{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T03:08:30Z","timestamp":1774494510512,"version":"3.50.1"},"reference-count":48,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,9,30]],"date-time":"2025-09-30T00:00:00Z","timestamp":1759190400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Oncol."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Reconstruction of large head and neck defects in oncologic patients often requires free vascularized tissue flaps. Successful flap design and elevation depend on accurate preoperative identification of perforator vessels. Preoperative Magnetic Resonance Angiography (MRA) could offer detailed insights into perforator course, caliber, origin, and main pedicle length, and thus is expected to surpass conventional handheld Doppler. This study introduces a novel approach for perforator mapping in reconstructive head and neck surgery that integrates MRA with 3D modelling and 3D-printing.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>The proposed workflow comprises four steps: 1) acquisition of contrast-enhanced MRA, 2) construction of a 3D anatomical model, 3) design and 3D-printing of a patient-specific perforator guide, and 4) transfer of perforator locations from the model to the patient\u2019s skin using the guide. To illustrate the clinical feasibility and potential utility of this approach, an initial cohort of patients undergoing perforator flap surgery for oncologic head and neck reconstruction was included. Flap types included fibula free flap (FFF), anterolateral thigh flap (ALT), and medial sural artery perforator flap (MSAP). Intraoperative findings were compared with the 3D models, and surgeons evaluated the models\u2019 usability for virtual planning of flap design and elevation using a five-point Likert scale questionnaire.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Ten patients were included for analysis: three FFF, two ALT, and five MSAP cases. In FFF and ALT patients, all perforators intraoperatively used for flap elevation were successfully visualized on MRA and represented in the 3D models. In MSAP patients, small-caliber perforators were not consistently visible. The mean absolute difference between pedicle lengths measured in the 3D models and intraoperatively was 1.0 cm (SD 0.9 cm). The usability questionnaire yielded an average score of 4.2 out of 5, suggesting the potential of MRA-based 3D models for virtual surgical flap planning.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>This is the first study to combine preoperative MRA with 3D modelling and 3D-printing for perforator mapping in head and neck reconstruction. The workflow offers a radiation-free, patient-specific planning tool that may enhance surgical precision and support personalized flap design in complex oncological cases.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fonc.2025.1655904","type":"journal-article","created":{"date-parts":[[2025,9,30]],"date-time":"2025-09-30T04:11:41Z","timestamp":1759205501000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Perforator mapping for head and neck reconstructive surgery: a novel personalized approach using magnetic resonance angiography based 3D models and 3D-printing"],"prefix":"10.3389","volume":"15","author":[{"given":"A.F.","family":"de Geer","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"I.","family":"Mulder","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"L.C.","family":"ter Beek","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"A.S.","family":"te Boekhorst","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"B.I.","family":"Plakk\u00e9","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"L.H.E.","family":"Karssemakers","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"R.","family":"Dirven","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"P.J.F.M.","family":"Lohuis","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"T.J.M","family":"Ruers","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"F.J.","family":"Siepel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"P.K.","family":"de Koekkoek-Doll","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"M.J.A.","family":"van Alphen","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"W.H.","family":"Schreuder","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2025,9,30]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","DOI":"10.1097\/PRS.0b013e3182778938","article-title":"Head and neck reconstruction","volume":"131","author":"Neligan","year":"2013","journal-title":"Plast Reconstruct Surg"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.1016\/j.coms.2024.07.003","article-title":"The past, present, and future of perforator flaps in head and neck surgery","volume":"36","author":"Wo","year":"2024","journal-title":"Oral