Reconstruction of Large Mandibulofacial Defects With the Composed Double Skin Paddle Fibula Free Flap: A Review of 32 Procedures

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1 The Laryngoscope VC 2013 The American Laryngological, Rhinological and Otological Society, Inc. Reconstruction of Large Mandibulofacial s With the Composed Double Skin Paddle Fibula Free Flap: A Review of 32 Procedures Franck M. Leclère, MD, PhD; Romain Bosc, MD, MSc; Stephane Temam, MD, PhD; Nicolas Leymarie, MD, MSc; Haitham Mirghani, MD, MSc; Benjamin Sarfati, MD, MSc; Frederic Kolb, MD, PhD Objectives/Hypothesis: The purpose of this study was to analyze our experience with the composed double skin paddle fibula free flap to reconstruct large mandibulofacial defects. Study Design: Between 2006 and 2011, a total of 32 composed double skin paddle fibula free flap procedures were performed on 32 patients (mean age years, mean follow-up period of years). Methods: A chart review was drawn up to determine the type of defects covered by each skin paddle, the vascular anatomy, the origin of the perforators, and any associated complications. Results: The distal septocutaneous skin paddle (Nakajima type B) was used for the reconstruction of the floor of the mouth in most cases. The proximal paddle (Nakajima type D) was used for base of the tongue, mobile tongue, soft palate, internal cheek, inferior lip, and the skin of the chin and neck. The lateral soleus pedicle arose from the fibular pedicle in 28 cases and directly from the tibial-fibular trunk in four cases. There were two partial soleus skin paddle losses. Seven complications required revision surgery: due to a cervical abscess in two cases, due to a hematoma in two cases, due to a disunion of the second skin paddle leading to an orostoma in two cases, and due to an exposition of the osteosynthesis material in one case. Conclusion: In large mandibulofacial defects, a second skin paddle raised on the soleus perforators may be of benefit when reconstructing the soft palate, neck, cheek, or tongue as the length of its pedicle renders a second free flap unnecessary. Key Words: Perforator flap, Nakajima classification, double skin paddle fibula free flap, fibula flap. Level of Evidence: 4. Laryngoscope, 124: , 2014 INTRODUCTION The twin purposes of maxillofacial reconstruction are the restoration of both form and function, necessitating the evaluations of appearance, mastication, deglutition, speech, and oral competence. 1,2 During reconstruction, the highly visible position of the maxillofacial area results in a significant emphasis placed on using tissue coverage, which imitates the resected native tissue in terms of both form and function. 3 Since its publication by Hidalgo in 1989, 4 the osteomyocutaneous fibula free flap has become the workhorse technique for correcting large mandible defects. However, its major drawback lies in the poor quality of its From the Department of Plastic and Reconstructive Surgery (FL., R.B., N.L., BS., F.K.); and the Department of ENT Surgery (S.T., H.M.), Gustave Roussy Cancer Campus Grand Paris, 94805, Villejuif Cedex, France. Editor s Note: This Manuscript was accepted for publication September 23, All the equipment for this study was provided by the Institut De Cancerologie Gustave Roussy, Villejuif Cedex, France. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Franck Marie Leclère; MD, PhD, Department of Plastic and Reconstructive Surgery, Gustave Roussy Cancer Campus Grand Paris, Villejuif Cedex, France. franckleclere@yahoo.fr or franck.leclere@igr.fr DOI: /lary soft tissue component. Large mandibulofacial defects require more than the skin paddle vascularized by the septocutaneous perforators (Nakajima type B). 