Operative Technique in Plastic Surgery – Kevin C.Chung

of intracranial bleeding may be a relative contraindication. Although there is
no consensus on the need for or type of anticoagulation that should be used, we
routinely use postoperative antiplatelet therapy for 5 days if not otherwise
contraindicated.
■ Once it is safe to do so, patients should be encouraged to ambulate.
■ Drains are usually removed when the output is less than 30 cc/d.
■ Sutures are removed when adequate healing has occurred depending on the
quality of the recipient tissues.
OUTCOMES
■ There is a 98% success rate using free tissue transfer for complex scalp
defects.9,10
■ STA/V is available and suitable for microvascular tissue transfer in oncologic
scalp reconstruction in most patients. Halvorson et al. found no statistical
difference in outcome between using superficial temporal vessels and neck
vessels.4
■ Debulking of the skin paddle can improve the appearance of the protuberant
grafts (FIG 2).

FIG 2 • A,B. Postoperatively, the skin paddle is
protuberant and bulky. C,D. Debulking of the skin
paddle greatly improves appearance and contour.
COMPLICATIONS
■ Complication rates were similar between ALT and LD flaps in a 15-year study
by Fischer et al.9
■ Some of the complications from free flap reconstruction include
■ Vascular thrombosis
■ Donor-site morbidity

■ Wound complications and infection, related to defect size, age, and smoking9
■ Flap loss
■ Partial flap loss
■ Exposed underlying hardware
REFERENCES
1. Tolhurst DE, Carstens MH, Greco RJ, et al. The surgical anatomy of the scalp.
Plast Reconstr Surg. 1991;87:603-612.
2. Mehrara B, Disa JJ, Pusic A. Scalp reconstruction. J Surg Oncol.
2006;94:504-508.
3. Lin S, Hanasono MM, Skoracki RJ. Scalp and calvarial reconstruction. Semin
Plast Surg. 2008;22:281-293.
4. Halvorson EG, Cordeiro PG, Disa JJ, et al. Superficial temporal recipient
vessels in microvascular orbit and scalp reconstruction of oncologic defects. J
Reconstr Microsurg. 2009;25:383-387.
5. Wolff KD, Grundmann A. The free vastus lateralis flap: an anatomic study
with case reports. Plast Reconstr Surg. 1992;89:469.
6. Bartlett SP, May JW, Yaremchuk M. The latissimus dorsi muscle: a fresh
cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg.
1981;67:631.
7. Fisher J, Bostwick J, Powell RW. Latissimus dorsi blood supply after
thoracodorsal vessel division: the serratus collateral. Plast Reconstr Surg.
1983;72:502.
8. Tobin G, Schusterman MA, Peterson G. The intramuscular neurovascular
anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast
Reconstr Surg. 1981;67:637.
9. Fischer J, Sieber B, Nelson JA, et al. A 15-year experience of complex scalp
reconstruction using free tissue transfer-analysis of risk factors for
complications. J Reconstr Microsurg. 2013;29:89-98.
10. Hussussian C, Reece G. Microsurgical scalp reconstruction in the patient with
cancer. Plast Reconstr Surg. 2002;109:1828-1834.

5
CHAPTER
Scalp Reconstruction With
Tissue Expansion
Finny George and Evan Matros
DEFINITION
■ Tissue expansion is the process by which an external force is applied to recruit
the viscoelastic properties of the scalp to increase the size of the available
healthy tissue.1,2
■ Restoration of the scalp to its prealopecia state is the primary goal of tissue
expansion of the scalp. It is a crucial tool in the restoration of hair-bearing
scalp.3
■ By expanding normal, healthy, hair-bearing scalp tissue, defects up to 50% of
the total surface area of the scalp can be resurfaced.
■ There are three commonly used tissue expander shapes: round, crescent, and
rectangular. The tissue expander shape used is not critical.
■ For large defects, multiple tissue expanders can be used simultaneously.
■ The base diameter of the expander should be approximately 2 to 2.5 times the
size of the defect.
ANATOMY
■ The layers of the scalp are the skin, subcutaneous network (contains blood
vessels, lymphatics, and nerves), galea aponeurotica, areolar plane, and
pericranium.4
■ The galea is a fibromuscular central tendinous confluence of the occipitalis
and frontalis muscles.
■ The loose areolar plane, deep to the galea, is the layer in which natural plane
of separation of the scalp from the cranium occurs.
■ The parietal scalp has the greatest mobility and so can be helpful in local
tissue recruitment. This quality can be used in tissue expansion.

■ During the process of expansion, predictable changes occur histologically1,2,5:
■ The epidermis thickens, dermis thins, muscle thins, quantity of
myofibroblasts increases, 30% to 50% of fat is permanently lost, high density
of blood vessels grow, and a collagen/fibroblast capsule forms around the
expander.
■ This increased angiogenesis that occurs in expanded flaps allows for
improved survival and reliability.
■ Expanders are placed in the subgaleal plane, superficial to the pericranium.
PATHOGENESIS
■ Alopecia of the scalp often results from trauma, burns, radiation, malignancy,
or congenital disease (FIG 1).
■ Irradiated scalp may not expand well or may be associated with higher
complication rates.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Pertinent history must be gathered from the patient and will include
information on:
■ Circumstances surrounding development of scalp alopecia
■ Prior treatment or operations that were done, including failed treatments
• Prior use of hardware or implants
■ History of radiation or chemotherapy
■ History of smoking, alcohol abuse, weight loss, diabetes, or bleeding
disorders
■ Physical examination should gather enough knowledge to prepare an accurate
preoperative plan.
■ Look for prior incisions.
■ Examine the skin quality and laxity.
■ Note unusual hair growth patterns including cowlicks.
SURGICAL MANAGEMENT
Preoperative Planning
■ Prior operative dictations should be reviewed to ensure that vascularity to the
proposed area of expansion has not been disrupted or the area has not been
irradiated.
■ The patient must be aware that he or she will have an abnormal appearance

during the expansion process and that they will have multiple office visits to
undergo the expansion.
FIG 1 • This patient had scalp closure with a skin graft
following excision of an adnexal tumor. After a disease-
free interval, she requested skin graft removal.
■ They must be informed that at least two operations will be needed for this
type of procedure.
• Tissue expander placement
• Tissue expander removal, scalp flap elevation, and closure with removal of
alopecia areas
■ Risks specific to this operation should be discussed with the patient. They
include alopecia along areas of new incisions, exposed tissue expander or
inflation port, dog ears, partial or complete scalp flap loss, asymmetry,
abnormal hair growth pattern, and the need for further surgery.
■ Preoperative antibiotics are administered.
■ Temporary markings should be placed on the patient in the preoperative area
where there is ideal lighting and exposure, areas of laxity can be assessed, and
hair growth patterns can be noted.

