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

The Arterial System of the Fasciocutaneous Deltoid Flap Pedicle on 320-Detector Row Computed Tomography and Clinical Application in the Foot and Hand

BACKGROUND

 Fasciocutaneous free deltoid flaps are used to reconstruct hand, foot, and maxillofacial defects. Although anatomical studies of this flap pedicle have been performed on cadavers, there are no reports on the use of 320-detector row computed tomography angiography (CTA-320) to investigate the deltoid flap pedicle in living humans. This study aimed to investigate the arterial characteristics of the deltoid flap pedicle using the CTA-320 system in living humans.

METHODS

 Twenty-seven adult Vietnamese patients with 54 healthy deltoid regions underwent CTA-320 to investigate arterial blood supply before clinical free-flap transfer. Two- and three-dimensional reconstruction images of the arterial pedicle were visualized, and clinical reconstruction results were evaluated.

RESULTS

 The cutaneous vessel branches of the deltoid flap were separated from the posterior circumflex humeral artery (PCHA) and originated from the axillary (77.78%), subscapular (12.96%), and brachial (9.26%) arteries. The PCHA penetrated the quadrangular space in 90.74% of patients. The cutaneous arterial branch was present in the deltoid-triceps groove in 100% of patients. The average diameter and length of the PCHA were 3.38 ± 0.58 and 43.08 ± 6.60 mm, respectively. The average diameter and length of the flap cutaneous branch were 1.49 ± 0.28 and 44.57 ± 4.83 mm, respectively. The findings of CTA-320 were aligned with the intraoperative clinical findings well. All deltoid flaps were successfully free-transferred with good outcomes.

CONCLUSION

 The CTA-320 is a practical and effective method for investigating deltoid flap pedicles. It enables accurate flap design and harvesting of flaps, thereby enhancing the clinical success of free-flap transfer.

Upper Extremity Diaphyseal Osseous Gap Reconstruction with Free Vascularized Bone Flaps: A Scoping Review

BACKGROUND

 Reconstruction of upper extremity osseous diaphyseal defects often requires complex reconstructions. In this study, we characterized and summarized the available literature on free vascularized bone flap (VBF) reconstruction for upper extremity diaphyseal defects.

METHODS

 A scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of VBF reconstruction of upper limb long bone defects. Articles with patient-level data were included. Descriptive statistics were performed using Python.

RESULTS

 Overall, 364 patients were included in this study. The most common indications for VBFs included atrophic nonunion (125, 34.3%), postoncologic resection (125, 34.3%), septic nonunion (56, 15.4%), and trauma (36, 9.9%). Mean defect size was 8.53 ± 5.14 cm. A total of 67 (18.4%) cases had defects < 6 cm, and 166 cases (45.6%) had defects > 6 cm. The fibula was the most utilized VBF (272, 74.73%), followed by the medial femoral condyle flap (69, 18.96%). Overall, primary union rate was 87.1%. Subsequent flap fracture rate was 3.3%. There were only two (0.6%) VBF losses reported in the included cases, and donor-site complications were similarly rare (17, 4.7%).

CONCLUSION

 VBF reconstruction is often utilized for postoncologic defects and recalcitrant nonunions. The fibula is the most utilized VBF, but the medial femoral condyle flap is used frequently for smaller defects. VBF reconstruction demonstrates high union rates and low flap fracture rate across indications.

The fusiform skin paddle in fibula free flap: a fusiform-designed skin paddle for maxillofacial soft defect reconstruction and reducing leg wound tension

Objective

To investigate the feasibility of leg wound closure and reconstruction of maxillofacial soft defect by a fusiform-designed skin paddle in fibula free flap (FFF).

Methods

Fifty patients who underwent FFF for reconstruction of maxillofacial soft defect were divided into two groups. The fusiform group (20 patients) was treated using a fusiform-designed skin paddle in FFF (skin paddle width less than 2 cm), and leg wound was closed using primary suturing. Reconstruction of the maxillofacial soft defect or filling of dead space was achieved by folding the fusiform skin paddle. The conventional group (30 patients) was treated using the conventional-designed skin paddle (skin paddle width no less than 2.5 cm). The leg wound was closed using mattress suturing or skin graft, while reconstruction of the maxillofacial soft defect or filling of dead space by conventional way. The average postoperative length of hospital stay, healing time of leg wound, and post-surgical complications were recorded at least 6 months after the surgery.

Results

Compared with traditional method, the fusiform-designed skin paddle reduced the average healing time of the leg wound (fusiform group: 11.05 days, conventional group: 14.77 days, P < 0.05). The average length-to-width ratio in fusiform group was significantly greater than that of in conventional group (fusiform group: 5.85, conventional group: 2.93, P < 0.05), and no difference was observed on the graft size of skin paddle between two groups (fusiform group: 23.13, conventional group: 27.13, P > 0.05). The post-surgical early complications of the leg wound in the conventional group were higher than that of in the fusiform group (fusiform group: 0%, conventional group: 6.67%), while the post-surgical late complication of the donor site between the two groups showed no case. Healing disorders of maxillofacial soft reconstruction in the conventional group were higher than that of in the fusiform group (fusiform group: 5.26%, conventional group: 20.69%).

Conclusions

Fusiform-designed skin paddle for closure of the leg wound and maxillofacial soft defect is a feasible alternative to the conventional- designed skin paddle. The fusiform- designed skin paddle resulted in the less postoperative length of hospital stay, shorter healing time of leg wound and less complication.

