Reconstructing segmental mandibular defects: A single-center, 21-year experience with 413 fibula free flaps

Authors: Allen RJ Jr, Zhang KK, Cohen Z, Shahzad F, Nelson JA, McCarthy CM, Patel SG, Boyle JO, Shah JP, Disa JJ, Cordeiro PG, Mehrara BJ, Matros E

Affiliation: Memorial Sloan Kettering Cancer Center, New York, NY

Journal: Plastic and Reconstructive Surgery

PMID: 41159801

Key takeaways

• 401 patients/413 fibula free flaps over 21 years; flap success 97.8%; total flap loss 2.2%.

• CAD/CAM adoption (40.7% of cases) was associated with shorter OR time (~50 min) and shorter LOS, without reducing major complications.

• Immediate dental implant placement (IDIP) in 23.7% increased over time alongside CAD/CAM and was linked to higher dental rehabilitation rates.

• Fixation shifted from mini-plates to custom reconstruction bars beginning 2016–2019, aligning with virtual planning.

• Despite workflow gains, recipient-site complications remained common (54.7% overall; 29.5% reoperation).

Background

Fibula free flap (FFF) is the workhorse for segmental mandibular reconstruction. Advances in virtual surgical planning (VSP/CAD‑CAM), custom fixation, and IDIP have changed workflow and rehabilitation, but the effect on outcomes is unclear.

Objective

Describe evolving trends and techniques (CAD/CAM, dental implants, fixation) and characterize operative metrics and complications after FFF‑based mandibular reconstruction at a single high‑volume cancer center.

Methods

• Design/setting/LOE: Retrospective review, single comprehensive cancer center, 2000–2021.

• Sample: 401 patients, 413 FFFs; median follow‑up 2.9 years. Demographics, comorbidities, treatments abstracted.

• Defects: Lateral (45.0%), hemimandible (32.7%), anterior (14.3%); composite oral cavity soft‑tissue defects 23.2%; external skin defect 19.9%.

• Techniques: Mini‑plates vs reconstruction bars; use of CAD/CAM (from 2010 → 100% by 2021) and IDIP (from 2017).

• Endpoints: Recipient and donor site complications (major = return to OR); flap loss; osteoradionecrosis; operative time; LOS; dental rehabilitation; temporal trends.

• Statistics: Descriptive statistics and year‑over‑year trend plots; subgroup comparisons (e.g., CAD/CAM vs no CAD/CAM); α = 0.05.

Results

• Cohort: Mean age 58.0; male 63.9%; prior radiation 77.2%; procedure length mean 675.6 ± 132.5 min; LOS median 14 days.

• Flap characteristics: Two‑segment (47.0%) and three‑segment (34.6%) constructs most common; skin paddle used in 79.2%; systemic heparin 77.2%.

• Trends: Case volume increased over time. Reconstruction bars supplanted mini‑plates beginning in 2019. CAD/CAM use rose to 100% by 2021; IDIP increased after 2017; dental rehabilitation rose in parallel (later dip during COVID‑era).

• CAD/CAM vs no CAD/CAM:

  • OR time: 646.4 ± 116.3 vs 695.7 ± 132.5 min; P = 0.0002.

  • LOS: 14.3 ± 5.7 vs 17.9 ± 9.2 days; P < 0.0001.

  • Major complications: 31.5% vs 32.7%; P = 0.813.

• Recipient‑site complications: 54.7% overall; major 29.5%; infection/cellulitis 15.3%; dehiscence 15.0%; fistula 12.4%; exposed hardware 13.1%; osteoradionecrosis 11.9%. Year‑to‑year major complication rates showed no clear trend.

• Flap outcomes: Total loss 2.2% (9/413); partial loss 1.5%; additional flap‑related complication 3.9%.

• Donor‑site complications: 32.9% overall, driven by delayed wound healing 28.3%.

  
  

Conclusion

Institutional adoption of CAD/CAM, IDIP, and custom reconstruction bars improved workflow (shorter OR time and LOS) and enabled dental rehabilitation but did not reduce major complication rates. Mandibular FFF reconstruction remains morbid yet reliable, with high flap success.

Strengths: Large contemporary cohort; long observation window; detailed operative/complication definitions; practical metrics (OR time, LOS, dental rehab); granular technique trends.

Limitations: Retrospective single‑center design; evolving protocols over decades; limited adjustment for confounding; lack of standardized functional outcomes or quality‑of‑life measures; potential survivorship and documentation bias.

Clinical Relevance

The free fibula flap remains the gold standard for segmental mandibular reconstruction, with reliable union and high flap survival. However, despite adoption of CAD/CAM planning, custom reconstruction bars, and immediate dental implants, major recipient-site complications have not declined.

Critiques/Questions

• Signal vs causation: CAD/CAM association with shorter OR time/LOS may reflect workflow optimization and learning‑curve effects rather than technology alone.

• Data gaps: Functional outcomes (speech, diet), bony union, and plate/bar exposure over time would sharpen conclusions.