Transoral Minimal Access Mandibular Reconstruction Using Fibula Free Flap in Osteoradionecrosis

To describe the use, indications, and outcomes of a limited transoral approach for segmental mandibulectomy reconstruction with minimal access vessel isolation and anastomoses in patients with mandibular osteoradionecrosis.

Retrospective review of patients who have undergone FFF reconstruction of segmental mandibulectomy via transoral plating and inset at our institution from 2022 to 2024.

Nine patients (median age of 66, 100% male) with mandibular ORN underwent FFF reconstruction via transoral approach with minimal access vessels isolation. The majority of patients failed conservative management of ORN, with eight patients receiving prior antibiotic therapy and seven undergoing hyperbaric oxygen therapy. Preoperative fracture/nonunion and fistula were noted in seven and four patients, respectively. The median length of hospitalization following this procedure was 6 days (range: 4-9). One patient developed nonunion in the postoperative period and required revision with anterolateral thigh fascia lata free flap and iliac crest bone grafting. An additional patient required takeback for hematoma and successful vascular salvage; however, complications were otherwise minimal, with no other patients experiencing operating room takeback, readmission within 30 days, hematoma, fistulas, or flap compromise. All patients demonstrated clinical and radiographic arrest of ORN at most recent follow-up. Median follow-up length was 13.9 months (range 7.7-34).

Mandibular reconstruction using a transoral approach with FFF provides a promising alternative to the traditional transcervical approach for patients with osteoradionecrosis, potentially reducing morbidity and improving outcomes.