Maxillofac Surg Clin North Am"},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(08)60728-X","article-title":"Head and neck cancer","volume":"371","author":"Argiris","year":"2008","journal-title":"Lancet"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.6004\/jnccn.2020.0031","article-title":"Head and neck cancers, version 2.2020, nccn clinical practice guidelines in oncology","volume":"18","author":"Pfister","year":"2020","journal-title":"J Natl Compr Cancer Netw J Natl Compr Canc Netw"},{"key":"B5","doi-asserted-by":"publisher","DOI":"10.3389\/fonc.2020.00140","article-title":"Best practice in surgical treatment of Malignant head and neck tumors","volume":"10","author":"Simon","year":"2020","journal-title":"Front Oncol"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1097\/00006534-198907000-00014","article-title":"Fibula free flap: A new method of mandible reconstruction","volume":"84","author":"Hidalgo","year":"1989","journal-title":"Plast Reconstr Surg"},{"key":"B7","doi-asserted-by":"publisher","DOI":"10.1055\/a-2059-4009","article-title":"The medial sural artery perforator flap versus other free flaps in head and neck reconstruction: A systematic review","volume":"50","author":"Al Omran","year":"2023","journal-title":"Arch Plast Surg"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.1007\/s12663-022-01837-9","article-title":"The free medial sural artery perforator flap (Msapf): an indispensable tool for head and neck reconstruction","volume":"22","author":"Bhardwaj","year":"2023","journal-title":"J Maxillofac Oral Surg"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.1002\/ohn.348","article-title":"Medial sural artery perforator flap: A middle ground between anterolateral thigh and radial forearm flaps","volume":"169","author":"Danielian","year":"2023","journal-title":"Otolaryngol Head Neck Surg"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.1055\/s-0042-1744425","article-title":"The medial sural artery perforator flap: A historical trek from ignominious to \"Workhorse","volume":"49","author":"Hallock","year":"2022","journal-title":"Arch Plast Surg"},{"key":"B11","doi-asserted-by":"publisher","DOI":"10.1002\/lary.27652","article-title":"The medial sural artery perforator flap: A better option in complex head and neck reconstruction","volume":"129","author":"Taufique","year":"2019","journal-title":"Laryngoscope"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.1016\/j.coms.2024.07.004","article-title":"Designing perforator flaps using ultrasound","volume":"36","author":"Bianchi","year":"2024","journal-title":"Oral Maxillofac Surg Clin North Am"},{"key":"B13","doi-asserted-by":"publisher","DOI":"10.1097\/prs.0000000000006966","article-title":"Preoperative vascular planning of free flaps: comparative study of computed tomographic angiography, color doppler ultrasonography, and hand-held doppler","volume":"146","author":"Gonz\u00e1lez Mart\u00ednez","year":"2020","journal-title":"Plast Reconstr Surg"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1016\/j.bjps.2009.06.002","article-title":"Magnetic resonance angiography to evaluate septocutaneous perforators in free fibula flap transfer","volume":"63","author":"Fukaya","year":"2010","journal-title":"J Plast Reconstr Aesthet Surg"},{"key":"B15","doi-asserted-by":"publisher","DOI":"10.1097\/01.prs.0000232216.34854.63","article-title":"Efficacy of the handheld doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap","volume":"118","author":"Yu","year":"2006","journal-title":"Plast Reconstr Surg"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.1016\/j.joms.2022.03.018","article-title":"Accuracy and precision of the computed tomographic angiography perforator localization technique for virtual surgical planning of composite osteocutaneous fibular free flaps in head and neck reconstruction","volume":"80","author":"Ettinger","year":"2022","journal-title":"J Oral Maxillofac Surg"},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1016\/j.bjps.2010.06.013","article-title":"An overview of methods for vascular mapping in the planning of free flaps","volume":"63","author":"Smit","year":"2010","journal-title":"J Plast Reconstr Aesthet Surg"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.1007\/978-981-97-7278-0","author":"Hong","year":"2024","journal-title":"Imaging for reconstructive microsurgery"},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.1055\/s-0041-1736316","article-title":"Comparison of various modalities utilized for preoperative planning in microsurgical reconstructive surgery","volume":"38","author":"Nassar","year":"2022","journal-title":"J Reconstr Microsurg"},{"key":"B20","doi-asserted-by":"publisher","first-page":"797","DOI":"10.1002\/jmri.28946","article-title":"Mra for preoperative planning and