Periosteal-Preserving Fibula Onlay Graft With Fibula Free Flap for Vertical Augmentation in Mandibular Reconstruction

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Abstract
Aim: To evaluate the clinical outcomes of double-strut fibula onlay bone graft combined with a vascularized fibula free flap for mandibular reconstruction, focusing on long-term graft volume changes and viability. Materials and Methods: This retrospective review included 9 patients (7 males, 2 females) who underwent simultaneous reconstruction with a fibula free flap and fibula onlay bone graft between 2017 and 2023. The mean follow-up period was 2.19±1.69 years. Clinical and radiologic data were collected to assess bone volume, speech, dietary function, and postoperative complications. Volumetric analysis was conducted using 3D imaging, and the Mann-Whitney U test was used to compare bone volume changes between the graft and flap groups. Results: The mean fibula onlay graft length was 5.9±1.7 cm (range: 2.8 to 7.6 cm). Postoperative imaging showed higher bone volumes in the fibula flap group at all time points. The onlay graft group exhibited a higher median percentage bone volume reduction (43.48%) compared with the fibula flap group (22.37%), although this difference did not reach statistical significance ( P =0.136), and the series was too small to exclude a clinically meaningful difference. Bone union was achieved in 88.9% of cases, with 1 graft failure (11.1%) and 1 wound infection (11.1%). Conclusion: In this small, uncontrolled series, the combination of a periosteal-preserving fibula onlay bone graft with a vascularized fibula free flap was feasible and achieved vertical augmentation with acceptable graft viability and a low complication rate. Larger controlled studies are required before the technique can be recommended over established alternatives.

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