Use of the spider limb positioner for fibular free flap reconstruction of head and neck bony defects

•Fibular free flaps remain the workhouse of maxillomandibular bony reconstruction.•We have now used the Spider Leg Positioner for harvest of 61 fibular free flaps.•Spider Leg affords superior ergonomics, ease of dissection, fine positioning changes.•Spider Leg associated with reduced tourniquet times, zero iatrogenic nerve injury. Osseous and osteocutaneous fibular free flaps are the workhorse of maxillomandibular reconstruction over 30 years after the initial description. Since 2019, we have routinely used the Spider Limb Positioner, adapted from its use in shoulder orthopedic procedures, for fibular free flap harvest. Herein, we describe this novel technique in our cohort. We describe our intraoperative setup and endorse the versatility and utility of this technique in comparison to other reported fibular free flap harvest techniques. The Spider Limb Positioner was used 61 times in 60 different patients to harvest osseous or osteocutaneous fibular free flaps. Median (range) tourniquet time for flap harvest was 90 (40–124) minutes. No iatrogenic nerve compression injuries or complications related to lower extremity positioning occurred. We describe a novel approach to fibular free flap harvest utilizing the Spider Limb Positioner, which affords optimal ergonomics, visibility, and patient repositioning. There were no nerve injuries or complications related to positioning in our series.