• Archives of Reconstructive Microsurgery
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• 제15권1호
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• pp.17-25
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• 2006

Twelve cases in eleven patients with segmental bone defects were treated with contralateral fibula free flap and ipsilateral island fibula flap in an antegrade, retrograde or bidirectional flow fashion. Five cases were managed with free flaps and seven were with ipsilateral fibula island transfer. Among seven cases, antegrade fashion was three, retrograde was three, and bidirectional was one. All patients were related with open tibial fractures and its sequelae except one who had open foot bone fracture. According to Gustilo's classification, ten patients were type IIIb and one was type IIIc. Basically, antegrade-flow flaps based on the peroneal vessels as in the conventional free flap were used for the proximal or middle one-third tibial defects. On the contrary, retrograde-flow flaps based on the communicating branch between the peroneal and posterior tibial vessels were used for the middle or distal one-third of the tibia. Bidirection-flow flap based on intact peroneal vessels were used for the middle portion of the tibia. The patients who have undergone ipsilateral fibula island flap had one of the following problems: a previously failed free flap, below-knee amputation of the opposite leg because of open tibial fracture, refusal to use the contralateral sound leg, or poor general condition to stand a lengthy operation. Six of the patients who have got ipsilateral fibula island flap also had an associated fibula fracture on the same leg, which was ultimately used as one of the osteotomy sites. The follow-up period was from 1 to 10 years. Two cases of free flap were failed: one patient had below-knee amputation and the other patient had ipsilateral fibula transfer. Other cases were successful and excellent hypertophy of the transferred fibula was achieved. Time to bone union ranged from 4 to 11 months. Time to full weight bearing was from 5 to 13 months after surgery. All of the transferred fibulas showed hypertrophy after weight bearing. In one case, stress fracture was developed during ambulation, which was healed conservatively. Nonunion occurred in two cases, which were treated with a long leg cast and cancellous bone graft, respectively. Length discrepancy of the legs was noted. The limb was shorter by an average 0.5 cm in three cases, longer by 1.1 cm in one case. In the case of island fibula transfer, limited arc of rotation was not a problem. Other disabling complications were not seen. We believe that these diverse modalities using a vascularized fibula will make us more comfortable to handle major bone defects.

• Journal of the Korean Association of Oral and Maxillofacial Surgeons
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• 제49권6호
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• pp.354-359
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• 2023

The temporomandibular joint is a unique structure composed of the joint capsule, articular disc, mandibular condyles, glenoid fossa of the temporal bone, surrounding ligaments, and associated muscles. The condyle is one of the major components of a functional temporomandibular joint. Reconstruction of large mandibular defects involving the condyle is a surgical challenge for oral and maxillofacial surgeons. To restore large mandibular defects, there are different options for free flap method such as fibula, scapula, and iliac crest. Currently, the vascularized fibula free flap is the gold standard for reconstruction of complex mandibular defects involving the condyle. In the present report, neocondyle regeneration after mandible reconstruction including the condyle head with fibula free flap was evaluated. In this report, two patients were evaluated periodically, and remodeling of the distal end of the free fibula was observed in both cases after condylectomy or mandibulectomy. With preservation of the articular disc, trapezoidal shaping of the neocondyle, and elastic guidance of occlusion, neocondyle bone regeneration occured without ankylosis. Preservation of the articular disc and maintenance of proper occlusion are critical factors in regeneration of the neocondyle after mandible reconstruction.

• Archives of Plastic Surgery
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• 제50권5호
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• pp.523-528
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• 2023

The Gustilo IIIB tibiofibular fractures often result in long bone loss and extensive soft tissue defects. Reconstruction of these complex wounds is very challenging, especially when it includes long bone grafts, because the donor site is limited. We describe our experience using a set of chimeric ipsilateral vascularized fibula grafts with a thoracodorsal artery perforator free flap to reconstruct the traumatic tibia defects. A 66-year-old male suffered a severe comminuted tibia fracture and segmented fibula fracture with large soft tissue defects as a result of a traffic accident. He also had an open calcaneal fracture with soft tissue defects on the ipsilateral side. All the main vessels of the lower extremity were intact, and the cortical bone defect of the tibia was almost as large as the fractured fibula segment. We used an ipsilateral vascularized fibula graft to reconstruct the tibia and a thoracodorsal artery perforator flap to resurface the soft tissue, using the distal ends of peroneal vessels as named into sequential chimeric flaps. After 3 weeks, the calcaneal defect was reconstructed with second thoracodorsal artery perforator free flap. Reconstruction was successful and allowed rapid rehabilitation because of reduced donor site morbidity.

