Computed Tomographic Angiography

Perforator Localization for Virtual

Surgical Planning of Osteocutaneous
Fibular Free Flaps in Head and Neck
Reconstruction
Kyle S. Ettinger, MD, DDS,* Amy E. Alexander, BSc, MS,y and Kevin Arce, MD, DMDz

Virtual surgical planning (VSP), computer-aided design and computer-aided modeling, and 3-dimensional
printing are 3 distinct technologies that have become increasingly employed in head and neck oncology
and microvascular reconstruction. Although each of these technologies have long been utilized for treat-
ment planning in other surgical disciplines such as craniofacial surgery, trauma surgery, temporomandib-
ular joint surgery, and orthognathic surgery, its widespread use in head and neck reconstructive surgery
remains a much more recent advent. In response to the growing trend of VSP being used for the planning
of fibular free flaps in head and neck reconstruction, some surgeons have questioned the technology’s im-
plementation based upon its perceived inadequacy in addressing other reconstructive considerations
beyond hard tissue anatomy. Detractors of VSP for head and neck reconstruction highlight its lack of capa-
bility in accounting for multiple reconstructive factors, such as recipient vessel selection, vascular pedicle
reach, need for dead space obliteration, and skin paddle perforator location. It is with this premise in mind
that we report a simple technique for anatomically localizing peroneal artery perforators during VSP for os-
teocutaneous fibular free flaps in which both bone and a soft tissue skin paddle are required for ablative
reconstruction. The technique allows for anatomic perforator localization during the VSP session based
solely upon data existent within the preoperative computed tomographic angiography (CTA) and it does
not require any modifications to preoperative clinical workflows. It is the authors’ presumption that
many surgeons in the field are unaware of this planning capability within the context of modern VSP for
head and neck reconstruction. The primary purpose of this manuscript is to introduce and further famil-
iarize surgeons with the technique of CTA perforator localization as a method of improving intraoperative
fidelity for VSP of osteocutaneous fibular free flaps.
Ó 2018 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 76:2220-2230, 2018

*Mayo Clinic Scholar, Division of Oral and Maxillofacial Surgery, Presented at the American Academy of Craniomaxillofacial Surgery
Department of Surgery, Mayo Clinic and Mayo College of Medicine, Annual Meeting, May 5, 2018, Portland, OR
Rochester, MN; Head and Neck Oncologic Surgery and Address correspondence and reprint requests to Dr Ettinger:
Microvascular Reconstruction Fellow, Department of Oral and Division of Oral and Maxillofacial Surgery, Department of Surgery,
Maxillofacial Surgery, Division of Head and Neck Surgery, Mayo Clinic Rochester Mail Code ro_ma_12_12econ, 200 First Street
University of Florida College of Medicine–Jacksonville, SW, Rochester, MN 55905; e-mail: [email protected]
Jacksonville, FL. Received November 17 2017
yBiomedical Engineer, Anatomic Modeling Lab, Mayo Clinic, Accepted April 3 2018
Rochester, MN. Ó 2018 American Association of Oral and Maxillofacial Surgeons
zAssistant Professor of Surgery and Program Director, Division of 0278-2391/18/30304-5
Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic https://doi.org/10.1016/j.joms.2018.04.002
and Mayo College of Medicine, Rochester, MN.
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.

