Pedicle Ossification-induced Thrombosis and Sequential Fibula Free Flap Failures

The fibula free flap (FFF) is one of the most widely used methods for head and neck bony reconstruction, yet pedicle ossification-though rare-can lead to complications. Although historically considered benign, ossification may cause vascular compromise, a phenomenon previously unreported. We present a unique case of consecutive FFF failures due to pedicle ossification-induced thrombosis. A 56-year-old man underwent FFF reconstruction following mandibulectomy for T4N0M0 squamous cell carcinoma. Despite adjuvant chemoradiotherapy, the first flap necrosed months later, with imaging revealing extensive pedicle ossification and thrombosis. A contralateral FFF was performed but similarly failed due to recurrent ossification and arterial thrombosis, confirmed histopathologically. This case challenged the assumption that pedicle ossification is benign and highlighted its potential for catastrophic flap loss. A literature review indicates that ossification rates vary (4.4%-21%), with meticulous periosteal dissection significantly reducing risk. Clinical presentation often includes trismus, submandibular induration, and pain, but complete necrosis had not been previously documented. This report underscored the need for technical modifications in high-risk cases, consideration of alternative flaps (eg, scapular), and systematic evaluation of late flap failure to exclude ossification-related thrombosis. Surgeons must recognize this underreported complication to optimize reconstructive outcomes.