Versatility and Reliability of Distal Perforator-Based Skin Island of the Free Fibula Flap for Facial Reconstruction of the High Energy Facial Trauma Patient in a Non-Asian Population

The reliability of the distal skin paddle in the free fibular osteocutaneous flap continues to be controversial despite its successful use in the Far East. This technique of harvesting a distal skin flap based solely on distal septocutaneous perforators lying within the posterior septal crura, allows great versatility and reliability needed for correction of complex high energy facial trauma injuries in patients presenting with a combination of skeletal, skin, and mucosal defects. The authors presented their experience, the largest reported series in trauma patients, with 10 consecutive facial trauma patients in whom this technique was used successfully. Ten lower extremity fresh cadaver dissections performed in the exact surgical technique utilized on patients, were injected with methylene blue and red latex, demonstrating the blood supply pattern to the skin via the distal septocutaneous perforators.

Ten consecutive free osteocutaneous fibula flaps were performed on Caucasian or African-American patients, characteristic of the trauma population. Surgical technique involved initial raising of the distal skin island based on the distal septocutaneous perforators, which lie within the very thin posterior septal crura. The remaining dissection proceeds in previously described techniques with emphasis on minimal to no muscle harvesting. Ten cadaver lower extremity dissections, mimicking the exact technique utilized in the operating room, were injected with methylene blue or red latex into the proximal peroneal artery only after isolation of the skin island on its septal perforators and ligation of all proximal blood supply.

No total or partial skin loss occurred. No orocutaneous fistulas or donor site morbidity were observed. The number of osteotomies ranged from one to three and fibular lengths ranged from 8 to 15 cm. Skin island dimensions ranged from 2 to 3 cm in width and 5 to 15 cm in length. Cadaver staining studies confirmed the blood supply pattern to the skin. The cadaver skin island dimensions ranged from 5 to 8 cm in width and 9 to 18 cm in length. The number of perforators varied from one to four, ranging in distance from 8 to 20 cm proximal to the lateral malleolus, but mostly located 10 to 15 cm proximal to the lateral malleolus.

The distal skin island in the free fibula osteocutaneous flap based on the septocutaneous perforators is both reproducible and reliable, enabling great versatility in the reconstruction of complex bony and soft tissue defects seen in the high energy facial trauma population.