2220
ETTINGER, ALEXANDER, AND ARCE 2221

Virtual surgical planning (VSP), computer-aided does introduce the potential for small degrees of surgi-
design (CAD) and computer-aided modeling, and 3- cal inaccuracy that, if compounded over the course of
dimensional (3D) printing are 3 distinct technologies a complicated procedure, will invariably lead to intra-
that have become increasingly employed within operative discrepancies that will need to be manually
head and neck oncology and microvascular recon- remedied by the surgeon in order to obtain a satisfac-
struction. Although each of these technologies have tory outcome. Those well versed in the nuances of
long been utilized for treatment planning of craniofa- VSP understand that the true realized benefit of the
cial surgery,1,2 trauma surgery,3-5 temporomandibular technology is only evident when the surgeon can
joint surgery,6,7 and orthognathic surgery,8,9 its reproduce the virtual surgical plan with a high level
widespread implementation in head and neck of intraoperative fidelity. Poorly devised or unrealistic
surgery, and specifically composite microvascular virtual surgical plans taken to the operating room
free tissue transfer, is a much more recent advent. without a combined understanding of hard and soft tis-
Although some have been quick to adopt the sue constraints can be fraught with intraoperative
technology as a method of decreasing the time and complications and can lead to devastating conse-
difficulty of executing complex maxillofacial quences for the patient and acceptance of potentially
reconstructions, others have highlighted the current avoidable suboptimal outcomes. In this regard, the
technological shortcomings of these adjunctive greater anatomic information available to the surgeon
techniques.10 Proponents of VSP for head and neck at the outset of the VSP session enables a higher degree
reconstruction have cited improved intraoperative ef- of foresight being employed during the planning ses-
ficiency, increased accuracy of reconstruction, sion and subsequently allows for a higher level of pre-
decreased intraoperative ischemia time, increased pre- cision in executing that plan intraoperatively. It is with
dictability of surgical outcomes, improved patient this premise in mind that that we report a straightfor-
satisfaction, and decreased complication rates.11-24 ward technique for anatomically localizing peroneal
However, there remains a subset of reconstructive artery perforators during VSP for osteocutaneous
surgeons who contend that VSP ignores many other fibular free flaps in which bone and a soft tissue skin
important aspects of composite maxillofacial paddle are required for ablative reconstruction. The
reconstruction—particularly those pertaining to soft technique is unique in that it allows for anatomic
tissue considerations, such as recipient vessel perforator localization during the VSP session based
selection, pedicle reach, soft tissue requirements, solely on the data existent within the preoperative
need for dead space obliteration, and skin paddle computed tomographic angiography (CTA) and does
perforator localization.10 These contentions remain a not require any pre-VSP clinical Doppler mapping of
viable concern for reconstructive surgeons, because perforator locations.
VSP in its current form does not possess the capability
of comprehensively addressing all these important
Technique
reconstructive soft tissue considerations. At our own
institution, the reconstructive surgeons initially resis- At the authors’ institution, the preoperative vascular
tant to the use of VSP for fibular free flap reconstruc- study of choice to verify patent 3-vessel runoff from
tions often highlighted the technique’s deficiency in the popliteal artery before harvest of a fibular free
planning for composite defects in which both bone flap is the CTA. The lower-extremity CTA images ob-
and a soft tissue skin paddle were required for the abla- tained at our institution are procured on dual-source
tive defect. The strongly held contention was that the 128-slice multidetector CT scanners (Somatom Defini-
preoperatively unknown location of the skin paddle tion Flash, Siemens, Erlangen, Germany) using arterial
perforator would potentially preclude the accurate phase imaging with intravenous nonionic iodinated
application of the patient-specific cutting guide in contrast media and a bolus tracking technique for
the circumstance that the location of the perforator timing of imaging acquisition. Exported CTA images
did not coincide favorably with the preplanned osteot- available for clinician review include high-resolution
omy segments. Thus, the accuracy and fidelity of the axial cuts with 2-mm slice thickness along with both
preoperative virtual surgical plan would be obviated coronal and sagittal reformats with equivalent
by the need to intraoperatively modify the plan by slice thickness.
translocating the cutting guide along the fibula to ‘‘cap- The first step in localizing perforators using this
ture’’ a more favorable relation between the bone and technique is for the surgeon to carefully scrutinize
skin paddle perforator or perhaps even abandoning the high-resolution CTA images in the axial plane to
the entire virtual surgical plan in favor of the tradi- identify the takeoff of a suitably positioned cutaneous
tional ‘‘freehand’’ technique. Although the latter sce- perforator from the peroneal artery (Fig 1). This can be
nario remains quite uncommon in the execution of a performed before the VSP session so that the surgeon
well-devised virtual surgical plan, the former scenario pre-emptively knows where the osteotomies should
2222 CTA PERFORATOR LOCALIZATION FIBULAR FREE FLAPS

FIGURE 1. Axial slices from computed tomographic angiography data of the right lower extremity depicting a cutaneous perforator takeoff
from the peroneal artery. A-H, Proceeding from proximal to distal, the red arrow delineates the course of the septocutaneous perforator from its
takeoff from the peroneal artery to its termination in the skin of the lateral leg.
Ettinger, Alexander, and Arce. CTA perforator localization fibular free flaps. J Oral Maxillofac Surg 2018.

