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TECHNICAL NOTES

Oral Maxillofac Surg6:1294-1298, 2008

Closure of Osteoseptocutaneous Fibula FreeFlap Donor Sites With Local Full-Thickness

Skin GraftsBerend van der Lei, MD, PhD,*

Christianne A. van Nieuwenhoven, MD,†

Jan G.A.M. de Visscher, MD, DDS, PhD,‡

and Stefan O.P. Hofer, PhD§

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he osteoseptocutaneous fibula free flap is a versa-ile flap that is ideal for use in reconstruction ofegmental defects of the mandible.1,2 The donorite can be either closed primarily or covered with split-thickness skin graft (STSG). Usually, safe pri-ary closure is possible only for smaller defects.

TSG closure has been associated with both short-nd long-term donor site morbity.2 Delayed healingnd breakdown of the STSG overlying the peronealendons may account for the significant complica-ion and morbidity rates of the donor site.3-11 More-ver, STSGs are associated with poor esthetic out-omes at the donor site.We propose harvesting a full-thickness skin graft

FTSG) in the proximal third of the lazy S-shapedncision on the leg to reduce the complication and

orbidity rate of the donor site and to reduce the

* Professor in Plastic Surgery and Esthetic Surgery, Department of Plas-

ic, Reconstructive, Aesthetic and Hand Surgery, Medical Center of Leeu-

arden, Leeuwarden, The Netherlands; University Medical Center of

roningen, Groningen, The Netherlands; and Private Clinic Heerenveen,

eerenveen, The Netherlands.

†Resident in Plastic Surgery, Department of Plastic, Reconstruc-

ive, Aesthetic and Hand Surgery, Medical Center of Leeuwarden,

eeuwarden, The Netherlands.

‡Oral and Maxillofacial Surgeon, Department of Oral and Maxil-

ofacial Surgery, Medical Center of Leeuwarden, Leeuwarden, The

etherlands.

§Associate Professor of Plastic Surgery and Plastic Surgeon, De-

artment of Plastic and Reconstructive Surgery, Erasmus Medical

enter, Rotterdam, The Netherlands.

Address correspondence and reprint requests to Dr van der Lei:

epartment of Plastic, Reconstructive, Aesthetic and Hand Surgery,

edical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD Leeu-

arden, The Netherlands; e-mail: b.van.der.lei@znb.nl

2008 American Association of Oral and Maxillofacial Surgeons

278-2391/08/6606-0032$34.00/0

toi:10.1016/j.joms.2006.11.042

1294

sthetic deformity. The harvesting site is closed pri-arily and the boat-shaped FTSG is in turn used to

lose the donor site.The purpose of this report is to present our expe-

ience with this new boat-shaped FTSG technique inlosing the donor site of the osteoseptocutaneousbula free flap and to compare this technique withur previous method of closing the donor site with aTSG obtained from the medial site of the upper leghistorical control group).

atients and Methods

LOCAL BOAT-SHAPED FTSG CLOSURE

The fibula free flap is designed as an osteoseptocu-aneous flap in the distal third part of the leg. In thisashion, it is optimally positioned over the fasciocuta-eous perforators. A lazy S-shaped incision is made forasy access for harvesting the fibula free flap and anTSG in the proximal third of the incision. The di-ensions of the boat-shaped FTSG depend on the size

f the skin island of the osteoseptocutaneous fibularee flap. The FTSG is as long as the skin island, butbout 20% narrower (Figs 1A,B).

After an incision made according to the flap design,he FTSG is harvested without subcutaneous fat andtored in saline-soaked gauze. Next, the fibula free flap isarvested in standard fashion and used for reconstruc-ion. Direct closure of the proximal donor site can beerformed easily (Fig 1C). The muscle compartment islosed distally, with a suction drain positioned betweenhe muscles. The boat-shaped FTSG is used to close theemaining fibula donor site defect. First, a layer of Vicryl-0 (Ethicon, Johnson & Johnson BV, Amersfoort, Theetherlands) sutures is placed, followed by a runningonocryl (Ethicon, Johnson & Johnson BV) mattress

uture. A nonadherent fat gauze is applied, followed byoist and fluffed coarse gauzes. Plaster cast immobiliza-

ion is used until donor site inspection after 7 days.

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VAN DER LEI ET AL 1295

inally, a lightweight splint is applied to immobilize theeg for an additional week.

