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--- resident:corrine_wong [2021/08/19 13:20] – [Thighplasty] taylor
+++ resident:corrine_wong [2022/06/15 09:23] (current) – [Fibula Flap for Mandible Reconstruction] lindsay
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 Photos\\
+{{:resident:img_2704.jpg?400|}}
 Tourniquet: finger / forearm / arm\\
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 Drains: 2x 15 french Blake drains, 1 on each side\\
-Dressing: Prineo, bolster, cover everything in telfa tegaderm, biopatch and tegaderm for the drain. Bolster is cotton balls, mineral oil and xeroform.\\
+Dressing: Prineo (or steri-strips and surgical glue), telfa bolster, cover everything in telfa tegaderm, biopatch and tegaderm for the drain. Bolster bacitracin, 3 layered telfa, tegaderm. **No longer using suture bolster**.\\
 Sutures: 2-0 PDS 3 point stitch. 3-0 nylon for drain. 3-0 silk for bolster. 3-0 vicryl for "SFS", 3-0 v-lock.\\
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 <WRAP half column>
 Photos:
-***
+{{:resident:img_5650.jpg?400|}}
 Tourniquet: None
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 Drains: 2x JP drains per leg - 1x at distal aspect of incision, 1x at superior aspect
-Sutures: ***
+Sutures: 3-0 drains, 2-0 v-loc SFS, 3-0 Vloc subcuticular, 3-0 monocryl rescue stitches
 Dressing: 1 inch steri strips, Exofen glue, ABD pads, compression leggings
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 </WRAP>
+==== Fibula Flap for Mandible Reconstruction====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Free fibula flap for mandible reconstruction\\
+\\
+A tracheostomy, vessel dissection and preparation of the mandible was performed by Dr. Glasgow. Please see his operative note for the technical details of his portion of the case.\\
+\\
+The distal and proximal portions of the fibula were palpated and marked and the entirety of the fibular was drawn to length along the lateral aspect of the right leg. A doppler was used to identify perforators should a skin paddle be needed. 6cm was measured from both the distal and proximal aspect of the fibula for the planned osteotomy sites and as to ensure that adequate bone length remained at both ends. A scalpel was used to make an incision the length between the two osteotomy sites. Dissection was started on the distal aspect of the fibula near were the perforators were found. Dissection was carried down and through the muscle fascia and then laterally looking for perforators. Two perforators were found and preserved. While palpating the fibula through the muscles of the lateral compartment the dissection was taken down to the fibula both distally and proximally. Care was taken to leave a small 2mm cuff of muscle on the fibula to preserve the periosteum. Dissection was taken around the fibula in a medial direction , removing muscle off the fibula, until the anterior compartment was entered. We transected the anterior crural septum. Care was taken to not injury the anterior tibial artery and neurovascular bundle. At this point the decision was made to perform the distal and proximal osteotomies to aid in dissection and exposure. The proximal and distal aspect that had been previously marked for the osteotomy sites were exposed by dissecting the periosteum off the bone circumferentially. Care was taken to not injure the pedicle. A narrow malleable was placed on the back side of the bone over the pedicle to protect the vessels. A bone saw was used to create both distal and proximal osteotomies. This freed the fibula and allowed for better visualization. Dissection continued through the muscle to the interosseous membrane which was carefully incised with sharp dissection. A doppler was used to identify the pedicle and its location. Once this was confirmed dissection continued around the pedicle into the deep posterior compartment. At this point the distal aspect of the pedicle was identified and ligated to free up the distal aspect of the fibula with the pedicle attached on the medial side. Dissection was then continued from the inferior to superior direction around the fibula , removing the surrounding muscle from the flap. The doppler was used continuously to ensure the location of the pedicle. All perforating vessels were clipped and ligated. One of the perforators for the skin paddle was coming from the soleus muscle and one from the septum. The skin paddle was approximately 6 cm x 3 cm. The perforator from the soleus muscle was ligated and the paddle was freed from the underlying fascia. Once the proximal aspect of the fibular was reached the pedicle was followed from the fibula proximally into the leg. The bifurcation of the posterior tibial vessels was clearly seen and identified. The peroneal vessels were circumferentially dissected and ligated freeing the entire fibula along with its vascular pedicle. Hemostasis was achieved in the leg incision. The flexor halicus longus was sutured to the interosseous membrane with 3-0 vicryl sutures. The peroneus longus and soleus muscle were then sutured together to close the muscle using 3-0 vicryl sutures. A 15 french blake drain was placed through a separate stab incision on the inferior aspect of the leg and secured with a 3-0 nylon. The incision was closed with 3-0 monocryl deep dermal sutures followed by a 3-0 v-lok suture. The incision was dressed with exofin glue followed by an island dressing.\\