5 In such cases, as reported by Cuzon et al. 6 a second free flap must also be considered. In 1988, Carr et al. described both septocutaneous perforators and soleus perforators of the peroneal artery, 7 and more recently Iorio et al. 8 have revisited the topic in performing a systematic review and pooled analysis of peroneal artery perforators for fibula osteocutaneous and perforator flaps. The era of perforator techniques brings a new possibility for addressing large mandibulofacial defects: A second skin paddle raised on a musculo-cutaneous perforator (Nakajima type D) arising from the lateral soleus artery can be harvested. The purpose of this study was to analyze our experience with the composed double skin paddle fibula free flap. We have reviewed the type of defects covered by each skin paddle, its vascular anatomy, origin of the perforators, and any associated complications. MATERIALS AND METHODS Patients This clinical study was conducted in accordance with the ethical guidelines of the Institut Gustave Roussy. Criteria for 1336

2 inclusion in the study was limited to procedures on adult patients with large mandibulofacial defects that could potentially be covered by a double skin paddle free fibula flap, which took place between 2006 and 2011 and with informed consent. Exclusion criteria consisted of cases where both parts of the double skin paddle were vascularised by septocutaneous perforators. The mean age of patients was years. Twenty six patients were smokers, three subjects had diabetes mellitus type 2, and 23 patients had high blood pressure. Etiologies and After Resection Etiologies were ameloblastoma in one case, osteoradionecrosis in five cases, sarcoma in three cases, and squamous cell carcinoma in 23 cases (Table IA and Table IB). Sites of defect after resection included the floor of the mouth and alveolar ridge in 32 cases, the pharynx in 10 cases, the base of the tongue in five cases, the mobile tongue in 12 cases, the soft palate in six cases, the internal cheek in three cases, the inferior lip in two cases, and the skin of the of the chin and neck in 14 cases. Surgical Technique The patient was placed in the dorsal decubitus position with the hip flexed at 45 degrees and the knee flexed at 135 degrees. Proximal and distal stumps of at least 5 cm and 7 cm, respectively, were left in situ to maintain ankle and knee joint stability and to avoid damage of the peroneal nerve. The operation was performed using a tourniquet : Exsanguination of the lower extremity with an Esmarch bandage began at the ankle so that some residual blood was maintained in the distal vessels to aid in the identification of small perforators. The dissection began by raising the proximal paddle (Type D) using the TABLE IA. Our Series of 32 Composed Double Skin Paddle Fibula Free Flap: s covered by each flap. N Surgical Indication Bone Length/ Number of Osteotomies Covered by the Fibula Bone Origin of the Soleus (Type D) A/V Soleus D-Flap Surface (cm 2 ) Covered by the D-Flap Origin of the Septocutaneous (Type B) A/V Septocutaneous B-Flap Surface (cm 2 ) Covered by the B-Flap 1 SCC 13/2 B, R FA/FV 3 12 TM1/2 FA/FV 2 18 FOM A TxN0Mx FOM LL 2 ORN 12/3 B, R, S FA/FV 72 CM FA/FV 2 16 FOMA 3 SCC 14/1 B, R, C FA/FV 1 SP FA/FV 2 T4aN2bM0 PHLL 4 SCC 14/3 B, R,C FA/FV 2 42 TB FA/FV 2 12 FOMLR T4N0Mx 5 SCC /2 B,S,B FA/FV 1 TM1/2 FA/FV 2 FOMA TxN0Mx FOMLR 6 SCC 14/2 B FA/FV 1 21 CM FA/FV 2 CCH T4N0Mx PHLL 7 ORN 21/4 S, B FA/FV 1 32 CM FA/FV 2 40 CCH PHLL 8 SCC 13/1 B, R,C FA/FV 2 18 SP FA/FV 2 CCH TxN2M1 PHLL 9 SCC 11/2 B,S,B FA/FV 3 60 TM1/2 FA/FV 2 20 FOMA TxN1M0 10 CS 13/1 B, R, S FA/FV 1 18 L FA/FV 2 18 T4Mo CL FOMA 11 ES 15/1 B, R, C FA/FV 2 21 SP FA/FV 2 35 FOMLR T4aN0M0 12 SCC 12/2 B, R FA/FV 1 CM FA/FV 2 FOM LL TxN2bM0 TM1/2 13 SCC 11/1 B, R,C FA/FV 1 80 TM1/2 FA/FV 2 80 FOM A TxN0M0 14 RMC- 8/1 B, R FA/FV 1 12 SP FA/FV 2 16 FOMLR 15 SCC 15/2 S FA/FV 2 12 TM1/2 FA/FV 2 18 FOMA T4aN0M0 1337

