Three-Step Approach to the Harvest of the Fibula Osteoseptocutaneous Flap

Introduction: The ability to reliably include a skin paddle with the fibula osteoseptocutaneous (OSC) flap is crucial both from the perspective soft tissue reconstruction and flap monitoring. In this study, we describe a three-step approach to the harvest of the fibula OSC flap that is reliable and versatile. Methods and Materials: Step 1 starts by exploring the posterior crural septum from the anterior incision of the skin island with the aim being to identify the septocutaneous vessels that will supply the skin. Step 2 proceeds from the posterior aspect of the skin island. The septocutaneous vessel is traced to its origin, and the peroneal artery is detached from flexor hallucis longus that covers the posterior aspect of the artery. Finally, step 3 entails detaching all muscles attached to the fibula from anteriorly and can be expediently completed as vessels supplying the skin component have already been secured. Results: This technique was used successfully in 52 flap harvests. Absent septal vessels was noted in 4% of cases. In both cases, musculocutaneous perforators arising from the soleus muscle was used to supply the skin component. In one case, the septocutaneous vessel was noted to arise from the posterior tibial artery. Flap harvest was successful in all cases. Conclusion: The three-step approach allowed us to reliably harvest the fibula OSC flap. We were able to visualize the anatomy clearly with this technique, and this has enabled us to detect anomalous anatomy early on in the dissection. These were successfully managed by using musculocutaneous perforators to the skin island that would normally be cut.