Sir: We read with great interest the article by Mosahebi et al. entitled “Reconstruction of Extensive Composite Posterolateral Mandibular Defects Using Nonosseous Free Tissue Transfer” (Plast Reconstr Surg. 2009;124:1571–1577). The authors claim that the extensive soft-tissue defects cannot be reconstructed always with an osteocutaneous free tissue transfer, although it provides bony reconstruction. The authors reviewed some osteocutaneous flaps that are widely used in reconstruction and explained why they do not like to use them. They prefer to use musculocutaneous flaps such as the vertical rectus abdominis musculocutaneous flap for covering entire through-and-through defects of the mandible and oral cavity. By so doing, they claim to return patients to normal life and oral alimentation more quickly than with other choices of reconstruction. The authors do not prefer osteomyocutaneous flaps, as their pedicle length and skin paddle will not be enough to cover the whole defect. They may be right on those aspects regarding the coverage of posterolateral defects and the oral cavity, but there are some points worth mentioning. First, the fibula osteocutaneous flap has a pedicle nearly 10 to 12 cm long, and the skin coverage can be adequate for most defects. Moreover, if the soleus muscle is also included in the flap, it would be used in closing the oral defect and providing bulk for contour reconstruction.1 However, it is true that the cutaneous part of the flap may not cover the entire posterolateral defect, which can be solved by local flaps alone. The iliac crest osteomyocutaneous flap is also a very reliable flap in reconstruction of bony defects of the mandible.2 It is very useful for contouring and space-filling purposes. Although the pedicle is not as long as a fibular flap, it is nearly 10 cm long and reliable for a large skin island to cover the defect. Skin paddle can be elevated to as large as 16 × 20 cm.3 The internal oblique muscle can be also included in the flap so that it can be used for closing intraoral mucosa defects. This flap has been used for bony reconstruction of oromandibular defects since Urken et al. popularized it in 1998. The claimed donor-site morbidity is under 6 percent in most of the literature, and most of the complications can be avoided if care is taken during its harvest.4 If closure of the defect is performed carefully, no hernias will be seen, and if the anterior superior iliac spine is preserved, no gait disturbances or contour deformities of the hip will occur.4 We also perform this reconstruction very often and did not encounter any significant or persistent donor-site morbidities except for the incision scar. The authors emphasize the importance of early maintenance of oral intake and quality of life. A total of 39 patients could have an oral diet, whereas only seven of 76 patients could have a regular diet. We believe that restoration of oral intake for life quality is directly related to not only swallowing but also chewing. Osteointegrated dental implants can be used after stabilization of the patient and the reconstructed site. If we consider that the patient during his or her remaining life has to eat, chew, talk, and so forth, dental restoration becomes an important issue. The restoration of quality of life is related more to the bony reconstruction if we consider that these patients have to return to normal or nearly normal life and function. Returning to normal oral nutrition does not mean solely having a soft diet in remaining life, but that mastication function has to be regained. Considering that these patients have oncologic diseases, their nutrition is far more important and somewhat defines their prognosis. From the date that bony flaps have been used for mandibular reconstruction, dental implants have been used.5,6 For this purpose, both fibular and iliac crest flaps can be used safely in selected cases. Although the bony segment of the fibular flap is thinner, it is still reliable for dental implants. If the defect is extensive and cannot be covered with one osteomyocutaneous flap alone, combined flaps can be used for reconstruction of bone and soft tissue, although it extends the operative time. Considering these facts, we believe that bony reconstruction of the mandible can be more appropriate even if the defect is extensive. Ersoy Konaş, M.D. Ebru Yoruk, M.D. Serdar N. Nasir, M.D. Department of Plastic Reconstructive and Aesthetic Surgery Hacettepe University Medical School Samanpazari, Ankara, Turkey
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Sep 30, 2011
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