Venous compromise remains one of the most critical challenges in free flap reconstruction, often threatening flap viability and surgical outcomes. This case report presents the management of venous thrombosis during fibular free flap reconstruction following segmental mandibulectomy for clear cell odontogenic carcinoma in a 58-year-old female. The initial venous anastomosis to the internal jugular vein (IJV) failed due to thrombosis. Despite revision anastomosis and the use of a vein graft, venous outflow could not be re-established. Ultimately, an end-to-end anastomosis to the IJV was performed, successfully salvaging the flap. This case not only emphasizes the successful use of end-to-end IJV anastomosis as a salvage technique but also highlights the importance of understanding and considering alternative strategies. A broader discussion explores options including thrombectomy and revision anastomosis, vein grafting, superficial venous system anastomosis, and pharmacological thrombolysis. Factors such as timing, thrombosis extent, vessel availability, and surgeon expertise significantly influence decision-making in such scenarios. Our experience reinforces that while end-to-end anastomosis to the IJV is a time-tested and effective technique, having a comprehensive grasp of multiple salvage options and maintaining intraoperative flexibility are vital to ensuring optimal outcomes in microvascular reconstruction.
Keywords: End-to-end anastomosis; Fibular free flap; Internal jugular vein.
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