The value of postoperative anticoagulants to improve flap survival in the free radial forearm flap: a systematic review and retrospective multicentre analysis.

BACKGROUND: Free radial forearm flap (FRFF) reconstruction is a valuable technique in head and neck surgery, which allows closure of large defects while striving to maintain functionality. Anticoagulative drugs are often administered to improve flap survival, although evidence regarding effectiveness is lacking. OBJECTIVE OF REVIEW: To investigate the effectiveness of postoperative anticoagulants to improve survival of the FRFF in head and neck reconstruction. TYPE OF REVIEW: Systematic review and multicentre, individual patient data meta-analysis. SEARCH STRATEGY: MEDLINE, EMBASE, Web of Science and CINAHL were searched for synonyms of 'anticoagulants' and 'free flap reconstruction'. EVALUATION METHOD: Studies were critically appraised for directness of evidence and risk of bias. Authors of the highest quality publications were invited to submit their original data for meta-analysis. RESULTS: Five studies were of adequate quality, and data from four studies (80%) were available for meta-analysis, describing 759 FRFF procedures. Anticoagulants used were as follows: aspirin (12%), low molecular weight dextran (18.3%), unfractioned heparin (28.1%), low molecular weight heparin (49%) and prostaglandin-E1 (2.1%). Thirty-one per cent did not receive anticoagulants. Flap failure occurred in 40 of 759 patients (5.3%) On univariate analysis, use of unfractioned heparin was associated with a higher rate of flap failure. However, these regimens were often administered to patients who had revision surgery of the anastomosis. In multivariate logistic regression analysis, anticoagulant use was not associated with improved flap survival or flap-related complications. CONCLUSIONS: The studied anticoagulative drugs did not improve FRFF survival or lower the rate of flap-related complications. In addition, some anticoagulants may cause systemic complications.

Breast cancer local recurrence after breast reconstruction.

The primary aim of surgery in breast cancer is to achieve local control of disease. Secondly, improving quality of life and patient satisfaction is of utmost importance. While the positive effect of postmastectomy reconstruction on the psychological well-being of women with breast cancer has been demonstrated, evidence-based data on its oncological safety remain sparse. There is concern that the presence of autologous tissue or an implant may mask locoregional recurrence. Furthermore, there is little agreement on the appropriateness of routine radiological surveillance of these patients as well as on the surgical treatment of locoregional recurrence. We attempt to review the impact of breast reconstruction on the incidence and detection of locoregional recurrence and discuss treatment options.

Simplifying microvascular head and neck reconstruction: a rational approach to donor site selection.

The purpose of this study was to review the authors' 13-year experience with free tissue transfer for head and neck oncology patients. This study was a retrospective review of 728 free flaps performed in 698 patients. Recipient sites were subdivided by region into the mandible (N = 253), mid face/orbit (N = 190), hypopharynx (N = 134), oral cavity (N = 104), skull base (N = 36), and scalp (N = 11). The overall free flap success rate was 98.6%. Seventy-nine flaps (10.9%) were reexplored for vascular compromise. Ten flaps (1.4%) were lost in their entirety. The overall complication rate was 17.5%. Four donor sites (forearm, fibula, rectus, and jejunum) were used for 92% of the patients. The results of the study confirm the efficacy of free tissue transfer in the reconstruction of oncological head and neck defects. In this series the free forearm, fibula, rectus, and jejunum flaps have become the workhorse donor sites for the vast majority of defects.

Management of radiated reoperative wounds of the cervicothoracic spine: the role of the trapezius turnover flap.

