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Page 2 of 6 Choudhary et al. Plast Aesthet Res 2022;9:3 https://dx.doi.org/10.20517/2347-9264.2021.68

INTRODUCTION
The free fibula flap has become one of the most commonly used vascularized bony flaps to reconstruct bony
[1]
defects in the body , particularly the mandible. It has a reliable blood supply and a sizable bone stock. It
enables the surgeon to harvest bone, skin, muscle, and fascia together and manipulate these components to
tailor them for various defects.

The peroneal vessel provides vascularity to both the skeletal and the cutaneous components. The fibula
receives its blood supply through the nutrient artery and periosteum, and at the same time, the skin is
perfused by septocutaneous/musculocutaneous perforators. Rarely, these skin perforators may arise from
posterior or anterior tibial vessels .
[2]
Here we present a peculiar case where lateral leg skin perforators originated from only the posterior tibial
vessels.

CASE REPORT
A 64-year-old male was diagnosed with squamous cell carcinoma at the right lower gingivobuccal sulcus by
our head and neck oncology team. The surgical plan was right segmental mandibulectomy with bilateral
modified neck dissection and reconstruction with free fibula osteo-musculocutaneous flap. The fibula flap
harvest started through the anterior approach. Perforator dissection revealed that its origin was from the
posterior tibial artery rather than peroneal artery.

The skin paddle was harvested on this perforator separately. The perforator was dissected untill its origin
from the posterior tibial artery was reached. The total length of this pedicle was around 8 cm. After
considering the short pedicle length, we decided to anastomose it with the distal end of the fibula. The skin
paddle was designed in eccentric fashion and the short limb was kept towards the distal end of the fibula for
easy anastomosis. In this whole process, the posterior tibial vessels were left intact and limb vascularity was
not compromised anywhere. At the same time, the required fibula along with the flexor hallucis longus
muscle was raised on the vascular pedicle of the peroneal vessels [Figure 1]. Single osteotomy was done in
the parasymphyseal region to contour the fibula in accordance with the bone defect. The bone was fixed
using mini-recon plates and screws.

After bony fixation, the proximal end of the peroneal artery was anastomosed end-to-end to the right
superior thyroid artery using intermittent 9-0 nylon sutures [Figure 2]. Out of the two venae comitantes, the
one with the best outflow was anastomosed end to end to the common facial vein using a 3 mm coupler.

The skin flap vascular pedicle was anastomosed to the osteo-muscular flap in series. The arterial
anastomosis was performed to the distal end of the peroneal artery in an end-to-end manner using
intermittent nylon 9-0 sutures [Figure 3]. The venae comitantes of the skin paddle were anastomosed end-
to-end to the peroneal venae comitantes. Both flaps were well perfused at the end of the procedure.

In follow-up period, both the donor leg and flap recipient sites healed uneventfully [Figures 4-6].

DISCUSSION
[3]
Taylor et al. evaluated microvascular fibula flaps used to reconstruct tibial bone gaps. The work of
Wei et al. established the reliability of the skin paddle of the osteo-septocutaneous fibula flap. Since then,
[4]
the skin has served a critical role as a cutaneous component. It serves a dual purpose, reconstruction of the