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Osteocutaneous Fibula Free Flap

last modified on: Fri, 12/29/2023 - 13:35

return to: Microvascular Surgery Protocols

see also: Case example: Anterior mandibular reconstruction and Prep and Drape Osteocutaneous Fibula Free Flap


  1. Indications
    1. The fibula flap has been used extensively for oromandibular reconstruction. A long segment of bone up to approximately 22 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 ample bone stock for the placement of osseointegrated implants.
  2. Contraindications
    1. See Microvascular Surgery General Considerations. Flap-specific contraindications include a history of peripheral vascular disease involving the lower extremities, preoperative color flow Doppler studies or angiography indicating significant atherosclerotic disease, or anomalous lower extremity vasculature. The most frequent anomaly is a hypoplastic anterior tibial artery with blood supply to the foot derived primarily from the peroneal artery via a perforating branch, which then forms the dorsalis pedis (this occurs in approximately 5% of individuals). The need for a large skin paddle that can be positioned independent of the placement of the bone is a relative contraindication. The skin paddle of the fibula is usually an elliptical shape, oriented parallel to the bone, and it can not be rotated to any significant degree. If a large skin paddle is needed, the scapula may be a more appropriate selection. Venous insufficiency is a contraindication due to the potential for donor site complications..
  3. Pertinent Anatomy
    1. The blood supply to the fibula is derived primarily from the peroneal artery, which branches from the popliteal or posterior tibial at the trifurcation point of the posterior tibial, anterior tibial, and peroneal just distal to the popliteal fossa. The primary blood supply to the harvested fibula flap is derived from periosteal perforators traveling circumferentially around the fibula. The fibula head lies 3 cm below the lateral femoral condyle. Distally the fibula is subcutaneous and forms the lateral malleolus. The fibula itself bears approximately 10% of the weight placed on the foot. The common peroneal nerve crosses the proximal fibula between 4 to 8 cm below the head and can be palpated as it crosses the bone. As the common peroneal nerve crosses the bone it lies under the extensor digitorum longus and peroneus longus muscles. The common peroneal nerve branches to form the superficial and deep peroneal nerves, both of which supply extensor muscles of the foot. Injury to these nerves may result in foot drop. The lateral septal band separating the anterior from posterior compartments carries 2 to 6 septocutaneous perforators that run between the peroneus musculature and the soleus. These septocutaneous perforators are primarily located in the region of the middle third of the fibula. These septocutaneous perforators occasionally run posterior to the true septum through the flexor hallucis longus and lateral soleus muscles and in this situation they are more appropriately termed musculocutaneous perforators. True septocutaneous perforators and some musculocutaneous perforators may be present in the same specimen. The skin supplied by these vessels lies on the lateral and posterior lower leg. The lower 7 to 8 cm of the fibula and its surrounding fibrous attachments are important for ankle mortise ligament support and should not be disrupted. Both the anterior tibial neurovascular bundle (anterior to the interosseous septum) and the posterior tibial neurovascular bundle (deep to the soleus and medial to the flexor hallucis longus muscle) are encountered during the dissection, and a thorough knowledge of the anatomy and care with the dissection are important to prevent injury to these structures. Branches of the lateral sural cutaneous nerve supply the area of the skin paddle and can be harvested to allow innervation of the flap. The sural nerve lies within the field and can be harvested as a vascularized nerve transfer with the flap. This robust nerve is used in cases where a cable nerve graft is required.


  1. Evaluation
    1. Careful examination of the lower extremities and history for any evidence of previous trauma or atherosclerotic disease. Palpation of dorsalis pedis and posterior tibial pulses. Occasionally the peroneal pulse may be palpated.
    2. Color flow Doppler evaluation of both lower extremities. If there is difficulty in demonstrating good flow in all 3 vessels due to obesity, an angiogram may be required. In general, for a predominantly unilateral defect with the vessels coming off posteriorly, the contralateral fibula is preferred if a skin paddle is to be used.
  2. Potential Complications
    1. See Microvascular Surgery General Considerations.
    2. Flap-specific complications include peroneal nerve palsy with resultant "foot drop," loss of skin graft, or breakdown of donor site incision resulting in exposed tendons, persistent foot edema, loss of ankle mobility, and loss of sensation over the anterior lower leg and top of foot. (This is an anticipated result of flap harvest in many cases, but patients should be aware of it.)


