LAUSR

The reconstruction for extensive composite mandibular defects using the combined anterolateral thigh flap and fibula osteoseptocutaneous flap is well established by Wei, Celik, Chen, Cheng, and Huang (2002). Accordingly, the skin paddle of the fibula flap resurfaces the intraoral lining, while the skin paddle of the anterolateral thigh flap provides the external coverage. The skin paddles of these two flaps have “equal” importance. However, the reliability of the fibula skin paddle is always a concern. Up to 10% of the fibula flaps lost their skin paddle, making the use of another skin flap inevitable even when their bones were still vascularized (Iorio, Cheerharan, & Olding, 2012; Wei et al., 2003). Therefore, we modified this combination from the “equal” into the “unequal” fashion. Namely, the fibula flap was mainly used to reconstruct the mandible while its skin paddle was designed to be a dispensable monitor flap, and the anterolateral thigh flap was modified into a myocutaneous flap to reconstruct all the soft tissue defects (Figure 1). The key element of this modification is to ensure the vascularity of the anterolateral thigh myocutaneous flap which composes the vastus lateralis muscle to replenish the soft tissue and to cover the fibula bone and a large skin flap to reconstruct both the inner mucosa and outer skin defects. The “unequal” combination has three main advantages. First, we do not have to use the skin paddle of the fibula flap to restore the inner mucosa and thus avoid the difficulty in handling it because of the restriction of the laterality of the donor leg or recipient vessels. Second, we do not have to rely on the unreliable skin paddle of the fibula flap. It is only used as a monitor flap and is designed to be dispensable. If the skin paddle shows vascular compromise, the necrotic skin can be debrided and the wound can be skin grafted or closed directly. There is no need for a third skin flap. Third, when the fibula flap is deemed failed, the fibula bone can just serve as a bone graft and is nourished by the surrounding well-vascularized vastus lateralis muscle. Therefore, the salvage for the failing fibula flap, which may disturb the innocent anterolateral thigh flap, becomes optional but not essential. Six patients were reconstructed with this “unequal” combination between January 2015 and December 2016. None of these patients returned to the operation room because of the circulation compromise. All of the anterolateral thigh flaps survived. One fibula flap had its skin paddle total necrosis and the resultant wound was healed by skin grafting on the exposed vastus lateralis muscle. Another one had partial skin necrosis and the resultant wound was closed directly. Fortunately, we have not yet encountered any long term complication, such as the fibula osteonecrosis. Although our case number is limited, we believe that the “unequal” combination may be a practical modification.