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Kim KB, Ryu J, Lee JY. Fibular free flap with proximal perforator skin paddle due to aberrant anatomy - a case report. Maxillofac Plast Reconstr Surg 2024; 46:5. [PMID: 38376599 PMCID: PMC10879059 DOI: 10.1186/s40902-024-00416-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/29/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND The fibular free flap is considered one of the most valuable options for mandible reconstruction. A perforator flap has gained widespread acceptance in oral and maxillofacial reconstruction. Typically, the fibula flap is obtained primarily with the distal perforator due to its reliable blood supply, with less attention given to the proximal perforators during the harvesting process. Normally, the distal perforator of the fibula exhibits stability and shows limited anatomical variations. However, there have been reported cases in which the distal perforator is absent. At times, these vascular abnormalities remain undetectable through Doppler examination or preoperative angiography evaluation. Therefore, this case details the experience of encountering the rare event of vascular abnormality in oral cancer surgery. CASE PRESENTATION This article reports the case of a patient who presented with a congenital absence of the distal perforator in the peroneal artery, attributed to a vascular abnormality. Additionally, we provide a review of the concept of utilizing the proximal perforator as an alternative approach in the flap harvesting process. CONCLUSIONS While the distal perforator of the peroneal artery is typically utilized for fibula free flap procedures, surgeons must remain cognizant of the potential for its absence due to aberrant anatomy. Recognizing an alternative approach in such cases can be pivotal for precise surgical planning and favorable outcomes in oral and maxillofacial reconstruction.
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Affiliation(s)
- Kyu-Bum Kim
- Department of Oral & Maxillofacial Surgery, School of Dentistry, Pusan National University, Yangsan, Korea
| | - Jihye Ryu
- Department of Oral & Maxillofacial Surgery, School of Dentistry, Pusan National University, Yangsan, Korea
| | - Jae-Yeol Lee
- Department of Oral & Maxillofacial Surgery, School of Dentistry, Pusan National University, Yangsan, Korea.
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Huang HH, Wu ZY, Chen XF, Shi YC, Xu SH, Wang SJ, Huang YS. A modified perforator-based stepladder V-Y advancement flap in the Achilles tendon area for coverage of larger posterior heel defects. J Plast Reconstr Aesthet Surg 2023; 77:31-38. [PMID: 36549121 DOI: 10.1016/j.bjps.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/21/2022] [Accepted: 11/16/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Posterior heel defect coverage is challenging because of the paucity of suitable flaps. The traditional local stepladder V-Y advancement flap is recommended only for small defects because of the lack of an axial pedicle. This study reports our experience of using the perforator-based stepladder V-Y advancement flaps in a larger posterior heel defect repair. METHODS Twenty-two patients with posterior heel defects were treated with modified perforator-based stepladder V-Y advancement flaps in the Achilles tendon area for 11 years. Sixteen males and six females aged 3-74 years underwent surgery. The defect size, perforator characteristics, flap size, flap movement, sural nerve, lesser saphenous vein, deep fascia, flap survival, and outcome quality were analyzed. RESULTS The perforators were found to predominate within two 2-cm intervals: 0-2 cm and 4-6 cm proximal to the tip of the lateral malleolus. Twenty-one perforator-based flaps healed uneventfully, and only one developed tip necrosis on the lower edge, which healed by secondary intention. The maximum distance of distal movement was 5.0 cm for the modified flap in contrast to 2.5 cm for the traditional flap. All flaps allowed adequate and durable reconstruction to be achieved, with excellent contouring after 2-28 months of follow-up. CONCLUSIONS The perforator-based stepladder V-Y advancement flap resulted in good outcomes for larger posterior heel defects compared with conventional transfer methods. The flap is a reliable, well-vascularized, sensate, and pliable local flap option that uses similar tissue from adjacent skin for defect repair and creates an internal gliding surface for the Achilles tendon.
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Affiliation(s)
- Hai-Hua Huang
- Department of Wound Repair, Institute of Wound Repair and Regeneration Medicine, Southern University of Science and Technology Hospital, Southern University of Science and Technology School of Medicine, Shenzhen, Guangdong, 518055, China
| | - Ze-Yong Wu
- Department of Plastic Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, 524001, China
| | - Xiu-Feng Chen
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, 524001, China
| | - Yu-Cang Shi
- Department of Plastic Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, 524001, China
| | - Shu-Hao Xu
- Department of Plastic Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, 524001, China
| | - Sui-Jiang Wang
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, 510317, China.
| | - Yue-Sheng Huang
- Department of Wound Repair, Institute of Wound Repair and Regeneration Medicine, Southern University of Science and Technology Hospital, Southern University of Science and Technology School of Medicine, Shenzhen, Guangdong, 518055, China.
