle measuring up to
10 x 20 cm in area
• Vascularized bone grafts may withstand early mechanical loading better than non-
vascularized grafts
• This may minimize the likelihood of bone resorption and stress fracture, as they can remodel over
time
17. ANATOMY
Nerve Supply
• Sensory: Lateral sural nerve & Terminal sensory branch of the superficial peroneal nerve
• Adequate in size to allow microscopic anastomoses
• Sensory feedback may improve oral function or tactile penile sensation if a phalloplasty is performed
18. FLAP COMPONENTS
• Harvested - As a bone flap/include regional musculature (soleus or flexor hallucis
longus), and/or overlying skin
Vascularized bone – a cuff of the lateral soleus, flexor hallucis longus and tibialis
posterior muscles is elevated with the fibula to preserve periosteal and nutrient
bone circulation
Vascularized muscle – lateral half of soleus muscle maybe elevated with the fibula
based on the peroneal branches to this muscle
Osseofasciocutaneuos flap – Skin paddle included
Sensory flap – the superficial peroneal nerve may be included with lateral leg skin to
provide an osseous neurosensory flap
20. FLAP APPLICATIONS
• Reconstruction – Ipsilateral tibia
• Microvascular transplantation
• Reconstruction
Head & Neck – Mandibular, Palatomaxillary recon
Upper extremity - skeletal defects >6cm due to tumor resection, trauma,
nonunion, osteomyelitis, or a congenital anomaly10,11,12
Lower extremity13 – Trauma, tumor resection, severe sepsis, tibial recon
10. Wood MB. Upper extremity reconstruction by vascularized bone transfer. Results and complications. J Hand Surg [Am]. 1987;12A:422–427
11. Tang C. Reconstruction of the bones and joints of the upper extremity by vascularized free fibular graft: report of 46 cases. J Reconstr Microsurg.
1992;8:285–292.
12. Tu Y, Yen C, Yeh W, et al. Reconstruction of posttraumatic long bone defect with free vascularized bone graft. Acta Orthop Scand. 2001;72:359–364.
13. Beris AE, Lykissas MG, Korompilias AV, Vekris MD, Mitsionis GI, Malizos KN, Soucacos PN. Vascularized fibula transfer for lower limb reconstruction.
21.
22. FLAP ADVANTAGES
• Length of available bone14 – Up to 26cm in adults
• Skin paddle - up to 25 cm in length and 5 cm in width15,16,17
• Concurrent harvesting
Two surgical teams, distant donor and recipient sites18
Supine position of patient
• Easy reconstruction of the mandible19
• Excellent results – Functionally & esthetically, particularly in children19
• Implantation - Thickness of the fibular diaphysis of at least 1 cm
Graft is bicortical - better fixation for the implants20
10. Wood MB. Upper extremity reconstruction by vascularized bone transfer. Results and complications. J Hand Surg [Am]. 1987;12A:422–427
11. Tang C. Reconstruction of the bones and joints of the upper extremity by vascularized free fibular graft: report of 46 cases. J Reconstr
Microsurg. 1992;8:285–292.
12. Tu Y, Yen C, Yeh W, et al. Reconstruction of posttraumatic long bone defect with free vascularized bone graft. Acta Orthop Scand.
2001;72:359–364.
13. Beris AE, Lykissas MG, Korompilias AV, Vekris MD, Mitsionis GI, Malizos KN, Soucacos PN. Vascularized fibula transfer for lower limb
reconstruction. Microsurgery. 2011 Mar;31(3):205-11
23. FLAP ADVANTAGES
• Mild donor site sequelae21 – Stability. (preserved 4cm of distal fibula)
• Children – Does not resulting in growth retardation at the leg
• Well-defined vascular supply - Allows for multiple osteotomies (2–3 cm bone segments)
Important in craniofacial contouring
• Well-defined vascular supply - For recipient site wound contamination, scarring,
Radiation, or infected bone post debridement
• Suitable donor vessels (peroneal artery, 1.5–2.5 mm; vein, 2–4 mm)
Anastomoses to large vessels in the head & neck, and
Upper/lower extremities
21. Youdas JW, Wood MB, Cabalan TD, et al: A quantitative analysis of donor site morbidity after vascularized fibula transfer J Ortbop Res 6:621, 1988.