• Archives of Reconstructive Microsurgery
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• 제13권1호
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• pp.24-28
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• 2004

The vascularity of a skin island in fibula osteocutaneous free flap often depends on musculocutaneous perforators that find their origin in the proximal peroneal artery. But a potential drawback has been reported on the unreliability of the skin paddle. The perforating vessels to the skin paddle of the fibula osteocutaneous free flap were rarely derived from a common tibio-fibula trunk, an anterior tibial artery and a posterior tibial artery. Previous studies have emphasized total loss of the overlying skin paddle, if the expected perforating vessels are not present. We report here on our experience that the skin paddle of the fibula osteocutaneous free flap was vascularized not by a peroneal artery but a direct branch of the posterior tibial artery. There were no intraseptal nor intramuscular pedicles in the posterior crural septum which connected to the overlying skin island. Therefore, we performed microsurgical anastomoses between distal peroneal vessels of the fibula and the perforating branches of the posterior tibial vessels of the skin paddle. The anastomosed skin paddle was salvaged with a peroneal flow through vascular anastomosis and was transferred to the bone and intraoral soft tissue defects with the fibula graft. The patient had no evidence of vascular compromise in the postoperative period and showed good healing of the intraoral skin flap.

• Archives of Reconstructive Microsurgery
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• 제6권1호
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• pp.63-72
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• 1997

We have evaluated the clinical results following the 46 cases of free vascularized osteocutaneous fibular flap transfer to the tibial defect combined with skin and soft tissue defect, which were performed from May 1982 to January 1997. Regarding to the operation, flap size, length of the grafted fibula, anastomosed vessels, ischemic time of the flap and total operation time were measured. After the operation, time to union of grafted fibula and the amount of hypertrophy of grafted fibula were periodically measured through the serial X-ray follow-up and also the complications and results of treatment were evaluated. In the 46 consecutive procedures of free vascularized osteocutaneous fibular flap transfer, initial bony union were obtained in the 43 grafted fibulas at average 3.75 months after the operation. There were 2 cases in delayed unions and 1 in nonunion. 44 cutaneous flaps among the 46 cases were survived but 2 cases were necrotized due to deep infection and venous insufficiency. One necrotized flap was treated with latissimus dorsi free flap transfer and the other was treated with soleus muscle rotational flap. Grafted fibulas have been hypertrophied during the follow-up periods. The fracture of grafted fibula(15 cases) was the most common complication and occurred at average 9.7 months after the operation. The fractured fibulas were treated with the cast immobilization or internal fixation with conventional cancellous bone graft. In the cases of tibia and fibula fracture at recipient site, the initial rigid fixation for the fibula fracture at recipient site could prevent the fracture of grafted fibula to the tibia.

• Journal of International Society for Simulation Surgery
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• 제2권1호
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• pp.1-6
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• 2015

Purpose Bisphophonate-related osteonecrosis of the jaw (BRONJ) is an emerging problem. Extensive osteonecrosis of the jaw needs free flap reconstruction. Free fibular flap is the most useful flap for maxilla-mandibular hard and soft tissue reconstruction. The advantages of fibular free flap are simultaneous soft and hard tissue reconstruction and placing implant in reconstructed mandible and maxilla. In this study, four consecutive BRONJ patients who underwent fibula free flap reconstruction using simulation surgery were reviewed. Materials and Methods Four BRONJ patients who underwent free fibula reconstruction between May 2006 and September 2014 were included in this study. Male to female ratio was 1:3 and average age was 67.3 years old (62-70). All patients need mandibular bone reconstruction. Three patients suffered from osteoporosis and one male patient had multiple myeloma. Postoperative flap survival, functional reconstruction, esthetic results, food taking were evaluated. Results Three osseous flaps and one osteocutaneous flap were used. All the fibular flaps were survived and patients were recovered without complications. Oro-cutaneous fistula was resolved after operation. All patients were satisfied with the esthetic results. Patients reported improved solid food intake after operation with partial denture. One fully edentulous patient had semi-fluid diet after operation. Conclusion Treatment of the BRONJ is difficult due to lack of standard protocol. Fibular free flap using simulation surgery is the workhorse flap for mandibular hard and soft tissue reconstruction, especially in stage III BRONJ patient. In this study, functional and esthetic results were successful in all patients. Normal diet was possible with partial dentures.