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Abstract
A 59-year-old male presented with recurrent mucoepidermoid carcinoma of the mandible. A resection with immediate free fibula flap reconstruction was done. The osteocutaneous free fibula flap relies on the peroneal artery and its distal perforators. Variant patterns necessitate consideration of the challenging to dissect proximal myocutaneous perforator raised on a single or double anastomosis, depending on origin. Even in cases of flap salvage, the fibula flap remains a reliable flap. This case describes a fibula flap with a sole proximal myocutaneous perforator identified during dissection despite a normal preoperative Doppler.
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Affiliation(s)
- Dieter Brummund
- Department of General Surgery, Aventura Hospital and Medical Center, Aventura, USA
| | - Angela Chang
- Department of Anesthesia, Aventura Hospital and Medical Center, Aventura, USA
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The suprafascial course of lower leg perforators: An anatomical study. Arch Plast Surg 2020; 47:165-170. [PMID: 32203994 PMCID: PMC7093275 DOI: 10.5999/aps.2019.00962] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 02/13/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Perforator mapping has been well described in the literature. Once the suprafascial plane is reached, the course of perforators is considered constant. However, the surgeon must be aware of whether an anastomosis exists between perforators superficially to the fascia, in order to choose the best vessel upon which to base the reconstruction. Our retrospective in vivo anatomical study of lower leg perforator flaps presents the first description of variations in the suprafascial path of perforators, which may influence preoperative flap design. METHODS An anatomical study of lower limb perforators was performed on 46 nonconsecutive patients who were referred to our department from June 2012 to October 2018. Reconstruction with perforator-based propeller flaps was planned for each of the patients. In total, 72 perforators were preoperatively identified and surgically isolated. The suprafascial course of each perforator was reported. RESULTS During suprafascial surgical exploration, branching patterns were observed in four perforators. These perforators had been classified as single vessels in the preoperative ultrasonographic analysis. However, after surgical dissection, distal converging branches were noted in two of them. CONCLUSIONS Our study is the first description in the literature of suprafascial converging perforators, which might constitute an obstacle to planned reconstruction procedures. Despite the accuracy of preoperative evaluations, anatomical variations were present. Knowledge of suprafascial perforator variations may help surgeons to choose the correct perforator upon which to base a planned flap.
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VIDEO: Preoperative CT Angiography for Fibular Free Flap Reconstructions. AJR Am J Roentgenol 2018; 210:W264. [PMID: 29702024 DOI: 10.2214/ajr.17.19154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this video article is to provide an introduction to the use of fibular free flaps. Normal and variant vascular anatomy of the fibular free flap is discussed, as are imaging acquisition and CT angiography interpretation, computer-assisted design and manufacturing, and the limitations of the fibular free flap. CONCLUSION The fibular free flap is commonly used for head and neck reconstructive surgery. Variation exists between individuals regarding the origin of the peroneal artery and the perforating arteries. Our method of performing CT angiography and reporting its findings for patients undergoing a fibular free flap procedure provides a reproducible means of identifying important elements of the vasculature and effectively communicating their locations to surgeons. Accurate communication can maximize the success of the flap harvesting and the preoperative manufacture of custom fibular cutting guides.
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Lykoudis EG, Dalianoudis I, Seretis K, Lykoudis GE, Lykissas MG. Single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata: A case report. Microsurgery 2017; 38:318-323. [PMID: 29205488 DOI: 10.1002/micr.30277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/29/2017] [Accepted: 11/17/2017] [Indexed: 11/10/2022]
Abstract
Reconstruction of complex soft tissue defects in the distal lower leg remains challenging, since anatomical constraints limit the local options available in this area. In this report, we present a case of single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata. A 55-year-old patient underwent wide excision of a synovial sarcoma in the distal lower leg, which resulted in a complex defect including the peroneus longus and brevis tendons (10 cm), and the overlying skin (14 × 8 cm). Functional reconstruction was achieved in a single stage with a composite anterolateral thigh flap with vascularized fascia lata of similar dimensions to those of the defect. The fascia lata component of the flap was longitudinally split in two segments. Each of them was rolled up, and that way, two separate vascularized neotendons were created. The neotendons bridged the gap of peroneal tendons, whereas the skin paddle of the flap provided stable soft tissue coverage to the reconstructed tendons. Flap pedicle was anastomosed to the anterior tibial vessels. Early and late postoperative periods were uneventful. Follow up at 1 year postoperatively showed excellent neotendon incorporation, as well as a very good functional and aesthetic outcome. The use of the method described may be a useful alternative in single stage functional reconstruction of composite defects comprising two or even more tendons and the overlying skin.
