The study and clinical application of the osteocutaneous flap of fibula

Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant

BACKGROUND

There are limited reconstructive options for the treatment of segmental bone defects of the upper extremity that are >6 cm in length, especially those that are associated with soft-tissue defects. The purpose of the present review was to report on our experience with fifteen patients who received an osteoseptocutaneous fibular transplant for reconstruction of a humeral defect.

METHODS

The study cohort included eight male patients and seven female patients with an average age of forty-one years. The indications for the procedure included segmental nonunion (nine patients), a gunshot wound (three), a defect at the site of a tumor resection (two), and failure of an allograft-prosthesis reconstruction (one). The fibular graft was fixed by means of intramedullary impaction in eleven patients, was used as an onlay graft in three, and was used as a strut between the intact diaphysis and the humeral head in one.

RESULTS

The average length of the segmental humeral defect was 9.3 cm. The average length of the fibular graft was 16.1 cm, and the average length and width of the skin paddle were 8.1 and 4.5 cm. The average duration of follow-up was twenty-four months. Three patients had venous thrombosis and underwent a successful revision of the anastomosis. Four patients had early failure of graft fixation. Three patients had a fracture of the fibular graft within the first year postoperatively. All but one of these latter seven patients were successfully treated with open reduction, internal fixation, and additional bone-grafting. One patient with an infection at the site of a nonunion and signs of graft resorption required a second fibular transplant.

CONCLUSIONS

The osteoseptocutaneous fibular transplant is an effective treatment for combined segmental osseous and soft-tissue defects of the arm. However, the application of this technique to the arm is more complex than application to the forearm and is associated with a higher rate of complications.

Donor site morbidity after harvest of free osteofasciocutaneous fibular flaps with an extended skin island

Since 1993, a total of 41 free osteofasciocutaneous fibular flaps with an extended skin island (average dimensions, 16.9 cm long [range, 12-22 cm] x 10.7 cm wide [range, -16 cm], or 180.8 cm [range, 112-352 cm ]) have been used in by the authors in various clinical applications. To evaluate donor site morbidity, the 41 patients involved were asked to answer a questionnaire and to present themselves for clinical and radiological examination. The subjective findings reported by these patients, and the examinations, showed that donor site morbidity was moderate. Apart from some occurrence of mild edema and pain, as well as modest motor weakness of the great toe, and deficiency of distal nervous segments, only 7 patients were found to have a slightly positive anterior drawer of the talus (anterior subluxation of the talus), but no instability. In conclusion, donor site morbidity after harvest of osteofasciocutaneous fibular flaps for different clinical indications, where extended skin islands were needed, is moderate.

The 'superficial' peroneal artery: a variation in cutaneous branching from the peroneal artery, nourishing the distal third of the leg

Two different vascular patterns were encountered in cutaneous branches from the peroneal artery to the posterolateral aspect of the distal third of the leg in 22 flaps from 22 patients who underwent cutaneous or osteocutaneous peroneal flap surgery. In the type 1 vascular pattern, a branch from the peroneal artery, named the 'superficial peroneal artery', nourished the posterolateral aspect of the leg by splitting into several septocutaneous branches. In the type 2 pattern a few septocutaneous branches originated directly from the main peroneal artery and nourished the same area as that fed by the type 1 branch. The type 1 vascular pattern has not been reported to date but was seen in nine out of the 22 consecutive peroneal flaps. The superficial peroneal artery, with its considerable vascular diameter, may serve as a recipient vessel for free flaps or may serve as a donor nutrient vessel for a cutaneous flap, which can be transferred without sacrificing the main peroneal artery. Awareness of these two vascular patterns in the distal third of the leg should also help to reduce the small percentage of skin-flap failures that occur when the cutaneous or osteocutaneous peroneal flap is used.

Reconstruction of mandible with fibula free flap

The fibula can be used as a donor for a free flap for mandible reconstruction. It has the advantages of low donor site morbidity, consistent shape, ample length, and distant location to enable a two-team approach, allowing multiple osteotomies because of its periosteal circulation. It can be raised with a skin island for composite tissue reconstruction. Eight segmental mandibular defects (average 11.62 cm) were reconstructed following resection for tumour. Six defects consisted of bone alone and the other two had only a small amount of associated intraoral soft-tissue loss. Two patients underwent primary reconstruction. We performed two or three osteotomies on each graft and used miniplates and wires for bone fixation. The flaps survived in all patients. All osteotomy sites healed primarily. The aesthetic result of reconstruction was satisfactory.

