Grabb’s Encyclopedia of Flaps Head and Neck

FIGURE 117.1 Diagram of a large cervicopectoral flap rotated to resurface an excised area of cheek. Note that
the flap border is 1 to 2 cm posterior to the anterior border of the trapezius and crosses the top of the axillary
fold.
FIGURE 117.2 A: Preoperative view showing the area of wide excision for melanoma and the outline of the
cervicopectoral flap. Flap elevation gave excellent exposure for a total parotidectomy and radical neck
dissection. B: Appearance 3 years postoperatively. No revisions have been performed. There is a good color
match of the adjacent cervical skin, a favorable scar location, and good cheek restoration.
Suction drains through the posterior neck skin hold the flap in close contact with the underlying contours. The
donor site is routinely closed primarily without skin grafting.
CLINICAL RESULTS
The flap has been used in all age groups, in patients from 17 to 75 years of age. Scars are favorably
located, giving an acceptable aesthetic result. Flap reliability has been excellent, but fluorescein testing of
viability still should be carried out. In all patients to date, the flap has accomplished the goals of coverage
and contour restoration, despite complications such as infection and hematoma, which may compromise
less hardy flaps (Fig. 117.2).
SUMMARY
The cervicopectoral skin flap is an excellent flap for coverage of large cheek defects.

References
1. Becker DW, Jr. A cervicopectoral rotation flap for cheek coverage. Plast Reconstr Surg 1978;61:868.
2. Daniel RK, Cunningham DM, Taylor GI. The deltopectoral flap: an anatomical and hemodynamic
approach. Plast Reconstr Surg 1975;55:275.

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Chapter 118
Inferiorly Pedicled Tongue-Shaped Smas Flap During Facelift
Surgery
JOSÉ M. SERRA-RENOM
JOSÉ M. SERRA-MESTRE*
*Neither author has a financial interest in any of the products, devices, or drugs mentioned in this chapter.
EDITORIAL COMMENT
The transposed superficial musculoaponeurotic system (SMAS) will help tighten the neck and define the
horizontal ramus of the mandible. Excess bulkiness in the postauricular area must be avoided.
INDICATIONS
The concept of the facelift has evolved considerably over the years. The various techniques currently in
use seek to obtain the most natural result possible without creating the stigmata associated with
conventional facelifting techniques: the loss of the sideburns, the presence of scars in front of the hairline,
or the distortion of the earlobe with anteroinferior displacement of the ear caused by cervical flap retraction.
The popularization of the dissection of the SMAS in 1976 (1) allowed the abandonment of the “skin-only
facelift” techniques, which achieved only short-lived results with a rapid loss of surgical effect.
ANATOMY
The SMASectomy technique described by Baker (2, 3) represented a step forward, as it permitted a more
conservative approach without the need to elevate a wide SMAS flap in order to obtain consistent results. This
technique is also safer because an ellipse of the SMAS is excised over the parotid gland and the facial nerve
branches are protected. An anterior mobile SMAS, which is not separated from the deeper planes and thus
maintains its vascularization and elasticity, is advanced along with a posterosuperior vector and sutured to the
posterior SMAS fixed by the retaining ligaments; the clinical consequences are an improvement of the nasolabial
folds and long-lasting results. Provided the SMAS vascularization is preserved, less atrophy will be induced and
cheek emptiness is avoided. Our facelift technique (4) shares the rationale and anatomical benefits of lateral
SMASectomy. What is more, instead of discarding the SMAS, we use it to create an inferiorly pedicle pointing
tongue-shaped superficial fascia flap, which rotates and is transposed to the mastoid to improve neck
contouring.
FLAP DESIGN AND DIMENSIONS
In our technique, we do not make an elliptical SMAS design, which allows maximal SMAS advancement at the
midportion of the ellipse and provides proper correction of the nasolabial fold but does not satisfactorily correct
the jowls. We make the base as wide as is necessary to reshape the cervicomandibular angle, while the width
and length of the rest of the flap are tailored to ensure good correction of the nasolabial folds. By suturing the
donor site and by rotating the flap in continuity with the platysma and suturing it at the level of the mastoid, we
are also able to improve the neck contour. As we do not perform extensive dissection of the malar region, we can

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correct the facial negative vector with fat grafting (5).
FIGURE 118.1 Closed suction-assisted lipoplasty of the neck and jowls (left) and platysmaplasty (right).
OPERATIVE TECHNIQUE
Neck Contouring
The neck is infiltrated subcutaneously with a solution containing 1:200,000 epinephrine and lidocaine. To
enhance the jaw line and neck contour, we dissect the cervical area without passing beyond the hyoid bone
using nonaggressive lipoaspiration and undermining with a 3-mm flat cannula and attempt to leave a layer of
subcutaneous fat attached to the skin. This maneuver is performed through three incisions: one incision that is 2
mm from the submental fold and two others at the insertions of the earlobes. In cases in which platysmal bands
are active, the submental incision is extended about 3 cm and a midline plication is performed after myotomy at
the level of the hyoid (Fig. 118.1).
Skin Flap Elevation and SMAS Flap
After infiltration of the tumescent solution, the skin flap is elevated through a preauricular incision that
commences at the upper insertion of the ear without reaching the hairline and then descends behind the tragus
and around the lobe. We proceed behind the ear with a 2-mm incision parallel to the retroauricular sulcus as far
as the posterior auricular muscle, without reaching the hairline. The cutaneous dissection in the cheek is also
limited above the parotid gland without undermining in the malar area and extends 4 to 5 cm below the angle of
the mandible with an arc of about 4 to 5 cm behind the ear up to the hairline.
A pointing tongue-shaped inferiorly pedicled SMAS flap is designed (4), overlying the parotid fascia and
extending from just below the lateral malar eminence to the angle of the mandible (2 cm below the inferior border
of the mandible), parallel to the nasolabial fold (Fig. 118.2). The width of the flap, which
may vary between 2 and 4 cm, depends on the amount of tissue that must be removed in order to correct cheek
flaccidity. This is assessed intraoperatively by a pulling test performed with a forceps. Especially in cases with
wider flaps, care should be taken not to injure the marginal mandibular branch. To facilitate the dissection of the
SMAS flap, it is infiltrated with the tumescent solution described above and then dissected from cephalic to
caudal leaving its base attached to the platysma muscle. We then rotate the flap and close the donor site of the
SMAS flap with absorbable 4-0 suture. We then apply traction to the flap in a posterosuperior direction under the

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angle of the mandible, suturing it behind the ear to the mastoid fascia. The redundant tip of the flap is excised
and the remainder is fixed with interrupted 3-0 absorbable sutures (Fig. 118.3).
FIGURE 118.2 Design and elevation of the SMAS flap. (From Serra-Renom JM, Serra-Mestre JM.
Rejuvenecimiento facial: vector negativo. In: Rómulo Guerrero Vicuña, ed. Rejuvenecimiento Facial: El
Concepto Iberolatinoamericano. Bogotá, Colombia: Impresión médica, 2013;413-422, with permission.)
FIGURE 118.3 Transposition of the SMAS flap in a posterosuperior direction, which is then secured to the
mastoid fascia. (From Serra-Renom JM, Serra-Mestre JM. Rejuvenecimiento facial: vector negativo. In: Rómulo
Guerrero Vicuña, ed. Rejuvenecimiento Facial: El Concepto Iberolatinoamericano. Bogotá, Colombia: Impresión
médica, 2013;413-422, with permission.)

FIGURE 118.4 Placement of the two attachment points of the skin flap to the external auditory canal, above and
below the tragus.
Skin Closure
First, we place an Allis on the anterior face of the skin flap about 4 cm from the edge of the incision and apply
traction obliquely and cephalically. Maintaining this traction, we place another Allis in the retroauricular region of
the skin flap and we apply traction in the direction of the ear, which is partially covered. After finding a position
that allows proper adaptation of the skin without the formation of dog ears at the two ends of the incisions, we
make two parallel sections of the skin flap until we see the upper and lower edge of the tragus, where we attach
the cheek skin flap to a fixed structure, the external ear canal, with two 3-0 Prolene stitches (Figs. 118.4 and
118.5).
FIGURE 118.5 Cutaneous resection has already been completed, which shows the excess skin used for the
reconstruction of the tragus. (From Serra-Renom JM, Serra-Mestre JM. Rejuvenecimiento facial: vector negativo.
In: Rómulo Guerrero Vicuña, ed. Rejuvenecimiento Facial: El Concepto Iberolatinoamericano. Bogotá,
Colombia: Impresión médica, 2013;413-422, with permission.)
To design the retroauricular closure, we fold the ear forward with the aid of two 4-0 silk stitches. Next, we apply
traction to the retroauricular skin of the flap cephalically and towards the ear without forming a fold above the
incision, and we resect the circular flap around the lobe without tension. We then place a 5-0 Vicryl stitch from
the lobe to the flap.
Next, we resect the excess retroauricular skin and suture without tension after the insertion of two suction drains.