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Affiliation(s)
| | - Ioannis Dalianoudis
- Department of Plastic Surgery, Ioannina University Hospital, Ioannina, Greece
| | | | - George E Lykoudis
- Department of Plastic Surgery, Ioannina University Hospital, Ioannina, Greece
| | - Marios G Lykissas
- Department of Orthopaedic Surgey, Ioannina University Hospital, Ioannina, Greece
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Redefining Vascular Anatomy of Posterior Tibial Artery Perforators: A Cadaveric Study and Review of the Literature. Ann Plast Surg 2017; 76:705-12. [PMID: 25003444 DOI: 10.1097/sap.0000000000000258] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Perforator flaps whether in a free or pedicled form are essential in leg reconstruction, requiring meticulous dissection based on a detailed understanding of vascular topographic anatomy. Numerous investigators have addressed this issue. However, the directionality of their fascial exit has not been greatly discussed in the literature. Subfascial course of the perforating vessel is a crucial determinant for optimal perforator selection especially when the propeller perforator flap option is considered, because an angulated fascial penetration would eventually result in perforator kinking which would additionally compromise vascular patency. The aim of the current study was to investigate the vascular anatomy of posterior tibial artery evaluating a wide range of parameters, including perforators' subfascial directionality, to precisely determine constant reliable perforator sites, in relation to surface landmarks on the medial aspect of the lower leg. MATERIAL AND METHODS Dissections in 30 lower legs from 25 fresh cadavers were performed. The lower leg was divided into 3 equal vascular zones. Measurements were taken in reference to anatomical landmarks. Perforator clusters to 5-cm intervals from medial malleolus were recorded and analyzed. Vessels with external diameter less than 0.5 mm were excluded. Data regarding the number, distribution, type, external diameter, length from posterior tibial artery, distance, and subfascial directionality were collected and treated. RESULTS A total of 155 perforators were identified (average number, 5 per leg; average diameter, 1.0 mm). Septocutaneous (127/155) perforators predominated, followed by musculocutaneous (19/155) and septomusculocutaneous (9/155). Most was concentrated in the middle (73/155) and distal (64/155) tertile. There were no septomusculocutaneous perforators at the distal third of the leg, whereas septocutaneous perforators were encountered into all vascular tertiles. An average of 2 comitant veins accompanied each perforator. Length and diameter related to the perforators' location. There was a significant association between perforator length and type. Cluster analysis revealed that reliable perforators were identified within the 21 to 25, 26 to 30, and 16 to 20 cm intervals. CONCLUSIONS Clinically optimal perforators for the first time were precisely located in relation to subfascial directionality, vascular diameter, and length from the source artery. Continuous improving details of vascular anatomy will further evolve perforator flaps' applications.
