eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Tissue Transfer, Fibula: Treatment

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

Treatment

Preoperative Details

Obtain informed consent, including the possibility of a second skin flap, as indicated.

Intraoperative Details

Unlike several other free flaps used for head and neck reconstruction, the fibula flap can be harvested simultaneously with the extirpation of the tumor by a second surgical team (see Image 2). The authors have found that the contralateral leg lends itself well to pedicle orientation for a mandibular defect. Reconstruction of the temporomandibular joint, however, is facilitated by harvesting the ipsilateral fibula. we have not used a tourniquet for harvest. However it may be used by some surgeons. If used it is inflated to 250 mm.

The fibula takes longer to harvest than a cutaneous flap. Therefore, the period of primary ischemia is longer than that of the radial forearm flap and necessitates quick osteotomies for rapid revascularization. A reconstruction plate (see Image 3 ) or miniplates may be used with equal efficacy. The authors' preference is to use a 2.0microvascular reconstruction plate, which is contoured prior to tumor extirpation if possible.

Proximally, 6 cm of bone is preserved to avoid injury to the peroneal nerve. Distally, 8 cm of bone is left to support the ankle mortise. The skin paddle is made slightly larger than the anticipated defect size. The incision is carried out around the skin paddle. Proximal and distal extensions allow for bone harvest and pedicle dissection. The anterior portion of the skin paddle is dissected. The peroneus longus is reflected anteriorly, and the fibular bone is identified.

The posterior crural septum is located. The monopolar cautery is not used in this area to avoid injury to the delicate perforators. Once visualized, the septum is examined for perforators. Further dissection anteriorly around the fibula is performed, transecting the extensor hallucis longus. The thick interosseous septum is identified. Posterior dissection is performed to free up the skin paddle from the soleus and gastrocnemius muscles, and the septum is identified from its posterior aspect. Bony cuts are made with an oscillating saw. The bone is pulled laterally with Dingman bone retractors as the interosseous membrane is transected.

The chevron-shaped tibialis posterior is transected carefully with bipolar scissors. Just underneath this muscle lies the pedicle, which is identified distally and ligated. The flexor hallucis longus and soleus muscles must be transected. Dissection is continued proximally to the posterior tibial bifurcation. The anterior and posterior tibial pulses are palpated prior to transecting the peroneal vessels.

The length of bone needed for reconstruction is measured. Proximal elevation of periosteum along the fibula allows sizing of the bone and lengthening of the pedicle. Some surgeons prefer to contour the bone while the flap is still vascularized in the leg while others prefer to transect the pedicle at this time and perform osteotomies on a back table. The authors have found that the ability to compare the bone with the defect facilitates contouring. So the authors routinely remove the flap from the leg for placement of the osteotomies.

The leg wound can be closed primarily if the defect is small or no skin was harvested. More commonly, a split thickness skin graft is needed. The skin graft is harvested from the lower leg donor site prior to harvesting the flap. This mitigates a second surgical site on the thigh. Pie crusting the graft with a sharp blade provides better cosmetic results than putting the graft through a mesher. Xeroform and a bolster are placed over the skin graft, if used. A posterior leg splint is fabricated and applied, either at this point or at the end of the case.

The bone is plated and inset into the defect following osteotomies. The pedicle is positioned along the lingual aspect of the flap, and the skin paddle is adjusted. After tension-free positioning is achieved, the skin paddle is inset with horizontal mattress sutures. The anastomosis is then performed with standard microvascular techniques.

Suction drains are carefully placed in the neck. The drains should be loosely held in position with absorbable sutures to prevent migration of the drain in proximity to the pedicle. If possible, a suture is placed on the external neck (skin) prior to closure to mark the location of the pedicle for postoperative Doppler examination. The remaining wounds are then closed. A feeding tube is placed if necessary.

Postoperative Details

Patients are closely monitored in the hospital. The skin paddle is monitored frequently for signs of vascular compromise in patients with osteocutaneous flaps. Good perfusion to the skin means that the pedicle is patent and thereby providing blood to the periosteum and bone. Conversely, patients may have inadequate perforators to the skin and compromised blood supply to the skin paddle yet still have good perfusion to the bone. If a question of bone viability exists, nuclear medicine imaging can be of benefit in assessing flow. This study is not routinely performed for an osseous flap.

The ideal technique by which a flap can be assessed is only theoretical and practically varies depending on the flap, the patient, available equipment, and other factors. Based on individual preference, cost, and familiarity with monitoring techniques, various monitors are available. The criterion standard, direct visualization and assessment of capillary refill with or without needle prick, is the most reliable in trained hands. Devices that may assist nurses or residents in monitoring a flap include a standard Doppler placed over the pedicle or a laser Doppler. Arterial problems usually manifest within 24 hours; venous congestion often develops 48-72 hours postoperatively. Frequent evaluation and careful monitoring allow for early identification of problems.

