Subtotal Mandible Reconstruction with a Free Fibula Flap and No Skin Incisions

Resection of large mandibular tumors followed by primary reconstruction using free tissue transfer is typically accomplished using transcutaneous cervical incisions, which provide access for ablation as well as inset of the osseous free flap. This approach offers wide exposure; however, it subjects the patient to potential facial scarring, marginal mandibular nerve injury, lip deformity/incompetence, formation of orocutaneous fistulae, as well as functional impairments to speech, mastication, and deglutition. To reduce morbidity and to preserve aesthetics, a transoral approach can be used in cases that do not require a neck dissection. This technique can be coupled with transoral dissection of the facial vessels for intraoral microanastomoses to avoid extraoral incisions altogether. We present a case of a large 17.2 cm subtotal mandibulectomy and 3-segment fibular free flap reconstruction using virtual surgical planning, with patient-specific cutting guides and reconstruction plate performed entirely transorally without any skin incisions. Although technically challenging, this is a safe and effective technique for large segmental mandibular defects, which provides superior cosmetic and functional outcomes.