A mandibulectomy with fibula free flap is a complex reconstructive surgery. It addresses significant jawbone defects caused by cancerous or benign tumors, severe trauma, or extensive infections. This procedure involves two main stages: removing the damaged jaw portion and then rebuilding it. Reconstruction uses bone and soft tissue harvested from the patient’s lower leg, specifically the fibula bone. The goal is to restore the jaw’s structural integrity and functional capabilities, which are important for speaking, swallowing, and facial appearance.
Mandibulectomy: Jaw Bone Removal
Mandibulectomy is the surgical removal of all or part of the lower jawbone, known as the mandible. This procedure is undertaken for various medical reasons, including the eradication of cancerous or non-cancerous tumors that have affected the jaw. It also treats conditions like osteonecrosis, a severe bone disease where bone tissue dies, or significant jaw trauma. The objective is to completely remove diseased or damaged tissue.
The extent of jawbone removal varies. A “marginal mandibulectomy” removes only a rim or outer portion of the jawbone, maintaining its continuity. This approach is used when a tumor is close to the jawbone but has not invaded it, preserving more native bone. In contrast, a “segmental mandibulectomy” cuts through the full thickness of the mandible, removing an entire section. This more extensive removal is necessary when disease has invaded the bone or a larger portion is compromised.
Surgeons aim for “clear margins” during mandibulectomy. This means removing affected tissue along with a surrounding area of healthy tissue to ensure no diseased cells remain. A pathologist examines the removed tissue under a microscope to confirm the edges are free of disease. This attention to margins is important for the procedure’s long-term success, especially in cancer cases, as it helps reduce recurrence.
Fibula Free Flap: Jaw Reconstruction
After jawbone removal, reconstruction often uses a fibula free flap. The fibula, a bone from the lower leg, is chosen for its length, strength, and reliable blood supply, which allows for successful transplantation. Using the fibula helps restore the jaw’s shape and provides a stable foundation, sometimes allowing for future dental implants.
The process begins with harvesting a segment of the fibula bone, its blood vessels, and often overlying skin and muscle. This tissue collection is a “free flap” because it is detached from its original site. While one surgical team prepares the fibula, another prepares the jaw’s recipient site, identifying suitable arteries and veins for connection.
The success of the fibula free flap depends on microvascular anastomosis. This involves meticulously connecting the fibula’s tiny blood vessels to blood vessels in the head and neck region. This procedure is performed under a high-powered microscope to ensure the flap receives a continuous blood supply. Once blood flow is established, the fibula bone is shaped and secured into the jaw defect using plates and screws, mimicking the original jaw’s curvature. The flap’s soft tissue then covers the reconstructed area, aiding function and appearance.
Recovery and Rehabilitation Journey
Recovery and rehabilitation after a mandibulectomy with fibula free flap is a gradual process requiring patience and dedicated care. Patients typically stay in the hospital for 10 to 14 days, focusing on pain management and monitoring the reconstructed flap. Swelling in the face and leg donor site is common, and medical teams closely observe the flap for signs of adequate blood flow.
A multidisciplinary team supports longer-term rehabilitation. Speech therapists help patients relearn how to articulate words clearly, as jaw structure and soft tissues change. Swallowing therapy is also an important component, guiding patients through exercises to regain the ability to safely eat and drink. Initially, a temporary feeding tube, placed through the nose or into the stomach, may be necessary to ensure adequate nutrition during early healing.
Physical therapy for the leg helps restore strength, mobility, and function at the fibula donor site. While the fibula is not a weight-bearing bone, some initial limitations in ankle movement or mild discomfort are possible. The timeline for returning to normal activities varies widely among individuals, often spanning several months to a year or more, reflecting the body’s healing and adaptation. As healing progresses, dental implants into the new fibula bone can be explored to enhance chewing function and aesthetic outcomes.
Potential Complications and Patient Considerations
Like any major surgery, a mandibulectomy with fibula free flap carries potential risks. General surgical risks include infection at the jaw or leg site, bleeding, and fluid collections (seromas or hematomas). These are common concerns and are monitored by the medical team.
Specific risks include flap failure, where the transferred fibula tissue does not establish adequate blood supply and dies. While uncommon, this complication may require further surgery. Nerve damage in the face can lead to numbness in areas like the lower lip or chin, as the inferior alveolar nerve may be affected or removed. Nerve irritation or damage in the leg can cause temporary or, less commonly, persistent numbness or weakness in the foot.
Other considerations include the potential for non-union of the bone, where the reconstructed fibula does not fully fuse with the remaining jawbone, requiring additional intervention. Patients may also experience ongoing issues with speech and swallowing, even after extensive therapy, or changes in facial aesthetics due to jaw structure and soft tissue alterations. A thorough discussion with the surgical team is important for patients to understand their individual risks and realistic expectations for functional and aesthetic outcomes. The psychological impact of this surgery can also be significant, emphasizing the importance of comprehensive support systems throughout recovery.