The Proximal Fibula Bone Flap for Complex Maxillary Reconstruction: Anatomic Evaluation and a Case Report

Total maxillectomy defects that involve both the supra- and infra-structure pose a reconstructive challenge. Accurate reconstruction of the orbital rim and alveolus is needed for orbital floor reconstruction and dental implant placement. The fibula is the workhorse flap for osseous craniofacial reconstruction. The distal fibula is harvested as vascularized bone while the proximal fibula is typically discarded after separating it from the pedicle. We evaluated the vascular anatomy of the proximal fibular segment for potential use as a separate bone flap.

The anatomy of the peroneal vessels was studied in clinical cases and with computed tomographic angiograms. The branches of the proximal peroneal artery and vein were dissected during routine fibula flap harvest in 25 patients. Lower extremity computed tomographic angiograms of 100 limbs were also studied. We reconstructed a hemi-maxillectomy defect resulting from resection of salivary gland adenocarcinoma in a 69-year-old female, with a vascularized bone flap supplied by this proximal peroneal branch. The conventional fibula bone flap based on the peroneal vessels was used for alveolar reconstruction and the proximal fibula based on the proximal peroneal branch was used for inferior orbital rim reconstruction as a flow-through flap anastomosed to the distal end of the peroneal vessels. A polytetrafluoroethylene-titanium implant was used to recreate the orbital floor.

In all fibula flap dissections and radiographic studies, a perforating branch of the peroneal vessels was seen supplying the proximal part of the fibula. The patient's postoperative course was uneventful, and adjuvant radiation was administered. At a follow-up of 1 year 3 months, the patient had excellent globe position, normal vision, and a moderate contour depression of the right cheek.

The proximal fibula bone is consistently supplied by a branch of the peroneal vessels and can thus be harvested as a vascularized perforator bone flap.