Infrapopliteal Segments on Lower Extremity CTA: Prospective Intraindividual Comparison of Energy-Integrating Detector CT and Photon-Counting Detector CT

BACKGROUND. The higher spatial resolution and image contrast for iodine-containing tissues of photon-counting detector (PCD) CT may address challenges in evaluating small calcified vessels when performing lower extremity CTA by energy-integrating detector (EID) CTA. OBJECTIVE. The purpose of the study was to compare the evaluation of infrapopliteal vasculature between lower extremity CTA performed using EID CT and PCD CT. METHODS. This prospective study included 32 patients (mean age, 69.7 ± 11.3 [SD] years; 27 men, five women) who underwent clinically indicated lower extremity EID CTA between April 2021 and March 2022; participants underwent investigational lower extremity PCD CTA later the same day as EID CTA using a reduced IV contrast media dose. Two radiologists independently reviewed examinations in two sessions, each containing a random combination of EID CTA and PCD CTA examinations; the readers assessed the number of visualized fibular perforators, characteristics of stenoses at 11 infrapopliteal segmental levels, and subjective arterial sharpness. RESULTS. Mean IV contrast media dose was 60.0 ± 11.0 (SD) mL for PCD CTA versus 139.6 ± 11.8 mL for EID CTA (p < .001). The number of identified fibular perforators per lower extremity was significantly higher for PCD CTA than for EID CTA for reader 1 (R1) (mean ± SD, 6.4 ± 3.2 vs 4.2 ± 2.4; p < .001) and reader 2 (R2) (8.8 ± 3.4 vs 7.6 ± 3.3; p = .04). Reader confidence for assessing stenosis was significantly higher for PCD CTA than for EID CTA for R1 (mean ± SD, 82.3 ± 20.3 vs 78.0 ± 20.2; p < .001) but not R2 (89.8 ± 16.7 vs 90.6 ± 7.1; p = .24). The number of segments per lower extremity with total occlusion was significantly lower for PCD CTA than for EID CTA for R2 (mean ± SD, 0.5 ± 1.3 vs 0.9 ± 1.7; p = .04) but not R1 (0.6 ± 1.3 vs 1.0 ± 1.5; p = .07). The number of segments per lower extremity with clinically significant nonocclusive stenosis was significantly higher for PCD CTA than for EID CTA for R1 (mean ± SD, 2.2 ± 2.2 vs 1.6 ± 1.7; p = .01) but not R2 (1.1 ± 2.0 vs 1.1 ± 1.4; p = .89). Arterial sharpness was significantly greater for PCD CTA than for EID CTA for R1 (mean ± SD, 3.2 ± 0.5 vs 1.8 ± 0.5; p < .001) and R2 (3.2 ± 0.4 vs 1.7 ± 0.8; p < .001). CONCLUSION. PCD CTA yielded multiple advantages relative to EID CTA for visualizing small infrapopliteal vessels and characterizing associated plaque. CLINICAL IMPACT. The use of PCD CTA may improve vascular evaluation in patients with peripheral arterial disease.

The profunda artery perforators: Anatomical study and radiological findings using computed tomography angiography in patients undergoing PAP flap breast reconstruction

BACKGROUND

The popularity of the profunda femoris artery perforator (PAP) flap is increasing; however, knowledge concerning the standardization of radiological findings and their clinical implications is limited. We evaluated the radiological architecture of posterior thigh perforators using Computed Tomography Angiography (CTA) to identify landmarks to facilitate flap dissection.

METHODS

A retrospective study was conducted on 35 patients who underwent unilateral breast reconstruction with a PAP flap. The preoperative CTA scans were analyzed, and the perforator characteristics were evaluated. The perforators were mapped using a Cartesian coordinate system. Data were normalized by anatomical landmarks and overlapped. Perioperative and postoperative results were analyzed. Radiological and intraoperative were compared.

RESULTS

Two CTA scans were excluded; 66 thighs were examined. The mean perforator number was 3.2. The mean diameter of chosen perforators was 2.7 mm (DS ± 0.6 mm) at the origin, 2.2 mm (DS ± 0.4 mm) at the adductor space midpoint, and 1.7 mm (DS ± 0.3 mm) at the deep fascia. The mean adipose tissue thickness was 3.35 cm (DS ± 0.94) at the deep fascia and 3.59 cm (DS ± 1.19) at the adductor space midpoint. Intraoperatively, the perforator was located 3.22 cm (DS ± 0.87) from the posterior border of the gracilis muscle and 8.98 cm (DS ± 1.44) from the inferior gluteal crease. A radiological area located 9.33 cm (DS ± 4.81) from the y-axis and 7.48 cm (DS ± 1.88) from the x-axis was identified.

CONCLUSIONS

CTA using the volume-rendering technique is a valuable method to study in vivo the radiological anatomy of the posterior thigh perforators.

Evolution of Medical Modeling and 3D Printing in Microvascular Midface Reconstruction: Literature Review and Experience at MD Anderson Cancer Center

Reconstruction of the midface represents a challenge for reconstructive microsurgeons given the formidable task of restoring both aesthetics and functionality. In particular, preservation of proper globe positioning and maintaining normal vision are as important as restoring the proper projection of the midface and enabling a patient to speak and eat as normally as possible. The introduction of virtual surgical planning (VSP) and medical modeling has revolutionized bony reconstruction of the craniofacial skeleton; however, the overwhelming majority of studies have focused on mandibular reconstruction. Here, we introduce some novel advances in utilizing VSP for bony reconstruction of the midface. The present review aims (1) to provide a review of the literature on the use of VSP in midface reconstruction and (2) to provide some insights from the authors' early experience.

Innovative Strategies in Microvascular Head and Neck Reconstruction

The field of reconstructive microsurgery has witnessed considerable advancements over the years, driven by improvements in technology, imaging, surgical instruments, increased understanding of perforator anatomy, and experience with microsurgery. However, within the subset of microvascular head and neck reconstruction, novel strategies are needed to improve and optimize both patient aesthetics and post-operative function. Given the disfiguring defects that are encountered following trauma or oncologic resections, the reconstructive microsurgeon must always aim to innovate new approaches, reject historic premises, and challenge established paradigms to further achieve improvement in both aesthetic and functional outcomes. The authors aim to provide an up-to-date review of innovations in head and neck reconstruction for oncologic defects.

