Fibular flap for mandibular reconstruction: are there old tricks for an old dog?

Fibular free flap is considered as an "old dog" in reconstructive surgery because it was first described by Taylor and his colleagues in 1975, and was then introduced for mandibular reconstruction by Hidalgo in 1989. There are some "tricks" for fibular free flap that have been used and recognized in many European maxillofacial surgical units over the past decade. These include: 1) harvesting the distal fibula when recipient vessels are distant; 2) flap selection based on the anatomy of perforators; 3) use of the skin paddle for postoperative flap monitoring; 4) protection of the flap's soft-tissue cuff; 5) preventing venous thrombosis which is essential to reduce flap complications; 6) aligning fibular struts and protecting the vascular pedicle when the double-barrel technique is used; 7) minimizing the gap between the double-barrel struts and implementing a long-term follow-up of dental implants; 8) selecting osteosynthesis materials; and 9) learning curve and clinical competence in microvascular reconstruction. We also reviewed current data from the literature, which would be useful for maxillofacial reconstructive surgeons. With these tricks, one can teach an "old dog" "old tricks".