• Archives of Plastic Surgery
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• 제49권3호
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• pp.413-417
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• 2022

The authors present a unique case of osteonecrosis of a cortical half of a fibula free flap that has not been reported in the literature yet. This complication was associated with the impairment of the vascularization of periosteum in the cortical half of fibula that was fixated with a nonlocking reconstructive 2.0-mm plate and screws but other factors could have been involved. The patient was submitted to excision of a cemento-ossifying fibroma that resulted in a left hemimaxilectomy mesoinfrastructure defect classified as the Cordeiro type 2B. The 42-year-old female patient was submitted to reconstruction with an osteomusculocutaneous fibula free flap plus a segment of fibula graft. The two bone segments of the free flap used to reconstruct the anterior and left alveolar crest were fixated with a reconstructive 2.0-mm plate of matrixMANDIBLE system. The only reported complication was an oronasal fistula that healed with conservative treatment and the referred osteonecrosis of the external cortical half of the fibula free flap with plate exposure at 2.5 years postoperatively. Surgical excision of the osteonecrosed cortical half of the fibula with the plate and screws was performed, while the other cortical underwent bone union as corroborated by computed tomography scans.

• Journal of International Society for Simulation Surgery
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• 제3권1호
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• pp.12-15
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• 2016

Functional and esthetic reconstruction after segmental mandibulectomy is one of the most challenging surgeries in microsurgical reconstruction field. Simulation surgery before free flap reconstruction has been performed for efficient surgery and successful results. Fibula free flap is the flap of the choice for reconstruction of the segmental mandibular defect. Straight nature of the fibula bone requires multiple segmentations to fit into mandible. 3D rapid prototype (RP) model gives a lot of information for mandibular reconstruction. The purpose of this study was to report mandibular reconstruction with free fibular flap using simulation surgery. A total of 30 consecutive patients were included for functional and esthetic evaluation. Among 30 patients, two flaps showed necrosis after radiotherapy. The other flaps were all survived and showed successful reconstruction in both function and esthetics.

• Archives of Reconstructive Microsurgery
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• 제10권1호
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• pp.34-37
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• 2001

The injury on the dorsum of foot is usually manifested in the defect of bone and soft tissue, so its reconstruction requires composite tissue. Free flap satisfies this defect but its indication is determined by the defect size, recipient status and so on. Iliac crest bone and fibular bone are useful bone flap but in more than 8cm defect, fibular flap is more useful. The drawback of fibular free flap is the absence of soft-tissue coverage, so another local flap and myocutaneous flap must be added. Fibula-hemisoleus ostemusculocutaneous free flap has been used for the reconstruction of upper and lower extremity. Its advantages are one stage operation, one donor site and the flexibility of the reconstruction with the use of muscle, bone, and skin. This flap has never been reported for the reconstruction of dorsum of foot. In our case, 20-year-old woman was referred with the 17 cm defect of 1st metatarsal bone and $16{\times}8cm$ sized soft tissue loss on the dorsum of the right foot. We reconstructed successfully the dorsum of foot with fibula-hemisoleus osteomusculocutaneous free flap and the patient can walk without crutches after 6 monthes.

• Maxillofacial Plastic and Reconstructive Surgery
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• 제35권6호
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• pp.437-447
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• 2013

The fibula is one of the most useful sources for harvest of a vascularized bone graft. The fibula is a straight, long, tubed bone, much stronger than any other available bone that can currently be used for a vascularized graft. It has a reliable peroneal vascular pedicle with a large diameter and moderate length. There is a definite nutrient artery that enters the medullary cavity, as well as multiple arcade vessels, which add to the supply of the bone through periosteal circulation. The vascularized fibula graft is used mainly for long segment defects of the long tubed bone of the upper and lower extremities. It can provide a long, straight length up to 25 cm in an adult. The fibula can be easily osteotomized and can be used in reconstruction of the curved mandible. Since the first description as a vascularized free fibula bone graft by Taylor in 1975 and as a mandibular reconstruction by Hidalgo in 1989, the fibula has continued to replace the bone and soft tissue reconstruction options in the field of maxillofacial reconstruction. For the better understanding of a fibular free flap, the constant anatomical findings must be learned and memorized by young doctors during the specialized training course for the Korean National Board of Oral and Maxillofacial Surgery. This article reviews the anatomical basis of a fibular free flap with Korean language.