Virtual Surgical Planning in Head and Neck Reconstruction

Virtual surgical planning is a revolutionary tool for the head and neck reconstructive surgeon. As with any tool, there are strengths and weaknesses. The strengths include shorter operative time, shorter ischemic time, streamlined dental rehabilitation, facilitation of complex reconstruction, non-inferior and possibly superior accuracy, and increased durability. The weaknesses are increased up-front costs, potential delays to operative management, limited flexibility on the day of surgery, and loss of familiarity with conventionally planned surgery.

Nitroglycerin improves the visibility of fibula-free flap perforators on computed tomography angiography in patients with oral or maxillofacial lesion

PURPOSE

To investigate the improvement of image quality and visualization of fibula-free flap (FFF) perforators on computed tomography angiography (CTA) after administration of sublingual nitroglycerin (NTG) tablets.

METHODS

A total of 60 patients with oral or maxillofacial lesions before CTA of the lower extremity were randomly divided into two groups (NTG group and non-NTG group). The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR), overall image quality and grading of vessels were evaluated and compared. The lumen diameters of the major arteries and the proximal and distal peroneal perforators were measured. The number of visible perforators in muscular clearance and muscular layer was also counted and compared between the two groups.

RESULTS

The CNR of posterior tibial artery and overall image quality of CTA images in the NTG group was significantly higher than that in the non-NTG group (p < 0.05), although the SNR and CNR of other arteries did not show significant differences (p > 0.05). The lumen diameters of the peroneal artery and its perforators, anterior tibial artery, and posterior tibial artery were significantly larger in the NTG group (p < 0.001), while no significant difference prevailed in the diameter of the popliteal artery between the two groups (p = 0.298). Compared with the non-NTG group, a significant increase in the number of visible perforators was noted in the NTG group (p < 0.001).

CONCLUSIONS

The administration of sublingual NTG in CTA of the lower extremity can improve the image quality and visualization of perforators, which aids to surgeons select the optimum FFF.

Unusual Vascular Distribution in the Third Segment of the Axillary Artery

The third segment of the axillary artery (TSAA) is the main vascular supply to the muscles of the upper limb. Numerous studies have reported atypical branching patterns of the TSAA, which can complicate operative interventions involving structures supplied by this segment of the artery. Our current study evaluated a previously undescribed branching pattern in the TSAA, in which the subscapular artery gave rise to an unusual posterior humeral circumflex artery, and a second subscapular artery. In addition, a third variant was found in the origin of the thoracodorsal artery: two collateral horizontal arteries supplying the deep medial surface of the latissimus dorsi muscle. Vascular anatomical variants may affect the classical upper limb interventions requiring modification of the traditional surgical approaches. This case report aims to evaluate these variants from a clinical perspective regarding the management of upper limb trauma, axillary, breast, and muscle flap surgery.

The Cost Utility of Virtual Surgical Planning and Computer-Assisted Design/Computer-Assisted Manufacturing in Mandible Reconstruction Using the Free Fibula Osteocutaneous Flap

BACKGROUND

 The use of virtual surgical planning and computer-assisted design and computer-assisted manufacturing (CAD/CAM) has become widespread for mandible reconstruction with the free fibula flap. However, the cost utility of this technology remains unknown.

METHODS

 The authors used a decision tree model to evaluate the cost utility, from the perspective of a hospital or insurer, of mandible reconstruction using CAD/CAM relative to the conventional (non-CAD/CAM) technique for the free fibula flap. Health state probabilities were obtained from a published meta-analysis. Costs were estimated using 2018 Centers for Medicare and Medicaid Services data. Overall expected cost and quality-adjusted life-years (QALYs) were assessed using a Monte Carlo simulation and sensitivity analyses. Cost effectiveness was defined as an incremental cost utility ratio (ICUR) less than the empirically accepted willingness-to-pay value of $50,000 per QALY.

RESULTS

 Although CAD/CAM reconstruction had a higher expected cost compared with the conventional technique ($36,487 vs. $26,086), the expected QALYs were higher (17.25 vs. 16.93), resulting in an ICUR = $32,503/QALY; therefore, the use of CAD/CAM in free fibula flap mandible reconstruction was cost-effective relative to conventional technique. Monte Carlo sensitivity analysis confirmed CAD/CAM's superior cost utility, demonstrating that it was the preferred and more cost-effective option in the majority of simulations. Sensitivity analyses also illustrated that CAD/CAM remains cost effective at an amount less than $42,903 or flap loss rate less than 4.5%.

CONCLUSION

 This cost utility analysis suggests that mandible reconstruction with the free fibula osteocutaneous flap using CAD/CAM is more cost effective than the conventional technique.

Utilization of the Pedicled and Free Fibula Flap for Ankle Arthrodesis

Ankle arthrodesis has become a common surgical procedure for individuals with end-stage ankle arthritis, chronic infection, and bony misalignment. Although arthrodesis is typically managed with arthrodesis in situ or realignment, reconstruction may be utilized for patients with more complicated cases that involve metatarsal defects. Our institution utilizes both the pedicled and free fibula flaps for surgical management pertaining to ankle arthrodesis. Our study looks to evaluate the work of a single plastic surgeon and identify patient postoperative outcomes.

A three-dimensional visualization of the full-field surgical region based on thin-slice MRI: A helpful approach for simultaneously guiding tumor resection and perforator flap elevation

Background

The goal of the current study was to explore the application of preoperative three-dimensional reconstruction (3DR) based on thin-slice magnetic resonance imaging (MRI) in the simultaneous guidance of en bloc tumor resection and adjacent perforator flap elevation.