Positioning
■ Depending on the location of the defect, the patient may need to be supine or
prone to properly expose not only the defect but also the proposed donor scalp.
■ Generally, the entire scalp needs to be prepped into the surgical field.
■ It is not essential to shave the scalp prior to surgery.
Approach
■ The tissue expander can be placed immediately adjacent to an area of alopecia
or through a remote incision. There are pros and cons to each approach that
must be carefully considered.
■ A marginal incision can be made approximately 1 cm beyond the area of
alopecia or skin graft.
■ A reliable closure needs to be ensured so there is no dehiscence once
expansions are initiated.
■ This incision will become the leading edge of the subsequent scalp flap.
■ Remote incisions to place the expander away from the area of alopecia will
have a more reliable closure; however, the placement of new incisions needs to
be along the same line as the future scalp flap. This can be difficult to
anticipate.
T E C H N I Q U E S
■ Insertion of Tissue Expander
■ Using a marking pen, the proposed incision should be drawn a minimum of
1 cm from the edge of the defect or prior skin graft (TECH FIG 1A).
■ This will allow for reliable suture purchase in healthy tissues away from
prior skin grafts.
■ Incisions should be made parallel to the defect margin.
■ The proposed incision is infiltrated with 1% lidocaine with epinephrine.
■ Incision should be made parallel to hair so that follicles are not disrupted.
■ The incision is carried through, full-thickness, to the subgaleal plane.
■ Adequate undermining is done so as to accommodate the size of the
expander with additional laxity to close the incision without tension.
■ An additional 2-cm remote incision is required to place the port of the

expander.
■ The expander is irrigated with bacitracin solution and evacuated of all air.
■ The expander is tested with 60 mL of injectable saline to satisfactorily
demonstrate competence without leaks. This fluid is then evacuated.
■ The expander is placed in the pocket, and the tubing is positioned away from
any potential inadvertent puncture (TECH FIG 1B).
■ The port is secured with two 5-0 Prolene sutures so that it does not flip in the
postoperative period, making location and port access difficult.
■ A drain is placed in the same pocket as the expander and is brought out
through a separate stab incision.
■ The scalp incisions are closed in layers (TECH FIG 1C).
■ Capillary refill is checked throughout the flap making sure that there is no
unfavorable tension on the skin or the incision.
TECH FIG 1 • A. The uninvolved scalp posterior to the
alopecia (bottom of photo) is proposed for expansion
and recruitment. The incision should be placed in
healthy scalp to facilitate reliable healing of the suture
line. B. The tissue expander (crescent shaped) and
the remote port for filling access. C. Placement of the
suture line posterior to the injured tissue and skin graft
is crucial for healing.
■ Advancement of Flap
■ The tissues should ideally be overexpanded at least 20% larger than the size
of the defect for tension-free closure after tissue recoil (TECH FIG 2A).

■ After the expansion process, the patient is brought back to the operating
room for removal of the expander and rotation/advancement of the flap.
■ As previously mentioned, the incision used to insert the expander was placed
1 cm posterior to the prior skin graft or original defect. During this operation,
this intervening bridge of skin is excised, as its blood supply is presumed to
be compromised.
■ The capsular pocket is entered and the expander is removed (TECH FIG
2B).
■ The old incision that was made to place the port is also opened and the port
is removed.
■ A proposed rotation advancement flap is drawn with a marking pen and
blood supply to the flap confirmed prior to committing to the incision.
■ The incision is made and the scalp elevated in the areolar plane.
■ A Burow triangle may need to be excised in order to equalize the two sides
of scalp along the incision.
■ Once the scalp is incised, the advancement is checked to ensure that the
defect will be adequately covered prior to excision of any skin graft (TECH
FIG 2C).
■ The periosteum under the skin graft is left intact.
■ A drain is placed in the former capsular pocket and brought out through a
separate stab incision.
■ Hemostasis is achieved, and the incision is closed in a layered fashion
(TECH FIG 2D).

TECH FIG 2 • A. The scalp has been expanded. B.
The expander is removed through the previous
incision. The expanded scalp is elevated and the
capsule is scored if necessary to allow for
advancement. C. The expanded scalp is draped over
the defect to be excised. The skin graft is not excised
until it is ensured that the scalp flap is sufficient in
dimension. D. The defect is excised, and the
expanded scalp is advanced over the defect and
closed, healthy tissue to healthy tissue. A drain is left
in place.

PEARLS AND PITFALLS
Planning
■ At least one main blood vessel must be included in the flap.
■ Prior incisions should be noted.
Technique
■ The tissue expander shape is not as important as its size. It must be
significantly larger than the defect to ensure a flap large enough to
excise all areas of alopecia.
■ It is more straightforward to place the expander adjacent to areas of
alopecia. This approach does not burn any bridges.
Avoid
■ Avoid additional incisions for placement of the expander that could
compromise subsequent scalp flap design.
■ Rapid expansion can lead to higher extrusion rates.
POSTOPERATIVE CARE
■ Inflation of the expander is started after the incisions have healed and
continued until enough soft tissue has been recruited.
■ Expansions are initiated 2 weeks after placement.
■ Inflation is done weekly.
■ The end of the expansion process can be difficult to determine clinically.
■ The amount of tissue available for rotation/advancement is approximately
equal to half the circumference of the inflated expander.
■ Drains must be left in place until less than 30 mL/d drainage.
■ Once the scalp has been sufficiently expanded, approximately 1 month is
waited before the second surgery.
■ The entire process of expander placement, expansion, and scalp flap takes
approximately 3 months.
OUTCOMES
■ The reported incidence of complications in scalp reconstruction with tissue
expansion is 6% to 25%.6
■ Governa et al. reported their study of 157 patients with 262 expanders.
Complete scalp coverage was obtained in only 62% of the patients.7
■ Postoperative result is shown in FIG 2.

FIG 2 • Six months postoperatively, the patient has
normal hair coverage on the scalp.
COMPLICATIONS
■ The most common complications with tissue expansion are
■ Pain
■ Scar widening
■ Expander or port exposure
■ Infection
■ Hematoma
■ Children under the age of 3 should not have scalp expansion because of
unfavorable effects on open cranial sutures.
■ Higher complications are associated with expansion in children under age 7
and in patients who have been radiated or burned.
■ Rarely, it may be possible to continue expansion if the port or expander itself
becomes exposed as long as there are no signs of infection.
■ Manders et al. detailed their experience with 41 expanders in 35 burn patients
with alopecia. In this review, 25% of patients had major complications
requiring alterations in the treatment plan, while 17% had minor problems.8

REFERENCES
1. Austad ED, Pasyk KA, McClatchy KD, Cherry GW. Histomorphologic
evaluation of guinea pig skin and soft tissue expansion. Plast Reconstr Surg.
1982;70:704-710.
2. Austad ED, Thomas SV, Pasyk KA. Tissue expansion: divided or loan? Plast
Reconstr Surg. 1986;78:63-67.
3. Gurlek A, Alaybeyoglu N, Demir C, et al. Aesthetic reconstruction of large
scalp defects by sequential tissue expansion without interval. Aesthetic Plast
Surg. 2004;28:245-250.
4. Tolhurst DE, Carstens MH, Greco RJ, et al. The surgical anatomy of the scalp.
Plast Reconstr Surg. 1991;87:603-612.
5. Pasyk KA, Argenta LC, Austad ED. Histopathology of human expanded
tissue. Clin Plast Surg. 1987;14:435-445.
6. Azzolini A, Riberti C, Cavalca D. Skin expansion in head and neck
reconstructive surgery. Plast Reconstr Surg. 1992;90:799.
7. Governa M, Bortolani A, Beghini D, Barisoni D. Skin expansion in burn
sequelae: results and complications. Acta Chir Plast. 1996;38:147-153.
8. Manders EK, Schenden MJ, Ferrey JA, et al. Soft tissue expansion: concepts
and complications. Plast Reconstr Surg. 1984;74:493-507.

