Robert M. Laughlin¹ and Christopher M. Harris²

¹Department of Oral and Maxillofacial Surgery, Naval Medical Center San Diego, San Diego, California, USA

²Department of Oral and Maxillofacial Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA

The harvest of a free vascularized fibula for the reconstruction of combined hard and soft tissue maxillofacial defects.

Indications

1. Reconstruction of surgical defects following oncologic ablative surgery, traumatic defects, and congenital anomalies requiring cutaneous and/or osseous vascularized tissue
2. Segmental continuity defects of the maxilla and mandible greater than 5 cm. A long segment of bone up to approximately 25 cm is available for harvest. The skin paddle has proven to be dependable if care is taken to preserve the fasciocutaneous perforators. Innervation of the flap is possible, and the flap has adequate bone stock to accept endosseous dental implants

Contraindications

1. Medical conditions that would not be compatible with extended operative procedures
2. Hypercoagulable states
3. Relative contraindications:
   1. Vasculitis
   2. Connective tissue disorders
   3. Peripheral vascular disease
   4. Venous insufficiency
   5. Congenital anomalies of the peroneal artery
   6. Other disorders that may impact coagulation and wound healing

Note: Evaluation of the patient’s physiologic status is more important than the chronologic age of the patient in determining the appropriateness of a free tissue transfer procedure.

Preoperative Studies

1. Bilateral lower extremity angiogram or magnetic resonance angiography. The arteriogram should demonstrate normal three-vessel runoff of the right and left popliteal artery with normal patency of the anterior, posterior, and peroneal vessels bilaterally.
2. Palpation of the dorsalis pedis (anterior tibial artery) and posterior tibial pulses.

Flap Anatomy

1. Dominant-peroneal artery
   • Length: 2.0 cm (2–4 cm)
   • Diameter: 1.5 mm (1–2.5 mm)
2. Minor-periosteal and muscular branches
   • Length: 1.2 mm (0.8–1.7 mm)
   • Diameter: 1.0 mm (0.8–1.7 mm)

Typically, 4–8 cutaneous arteries arise from the peroneal artery. These typically are septal or septo-muscular cutaneous perforators coursing through the posterior crural (lateral) septum.

Surgical Anatomy

The lower leg can be viewed as four compartments:

• Lateral compartment: Bordered by the posterior crural septum and the anterior crural septum and contains the peroneus longus and peroneus brevis muscles.
• Anterior compartment: Bordered by the anterior crural septum and the interosseous membrane and contains the extensor digitorium longus and extensor hallucis longus muscles. The anterior tibial vasculature and deep peroneal nerve lie on the superficial aspect of the interosseous membrane in the anterior compartment.
• Superficial posterior compartment: Bordered by the interosseous membrane and the intermuscular membrane of the flexor hallucis longus and soleus muscles. The peroneal vessels lie on the deep aspect of the interosseous membrane and course distal along the fibula. The posterior tibial vessels are deep to the tibialis posterior muscle.
• Deep posterior compartment: Bordered by the intermuscular membrane of the flexor hallucis longus and soleus muscles and the posterior crural septum; it contains the lateral aspect of the soleus muscle.

Preoperative Preparation

1. A bump may be placed under the ipsilateral hip to aid in access to the lateral surface of the lower extremity.
2. A heel bump (i.e., a 5 lb. sandbag or 1 L IV fluid bag) is placed on the operating room table that allows the lower extremity to maintain 90° of flexion at the knee; it will aid in the graft harvest.
3. Doppler flow meter.
4. Tourniquet (recommended but optional).
5. A second set of instruments for the harvest team.

Surgical Procedure

1. A normal preoperative arteriogram of bilateral lower extremities demonstrating three-vessel runoff of the right and left popliteal artery with normal patency of all distal vessels.
2. The patient is placed in a supine position. The knee is flexed to 90°, and the hip is internally rotated with the use of a hip bump. The heel is then placed on a gel bumper, which is secured to the table. The patient is prepped and draped in a sterile fashion. A sterile tourniquet is applied.
3. Anatomic landmarks are palpated and marked (Figure 59.1) to include the head of the fibula and the lateral malleolus of the ankle. The dorsalis pedis and posterior tibial pulses are palpated and marked with Doppler accordingly. With a surgical pen, a mark is placed 6–8 cm inferior to the head of the fibula and 6–8 cm superior to the lateral malleolus. This allows the proximal and distal 6–8 cm of the fibula and its ligamentous attachments to be preserved. A line is drawn along the posterior crural septum connecting the two marks.
4. If a skin flap is to be harvested in conjunction with the fibula, the flap should be designed along the posterior septal crural. A Doppler will allow for the identification of septocutaneous perforating vessels (Figure 59.2). Typically, the skin flap is designed in the distal one-third of the flap.
5. The extremity is exsanguinated, and the tourniquet inflated to 300 mmHg. Time of inflation must be recorded. Inflation time must be keep under 2 hours to avoid possible ischemic events.

6. A skin incision is made to the depth of the superficial fascia along the length of the incision t/>

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