  1. Room Setup
    1. See Free Flap Room Setup
  2. Instrumentation and Equipment
    1. Standard
      1. Major Instrument Tray 1, Otolaryngology
      2. Major Instrument Tray 2, Otolaryngology
      3. Bipolar Forceps Trays
      4. Microsurgery Instrument Tray, Otolaryngology
      5. Hall Micro Sagittal Saw Tray (Pneumatic) x 2
    2. Special
      1. KLS Free Flap Implant - Instrument Tray or
      2. KLS Oto Trauma Implant - Instrument Tray or
      3. KLS Locking Reconstruction Threadlock Instrument Tray or
      4. KLS mandibular or
      5. KLS maxillectomy
      6. Bien Otologic Electric Drill Tray
      7. Sterile tourniquet, size 24 and 36
      8. Sterile soft roll and Esmarch bandage
      9. Dermatome set-up (available only)
  3. Medications (specific to nursing)
    1. Antibiotic ointment
    2. Heparin sodium injection, 1,000 units per ml, 10ml vial
    3. Papaverine injection, 60 mg per 2 ml, 2 ml ampule x 2
    4. PhysioSol irrigation solution, 500 ml (Be sure the PhysioSol is in the warmer in sufficient time to be warm when the surgeon requests it.)
  4. Prep and Drape click for photos:  Prep and Drape Osteocutaneous Fibula Free Flap
    1. Standard prep, 10% providone iodine (circumferential to leg, from foot to groin)
    2. Drape
      1. Prep the head and neck separately from the leg.
      2. Impervious drape under the leg (may use sandbags for positioning)
      3. Towels around the operative leg circumferentially; a sticky drape is wrapped circumferentially around the ipsilateral leg on the extreme aspect of the upper thigh to separate the groin from the operative field. The upper lateral thigh is draped to allow harvest of a skin graft.
      4. Split sheet around the leg
  5. Drains and Dressings
    1. Fully perforated 10 mm flat suction drain
    2. Adaptic
    3. Sterile web roll applied loosely to arm from below elbow to wrist
    4. Ace wrap 6 in x 2; and 4 in x 2
    5. Plaster splint 5 x 35 in
  6. Special Considerations
    1. Heparin sodium injection 5,000 units in sodium chloride 0.9% 500 ml in syringe, Luer tip 5 cc syringe with 24-gauge IV cannula is used to irrigate vessels.
    2. Papaverine 60 mg in 500 cc sodium chloride 0.9% in a Luer tip 10 cc syringe with 18-gauge IV cannula will be used topically to irrigate for vasospasm.
    3. Use all measures to keep body temperature at least 37° warming blanket, room temperature.
    4. See Skin graft protocol if necessary for procedure.
    5. Varidyne vacuum suction (7 mm or 5 mm) under flap.
    6. SoftRoll, 4 in and 6 in used under the tourniquet during the surgery and under plaster splint
    7. Oscillating saw and bone fixation plating set. For edentulous patients a 2 mm mandibular plating system is used; for dentate patients a reconstruction plate system that allows plate contouring and placement prior to mandibular resection is used.


  1. General
    1. The patient is supine on the table that will be turned 180° from the anesthesiologist.
    2. A large bump or pillow should be placed under the ipsilateral hip. This prevents the leg from straightening out during the flap harvest. The arms should be tucked.
  2. Specific
    1. All IV and arterial lines should be on the contralateral side. The blood pressure cuff should also be on the contralateral side.
    2. The tourniquet is placed around the lower thigh above the knee.


