Narrative review: fibula free flap, indications, tips, and pitfalls

The fibula free flap is a reliable reconstruction option, also known as the “work horse” of mandibular reconstruction. Its advantages are its size and length, ability to utilize both hard and soft tissues, and its distance from the head and neck which allows for a two team approach. Pre operatively one must evaluate perfusion to the foot, as well as vasculature supplying the flap. Many adjuncts can facilitate easier harvest, inset, and monitoring. Virtual surgical planning, SPY angiography, and the WalterLorenzTM Surgical Assist Arm are all examples. Post operatively, by utilizing enhanced recovery after surgery protocols one can standardize care, which can produce more consistent results. Utilizing step down units, instead of the intensive care unit (ICU), can also help avoid common complications such as pneumonia and delirium, as well as reduce costs. Opioid use after surgery can be reduced by utilizing multimodal pain management strategies, including use of regional anesthesia blocks and indwelling catheters. By utilizing these techniques, we have found we are able to perform fibula free flap reconstruction more efficiently, with less staff, less complications, and are able to utilize less opioids post operatively. The fibula free flap continues to be extremely important for head and neck reconstruction, due to its reliability, versatility, and ability to place dental implants for total dental rehabilitation.