Grabb’s Encyclopedia of Flaps Head and Neck

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FLAP DESIGN AND DIMENSIONS
A fusiform area is marked along the nasolabial fold of the affected side (Figs. 152.1 and 152.2B) from the upper
pole of the ala nasi to the border of the mandible. The average size of the flap is 9 cm long and 3 cm wide. The
rich blood supply
of the nasolabial area allows the raising of quite long flaps that are narrowly based at the corner of the mouth.
FIGURE 152.2 A: A 51-year-old man before surgery. B: Outline of the flap. C: The deepithelialized dermal
suspension flaps before being tunneled. D: Same patient 2 years after surgery. (From Wexler et al., ref. 5, with
permission.)
OPERATIVE TECHNIQUE
The skin is very superficially incised around the marked fusiform area, which is carefully deepithelialized. The
circumference of the deepithelialized area then is incised to the subcutaneous tissue except for the area adjacent
to the corner of the mouth, the base of the flap. It then is incised in its middle (Fig. 152.1), thus creating two
dermal flaps attached to the corner of the mouth. One is short, about 4 cm long, and the second is longer, about
10 cm, and about 1 to 2 cm wide.
The cheek is undermined from the corner of the mouth to the corner of the orbit over the zygoma and the
zygomaticofrontal process. A 3-cm incision is made in this region parallel to the senile creases (crow's feet). A
tunnel is created from this incision toward the medial canthal tendon along the lower eyelid. The long flap is
passed through the cheek tunnel, thus pulling the corner of the mouth obliquely upward (Fig. 152.2). Two

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separate 3-0 nylon sutures are woven into the dermis flap and pulled with it from the corner of the mouth to the
zygoma. Then 4-0 nylon sutures are used to anchor the dermis flap to the periosteum in that location.
If ectropion of the lower eyelid is present as well, the end of the flap is rotated medially and passed through the
lower eyelid tunnel, anchoring it lower to the medial canthal tendon and then pulling it laterally to attach it to the
periosteum of the lateral orbital wall on the zygomaticofrontal process. The short flap is pulled upward and
sutured to the periosteum of the inferior orbital margin.
FIGURE 152.3 A: A 28-year-old woman before surgery. B: Same patient 1 year after surgery. The lateral flap
was not rotated to the medial canthal region. (From Wexler et al., ref. 5, with permission.)
FIGURE 152.4 A complication of pilonidal cyst formation in a male patient that had to be excised. (From Wexler
et al., ref. 5, with permission.)
CLINICAL RESULTS
Improvement was noted in all patients, especially after our addition of 3-0 nylon suspension sutures to the
dermis flap (Figs. 152.2 and 152.3). Since then, we have noticed that there is no recurrence of drooping of
the corner of the mouth, and our initial overcorrection is now done more conservatively. We have not

observed flap necrosis with subsequent drop of the oral commissure.
This procedure is not suitable for hairy patients, in whom pilonidal cysts may appear and in whom long-term
infection may persist for 1 to 6 months postoperatively (Fig. 152.4). The technique does not restore
animation to the face, but it does improve the obvious deformity.
SUMMARY
Dermal nasolabial flaps can be used to improve the appearance of patients who have facial paralysis. Such
flaps are good for patients who are not suitable for more extensive nerve-grafting procedures.
References
1. Freeman BS. Facial palsy. In: Converse JM, ed., Reconstructive plastic surgery, 2d ed. Philadelphia: WB
Saunders, 1977;1774-1867.
2. Anderl H. Reconstruction of the face through cross-face nerve transplantation in facial paralysis. In:
Converse JM, ed., Reconstructive plastic surgery, 2d ed. Philadelphia: WB Saunders, 1977;1848-1864.
3. Thompson N. Autogenous muscle grafts in the reconstruction of the paralyzed face. In: Converse JM, ed.,
Reconstructive plastic surgery, 2d ed. Philadelphia: WB Saunders, 1977;1841- 1848.
4. Pitanguy I, Cavalcanti MA, Caland M, Guevara E. Steps for the diagnosis and treatment of peripheric facial
palsy. Rev Bras Cir 1976;66:63.
5. Wexler MR, Kaplan H, Peled I, Rousso M. Nasolabial dermal flaps for lower facial palsy improvement. In:
Bernstein L, ed., Transactions of the Third International Symposium of Plastic and Reconstructive Surgery
of the Head and Neck, Vol. 2. New York: Grune & Stratton, 1981;108.

Chapter 153
Microneurovascular Free Gracilis Muscle Transfer for Facial
Reanimation
K. HARII
H. ASATO
The free gracilis muscle transfer with microneurovascular anastomoses is currently a worthwhile and reliable
procedure, especially in the successful reconstruction of a paralyzed face.
INDICATIONS
Since our clinical introduction of the free gracilis muscle transfer with microneurovascular anastomoses in
1976 (1), this procedure has provided many advantages for successful facial reanimation in long-standing
or established facial paralysis. This procedure is indicated for a complete paralysis without regard to
etiology. It can also be used for incomplete or partial paralysis.
The motor nerve of the gracilis muscle can be sutured to either the ipsilateral facial nerve or the stump of a
previously performed cross-facial nerve graft (2). On some occasions, a branch of the hypoglossal nerve
can be used.
ANATOMY
The gracilis muscle is the most superficially located muscle in the thigh adductor group. It arises from the medial
margin of the lower half of the pubic arch and inserts into the medial surface of the upper end of the tibia. It forms
a flat and narrow muscle belly.
FIGURE 153.1 A: Vascular supply to the gracilis muscle. Arrow A, dominant nutrient vessels. Arrow B, small
additional nutrient vessels. B: Elevated gracilis muscle. Arrow A, pedicle vessels. Arrow N, motor nerve.
The dominant nutrient vessels of the gracilis muscle originate from either the profunda femoris or the medial
circumflex femoral vessels and enter the muscle from its upper third. Although there are a few additional small
nutrient vessels ramifying directly from the femoral vessels to the distal portion of the muscle, the dominant
nutrient vessels alone can nourish the entire muscle belly (Fig. 153.1A).
The motor nerve of the gracilis muscle is derived from the anterior branch of the obturator nerve with the sensory
nerve to the thigh, which separates from the motor nerve at the gracilis hilus and finally terminates at the skin of

