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.

KEY WORDS

Free fibula flap - musculocutaneous perforators - septo cutaneous perforators - skin paddle - vascular supply

• 1 Taylor GI, Miller GD, Hamm FJ. The free vascularised bone graft. Plast Reconstr Surg 1975;55:533.
• 2 Wei FC, Chen HC, Chuang CC, Noordhoff MS. Fibular osteocutaneous flap: Anatomic study and clinical application. Plast Reconstr Surg 1986;78:191-200.
• 3 Hidalgo DA. Fibular free flap: A new method of mandibular reconstruction. Plast Reconstr Surg 1989;84:574-85.
• 4 Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg 1994;93:294-304.
• 5 Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 1995;96:585-96.
• 6 Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Reconstruction of mandible with osseous free flaps: A 10 year experience with 150 consecutive patients. Plast Reconstr Surg 1999;104:1314-20.
• 7 Yadav PS, Ahmad QG, Shankhdhar VK, Nambi GI. There is no donor side specificity of fibula free flap for complex oromandibular reconstruction. Indian J Plast Surg 2010;43:177-80.
• 8 Wong CH, Tan BK, Wei FC, Song C. Use of the soleus musculocutaneous perforator for skin paddle salvage of the fibula osteoseptocutaneous flap: Anatomical study and clinical information. Plast Reconstr Surg 2007;120:1576-84.
• 9 Tan BK, Wong CH. An anomalous septocutaneous perforator to the skin paddle of the fibula osteocutaneous flap originating from the posterior tibial artery. J Plast Reconstr Aesthet Surg 2009;62:690-2.
• 10 Yadav PS, Ahmad QG, Shankhdhar VK, Nambi GI. Successful management of free osteocutaneous fibula flap with anomalous vascularity of the skin paddle. Indian J Plast Surg 2009;42:255-7.
• 11 Ahmad QG, Yadav PS, Shankhdhar VK, Nambi GI. Use of fibula pedicle as a composite interposition vascular graft to salvage large skin paddle with anomalous vascular supply. Eur J Plast Surg 2011;34:413-6.
• 12 Jones NF, Monstrey S, Gambier BA. Reliability of the fibula osteocutaneous flap for mandibular reconstruction: Anatomical and surgical confirmation. Plast Reconstr Surg 1996;97:707-16.
• 13 Winters HA, de Jongh GJ. Reliability of the proximal skin paddle of the osteocutaneous free fibula flap: A prospective clinical study. Plast Recostr Surg 1999;103:846-9.
• 14 Schusterman MA, Reece GP, Miller MJ, Harris S. The osteo cutaneous free fibula flap: Is the skin paddle reliable? Plast Reconstr Surg 1992;90:787-93.