Figure 5

Patient 4 underwent composite mandibular resection for squamous cell carcinoma (SCC) of the mandible and floor of mouth with adjuvant chemotherapy and radiation therapy, followed by multiple failed reconstruction attempts. (A) Pre-operative full thickness defect involving the lateral cheek and hemi-mandible with an exposed, tethered tongue after failed pectoralis major, supraclavicular, deltopectoralis and tongue flap reconstructions. Note the laparotomy scar from gastrectomy secondary to gastric ulcer. (B) Harvest of the right PIMOC containing the 7th rib (*) osteomyocutaneous (2) and VRAM (1) components. (C) Rotation of the PIMOC to the contralateral face. (D) Inset of the intercostal perforator skin island for reconstruction of oral lining. (E) Fixation of the rib (*) for mandible reconstruction with large reconstruction plate. VRAM (1) for neck skin resurfacing. (F) Post-op 5 months with complete healing of the initial defect and donor site. The residual deltopectoralis flap was used for additional external coverage. The patient regained oral competence and speech and swallow capabilities. Planned revision of the excess external skin was postponed due to cranial base SCC recurrence. IMA (blue arrow); musculophrenic artery (green arrow); DSEA (yellow arrow); pivot point of IMA pedicle (white arrow); tracheostomy site (black arrow).