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Surgical and Radiologic Anatomy
Published in: Surgical and Radiologic Anatomy 4/2010

01-04-2010 | Original Article

Clinical study of peroneal artery perforators with computed tomographic angiography: implications for fibular flap harvest

Authors: Diego Ribuffo, Matteo Atzeni, Luca Saba, Maristella Guerra, Giorgio Mallarini, Ernesto Biagio Proto, Damien Grinsell, Mark W. Ashton, Warren M. Rozen

Published in: Surgical and Radiologic Anatomy | Issue 4/2010

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Abstract

Purpose

Previous studies of cutaneous perforators of the peroneal artery have shown great variability, and attest to the significant anatomical variability in this region. Furthermore, the vascular anatomy of the region has been considered unreliable in the prediction of ideal perforator topography. Preoperative imaging has been suggested as a means for improving preoperative awareness, with Doppler ultrasound and eco-colour (duplex) ultrasound as useful tools. Multi-detector row computed tomographic angiography (CTA or angio CT), has emerged as a significant improvement, providing non-invasive operator-independent details of the vascular anatomy. We utilised this tool to perform an in vivo, anatomical study of the peroneal artery perforators, and demonstrating the usefulness of CTA in planning the osteocutaneous free fibula flap.

Methods

Forty-one consecutive patients (82 limbs) underwent CTA of the lower limb vasculature, with the anatomical details of the peroneal artery cutaneous perforators assessed.

Results

CTA was able to demonstrate the size, course and penetration pattern of all perforators over 0.3 mm in diameter, with measurements for perforators over 0.8 mm diameter recorded for analysis. Of 171 such perforators, accurate identification of the size (mean diameter 1.91 mm), course (59.6% septocutaneous, 29.2% musculocutaneous and 11.1% septomusculocutaneous) and location was achieved.