Soleus-fibula free transfer in lower limb reconstruction

Free-fibula transfer has been widely used since 1975. Many modifications have been described; one of them, association of the lateral part of the soleus muscle to the fibula, is reported here through a 14-case series. This composite flap is intended for extensive defects of the lower limbs involving bone and soft tissues. The flap is considered by the authors to be reliable, with a constant vascularization. A 20-cm length offibula may be harvested associated either with the lateral part of the soleus muscle or with the whole muscle. Moreover, the soleus muscle represents a vascular security inasmuch as it preserves both medullar and periosteal bone supply. Fourteen cases have been performed by the authors since 1978 and could be reviewed with a minimum 2-year follow-up. Average length of bone defect was 12 cm, and average length offibula harvested was 18.6 cm. Soft-tissue defect was always associated and ranged from 8 x 4 cm to 20 x 30 cm. The fibula was harvested with the lateral part of the soleus muscle in 10 cases and with the whole soleus muscle in 4 cases. One total treatment failure was reported and was related to intimal degenerative lesions on veins used for arteriovenous bypass. In other patients, mean time for bone healing was 11 months. Patients could walk again, on average, 17 months after reconstruction. Sequelae at the donor site were minimal.

Ilizarov bone transport treatment for tibial defects

OBJECTIVES

To evaluate the results and complications of Ilizarov bone transport in the treatment of tibial bone defects.

DESIGN

Retrospectively reviewed consecutive series.

METHODS

Nineteen patients with tibial bone defects were treated by the Ilizarov bone transport method. The mean bone defect was ten centimeters, and there were eight soft-tissue defects. The mean external fixation time was sixteen months. Ten patients required debridement of the bone ends and/or bone grafting of the docking site at the end of transport.

RESULTS

Union was achieved in all cases. One refracture of the docking site required retreatment with the Ilizarov apparatus to achieve union. There was one residual leg length discrepancy greater than 2.5 centimeters and two angular deformities greater than 5 degrees. There were no recurrent or residual infections. Seven of the eight soft-tissue defects were closed by soft-tissue transport; the eighth required a free-vascularized flap. The bone results were graded as fifteen excellent, three good, and one fair. The functional results were graded as twelve excellent, six good, and one poor. There were twenty-two minor complications, sixteen major complications without residual sequelae, and three major complications with residual sequelae. To treat the bone defect and the complications, a mean of 2.9 operations per patient was required.

CONCLUSIONS

Our results compare favorably with those for other methods of bone grafting as well as with those from other published accounts of the Ilizarov method, especially considering the large defect size in this series. The main disadvantage of the Ilizarov method is the lengthy external fixation time.

Osteosynthesis and bony healing between two consecutive free fibular bone grafts

This case report describes a recurrent squamous cell carcinoma in the oral cavity requiring two consecutive free fibula transfers at different times. In a unique application of the fibula, rigid miniplate fixation was used between the two independent free flaps to reconstitute the contour of the mandible for an extensive composite oromandibular defect, extending from the left angle to the right ascending ramus. This application underscores the utility of the free osteocutaneous fibular flap for reconstruction of complex mandibular defects.

Transarticular bony defects after trauma and sepsis: arthrodesis using vascularized fibular transfer

Ten male patients with previously infected bony defects involving both sides of an articulation underwent arthrodesis using a vascularized fibular transfer. The average age of these patients was 38 years (range, 20 to 60 years). The size of the bony defect averaged 9 cm (range, 3 to 21 cm). The ankle was involved in five patients, the knee in two patients, the wrist in two patients, and the elbow in one patient. Nine cases represented septic pseudarthroses (eight after trauma and one after attempted ankle arthrodesis). One patient had a defect across the wrist after debridement of a chronic infection. The patients were followed for an average of 71 months (range, 26 to 144 months). Nine patients healed after the index vascularized fibular transfer, and one patient (ankle arthrodesis) required a second cancellous bone-grafting procedure for delayed union at the junction of the fibula with the talus. Four of seven patients with lower limb involvement had residual leg length discrepancies averaging 5 cm (range, 3 to 8 cm), and one had a persistent 20-degree internal rotation deformity. Two of the patients with upper limb involvement had stiff digits. Five of the nine previously employed patients returned to their former occupation (including heavy labor in four cases). Complications included two wound separations, one case of instability of the donor ankle after removal of a large fibular graft (related in part to a prior injury), and one fracture at the junction of the fibular graft with the local bone 10 months after the index procedure, which united after plate fixation and application of autogenous cancellous bone graft. Arthrodesis using a transfer of vascularized fibular bone represents a viable option for limb salvage in the face of an infected transarticular bony defect.