Fluid balance and overall patient condition are monitored, as well. The authors use prophylactic antibiotics and steroids for 24 hours; many routinely use prophylactic antibiotics much longer. An aspirin (325 mg) is administered rectally, orally, or per feeding tube starting on the first postoperative day; many administer the medication immediately after the patient leaves the operating room.

The patient is allowed to ambulate in a non–weight-bearing fashion on the second postoperative day. The splint is removed and the skin graft assessed on the fifth postoperative day. The patient is then allowed to bear weight, using a walker or other assistive device, if necessary. When a skin graft is not used, the splint is not placed, and the patient is allowed to bear weight on the second day following surgery.

Follow-up

Upon discharge from the hospital, the patient is continued on one aspirin each day unless contraindicated. The first postoperative visit generally occurs 1-2 weeks after release from the hospital. Flap and skin graft viability are assessed. Any remaining sutures are removed. If not already initiated preoperatively or as an inpatient, physical therapy is instituted to restore ankle function when the donor site has healed. The recipient site is evaluated for complications. Removal of the feeding tube and/or tracheotomy tube, if still present, is considered. The patient is also evaluated by a speech pathologist, physical therapist, and other specialists, as required. Patients generally resume an oral diet approximately 2-3 weeks following discharge if no complications arise. Continuing dental/oral surgery evaluation and management allows for placement of dentures or implants at an appropriate time.

Complications

As with any free flap, complications may be divided into donor and recipient site problems. Major donor site complications with a fibula free flap are uncommon. Loss of the skin graft or a portion thereof is possible. As with any surgery, hematoma or infection may develop. Drains are used in the leg until output is sufficiently low for removal. Compartment syndrome is prevented by avoiding overtight closure of the leg, using skin grafts, and using drains to avoid hematomas. The posterior splint should allow for visualization of the toes and palpation of the pedal pulses. Ischemia to the foot is rare but must be evaluated urgently. Ankle instability is possible if the distal fibula is overresected. Range of motion of the foot may be limited because of scarring and muscle resection. Prolonged pain is rare but may also develop. The authors have found that with the increasing use of other boney flaps our selection of patients allows us to eliminate those with any evidence of circulation problems. This greatlyreduces the incidence of lower leg healing issues.

As with any microvascular surgery, free flap failure is a risk. Flap salvage following venous or arterial thrombosis is possible if early identification of vascular compromise leads to early (urgent) operative intervention. If thrombosis is identified and appropriately managed or pedicle geometry is optimized if twisting had occurred, the flap may be saved. Thrombectomy and revision of thrombosed vessel(s) are performed if required; occasionally, this necessitates vein grafting.

For flaps with venous congestion where patients cannot be returned to the OR immediately, leeches may be used to temporarily relieve the congestion. This technique rarely should be used for long-term salvage. Leeches work by removing the engorged blood from the flap and thereafter allowing an artificial venous outflow through their bite in the patient's flap skin. Blood flow through the bite is enhanced by an enzyme, hirudin, found in the leech saliva. This enzyme is a powerful anticoagulant and, together with removal of the tiny clot that forms at the bite site, allows flaps to slowly bleed for hours. Leeches can transmit Aeromonas hydrophila, a gram-negative rod when used, and patients should prophylactically receive an antibiotic that covers beta-lactamase–resistant organisms if leech therapy is used.

If one or all of the veins are thrombosed, the arterial anastomosis may be allowed to remain intact at the discretion of the surgeon. Venous drainage occurs through the unattached veins. The authors irrigate University of Washington solution (streptokinase and heparin), shown to improve flap survival, through the flap. Systemic heparin should generally be started in the operating room and continued in the postoperative period for 7 days. Hematomas may develop as a result of anticoagulation. Drains should be carefully placed in the OR and not removed until the heparin has been discontinued. Venous return through the bone marrow has been cited in survival of fibular reconstruction despite venous thrombosis of the pedicle. If the skin appears thrombosed at the time of takeback, but the bone is viable, the perforators through the septum should be evaluated. If the skin fails, but the bone survives, the bone may be covered with a second free flap (fasciocutaneous) or a pedicled flap.

Plate exposure and extrusion are rare complications. Patients who report postoperative pain with chewing are evaluated with radiographic imaging. If screw loosening is suspected, patients are returned to the OR for removal of the plate, if necessary. A single loose screw may occasionally be removed under local anesthesia in the clinic setting. Trismus is possible as a result of surgical manipulation and/or resection of the masticator muscles and disturbances in mandibular integrity. Patients are monitored by speech therapists and counseled on jaw-opening exercises to minimize the impact of this complication. Patients continue exercises through radiation therapy because significant scarring of the muscles may develop.

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