Fibula Free Flap for Jaw Reconstruction: Rebuilding the Mandible

When a patient needs surgery to remove a significant portion of the jaw — whether because of oral cancer, bone invasion from a gingival tumor, or osteoradionecrosis after prior radiation with infection — the prospect of living without a complete mandible is frightening. The jaw is not just a structural frame. It defines the shape of your face, enables you to chew and swallow, and anchors your lower teeth. Losing part of it, without reconstruction, would mean a permanent, disfiguring defect and a dramatic loss of function. Thankfully, that is avoidable. The fibula free flap is one of the most reliable and versatile reconstructive techniques in head and neck surgery, and it has transformed what's possible for patients who require jaw resection.

What Is the Fibula, and Why Do We Use It to Rebuild the Jaw?

The fibula is the long, slender bone that runs along the outside of your lower leg, parallel to the tibia. Most people don't realize it's not a primary weight-bearing bone — your tibia does the heavy lifting. The fibula contributes to ankle stability, but a substantial segment of it can be safely removed without compromising your ability to walk. That combination of expendability and structural quality makes it an ideal donor for jaw reconstruction.

What makes the fibula particularly valuable for mandibular reconstruction is its length and its blood supply. A typical reconstruction may require anywhere from 6 to 14 centimeters of bone, sometimes more — and the fibula provides that length readily. It can also be cut into multiple segments and repositioned at precise angles using small titanium plates, allowing the surgical team to recreate the curvature of the native jaw rather than placing a straight segment of bone where a curved one belongs. And because the fibula comes with its own dedicated artery and vein — which we reconnect to vessels in your neck using microsurgical technique — the transplanted bone arrives with a living blood supply, which is essential for healing and long-term survival of the graft.

Who Needs This Operation?

The most common reason I perform fibula free flap reconstruction in my practice is oral cavity cancer — specifically tumors of the floor of mouth, lower gum (alveolar ridge), or inner surface of the cheek that have grown into or adjacent to the bone of the mandible. When a tumor has invaded the jaw, the standard oncologic principle is to remove the involved bone with adequate margins. That resection — called a segmental mandibulectomy when the full thickness of the bone is removed — creates a gap that must be filled.

Other patients who may benefit from this reconstruction include those with osteoradionecrosis, a condition in which bone that was irradiated years earlier loses its blood supply, becomes necrotic, and can no longer heal. In advanced cases, the only definitive treatment is removal of the affected bone segment followed by reconstruction with healthy, well-vascularized tissue — exactly what the fibula provides. A smaller number of patients require jaw reconstruction after treatment for other bone tumors or severe injury.

The decision to use the fibula versus another reconstructive option depends on how much bone needs to be replaced, whether adjacent soft tissue also needs to be included in the reconstruction, and individual patient factors including leg anatomy and vascular status. I typically obtain a CT angiogram of the leg before surgery to confirm that the blood vessels supplying the fibula are healthy and suitable for harvest.

What Happens During the Surgery

Fibula free flap reconstruction is performed under general anesthesia and typically takes six to ten hours. Two surgical teams generally work simultaneously — one operating in the mouth and neck to remove the tumor and prepare the recipient blood vessels, the other working on the leg to harvest the fibula.

Once the jaw resection is complete, the fibula segment is shaped and fixed into position using a reconstruction plate — a rigid titanium bar that spans the gap and secures the new bone in place while healing occurs. The cuts in the fibula are planned with the help of computer-generated surgical guides in most of my cases, which allows us to custom shape the titanium plate to match the precise geometry of your jaw. This virtual surgical planning has meaningfully improved the precision of jaw reconstruction over the last decade I have been using this in my practice. And it shortens the operative time substantially.

With the bone secured, I connect the fibula's artery and vein to blood vessels in the neck — usually branches of the external carotid artery and the internal jugular vein — under a high-powered surgical microscope. These connections, called anastomoses, are made with sutures finer than a human hair. Once flow is restored, the transplanted bone begins receiving its own blood supply and becomes a living part of your body. The leg donor site is closed directly, or with a skin graft if necessary, and the wound is dressed.

What to Expect: The Leg

Patients are often more anxious about the leg than about the head and neck portion of the surgery, which is understandable — it's a second surgical site on a part of the body most of us rely on heavily. In my experience, leg function after fibula harvest is generally very well preserved. Most patients are out of bed within a day or two of surgery, and the majority return to normal walking within a few weeks.

The leg incision heals over several weeks. There is typically some tightness and numbness along the outer lower leg — the skin over the fibula is supplied by a nerve that runs alongside it, and some change in sensation in that area is common. Most patients adapt to this without significant functional limitation. Long-term leg complaints are relatively uncommon, though I counsel patients that some degree of outer ankle stiffness or calf tightness can persist. There will be weakness of the elevation of the big toe.

The Recovery: Jaw and Overall

Hospital stay after this surgery is typically one to two weeks. During the first several days, you will be closely monitored for the health of the transplanted flap — the surgical team checks the reconstruction regularly for signs of adequate blood flow. Patients frequently have a tracheostomy (a temporary breathing tube in the neck) and a feeding tube in place for the initial recovery period while swelling resolves and healing begins.

The jaw itself heals over a period of months. Bone consolidation — the process by which the fibula integrates fully into the surrounding tissue — takes time, and most patients are on a soft or liquid diet for the first six to eight weeks after surgery. Speech and swallowing function depend heavily on how much tissue was removed in addition to the bone, and most patients work with a speech-language pathologist as part of their recovery.

One of the significant long-term advantages of the fibula free flap over purely soft-tissue or prosthetic reconstruction is the possibility of dental implants. Because the fibula is living bone with an intact blood supply, it can support osseointegrated implants — titanium posts that fuse with the bone and anchor replacement teeth. This is not immediate; implants are typically placed six to twelve months after reconstruction, once healing is complete and any adjuvant radiation therapy has finished. Not every patient is a candidate, but for those who are, dental rehabilitation with implant-supported prosthetics can restore chewing function and aesthetics in a meaningful way.

A Procedure Built on Precision

Rebuilding the mandible is one of the most technically demanding operations in head and neck surgery. It requires oncologic expertise to achieve clean margins, reconstructive expertise to restore form and function, and microsurgical skill to ensure the transplanted tissue survives. When these come together well, patients can emerge from jaw resection with a face that looks and functions in a way that allows them to live their lives fully.

If you or someone you love is facing a diagnosis that may require jaw reconstruction, I encourage you to discuss your options with a surgeon who performs this procedure regularly and who can walk you through what to expect specific to your situation. To schedule a consultation, call 414-649-3920.

Dr. Steven Sperry is a fellowship-trained head and neck surgeon specializing in head and neck cancer surgery and microvascular free flap reconstruction at Aurora St. Luke's Medical Center in Milwaukee, Wisconsin.