Microvascular reconstruction of the mandible: An argument for the fibula osteocutaneous free flap

a b s t r a c t Introduction/objective: The fibula osteocutaneous free flap has been a workhorse for mandibu- lar reconstruction since Hidalgo's original description for its use for this purpose. The objective of this manuscript is to review the use of the fibula flap in mandibular reconstruc- tion and to answer some of the commonly held misconceptions as to why some surgeons view it as an inferior reconstructive option to the vascularized iliac crest flap. Materials/methods: Review of the literature as it relates to the use of the fibula free flap in mandibular reconstruction and the senior author's experience. Results: The bicortical nature of the fibula provides a stable platform for endosseous implant placement, thus allowing for comprehensive oral rehabilitation and improving the quality of life in reconstructed patients. The fibula osteocutaneous free flap, however, is the longest vascularized bone flap available, allowing for reconstruction of the entire mandible. Given these attributes, it would seem unlikely that doubts regarding the adequacy of the fibula free flap in mandibular reconstruction exists. However, the principal arguments challenging the use of the fibula osteocutaneous free flap are the lack of height of the reconstructed fibula compared to the native mandible, unreliable skin perforators to support a skin paddle, insufficient soft tissue coverage, and the presence of vascular anomalies which may preclude its use. These presumed shortcomings are circumvented with various proven techniques to increase fibular height and anatomic studies demonstrating the cutaneous perforator patterns. Conclusions: With these simple solutions in mind, the fibula osteocutaneous free flap will likely remain a workhorse for mandibular reconstruction, allowing for the reconstruction of virtually any oromandibular defect. It allows for both aesthetic, as well as, functional reconstruction of the mandible.