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the inner medial thigh. The motor nerve of the gracilis muscle is accompanied by the dominant nutrient vessels
and can easily be identified between the adductor longus and brevis muscles (Fig. 153.1B).
OPERATIVE TECHNIQUE
Isolation of the Muscle
An incision approximately 10 cm long is placed along the posterior border of the adductor muscle. After
separation of the fascia over the adductor longus and gracilis muscles, the dominant nutrient pedicle of the
gracilis is normally identified
between the adductor longus and brevis muscles. Blunt careful finger dissection around the muscles can easily
expose the pedicle vessels and nerve without injury.
FIGURE 153.2 A: A 25-year-old woman with complete paralysis of the left lower face after multiple ablative
procedures for a large lymphangioma of the left cheek. Preoperative view. B: A gracilis muscle transplanted
beneath the undermined cheek skin, with suturing of its motor nerve to a stump of the facial nerve severed in the
previous ablative surgery. Arrow G, Gracilis muscle; A, site of vessel anastomoses; N, site of nerve suture C:
One-and-a-half years postoperatively. Good contraction of the transplanted muscle upon smiling is obtained.
Following exposure of the pedicle vessels and the accompanying motor nerve, the distal part of the muscle is
bluntly dissected. The pedicle vessels and nerve should be extensively dissected toward their origin to obtain as
long and large a pedicle as possible. Finally, a muscle belly of the required size is harvested. A proximate linear
cutter (Ethicon Co.) is useful to cut the muscle belly. It can simultaneously achieve hemostasis and creation of a
rigid muscle stump by its staplers. This facilitates a secure fixation of the muscle stump to the subcutaneous
tissues of the face upon transplantation.
One-Stage Reconstruction
In cases of facial paralysis such as those following excision of buccal or parotid tumors (including a facial nerve
or a major portion of the mimetic muscles), the transected facial nerve stump is usually available as a motor
source in the recipient paralyzed cheek. An acquired contraction of the transferred muscle, innervated with the
ipsilateral facial nerve, can be quite natural.
Through a preauricular incision in the affected cheek, a cheek flap is raised, and suitable vessels and the facial
nerve stump are exposed first. Usually, either the superficial temporal artery and vein or the facial artery and vein
are available for the recipient vessels. The facial nerve stump is simultaneously exposed at its transected site. It
is further dissected proximally to obtain a healthy stump. The facial nerve canal in the temporal bone can be

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opened to acquire a suitable nerve stump.
The cheek then is widely undermined to accept the subsequent muscle transfer. Subcutaneous soft tissue over
the zygoma should be partly excised to avoid bulkiness after fixing the muscle in this region.
Simultaneously with the preparation of the recipient cheek, the gracilis muscle is harvested by a second
operating team. The harvested muscle is finally transferred to the recipient cheek, and the neurovascular
anastomoses are performed under an operating microscope. After revascularization and neurorrhaphy of the
muscle, the two ends of the muscle are fixed to the zygoma and the nasolabial region under proper tension (Fig.
153.2).
Two-Stage Operation
In many cases with long-standing paralysis, the facial nerve stump is not available in the paralyzed cheek (3). A
new facial nerve stump, created by a cross-facial nerve graft from the intact facial nerve branch, has great
potential for reinnervation of the transferred muscle, thereby obtaining a natural or near-natural facial animation.
The operative procedure is performed in two stages. In the first stage, through a 2-cm vertical incision at the
anterior margin of the parotid gland, as many buccal and zygomatic branches as possible are exposed after their
emergence from the anterior border of the parotid gland. A long sural nerve graft approximately 20 cm long and
harvested by the second team is placed subcutaneously from the intact cheek to the affected cheek. Endoscopic
harvest of the sural nerve can leave a minimal scar.
Usually, the sural nerve graft is reversed. The distal stump of the nerve graft, placed close to the exposed facial
nerve branches at the intact cheek, is sutured to selected funiculi in the facial nerve branches. The proximal
stump is passed through either the upper lip or the chin and anchored subcutaneously close to the suitable
vessels expected to be used as recipient vessels in the second-stage operation.
In the second stage, about 8 to 10 months after the first-stage operation or 1 to 2 months after a Tinel's sign has
advanced to the grafted nerve stump in the affected cheek, a cheek flap is elevated, and the cross-facial nerve
stump and the recipient vessels are exposed. The gracilis muscle then is transferred with microneurovascular
anastomoses (Fig. 153.3).

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FIGURE 153.3 A: A 34-year-old woman with long-standing complete paralysis of her left face. In the first stage of
reconstruction, a sural nerve graft was crossed from the right intact facial nerve branches to the affected cheek.
A temporal muscle sling transposition to the left eyelid was undertaken. Preoperative view. B: In the second-
stage operation, 10 months later, a cheek skin undermining through a preauricular incision was achieved,
exposing both the recipient superficial temporal vessels and the distal stump of the cross-facial sural nerve graft.
C: Gracilis muscle segment. A, dominant nutrient vessels; N, motor nerve. D: Gracilis muscle set in place; note
creation of nasolabial fold. Microneurovascular anastomoses were performed. E: Two-year postoperative view
upon smiling, which corresponds well to contralateral facial animation. F: Electromyogram showing good action
potentials at postoperative follow-up 15 months later. G: Low evoked potentials on stimulation to the
contralateral facial nerve trunk were recorded from the transplanted muscle at the 10th postoperative month.
Evoked potentials then became higher and the distal latency shortened when muscle neurotization became
complete.

