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Considerations
Considerations
Anatomy
Tissue
Bone with periosteum, up to 25 cm
Segmental blood supply allows multiple osteotomies
Adjacent soft tissue with or without skin paddle
Pedicle
Artery: Peroneal
Large caliber: 1.5 - 4 mm
Courses deep to the fibula, just posterior to the interosseous membrane
Vein: Two venae comitantes
Similar caliber to artery; One is often larger
Length
Relatively short
Lengthen by dissecting the pedicle free from proximal fibula while maintaining distal bone as needed for reconstruction
Perforators
Sensory innervation
Variable: lateral sural cutaneous nerve
Key structures
YouTube (4:18) - Anatomy Of The Lower Leg - Everything You Need To Know
YouTube (16:32) - Muscles of the Leg - Part 1 - Posterior Compartment - Anatomy Tutorial
YouTube (16:10) - Muscles of the Leg - Part 2 - Anterior and Lateral Compartments - Anatomy Tutorial
Anterior compartment - 5 extensors
Lateral compartment - 2 peroneal muscles
Posterior compartment - 7 flexor muscles
Indications
Defects involving bone and soft tissue; Ideal defects include
Anterior and/or lateral mandibular arch
Palate
Midface
TMJ
Contraindications
Peripheral vascular disease
Unfavorable imaging of the lower extremity
Venous insufficiency
Need for independent positioning of the soft tissue relative to the bone
Anomalous lower extremity vasculature (Class III vasculature of the leg)
Strengths
Excellent bone stalk for osseointegrated dental reconstruction
Bone can be divided allowing bending
Limitations
Only allows 2-dimensional molding of soft tissue given its anchor to bone
Limited soft tissue volume
Pre-operative exam of the donor site
Vascular flow
Arterial pulses - Dorsalis pedis and Posterior tibialis
Venous congestion
Tissue quality
Color, scars, hair, etc.
Imaging - controversial; some recommend while others pursue only if the physical exam of pulses is concerning
Doppler ultrasound
Optional: Angiogram, or magnetic resonance angiography (MRA)
Flap orientation
Determine the following
The nature of the defect
If a skin paddle is needed
The ideal pedicle orientation
Visualization the orientation, keeping in mind
The lateral surface of the fibula becomes the outer surface of the “neomandible” and is the surface to which the reconstruction plate is applied
For the mandible, orientation rules to guide you
If you need the skin paddle intraoral and pedicle posterior - use the contralateral leg
If you need the skin paddle intraoral and pedicle anterior - use the ipsilateral leg
2006: Donor side selection in mandibular reconstruction using a free fibular osteocutaneous flap
Plating options
2.0 microvascular recon plate
Miniplates
Simultaneous harvest with two surgical teams
Virtual Surgical Planning (VSP)
Technique
2012: Step-by-step mandibular reconstruction with free fibula flap modelling
2013: Fibular flap for mandibular reconstruction: are there old tricks for an old dog?