6
CHAPTER
Calvarial Reconstruction
With Split Rib Grafts
David A. Staffenberg and Gerald J. Cho
DEFINITION
■ The rib cage is made up of paired ribs, sternum, and thoracic vertebrae acting
to protect and stabilize the chest cavity.
■ Because the rib cage is comprised of 24 ribs and resection of as many as 2 ribs
is well tolerated (ie, does not cause chest wall instability), the rib cage is an
abundant source of bone graft material.
ANATOMY
■ The rib cage or the thoracic cage consists of bone and cartilage.
■ Normally, there are 12 ribs on each side. Each rib articulates with the thoracic
vertebral column posteriorly, and the first 10 ribs articulate with the sternum
via the costal cartilage.
■ The caudal two ribs are “floating ribs” and lack corresponding costal
cartilages (FIG 1).
■ Rib grafts are technically easier and safer to obtain than split calvarial grafts in
children below the age of 8 because the diploe of the calvarium at this age is
poorly developed. Moreover, unlike the iliac crest donor site, rib graft harvest
is less painful and does not affect growth potential of the pelvis.
■ The rib is circumferentially surrounded by cortical bone and has a cancellous
core. The rib can be split into two mirror images to increase the surface area.

FIG 1 • The rib cage. Normally, there are 12 ribs on
each side. The caudal two ribs are “floating ribs” and
lack corresponding costal cartilages.
■ Splitting the bone also makes it more malleable to match the cranial contour.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history and physical exam should document prior history of chest
surgery or trauma particularly previous scars and their location, as well as
history of prior rib graft harvest.
IMAGING
■ Preoperative chest x-rays are rarely necessary prior to harvesting of rib grafts
unless there is an unusual finding on physical exam.
■ Similarly, postoperative chest x-rays are usually unnecessary even if there is a
small violation of the parietal pleura as this rarely leads to a clinically

significant pneumothorax. If there is suspicion of injury to the visceral pleura
or lung parenchyma, then a chest x-ray and close clinical observation may be
warranted.
SURGICAL MANAGEMENT
Preoperative Planning
■ Skin incisions are marked along the relaxed skin tension lines to minimize
postoperative scarring.
■ In females, an inframammary fold incision may be used and is located at
approximately the level of the fifth rib.
■ Incisions are placed lateral to the costochondral junction to avoid harvesting of
the costal cartilage, which is not useful for calvarial reconstruction.
■ The length of the incision is related to the amount of bone that is necessary.
Nevertheless, it is possible to minimize the length of the incision with the use
of angled Horsley rib cutters.
■ Harvesting of more than two adjacent ribs should be avoided to minimize the
risk of flail chest and respiratory compromise.
Positioning
■ The patient can be positioned prone or supine as rib harvest is possible from
both the anterior and posterior chest.
■ The choice for positioning depends largely on the cranioplasty defect to be
treated and aiming to avoid repositioning during surgery.
T E C H N I Q U E S
■ Rib Graft Harvest
■ The skin is incised and dissection is carried down to the anterior rectus fascia
for the anterior approach. The fascia and muscle are split along the
underlying rib using careful palpating as a guide (TECH FIG 1A).
■ The periosteum of the rib is elevated along the length of the bone using Freer
or Joseph elevators.
■ Care is directed at the inferior border of each rib where the neuromuscular
bundle lays under a small overhang. The neuromuscular bundle is carefully

preserved.
■ A Doyen elevator (available in pediatric and adult sizes) is used to continue
periosteal dissection under the rib and extend the dissection laterally.
■ It is most advantageous to first separate the bony rib from the costal cartilage
(in the anterior approach) or to use a scalpel to divide the cartilage just
medial to the junction while a malleable retractor protects the underlying
periosteum and pleura (TECH FIG 1B).
■ A wet gauze is wrapped around the medial end of the rib being harvested and
a Kocher is used to cinch the gauze snugly around the rib. This will prevent
unwanted split ends (TECH FIG 1C).
■ The surgeon’s index finger can then gently provide additional length of the
graft by sliding it laterally along the rib separating additional periosteal
attachments.
■ The Horsley rib cutter is carefully placed in position. The surgeon’s index
finger confirms placement by palpating along the rib and the rib is cut.
■ Some surgeons will ask the anesthesiologist to decrease the tidal volume
during the harvest.
■ The rib graft is placed in saline, and attention is directed to the harvest site.
TECH FIG 1 • A. Surface anatomy. Note prior incision.
The regenerated rib can be harvested again, split, and
used. B. For the anterior approach, the bony rib is first
separated from the costal cartilage by using a scalpel
to divide the cartilage just medial to the junction, while
a malleable retractor protects the underlying
periosteum and pleura. C. A wet gauze is the wrapped
around the medial end of the rib being harvest and a
Kocher is used to cinch the gauze snugly around the

rib. This will prevent unwanted split ends.
■ Checking the Harvest Site and Completion
■ The harvest site is filled with saline and the anesthesiologist is asked to
provide 40 mm Hg pressure to the airway and hold it while the surgeon
observes for persistent bubbling.
■ After a suitable period of observation (usually 5–10 seconds), the
anesthesiologist resumes normal ventilation.
■ Initial but nonsustained bubbling indicates that the parietal pleura has been
transgressed, whereas persistent bubbling indicates that both parietal and
visceral pleura are injured.
■ In the former scenario, the donor site can be closed without additional
attention.
■ In the latter scenario, the surgeon must attempt to identify an obvious rent
in the parietal pleura and place a red rubber catheter through it, leaving the
wide end above the level of the skin. The donor site is then closed around
the catheter. Because the lungs are ventilated with positive pressure,
suction does not need to be applied to the red rubber catheter. The catheter
is removed after the donor site is closed.
■ Closure is performed in layers using resolvable sutures to reapproximate the
periosteum. In infants and young patients, the harvested rib may regrow (we
have been able to reharvest ribs years later because of this phenomenon).
■ Additional anesthetic may be injected into the donor site for postoperative
comfort (0.25% Marcaine is frequently used). The surgeon may also make
use of commercially available systems to deliver pain medicine to the donor
site via a catheter.
■ A chest x-ray may be obtained postoperatively to rule out a pneumothorax or
hemothorax. When suspicion of a pleural rent is minimal, an x-ray may be
avoided.
■ The harvested rib is inspected. Any cartilage remnant is removed.
■ In children, thin spatula osteotomes are ideal for manually splitting the ribs
in a sagittal plane without use of a mallet (TECH FIG 2).
■ In infants, a scalpel blade will frequently suffice, whereas in adults, a
Freihofer with a mallet will work well.