SUMMARY
The paralyzed face can be reanimated successfully with a free gracilis muscle graft. Microneurovascular
anastomoses can be performed to the recipient vessels and the nerve, which is either the ipsilateral facial
nerve, if available, or the stump of a previously performed cross-facial nerve graft. Innervation to the grafted
muscle will usually occur between 8 to 10 months postoperatively. The muscle contractile power will then
increase and on average, reach its maximum at two years postoperatively.
References
1. Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation with microneurovascular anastomoses for
the treatment of facial paralysis. Plast Reconstr Surg 1976;57:133-143.
2. Harii K. Microneurovascular free muscle transplantation. In: Rubin LR, ed. The paralyzed face. St. Louis:
Mosby-Year Book, 1991.
3. Harii K. Refined microneurovascular free muscle transplantation for reanimation of paralyzed face.
Microsurgery 1988;9:169-176.

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Chapter 154
Microvascular Free Transfer of A Partial Gracilis Muscle to The
Face
R. M. ZUKER
EDITORIAL COMMENT
This is an elegant modification of the use of the free gracilis muscle for restoration of the paralyzed face. It
allows a sufficient amount of muscle to be transferred to the face and avoids some of the bulkiness that was
associated with the transfer of the entire muscle.
The use of a portion of the gracilis muscle is particularly well suited for facial reanimation. The desired length of
muscle can be harvested with a percentage of muscle circumference as long as great care is taken to maintain
the integrity of the pedicle (1, 2). Excess bulk can be avoided (3), and a reliable, innervated flap of the required
dimensions can be obtained.
INDICATIONS
Indications for facial reanimation using innervated muscle flaps relate to the extent of the paralysis, the age
of the patient, and the patient's needs and desires. A significant degree of facial paralysis, with inability to
elevate the commissure and upper lip, warrants consideration for reconstruction. Although possible in older
age groups, I believe that reinnervation of a transferred muscle, particularly through cross-face nerve grafts,
begins to lose its effectiveness in the sixth and seventh decades of life. Some patients require a rapid,
static, alteration and would not benefit from the time-consuming cross-face nerve graft/free muscle transfer.
Other patients may be quite well adjusted to their condition and not wish to undergo any surgical
reconstruction. Thus, it is crucial to present what is possible and what is not possible to the patient.
Elevation of the commissure and upper lip is usually an attainable goal (4). The direction of movement can
be adjusted to match the normal side; however, perfect symmetry is never achieved. This procedure
addresses only elevation of the commissure and upper lip and does not reconstruct the multitude of other
fine movements of the face associated with smiling.
There are three situations that can be addressed by muscle transfer in facial paralysis, depending on the
availability of a motor nerve (5). If the stump of the ipsilateral facial nerve is available, as may follow tumor
excision, this stump can be used
directly to innervate the transferred gracilis. The second situation is a unilateral facial paralysis where there
is no ipsilateral facial nerve; for example, a case following acoustic neuroma surgery where the seventh
nerve is nonfunctional at the intracranial level. In this case, a portion of nerve activity from the normal side
can be transferred across the face through a cross-face nerve graft. This involves a preauricular incision
with dissection of the normal nerve. The specific branches that go to the zygomatics major and minor are
identified, and a portion of these can be taken for anastomosis to the nerve graft. The sural nerve graft is
tunneled across the face through incisions in the nasal floor and preauricular region; after nerve repair on
the normal side, it is banked in the preauricular area of the paralyzed side. One year later, this banked
stump of the sural nerve can be used to innervate the transferred partial gracilis.

A third situation is when there is no facial nerve available bilaterally, as occurs in congenital conditions such
as Mobius syndrome and also occasionally in patients with bilateral acoustic neuromata. In this situation, a
partial gracilis transfer can be used to provide elevation of the commissure and upper lip, but it must be
innervated by a regional motor nerve. Available motor nerves include the fifth, the eleventh, and the twelfth.
I have found the motor branch to the masseter (V) to be extremely useful in this situation.
The advantages of the partial gracilis are numerous. The neurovascular pedicle is reliable and the flap can
be easily harvested. The partial gracilis can be specifically designed and sculpted to meet specific
requirements for variability of length and width. The bulkiness of the transfer is minimized by using only a
partial segment of the muscle. Finally, there is virtually no donor-site morbidity except for the scar in the
upper medial portion of the thigh and minimal early postoperative discomfort.
ANATOMY
The basic anatomy of the gracilis muscle is adequately described elsewhere in this volume (see Chapter 342).
The muscle is identified and isolated, and the neurovascular pedicle is carefully dissected. The muscle remains
on its vascular pedicle until it has been fully prepared and is ready for transfer, as described subsequently.
FLAP DESIGN AND DIMENSIONS
The required length of muscle then is assessed. The muscle will originate from the zygomatic arch and temporal
fascia and will insert into preplaced sutures that have been sited carefully to replicate the activity on the normal
side. Generally, four such sutures are used. One is into the lower lip, the second is into the modiolus, the third is
into the more lateral portion of the upper lip, and the fourth is into the midportion of the upper lip. These four
sutures are securely anchored; they will be used to maintain insertion of the muscle flap into place.
The functional length of the muscle is measured from the modiolus to the most lateral portion of the zygomatic
arch. The obliquity of the muscle can be adjusted by altering the position of the origin to match the normal side.
To provide sufficient muscle tissue for suturing, 1-cm length is added at each end. Thus, if the functional length
required is 9 cm, 11 cm of muscle would be harvested.
The volume of the muscle is assessed in the thigh; usually, about 40% to 50% of the circumference of the
muscle is sufficient. This volume is determined by the size of the gracilis in the thigh, the location of the
neurovascular pedicle, and the innervation pattern, as will be described.
OPERATIVE TECHNIQUE
With a nasotracheal tube in the contralateral side, the involved side is prepared and the operative field extended
to include the entire mouth, chin, and neck region. The ipsilateral thigh is generally used, and the limb is
prepared to at least below the knee and draped free. The facial dissection begins with a preauricular incision
and a submandibular extension. The cheek is elevated above the level of the submuscular aponeurotic system
(SMAS). Appropriate anchoring sutures are placed into the lower lip, modiolus, and upper lip, as described
above. The site of origin of the muscle is prepared on the zygomatic arch and temporal fascia. The recipient
vessels then are dissected free; these are usually the facial artery and vein. They are traced upward, divided,
and then reflected posteriorly, where they will lie in an excellent position for anastomosis to the vessels of the
gracilis. Last, the motor nerve that will power the muscle is found.
If there is an ipsilateral branch of the facial nerve, a standard facial nerve dissection is necessary. If innervation
is to be by a cross-facial nerve graft, the graft generally is found quite easily and traced a sufficient distance to
be reflected downward to provide for a tensionless nerve repair. If the motor nerve to the masseter is to be used,
it is found on the undersurface of the masseter muscle. The masseter is reflected downward from the zygomatic

