Bony free flap reconstruction of the facial skeleton following ablative surgery is common. Replacement with like for like tissues to reduce morbidity and facilitate rehabilitation is accepted gold standard. Current microvascular flap transfers have success rates in excess of 90% commonly. The greatest risk is a failure of the flap but occasionally different problems can occur. The fibula free flap is routinely used to reconstruct maxillary or oromandibular bony defect reconstruction. The main advantages are minimal donor site morbidity, good length of bone, possibly of implant rehabilitation and good length of the pedicle. The length of the pedicle is enhanced by taking all the available bone and then discarding the proximal portion of the bone. This then allows for the greatest length of the pedicle. The bone is removed subperiosteally and in fact, the remaining periosteum is left as intact as possible. The osteogenic potential of intact vascularised periosteum is well studied and recognised. Rarely this free flap pedicle can undergo calcification and cause pain, trismus and impair oral function. This paper from Germany describes this uncommon phenomenon in three cases. Patients from two centres that had fibula free flap reconstruction from January 2010 until January 2016: 68 cases had fibula free flap reconstruction and three cases are identified. Their rate of this uncommon complication is 4.4%. All three patients presented with pain and trismus. Fifty-five cases of fibula free flap were to reconstruct the mandible (80.9%) and 13 (19.1%) were to reconstruct the maxilla. It was also interesting that all three cases reported were to reconstruct the maxilla and were anastomosed to the facial artery. It is well accepted that stretching stress associated with chewing and speaking is an essential stimulus. The authors quite correctly conclude the incidence of this complication is rare, but surgeons must be aware as it can mimic recurrent disease. Often radiology can confirm and show the ossification, finally, they suggest surgery only be carried out when the patient is symptomatic. In the relevant discussion, a full review of the literature is presented, and they describe their own technique of fibula flap harvest to reduce this. This was an excellent paper that describes an uncommon complication and full literature review.

Fibula free flap pedicle ossification: Experience of two centres and a review of the literature.
Baserga C, Massarelli O, Bolzoni AR, et al.
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Sunil K Bhatia

Royal Shrewsbury Hospital, Shrewsbury, UK.

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