Accurate preoperative mapping of skin-paddle perforators is vital for osteocutaneous fibula free flap (FFF) success. While handheld Doppler (HHD) is widely used due to its convenience, its performance compared with color Doppler ultrasound (CDU) in FFF planning remains uncertain.

In this prospective study, 50 consecutive patients undergoing FFF reconstruction after head and neck cancer resection were evaluated. Each patient underwent HHD and CDU mapping on the day before surgery. Perforator skin surface location, anatomical type (septocutaneous vs. musculoseptocutaneous), peak systolic velocity, and source vessel (peroneal vs. posterior tibial) were recorded. Mapping marks were concealed between examinations.

A total of 185 perforators were confirmed intraoperatively (mean 3.7 per limb). CDU identified 179 candidates, yielding 95% sensitivity, 92% specificity, and 94% accuracy. HHD detected 155 sites, achieving 59% sensitivity, 6% specificity, and 48% accuracy, with significantly more false positives and negatives (p < 0.001). Both overall and dominant perforators clustered in the fourth decile of the lower leg (counting from lateral malleolus to fibular head). Distal regions were dominated by septocutaneous vessels, while musculoseptocutaneous types were more common in proximal regions. Anatomical variants—perforators draining into the posterior tibial instead of the peroneal vessels—occurred in 8% of cases and were identified exclusively by CDU.

CDU outperforms HHD for preoperative perforator mapping in osteocutaneous FFF, combining high spatial precision with reliable hemodynamic assessment and variant detection. Incorporation of CDU into routine surgical planning promises to enhance flap design accuracy and minimize intraoperative uncertainty.

Received: 15 September 2025

Accepted: 13 January 2026

Accepted Manuscript online:
18 February 2026

Article published online:
13 March 2026

© 2026. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA