Neurovascular Anatomy

The peroneal artery and its vena comitans travel along the inner border of the fibula to supply its distal two-thirds. An endosteal branch enters near the midfibula but the bone is supplied primarily through its periosteal attachments. The skin overlying the posterior crural intermuscular septum (PCIM) is supplied by septocutaneous per- c forators from the peroneal artery that course around the posterior border of the fibula through the PCIM and musculocutaneous perforators from the peroneal artery via the soleus muscle (Fig. 38). The septocutaneous perforators tend to be more numerous in the distal half of the leg. Cuffs of soleus muscle may provide more o soft tissue (although closely adherent to the bone) and will aid in the preservation and inclusion of these perforators with the flap. The peroneal artery and vena

Figure 36 A harvested osteocutaneous fibular free flap temporarily pedicled on the peroneal vessels. Note the close and broad attachment of the skin paddle to the bone.

comitans are relatively large-diameter vessels: the artery is 2-4mm and the venae comitantes are 2-3 mm each.

The length of the vascular pedicle varies depending on the size of the leg, the level at which the vascular pedicle branches from the posterior tibial artery, the -g length of bone required, and the segment along the length of bone used for recon- |

struction. Preoperative vascular studies may be helpful in determining which leg »

has the longer vascular pedicle. The middle two-thirds of the fibula (preserving c

5 cm proximally and 10 cm distally for knee and ankle stability) provides ample bone ^

for most mandibular defects. Excess bone can be discarded proximally by first strip- >3

ping its periosteum and the overlying tissues and cutting away the unneeded bone, which effectively lengthens the vascular pedicle.

Sadove (1993) first described successful incorporation of a sensory nerve §

with the osteocutaneous fibula flap for penile reconstruction (54). The lateral sural

Figure 37 An osseous flap harvested with its proximal vascular pedicle. Note that the vascular "mesentery" is oriented away from the neoalveolar surface. Closed or open osteotomies can be made to shape the bone. Closed osteotomies are demonstrated here.

cutaneous (LSC) nerve is the most consistent and accessible donor sensory nerve in the posterior leg for harvest with the osteocutaneous fibula free flap. Congenital absence of the LSC nerves is rare, occurring in 1.7-22% of legs (45,55). The origin of the common LSC nerve from the peroneal nerve is at or above the head of the fibula (HF). The peroneal nerve is typically identified and traced superiorly to the |

common LSC nerve. The diameter of the nerve is approximately 3 mm at the HF, »

making identification and dissection of the nerve straightforward. However, it is c approximately 1 cm below the skin surface in the subcutaneous tissues, requiring ^

more dissection than might be anticipated in harvesting a sensory nerve. The common LSC is then followed inferiorly into the posterior calf to its division into the medial LSC and lateral LSC (Fig. 39). The level of the division is inconstant, o ranging from 5 cm above to 8 cm below the HF. The medial LSC terminally §

arborizes approximately in the midleg and the lateral LSC nerve terminally arborizes @

Figure 38 Fibular septocutaneous perforators (arrows).

within 7 cm below the HF. The lateral division is approximately 3 cm medial to the PCIM and must be incorporated into the design of the skin paddle.

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