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Behind the ear, we take great care not to reach the hairline. To do this, after suturing the back of the lobe and
reaching the concha, we place sutures, wrinkling the skin and attaching it to the ear. After performing the
posterior closure, we reconstruct the tragus with the excess tissue between the two fixation stitches. It is very
important to defat the tragal flap so that it contours correctly (Fig. 118.6). Once the incisions are
sutured, we inject 7 to 10 mL of activated platelet-rich plasma throughout the dissected area of the cheek and
the retroauricular region. The injection of PRP in combination with lifting allows us to reduce ecchymosis and
postoperative drainage at 24 hours.
FIGURE 118.6 Completion of the skin closure.
FIGURE 118.7 Fat grafting in the malar region for correction of the facial negative vector.
Subsequently, a compressive cervicofacial bandage is applied with a layer of sponge in the cervical and
retroauricular area, which helps to contour the neck and avoids swelling. The suction drains are not opened until
4 hours later, to allow the action of the antiplatelet agents in the dissected area.
Correction of the Facial Negative Vector with Fat Grafting
Fat grafting in the malar region is a procedure that we always perform in combination with lifting because it
allows the correction of the facial negative vector by remodeling the facial contours. The term “negative vector”
refers to the ptosis and atrophy of the malar tissues, causing the lower lid to appear to be very long when seen in
profile and the angle of the cheek posterior to the surface of the cornea (5, 6, 7). After preparing the fat with the
Coleman method, we make two incisions, one along the proximal third of the zygomatic arch and one in the
nasolabial fold at the level of the oral commissure. Fat is injected by creating multiple tunnels and crossing the
tunnels made from one incision to another with a curved 17-gauge cannula, injecting 7 to 12 mL of fat per cheek
(5) (Fig. 118.7). In cases where a pronounced tear trough needs correction, microfat grafting achieves

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satisfactory results. We then suture the incisions and bandage the donor site (Figs. 118.8A-D, 118.9A and B,
118.10A and B).
CLINICAL RESULTS
Clinical cases are shown in Figures 118.8, 118.9, 118.10. Note the marked improvement in neck contour
achieved with the technique.
SUMMARY
The inferiorly pedicled tongue-shaped SMAS is a safe and effective flap used in contouring the jaw line and
neck. It can effectively be combined with fat grafting to further improve the contour of the midface.
FIGURE 118.8 A: Preoperative frontal and profile image. (Continued)

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FIGURE 118.8 (Continued) B: Postoperative image 5 days after surgery. C: 15 days after surgery. D: After
1 year.

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FIGURE 118.9 A: Preoperative and postoperative frontal image. B: Preoperative and postoperative profile
image. (From Serra-Renom JM, Serra-Mestre JM. Rejuvenecimiento facial: vector negativo. In: Rómulo
Guerrero Vicuña, ed. Rejuvenecimiento Facial: El Concepto Iberolatinoamericano. Bogotá, Colombia:
Impresión médica, 2013;413-422, with permission.)

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FIGURE 118.10 A: Preoperative and postoperative frontal image. B: Preoperative and postoperative profile
image. (From Serra-Renom JM, Serra-Mestre JM. Rejuvenecimiento facial: vector negativo. In: Rómulo
Guerrero Vicuña, ed. Rejuvenecimiento Facial: El Concepto Iberolatinoamericano. Bogotá, Colombia:
Impresión médica, 2013;413-422, with permission.)
References
1. Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid gland and cheek
area. Plast Reconstr Surg 1976;58(1):80-88.
2. Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997;100(2):509-513.
3. Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy: evolution and
application. Aesthet Surg J 2001;21(1):14-26.

4. Serra-Renom JM, Diéguez JM, Yoon T. Inferiorly pedicled tongue-shaped SMAS flap transposed to the
mastoid to improve the nasolabial fold and jowls and enhance neck contouring during face-lift surgery. Plast
Reconstr Surg 2008;121(1):298-304.
5. Serra-Renom JM, Serra-Mestre JM. Periorbital rejuvenation to improve the negative vector with
blepharoplasty and fat grafting in the malar area. Ophthal Plast Reconstr Surg 2011;27(6):442-446.
6. Pessa JE, Desvigne LD, Zadoo VP. Changes in ocular globe-to-orbital rim position with age: implications
for aesthetic blepharoplasty of the lower eyelids. Aesthet Plast Surg 1999;23:337-342.
7. Yaremchuk MJ. Improving periorbital appearance in the “morphologically prone.” Plast Reconstr Surg
2004;114:980-987.

Chapter 119
Kite Flap in Facial Reconstructive Surgery
J.-L. DUCOURS
P. POIZAC
D. RICHARD
J. AFTIMOS
J. UNANUE
B. MARAUD
A. WANGERMEZ
C. ORRETEGUY
C. AUGUSTIN
EDITORIAL COMMENT
This is a nice design modification of the subcutaneous advancement flap that will cover a circular defect
with good cosmetic results.
The kite flap is a triangular cutaneous advancement flap with a subcutaneous pedicle. Vascularization is ensured
by a segmental arterial network made up of vertical ascending branches that guarantee considerable security.
The flap is relatively easy to transfer and yields excellent cosmetic results (1, 2).
INDICATIONS
Use of this flap is mainly in reconstructive facial surgery for repair of defects following excision of cutaneous
tumors (3), preferentially in the cheek and in the suborbital and glabellar regions. Because the flap depends
on linear sliding rather than rotation, distortion is reduced in adjacent areas, and the initial loss of substance
in the defect can be distributed around the flap and along the V-Y closure. For extensive orbital tumors (4),
external canthus loss near the eyelid edge (5), or scar ectropion requiring skin grafting (6), solutions other
than the kite flap are necessary. This applies also to defects of the chin or upper lip.
ANATOMY
The area of the subcutaneous pedicle is not well defined, and its extent is greater than mere projection from the
cutaneous plane would indicate. Mobilization of the cutaneous triangle of the kite flap requires a considerable
amount of adjacent subcutaneous tissue. This increases flap vascularization and ensures greater ease of
transfer. The pedicle is usually fatty but sometimes can be muscular, particularly in the suborbital region when
pedicled on the orbicularis oculi muscle.
According to the arterial classification proposed by Kunert (7), the kite flap is a segmental flap based on
ascending vessels from an axial network comprising longitudinal vessels that make the flap quite reliable (see
Fig. 119.3). Venous return is modeled on the arterial network.
FLAP DESIGN AND DIMENSIONS

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The flap is designed after tumor excision (Figs. 119.1 and 119.2), when the margins of healthy tissue can be
determined. To ensure optimal advancement, the subcutaneous tissue must be sufficiently thick and loose to
allow efficient flap transfer. A line is drawn from the center of the defect and parallel to minimal lines of tension on
the skin. The tip of this triangular-shaped flap is positioned on the initial vertical incision line (Fig. 119.3). Flap
length is generally equal to 2.5 times its width. The kite-flap variation proposed by Ichiro (8), although reducing
the length of the necessary incision and allowing the scar to be inserted in a fold slightly outside the area of flap
excision, nevertheless appears to create local distortion of the subcutaneous tissue.
FIGURE 119.1 Basal-cell carcinoma of the median suborbital region. A: Flap design and excision limits. B: Flap
in place.
FIGURE 119.2 After excision of nasogenian basal-cell carcinoma. A: Drawing of the flap. B: Immediate result.
OPERATIVE TECHNIQUE
The incision reaches the fatty subcutaneous plane. It is advisable to undermine widely around the flap in the
same plane, especially at the flap tip, to ensure ease of transfer. Traction with Gillies' hooks enables noting the
areas where additional tissue removal is necessary.

