Double free flaps in reconstruction of extensive composite mandibular defects in head and neck cancer

Extensive composite defects of the lower jaw are defined as those that involve skin, mandible, oral mucosa, and soft tissues. The enormous size and multilayered nature of these defects challenge most of the current reconstructive techniques. For reconstruction of extensive composite mandibular defects in 36 advanced oral cancer patients, two free flaps were used simultaneously in a complementary fashion. The aim was to provide bone reconstruction and adequate soft-tissue coverage in an optimal form. Primary reconstruction was carried out in 34 of 36 cases. The fibula osteoseptocutaneous-radial forearm fasciocutaneous flap combination was most commonly used (n = 20), followed by the fibula osteoseptocutaneous-rectus abdominis myocutaneous flap (n = 11). The other combinations included the fibula osteoseptocutaneous-tensor fasciae latae, the fibula osteoseptocutaneous-rectus femoris, the iliac crest-radial forearm, and the iliac crest-tensor fasciae latae flaps. In 11 cases, the second free flaps were attached to the distal runoff of the first free flaps because of unavailability of recipient vessels. The mean operation time was 12 hours 10 minutes. The complete flap survival rate was 93 percent (67 of 72 flaps) with 2.8 percent total (2 of 72) and 4.2 percent partial (3 of 72) flap failures. Median follow-up time was 14 months, and 44 percent of the patients were alive at the time of evaluation, surviving an average of 36 months. The average survival time for those who died was 11.1 months. The authors believe that in selected cases the double free-flap procedure for one-stage reconstruction of massive mandibular defects is justified because it is safe and effective and improves the quality of life and the number of days spent outside of the hospital for these patients.