3 TABLE IA. (Continued) N Surgical Indication Bone Length/ Number of Osteotomies Covered by the Fibula Bone Origin of the Soleus (Type D) A/V Soleus D-Flap Surface (cm 2 ) Covered by the D-Flap Origin of the Septocutaneous (Type B) A/V Septocutaneous B-Flap Surface (cm 2 ) Covered by the B-Flap 16 ORN 15/2 B, S, B TFT/FV 1 30 CN FA/FV 2 16 FOMA FOMLR 17 SCC 12/1 B, R FA/FV 1 CN FA/FV 2 CCH T4N0Mx 18 AMB 10/1 B, R,C FA/FV 1 24 TB FA/FV 3 27 FOMLR T4M0 19 SCC 16/2 B, S, B FA/FV 1 21 CM FA/FV 2 21 FOMA TxN0Mx FOMLR 20 SCCTxN0Mx 12/2 S FA/FV 2 TM1/2 FA/FV 2 FOMA 21 SCC 12/2 S TFT/FV 3 32 TM1/2 FA/FV 2 48 T3N2bM0 TB1/2 FOMA 22 SCC 10/2 B, R,C FA/FV 2 28 SP FA/FV 2 24 FOMLR T4aN2bM0 23 ORN 12/1 B, R FA/FV 3 10 CCH FA/FV 2 50 FOMA 24 SCC 14/2 S, B TFT/FV 2 30 TM1/2 FA/FV 3 33 FOMA T4N2bM0 25 SCC 12/2 S, B FA/FV 2 55 TM1/2, FA/FV 2 27 FOMA TB1/2 T1M0 FOMLR 26 SCC 14/2 B, R FA/FV 2 23 SP FA/FV 2 96 PHLL T4N1M0 TB1/4 27 SCC 14/2 B, S, B FA/FV 1 30 MT1/2 FA/FV 3 33 FOMA T4N2bM0 28 SCC 12/3 B, S FA/FV 2 50 CCH FA/FV 2 69 TxNXM0 TM1/4 29 SCC 12/2 S, B TFT/FV 2 15 CL FA/FV 1 36 FOMA TxNxM0 30 SCC 12/2 B, S FA/FV 2 18 CCH FA/FV 3 33 FOMA TxNxM0 31 0RN 14/2 B, S, B FA/FV 2 42 CM FA/FV 2 55 FOMA CN 32 SCC 12/2 B, S FA/FV 2 25 CM FA/FV 2 36 FOMA T4aNoMo AMB 5 ameloblastoma; B 5 body; C 5 condyl; CA 5 cervical abscess; CCH 5 internal cheek; CM 5 skin of the chin; CN 5 skin of the neck; CS 5 chondrosarcoma; EOM 5 exposition of the osteosynthesis material; ES 5 Ewing sarcoma; FA/FV 5 fibular artery/fibular vein; FOMA/LL/LR 5 floor of the mouth anterior/lateral laft/right; H 5 hematoma; LR 5 local recurrence; M 5 metastasis; MI 5 myocardial infarction; N/Ch 5 neoadjuvant/chemotherapy; NR 5 node reccurence; ORN 5 osteoradionecrosis; OROST 5orostoma; PH 5 pharynx; PNSF 5 partial necrosis of the skin flap; R 5 ramus; Re 5 Remission; RMC 5 rhabdomyosarcoma; Rth 5 radiotherapy; S 5 symphyse; SCC 5 squamous cell carcinoma; SP 5 soft palate; TB 5 base of the tongue; TFT 5 tibial-fibular trunk; TM 5 mobile tongue. perforator flaps technique; the anterior skin incision of the proximal flap was made through the deep muscle fascia, and the skin paddle was elevated up to the D-perforator(s). The perforators were continued up to the fibular vessels passing through the soleus behind the upper third of the fibula bone. The bifurcation between the tibiofibular trunk and the peroneal vessels was identified at the start of the dissection. In our technique, the initial dissection of the proximal part of the fibular pedicle eliminated the need for overly proximal osteotomies and unnecessary surplus of fibula bone. After dissection of D-perforators and proximal part of the fibular vessels, the design of the D-flap was adapted so as to precisely match the D-perforator area(s). The remainder of the dissection proceeded in the standard way. The anterior skin incision of the distal paddle was made through the deep muscle fascia, and the skin paddle was 1338

4 TABLE IB. Our Series of 32 Composed Double Skin Paddle Fibula Free Flap: Microsurgery and Outcomes N Raising Time (min.) Number of Microanastomoses Flap Ischemia (min.) Complications Complementary Treatment Long-Term Assessment Follow-Up (years) RTh, Ch R R CA NCh RTh, Ch LR (2V) 80 RTh, Ch NR R (2V) 60 NCh RTh, Ch R CA RTh, Ch LR RTh, Ch LR (2V) 60 H RTh, Ch R RTh, Ch R RTh, Ch R RTh, Ch R (2V) 90 NCh RTh R (2V) 100 H NCh RTh, Ch M, death (2A, 2V) 100 PNSF 0 R OROST RTh, Ch R RTh, Ch R RTh, Ch R OROST RTh, Ch R (2A, 2V) 80 RTh, Ch R MI NCh RTh, Ch death R (2A, 2V) 80 O RTh, Ch R PNSF NCh Rth, Ch R RTh, Ch R RTh, Ch R RTh, Ch R EOM RTh, Ch R (2V) 80 RTh, Ch R (2A, 2V) 70 0 R RTh, Ch R 1 AMB 5 ameloblastoma; B 5 body; C 5 condyl; CA 5 cervical abscess; CCH 5 internal cheek; CM 5 skin of the chin; CN 5 skin of the neck; CS 5 chondrosarcoma; EOM 5 exposition of the osteosynthesis material; ES 5 Ewing sarcoma; FA/FV 5 fibular artery/fibular vein; FOMA/LL/LR 5 floor of the mouth anterior/lateral laft/right; H 5 hematoma; LR 5 local recurrence; M 5 metastasis; MI 5 myocardial infarction; N/Ch 5 neoadjuvant/chemotherapy; NR 5 node reccurence; ORN 5 osteoradionecrosis; OROST 5orostoma; PH 5 pharynx; PNSF 5 partial necrosis of the skin flap; R 5 ramus; R 5 Remission; RMC 5 rhabdomyosarcoma; Rth 5 radiotherapy; S 5 symphyse; SCC 5 squamous cell carcinoma; SP 5 soft palate; TB 5 base of the tongue; TFT 5 tibial-fibular trunk; TM 5 mobile tongue. elevated up to the posterolateral intermuscular septum. The B-perforators were identified