Methods

The prospective cohort included 35 patients diagnosed with either soft tissue sarcoma or squamous cell skin cancer between 2019 and 2021. The preoperative 3DR based on thin-slice MRI illustrated the spatial anatomical relationship among the tumor, underlying muscle, adjacent perforator vessels, and bone around the surgical region. The accuracy of preoperative imaging data was verified by intraoperative vessel dissection and postoperative pathological measurements.

Results

Tumor size from 3DR data showed relatively high concordance rates with pathological measurements within the 95% limits of agreement. An average of three perforators (range: 1–7) with a mean diameter of 0.32 cm (range: 0.18–0.74 cm) from the 3DR were present in our study. The average distance between tumor boundary and perforator piercing sites on the 3DR was 2.2 cm (range: 1.2–7.7 cm). The average length of artery perforator coursing along the subcutaneous tissue was 5.8 cm (range: 3.3–25.1 cm). The mean flap harvest time was 55 mins (range: 36–97 min). The average flap size was 92.2 cm² (range: 32–126 cm²). One perforator flap occurred distal partial necrosis.

Conclusion

A thorough understanding of anatomical structures in the surgical region according to full-field 3DR based on thin-slice MRI can improve the performance of radical resection of the tumor and adjacent perforator flap transfer, especially for junior surgeons with a poor experience.

Iatrogenic Thrombosis of the Deep Inferior Epigastric Artery During Diagnostic Angiography – A Rare Complicating Factor During Rectus Free Flap Harvest

We describe a 28-year-old man who sustained an open IIIB left ankle fracture dislocation with heel pad avulsion. The patient underwent formal angiography of the left lower extremity, followed by free tissue transfer of a rectus abdominis flap several days later. Intraoperatively, a thrombus was identified in the deep inferior epigastric artery above the femoral artery access site requiring thrombectomy. Histologic analysis estimated the thrombus age at 12 to 72 hours, raising concern that the thrombus was induced during angiogram instrumentation. Donor and recipient site-specific risks of arterial instrumentation (including invasive diagnostics) should be considered when planning free tissue transfer.

The Value of Three-Dimensional Modeling on Repositioning and Soft Tissue Filling in Microsurgical Reconstruction of Secondary Mandibular Defects: A Retrospective Study

Purpose

Secondary mandibular defect reconstruction is a challenging operation. It is performed rather rarely, as in most of the cases a primary reconstruction is preferable. Restoration of function and symmetry, in secondary reconstruction of mandibular defects, requires accurate repositioning of segments and appropriate soft tissue filling. The purpose of this study is to estimate the value of three-dimensional (3D) digital modeling to meet the above requirements, in secondary microsurgical reconstruction of mandibular defects.

Methods

Five cases of mandibular defects, with various degrees of asymmetry and dysfunction, were restored secondarily, with fibula flaps, after virtual reconstruction on a 3D model derived from their computed tomography, with the utilization of CAD-CAM software. Software reproduced symmetrical 3D models by mirroring the healthy side. Occlusion was restored by fine adjustments on 3D models and finally a reconstruction plate was pre-bent on them, prior to its sterilization for use in surgery. Three out of the five cases received an osteo-cutaneous flap, while in the other two patients, an osseous flap was used. Lower face symmetry, mouth opening, and main patient’s complaints were evaluated pre- and postoperatively to assess the value of the 3D modeling.

Results

All flaps survived. Hematoma occurred in two patients and was resolved after evacuation. In two patients, a fistula observed, was attributed to screw loosening, and treated after a surgical debridement and screw replacement. Intraoral exposure in the posterior part of the fibula flap was recorded in one patient, possibly from wound dehiscence due to tension of the intraoral tissue, and successfully covered with an ipsilateral nasolabial flap. The resulting symmetry and function were satisfactory in all the patients.

Conclusion

Secondary mandibular defects are often related with cosmetic disfigurement, misalignment of mandibular segments, and mandibular malfunction. For the correction of mandibular continuity, symmetry, and restoration of function, preoperative 3D modeling may be an important tool, according to our results.

Unexpected Change of Surgical Plans and Contingency Strategies in Computer-Assisted Free Flap Jaw Reconstruction: Lessons Learned From 98 Consecutive Cases

Background

Computer-assisted surgeries (CAS) are increasingly being adopted as the treatment of choice for jaw reconstructions with osseous free flaps. Although unexpected change of surgical plans remains a major concern of CAS, there are few studies focusing on this unfavorable clinical scenario. The aim of the present study was to investigate the rate of unexpected change of surgical plans and potential influential parameters, and to discuss the contingency strategies.

Methods

A retrospective study was performed to evaluate all the patients who underwent computer-assisted jaw resections and osseous free flap reconstructions. The postoperative radiographs were reviewed and compared with the preoperative surgical plans. Operating records were examined to analyze the reasons for unexpected change of surgical plans and the management. The potential influential parameters for the change of surgical plans were analyzed using Fisher-exact test. The difference was regarded as statistically significant for a p-value less than 5%.

Results

From Nov 2014 to Oct 2021, a total of 98 consecutive computer-assisted free flap jaw reconstruction cases with osseous free flaps were included in this study. Our experience showed that 5.1% of the patients (five cases) needed intra-operative change of the surgical plans. We summarized the unexpected change of surgical plans and the contingency strategies as four clinical scenarios, including extended resection and reconstruction, shortened resection and reconstruction, modified resection without changing reconstruction, and modified reconstruction without changed resection. None of the potential influential parameters was identified as significant in relation to unexpected change of surgical plans intraoperatively.