Reliability of the proximal skin paddle of the osteocutaneous free fibula flap: a prospective clinical study

The vascularization of the skin paddle of 20 osteocutaneous fibula free flaps in 20 patients was studied. All skin paddles were designed over the proximal and middle third of the fibula. A parallel vascularization of the skin was found in 10 cases. In these cases, an axial (septo)musculocutaneous perforator was found to originate high in the peroneal artery or even in the popliteal artery. This branch runs parallel to the peroneal artery without any further connections with it. In 5 of these 10 cases, no other skin perforators were located within the boundaries of the skin paddle. Harvesting such a flap in the traditional way by blind inclusion of a muscle cuff results in ligation of the supplying vessel of the skin paddle and subsequent loss of the skin. In this series, this would have been the case in 5 of the 20 patients (25 percent). This might explain the bad reputation of the skin paddle of this flap. The high prevalence of the described vascular configuration in a proximally designed skin paddle justifies à vue dissection of all musculocutaneous perforators up to their origin, unless one or more septocutaneous perforators are found within the boundaries of the flap.

Free composite myo-osseous flap with serratus anterior and rib: indications in head and neck reconstruction

BACKGROUND

Although the microvascular transfer of the serratus/rib myo-osseous composite flap has been previously described, the indications for its use in head and neck reconstruction have not been fully explored. Slender and easily contoured, rib bone offers reconstructive advantages over other bone sources under certain circumstances. The serratus/rib myo-osseous flap can provide vascularized muscle, bone, and cartilage; in combination with the latissimus dorsi muscle, the serratus/rib flap provides additional soft-tissue bulk on a single thoracodorsal vascular pedicle unrestricted by orientation requirements of the bone. Many orientations of bone and soft tissue are possible.

METHODS

We describe, through three illustrative cases, the indications for this flap, which might include bony, cartilaginous, and soft-tissue requirements in the retromolar trigone region, large calvarial defects, and large composite full-thickness cheek and mandibular defects.

CONCLUSIONS

The serratus/rib composite myo-osseous flap reliably provides vascularized bone of relatively delicate composition which offers advantages in certain reconstructive circumstances. In addition, when combined with latissimus dorsi muscle on a single vascular pedicle, it supplies additional soft-tissue bulk which can be positioned without being constrained by the bone placement. Finally, this is a useful "backup" supply of vascularized bone when other sources cannot be used due to, for example, inability to use fibula in the face of severe peripheral vascular disease and inability to use iliac crest if this has been previously used as a donor site for nonvascularized free grafts (as in secondary reconstructions).

The distally based lateral adipofascial flap

The distally based lateral adipofascial flap can be based either on the lowermost perforator or the anterior perforating branch of the peroneal artery avoiding sacrifice of the main peroneal artery. It has been used successfully to resurface soft tissue defects either on the lateral or medial aspect of the lower third of the leg in 13 cases. The size of these flaps varied from 2.0 cm x 5.0 cm to 4.5 cm x 15.0 cm in size. These cases had minimal donor site morbidity and had positive aesthetic results. The advantages were: 1. Choice of either the lowermost perforator or the anterior perforating branch giving a wide arc of rotation; 2. Preservation of the superficial peroneal nerve; 3. Primary closure of the donor site.

