Video+

Nuances and Pearls of the Free Fibula

Osteoseptocutaneous Flap for Reconstruction of
a High-Energy Ballistic Injury Mandible Defect
Sammy Sinno, M.D.
Summary: A clinical case demonstrating the use of a free fibula osteoseptocu-
Eduardo D. Rodriguez,
taneous flap for reconstruction of a high-energy ballistic mandible defect is
M.D., D.D.S.
detailed. The surgical videos highlight key nuances and pearls of flap design,
New York, N.Y.
harvest, dissection, and execution of microsurgical anastomosis. Attention is also
given to preoperative surgical planning and postoperative care. (Plast. Reconstr.
Surg. 137: 280, 2016.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

T PREOPERATIVE CONSIDERATIONS
he free fibula osteoseptocutaneous flap
has become the dominant means of recon- In this case, our patient suffered severe facial
struction of the craniofacial skeleton and avulsion, losing his nose, anterior one-third of
extremities. First introduced by Hidalgo, the his tongue, hard palate, maxilla, and the major-
fibula flap is now the preferred method of vas- ity of his mandible. A multistage surgical plan
cularized mandibular reconstruction.1–4 It is that would involve extraction of teeth, free flap
able to provide a long segment of vascularized reconstruction of the maxilla and nose, and costo-
bone that can undergo multiple osteotomies, chondral graft to the nose with paramedian fore-
which is particularly important for craniofacial head flap was initiated with a free fibula flap for
skeleton contouring. With the advent of com- reconstruction of the mandible. We used presurgi-
puter modeling and virtual surgery, the fibula cal medical modeling to design a patient-specific
has been optimized to produce functionally sus- mandible and fibula graft guides, and a planned
tainable and aesthetically pleasing results.5–7 In outcome model. (See Video, ­Supplemental ­Digital
this article, we detail the utility of the free fibula ­Content 1, which demonstrates preoperative plan-
osteoseptocutaneous flap for reconstruction of a ning. This video is available in the “Related Videos”
high-energy ballistic mandible defect and high- section of the full-text article on PRSJournal.com
light important nuances and pearls in the surgi- or available at http://links.lww.com/PRS/B521.)
cal approach. It is important to identify patients who have
a history of peripheral vascular disease, trauma,
FLAP CHARACTERISTICS vasculitis, or deep vein thrombosis, as unreliability
The fibula flap is supplied by the peroneal of the peroneal artery may preclude it as a pedicle
artery. Minor blood supply is derived from its for free tissue transfer. Angiography should be
periosteal and muscular branches. Venous drain- considered in these patients or if the distal foot
age is primarily from the venae comitantes of the pulse examination is abnormal.
peroneal vein, with sensory innervation from the
lateral sural nerve. The flap can be harvested as Disclosure: The authors have no conflicts of interest
a bone flap and can include muscle (flexor hal- to disclose.
lucis longus, tibialis posterior, or soleus), fascia,
and/or skin.
Supplemental digital content is available for this
From the Wyss Department of Plastic Surgery, New York Uni- article. Direct URL citations appear in the text;
versity Langone Medical Center. simply type the URL address into any Web browser
Received for publication June 2, 2015; accepted August 24, to access this content. Clickable links to the mate-
2015. rial are provided in the HTML text of this article
Copyright © 2015 by the American Society of Plastic Surgeons on the Journal’s website (www.PRSJournal.com).
DOI: 10.1097/PRS.0000000000001899

280 www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 137, Number 1 • High-Energy Ballistic Mandible Defect

Video 1. Supplemental Digital Content 1 demonstrates preopera-

tive planning. This video is available in the “Related Videos” section
of the full-text article on PRSJournal.com or available at http://links.
lww.com/PRS/B521.

