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Saturday, September 24

A Prospective Study of Preoperative Computed Tomographic Angiography of Fibula Osteocutaneous Flaps for Head and Neck Reconstruction

Garvey, Patrick B. MD; Selber, Jesse C. MD; Madewell, John E. MD; Liu, Jun PhD; Skoracki, Roman MD; Yu, Peirong MD; Hanasono, Matthew M. MD

Plastic and Reconstructive Surgery: October 2011 - Volume 128 - Issue Supplement 4S - p 24
doi: 10.1097/01.prs.0000406236.89996.5a
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Introduction:

During fibula flap harvest, inadequate or absent perforators may necessitate modification of the flap design, exploration of the contralateral leg, or additional flap harvest (1-4). We performed this pilot study to determine the predictive power of computed tomographic angiography (CTA) in fibula flap planning and execution.

Methods:

We studied a prospective series of 25 consecutive patients who underwent preoperative CTA mapping of the peroneal artery and subsequent free fibula flap reconstruction of complex mandibular or maxillary defects (Figure 1). We compared perforator location and size, peroneal artery origin, and fibula length relative to bony landmarks between CTA and intraoperative findings.

Figure 1
Figure 1:
CTA image of a peroneal artery perforator.

Results:

Among the 25 fibula flaps, 59 of 61 peroneal artery perforators identified intraoperatively were visualized on CTA, resulting in an overall sensitivity of 96.7% (95% CI=0.888-0.991). Intraoperatively, perforators averaged 1.8 mm from their CTA-predicted locations. The peroneal artery origin from the tibioperoneal trunk averaged 5.9 mm from its CTA-predicted location. Average length of the fibula differed from the CTA-predicted length by 8.3 mm. CTA accurately predicted perforator size only 69.5% (95% CI=0.569-0.797) of the time. Surgeons modified the operative plan in 24% of cases based on CTA findings, including relocating skin islands and osteotomies in relationship to perforators and peroneal artery origins. All fibula flaps were successfully elevated and survived.

Conclusion:

CTA accurately predicted the location of the peroneal artery origin and perforators, which was particularly useful when creating the superior fibular osteotomy and cutaneous skin island. Perforator size was less accurately estimated by CTA, likely due to variations in contrast delivery. Although preoperative CTA of the lower extremity is similar to standard angiography in confirming lower leg vessel patency in patients for whom imaging is clinically indicated, CTA is superior to standard angiography in its ability to also accurately map perforators.

References:

1. Hanasono MM, Jacob RF, Bidaut L, Robb GL, Skoracki RJ. Midfacial reconstruction using virtual planning, rapid prototype modeling, and stereotactic navigation. Plast Reconstr Surg. 2010;126:2002–2006.

2. Roser SM, Ramachandra S, Blair H, et al.. The accuracy of virtual surgical planning in free fibula mandibular reconstruction: Comparison of planned and final results. J Oral Maxillofac Surg 2010;68:2824–2832.

3. López-Arcas JM, Arias J, Del Castillo JL, et al.. The fibula osteomyocutaneous flap for mandible reconstruction: A 15-year experience. J Oral Maxillofac Surg. 2010;68:2377–2384.

4. Hidalgo DA. Fibula free flap: A new method of mandible reconstruction. Plast Reconstr Surg. 1989;84:71–79.

©2011American Society of Plastic Surgeons