Use of the vascular pedicle of a previously transferred muscle as the recipient vessel for a subsequent vascularized bone flap

In six complex lower extremity defects, we have been able to reconstruct combined bone and soft-tissue defects with primary free-muscle transfer, followed by secondary free vascularized bone transfer. Indications for this technique are long segmental bone defects of the tibia associated with large soft-tissue defects, which are not suitable for one-stage composite bone and soft tissue transfer. In the first stage of reconstruction, a well-vascularized muscle flap is used to obliterate the soft-tissue defect to prevent infection. At the second stage, a fibula osteocutaneous flap from the contralateral leg is used to complete the reconstruction. The vascular pedicle of the first muscle flap surrounded by fibrofatty cuff, serves as the recipient vessels free of scar at the time of the second vascularized bone transfer. This method provides great advantages in two-stage free-flap reconstruction of complicated cases in which localization of suitable recipient vessel is technically difficult.

Treatment of segmental defects of the radius with use of the vascularized osteoseptocutaneous fibular autogenous graft

Nine patients who had a complex, combined skeletal and soft-tissue defect involving the radius were managed with operative reconstruction with use of a vascularized osteoseptocutaneous fibular autogenous graft. All of the patients were male, and the average age was thirty-two years (range, twenty-one to forty-two years). Three patients sustained the injury as the result of a gunshot wound and two each, as the result of a motor-vehicle accident, a fall from a height, or a machinery-related accident. Five patients had a concomitant fracture of the ulna. The average length of the radial defect was seven centimeters. Six patients had a deep osseous infection. The average length of the fibular autogenous graft was 7.9 centimeters, and the average size of the associated fasciocutaneous component was 11.8 by 5.9 centimeters. Two patients had a concomitant arthrodesis of the wrist. A split-thickness skin graft was used to close the donor site in six patients. Two patients had postoperative vascular complications that necessitated revision with an autogenous vein graft. One patient had a second operation six months postoperatively to correct an angular deformity that had developed secondary to a non-union at the graft-host bone junction. After an average duration of follow-up of twenty-four months, all but one of the patients had radiographic evidence of osseous union at both the proximal and the distal graft-host bone junction. No patient had evidence of resorption of the graft or symptoms referable to the donor leg at the time of the most recent examination. Six patients had returned to their preinjury occupation.

Experience with the osteocutaneous fibula flap: an analysis of 24 consecutive reconstructions of composite mandibular defects

Based on findings from anatomical dissections of the skin of the peroneal artery, we used the osteocutaneous fibula flap for combined replacement of the mandible and floor of the mouth in 24 patients, form November 1993 to December 1995. There were 22 primary and 2 secondary reconstructions; the mean age of the patients (2 women and 22 men) was 64 years. The length of the fibula segments ranged between 5.5 and 18 cm, the size of the skin component between 3 x 5 and 6 x 15 cm. Corresponding to the results of our anatomical studies, the skin island was exclusively raised form the distal third of the lower leg, and the donor sites were generally covered with split thickness skin grafts. The average length of the dissected vascular pedicle was 11 cm, so that a vein graft was only required in one case. Flap raising and tumour resection were always carried out simultaneously. Fibula osteosynthesis was done with titanium miniplates; the insertion of endosseous implants followed secondarily. The success rate was 95.8% with one transplant loss and pseudarthrosis in one case. Despite the limited width of the fibula, the shape of the mandible was satisfactorily reconstructed in all patients, and the thin, pliable component enabled intraoral coverage with only negligible surplus volume. Chronic wound-healing disturbances at the donor site of the skin island occurred in two cases; impairment of walking ability was not detected. According to our experience, the use of the osteocutaneous fibula flap is a valuable method for the reconstruction of composite mandibular defects.

Reliability of the fibular osteocutaneous flap for mandibular reconstruction: anatomical and surgical confirmation

