Magnetic Resonance Angiography for Free Fibula Flap Transfer

ABSTRACT

Recent refinements of magnetic resonance angiography (MRA) allow imaging vessels as small as the septocutaneous perforators (≤ 1 to 2 mm diameter), but a Medline review reveals no report of septocutaneous vessel imaging for free flap surgery. Challenges in fibula free flap preparation include knowledge of: (1) tibioperoneal anatomy, (2) the positions of the perforator vessels on the peroneal artery and their course in the posterolateral intermuscular septum, and (3) the cutaneous distribution of the perforators. Questioning whether high-resolution MRA could image these, we studied the lower extremities of nine healthy volunteers. MRA demonstrated tibioperoneal anatomy in sufficient detail to exclude anatomic variants and significant peripheral vascular disease and showed septocutaneous perforators arising from the peroneal artery and coursing in the posterolateral intermuscular septum to the skin. High-resolution MRA provided anatomic and clinical information that conventionally has been impossible to obtain preoperatively or has required multiple tests, often of an invasive nature.

KEYWORDS

Free fibula flap - septocutaneous perforator - MRA

REFERENCES

• 1 Taylor G I, Miller G D, Ham F J. The free vascularized bone graft. A clinical extension of microvascular techniques.  Plast Reconstr Surg. 1975;  55 533-544
• 2 Chen Z W, Yan W. The study and clinical application of the osteocutaneous flap of fibula.  Microsurgery. 1983;  4 11-16
• 3 Yoshimura M, Shimamura K, Iwai Y et al.. Free vascularized fibular transplant. A new method for monitoring circulation of the grafted fibula.  J Bone Joint Surg Am. 1983;  65 1295-1301
• 4 Yoshimura M, Imura S, Shimamura K et al.. Peroneal flap for reconstruction in the extremity: preliminary report.  Plast Reconstr Surg. 1984;  74 402-409
• 5 Wei F C, Chen H C, Chuang C C, Noordhoff M S. Fibular osteoseptocutaneous flap: anatomic study and clinical application.  Plast Reconstr Surg. 1986;  78 191-200
• 6 Hidalgo D A. Fibula free flap: a new method of mandible reconstruction.  Plast Reconstr Surg. 1989;  84 71-79
• 7 Yim K K, Wei F C. Fibula osteoseptocutaneous flap for mandible reconstruction.  Microsurgery. 1994;  15 245-249
• 8 Jones N F, Monstrey S, Gambier B A. Reliability of the fibular osteocutaneous flap for mandibular reconstruction: anatomical and surgical confirmation.  Plast Reconstr Surg. 1996;  97 707-716 discussion 717-708
• 9 Hidalgo D A. Fibula free flap mandible reconstruction.  Microsurgery. 1994;  15 238-244
• 10 Carroll W R, Esclamado R. Preoperative vascular imaging for the fibular osteocutaneous flap.  Arch Otolaryngol Head Neck Surg. 1996;  122 708-712
• 11 Young D M, Trabulsy P P, Anthony J P. The need for preoperative leg angiography in fibula free flaps.  J Reconstr Microsurg. 1994;  10 283-287 discussion 287-289
• 12 Kim D, Orron D E, Skillman J J. Surgical significance of popliteal arterial variants. A unified angiographic classification.  Ann Surg. 1989;  210 776-781
• 13 Beppu M, Hanel D P, Johnston G H et al.. The osteocutaneous fibula flap: an anatomic study.  J Reconstr Microsurg. 1992;  8 215-223
• 14 Lamberty B G, Cormack G C. Progress in flap surgery: greater anatomical understanding and increased sophistication in application.  World J Surg. 1990;  14 776-785