Conclusion

The vascular anatomy of peroneal artery perforators is highly variable, and thus there is a role for preoperative imaging. CTA can demonstrate cases where there is aberrant or non-preferred anatomy, or select the limb of choice for harvest.
Literature
1.
Anthony JP, Ritter EF, Young DM et al (1993) Enhancing fibula free flap skin island reliability and versatility for mandibular reconstruction. Ann Plast Surg 31(2):106–111CrossRefPubMed
2.
Bardsley JL, Staple TW (1970) Variations in branching of the popliteal artery. Radiology 94(3):581–587PubMed
3.
Beppu M, Hanel DP, Johnston GH et al (1992) The osteocutaneous fibula flap: an anatomic study. J Reconstr Microsurg 8(3):215–223CrossRefPubMed
4.
Blondeel PN, Beyens G, Verghaege R (1998) Doppler flowmetry in the planning of perforators flaps. Br J Plast Surg 51:202CrossRefPubMed
5.
Bretzman PA, Manaster BJ, Davis WL et al (1994) MR angiography for preoperative evaluation of vascularized fibular grafts. J Vasc Interv Radiol 5(4):603–610CrossRefPubMed
6.
Cambria RP, Kaufman JA, L’Italien GJ et al (1997) Magnetic resonance angiography in the management of lower extremity arterial occlusive disease: a prospective study. J Vasc Surg 25(2):380–389CrossRefPubMed
7.
Chen ZW, Yan W (1983) The study and clinical application of the osteocutaneous flap of fibula. Microsurgery 4(1):11–16CrossRefPubMed
8.
Cho BC, Kim SY, Park JW et al (2001) Blood supply to osteocutaneous free fibula flap and peroneus longus muscle: prospective anatomic study and clinical applications. Plast Reconstr Surg 108(7):1963–1971CrossRefPubMed
9.
Chow LC, Napoli A, Klein MB et al (2005) Vascular mapping of the leg with multi-detector row CT angiography prior to free-flap transplantation. Radiology 237(1):353–360CrossRefPubMed
10.
Cordeiro PG, Disa JJ, Hidalgo DA et al (1999) Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients. Plast Reconstr Surg 104(5):1314–1320CrossRefPubMed
11.
Dublin BA, Karp NS, Kasabian AK et al (1997) Selective use of preoperative lower extremity arteriography in free flap reconstruction. Ann Plast Surg 38(4):404–407CrossRefPubMed
12.
Fukaya E, Grossman RF, Saloner D et al (2007) Magnetic resonance angiography for free fibula flap transfer. J Reconstr Microsurg 23(4):205–211CrossRefPubMed
13.
Futran ND, Stack BC Jr, Payne LP (1997) Use of color Doppler flow imaging for preoperative assessment in fibular osteoseptocutaneous free tissue transfer. Otolaryngol Head Neck Surg 117(6):660–663CrossRefPubMed
14.
Futran ND, Stack BC Jr, Zaccardi MJ (1998) Preoperative color flow Doppler imaging for fibula free tissue transfers. Ann Vasc Surg 12(5):445–450CrossRefPubMed
15.
Giunta RE, Geisweid A, Feller AM (2000) The value of preoperative Doppler sonography for planning free perforator flaps. Plast Reconstr Surg 105(7):2381–2386CrossRefPubMed
16.
Hallock GG (2003) Doppler sonography and color duplex imaging for planning a perforator flap. Clin Plast Surg 30:347CrossRefPubMed
17.
Harrison DH (1986) The osteocutaneous free fibular graft. J Bone Joint Surg Br 68(5):804–807PubMed
18.
Hidalgo DA (1989) Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 84(1):71–79CrossRefPubMed
19.
Hingorani A, Ascher E, Markevich N et al (2004) A comparison of magnetic resonance angiography, contrast arteriography, and duplex arteriography for patients undergoing lower extremity revascularization. Ann Vasc Surg 18(3):294–301CrossRefPubMed
20.
Isenberg JS, Sherman R (1996) The limited value of preoperative angiography in microsurgical reconstruction of the lower limb. J Reconstr Microsurg 12(5):303–305 discussion 306CrossRefPubMed
21.
Johnson PT, Heath DG, Kuszyk BS et al (1996) CT angiography with volume rendering: advantages and applications in splanchnic vascular imaging. Radiology 200:564–568PubMed
22.
Jones NF, Monstrey S, Gambier BA (1996) Reliability of the fibular osteocutaneous flap for mandibular reconstruction: anatomical and surgical confirmation. Plast Reconstr Surg 97(4):707–716CrossRefPubMed
23.
Kessler P, Wiltfang J, Schultze-Mosgau S (2001) The role of angiography in the lower extremity using free vascularized fibular transplants for mandibular reconstruction. Craniomaxillofac Surg 29(6):332–336
24.
Kim D, DE Orron, Skillman JJ (1989) Surgical significance of popliteal arterial variants. A unified angiographic classification. Ann Surg 210(6):776–781CrossRefPubMed
25.
Koelemay MJ, Lijmer JG, Stoker J et al (2001) Magnetic resonance angiography for the evaluation of lower extremity arterial disease: a meta-analysis. JAMA 285(10):1338–1345CrossRefPubMed
26.
Lutz BS, Wei FC, Ng SH et al (1999) Routine donor leg angiography before vascularized free fibula transplantation is not necessary: a prospective study in 120 clinical cases. Plast Reconstr Surg 103(1):121–127CrossRefPubMed
27.
Mauro MA, Jaques PF, Moore M (1988) The popliteal artery and its branches: embryologic basis of normal and variant anatomy. AJR Am J Roentgenol 150(2):435–437PubMed
28.
Nakazawa H, Nozaki M, Higasimori T et al (2005) Fibula osteoseptocutaneous flap with a variant perforator and peroneal artery arising from the anterior tibial artery. J Reconstr Microsurg 21(2):119–124CrossRefPubMed
29.
Napel S, Rubin GD, Jeffrey RB Jr (1993) STS-MIP: a new reconstruction technique for CT of the chest. J Comput Assist Tomogr 17(5):832–838
30.
Prokop M, Shin HO, Schanz A et al (1997) Use of maximum intensity projections in CT angiography: a basic review. RadioGraphics 17:433–451PubMed
31.
Ribuffo D, Atzeni M, Corrias F et al (2007) Preoperative angio-CT preliminary study of the TRAM flap after selective vascular delay. Ann Plast Surg 59(6):611–616CrossRefPubMed
32.
Ribuffo D, Atzeni M, Saba L et al (2009) Angio CT preoperative evaluation for anterolateral thigh flap harvesting. Ann Plast Surg 62:368–371CrossRefPubMed
33.
Rozen WM, Anavekar NS, Ashton MW et al (2008) Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction? Microsurgery 28(7):516–523CrossRefPubMed
34.
Rozen WM, Ashton MW, Stella DL et al (2008) Magnetic resonance angiography and computed tomographic angiography for free fibular flap transfer. J Reconstr Microsurg 24(6):457–458CrossRefPubMed
35.
Rozen WM, Ashton MW, Pan WR et al (2009) Anatomical variations in the harvest of anterolateral thigh flap perforators: a cadaveric and clinical study. Microsurgery 29(1):16–23CrossRefPubMed
36.
Rozen WM, Ribuffo D, Atzeni M et al. (2009) Current state of the art in perforator flap imaging with computed tomographic angiography. Surg Radiol Anat. Mar 6
37.
Saba L, Caddeo G, Sanfilippo R et al (2007) Efficacy and sensitivity of axial scans and different reconstruction methods in the study of the ulcerated carotid plaque using multidetector-row CT angiography: comparison with surgical results. AJNR Am J Neuroradiol 28(4):716–723PubMed
38.
Saba L, Sanfilippo R, Montisci R et al (2008) Accessory renal artery stenosis and hypertension: are these correlated? Evaluation using multi-detector-row computed tomographic angiography. Acta Radiol 49(3):278–284CrossRefPubMed
39.
Schusterman MA, Reece GP, Miller MJ et al (1992) The osteocutaneous free fibula flap: is the skin paddle reliable? Plast Reconstr Surg 90(5):787–793 discussion 794–798PubMed
40.
Soutar DS (1996) Reliability of the fibular osteocutaneous flap for mandibular reconstruction: anatomical and surgical confirmation. Plast Reconstr Surg 97(4):707–716 discussion 717–719CrossRef
41.
Steffens K, Grübmeyer H, Eren S (1987) Doppler sonography alone in the preoperative planning of free flap transplantations. Handchir Mikrochir Plast Chir 19(5):284–287PubMed
42.
Tan BK, Wong CH (2009) An anomalous septocutaneous perforator to the skin paddle of the fibula osteocutaneous flap originating from the posterior tibial artery. J Plast Reconstr Aesthet Surg 62(5):690–692CrossRefPubMed
43.
Taylor GI, Miller GD, Ham FJ (1975) The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 55(5):533–544PubMed
44.
Weber RA, Pederson WC (1995) Skin paddle salvage in the fibula osteocutaneous free flap with secondary skin paddle vascular anastomosis. J Reconstr Microsurg 11(4):239–241 discussion 242–244CrossRefPubMed
45.
Wei FC, Chen HC, Chuang CC et al (1986) Fibular osteoseptocutaneous flap: anatomic study and clinical application. Plast Reconstr Surg 78(2):191–200CrossRefPubMed
46.
Wei FC, Seah CS, Tsai YC et al (1994) Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg 93(2):294–304 discussion 305–306PubMedCrossRef
47.
Winters HA, de Jongh GJ (1999) Reliability of the proximal skin paddle of the osteocutaneous free fibula flap: a prospective clinical study. Plast Reconstr Surg. 103(3):846–849CrossRefPubMed
48.
Wong CH, Tan BK, Wei FC et al (2007) Use of the soleus musculocutaneous perforator for skin paddle salvage of the fibula osteoseptocutaneous flap: anatomical study and clinical confirmation. Plast Reconstr Surg. 120(6):1576–1584CrossRefPubMed
49.
Yokoo S, Komori T, Furudoi S et al (2001) Rare variant of the intrasoleus musculocutaneous perforator: clinical considerations in raising a free peroneal osteocutaneous flap. J Reconstr Microsurg 17(4):225–228CrossRefPubMed
50.
Yoshimura M, Shimamura K, Iwai Y et al (1983) Free vascularized fibular transplant. A new method for monitoring circulation of the grafted fibula. J Bone Joint Surg Am 65(9):1295–1301PubMed
51.
Young DM, Trabulsy PP, Anthony JP (1994) The need for preoperative leg angiography in fibula free flaps. J Reconstr Microsurg 10(5):283–287 discussion 287–289CrossRefPubMed
Metadata
Title
Clinical study of peroneal artery perforators with computed tomographic angiography: implications for fibular flap harvest
Authors
Diego Ribuffo
Matteo Atzeni
Luca Saba
Maristella Guerra
Giorgio Mallarini
Ernesto Biagio Proto
Damien Grinsell
Mark W. Ashton
Warren M. Rozen
Publication date
01-04-2010
Publisher
Springer-Verlag
Published in
Surgical and Radiologic Anatomy / Issue 4/2010
Print ISSN: 0930-1038
Electronic ISSN: 1279-8517
DOI
https://doi.org/10.1007/s00276-009-0559-y

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