Purpose:
The standard fibula flap utilizes perforators locating on lower third of the fibula, where the skin paddle lacks redundancy so that skin grafting is inevitable for donor site coverage. This study aims to achieve donor site primary closure with different flap designs for reconstruction.

Material and method:
This retrospective study reviewed patients diagnosed as head and neck cancer and accepted fibula flap reconstruction in E-DA hospital from January 2014 to August 2022. 4 different flap designs were chosen according to different reconstruction requirement and location of perforators, including tear-drop shape design(A), secondary propeller flap closure technique(B), proximal lateral leg flap as skin paddle with fibula bone flap(C), and dual skin paddle composed of tear-drop shape design and proximal lateral leg flap(D). A: perforators proximal to lower third of fibula. B: perforators on lower third of fibula. C: single and large soft tissue defect D: multiple soft tissue defect.
Statistic data included number of flap design, number of closure method, skin paddle size (length and width), length of bone and donor site complication.
Result:
28 patients were included in this study. Patient number of four different designs are 13(tear-drop shape design), 10(dual skin paddle design), 2(propeller flap technique), and 2(fibula bone flap with proximal lateral leg flap). 20 patients could achieve donor site primary closure, and 1 patient attempted donor site primary closure at first but failed due to compartment syndrome then changed to skin grafting (successful rate 20/21, 95.2%). 7 patients needed skin grafting, and 1 of them suffered from donor site wound poor healing. Donor site closure method was significantly associated with width(p=0.004) and length(p<0.001), but not bone length (p=0.348). Average width of skin paddle in primary closure(5.32cm) was wider than 4cm suggested by Shipitzer et al.(1997).

Conclusion:
Donor site primary closure can be mostly achieved in our designs with wider skin paddles. Besides, dual skin paddle design is a useful method for multiple soft tissue defect with single flap harvest.

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