Conclusion

Our experience shows that with the comprehensive methodology for computer-assisted free flap jaw reconstruction surgery planning, we can minimize the possibility of unexpected change of surgical plans during surgery. The lessons learned from our 98 consecutive cases can help beginners prevent unexpected change of surgical plans and rationalize contingency strategies in computer-assisted free flap jaw reconstruction.

Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning

Background

Virtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success.

Method

This retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply.

Result

A total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs’ vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP.

Conclusion

In general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome.

Computed Tomography Angiography (CTA) before Reconstructive Jaw Surgery Using Fibula Free Flap: Retrospective Analysis of Vascular Architecture

Computed tomography angiography (CTA) is widely used in preoperative evaluation of the lower limbs' vascular system for virtual surgical planning (VSP) of fibula free flap (FFF) for jaw reconstruction. The present retrospective clinical study analysed n = 72 computed tomography angiographies (CTA) of lower limbs for virtual surgical planning (VSP) for jaw reconstruction. The purpose of the investigation was to evaluate the morphology of the fibular bone and its vascular supply in CTA imaging, and further, the amount and distribution of periosteal branches (PB) and septo-cutaneous perforators (SCPs) of the fibular artery. A total of 144 lower limbs was assessed (mean age: 58.5 ± 15.3 years; 28 females, 38.9%; 44 males, 61.1%). The vascular system was categorized as regular (type I-A to II-C) in 140 cases (97.2%) regarding the classification by Kim. Absent anterior tibial artery (type III-A, n = 2) and posterior tibial artery (type III-B, n = 2) were detected in the left leg. Stenoses were observed mostly in the fibular artery (n = 11), once in the anterior tibial artery, and twice in the posterior tibial artery. In total, n = 361 periosteal branches (PBs) and n = 231 septo-cutaneous perforators (SCPs) were recorded. While a distribution pattern for PBs was separated into two clusters, a more tripartite distribution pattern for SCPs was found. We conclude that conventional CTA for VSP of free fibula flap (FFF) is capable of imaging and distinguishing SCPs and PBs.

Preoperative Angiography for Free Fibula Flap Harvest: A Case Series

Purpose:

To assess if preoperative angiography of the lower extremity is necessary to detect abnormalities that alter operative planning of a free fibula flap (FFF). The secondary objective is to determine whether abnormalities are identified on physical examination.

Methods:

A retrospective case series of patients receiving preoperative lower extremity angiography for FFF was performed. Between November 2004 and July 2016, patients assessed for FFF reconstruction by a single surgeon were reviewed. Outcomes analyzed were preoperative physical examination, angiography findings, changes in operative plan, and perioperative complications including flap failure and limb ischemia. Level of agreement between physical examination and angiography findings was analyzed.

Results:

A total of 132 consecutive patients were assessed for FFF, of which 70 met the inclusion criteria. Mean age was 60.9 (range: 22-88) years old. All patients underwent aortic angiogram runoff, except for 2 who received computed tomography angiography. The surgical plan was altered based on angiography findings in 9 (12.9%) patients, and 7 (77.8%) of these cases had a normal physical examination. A further 6 (8.6%) patients had physical examination findings precluding the use of FFF, whereas imaging demonstrated the contrary. Physical examination demonstrated low predictability of aberrant vascular anatomy, with a sensitivity of 22.2%. There were no limb ischemia complications.

Conclusions:

Routine preoperative angiography of the lower extremity for all patients being evaluated for FFF is important to ensure safety and success of the procedure. Physical examination alone is insufficient to detect vascular abnormalities that may result in limb or flap compromise.

Accuracy of Computer-Assisted Surgery in Maxillary Reconstruction: A Systematic Review

Computer-assisted surgery (CAS) in maxillary reconstruction has proven its value regarding more predictable postoperative results. However, the accuracy evaluation methods differ between studies, and no meta-analysis has been performed yet. A systematic review was performed in the PubMed, Embase, and Cochrane Library databases, using a Patient, Intervention, Comparison and Outcome (PICO) method: (P) patients in need of maxillary reconstruction using free osteocutaneous tissue transfer, (I) reconstructed according to a virtual plan in CAS software, (C) compared to the actual postoperative result, and (O) postoperatively measured by a quantitative accuracy assessment) search strategy, and was reported according to the PRISMA statement. We reviewed all of the studies that quantitatively assessed the accuracy of maxillary reconstructions using CAS. Twelve studies matched the inclusion criteria, reporting 67 maxillary reconstructions. All of the included studies compared postoperative 3D models to preoperative 3D models (revised to the virtual plan). The postoperative accuracy measurements mainly focused on the position of the fibular bony segments. Only approximate comparisons of postoperative accuracy between studies were feasible because of small differences in the postoperative measurement methods; the accuracy of the bony segment positioning ranged between 0.44 mm and 7.8 mm, and between 2.90° and 6.96°. A postoperative evaluation guideline to create uniformity in evaluation methods needs to be considered so as to allow for valid comparisons of postoperative results and to facilitate meta-analyses in the future. With the proper validation of the postoperative results, future research might explore more definitive evidence regarding the management and superiority of CAS in maxillary and midface reconstruction.

Combination of CAD/CAM and Augmented Reality in Free Fibula Bone Harvest

Supplemental Digital Content is available in the text.

