The fibula free flap1,2 is a method of reconstructing composite defects after oral cancer ablation and restoring nonneoplastic defects. It is also used in preprosthetic surgery because of its reliability and effectiveness. The primary use of the fibula free flap is to reconstruct segmental defects of the mandible. The classic harvest of this fibula flap requires the sacrifice of the entire fibula and the complete opening of the leg compartments.3 We present refinements in fibula flap design and harvesting, and introduce a modified approach customized to the actual needs of the patient to decrease postoperative morbidity. (See Video, Supplemental Digital Content 1, which demonstrates a minimally invasive free fibula flap surgical technique, http://links.lww.com/PRS/A674.) Recently, Wolff and Hölzle4 proposed modifications of the standard technique for harvesting fibula free flaps, which we adopted in part.
The incision starts 5 cm below the lateral epicondyle of the fibula and runs 10 to 15 cm in a distal direction on the lateral aspect of the leg. Through the intermuscular septum, between the long head of the peroneal muscle and the sural muscle, the fibula is identified. In this step, the fibula is exposed according to the size of the defect and the length of the pedicle required based on the cervical anatomy and reconstruction site. The fibula is separated from the short head of the peroneal muscle, and the interosseous membrane is exposed and cut. The proximal and distal osteotomies are performed according to the length of the vascular pedicle needed to reach the cervical vessels. A 1-cm error in calculating the length of pedicle needed is possible, since the pedicle runs in a cranial and medial direction for several centimeters before reaching the posterior tibial artery. The most important step is the second osteotomy. At this time, the surgeon should know the exact length of bone and pedicle needed. Once the second bone cut is made, it is impossible to lengthen the pedicle or bone. The pedicle plane is easily identified and can be dissected from the lateral aspect and from the back with gentle retraction of the soleus and posterior tibial muscle. The dissection continues on the sural aspect of the fibula, and the posterior muscle can be dissected, leaving a muscular cuff very close to the bone. In this phase, it is easy to identify and ligate the perforator vessels in the sural muscle. The dissection proceeds as with the classic harvest. Sometimes it is necessary to cut the muscles of the posterior compartment to find the distal portion of the vascular pedicle. After the collateral vessels are tied off, it is possible to isolate the vascular pedicle and proceed with its ligation.
Four patients underwent the modified free fibula flap technique to reconstruct oral cavity composite defects and were included in a preliminary study (Table 1). They were compared with patients who had undergone the classic technique in terms of analgesia, recovery of walking, radiographic evaluation of the fibula stump (Fig. 1), vascularization of the leg using magnetic resonance angiography (Fig. 2), and postoperative gait test, with encouraging results.5
Alessandro Baj, M.D.
Giada A. Beltramini, M.D.
Department of Maxillofacial Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
Olindo Massarelli, M.D.
Department of Maxillofacial Surgery, Azienda Ospedaliero-Universitaria di Sassari, University of Sassari, Sassari, Italy
Doris Ali Youssef, M.D.
Aldo B. Giannì, M.D.
Department of Maxillofacial SurgeryFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
The authors have no financial interest to declare in relation to the content of this article.
1. Urken ML, Weinberg H, Vickery C, Buchbinder D, Lawson W, Biller HF. Oromandibular reconstruction using microvascular composite free flaps: Report of 71 cases and a new classification scheme for bony, soft tissue and neurologic defects. Arch Otolaryngol Head Neck Surg. 1991;117:733–744.
2. Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg. 1994;93:294–304.
3. Urken ML, Weinberg H, Buchbinder D, et al.. Microvascular free flaps in head and neck reconstruction: Report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg. 1994;120:633–640.
4. Wolff D, Hölzle F. Fibular flap. In: Raising of Microvascular Flaps. Berlin: Springer; 2005:107–134.
5. Lin JY, Djohan R, Dobryansky M, et al.. Assessment of donor site morbidity using balance and gait test after bilateral fibula osteoseptocutaneus free flap transfer. Ann Plast Surg. 2009;62:246–251.
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