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The amount of muscle that should be retained on the free fibula during harvest is unresolved. Muscle is used to protect the periosteum, but by harvesting a large muscle cuff, the recipient and donor site morbidity increases. A retrospective review of 47 free fibula flaps performed between January 1997 and March 2002 was undertaken. There was an average follow-up of 15 months. The dissection method used for all cases was a muscle sparing technique where the peroneal vessels were skeletonised anteromedially. Only a very thin rim of muscle (1–2 mm) was left attached to the fibula. The recipient and donor vessels were flushed with heparin saline solution intra-operatively and a Dextran 40 infusion was used for four days post-operatively in all cases. Of the 47 flaps, 39 were used for mandible reconstruction, six for maxillary reconstruction and two for long bone reconstruction following trauma. The average age was 47.7 years (range 13–82) and two-thirds (28/43) of the patients were male. There was one post-operative death. The overall failure rate was 10.9% (5/46). Two flaps were lost as a result of arterial thrombosis, one from venous thrombosis, one from sepis and in one case the cause could not be determined. There were 2 (4.3%) recipient site haematomas. It is suggested that the low recipient site haematoma rate in this series may be related to the limited muscle bulk transferred with the flap. Harvesting less muscle also enables easier insetting and folding of skin flap, and reduces the donor site problems of haematoma and weakness of the foot. The blood supply to the fibula does not appear to be compromised.
to reconstruct a large tibial defect, and it has since become one of the workhorse flaps for mandible and long bone reconstruction. Originally, the flap was dissected using a posterior approach that commenced in the popliteal fossa.
advocated the lateral approach, which has subsequently become the standard method of dissection. The next development occurred in 1983 when the osteocutaneous flap was described by Chen and Yan.
in 1986 further clarified the cutaneous anatomy by demonstrating that the septocutaneous perforators alone provide an adequate blood supply to the skin paddle. This knowledge allowed the technique to be refined to its present form as an osteoseptocutaneous flap.
Several detailed descriptions of the technique of free fibula harvest,
Microsurgery: transplantation–replantation: an atlas/text. Microsurgery: transplantation–replantation: an atlas/text. Lea and Febiger,
Philadelphia1992
have been published over the years, but despite this, one aspect remains unclear: how much muscle should be retained on the fibula and its pedicle? There is a wide range in the amount of muscle that different surgeons harvest with a free fibula and no standard method of dissection exists. Some surgeons
in his original description, did not dissect out the peroneal vessels and retained a 1 cm sleeve of muscle around the fibula and vascular pedicle. In contrast, Buncke
Microsurgery: transplantation–replantation: an atlas/text. Microsurgery: transplantation–replantation: an atlas/text. Lea and Febiger,
Philadelphia1992
described a technique in which a 1–2 mm rim of muscle was retained on the fibula when dissecting off the anterior and lateral compartment muscles, but a much thicker cuff of flexor hallucis longus (FHL) and tibialis posterior (TP) retained on the posterio-medial aspect of the fibula and the peroneal vessels. Masquelet
describe leaving a ‘minimal muscle cuff’ but the amount left is difficult to determine, as it is not clear from their descriptions how much muscle is retained on the fibula itself. More recent reports
define a thin muscle cuff as being between 1 and 10 mm thick, highlighting the fact that, as yet, there is no standard technique for free fibular dissection.
A muscle-sparing technique for dissection of the fibula free flap is described, which has been employed in this unit since 1997. The peroneal vessels are skeletonised and only a very thin (1–2 mm) cuff of muscle is retained on the fibula itself (Fig. 1) . This retrospective review of 47 free fibula flaps performed between 1997 and March 2002 was undertaken to evaluate the results of this technique.
Fig. 1Dissection of the pedicle with anterior skeletonisation of the peroneal vessels.
The patient is positioned in the decubitus position with a sandbag under the ipsilateral hip. Dissection is under tourniquet control using loupe magnification, and starts with the standard lateral approach. The skin island is raised first with dissection along the lateral intermuscular septum proceeding to the posterolateral border of the fibula. The lateral compartment muscles are retracted anteromedially and electrocautery is then used to dissect these muscles from the attachment to the lateral border of the fibula leaving at most a 1–2 mm cuff (Fig. 2) . The septum between the lateral and anterior leg compartments is divided close to the fibula, and the anterior compartment muscles are retracted anteromedially with a Langenbeck retractor. Extensor hallucis longus and extensor digitorum longus are then separated from the fibula using electrocautery, again leaving a 1–2 mm cuff of muscle. Having identified the anterior tibial vessels and deep peroneal nerve, these structures are protected by retracting them medially with a Langenbeck retractor. The interosseous membrane is then divided longitudinally close to the fibula to expose the TP muscle (Fig. 3) .
