The fibula free flap procedure is a highly specialized form of reconstructive surgery used to rebuild significant defects in the lower jaw, or mandible. It is classified as a “free flap” because it involves completely relocating tissue, including its own artery and vein, from a donor site to the head and neck. The mandible is a horseshoe-shaped bone that forms the scaffold for the lower face and is central to chewing, speaking, and maintaining facial appearance. When a large segment is lost, a reconstructive method providing strong, living bone is necessary to restore both form and function.
Understanding the Need for Mandibular Reconstruction
Mandibular reconstruction is necessary when a portion of the jawbone is removed or damaged beyond repair. The most common indication is the surgical removal of malignant tumors, such as squamous cell carcinoma, which requires removing a segment of bone to achieve clear margins. Other conditions necessitating reconstruction include severe traumatic injuries, chronic infections, and osteoradionecrosis (bone death resulting from prior radiation therapy).
A major defect in the mandible compromises the ability to perform basic actions like swallowing and mastication. The goal of reconstruction is to restore continuity to the jaw, providing a stable platform for the oral cavity and preventing the collapse of the chin and lower lip, known as the “Andy Gump” deformity. Using a vascularized bone flap ensures the transplanted tissue remains alive and integrates with the surrounding bone, a significant advancement over older, non-vascularized techniques.
Why Surgeons Choose the Fibula Free Flap
The fibula, the smaller of the two bones in the lower leg, is the preferred donor site for mandibular reconstruction. A major advantage is the substantial length of bone available (up to 26 centimeters), allowing for the reconstruction of large jaw defects. The fibula’s shape and density are also well-suited for being sculpted and contoured to mimic the natural curve of the mandible.
The fibula free flap is an osteocutaneous flap, meaning it can be harvested with a segment of skin (a skin paddle) and its own blood vessels. This skin paddle replaces missing inner lining of the mouth or outer facial skin, providing both bone and soft tissue restoration in a single transfer. The bone quality is dense enough to accept dental implants, which is important for long-term functional recovery. Furthermore, the fibula’s distance from the head and neck allows for a two-team surgical approach, where cancer removal and flap harvesting occur simultaneously, shortening the total operative time.
Navigating the Surgical Process
The procedure is a highly coordinated operation, usually involving a head and neck surgical team and a reconstructive plastic surgery team working in parallel. The process begins with the head and neck surgeon performing the ablative surgery, removing the diseased or damaged segment of the jaw. Simultaneously, the reconstructive team harvests the fibula flap from the lower leg, ensuring the peroneal artery and veins are included to maintain the tissue’s blood supply.
Before the fibula is transferred, surgeons use pre-operative planning, often involving 3D models and cutting guides, to precisely shape the bone. The fibula is cut into several segments (osteotomies) and secured to a custom-bent titanium plate to replicate the curve of the missing mandible. This contouring ensures the new jaw segment matches the patient’s native anatomy, restoring proper dental occlusion.
The most delicate step of a free flap procedure is the microvascular anastomosis. Once the shaped fibula is fixed into the jaw defect, the artery and vein attached to the flap are connected to recipient blood vessels in the neck, typically the facial or superior thyroid vessels. This connection is performed under a high-powered microscope using extremely fine sutures, as the vessels are often less than three millimeters in diameter. Successful anastomosis restores blood flow to the transplanted bone, ensuring its long-term survival and integration.
Post-Operative Recovery and Long-Term Results
Immediate post-operative care focuses on closely monitoring the transplanted flap for adequate blood flow, often using a Doppler ultrasound every hour for the first two days. The hospital stay typically averages around three weeks. During this time, the patient is managed with a feeding tube until swelling subsides and the oral cavity has healed sufficiently for swallowing. Patients usually begin walking within a week or two, as removing a section of the fibula does not significantly affect the leg’s stability, since the tibia bears the majority of the body’s weight.
Long-term functional recovery is a multi-stage process focusing on restoring speech and the ability to chew. Swallowing and speech therapy are often initiated early to help the patient adapt to the reconstructed jaw structure. The ultimate goal is dental rehabilitation, which involves placing osseointegrated dental implants directly into the newly healed fibula bone.
The fibula bone provides a stable foundation for these implants. They can be placed either during the initial surgery or in a delayed procedure after the bone has fully healed, typically nine to twelve months later. Long-term studies show the overall implant survival rate is reliable, ranging from 83% to over 90% at the five-year mark, confirming the procedure’s success in restoring both facial form and oral function.