Osseous and Osseocutaneous Free Flaps Fibula

The fibula can be transferred as a free osseous or free osseocutaneous flap. Since introduced first for mandible reconstruction in 1989, the fibula free flap has been applied for reconstruction of challenging defects in the head and neck.79 However, the primary application of the fibular donor site is in the reconstruction of segmental defects of the mandible, as described elsewhere in this text.80 In addition, the fibula osseocutaneous free flap has been described for reconstruction of maxillary defects alone or in combination with mandible defects.81

Approximately 22 to 25 cm of bone can be harvested from the fibula. This thick cortical long bone receives its endosteal and periosteal blood supply from the peroneal artery and veins which run along

Figure 18-29. A, Surgical specimen after anterior skull base resection with orbital exenteration. B, Reconstruction with vertical rectus abdominis myocutaneous free flap.
Figure 18-30. A, Squamous cell carcinoma of scalp—arrow shows area of exposed skull. B, Defect of scalp and skull. C, Reconstruction of scalp with latissimus dorsi free flap. D, Split-thickness skin graft over flap.

the entire length of the fibula.82 The excellent periosteal circulation permits multiple osteotomies with reliable perfusion on each bony segment; thus allowing shaping and remodeling of the bone to duplicate the inferior border of the mandible. The skin over the lateral aspect of the calf is supplied by either septocutaneous or musculocutaneous perforators arising from the peroneal artery and vein83 (Figure 18-31). In spite of the skin island of the fibula free flap being considered initially unreliable in 10 percent of cases due to unpredictable vascular sup-ply,79 it is now acknowledged that identification and inclusion of one single septocutaneous perforator can adequately perfuse a skin island as large as 10 x 22 cm.82 This skin island may be used to reconstruct oromandibular defects that include the external skin, inner lining or both82-84 (Figure 18-32). The flexor hallucis longus muscle may be transferred with the bone as well to provide some soft-tissue fill for the submental region.

Additional advantages of the fibula for reconstruction of the mandible include the ability to dissect the flap with the patient supine (allowing a two-team approach), and adequate bone stock for incorporating osseointegrated dental implants.85 Donor site morbidity is usually minimal. The leg defect may be closed primarily when a narrow skin island (less than 4 cm in width) is included with the flap; otherwise a skin graft is necessary to close the donor site. Some patients may experience transitory stiffness in the ankle joint, however, no physical limitations are usually observed.80

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