Fig. 2Dissection of lateral and anterior compartment muscles leaving a 1–2 mm cuff.
The distal osteotomy is performed with an oscillating saw usually 5 cm above the lateral malleolus. The peroneal vessels are identified distally, ligated and then transected. The fibula is then retracted laterally and slightly posteriorly at the distal osteotomy site using a blunt bone hook. A flat metal retractor can then be placed in the avascular plane between TP, FHL and the peroneal vessels. This retractor lies on the vessels and protects the pedicle while the overlying muscle is completely dissected off using a combination of electrocautery and scissors (Fig. 4) . Muscle perforators are identified and divided after clipping. After a variable distance, when vision becomes restricted, the proximal osteotomy is performed. This is usually about 5 cm below the fibula head. The vessels can then be traced upwards to their junction with the posterior tibial artery and vein (Fig. 5) .
Fig. 4Dissection of tibialis posterior off the pedicle. Tip of the scissors is in the avascular plane between tibialis posterior and the pedicle.
The posterior dissection is then performed and starts with blunt mobilisation of the soleus off the FHL. This exposes the FHL, which is then dissected off the posterior aspect of the fibula leaving a 2–3 mm muscle cuff. The dissection continues medially with skeletonisation of the pedicle. Thus, the pedicle is skeletonised anteriorly and medially and only a 2–3 mm rim of muscle is retained posterior to the fibula (Fig. 6) . The pedicle is left intact while the fibula is cut, shaped and rigidly fixed with plates if a mandible reconstruction is intended.
Fig. 6View of posterior dissection of fibula showing skeletonisation of the pedicle with 2–3 mm rim of muscle on the fibula.
The recipient and donor vessels are flushed with heparin saline solution (100 u/ml) intra-operatively and a Dextran 40 infusion is used for four days post-operatively in all cases. Patients are usually returned to the ward post-operatively.
2. Method
A retrospective review was undertaken of all free fibula flaps performed at Groote Schuur Hospital, and two other private hospitals in Cape Town, South Africa, using the technique described above. All patients operated between January 1997 and March 2002 were included in the study. Patient data evaluated the age and sex of the patient as well as the indication for the free fibula transfer. The success of the technique was analysed. The complications were divided into those which occurred at the donor site and those at the recipient site.
All the free fibula dissections and microanastomoses were performed by the senior plastic surgeon in the head and neck unit (van Zyl).
3. Results
Forty-seven free fibula flaps were performed in 43 patients. The average age was 47.7 years (range 13–82 years) and 28 (65.1%) were men. One patient died 5 days post-operatively and was excluded from the study. There was an 89.1% (41/46) flap survival rate at an average follow-up of 15 months. Two flaps failed as a result of arterial thrombosis, one secondary to venous thrombosis and one as a result of severe sepsis. The cause of failure in one flap could not be determined.
Thirty-nine patients underwent free fibula transfer for mandible reconstruction. The majority (37/39) of the mandibular defects were the result of resections for malignancy. One patient required reconstruction following trauma and another after debridement for mandibular osteomyelitis. There were four flap failures in this group (10.3%), two of which occurred in the same patient. Subsequent salvage was achieved in this patient with a free iliac crest transfer.
Eight patients required a free fibula flap to reconstruct other defects. Six patients underwent reconstruction of their maxillae following resection for malignancy, while two patients had long bone reconstructions following trauma. One flap failure occurred in a patient undergoing maxillary reconstruction, the cause of which could not be determined. Salvage was achieved with a repeat free fibula flap.
Early complications related to the donor site were few. Minor wound infections occurred in seven patients (15.2%), which resulted in partial skin graft loss in four patients. Repeat split skin grafting was necessary in one of the four patients.
There were also few major recipient site complications. There were 2 (4.3%) post-operative haematomas that required evacuation in theatre and both flaps survived. Two recipient site wound infections occurred, one of which was minor and responded to antibiotics. The other infection resulted in loss of the flap. Plate exposure occurred in 17.5% of patients. Exposed plates were removed.
