eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Tissue Transfer, Fibula

Author: Mark K Wax, MD, Professor and Program Director, Department of Otolaryngology-Head and Neck Surgery, Oregon Health Sciences University; Service Chief, Department of Surgery, Section of Otolaryngology, Veterans Affairs Medical Center
Coauthor(s): Catherine P Winslow, MD, Consulting Surgeon, Winslow Facial Plastic Surgery, LLC
Contributor Information and Disclosures

Updated: Mar 18, 2009

Introduction

Tissue loss resulting from cancer ablation, debridement of infected tissues, or secondary to trauma provides the surgeon with various reconstructive challenges. Defects of the head and neck may involve various tissues including skin, fascia, and bone. Although reconstruction of soft-tissue defects requires a fasciocutaneous or musculocutaneous flap, composite tissue loss that includes bone should be managed with a flap that contains vascularized bone. In the unusual case in which only bone is missing, an osseus flap is needed to reconstruct the defect.

The fibula free flap provides a strong long segment of bone and can include a large fasciocutaneous component as well. As such, this versatile flap may be harvested as an osteocutaneous flap or a purely osseous flap. The pedicle runs the length of the fibula, with perforators extending to the skin paddle. It provides the longest segment of bone currently available for harvest; up to 26 cm can be taken without affecting leg function. A segment of bone is preserved distally and proximally to support the ankle and preserve the peroneal nerve, respectively.

History of the Procedure

Until the advent of free tissue transfer, reconstruction of defects of the mandible and mid face was suboptimal. Anterior mandibular arch defects resulted in the so-called "Andy Gump" deformity, a term coined in 1978 in a dental publication referring to the appearance of a chinless cartoon character from early in the 20th century. These patients had not only an obvious cosmetic deformity, but also severe functional problems such as poor oral competence with drooling, making them in many cases social cripples. Patients with small lateral defects had less severe problems, but they too had difficulties with chewing, swallowing, and speaking.

Plating across defects with or without nonvascularized bone grafts usually eventually resulted in plate exposure, particularly in irradiated patients. Bulky pedicled flaps were used to cover these plates with varying degrees of success. Plate exposure or loss of bone grafts happened in 505 of cases.

The fibula free flap was introduced in the mid 1970s and was first described as a technique for mandibular reconstruction in 1989 by Hidalgo. It is now the most popular method of mandibular reconstruction. The use of fibular reconstruction for maxillary defects has also been widely reported and is now the criterion standard for reconstruction of both mandibular and maxillary bony defects. The presence of both endosteal and periosteal blood supplies to the bone allows for multiple osteotomies and thereby precise contouring to approximate the shape of the native mandible. Pedicle diameter allows relatively easy anastomoses: veins are 1.5-3 mm and the artery is 2.5-3.0 mm. One drawback is the relatively short pedicle length. Although its exact length depends on the amount of proximal bone discarded, it is generally 3-6 cm.

Since its initial description as an osseus flap, the flap has been modified to include a cutaneous portion and thereafter described with a sensate paddle of skin. In the early 1990s, many surgeons were reluctant to use the osteocutaneous flap because of reported problems with vascular reliability of the skin. This resulted in some surgeons advocating that the flap be used only as an osseous flap. However, experience and an improved understanding of skin paddle anatomy have led to an improved ability to maintain the delicate perforators. Surgeons now realize that skin viability is more technique-dependent with this flap than in many other free flaps. Cutaneous perforators may be septocutaneous or musculocutaneous. Harvesting a piece of the Soleus muscle ensures adequate blood supply to the skin.

Size of the skin paddle, whether to design the paddle proximally or distally, and use of a tourniquet are dictated by individual preferences and patient requirements.

Problem

Tissue loss secondary to cancer ablation, trauma, and infection results in various reconstructive challenges, especially for osseus defects of the head and neck.

Presentation

In conjunction with the extirpative team, preoperatively evaluate all patients with head and neck carcinoma for the extent of tumor, presence of regional and distant metastases, bone involvement, and general medical condition. Specifically related to patients needing this flap, evaluate the patient's dorsalis pedis and tibialis posterior pulses. The feet and legs are also assessed for color, edema, scars, any signs of venous congestion and other abnormalities.

Obtain dental, oral surgery, social work, and physical therapy consults. Preoperatively plan dental extractions or perform them at the time of surgery. Patients undergoing fibula free flap repair of mandibular or maxillary defects may be candidates for osseointegrated implants; however, such devices are very expensive and their cost is seldom covered by insurance.

Patients with abnormal pedal pulses or abnormal skin texture should undergo further testing. The role of preoperative Doppler examination, angiographic imaging, or magnetic resonance angiography (MRA) to evaluate the vascular anatomy of the leg is undetermined (see Future and Controversies). Currently, angiography is the end standard to assess the vascular supply of the leg. Preoperative angiography can cause vascular spasm if it is performed within a week of surgery.