Preparation
Preparation
Position
Flex knee, bump and pillow under the hip
Place foot on a bump; A foam square used for the prone face works well
Another option is to tape a sandbag to the bed, under the sheet
Clip hair on the leg and thigh
Catch hair with a chuck under the leg
Identify landmarks
Mark fibular head and 8 cm distal, allowing peroneal nerve protection
Mark lateral malleolus and 8 cm proximal, allowing ankle stability
Draw a line connecting the fibular head and lateral malleolus
Optional: Doppler skin perforators
Identify and mark 2-6 perforators
Design skin paddle
Place an ellipse in the distal aspect, allowing for increased pedicle length
Pinch test to determine if primary closure is feasible
Equipment
Optional: Doppler
Tourniquet
Respective trays
If needed, skin graft materials
Dressing and cast materials
Procedure
Procedure
Inflate the tourniquet at 350 mmHg
Option: Some set the pressure to 150 mmHg above the patient's systolic blood pressure
Incise the anterior skin paddle to the level of the peroneus muscles' fascia
Option: If no skin paddle is needed, incise one finger breadth posterior and in parallel to the axis of the fibula
Incise the peroneus fascia along the length of the skin incision
Bluntly dissect posteriorly to identify the posterior intermuscular septum
Sharply dissect the peroneus muscle away from the fibula
Identify and incise the anterior intermuscular septum preserving a 1 mm cuff attached to the fibula
Dissect the extensor musculature away from the fibula
Identify and preserve the anterior tibial neurovascular bundle
Identify and incise the interosseous membrane
Incise the posterior skin paddle
Avoid the sural nerve
Avoid the saphenous vein
Identify and incise the soleus fascia
Identify and preserve the skin perforators of the peroneal artery
Distal and the proximal osteotomies
Place a large right angle clamp (or Army-Navy short end) along the medial aspect of the fibula
Cut using the sagittal saw
Rotate the bone laterally with a bone hook or bone clamp
Identify and ligate the distal peroneal pedicle
Dissect the peroneal pedicle from distal to proximal
Identify and divide the tibialis posterior muscle (V-shaped configuration), superficial to the pedicle
Identify and divide the flexor hallucis longus
Identify the proximal peroneal pedicle at its junction with the posterior tibial vessels
Deflate the tourniquet
Harvest the flap
Obtain hemostasis
Place closed suction drain exiting from separate stab incision superior to the wound and on the posterior side
Deep closure
Place 4-5 interrupted 2-0 or 3-0 vicryl sutures to approximate the muscle / fascia
Skin closure - Primary vs STSG
Attempt to close primary, often difficult if skin paddle > 3-6 cm in width (dependent on the patient's anatomy)
Can try to place a double buried stitch in key areas to bring tissues together. Basically, it is just 2 interrupted sutures in a row prior to tying it down. Allows for more tissue to be pulled together under shared tension.
Approximate the dermis with multiple buried 2-0 or 3-0 vicryl sutures
Approximate the epidermis with running 5-0 Fast or subcuticular 5-0 Biosyn or your choice of permanent suture if tension if desired vs staples
Apply Bacitracin and Telfa
If skin graft is needed, utilize the skin graft donor site on designated thigh (see STSG page). Briefly...
Make sure it is along the antero-lateral surface of the thigh. Find an area where it is flat
Assistant role is key
Pour mineral oil on thigh and use tongue blade to spread out
Have assistant push down and pull back towards themselves while you advance the dermatome
Keep firm and steady pressure especially at the sides where the skin flap tends to get narrow/thin
Place Telfa soaked in topical 1:1000 Epinephrine on the STSG donor site for hemostasis
Inset the STSG on receipient site and make sure it is big enough. Edges should be sutures down without the tissue "tenting" up
Use pickups and tenotomy scissors to gently make vertical 5 mm slits in the graft. DO NOT EXPOSE TENDON IN THIS STEP
Use 5-0 fast sutures to grab a small bite of muscle superior or inferior to the slit and tie down. This helps with adherence
Repeat liberally as needed. You can't really overdo it.
Place posterior lower leg splint
Dr. Fong option: Mepitel directly over the STSG
Start by using Xeroform and making a bolster
Place it directly over the graft recipient site and secure it with 3 sets of 2-0 nylon sutures in an "X" fashion so that it is secured and tacked down. Do not suture the xeroform to the skin. You are merely placing sutures to hold the xeroform down
Place fluffs over this
Wrap the leg in Kerlix
Wrap in Webril
Pad the lateral malleolus
Measure and fold the 4 or 6 inch fiberglass roll
Soak it in water to active it
Fold it on itself roughly the length of the leg
Hold it in place on the leg with the ankle flexed
Wait until it gets hard
Wrap in ACE bandage
Keeps toes exposed to allow movement movement and subsequent neurovascular examination
STSG donor site
Dr. Fong
Mepitel
Abd pad secured with tape
Remove Abd in 2 days then leave open, keeping dry, allowing Mepitel to stay in place until it no longer sticks
Dr. G
Place tegaderm over site
Take off after 2 days or if it starts to leak
Then leave open to air
Need to constantly remind RNs and patient
Can apply ointment/vaseline once it dries out
Sample operative report
Sample operative report
The patient was already on the OR table. The resection of the tumor was completed.
