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Computed Tomography Angiography-Based Mapping of Septocutaneous Fibular Artery Perforators: An Anatomical Analysis
Jannik Ketschau1, Jonathan Mohr1, Yannik Leonhardt2
1Department of Oral and Maxillofacial Surgery, TUM University Hospital Klinikum Rechts der Isar, School of Medicine and Health, Technical University of Munich, Munich, Germany.
Background:
Reliable localization of septocutaneous fibular artery perforators is essential for fibula free flap planning. However, the influence of lower-leg vascular anatomy on perforator number and spatial distribution remains unclear. This study aimed to analyze perforator number and spatial distribution using computed tomography angiography (CTA) with both fibula- and artery-based reference systems.
Methods:
In this retrospective study, patients undergoing lower-extremity CTA before mandibular continuity resection were screened. Parameters included run-off status, Kim classification, vascular anomalies, atherosclerotic plaque, and morphometric characteristics of the fibula and fibular artery. Perforator number per limb and relative perforator position were assessed using fibula- and artery-based reference systems. Associations were evaluated using nonparametric tests and multivariable regression models.
Results:
A total of 491 limbs from 247 patients were included, yielding 812 septocutaneous perforators. Limbs with fibular artery stenosis showed fewer perforators compared with limbs without stenosis (median 0.5 [0-2] vs. 2 [1-2], p < 0.001). Perforator distribution was nonuniform in both reference systems, with clustering in mid-segments (p < 0.001). Notably, spatial distribution patterns differed depending on the reference system used. In multivariable analyses, non-1A Kim run-off classification was associated with a more proximal perforator position along the fibula (β = -10.0 percentage points, p < 0.001), whereas no limb-level factor was associated with artery-referenced perforator position, indicating greater stability of artery-based mapping.
Conclusion:
Septocutaneous fibular artery perforators show reference-dependent spatial variability. Fibular artery stenosis is associated with fewer perforators, whereas only Kim run-off classification affects fibula-referenced location. These findings support artery-based mapping for fibula flap planning.
