Abstract
BACKGROUND: Orocutaneous fistula is a challenging postoperative complication often encountered in head and neck reconstruction, typically resulting from surgical site dehiscence, infection, or compromised flap vascularity. While the pectoralis major myocutaneous flap has historically been a reliable option for reconstruction, its failure-though uncommon-can lead to persistent fistula formation. This case highlights the effective use of combined local tissue rearrangement and free anterolateral thigh flap for successful secondary reconstruction following pectoralis major myocutaneous flap failure. CASE PRESENTATION: A 31-year-old Indian male patient, previously treated with composite resection and pectoralis major myocutaneous flap reconstruction for carcinoma of the buccal mucosa, presented with orocutaneous fistula due to pectoralis major myocutaneous flap dehiscence and partial necrosis. Conservative wound care failed to achieve closure. The patient underwent secondary reconstruction using local tissue rearrangement and a free anterolateral thigh flap. Postoperative recovery was uneventful, with successful closure of the fistula and restoration of orofacial continuity. CONCLUSION: This case underscores the importance of timely secondary intervention using free tissue transfer and local flap adjustment in managing orocutaneous fistula following pectoralis major myocutaneous failure. The combined approach provided durable closure and functional restoration, offering a viable option in complex salvage scenarios.