Double-flap Mandibular Reconstruction around the Condylar Head Using Fibula and Anterolateral Thigh Flaps

We applied double-flap reconstruction with a vascularized fibula osteo flap and a Y-shaped anterolateral thigh (ALT) flap, which was separated into a fascial flap and a de-epithelialized fat flap to replace the temporomandibular joint capsule and temporal soft tissue volume, respectively. This technique achieved excellent functional and cosmetic results with acceptable operation time and donor site scarring. A 16-year-old girl had a rapidly growing mandibular osteosarcoma. Right mandibulectomy from the right first premolar tooth to right condylar head (including temporalis muscle, masseter muscle, buccal mucosa, and part of the right maxilla) was performed. A left fibula osteo flap and left ALT flap were prepared in a prefabricated manner using a three-dimensional model and a prebent titanium plate. The area of the ALT flap was 23 × 6 cm. A proximal 8 × 4 cm skin flap was positioned to replace the left cheek mucosa, and the distal part was divided into two layers: a de-epithelialized fat flap and a fascial flap. The de-epithelialized fat flap was used to prevent the depression deformation at the temporal area, and the fascial flap was used to cover around the alternate condylar head made by the fibula instead of the resected temporomandibular joint capsule. The peroneal artery and veins were microscopically anastomosed to the distal end of the artery and veins of the descending branch of the ALT flap in a flow-through manner. At 12 months after surgery, the occlusal function and aesthetic balance were excellent.