be planned or it can be completed during the planning secondary ancillary benefit of localizing the perforator
session with the biomedical engineer present. Before in this fashion is that the tracing will also inherently
the VSP session, the biomedical engineer will import provide the surgeon with valuable knowledge
the CTA Digital Imaging and Communications in Med- regarding the septocutaneous or musculocutaneous
icine (DICOM) data into Mimics Medical 19.0 (Materi- trajectory of the perforator from the source vessel to
alise, Leuven, Belgium) to convert the anatomy into 3D the skin, as the flexor hallucis longus, soleus, lateral
objects. Once the perforator is identified, the biomed- compartment musculature, and posterior crural
ical engineer or the surgeon can place markers along septum are all easily identifiable on the CTA images.
the course of the perforator with the ‘‘spline’’ feature Once the visualized portions of the cutaneous perfo-
of the Mimics Medical software’s Analyze module. A rator have been traced, the CTA data and the positional
ETTINGER, ALEXANDER, AND ARCE 2223

FIGURE 1 (cont’d).
Ettinger, Alexander, and Arce. CTA perforator localization fibular free flaps. J Oral Maxillofac Surg 2018.

markers are transferred into 3-Matic Version 11.0 priate perforator is being targeted during the intrao-
(Materialise, Leuven, Belgium) for additional 3D perative dissection. Once completed, the surgeon
rendering and CAD. Once imported, the biomedical and biomedical engineer can begin designing fibular
engineer can connect the previously placed markers osteotomy segments to suit the anticipated recon-
to generate a linear 3D object corresponding to the structive needs using ProPlan CMF 2.1 (DePuy Syn-
mapped course of the perforator, which is then thes/Materialise, West Chester, PA; Fig 2B).
registered to the virtual 3D rendering of the bony Identification and overlaying of the perforator data
anatomy of the lower extremity (Fig 2A). The distance enable the surgeon to ‘‘centralize’’ the perforator on
from the lateral malleolus to the level of the perforator the osteotomy segment of interest or, alternatively,
as it crosses the posterolateral aspect of the fibula is ‘‘place’’ the perforator along an area of usable fibula
then measured and recorded to ensure that the appro- that maximizes residual pedicle length and prevents
2224 CTA PERFORATOR LOCALIZATION FIBULAR FREE FLAPS

FIGURE 2. Three-dimensional rendering of the perforator trajectory based on the surgeon-directed computed tomographic angiography
tracing. A, Posterior view displaying the path of the cutaneous perforator as it courses around the posterior aspect of the fibula to supply the
skin of the lateral leg (note the oblique course of the perforator from the peroneal take takeoff to its termination in the skin). B, Designed fibular
osteotomy segments taking into account the cutaneous perforator takeoff and trajectory identified during the surgeon-directed computed tomo-
graphic angiography tracing.
Ettinger, Alexander, and Arce. CTA perforator localization fibular free flaps. J Oral Maxillofac Surg 2018.

against perforator takeoff directly in the area of a fibular free flap reconstruction from the unoperated
planned osteotomy. This is particularly useful when right lower extremity, and a tracheostomy for perioper-
multiple fibular segments are required for reconstruc- ative airway protection. The anticipated surgical defect
tion and positioning of the perforator along a specific would require a 3-segment fibular free flap to recon-
fibular segment is advantageous from a skin paddle in- struct the right mandibular condyle, ramus, body, and
setting standpoint. An index marker also can be de- parasymphysis in addition to a cutaneous skin paddle
signed onto the fibular cutting guide to serve as an for oral cavity relining. A preoperative head and neck
additional reference point for correlation with the in- CT scan did not identify any pathologic regional aden-
traoperative location of the perforator. opathy and preoperative positron-emission tomo-
graphic (PET) CT scan did not demonstrate any
distant avidity suggestive of metastatic disease. A
Report of Case
lower-extremity CTA was obtained to confirm patent
A 56-year-old man with a history of right mandibular 3-vessel runoff in the unoperated right lower extremity.
osteomyelitis and prior segmental resection and fibular VSP was performed using the CTA perforator localiza-
free flap reconstruction was evaluated by the Division tion protocol described above (Figs 1, 2). The plan for
of Oral and Maxillofacial Surgery at the Mayo Clinic (Ro- the orientation of the fibula was for the vascular
chester, MN) for a new biopsy-proven squamous cell pedicle to be directed anteriorly, as the high take-off
carcinoma arising in the right neomandibular recon- of a posterior vascular pedicle orientation would
struction bed. The primary tumor arose in the mid- preclude reach into the neck for microvascular
body region of the right neomandible, involved the ret- anastomosis. Based on the need for a 3-segment
romolar trigone area posteriorly, and extended to the fibular reconstruction, selection of a perforator that
right parasymphyseal region anteriorly. The tumor would allow for the skin paddle to be based along the
was also noted on preoperative Panorex and CT imag- middle fibular segment (the neomandibular body)
ing to extend into and erode the underlying neomandib- was clearly the most advantageous design to facilitate
ular fibular bone (Fig 3). Accordingly, the patient was soft tissue in-setting at the time of surgery (Fig 2B).
planned for a composite segmental mandibulectomy, Intraoperatively the fibular free flap was dissected in
ipsilateral select neck dissection, osteocutaneous typical fashion using a lateral anterior approach
ETTINGER, ALEXANDER, AND ARCE 2225