Reoperation for malignant disease of the cervicothoracic spine can lead to compromised wound healing secondary to poor tissue quality from previous operations, heavily irradiated beds, and concomitant steroid therapy. Other complicating factors include exposed dura and spinal implants. Introducing well-vascularized soft tissue to obliterate dead space is critical to reliable wound healing. The purpose of this study was to determine the efficacy of the trapezius turnover flap in the management of these complex wounds. This study is a retrospective review of all patients undergoing trapezius muscle turnover flaps for closure of complex cervicothoracic wounds after spinal operations for metastatic or primary tumors. Six patients (3 male/3 female) were operated over an 18-month period (mean patient age, 43 years). Primary pathologies included radiation-induced peripheral nerve sheath tumor (N = 2), chondrosarcoma (N = 1), nonsmall-cell lung cancer (N = 1), paraganglioma (N = 1), and spindle cell sarcoma (N = 1). Trapezius muscle turnover flaps were unilateral and based on the transverse cervical artery in every patient. Indication for flap closure included inability to perform primary layered closure (N = 3), open wound with infection (N = 2), and exposed hardware (N = 1). All patients had previous operations of the cervicothoracic spine (mean, 5.8 months; range 2-9 months) for malignant disease and prior radiation therapy. Exposed dura was present in all patients, and 2 patients had dural repairs with bovine pericardial patches. Spinal stabilization hardware was present in 4 patients. All patients underwent perioperative treatment with systemic corticosteroids. All flaps survived, and primary wound healing was achieved in each patient. The only wound complication was a malignant pleural effusion communicating with the back wound, which was controlled with a closed suction drain. All wounds remained healed during the follow-up period. Four patients died from progression of disease within 10 months of surgery. The trapezius turnover flap has been used successfully when local tissue conditions prevent primary closure, or in the setting of open, infected wounds with exposed dura and hardware. The ease of flap elevation and minimal donor site morbidity make it a useful, single-stage reconstructive option in these difficult wounds.

Reconstruction of the hypopharynx and cervical esophagus.

Hypopharynx and cervical esophageal defects are challenging problems for the reconstructive surgeon. Prior surgery and radiation therapy contribute to the difficulty in managing these patients. The surgeon must possess a reconstructive algorithm that varies depending on the defect, available donor sites, and his or her experience. The free jejunal flap is the flap used for most of these defects. The radial forearm flap is reserved for partial defects measuring less than 50% of the circumference of the pharynx. The gastric pull-up is used when an intrathoracic esophagectomy is necessary. The pectoralis flap is reserved for situations when external coverage is necessary in addition to hypopharyngeal reconstruction or when a free-tissue transfer is not appropriate. Reconstruction can offer most patients successful swallowing while minimizing complications.

Correction of scapular winging by supraclavicular neurolysis of the long thoracic nerve.

Injury to the long thoracic nerve results in winging of the scapula. When there is no known direct site of injury to this nerve, the traditional treatment consists of bracing the shoulder and, if recovery of function does not occur, then carrying out a muscle transfer to reconstitute the forces required to bring the scapula into appropriate position with respect to the thorax. The present report describes four patients in whom a site of compression of the long thoracic nerve within the scalene muscles proved to be the site of compression. A supraclavicular neurolysis of the long thoracic nerve resulted in correction of the winged scapula in all four of these patients.

Evaluation of a combined calcium sodium alginate and bio-occlusive membrane dressing in the management of split-thickness skin graft donor sites.

The optimal treatment of the split-thickness skin graft (STSG) donor site remains an unresolved issue. This study was conducted to evaluate the combined use of calcium sodium alginate and a bio-occlusive membrane dressing in the management of STSG donor sites. This study was a prospective evaluation of all patients requiring an STSG over a 6-month period ending October 1998. There were 57 patients with a mean age of 61 years. All skin grafts were harvested with an electric dermatome from the anterior thigh and were 0.012 to 0.016 inches thick. Donor sites were dressed with calcium sodium alginate followed by a bio-occlusive dressing. Postoperatively, the skin graft donor site dressing was removed and replaced. The mean skin graft area was 114 cm2. The first dressing change occurred, on average, 3 days postoperatively. All dressings were taken down and the wounds reevaluated 7 days postoperatively. Fifty-two patients (91%) had achieved complete reepithelialization by this time. Five patients (9%) required an additional dressing. All wounds were healed completely by postoperative day 10. Donor site discomfort was minimal and limited to the time of dressing change. There were no wound-related complications. The average cost of dressing supplies was $48.00 per patient and $23.00 per dressing. This method of managing STSG donor sites allowed for unimpeded reepithelialization without wound complication. The bio-occlusive dressing eliminated the pain typically associated with fine mesh gauze dressings. The absorptive property of the calcium sodium alginate eliminated the problem of seroma formation and leakage seen routinely with the use of a bio-occlusive dressing alone. These results confirm that this technique is both efficacious and cost-effective.

Soft-Tissue reconstruction of the face using the folded/multiple skin island radial forearm free flap.

