这是一个很好用的腓骨骨（肌）皮瓣设计技巧。
A hand-model method for designing, orienting and insetting the osteoseptocutaneous fibula flap in mandibular reconstruction.
Source: AL Deek NF, Tsao CK, Wei FC. The Surgeon’s Fist with the Thumb Up to Guide the Design and Inset of the Osteoseptocutaneous Fibula Flap in Mandibular Reconstruction. Plast Reconstr Surg. 2017;140(6):1259–1262.
Section: Ideas and Innovations · 4 pages, 4 figures, 4 references
DOI: 10.1097/PRS.0000000000003854
Affiliation: Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taipei, Taiwan
Disclosure: The authors have no financial interest to declare.
1. Summary
Problem addressed
The osteoseptocutaneous fibula flap is the workhorse flap for oromandibular reconstruction, but inset remains an experience-demanding endeavor. Mistakes during inset may lead to compression, tethering, overstretch, or kink of the blood supply to the skin paddle.
This is largely due to the complex interrelationship among four flap components:
- Peroneal vessels
- Fibula bone
- Posterior crural septum (carrying septal skin vessels)
- Skin paddle
Failure to restore their optimal arrangement during reconstruction of an oromandibular defect is the underlying cause of inset complications.
The laterality controversy
- Some authors attribute inset difficulty to the laterality concept — i.e., selection of the right vs. left fibula depending on the location of the mandibular defect (Hwang et al.).
- The senior author (F.C.W.) instead uses the left-side fibula, when available, regardless of defect location (Wei et al.).
- This article reconciles the two views: laterality exists, but it can be tackled if the following are thought through before inset starts:
- the peroneal vessels
- the lateral bone surface
- the posterior crural septum (septal vessels to the skin paddle)
- the width of the skin paddle
Planning logic
The lateral bony surface is the side dominantly used for fixation. Given that, the pedicle (peroneal vessels) can be brought to the recipient vessels in the neck in two ways:
| Arrangement | Proximal bone end | Recipient vessels |
|---|---|---|
| A | Posterolateral in the oromandibular defect | Ipsilateral neck vessels — easier reach |
| B | Fibula rotated 180° around its center → proximal end anteromedial | Contralateral vessels; or ipsilateral vessels to a lesser degree, after confirming an appropriate curve of the pedicle |
Each arrangement changes the orientation and reach of the skin paddle into either the oral cavity or the external facial/neck skin.
Planning is especially important when:
- the skin paddle is designed narrow to achieve primary closure at the donor site,
- the defect is a composite segmental defect,
- it is a secondary oromandibular reconstruction where recipient vessels are scarce.
Proposed solution
Use the surgeon’s own fist with the thumb up as a physical model of the fibula flap, to understand the interrelationship among the three components and to plan in advance — without confusion — the inset, the skin paddle design, and recipient vessel selection.
Reported experience
- Used for 2 years in 50 clinical cases.
- No difficulties experienced and the plan was never found to be wrong.
- Easy to follow; requires no sophisticated planning or preoperative navigation (unlike computer-based mandibular reconstruction).
- Can be done at any time with zero cost.
- Strongly recommended for young surgeons.
2. The Surgeon’s Fist Method — Details
2.1 The hand model
Use the left hand to model the left fibula. For a planned right fibula, use the right hand instead.
Form a fist with the thumb up.
| Hand landmark | Represents |
|---|---|
| Thumb (pointing up) | The peroneal vessels and the proximal end of the bone |
| Knuckle line (MCP joints) | The location of the posterior crural intermuscular septum |
| Dorsal surface of the proximal phalanges | The lateral surface of the fibula bone — used for fixation to the inner side of the reconstruction plate / miniplates |
| Skin paddle (envisaged) | Centered along the knuckle line, extending over both the dorsum of the hand and the dorsum of the proximal phalanges |
Figures in the article
- Fig. 1 — The left fist with thumb up as a model for the fibula osteoseptocutaneous flap.
- Fig. 2 — The left fist with thumb up, with orientation to properly mimic the left fibula.
- Fig. 3 — Flap and hand together, external defect: left fibula → left mandibular defect. Thumb points to the posterolateral mandibular defect and the pedicle; skin fits the external skin/neck defect smoothly. (Annotated: PIPj = proximal interphalangeal joint, MPj = metacarpophalangeal joint.)
- Fig. 4 — Flap and hand together, intraoral defect: left fibula → left mandibular defect. Thumb points to the anteromedial defect; the pedicle also reaches the contralateral vessels, or can be curved to ipsilateral vessels; skin fits the intraoral defect smoothly.
2.2 Step-by-step
-
Start with fixation.
Begin planning using the dorsal surface of the proximal phalanges — the lateral bony surface — for fixation to the plate. -
Rotate the hand 180° around its center.
This brings the thumb (peroneal vessels + proximal bony end) either anteromedially or posterolaterally in the oromandibular defect. -
Note how the skin paddle’s reach changes with each rotation, and how this changes recipient vessel selection.
-
If recipient vessel selection is not a concern:
Select the position that allows the fibula skin paddle to smoothly reach the defect — whether oral lining or facial skin — without tethering. -
If a particular recipient vessel must be used:
- Follow the same steps, but orient the hand so the thumb points toward the side of the chosen recipient vessel.
- Assess how the skin paddle fits the defect.
- Overcome any potential stretch or limitation by increasing the width of the skin paddle in the direction that matters.
- In other words, an 8-cm skin paddle need not be centered along the posterior border of the bone — it can be made 3:5, 5:3, or wider.
-
Composite mandibular defects (skin + oral lining), fibula as the only flap:
- Follow the same considerations and steps.
- Choose the orientation that allows the skin to address the larger component of the defect (facial skin/neck or oral cavity).
- Address the smaller component by increasing the skin paddle width in the suitable direction.
2.3 The core idea in one line
Use the fist to fix the bone-to-plate relationship and the thumb (pedicle) direction first, then exploit the 180° rotation and asymmetric paddle width to make the skin reach the defect without tethering — regardless of fibula laterality.
2.4 Take-home points
- Converts an experience-dependent 3-D inset problem into a tangible, reproducible rehearsal using the surgeon’s own hand.
- Works for either laterality: left fist for left fibula, right fist for right fibula.
- Separates the two decisions: satisfy the pedicle/recipient-vessel constraint (thumb direction) first, then optimize skin coverage (180° rotation + asymmetric paddle design).
- Zero cost, no navigation, available any time — recommended especially for less experienced surgeons.
3. References (as cited)
- Okay D, Al Shetawi AH, Moubayed SP, Mourad M, Buchbinder D, Urken ML. Worldwide 10-year systematic review of treatment trends in fibula free flap for mandibular reconstruction. J Oral Maxillofac Surg. 2016;74:2526–2531.
- Deek NF, Wei FC. Computer-assisted surgery for segmental mandibular reconstruction with the osteoseptocutaneous fibula flap: Can we instigate ideological and technological reforms? Plast Reconstr Surg. 2016;137:963–970.
- Hwang L, Natividad EM, Ellis M. Fibula flap harvest: How leg selection impacts inset for mandible defects. Microsurgery. 2017;37:459–460.
- Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg. 1994;93:294–304; discussion 305–306.
Correspondence: Fu-Chan Wei, M.D., Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, 199 Tun-Hwa North Road, Taipei 10591, Taiwan. fuchanwei@gmail.com