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FIGURE 119.3 Instead of designing the area of the mobile flap in the axis of the excision itself, its axis is moved
so that it is parallel to the axis of the excision, of a width corresponding to the radius of the area of excision.
When the upper part of the flap can be easily inset into the defect without tension, the first subcutaneous stitch is
placed at the middle of the flap base and then at both ends, corresponding to an acute angle that matches the
shape of the defect. Subcutaneous stitches then are placed from the base to the tip of the flap. These are
important in avoiding the “cushion” effect that some detractors of this flap have criticized (9).
Closure of the donor site is carried out in a simple V-Y fashion. It is often necessary to position the closure to
avoid a cutaneous dog-ear. A corner stitch is placed at the junction of the V-Y flap closure, and overstitching with
Prolene ensures optimal apposition of the cutaneous edges.
CLINICAL RESULTS
The kite flap has been used in areas where slackness and thickness of subcutaneous tissue allow optimal
advancement. In the suborbital region, it has been used for external and median defects, with care taken
not to turn out the lower eyelid. In the nasogenian region, we have repaired defects not extending into the
nasal or orbital regions, and the flap has also been used in the glabellar region for defects between the
eyebrows. The kite flap should not be used for reconstructing defects of the chin or upper lip.
SUMMARY
Because this flap allows cutaneous transfer by linear sliding, without rotation or distortion, it can yield
excellent cosmetic results.
References
1. Dufourmentel C. Le lambeau cerf-volant: Le lambeau insulaire de glissement avec plastie en VY. Ann Chir
Plast 1970;15:344.
2. Marchac D. Chirurgie des baso de la face, Geneva: Medicate Hygiene, 1986.
3. Ducours JL, Richard D, Aftimos J, et al. Le lambeau “cerf-volant” dans la reconstruction après exérèse de
carcinome baso-cellulaires de la face. Rev Stomatol Chir Maxillofac 1989;90:345.
4. Mustardé JC. The use of flaps in the orbital region. Plast Reconstr Surg 1970;45:146.
5. Converse JM. Reconstructive plastic surgery, vol. II. Philadelphia: WB Saunders, 1964;676.
6. Grignon JL. L'ectropion de la paupière inférieure post-traumatique et après chirurgie correctrice. Ann Chir
Plast 1971;16:127.
7. Kunert P. Structure and construction: the system of skin flaps. Ann Plast Surg 1991;27:509.

8. Ono I, Gunji H, Sato M, Kaneko F. Use of the oblique island flap in excision of small facial tumors. Plast
Reconstr Surg 1993;91:1245.
9. Lejour M, De Mey A, Andry G. Revue de 52 lambeaux de glissement en llot de la joue. Ann Chir Plast
1982;27:20.

Chapter 120
Posterior Cervical Flaps
I. K. DHAWAN
N. C. MADAN
EDITORIAL COMMENT
This is a very courageous flap; however, the editors caution that this flap may require a preliminary delay
because the circulation, when extended into the scalp, appears to be primarily from the temporal vessels
anteriorly. The postauricula branches appear to be divided when the long length of this flap is used.
The skin from the back of the neck has not been used often for facial reconstruction. Its use as a random flap
raised in vascular areas of the scalp on the neck has been described for the repair of pharyngeal fistulas (1) and
for other head and neck defects (2). We have described a posterior cervical flap for facial defects (3).
INDICATIONS
We have used this flap in the repair of cheek and lip defects after excisional surgery for tumors and trauma
(see Figs. 120.2 and 120.3). It can provide either lining or cover or both for a full-thickness defect.
ANATOMY
The flap depends on the occipital artery for its nutrition, and its base is formed by a horizontal line joining the
mastoid process to the midline posteriorly. The flap extends vertically downward to the nape of the neck, up to
the D2-3 spinous process (Fig. 120.1). For better reach, the trunk of the occipital artery may be divided and the
flap extended into the temporal region, where it depends for its blood supply on the posterior branch of the
superficial temporal artery and its anastomosis with the occipital artery (see Fig. 120.3).
The occipital artery runs on the superior oblique muscle and enters the superficial fascia of the scalp at the
junction of the medial and intermediate thirds of the superior nuchal line, passing either through the trapezius or
between the trapezius and the sternocleidomastoid. At this point, its pulsations are palpable. Its terminal
branches anastomose freely with the superficial temporal artery, and a descending branch has been described
arising from it.
FLAP DESIGN AND DIMENSIONS
Such a flap in an adult is usually about 8 cm wide and 20 cm long. It is unlikely to survive when the external
carotid artery has been ligated during excisional surgery of the face. The flap needs to be raised in a lateral
position, which involves either a change of position after excisional surgery or carrying out the excisional surgery
in a lateral position, which is a bit awkward. The base of the flap is on the superior nuchal line, and the incisions
extend vertically down to the D2-3 level. Such a flap can be rotated through 90 degrees with its pivot point at the
medial end of the base and will reach to provide hairless lining or cover for cheek defects. The flap leaves no
frontal defect and can provide a large amount of skin.
OPERATIVE TECHNIQUE

The occipital artery is marked preoperatively at the superior nuchal line as it enters the superficial fascia of the
scalp. The posterior branch of the superficial temporal artery is also marked. The flap is raised with the patient in
the lateral position. The incisions extend through the deep fascia, the flap is raised with the deep fascia up to the
nuchal line, and great care is taken to preserve the occipital artery. Because the deep fascia is closely applied to
the muscle, raising the flap necessarily involves cutting through the muscle.
When a longer length of carrier segment is required, however, such as when the flap needs to be turned in for
lining also, the trunk of the occipital artery may be ligated deep to the trapezius insertion and very close to the
periosteum. The flap is then extended to the temporal region on a pedicle that includes the posterior branch of
the superficial temporal artery. The pedicle is raised in a plane between the periosteum and the aponeurosis.
The flap then derives its blood supply from the posterior branch of the superficial temporal artery and its free
anastomosis with the occipital artery. When using this flap for lining and cover, it should preferably be folded
axially unless the amount of lining required is small (Figs. 120.2 and 120.3).
FIGURE 120.1 A,B: The flap may have its base between the mastoid and occiput and is then served by the
occipital artery. B-D: When an extra length is required for a longer reach, however, it may be extended into the
temporal region, where it is served by the posterior branch of the superficial temporal artery and its anastomosis
with the occipital artery. (From Dhawan et al., ref. 3, with permission.)
CLINICAL RESULTS
We have used the posterior cervical flap based on the occipital artery in 16 patients to provide lining (13
patients), cover (two patients), and for both functions (one patient) in large orocutaneous fistulas left after
excision of cheek cancer. Among these 16 patients, one flap was lost, and an additional flap was required.
There was partial marginal loss in another three patients, but these did not require new flaps. In the
remaining 12 patients (75%), there was no loss and the flaps functioned well.

FIGURE 120.2 A: The defect after excision of cheek mucosa cancer B: The posterior cervical flap in place
for lining. Cover was provided by a scalp flap. (From Dhawan et al., ref. 3, with permission.)
Extension of the posterior cervical flap into the temporal region to the territory of the posterior branch of the
superficial temporal artery was used in another 12 patients. With these, there was no loss in seven patients
(about 60%). There was a partial loss in two patients (16%), requiring additional flaps. In 10 of the 12
patients, the flap was used to provide lining and cover in large orocutaneous fistulas left after excision of
cheek cancer. In another two patients, it was used to provide total repair of upper lip loss following an injury.
Flap loss can be reduced when providing both lining and cover by folding the flap axially rather than
contraaxially. In addition, the mouth should be kept open, because a closed mouth is likely to compress the
flap at the fold.
FIGURE 120.3 A: A large squamous cell cancer of the lip. The defect left after excision and the posterior
cervical flap raised and extended into the temporal region. B: The appearance after the flap is inserted. C:
The final result. (From Dhawan et al., ref. 3, with permission.)
SUMMARY
A posterior cervical flap can be used for both lining and cover in the reconstruction of cheek defects.
References
1. Zovickian A. Pharyngeal fistulae, repair and prevention, using mastoid occiput based shoulder flaps. Plast
Reconstr Surg 1957;19:355.

