Clinical outcomes of fibular and scapular free osseous flaps in head and neck reconstruction: a retrospective comparative study

Purpose Osseous microvascular reconstruction of the head and neck following oncologic or osteoradionecrotic resection remains surgically challenging. The fibular free flap is the gold standard for mandibular reconstruction, whereas the scapular free flap has emerged as a viable alternative in selected scenarios. Methods A retrospective comparative analysis was performed on 69 adults undergoing cervicofacial reconstruction with fibular ( n = 37) or scapular ( n = 32) osseous free flaps (2015–2025). Surgical, functional, and patient-reported outcomes (DASH, EFAS, SHI, MDADI, EORTC QLQ-H&N35, FACE-Q) were assessed. Results Demographics and clinical profiles were similar, though scapular recipients were older. Fibular flaps predominate in mandibular, scapular in maxillary reconstructions. Fibular reconstructions used more custom plates and had longer follow-up but exhibited higher donor-site complication (24.3%) and elective revision (62.2%) rates. PROMs were comparable; extensive scapular flaps caused mild upper limb function decline. Conclusion Scapular flaps demonstrated lower donor-site complication rates and comparable functional and patient-reported outcomes in this cohort. These findings suggest that the scapular flap represents a valuable reconstructive alternative, particularly in patients in whom fibular harvest may be less suitable.