Innovative Approaches for Utilizing the Fibula Flap Skin Paddle in the Presence of Alternate Vessel Anatomy—A Report of Three Clinical Cases

The fibula free flap is a versatile option for reconstructing complex defects, particularly in the head and neck region. However, variations in the vascular anatomy of the skin paddle can pose challenges during flap harvest and inset. We identified three clinical cases of patients who were found to have alternative or aberrant vessel anatomy to the fibula skin paddle. Operative notes and photo documentation were used to determine variations in vessel anatomy to the fibula skin paddle. A total of three cases were identified in which alternative or aberrant vessel anatomy was noted to the fibula skin paddle. Variations identified included skin paddle perfusion via a perforating branch of the posterior tibial artery, a perforating branch of the tibioperoneal trunk, and absence of distal perfusion requiring use of a proximal peroneal artery perforator. There were no cases of partial or total flap loss or incidences of reoperation. These findings illustrate that awareness of potential vascular variations and management strategies, such as identifying alternative vascular sources and utilizing flow-through flaps or freestyle perforator flaps, can help to successfully harvest and inset the fibula skin paddle in the presence of alternate vessel anatomy. An alternate donor site may be necessary when no suitable perforators are identified.