TECH FIG 2 • A. A thin spatula osteotome is used to
split the rib. B. Splitting rib effectively doubles the
surface area.
PEARLS AND PITFALLS
Indications
■ Split rib grafts are indicated for cranioplasty particularly in children
who are less than 8 years old.
Splitting rib
graft
■ Doubles effective surface area, grafts are more malleable to better
match contour.
Prior rib
harvest
■ Regenerated rib can be harvested again, split, and used.
Damage to
pleura
■ Rarely clinically significant if limited to parietal pleura.
Amount of
rib
harvested
■ It is not recommended to harvest more than two adjacent ribs to
minimize the risk of respiratory compromise from a flail chest.
POSTOPERATIVE CARE
■ Intercostal nerve blocks and infiltration of surrounding soft tissue with local
anesthetics can help reduce postoperative pain at the rib donor site.

■ Patients can resume their regular activities/return to school after 2 weeks
postop.
OUTCOMES
■ Reliable grafts that incorporate well into the adjacent calvarium and
accommodate the growing skeleton.1,2
■ Split rib grafts contour well and maintain their shape over time.3,4
COMPLICATIONS
■ Pneumothorax/hemothorax: If a pneumothorax is present, a small red rubber
catheter is placed into the pleural cavity. The overlying muscle is
reapproximated and the catheter withdrawn while the anesthesiologist applies
positive pressure ventilation.
■ Hypertrophic scarring of chest wall incision: Transverse incisions parallel to
the resting skin tension lines typically heal more favorably than oblique
incisions.
■ Chest wall deformity: Rarely, a problem when perichondrium is left intact as
there is usually complete regeneration of the donor rib in children. Avoiding
violation of the sixth rib margin can prevent outward flaring of the rib as the
child grows. Chest wall deformity is more noticeable in extremely thin
patients.5
■ Resorption of graft: Rib grafts have a higher rates of resorption clinically and
in animal studies as compared to calvarial bone grafts.6
REFERENCES
1. Beekmans SJ, Don Griot JP, Mulder JW. Split rib cranioplasty for aplasia cutis
congenita and traumatic skull defects: more than 30 years of follow-up. J
Craniofac Surg. 2007;18:594-597.
2. Brent B. Technical advances in ear reconstruction with autogenous rib
cartilage grafts: personal experience with 1200 cases. Plast Reconstr Surg.
1999;104(2):319-334.
3. DeLuca L, Raszewski R, Tresser N, Guyuron B. The fate of preserved
autogenous bone graft. Plast Reconstr Surg. 1997;99(5):1324-1328.
4. Derek AT, Arnold HM. Successful use of rib grafts for cranioplasty in
children. Pediatr Neurosurg. 2001;34:149-155.
5. Ohara K, Nakamura K, Ohta E. Chest wall deformities and thoracic scoliosis
after costal cartilage graft harvesting. Plast Reconstr Surg. 1997;99:1030.

6. Longacre N, DeStefano GA. Further observations of the behavior of
autogenous split rib grafts in reconstruction of extensive defects of the cranium
and face. Plast Reconstr Surg. 1957;20:281-296.

7
CHAPTER
Calvarial Reconstruction
With Split Calvarial Grafts
David A. Staffenberg and Gerald J. Cho
DEFINITION
■ Split calvarial grafts are cortical bone grafts harvested from the skull.
■ These grafts can be either partial-thickness grafts where only the outer cortex
is removed or full-thickness grafts that are then split along the diploic space to
separate the bicortical graft into two pieces.
ANATOMY
■ The calvarium (skull) consists of separate bone plates encasing the brain. Each
named bone plate adjoins the adjacent bone plates at the cranial sutures.
■ Paired frontal bones
■ Paired parietal bones
■ Occipital bone (occasionally with an accessory suture or mendosal suture)
■ The skull consists of three layers of variable thickness:
■ Outer table (cortical bone)
■ Middle layer (cancellous bone)
■ Inner table (cortical bone)
■ These three layers are not present at the cranial sutures.
■ The entire calvarium can serve as a donor site for split calvarial grafts. There
are two main danger zone, however:
■ The midline, where the sagittal sinus resides subcortically
■ Below the temporal crest, where the bone tends to be thinner, increasing the
risk for inadvertent intracranial entry
■ Frontal bone can also be used when this is the site of surgery (eg, a frontal
craniotomy is performed by the neurosurgeons for tumor access.
■ The craniotomy bone flap can be split, during the neurosurgical portion of the

procedure, if additional bone will be required for repair).
■ The thickest bone resides in the parietal and occipital bones.1 Parietal bone is
the most common donor site because it is the thickest.
■ Transcortical emissary veins can cause brisk bleeding during the osteotomy.
This can usually be controlled with bone wax.
■ Subcortical vessels can cause thinning, and thus, weaken the inner cortex.
■ The split calvarial graft may be a superior alternative to other bone graft donor
sites.
■ It offers a hidden scar if placed within the hair-bearing scalp.
■ It is frequently a painless donor site, particularly when compared with iliac
crest and rib.
■ Split calvarium will typically provide cortical bone grafts that have the
following advantages over iliac crest and rib:
■ Smooth surface
■ Able to hold screws
■ Able to bear load
■ Warp resistant
■ In experienced hands, a large quantity of cortical bone can be harvested.
■ Splitting the calvarium is easiest when the diploe is well-developed.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ When a donor site is being selected, note the patient’s handedness. This is to
decrease potential morbidity in case there is inadvertent intracranial entry and
damage to the motor cortex.
■ A left-handed patient will have a left side donor site.
■ A right-handed patient will have a right side donor site.
■ When there has been previous surgery, the surgeon must take note of:
■ Previous scars, their condition and location
■ Mobility of the scalp: An adherent scalp may indicate loss of the intermediate
layers of the scalp and therefore the potential for subsequent wound healing
problems.
■ Palpable bony defects or hardware
IMAGING
■ Imaging may be useful to determine the characteristics of available sites.
■ CT scanning with bone windows is currently the most useful imaging

