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Part IV
Osseous and Osteocutaneous Flaps and Grafts
The Free Fibula Flap
13
JasonCohn andFiyinSokoya
Introduction/History
First described by Hidalgo in 1989, the free bular ap (FFF) is the workhorse for
reconstructing soft tissue and bony defects of the head and neck [1]. FFF is a diverse
ap that may be harvested as an osseous, osteocutaneous or osteofascial ap and
may be precisely tailored to the defect by using multiple osteotomies, double
perforator- based skin aps, muscle component, and “double-barreling”, amongst
others [2–7].
The bula is a long, bicortical bone that can be harvested up to 25cm in length
[8]. This allows for complete angle-to-angle mandibular reconstruction [9]. Using a
two-team approach, simultaneous ablation and free tissue harvest are attainable.
Multiple osteotomies can be performed and precise shaping of the ap can be
achieved, with up to ve bony segments generally used [8].
Due to its rich periosteal blood supply, the FFF permits the placement of osseointegrated implants [9]. Not only does this allow the patient to masticate, but
implants have been shown to improve aesthetics and lip support aiding in oral competence [10].
J. Cohn
Sunrise ENT and Facial Plastics, Lindenhurst, NY, USA
F. Sokoya (*)
Wellstar Health Systems, Atlanta, GA, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_13
171
172
J. Cohn and F. Sokoya
Anatomy
The main blood supply to the osteocutaneous bular ap is the peroneal artery via
perforators, which are divided into septocutaneous, musculocutaneous, and septomusculocutaneous [11, 12]. One study dened the peroneal skin branches into three
patterns:
Type A located in the proximal third of the leg, pass through the peroneus longus or
the soleus muscles;
Type B located throughout the leg, pass between the soleus and peroneal muscles
and branch to adjacent muscles;
Type C located in the middle and distal thirds of the leg, same as Type B but do not
branch to adjacent muscles [12].
Yoshimura etal. determined the average number of cutaneous branches to be 4.8
per leg. Cutaneous branches from the peroneal artery were located 6–30cm distal
from the bular head, with the greatest conuence of vessels 24cm distal from the
bular head [12].
Indication/Contraindications
Maxillary and mandibular reconstruction are performed after resection due to
malignant tumors, nonmalignant tumors, congenital conditions, trauma, osteoradionecrosis, infection, and previous ap failure [7–9]. FFF is often the ap of choice
for mandibular reconstruction including bone-only defects, anterior reconstruction
requiring external replacement of the skin and internal oor of mouth, as well as
hemi-mandible defects with adjacent lateral oor of mouth and buccal mucosa loss
[13] (Fig.13.1).
One main disadvantage of the FFF is that the skin island is not reliable in every
patient. Retromolar trigone defects have large mucosal requirements with a short
bone gap. In these situations, a unicortical radial forearm ap would be more appropriate. Lateral defects with large internal and external tissue loss would also exclude
FFF reconstruction. For this scenario, the scapular free ap would provide enough
reliable soft tissue coverage [13]. Anatomical variants and peripheral arterial disease of the lower extremity can also preclude the use of this ap [11].
Preoperative Planning
Preoperative models with or without prefabricated reconstruction plates and cutting
guides may be used and have shown to decrease ischemia time, operative time, and
length of stay and in some reports also improve operative outcome [4, 7, 14–16]. In
addition, virtual planning allows the surgical team to customize the operation to the
patient needs within 2–4mm of accuracy [16].
13 The Free Fibula Flap
Fig. 13.1 Segmental
mandible defect from
symphysis to angle after
plate reconstruction
173
Computer planning sessions typically occur with vendors via virtual meetings.
Each session can take up to 1h; however, with each successive session, meetings
can be streamlined. During the session, data is extracted from the patient’s CT scan
and it is used to plan the resection and reconstruction. Following this, a surgical plan
is created and reviewed by the surgical team, allowing for changes prior to the surgery. The ablative and reconstructive teams then coordinate how many osteotomies
and bone segments will be required. Surgical models including cutout templates of
the various angles of the dentoalveolar arch are then prepared with cutting guides.
Finally, plate bending is planned, further saving of operative time [7, 16].
The need for preoperative angiography remains controversial. One study indicated that there is low-quality evidence to suggest the need for lower limb angiography with ap. However, physical examination alone is insufcient in detecting
poor limb perfusion [9]. Specically, the ankle–brachial index was found to be
insufcient in detecting vascular anomalies or subclinical peripheral arterial disease
[17, 18]. A more recent study demonstrated that computed tomographic angiography accurately predicted the course and location of the peroneal artery and perforators. However, perforator size was less accurately estimated [19].
Intraoperative indocyanin green (ICG) videoangiography can be used to assess
perfusion to the bula ap to ensure ap viability especially in individuals at risk for
ap loss [20, 21]. However, ICG imaging cannot visualize the macrovascular (tibioperoneal) and bula bony anatomy and is only available intraoperatively, not allowing for preoperative planning [19].
