Double Free Flap

RECONSTRUCTIVE INDICATIONS OF SIMULTANEOUS DOUBLEFREE FLAPS IN THE HEAD AND NECK: A CASE SERIES ANDLITERATURE REVIEW

DEEPAK BALASUBRAMANIAN, M.S., D.N.B.,1 KRISHNAKUMAR THANKAPPAN, M.S., D.N.B., M.Ch.,1*

MONI ABRAHAM KURIAKOSE, M.D., F.R.C.S.,2 SRIPRAKASH DURAISAMY, M.S.,1 RAJEEV SHARAN, M.S., M.Ch.,1

JIMMY MATHEW, M.S., M.Ch.,1 MOHIT SHARMA, M.S., M.Ch.,1 and SUBRAMANIA IYER, M.Ch., F.R.C.S.1

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge.The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck onco-logical surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection andreconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had priorhistory of radiotherapy or chemo-radiotherapy. Forty-two free flaps were used in these patients. The predominant combination was that offree fibula osteo-cutaneous flap with free anterolateral thigh (ALT) fascio-cutaneous flap. The indications of the simultaneous use of doublefree flaps can be broadly classified as: (a) large oro-mandibular bone and soft tissue defects (n 5 13), (b) large oro-mandibular soft tissuedefects (n 5 4), (c) complex skull-base defects (n 5 2), and (d) dynamic total tongue reconstruction (n 5 2). Flap survival rate was 95%.Median follow-up period was 11 months. Twelve patients were alive and free of disease at the end of the follow-up. Eighteen of 19 patientswith oro-mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomydependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for anextensive oro-mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneoususe of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combina-tion permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications isproposed. VVC 2012 Wiley Periodicals, Inc. Microsurgery 32:423–430, 2012.

Free flap reconstruction is now an integral part of the surgi-

cal management of head and neck malignancies.1–5 Recon-

struction after resection of very advanced malignancies often

poses a challenge to the surgeon. They become challenging

mainly due to the extensiveness and complexity of the defects

involving multiple anatomical and functional subunits. These

reasons in the past would have limited the surgical oncologist

from offering treatment to these patients with advanced dis-

eases, which were otherwise resectable. Use of double free

flaps has shown benefit in the reconstruction, in such situa-

tions. The purpose of this study is to elucidate the reconstruc-

tive indications of the use of simultaneous double free flaps

in head and neck oncological surgery and to propose an algo-

rithm for the right choice of flap combination.

METHODS

This is a retrospective review of consecutive cases of

head and neck malignancies treated surgically. Only the

cases treated with resection and reconstruction with si-

multaneous double free flaps were included. Cases with

prior treatment with radiotherapy or chemoradiotherapy

were also included. Benign cases were excluded. The

patients who had similar defect reconstruction with a

combination of a pedicled flap and a free flap were also

excluded. An institutional review board approval was

obtained for this review. A prospectively maintained tu-

mor board database, electronic medical records including

case records, operative details, and follow-up data were

studied. The study period was for 6 years from March

2006 to February 2011.

RESULTS

Twenty-one patients (male, 17; female, 4) underwent

reconstruction with simultaneously done double free flaps

during the study period. The mean age was 50.2 years

(range 32–70 years). Nineteen of 21 patients had T4 pri-

mary tumor stage. The pathology was squamous cell car-

cinoma in 20 patients and adenoid cystic carcinoma in

one patient. Eleven patients had prior history of radio-

therapy or chemo-radiotherapy. The primary tumor and

treatment characteristics are shown in Table 1. A total of

42 free flaps were used in these patients. Reconstructive

indications of simultaneously double free flaps were

broadly classified as: (a) large oro-mandibular bone and

soft tissue defects (n 5 13), (b) large oro-mandibular soft

tissue defects (n 5 4), (c) complex skull-base defects

(n 5 2), and (d) dynamic tongue reconstruction (n 5 2).