Resection of malignant soft-tissue tumors of the face often results in defects of skin, lining, and contour. When local tissues are unavailable, the folded/multiple skin island forearm free flap has been used to correct complex lining, skin, and contour defects concomitantly. This study is a retrospective review of all patients reconstructed with folded/multiple skin island forearm flaps from 1992 to 2000. Facial defects included facial skin, mucosal lining, and intervening soft tissue. Reconstruction was immediate and was not combined with another local flap. There were 17 patients (mean age, 61 years). Five patients had cutaneous malignancies and 12 patients had either mucosal or salivary gland malignancy. Defects were of the cheek and nose either alone or in combination. Defects ranged from 9 to 54 cm2. Nine patients had defects of either the skin or the mucosa with an associated soft-tissue component. These were reconstructed with a folded forearm flap with one skin island. Eight patients had full-thickness defects and were reconstructed with a folded flap with two skin islands. Flap survival was 100%. One case required reexploration for hematoma. Aesthetic results were good to excellent in 76% of patients. Delayed wound healing at the donor site occurred in 2 patients (11%). The folded/multiple skin island forearm flap is a useful tool for single-stage reconstruction of complex facial defects requiring replacement of skin, lining, and intervening soft tissue. Good to excellent aesthetic results can be expected in most patients.

Recurrent Merkel cell carcinoma of the upper extremity.

We report a case of recurrent Merkel cell carcinoma (MCC) of the upper extremity, treated aggressively with wide local excision, regional lymphadenectomy, and immediate reconstruction. Five years after surgery, there is no clinical or diagnostic evidence of locoregional recurrence or distant disease. The patient's upper extremity and hand remain fully functional, without evidence of median or ulnar nerve dysfunction. No donor site morbidity has been noted.

Managing the oncology wound: reconstructive issues in breast cancer.

Oncology wounds are related to both the patient's cancer and the treatment of the cancer. Patients who have oncology wounds suffer from significantly impaired wound healing. Treating these patients and their wounds successfully requires overcoming their healing impairment. Reconstructive surgeons are increasingly playing a role in oncologic wound management, particularly among breast cancer patients. Breast reconstruction is perhaps the best contemporary model of conquering healing impairment in cancer to successfully restore the patient.

Challenges in midface reconstruction.

Defects of the midface and maxilla are often the most challenging problems faced by the reconstructive surgeon. Resections that involve critical structures of the face such as the nose, eyelids, and lips in conjunction with the maxilla can be particularly difficult to reconstruct. The algorithm for reconstruction of these defects is usually based on the extent of maxilla that is resected. A classification system for maxillectomy defects is the most useful way to approach these reconstructions. A vast majority of extensive defects involving the maxilla and midface require free flap reconstructions. The type of flap selected is based on the extent of skin, soft tissue, and bone that is resected. Smaller volume defects with large skin surface requirements are best reconstructed with the radial forearm fasciocutaneous or osteocutaneous flaps. Larger soft-tissue volume and skin surface can be provided by the rectus abdominus myocutaneous flap. Critical structures such as lips, eyelids, and nose should be reconstructed separately, using local flaps if at all possible. The free tissue transfer should ideally not be incorporated into these structures. Most patients with even the largest resections can be restored to fairly good function by following this algorithm. Semin. Surg. Oncol. 19:218-225, 2000.

Mandible reconstruction with microvascular surgery.

Microvascular surgery has become the preferred method for mandible reconstruction. Whenever possible, immediate reconstruction at the time of segmental mandible resection will provide the best aesthetic and functional result. Four donor sites (fibula, iliac crest, radial forearm, and scapula) have become the primary sources of vascularized bone and soft tissue for the reconstruction. The fibula has multiple advantages, including bone length and thickness, donor site location permitting flap harvest simultaneously with tumor resection, and minimal donor site morbidity. The fibula donor site should be the first choice for most defects, particularly those with anterior or large bony defects requiring multiple osteotomies. Use of an alternative donor site is best reserved for cases with large soft tissue and minimal bone requirements. Dental rehabilitation through the use of prostheses and osseointegrated dental implants is an important part of the reconstructive process to optimize aesthetics and function. An algorithm for mandible reconstruction with microvascular osseous flaps is presented. Semin. Surg. Oncol. 19:226-234, 2000.

Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases.