STSG CLOSURE (HISTORICAL CONTROL GROUP)

Before introduction of the new technique, harvest-ng of the fibula free flap was done in the standardashion just outlined. The donor site was closed at thend with an STSG harvested from the medial site ofhe upper leg and sutured into the defect with aonocryl (Ethicon, Johnson & Johnson BV) mattress

uture. The aftercare was similar to that for our newechnique with the FTSG. The donor site of the uppereg was also covered with a nonadherent fat gauze,ollowed by moist and fluffed coarse gauzes. This waseft in place for 7 to 10 days until complete healing ofhe STSG donor site occurred.

esults

LOCAL BOAT-SHAPED FTSG CLOSURE

Our technique of the boat-shaped FTSG has been

IGURE 1. A, Preoperative and perioperative design of the harvestpatient 2 from Table 1). Crosses identify perforator vessels of the fibuas been harvested in the proximal area, and all lines of incision havf the fibula donor site skin defect with the FTSG. In the distal third of th

ension. D, Result of the fibula donor site after 15 months. Note the ro

an der Lei et al. Fibula Flap Donor Site Closure. J Oral Maxillo

pplied in a series of 15 consecutive patients with an p

verage follow-up of 9 months, with a range of 1 to 18onths (Table 1). The flap sizes ranged from 8 to

4 � 3 to 5 cm, with an average range of 9.3 � 4.1m. In all but 2 patients (13%), the graft take wasirtually complete, even over the peroneal tendons.n these 2 patients, the graft did not take because ofverly early mobilization against advice (both patientsere restless and started to smoke and drink again; 1atient had Korsakov’s disease). The extent of graftontake was 5% in 1 patient and 15% in the other. Inhe first patient, healing was completed in 4 weeks byecondary healing. The second patient received a.5 � 1.0 cm STSG after 3 weeks, which healedithout complications in 2 weeks.After complete healing, no cases of late wound

reakdown or scarring of a grafted donor site wereeen. Good cosmetic results were obtained in all pa-ients (Fig 1D), with no depression of the donor siterea of the fibula and no problems (ie, wound dehis-ence) with the donor site area of the FTSG. All

ula osteoseptocutaneous free flap with a moderate-sized skin islandThe striated area is the planned FTSG donor site area. B, The FTSGcut. C, Primary closure of the proximal FTSG donor site and closure

t is usually not possible to close a skin defect of this size without unduend excellent esthetic appearance.

g 2008.

of a fibla flap.e beene leg, ibust a

atients were satisfied with the appearance of the

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van der Lei et al. Fibula Flap Donor Site Closure. J Oral Maxillofac Surg 2008.

1296 FIBULA FLAP DONOR SITE CLOSURE

Table 2. DEMOGRAPHIC DATA FOR THE HISTORICAL CONTROL GROUP AND RESULTS OF THE DONOR SITE OF THEFIBULAR OSTEOSEPTOCUTANEOUS FLAP CLOSED WITH A STSG

Patient GenderAge(yrs)

Follow-Up(mo) Tumor Stage

Skin Flap Size(cm) Event Treatment

1 F 54 58 pT4N1M0 12 � 6 Healing uneventful2 M 60 59 ORN 12 � 8 Healing uneventful3 M 71 12 pT4N0M0 10 � 6 Healing uneventful4 M 55 30 pT4N0M0 12 � 8 Healing uneventful5 F 68 55 ORN 14 � 8 Healing uneventful6 F 41 54 pT4N0M0 18 � 10 Healing uneventful7 F 65 6 T3N0M0 10 � 7 Healing uneventful8 M 62 16 Rec SCC 10 � 8 100% loss of STSG Two debridements; healing in

8 weeks.9 F 70 10 pT4N0M0 10 � 5 Healing uneventful

10 F 72 17 pT4N2M0 12 � 6 Healing uneventful11 M 48 50 pT4N0M0 14 � 7 Healing uneventful12 M 45 48 pT4N0M0 12 � 6 Healing uneventful13 M 62 47 ORN 12 � 6 Healing uneventful14 M 64 45 ORN 8 � 4 Healing uneventful15 M 60 44 ORN 20 � 6 Healing uneventful16 F 76 42 pT4N0M0 8 � 4 Healing uneventful17 F 48 34 pT4N0M0 10 � 6 Healing uneventful18 F 62 38 ORN 12 � 8 60% loss of STSG Secondary healing in 6 weeks.19 M 56 27 pT4N2M0 12 � 6 Healing uneventful20 M 80 11 Rec. SCC 10 � 5 Healing uneventful21 F 71 36 ORN 12 � 6 50% loss of STSG Re-STSG; uneventful healing

in 3 weeks.22 F 55 33 ORN 6 � 4 Healing uneventful

Mean 61 35 11.6 � 6.4Range 41 to 80 6 to 59 6 to 18 � 4 to 10

Table 1. DEMOGRAPHIC DATA FOR THE PATIENTS AND RESULTS OF THE DONOR SITE OF THE FIBULAROSTEOSEPTOCUTANEOUS FLAP CLOSED WITH A LOCAL FULL-THICKNESS SKIN GRAFT

