Skin paddle vascularity of free fibula flap - A study of 386 cases and a classification based on contribution from axial vessels of the leg

Abstract

Objective:The skin paddle of the free fibula flap receives its vascular supply from septocutaneous perforators, musculocutaneous perforators or from both, and these perforators might originate from the peroneal or posterior tibial vessels or from both. The objective of this study was to classify the skin paddles based on the dominance of vascular contribution by these axial vessels through their different perforator systems.Materials and Methods:A retrospective analysis of 5-year data of 386 free fibula flaps used in oro-mandibular reconstruction was done and the skin paddle vascularity was studied. While majority of the skin paddles received their blood supply from the peroneal septocutaneous perforators, a few had their dominant supply from the soleus musculocutaneous perforators in addition to peroneal septocutaneous perforators. In few cases, the soleus musculocutaneous perforators were the sole source of blood supply to the skin paddle. The limitation in this study was the inability to augment the clinical observation with cadaveric study.Results:The skin paddle of the free fibula flap was classified into four different types (a–d) based on the dominance of vascular contribution by axial vessels of the leg.Conclusion:The skin paddle of the free fibula flap has reliable blood supply, but a thorough knowledge of the variations in vascular pattern of the skin paddle is required especially to salvage the larger paddles used in the reconstruction complex oro-mandibular defects.

Partial and Total Flap Failure after Fibula Free Flap in Head and Neck Reconstructive Surgery: Retrospective Analysis of 180 Flaps over 19 Years

“…Other authors found a stable and sufficient vascular supply of the septo-cutaneous skin paddle by the septum intermusculare posterius and perforator vessels around the musculus soleus [ 54 , 55 , 56 ]. They emphasize the necessity of a muscle cuff around the posterior septum, which contains vessels that are crucial for skin paddle survival [ 24 ].…”

“…Comparative results of partial loss were reported with a range of 3–14% [ 16 , 23 ]. This should be considered when the often-described advantage of the skin paddle as a vital monitor is advocated [ 24 , 25 ]. Gennaro et al mentioned that a thin muscle cuff around bone, e.g., the fibula or vascularized iliac crest bone flap, is needed for flap harvesting.…”

Fibular osteofasciocutaneous flap in computer-assisted mandibular reconstruction: technical aspects in oral malignancies

“…In our experience, the use of the hand-held Doppler associated with CT angiography 36 for the identification of the perforator vessels and manual measurement of the distance between the external malleolus and the vessel itself has proven to be a good method in CAMR with an osteocutaneous flap. It must be said, however, that the surgeon is ready to modify, even if minimally, the morphology of the guides if these interfere with the only perforating vessel 37 .…”

Synchronous reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular osteocutaneous flap in patients with nasopharyngeal carcinoma

“…We harvested skin paddles based on proximal and distal perforators. It has been demonstrated that proximal perforators are consistently located one third of the length along the line from the fibula head to the lateral malleolus . We found that 30 patients presented proximal perforators arising from the peroneal pedicle, and skin islands were created in those patients.…”