Conventional free flap monitoring techniques (clinical observation, hand-held Doppler ultrasonography, surface temperature probes, and pinprick testing) are proven methods for monitoring free flaps with an external component. Buried free flaps lack an external component; thus, conventional monitoring is limited to hand-held Doppler ultrasonography. Free flap success is enhanced by the rapid identification and salvage of failing flaps. The purpose of this study was to compare the salvage rate and final outcomes of buried versus nonburied flaps monitored by conventional techniques. This study is a retrospective review of 750 free flaps performed between 1986 and 1997 for reconstruction of oncologic surgical defects. There were 673 nonburied flaps and 77 buried flaps. All flaps were monitored by using conventional techniques. Both buried and nonburied flaps were used for head and neck and extremity reconstruction. Only nonburied flaps were used for trunk and breast reconstruction. Buried flap donor sites included jejunum (n = 50), fibula (n = 16), forearm (n = 8), rectus abdominis (n = 2), and temporalis fascia (n = 1). Overall flap loss for 750 free flaps was 2.3 percent. Of the 77 buried flaps, 5 flaps were lost, yielding a loss rate of 6.5 percent. The loss rate for nonburied flaps (1.8 percent) was significantly lower than for buried flaps (p = 0.02, Fisher's exact test). Fifty-seven (8.5 percent) of the nonburied flaps were reexplored for either change in monitoring status or a wound complication. Reexploration occurred between 2 and 400 hours postoperatively (mean, 95 hours). All 44 of the salvaged flaps were nonburied; these were usually reexplored early (<48 hours) for a change in the monitoring status. Flap compromise in buried flaps usually presented late (>7 days) as a wound complication (infection, fistula). None of five buried flaps were salvageable at the time of reexploration. The overall salvage rate of nonburied flaps (77 percent) was significantly higher than that of buried flaps (0 percent, p<0.001, chi-square test). Conventional monitoring of nonburied free flaps has been highly effective in this series. These techniques have contributed to rapid identification of failing flaps and subsequent salvage in most cases. As such, conventional monitoring has led to an overall free flap success rate commensurate with current standards. In contrast, conventional monitoring of buried free flaps has not been reliable. Failing buried flaps were identified late and found to be unsalvageable at reexploration. Thus, the overall free flap success rate was significantly lower for buried free flaps. To enhance earlier identification of flap compromise in buried free flaps, alternative monitoring techniques such as implantable Doppler probes or exteriorization of flap segments are recommended.

The premature removal of tissue expanders in breast reconstruction.

The role of tissue expanders in breast reconstruction is well established. Little information exists, however, regarding the incidence and etiology of premature removal of the tissue expander before planned exchange to a permanent breast implant. The purpose of this study was to review our 10-year experience with tissue expander breast reconstruction and identify factors relating to the premature removal of the tissue expander. This study is a retrospective review of 770 consecutive patients who underwent breast reconstruction with tissue expanders over the past 10 years. Breast reconstruction was immediate in 90 percent of patients. Patients were expanded weekly, and adjuvant chemotherapy was begun during the expansion process when required. Factors potentially affecting premature expander removal (chemotherapy, diabetes, obesity, radiation therapy, and smoking) were evaluated. Fourteen patients (1.8 percent) with a mean age of 47 years (range, 38 to 62 years) required premature removal of their tissue expander. Expanders were removed a mean of 3.2 months (0.1 to 8 months) after insertion. Causes for premature removal of the tissue expander included infection (7 patients), exposure (2), skin necrosis (2), patient dissatisfaction (2), and persistent breast cancer (1). Positive wound cultures were obtained in four of the seven infected patients (57 percent), requiring expander removal for infection. Tissue expanders were removed in 11 patients for complications directly related to the expander. Among these, six (55 percent) were receiving adjuvant chemotherapy, and one was a smoker. Diabetes, obesity, other concomitant medical illnesses, and prior mantle irradiation were not associated with expander removal. Premature removal of the tissue expander was required in only 1.8 percent of the patients in this series. Infection was the most common complication necessitating an unplanned surgical procedure to remove the expander. This study demonstrates that the use of tissue expanders in breast reconstruction is reliable, with the vast majority of patients completing the expansion process.

Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients.

