Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 16:
Fibular Free Flaps
  C. Cross-section of the leg. The four muscle compartments of the leg are identified: anterior, lateral superficial posterior, and deep posterior. The fibula lies between the lateral and posterior muscle groups. Both the peroneal artery, closely related to the fibula, and the posterior tibial artery lie in the posterior compartments. The anterior tibial artery is anterior to the interosseous membrane but is also close by. The shaded areas represent the muscle cuff included in the transplant to maintain the important periosteal supply to the bone.

PLATE XVI-2. Donor Site

A. The incision is made longitudinally along the posterior border of the skin island and subcutaneous palpable borders of the fibula. The common peroneal nerve running around the fibular neck proximally must be carefully avoided.

B. Dissection is carried down between the posterior and lateral muscle groups, directly onto the lateral surface of the fibula. With sharp dissection distally, the tissues are separated from the bone, leaving the periosteum intact. At the site of the proposed distal osteotomy, the periosteum is incised transversely and a narrow, curved periosteal elevator is passed around the fibula directly on the bone. This maneuver must be done gently to protect the peroneal vessels on the deep surface of the interosseous membrane close to the fibula shaft. A right-angle clamp is then used to bring the Gigli saw around the fibula at this site. Once the required length is checked, the distal osteotomy is performed. A malleable retractor is useful to keep the vessel and soft tissues out of the way. Distally, one-fourth of the fibula must remain to provide adequate ankle stability so that the distal interosseous ligaments are not injured.


C. Once the fibula has been divided, dissection is carried onto the anterior surface and then to the posterior surface of the bone from distal to proximal. During this dissection, the peroneal artery is identified in the posterior compartment and is doubly ligated distal to the osteotomy site and divided. A cuff of thin muscle is left attached to the fibula so that the peroneal vessels and their connections to the bone are protected as proximal dissection is carried out medially to free the bone.

D. The dissection is continued proximally, visualizing the peroneal vessels on the interosseous membrane up to the junction of the vessels with the posterior tibial vessels. The peroneal vessel stalk may be short. Numerous large venae comitantes must be isolated.

E. Once the fibula, peroneal artery, and muscle cuff have been separated from the surrounding tissues, the proximal osteotomy is performed with a Gigli saw passed between the bone and the peroneal artery and the vessels are ligated when the recipient site is ready to receive the transplant.

Clinical Cases


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