FIGURE 3. Preoperative panoramic radiograph depicting an area of saucerized osteolysis involving the proximal segment of the patient’s pre-
vious right neomandibular fibular free flap reconstruction due to bone erosion from the patient’s primary tumor.
Ettinger, Alexander, and Arce. CTA perforator localization fibular free flaps. J Oral Maxillofac Surg 2018.

(Fig 4A). A handheld Doppler was used before tourni- The Mayo Clinic does not require institutional re-
quet inflation to verify cutaneous perforator location view board approval for nonsystematic investigations,
at the level of the skin and to ensure that the skin pad- including technical notes and case reports.
dle design was centered on the targeted perforator
(Fig 4B). Note that the oblique trajectory of the perfo-
Discussion
rator through the posterior crural septum toward the
skin that was identified from the preoperative CTA The primary purpose of this manuscript was to intro-
tracing also was evident in vivo upon skin paddle duce or further familiarize existing head and neck
and fibular elevation (Fig 4A, C). Once the fibula was reconstructive surgeons with a new technique of CTA
fully elevated, the patient-specific 3D printed fibular perforator localization that affords numerous advan-
cutting guide was applied to the lateral surface of tages for VSP of osteocutaneous fibular free flaps. While
the fibula and secured in place with multiple mono- we are likely not the only institution to have incorpo-
cortical screws (Fig 4C). The fibula was then osteotom- rated this technique into the routine planning of com-
ized according to the virtually planned segmentation posite fibular free flaps, it is our presumption that
pattern and the anticipated location of the cutaneous many surgeons within the field are also unlikely to be
perforator relative to the osteotomized segments was aware of this planning capability within the context
noted to be replicated with a high degree of accuracy of modern VSP for head and neck reconstruction.
intraoperatively (Fig 4D). Once the fibula was osteo- Although the identification and tracing of the perforator
tomized, the pedicle was divided from the leg and during VSP does extend the length of the planning ses-
the vascular system was irrigated with heparinized sa- sion slightly, we strongly believe that the knowledge
line. The fibula was then oriented and plated using a and understanding of the perforator anatomy gained
3D printed plating tray conceived and collectively de- with this technique vastly outweighs any potential
signed by the 3 authors (K.S.E., A.E.A., and K.A.; Fig 5). drawbacks to lengthening the VPS meeting. The act
Figure 5 demonstrates the degree of operative fidelity of localizing the perforators from the CTA data not
that was achieved in replicating the virtual surgical only provides the surgeon valuable information relative
plan relative to the hard and soft tissue components to the septocutaneous or musculocutaneous course of
of the reconstruction. No secondary modifications the perforator, but it also alerts the surgeon of any obli-
were required to obtain the relation of the fibular seg- que trajectory of the perforator during its takeoff from
ments shown in Figure 5 and this construct could be the peroneal artery to its termination at the level of the
transferred directly from the operative table to the sur- skin (as demonstrated by the presented clinical case).
gical field for flap in-setting and completion of micro- Being able to directly visualize the exact location of
vascular anastomosis. the perforator takeoff from the peroneal artery also
2226 CTA PERFORATOR LOCALIZATION FIBULAR FREE FLAPS

FIGURE 4. Intraoperative dissection of the right fibular free flap. A, Elevated fibular bone and skin paddle. Note the oblique course of the
perforator through the posterior crural septum toward the skin (black arrow). B, Blue marking on the skin paddle corresponding to the intrao-
perative transcutaneous handheld Doppler verification of the perforator. (Fig 4 continued on next page.)
Ettinger, Alexander, and Arce. CTA perforator localization fibular free flaps. J Oral Maxillofac Surg 2018.

