LAUSR

To the Editor: We read the interesting work of Krane and colleagues “Simultaneous maxillary and mandibular reconstruction with a single osteocutaneous fibula free flap: A description of three cases” (Krane et al., 2021). We would like to congratulate the authors for their contribution presenting this work. Complex facial bone defects may require more than one flap to obtain acceptable functional and aesthetic results. Nevertheless, free fibula flap has been previously used to repair maxilla and mandible defects with good outcomes (Krane et al., 2021; Laure et al., 2008; Mericli et al., 2017). On the other hand, new technologies and preoperative virtual planning provide help to surgeons with the number and placement of the osteotomies, optimizing the possibilities for complex bone reconstruction with a single flap (Kääriäinen et al., 2016; Powcharoen et al., 2019). Herein, we report a case of simultaneous mandible and zygomatic arch reconstruction with a single fibula free tissue transfer. A 30-yearold woman was referred to our department to assess facial reconstruction. The patient had a facial embryonal rhabdomyosarcoma at the age of 9 years old, treated with parotidectomy and resection of the zygomatic arch, mandibular branch and condyle, the temporal lower third, masseter, pterygoid muscle, and radical cervical lymph node dissection with subsequent radiochemotherapy. Seven years later, an ALT free flap was performed in order to fill the facial soft tissue defect, as well as cross-facial nerve grafting for first stage of facial reanimation. The patient arrived at our institution for assessment of severe aesthetic and functional sequelae with significant mandibular deviation. After preoperative planning, we performed a simultaneous reconstruction of the mandibular branch, condyle and zygomatic arch with a fibula free flap in two segments (Figure 1). The proximal portion of the fibula was used to reconstruct the mandible. It was secured to the mandibular body with a reconstruction plate and the distal stump was rounded to fit into the glenoid fossa. The second segment was used for zygomatic arch reconstruction and secured to malar and temporal bones with miniplates. Vascular anastomoses were performed to the contralateral facial vessels using a vascular loop with the great saphenous vein. A gracilis free flap was also harvested for facial reanimation and anastomosed in a flow-through manner to the distal stump of the peroneal vessels. Neurorrhaphy was performed to previous cross-nerve graft. The postop was uneventful and the patient was discharged after 7 days. Despite minor revision surgeries such as facial lipofilling and temporomandibular joint arthrolysis were required, long-term outcomes were satisfactory. Forty-three months after the surgery the patient presents significant aesthetic improvement as well as a sufficient oral opening and occlusion. Functional muscle recovery was suboptimal. We agree with the authors in the use of a single bone flap to reconstruct two anatomical structures. Although it is not essential to restore the zygomatic arch with vascularized bone transfer, it is suggested in irradiated areas, and in our case, it could be performed simultaneously with mandibular reconstruction using the same free bone flap.