FIBULA FLAP

History

Taylor, 1975 (PRS), Gilbert 1979 (Int J Micro)

Principles

Septocutaneous perforators pass from peroneal artery along posterior peroneal septum to reach the skin. Largest perforators are 10-20 cm below fibula head. Skin ellipse should be shaped to include as many skin perforators as possible – 1/3 of skin anterior to fibula; 2/3 of skin posterior to fibula.

Uses

Head and Neck, Lower limb, Upper limb

Dissection

Skin ellipse if myocutaneous flap to be taken. Posterior or anterior approach to vessel:

Long vertical axis in line with posterior intermuscular septum. Skin incised down to fascia. Fasciocutaneous flap raised till posterior intermuscular septum. Narrow cuff of soleus is included to maintain the cutaneous vessels. Peroneus longus and brevis are detached off fibula. Proximal and distal osteotomy can be performed after identification of common peroneal nerve – rotation of fibula can be performed to improve visualisation of anatomy. Longest length of bone = 4cm below head / 6cm above lateral malleolus. Skin paddle can be 14cm wide. Donor site closure usually with SSG, but can be directly closed if skin width <6cm.

Bony segment should be 4cm longer than defect to allow for fixation and osteotomy

A preoperative arteriogram is recommended to confirm the patency of the peroneal artery. In 10% of the population the peroneal artery is the dominant arterial supply to the foot (peroneal arteria magna). In these cases the contralateral leg should be evaluated as a potential flap donor site.

Although the fibula is the most useful donor site for vascularized bone graft, the overlying skin island has not always been reliable. The inclusion of a cuff of flexor hallucis longus muscle and soleus muscle to include the cutaneous branches will improve the reliability of this skin island.

Removal of the fibula does not result in morbidity. However, the lower 6 to 8 cm should be preserved. Harvesting of the entire length may create instability of the ankle joint.

Prior to the proximal fibula osteotomy the peroneal nerve is identified and protected from injury

References

	Flemming AFS, Brough MD, Evans ND, Grant HR, Harris M, Lawler M, Laws IM. Mandibular reconstruction using vascularized fibula. Br J Plast Surg 43:403, 1990.
	Hidalgo DA. Fibula free flap: A new method of mandible reconstruction. Plast Reconstr Surg 84:71, 1989.
	Hidalgo DA. Aesthetic improvement in free flap mandible reconstruction. Plast Reconstr Surg 88:574, 1991.
	O'Brien BMcC, Gumley GJ, Dooley BJ, Pribaz JJ. Folded free vascularized fibula transfer. Plast Reconstr Surg 82:311,1988.
	Taylor GI, Miller G, Ham E The free vascularized bone graft: A clinical extension of microvascular techniques. Plast Reconstr Surg 55:533, 1975.
	Taylor GI, Wilson KR, Rees MD, Corlett RJ, Cole WG. The anterior tibial vessels and their role in epiphyseal and diaphyseal transfer of the fibula: Experimental study and clinical applications. Br J Plast Surg 41:451,1988.
	Wei FC, Chen HC, Chuang CC, Noordhof MS. Fibula osteoseptocutaneous flap: Anatomic study and clinical application. Plast Reconstr Surg 78:191, 1986.
	Donski PK, Buchler U, Ganz R. Combined osteocutaneous microvascular flap procedure for extensive bone and soft tissue defect in the tibia. Ann Plast Surg 16:386, 1986.
	Schusterman MA, Rees GP, Miller MJ, Harris S. The osteocutaneous free fibula flap: Is the skin paddle reliable? Plast Reconstr Surg 90:787, 1992.
	Townsend PLG. Vascularized fibular graft using reverse peroneal flow in the treatment of congenital pseudarthrosis of the tibia. Br J Plast Surg 43 :261, 1990.