enables the surgeon to plan the fibular segmentation in fibula will ultimately affect the overall accuracy of the
a manner that prevents the perforator position from final reconstructive construct. Undoubtedly, a factor
directly coinciding with a planned osteotomy site. that most frequently leads to intraoperative modifica-
This not only minimizes the chances of perforator dam- tion of virtually planned osteocutaneous fibular free
age during manipulation for segmentation of the fibula, flaps is the preoperatively unknown position of the
but it also increases the likelihood of maintaining surgi- cutaneous perforators. However, with the described
cal accuracy when executing a virtual surgical plan in- CTA perforator localization technique cutaneous perfo-
traoperatively. The latter is particularly true for rator anatomy can now be directly incorporated into
multisegment reconstructions, when multiple fibular preoperative VSP workflows and accounted for with a
skin paddles are required, when patient-specific fibular high level of accuracy within the virtual surgical plan.
cutting guides are employed, and in cases in which Historically, preoperative duplex ultrasound or
custom titanium plates are utilized as any translation handheld Doppler mapping was the only way for sur-
or alteration in the cutting guide position along the geons to identify potential perforator locations on the
ETTINGER, ALEXANDER, AND ARCE 2227

FIGURE 4 (cont’d). C, Application of the custom 3-dimensional printed patient-specific fibula cutting guide with the highlighted location of the
perforator relative to the central fibular segment (black arrow). D, Fully osteotomized fibula before harvest from the leg with the perforator loca-
tion in the posterior crural septum highlighted (black arrow).
Ettinger, Alexander, and Arce. CTA perforator localization fibular free flaps. J Oral Maxillofac Surg 2018.

lateral aspect of the leg before undertaking an intrao- considerations, many reconstructive surgeons do not
perative dissection. Although Doppler ultrasound use any form of preoperative perforator mapping
can aid in localization of perforators at the level of before osteocutaneous fibular free flap elevation and
the skin, it does not reliably provide any information instead rely only on the intraoperative dissection for
relative to the septocutaneous or musculocutaneous perforator identification. Although certainly a tried-
course of the perforator from the underlying peroneal and-true method of ensuring appropriate skin paddle
artery.25-27 In addition, duplex ultrasound mapping is positioning relative to the underlying perforator, in
incapable of alerting surgeons of a potentially the context of VSP, the lack of preoperative perforator
aberrant perforator origin from other dominant knowledge can detrimentally affect the accurate
source vessels within the leg, as cutaneous execution of a virtual surgical plan in the operating
perforator takeoffs from the anterior tibial artery and room—particularly if the perforator location does
the posterior tibial artery to the lateral have both not coincide favorably with the planned region of
been previously described.28-31 In light of these the fibula being used for the reconstruction. It is this
2228 CTA PERFORATOR LOCALIZATION FIBULAR FREE FLAPS

