Free Fibula Flap with Dr. Evan Matros

Flap Cast

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Anatomy Overview:

  • Four compartments of the leg – anterior, lateral, superficial posterior, and deep posterior.
  • In this flap elevation all of the compartments are encountered and are therefore important
  • Blood supply to the fibula is based off the peoneal artery. This flap can be raised as a bone only, osteocutaneous, or osteomyocutaneous flap. In terms of length of bone – we can typically get about 15cm. 
  • It’s important to remember that we typically want to leave at least 6cm of bone proximally and distally in order to maintain knee and ankle stability, respectively.
  • Proximally, preserve muscular attachments to the fibular head, and avoid injury to the common peroneal nerve.

Topics Included:

  • What are your general thoughts on the free fibula, is it a flap that you commonly use? What do you think are some of the advantages/disadvantages? 
    • Many of us have seen a free fibula used for mandibular reconstruction, however, what are some other bony defects that you think the free fibula flap is a good reconstructive option. 
  • Preoperative 
    • How do you preoperatively assess the vascular anatomy of the leg? Do you routinely obtain CTA’s on all of your patients preoperatively? If not, do you have criteria for patients who require preoperative imaging?
    • When you are taking an osteocutaneous flap for mandibular reconstruction with a skin or intraoral defect, what is your thought process regarding which leg to use as a donor site? 
    • What are your thoughts on preoperative planning for patients that have both intraoral and extraoral defects? 
  • Intraoperative: 
    • Can you take us through your basic markings for a fibula flap? How does this change when you are marking for an osteocutaneous flap? How do you plan the positioning of your skin paddle? 
    • What are some operative pearls you can share for raising a free fibula?
      • Skeletonizing pedicle vs. taking cuff of muscle? 
      • Do you have any pearls for identifying and avoiding critical structures during the dissection such as the common and superficial peroneal nerves? 
      • At what point do you make your osteotomies? Do you leave the fibula in situ or make the cuts on a back table? How much bone are you comfortable taking?
      • What do you do with FHL if it has been significantly damaged during the dissection? Do you ever remove the muscle in its entirety? 
    • When you are doing a mandibular reconstruction what vessels in the neck do you routinely use? If the facial vessels are damaged due to radiation what is your second option?
  • Postoperative: 
    • For bone only reconstruction how do you monitor the flap? Do you typically use Cook dopplers? 
    • At what point do you evaluate for bony union following reconstruction? 
  • Other
    • For mandibular reconstruction – do you commonly use VSP and custom cutting guides? Do you find these helpful? Are there any downsides to VSP? 
    • This flap is commonly used for mandibular reconstruction – if not a viable option what is your second-line bone flap for mandibular reconstruction?
  • BONUS QUESTION — For those applying into microsurgery fellowships – what is one thing that you wish all applicants knew before going into the fellowship match process?

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