The predominant flap combination was that of free fibula

1Department of Head and Neck Surgery and Oncology, Amrita Institute ofMedical Sciences, Kochi, Kerala, India2Department of Head and Neck Surgery, Mazumdar-Shaw Cancer Centre,Narayana Hrudayalaya, Bangalore, India

*Correspondence to: Krishnakumar Thankappan, M.S., D.N.B., M.Ch.,Department of Head and Neck Surgery, Amrita Institute of Medical Sciences,Kochi, Kerala, India. E-mail: [email protected]

Received 23 August 2011; Revision accepted 20 December 2011;Accepted 28 December 2011

Published online 21 March 2012 in Wiley Online Library (wileyonlinelibrary.com).DOI 10.1002/micr.21963

VVC 2012 Wiley Periodicals, Inc.

osteo-cutaneous flap with free anterolateral thigh (ALT)

fascio-cutaneous flap (n 5 8). A combination of free fib-

ula flap with free radial forearm flap was used in five

patients and ALT flap with free radial forearm flap was

used in three patients. The indications, details of the

flaps, and their combinations are depicted in Table 2. The

mean size of the skin defect in oro-mandibular defects

was 9 cm 3 7 cm. Also the mean size of the mucosal

defect in such defects was 8 cm 3 6 cm. The mean oper-

ating time was 14 hours (range 10–18 hours). One patient

died in the immediate postoperative period due to sys-

temic complications. Excluding the two flaps in this

patient, the flap survival rate was 95% (38/40). Two

patients had complete flap loss. The contralateral fibula

flap replaced the lost fibula in a patient. ALT flap loss in

another patient was salvaged with a pectoralis major

myo-cutaneous (PMMC) flap. The histopathological ex-

amination of specimens showed that the resection was

adequate with wide margins in 16 patients, while five

patients had close or positive margins. Median follow-up

period was 11 months. Twelve patients were alive and

free of disease at the end of the follow-up. Eighteen of

19 patients with oro-mandibular and glossectomy defects

were able to resume an oral diet within 2 months while

one patient remained gastrostomy dependant till his death

due to disease not related to cancer. This patient had a

combination of free fibula flap with ALT flap, for an

extensive oro-mandibular defect. The associated large

defect involving the tongue accounted for the swallowing

difficulty. Figures 1a–1c show a patient with a large oro-

mandibular bone and soft tissue defect. The lesion was

involving lip and commissure. Only soft tissue defect

was reconstructed with a combination of free ALT flap

and free radial forearm flap. ALT flap was used for

reconstructing the outer skin defect, while radial forearm

flap was used for the mucosal lining and for reconstruct-

ing the lip. Figures 2a–2d show a patient with adenoid

cystic carcinoma of the lateral skull base with intracranial

extension, involvement of the oral mucosa, and skin. A

combination of free rectus abdominis flap and ALT flap

was used. Rectus muscle with skin was used for the

skull-base defect and oral mucosal lining. ALT flap was

used for the skin cover. Figures 3a–3c show an extensive

tongue lesion resected and reconstructed with a combina-

tion of free gracilis muscle flap and free gastro-omental

flap. The motorized free gracilis muscle, anchored

between the hyoid bone and the mandible worked as the

functional motor unit for providing tongue movements

and elevation, together with stomach component of gas-

tro-omental flap, turned inside out for the mucosal sur-

Table 1. Primary Tumor and Treatment Characteristics

Number

Site (n 5 21)

Tongue 3

Buccal mucosa/cheek 7

Lower alveolus 5

Upper alveolus 1

Floor of the mouth 3

Skullbase 2

T stage

T2 1

T3 1

T4a 12

T4b 7

Free flap (n 5 42)

