Week 4 - Pooja Nair

Name: Pooja Nair

Clinical Mentor: Dr. Jason Spector

This week I’m highlighting one of the most complex reconstructive procedures I observed: a free fibula flap for mandibular reconstruction. The case involved a patient requiring restoration of the mandible after resection of a cystic jaw lesion or benign tumor. In this approach, a fibula free flap provides vascularized bone, soft tissue, and skin for rebuilding the jaw.

Two surgical teams worked in parallel. The oral and maxillofacial surgery team performed the tumor resection and prepared the mandibular defect, while Dr. Spector and the plastic and reconstructive surgery team harvested the fibula along with its artery, vein, and overlying soft tissue. Preoperative planning was extensive, with custom titanium guides and cutting templates created for both the mandible and fibula to ensure precise alignment of the reconstructed segments and to support future dental implants.

During the harvest, the central portion of the fibula was removed, with approximately 5 cm preserved proximally to protect the common peroneal nerve and 5 cm distally to maintain ankle stability. I learned that the fibula bears only a portion of the leg’s weight load, allowing most patients to return to normal activity after recovery despite partial bone removal. Once harvested, the fibula was contoured to recreate the mandibular arch and shaped to accommodate future dental implants.

After the flap was cut and its blood supply was interrupted, timing became critical because the tissue remains ischemic until it is connected to the recipient vessels. The fibula was transferred to the jaw, and microsurgical vascular anastomosis was performed to connect the flap’s vessels to recipient vessels in the neck, restoring perfusion. At the donor site, once the leg was closed, a split‑thickness skin graft was harvested from the thigh using a dermatome to cover the remaining soft‑tissue defect.

Postoperatively, we followed the patient during rounds. Flap viability was monitored using an implanted Doppler to confirm continuous perfusion and ensure the microsurgical connections remained patent. Indocyanine green (ICG) fluorescence imaging was another method discussed for visualizing real‑time blood flow. The patient initially received nutrition through a feeding tube to protect the reconstruction during early healing; prolonged support is sometimes required in patients with prior radiation, though this patient did not have that history. During rounds, the skin graft appeared bluish because its thin, translucent nature allowed underlying tissue to show through. Over time, the thigh donor site re‑epithelializes, and careful dressing management supports healing while preventing excessive granulation tissue.

As recovery progressed, the patient was eventually decannulated, the implanted Doppler was removed, and they were discharged with a well‑perfused flap and stable donor sites. One concept emphasized during the case was Wolff’s Law: bone remodels in response to mechanical loading. Over months to years, the transferred fibula can hypertrophy and adapt to its new role as part of the mandible.1,2

 

References

1.      Molteni, G. et al. Fibula Free Flaps. Free Flaps in Head and Neck Reconstruction: A Step-By-Step Color Atlas 131–146 (2024) doi:10.1007/978-3-030-29582-0_13.

2.      Al Shetawi, A. H. & Buchbinder, D. Mandibular reconstruction. Contemporary Oral Oncology 3, 65–96 (2017).

 

 

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