Fibula free flap perforasomes: vascular anatomical study and clinical applications

Purpose: This study assesses the anatomical features of the cutaneous fibular perforators and perforasomes of fibular free flap to determine the clinical implications therein.

Methods: This anatomical study was performed with 16 fresh cadavers after selective arterial injections of inked serum. The numbers of perforators, diameter, location of the perforasome center, perforator course, the distance between perforator origin and tibiofibular division, and the perforasome area were all documented.

Results: Thirty-one lower legs were dissected. Eighty-eight cutaneous perforators were found, averaging 2.8 per leg (1-4). The mean diameter was 1.7 mm and decreased from proximal to distal (p < 0.001). The centers of the perforasomes were aligned on an oblique projection from proximal to distal and anterior to posterior. Seventeen perforators (19%) were musculocutaneous, all in the proximal half of the leg, whereas 71 perforators were septocutaneous (81%), including 18 in the proximal half of the leg. Six of the uppermost perforators originated from the fibular artery less than 10 mm from the tibiofibular division. The mean area perforasome was 37.2 cm² (7.9-106 cm²) and decreased from proximal to distal (p < 0.01).

Conclusion: Distal and proximal fibular flap perforasomes sported different features. Large skin paddles supplied by large and often intramuscular perforators were found in the proximal half of the leg. Distal skin paddles were smaller, more posterior, and featured septocutaneous perforators. These factors should be considered in the skin paddle choice during the fibular free flap harvest.