The fibula osteocutaneous flap in head and neck reconstruction: a critical evaluation of donor site morbidity.

OBJECTIVES: To (1) compare the complications and functional outcome of primary closure vs split-thickness skin grafting of the fibula osteocutaneous flap donor site, (2) identify patient-mix or treatment factors related to donor site complications, and (3) address early detection and management of donor site complications.
DESIGN: Retrospective review and questionnaire study.
SETTING: Two university tertiary referral centers. PATIENTS: Fifty-three patients (31 men and 22 women, ages 20 to 80 years) who underwent fibula osteocutaneous free tissue transfer between February 1992 and January 1997. MAIN OUTCOME MEASURES: Minor complications; major complications; and postoperative function, including sensory and motor deficits, pain, swelling, temperature intolerance, and activities of daily living.
RESULTS: Four patients developed major wound complications (group 1), 11 patients developed minor wound complications (group 2), and 38 patients had no wound complications (group 3). The donor site was closed primarily in 26 patients and with a split-thickness skin graft in the remaining 27 patients. Major wound complications developed in 3 patients (12%) who underwent primary closure and 1 patient (4%) who underwent split-thickness skin grafting. Minor wound complications developed in 7 (27%) of the patients who underwent primary closure and 4 patients (15%) who underwent split-thickness skin grafting. Three patients who had major complications had residual sensory or motor deficits that resulted in impaired gait or alteration in their daily activities. Comparing all patients with complications (groups 1 and 2) to patients with no complications (group 3) demonstrated an increased incidence of donor site complications in heavy smokers (P<.05) and a strong trend toward higher donor site complications in patients who underwent primary closure (P =.10). Although trends were identified, no significant differences were found in age, comorbid illnesses, alcohol use, preoperative laboratory values, operating time, tourniquet time, or skin paddle width.
CONCLUSIONS: A variety of patient-mix and operative factors are likely related to the development of donor site wound complications. Width of the skin paddle alone is not a reliable criterion for determining the need to skin graft the donor site. Primary closure tended to result in a higher rate of both major and minor wound complications compared with split-thickness skin grafting. Primary closure of fibula donor site defects should be undertaken if this can be accomplished with no tension along the suture line. If tension at the suture line is present, a skin graft should be strongly considered to minimize the possibility of a wound complication. Arch Otolaryngol Head Neck Surg. 2000;126:1467-1472