Research Article| Volume 53, ISSUE 4, P1430-1437, April 2022

One-stage reconstruction of extensive composite extremity defects with low donor site morbidity: A retrospective case series of combined transfer of a vascularized fibula flap and a perforator flap

Published:February 09, 2022DOI:
      • Extensive composite extremity defects after high-energy trauma represent a significant challenge for plastic surgeons.
      • An ideal technique would allow one-stage reconstruction while causing minimal donor site morbidity.
      • In 14 patients, we avoided amputation using a combination of a vascularized fibula bone flap and a perforator flap in a one-stage surgery with a good functional and aesthetic outcome.



      Extensive composite extremity defects remain a challenge in plastic and reconstructive surgery. To preserve the extremity, we used combined transfer composed of the vascularized fibula flap and a perforator flap from various body parts to reconstruct extensive composite extremity defects.

      Patients and methods

      From January 2004 to December 2018, 14 male patients aged 9 to 55 years with extensive composite extremity defects (large soft-tissue and long bone defect) underwent reconstructive surgery in our institution. The combined transfer surgery consisted of the vascularized fibula bone flap and a perforator flap, such as anterolateral thigh flap, deep inferior epigastric perforator flap, or thoracodorsal artery perforator flap.


      All fourteen patients were treated successfully using the combined transfer method. The dimensions of the different perforator flaps ranged from 13 × 6 cm2 to 26 × 11 cm2, and the size of the skin paddle of the fibular osteocutaneous flap ranged from 9 × 3 cm2 to 21 × 7 cm2. The median length of the fibular graft was 15 cm. No serious donor site complications were observed. Only one patient developed venous congestion and was salvaged. Another patient had hematoma at the recipient site and underwent debridement. Though all patients achieved bone union (median time of 8 months), two developed a stress fracture of the transferred free fibula.


      We were able to minimize donor site morbidity and avoid amputation in these patients using the combined transfer technique Our results show that the combined transfer of perforator flap and vascularized fibula flap with or without a skin paddle is a feasible reconstruction option for the treatment of the extensive composite extremity defects.


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