The involvement of both sides of the mandible is a serious but uncommon complication of radiation therapy for head and neck malignancies. In the management of this scenario, several factors must be taken into account, such as general conditions and health status of the patient, hard and soft tissue defect extent and vessel conditions. While conservative treatment such as the administration of antibiotic therapy, hyperbaric oxygen therapy or limited debriding may prove successful in a share of cases, a remarkable amount of patients requires more aggressive treatments due to recurrence of infections or to excruciating pain, as was the presented case. Concerning reconstructive strategies, ORN-related endothelial damage leads to poor oxygen diffusion and therefore may impair wound healing [9]. As previously mentioned, the use of vascularized bony tissues represents the best option to deal with such defects. Given the availability of bone tissue and the pedicle length, fibula flap is probably the most versatile flap to address similar scenarios; this can be accomplished in multiple ways. In fact, other therapeutic options could have been used in the case described. For example, each resected segment could have been replaced at that time or at a later date with a single vascularized flap [10]. It must nevertheless be remembered that patients with ORN generally present a poor vascular patrimony both because of the radiotherapy itself and the surgical procedures that they might have undergone in the past [11]. The native mandibular symphysis could have been sacrificed regardless of its non-involvement in the ORN process generating in that way an angle to angle defect permitting a more traditional management as far as a single flap reconstruction was concerned. In the case described here, the surgeons’ aim was that of using a technically more complex methodology that, if successful, could avoid recourse to more than one flap and/or to more than one procedure. At the same time, they intended to preserve the mandibular symphysis and relative dental elements to assure a good functional outcome as far as speech and swallowing were concerned by maintaining the attachment of the tongue and laryngeal muscles. Crucially, the labial competence and the projection of the soft tissues of the lower third of the face were preserved thus contributing to a satisfactory facial aesthetic which would no doubt have a positive impact on the patient’s psychological well-being and self-esteem. The technique adopted here permitted us to reach these aims limiting the procedure’s morbidity both immediately and over the long term. The underlying premise was based on the anatomic peculiarity of a vascularization of the fibula enabling the surgeon to perform osteotomies and consequent independent bone segments to be perfused by a single pedicle. The periosteal collaterals of the peroneal artery provide the blood supply of the single elements. As has been noted in the past and was demonstrated even in this case, removing bone segments a few centimeters long from a fibula flap does not compromise the blood supply of the flap when the dissection and preservation of the periosteal plane and relative muscle are carefully planned and executed. Jacobson et al. [12] first reported that the distal segment of the fibula could be vascularized by the periosteal vessels passing circumferentially around the fibula from the distal continuation of the peroneal artery and by perfusion through the connected periosteum. Fan et al. [13] reported a series of 31 patients who underwent bilateral reconstruction of advanced ORN in the mandible using a single fibular osteocutaneous flap; in 29 cases, the native symphysis was preserved, with an approach that can be considered substantially analogous to the case we described. Considering a follow-up time ranging from 7 to 72 months, all fibular flaps survived, with only a partial necrosis of the skin paddle reported in one case. As pointed out by the aforementioned Authors, this technique faces a drawback when the resection is extended to the ascending ramus because of the limitation of movements determined by the central periosteal bridge. To cope with such condition without harvesting a second flap, some Authors [3] proposed separating the central bridge and generate therefore two distinct flaps from a single fibula. However, this implies the need to prepare two recipient pedicles (which can be challenging in a vessel-depleted neck) and consequently two flap pedicles with an adequate length. Last, two separate skin paddles based on perforators should also be designed.