2. Chretien PB, Ketcham AS, Hage RC, Gretner HR. Extended shoulder flap and its use in reconstruction of
the defects of head and neck. Am J Surg 1969;18:752.
3. Dhawan IK, Madan NC, Mehta, SN. Posterior cervical flaps for the repair of defects of the face. In:
Transactions of the sixth international congress of plastic and reconstructive surgeons. Paris: Masson,
1976;387.

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Chapter 121
Submental Advancement Skin Flap to The Chin
J. W. SNOW
Occasionally, one is presented with the problem of resurfacing the skin over the chin, a situation usually
secondary to a skin defect created by excision of cancerous or precancerous tissue.
FLAP DESIGN AND DIMENSIONS
A submental advancement flap whose superior margin is the mental sulcus can be used for resurfacing the chin.
Excision of most of the anatomic unit of the chin is marked out (Fig. 121.1A). As much skin and deeper tissue as
necessary is removed for complete tumor excision. The fat pad will be carried with the submental skin to help
carry the blood supply.
OPERATIVE TECHNIQUE
Figure 121.1B shows the outline of the submental flap. The submental keyhole-like flap was elevated to the
junction with the neck. The lateral triangles produced by the configuration of the flap (Fig. 121.1C) were sutured
together to advance the submental flap. The neck then was slightly flexed and the flap advanced to the mental
sulcus. Subcuticular sutures were used at the base of the flap to advance it distally and to release pressure at
the distal suture line (Fig. 121.1D).
CLINICAL RESULTS
The wound healed per primam in the patient illustrated. The multicentric basal cell carcinoma was
completely excised. With healing, full neck extension was obtained gradually, and the patient's cosmetic
results were satisfactory (Fig. 121.1E). It has now been 6 years since her surgery; there has been no
evidence of recurrence, and her surgical reconstruction is generally not noticeable.
SUMMARY
A submental skin flap can be advanced to reconstruct chin defects.

FIGURE 121.1 A: In the midportion of the chin was what appeared to be a 3 × 1.5-cm basal cell carcinoma
with adjacent atrophic skin and suspicious additional small lesions as seen in multicentric basal cell
carcinoma. Notice the outline of area to be resected and the dotted outline of the position of tumor that did
not show well on the photograph. B: Outline of keyhole-shaped submental flap. C: Tumor excised and flap
elevated back to the neck, leaving the submental fat pad attached to the flap. Note triangles A and B. D:
Triangles A and B sutured together and subcuticular stitches and flexion of the neck allow advancement of
the flap to resurface the chin. E: Appearance 6 months postoperatively.

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Chapter 122
Bipedicle Submental Skin Flap
V. Y. BAKAMJIAN
INDICATIONS
The same cervical skin flaps that were described for intraoral lining (see Chapter 188) are easily applied for
both the external and internal coverage of facial defects (1). Cervical skin flaps also provide distinctly
cosmetic advantages—those of matching color, texture, and degree of hairiness with facial skin.
FLAP DESIGN AND DIMENSIONS
Two mirror-image flaps of a transverse or slightly oblique projection meeting across the midline form a
particularly safe bipedicle variant that may be very useful for chin and lip area applications. The central segment
of the bipedicle flap is applied to the area of reconstruction; the pedicles are tubed as carriers on each side.
FIGURE 122.1 Bipedicle submental skin flap to lower lip. A: Squamous cell carcinoma. B: Lower lip total
resection. C: Skin flap supplying outer layer and lingual flap providing inner layer and vermilion for the new lip.
D: Submental closure of the donor wound. E: Final result. (From Bakamjian, ref. 1, with permission.)
OPERATIVE TECHNIQUE
Depending on its width, the cervical donor wound is closed either by direct approximation of the edges or with a
skin graft. At the time of division, the pedicles are returned to replace all or most of the skin-graft covering on the
donor wound (Figs. 122.1 and 122.2).

FIGURE 122.2 Bipedicle cervical skin flap to upper lip. A: Squamous cell carcinoma of upper lip, nasal
vestibules, and columella persisting after radiotherapy. B: The defect after resection, and outline of the flap. C:
The repair, with central segment of the flap folded to provide both layers, and skin graft for the donor wound. D:
Division of pedicles. E: Pedicles returned to replace most of the skin graft on the neck. (From Bakamjian, ref. 1,
with permission.)
SUMMARY
Bipedicle submental cervical skin flaps can be used to cover full thickness lip and other facial defects.
Reference
1. Bakamjian VY. The reconstructive use of flaps in cancer surgery of the head and neck. In: Saad MN,
Lichtveld P, eds. Reviews in plastic surgery: general plastic and reconstructive surgery. Amsterdam:
Excerpta Medica, 1974.

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Chapter 123
Submental Island Skin Flap
D. MARTIN
P. PELISSIER
J. BAUDET
EDITORIAL COMMENT
Use of the submental area as donor tissue for reconstruction of facial defects has depended on the
description of the anatomy by these authors. This is an extremely useful local pedicle flap, or it can be used
as a free flap. The mandibular branch of the facial nerve should be identified and left undisturbed.
The submental island flap is presented as another cervical flap (1, 2) that provides a reliable technique for soft-
tissue coverage of the face and also overcomes some inherent disadvantages of random (3, 4), superiorly based
platysmal muscular or myocutaneous (5, 6, 7, 8), and supraclavicular neurovascular flaps (9) (e.g., limited
mobility, unacceptable donor-site scars, unpredictable outcomes).
INDICATIONS
This flap has a long (up to 8 cm), reliable pedicle, and cutaneous dimensions can reach up to 7 × 16 cm. It
can be used as a cutaneous, musculofascial (cervicofascial and platysma), or osteocutaneous flap. It has
an excellent skin color match and a wide arc of rotation, and it can extend over the whole face except for
part of the forehead and the whole oral cavity (9). The donor-site scar, concealed under the mandibular
arch, is quite acceptable.
ANATOMY
The submental artery (SMA) is a constant branch arising 5 to 6.5 cm from the origin of the facial artery (1, 10, 11)
(Fig. 123.1). The SMA runs in a groove on the medial aspect of the submandibular gland and is bound medially
by the mylohyoid muscle and above by the mandibular border. It ends at the level of the anterior belly of the
digastric muscle and may give off a branch to the sublingual gland or one to the lower lip. The skin territories
measure 4 × 5 cm to 15 × 7 cm, but possible dimensions of the skin flap are much larger because of the rich
subcutaneous and subdermal anastomoses between the two submental arteries.
There is a constant submental vein draining into the facial vein and at least one anastomosing vein between
facial and external jugular veins. In some cases, the submental vein may be used for venous drainage of the flap.
FLAP DESIGN AND DIMENSIONS
The upper limit of the flap is along the mandibular arch in the submental region, from the ipsilateral angle to a
contralateral point across the midline (Fig. 123.2). The extent of the flap depends on the width of the cutaneous
paddle at the midline. If cervical and submental skin has enough laxity, a 7 × 16-cm flap is possible. A pedicle
flap may reach any part of the oral cavity or the lower two thirds of the side of the face and a part of the
forehead. A free flap, using good-caliber vessels in the pedicle, including facial artery and veins, and is extremely

reliable. It is also possible to use a distal or composite pedicle, taking a segment of the internal basilar margin
(Fig. 123.3).
FIGURE 123.1 Diagram of the anatomy: 1, facial vessels; 2, mandibular branch of facial nerve; 3, submental
artery and vein; 4, digastric muscle; 5, common carotid artery; 6, sternocleidomastoid muscle. (From Martin et al.,
ref. 1, with permission.)
FIGURE 123.2 Outlining of the flap. (From Martin et al., ref. 2, with permission.)
For a distally based flap with a slightly greater arc of rotation than the proximally based flap, the position of the
mandibular branch of the facial nerve, which is the pivotal point for flap rotation, may be a restricting factor in
dissection of the pedicle. An osteocutaneous flap can be raised along with a segment of the rim of the mandible,
supplied by small periosteal vessels (Fig. 123.4). Inner cortex is preferable to preserve a smooth mandibular
contour. Care should be taken not to injure the inferior alveolar nerve. This flap may be useful in reconstruction
of segmental contralateral mandibular defects or those of the malar region. It is also possible to harvest just the
subcutaneous fascia along with the platysma and adipose tissue to correct soft-tissue defects due to trauma or
as a result of Romberg's disease (Fig. 123.5).