24. FLAP ADVANTAGES
• Its anatomy - Triangular, high-density cortical bone
Resists angular and rotational stresses, considered ideal for extremity
axial skeleton reconstruction
• Size - Matches the size of the radius and ulna
Snugly fits into the medullary cavity of the humerus, femur, and tibia.
Image 7. Borrowed from Distal Femur Fractures & Nonunion Fibular Graft - Everything You Need To Know
25. FLAP DISADVANTAGES
• Multiple osteotomies – Destruction of the centromedullary fibular pedicle
• Pedicle kinking - In complex reconstructions, poor vascularization of the distal fragments
• Aesthetic sequelae – Leg scar
• Not suitable in patients with ischemic disease of the lower limbs
Poor flap vascularization
Fibular artery as only collateral supply to the distal lower limb
• Short length of its pedicle - difficult anastomoses
No more than 5 cm is available
• Skin paddle inadequacy in large soft tissue reconstruction22
• Technique of flap harvest - steep learning curve
22. Menard PH, Germain MA, Kapron AM, et al: Reconstruction mandibulaire par transfert libre de perone. Rev Stomatol Chir
26. PREOPERATIVE PREPARATION
• Medical History
• Medical conditions - unreliability of the peroneal artery as a pedicle for free tissue transfer
• Peripheral vascular disease, deep vein thrombosis, trauma, venous stasis disease, arteritis,
DM, *HIV
• Clinical Examination
• Knee & ankle joints - Assess for range of motion and laxity
• Doppler foot Allen’s test - Ensure a signal for the dorsalis pedis and posterior tibial artery
• Rule out Peronea magna
• Evaluate blood flow to the extremity - CT angiograms (trauma)
- Duplex ultrasonography
*Intraoperatively – Visualize Post Tibial artery before severing peroneal artery
27. Peroneus Magnus -
Solid arrow: anterior
tibial artery. Hollow
arrow: peroneal
artery. Short arrow:
plantar artery from
posterior tibial
artery.
Image 8. Borrowed from Medscape; Fibula Tissue Transfer Updated: Sep 19, 2018 Author: Mark K Wax, MD; Chief Editor:
Arlen D Meyers, MD, MBA
28. FLAP DESIGN
PATIENT POSITIONING
• Supine
• Knee flexion and internal rotation of the hip
• Foot fixed on the table
• Heel raised
• Tourniquet – Full
Intermediate short term23
Non tourniquet
23. Thiele OC, Scuto I, Allamprese F, Freier K, Hoepner C, Simon R. Intermediate short-term tourniquet use during the preparation of a free vascularised fibula flap
for mandibular reconstruction. A case report. Minerva Stomatol. 2008 Jan-Feb;57(1-2):53-5, 56-7. English, Italian. PMID: 18427371.
29. FLAP DESIGN
ANATOMIC LANDMARKS & MARKINGS
• Fibula head & Lateral malleolus
• Interconnecting line along posterior
border of fibula
• A point 4 cm below head of fibula
• A point 6 cm above lat. Malleolus
• Doppler – Perforators
• Midpoint – Nutrient vessel
30. FLAP DESIGN
FLAP DIMENSION
VASCULARIZED BONE FLAP
• Bone Length
Average 16 cm, max 30 cm
• Line - fibular head to lateral
malleolus
Indicates the submuscular and
subcutaneous course of the fibula
31. FLAP DESIGN
FLAP DIMENSION
SKIN ISLAND
• Skin Island Length
Average 15 cm
• Skin Island Width
Average 8 cm
• Septocutaneous and
musculocutaneous perforators
32. FLAP DESIGN
INCISION & DISSECTION
• Anterior incision - down
to the level of fascia
• Fascial incision - over the
lateral compartment
• Subfascial dissection -
proceeds posteriorly
until the posterior
intermuscular septum is
encountered and skin
perforators are seen
traveling within this
septum
33. FLAP DESIGN
INCISION & DISSECTION
• Lateral compartment
muscles - dissected off of
the fibula
• Leave a 3 mm cuff of
muscle - protect the
periosteal blood supply
• Anterior intermuscular
septum is incised
34. FLAP DESIGN
INCISION & DISSECTION
• Anterior compartment
muscles are dissected off
of the fibula bone
• The proximal and distal
fibula bone is cut.
35. FLAP DESIGN
INCISION & DISSECTION
• Interosseous septum is
incised
• The deep posterior
compartment muscles
are exposed.