Fibula 13

Radial forearm 11

ALT 12

Rectus abdominis 2

Gastro-omental 2

Flap complications

Partial flap loss 0

Total flap loss 2

Wound dehiscence 3

Re-exploration (venous problems) 4

Table 2. Indications and Combinations of Simultaneous Double Free Flaps

Indications

Total number

of patients Site Flap combination

Number of

patients

Large oro-mandibular

bone and soft tissue

defects

13 Oral cavity FFF RFFF 5

FFF ALT 8

Large oro-mandibular

soft tissue defects

4 Oral cavity

Buccal mucosa, skin ALT RFFF 2

Buccal mucosa, skin,

lip commissure

ALT RFFF 1

RFFF RFFF 1

Complex skull-base

defects

2 Maxilla Rectus ALT 1

Rectus RFFF 1

Dynamic tongue

reconstruction

2 Tongue Gracilis Gastro-omental 2

Total 21 21

FFF, free fibula flap; RFFF, radial forearm free flap; ALT, free anterolateral thigh flap; rectus, free rectus abdominis flap; gracilis, free gracilis muscle flap; gas-tro-omental, Free Gastro-omental flap.

424 Balasubramanian et al.

Microsurgery DOI 10.1002/micr

face, as an added source of secretion. The attached omen-

tum provided adequate bulk.

DISCUSSION

In the head and neck, when the resection involves

complex multiaxial subunits, it may not be possible to

reconstruct the defect with single flap. The subunits may

be of skin, bone, or large mucosal defects. Simultaneous

use of double free flaps will be helpful in these situa-

tions. The purpose of this study is to elucidate the recon-

structive indications of the use of simultaneous double

free flaps in head and neck cancer surgery. Previous stud-

ies have brought about the efficacy and outcome of dou-

ble free flaps in head and neck reconstruction.6–8 Some

reports have also dealt with the oncological indications of

such surgery.9,10 The goals, indications, and functional

results of reconstruction in these different subsites would

be different. However, at the same time, there are situa-

tions in these areas that demand a complex simultaneous

double free flap reconstruction.

Large Oro-Mandibular Bone and Soft

Tissue Defects

They include through and through defects after the

composite resection of the mandible, maxilla, part of the

tongue, floor of mouth, and the cheek skin. Fibula free

osteocutaneous flap is the commonest choice for com-

bined bony and soft tissue reconstruction. Unfortunately,

there is a limit for the soft tissue and skin that can be

taken along with the fibula. They may not always be suf-

ficient enough to replace all the resected tissue. Also

there are limitations due to the orientation of the fibula

skin paddle and muscular tissue in relation to the bone. If

the skin paddle is used for an extensive oral cavity lining,

it necessitates the use of a simultaneous soft tissue flap

for the skin cover. The choice would be to combine a

free radial forearm flap or free ALT flap along with fibu-

lar bone. This is the commonest indication of the present

series (n 5 13). Free fibula flap with free radial forearm

flap combination was used in five patients and free fibula

flap with ALT flap was used in eight patients. Wei et al.6

has described the use of double free flaps for this purpose

in 36 oral cancer patients with good results. Free fibula

flap with free radial forearm flap was the commonest

combination used (n 5 20) by them. In a separate paper,

Wei et al. describes the use of combined ALT flap and

vascularized fibula osteo-septocutaneous flap in recon-

struction of 22 extensive composite mandibular defects

with good esthetic and functional results.11 Jeng et al.12

has described the reconstruction of extensive composite

mandibular defects with large lip involvement by using

double free flaps and fascia lata grafts for oral sphincters.

Recent work by Posch et al. has noted a modest improve-

Figure 1. (a): Patient with a large oro-mandibular bone and soft tis-

sue defect. The lesion involving lip and commissure. (b): Computed

tomography scan. (c): Reconstructed outcome. Only soft tissue

defect was reconstructed with a combination of free ALT flap and

free radial fore arm flap. [Color figure can be viewed in the online

issue, which is available at wileyonlinelibrary.com.]

Simultaneous Double Free Flaps in the Head and Neck 425


ment in function and esthetics in double free flap recon-

struction in through and through defects.13

Large Oro-Mandibular Soft Tissue Defects

These defects are similar to the above category but

include those where a bony reconstruction is not planned.

