Interestingly, patients with severe injuries (blast, R.T.A.) had all opted to a one-stage rather than a two-stage reconstruction, Supplementary Digital Content, Table 1, http://links.lww.com/SCS/C535. Even more, a bone graft was only used in the one case with R.T.A. The distribution according to the classification of the defect, Supplementary Digital Content, Table 2, http://links.lww.com/SCS/C538 shows that most patients who agreed to have a second surgery were those without a C component in their Boyd classification. Also, 90% of the patients in the one-stage reconstruction group had injuries elsewhere in the body. These observations highlight that patients with severe injuries are less likely to agree/proceed with a multi-stage reconstruction and tend to be satisfied with the simplest available form of reconstructive treatment. Many of them, however, might have to undergo revision surgeries later according to a recent meta-analysis. 11 This is also supported by the fact that 7 cases which were initially planned for two-stage reconstruction did not go through with the second stage. Most of these cases were males possibly because their esthetic requirements are not as high as females. 12 Bone grafts were successfully involved to bridge defects even larger than the maximum 6 cm limit (2). This decision was made because microvascular reconstruction is not available as a treatment option in our facility. Therefore, nonvascularized bone graft is indicated as long as it would have enough soft tissue cover at the time of wound closure (as determined during the treatment planning stage). 13 Figure 1A shows an example of successful case beyond this limit.The correlation between TMJ/occlusal complications and HL type was apparent (all 8 cases had L component). However, C type correlation with esthetic issues was not clear in our sample (only one of the three cases had a C component). 1,2 In fact, the authors noted that esthetic complains were mainly attributed to permanent facial nerve damage (2 out of the 3). It is therefore prudent not to promise symmetry and to lower patient's expectations in cases of facial nerve damage.The outcome results in Supplementary Digital Content, Table 4, http://links.lww.com/SCS/C541 suggest that one-stage and twostage procedures had nearly equal success rates in the study sample.In this study, sample patients did not attend follow-up appointments if they were unsatisfied with the initial results. This observation contradicts the results of Elegbede et al 14 investigation. This also would explain the disagreement of our failed cases distribution with previous studies stating that lower success is expected with repeated surgery. 2,4 The authors conclude that mandibular reconstruction with nonvascularized bone graft is a successful treatment with a high predictability of possible complications. Most of such complications are temporary, easily managed and rarely reach the necessity for graft removal. It is a good option to consider in the absence of vascularized flaps as opposed to ove...
