Introduction: The free fibula (FF) and radial forearm (RF) osteocutaneous flaps are commonly used flaps in oromandibular reconstruction. There is ongoing controversy as to the indications of each flap.

Purpose: To compare the FF and RF flaps in oromandibular reconstruction with respect to flap failure rate, donor and recipient site complications, length of surgery and hospital stay.

Methods: Records of patients undergoing oromandibular reconstruction for cancer at St. Joseph’s Healthcare, Hamilton, Canada were reviewed from 1983 to 2002. A retrospective cohort was identified in which 76 patients underwent RF flaps and 34 patients underwent FF flaps.

Results: The FF had a significantly higher complete flap failure rate (9 % vs 1 %). The overall microvascular complication rate was slightly higher for the FF (17.5% vs. 14.5%). Ten of the 12 cases of partial flap necrosis of the RF flap experienced necrosis of the skin paddle not severe enough to merit replacement of the paddle, 1 of the bone (osteoradialnecrosis) (a result of post-operative radiotherapy), and 1 of skin paddle and bone. The FF had a significantly higher complete flap failure rate (9% vs 1%) and two of the 3 FF flaps that failed were replaced with another FF flap and one by a RF flap.

There were no important donor site complications associated with the FF flap. The RF flap however experienced a 14.5% fracture rate of the donor radius and in 6/11 fractures, the fracture was associated with weight bearing on the arm within 14 days of surgery. With regard to fracture of the donor radius, a fracture rate of 28% was experienced in patients 65 and over vs. 8% in those under 65. The FF was associated with a greater plate and bone exposure due to the higher combined partial and total flap necrosis noted in this flap. The surgery time for the RF procedure was 11.7 hrs vs. 10.5 hrs for the FF. Patients with an RF flap had a significant longer hospital stay (19.69 days) than those with a FF flap (13.76 days).

Conclusion: Both RF and FF flaps are safe and reliable for oromandibular reconstruction. The RF flap is more effective when soft-tissue lining is a critical part of the reconstruction. However, the FF is superior when bone support is the main requirement and for patients 65 and older due to its lower complication rate.