Severe trismus secondary to periosteal osteogenesis after fibula free flap maxillary reconstruction

Background. Fibula free tissue transfer is routinely used for reconstruction of bony defects in the head and neck. During flap preparation, well-vascularized periosteum is left adjacent to the proximal vascular pedicle. It is known that periosteum can have significant osteogenic potential in the proper settings. Complications related to periosteal osteogenesis of a fibula free flap pedicle have not been previously reported. Case History. A 12-year-old girl with a history of squamous cell carcinoma of the maxilla underwent delayed fibula free flap reconstruction of a maxillary defect. The patient had severe trismus develop postoperatively and was found to have osteogenesis along the vascular pedicle. This bone formed a solid bridge from the maxilla to the mandible. Two resections were required, which included excision of the vascular pedicle, to eliminate further osteogenesis and resolve the patient's trismus. Conclusions. The potential for periosteal osteogenesis does exist with fibula free tissue transfer and can have significant consequences. Potential promoters of osteogenesis should be identified and if possible altered in certain clinical scenarios to prevent complications from new bone growth.