FIGURE 123.3 Arc of rotation of the flap. A: Proximally based. B: Distally based. (From Martin et al., ref. 2, with
permission.)
FIGURE 123.4 Compound osteocutaneous flap. (From Martin et al., ref. 1, with permission.)
OPERATIVE TECHNIQUE
The flap is marked with the patient in the supine position and the head extended (see Fig. 123.2). The inferior
limit (possible width) is outlined by an index finger-thumb pinch test to assess primary closure. An incision is
made at the lower margin of the flap. Undermining is continued superiorly, keeping the subcutaneous adipose
tissue with the flap and dissecting close to the submandibular gland and mylohyoid and digastric muscles (Fig.
123.6).

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FIGURE 123.5 Fascioplatysmal flap. (From Martin et al., ref. 1, with permission.)
FIGURE 123.6 Undermining of the flap close to the submandibular gland. (From Martin et al., ref. 2, with
permission.)
An incision then is made at the upper extent of the flap along the mandibular margin, and the flap is raised
beginning at the distal tip and including the platysma and adipose tissue layers; gentle traction eases dissection.
Dissection is carried down to the origin of the facial artery (Fig. 123.7), and the facial vein also is identified.
When raising the flap, it is important to begin the dissection by the exposure of the submandibular gland. This
gland will be thoroughly undermined until it remains attached only by its inferior aspect. Care should be taken
during the dissection to ligate the very short vessels coming from the facial and submental pedicles.
When one needs a very wide arc of rotation for the flap, for instance, to reach the forehead, the facial vein is too
short. In such a situation, it is possible to use the constant anastomosing vein between the facial and external
jugular vein as the drainage of the flap by dividing the facial vein. We have used this reliable procedure six times
in our 19 submental flaps. We have described it as a Y-V lengthening of a vein. It avoids the need for a
microsurgical anastomosis when transferring a submental flap as far as the forehead.
Closure of the donor area is accomplished by some undermining, restricted to cervical skin only. The skin is

sutured to the hyoid bone to create a well-defined cervicomental angle. Flexion of the neck to facilitate closure
should be avoided because it causes subsequent hypertrophic scars.
FIGURE 123.7 Raising the flap from distal to proximal. (From Martin et al., ref. 2, with permission.)
CLINICAL RESULTS
In a series of 19 patients, only one complication was encountered: A hematoma at the recipient site was
evacuated with an uneventful final outcome. The blood supply is robust, the vascular pedicle is constant,
and the dissection is not difficult, with care taken to avoid injury to the mandibular branch of the facial nerve.
There are a few limitations to its use, including thickness of the flap and hairy skin in males.
SUMMARY
When considering orofacial or similar reconstructions, the submental flap is recommended for excellent
color match, for overcoming the disadvantages of other local flaps, and for its versatility of design as a
composite flap.
References
1. Martin D, Baudet J, Mondie JM, Peri G. A propos du lambeau cutané sous mental en îlot: protocole
opératoire. Perspectives d'utilisation. Ann Chir Plast 1990;35:480.
2. Martin D, Pascal JF, Baudet J, et al. The submental island flap: a new donor site. Anatomy and clinical
applications as a free or pedicled flap. Plast Reconstr Surg 1993;92:867.
3. Jellouli M, Soussaline M, Richard JM, Luboinski B. Choix des méthodes de reconstruction de la joue après
exérèse carcinologique au vu d'une étude retrospective de 32 cas sur 8 ans de 1980 à 1987, a l'Institut
Gustave Roussy. Ann Otolaryngol Chir Cervicofac (Paris) 1990;107:265.
4. Mazzola RF, Oldini C, Sambataro G. Use of the submandibular flap to close pharyngostomes and other

defects of the lower anterior neck region. Plast Reconstr Surg 1979;64:340.
5. Coleman JJ, III, Nahai F, Mathes SJ. Platysma musculocutaneous flap: Clinical and anatomic
considerations in head and neck reconstruction. Am J Surg 1982;144:477.
6. Fan HW, Jean-Gilles B, Die A. Cervical island skin flap repair of oral and pharyngeal defects in the
composite operation for cancer. Am J Surg 1969;118:759.
7. Futrell JW, Johns ME, Edgerton MT, et al. Platysma myocutaneous flap for intraoral reconstruction. Am J
Surg 1978;136:504.
8. Hurwitz DJ, Rabson JA, Futrell JW. The anatomic basis for platysma skin flap. Plast Reconstr Surg
1983;72:302,22.
9. Baudet J, Martin D, Ferreira R, et al. The supraclavicular neurovascular free flap: anatomy and clinical
application. In: G. Brunelli, ed., Textbook of Microsurgery. Paris: Masson, 1988.
10. Salmon M. Les arteres de la peau. Paris: Masson, 1936.
11. Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of vascular territories and perforating
cutaneous vessels. Plast Reconstr Surg 1992;89:591.

Chapter 124
Platysmal Flaps for Cheek and Intraoral Reconstruction
J. N. BARRON
M. N. SAAD
L. O. VASCONEZ
EDITORIAL COMMENT
The figures were originally included in Chapter 103, but because they are actually illustrations of platysma
musculocutaneous flaps, a separate chapter was created for them, and text has been added. Special care
must be taken to include the blood supply to the platysma in the pedicle.
A turnover platysma muscle flap based superiorly and including an island of skin in its distal third is admirably
suited for resurfacing the intraoral mucosa following excision of buccal mucosal tumors and cicatricial release of
caustic burn scars as well as for resurfacing the oral surface of the lower lip and creating a deeper sulcus. It has
the added attraction of providing sensitive skin to the buccal mucosa as well as to the lower lip (1).
INDICATIONS
Clinical experience has demonstrated that defects in the buccal mucosa should be resurfaced with flap
tissue, avoiding the use of skin grafts, which usually contract and produce trismus. The platysma is
admirable for this purpose because it provides a flap that is quite thin and has skin devoid of hair. As a
turnover flap pivoting along the mandible, it is introduced intraorally through a small tunnel. Although the
flap has been used for extraoral coverage, to accomplish this, an additional twist must be added that may
compromise the blood supply.
ANATOMY
The platysma is a well-defined, thin muscular sheet in males, but it can be hypoplastic, especially in females. It
consists of paired muscles that are obliquely oriented and flat and that phylogenetically represent the remnants
of the panniculus carnosus (2).
The platysma extends from above the mandible to below the clavicle, and its cephalad and caudad edges insert
into the skin. The blood supply to the muscle comes most often from the submental branch of the facial artery
superiorly, and a smaller vessel is noted that is a branch of the superficial cervical artery inferiorly. The skin
overlying the platysma derives its sensory supply from the cutaneous branches of the cervical plexus. Its medial
and lateral borders are easily identified from the strap muscles and the trapezius muscle, respectively.
FLAP DESIGN AND DIMENSIONS
A skin-flap island is designed in the form of an ellipse on the lateral aspect of the neck and above the clavicle.
Because the blood supply to the flap is from the submental branches of the facial artery, one should be careful in
the dissection along the medial edge and also should avoid elevating the flap beyond the lower border of the
mandible. It is safer to make a back-cut on the posterior edge along the trapezius muscle. The flap usually
reaches the highest point of the intraoral buccal mucosa and also will reach and serve quite well to recreate the

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commissure of the mouth, both on the inner lining and outer layer.
OPERATIVE TECHNIQUE
Vertical and lateral extensions are made through the skin, and the superior skin flap is dissected above the
mandible superficial to the platysma muscle. The inferior skin flap is also dissected to just below the clavicle.
The muscle is divided at least 1 cm below the lower edge of the skin island and is freed up along its medial
extent from the strap muscles in a relatively avascular plane. The muscle is also freed up laterally from the
anterior edge of the trapezius muscle, but care must be used to avoid an injury to the eleventh cranial nerve. The
muscle and the skin island are freed up to the level of the mandible, where the mandibular branch of the facial
nerve is identified and preserved intact. At this point, the intraoral defect has been marked out or created and a
tunnel is opened bluntly to allow for passage of the flap. Once this is done, the flap is inset with fine sutures.
Back-cutting on the posterior edge along the trapezius muscle and careful dissection along the medial flap edge,
as well as avoiding flap elevation beyond the lower mandibular border, will prevent disturbing the blood supply
from the submental branches of the facial artery.
The neck incision then is resutured with fine nylon. Small defects usually close primarily. A temporary Penrose
drain may be left in place (Figs. 124.1 and 124.2).