The CAD/CAM technology for mandibular reconstruction has improved the results in terms of outcomes in restoring mandibular complex defects. Augmented reality (AR) represents an evolution of the navigation-assisted surgery. This technology merges the images of the virtual planning with the anatomy of the patient, representing in this way an enhanced scene for the surgeon’s eye. AR can also display in a single scene additional information for the surgeon. Despite of classical navigation, this scenario can be obtained with marker-less registration method, without using reference points or fiducial markers. This technologic evolution together with the large use in our experience of CAD/CAM protocol for mandibular reconstruction we developed this feasibility study to evaluate the possibility of using a marker-less image registration system. Moreover, we tried to evaluate the overlaying of the virtual planning and its reproducibility using AR. We performed a case series of 3 consecutive patients who underwent mandibular reconstruction using AR-assisted fibular free flap harvesting applying our digital workflow. Once launched, the mobile app installed on our tablet, the registration is performed according to a shape recognition system of the leg of the patient, rendering in real time a superimposition of the anatomy of the bony, vascular, and skin of the patient and also the surgical planning of the reconstruction. AR-assisted fibular free flap harvesting was performed. We believe that AR can be a prospective improving technology for mandibular complex reconstruction.

Contemporary Approach to Locally Advanced Oral Cavity Squamous Cell Carcinoma

PURPOSE OF REVIEW

Surgical management of locally advanced oral cavity squamous cell carcinomas (OCSCC) has long been recognized as a primary treatment modality. Technological advances have led to significant improvements in our surgical approach, from improvement in the visualization of tumors to more efficient and precise reconstruction. Here, we review the latest technological advances in surgical extirpation and reconstruction of locally advanced OCSCCs.

RECENT FINDINGS

The focus of technological innovation in surgical extirpation has been on improving visualization, with the use of intraoperative ultrasound for margin delineation, intraoperative navigation, narrow-band imaging, and the use of fluorescence. Though early, these are promising steps to ensuring complete resection of the cancer. Advances in reconstruction have been centered on the incorporation of computer assisted design, manufacturing, and virtual surgical planning, allowing for more complex three-dimensional defects to be expeditiously reconstructed. As these technologies are still under development, their impact on oncologic outcomes are not yet robustly defined; however, as technology continues to advance and become more widely available, new technologies will undoubtedly become integrated into enhancing surgical precision and planning.

Effectiveness of computer-assisted virtual planning, cutting guides and pre-engineered plates on outcomes in mandible fibular free flap reconstructions: a systematic review protocol

OBJECTIVE

The objective of this review is to synthesize the best available evidence on the outcomes of mandibular fibular free flap (MFFF) reconstructions using computer-assisted techniques versus traditional freehand techniques.

INTRODUCTION

Fibular free flaps are the most commonly used free flap for mandible reconstruction and are considered best practice for mandible reconstructions following resection of head and neck cancers. There are several reported advantages of computer-assisted MFFF reconstructions, including increased accuracy, decreased operation time, decreased ischemia time, decreased overall cost and improved patient outcomes. It is important to assess the advantages and potential harms of these techniques in a systematic review.

INCLUSION CRITERIA

Eligible studies will consider patients of all ages undergoing MFFF reconstruction. Studies will compare computer-assisted techniques to traditional freehand techniques for the primary outcomes of flap failure, patient-reported outcomes and bony resection margin status. Studies published in English from 2008 will be included. Experimental, quasi-experimental, prospective and retrospective cohort, case-control and analytical cross-sectional studies will be considered.

METHODS

MEDLINE, Embase, Scopus and the Cochrane Central Register of Controlled Trials will be searched. Gray literature sources will include Google Scholar and the World Health Organization International Clinical Trials Registry Platform. Two independent reviewers will screen titles and abstracts, assess full-text papers against the inclusion criteria, evaluate methodological quality using standardized critical appraisal instruments and extract data using a customized form. If possible, data will be pooled for statistical meta-analysis, and a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings will be presented.

Magnetic resonance angiography for free fibula harvest: anatomy and perforator mapping

The purpose of this study was to outline lower leg vessel anatomy and to investigate reliability and limitations of magnetic resonance angiography (MRA) in patients proposed for microvascular fibula transplantation (free fibula flap (FFF)). We retrospectively investigated MRAs of 99 patients considered for FFF. Frontal MRA planes and maximal intensity projections (MIPs) were evaluated for fibula lengths, anatomical branching pattern, arterial stenoses and fibular perforator positions in both legs (n=198). Normal branching patterns were observed in 168 (85.3%) legs. Twenty-nine (14.7%) legs presented abnormal branching patterns. Once (0.5%) the anterior, 19 times (9.6%) the posterior tibial artery were absent or hypoplastic. Nine (4.6%) lower legs presented an arteria peronea magna. Average length of the tibiofibular trunk (TFT) was 3.3±0.15cm. A total of 492 perforators were found with an average of 2.5 (±0.82±0.99) perforators per leg. A mapping of perforator run-offs was illustrated true to scale. Lower limb stenoses were distributed in the anterior tibial artery (14.1%), in the posterior tibial artery (11.1%) and in the fibular artery (8.1%). Smoking (P=0.828), diabetes (P=0.727) and peripheral arterial occlusive disease (P=0.172) did not correlate with presence of stenoses. Preoperative lower limb angiography avoids postoperative complications. MRA reliably and non-invasively identifies anatomical variants and arterial stenoses without radiation. Illustration of perforator run-offs enhances incision planning for fibula harvest.

VIDEO: Preoperative CT Angiography for Scapula Osteocutaneous Free Flap Reconstructions

OBJECTIVE. The objective of this video article is to discuss the use of the scapular osteocutaneous free flap in reconstructive procedures. We attempt to discuss normal and variant vascular anatomy, image acquisition via CT angiography, and image interpretation as well as computer-assisted design and manufacturing. CONCLUSION. The scapular osteocutaneous free flap is commonly used for maxillary and mandibular reconstructive surgery. The complex vasculature supplying the scapular region allows flap versatility. There are anatomic variations in the origin of the circumflex scapular and angular arteries. Our method of performing and reporting CT angiography for patients scheduled to undergo scapular osteocutaneous free flap procedures provides a reliable and reproducible means of communicating important elements of vasculature to surgeons. This in turn can facilitate the manufacturing of custom scapular cutting guides and improve surgical outcomes.