Patient GenderAge(yrs)

Follow-Up(mo)

TumorStage

Skin Flap Size(cm) Event Treatment

1 F 61 18 pT2N1M0 10 � 4 Healing uneventful2 F 73 15 pT3N0M0 8 � 3 Healing uneventful3 M 52 12 pT4N1M0 9 � 4 Wound breakdown 5% Secondary healing4 F 63 11 pT4N1M0 8 � 4 Healing uneventful5 M 55 10 pT4N2bM0 9 � 4 Healing uneventful6* M 60 11 pT4N0M0 8 � 4 Early mobilization against

advice; 100% lossDebridement; STSG of defect

7* M 57 9 pT4N0M0 8 � 3 Early mobilization againstadvice; 100% loss

Debridement; vacuum-assistedclosure wound management;STSG of defect

8 F 65 13 pT3N0M0 8 � 3 Healing uneventful9 M 43 5 pT4N0M0 10 � 4 Healing uneventful

10 F 74 9 pT4bN0M0 10 � 5 Wound breakdown 15% STSG of 1 � 1.5 cm after 3weeks

11 M 67 7 pT4aN2bM0 9 � 4 Healing uneventful12 M 59 7 pT4aN0M0 10 � 5 Healing uneventful13† M 65 7 pT4aN0M0 14 � 5 Healing uneventful14‡ M 46 5 pT4aN0M0 10 � 5 Healing uneventful15* F 48 1 pT4aN0M0 8 � 4 Healing uneventful

Mean 60 9 9.3 � 4.1Range 44 to 75 1 to 18 8 to 14 � 3 to 5

*Korsakow’s syndrome.†Salvage operation after pectoralis major muscle transfer and plating of the mandibular defect.‡Osteoradionecrosis.

an der Lei et al. Fibula Flap Donor Site Closure. J Oral Maxillofac Surg 2008.

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onor site area of the fibula and the FTSG. There haveeen no requests for donor site revision.

STSG CLOSURE (HISTORICAL CONTROL GROUP)

In the historical group of 22 patients, the averageollow-up was 35 months (range, 6 to 59 months)Table 2). The flap sizes ranged from 6 to 18 � 4 to 10m, with an average size of 11.6 � 6.4 cm. All patientseported some discomfort at the STSG donor site,arying from slight itching to slight burning pain. Inll but 3 patients (14%), the graft take was virtuallyomplete; these 3 patients experienced impairedealing with 100%, 60%, and 50% loss of the STSG,espectively. The first patient needed multiple de-ridements, with secondary healing occurring overhe subsequent 8 weeks. In the second patient, heal-ng was completed by secondary intention after 6

eeks. In the third patient, a second STSG was ap-lied, after which healing was completed in 2 weeks.After complete healing, none of the patients devel-

ped late wound breakdown. However, 12 patientsad a moderate to poor result of the skin graft at thebula donor site, because of a clearly visible depres-ion of the grafted area according to the Likert scaledata not shown; Fig 2). The donor area of the STSG

IGURE 2. Final result of the fibula donor site (STSG in patient 12rom Table 2) after 48 months.

ian der Lei et al. Fibula Flap Donor Site Closure. J Oral Maxillo-ac Surg 2008.

n the upper leg was still visible as an area of slightiscoloration in most patients.

iscussion

The purpose of this study was to present a novelechnique for donor site closure of the osteoseptocu-aneous fibula free flap aimed at reducing donor siteorbidity. The esthetic deformity and donor site mor-

idity of donor site closure of the osteoseptocutane-us fibula free flap are well-recognized disadvantageshen using a STSG. Donor site morbidity of the os-

eoseptocutaneous fibula free flap has been reportedn 30% to greater than 50% of cases.3-11 In general, thebula free flap donor site is closed by either primarylosure or an STSG. In our experience, primary clo-ure of a defect in the distal third of the lower leg canead to excessive tension, resulting in wound healingroblems. Compartment syndrome has been reported

n these cases.12 An STSG, on the other hand, fulfillsost criteria of an ideal closing method. In most cases

t heals well, although wound breakdown and expo-ure of the peroneal tendons occasionally occur. Thesthetic results are often unpleasing, however.Our experience with closure of the donor site of

he radial forearm flap with an FTSG taken proximallyrom the radial forearm flap donor site has shownood results.13,14 From this experience, we devel-ped a similar procedure for the fibula free flap,aking an FTSG proximally from the donor site of thebula free flap. At this location, primary skin closure

s easy and tension-free, which promotes reliableound healing.The results in our series of patients in whom a local