Presence of severe trismus is an instance when a bony

reconstruction may not be done. Replacement of bone may

hinder adequate mouth opening postoperatively. Presence

of large skin defects including that of the neck along with

mucosal effects of the oral cavity is also included in this

category. These kinds of defects can be effectively dealt

with the use bipaddling of soft tissue flaps like ALT flaps

or PMMC pedicled flap. However, such bipaddling may be

difficult if the defects are too big or may be not suitable

because of the bulkiness that would lead to a functionally

compromise. Use of double free flaps may suit better in

these defects. This study includes two patients where a

combination of ALT flap with free radial forearm flap was

performed as bipaddling of the ALT flap would have been

suboptimal. The other indication for the use of double free

flaps for soft tissue reconstruction alone is the significant

simultaneous involvement of lip, commissure, and soft tis-

sues of the cheek. Using a single free flap does not allow

proper reconstruction of a competent lip. The combination

used was ALT flap and free radial forearm flap, with

bipaddled ALT flap for providing the skin and buccal mu-

cosal lining and radial forearm flap with palmaris longus

tendon for lip and the commissure. Two patients were

included in the present series, where double free flaps were

used to reconstruct combined cheek skin, buccal mucosa,

and lip defects.

Complex Skull-Base Defects

Large defects after anterolateral and lateral skull-base

resections usually require a muscle flap like free rectus

abdominis muscle for reconstruction.14 However, when

such defects are associated with complex defects involv-

ing bone, skin, and mucosal lining, tissue available with

a single flap may not be sufficient. The present series

Figure 2. (a): Patient with adenoid cystic carcinoma of the lateral skull base. (b): Surgical defect involving the skull base, dura, oral muco-

sal defect, and skin. (c): A combination of free rectus abdominis and ALT flap was used. Rectus muscle with skin was used for the skull-

base defect and oral mucosal lining. (d): Reconstructed outcome. ALT was used for the skin cover. [Color figure can be viewed in the

online issue, which is available at wileyonlinelibrary.com.]



include two such patients. We have used a combination

of free rectus abdominis muscle along with free radial

forearm flap or ALT flap. Free rectus abdominis flap was

used for the skull-base defect. Radial forearm flap or

ALT flap was used for the skin cover.

Dynamic Tongue Reconstruction

Total glossectomy and near total glossectomy defects

are often reconstructed with free soft tissue flaps like free

rectus abdominis or ALT flaps.15,16 The use of gastro-

omental free flap along with free gracillis muscle flap to

achieve functional dynamic reconstruction of the tongue

is reported earlier.17 The free gracilis muscle flap worked

as functional motor unit for providing tongue movements

and elevation, together with free stomach component of

gastro-omental flap, turned inside out for the mucosal

surface, as an added source of secretion. The attached

omentum provided adequate bulk.17 The hypoglossal

Figure 3. (a): Tongue carcinoma involving near total tongue. Computed tomography scan showing the lesion. (b): The scheme of recon-

struction with double free flaps. Inverted gastric mucosa over the omentum. Free gracilis muscle was hitched between the hyoid and the

mandible. (c): Reconstructed tongue. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]



nerve end was anastomosed to obturator nerve, the motor

supply to gracillis muscle. Two patients underwent such

reconstruction with successful outcome.

With the exception of functional reconstruction of

tongue, in all other indications, one of the free flaps

could be substituted by a pedicled flap like PMMC flap

or a forehead flap. Although not included in this report,

we had on six occasions, used a pedicled flap for the

outer cover with a free flap for the lining; five PMMC

flaps and one forehead flap (data not shown). However,

they are useful in limited coverage of skin or mucosal

defects. Use of these pedicled flaps along with the free

flaps is more demanding technically to position and pro-

tect the pedicle. They also carry with them the inad-

equacy of being less pliable to suit the three-dimensional

defects.