Osseous free flaps have become the preferred method for reconstructing segmental mandibular defects. Of 457 head and neck free flaps, 150 osseous mandible reconstructions were performed over a 10-year period. This experience was retrospectively reviewed to establish an approach to osseous free flap mandible reconstruction. There were 94 male and 56 female patients (mean age, 50 years; range 3 to 79 years); 43 percent had hemimandibular defects, and the rest had central, lateral, or a combination defect. Donor sites included the fibula (90 percent), radius (4 percent), scapula (4 percent), and ilium (2 percent). Rigid fixation (up to five osteotomy sites) was used in 98 percent of patients. Aesthetic and functional results were evaluated a minimum of 6 months postoperatively. The free flap success rate was 100 percent, and bony union was achieved in 97 percent of the osteotomy sites. Osseointegrated dental implants were placed in 20 patients. A return to an unrestricted diet was achieved in 45 percent of patients; 45 percent returned to a soft diet, and 5 percent were on a liquid diet. Five percent of patients required enteral feeding to maintain weight. Speech was assessed as normal (36 percent), near normal (27 percent), intelligible (28 percent), or unintelligible (9 percent). Aesthetic outcome was judged as excellent (32 percent), good (27 percent), fair (27 percent), or poor (14 percent). This study demonstrates a very high success rate, with good-to-excellent functional and aesthetic results using osseous free flaps for primary mandible reconstruction. The fibula donor site should be the first choice for most cases, particularly those with anterior or large bony defects requiring multiple osteotomies. Use of alternative donor sites (i.e., radius and scapula) is best reserved for cases with large soft-tissue and minimal bone requirements. The ilium is recommended only when other options are unavailable. Thoughtful flap selection and design should supplant the need for multiple, simultaneous free flaps and vein grafting in most cases.

Evaluation of bone height in osseous free flap mandible reconstruction: an indirect measure of bone mass.

Osseous free flaps have become the preferred method of mandibular reconstruction after oncologic surgical ablation. To elucidate the long-term effects of free flap mandibular reconstruction on bone mass, maintenance or reduction in bone height over time was used as an indirect measure of preservation or loss in bone mass. Factors potentially influencing bone mass preservation were evaluated; these included site of reconstruction (central, body, ramus), patient age, length of follow-up, adjuvant radiotherapy, and the delayed placement of osseointegrated dental implants. A retrospective analysis of patients undergoing osseous free flap mandible reconstruction for oncologic surgical defects between 1987 and 1995 was performed. Postoperative Panorex examinations were used to evaluate bone height and bony union after osteotomy. Fixation hardware was used as a reference to eliminate magnification as a possible source of error in measurement. There were 48 patients who qualified for this study by having at least 24 months of follow-up. There were 27 male and 21 female patients, with a mean age of 45 years (range, 5 to 75 years). Mandibular defects were anterior (24) and lateral (24). Osseous donor sites included the fibula (35), radius (6), scapula (4), and ilium (3). There were between zero and four segmental osteotomies per patient (excluding the ends of the graft). Nineteen percent of all patients had delayed placement of osseointegrated dental implants. Initial Panorex examinations were taken between 1 and 9 months postoperatively (mean, 2 months). Follow-up Panorex examinations were taken 24 to 104 months postoperatively (mean, 47 months). The bony union rate after osteotomy was 97 percent. Bone height measurements were compared by site and type of reconstruction. The mean loss in fibula height by site of reconstruction was 2 percent in central segments, 7 percent in body segments, and 5 percent in ramus segments. The mean loss in bone height after radial free flap mandible reconstruction was 33 percent in central segments and 37 percent in body segments; ramus segments did not lose height. The central and body segments reconstructed with scapular free flaps did not lose height, but one ramus segment lost 20 percent of height. There was no loss in bone height in mandibular body reconstruction with the ilium free flap. Fibula free flaps did not significantly lose bone height when evaluated with respect to age, follow-up, radiation therapy, or dental implant placement. The retention in bone height demonstrated in this study suggests that bone mass is preserved after osseous free flap mandible reconstruction. The greatest amount of bone loss was seen after multiply osteotomized radial free flaps were used for central mandibular reconstruction. The ability of the fibula free flap to maintain mass over time, coupled with its known advantages, further supports its use as the "work horse" donor site for mandible reconstruction.

Reconstruction of lateral skull base oncological defects: the role of free tissue transfer.

