Novel Technique with Double Free Flap Design for Advanced Mandibular Osteoradionecrosis: A Case Series

Abstract

Advanced mandibular osteoradionecrosis is arguably among the most challenging cases for reconstructive head and neck surgeons. Several reconstructive methods for complex mandibular defects have been reported; however, for advanced mandibular osteoradionecrosis, a safe option that minimizes the risk of renewed fistulation and infections is needed. For this purpose, we present a new technique using a fascia-sparing vertical rectus abdominis musculocutaneous flap as protection for a vascularized free fibula graft (FFG). This technique also optimizes recipient site healing and functionality while minimizing donor site morbidity. Our initial experiences from a 4 patient case series are included. Mean operative time was 551 minutes (SD: 81 minutes). All donor sites were closed primarily. Mean time to discharge was 13 days (SD: 7 days), and mean time to full mobilization was 2 days (SD: 1 days). This double free flap technique completely envelops the FFG and plate with nonirradiated muscle. It allows for the transfer of an FFG without a skin island, thus avoiding the need for split skin graft closure. This results in faster healing and minimizes the risk of fibula donor site morbidity. The skin island of the vertical rectus abdominis musculocutaneous flap has the added benefit of providing intraoral lining, which minimizes contractures and trismus. Although prospective long-term studies comparing this approach to other double flap procedures are needed, we argue that this technique is an optimal approach to safeguard the mandibular FFG reconstruction against the inherent risks of renewed complications in irradiated unhealthy tissue.

Fig. 1.

A diagram illustrating the harvest of the fascia-sparing VRAM flap. The vertical rectus abdominis musculocutaneous flap is based on the deep inferior epigastric vessels (a) with 1 or more skin perforators (b). The fascia is incised in close proximity to the skin perforators and with a total width being <1 cm (c), following which the rectus muscle is enucleated to its second cranial intersection and to the pubic symphysis (d). The fascia is closed primarily without the use of a mesh. See text for more details.

Fig. 2.

Illustration of a double free flap design for mandibular reconstruction. The vascularized free fibula graft with plate in place with its pedicle tunnulated to the contralateral facial recipient vessels (a). The skin island of the VRAM flap is used as intraoral lining (b), allowing the muscle to completely envelop the fibula graft and anterior neck (c). An extended skin island flap is sometimes used to cover both intra- and extraoral defects (d), in which case the junction uniting the intra- and extraoral part is deepithelialized. This is especially useful when the irradiated skin tissue (e) is too fragile for it to reach the midline.