Rhabdomyolysis is a spectrum of the clinical picture due to the damage of myocytes and the leakage of cellular materials to the vascular stream. The clinical feature of rhabdomyolysis varies from the asymptomatic elevation of the liver functional lab result to motility, electrolyte imbalance, and acute kidney injury [8, 9]. Postoperative rhabdomyolysis is associated with several factors: non-supine position (prone, lateral, and variations of lithotomy) during surgery, prolonged surgery time, and use of tourniquet during surgery [10]. Figure 3 describes the mechanisms of rhabdomyolysis. (Fig. 3).
If there is no suspicion, the diagnosis of rhabdomyolysis may be missed because myalgia and swelling may not be observed. Therefore, the laboratory test result, such as CK and urine myoglobin, should be confirmed for the definitive diagnosis of rhabdomyolysis. Additionally, biopsy may be done to ascertain the diagnosis. There are no specific diagnosis criteria in rhabdomyolysis, but many clinicians determine diagnosis when a serum enzyme, such as CK and myoglobin, is five times higher than the normal range [11].
Although a rare complication of the operation, especially in maxillofacial surgery, postoperative rhabdomyolysis has been reported in several surgical fields, including urology, neurosurgery, and orthopedic, cardiovascular, and bariatric surgeries. Several risk factors have been identified, including long-term surgery (> 7 h) without proper repositioning, location of the patient (generally crush or side pressure sores), extended tourniquet time (> 1 h), and other systemic complications, such as diabetes, hypertension, and peripheral vascular disease [8,9,10, 12,13,14,15].
Our patients meet a variety of causes or conditions that contribute to the development of rhabdomyolysis, such as diabetes, hypertension, use of pneumatic tourniquets, dehydration, and prolonged surgery. However, in this patient’s case, it is very difficult to determine the exact cause of rhabdomyolysis.
No matter what the cause, while under the diagnosis of rhabdomyolysis, hydration therapy should be applied, and toxic enzyme must be removed out of the bloodstream. To avert continuous muscle damage, such as trauma, infection must be determined and managed directly [16]. With early and definitive diagnosis and treatment, it is believed that the patient can have a bright prognosis. Moreover, the recovery of full renal function is also warranted [11]. Additionally, it is recommended that daily routine measurements of liver functional lab, especially CK and myoglobin, be administered [14].
Despite the advantages of the free fibular flap operation, clinicians must be aware of the risk of complications because there are multiple factors that could result in rhabdomyolysis, such as duration of the operation, position of the subject, and existing conditions of diabetes and hypertension. Therefore, close monitoring of certain measures is required, and it is recommended that procedures may be divided into two or three stages to avoid prolonged muscle compression when prolonged surgical time is anticipated. Once a diagnosis of rhabdomyolysis is confirmed, a prompt treatment plan should be made and applied as soon as possible. This will increase the chance of a full recovery for the patient who is exhibiting symptoms of rhabdomyolysis.