Avoiding second donor site and the second set of neck vessels in a case of absent peroneal skin perforators

This report describes the procedure of a case in which the skin paddle of the free fibula flap derived its supply solely from a soleal musculocutaneous perforator originating from the posterior tibial system. In contrast, the osteo-muscular component was supplied by the peroneal vascular system. We harvested the skin paddle with its vascular supply from the posterior tibial artery separately, and the osteo-muscular fibula was harvested with its supply from peroneal vessels. In this way, we avoided violation of the second donor site for the skin paddle. In addition, we used the distal end of peroneal vessels to salvage our skin paddle instead of sacrificing another set of neck vessels for anastomosis. This technique may also be utilised in cases where the neck vessels may not be available due to previous surgeries, radiation therapy, or decision by the surgery team to not sacrifice two sets of neck vessels for anastomosis.