# Fibular free flap with proximal perforator skin paddle due to aberrant anatomy — a case report

## TL;DR

This case report describes a rare instance where a patient's fibular free flap surgery required using a proximal perforator due to an absent distal perforator, highlighting the importance of alternative surgical approaches.

## Contribution

The paper presents a novel case of using a proximal perforator as an alternative in fibular free flap surgery when the distal perforator is absent due to vascular abnormalities.

## Key findings

- The distal perforator of the peroneal artery was congenitally absent in the reported case.
- The proximal perforator was successfully utilized as an alternative for flap harvesting.
- Vascular abnormalities may not always be detectable via Doppler or preoperative angiography.

## Abstract

The fibular free flap is considered one of the most valuable options for mandible reconstruction. A perforator flap has gained widespread acceptance in oral and maxillofacial reconstruction. Typically, the fibula flap is obtained primarily with the distal perforator due to its reliable blood supply, with less attention given to the proximal perforators during the harvesting process. Normally, the distal perforator of the fibula exhibits stability and shows limited anatomical variations. However, there have been reported cases in which the distal perforator is absent. At times, these vascular abnormalities remain undetectable through Doppler examination or preoperative angiography evaluation. Therefore, this case details the experience of encountering the rare event of vascular abnormality in oral cancer surgery.

This article reports the case of a patient who presented with a congenital absence of the distal perforator in the peroneal artery, attributed to a vascular abnormality. Additionally, we provide a review of the concept of utilizing the proximal perforator as an alternative approach in the flap harvesting process.

While the distal perforator of the peroneal artery is typically utilized for fibula free flap procedures, surgeons must remain cognizant of the potential for its absence due to aberrant anatomy. Recognizing an alternative approach in such cases can be pivotal for precise surgical planning and favorable outcomes in oral and maxillofacial reconstruction