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FIGURE 124.1 A: Squamous cell carcinoma of the lower lip and left commissure of the mouth. B,C: Proposed
excision and repair with a platysma musculocutaneous flap based on the same side. D: Lesion excised and flap
raised. E,F: Flap inset into lower edge of the mucosal defect. G: Repair of lining defect completed. H: Final
result. The skin defect was repaired by advancement of the neck skin.

FIGURE 124.2 A: Malignant melanoma of the cheek. B: Planned repair with a platysma musculocutaneous flap.
C,D: Flap in situ. The neck defect was too large for direct suture, and a skin graft was applied.
Precautions
Injury to the eleventh nerve is potentially disastrous, particularly as one dissects and frees up the posterior edge
of the platysma muscle. An injury to the mandibular as well as the cervical branches of the facial nerve is also
possible.
In patients with thin platysma muscles, it is quite easy to “buttonhole” the muscle and thus to jeopardize the
blood supply. Obviously, the procedure is not possible in patients who have undergone neck dissections and is
not advised on irradiated necks.
CLINICAL RESULTS
Considerable safety has been reported in using the musculocutaneous unit for the resurfacing of intraoral
defects, with relatively minor complications and no significant deficits other than the occasional loss of the
eleventh nerve and some asymmetry of the lower lip.
SUMMARY
The platysma muscle with an island of skin provides an elegant way to resurface intraoral defects.
References
1. Coleman J, Jurkiewicz MJ, Nahai F, Mathes SJ. The platysma musculocutaneous flap: experiences with
24 cases. Plast Reconstr Surg 1983; 72:315.

2. Hurwitz DJ, Rabson JA, Futrell JW. The anatomic bases for the platysma skin flap. Plast Reconstr Surg
1983;72:302.

Chapter 125
Nape of The Neck Flap
T. D. R. BRIANT
V. V. STRELZOW
EDITORIAL COMMENT
When this flap is taken without the underlying trapezius muscle to augment its circulation, it often creates
difficulties with the very distal circulation, resulting in the loss of the most important part of the flap.
In 1842, Mutter first described his “autoplasty technique,” using a superiorly based posterolateral neck flap from
the shoulder and deltoid region to correct a cicatricial burn contracture of the anterior neck (1). Since then,
several variously named, constructed, and applied shoulder neck flaps have been suggested (2, 3, 4, 5, 6, 7, 8,
9).
INDICATIONS
The nape of neck flap has been used to cover a wide variety of defects. In the neck, these include closure
of pharyngocutaneous fistulas, replacement of soft tissue lost through excision or slough,
pharyngolaryngeal reconstruction, release of contractures, and provision of protective coverage for the
great vessels.
Uses on the face or scalp include replacement of excised facial or scalp skin (see Fig. 125.5), repair of
through-and-through cheek defects, closure of orocutaneous fistulas (see Fig. 125.4), and coverage along
an exposed mandible. Repair of the lower face and mandibular margin is often beyond the range of the
forehead flap and somewhat awkward for the deltopectoral flap.
Intraoral applications include palate reconstruction, floor of mouth repair, coverage of lateral oropharyngeal
wall defects, and lateral commissure reconstruction. This flap is a particularly useful alternative to the
forehead flap in repair of palatal defects, both because of its proximity and also because its bulk provides a
very appropriate thickness to the reconstructed palate (see Fig. 125.3).
The advantages of the flap include its high reliability, ease of construction, and constant anatomic basis.
The bulk and generous amount of usable flap area are sufficient for large, full-thickness defect replacement
with or without the use of other flaps. The donor site is usually beyond neck radiation fields, thus allowing
the flap to be used even in heavily irradiated necks. Cosmetically, the texture and color match are good and
the donor-site defect, after skin grafting, is acceptable. This compares with the forehead flap and anterior
chest wall flap, which usually result in a much more obvious cosmetic deformity, especially in women.
ANATOMY
The blood supply of the nape of the neck flap usually has been described as being based on main branches of
the posterior auricular and occipital arteries, implying it to be primarily an arterialized flap in its proximal half, with
random supply by means of perforating vessels in its distal half. No significant branches, however, have been
found running longitudinally within this flap (10, 11). There is strong evidence that the nape of the neck flap has
a random vascular supply by means of perforating vessels (Fig. 125.1). Should the flap be used in its

musculocutaneous form, the trapezius musculocutaneous flap, the descending branch of the occipital artery,
running deep to the trapezius muscle, then is included in the proximal part of the flap (see Chapter 133).
FIGURE 125.1 The blood supply to the nape of the neck flap is mainly random via perforating vessels. An axial
supply to the proximal flap is disputed. (From Briant et al., ref. 11, with permission.)
FIGURE 125.2 Outline of the flap. Posteriorly, its inferior margin crosses the midline to ensure optimal blood
supply, and anteriorly, its margin continues along the trapezius muscle edge. (From Briant et al., ref. 11, with
permission.)

FIGURE 125.3 A: Delayed right nape of the neck flap in a patient with adenoid cystic carcinoma of the
oropharynx and palate. B,C: The flap has been inwardly tubed and passed into the palatal region under previous
neck flap. D: The flap inset into the palatal defect. (From Briant et al., ref. 11, with permission.)
FLAP DESIGN AND DIMENSIONS
After routine assessment of defect size, need for lining, and distance from the flap turning point, the nape of neck
flap is measured and outlined on the patient (Fig. 125.2). The anterior margin descends from the region of the
mastoid tip along the leading edge of the trapezius muscle for the desired length. The posterior margin begins 2
to 3 cm across the midoccipital line and curves down the neck to become approximately horizontal over the
scapular spine. The outline is roughly rectangular, approximately 10 to 12 cm wide at its base, with a length
approaching 30 to 35 cm. The flap often tapers gently as it continues farther down onto the shoulder.
OPERATIVE TECHNIQUE
If only a short flap is required (i.e., one not extending beyond the midclavicular point) delay of the flap is
unnecessary (7, 8, 9); however, we believe that if a longer flap is required or if the distal tip of the flap requires
split-thickness skin graft lining, the flap should be delayed for 3 weeks (Fig. 125.3A). This is accomplished by
elevating the distal half to two thirds of the flap along with the fascia of the underlying muscles and then
resuturing it to its bed. Should the flap be used in its musculocutaneous form (by dividing the trapezius muscle
and leaving the proximal portion of the trapezius muscle in continuity with the proximal third to half of the flap),
the flap need not be delayed unless it is extended well over the shoulder.

FIGURE 125.4 A: A 63-year-old woman with a left base of tongue carcinoma previously unsuccessfully treated
with cryotherapy and radiotherapy who underwent a left composite resection complicated by an orocutaneous
fistula. B: A left nape of the neck flap was used for closure of the fistula. (From Briant et al., ref. 11, with
permission.)
After transferring the flap, the bared shoulder area is covered with a split-thickness skin graft. Tubing the
proximal flap with skin rolled inward (Fig. 125.3B and C) or outward is often expedient where the flap is
transposed over or transferred beneath intact skin en route to its final destination. It is better to insert the whole
pedicle when possible, by removing any poor-quality skin that it may cross, to provide better tissue cover and
resultant cosmetic effect (Fig. 125.4). After 3 weeks, the final detachment of the distal portion of the flap is
undertaken, and the remaining unused pedicle is returned to the donor site (Fig. 125.5).
FIGURE 125.5 A: A 59-year-old woman with a squamous cell carcinoma of the occiput previously unsuccessfully
treated with local surgery and radiotherapy. B: After a radical full-thickness excision including occipital bone, a
right nape of neck flap was placed over dura. The donor defect was covered with split-thickness skin grafts.
(From Briant et al., ref. 11, with permission.)
CLINICAL RESULTS
Of 13 patients, in only one, a hemiplegic with severe premature arteriosclerotic vessel disease, was full-
thickness loss of the distal 1.5 cm of the flap noted (the flap was delayed). The resultant defect healed
uneventfully by secondary intention. In such cases, or in patients who appear significantly undernourished