and the skin paddle adjusted correspondingly. The peroneus longus and brevis muscles were freed from the anterolateral aspect of the fibula, allowing access to the anterior septum. The anterior tibial muscle was freed from the medial aspect of the fibula, allowing access to the interosseus membrane. The posterior skin incision was then made through the deep muscle fascia, and the skin paddle was elevated to the edge of the soleus muscle. A 1-cm cuff of soleus muscle was taken from the lateral edge. Proximal and distal osteotomies were made in the fibula and the pedicle controlled distally. The interosseous membrane was released. The flap dissection continued from distal to medial in a medial to lateral direction to avoid injury to the perforating vessels of the distal skin paddle. The pedicle was then traced proximally to its origin. The fibular osteotomies and modeling of the mandible were made in situ while the graft was still being perfused. Once the status of the neck vessels was assured, the peroneal vessels were divided, and the combined flap was transferred to the site of the mandibulofacial defects. Intraoperative Assessment A chart review was used to determine the type of defects covered by each skin paddle and the size of the flaps. The Nakajima classification system 5 was used for the perforators. The origin and number of the musculocutaneous perforators, type D in this classification, were carefully reviewed. Only septocutaneous perforators included in the distal paddle were counted. The time necessary to raise the flap, the time of ischemia, and the number of microanastomoses were recorded in each case. 1339

5 Fig. 1. (A) Flap design for reconstruction of the internal cheek and skin of the chin. (B) the proximal flap vascularized by two D-perforators and the distal combined flap vascularized by the B-perforators. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Fig. 3A B. Origin of the perforators. In this case, the D-perforators (grey arrow) arose directly from the tibiofibular trunk, which necessitated four microanastomoses (white arrow 5 fibular pedicle). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Postoperative Assessment Complications, the need for revision, and flap losses were recorded in each case. The regular follow-up controls were performed both by a ENT surgeon and a plastic surgeon. Longterm assessment included complementary cancer treatments, as well as recurrence rates and survival rates. Measured Parameters In this retrospective study, 32 composed double skin paddle fibula free flap procedures were performed on 32 patients. Data is presented as mean 6 standard error of the mean (SEM). Statistical analysis was performed using the SSPS Statistical Program (IBM, Armonk, NY). RESULTS covered by Each Skin Paddle (Fig. 1 5) In cases of mandibulofacial defect, the distal skin paddle allowed for the reconstruction of the floor of the mouth and the alveolar ridge in most cases. The proximal skin paddle was used to reconstruct the base of the tongue in four cases, the mobile tongue in 10 cases, the soft palate in six cases, the internal cheek in three cases, the inferior lip in two cases, and skin of the chin and neck in 10 cases (Table IA and Table IB). Anatomy of the The anatomy of the perforators is presented in Table IA and Table IB. The number of soleus perforators ranged between 1 and 3 (Fig. 1). The lateral soleus pedicle arose from the fibular pedicle in 28 cases and directly from the tibial-fibular trunk in four cases (Fig. 3A B). Fig. 2. The composed double skin paddle fibula free flap. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Fig. 4. The distal paddle (white arrow) may be beneficial to the reconstruction of the floor of the mouth and alveolar ridge (A,B), whereas the proximal skin paddle raised on the soleus perforators (grey arrow) may be adapted for the reconstruction of the skin of the chin (for example) (B) as the length of its pedicle eliminates the need for a second free flap. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] 1340