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arch and the nerve coursing transversely and then entering the deep surface of the masseter is found. It is
traced into the muscle, divided, and reflected upward so that it lies at the level of the zygomatic arch and
provides ease in repair.
The muscle is dissected simultaneously. A segment of muscle is freed circumferentially, and the neurovascular
pedicle is dissected fully. The single artery and paired veins are dissected back to their origin so that the longest
possible pedicle is obtained. The nerve is also dissected proximally as it courses upward and anteriorly,
bisecting the 90-degree angle of muscle and the vascular pedicle. Depending on the length of nerve required, it
can be traced all the way to the inguinal ligament. Then it is divided proximally and reflected downward so that
each of its fascicles can be evaluated and stimulated individually. The muscle itself is freed circumferentially
above and below the pedicle so that the required length can be removed easily. In general, the pedicle should lie
at about the midportion of the selected segment of muscle so that adequate vascularity is assured on both ends.
The width is assessed, and the segment of muscle that will be harvested is determined. Usually, 40% to 50% of
the muscle circumference is required, as this provides a healthy strip of about 2 cm in width without excessive
bulk.
A nerve stimulator is used to stimulate each of the fascicles at the site of division. The muscle is observed for
segmental contraction so that if only a single fascicle is available for innervation, the appropriate fascicle in the
motor nerve to the gracilis can be determined.
The location of the pedicle relative to the entire muscle in an anterior/posterior plane then is assessed. Usually,
the anterior 40% of the muscle can be taken, preserving the vascular pedicle. Evaluation of the muscle includes
determination of the natural cleavage plane. This plane is dissected, with division of the nerves and vessels
going to the more inferior portion, which will not be used. During this segment of the dissection, great care must
be taken not to damage the main pedicle.
FIGURE 154.1 Schematic diagram of a selected segment of gracilis muscle.
The required length of muscle is separated from the posterior segment, which will be left behind. The required
length is measured with the hip in abduction and the knee in extension. In this way, the segment of muscle that
will be taken is in a stretched position. If 11 cm is required, then 5.5 cm is taken on either side of the pedicle (Fig.
154.1). The muscle then is divided on either end and thus remains attached only by its vascular pedicle.
After the muscle segment has been isolated and divided, the end that will insert into the commissure and lips is
prepared. A small central wedge of about 0.5 cm of muscle tissue is removed from this end, and the outer

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components are sutured together with mattress sutures and carried out along the free edge of the muscle. They
will function as anchors or the insertion sutures that have been placed in the lower lip, modiolus, and upper lip.
Muscle preparation is now complete and, after the circulatory status has been assured, the muscle can be
removed and transferred (Fig. 154.2). The vascular pedicle of the partial gracilis is divided and the donor site
closed in layers. The muscle is transferred to the face, where the insertion sutures are placed just proximal to the
anchorage mattress sutures that were previously inserted. The muscle then is drawn beneath the cheek flap
toward the mouth, and the sutures are tied sequentially. The muscle is stretched to its normal resting length and
then tacked to its site of origin with mattress sutures. Tension is such that it just barely pulls on the modiolus.
Measurements will show that this is the maximal resting extended length. The muscle is anchored securely to the
zygomatic arch and temporal fascia. It is spread over the fascia to avoid any excessive bulk in this region.
FIGURE 154.2 Partial gracilis muscle prepared and ready for insertion into face.
Then the microvascular repairs are carried out. First, the larger vena comitans of the partial gracilis is sutured to
the facial vein end-to-end. The artery to the partial gracilis then is anastomosed to the facial artery, again in an
end-to-end fashion. Once the circulation has been reestablished, the nerve repair is carried out (Fig. 154.3). This
is a crucial part
of the procedure and must be done with extreme precision. The stump of the facial nerve, the cross-facial nerve
graft, or the motor nerve to the masseter is sutured to the motor nerve of the gracilis. This repair is done without
tension under high magnification, with appropriate fascicles accurately aligned. The wound then is closed in
layers, with a Penrose drain below the earlobe. No suction drains are used.
FIGURE 154.3 Partial gracilis muscle in the face with microvascular and microneural repairs.

FIGURE 154.4 Unilateral congenital facial paralysis. A: Preoperative: smiling. B: Postoperative: at rest. C:
Postoperative: smiling. (From Zuker, ref. 5, with permission.)
The muscle begins to function about 2 to 3 months after the transfer if a direct nerve repair has been carried out.
If a cross-facial nerve graft has been used, reinnervation is somewhat slower and may not occur until 4 to 5
months. Once reinnervation begins however, simple exercises are used to increase excursion of the muscle and
to achieve symmetry. In bilateral cases, the second side is done 3 to 6 months after the first side.
CLINICAL RESULTS
Results of the procedure have been quite satisfactory. The degree of excursion produced by the gracilis
seems to be adequate, especially in cases where direct nerve repairs are carried out. In congenital facial
paralysis, there is often some activity around the eye or in the paranasal region. The main deficit appears to
be in elevation of the corner of the mouth and upper lip. In this situation, a cross-facial nerve graft, followed
by a partial gracilis transfer, provides an acceptable reconstruction (Fig. 154.4). I have also been pleased
with the results of the reconstruction that can be achieved in bilateral conditions, such as Mobius syndrome.
This procedure allows one to tailor the size of the muscle to the dimensions required, thus avoiding
excessive bulk. It also allows the surgeon to place the muscle in the exact location that will produce the
required movement. Thus, the muscle can be placed to provide symmetrical motion with the normal side. In
unilateral cases, the appropriate nerve (seventh nerve) can be used to innervate the muscle, thus achieving
synchronous and spontaneous activity.
SUMMARY
The gracilis muscle can be sculpted to provide the exact length required with minimal bulk. It has been
successfully used in facial reanimation for congenital or acquired conditions, whether unilateral or bilateral.
Appropriate positioning of the muscle is possible, and adequate excursion can be achieved. By using only a
portion of the muscle, the problem of excess bulk is avoided.
References
1. Manktelow RT, Zuker RM. Muscle transplantation by fascicular territory. Plast Reconstr Surg