• Posterior incision is made
• Skin island dissected in
the subfascial plane
anteriorly until the
posterior intermuscular
septum is met
• Gastrocnemius & Soleus
are dissected away from
the skin island
36. FLAP DESIGN
INCISION & DISSECTION
• Distal peroneal vessels are
ligated
• FHL is dissected away from
the fibula bone from distal to
proximal
• Tourniquet is released for
20 min
• Flap is harvested
37. FLAP DESIGN
DONOR SITE CLOSURE
• Primary closure possible if island
<5cm was raised
• Larger defect
Exposed muscles sutured/covered with
graft
VAC dressing then graft
38. ANASTOMOSIS
• Considerations
• Away from site of radiation
• Recipient vessels - Good flow character and volume
• Contralateral - Vein graft
• Short vessels – Vein graft
• Non viable proximal flap vessels – Use distal end of the flap pedicle vessels for anastomosis with
e.g. facial artery, so as to establish the vascular flow in a retrograde manner24
• Single vs. dual venous anastomosis?25
• Vessels used: -Superior thyroid artery
-Facial artery & facial vein
24. Nambi, G. I., & Dhiwakar, M. (2013). Retrograde vascularisation of fibula free flap in composite oro-mandibular reconstruction. Indian journal of
plastic surgery
39. MODIFICATIONS
• Contouring – Single or multiple osteotomies
• Vertical height discrepancy – osteotomy and fold in a parallel fashion to a “double
barrel”26 shape
26. Bähr W, Stoll P, Wächter R. Use of the "double barrel" free vascularized fibula in mandibular reconstruction. J Oral Maxillofac Surg. 1998 Jan;56(1):38-44. doi:
10.1016/s0278-2391(98)90914-4. PMID: 9437980.
25.
40.
41.
42. COMPLICATIONS
DONOR SITE
• Compartment syndrome
• Distal ischemia
• Edema
• Ankle instability
• Restricted range of motion
• Foot drop
• Pain
• Impaired ambulation
• Infections27
• Dehiscence
• Skin graft loss27
• Bone & tendon exposure28
27. 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: 146– 152
28. Shindo M, Fong BP, Funk GF, Karnell LH. The fibular osteocutaneous flap in head and neck reconstruction: a critical evaluation of donor site morbidity. Arch Otolaryngol
Head Neck Surg 2000; 126: 1467– 1472.
43. COMPLICATIONS
RECEPIENT SITE29
• Arterial insufficiency
• Venous congestion
• Hemorrhage
• Hematoma
• Skin island necrosis
• Extraoral wound dehiscence
• Intraoral wound dehiscence
• Infection
• Plate fracture
• Osteonecrosis
• Nonunion
29. van Gemert, J., Abbink, J. H., van Es, R., Rosenberg, A., Koole, R., & Van Cann, E. M. (2018). Early and late complications in the reconstructed mandible with free fibula
flaps. Journal of surgical oncology, 117(4), 773–780. https://doi.org/10.1002/jso.24976
45. CONTRAINDICATIONS
RELATIVE
• HIV positive with low CD4 count30
• Vasculitis
• Connective tissue disorders
• Coagulation disorders
• Absence of vessels at the
donor/recipient site eg. Prior neck
dissection surgery
• Donor/recipient site irradiation
• Small skin pedicle available for flaps
• Smoking and healing status of the
patient
• Severe obesity
30. Wanjala F. Nangole, Stanley Khainga, Joyce Aswani, Loise Kahoro, Adelaine Vilembwa, "Free Flaps in a Resource Constrained Environment: A Five-Year Experience—
Outcomes and Lessons Learned", Plastic Surgery International, vol. 2015, Article ID 194174, 6 pages, 2015. https://doi.org/10.1155/2015/194174
46. CONTRAINDICATIONS
ABSOLUTE
• Peripheral vascular disease involving the
lower extremities
• Hypoplastic anterior tibial artery (5% of
the population)
• Venous insufficiency
• Deep vein thrombosis
• Significant atherosclerotic disease
• History of contralateral lower extremity
amputation
47. REFERENCES
1. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular
techniques. Plast Reconstr Surg. 1975 May;55(5):533-44. doi: 10.1097/00006534-197505000-00002.
PMID: 1096183.
2. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989
Jul;84(1):71-9. PMID: 2734406.
