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Fibular Flap

The fibular flap has become a staple technique for reconstructing challenging composite defects, especially involving long bone. Based on the peroneal artery, the fibular flap provides osseous and soft tissue components with a long vascular pedicle. Anatomy and Blood Supply The fibular flap receives its circulation from the peroneal artery, which descends in the flexor hallucis longus muscle septum. Septocutaneous perforators supply the overlying skin. The segmental endosteal and periosteal circulation provides blood supply to the harvested fibula bone. Indications The fibular flap has the unique ability to reconstruct defects requiring both bone stock and soft tissue coverage. This makes it ideal for complex defects of the extremities, craniofacial skeleton, and mandible. The flap can be osteocutaneous or osseous only. Surgical Technique A skin paddle is designed over the middle or distal fibula. The fibula is exposed through lateral leg incisions, transecting the fibula proximally and distally while preserving at least 6 cm for ankle stability. The bone segment is retained on its vascular pedicle using the flexor hallucis longus muscle cuff. The flap is transferred to the defect and anchored with hardware for bone fixation and sutures for the skin paddle. Advantages The fibular flap provides up to 25 cm of bone stock with a long and reliable vascular pedicle. Bone stock can be shaped into multiple configurations. There is high flap versatility, low donor site morbidity, and capability to tolerate postoperative radiation. Disadvantages include technical demand of flap dissection, limited bone width, and relative inadequacy for weight-bearing. There is risk of ankle instability if excessive fibula length is harvested. Overall, the fibular flap remains a reconstructive workhorse for complex osseous and soft tissue defects throughout the body due to its unique composition, blood supply, and versatility.