Evolution in Indication

Since the introduction of reconstructive technique using the fibula flap, the indications for use of this graft have evolved. The fibula graft may provide skin islands, up to 25 cm and 14 cm wide, suitable for reconstruction of associated soft tissue defects. The dual endosteal and periosteal blood supply ensures bony viability despite multiple osteotomies. Hidalgo in 1989 described the first lower jaw reconstruction with a fibular flap, using osteotomies to mimic the shape of the mandible after oncological or traumatic defects. Multiple skin islands can be harvested with the fibula graft providing an osteomyocutaneous flap, including those based on septocutaneous as well as on musculocutaneous peroneal perforators. This graft provides convenient tissue for simultaneous reconstruction of bony and soft tissue defects inside as well as outside the oral cavity, bringing viable tissue to a mostly irradiated and contaminated field, with the lowest complication rate among osteocutaneous flaps. Soleus muscle connected to motor branches at the recipient site is described to restore the motor function or by using the sural cutaneous nerve together with a skin island for restoring sensation. Flap combinations were performed by anastomosing a second free flap to the distal peroneal artery and vein, which do not significantly reduce in caliber and thus can also serve at the recipient site. The use of free vascularized fibula has become the gold standard for mandibular and maxillary extensive defects.