3. Zlotolow IM, Huryn JM, Piro JD, Lenchewski E, Hidalgo DA. Osseointegrated implants and functional
prosthetic rehabilitation in microvascular fibula free flap reconstructed mandibles. Am J Surg. 1992
Dec;164(6):677-81. doi: 10.1016/s0002-9610(05)80733-0. PMID: 1463123.
4. Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of
composite mandibular defects. Plast Reconstr Surg. 1994 Feb;93(2):294-304; discussion 305-6. PMID:
8310021.
5. O'Leary MJ, Martin PJ, Hayden RE. The neurocutaneous free fibula flap in mandibular reconstruction.
Otolaryngol Clin North Am. 1994 Dec;27(6):1081-96. PMID: 7885692.
6. Kuo YR, Shih HS, Chen CC, Boca R, Hsu YC, Su CY, Jeng SF, Wei FC. Free fibula osteocutaneous flap
with soleus muscle as a chimeric flap for reconstructing mandibular segmental defect after oral cancer
ablation. Ann Plast Surg. 2010 Jun;64(6):738-42. doi: 10.1097/SAP.0b013e3181a72f62. PMID: 20407367
48. REFERENCES
• 7. Taqi M, Raju S. Fibula Free Flaps. [Updated 2021 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564337/
• 8. Golas AR, Levine JP, Ream J, Rodriguez ED. Aberrant Lower Extremity Arterial Anatomy in
Microvascular Free Fibula Flap Candidates: Management Algorithm and Case Presentations. J Craniofac
Surg. 2016 Nov;27(8):2134-2137. doi: 10.1097/SCS.0000000000003220. PMID: 28005769.
• 9. Sparks DS, Saleh DB, Rozen WM, Hutmacher DW, Schuetz MA, Wagels M. Vascularised bone transfer:
History, blood supply and contemporary problems. J Plast Reconstr Aesthet Surg. 2017 Jan;70(1):1-11.
doi: 10.1016/j.bjps.2016.07.012. Epub 2016 Jul 27. PMID: 27843061.
• 10. Wood MB. Upper extremity reconstruction by vascularized bone transfer. Results and
complications. J Hand Surg [Am]. 1987;12A:422–427
• 11. Tang C. Reconstruction of the bones and joints of the upper extremity by vascularized free fibular
graft: report of 46 cases. J Reconstr Microsurg. 1992;8:285–292.
• 12. Tu Y, Yen C, Yeh W, et al. Reconstruction of posttraumatic long bone defect with free vascularized
bone graft. Acta Orthop Scand. 2001;72:359–364.
• 13. Beris AE, Lykissas MG, Korompilias AV, Vekris MD, Mitsionis GI, Malizos KN, Soucacos PN.
Vascularized fibula transfer for lower limb reconstruction. Microsurgery. 2011 Mar;31(3):205-11
49. REFERENCES
14. Wood MB. Upper extremity reconstruction by vascularized bone transfer. Results and complications. J
Hand Surg [Am]. 1987;12A:422–427
15. Tang C. Reconstruction of the bones and joints of the upper extremity by vascularized free fibular
graft: report of 46 cases. J Reconstr Microsurg. 1992;8:285–292.
16. Tu Y, Yen C, Yeh W, et al. Reconstruction of posttraumatic long bone defect with free vascularized
bone graft. Acta Orthop Scand. 2001;72:359–364.
17. Beris AE, Lykissas MG, Korompilias AV, Vekris MD, Mitsionis GI, Malizos KN, Soucacos PN. Vascularized
fibula transfer for lower limb reconstruction. Microsurgery. 2011 Mar;31(3):205-11
18. Youdas JW, Wood MB, Cabalan TD, et al: A quantitative analysis of donor site morbidity after
vascularized fibula transfer J Ortbop Res 6:621, 1988.
19. Menard PH, Germain MA, Kapron AM, et al: Reconstruction mandibulaire par transfert libre de
perone. Rev Stomatol Chir Maxillofac 93:98, 1992
20. Thiele OC, Scuto I, Allamprese F, Freier K, Hoepner C, Simon R. Intermediate short-term tourniquet
use during the preparation of a free vascularised fibula flap for mandibular reconstruction. A case report.
