# Donor Site Morbidity in Fibula Free Flaps: A Technique‐Dependent Comparative Analysis of Donor Site Wound Healing

## TL;DR

This study compares different techniques for closing donor sites after fibula free flap surgery and finds that using split-thickness skin grafts with negative pressure wound therapy reduces complications.

## Contribution

The study introduces and evaluates a two-stage closure technique for donor site wound healing in fibula free flap surgery.

## Key findings

- STSG without NPWT had the highest complication rate at 91.0%.
- Two-stage closure showed complication rates comparable to one-stage closure with NPWT.
- STSG with NPWT and two-stage closure were protective factors for wound healing complications.

## Abstract

The fibula free flap (FFF) is a mainstay in maxillofacial reconstruction, yet donor site morbidity remains a significant clinical concern. Closure technique is a key factor influencing complication rates, but comparative data remain heterogeneous. This study provides a technique‐dependent analysis of 60‐day donor site wound healing in FFF with skin paddles and reports a two‐stage closure approach.

A retrospective review of 211 patients undergoing FFF between 2017 and 2024 was conducted. Donor site complications within the first 60 postoperative days were assessed and stratified by closure technique: one‐stage split‐thickness skin grafting (STSG) with or without negative pressure wound therapy (NPWT), and a two‐stage closure consisting of one‐week NPWT followed by STSG. Multivariate logistic regression was applied to identify independent predictors for complications.

Overall, 50.2% of patients experienced donor site complications, with wound healing disorders (31.8%) and (partial) skin necrosis (23.7%) most prevalent. Regarding wound closure, STSG coverage without NPWT was associated with the highest morbidity and a complication rate of 91.0%. Despite being limited in sample size, the two‐stage closure, despite larger skin defects, showed complication rates comparable to one‐stage closure with NPWT. Multivariate analysis identified STSG with NPWT (OR 0.1 [0.01; 0.4], p = 0.002) and two‐stage closure (OR 0.1 [0.01; 0.5], p = 0.01) as protective factors for wound healing complications.

Donor site morbidity following FFF harvest with skin paddles is significantly impacted by closure technique. Wound management using one‐ or two‐stage STSG with NPWT is preferred. Initial results of the two‐stage closure indicate potentially beneficial outcomes for extensive defects and warrant further prospective validation.