postoperative management of perforator flap surgeries: A review","volume":"59","author":"Thimmappa","year":"2024","journal-title":"J Magn Reson Imaging"},{"key":"B21","doi-asserted-by":"publisher","DOI":"10.1016\/j.jss.2022.11.036","article-title":"Customizing anterolateral thigh flap with magnetic resonance angiography differential subsampling with cartesian ordering imaging for individualized reconstruction of extremity defects","volume":"283","author":"Hu","year":"2023","journal-title":"J Surg Res"},{"key":"B22","doi-asserted-by":"publisher","DOI":"10.1097\/prs.0000000000004070","article-title":"Updates in head and neck reconstruction","volume":"141","author":"Largo","year":"2018","journal-title":"Plast Reconstruct Surg"},{"key":"B23","doi-asserted-by":"publisher","DOI":"10.1097\/prs.0000000000006261","article-title":"Computer-assisted versus conventional freehand mandibular reconstruction with fibula free flap: A systematic review and meta-analysis","volume":"144","author":"Powcharoen","year":"2019","journal-title":"Plast Reconstr Surg"},{"key":"B24","doi-asserted-by":"publisher","first-page":"52","DOI":"10.1016\/j.oraloncology.2018.07.004","article-title":"Accuracy of computer-assisted surgery in mandibular reconstruction: A systematic review","volume":"84","author":"van Baar","year":"2018","journal-title":"Oral Oncol"},{"key":"B25","doi-asserted-by":"publisher","first-page":"196","DOI":"10.1186\/s12957-022-02654-7","article-title":"Novel computer-aided reconstruction of soft tissue defects following resection of oral and oropharyngeal squamous cell carcinoma","volume":"20","author":"Xu","year":"2022","journal-title":"World J Surg Oncol"},{"key":"B26","doi-asserted-by":"publisher","DOI":"10.1016\/j.bjoms.2020.04.017","article-title":"Patient-specific soft tissue reconstruction: an ideal stage I report of hemiglossectomy reconstruction and introduction of the pansofos flap","volume":"58","author":"Koumoullis","year":"2020","journal-title":"Br J Oral Maxillofac Surg"},{"key":"B27","doi-asserted-by":"publisher","DOI":"10.1016\/j.oooo.2021.12.130","article-title":"Computed tomography angiography\u2013aided individualized anterolateral thigh flap design in the reconstruction of oral and maxillofacial soft tissue defects","volume":"134","author":"Rao","year":"2022","journal-title":"Oral Surgery Oral Med Oral Pathol Oral Radiol"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijom.2015.11.020","article-title":"Individual design of the anterolateral thigh flap for functional reconstruction after hemiglossectomy: experience with 238 patients","volume":"45","author":"Wang","year":"2016","journal-title":"Int J Oral Maxillofac Surg"},{"key":"B29","doi-asserted-by":"publisher","DOI":"10.1007\/s00238-021-01928-9","article-title":"Free fibula osteomyocutaneous flap with lateral supramalleolar and soleus muscle flap\u2014a novel chimeric flap combination","volume":"45","author":"Naalla","year":"2022","journal-title":"Eur J Plast Surg"},{"key":"B30","doi-asserted-by":"publisher","DOI":"10.1007\/s00276-018-2166-2","article-title":"Vascular anatomy of the free fibula flap including the lateral head of the soleus muscle applied to maxillo-mandibular reconstruction","volume":"41","author":"Nokovitch","year":"2019","journal-title":"Surg Radiol Anat"},{"key":"B31","doi-asserted-by":"publisher","DOI":"10.1097\/TA.0b013e3181d8944e","article-title":"Three-step approach to the harvest of the fibula osteoseptocutaneous flap","volume":"69","author":"Wong","year":"2010","journal-title":"J Trauma"},{"key":"B32","doi-asserted-by":"publisher","DOI":"10.1007\/s10006-022-01108-4","article-title":"Utility of preoperative colour flow doppler assessment of perforator anatomy in medial sural artery perforator (Msap) free flaps","volume":"27","author":"Steel","year":"2023","journal-title":"Oral Maxillofac Surg"},{"key":"B33","doi-asserted-by":"publisher","DOI":"10.1016\/j.coms.2024.07.009","article-title":"Customized soft tissue free flaps in head and neck reconstruction","volume":"36","author":"Heredero","year":"2024","journal-title":"Oral Maxillofac Surg Clin North Am"},{"key":"B34","doi-asserted-by":"publisher","DOI":"10.1002\/micr.22128","article-title":"Preoperative mr angiography for free fibula osteocutaneous flap transfer","volume":"33","author":"Akashi","year":"2013","journal-title":"Microsurgery"},{"key":"B35","doi-asserted-by":"publisher","DOI":"10.2214\/ajr.04.1950","article-title":"Preoperative mr angiography in free fibula flap transfer for head and neck cancer: clinical application and influence on surgical decision making","volume":"188","author":"Kelly","year":"2007","journal-title":"Am J Roentgenol"},{"key":"B36","doi-asserted-by":"publisher","DOI":"10.1002\/micr.22146","article-title":"Evaluation of the lower limb vasculature before free fibula