174
J. Cohn and F. Sokoya
Instrumentation
Standard operative instrumentation and microsurgical instrumentation are required.
These include major plastic surgery/otolaryngology trays and biceps forceps trays.
Specically, necessary instruments include dissecting scissors, such as Stevens and
Metzenbaum, hemoclip appliers, and nylon sutures. Additionally, Browns, Addisonbrowns, and jeweler forceps are also helpful during dissection. Iris and double skin
hooks, Army-Navy, and Senn retractors all have a role in exposure. Finally, bovie
cautery and various blade sizes are necessary for dissection dependent on surgeon
preference and experience. The specic details of tool vary by surgeon preference
and institutional tray setup. In most cases, a dermatome will be required for skin
graft harvest, and a pneumatic tourniquet cuff will be utilized during ap dissection.
Flap Design andSurgical Technique
Flap Design andPreparation
Hidalgo, the rst to describe bula free ap for mandibular reconstruction, proposed that the skin island should span the entire length of the bula. It should taper
proximally and distally relative to the main skin island and should be centered over
the midpoint of the bula [1]. Based upon further anatomical studies, osteocutaneous free bular aps should be designed 10–20cm from the bular head and should
include the soleus and exor hallicus longus muscle cuff to incorporate potential
septocutaneous perforators [22]. The long axis of the skin island is centered over the
posterior border of the bula in order to capture the septal blood supply [13].
During hemimandibular reconstruction, the ipsilateral leg is typically selected
(Fig. 13.2). The rationale is that the exor hallucis longus muscle lies directly
underneath the bula. In addition, the skin island can easily be rotated up and over
the bula to reach the oral cavity for mucosal reconstruction. Reconstruction is
Fig. 13.2 Skin paddle and
perforators identied. Note
depiction of lateral
malleolus and ankle
mortise and distance from
the joints marked
13 The Free Fibula Flap
175
planned so that the pedicle enters the bone at the angle of the mandibular ap. This
maximizes the pedicle length. For more anterior defects, the ap design is shifted
more distally. The proximal bone is removed in the subperiosteal plane, adding
more pedicle length [13].
A helpful rule in determining the laterality of leg selection is the rule of the surgeon’s st. The surgeon’s st with the thumb up can be used to replicate the bula
and the peroneal vessels. The skin and the lateral surface of the bula bone are
represented by the back of the hand and ngers, and the pedicle is represented by
the thumb. This method is helpful in vessel selection, skin paddle selection, and
orientation and complication avoidance.
Dissection andElevation
The tunneling technique popularized by Dr. Ducic makes for expedited harvest of
the bular free ap. First, the ap is designed by centering it along a vertical line
slightly anterior to the posterior intermuscular septum. The skin paddle, if needed,
is oriented lengthwise and is centered over this line. Under tourniquet control of
350mmHg, the skin paddle is incised and relaxing incisions carried inferiorly to
within 5–6cm of the ankle mortise and superiorly to within 6cm of the head of the
bula (Fig.13.3). Care is taken to avoid the peroneal nerve in this region. The incision is carried right down to the peroneal muscles. The peroneus longus and brevis
are retracted anteriorly. Dissection is then carried anteriorly past the lateral surface
of the bula. The anterior septum is traversed at this point. Dissection is then carried
past the extensor digitorium longus and the extensor hallucis longus. Next a small
perforation is made in the central portion of the interosseous membrane. Finger dissection is then performed superiorly and inferiorly along the anticipated portion of
bula harvest (Fig.13.4).
Next, the periosteum in the area of proposed osteotomy is then elevated using a
periosteal elevator. The elevator is then placed medial to the bone in the area of
elevated periosteum to help protect the pedicle. An oscillating saw is then used to
perform an osteotomy distally then proximally. The hallucis longus muscle is then
sectioned and the distal pedicle controlled with hemoclips. Finger dissection is performed in the tunnel of dissection deep to the tibialis posterior and medial to the
vessels. This is a loose areolar, avascular plane that runs superiorly to the takeoff of
the peroneal artery in all cases. The tibialis posterior muscle supercial to the index
nger which rests within the dissection tunnel can be divided with Metzenbaum
scissors. Now, the bula osteomyocutaneous ap should be pedicled just on the
peroneal artery and its paired venae comitantes. The pedicle is then divided at the
takeoff (Fig.13.5). The tourniquet is removed and the pedicle is tied off once vascularity is veried [23]. Typical microvascular anastomosis is performed with 9.0
nylon sutures and venous couplers. One or both veins may be utilized, depending on
ow (Fig.13.6).
176
Elliptical incision:
septum
hallucis
Extensor
Tibialis anterior m.
longus m.
J. Cohn and F. Sokoya
Anterior tibial artery
veins and nerve
Tibia
Interosseous
membrane
Tibialis posterior m.
Posterior tibial
artery and nerve
Finger dissection
space
Flexor hallucis
longus m.