or debilitated, or if previous radiation fields overlap the lower lateral neck, a second delay may be
contemplated.
It should be noted that commonly after elevation of the flap the distal few centimeters may appear mottled
and may stay so for several days. Rarely, some epithelial sloughing is seen in association with this
discoloration. These events appear to be independent of the patency of the external carotid artery system.
Disadvantages of the flap include delay procedures that we believe necessary to ensure reliability of long
flaps and that can mean that head and neck reconstructive procedures may become three- or four-stage
operations. Certain midline defects, especially high on the face, or those extending vertically in the neck
region are either not accessible or may require bilateral flap closure.
SUMMARY
The nape of neck flap is a superiorly based posterolateral neck flap that can be used to cover defects of the
neck, face, scalp, and intraoral region.
References
1. Mutter TD. Case of deformity from burns relieved by operation. Am J Med Sci 1842;4:66.
2. Owens N. A compound neck pedicle designed for the repair of massive facial defects: formation,
development and application. Plast Reconstr Surg 1955;15:369.
3. Zovickian A. Pharyngeal fistulas: repair and prevention using mastoid-occipital based shoulder flaps. Plast
Reconstr Surg 1957;19:355.
4. Kirschbaum S. Mentosternal contracture: preferred treatment by acromial flap. Plast Reconstr Surg
1958;21:131.
5. Corso PF, Gerold FP, Frazell EL. Rapid closure of large salivary fistulae by an accelerated shoulder flap
technique. Am J Surg 1963;106:691.
6. Chretien PB, Ketcham AS, Hoy RC, Gertren HR. Extended shoulder flap and its use in reconstruction of
defects of head and neck. Am J Surg 1969;188:752.
7. Conley J. The use of regional flaps in head and neck surgery. Ann Otol 1960;69:1223.
8. Tardy MD. Regional flaps, principles and application. Otolaryngol Clin North Am 1972;5:551.
9. Shumrick DA. Reconstructive flaps in head and neck surgery. Otolaryngol Clin North Am 1969;2:685.
10. Scheim MD, Kahane JC, Myers EN. Blood supply to nape of neck flap: Implications from a fetal anatomic
study. Ann Otol 1977;86:329.
11. Briant TDR, Strelzow VV, Bird RJ. Nape of neck flap. J Otolaryngol 1980;9:35.

(Trang không có chữ)

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Chapter 126
Vascularized Groin Lymph Node Flap Transfer for
Postmastectomy Upper Limb Lymphedema
MING-HUEI CHENG
DALIA TOBBIA
EDITORIAL COMMENT
As a last gasp technique for failed lymphedema patients, this technique looks like a reasonable procedure
to try. It might be best to insert the flap in the axilla, allowing for lymphatic drainage from the entire upper
extremity.
Historically, it was Clodius (1) who first reported vascularized groin lymph node (VGLN) flaps to treat extremity
lymphedema. Further studies by Chen et al. (2) in a canine model and later by Tobbia et al. (3) in a sheep model
demonstrated the basis and feasibility for this novel concept. Becker et al. (4) successfully transferred the VGLN
to the axilla and elbow in patients with upper limb lymphedema and showed promising long-term results. This
physiologic lymph drainage procedure was transferred to the dependent wrist site with improved outcomes by
Cheng's group (5, 6).
INDICATIONS
The VGLN flap is indicated for postmastectomy upper limb lymphedema in patients who are not responsive
to physical therapy with repeated episodes of cellulitis for 6 months, circumferential difference greater than
20%, or total occlusion on lymphoscintigraphy. It works by shunting the lymph from the surrounding
interstitial tissue to the recipient vein (5, 7). Concerns regarding the donor site morbidity were reported (8,
9, 10). Theoretically, the risk of donor site lymphedema can be minimized by reverse mapping technique
(11).
ANATOMY
The superficial groin lymph nodes can be divided into two distinct groups, which are supplied by the superficial
circumferential iliac artery (SCIA) and a consistent medial branch that originates from the common femoral artery
(CFA), 3 cm distal to the SCIA. The former has a pedicle length and diameter of 2.5 cm and 1.5 mm, and the
latter 1.9 cm and 1 mm, respectively (6). The SCIA arises from anterolateral aspect of the CFA 2.5 cm inferior to
the inguinal ligament. Shortly after its origin, the SCIA divides into superficial and deep branches. The superficial
branch runs into the subcutaneous tissues 2 cm below and parallel to the inguinal ligament and provides
vascular supply to the superficial inguinal lymph nodes. There is an average of 6 sizable superficial groin lymph
nodes that can be harvested with a regular pedicle (6). Recently, an MRI study revealed that a mean of 8
superficial inguinal lymph nodes are confirmed below the inguinal ligament (12) (Figs. 126.1, 126.2, 126.3,
126.4).

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FIGURE 126.1 A: An 80-year-old patient with a history of secondary lymphedema in her right upper limb for 2.5
years, as a consequence of modified radical mastectomy, lymph node dissection, and radiotherapy treatment for
breast cancer. B: Illustration depicting the anatomy and vascular supply of the superficial groin lymph node flap.
FLAP DESIGN AND DIMENSIONS
The inguinal ligament is first marked. The junction of the medial third and lateral two-thirds of the inguinal
ligament and a 3-cm perpendicular line extending inferiorly is a landmark where superficial lymph nodes tend to
cluster (11). A line is drawn 4 cm below and parallel to the inguinal ligament representing the long axis of the
flap; the flap is centered on this line. Femoral pulses are palpated and marked. A handheld Doppler is used to
identify the location of skin perforators of the SCIA. The elliptical design of the flap is then outlined approximately
5 cm wide and 10 cm long to include the perforators and vascular pedicle with its medial edge lying directly over
the common femoral vessels. The groin lymph nodes can also be harvested without the skin paddle and
transferred with or without the DIEP/TRAM flap to the axilla (4, 13).
FIGURE 126.2 A: Preoperative marking of the vascularized groin lymph node flap measuring 10 × 5 cm, below
the inguinal ligament with an axis 3 cm below and parallel to the inguinal ligament. The medial margin usually
reaches to the common femoral vessels. B: Flap dissection and elevation based on the medial artery prior to
disconnection of the vascular pedicle. The white loop indicates the superficial femoral cutaneous nerve, which
can be preserved. The pedicle, medial artery, and vein are looped with red and blue loop, respectively.

FIGURE 126.3 A: The pedicle of the vascularized groin lymph node flap was divided. Medial artery, red arrow;
medial vein, blue arrow. B: The anastomoses were completed between the medial artery and vein and radial
artery dorsal branch (red loop) and cephalic vein (blue loop). C: Near-infrared fluorescence imaging using
indocyanine green after microvascular anastomosis of the vascularized groin lymph node flap, highlighting the
uptake of dye injected into the recipient limb by the flap vein (yellow arrow).
FIGURE 126.4 A: Two months after vascularized groin lymph node flap transfer to the right wrist shows a
reduction in circumference measurements above elbow of 25%, and below the elbow of 27%. B: At 20 months
post vascularized groin lymph node flap transfer, the flap was debulked for better cosmesis and further
improvement of limb circumference is evident. Above the elbow is a 95% reduction and below the elbow is a
62.5% reduction compared with preoperative measurements.