The flap is marked while palpating the lat- elevating the heel. A sterile thigh tourniquet
eral malleolus, fibula head, and anterior and is used. A two-team approach is used whenever
posterior borders of the fibula bone. The skin possible.
paddle is outlined, and perforators that can be
assessed by Doppler imaging preoperatively are
OPERATIVE TECHNIQUE
also marked. Special consideration in preopera-
tive planning is given for eventual flap orienta- A midlateral incision posterior to the palpable
tion and inset. fibula bone is made. Skin flaps are then elevated
The patient is positioned with knee flexed,
pelvic girdle rotated internally, and a bump

Video 3. Supplemental Digital Content 3 demonstrates pre-

operative modeling jigs, transection of the posterior tibialis
Video 2. Supplemental Digital Content 2 demonstrates dissec- muscle, mobilization of the bone flap and perforator dis-
tion around the peroneus longus muscle, incision of the anterior section, visualization of the proximal neurovascular bundle,
muscular septum, interosseous membrane incision, and preser- fibula flap dissected in situ, osteotomies, and skin graft. This
vation of cuff of muscle. This video is available in the “Related video is available in the “Related Videos” section of the full-
Videos” section of the full-text article on PRSJournal.com or text article on PRSJournal.com or available at http://links.
available at http://links.lww.com/PRS/B522. lww.com/PRS/B523.

281
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • January 2016

Video 4. Supplemental Digital Content 4 demonstrates bone Video 6. Supplemental Digital Content 6 demonstrates post-
plating and modeled inset, completed neck dissection and operative management. This video is available in the “Related
inset, and flap inset. This video is available in the “Related Vid- Videos” section of the full-text article on PRSJournal.com or
eos” section of the full-text article on PRSJournal.com or avail- available at http://links.lww.com/PRS/B526.
able at http://links.lww.com/PRS/B524.
stability. Next, the anterior intermuscular septum
above the fascia, and the posterior intermuscu- is incised. The interosseous membrane is identi-
lar septum is identified, because this is the loca- fied and incised, after which the posterior com-
tion where fasciocutaneous perforators entering partment musculature can be visualized. A cuff of
the skin paddle travel. The skin flap is centered flexor hallucis muscle can be elevated with the tri-
around these dominant perforators. After incis- angular fibula bone to preserve periosteal circula-
ing the superficial muscular fascia, the peroneus tion. (See Video, Supplemental Digital Content 2,
longus muscle is identified, and a small cuff is which demonstrates dissection around the pero-
preserved on the fibula. The peroneus longus neus longus muscle, incision of the anterior mus-
tendon is preserved by incising the fascia slightly cular septum, interosseous membrane incision,
posterior to the tendon for preservation of ankle and preservation of cuff of muscle. This video is
available in the “Related Videos” section of the
full-text article on PRSJournal.com or available at
http://links.lww.com/PRS/B522.)
Advances in computer-aided modeling have
been tremendous in terms of allowing preci-
sion with intraoperative flap shaping and design.
Using preoperative modeling jigs, the dominant
perforator is oriented in the most favorable posi-
tion for flap inset. Approximately 6 cm of bone
is preserved proximally and distally to ensure
knee and ankle stability. With the interosseous
membrane exposed, the posterior compartment
muscles are visualized. The posterior tibialis mus-
cle, a chevron-shaped muscle, is divided layer by
layer, exposing the posterior tibial vessels and
tibial nerve. Any perforating vessels encountered
are ligated and divided. With continued mobiliza-
Video 5. Supplemental Digital Content 5 demonstrates micro- tion of the bone flap, the proximal neurovascular
surgery setup and arterial microsurgical anastomosis with the bundle is visualized. Proximally, a small amount
chop-stick method. This video is available in the “Related Videos” of fat is noted adjacent to the tibial nerve. The
section of the full-text article on PRSJournal.com or available at fibula is isolated as proximal as possible to the
http://links.lww.com/PRS/B525. posterior tibial artery. Once the fibula flap is

282
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 137, Number 1 • High-Energy Ballistic Mandible Defect

Fig. 1. (Above, left and above, center) Preoperative views showing extensive facial avulsion with loss of the majority
of the mandible. (Above, right and below, left) Three-month postoperative views showing restoration of mandibular
contour. (Below, center and below, right) Postoperative imaging.