modality.
■ CT is particularly helpful when there are palpable bony defects or hardware
present.
■ The thickness of the inner and outer tables of the calvarium, as well as the
thickness of the diploe, should be noted by the surgeon.
■ Imaging is recommended until the surgeon has gained suitable experience.
SURGICAL MANAGEMENT
Preoperative Planning
■ If coronal incision is being used, the scalp flaps can be retracted to expose the
graft donor site.
■ The coronal flap is elevated in a subperiosteal plane if a full outer cortical
graft is being harvested down to diploe.
■ If a split-thickness (partial thickness outer table) calvarial graft is being
harvested, a subgaleal plane is elevated to preserve the periosteum.
■ If a coronal incision is not being used, we recommend a sigmoid-shaped
incision over the donor site for wide exposure.
■ The flaps are elevated in a subperiosteal plane if a full outer cortical graft is
being harvested down to diploe.
■ If a split-thickness (partial thickness outer table) calvarial graft is being
harvested, a subgaleal plane is elevated to preserve periosteum on the
intended bone graft.
Positioning
■ The patient can be positioned supine or prone.
■ The patient’s head should be secured and on a firm surface (ie, avoid cushions)
to minimize “bouncing” while the osteotomes are driven with a mallet.
Approach
■ Ex vivo calvarial split is a useful technique when neurosurgeons are
performing a craniotomy for an intracranial procedure and additional cortical
bone is required at the completion of the procedure.
■ In situ split calvarial is a reasonable option for adult patients and is useful
when a craniotomy is not necessary for the surgery at hand. However, there is
a greater learning curve than ex vivo technique because inadvertent injury to
the inner table may cause dural tears or intracranial injury.

T E C H N I Q U E S
Video p3-c007
■ Ex Vivo Split Calvarial Graft From Craniotomy
Bone Flap
■ The craniotomy bone flap is placed in saline on a sterile back table.
■ We use a table with a drill/saw system secured to a pole because this allows
efficient use of the time while the neurosurgery team is working.
■ Bone is kept in saline when not being used.
■ Instruments are selected based on the age of the patient and the
characteristics of the bone to be split.
■ In infants as young as weeks of age, a no. 15 scalpel blade may be an
efficient tool for splitting bone through the diploe. A sterile vise applied to
the side of the back table is helpful to minimize injuring the surgeon’s
nondominant hand.
■ In infants from a few months old, a series of spatula osteotomes can be
used to gently split the calvarium along the diploe (TECH FIG 1A,B).
■ After roughly 6 months of age, a C-1 side-cutting bit on a Midas Rex can
be used to create a series of adjacent drill holes while applying copious
saline irrigation to prevent thermal necrosis. The C-1 bit can then be used
to gently connect each hole (TECH FIG 1C–E).
■ Several of the popular saw systems have developed flexible saw blades as
00:00 / 00:00

thin as 0.3 mm. I prefer using the reciprocating saw for this purpose. Again,
use caution to avoid injury to your own hands or those of your assistants.
■ While working with the saw, a vise or Kocher clamp can be used to reduce
vibration.
TECH FIG 1 • A,B. C-1 side-cutting bur on Midas Rex
is used to separate the inner cortex from the outer
cortex along the diploic space. Note that the maximal
width of bone graft obtained is dictated by the length
of the drill. C. The drill is used to perforate the inner
cortex in a “postage stamp” manner. D. The
perforations are connected using the drill. E. Split
calvarial graft is obtained.
■ In Situ Split Calvarial Graft
■ The desired donor site is exposed in a subperiosteal plane.
■ The desired graft is marked with a sterile pencil, bonny blue, or the like.
■ A saline-cooled bur is used to create a trough around the border of the

desired graft; the trough is continued into the diploe. The depth is noted when
cancellous bleeding is seen (TECH FIG 2A).
■ Plan to drive the osteotome toward the floor. Use the bur to bevel the upper
margin to make the proper position and angle of the osteotome easier.
■ A selection of slightly curved osteotomes is used along the diploe. Care is
exercised to avoid directing the osteotome into the inner table. An assistant
secures the patients head to avoid bouncing, while the mallet drives the
osteotomes. Rapid light taps are safer and allow frequent correction and
adjustment of the osteotome (TECH FIG 2B).
■ Once the outer table is harvested, the inner table integrity is confirmed.
Compromise of the inner table should prompt consideration of a
neurosurgical consult intraoperatively.
■ Judicious use of bone wax can control bleeding from the diploe.
■ The saline-cooled bur is used to bevel the edges of the donor site to
minimize palpability of the step-off.
■ Filling the donor site with an alloplastic “bone paste” may be considered in
the hairless, or shaven, patient.
■ The scalp is closed in layers. A drain may be used based on the surgeon’s
preference. I favor a craniofacial dressing over the use of a drain.
TECH FIG 2 • A. A cutting bur is used to make a
trough through the outer cortex and into the diploe.
The outer edges are contoured and feathered

peripherally. B. The outer cortex is removed using a
right-angled oscillating saw, or alternatively, it can be
chiseled off using a curved osteotome.
■ Thin Split-Thickness In Situ Calvarial Bone Graft
■ Periosteum attached to the intended graft is imperative.
■ An incision is made around the desired dimensions of the graft (scalpel or
cautery is acceptable).
■ A wide, sharp osteotome is selected and oriented at about 45 degrees off the
outer table with the surgeon’s nondominant hand.
■ The surgeon’s dominant hand is used to strike the osteotome with a mallet
with light but rapid contact. This will “shave” a thin split calvarial bone graft,
which is comminuted but held together by the periosteum.
■ The comminution allows the graft to curl, which makes it ideal for repair of
an orbital floor defect, ie, acute pure orbital blow-out fracture.
PEARLS AND PITFALLS
Patient age
■ Patients at the extremes of age pose a technical challenge and
experience is even more critical to minimize morbidity in these
patients. Neonates may have an undeveloped diploe, whereas elderly
patients lose the diploe, which may present a technical challenge. In
situ split-thickness harvesting in these two groups is not
recommended.
Intracranial
pressure
■ Patients with even subclinical increased intracranial pressure (eg,
syndromic craniosynostosis, some nonsyndromic craniosynostosis)
may lose the inner table and simply manifest with a monocortical
calvarium. Splitting is increasingly more difficult or impossible in
areas where the calvarium has thinned.
Know your
instruments
■ Know the capability of your instruments (saws, osteotomes, burs,
etc.)
Know your
own
■ Practice. There is a real learning curve.

capabilities
POSTOPERATIVE CARE
■ Limited exposure and smaller grafts can be managed with simple compressive
dressings, which can be removed after a few days.
■ Wide exposure for large grafts may require a closed suction drain.
OUTCOMES
■ Calvarial bone grafts are considered the standard for autogenous craniofacial
reconstructions.1,2
■ No controlled human studies currently exist that characterize the volume or
rate of absorption. However, numerous clinical studies demonstrate excellent
graft stability along the entire craniofacial skeleton. Animal studies have
shown calvarial grafts to be superior to rib and iliac crest bone grafts.
■ Donor-site complications are rare across all studies.3
COMPLICATIONS
■ Dural exposure
■ If small (less than 1 cm2), there is no need for calvarial reconstruction
■ Larger (greater than 1 cm2) defects can be reconstructed with another split
calvarial graft or alloplastic mesh.
■ Dural tear
■ This complication requires prompt neurosurgical intervention. Injured dura
should be adequately exposed and the brain evaluated for injury. In the
absence of brain parenchyma damage, the dura should be closed primarily
when possible. Larger dural tears may require dural grafts.
■ CSF leak
■ Small CSF leaks can be managed with bed rest.
■ Larger CSF leaks may require external drainage.
■ Donor-site contour deformities
■ Rarely, a cosmetic problem (widened scar) when donor site is in hair-bearing
scalp.
■ Burring down sharp edges of graft site can help camouflage defect.
REFERENCES
1. DeLuca L, Raszewski R, Tresser N, Guyuron B. The fate of preserved

autogenous bone graft. Plast Reconstr Surg. 1997;99(5):1324-1328.
2. Gruss JS, Mackinnon SE, Kassel EE, Cooper PW. The role of primary bone
grafting in complex craniomaxillofacial trauma. Plast Reconstr Surg.
1985;75(1):17-24.
3. Pensler J, McCarthy JG. The calvarial donor site: an anatomic study in
cadavers. Plast Reconstr Surg. 1985;75:648-651.

