Fibula free flap - Osteocutaneous

Considerations

Preparation

Procedure

Sample operative report

The patient was already on the OR table. The resection of the tumor was completed.

The *** lower extremity had been prepped out in standard fashion with a bump underneath the *** hip and a foot rest taped in place to rest the foot on. The medial malleolus and the lateral intramuscular septum were marked. An anterior incision was marked just over the peroneus longus tendon. The fibula was then marked 8 cm from the lateral malleolus. Webril was then placed on the thigh, followed by the tourniquet. The leg was exsanguinated with the Esmarch bandage and the tourniquet then inflated to 350 mmHg. The Esmarch bandage was removed.

The incision was completed through the skin and subcutaneous tissue down to the level of the musculature. The fascia overlying the peroneus longus was divided and dissected away until the lateral intramuscular septum was reached. A perforator in the *** third of the leg was identified. The peroneus longus muscle was then further elevated away from the fibula bone. The muscles were continually dissected away from the medial aspect of the bone. The osteotomy sites were identified, first inferiorly at approximately 8 cm from the lateral malleolus. A right angle clamp was placed around the fibular bone and an Army-Navy retractor was placed to retract the medial muscles. A saw was then used to make the osteotomy cut inferiorly. Attention was then paid to the superior osteotomy site. The common peroneal nerve was retracted, along with the medial muscles and, again, a right angle clamp was used to protect the structures deep to the fibula. The saw was then used to make the superior cut.

A double-pronged skin hook was then to retract the fibula laterally. The interosseous membrane was divided and the posterior tibialis was divided to expose the peroneal artery and venae comitantes. The pedicle was traced from an inferior to superior direction up to the take-off from the posterior tibial vessels. The posterior cut on the skin paddle was then made down to the soleus muscle. The skin paddle was *** cm in dimension. A cuff of soleus muscle was then completed to insure that any intramuscular branches to the skin paddle were included. A heavy scissors was then used to cut the muscle from an inferior to superior direction. Any perforating veins and arteries were clamped, divided and ligated along the way. The proximal portion of the pedicle was then dissected out. The peroneal artery was dissected to the posterior tibial artery and freed up from the surrounding soft tissue. The veins were traced to the posterior tibial vein.

The tourniquet was then let down. Total tourniquet time was *** minutes. Excellent flow was noted through the pedicle and excellent bleeding was noted on the periosteum muscle and skin paddle. After approximately half an hour, the vessels were then ligated with 3-0 Silk and divided. A drain was placed into the space where the fibula had previously been located. The operative site bed was then irrigated with copious amounts of bacitracin irrigation. The muscles were then re-approximated with 3-0 Polysorb. The subcutaneous tissues was approximated with 3-0 Polysorb and the skin was closed subcuticularly with 5-0 Biosyn suture and Steri-Strips. A posterior leg splint was then placed in standard fashion. 

In the meantime, the flap had been brought to a back table. It was irrigated with heparinized saline. The pedicle on the periosteum was then stripped down from the proximal portion of the fibula. The fibula was then brought to the head and neck area.

The defect in the *** anterior mandible was approximately *** cm. *** pieces were then designed. The osteotomies were then made with the saw. The flap was then secured to the plate with 8 mm screws. The skin paddle was then brought up into the oral cavity. The pedicle was brought down into the *** neck. The screws holding the plate in place on the native portion of the mandible were then removed, allowing the flap to drop down inferiorly and to have better access to the oral cavity. The tongue was then closed primarily in the midline with vertical mattress sutures and with 3-0 Polysorb. The flap was then sutured to the floor of mouth and ventral tongue with 3-0 Polysorb in a vertical mattress suture fashion. The flap was then brought up around the gingiva and onto the labial mucosa. The chin was then closed deeply with 3-0 Polysorb. The musculature was re-approximated using 3-0 Polysorb.

The vessels were then brought down into the neck and the adventitia of the artery and vein were then cleaned. The *** was reflected and cleaned of its adventitia, divided and approximated with the peroneal artery on the 3V microvascular clamps. The anastomosis was then completed with 9-0 nylon on an MV-100 needle in simple interrupted fashion. The common vena comitantes was then brought and approximated to the *** vein. The adventitia was both cleaned and approximated using 3-V microvascular clamps. This was performed using 9-0 nylon on an MV-100 needle. It was performed in a running fashion. The clamps were then released. Excellent flow was noted through the flap. The muscle, periosteum and skin were noted to be bleeding after release of the clamps. 

The neck was then irrigated with warm bacitracin irrigation. Any bleeding that was seen was controlled with either bipolar electrocautery or ligation or hemoclips. *** drains were placed in the neck, one in *** and then one into the *** and secured to the skin using 3-0 nylon. The lip was then repaired using 5-0 Surgipro in a vertical mattress suture fashion. The neck was then closed using 3-0 Polysorb deeply and a 5-0 Surgipro on the skin in a running fashion. The endotracheal tube was then removed.

A #*** LPC Shiley tracheostomy was placed and secured to the skin using 3-0 Nylon. A Dobbhoff feeding tube had been placed into the patient's nasal cavity and secured to the membranous nasal septum using 3-0 Nylon. 

Final needle and sponge counts were correct. No complications were encountered. The patient was transported to ICU in stable condition

Post op

Pearls & Pitfalls

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