The *** lower extremity had been prepped out in standard fashion with a bump underneath the *** hip and a foot rest taped in place to rest the foot on. The medial malleolus and the lateral intramuscular septum were marked. An anterior incision was marked just over the peroneus longus tendon. The fibula was then marked 8 cm from the lateral malleolus. Webril was then placed on the thigh, followed by the tourniquet. The leg was exsanguinated with the Esmarch bandage and the tourniquet then inflated to 350 mmHg. The Esmarch bandage was removed.
The incision was completed through the skin and subcutaneous tissue down to the level of the musculature. The fascia overlying the peroneus longus was divided and dissected away until the lateral intramuscular septum was reached. A perforator in the *** third of the leg was identified. The peroneus longus muscle was then further elevated away from the fibula bone. The muscles were continually dissected away from the medial aspect of the bone. The osteotomy sites were identified, first inferiorly at approximately 8 cm from the lateral malleolus. A right angle clamp was placed around the fibular bone and an Army-Navy retractor was placed to retract the medial muscles. A saw was then used to make the osteotomy cut inferiorly. Attention was then paid to the superior osteotomy site. The common peroneal nerve was retracted, along with the medial muscles and, again, a right angle clamp was used to protect the structures deep to the fibula. The saw was then used to make the superior cut.
A double-pronged skin hook was then to retract the fibula laterally. The interosseous membrane was divided and the posterior tibialis was divided to expose the peroneal artery and venae comitantes. The pedicle was traced from an inferior to superior direction up to the take-off from the posterior tibial vessels. The posterior cut on the skin paddle was then made down to the soleus muscle. The skin paddle was *** cm in dimension. A cuff of soleus muscle was then completed to insure that any intramuscular branches to the skin paddle were included. A heavy scissors was then used to cut the muscle from an inferior to superior direction. Any perforating veins and arteries were clamped, divided and ligated along the way. The proximal portion of the pedicle was then dissected out. The peroneal artery was dissected to the posterior tibial artery and freed up from the surrounding soft tissue. The veins were traced to the posterior tibial vein.
The tourniquet was then let down. Total tourniquet time was *** minutes. Excellent flow was noted through the pedicle and excellent bleeding was noted on the periosteum muscle and skin paddle. After approximately half an hour, the vessels were then ligated with 3-0 Silk and divided. A drain was placed into the space where the fibula had previously been located. The operative site bed was then irrigated with copious amounts of bacitracin irrigation. The muscles were then re-approximated with 3-0 Polysorb. The subcutaneous tissues was approximated with 3-0 Polysorb and the skin was closed subcuticularly with 5-0 Biosyn suture and Steri-Strips. A posterior leg splint was then placed in standard fashion.
In the meantime, the flap had been brought to a back table. It was irrigated with heparinized saline. The pedicle on the periosteum was then stripped down from the proximal portion of the fibula. The fibula was then brought to the head and neck area.
The defect in the *** anterior mandible was approximately *** cm. *** pieces were then designed. The osteotomies were then made with the saw. The flap was then secured to the plate with 8 mm screws. The skin paddle was then brought up into the oral cavity. The pedicle was brought down into the *** neck. The screws holding the plate in place on the native portion of the mandible were then removed, allowing the flap to drop down inferiorly and to have better access to the oral cavity. The tongue was then closed primarily in the midline with vertical mattress sutures and with 3-0 Polysorb. The flap was then sutured to the floor of mouth and ventral tongue with 3-0 Polysorb in a vertical mattress suture fashion. The flap was then brought up around the gingiva and onto the labial mucosa. The chin was then closed deeply with 3-0 Polysorb. The musculature was re-approximated using 3-0 Polysorb.