The surgical management of advanced through and

through tumors of the oral cavity poses a challenge in

the surgical reconstruction. Urken et al.18 and Jewer

et al.19 reported the multiunit reconstruction of oro-man-

dibular defects using a single iliac crest flap. The iliac

crest has the advantage of being either an osseous or an

osseo-cutaneous flap. The addition of the internal oblique

muscle permitted the reconstruction of mucosal and pha-

ryngeal defects. Boyd et al.20 compared the osseo-cutane-

ous radial forearm flap with the iliac crest flap for oro-

mandibular reconstruction. In Boyd’s study, majority was

the iliac crest transfers and this group had a higher inci-

dence of intraoral breakdown and bone exposure. They

also reported good function with regard to speech and

swallowing in extensive T4 lesions with through and

through defects with composite oro-mandibular recon-

struction. All the above papers related to the use of a sin-

gle flap reconstruction for oro-mandibular defects. How-

ever, in extensive T4 lesions, there is a need for a large

and robust skin and soft tissue component that is seldom

available with the fibula or the iliac crest. The earliest

reports of double free flap transfer was for oro-mandibu-

lar reconstruction.8,21–23 The radial forearm flap when

used, is thin, pliable, does not add to excess bulk and can

be used to reconstruct the lip in combination with palma-

ris longus tendon.22 However, in certain cases of oro-

mandibular defects, a larger soft tissue component is

required. Ao et al.21 first reported the use of the ALT

flap in combination with a free fibula flap. Wei et al.6

reported the first large series of 36 patients who under-

went double free flap transfer. In Wei’s series, a wide va-

riety of flaps were used, the most common being free ra-

dial forearm flap with free fibula flap. The flap success

rate was 93%. Forty-four percentage of the patients in his

series survived for 36 months. In a subsequent publica-

tion, Wei et al.11 reported the use of an ALT flap in

combination with the free fibula flap in 22 patients.

According to the author, the radial forearm flap does not

offer enough tissue to cover the bone, reconstruction

plate, and the soft tissue defect. The flap success rate

was 90.9% in this series. Gabr et al.24 in a series of 40

patients used a single flap (17 patients—osseo-musculo-

cutaneous fibula flap) and double flap (23 patients—iliac

crest and ulnar free flap) for complex oro-mandibular

defects. Overall flap survival was 96.8% (100% of fibular

flaps and 95.65% of iliac/ulnar flaps). A distinct advant-

age of using simultaneous double free flaps is in recon-

structing lip defects. Jeng et al.12 reported the use of a

fascia lata sling in combination with ALT flap and free

fibula flap. This ‘‘neo" oral sphincter allows for return of

some function and provides better results.

Posch et al.13 attempted to study the functional and

esthetic results following double free flap reconstruction.

More than half of the patients in his series had functional

problems following surgery (deteriorated speech, oral

incontinence, color mismatch, and flap contracture of

flaps). Hanasono et al.25 reported a group of 39 patients

who received double free flaps for a variety of defects

(mandible, cheek, tongue, and palate). Functionally, out

of 29 patients who were feeding tube dependant prior to

surgery, 23 resumed oral diet following surgery. This

indicates a good functional result with regard to swallow-

ing after double free flap transfer. One of the issues with

double free flap transfer is the availability of recipient

vessels in the neck for anastamosis especially in radiation

failure or previously operated cases. Lin et al.26 reported

a series of 55 patients, out of which 39 had the second

anastamosis to the distal run off of the fibula flap. The

rest of the patients underwent two vessel anastamosis.

There was no difference between the outcomes between

the two groups. In certain cases, one may need to com-

bine a free flap and a local flap for defect closure. Bian-

chi et al.27,28 reported such a combination with good es-

thetic results even in anterior mandible defects.