1984;73:751.
2. Manktelow RT. Microvascular reconstruction: anatomy, applications and surgical techniques. Facial
paralysis reconstruction. Heidelberg: Springer Verlag, 1986;128.
3. Zuker RM. Facial reanimation: Cross-face nerve grafting and muscle transplantation. In: Cohen M, ed.
Mastery of plastic and reconstructive surgery. Facial reanimation, cross face nerve grafting and muscle
transplantation; Vol. 1, Boston: Little, Brown, 1994. Chap. 58.
4. Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation with microvascular anastomoses for the
treatment of facial paralysis. Plast Reconstr Surg 1976;57:133.
5. Zuker RM. Facial paralysis in children. Clin Plast Surg 1990;17:95.
6. Zuker RM, Manktelow RT. A smile for the Mobius syndrome patient. Ann Plast Surg 1989;22:188.

Chapter 155
Microneurovascular Free Transfer of The Serratus Anterior Muscle
J. C. GROTTING
The serratus anterior muscle is a small, thin muscle that can be used as a free vascularized transfer for cover or
function, especially in the hand, foot, and face (1, 2, 3). It has a predictable anatomic configuration and blood
supply. As long as its upper portion is kept intact, the use of the lower one to three slips in reconstruction has
little, if any, effect on normal function.
INDICATIONS
The serratus anterior muscle has been most useful in situations where a small, relatively thin, and
potentially functional muscle is needed. As a free transfer, one or two slips are ideal for use in the hand or
foot (4). The segmental organization allows careful axial division between slips for placement of portions of
the muscle into various locations within a wound. Reanimation in facial paralysis requires three slips. In
most cases, a cross-facial nerve graft is performed as a first stage. When axonal growth has advanced
across the face, the lower three slips of the serratus can be inserted for functional replacement of the
paralyzed muscle units (Fig. 155.1). With the muscle turned over, the neurovascular repairs are protected
and only a short pedicle is required.
ANATOMY
The serratus anterior muscle is a broad, flat muscle that forms the medial wall of the axilla. Its dual blood supply
and unique organization into separate slips that originate from each of the first nine ribs make it ideal for
segmental transfer of only the lower three to four slips, thereby preserving muscle function (Fig. 155.2). The
lateral thoracic artery vascularizes the upper four or five slips, whereas the lower portion is consistently supplied
by a large branch of the thoracodorsal artery. This vessel enters the serratus in its posterior third and gives off
segmental branches to each of the lower five slips (Fig. 155.3), each branch accompanied by a corresponding
vein and a twig of the long thoracic nerve. The most inferior three slips are particularly suitable for use as a free
muscle transfer and will have a long pedicle if the serratus branch is dissected back to include the subscapular-
thoracodorsal axis (Fig. 155.4).
The serratus anterior stabilizes the scapula by its broad insertion along the medial and inferior border. It is
innervated by the long thoracic nerve that arises from C5, C6, and C7 and travels inferiorly along the serratus
fascia, joining with the serratus branch of the thoracodorsal artery at about the level of the sixth slip (Fig. 155.3).
Loss of the long thoracic nerve will cause winging of the scapula, a complication that can be avoided by
separating the discrete fascicles of the long thoracic nerve to only the lower three slips. The proximal serratus
innervation must be preserved to maintain the muscle as a functional unit. With magnification, the long thoracic
nerve can be split into fascicular groups to the level of the axillary vein, but this tedious exercise probably puts
the proximal nerve at unnecessary risk of injury. Therefore, it is better to use a shorter nerve segment and to
interpose a nerve graft at the recipient site if a long nerve pedicle is needed. Removal of the lowest three slips of
the serratus will not result in winging of the scapula as long as the proximal muscle retains its innervation.

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FIGURE 155.1 The serratus can be used for reanimation in facial paralysis. The muscle is innervated and split
into slips, as illustrated, to restore segmental motion. The long thoracic nerve segment is kept short and is
anastomosed to a previously placed cross-facial nerve graft.
FIGURE 155.2 A cadaver dissection of the serratus anterior muscle illustrates its organization into separate slips.
(In this case, ten are present; usually only nine are found.)
Because the blood supply to the lower portion of the serratus anterior arises from the subscapular-thoracodorsal
axis, a long vascular pedicle can be obtained by dividing the thoracodorsal branch to the latissimus dorsi and
continuing the dissection superiorly, taking the subscapular artery off at its origin from the third portion of the
subclavian artery. A 15-cm pedicle can be obtained by this technique, but if a long pedicle is not needed, the
serratus branch from the thoracodorsal artery is usually large enough for a technically straightforward
microvascular anastomosis, thereby preserving the major blood supply to the latissimus dorsi.
Although the proximal serratus anterior has a broad insertion along the medial border of the scapula, the
seventh, eighth, and ninth slips tend to merge and overlap each other, inserting at the inferior pole by means of a
short tendinous attachment. The latissimus dorsi must be raised off the lower pole of the scapula to facilitate this
portion of the dissection.