Computer-assisted surgery for reconstruction of complex mandibular defects using osteomyocutaneous microvascular fibular free flaps: Use of a skin paddle-outlining guide for soft-tissue reconstruction. A technical report

INTRODUCTION

We present our pre-operative virtual planning of complex mandibular reconstruction with a microvascular fibular composite free flap and its harvesting using our novel cutaneous positioning guide based on the perforator vessels for our soft tissue reconstructive surgery.

TECHNICAL REPORT

We applied our protocol to 42 consecutive patients needing mandibular composite reconstruction. All patients were preoperatively studied with a CTA scan to evaluate the fibular pattern of vascularization and the perforator vessels three-dimensional path and position. Computer assisted surgery (CAS) was performed: a skin paddle outlining guide (SPOG) was designed to reproduce the shape and area of the planned soft tissue resection. CTA measurements and in vivo findings were compared. After performing the CTA, we classified the viable perforators in High Perforators, Medium Perforators and Low Perforators. The average diameter of the perforator vessels was 3 mm. The average difference between the measurements performed on the CTA and the intra-operative measures was 1, 4 mm. The SPOG was based on calf proximal and distal diameters. The anatomical fitting of the guide was obtained thanks to two customized flanges that embrace circumferentially the proximal and distal portions of the leg. The SPOG encompassed appropriate skin/leg regions, allowing the surgeon to localise the required perforator vessel.

CONCLUSIONS

CTA protocol appears to be a valuable approach to asses and virtually simulate composite mandibular reconstructions. The SPOG seems to be a valuable tool to reproduce intra-operatively the planned soft tissue area to be reconstructed.

Vascular anatomy of the free fibula flap including the lateral head of the soleus muscle applied to maxillo-mandibular reconstruction

PURPOSE

Initially described by Baudet in 1982, the fibula flap including the lateral head of the soleus muscle allows a one-stage reconstruction for large maxillo-mandibular defects. The aim of this study was to evaluate the number of muscular branches destined to the soleus muscle and their distance from the origin of the fibular artery, to assess the vascular anatomy of the free fibula flap including the lateral head of the soleus muscle applied to maxillo-mandibular reconstruction.

METHODS

We performed a cadaveric anatomic study on ten lower limbs, and a CT angiography anatomic study on 38 legs. The number of soleus branches originating from the fibular artery, and the distance between the origin of the fibular artery and each of the identified branches were measured.

RESULTS

The number of soleus branches destined to the lateral head of the soleus muscle is variable, with in our study 1-3 branches found. Soleus branches destined to the lateral head of the soleus muscle emerged at a distance ranging between 0 and 2.9 cm (mean value = 1.82 cm) from the origin of the fibular artery in 40% of cases, between 3 and 5.9 cm (mean value = 4.27 cm) from the origin of the fibular artery in 37% of cases, and was at a distance of 6 cm or more (mean value = 6.93 cm) from the origin of the fibular artery in 20% of cases.

CONCLUSIONS

An origin of the soleus vessels in close proximity to the origin of the fibular artery represents the main limitation of this flap, the length of the remaining fibular pedicle making it difficult to achieve secure anastomosis in the cervical area. The vascular distribution of the proximal part of the lateral head of the soleus muscle being segmental, it is possible to lengthen the flap pedicle ligating the most proximal soleus branches originating from the fibular artery.

Updates in Head and Neck Reconstruction

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Have a basic understanding of virtual planning, rapid prototype modeling, three-dimensional printing, and computer-assisted design and manufacture. 2. Understand the principles of combining virtual planning and vascular mapping. 3. Understand principles of flap choice and design in preoperative planning of free osteocutaneous flaps in mandible and midface reconstruction. 4. Discuss advantages and disadvantages of computer-assisted design and manufacture in reconstruction of advanced oncologic mandible and midface defects.

SUMMARY

Virtual planning and rapid prototype modeling are increasingly used in head and neck reconstruction with the aim of achieving superior surgical outcomes in functionally and aesthetically critical areas of the head and neck compared with conventional reconstruction. The reconstructive surgeon must be able to understand this rapidly-advancing technology, along with its advantages and disadvantages. There is no limit to the degree to which patient-specific data may be integrated into the virtual planning process. For example, vascular mapping can be incorporated into virtual planning of mandible or midface reconstruction. Representative mandible and midface cases are presented to illustrate the process of virtual planning. Although virtual planning has become helpful in head and neck reconstruction, its routine use may be limited by logistic challenges, increased acquisition costs, and limited flexibility for intraoperative modifications. Nevertheless, the authors believe that the superior functional and aesthetic results realized with virtual planning outweigh the limitations.

Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases

Sensate, durable heel pad reconstruction is challenging. The present study assessed the functional outcomes after heel pad reconstruction using various flap techniques at our institution. From June 2011 to June 2016 (5-year period), 7 consecutive patients underwent heel pad reconstruction for various etiologies, with 3 microvascular free flaps (42.9%; 2 musculocutaneous flaps [66.7%] and 1 contralateral medial plantar flap [33.3%]) and 4 local pedicle flaps (57.1%; 3 instep medial plantar artery flaps [75.0%] and 1 distally based reverse sural flap [25.0%]). The patient records and demographic data were reviewed, and surgically related information was obtained and analyzed. The subjective components of the American Orthopaedic Foot and Ankle Society hindfoot clinical ratings scale were used to evaluate the pain and functional outcomes. Sensation was assessed using Semmes-Weinstein monofilaments, and ulcer recurrence was recorded. The mean age of the patients was 41.7 (range 11 to 70) years, the mean defect size was 59 (range 12 to 270) cm², and the mean follow-up duration was 22 (range 15 to 43) months. Complete flap survival was achieved without significant complications in all 7 patients. Patients treated with the sensate medial plantar artery flap recorded the highest mean American Orthopaedic Foot and Ankle Society score of 57.3 (maximum score of 60) and experienced a return of deep sensation at 6 (range 6 to 24) months and protective sensation at 1 year. This was followed by the reverse sural flap and the musculocutaneous flap. No recurrent heel ulceration was observed in our series of patients. In conclusion, the sensate medial plantar flap is a satisfactory method for coverage of small- to moderate-size heel defects.

