Closure of the osteocutaneous fibula flap donor site with a tonearm (propeller) flap: Anatomic considerations and surgical indications

Background: Skin graft is frequently used for donor site closure after osteocutaneous fibula free flap (OCFFF) harvest when primary closure is not possible. Partial skin graft loss requiring wound care is a common complication. The purposes of this prospective study were to investigate the perforator anatomy for local propeller or tonearm flap closure and compare the outcomes to those of skin graft closure.

Methods: All patients undergoing OCFFF for head and neck reconstruction from February 2022 to October 2023 were considered for the tonearm flap. Intraoperative perforator anatomy was prospectively recorded. Surgical techniques and criteria for tonearm flap reconstruction were described. A minimum follow-up period of 6 months was required. Outcome measures included the rate of flap success and wound complications.

Results: Forty consecutive patients were included. The tonearm flap was not possible in 16 patients (40%) due to unfavorable perforator anatomy and 2 patients underwent primary closure. All successful tonearm flaps were eccentrically designed on a proximal lower leg perforator, located 13.5 ± 1.99 cm from the fibular head. Most proximal perforators were musculocutaneous through the soleus muscle (n = 20, 90.9%), whereas the rest were septocutaneous (n = 2, 9.1%), originating from the peroneal artery. Three patients experienced distal partial flap loss; one required an additional skin graft. Only half of the skin graft cohort (n = 99, 50.8%) achieved complete skin graft take. The average skin graft loss was 34.3%, and wound care was required for an average period of 51.6±52.8 days.

Conclusions: The study findings demonstrate that local tonearm flaps, when anatomically feasible, can be successfully performed with superior outcomes compared to skin graft closures.