There is ongoing controversy regarding the reliability of the skin island associated with the fibular osteocutaneous flap for mandibular reconstruction. Anatomical dissections and a clinical series of mandibular reconstructions using the fibular osteocutaneous flap have demonstrated unequivocally that a skin flap can be reliably harvested with the fibula based purely on the septal perforators, without needing to incorporate portions of the soleus or flexor hallucis longus muscles or to perform any intramuscular dissection or anastomosis of the muscle perforators. However, the skin island should be designed more distally over the distal third of the lower leg at the junction of the middle and distal thirds of the fibula. A fibular osteocutaneous flap was designed over the distal third of the fibula in 60 fresh cadavers, and each flap was completely isolated on the septum and all muscle perforators were ligated before dye injection. A major perforator through the soleus muscle or flexor hallucis muscle was identified in 41 of 60 dissections (67 percent) and discrete septal perforators were identified under loupe magnification in 45 dissections (75 percent). All 60 flaps demonstrated 100 percent reliable perfusion of the skin island after injection of the proximal peroneal artery with methylene blue or red latex. This anatomical study was corroborated with 100 percent survival of 34 fibular osteocutaneous flaps for mandibular reconstruction with the skin island designed over the distal third of the lower leg and based only on septal perforators without incorporating the soleus or flexor hallucis muscles. Reliability of this fibular osteocutaneous flap for mandibular reconstruction is attributed to (1) design of the skin island more distally over the distal third of the lower leg, (2) preoperative precision Doppler mapping of the perforators, and (3) design of the closing wedge osteotomies of the fibula to protect the septocutaneous perforators transversing through the posterior periosteum of the fibula.

The osteoseptocutaneous or purely septocutaneous peroneal flap with a supramalleolar skin paddle

There are many indications for using the peroneal flap in maxillofacial reconstructive surgery, either as a cutaneous flap or combined with a fibula segment. According to the results of our anatomic study and clinical experience with 14 patients, the supramalleolar segment is especially suitable as donor region because the highest density of septocutaneous perforating vessels exists here; hence, the preparation of a long vascular pedicle is possible. The donor site leaves an acceptable defect with appropriate patient selection.

The free vascularised fibular transfer as a definitive treatment in femoral septic non-unions

Free vascularised bone transfer (fibula, iliac crest, or rib) is an accepted method of bone grafting in malignant and non-union bone surgery. The vascular microanastomoses have transformed the bone healing by creeping substitution seen after non-vascularised grafting (a long and often insufficient process) into normal healing of the fracture site. The presence of its own vascular support allows bone healing in such compromised circumstances as sclerosis and infection. We present the clinical history of five patients with septic femoral non-unions, in which only the final vascular fibular graft provided an acceptable outcome. Discussion about the indication and timing of this microsurgical salvage procedure is still controversial.

The distally based peroneal island flap

A distally based island septocutaneous flap supplied by distal perforators of the peroneal vessels is described for repair of soft tissue defects of the lower third of the leg. The flap can be rotated up to 180 degrees on the axis of the pedicle vessels. A series of 10 patients is presented. 7 had uneventful reconstructions, 2 had partial necrosis of the tip of the flap but reconstruction was satisfactory, and one had necrosis of the distal third of the flap resulting in a recurrent leg ulcer.

Repair of a mandibular defect with a free vascularized coccygeal vertebra transfer in a dog

Bilateral mandibular defects in a male mongrel dog were repaired. On the left side, a free vascularized coccygeal bone graft that included the median caudal artery and caudal vein was used to correct the defect. On the right side, the defect was bridged with a bone plate and screws. For further immobilization, the muzzle was temporarily taped for 3 weeks and a pharyngostomy tube was used for nutritional support. The dog was able to eat dry commercial food satisfactorily within 2 months of surgery despite mild malocclusion. Radiographs taken 2 months and 18 months postoperatively showed bony union with graft hypertrophy in the left mandible, whereas the right mandibular defect showed protracted nonunion. The results indicate that vascularized coccygeal vertebra transfer provides an alternative for the management of canine mandibular defects.

Primary mandibular reconstruction with bridging plates

25 cases in which the mandible was resected and reconstructed using a reconstruction plate (AO titanium reconstruction system and Leibinger titanium reconstruction system) are presented. 16 patients suffered from oral carcinoma, 7 presented with odontogenic tumours and 2 had chronic osteomyelitis of the mandible. The mean age was 54.2 years, the male to female ratio was 2.6:1. 3 patients had a reconstruction plate for mandibular resection without continuity defect (marginal resection), in all the other patients the reconstruction plate bridged a mandibular resection with a continuity defect: 13 were located in the body, body-angle or ascending ramus with preservation of the mandibular condyle; 4 hemimandibulectomies with disarticulation of the TMJ; and 5 involved the anterior arch, crossing the midline. 12 patients received radiotherapy (3 pre-operatively). Only 3 patients with significant local side effects needed the treatment to be stopped for a period of time. There was no perioperative mortality. Only one plate was removed. Although minor complications were noted in 11 patients, the general improvement in the functional and cosmetic balance of the patients when compared with patients in whom no plate was used, justifies the use of this reconstruction system, in our opinion.

