Strategic Muscle Coverage in Free Fibular Mandibular Reconstruction: An Osteotomy Approach to Minimize Plate Exposure, A Retrospective Analysis of 580 Consecutive Patients

Abstract

Background

Free fibula flap reconstruction represents the gold standard for mandibular reconstruction following oncologic resection. However, plate exposure remains a significant complication, particularly in patients receiving postoperative radiotherapy. Traditional reconstructive approaches emphasize precise hardware contouring and basic soft tissue coverage but frequently fail to provide adequate muscle protection over hardware, especially in irradiated tissues.

Methods

A retrospective analysis was conducted of 580 consecutive free fibula flap reconstructions performed between 2018 and 2024. Patients were stratified into two cohorts based on plate exposure occurrence. The modified surgical technique involved strategic fibular segment rotation to position the flexor hallucis longus muscle directly over critical hardware fixation points. Statistical analyses included Mann–Whitney U tests, Fisher's exact tests, and logistic regression modeling to identify significant risk factors for plate exposure.

Results

Adequate muscle coverage was present in 33.33% of patients with plate exposure compared with 97.02% of those without exposure (p < 0.0001). Among patients receiving postoperative radiotherapy, adequate muscle coverage was achieved in 96.34% of cases without exposure compared to 50% in the exposure group (p = 0.001). Multivariate analysis confirmed inadequate muscle coverage as an independent predictor of plate exposure (OR: 22.669, 95% CI: 3.79–135.596).

Conclusion

The described osteotomy modification was associated with consistent muscle coverage over reconstructive hardware and was associated with lower plate exposure rates, particularly in patients undergoing postoperative radiotherapy. Prospective studies are required for long-term assessment.