entirely dissected in situ, the pedicle is cut and guide can be used to model inset. Attention is
the flap is ready for transfer. At this point, the then turned to the neck, where recipient vessels
osteotomies are made. The donor site is closed are identified and selected for microsurgical
using split-thickness skin grafting and a closed anastomosis. The flap is inset with the proper
suction drain. (See Video, Supplemental Digi- orientation of the skin paddle and pedicle. (See
tal Content 3, which demonstrates preoperative Video, Supplemental Digital Content 4, which
modeling jigs, transection of the posterior tibialis demonstrates bone plating and modeled inset,
muscle, mobilization of the bone flap and per- completed neck dissection and inset, and flap
forator dissection, visualization of the proximal inset. This video is available in the “Related
neurovascular bundle, fibula flap dissected in Videos” section of the full-text article on PRS-
situ, osteotomies, and skin graft. This video is Journal.com or available at http://links.lww.com/
available in the “Related Videos” section of the PRS/B524.)
full-text article on PRSJournal.com or available at Attention is then turned to the microsurgical
http://links.lww.com/PRS/B523.) setup. After the 180-degree stitches are placed,
The flap can be plated on the back table the arterial anastomosis is executed using the
if needed; in addition, a computer-generated “chop-stick” technique. (See Video, Supplemental

283
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • January 2016

Digital Content 5, which demonstrates microsur- modeling, a tailored approach to patients with
gery setup and arterial microsurgical anastomosis complex mandibular defects.
with the chop-stick method. This video is available
Eduardo D. Rodriguez, M.D., D.D.S.
in the “Related Videos” section of the full-text arti- Wyss Department of Plastic Surgery
cle on PRSJournal.com or available at http://links. New York University Langone Medical Center
lww.com/PRS/B525.) 305 East 33rd Street
New York, N.Y. 10016
[email protected]
POSTOPERATIVE CARE
Deep venous thrombosis prophylaxis is nec-
patient consent
essary following surgery. Patients are placed in
a boot with the ankle at 90 degrees and with Patient provided written consent for the use of
no ambulation during the initial postoperative his images.
period. (See Video, Supplemental Digital Con-
tent 6, which demonstrates postoperative man- references
agement. This video is available in the “Related 1. Hidalgo DA, Rekow A. A review of 60 consecutive fibula
Videos” section of the full-text article on PRS- free flap mandible reconstructions. Plast Reconstr Surg.
Journal.com or available at http://links.lww. 1995;96:585–596; discussion 597.
com/PRS/B526.) Flap monitoring can be accom- 2. Hidalgo DA. Fibula free flap mandibular reconstruction.
plished on the skin paddle using a hand-held Clin Plast Surg. 1994;21:25–35.
3. Hidalgo DA. Fibula free flap mandible reconstruction.
Doppler probe. Our patient had an unevent- Microsurgery 1994;15:238–244.
ful postoperative course; he is now preparing 4. Hidalgo DA. Fibula free flap: A new method of mandible
for subsequent stages of facial reconstruction reconstruction. Plast Reconstr Surg. 1989;84:71–79.
(Fig. 1). 5. Avraham T, Franco P, Brecht LE, et al. Functional outcomes
of virtually planned free fibula flap reconstruction of the
mandible. Plast Reconstr Surg. 2014;134:628e–634e.
CONCLUSIONS 6. Seruya M, Fisher M, Rodriguez ED. Computer-assisted ver-
The free fibula osteoseptocutaneous flap is sus conventional free fibula flap technique for craniofacial
reconstruction: An outcomes comparison. Plast Reconstr Surg.
a versatile workhorse flap for mandibular recon- 2013;132:1219–1228.
struction. It provides an excellent source of cor- 7. Schultz BD, Sosin M, Nam A, et al. Classification of mandi-
tical vascularized bone, a versatile skin paddle ble defects and algorithm for microvascular reconstruction.
and, with recent advances in computer-aided Plast Reconstr Surg. 2015;135:743e–754e.

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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.