Avoiding secondary skin graft donor site morbidity in the fibula free flap harvest

To compare donor site morbidity in patients who have undergone fibula free flap reconstruction in which the skin graft was taken from the expected cutaneous paddle of the fibula with the known complications of the popular technique of obtaining a split-thickness skin graft (STSG) from a secondary donor site.

Cohort study.

The tertiary care centers at Loma Linda University Medical Center and University of California, Los Angeles, Medical Center.

From September 1, 2006, to March 30, 2007, 30 patients underwent fibula free flap harvest by 2 surgeons at separate tertiary care centers. Twenty-one of those procedures took place at the University of California, Los Angeles, and 9 at Loma Linda University. Patients included 15 men (50%) and 15 women (50%), with a mean age of 58 (range, 19-88) years. All 30 patients underwent fibula free flap harvest with a split-thickness skin graft (graft thickness, 0.04 cm), obtained from osteocutaneous paddle using a 5.1-cm-wide dermatome, as well as oral cavity and oropharyngeal reconstruction with the de-epithelialized skin paddle.

Measures of donor site morbidity, including graft failure and wound breakdown, and measures of recipient site morbidity, including flap failure, hardware complications, intraoral complications, and the need for additional surgery.

Of the 30 patients who underwent this procedure, 4 had partial skin graft failures, for a complete skin graft survival of 87%. There were no complete skin graft losses. Regarding the fibula osteocutaneous free flap, there were no complete flap losses, 1 skin paddle necrosis that required debridement, 2 postoperative orocutaneous fistulas, 1 case of infected/extruded hardware, and 1 adhesion formation that required additional surgery for lysis of adhesion and placement of the split-thickness skin graft.

The outlined novel technique has similar rates of free flap survival and skin graft take compared with previously described methods. Harvesting the skin graft over the expected osteocutaneous paddle results in decreased lower extremity morbidity by providing equivalent graft tissue for donor site closure and eliminating the morbidity of a secondary donor site. As long as there will not be 2 large opposing grafted surfaces, this technique should be considered when harvesting fibula free flaps for reconstruction of oromandibular resection defects, especially in cancers of the alveolar ridge and floor of the mouth.