Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 16:
Fibular Free Flaps
  The advent of free bone flaps (often inappropriately called vascularized bone grafts) has led to the successful replacement of extensive areas of bone loss in the upper and lower extremities.1-18 Unlike conventional bone grafts, microvascular free bone flaps have an intact circulation and heal without the process of necrosis and regeneration. Not only is healing faster and without bone absorption or atrophy, but because the bone is vascularized, 19-25 a fibular free flap can be used to bridge long gaps (up to 22 cm), can heal in the hostile environment of a scarred bed, and is more resistant to infection.26-28.

In 1975, Taylor29 successfully used a free fibular flap to treat an open fracture of the tibia and fibula. Later,30 he used the flap to reconstruct a traumatic defect of the femur. Gilbert,31 Chung-Wei,32 Tamai,33 and others34-39 refined Taylor's technique and considerably reduced the operating time for the fibular flap.

Buncke40 and others41-46 used vascularized free rib to repair mandibular and tibial defects. In 1978, Taylor and Watson47 described the use of an osteocutaneous flap based on the deep circumflex iliac artery. This flap48-51 provides both cancellous and cortical bone with a skin flap, but the curvature of the crest requires an osteotomy to straighten it, and this may compromise the vascularity of the distal segment. The skin paddle is not always reliable, and we have often had to do an "internal shunt" from the deep circumflex iliac artery (DCIA) to the superficial circumflex iliac artery (SCIA) to augment the vascularity of the cutaneous portion of the combined flaps. (See Chapter 15.)


The fibular flap has the following advantages:

1. It is a straight, tubular, compact bone, suitable for early weight bearing.

2. It provides enough bone to bridge gaps up to 22 cm or may be osteotomized to provide two struts of bone on a singular vascular pedicle.

3. The pedicle (peroneal) vessels are relatively large and easy to anastomose.

4. The flap may be raised as an osseous-only, myo-osseous, osteocutaneous, or myo- osteocutaneous flap.

5. The flap is easy to raise.

6. There is minimal donor site morbidity; the donor site can be closed primarily and has a very acceptable cosmetic result.

7. The skin paddle of the compound flap is easily monitored (the osseous-only flap can be difficult).

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