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This case report describes a 56-year-old man who developed months-later flap necrosis after mandibulectomy reconstruction, with imaging showing extensive pedicle ossification and thrombosis. A second contralateral fibula free flap also failed due to recurrent ossification-driven arterial thrombosis confirmed pathologically. The report challenges benign assumptions, summarizes clinical features, and emphasizes meticulous periosteal dissection and consideration of alternative flap strategies and late failure evaluation.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/pedicle-ossification-induced-thrombosis-and-sequential-fibula-free-flap-failures-case-report/435634/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/pedicle-ossification-induced-thrombosis-and-sequential-fibula-free-flap-failures-case-report/435634.png","ImageObject",300,407,{"name":92,"@type":93},"dhado","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":44},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What complication is highlighted in this case report?","Question",{"text":112,"@type":113},"Pedicle ossification-induced thrombosis leading to sequential fibula free flap failures and catastrophic flap necrosis.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How many consecutive fibula free flaps failed in the patient?",{"text":117,"@type":113},"Two consecutive fibula free flaps failed due to recurrent pedicle ossification with vascular compromise.",{"name":119,"@type":110,"acceptedAnswer":120},"What imaging and pathology findings supported the diagnosis?",{"text":121,"@type":113},"Imaging revealed extensive pedicle ossification and vascular compromise, and the thrombosis etiology was confirmed histopathologically after the second failure.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},435634,1790716926,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":44,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":81,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":39,"preview_page_count":4},5909893218464,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Case RepoRt   \nReconstructive  \nPedicle Ossification-induced Thrombosis and Sequential Fibula Free Flap Failures  \nKhaled Al Tabaa, MD*† Louis Morin, MD* Diane Roudie, MD* Florent Couineau, MD*  \nSummary: The fibula free flap (FFF) is one of the most widely used methods for head and neck bony reconstruction, yet pedicle ossification—though rare—can lead to complications. Although historically considered benign, ossification may cause vascular compromise, a phenomenon previously unreported. We present a unique case of consecutive FFF failures due to pedicle ossification-induced thrombosis. A 56-year-oldman underwent FFF reconstruction following mandibulectomy for T4N0M0 squamous cell carcinoma. Despite adjuvant chemoradiotherapy, the first flap necrosed months later, with imaging revealing extensive pedicle ossification and thrombosis. A contralateral FFF was performed but similarly failed due to recurrent ossification and arterial thrombosis, confirmed histopathologically. This case challenged the assumption that pedicle ossification is benign and highlighted its potential for catastrophic flap loss. A literature review indicates that ossification rates vary (4.4%–21%), with meticulous periosteal dissection significantly reducing risk. Clinical presentation often includes trismus, submandibular induration, and pain, but complete necrosis had not been previously documented. This report underscored the need for technical modifications in high-risk cases, consideration of alternative flaps (eg, scapular), and systematic evaluation of late flap failure to exclude ossification-related thrombosis. Surgeons must recognize this underreported complication to optimize reconstructive outcomes. (Plast Reconstr Surg Glob Open 2026;14:e7398; doi: 10.1097/GOX.0000000000007398; Published online 5 January 2026.)  \nThe fibula free flap (FFF) is one of the most widely  \nused methods for head and neck bony reconstruc  \ntion, yet ossification of its vascular pedicle—though uncommon—can lead to underrecognized complications.1 Although pedicle ossification has historically been considered benign, often presenting as a suspicious neck mass during oncological follow-up, its clinical implications may extend beyond diagnostic ambiguity.1 The osteogenic potential of residual periosteum along the pedicle, particularly after subperiosteal dissection during FFF harvest, is well documented1; however, reports of ossification causing pedicle thrombosis and flap necrosis are absent in the literature. Here, we present a unique case of a patient who experienced 2 consecutive FFF failures due to pedicle  \nFrom the *Otolaryngology-Head and Neck Surgery Department, NOVO Hospital, Pontoise, France; and †CY Cergy-Paris University, ERRMECe, Neuville sur Oise, France.  \nReceived for publication July 28, 2025; accepted November 11, 2025.  \nCopyright © 2026 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.  \nDOI: 10. 1097/GOX.0000000000007398  \nossification-induced thrombosis, despite meticulous free periosteal dissection during both harvests. The first flap, performed for squamous cell carcinoma with mandibular bone involvement, necrosed months postoperatively. Following multidisciplinary tumor board review, this failure was initially attributed to osteoradionecrosis based on clinical and radiographic findings. However, subsequent analysis revealed the true etiology to be progressive pedicle ossification and subsequent vascular compromise. Consequently, a second FFF was harvested following necrosis of the initial reconstruction, but it similarly developed pedicle ossification leading to","cbCaieTlvvie12hg","https://ap.wps.com/l/cbCaieTlvvie12hg","pdf",482325,"English","# Summary\n# Case Presentation\n## Diagnosis and Initial Treatment\n## First Flap Failure and Etiology Reassessment\n## Second Flap Failure\n# Discussion and Clinical Implications","[{\"question\":\"What complication is highlighted in this case report?\",\"answer\":\"Pedicle ossification-induced thrombosis leading to sequential fibula free flap failures and catastrophic flap necrosis.\"},{\"question\":\"How many consecutive fibula free flaps failed in the patient?\",\"answer\":\"Two consecutive fibula free flaps failed due to recurrent pedicle ossification with vascular compromise.\"},{\"question\":\"What imaging and pathology findings supported the diagnosis?\",\"answer\":\"Imaging revealed extensive pedicle ossification and vascular compromise, and the thrombosis etiology was confirmed histopathologically after the second failure.\"}]","Pedicle Ossification-induced Thrombosis and Sequential Fibula Free Flap Failures - Case Report | PDF",1790674449]