Mandible Reconstruction with Fibula Free Flap. Is this an option?

Posted by William Olsen, Volunteer Mentor @hrhwilliam, Aug 6, 2023

In cases of radiation to the jaw resulting in Osteoradionecrosis (radiation bone death) or Ameloblastoma or similar growths on the mandible, reconstruction surgery is sometimes recommended. The mandible (lower jaw bone) has become constantly infected, weak causing pain, teeth failing, habitually sore or troublesome, after radiation therapy often years in the past. Your doctors or dentists may be suggesting surgery. Ameloblastoma patients sometimes have little choice due to the tumor often embedded in the mandible itself. While there are options to mandible reconstruction, what works very well is replacement of the infected section with your own transplanted bone and tissue.

When replacing a mandible section with harvested bone, the bone section selected will have the blood supply attached (free flap) which will be reconnected to an existing artery to keep the bone alive. This allows for healing and complete attachment to the existing mandible. Mayo Clinic Rochester, one of only a few places in the world that perform this type of surgery, uses either a section of bone from the Fibula or from the hip or shoulder area. The Fibula is a flexible bone in the lower leg which is non-weight bearing and won’t be particularly missed.

Dr’s Arce and Ettinger among others in the Oral and Maxillofacial Surgery group removed a section of my left fibula and surrounding tissue and fit that precisely into my left mandible along with peg inserts to support prosthetic teeth. 3-D models of my jaw were worked up and used as templates prior to surgery so that everything fit as necessary. The entire procedure for my end was about six hours of happy sleep. Recovery was a bit longer of roughly a week before I was released from hospital.

I had a feeding tube installed for nutrition and medication as well as a CAM-boot on my leg to promote healing. The feeding tube was removed after three weeks whilst the CAM-boot was probably gone after two. The healing while not comfortable was certainly manageable and I returned to work (restricted mostly to a desk) about four weeks after surgery.

Healing continued with return visits to Mayo for teeth prosthesis and to have my trach closed, which it did not do on it’s own because things like that happen to me. Nine months out I was eating corn on the cob for the first time in many years and walking without issue, miles per day. Now two years out, other than meticulously cleaning my teeth thrice-daily, I really have no issues with eating, talking, or walking. The healing was certainly much faster than the cancer treatments that proceeded this adventure twenty years prior.

Has anyone else been troubled by teeth or jaw since radiation or surgery? Has Mandible Reconstruction been considered?

Interested in more discussions like this? Go to the Head & Neck Cancer Support Group.

Tom Schwerdt | @tomschwerdt | Oct 23 3:41pm

In reply to @hrhwilliam "MD Anderson is a good option." + (show)

I'll second exploring the MD Anderson option if you're in Texas, specifically the Head and Neck Center. While I'm having targeted chemotherapy, I did discuss the radical resection and fibular flap with Dr. Gillenwater. Very knowledgable. They will take a team approach.
https://www.mdanderson.org/patients-family/diagnosis-treatment/care-centers-clinics/head-neck-center.html

joylondon | @joylondon | Oct 23 1:17pm

In reply to @ld1262 "Any particular sugeon?" + (show)

Stephen Y. Lai, M.D., Ph.D. at MD Anderson authored a paper titled "Radiomic Correlates of Mandibular Osteoradionecrosis after Radiation Treatment of Head and Neck Cancer Patients" You might want to start with him. https://faculty.mdanderson.org/profiles/stephen_lai.html

ld1262 | @ld1262 | Oct 23 1:06pm

In reply to @hrhwilliam "MD Anderson is a good option." + (show)

Any particular sugeon?

William Olsen, Volunteer Mentor | @hrhwilliam | Oct 23 12:59pm

In reply to @ld1262 "Actually in Texas, but not opposed to travel. The only thing that concerns me are the..." + (show)

MD Anderson is a good option.

ld1262 | @ld1262 | Oct 23 12:54pm

In reply to @joylondon "Dear ld1262, I'm not sure where you're located, but if you're anywhere near the East Coast,..." + (show)

Actually in Texas, but not opposed to travel. The only thing that concerns me are the follow-ups. Thanks for your input

ld1262 | @ld1262 | Oct 23 12:53pm

In reply to @darcybechtel67 "So you didn't have your upper teeth replaced, I have no teeth except a few on..." + (show)

I did not need to, still have all my uppers. Prosthodontist says my front 4 are not in good shape and is recommending implants at some time in the future. I have trismus as well, very painful at times. Is there any meds or therapy to treat this condition? After my cancer treatment in 2016 where I went from 180+ to around 150, I have held my own every since.

ld1262 | @ld1262 | Oct 23 6:35am

Thank you

joylondon | @joylondon | Oct 22 11:18pm

In reply to @ld1262 "I had the Mandible Reconstruction with Fibula Free Flap surgery done last year in 2023. It..." + (show)

Dear ld1262,

I'm not sure where you're located, but if you're anywhere near the East Coast, you might want to speak to: (1) Mark Urken, MD and Eric Genden, MD; both are at Mt. Sinai Hospital (New York City), and (2) Gregory Farwell, MD at Penn Medicine (Philadelphia).

I wish you the very best.

William Olsen, Volunteer Mentor | @hrhwilliam | Oct 21 4:56pm

In reply to @ld1262 "I had the Mandible Reconstruction with Fibula Free Flap surgery done last year in 2023. It..." + (show)

hi @ld1262 Welcome to the Head and Neck group. Ouch! Third time? I would definitely find a different health center with experience. If the surgeons haven't done at least fifty of these, run away. And yes you are allowed to ask and you should. This is your mandible, not theirs. The micro surgery involved in the reconstruction is the most critical part and must be done by a steady, knowledgable surgeon.
I had fibula free flap used for mandible reconstruction in 2020, also due to osteoradionecrosis from cancer treatment like you. Successful. Had some infection due to excess flap material growing around the prosthetic teeth which had to be dealt with, twice. Aside from that, I'm doing great. Surgery done at Mayo, Rochester by the folks who pretty much perfected this and train others worldwide.
You might want to consider not having pegs for teeth and just get the jaw repair done. Seek out the best is all I can tell you. If you have further questions, there are several of us here who have had this rare procedure. So feel free to reach out and ask.

ld1262 | @ld1262 | Oct 21 4:38pm

I had the Mandible Reconstruction with Fibula Free Flap surgery done last year in 2023. It was a rough time, the first interior flap failed due to an infection and they did another skin graft from my radial fore arm. Not to go into a lot of detail but surgeon cleared me early this year to proceed with prosthetic teeth, I have only one original tooth in my lower jaw. Oral surgeon had to thin the tissue to make way for the implants and in doing so exposed the bone and some of the hardware which is not healing. I was then advised that one of the fibular segments did not heal, so their is no blood supply which is causing the tissue not to grow back over and cover. I was informed today that I would have to go through the procedure again from the original surgeon that performed the first procedure. A little more history had oral cancer 8 years ago with chemo and radiation which developed into Osteoradionecrosis. I am currently cancer free. I have been on a liquid diet since March 2023. I am looking for the top 5 surgeons or surgical teams in the country that do this type of procedure for a second opinion.