Maxillofacial Surgery Unit, S. Orsola-Malpighi Hospital, Department of Biomedical and Neuromotor Sciences (Head: Prof. Claudio Marchetti), Alma Mater Studiorum University of Bologna, Via S. Vitale 59, 40125 Bologna, Italy.
Radiology Department (Head: Prof. Maurizio Zompatori), S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Italy.
J Craniomaxillofac Surg. 2017 Oct;45(10):1681-1686. doi: 10.1016/j.jcms.2017.07.017. Epub 2017 Jul 29.
Mandibular reconstruction performed after virtual planning has become more common during recent years. The gold standard for extensive mandibular reconstruction is of course a fibular free flap. In designing an osteomyocutaneous fibula flap, poor planning, aberrant anatomy and/or inadequate perforator vessels are the most frequent causes of complications and may force the surgeon to modify the flap design, explore the contralateral leg or harvest an additional microvascular flap. The goal of our study was to pre-operatively evaluate the vascular anatomy of the fibula and localize the cutaneous perforator vessels, so to create the fibular cutting guide based on the position of the cutaneous perforator and safely harvest the reconstructive flap.
Twenty consecutive patients who were candidates for mandibular reconstruction using a fibular microvascular free flap were enrolled in this study between January 2016 and August 2016. The patients were preoperatively assessed with a Computed Tomographic scan of head and neck and with a Computed Tomographic Angiography (CTA) scan of the lower limbs to evaluate the vascular anatomy of the fibula. Virtual planning was carried out for all patients. The fibular cutting guide was based on the position of the perforator cutaneous vessels, which were used to harvest the cutaneous part of the flap. Preoperative CT measurements were performed in order to identify the cutaneous perforators on the patients' skin. Intraoperative checking was performed to evaluate the accuracy of the perforators' position and the reproducibility of the virtual planning.
In 5 patients out of 20 (25%), anatomical anomalies were discovered, without clinical evidence. The perforator vessels were localized in all patients. The average difference between the CTA and the intraoperative perforator localization was 1 mm (range 0-2 mm). Fibular cutting guide was positioned and fitted the anatomy of the patients in all treated patients. This allowed us to perform the planned segmentation of the fibula, obtaining the correct number of segments. In all cases, flap insetting was carried out and skin paddle was positioned as preoperatively planned. Neither donor site complications nor flap complications occurred.
Preoperative evaluation of the legs using CTA, in patients who undergo an osteomyocutaneous fibular free flap for mandibular reconstruction, is a valuable approach to reduce altered-anatomy related complications and to improve the accuracy and outcomes of the reconstruction, especially in reconstructions of complex defects. In these cases, a soft tissue-based cutting guide can be planned based on the perforator vessels of the skin paddle, minimizing the harvesting risks of vascular lesions. Further studies and longer follow-ups are needed to evaluate the long-term outcomes and advantages of this procedure.
近年来，虚拟规划后的下颌骨重建变得越来越普遍。广泛下颌骨重建的金标准当然是游离腓骨瓣。在设计肌皮骨腓骨瓣时，规划不佳、异常解剖结构和/或不足的穿支血管是并发症最常见的原因，可能迫使外科医生修改皮瓣设计，探索对侧肢体或采集额外的微血管皮瓣。我们的研究目的是术前评估腓骨的血管解剖结构，并定位皮穿支血管，以便根据皮穿支的位置创建腓骨切割引导，并安全采集重建皮瓣。
2016 年 1 月至 2016 年 8 月，连续 20 例接受游离腓骨微血管皮瓣下颌骨重建的患者纳入本研究。所有患者均行头颈部 CT 扫描和下肢 CT 血管造影（CTA）扫描，评估腓骨的血管解剖结构。所有患者均进行了虚拟规划。腓骨切割引导器基于皮穿支血管的位置，用于采集皮瓣的皮肤部分。为了识别患者皮肤上的皮穿支，进行了术前 CT 测量。术中检查评估了穿支位置的准确性和虚拟规划的可重复性。
20 例患者中有 5 例（25%）发现解剖异常，但无临床证据。所有患者均定位皮穿支血管。CTA 与术中皮穿支定位的平均差异为 1mm（范围 0-2mm）。腓骨切割引导器在所有治疗患者中均定位并适应患者的解剖结构。这使得我们能够按照计划对腓骨进行分割，获得正确数量的节段。在所有病例中，均进行了皮瓣插入，皮瓣皮瓣按术前计划放置。供区和皮瓣均无并发症。
在接受游离腓骨肌皮瓣下颌骨重建的患者中，术前使用 CTA 评估下肢是减少因解剖异常引起的并发症，提高重建准确性和效果的一种有价值的方法，特别是在复杂缺损的重建中。在这些情况下，可以根据皮瓣的穿支血管设计基于软组织的切割引导器，最大限度地降低血管损伤的采集风险。需要进一步的研究和更长时间的随访来评估该手术的长期效果和优势。