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Sur YJ, Morsy M, Mohan AT, Zhu L, Michalak GJ, Lachman N, Laungani AT, van Alphen N, Saint-Cyr M. Three-Dimensional Computed Tomographic Angiography Study of the Interperforator Flow of the Lower Leg. Plast Reconstr Surg 2016; 137:1615-1628. [DOI: 10.1097/prs.0000000000002111] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hupkens P, Schijns W, Van Abeelen M, Kooloos JG, Slater NJ, Ulrich DJ. Lateral lower leg perforator flaps: An anatomical study to localize and classify lateral lower leg perforators. Microsurgery 2014; 35:140-7. [DOI: 10.1002/micr.22313] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 08/17/2014] [Accepted: 08/19/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Pieter Hupkens
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein 10 Nijmegen The Netherlands
| | - Wendy Schijns
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein 10 Nijmegen The Netherlands
| | - Marjolijn Van Abeelen
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein 10 Nijmegen The Netherlands
| | - Jan G.M. Kooloos
- Department of Anatomy and Embryology; Radboud University Medical Center (Radboudumc); Geert Grooteplein Noord 21 Nijmegen The Netherlands
| | - Nicholas J. Slater
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein 10 Nijmegen The Netherlands
| | - Dietmar J.O. Ulrich
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein 10 Nijmegen The Netherlands
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John JR, Tripathy S, Sharma RK, Balan JR, Jadhav C, Bhattacharya S. Peroneal artery perforator-based flaps for reconstruction of middle and lower third post-traumatic defects of the leg. ANZ J Surg 2014; 85:869-72. [PMID: 24602157 DOI: 10.1111/ans.12556] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Grade IIIb open tibial fractures require local or free flaps for cover of the fracture site. Perforator flap surgery is an innovative method for wound cover in this setting. The anatomy of perforating vessels of the peroneal artery is well described. METHODS All patients who underwent peroneal artery perforator-based flap cover for acute Grade IIIb fracture tibia between December 2011 and March 2013 were prospectively studied. The wounds were located either in middle or in lower third of the tibia. Flaps were performed under loupe magnification after identifying perforators preoperatively with handheld Doppler. All flaps were of a hockey stick or J design, incorporating the peroneal skin territory and completely islanded. Patients were followed up until all wounds were epithelialized. RESULTS Eleven patients were identified. Eleven flaps were performed, out of which 10 survived entirely and served the purpose of stable wound cover. One patient sustained partial flap necrosis, which was debrided, and another local flap was performed. More than one perforator could be identified and retained in six of these 11 patients. CONCLUSION The peroneal artery perforator-based flap is reliable and reproducible in an acute post-traumatic setting. It should be considered as a suitable alternative for reconstruction for limited defects with exposed fractured tibia over the middle and lower third of the leg.
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Affiliation(s)
- Jerry R John
- Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Satyaswarup Tripathy
- Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramesh Kumar Sharma
- Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jyoshid R Balan
- Department of Plastic Surgery, Elite Hospital, Thrissur, Kerala, India
| | - Chandan Jadhav
- Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Saptarshi Bhattacharya
- Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Leclère FM, Bosc R, Temam S, Leymarie N, Mirghani H, Sarfati B, Kolb F. Reconstruction of large mandibulofacial defects with the composed double skin paddle fibula free flap: A review of 32 procedures. Laryngoscope 2013; 124:1336-43. [DOI: 10.1002/lary.24452] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 09/03/2013] [Accepted: 09/23/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Franck M. Leclère
- Department of Plastic and Reconstructive Surgery; Institut Gustave Roussy; 94805 Villejuif Cedex France
| | - Romain Bosc
- Department of Plastic and Reconstructive Surgery; Institut Gustave Roussy; 94805 Villejuif Cedex France
| | - Stéphane Temam
- Department of ENT Surgery; Gustave Roussy Cancer Campus Grand Paris; 94805 Villejuif Cedex France
| | - Nicolas Leymarie
- Department of Plastic and Reconstructive Surgery; Institut Gustave Roussy; 94805 Villejuif Cedex France
| | - Haitham Mirghani
- Department of ENT Surgery; Gustave Roussy Cancer Campus Grand Paris; 94805 Villejuif Cedex France
| | - Benjamin Sarfati
- Department of Plastic and Reconstructive Surgery; Institut Gustave Roussy; 94805 Villejuif Cedex France
| | - Frédéric Kolb
- Department of Plastic and Reconstructive Surgery; Institut Gustave Roussy; 94805 Villejuif Cedex France
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Computed Tomographic Angiography for Localization of the Cutaneous Perforators of the Leg. Plast Reconstr Surg 2013; 131:792-800. [DOI: 10.1097/prs.0b013e3182818cb4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gefäßgestielte Arteria-peronea-Perforatorlappenplastik. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2013; 25:170-5. [DOI: 10.1007/s00064-012-0200-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Garvey PB, Chang EI, Selber JC, Skoracki RJ, Madewell JE, Liu J, Yu P, Hanasono MM. A prospective study of preoperative computed tomographic angiographic mapping of free fibula osteocutaneous flaps for head and neck reconstruction. Plast Reconstr Surg 2012; 130:541e-549e. [PMID: 23018715 PMCID: PMC3749731 DOI: 10.1097/prs.0b013e318262f115] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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.
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Affiliation(s)
- Patrick B. Garvey
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Edward I. Chang
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jesse C. Selber
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roman J. Skoracki
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John E. Madewell
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jun Liu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew M. Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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