Selective preoperative lower extremity computed tomography angiography before mandibular reconstruction: Identifying patients unlikely to require fibula free flap reconstruction

Abstract Purpose Not every patient undergoing mandibular continuity resection requires free fibula flap (FFF) reconstruction. Whether clinical judgment reliably identifies patients unlikely to benefit from preoperative lower-extremity computed tomography angiography (CTA) remains unknown, despite the relevance of this question for cost-conscious and resource-efficient imaging strategies. Methods A retrospective outcome-based validation was conducted in patients undergoing mandibular continuity resection between July 2012 and June 2023. The primary outcome was secondary FFF reconstruction among patients not initially selected for CTA. Factors associated with CTA utilization were assessed by multivariable logistic regression. Results 316 consecutively operated patients were included. Prior radiotherapy (OR 2.67, p = 0.005) and smoking history (OR 1.98, p = 0.032) were independently associated with CTA utilization. Among 111 patients without primary FFF reconstruction, four (3.6%) required secondary FFF reconstruction, all of whom had undergone CTA. No patient managed without CTA subsequently required FFF reconstruction. Conclusions In this cohort, clinical judgment was associated with successful identification of patients who did not subsequently require fibular reconstruction. Omission of CTA in carefully selected patients was not associated with subsequent reconstructive deficiency, though larger prospective studies are needed to confirm these findings.