Quantitative Preoperative Peroneal Vessel Assessment in Fibula Free Flap Surgery

Abstract

Background

Fibula free flap (FFF) surgery complications can arise from vascular disease within the donor peroneal artery. Computed tomography angiography (CTA) has become standard for preoperative evaluation. However, current methods rely on qualitative assessments to determine surgical eligibility. This study aims to improve preoperative risk evaluation by implementing two quantitative scoring systems, the Bollinger score and the lower limb arterial calcification score (LLACS), assessing distinct vascular health components. The Bollinger score quantifies intraluminal stenosis caused by atherosclerotic plaques, while the LLACS quantifies arteriosclerosis by evaluating calcification within the arterial walls.

Methods

A retrospective review was conducted on all head and neck microvascular FFF procedures performed at a university-affiliated tertiary care center between August 2021 and March 2023. Data collected included patient demographics, medical history, operative details, and postoperative complications (infection, hematoma, seroma, fistula, dehiscence, or flap failure) within 90 days. Peroneal artery Bollinger scores and crural segment LLACSs from the donor lower extremity were calculated from preoperative CTAs.

Results

A total of 117 patients were included. Increasing Bollinger scores were significantly associated with an increased risk of complications and longer hospital stays, even after controlling for potential confounders. Combining both scores improved risk stratification, with high-risk patients experiencing an 8.36-fold higher risk of complications.

Conclusion

Our findings suggest that quantitative preoperative peroneal vessel assessment improves risk stratification for patients undergoing FFF surgery. These scoring systems may enhance patient selection and guide strategies to minimize postoperative complications. Integrating multiple scoring systems is key to the comprehensive assessment of vascular health.

Keywords

fibula free flap - quantitative - Bollinger score - calcium score - risk stratification - peroneal vessel

Contributors' Statement

All the authors contributed to conceptualization, design, data collection, analysis and interpretation, and drafting and revision, and approved the manuscript.

Publication History

Received: 08 June 2025

Accepted: 20 September 2025

Accepted Manuscript online:
10 October 2025

Article published online:
27 October 2025

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