  1. Mark outline of fibula measure 7-9 cm from lateral malleolus and mark. The inferior bone cut will be at this point.
  2. Use Doppler to localize septocutaneous perforators (they may not be of a size that will allow localization).
  3. Mark the incision line. This will begin at fibula head curving gently anteriorly over peroneus musculature at midpoint the curve is gently back to end about 2 cm above the lateral malleolus over the fibula bone. This allows the skin paddle to be positioned anywhere along the incision pending the location of the perforators.
  4. Begin careful elevation of skin flap anteriorly under the peroneus muscular fascia. Identify septocutaneous perforators. Locate skin paddle as needed to incorporate at least 2 of the perforators.
  5. If lateral sural cutaneous innervation is desired, identify the nerve branch proximally and carefully trace it distally to the intended skin paddle.
  6. Make posterior incision down to soleus, elevate skin paddle anteriorly, and identify perforators. Carefully trace the perforators. If they enter the soleus, a cuff of soleus will need to be taken with the paddle.
  7. Dissect bluntly around the bone at proximal and distal osteotomy sites and clean the periosteum from bone in these areas. Use careful retraction proximally to avoid injury to peroneal nerves.
  8. Perform bone cuts with oscillating saw. Some dissection of the peroneus and extensor digitorum can be done before the bone cuts are made.
  9. With lateral retraction of fibula, begin anterior dissection of muscle off of fibula leaving 1 to 2 mm cuff of muscle. Do not injure periosteum. Muscles encountered will be peroneus, extensor digitorum longus, and extensor hallucis longus. At this point, the interosseous septum is encountered. Medially the anterior tibial neurovascular bundle will be present under the anterior tibial muscle bundle.
  10. Carefully incise interosseous septum along fibula leaving several mm to protect periosteal vessels.
  11. Identify peroneal artery distally and ligate. Trace peroneal artery superiorly with dissection of overlying tibialis posterior muscle. Posterior tibial neurovascular bundle will be medial to this dissection.
  12. The flap remains attached now primarily by the vascular pedicle, the soleus, and the flexor hallucis longus. With care not to injure the septocutaneous or musculocutaneous perforators to the skin paddle, dissect these muscles away from the bone flap posteriorly. The flap now remains attached only by the vascular pedicle.
  13. Trace the artery and venae comitantes proximally and identify the posterior tibial artery and veins. If the removal of 1 or 2 more cm of the proximal fibula will facilitate further dissection of the vascular pedicle, this can be done if the common peroneal is clearly out of the field.
  14. The flap can be replaced in its normal anatomic position until it is needed.
  15. If the sural nerve is to be harvested as a vascularized nerve, it should be elevated with the skin paddle when that is done by including it in subcutaneous tissue elevated with the skin paddle.
  16. The majority of the flap is dissected under tourniquet. The time should not exceed 2 hours. The tourniquet pressure should be 300-350 mm Hg.
  17. Closure is done over 1 or 2 large suction drains in the defect. If the skin edges cannot be closed without tension, a skin graft is placed regardless of the size of flap harvested. Try to avoid using the skin graft over the peroneus tendons. The wound is dressed with antibiotic ointment and a nonadhesive dressing, and the lower leg is wrapped with sterile web roll. A posterior splint is applied with the ankle in dorsiflexion. This is wrapped with an Ace wrap. The toes are to remain visible.
  18. See Fixation of Vascularized Bone Flaps.


  1. See General microvascular protocol.
  2. Patient should have neurovascular checks of the operated lower extremity in conjunction with free flap checks every hour for the first 48 hours then every 4 hours for 3 days.
  3. Bed rest for approximately 24 hours; operated leg remains elevated on 2 pillows.
  4. On postoperative day 2, the patient should be up to a chair and may ambulate with a walker assisted by a physical therapist. The patient should be nonweight-bearing on the operated leg for 4 to 5 days. When up to a chair, the operated leg should be elevated on a stool with pillows.
  5. The splint can be removed on postoperative day 4 and the patient may ambulate with a walker, limited weight bearing. A physical therapist should help the patient. After the first 4 to 5 days postoperatively, the patient may advance ambulation as tolerated.


Anthony JP, Rawnsley JD, Benhaim P, et al. Donor leg morbidity and function after fibula free flap mandible reconstruction. Plast Reconst Surg. 1995;96:146-152.

Beppu M, Hanel DP, Johnson GHF, et al. The osteocutaneous fibula flap: an anatomic study. J Recon Microsurg. 1992;8:215-223.

Blackwell KE. Donor site evaluation for fibula free flap transfer. Am J Otolaryngol. 1998;19:89-95

Coghlan BA, Townsend PLG. The morbidity of free vascularized fibula flap. Br J Plast Surg. 1993;46:466-469.

Disa JJ, Cordeiro PG. The current role of preoperative arteriography in free fibula flaps. Plast Reconst Surg. 1998;102:1083-1088.

Futran ND, Stack BC, Zaccardi MJ. Preoperative color flow Doppler imaging for fibula free tissue transfers. Ann Vasc Surg. 1998;12:445-450.

Hidalgo DA, Rekow A. Review of 60 consecutive fibula free flap mandible reconstruction. Plast Recon Surg. 1995;96:585-596.

O'Leary MJ, Martin PJ, Hayden RE. The neurocutaneous free fibula flap in mandible reconstruction. Otolaryngol Clin North Am. 1994;27:1081-1096.

Woerdeman LAE, Chaplin BJ, Grifioen FMM, Bos KE. Sensate osteocutaneous fibula flap: anatomic study of the innervation pattern of the skin flap. Head Neck. 1998;20: 310-314.

Last updated 10:13:18 PM 11/21/2008 by NP