Retrograde vascularisation of fibula free flap in composite oro-mandibular reconstruction
A 64-year-old gentleman with a post radiation recurrent squamous carcinoma of the left lower alveolus was posted for composite resection and reconstruction with fibula free flap by simultaneous two team approach. The left fibula was selected and after flap harvest, the left neck vessels (superior thyroid and facial) were assessed for the volume and character of the flow and were found to be good. The bone defect was extending from midline anteriorly to proximal ramus posteriorly and the soft-tissue defect was confined to the oral cavity []. The flap was designed in a manner so that the superior thyroid vessels were to be used as donor vessels as they were away from the previous zone of irradiation and the blood flow was also good after dissecting them and dividing to look for the volume and adequacy of blood flow. After osteotomy and preliminary intra oral in setting of the skin paddle, and during the time of anastomosis, it was found that the flow in the superior thyroid artery was inadequate after initial good flow. Routine measures such as application of warm saline, xylocaine solution and later papaverine did not improve the flow and in such a situation, the options available were\nTo open the right neck and use vessels from that side either directly or with a vein graft To use a vein graft and anastomose with the facial artery on the same (left) side as the flow in this vessel was good To use the distal end of the flap pedicle vessels for anastomosis with left facial artery, so as to establish the vascular flow in a retrograde manner. This was because the clipped distal ends of the peroneal pedicle vessels were near to the left facial artery.\nBefore exploring the opposite neck or harvesting a vein graft, a decision was made to attempt retrograde vascularisation of the flap via the distal end of the peroneal vessels. First, the arterial anastomosis was completed between the distal end of the peroneal artery and left facial artery (end-to-end) and the flow was checked. The arterial flow was good as evidenced by the pulsations of the donor and recipient vessels and with the venous outflow from the distal end of the peroneal venae commitantes. This was followed by venous anastomosis between the distal end of the peroneal venae commitantes and a tributary of the left internal jugular vein (end to end). The skin paddle bleeding was also good with a sterile needle prick. Thus, the vascularity was restored with retrograde flow and was well established by the time the intra oral inset was completed []. The neck was then closed and post-op period was uneventful. After 6 weeks, a computed tomography (CT) angiogram revealed good establishment of blood flow to the neo mandible [Figures and ].