PMC4793788_01
A case of a 56-year-old male patient who underwent a composite resection of a T4 N2c M0 squamous cell carcinoma of the lower face as well as double free flap reconstruction with a free fibula - and ALT flap: Panel A: Patient 1 preoperative. Panel B: Patient 1 intraoperative after composite resection of his tumor. Panel C: Patient 1 after double free flap reconstruction with an ALT- and free fibula flap on 3-month follow-up. Panels D and E: 7-month follow-up. Panel F: Patient 1 7 days after reconstruction of the lip-chin unit with a second ALT flap 4 years after his initial double free flap reconstruction.
icrp-2-67.01.jpg
PMC4793788_01_icrp-2-67.01.jpg
F1
A). After composite resection of the tumor and bilateral neck dissection, the final defect measured over 200 cm2 including the intraoral buccal mucosa, the mandible (from angle to angle), lower muscles of facial expression, the oral commissure and modiolus on both sides, the entire lower lip, 50% of the upper lip, the chin and submental soft tissue (Figure 1, Panel B). On 3-month and 7-month follow-up his tissue coverage was stable and oral competence was adequate (Figure 1, Panel C,D,E). Seven days postoperatively the patient was able to feed by oral soft diet (Figure 1, Panel F).
A free ALT flap folded around a rolled tensor fascia lata sling anchored to the zygoma bilaterally was employed to restore oral competence: (1) skin paddle of the free ALT flap; (2) skin paddle of the free fibula flap and (3) tensor fascia lata sling.
icrp-2-67.02.jpg
PMC4793788_01_icrp-2-67.02.jpg
F2
In order to create oral competence the skin paddles of the ALT and fibula flaps were tailored and the folded ALT flap (reconstructed lower lip) was suspended with a rolled tensor fascia lata sling from the right thigh, which was anchored bilaterally on the anterior aspect of the zygoma (Figure 2).   
PMC4793788_02
Tensor fascia lata graft in Patient 2 intraoperative after anastomosis and placement of the free fibula flap with reconstruction plate.
icrp-2-67.03.jpg
PMC4793788_02_icrp-2-67.03.jpg
F3
ALT flap was anastomosed to the ipsilateral facial artery and the internal jugular vein. As in the previous case, a tensor fascia lata sling anchored bilaterally on the anterior aspect of the zygoma was used to suspend the lower lip reconstruction and restore oral competence (Figure 3). 