surements were then transferred to the VSP rendering

of the fibula and osteotomies were designed to
centralize the location of the handheld Doppler posi-
tion along the desired fibular segment. In 4 of the 6
cases reported by Berrone et al,32 they noted good cor-
relation between the position of the perforating ves-
sels localized by handheld Doppler measurement
and the bone segment being used for reconstruction.
However, they did not provide specific information
regarding the 2 cases in which the perforator locations
and the fibular segments did not coincide favorably.
Berrone et al32 commented in their discussion that sur-
geons must be prepared for the often imprecise
concordance between handheld Doppler measure-
ments of cutaneous perforator locations and the actual
perforator locations identified from direct visualiza-
tion during operative dissection.
The second and more recent study reporting on
perforator localization for VSP of osteocutaneous
fibular free flaps was published just before finalization
of the present report. In this study, Battaglia et al33 re-
ported on a series of 20 patients undergoing head and
neck reconstruction with osteocutaneous fibular free
flap for benign or malignant head and neck tumors at
a single institution. Analogous to the techniques re-
ported in the present manuscript, they identified
perforator locations purely based on preoperative
FIGURE 5. Plated fibula on a custom 3-dimensional printed patient-
specific plating tray before in-setting. A, Anterior view with skin pad- CTA imaging. Battaglia et al33 also used the lateral
dle draped in the natural in-setting position. B, Oblique view with prominence of the lateral malleolus as an external
skin paddle elevated to display the precision of fit of the fibular seg- reference point from which to measure the location
ments without the need for any secondary modifications to the
fibular osteotomies. of the perforator identified on the CTA images. They
Ettinger, Alexander, and Arce. CTA perforator localization fibular
measured the distance from the midpoint of the lateral
free flaps. J Oral Maxillofac Surg 2018. malleolus to a subcutaneous position of the perforator
based on the CTA images. Once the perforator was
identified intraoperatively, Battaglia et al33 cross-
very complication that has led some surgeons to ques- referenced the intraoperative perforator locations
tion the routine implementation of VSP technology for with the preoperative virtual measurements obtained
planning of osteocutaneous fibular free flaps.10 How- from the CTA images. They report an average distance
ever, with the CTA perforator localization method, sur- between the CTA perforator locations and intraopera-
geons can directly account for the cutaneous tive perforator locations for their cohort of 20 patients
perforator’s location, its septocutaneous or musculo- to be 1 mm (range, 0 to 2 mm). Battaglia et al33
cutaneous course, and identify a potentially aberrant concluded that preoperative CTA evaluation to investi-
takeoff from an alternative source vessel—all during gate lower-extremity vascular patterns for patients un-
the preoperative VSP session. dergoing composite osteocutaneous fibular free flaps
At the time of this manuscripts preparation, only 2 is a valuable approach for decreasing complications
previously published studies have specifically re- arising from variable vascular anatomy for VSP, but
ported on the incorporation of preoperative perfo- that additional follow-up studies would be required
rator localization into VSP for osteocutaneous fibular to evaluate the long-term outcomes and advantages
free flaps. The first study, published by Berrone of this contemporary technique.
et al,32 reported on a case series of 6 consecutive pa- Undoubtedly, the application of VSP to head and
tients undergoing composite osteocutaneous fibular neck microvascular reconstructive surgery still re-
free flap reconstruction for oral cavity squamous cell mains in its infancy, as its various technical shortcom-
carcinomas. They used a hybrid technique of corre- ings and inadequacies are only becoming more fully
lating perforator location based on pre-VSP clinical elucidated through the increasing level of acceptance
handheld Doppler mapping of perforator locations of the technology among providers. Currently, there is
relative to the lateral malleolus of the leg. These mea- a relative paucity of high-level evidence from which
ETTINGER, ALEXANDER, AND ARCE 2229

surgeons can objectively weigh the merits and draw- 10. Deek NF, Wei FC: Computer-assisted surgery for segmental
mandibular reconstruction with the osteoseptocutaneous fibula
backs of VSP technology for applications in complex
flap: Can we instigate ideological and technological reforms?
head and neck reconstruction, yet the body of evi- Plast Reconstr Surg 137:963, 2016
dence investigating the benefits of VSP is slowly begin- 11. Hou JS, Chen M, Pan CB, et al: Immediate reconstruction of bilat-
eral mandible defects: Management based on computer-aided
ning to grow. Given the clear need for further design/computer-aided manufacturing rapid prototyping tech-
systematic analysis of nuanced techniques unique to nology in combination with vascularized fibular osteomyocuta-
VSP for head and neck reconstruction, we are neous flap. J Oral Maxillofac Surg 69:1792, 2011
12. Hayden RE, Mullin DP, Patel AK: Reconstruction of the
currently in the process of prospectively collecting segmental mandibular defect: Current state of the art. Curr
data in a multi-institutional fashion on the accuracy Opin Otolaryngol Head Neck Surg 20:231, 2012
and reliability of the CTA perforator localization 13. Bell RB, Weimer KA, Dierks EJ, et al: Computer planning and in-
traoperative navigation for palatomaxillary and mandibular
method described above. It is our hope that with reconstruction with fibular free flaps. J Oral Maxillofac Surg
further investigation of this technique that CTA acqui- 69:724, 2011
sition protocols and existing VSP workflows can be 14. Hanasono MM, Skoracki RJ: Computer-assisted design and rapid
prototype modeling in microvascular mandible reconstruction.
modified in a universal fashion to allow for more rapid Laryngoscope 123:597, 2013
and accurate presurgical modeling of cutaneous perfo- 15. Lethaus B, Poort L, Bockmann R, et al: Additive manufacturing
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head and neck reconstruction to begin incorporating
16. Roser SM, Ramachandra S, Blair H, et al: The accuracy of virtual
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