TSG was used for closure of the donor defect of thesteoseptocutaneous fibula free flap clearly demon-trate that this technique has several advantages, com-arable to those of closure of the donor site of theadial forearm free flap with an FTSG13,14: 1) a single-tage procedure requiring no secondary donor site,) no depression in the area of the FTSG overhe fibula donor site and excellent color match of aTSG of the leg, and 3) no late wound breakdowns,ot even over the peroneal tendons. We noted com-lete graft loss in 2 patients, who could not betopped from ambulating a few days postoperativelyecause of their Korsakov’s disease. Patients’ non-ompliance or uncooperative behavior, either be-ause of their personality or a disease (as in the casesf Korsakov’s syndrome), appears to be an importantonsideration in the decision of whether or not to usen FTSG. In those cases, either perforation of an FTSGr harvesting of a STSG from the same region, fol-

owed by excision and primary closure of the remain-

ng deeper skin layer, might be a better solution.

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1298 FIBULA FLAP DONOR SITE CLOSURE

The proposed method for closing the donor site ofhe osteoseptocutaneous fibula free flap with a boat-haped FTSG is suitable in most cases and results in aetter esthetic appearance with less donor site mor-idity compared with the use of an STSG. Only whenery large skin flaps are needed for reconstructionill a “conventional” STSG or an FTSG harvested from

nother area, such as the groin region or the abdom-nal wall, be needed.13,14

cknowledgments

The authors thank K. Koster for the photography.

eferences1. Hidalgo DA: Fibula free flap: A new method of mandibular

reconstruction. Plast Reconstr Surg 84:71, 19892. Hidalgo DA: A review of 60 consecutive fibula free flap man-

dible reconstructions. Plast Reconstr Surg 96:585, 19953. Lee EH, Goh JCH, Helm R, et al: Donor site morbidity following

resection of the fibula. J Bone Joint Surg 72B:129, 19904. Shpitzer T, Neligan P, Boyd B, et al: Leg morbidity and function

following fibular free flap harvest. Ann Plast Surg 38:460, 1997

5. Tang CL, Mahoney JL, McKee MD, et al: Donor site morbidityfollowing vascularized fibular grafting. Microsurgery 18:383,1998

6. Babovic S, Johnson CH, Finical SJ: Free fibula donor-site mor-bidity: The Mayo experience with 100 consecutive harvests. JReconstruct Microsurg 16:107, 2000

7. Zimmerman CE, Borner BI, Hasse A, et al: Donor site morbidityafter microvascular fibula transfer. Clin Oral Invest 5:214, 2001

8. Papadopulos NA, Schaff J, Bucher H, et al: Donor site morbidityafter harvest of free osteofasciocutaneous fibular flaps with anextended skin island. Ann Plast Surg 49:138, 2002

9. Hartman EHM, Spauwen PHM, Jansen JA: Donor site compli-cations in vascularized bone flap surgery. J Investig Surg 15:185, 2002

0. Meagher PJ, Morrison WA: Free fibula flap. Donor site morbid-ity: Case report and a review of the literature. J ReconstructMicrosurg 18:465, 2002

1. Bodde EWH, Visser E, Duysens JEJ, et al: Donor site morbidityafter free vascularized autogenous fibular transfer: Subjectiveand quantitative analyses. Plast Reconstr Surg 111:2237, 2003

2. Saleem M, Hashim F, Babu Monohar M: Compartment syn-drome in a free fibula osteocutaneous flap donor site. Br J PlastSurg 51:405, 1998

3. van der Lei B, Spronk CA, Visscher JG: Closure of radial forearmfree flap donor site with local full-thickness skin graft. Br J OralMaxillofac Surg 37:119, 1999

4. Zuidam JM, Coert JH, Hofer SOP: Closure of the donor site ofthe free radial forearm flap: A comparison of full-thickness graft

and split-thickness skin graft. Ann Plast Surg 5:612, 2005