Sandwich flaps as a feasible solution for the management of huge mandibular composite tissue defects

In the current therapy of head and neck defects, surgical reconstruction with the aid of pedicle or free flaps is common practice. Suitable single flaps are available to solve most reconstructive challenges. However, reconstruction can become a problem in extensive mandibular defects, as they are often caused by large primary tumors or osteoradionecrosis. These composite defects often lead to large intraoral or extraoral fistulas due to the involvement of mucosa, skin, mandible and soft tissue. These issues call for a double flap approach in order to achieve adequate reconstruction. Therefore, we developed a surgical sandwich technique as presented in this study. The procedure features the acquisition and use of two vascular flaps which can be freely combined according to their desired features (for example being of high tissue volume or osteomyocutaneous). In our study we included 11 patients (ten male, one female) with a mean age of 57 years. Seven of the patients had defects due to osteoradionecrosis and four due to tumor resection. A sandwich technique was performed in a single operation in eight patients, whereas for three patients several operations were necessary. The flaps used included: fibula free flap (FFF); anterolateral thigh (ALT); radial forearm flap (RFF); deltopectoral flap (DPF) and tensor fascia lata (TFL). The following combinations were used: FFF and ALT (three cases), FFF and RFF (two), FFF and DPF (three), ALT and TFL (two), and two ALT flaps (one). The sandwich technique proved suitable for complex reconstructions and led to desirable esthetic and functional results. The flexibility in combining different free or pedicle flaps made it possible to address various defect situations and consequently offer satisfactory surgical reconstruction for complex cases.