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FIGURE 155.3 The upper five slips of the serratus anterior receive their blood supply from the lateral thoracic
artery. The lower three to four slips are consistently supplied by a large branch of the thoracodorsal artery. The
long thoracic nerve lies on the serratus fascia anterior to this large branch.
OPERATIVE TECHNIQUE
The serratus anterior is most easily dissected with the patient in either the full-lateral or half-lateral position. The
tip of the scapula must be accessible and the arm prepped free, as in the latissimus dissection. The incision is
planned 3 to 4 cm anterior to the posterior axillary fold formed by the latissimus muscle. I have found it useful to
curve the incision anteriorly over the eighth rib to allow access to the origin of the muscle
(Fig. 155.5). The incision is deepened to the deep fascia, and the anterior edge of the latissimus is identified.
FIGURE 155.4 The lowest three slips of the serratus can be taken as a free, potentially functional muscle flap
without producing winging of the scapula. The segmental nature of the blood supply and innervation to each slip
is illustrated.
Dissection of the posterior skin flap off the anterior latissimus fold to below the ninth rib will help identify the
important landmarks. The latissimus and serratus muscles are easily separated superiorly because the serratus

muscle passes deep to the latissimus. Inferiorly, however, the fibers of the two muscles interdigitate and must be
separated sharply. As the latissimus is dissected from the underlying serratus, the thoracodorsal artery and vein
soon will come into view. The branch to the lower slips of the serratus anterior then can be identified and must
be carefully protected.
The long thoracic nerve is always located anterior to the serratus branch and runs over the surface of the
muscle, joining the artery and vein at about the sixth slip. The dissection of these structures should be left until
after the entire outer surface of the lowest slips have been exposed. The long thoracic nerve can be densely
adherent to the serratus fascia.
The fascia below the ninth slip is sharply incised, mobilizing the inferior border of the serratus from its origin
along the ribs to the scapular tip. The plane between the chest wall and the serratus is avascular and can be
developed easily with the gloved hand. From the undersurface of the serratus, the slips can be palpated and the
true division between them identified. Using a hand behind the muscle as a guide, the fascia between the sixth
and seventh slips can be incised, staying well in front of the neurovascular pedicle. Posterior to the
neurovascular pedicle, the division between slips is less distinct and must be sharply divided.
If the serratus is being used for function, the length of the muscle should be measured and markers placed every
5 cm before dividing the origin and insertion. This allows careful reapproximation of the resting length after
transfer, an important consideration in restoring its ability to perform work.
The neurovascular pedicle is isolated next. If the lowest three serratus slips are to be used, the small branches
that enter slips 5 and 6 must be carefully divided between fine ligatures to gain pedicle length. If these tiny
branches are overlooked, accidental avulsion and injury to the main vessels may be precipitated. The branches
from the long thoracic nerve to the upper serratus slips must be separated from the fascicles continuing into the
flap if neural repair is anticipated. Otherwise, the nerve may be divided distal to its last branch to the sixth slip.
Intraneural dissection can be accomplished quite far proximally if performed with care under loupe magnification.
A 3- to 5-cm nerve pedicle is usually all that is necessary when using the serratus for facial reanimation. If a long
nerve pedicle is required, an interpositional nerve graft will place the proximal long thoracic nerve at less risk of
inadvertent division. The vascular pedicle can be extended to 15 cm by continuing the dissection to the level of
the axillary vein. The origin and insertion of the serratus are divided sharply. Intercostal perforators that are
encountered must be ligated. The lowest slip often interdigitates with the fibers of the external oblique muscle.
The insertions of the lowest three slips seem to wrap around the tip of the scapula and attach to it by a very
short tendon that also will bleed when divided. When the muscle is to be used as a free transfer, it should be
allowed to perfuse on its dissected pedicle for 10 to 20 minutes before division and transfer.
Because the perforating intercostal vessels communicate with the serratus branch from the thoracodorsal
system, the serratus muscle may support an osseous component consisting of the underlying one or two ribs
(see Chapter 211). The muscle also can be taken with a skin island.
SUMMARY
The serratus anterior muscle flap can be transferred as a free flap. It is particularly applicable for facial
reanimation, as three or more slips can be used separately.

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FIGURE 155.5 The incision is planned just anterior to the latissimus dorsi fold and is extended forward
along the eighth rib. This allows access for both the origin and insertion of the serratus anterior muscle.
References
1. Buncke HJ, Alpert BS, Gordon L, Evans HB, eds. Atlas of clinical reconstructive microsurgery.
Philadelphia: Lea and Febiger, 1986.
2. Buncke HJ, Alpert BS, Gordon L, et al. The serratus anterior muscle for unilateral facial paralysis. In:
Buncke HJ, Gordon L, Alpert BS, eds. Atlas of clinical reconstructive microsurgery. Philadelphia: Lea and
Febiger, 1986.
3. Takayanagi S, Tsukie T. Free serratus anterior muscle and myocutaneous flaps. Ann Plast Surg
1982;8:277.
4. Gordon L, Rosen J, Alpert BS, Buncke HJ. Free microvascular transfer of second toe ray and serratus
anterior muscle for management of thumb loss at the carpometacarpal joint level. J Hand Surg 1984;9:642.

Chapter 156
Microneurovascular Free Transfer of Extensor Digitorum Brevis
Muscle for Facial Reanimation
V. K. RAO
J. A. BUTLER
Because of its size, several bellies, and long neurovascular pedicle, the extensor digitorum brevis muscle
seemed ideally suited for use in facial reanimation; however, results have been unpredictable (1, 2, 3, 4, 5).
Currently, use of this muscle in facial reanimation has been superseded by gracilis (6, 7) (see Chapter 153) and
pectoralis minor transfer (8) (see Chapter 157) because of the larger size and greater power of these muscles.
INDICATIONS
Surgical attempts to reanimate the paralyzed face have been more notable for their failures than for their
successes. The use of fascial slings (9), hypoglossal nerve transposition (10), masseter and temporalis
muscle (11), primary nerve repair (12), cross-face grafting (13), and the free vascularized transfer of
extensor digitorum brevis (4), latissimus dorsi, gracilis (6, 14), and pectoralis minor muscles (8) testifies to
the challenge of facial reanimation.
Any attempt at microneurovascular transfer of muscles for facial reanimation should be postponed until
attempts to repair the facial nerve, either with direct approximation or interpositional nerve grafts, have
failed or have been rejected as inappropriate. Facial paralysis that has persisted for longer than 6 months is
best treated with microneurovascular transfer of muscles; this technique does not result in the mass
movements associated with some reinnervation techniques, and it prevents the distorted facial movements
that follow local muscle rotation.
Contraindications for microneurovascular muscle transfer in patients with facial paralysis include (a)
excessive operative risks, (b) peripheral neuropathy, and (c) peripheral vascular disease.
ANATOMY
The extensor digitorum brevis muscle has four bellies with distal tendons; it is about 5 cm wide, 8 cm long, and 1
cm thick; and it is located on the dorsum of the foot (Fig. 156.1). Its origin is the lateral and superior aspect of the
calcaneus. Its insertion is the lateral aspect of the extensor hallucis longus and extensor digitorum longus, which
serve the second through fourth toes at the level of the proximal phalanx. It also may insert on the proximal
phalanx of the big toe.
The arterial supply is the anterior tibial artery by means of the lateral tarsal branches of the dorsalis pedis artery;
venae comitantes provide venous drainage.
The muscle is innervated from the L5 and sometimes the S1 roots. The deep peroneal (anterior tibial) nerve runs
midway between the malleoli and provides motor innervation to the extensor digitorum brevis by means of the
lateral tarsal branches. The deep peroneal nerve then continues distally to provide sensory innervation to the
region of the first web space.
OPERATIVE TECHNIQUE
When used for facial reanimation, the extensor digitorum brevis muscle is used alone without overlying skin. The