VIDEO: Preoperative CT Angiography for Fibular Free Flap Reconstructions

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.

Virtual Surgical Planning: The Pearls and Pitfalls

Objective

Over the past few years, virtual surgical planning (VSP) has evolved into a useful tool for the craniofacial surgeon. Virtual planning and computer-aided design and manufacturing (CAD/CAM) may assist in orthognathic, cranio-orbital, traumatic, and microsurgery of the craniofacial skeleton. Despite its increasing popularity, little emphasis has been placed on the learning curve.

Methods

A retrospective analysis of consecutive virtual surgeries was done from July 2012 to October 2016 at the University of Montreal Teaching Hospitals. Orthognathic surgeries and free vascularized bone flap surgeries were included in the analysis.

Results

Fifty-four virtual surgeries were done in the time period analyzed. Forty-six orthognathic surgeries and 8 free bone transfers were done. An analysis of errors was done. Eighty-five percentage of the orthognathic virtual plans were adhered to completely, 4% of the plans were abandoned, and 11% were partially adhered to. Seventy-five percentage of the virtual surgeries for free tissue transfers were adhered to, whereas 25% were partially adhered to. The reasons for abandoning the plans were (1) poor communication between surgeon and engineer, (2) poor appreciation for condyle placement on preoperative scans, (3) soft-tissue impedance to bony movement, (4) rapid tumor progression, (5) poor preoperative assessment of anatomy.

Conclusion

Virtual surgical planning is a useful tool for craniofacial surgery but has inherent issues that the surgeon must be aware of. With time and experience, these surgical plans can be used as powerful adjuvants to good clinical judgement.

Three-Dimensional Image Fusion of 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography and Contrast-Enhanced Computed Tomography for Computer-Assisted Planning of Maxillectomy of Recurrent Maxillary Squamous Cell Carcinoma and Defect Reconstruction

PURPOSE

The purpose of this study was to describe new technology assisted by 3-dimensional (3D) image fusion of ¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced CT (CECT) for computer planning of a maxillectomy of recurrent maxillary squamous cell carcinoma and defect reconstruction.

MATERIALS AND METHODS

Treatment of recurrent maxillary squamous cell carcinoma usually includes tumor resection and free flap reconstruction. FDG-PET/CT provided images of regions of abnormal glucose uptake and thus showed metabolic tumor volume to guide tumor resection. CECT data were used to create 3D reconstructed images of vessels to show the vascular diameters and locations, so that the most suitable vein and artery could be selected during anastomosis of the free flap. The data from preoperative maxillofacial CECT scans and FDG-PET/CT imaging were imported into the navigation system (iPlan 3.0; Brainlab, Feldkirchen, Germany). Three-dimensional image fusion between FDG-PET/CT and CECT was accomplished using Brainlab software according to the position of the 2 skulls simulated in the CECT image and PET/CT image, respectively. After verification of the image fusion accuracy, the 3D reconstruction images of the metabolic tumor, vessels, and other critical structures could be visualized within the same coordinate system. These sagittal, coronal, axial, and 3D reconstruction images were used to determine the virtual osteotomy sites and reconstruction plan, which was provided to the surgeon and used for surgical navigation.

RESULTS

The average shift of the 3D image fusion between FDG-PET/CT and CECT was less than 1 mm. This technique, by clearly showing the metabolic tumor volume and the most suitable vessels for anastomosis, facilitated resection and reconstruction of recurrent maxillary squamous cell carcinoma.

CONCLUSIONS

We used 3D image fusion of FDG-PET/CT and CECT to successfully accomplish resection and reconstruction of recurrent maxillary squamous cell carcinoma. This method has the potential to improve the clinical outcomes of these challenging procedures.

Successful Harvest of Free Fibula Flap in a Rare Anomalous Variant of the Peroneal Artery

We present a case of successful harvest and anastomosis of a free fibula flap with 15 cm of bone where the peroneal artery was only 1.0 cm long and situated in the distal 1/3rd of the fibula.

Improved operative efficiency of free fibula flap mandible reconstruction with patient-specific, computer-guided preoperative planning

BACKGROUND

Free fibula osteocutaneous flaps are the primary option for reconstruction after segmental mandibulectomies. This study evaluates the impact of CT-guided preoperative planning on operative outcomes after free fibula mandible reconstruction.

METHODS

We conducted a retrospective review of all patients undergoing free fibula reconstruction of the mandible from 2002 to 2011.

RESULTS

Fifty-seven patients underwent free fibula osteocutaneous flap reconstruction for head and neck cancers involving the mandible. Twelve patients had shaping of the neomandible performed on the back table while 20 patients underwent shaping in situ without the use of any adjunctive technology. The remaining 25 patients underwent preoperative CT imaging, which significantly decreased operative time (707 minutes vs 534 minutes; p < .0003) as well as overall costs ($24,532.50 vs $20,950.48). There were no significant differences in outcomes or complications.

CONCLUSION

Preoperative, patient-specific CT modeling, and cutting guide fabrication outweigh the costs associated with the additional technology without jeopardizing overall outcomes or increasing complication rates.