4. Discussion
There are many potential advantages to limiting muscle dissection, but these can only be justified if the blood supply to the fibula is not compromised. This study suggests that skeletonising the pedicle does not compromise the blood supply to the fibula so long as the periosteum remains intact. This is based on evidence that there were no cases of osteitis or sequestrum (at an average follow-up of 15 months) and only one case of severe sepsis occurred in a patient having a mandible reconstruction, which is performed in a contaminated field. The fact that so many mandible reconstructions were undertaken without sepsis occurring suggests that the blood supply to the periosteum was maintained. This concurs with Wei et al.
who also recommended minimising the amount of muscle harvested.
There are several advantages to limiting the size of the muscle cuff. There is less bleeding from the smaller muscle bulk thus reducing post-operative haematoma formation at the recipient site. The haematoma rate of 4.4% (despite using Dextran 40) compares favourably with that of Coghlan and Townsend
who reported a 25% incidence of post-operative haematoma formation at the recipient site. It must be noted, however, that all their free fibula flaps were performed for long bone reconstructions and were not used in head and neck reconstructions. Also, less muscle harvest reduces the dead space at the donor site, which decreases the risk of haematoma formation at the donor site. In this study, there were no donor site haematomas.
There may also be less risk of damage to the proximal part of the pedicle (i.e. where the pedicle passes from the fibula and crosses to join the trifurcation) when compared to other techniques where more muscle bulk is harvested posteriorly. Hidalgo
describes a technique whereby the TP is divided in the median raphe (thus retaining half this muscle with the fibula) and notes that the pedicle is at risk of injury proximally, where it crosses from medial to lateral. However, by dissecting TP off the fibula, and thereby directly seeing and skeletonising the vessels, this danger point is avoided and any potential damage to the posterior tibial artery and nerve is averted. Additionally, skeletonisation of the pedicle facilitates the identification of muscle branches, which are then simply ligated, and the problems of vessel avulsion from the pedicle or vessel retraction into the muscle mass are minimised, thus reducing the potential for blood loss and haematoma formation.
Harvesting less muscle bulk with the flap increases the relative length of the lateral crural septum and facilitates folding of the skin paddle around the fibula. This is particularly useful in mandible reconstruction where a large amount of bone with multiple osteotomies is required, the pedicle is often short and skin is required to close the defect in the floor of mouth. In this situation the skin paddle may be passed either superior or inferior to the fibula to reach the floor of mouth.
Another benefit of harvesting less muscle is that donor limb strength is preserved. This aspect was not adequately assessed in this study, but there are a number of studies
evaluated 41 donor limbs in which the fibular flaps were harvested with a thin (1–2 mm) muscular cuff. They found that 10% of patients had weakness of extension and flexion when compared with the unoperated leg and that an additional 12% of patients had weakness of flexion of the big toe. Vail and Urbaniak
performed an extraperiosteal dissection leaving only a thin muscle cuff in 247 fibular dissections and reported a 10% incidence of extensor and FHL muscle weakness at long-term follow-up. In contrast, Anthony et al.
evaluated 11 patients with isokinetic testing and compared the strength of the normal leg with that of the donor leg. Their technique of dissection included a thick muscle cuff of about 1 cm. In 100% of their patients, the strength of the donor leg was much lower than that of the unoperated control leg. Tang et al.
where a thin cuff of muscle is left anteriorly and a thicker 1 cm cuff is left on the fibular posteromedially. They found a 43% incidence of weakness in big toe extension and a 29% incidence of weakness of flexion of the big toe.
There is a wide variation in the amount of muscle that surgeons harvest with a free fibula flap with the reported thickness varying between 1–2 mm and about 1 cm. A dissection method, which leaves a very thin cuff of muscle on the fibula and skeletonises the pedicle, offers a number of advantages. These include a reduced recipient and donor site haematoma rate, safer dissection of the pedicle, easier folding of the skin paddle around the fibula and greater donor leg strength. It appears that harvesting less muscle does not compromise the blood supply as long as all the periosteum is left intact.
References
Taylor G.I
Miller G.D.H
Ham F.J
The free vascularized bone graft. A clinical extension of microvascular techniques.
Microsurgery: transplantation–replantation: an atlas/text. Microsurgery: transplantation–replantation: an atlas/text. Lea and Febiger,
Philadelphia1992 (p. 328–44)
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