flap transfer. A prospective blinded comparison between magnetic resonance angiography and digital subtraction angiography","volume":"33","author":"Klein","year":"2013","journal-title":"Microsurgery"},{"key":"B37","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1001\/archfacial.2010.110","article-title":"Preoperative magnetic resonance angiography detection of septocutaneous perforators in fibula free flap transfer","volume":"13","author":"Miller","year":"2011","journal-title":"Arch Facial Plast Surg"},{"key":"B38","doi-asserted-by":"publisher","DOI":"10.2214\/ajr.09.3766","article-title":"Time-resolved and bolus-chase mr angiography of the leg: branching pattern analysis and identification of septocutaneous perforators","volume":"195","author":"Sandhu","year":"2010","journal-title":"Am J Roentgenol"},{"key":"B39","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijom.2019.09.005","article-title":"Magnetic resonance angiography for free fibula harvest: anatomy and perforator mapping","volume":"49","author":"Schuderer","year":"2020","journal-title":"Int J Oral Maxillofac Surg"},{"key":"B40","doi-asserted-by":"publisher","DOI":"10.3348\/kjr.2021.0696","article-title":"Differential subsampling with cartesian ordering contrast-enhanced magnetic resonance angiography for the preoperative assessment of anterolateral thigh flap","volume":"23","author":"Shen","year":"2022","journal-title":"Korean J Radiol"},{"key":"B41","doi-asserted-by":"publisher","DOI":"10.3892\/etm.2016.3387","article-title":"Three-dimensional contrast-enhanced magnetic resonance angiography for anterolateral thigh flap outlining: A retrospective case series of 68 patients","volume":"12","author":"Jiang","year":"2016","journal-title":"Exp Ther Med"},{"key":"B42","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcms.2018.11.018","article-title":"Computer-assisted surgery for reconstruction of complex mandibular defects using osteomyocutaneous microvascular fibular free flaps: use of a skin paddle-outlining guide for soft-tissue reconstruction. A technical Report","volume":"47","author":"Battaglia","year":"2019","journal-title":"J Cranio-Maxillofacial Surg"},{"key":"B43","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcms.2023.11.004","article-title":"Introduction and preliminary application report for a novel 3d printed perforator navigator for fibular flap surgery","volume":"52","author":"Wei","year":"2024","journal-title":"J Cranio-Maxillofacial Surg"},{"key":"B44","doi-asserted-by":"publisher","DOI":"10.4317\/medoral.25558","article-title":"Anterolateral thigh perforator flap made by customized 3d-printing fabrication of fixed positioning guide for oromaxillofacial reconstruction: A preliminary study","volume":"28","author":"Li","year":"2023","journal-title":"Med Oral Patol Oral Cir Bucal"},{"key":"B45","doi-asserted-by":"publisher","first-page":"1634","DOI":"10.3390\/jcm12041634","article-title":"Evaluation of lower leg arteries and fibular perforators before microsurgical fibular transfer using noncontrast-enhanced quiescent-interval slice-selective (Qiss) magnetic resonance angiography","volume":"12","author":"Lebenatus","year":"2023","journal-title":"J Clin Med"},{"key":"B46","doi-asserted-by":"publisher","first-page":"e3174","DOI":"10.1097\/gox.0000000000003174","article-title":"Noncontrast magnetic resonance imaging of perforators for preoperative evaluation of anterolateral thigh flaps","volume":"8","author":"Chen","year":"2020","journal-title":"Plast Reconstr Surg Glob Open"},{"key":"B47","doi-asserted-by":"publisher","DOI":"10.1016\/j.crad.2023.07.004","article-title":"Improving the visualisation of perforator arteries for anterolateral thigh flaps harvest in ct angiography via sublingual glyceryl trinitrate","volume":"78","author":"Lu","year":"2023","journal-title":"Clin Radiol"},{"key":"B48","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejrad.2023.110877","article-title":"Nitroglycerin improves the visibility of fibula-free flap perforators on computed tomography angiography in patients with oral or maxillofacial lesion","volume":"164","author":"Yang","year":"2023","journal-title":"Eur J Radiol"}],"container-title":["Frontiers in Oncology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fonc.2025.1655904\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,30]],"date-time":"2025-09-30T04:11:42Z","timestamp":1759205502000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fonc.2025.1655904\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,30]]},"references-count":48,"alternative-id":["10.3389\/fonc.2025.1655904"],"URL":"https:\/\/doi.org\/10.3389\/fonc.2025.1655904","relation":{},"ISSN":["2234-943X"],"issn-type":[{"value":"2234-943X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,30]]},"article-number":"1655904"}}