The outcome of double free flap reconstruction in our

series was good. The flap survival rate was 95%. Nine-

teen of 21 patients were of T4 clinical T stage. Seven

(33%) patients were staged as T4b, the very advanced

lesions. Simultaneous free flap reconstruction had aided

the reconstruction after such extensive resections. The

functional outcome was also satisfactory. All but one

patient were able to resume oral diet. All of the tumors

were T4 stage (14 T4a and seven T4b). Majority of our

patients were buccal mucosa tumors. Twelve out of 21

patients (52.4%) were alive and disease free at the end of

the follow-up. Considering the extensiveness of the

tumors, these oncological results were good. Also the

buccal mucosal tumors are chewing tobacco related and

show a better outcome. Although locally advanced, they

did not have nodal metastasis at presentation and remain

disease free after appropriate local surgery and adjuvant

treatment. The complex reconstructions have aided this.



CONCLUSIONS

Simultaneous use of double free flap aided the recon-

struction in certain large complex defects after head and

neck oncologic resections. Such combinations permit bet-

ter complex multiaxial subunit reconstruction. The out-

come in terms of flap survival, oncological results, and

functional results in such patients with extensive tumors

was good. This retrospective analysis has elucidated the

reconstructive indications of the use of simultaneous dou-

ble free flaps in head and neck cancer surgery and pro-

poses an algorithm for the right choice of flap combina-

tion (Fig. 4).

REFERENCES

1. Kalavrezos N, Bhandari R. Current trends and future perspectives inthe surgical management of oral cancer. Oral Oncol 2010;46:429–432.

2. Wong CH, Wei FC. Microsurgical free flap in head and neck recon-struction. Head Neck 2010;32:1236–1245.

3. de Bree R, Rinaldo A, Genden EM, Suarez C, Rodrigo JP, Fagan JJ,Kowalski LP, Ferlito A, Leemans CR. Modern reconstruction techni-ques for oral and pharyngealdefects after tumor resection. Eur ArchOtorhinolaryngol 2008;265:1–9.

4. Smith RB, Sniezek JC, Weed DT, Wax MK. Microvascular surgerysubcommittee of American academy of otolaryngology—Head andneck surgery. Utilization of free tissue transfer in head and neck sur-gery. Otolaryngol Head Neck Surg 2007;137:182–191.

5. Shah JP, Gil Z. Current concepts in management of oral cancer-sur-gery. Oral Oncol 2009;45:394–401.

6. Wei FC, Demirkan F, Chen HC, Chen IH. Double free flaps inreconstruction of extensive composite mandibular defects in headand neck cancer. Plast Reconstr Surg 1999;103:39–47.

7. Wei FC, Yazar S, Lin CH, Cheng MH, Tsao CK, Chiang YC. Dou-ble free flaps in head and neck reconstruction. Clin Plast Surg 2005;32:303–308.

8. Serletti JM, Coniglio JU, Tavin E, Bakamjian VY. Simultaneoustransfer of free fibula and radial forearm flaps for complex oroman-dibular reconstruction. J Reconstr Microsurg 1998;14:297–303.

9. Guillemaud JP, Seikaly H, Cote DW, Barber BR, Rieger JM, Wolf-aardt J, Nesbitt P, Harris JR. Double free-flap reconstruction: Indica-tions, challenges, and prospective functional outcomes. Arch Otolar-yngol Head Neck Surg 2009;135:406–410.

10. Andrades P, Bohannon IA, Baranano CF, Wax MK, Rosenthal E.Indications and outcomes of double free flaps in head and neckreconstruction. Microsurgery 2009;29:171–177.

11. Wei FC, Celik N, Chen HC, Cheng MH, Huang WC. Combined an-terolateral thigh flap and vascularized fibula osteoseptocutaneous flapin reconstruction of extensive composite mandibular defects. PlastReconstr Surg 2002;109:45–52.

12. Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction ofextensive composite mandibular defects with large lip involvementby using double free flaps and fascia lata grafts for oral sphincters.Plast Reconstr Surg 2005;115:1830–1836.

