A novel double paddled fibular flap – A laboratory study translated to clinical practice in head and neck surgery

The fibular flap has become a widely used and reliable reconstructive method in head and neck surgery. Since its first description there have been several modifications and developments to improve the reliability of the skin flap, including the incorporation of muscular perforators.

One of the main drawbacks of the fibular flap is the relative lack of flexibility with regards to the soft tissue reconstruction. Reconstruction of through and through mandibular defects has previously often required the use of a second flap. A cuff of hemisoleus has been described previously and more recently there have been reports of using a skin paddle divided on the basis of the perforator anatomy to address this issue. It has also been our experience and the observation of others when raising a standard fibular flap that there are consistent perforators at the proximal aspect of the fibula which would appear to be capable of supporting a second proximal skin paddle.

The main advantages to a double paddled fibular flap are single donor site morbidity and the ability for synchronous harvest of the flap whilst the ablative surgery is being undertaken and the consequent reduction in overall operative time.

We performed an anatomical study to assess the feasibility, safety and reliability of raising a double paddled fibular flap where the paddles were remote to each other.

To assess the reliability of skin paddles based on proximal peroneal artery perforators we performed a cadaveric study on 10 fresh frozen lower limbs infused with a mixture of barium and latex via the femoral artery. We raised double paddled fibular flaps with 6cm skin paddles centred at 1/3 of the distance from the fibular head to lateral malleolus and a second separate skin paddle at the conventional 2/3rds position. The relevant surgical anatomy was noted.

The raised flaps were then CT scanned and reformatted in 3D. An assessment was made as to the number of perforators which had been incorporated in each flap. We also noted the pedicle length which we defined as the distance from the proximal end of the pedicle after division at the origin of the peroneal artery and the first perforator to the upper skin paddle.

Analysis of our CT data showed that the upper skin paddle had on average 2.9 perforators (Range 1-5). 90% of the upper flaps had > 1 perforator and 60% had > 2 perforators.

The lower skin paddle had on average 2.8 perforators (Range 1-4). Similarly the lower flaps 90% had >1 perforator and 60% had > 2 perforators.

The average pedicle length achieved, ie distance from the origin of the peroneal artery to the main perforator was 18.3mm  (Range 31.4 – 9mm), which we deemed adequate to perform successful microvascular anastamosis.

We conclude that there are sufficient reliable perforators to support a second independent skin paddle at the 1/3^rdposition.

Following on from our lab based study we have been able to transfer the anatomical data in to clinical practice and have successfully used the double paddled fibular flap in head and neck reconstruction.