Vascular Testing to Overcome Anatomical Contraindication: Fibula Free Flap in Bilateral Peronea Arteria Magna

BACKGROUND: Peronea arteria magna (PAM) is an established contraindication for fibula free flap due to concern for vascular compromise of the lower leg. METHODS: This is a case of a 74-year-old male with a history of multiply recurrent oral cavity cancer who had undergone prior free flap reconstruction who presented with a new oral cavity primary requiring bony reconstruction. On preoperative CTA, the patient was identified as having bilateral PAM contraindicating fibula free flap. RESULTS: A preoperative balloon occlusion testing of the peroneal artery showed adequate arterial perfusion from collateral vasculature supported by arterial duplex ultrasound and venous mapping. A distal connection between the posterior tibial and peroneal artery was identified intraoperatively. The patient then underwent a fibula free flap without postoperative donor site complication. CONCLUSIONS: Fibula free flap reconstruction can be safely performed in patients with diagnosed PAM on CT angiography provided there are sufficient arterial collaterals.