Integration of Perforator Vessels in CAD/CAM Free Fibula Graft Planning: A Clinical Feasibility Study



Commercial CAD/CAM planning of free osteocutaneous microvascular fibula flap does not support integration of soft tissue structures including perforator vessel anatomy. Therefore, in a clinical trial, a method for such a combined hard- and soft tissue 3D-fibula planning was assessed.

Materials and Methods

In a clinical study on 24 patients needing reconstruction with osteocutaneous fibula graft, skin perforators of the respective leg were detected via Doppler sonography and documented on a measurement device. Each of the perforators’ localization was transferred to a CAD/CAM planning software and included in each planning step as well as in the surgical cutting guide. A comparison between sonography and clinical localization, damage to perforator vessels during surgery as well as a subjective evaluation of feasibility and usefulness of the procedure was carried out.


In total, 19 skin paddles were placed orally, 2 extraorally and 3 at both sites at once. Survival rate was 92% (22/24). In addition, 3 skin paddles were lost complete and 2 partially. Anatomical sites of perforator vessels were never < 1 cm from planned positions and not damaged at all (n = 75). Planning was judged useful for skin paddle design and positioning of osteotomies. In accordance, surgical guides were always implemented successfully without the need of changing planned procedures during surgery.


Integration of skin perforators into 3D planning of microvascular fibular graft is feasible and may even decrease involuntary dissection of perforator vessels. Even so, clinical studies for comparison are needed.

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  1. 1.

    Taylor GI, Miller GD, Ham FJ (1975) The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 55(5):533–544

    CAS  Article  Google Scholar 

  2. 2.

    Hidalgo DA (1989) Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 84(1):71–79

    CAS  Article  Google Scholar 

  3. 3.

    Hölzle F, Franz EP, von Diepenbroick VH, Wolff KD (2003) Evaluation der Unterschenkelarterien vor mikrochirurgischem Fibulatransfer. Mund Kiefer GesichtsChir 7(4):246–253.

    Article  PubMed  Google Scholar 

  4. 4.

    Kansy K, Mueller AA, Mücke T, Kopp J-B, Koersgen F, Wolff KD et al (2014) Microsurgical reconstruction of the head and neck—current concepts of maxillofacial surgery in Europe. J Cranio Maxillofac Surg 42(8):1610–1613.

    Article  Google Scholar 

  5. 5.

    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):846–849

    CAS  Article  Google Scholar 

  6. 6.

    Iorio ML, Cheerharan M, Olding M (2012) A systematic review and pooled analysis of peroneal artery perforators for fibula osteocutaneous and perforator flaps. Plast Reconstr Surg 130(3):600–607.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Wolff KD, Bauer F, Wylie J, Stimmer H, Hölzle F, Kesting M (2012) Peroneal perforator flap for intraoral reconstruction. Br J Oral Maxillofac Surg 50(1):25–29.

    Article  PubMed  Google Scholar 

  8. 8.

    Futran ND, Stack JBC, Zaccardi MJ (1998) Preoperative color flow Doppler imaging for fibula free tissue transfers. Ann Vasc Surg 12(5):445–450.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Rodby KA, Turin S, Jacobs RJ, Cruz JF, Hassid VJ, Kolokythas A et al (2014) Advances in oncologic head and neck reconstruction: systematic review and future considerations of virtual surgical planning and computer aided design/computer aided modeling. J Plast Reconstr Aesthet Surg 67(9):1171–1185.

    Article  PubMed  Google Scholar 

  10. 10.

    Rohner D, Guijarro-Martínez R, Bucher P, Hammer B (2013) Importance of patient-specific intraoperative guides in complex maxillofacial reconstruction. J Cranio Maxillofac Surg 41(5):382–390.

    Article  Google Scholar 

  11. 11.

    Alassaf MH, Li W, Joshi AS, Hahn JK (2014) Computer-based planning system for mandibular reconstruction. Stud Health Technol Inform 196:6–10

    PubMed  Google Scholar 

  12. 12.

    General Assembly of the World Medical A (2014) World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Coll Dent 81(3):14–18

    Google Scholar 

  13. 13.

    Holzle F, Kesting MR, Holzle G, Watola A, Loeffelbein DJ, Ervens J et al (2007) Clinical outcome and patient satisfaction after mandibular reconstruction with free fibula flaps. Int J Oral Maxillofac Surg 36(9):802–806.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Ribuffo D, Atzeni M, Saba L, Guerra M, Mallarini G, Proto E et al (2010) Clinical study of peroneal artery perforators with computed tomographic angiography: implications for fibular flap harvest. Surg Radiol Anat 32(4):329–334.

    Article  PubMed  Google Scholar 

  15. 15.

    Saba L, Atzeni M, Rozen WM, Alonso-Burgos A, Bura R, Piga M et al (2013) Non-invasive vascular imaging in perforator flap surgery. Acta Radiol 54(1):89–98.

    Article  PubMed  Google Scholar 

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This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. People shown gave written consent in publication of their photographs. We would like to thank Ms. Tina Rodemer for volunteering for the pictures.

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Correspondence to Elisabeth Goetze.

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Goetze, E., Kämmerer, P.W., Al-Nawas, B. et al. Integration of Perforator Vessels in CAD/CAM Free Fibula Graft Planning: A Clinical Feasibility Study. J. Maxillofac. Oral Surg. 19, 61–66 (2020).

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  • Head and neck cancer
  • Reconstruction
  • Osteocutaneous microvascular flap
  • Perforator anatomy
  • Computer aided