8
CHAPTER
Section IV: Skull Base and
Midface
Free Fibula Flap for Midface
Reconstruction
J. Rodrigo Diaz-Siso and Eduardo D. Rodriguez
DEFINITION
■ Composite midface defects, involving skin, bone, and mucosa, are commonly
the result of oncologic resection, high-energy trauma, inflammatory diseases,
or congenital anomalies.
■ Unreconstructed midface defects may lead to impaired speech, oral
incompetence, and limited masticatory, deglutitive, orbital, and respiratory
functions, in addition to facial disfigurement and associated decreased quality
of life.
■ The free fibula is a versatile flap that can include a long segment of
vascularized bone, which can be shaped as needed through multiple
osteotomies.
■ The flap can include muscle, fascia, and/or skin, making it an ideal
reconstructive option for composite defects.
■ The reconstructive goals are to replace the facial buttresses, resurface internal
and external soft tissue lining, separate the oral and nasal cavities, and restore
the alveolus, resulting in a patent nasal airway, adequate midfacial projection
and ocular globe position, and allowing for endosseous dental rehabilitation.
ANATOMY
■ The skeletal foundation of the lower leg is composed of the tibia (medial) and
fibula (lateral), parallel long bones connected by an interosseous membrane,

which divides the leg into anterior and posterior compartments (FIG 1).
■ The anterior compartment is bordered laterally by the anterior intermuscular
septum. The anterior tibial vessels and deep peroneal nerve are directly
anterior to the interosseous membrane.
■ The lateral compartment, which includes the peroneus longus and peroneus
brevis muscles, is bordered posteriorly by the posterior intermuscular septum,
which contains the perforator vessels that perfuse the lateral skin of the lower
leg, and thus the skin island of the flap when applicable.
FIG 1 • Cross section of the middle leg showing fascial
compartments and relevant anatomical structures.
■ The deep posterior compartment includes, from medial to lateral: flexor
digitorum longus, tibialis posterior, and flexor hallucis longus muscles; the
fibular vessels run between the latter two. The posterior tibial vessels and

tibial nerve are found lateral to the flexor hallucis longus, posterior to the
tibialis posterior muscle, and anterior to the transverse intermuscular septum.
■ The posterior compartment includes the soleus and gastrocnemius muscles.
■ The fibula is nonweight bearing, but the proximal and distal epiphyses are
crucial to the integrity and stability of the knee and ankle joints, respectively.
■ The common fibular nerve wraps around the neck of the fibula before dividing
into the deep and superficial fibular nerves, limiting proximal dissection and
procurement. Even after epiphyseal preservation, approximately 25 cm of
vascularized bone can be harvested.
■ The fibular artery provides the dominant blood supply to the fibula,
supplemented by periosteal and muscular branches; the vascular pedicle can be
considerable, yielding up to 15 cm. The well-defined vascular supply allows
the division of the free fibula into segments as small as 2 to 3 cm.
■ The two venae comitantes of the fibular artery are responsible for venous
drainage.
■ The lateral sural nerve supplies the sensory innervation of the lateral leg skin;
sensory nerve coaptation is possible, but not routinely performed.
■ Muscles commonly included in a free fibula flap include the flexor hallucis
longus and the tibialis posterior, located in the deep posterior leg compartment.
The soleus, located directly posterior to the posterior and transverse
intermuscular septa, can also be included.
■ The midface contains three vertical and two horizontal skeletal buttresses1
(FIG 2).

FIG 2 • Illustration of the horizontal and vertical skeletal
buttresses of the midface.
■ Vertical: The nasomaxillary, zygomaticomaxillary, and pterygomaxillary
buttresses maintain facial height and resist occlusal load.
■ Horizontal: The inferior orbital rim maintains the position of the ocular
globe, and together with the maxillary alveolus and the malar prominence, it
is responsible for maintaining the facial profile and width, respectively.
■ A classification of skeletal midface defects focuses on the absence of these
essential functional subunits of the maxilla2 (FIG 3):
■ Class I: unilateral dentoalveolar defect
■ Class II: unilateral dentoalveolar and orbital rim defect
■ Class III: bilateral dentoalveolar defect
■ Class IV: bilateral dentoalveolar and orbital rim defect
■ Depending on concomitant skin deficits, and/or pterygoid injury, which affects

the complexity of the posterior fixation of the flap, this classification is
designed to determine flap selection for microsurgical reconstruction.2
■ Important: instead of attempting to recreate the absent curvilinear structures of
the facial skeleton, segments of vascularized bone are strategically placed to
serve as girders that are capable of (and necessary for) preserving function and
maintaining aesthetic facial proportions and contour.3
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A detailed medical history must be performed to identify patients with current
or prior peripheral vascular disease, deep vein thrombosis, vasculitis, or lower
leg trauma, which may increase the risk of an unreliable fibular vascular
pedicle.
■ The popliteal, dorsalis pedal, and posterior tibial pulses are examined.
■ Lower extremity Allen test can be performed to ensure that both the dorsalis
pedis and posterior tibial arteries perfuse the distal lower extremity.
■ Anatomic variations, like peronea magna (hypoplasia or absence of anterior
and posterior tibial arteries), must be identified4 (FIG 4).
■ The range of motion and stability of the knee and ankle joints are assessed.
■ Facial anthropometrics are assessed, including horizontal thirds and vertical
fifths.
■ Dental/facial midlines, dental show at rest and smiling, and maxillomandibular
occlusal relationships are recorded when applicable.
IMAGING
■ Angiography is not routinely performed but can be considered if history is
positive for possible tibial artery damage or injury, and/or if distal pulse
assessment is abnormal or suspicious.
■ Other imaging modalities (CT or MR angiography) are also effective
alternatives.
■ In traumatic defects, three-dimensional maxillofacial CT will allow precise
analysis of the missing bone that will be reconstructed, in addition to soft tissue
analysis.
■ When computerized surgical planning (CSP) is employed, three-dimensional
lower leg- and maxillofacial CTs are performed to aid the design of the flap,
which is based on an existing traumatic defect or the predicted absent
maxillary bone that will result from planned ablative surgery.

