CTA perforator localization for virtual surgical planning of osteocutaneous fibular free flaps in head and neck reconstruction

Publication date: Available online 10 April 2018
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Kyle S. Ettinger, Amy E. Alexander, Kevin Arce
Virtual surgical planning (VSP), computer aided design (CAD)/computer aided modeling (CAM), and 3D printing are three distinct technologies that have become increasingly employed within head and neck oncology and microvascular reconstruction. While each of these technologies have long been utilized for treatment planning within other surgical disciplines such as craniofacial surgery, trauma surgery, temporomandibular joint surgery, and orthognathic surgery, its widespread use within the field of head and neck reconstructive surgery remains a much more recent event.In response to the growing trend of VSP being employed for the planning of fibular free flaps within head and neck reconstruction, some surgeons have questioned the technology's implementation on the basis of its inadequacy in addressing other reconstructive considerations beyond hard tissue anatomy. Detractors of VSP for head and neck reconstruction highlight its lack of capability in accounting for multiple reconstructive factors such as recipient vessel selection, vascular pedicle reach, need for dead space obliteration, and skin paddle perforator location. It is with this premise in mind that that we report a straightforward technique for anatomically localizing peroneal artery perforators during virtual surgical planning for osteocutaneous fibular free flaps where both bone and a soft tissue skin paddle are required for ablative reconstruction. The technique allows for anatomical perforator localization during the virtual surgical planning session solely based on data existent within the preoperative computed tomographic angiography (CTA); it does not require any modifications to preoperative clinical workflows. It is our presumption that many surgeons within the field are unaware of this planning capability within the context of modern VSP for head and neck reconstruction. The primary purpose of this manuscript is to introduce and further familiarize surgeons with the technique of CTA perforator localization as a method of improving intraoperative fidelity for virtual surgical planning of osteocutaneous fibular free flaps.



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