A prospective study of preoperative computed tomographic angiographic mapping of free fibula osteocutaneous flaps for head and neck reconstruction

Abstract

Background: In designing an osteocutaneous fibula flap, poor planning, aberrant anatomy, or inadequate perforators may necessitate modification of the flap design, exploration of the contralateral leg, or additional flap harvest. The authors studied the predictive power of computed tomographic angiography in osteocutaneous fibula flap planning and execution.

Methods: The authors studied a prospective cohort of 40 consecutive patients who underwent preoperative computed tomographic angiography mapping of the peroneal artery and its perforators and subsequent free fibula flap reconstruction of mandibular or maxillary defects. The authors compared their analysis of perforator anatomy, peroneal artery origin, and fibula length with intraoperative clinical findings.

Results: Overall, computed tomographic angiography identified 94.9 percent of the cutaneous perforators found intraoperatively. Clinically, perforators were located an average of 8.7 mm from their predicted locations. The peroneal artery origin from the tibioperoneal trunk averaged 6.0 mm from its predicted location. The average length of the fibula differed from the predicted length by 8.0 mm. Computed tomographic angiography accurately predicted perforators as either septocutaneous or musculocutaneous 93.0 percent of the time. Perforator size was accurately predicted 66.7 percent of the time. Skin islands and osteotomies were modified in 25.0 percent of the cases on the basis of computed tomographic angiography findings. Two patients had hypoplastic posterior tibial arteries, prompting selection of the contralateral leg. There were no total flap or skin paddle losses.

Conclusions: Computed tomographic angiography accurately predicted the course and location of the peroneal artery and perforators; perforator size was less accurately estimated. Computed tomographic angiography provides valuable information to facilitate osteocutaneous fibula flap harvest.

Figure 1

Example of CTA and intraoperative images of peroneal artery perforators: (a) proximal perforator (yellow arrow), (b) distal perforator (yellow arrow), (c) intraoperative appearance of perforators seen in preoperative CTA (yellow arrows).

Figure 2

CTA three-dimensional reconstruction demonstrating the distances between fibular heads and peroneal artery origins from tibioperoneal trunks (yellow arrows).

Figure 3

Septocutaneous course of peroneal artery demonstrated by preoperative CTA.

Figure 4

Histogram presentation of the perforator distribution based on CTA analysis and intraoperative exploration.

Figure 5

Frequency of perforator locations along the length of the fibula by CTA (blue line) and by intraoperative observation (red line).

Figure 6

CTA appearance of hypoplastic right posterior tibial artery. The peroneal artery (yellow arrow) appears to be the dominant vascular supply to the distal right lower leg. Normal infrapopliteal arterial trifurcation is demonstrated in the contralateral left leg.