Class I| Class II Class III Class IV

FIG 3 • Classification of midface skeletal defects in
ascending order of reconstructive complexity, and
illustrations of possible free fibula flap reconstruction of
each defect. Class I: Unilateral dentoalveolar defect.
Class II: Defect involves inferior orbital rim and
ipsilateral maxilla. Class III: Bilateral dentoalveolar
defect. Class IV: Defect involves bilateral dentoalveolar
loss and at least one orbital rim.

3D modeling? NO YES Abnormal pulse exam or history of trauma/PAD? CT Angiogram for surgical planning NQ YES CTA vs MRA for all patients? Mandatory CTA vs MRA YES NO YES. Normall radiographic anatomy? NO Begin free fibula flap dissection Normall intraoperative anatomy? YES NO Peroneal artery present/normal? YES: Clamp peroneal artery and release tourniquet Foot well perfused? NO Return flap to donor site YES. Proceed with free fibula flap elevation Alternate reconstructive procedure

FIG 4 • Algorithm to rule out aberrant lower extremity
vascular anatomy in a free fibula flap reconstruction
candidate.
NONOPERATIVE MANAGEMENT
■ Prosthetic obturation is among the earliest techniques developed to reconstruct
facial defects.
■ Midfacial prostheses can be considered in patients who are poor candidates for
—or unwilling to pursue—free tissue transfer.
■ Advanced age, medical comorbidities, smokers, contaminated wounds, etc.
■ In pediatric patients, prosthetic obturation can serve as a temporary
reconstructive solution during growth.
■ Permanent free flap reconstruction can be revisited once the patient reaches
skeletal maturity.
SURGICAL MANAGEMENT
■ Reconstruction of composite midface defects may not be possible in a single
stage; surgical plans and patient expectations must be managed with this in
mind.
■ Phase 1 goals: restore skeletal anatomy, eliminate dead space if necessary,
and deliver soft tissue volume in slight excess for future refinement.
■ Consider early involvement of dental colleagues:
■ Close collaboration and detailed planning of osseointegrated implant
placement is essential to optimizing dental rehabilitation and long-term
outcomes.
Preoperative Planning
■ VSP can accurately predict and facilitate fibular osteotomy and flap inset sites
based on 3D reconstructions of CT data (FIG 5).
■ 3D-printed osteotomy guides ensure maximal precision during separation of
the fibular segment from the lower leg, division of the bone flap into multiple
segments, and fixation of the resulting segments to accommodate a desired
flap shape.
■ VSP also identifies the best point of fixation on the midface, in addition to
aiding the design of recipient-site osteotomies that may be required prior to

optimal flap inset and fixation.
■ A 3D-printed model of the patient’s skull and the desired shape of the bone
segment(s) help preoperative contouring of a 2.0-mm titanium miniplate,
minimizing ischemia time. If required, minor adjustments in the shape of the
plate can be made prior to flap inset.
• Alternatively, stereolithographic models of the patient’s facial skeleton and
remaining dentition can be used intraoperatively for this purpose.
■ Preferred recipient pedicles are the superficial temporal and facial vessels.
■ Unilateral defects: whenever possible, ipsilateral vessels are preferred.
■ Bilateral defects: less relevant; will depend on quality of local tissues; may
determine recipient site selection.
■ Class IV defects (bilateral dentoalveolus and inferior orbital rim): multiple
free flaps may be indicated; bilateral recipient vascular pedicles will likely be
necessary.
■ When choosing between ipsilateral and contralateral donor fibula, consider the
following:
■ The fibular vessels are located on the medial surface of the fibula, and the
flap’s vascular pedicle extends superiorly from the proximal end of the
procured bone segment.
■ Thus, the fixation plates will be screwed onto the lateral surface of the fibula,
which will become the anterior surface of the reconstructed midface bone
(flap vasculature will run on posterior surface).
■ Recipient vessel selection may be limited in extensive defects, and vascular
compromise of one leg may force the surgical team to procure the flap from
the opposite side. Nevertheless, fibula flaps can be rotated 180 degrees to
reach ipsilateral or contralateral recipient vessels depending on reconstructive
needs.
■ A fibula flap ipsilateral to the chosen recipient vessels may be oriented more
easily so that, upon inset, the donor vascular pedicle does not cross the
midline to reach the recipient vessels.

FIG 5 • Computerized surgical plan to reconstruct a
midface defect that resulted from the resection of a right
maxillary oncologic deformity in a 58-year-old man. A.
Synthes ProPlan software was used to calculate the
overall length of the fibula segment to be elevated, as
well as the length of each fibula segment to be
osteotomized and reshaped before flap inset. B.
Patient’s preoperative anatomy showing the right

maxillary defect, and the virtually planned postoperative
result with the fibula segments recreating the horizontal
maxillary buttresses.
• This limits interference with anesthesia and decreases the required length of
the flap’s vascular pedicle.
■ For unilateral soft tissue defects, determine/anticipate the extent of absent
skin vs floor of mouth.
• If more external skin is required, the skin paddle from an ipsilateral fibula
flap may lie more favorably upon inset.
• If more floor of mouth tissues are required, a contralateral fibula flap may
be more favorable by extending the skin paddle resection posteriorly.
Positioning
■ The patient is positioned supine, with the knee of the donor leg flexed, the
pelvic girdle rotated internally, and with towels or a sandbag elevating and
stabilizing the heel.
Approach
■ A two-team approach to reconstruction is used whenever possible.
■ One team elevates the flap while the other explores the midfacial defect.
■ Early reports describe a posterior approach,5 but lateral surgical approach has
proven simpler and quicker.
T E C H N I Q U E S
■ Preparation of Midface Defect
■ The mechanism of injury will determine the extent and complexity of defect
preparation.
■ Mass resection: the defect is created by the ablative surgery team.
■ Reconstructive team must precisely assess the resulting skeletal and soft
tissue requirements before finalizing and/or adjusting previous flap design
if necessary.
■ High-energy trauma: early reconstruction is advocated.

■ Aggressive debridement of nonviable tissues is necessary to determine the
eventual defect.
■ Reconstruction before scar formation and contracture (within 2 weeks)
facilitates dissection, precise skeletal alignment, and maintains adequate
volume of the soft tissues.
• Delayed reconstruction is approached as a secondary reconstruction,
requiring defect recreation, scar tissue removal, skeletal realignment, and
soft tissue reexpansion.
■ Necessary corrective osteotomies or skeletal realignments are performed at
this time to streamline bone inset.
■ VSP dental positioning guides are fixated to determine and maintain
occlusion during surgery.
■ VSP osteotomy guides are fixated onto applicable bone sites.
■ Osteotomies are performed using an oscillating saw.
• Guides are removed.
■ Free Fibula Flap Harvest: Lateral Approach
Donor Site Marking
■ Once the donor site has been selected, as described in Preoperative Planning,
the fibula is outlined and marked by palpating the fibular head, the lateral
malleolus, and the anterior and posterior fibular borders on the lateral leg
(TECH FIG 1).
■ The most proximal 5 to 7 cm of the fibula is marked; this segment is usually
not be included in the flap to avoid injury to the common peroneal nerve
during dissection and to prevent postoperative knee instability.
■ The distal-most 5 to 7 cm of the fibula is also measured, marked, and
excluded from the flap to avoid ankle instability.
■ The fibular segment that will be included in the flap is marked as distally as
possible to maximize (proximal) pedicle length.
■ A Doppler pencil probe is used to identify skin perforators within the
posterior intermuscular septum, located in close proximity to the posterior
border of the fibular outline.
■ The skin paddle is designed and marked on the distal two-thirds of the lateral
leg, ensuring that a perforator emitting a prominent signal is located in the
center of the flap area.