6 Fig. 5. Patient 9 of the series with squamous cell carcinoma localized at the mandible, mobile tongue (A), and floor of the mouth. (B) B- and D-Flaps drawings. (C) The D-flap is vascularized by three perforators. (D) The harvested B- and D- flap. (E) The resected tumor. (F) Intraoperative situation after reconstruction. (G) Good healing of both flaps after 6 weeks. (H,I) Patient 1 year after operation. (J) CT-scan (reconstruction) showing bone consolidation 6 months after operation. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] In these cases, four microanastomoses had to be performed. The number of septocutaneous perforators ranged between 1 and 3. Time necessary included dissection of both perforators until their origin was minutes. The mean time of flap ischemia was minutes. period was years. Three patients were lost to follow-up 1, 2, and 4 years, respectively, postsurgery. Among the patients there were five recurrences: local recurrences in three cases, node recurrence in one case, and metastasis in another individual. This particular patient died 9 months after the procedure. Complications One patient with squamous cell carcinoma of the oral cavity, diabetes mellitus, and high blood pressure died on postoperative day 6 from myocardial infarction. There were two partial flap losses: The soleus skin paddle in both cases due to twisting of the pedicle in one case and fistulae in the other case. Seven other cervical complications required revision surgery: cervical abscess in two cases, hematoma in two cases, disunion of the second skin paddle leading to an orostoma in two cases, and exposition of the osteosynthesis material in one case. An autologous skin graft was required in 15 patients to remedy defect after harvesting of the distal flap (10 patients) or both flaps (distal and proximal: 5 patients). There was one wound dehiscence and one partial skin graft loss in the series. Long-Term Assessment Postsurgical complementary treatments are reported in Table IA and Table IB. The mean follow-up DISCUSSION In this study, a total of 32 composed double skin paddle fibula free flap procedures were performed on 32 patients to reconstruct large mandibulofacial defects secondary to carcinologic resection. One patient died on postoperative day 6 from myocardial infarction. There were two partial flap losses and seven complications necessitating revision surgery. Among the patients there were five recurrences: local recurrences in three cases, node recurrence in one case, and metastasis in one patient. This particular patient expiring 9 months after the procedure. A substantial body of literature already exists on the anatomy of perforators. In 1988, Carr et al. 7 described the septocutaneous and intramuscular perforators corresponding to type B and type D, respectively, in the Nakajima classification system. 5 Recently, Iorio et al. 8 provided guidelines on the regional density and classification of peroneal artery perforators. In their study, the fibula was divided into 10 discrete intervals 1341

7 for perforator grouping. reported at specific numerical distances from the fibular head were converted into intervals along the fibula by calculating the ratio between the distance from the fibular head and the entire length of the fibula and grouping each value into its corresponding interval. The markers for these intervals included the proximal fibular head and the lateral malleolus, with the most proximal region defined as the 0.1 interval and proceeding distally. Subgroup analysis of septocutaneous perforators (Nakajima type B) was based on 345 legs and 608 perforators. The 0.6 interval was the densest, with 110 perforators and a frequency of 18.1 percent. The musculocutaneous (Nakajima type D) subgroup analysis was based on the study of 292 legs and 831 perforators; it recorded the densest interval at 0.4, with 157 perforators raised from this interval and a frequency of 18.9%. The overall analysis that pooled data from three clinical series 9 11 and six cadaveric reports described very precisely the localization of both D and B perforators. However, it discussed only little the technical possibilities offered by the perforators. In fact, when harvested into a combined double paddle fibula free flap, the B- and D-perforators offer many advantages for reconstruction of large mandibulofacial defects: 1) it can cover larger areas in comparison withthesinglepaddlefibulaflap.ourstudyhasshown that the area of defect which could potentially be covered by the proximal paddle could reach up to 80 cm 2 and the other covered area covered by the distal paddle could be as much as 96 cm 2. 