The vessels were then brought down into the neck and the adventitia of the artery and vein were then cleaned. The *** was reflected and cleaned of its adventitia, divided and approximated with the peroneal artery on the 3V microvascular clamps. The anastomosis was then completed with 9-0 nylon on an MV-100 needle in simple interrupted fashion. The common vena comitantes was then brought and approximated to the *** vein. The adventitia was both cleaned and approximated using 3-V microvascular clamps. This was performed using 9-0 nylon on an MV-100 needle. It was performed in a running fashion. The clamps were then released. Excellent flow was noted through the flap. The muscle, periosteum and skin were noted to be bleeding after release of the clamps.
The neck was then irrigated with warm bacitracin irrigation. Any bleeding that was seen was controlled with either bipolar electrocautery or ligation or hemoclips. *** drains were placed in the neck, one in *** and then one into the *** and secured to the skin using 3-0 nylon. The lip was then repaired using 5-0 Surgipro in a vertical mattress suture fashion. The neck was then closed using 3-0 Polysorb deeply and a 5-0 Surgipro on the skin in a running fashion. The endotracheal tube was then removed.
A #*** LPC Shiley tracheostomy was placed and secured to the skin using 3-0 Nylon. A Dobbhoff feeding tube had been placed into the patient's nasal cavity and secured to the membranous nasal septum using 3-0 Nylon.
Final needle and sponge counts were correct. No complications were encountered. The patient was transported to ICU in stable condition
Post op
Post op
Post-operative check
Examine toe sensation, warmth, cap refill daily
Keep compartment syndrome in mind
Document color of flap, speed and color of bleed
Positioning
Keep leg elevated on 2 pillows while in bed
Activity
POD 0 - bed rest
POD 1-4 - NWB, patient should still be sitting in chair at bedside
POD 5-9 - toe touch weight bearing
POD 10-14 - partial weight bearing
POD 15 - full weight bearing
Consults
PT consult starting POD 1; Include activity plan in the consult order
If applicable, also request shoulder evaluation and rehabilitation recommendations
Wound
POD 5 - remove cast, remove drain if output less than 30 ml over 24 hours
If skin graft present, leave Mepitel in place; Replace xeroform, telfa, kerlix wrap
Follow-up
Assess the need for outpatient PT
RTC 1 week post discharge
Schedule for 30 minutes with the operating surgeon and notify the Speech Therapist to be present for clinic swallow evaluation and possible NGT removal
Complications
Donor site
Standard - infection, hematoma, dehiscence
Skin graft loss
Compartment syndrome
Foot ischemia
Ankle instability
Tibia fracture
Pearls & Pitfalls
Pearls & Pitfalls
Pearls
The anterior approach is standard, while the posterior approach is considered more technically demanding but allows
Early identification of the posterior tibial vessels
Early identification of the perforators
Increased muscle preservation, specifically of the flexor hallucis longus
Proximally, perforators tend to run within the soleus
Pitfalls
High-Yield
High-Yield
Are tibia fractures a common complication after fibula free flap harvest?
No; this is a rare complication, based on review of case reports
Does neoadjuvant or adjuvant radiation therapy significantly impact the complication rate of fibula free flaps?
No; there is no complication rate difference in this series (n = 100)
What is the critical ischemia time for the fibula free flap?
5 hours; After 5 hours overall flap complications increase
Are fibula free flaps ideal for osseointegrated implants?
Yes; Of note, both iliac crest and fibula bone dimensions are consistently adequate
Links
Links
YouTube (5:10) - Fibula Osteocutaneous Free Flap Harvest from AHNS
YouTube (7:09) - Fibula Osteocutaneous Free Flap Dissection Video
YouTube (10:32) - Fibula Flap by Microsurgery Made Easy - Instructional cadaver dissection (excellent)
YouTube (13:01) - Fibula flap HD
YouTube (37:33) - MICROSURGERY - Fibula flap harvest from the posterior approach by World Microsurgery; Shows a posterior approach
Iowa Head and Neck Protocols - Osteocutaneous Fibula Free Flap
UTMB - Microvascular Free Flaps Used in Head and Neck Reconstruction
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