■ Flap procurement is performed after partial exsanguination and placement of
a thigh tourniquet, which is inflated to 100 mm Hg higher than the patient’s
systolic blood pressure.
Incision and Skin Paddle Dissection
■ A mid-lateral incision is made posterior to the palpable fibula and skin flap is
elevated above the fascia.
■ The superficial peroneal nerve lies in this layer, and care is taken to avoid
injury.
■ The anterior border of the skin paddle marking is incised; dissection
proceeds in a posterior direction until the posterior intermuscular septum is
identified (TECH FIG 2).
■ The fasciocutaneous perforators that perfuse the flap are located in the
posterior intermuscular septum, which is thin and fragile and must be
dissected cautiously.
TECH FIG 1 • Surgical markings for free fibula flap
elevation. Location of perforators is identified, and skin
paddle marked accordingly. Proximal and distal 7 cm
of the fibula are also marked and excluded from the
flap.
■ Dissecting medially, the peroneus longus and peroneus brevis muscles are
sharply separated from the posterior intermuscular septum until the fibula is
identified.

■ The posterior margin of the skin paddle is incised and elevated anteriorly
above the fascia until reaching the posterior intermuscular septum.
Lateral and Anterior Compartment Dissection
■ Anterior to the perforators, the superficial muscular fascia is incised.
Beginning inferiorly, the peroneal muscles are sharply dissected off the
fibula.
■ To maintain periosteal circulation, a small cuff of peroneus brevis muscle
is preserved on the fibula.
■ Superiorly, the common peroneal nerve is identified and preserved.
■ The peroneal muscles are reflected anteriorly, and the anterior intermuscular
septum is incised, accessing the anterior compartment.
TECH FIG 2 • Path of dissection of a free fibula flap
that requires a skin paddle. The posterior

intermuscular septum is separated from the lateral
compartment until the fibula is identified.
■ The extensor digitorum longus and extensor hallucis longus are elevated
from the fibula until the interosseous membrane is identified.
■ The anterior tibial artery and deep peroneal nerve lie anterior to the
interosseous membrane.
■ Medial retraction of the lateral and anterior compartment musculature
helps visualize and protect the neurovascular pedicle during dissection.
■ The interosseous membrane is incised, resulting in anterior access to the
deep posterior compartment and visualization of the tibialis posterior muscle
(TECH FIG 3).
Posterior Compartment Dissection and Distal Osteotomy
■ If soleus muscle is included in an osteomyocutaneous flap design, the lateral
half of the soleus is separated posteriorly from the lateral head of the
gastrocnemius.
■ When the midline of the soleus is reached, the dissection veers
anterolaterally toward the fibula until the transverse intermuscular septum
is identified.
■ Based on a separate muscular perforator, the lateral half of the soleus
muscle can be elevated as part of a chimeric osteomyocutaneous flap
design.
■ If the soleus muscle is not included in the flap design, proceeding medially,
the soleus muscle is bluntly separated from the posterior intermuscular
septum until reaching the transverse intermuscular septum.
■ In all cases, the transverse intermuscular septum is incised, resulting in
posterior access to the deep posterior compartment and visualization of the
flexor hallucis muscle (see TECH FIG 3).
■ The custom osteotomy guide is fixated onto the lateral surface of the fibula.
■ Depending on individual patient needs and flap design, efforts are made to
position the osteotomy guides favorably in relation to dominant skin
perforators.
■ The distal osteotomy is performed using an oscillating saw.
Deep Posterior Compartment Dissection and Proximal
Osteotomy

■ Anteriorly, the distal posterior tibialis muscle is transected at the chevron-
shaped decussation of its fibers.
■ Dissection proceeds in a proximal direction by exposing the peroneal vessels
on the medial surface of the fibula and the flexor hallucis longus muscle
posteriorly (see TECH FIG 3).
■ The amount of posterior tibialis muscle elevated with the flap can also be
adjusted depending on recipient site soft tissue requirements, but at least a
small cuff is preserved on the fibula to maintain periosteal circulation.
■ Gentle lateral retraction of the fibula can facilitate dissection and ligation
of perforators emerging from the fibula.
■ The posterior tibial vessels and the tibial nerve can be visualized medially
and avoided during dissection.
■ The flexor hallucis longus muscle is carefully separated from the fibula in a
proximal direction, exposing perforator branches.
■ To maintain periosteal circulation, a small cuff of flexor hallucis longus
muscle is preserved on the fibula.
■ A larger lateral portion of the flexor hallucis muscle can also be elevated
with the fibula if necessary.
■ Perforator branches are cautiously dissected, ligated, and traced proximally
to identify the proximal fibular vessels and the common peroneal nerve.
■ The proximal osteotomy is performed, allowing mobility of the flap and
excellent visibility of the proximal fibular pedicle, which is dissected until
visualizing its branching point from the proximal posterior artery.

TECH FIG 3 • The path of dissection during elevation
of a free fibula flap. Red arrow shows dissection of the
lateral and anterior compartments and through the
interosseous membrane. Green arrow demonstrates
posterior compartment dissection in cases where
additional muscle is not necessary. Blue arrow shows
the path of dissection when soleus muscle
procurement is warranted for coverage or soft tissue
bulk.
Completion
■ When applicable, osteotomies to reshape the elevated fibula are performed
once the flap has been dissected in situ (TECH FIG 4).
■ The proximal fibular vascular pedicle is ligated, and the flap can be

transferred to the back table for further customization.
■ The tourniquet is removed and meticulous hemostasis is obtained.
■ The skin flap donor site is skin grafted.
■ Skin incision proximal and distal to skin paddle are closed primarily.
TECH FIG 4 • Elevated, osteotomized, and reshaped
fibula flap with vascular pedicle still attached.
■ Free Fibula Flap Customization, Skeletal Fixation,
and Inset
■ The free fibula flap’s versatility makes it applicable to different defect types
(see FIG 3).
■ Small defects: can be reconstructed using a single linear bone segment
(Class I).
■ Multiple osteotomies: the fibula can be fixated into a polygonal chain of
bone segments that can be shaped to accommodate contoured defects
(Class I, II, III, IV) or increase the vertical height of the flap (Class II, IV).
■ Soft tissue adaptability: multiple skin paddles based on individual