Preoperative High-Resolution Ultrasound-Guided Design of the Fibula Osteoseptocutaneous Flap: A Structured Surgeon-Performed Protocol

Background/Objectives: The fibula osteoseptocutaneous flap is an established option for head and neck reconstruction. Preoperative planning requires assessment of donor-limb arterial anatomy and localization of cutaneous perforators. This study describes a structured surgeon-performed Conventional High-Frequency Ultrasound (CHFUS) protocol and evaluates its correlation with intraoperative findings. Methods: This retrospective study included patients undergoing reconstruction with a fibula osteoseptocutaneous free flap between January 2024 and December 2025. A standardized two-phase CHFUS workflow was used to assess infrapopliteal arterial anatomy and identify, characterize, and mark perforators at their deep fascial emergence. Preoperative findings were compared with intraoperative anatomy. Results: Ten patients underwent fibula flap reconstruction. Eighteen perforators were mapped, with a mean of 1.80 ± 0.63 per patient. The most common Kim–Lippert vascular pattern was type I (90%). Mean peroneal artery diameter at its origin was 2.83 ± 0.15 mm, and mean dominant perforator diameter at deep fascial emergence was 1.04 ± 0.14 mm. All 10 patients met the predefined anatomical agreement threshold of ≤1 cm (100%; exact two-sided 95% confidence interval, 69.2–100%). No flap required intraoperative redesign because of perforator anatomy. All flaps survived, without partial skin-paddle necrosis, donor-site ischemia, or vascular complications. Conclusions: This structured surgeon-performed CHFUS protocol was feasible and useful for fibula osteoseptocutaneous flap planning, enabling assessment of arterial anatomy, reliable perforator localization, and translation of preoperative findings into skin-paddle design. CHFUS should be considered complementary to CT angiography. Larger prospective studies are required to evaluate interoperator reproducibility and the diagnostic performance of CHFUS for clinically relevant arterial variants.