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OPERATIVE TECHNIQUE
The skin incision is made along the superior border and continued down to the sartorius fascia. The dissection is
angled away from the flap edges in order to include as many lymph nodes and their natural lymphaticovenous
connections as possible. The common femoral vessels are identified, and both the SCIA and medial artery can
be found branching off the CFA. VGLNs can be harvested based either on the superficial branch of SCIA or the
medial branch. Once the main pedicle is identified, the rest of the flap can be elevated from lateral to medial in
the suprafascial plane. The great saphenous vein is usually not included in the flap since the flap does not drain
into this vein. One or two additional subcutaneous veins are also harvested, if available, for a second vein
anastomosis. No further dissection of lymph nodes is attempted within the flap in order to protect the delicate
natural lymphaticovenous connections.
Careful flap inset is important since the pedicle is short and the flap is thick. In a lymphedematous limb, the
severe fibrotic subcutaneous tissue and reduced compliance of the skin make flap inset and wound closure
difficult. Therefore, a well proportionate donor flap skin paddle and preparation of a generous pocket by
mobilizing the wound edges and excision of adjacent fibrotic tissue are critical to achieve a tension-free wound
closure without compression of the pedicle. In severe cases of lymphedema, an approximately 10 cm length of
dense fibrotic adventitia of the recipient vein can be stripped around the anastomosis site, allowing for improved
venous flow. Intraoperative indocyanine green lymphography is performed to view lymph uptake by the flap and
its shunting to the venous system upon the completion of the pedicle anastomosis (7).
CLINICAL RESULTS
The lymph nodes within the transferred flap act like suction pumps, facilitating lymph clearance and
restoring local immune response (5, 6, 7). Clinically, the lymphedematous limb becomes softer on palpation
and less heavy, and increased range of joint movements and skin wrinkling may start to appear in some
cases around the wrist within 1 week postoperatively. The reported mean circumferential reduction rate in
the lymphedematous limb following this procedure is 40% to 50% (5, 6). This improvement is sustainable
over time because the transferred lymph nodes continue to work at shunting lymph from an expanding
catchment of the surrounding tissues to the venous system.
Of the three possible recipient sites in the upper limb, preparation of the axilla can be the most arduous
because of scarring and irradiation changes to the tissues. The elbow and wrist, on the other hand, tend to
be healthier recipient sites. However, the best symptomatic improvement can be seen with more distal flap
placement, which can be de-epithelialized or debulked for better cosmesis 1 year after surgery (5, 6).
SUMMARY
The VGLN flap transfer is an efficacious approach with constant vascular anatomy and reliable lymph
nodes for treating postmastectomy upper limb lymphedema.
References
1. Clodius L, Smith PJ, Bruna J, et al. The lymphatics of the groin flap. Ann Plast Surg 1982;9(6):447-458.
2. Chen HC, O'Brien BM, Rogers IW, et al. Lymph node transfer for the treatment of obstructive

lymphoedema in the canine model. Br J Plast Surg 1990;43(5):578-586.
3. Tobbia D, Semple J, Baker A, et al. Experimental assessment of autologous lymph node transplantation as
treatment of postsurgical lymphedema. Plast Reconstr Surg 2009;124(3):777-786.
4. Becker C, Assouad J, Riquet M, et al. Postmastectomy lymphedema: long-term results following
microsurgical lymph node transplantation. Ann Surg 2006;243(3):313-315.
5. Cheng MH, Chen SC, Henry SL, et al. Vascularized groin lymph node flap transfer for postmastectomy
upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg
2013;131(6):1286-1298.
6. Lin CH, Ali R, Chen SC, et al. Vascularized groin lymph node transfer using the wrist as a recipient site for
management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg 2009;123(4):1265-1275.
7. Cheng MH, Huang JJ, Wu CW, et al. The mechanism of vascularized lymph node transfer for
lymphedema: natural lymphaticovenous drainage. Plast Reconstr Surg 2014;133(2):192e-198e.
8. Pons G, Masia J, Loschi P, et al. A case of donor-site lymphoedema after lymph node-superficial
circumflex iliac artery perforator flap transfer. J Plast Reconstr Aesthet Surg 2014;67(1):119-123.
9. Vignes S, Blanchard M, Yannoutsos A, et al. Complications of autologous lymph-node transplantation for
limb lymphoedema. Eur J Vasc Endovasc Surg 2013;45(5):516-520.
10. Viitanen TP, Maki MT, Seppanen MP, et al. Donor-site lymphatic function after microvascular lymph node
transfer. Plast Reconstr Surg 2012;130(6):1246-1253.
11. Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new technique for maximizing safety in
vascularized lymph node transfer. Plast Reconstr Surg 2015;135(1):277-285.
12. Dayan JH, Dayan E, Kagen A, et al. The use of magnetic resonance angiography in vascularized groin
lymph node transfer: an anatomic study. J Reconstr Microsurg 2014;30(1):41-45.
13. Saaristo AM, Niemi TS, Viitanen TP, et al. Microvascular breast reconstruction and lymph node transfer
for postmastectomy lymphedema patients. Ann Surg 2012;255(3):468-473.

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Chapter 127
Deltopectoral Skin Flap
V. Y. BAKAMJIAN
EDITORIAL COMMENT
This landmark chapter should be studied with considerable care and detail. The deltopectoral flap preceded
the pectoralis major flap in head and neck reconstruction, and although it is not as reliable as the latter for
intraoral resurfacing or in postradiation patients, the versatility and reach of the deltopectoral flap are
admirable. Safety is ensured by preservation of the second perforating branch of the internal mammary
artery and by flap design and subfascial elevation, as emphasized by the author.
Developed in the early 1960s, the deltopectoral flap was the first axial-pattern skin flap derived from an outside
area for direct reconstructive applications in regions of the head and neck (1, 2, 3, 4, 5, 6, 7, 8, 9, 10).
INDICATIONS
With optimal flap reach occurring in stockier patients with broad shoulders and short necks, the flap may
serve at almost any head and neck level below the ipsilateral eyebrow (Fig. 127.1) or below midlevel of the
contralateral face, if necessary (Fig. 127.2).
The deltopectoral flap can be used for either external cover or intraoral lining or both simultaneously. It also
can be combined with another deltopectoral flap or a pectoralis major musculocutaneous flap (11, 12, 13,
14, 15).
ANATOMY
Two contiguous but separate axially vascularized zones are distinguishable in the area of the flap (Fig. 127.3),
with or without a random narrow zone at the far end (16). Intercostal perforating branches from the internal
mammary artery arborize outward in the pectoral zone; a cutaneous vessel from the thoracoacromial artery does
the same in the deltoid zone; and a few musculocutaneous short twigs from the subscapular and circumflex
humeral vessels pierce into the random distal zone. When the flap is elevated, however, its survival will depend
entirely on the flow of blood in the branches from the internal mammary to the pectoral zone passing by means of
rich dermal and subdermal plexus connections into the axially oriented vasculature of the deltoid zone and
beyond. Clinical experience has amply demonstrated that the blood supply of internal mammary origin suffices
for full survival of the flap, without delay, in 85% to 90% of patients.
FLAP DESIGN AND DIMENSIONS
Based parasternally over the three or four upper intercostal spaces, the flap extends horizontally to the anterior
aspect of the shoulder, where its curvilinear distal margin may reach to the anterolateral, midlateral, or even
posterolateral contour
line of the deltoid region, depending on specific case requirements (Fig. 127.4). It then can carry a generous
portion of deltoid skin, not damaged by prior radiotherapy or compromised by incisions used in resecting head

and neck cancer, on the end of a pedicle of pectoral skin.
FIGURE 127.1 Ipsilateral high reach of the flap.
FIGURE 127.2 Contralateral reach of the flap.
The actual reach of the raised flap is longer than would be surmised from its outlined dimensions when the
patient's arm lies by his or her side. This can be explained by the considerable elongation that characteristically
occurs along the lower border of the flap as it is raised in cephalad rotation. The phenomenon is due to the
better than average stretching ability of skin in the vicinity of the axillary fold—essential for the full range of
abduction and elevation of the arm (Fig. 127.5). Consequently, the pivot point for rotation of the flap shifts from
the lower to the upper medial corner of its base. Tilting the patient's head toward the base of the flap also helps
determine proper flap dimensions.

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FIGURE 127.3 Arterial anatomy of donor area skin of the flap.
FIGURE 127.4 Outline of a typical deltopectoral flap. Infrared photograph showing the axiality of venous return.
OPERATIVE TECHNIQUE
Should the poor general health of a patient—anemia, advanced arteriosclerosis, diabetes, or lupus—give cause
for concern, a simple delay some 7 to 10 days before using the flap may be a wise choice.
In the case of a flap of conventional size, incising its outline and limited undermining into the triangle of the
infraclavicular fossa to divide the cutaneous branch of the thoracoacromial artery should suffice (Fig. 127.6A). In
effect, this will amount to cutting nearly all flow into and out of the area of the flap, except that which enters and
leaves by means of
the vessels of the base. For a delay with equivalent effect in a longer and larger flap than is conventional,
however, additional undermining of the narrow random zone of its far end will be needed (Fig. 127.6B).