+\\
+The presurgical planning bone template was secured to the fibula at the most distal end and the osteotomy and screw hole sites confirmed and scored with a bovie. Working proximally on the fibula the periosteum and surrounding tissue was elevated off the bone with great care taken to not damage the pedicle. This was taken all the way down to the point of the proximal osteotomy. The middle osteotomy sites were similarly cleared of surrounding tissues. The lingual end of the fibua was lengthened as the condyle from the mandible was removed in order to provide additional bone. The harvested skin paddle would not fit in the reconstruction and was removed. Screw holes were pre drilled for the fixation and reconstructive bar screws. Fixation screws were placed to keep the template on the bone. A bone saw was used to make the osteotomies with care taken to avoid injury to the pedicle. The fixation screws were then removed and the bone segments aligned to the reconstruction bar. Screws were then placed and the fibula fixed to the reconstructive bar. The proximal aspect of the fibula that was to be placed in the cranial fossa for mandibular articulation was filed smooth and round by the OMFS team with a pineapple bur. The flap and reconstructive bar was inset and found to be in an adequate position. \\
+\\
+Following inset, the peroneal pedicle was dissected out and cleaned under a microscope. The left facial artery and branches of the external and internal jugular veins, which had been dissected out by the OMFS team were in good position relative to the pedicle vessels. Once the vessels were cleaned and aligned a vein sizer was placed under the scope and a 4.0 size flow coupler was used to complete the anastomosis using a Synovis flow coupler device. A hemostat was then used to ensure the two rings of the flow coupler were securely closed. The second vein was also anastomosed in the same fashion using a 3.0 flow coupler. Next our attention was turned to the arterial anastomosis. Adequate flow was noted from the facial artery which was clamped with a Biover clamp. After cleaning the vessel the anastomosis was performed in a back to front fashion with interrupted 8.0 nylon sutures. Next an implantable Cook arterial doppler was placed around the flap side of the anastomosis by wrapping the two ends around the artery and then using small clips to secure it in place. The incision was irrigated and hemostasis was achieved with electrocautery. A 15 F blake drain was placed through a stab incision on the inferior and lateral portion of the patients neck. The sub-maindibular incision was closed with interrupted 3-0 vycril sutures followed by staples. Elastic bands were placed to place the patient in MMF by the OMFS team. The incisions were dressed bacitracin.\\
+</WRAP>
+<WRAP half column>
+Photos\\
+{{:resident:ab7bdb58-aeb7-4cd5-8636-0b7f0444f964.jpeg?400|}}
+Tourniquet: Thigh (optional)\\
+Drain: 15 round french in neck and donor site\\
+Sutures: Donor - 3-0 vicryl for muscle, 3-0 monocryl deep dermal (few) and 3-0 v-lok. Neck 3-0 vicryl deep. Staples.\\
+Dressing: Surgical glue and island dressing for leg. Baci for neck\\
+Anatomy: \\
+Prefers Michael Zenn book free fibula chapter.\\
+Post-operative care:\\
+POD#0: ASA suppository (300 mg), NPO **per mouth** (okay for tube feeds), Unasyn q8 for 72 hours, peridex, light teeth brushing, no objects in mouth, drain care, ICU status with q1 hour flaps, wean vent, CAM boot for walking (6 weeks)\\
+POD#1: Q1 hour flap checks, ASA 81 daily, start lovenox daily\\
+Order PT/OT, SLP for speaking valve, RT to discuss downsizing trach/decannulation, nutrition for tube feeds\\
+POD#2-4: Space flap checks as appropriate\\
+POD#7: Check with OMFS to see if patient can be taken out of elastics. Dr. Wong is usually okay with discharge at 1 week. Donor site drain can be removed. Check with Dr. Wong regarding neck drain -- watching for spit.\\
+POD#14: Swallow test (MBSS) - if passes can have pureed diet.\\
+\\
+Discharge:\\
+Patient will leave with NG/PEG for tube feeds.\\
+Cut wires for flow coupler and cook doppler and tape with tegaderm. They will be pulled at clinic.\\
+ASA 81 for 1 month. No lovenox necessary.\\
+Attending Pearls (Learning points/Pimp Questions):\\
+Will ask about CPN\\
+Will ask about the compartment of the leg.\\
+- Try TPA if arterial anastomosis clots off
+- 5000U of heparin
+</WRAP>
+</WRAP>