contralateral muscle provides a preferable neurovascular pedicle orientation. In most cases, motor innervation
must be obtained with a nerve graft, either from the involved side proximal to the lesion or by means of a cross-
face graft using innervation from branches of the facial nerve on the nonparalyzed side from a sural nerve graft.
FIGURE 156.1 Anatomy of the extensor digitorum brevis muscle.
Sural Nerve Graft
The sural nerve provides sensory innervation of the posterolateral ankle and the lateral aspect of the foot. The
contralateral leg is prepared after placement of a pneumatic tourniquet. The nerve is removed through a series of
transverse incisions, beginning distally at the midpoint of the Achilles tendon and the lateral malleolus (Fig.
156.2). The wounds are closed with simple monofilament sutures after the proximal portion of the nerve is buried
in muscle to minimize the possibility of neuroma.
Facial Nerve Grafting
The facial nerve on the unaffected side is exposed by means of a preauricular incision. A nerve stimulator is
used to locate the nerve and to identify branches that innervate the zygomatic and orbicularis oris muscles.
Three or four of these facial nerve branches are sectioned and anastomosed to the sural graft, which has been
split into a similar number of branches.
The nerve then is extended through a subcutaneous tunnel in the upper lip and secured in a subcutaneous
pocket created on the paralyzed side. The location of the nerve end is recorded and surgically marked with a
permanent suture. Nerve ingrowth is then allowed to occur over the next 6 to 9 months.
Harvest of the Extensor Digitorum Brevis
The muscle is exposed through a longitudinal incision just lateral to the neurovascular bundle and extending
toward the second toe. Superior and inferior lateral extensions provide a wide exposure of the origin of the
extensor digitorum brevis. The anterior tibial and dorsalis pedis vascular pedicle then is dissected. Occasionally,
it is necessary to transect the extensor retinaculum with a more proximal dissection of the anterior tibial vessels
and nerve.

FIGURE 156.2 Diagram of removal of the sural nerve.
The tendinous insertions of the extensor digitorum brevis into the extensor hallucis and extensor digitorum of the
second, third, and fourth toes are next identified. These tendons can be transected through small, individual
incisions over the proximal phalanx of each toe. The tendons then are retracted into the wound and used to
provide gentle traction during the remaining dissection.
The dissection then proceeds to identification of the dorsalis pedis artery, which lies beneath the distal aspect of
the retinaculum of the ankle between the extensor hallucis longus and extensor digitorum longus tendons. The
nerve is dissected beyond the lateral branches supplying motor function to the extensor digitorum brevis and
then transected.
The dissection proceeds proximally toward the origin of the muscle (the overlying peroneus tertius is preserved).
The muscle is removed from its origin at the periosteal level. Small perforating arteries to the lateral portion of the
muscle must be cauterized.
Before the pedicle is transected, the tourniquet is deflated so that the perfusion of the muscle can be assessed.
If perfusion is satisfactory, the vascular pedicle is transected between ligatures. The dorsum of the foot then is
inspected, and hemostasis is evaluated. A subcutaneous suction drain is placed, and the flaps are closed. A
gentle compression dressing is applied and left in place for several days.
Transfer of Extensor Digitorum Brevis
A preauricular incision on the paralyzed side of the face is used to gain access to the end of the sural nerve graft
(Fig. 156.3). The neuroma at the end of the graft is resected.
The subcutaneous pocket is enlarged to accept the extensor digitorum brevis muscle, and the dissection
proceeds into the upper and lower lips. The muscle is secured to the zygomatic arch on the paralyzed side using
nonabsorbable sutures. Two tendons are used to traverse the upper lip, and two are used to traverse the lower
lip. Incisions in the upper and lower lips on the nonparalyzed side allow access to the subcutaneous plane,
where tendons from above and below are approximated with permanent sutures and fixed to the dermis.
When used for eyelid closure, the tendons are sutured into the dermis at the medial corner of the upper and
lower eyelids. Tension on the tendons should provide a slight overcorrection. Marking the commissures,
nasolabial folds, and midline preoperatively helps maintain symmetry. Microsurgical arterial and venous
anastomoses are performed either to the facial vessels or to the superficial temporal vessels. Next the motor
nerve to the muscle is anastomosed to the sural nerve graft. Drains are inserted, the wounds are closed, and a