2) Moreover, the distal paddle is well adapted for the reconstruction of the floor of the mouth and alveolar ridge, whereas the proximal skin paddle raised on the soleus perforators may be advantageous for reconstruction of the the base of the tongue, the mobile tongue, the soft palate, the internal cheek, the inferior lip, and the skin of the chin and neck because the length of its pedicle renders a second free flap unnecessary. 3) Additionally, compared to the subscapular system of flaps, this combined flap which includes the fibula bone allows bone reconstructions of a bigger size. In this context, new studies have pointed out the possibilities to generate in vivo axially vascularized bony substitutes. Recently, Eweida et al. 18 have presented a pioneering method demonstrating the feasibility of combining this technique with synthetic porous scaffold materials and biological tissue adhesives to grow cells and tissue. This new method may offer new possibilities for reconstructing large mandibulofacial defects, including large mandible defects. 4) Moreover, following carcinologic resection and node dissection, the number of recipient vessels may be greatly reduced. The proposed technique offers a major advantage over the double free flap procedure in addressing this problem. However, as seen in our study, the origin of the perforators may be different and can nevertheless necessitate further microanastomoses. This anatomic variant, which was present in four cases of in our study, has been already described in studies by Winters and de Jongh. 19 In their series of 20 proximally based skin paddles, three studies were dependent on a musculocutaneous branch that ran parallel to the peroneal system but did not rejoin the peroneal artery within the region of the harvested flap; therefore, they required a separate anastomosis. 5) Finally, despite the lack of more precise measurements on donor site morbidity, it is clear that it is greatly reduced when compared to the levels of donor site morbidity resulting from the combination of a simple skin paddle fibular free flap and another free flap such as the antebrachial free flap. Moreover, we noticed that it is generally possible to close the leg without graft after flap harvesting because the distal flap used for the floor of the mouth is generally thin and the proximal flap is easy to close because of the lack of tension at the upper third of the leg. Despite the relatively long period covered in this study, five methodologic limitations remain: 1) This study was limited by its nature as a retrospective analysis. Nonetheless, all the flap details were precisely registered on the clinic s electronic database. 2) No control group was employed. Any such study comparing a twoflap group (simple skin paddle free fibula flap combined with another flap) with a double skin paddle free fibula flap would have been difficult to justify in ethical terms for several reasons. For example, procedural time is greatly reduced when using the double skin paddle technique; the number of associated microanastomoses is two (except in 4 cases where the perforators did not arise from the fibular artery) with the double paddle flap compared to four microanastomoses when two flaps are used; and the residual defect after flap harvesting is reduced. 