• 15 Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization.  Ann Plast Surg. 1986;  16 1-19
• 16 Schusterman M A, Reece G P, Miller M J. Osseous free flaps for orbit and midface reconstruction.  Am J Surg. 1993;  166 341-345
• 17 Yoshimura M, Shimada T, Hosokawa M. The vasculature of the peroneal tissue transfer.  Plast Reconstr Surg. 1990;  85 917-921
• 18 Schusterman M A, Reece G P, Miller M J, Harris S. The osteocutaneous free fibula flap: is the skin paddle reliable?.  Plast Reconstr Surg. 1992;  90 787-793 discussion 794-788
• 19 Anthony J P, Ritter E F, Young D M, Singer M I. Enhancing fibula free flap skin island reliability and versatility for mandibular reconstruction.  Ann Plast Surg. 1993;  31 106-111
• 20 Harrison D H. The osteocutaneous free fibular graft.  J Bone Joint Surg Br. 1986;  68 804-807
• 21 Wei F C, Chuang S S, Yim K K. The sensate fibula osteoseptocutaneous flap: a preliminary report.  Br J Plast Surg. 1994;  47 544-547
• 22 Wolff K D, Ervens J, Herzog K, Hoffmeister B. Experience with the osteocutaneous fibula flap: an analysis of 24 consecutive reconstructions of composite mandibular defects.  J Craniomaxillofac Surg. 1996;  24 330-338
• 23 Yim K K, Wei F C. Fibula osteoseptocutaneous free flap in maxillary reconstruction.  Microsurgery. 1994;  15 353-357
• 24 Hidalgo D A. Aesthetic improvements in free-flap mandible reconstruction.  Plast Reconstr Surg. 1991;  88 574-585 discussion 586-577
• 25 Hingorani A, Ascher E, Markevich N et al.. A comparison of magnetic resonance angiography, contrast arteriography, and duplex arteriography for patients undergoing lower extremity revascularization.  Ann Vasc Surg. 2004;  18 294-301
• 26 Meuli R A, Wedeen V J, Geller S C et al.. MR gated subtraction angiography: evaluation of lower extremities.  Radiology. 1986;  159 411-418
• 27 Cambria R P, Kaufman J A, L'Italien G J et al.. Magnetic resonance angiography in the management of lower extremity arterial occlusive disease: a prospective study.  J Vasc Surg. 1997;  25 380-389
• 28 Hoch J R, Tullis M J, Kennell T W et al.. Use of magnetic resonance angiography for the preoperative evaluation of patients with infrainguinal arterial occlusive disease.  J Vasc Surg. 1996;  23 792-800 discussion 801
• 29 Manaster B J, Coleman D A, Bell D A. Magnetic resonance imaging of vascular anatomy before vascularized fibular grafting.  J Bone Joint Surg Am. 1990;  72 409-414
• 30 Carriquiry C, Aparecida Costa M, Vasconez L O. An anatomic study of the septocutaneous vessels of the leg.  Plast Reconstr Surg. 1985;  76 354-363
• 31 Hidalgo D A. Fibula free flap mandibular reconstruction.  Clin Plast Surg. 1994;  21 25-35
• 32 Anthony J P, Rawnsley J D, Benhaim P et al.. Donor leg morbidity and function after fibula free flap mandible reconstruction.  Plast Reconstr Surg. 1995;  96 146-152
• 33 Flemming A F, Brough M D, Evans N D et al.. Mandibular reconstruction using vascularised fibula.  Br J Plast Surg. 1990;  43 403-409
• 34 van Twisk R, Pavlov P W, Sonneveld J. Reconstruction of bone and soft tissue defects with free fibula transfer.  Ann Plast Surg. 1988;  21 555-558
• 35 Onishi K, Maruyama Y, Iwahira Y. Cutaneous and fascial vasculature of the leg: anatomic study of fasciocutaneous vessels.  J Reconstr Microsurg. 1986;  2 181-189
• 36 Goodacre T E, Walker C J, Jawad A S et al.. Donor site morbidity following osteocutaneous free fibula transfer.  Br J Plast Surg. 1990;  43 410-412