"Mini paddle" for monitoring the fibular free flap in mandibular reconstruction

The use of a "mini" skin paddle to monitor the fibular free flap for mandibular reconstruction is described. The paddle is easy to inset, can be excised later under local anesthesia, and yet is adequate for postoperative monitoring.

Free fibular graft still has a place in the treatment of bone defects

We report on 27 patients illustrating the use of non-vascularized single fibular strut graft, augmented with a corticocancellous bone graft to bridge bone defects. The indications were varied and included infection, fracture with bone loss, non-union, bone tumour, bone cyst and congenital pseudarthrosis. Primary union was achieved in 92 per cent. Stress fracture occurred in 26 per cent and no significant fibular graft hypertrophy occurred. The aim of this paper is to show that the non-vascularized single fibular graft, if augmented with corticocancellous bone graft along its whole length, is a simple procedure that is still valid to bridge bone defects.

Foot reconstruction using vascularised fibula

Vascularised fibula has been used to treat three patients with skin-bone defects of the foot following severe trauma. Similarity between fibula and metatarsal bone is obvious and makes fibula an ideal choice in the replacement of defects in the first metatarsal. Depending on the size of soft tissue defects, different combinations of fibula-skin transfer were used.

The supramalleolar flap based on septocutaneous perforators from the peroneal vessels for intraoral soft tissue replacement

In cadavers the septocutaneous perforating vessels branching off the distal segment of the peroneal artery were studied. An area of skin approximately 7 x 12 cm above the ankle was noted to be perfused by these and intraoral defects in 8 patients have been repaired using the supramalleolar flap as a variation of the peroneal flap developed by Yoshimura. Owing to its thinness and the long and wide vascular pedicle, the flap is particularly suitable for reconstructing mobile parts of the oral cavity, and in selected cases may be considered as an alternative to a radial flap.

Free peroneal and its composite flap: a distant donor for head and neck reconstruction

Free peroneal or its composite flap from the leg has been transferred in four patients for oro-mandibular and hypopharyngeal defects following surgery for malignancy. These flaps were successfully transplanted in all patients: two cases of free peroneal flap and two of free fibular graft with skin with no resulting problems with the leg. The peroneal osteocutaneous flap offers the following advantages: The axial vessels are preferable for microvascular surgery. Two flaps can be used with two cutaneous branches. A flap measuring up to 16 x 4.5 cm can be utilized with primary closure at the donor site. A long bone can be obtained together with skin. Surgery on the neck and harvesting of the flap can be done at the same time. The donor site is not conspicuous.

Microvascular reconstruction of soft tissue and bone loss in war wounds

Seventy-seven skin and bone defects caused by high velocity missiles have been repaired with various combinations of microvascular free transfer of skin flaps and vascularised bone grafts. We concluded that the free osteoseptocutaneous fibula transfer (1,4) is the best method of reconstruction if a long bone defect is associated with skin loss.

The versatility of the free fibula flap in the management of traumatic long bone defects

The free fibula flap has been used to treat ten patients with important long bone defects (mean length 14 cm) following severe trauma. Defects in all the long bones of the limbs have been treated by this technique. Five free osseous and five osteocutaneous flaps were performed. Primary skeletal union occurred at 17 bone junctions (85 per cent) within 5 months. No secondary grafting procedures were required. The mean delay in referral was 17 months and eight patients had already undergone three or more unsuccessful surgical procedures to promote union. The versatility of the vascularized free fibula flap is presented as a one-stage reconstruction for large bony and soft tissue defects, stressing the importance of prompt referral and recognition of cases. A combined orthopaedic and plastic surgical approach to these patients is advisable from the onset.

Progress in free tissue transfer

The development of microsurgical techniques has supplied plastic surgery with a new chance to transfer tissue to nearly any recipient site of the body. Classical methods still have their value but also their limits in many circumstances. Free tissue transfer has proved its advantages, especially in covering defects in the lower extremity; but microsurgical flaps also gain ground in reconstructive surgery of the head and neck, the female breast, the abdominal wall, and the hands. This article will survey well-classified microsurgical flaps, their indications, and their limits. In addition to a description of skin, fasciocutaneous, septocutaneous, and musculocutaneous flaps, we also include the latest detailed knowledge of free transfer of muscles, vascularized tendons, nerves, bones, and even joints, digits, and jejunal transfer. An outlook toward new perspectives with so-called prefabricated flaps will also be discussed.