3) The number of patients used in our study was very small compared to the patients undergoing procedures using a simple paddle fibula free flap. However, this is because the composed double skin paddle fibula free flap is only needed in case of large mandibulofacial defects. For simpler defects (which are more frequent owing to prompt treatment in the country of study), a simple skin paddle fibula free flap is generally sufficient. 4) Additionally, there were no preoperative evaluations of perforator anatomy. However, in order to ensure viability of both flaps, the design of the flaps was always adapted intraoperatively in order to precisely match the perforator area. 5) Finally, a more in-depth evaluation of residual sequelae after flap harvesting would have been beneficial, but further progress on this study continues and more information will be forthcoming. CONCLUSION The composed double skin paddle fibula free flap appears well suited for the reconstruction of large mandibulofacial defects: The distal paddle may be beneficial for the reconstruction of the floor of the mouth and alveolar ridge, whereas the proximal skin paddle raised on the soleus perforators may be adapted for the reconstruction of the soft palate, cheek, or tongue because the length of its pedicle eliminates the need for a second free flap. BIBLIOGRAPHY 1. Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: a 10-year follow-up study. Plast Reconstr Surg 2002;110:

8 2. Valentini V, Agrillo A, Battisti A. Surgical planning in reconstruction of mandibular defect with fibula free flap: 15 patients. J Craniofac Surg 2005;16: Kim EK, Evangelista M, Evans GR. Use of free tissue transfers in head and neck reconstruction. J Craniofac Surg 2008;19: Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84: Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization. Ann Plast Surg 1986;16: Kuzon WM Jr, Jejurikar S, Wilkins EG, Swartz WM. Double free-flap reconstruction of massive defects involving the lip, chin, and mandible. Microsurgery 1998;18: Carr AJ, MacDonald DA, Waterhouse N. The blood supply of the osteocutaneous free fibular graft. J Bone Joint Surg 1988;70B: Iorio ML, Cheerharan M, Olding M. A systematic review and pooled analysis of peroneal artery perforators for fibula osteocutaneous and perforator flaps. Plast Reconstr Surg 2012;130: Yu PY, Chang EI, Hanasono MM. Design of a reliable skin paddle for the fibula osteocutaneous flap: perforator anatomy revisited. Plast Reconstr Surg 2011;128: Cho BC, Kim SY, Park JW, Baik BS. Blood supply to osteocutaneous free fibula flap and peroneus longus muscle: prospective anatomic study and clinical applications. Plast Reconstr Surg 2001;108: Sandhu GS, Rezaee RP, Wright K, Jesberger JA, Griswold MA, Gulani V. Time-resolved and bolus-chase MR angiography of the leg: branching pattern analysis and identification of septocutaneous perforators. Am J Roentgenol 2010;195: Schaverien M, Saint-Cyr M. of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flaps. Plast Reconstr Surg 2008;122: Lykoudis EG, Koutsouris M, Lykissas MG. Vascular anatomy of the integument of the lateral lower leg: an anatomical study focused on cutaneous perforators and their clinical importance. Plast Reconstr Surg 2011;128: Yoshimura M, Shimada T, Hosokawa M. The vasculature of the peroneal tissue transfer. Plast Reconstr Surg 1990;85: Papadimas D, Paraskeuopoulos T, Anagnostopoulou S. Cutaneous perforators of the peroneal artery: cadaveric study with implications in the design of the osteocutaneous free fibular flap. Clin Anat 2009;22: Schusterman MA, Reece GP, Miller MJ, Harris S. The osteocutaneous free fibula flap: is the skin paddle reliable? Plast Reconstr Surg 1992;90: Choi SW, Kim HJ, Koh KS, Chung IH, Cha IH. Topographical anatomy of the fibula and peroneal artery in Koreans. Int J Oral Maxillofac Surg 2001;30: Eweida AM, Nabawi AS, Elhammady HA, et al. Axially vascularized bone substitutes: a systematic review of literature and presentation of a novel model. Arch Orthop Trauma Surg 2012;132: Winters HA, de Jongh GJ. Reliability of the proximal skin paddle of the osteocutaneous free fibula flap: a prospective clinical study. Plast Reconstr Surg 1999;103: