Reconstruction of Composite Posterolateral Mandibular Defects

Abstract

Sir: We read the article by Dr. Mosahebi et al. entitled “Reconstruction of Extensive Composite Posterolateral Mandibular Defects Using Nonosseous Free Tissue Transfer” (Plast Reconstr Surg. 2009;124:1571–1577) with much interest. It is significant to note the indications for nonosseous free flap reconstruction for composite defects from a center that popularized the osseous reconstruction with free fibula for mandible defects. We appreciate the authors' justification to reconstruct such extensive defects with soft tissue to provide early and reasonable function. We are indeed impressed with the results shown; however, we would like to point out our views on this article. We are keen to know the definition and inclusion criteria for “extensive” or “composite” defects from the defect classification of type I to V, which ranges from a single anatomical zone to more extensive, complex defects. In this retrospective analysis, 60 percent of the patients had either type I or type II defects that were reconstructed with soft tissue only. Although the patients with such defects reconstructed using osseous flaps were excluded from the study, it would be interesting to know the comparative outcomes for type I and type II reconstruction with osseous versus soft tissue–only reconstruction. Although the authors have mentioned without referring to a specific type of defect that the limited skin paddle of free fibula might lead to inadequate closure and fistula, we still believe that the type I defects merit osseous reconstruction for a better aesthetic and functional results, especially in a group whose disease-free survival chances are higher. In our practice, full-thickness moderate sized defects of the posterolateral mandible are reconstructed with fibula along with a sufficiently large skin paddle that can be folded and used for both mucosa and skin by removing a strip of skin at the folding line. A large skin paddle of fibula flap generally includes more than one perforator and can be safely divided. In extensive posterolateral defects, we prefer the anterolateral thigh flap, which is well suited to line epithelial surfaces and to give bulk. Again, we found that it is quite safe to remove a strip of skin to separate oral and mucosal lining, even when the flap is based on a single perforator (Figs. 1 and 2). The study by Dr. Mosahebi et al., which has a follow-up rate of less than 50 percent, itself suggests advanced staged disease and associated morbidity and mortality. It would have been interesting to know the correlation of morbidly and mortality in patients who have previously undergone irradiation and in patients with a higher defect grade.Fig. 1.: A composite posterolateral mandibular defect reconstructed with an anterolateral free flap. Note the strip of skin excised to facilitate flap suturing separately to mucosa and skin.Fig. 2.: A well-settled anterolateral thigh flap.DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. PATIENT CONSENT The patient provided written consent for the use of his image. Dinesh Kadam, M.S., M.Ch. Department of Plastic Surgery A J Institute of Medical Sciences Manjushree Kadam, M.D.S. A J Institute of Dental Sciences Trivikram Tantry, M.D. Department of Plastic Surgery A J Institute of Medical Sciences Mangalore, Karnataka, India