Sequential connection of flaps: a logical approach to customized mandibular reconstruction

Microsurgery has improved the success rate for reconstruction of composite defects in the head and neck. Restoration of mandibular continuity alone is not adequate for reconstruction. Replacement of the oral lining with thin tissue is necessary to improve tongue mobility and to set the stage for later dental restoration. There is currently no ideal osteocutaneous free flap that provides unlimited length of bone, can undergo multiple osteotomies to produce the proper curve to the reconstructed mandible, and provides thin skin for oral lining. Combining free flaps can take advantage of the strengths of the individual donor sites and eliminate some of the problems with current osteocutaneous flaps. In six patients, a fibular osseous free flap was combined with either a radial forearm flap or a lateral arm flap to provide bone and oral lining in reconstruction of mandibular composite defects. In these selected patients, the fibula provided the blood supply for the second free flap, which was placed sequentially. The distal peroneal vessels were used to anastomose to the radial forearm vessels or the lateral arm pedicle. This approach allows the surgeon to customize the defect by improving both the functional and aesthetic aspects of reconstruction and is of use in cases where vascular access is limited, such as following head and neck surgery and radiation.

Mandibular reconstruction using vascularised fibula

The osteocutaneous fibula flap has been used to reconstruct large segments of mandible in cases following ablation for cancer or radionecrosis. The bone can be cut to the appropriate shape and the fasciocutaneous flap may be used simultaneously to provide oral cavity lining or skin cover. The technique is described and its successful use in seven patients is reported with details of the complications encountered.

Traumatic soft-tissue defects of the extremities. Implications and treatment guidelines

The presence of traumatic soft-tissue defects in the extremity indicates serious damage that may compromise the systems of motion, circulation or sensibility and therefore jeopardize functional rehabilitation. This overview highlights the significance and the various causes of soft-tissue defects, of which several types may be distinguished. Principles for the selection of various flap procedures are outlined, in accordance with the need for elevation and early motion therapy. The requirements placed on flap tissue are described, such as surface characteristics, ability to restore sensibility, cosmesis, capacity to fill voids in the depth of defects and revascularization of adjacent areas.

Vascularized fibular osteocutaneous graft: surgical technique and clinical study

This paper presents a detailed description of the dissection of the vascularized fibular osteocutaneous graft. The fibular graft is vascularized by the peroneal artery. A cutaneous vessel takes origin from the peroneal artery within 2 cm of the fibular midpoint in more than 90% of legs. The reliability of this vessel allows a skin island to be transferred with bone, to act as a monitor of vascularity and provide for skin loss. Ten clinical cases confirmed the reliability of the surgical dissection when centred at the midpoint of the fibula.

Vascularized fibular graft to replace resected cervical vertebral bodies. Case report

Use of a vascularized free fibular graft is described as a method of replacing excised cervical vertebrae when severe instability is present. The vascularized bone graft heals more rapidly and with greater strength than a nonvascularized autogenous graft.

Anterior tibial artery flap: anatomy and case report

A simple, large fasciocutaneous flap based on the perforating branches of the proximal anterior tibial artery and venae comitantes can be raised which is particularly suitable as an inferiorly based island pedicle flap to cover cutaneous defects of the lower third of the lower leg, an area notoriously difficult to cover with local flaps. The flap has an extremely wide arc of rotation and can reach from the knee superiorly to the sole inferiorly. It can be transferred as a fascial flap or as a free flap. The secondary donor site defect overlies muscle bellies, lies well away from bone and readily accepts split skin grafts.