Minerva Stomatol. 2008 Jan-Feb;57(1-2):53-5, 56-7. English, Italian. PMID: 18427371
50. REFERENCES
21. Nambi, G. I., & Dhiwakar, M. (2013). Retrograde vascularisation of fibula free flap in composite oro-
mandibular reconstruction. Indian journal of plastic surgery
22. Zhengxue Han D.D.S., Ph.D. Single versus dual venous anastomoses of the free fibula osteocutaneous
flap in mandibular reconstruction: A retrospective study, 03 September 2013
23. Bähr W, Stoll P, Wächter R. Use of the "double barrel" free vascularized fibula in mandibular
reconstruction. J Oral Maxillofac Surg. 1998 Jan;56(1):38-44. doi: 10.1016/s0278-2391(98)90914-4. PMID:
9437980.
24. 27. 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: 146– 152
25. Shindo M, Fong BP, Funk GF, Karnell LH. The fibular osteocutaneous flap in head and neck
reconstruction: a critical evaluation of donor site morbidity. Arch Otolaryngol Head Neck Surg 2000; 126:
1467– 1472.
26. van Gemert, J., Abbink, J. H., van Es, R., Rosenberg, A., Koole, R., & Van Cann, E. M. (2018). Early and
late complications in the reconstructed mandible with free fibula flaps. Journal of surgical oncology,
117(4), 773–780. https://doi.org/10.1002/jso.24976
53. CHOICE OF JOURNAL
• Well written
• Content
• Data one study design can yield – Complications
- Risk factors for complications
54. TITLE
• Ambiguity; Too general or too specific? Balanced
• General enough ensuring the paper doesn’t have limited appeal to the journal’s readership.
• Too general that it may be misleading or irrelevant to many readers’ needs.
• Title length – Adequate at 12 words/81 characters
• Communicate to the reader?
• Use of key words
• Accuracy?
55. AUTHORS
• Authors names, Qualifications & Affiliations – stated
• Affiliations – Department, University, Town/City, Country
• Previous publications on a similar topic?
• Van Gemert JT, Van Es RJ, Rosenberg AJ, et al. Free vascularized flaps for reconstruction of the mandible:
complications, success, and dental rehabilitation. J Oral Maxillofac Surg. 2012;70:1692–1698.
• Corresponding author and address – stated, limited to 1
56. KEYWORDS & ABSTRACT
• Keywords – relevant, informative
• Added – risk factors
• Abstract
• Slightly over 200 words
• Use of abbreviations?
57. TEXT
• Retrospective study design
• Structured? Generally follows IMRAD guidelines
• Introduction
• Materials and methods
• Results
• Discussion
• Conclusion
• Acknowledgement
• Disclosure
• References
• 1 spelling error – page 7, paragraph 2, line 5
59. INTRODUCTION
• Study aim – Risk factors
associated with early
and late major
complications
• Title – Early & late
complications
• Ended intro with aim of
study
60. MATERIALS & METHODS
• Location of study – stated
• Mention of;
Surgeons
Pre op evaluation Technique
Type of plates used
• Medication given and duration
• Definitions and terms – outlined
• Radiotherapy and its onset of effects
• Binary logistic regression used
• A two tailed P-value equal or less than 0.05 - statistically significant.
61. RESULTS
• 79 free fibula flaps (FFF’s) were used to reconstruct the mandible in 76 patients, between
September 1999 and June 2013
• 1st table - Major recipient site complications in 79 patients who underwent free fibula
flap reconstructions of the mandible
• 2nd table - Effect of categorical factors on early recipient site complications (within 6
weeks), requiring intervention
• 3rd table - Effect of continuous factors on early recipient site complications (within 6
weeks), requiring intervention
• 4th table - Effect of categorical factors on late recipient site complications (later than 6
weeks), requiring intervention
• 5th table - Effect of continuous factors on late recipient site complications (later than 6
weeks), requiring intervention
62. RESULTS
• STUDY LIMITATIONS
Retrospective study
Small sample size
• “These prolonged treatments are a heavy burden for the patient and for the
hospital's resources in addition to the final surgical intervention.”
• Missed opportunity to study cost of prolonged non surgical therapies for
management of complications before surgical intervention.
• Setting with super specialists may have influenced outcome
• ? Reproducibility of study in settings without super specialists
63. CONCLUSION
• The different influence of risk factors on early and late complications in
mandibular reconstruction with free fibula flaps has not been described before
• Study aim well captured
ACKNOWLEDGEMENT, DISCLOUSRE AND
REFERENCES
• Well outlined