Surgical ablation for oncological disease of the lateral skull base can result in extensive defects, with exposed bone and dura. Inadequate coverage can result in meningitis, osteomyelitis, or delay in adjuvant therapy. Successful reconstruction requires well-vascularized soft tissue and often a large cutaneous component. This study evaluates the role of free tissue transfer in reconstruction of lateral skull base defects. This study is a retrospective review of all patients undergoing lateral skull base resection for oncological disease and immediate reconstruction from 1993 through 1997. There were 18 patients with a mean age of 57 years. The temporal bone was resected in 50% of patients. All defects were reconstructed with free tissue transfers from the following donor sites: rectus abdominis (N = 14), latissimus dorsi (N = 2), anterolateral thigh (N = 1), and lateral arm (N = 1). A cutaneous skin island was employed in all patients. Free flap survival was 100%. Flap-related complications occurred in 33% of patients but did not delay the onset of adjuvant therapy. Vein grafts were not required to lengthen the vascular pedicle. Two patients required split-thickness skin grafts because of inadequate size of the skin island. Four patients underwent flap revision for contour deformity a mean of 4 months postoperatively. Free tissue transfer is a highly reliable method of reconstructing lateral skull base defects in a single stage. Careful flap selection and design can minimize the need for skin and vein grafts. The rectus abdominis donor site is preferred because of its location, large skin island, and excellent vascular pedicle.

A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique.

Free-tissue transfer has become an important method for reconstructing complex oncologic surgical defects. This study is a retrospective review of a 10-year experience with 716 consecutive free flaps in 698 patients. Regional applications included the head and neck (69 percent), trunk and breast (14 percent), lower extremity (12 percent), and upper extremity (5 percent). Donor sites included the rectus abdominis (195), fibula (193), forearm (133), latissimus dorsi (69),jejunum (55), gluteus (28), scapula (26), and seven others (17). Microvascular anastomoses were performed to large-caliber recipient vessels using a continuous suture technique; end-to-end anastomoses were preferred (75 percent). Flaps were designed to avoid the need for vein grafts. Conventional postoperative flap monitoring methods were used. These included clinical observation supplemented by Doppler ultrasonography, surface temperature probes, and pin prick testing. Buried flaps were either evaluated with Doppler ultrasonography or not monitored. The overall success rate for free-flap reconstruction of oncologic surgical defects was 98 percent. Fifty-seven flaps (8 percent) were reexplored for either anastomotic or infectious problems. Reexplored flaps were salvaged in 40 cases (70 percent). Surviving flaps resulted in a healed wound and did not delay postoperative radiation or chemotherapy. The incidence of major and minor postoperative complications was 34 percent. The mean duration of hospitalization was 20 days, and the average cost was $40,224. The results of this study support the need for only seven donor sites to solve the majority (98 percent) of oncologic problems requiring microsurgical expertise. The evolution of preferred donor sites for specific regional applications is illustrated in this 10-year experience. Technical refinements have simplified performing the microsurgical anastomoses and essentially eliminated the need for vein grafts. Conventional monitoring has led to the rapid identification of vascular compromise and subsequent flap salvage in the majority of non-buried free flaps.

The current role of preoperative arteriography in free fibula flaps.

The free fibula flap has become a "workhorse" flap for reconstructive surgeons, yet the indications for preoperative arteriography for the donor extremity remain unclear. Therefore, a retrospective review of all free fibula candidates over a 4-year period was conducted to clarify the need for preoperative arteriography. One hundred consecutive patients were evaluated as potential candidates for free fibula reconstruction. Twenty-one patients were deemed unsuitable because of associated comorbid conditions (15) or unusable limbs (6). The remaining 79 patients were candidates for fibula free flap reconstruction. Eight patients (10 percent) who had an abnormal lower extremity vascular physical examination (diminished or absent pedal pulses) underwent arteriography to evaluate the fibula donor site. Free fibula transfer was performed in 77 patients (mean age, 41; range, 3 to 80 years) to the following sites: mandible (65), upper limb (4), lower limb (6), and trunk (2). The overall free flap success rate was 99 percent. Results of arteriography included: normal three-vessel runoff (6), bilateral peroneal arteria magna (1), and bilateral posterior tibial artery occlusion with reconstitution via the peroneal artery (1). Two patients with unusable fibula donor sites (determination based on arteriographic findings) were reconstructed with ilium and radius. All others underwent uncomplicated free fibula transfer. Ischemic complications at the fibula donor site did not occur in any patient. This study supports the use of lower extremity vascular physical examination as the primary means of evaluating the fibula donor site. Routine preoperative arteriography is unnecessary and should be reserved for those patients with abnormal vascular examinations.