13. Posch NA, Mureau MA, Dumans AG, Hofer SO. Functional and aes-thetic outcome and survival after double free flap reconstruction inadvanced head and neck cancer patients. Plast Reconstr Surg 2007;120:124–129.

14. Gullane PJ, Lipa JE, Novak CB, Neligan PC. Reconstruction of skullbase defects. Clin Plast Surg 2005;32:391–399.

15. Calabrese L, Saito A, Navach V, Bruschini R, Saito N, Zurlo V,Ostuni A, Garusi C. Tongue reconstruction with the gracilis myocu-taneous free flap. Microsurgery 2011;31:355–359.

16. Vartanian JG, Magrin J, Kowalski LP. Total glossectomy in theorgan preservation era. Curr Opin Otolaryngol Head Neck Surg 2010;18:95–100.

17. Sharma M, Iyer S, Kuriakose MA, Vijayaraghavan S, Arun P,Sudhir VR, Chatni SS, Sharan R. Functional reconstruction ofnear total glossectomy defects using composite gastro omental-dynamic gracilis flaps. J Plast Reconstr Aesthet Surg 2009;62:1277–1280.

18. Urken ML, Vickery C, Weinberg H, Buchbinder D, Lawson W,Biller HF. The internal oblique-iliac crest osseomyocutaneous freeflap in oromandibular reconstruction. Report of 20 cases. Arch Oto-laryngol Head Neck Surg 1989;115:339–349.

19. Jewer DD, Boyd JB, Manktelow RT, Zuker RM, Rosen IB,Gullane PJ, Rotstein LE, Freeman JE. Orofacial and mandibularreconstruction with the iliac crest free flap: A review of 60 casesand a new method of classification. Plast Reconstr Surg 1989;84:391–403.

20. Boyd JB, Rosen I, Rotstein L, Freeman J, Gullane P, Manktelow R,Zuker R. The iliac crest and the radial forearm flap in vascularizedoro-mandibular reconstruction. Am J Surg 1990;159:301–308.

21. Ao M, Asagoe K, Maeta M, Nakagawa F, Saito R, Nagase Y. Com-bined anterior thigh flaps and vascularized fibular graft for recon-

Figure 4. An algorithm for the choice of flap combination for the appropriate indications. ALT (free ALT flap) and RFFF (radial forearm free

flap). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]



struction of massive composite oromandibular defects. Microsurgery1998;18:372–378.

22. Kuzon WM Jr, Jejurikar S, Wilkins EG, Swartz WM. Double free-flap reconstruction of massive defects involving the lip, chin, andmandible. J Reconstr Microsurg 1998;14:529–534.

23. Koshima I, Hosoda S, Inagawa K, Urushibara K, Moriguchi T. Freecombined anterolateral thigh flap and vascularized fibula for wide,through-and-through oromandibular defects. Plast Reconstr Surg1999;103:39–47.

24. Gabr E, Kobayashi MR, Salibian AH, Armstrong WB, Sundine M,Calvert JW, Evans GR. Mandibular reconstruction: Are two flapsbetter than one? Plast Reconstr Surg 2005;115:1830–1836.

25. Hanasono MM, Weinstock YE, Yu P. Reconstruction of extensivehead and neck defects with multiple simultaneous free flaps. J ReconstrMicrosurg 2009;25:191–195.

26. Lin PY, Kuo YR, Chien CY, Jeng SF. Reconstruction of head andneck cancer with double flaps: Comparison of single and double re-cipient vessels. Microsurgery 2010;30:517–525.

27. Bianchi B, Ferri A, Ferrari S, Copelli C, Boni P, Baj A, Sesenna E.Reconstruction of lateral through and through oro-mandibular defectsfollowing oncological resections. Microsurgery 2010;30:517–525.

28. Bianchi B, Ferri A, Ferrari S, Copelli C, Boni P, Sesenna E. Recon-struction of anterior through and through oromandibular defects fol-lowing oncological resections. Microsurgery 2010;30:97–104.



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