Experience with transplantation of composite tissues by means of microsurgical vascular anastomoses. I. Indications, techniques and early results

The clinical experience with 65 transplantations of composite tissues by means of microsurgical vascular anastomoses is reported with emphasis on indications, operative techniques, vascular complications and soft tissue healing. Donor tissues, comprising 28 latissimus dorsi flaps, 20 groin flaps, 2 saphenous flaps, 4 fibular flaps, 9 dorsalis pedis artery flaps and 2 second toes, were transplanted to recipient sites in the head and neck area (18), upper extremity (8), torso (2) and lower extremity (37) in sixty-two patients with defects caused by traumata (45), tumor excisions (16) or congenital malformations (1) in which on average 3 therapeutic attempts had been unsuccessful. The reconstruction failed in 3/65 (5%) cases due to vascular thrombosis at the anastomotic sites. Early circulatory impairment (less than 1 week postoperatively) in the transplanted tissues was seen in 16/65 (25%) cases, thirteen of which were successfully managed by evacuation of a haematoma (9) and/or by resection of the anastomotic site and reconstruction of vascular continuity (5). Late circulatory impairment (greater than 1 week postoperatively) secondary to local infection was seen on 2 occasions and resulted in total loss of one flap. In one case persistent posttraumatic ostitis resulted in partial loss of a flap necessitating further reconstructive attempts. Altogether the reconstructive attempt failed in the early postoperative period (less than 3 months) in 5 cases (8%). It is concluded, that difficult reconstructive problems may be solved in a single stage using microsurgical composite tissue transplantation in patients who otherwise would have faced prolonged multistaged reconstructions and/or major limb amputations. Microsurgical composite tissue transplantation has widened the possibilities of reconstructive surgery and seems to be a reliable method, at least as safe as conventional reconstructive flap procedures.

Experience with transplantation of composite tissues by means of microsurgical vascular anastomoses. II. Late results and comments

In a series of 65 composite tissue transplantations the results were evaluated 6-68 (median 28) months postoperatively. The donor tissues, comprising skin flaps (7), neurovascular skin flaps (2), musculocutaneous flaps (26), tendinocutaneous flaps (2), muscle flaps (2), osteocutaneous flaps (18), bone grafts (6), and digits (2), were transplanted to recipient sites in the head and neck area (18), upper extremity (8), torso (2) and lower extremity (37) in sixty-two patients with defects caused by traumata (45), tumor excisions (16) or congenital malformations (1) in which on average 3 therapeutic attempts had been unsuccessful. In 5 cases the reconstruction failed within the first two postoperative weeks while the reconstructed part was included in lower extremity amputations 6-24 months postoperatively in 3 cases. The intended purpose was achieved in 27/34 cases of soft tissue reconstruction, 3/3 cases of combined tendon and skin repair, 18/19 cases of combined skin coverage and bone reconstruction, 4/5 cases of segmental bone reconstruction, 2/2 cases of thumb reconstruction and in 2/2 cases of facial reanimation. In 21 cases of 37 lower extremity reconstructions a major amputation would have been the alternative. Four of these patients were in fact amputated above the knee (1) or below the knee (3). Altogether, the reconstructions were successful in 56/65 (= 86%) cases. It is concluded that difficult reconstructive problems, especially those related to head and neck surgery, orthopaedic surgery and hand surgery may be amenable to successful reconstruction using microsurgical composite tissue transplants with an expected success rate averaging 9 out of 10 cases.

The free vascularized sural nerve graft

The sural nerve was described as a new donor nerve of the free vascularized nerve graft in a fresh cadaver's dissection and in four clinical cases. The vascularized sural nerve is nourished by the cutaneous branch of the peroneal artery or the muscular perforating branch of the posterior tibial artery in our grafts. Compared to other vascularized nerve grafts, the sural nerve has many advantages: 1) A "two- or three-fold nerve graft" can be designed on itself without damage to the blood supply of the nerve, 2) survival of the nerve can be reasoned by the accompanying flap and the flap can close the skin defect simultaneously without additional vascular anastomosis, and 3) sensory loss at the donor site is negligible. The final extent of sensory recovery in our clinical cases could require several months, but a quickly advanced Tinel's sign suggested the technique's superiority.

Distally based fasciocutaneous flap from the sural region. A preliminary report

Based on the principle of skin vascularization through perforating branches along intermuscular septa, a new distally based fasciocutaneous flap from the sural region is presented. Its use in reconstruction of defects in the middle and lower third of the leg is demonstrated by the clinical application in our sample of 3 cases. The limits of the extent and the exact basis of its vascularity have to be determined by further investigations.