Mandibular Reconstruction Using the Scapular Tip Free Flap in Patients Unsuitable for Fibula Harvest Based on...

The fibula free flap is considered the gold standard for mandibular reconstruction. However, lower-extremity vascular abnormalities may increase the risk of donor-site ischemic complications and render fibula harvesting unsuitable. This study evaluated the effect of preoperative computed tomography angiography (CTA) on reconstructive decision-making. A retrospective review of consecutive patients who underwent preoperative lower-extremity CTA for planned mandibular reconstruction between April 2018 and November 2025 was conducted. At our institution, fibula harvesting is avoided in patients with vascular findings suggestive of distal lower-extremity perfusion risk, including the absence or occlusion of the tibial artery and severe 3-vessel calcification. Patients' clinical characteristics, CTA findings, reconstructive procedures, and outcomes were reviewed. Overall, 112 patients underwent preoperative lower extremity CTA. Fibula free flap harvesting was avoided in 3 patients (2.7%) due to significant vascular abnormalities identified on CTA, including extensive bilateral calcification involving all 3 lower leg arteries in one patient and bilateral absence of the posterior tibial artery in 2 patients. These 3 patients underwent mandibular reconstruction using a scapular tip free flap. Complete flap survival was achieved without intraoperative vascular complications and postoperative imaging demonstrated satisfactory bone union, and no clinically significant donor site morbidity was observed. In the remaining 109 patients, fibula free-flap harvesting was performed without documented donor site ischemic complications. In conclusion, this study highlights the practical value of preoperative vascular assessment for guiding safe flap selection for mandibular reconstruction and emphasizes that preoperative CTA is crucial for identifying patients unsuitable for fibula free flap harvesting and reconstructive decision-making.