ETD

• color-coded duplex sonography
• fibula osteoseptocutaneous flap
• high-resolution ultrasound
• perforator mapping
• ultrasound flap design
• vascular anatomy

The fibula osteoseptocutaneous flap is one of the most reliable and versatile reconstructive options in microsurgery and has become the workhorse flap for the reconstruction of complex maxillofacial defects. Its success depends not only on meticulous surgical technique but also on accurate preoperative assessment of the donor-site vascular anatomy and precise identification of the cutaneous perforators supplying the skin paddle.
Recent technological advances in ultrasound, particularly High-Resolution Ultrasound (HRUS), have considerably expanded its role in reconstructive microsurgery by enabling real-time evaluation of vascular anatomy and perforator morphology without exposure to ionizing radiation or the administration of contrast agents. Despite these advances, a standardized surgeon-performed workflow specifically dedicated to preoperative planning of the fibula osteoseptocutaneous flap has not been clearly established.
The aim of this thesis was to develop and evaluate a practical, standardized HRUS-guided methodology for preoperative planning of the fibula osteoseptocutaneous flap. A retrospective study was conducted on patients who underwent head and neck reconstruction with a fibula free flap between January 2024 and December 2025. The proposed protocol integrates systematic assessment of the infrapopliteal vascular anatomy, identification of clinically relevant vascular variants, perforator mapping and patient-specific skin paddle design within a single ultrasound examination. Preoperative findings were subsequently compared with the corresponding intraoperative anatomy.
The proposed methodology proved feasible in all patients included in the study. Preoperative ultrasound findings showed complete agreement with intraoperative anatomy, allowing accurate localization and characterization of perforators and successful transfer of the preoperative flap design to the operative field without the need for intraoperative redesign related to unexpected vascular anatomy. No major flap-related complications were observed.
Beyond demonstrating the clinical applicability of HRUS for fibula flap planning, this thesis proposes a structured surgeon-performed workflow designed to facilitate reproducible ultrasound assessment in routine reconstructive practice. By integrating vascular evaluation, perforator mapping and flap design into a single examination, the protocol supports patient-specific surgical planning and may contribute to reducing operative uncertainty while simplifying the adoption of ultrasound by reconstructive surgeons.
Further prospective studies involving larger patient cohorts are required to validate the reproducibility of the proposed methodology, define its learning curve, evaluate its integration with contemporary digital surgical planning workflows and clarify its role alongside or, in selected patients, as a potential alternative to Computed Tomographic Angiography for preoperative planning of the fibula osteoseptocutaneous flap.