Fibula free flap with type IIIB popliteal artery branching: a case report and recommendations

Abstract

Planning for fibula free flap (FFF) reconstruction generally involves preoperative vascular imaging by computed tomographic angiography, magnetic resonance angiography or digital subtraction angiography to identify congenital variants or acquired pathology that contraindicate flap harvest. Two cases of successful FFF without ischaemic donor site morbidity in legs with type IIIB popliteal artery branching and no cases of unsuccessful harvest exist in the literature, suggesting the safety of harvesting a fibula free flap in these cases. We present a case where attempted FFF harvest in a leg with known type IIIB popliteal artery branching was aborted due to intraoperative evidence of inadequate peripheral perfusion measured by great toe pulse oximetry. There are no recommendations for additional testing to determine safety of FFF harvest in legs with type IIIB anatomy, with most authors considering this a contraindication to raising a FFF. We recommend preoperative functional testing by balloon angiography to assess the adequacy of collateral circulation where harvest of FFF is considered in legs with type IIIB popliteal branching. Level of evidence: Level V, therapeutic study.