Pitfalls during mandible reconstruction with free fibula flap and its salvage: a case report

Primary restoration of mandibular continuity remains the standard of care for mandibular defects. The free fibular flap has been the preferred choice for reconstruction for more than a decade, owing to its thickness and reliable blood supply. However, flap failure may occur due to intraoperative mishaps, postoperative complications, or the patient's overall health status. When secondary reconstruction becomes inevitable, it poses a formidable challenge. Several factors must be considered in salvage surgery, including the choice between a flap and a patient-specific implant, the availability of vessels for microvascular anastomosis, strategies to prevent thrombosis and venous congestion, and the potential for dental rehabilitation with implants to restore both function and aesthetics. While flap failure is often attributed to common causes, we highlight unusual contributing factors, such as a short neck, tracheal obstruction, and microvascular failure, that necessitate salvage surgery following a failed free fibular flap.

We present the case of a 30-year-old Indian female who reported swelling in the left mandibular region for 1 year. Histopathological examination confirmed ameloblastoma of the mandible. The patient underwent resection and reconstruction with a free fibular flap. However, intraoperative complications, postoperative challenges, and poor health status lead to flap failure. Salvage surgery was subsequently performed using a new fibular flap, effectively addressing the pitfalls and achieving a successful outcome. This case highlights the pitfalls encountered during primary surgery and the measures adopted to overcome them during salvage procedures. The key strategies included opting for a fibular flap instead of a patient-specific implant, anastomosing the peroneal vessels with the facial artery and internal jugular vein on the contralateral side to ensure straight-line blood flow, reducing the risk of venous congestion, and providing improved postoperative care. These measures have contributed to the success of salvage surgery, resulting in increased patient satisfaction, improved quality of life, and the potential for dental rehabilitation with implants.

Salvage surgery for failed mandibular reconstruction is challenging because of factors such as loss of surgical planes, limited availability of vessels for anastomosis, disturbed patient homeostasis, and prolonged ischemia time of the fibular flap. Nevertheless, these challenges can be successfully addressed through meticulous treatment planning and precise surgical execution.