The free fibula flap technique involves harvesting a skin paddle and segment of the fibula bone based on a vascular pedicle from the peroneal artery. Key steps include: 1. Identifying perforators from the peroneal artery to the skin and outlining a skin paddle. 2. Elevating muscles from the fibula bone and performing osteotomies to harvest the fibula segment. 3. Dissecting the peroneal artery and its branches to isolate the vascular pedicle. 4. Verifying adequate blood flow to the foot before transecting the pedicle to the desired length.

1. Free Fibula flap technique
Dr jameel kifayatullah
Oral and maxillofacial surgeon
peshawar ,Pakistan

2. ANATOMY OF FIBULA FLAP
• The cross section of the lower limb can be
divided into two main compartments:
• Anterior compartment
– Anterior
– Lateral
• Posterior compartment
• These compartments are divided by the
interosseus membrane between the tibia and
the fibula.

4. Anterior compartment
Lateral compartment
Deep posterior compartment
Superficial posterior compartment

5. The vascular pedicle
• The vascular pedicle consists of the peroneal
artery (1.0 -2.3 mm diameter) and venae
comitantes (2-4 mm).
• The main anatomical structures are shown
from both an anterior and posterior view.

7. FREE FIBULA ANATOMY
• The skin perforators originate from the
peroneal artery, pass along the lateral septum
located at the posterior border of the fibula
and supplies the lateral skin of the lower limb.
The majority of the perforators are located at
the inferomedial part of the fibula

8. SKIN PERFORATORS

9. Torniquet
• If a tourniquet is used, it is placed at the
middle of the thigh and inflated (up to 90
minutes) to twice the systolic pressure.
• Inflate the torniquet at 350 mm Hg

10. Torniquet

12. SURGICAL LANDMARKS
• The fibular head and the lateral malleolus are
marked. An outline of the skin incision is then
inscribed using a surgical marker.

13. SURGICAL LANDMARKS

14. FLAP HARVEST
• The incision is outlined starting 2 cm inferior
to the fibular head (to avoid damage to the
common peroneal nerve).
• The shape of the incision may be curved or a
straight line. This author prefers a S-shaped
incision.

15. Free fibula harvest technique
• Anterior compartment dissection
The skin is incised down to the deep fascia of
the skin and a subfacial elevation of the skin is
made to identify the perforators to the skin

16. Free fibula harvest technique
Anterior compartment dissection

17. • Once the perforators are identified, the skin
paddle is outlined, centered over the
perforators.

18. Flap harvest

19. Flap harvest
• The peroneal muscles are elevated from the
periosteum of the fibula and retracted
anteriorly to expose the fibular bone. Care
should be taken to preserve the periosteum
over the bone, especially in the area of the
perforator.

20. DISSECTION OF PERONEUS MUSCLE

21. DISSECT THE EXTENSOR MUSCLE
• Sharp dissection is then carried to the
interosseous membrane leaving a thin layer of
the extensor hallucis longus and the extensor
digitorum longus attached to the fibula.

22. Flap harvesting

23. Muscles encountered when raising a
FFF
– Peroneus longus
– Peroneus brevis
– Extensor digitorum longus
– Tibialis posterior
– Soleus
– Flexor hallucis longus

24. Osteotomies
• Subperiosteal dissection is performed 360°
around the fibula at the osteotomy sites.

25. preserve distal 5-6cms of fibula to preserve
stability of ankle

26. Flap harvest

27. OSTEOTOMIES
• While protecting the peroneal vessel with a
periosteal elevator, an osteotomy is then
carried out from posterior to anterior using a
giggly saw or a sagittal saw.
• Alternatively the osteotomy may be
performed form anterior to posterior. In this
case care has to be taken not to compromise
the vascular pedicle.

28. Flap harvest

29. FLAP HARVEST
• The interosseous membrane is cut

30. Dissection of the posterior
compartment
• The posterior tibialis is divided to expose the
pedicle.

31. Dissection of the posterior
compartment

32. Flap harvest
• The osteotomized bone segment is retracted
laterally to expose the peroneal vessels.
The distal branches of the pedicle is now
identified and ligated.

33. Flap harvest

34. FLEXOR HALLUCIS TRANSECTION
• While retracting the bone segment, the flexor
hallucis is transected from inferior to superior
leaving a thin muscle cuff in order to protect
the vascular pedicle.

36. Free fibula flap technique
Pedicle dissection
• The proximal pedicle could be dissected up to the
bifurcation area of the posterior tibialis and the
peroneal vessels.
• If any major branches are found, it has to be
verified whether it is the main blood supply to the
lower limb. If it is not the main blood supply, it is
ligated.

37. Pedicle dissection

38. Verification of main blood supply
• To verify that the blood supply to the foot is
intact, the tourniquet is deflated and the
proximal peroneal artery temporarily occluded
with an artery clamp. The arterial oxygen
saturation is then measured to verify
adequate blood supply to the foot.
Alternatively a pulse of the dorsal foot
(dorsalis pedis) is found by palpation.

40. • When the reconstruction site is ready, the
pedicle can be transected. Pedicle length will
be determined as required.

42. Closure
• Note: Great care must be taken to ensure that
the closure is not under tension. A skin graft
should be utilized when in doubt to avoid
compartment syndrome.
• A drain is inserted and a subcutaneous
undermining is performed to allow for wound
closure.

44. CLOSURE
• If the skin paddle is narrow, primary closure of
the skin can be accomplished as long as it is
tension free.
• Note: The surgeon should have a very low
threshold for skin grafting the skin paddle site.
Any undue tension of the closure will result in
compression of the underlying structures and
a compartment syndrome.