Indications

Many bony defects of the head and neck region are well suited for reconstruction with a fibula free flap. Mandibular arch defects or lateral defects in patients who are to undergo osseointegrated dental reconstruction are ideal defects for fibular reconstruction (see Image 1). The palate and mid face can also be reconstructed successfully with this flap. The temporomandibular joint may be reconstructed with a suture to anchor the sculpted fibula to the joint disc.

In cases in which the defect includes a soft-tissue component, an osteocutaneous flap can be harvested to replace intraoral or external skin defects. The skin of the flap is anchored to the bone by the septum through which the septocutaneous perforators run. Thus, the skin paddle is only moldable to fit a 2-dimensional defect. Three-dimensional defects require different reconstructive techniques. The volume of tissue that can be harvested is also limited.

Relevant Anatomy

Three vessels provide the vascular supply to the lower leg. In the knee, the popliteal artery bifurcates into the anterior tibial artery and the tibioperoneal trunk. The latter divides into the posterior tibial artery and the peroneal artery. In the lower leg, the anterior tibial vessels lie on the dorsum of the foot and are palpable as the dorsalis pedis pulse. The posterior tibial vessels run deep in the leg along the lateral aspect and can be palpated as the posterior tibial pulse. The peroneal vessels lie in close proximity to the fibula, coursing the entire distance of the bone along its medial aspect. The artery is accompanied by paired venae comitantes, which may join together proximally.

Although variations of the lower leg anatomy are uncommon, they are important to identify if a fibular flap is planned. When a dominant peroneal artery exists, pedal circulation is more dependent on this vessel. Sacrifice of the peroneal artery in such cases renders the foot susceptible to ischemia when the fibula flap is harvested.

The peroneal nerve lies superficial to the upper lateral fibula. It crosses the fibula about 3 cm distal to the proximal fibular head and is susceptible to injury with bone harvest. To minimize risk, the superior 4-6 cm of fibular bone is preserved. Reinnervation of the cutaneous paddle is possible via the lateral sural cutaneous nerve that can be traced medially when the soft tissue is harvested. However, the skin paddle may or may not actually be supplied by this nerve.

The skin paddle is supplied by perforators from the peroneal vessels that enter the skin via the posterior crural septum, which is identified between the peroneus longus and soleus muscles. One to 3 perforators are identified for skin harvest. They can be identified preoperatively with duplex Doppler imaging or in the operating room before the incision is made with a hand-held Doppler unit. They should be directly visualized in the fasciocutaneous tissues of the septum during the dissection. Perforators may also be encountered coming directly from the muscle, which do not course through the septum. These may or may not originate from the peroneal vessels. These muscular perforators may be preserved by harvesting a cuff of soleus muscle.

The maximum density of perforating vessels in the leg appears to be in its proximal and distal aspect rather than in the midportion of the lower extremity. In deciding ideal placement of the skin paddle, the surgeon is typically limited by the need to harvest a pedicle of sufficient length, necessitating distal harvest. The paddle is thus centered at the junction of the middle third and distal third of the fibula. The increased reliability of the skin paddle over the past decade probably is a result of harvesting larger (longer) skin paddles, an increasing knowledge of perforating vessel anatomy, more reliable identification of perforating vessels, and more expert dissection of the septum. Trauma, tension, or injury to the septum may result in loss of the skin paddle because of perforator injury.

Contraindications

Abnormalities of the lower leg vascular anatomy may preclude safe harvest of the fibula. A dominant peroneal circulation may exist in patients with congenital absence or underdevelopment of the anterior tibial vessels. An enlarged peroneal artery is known as peroneus magnus and is a major blood supply to the foot. Patients with peroneus magnus or impaired circulation to the leg should not undergo fibula transposition.

Caution is advised in patients who have had extensive leg trauma or surgery prior to planning fibular surgery. Also, patients who are diabetic and have significant venous stasis or peripheral edema, poor circulation or healing, or cutaneous ulcers are poor candidates for this flap. Alternatives include no reconstruction, plating only, an iliac crest or scapula flap, radial forearm with bone, or soft-tissue coverage only. One should carefully evaluate the functional status of the patient because the patient will have some impairment temporarily following harvest.

Although not contraindicated per se, patients with large bone and skin defects may require 2 flaps to properly reconstruct the defect. Some surgeons would choose another flap rather than using 2 free flaps. In these patients, a separate fasciocutaneous flap may be required to resurface the skin, especially if the skin defect is not in immediate proximity to the bony loss. The fasciocutaneous portion of the fibula flap limits its ability to conform to complex 3-dimensional defects.

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