Peroneal artery
and veins
Postorior
innermuscular
Extensor
digitorum
Anterior
intermuscular
longus m.
septum
Fibula
Peronous
longus m.
Tibia
Head of fibula
Peroneal nerve
brevis m.
Peroneus
Approximation
of posterior
intermuscular
septum
1/3 anterior to
septum
posterior to
septum, 2/3
Deep fascia
Lateral view right leg
eral malleolus
Fig. 13.3 Compartments of the leg. Fibula anatomy
Interosseous
artery and
Interosseous membrane
Tibialis
artery and venae
vessies
13 The Free Fibula Flap
177
Tibia
Peroneal
veins
T
ibia
Tibia
Fibula
Fibula
membrane
LATERALMEDIAL
Fig. 13.4 Traversing the interosseous membrane
posterior
Fibula Fibula
muscle
Fibula
Peroneal
artery
and veins
Fig. 13.5 Tunneling method
Finger in
dissection space
protecting
Peroneal artery
and venae
comitantes
Posterior tibial
comitantes
178
Fig. 13.6 Venous
anastomosis with coupler
and arterial anastomosis
with adjacent implantable
Doppler
Donor Site Closure
J. Cohn and F. Sokoya
The donor site was initially thought to be closed primarily the majority of the time
[12]. However, primarily closure is sometimes associated with excess tension which
can lead to wound breakdown, necrosis, infection, and compartment syndrome. It is
now recommended to use a skin graft to close most defects, regardless of the width
of the skin paddle. Some studies advocate for the placement of a bolster dressing or
negative-pressure wound therapy, while others state that it has no impact on donor
site healing [24]. One systematic review and meta-analysis concluded that ap
reconstruction of the donor site resulted in less short-term complications compared
to skin grafting [25]. However, most studies have shown overall complication rates
to be the same regardless of closure technique [26].
Postoperative Management
One of the main drawbacks of the FFF is monitoring its blood supply because the
ap is often buried within the mandible. This can be mitigated by externalizing a
small skin island, monitoring an intraoral skin island, selective angiography, and
technetium-99m bone scanning [12, 13]. An implanted Doppler can also be used to
monitor arterial and/or venous ow.
Flap checks of the peroneal artery with a pencil Doppler are recommended every
1–2 h for the rst 48 h postoperatively. In one study, the use of an implantable
Doppler device reduced ap failure from 56% to 21% [8]. Panoramic X-ray studies
13 The Free Fibula Flap
179
or CT scans are utilized to monitor bone stock healing. Patient free of disease can
receive osseointegrated implants 6–12 months following reconstruction [13].
Although radiation exposure can show a trend toward implant failure, this has not
been shown to be signicant. Some advocate waiting 6months following radiation
for implantation [10]. As in most scenarios, edentulous bone experiences signicantly higher rates of bone resorption and atrophy when compared to the dentulous
mandible [27].
Ambulation is encouraged as soon as 2days postsurgery, but this can be negatively impacted by skin grafting and donor site morbidity for up to 3weeks. Some
advocate the use of a splints, and boots for 6weeks with weight-bearing [12, 26]. In
the initial 60 patient series by Hidalgo, all patients were eventually able to ambulate
normally. Two patients experienced running limitations. In this same series, most
individuals were able to maintain an oral diet. Specically, 51% had no restrictions,
42% tolerated a soft diet and only 7% required tube feedings. Furthermore, speech
was documented as normal in 39%, mildly impaired in 32%, hard to understanding
in 19%, and unintelligible in 10% of patients [28].
Pearls/Pitfalls
• The mainstay option for mandibular reconstruction is the bula free ap. Other
options include rib, metatarsal, ilium, radius, and scapula [28].
• When elevating the ap proximally, care should be taken to not transect the ped-
icle near its origin as it crosses the tibialis posterior muscle raphae from medial
to lateral [13].
• Flap failure can occur in up to 13% of cases due to arteriovenous complications
and difculties of monitoring buried aps [8, 12].
• The more common recipient site complications include wound dehiscence, hard-
ware extrusion, inadequate xation, stula formation, bone loss, osteoradione-
crosis, and surgical-site infections [8, 28].
• Donor site morbidity can affect up to 30% of patients [8].
– Long-term effects can include persistent pain, edema, numbness, cold intoler-
ance, compartment syndrome, and decreased strength and range of motion of
the ankle [9, 13, 24, 29].
– Planar exion and foot eversion can be preserved provided foot exors and
peroneus brevis muscle remains intact [12].
– Early ambulation, less bedrest, and physical therapy before and after surgery
play an important role in minimizing these issues [9, 24].
• One should consider an alternate reconstructive option in high-performance ath-
letes, as they will not tolerate any degree of functional impairment due to the
need for lateral mobility offered by the bula bone [9].
• Computer-assisted virtual planning has been shown to achieve high rates of den-
tal rehabilitation [7].