gentle compression dressing is applied.
No facial movement should be expected for about the first 3 months postoperatively, but improvement can
continue for as long as 12 months.
CLINICAL RESULTS
The extensor digitorum brevis has been variously used to treat facial paralysis. In 1971, earlier attempts at
nonvascularized transfer of skeletal muscle were summarized (1), showing that, in general, such transfers
produced a fibrotic conversion of the muscle but that prior denervation does allow successful free transfer.
In a later study (2), a review was done of 103 cases in which the extensor digitorum brevis was used to
reanimate either the eyelid or the mouth in 79 patients. In 66 of these cases, the muscle was transplanted to
the temporalis or orbicularis oculi to provide muscular neurotization for eyelid closure. In 14 of the 79
patients, the muscle was transplanted to replace orbicularis oris function. This study suggested that free
(nonvascularized) transplants of extensor digitorum brevis produced good long-term results in 90% of
patients in whom the muscle was used to restore mouth function, but good results in only 50% of patients in
whom it was used to obtain eye closure.
FIGURE 156.3 Diagram of transfer of the extensor digitorum brevis to the face (facial vessels used in this
case).
In 12 patients, a free transfer of extensor digitorum brevis muscle was used, but the anterior tibial nerve was
tunneled within the upper lip, thus allowing a microscopic anastomosis to the funiculi on the nonparalyzed
side. After 6 months of observation, there was evidence of function in six patients.
Microsurgery provided new methods for using the extensor digitorum brevis, namely, transferring the muscle
with microneurovascular anastomoses. In an early case, the descendens hypoglossi was used instead of
the opposite facial nerve; in a second case, the muscle was not successfully vascularized. In both cases,
the only benefit was a static sling. Subsequent attempts (3, 5) with microneurovascular transfer of the
extensor digitorum brevis gave unpredictable results.
Why does the extensor digitorum brevis not work well for complete facial reanimation? There are several
possibilities: (a) the small initial size of the muscle, (b) restricted motion resulting from extrinsic and intrinsic
scarring, (c) incomplete muscular reinnervation, (d) an abnormal tensioning of the muscle, and (e) innate
loss of power. Loss of power alone probably militates against any predictable use of the muscle for facial
reanimation (15). Even in muscle transferred with microneurovascular techniques, the resulting power is
only 25% of the in situ value. This loss of power, combined with the increased workload due to decreased
compliance in the scarred cheek, may overload the transplanted extensor digitorum brevis muscle and make
for unpredictable surgical results.

SUMMARY
The microneurovascular free transfer of the extensor digitorum brevis muscle does not appear to provide
enough power to reanimate the completely paralyzed face; however, it can be used for limited reanimation
of the paralyzed face, such as the restoration of eye closure in selected patients. It also can be used to
reanimate the orbicularis oris in patients with normal eye closure.
References
1. Thompson N. Autogenous free grafts of skeletal muscle: A preliminary experimental and clinical study.
Plast Reconstr Surg 1971;48:11.
2. Thompson N, Gustayson EH. The use of neuromuscular free autografts with microneural anastomosis to
restore elevation to the paralyzed angle of the mouth in cases of unilateral facial paralysis. Chir Plast (Berl)
1976;3:165.
3. O'Brien BM. The Henry Windsor lecture: II. The contributions of microvascular surgery to medicine. Aust N
Z J Surg 1979;49:403.
4. O'Brien BM. Microvascular free muscle transfer. In: O'Brien BM, ed. Microvascular reconstructive surgery.
Edinburgh: Churchill-Livingstone, 1977; Chap. 15.
5. O'Brien BM, Franklin JD, Morrison WA. Cross-facial nerve grafts and microneurovascular free muscle
transfer for long-established facial palsy. Br J Plast Surg 1980;33:202.
6. Harii R, Ohmori K, Torii S. Free gracilis muscle transplantation with microneurovascular anastomosis for
the treatment of facial paralysis. Plast Reconstr Surg 1976;57:133.
7. Harii K. Microneurovascular free muscle transplantation for reanimation of facial paralysis. Clin Plast Surg
1979;6:367.
8. Harrison DH. The pectoralis minor vascularized muscle graft for the treatment of unilateral facial palsy.
Plast Reconstr Surg 1985;75:206.
9. Gillies H. Experiences with fasciae latae grafts in the operative treatment of facial paralysis. Proc R Soc
Lond 1934;27:127.
10. Conley J, Baker DC. Hypoglossal-facial nerve anastomosis for reinnervation of the paralyzed face. Plast
Reconstr Surg 1979;63:62.
11. Baker DC, Conley J. Regional muscle transposition for rehabilitation in the paralyzed face. Clin Plast
Surg 1979;6:31.

12. Bunnell S. Surgical repair of the facial nerve. Arch Otol 1937;25:23.
13. Anderl H. Reconstruction of the face through cross-face nerve transplantation in facial paralysis. Chir
Plast (Berl) 1973;2:17.
14. Krag C. Experience with transplantation of composite tissues by means of microsurgical vascular
anastomoses: II. Late results and comments. Scand J Plast Reconstr Surg 1985;19:157.
15. Terzis JK, Sweet RC, Dykes RW, Williams HB. Recovery of function in free muscle transplants using
microneurovascular anastomoses. J Hand Surg 1978;3:37.

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Chapter 157
Microneurovascular Free Transfer of Pectoralis Minor Muscle for
Facial Reanimation
J. K. TERZIS
The pectoralis minor muscle seems to have the best qualities of both the gracilis and extensor digitorum brevis
muscles, previous choices for facial reanimation, but without their disadvantages. The pectoralis minor is an
ideal shape, has adequate bulk, and possesses a dual nerve supply that allows for independent movements of
its upper and lower portions. These characteristics make the muscle a more intelligent choice than either the
gracilis or extensor digitorum brevis for substitution of atrophied facial musculature (1, 2, 3, 4, 5, 6, 7).
INDICATIONS
The best indication for use of the pectoralis minor muscle flap is in developmental facial paralysis in young
children. For use in a 4- or 5-year-old child, the muscle dimensions are ideal (i.e., 6 to 10 cm long and 0.4 to
0.6 cm wide). In these patients, the muscle can be used totally, without thinning or shortening. The muscle
also can be an excellent choice for adults, especially patients who are not athletic and have not built up
muscles of the upper torso through sports or exercise. Its use is not recommended in well-developed
patients, especially weightlifters or swimmers, because of excessive bulk, unless substantial debulking is
undertaken.
Donor-site morbidity is minimal, limited to a small incision over the anterior axillary fold, an imperceptible
loss of pectoralis major bulk that is not appreciated by the patient but only by careful inspection of the upper
thoracic area, and no reportable functional loss.
The muscle is flat and is composed of several slips that can be separated in a distoproximal fashion for a
substantial length without fear of vascular and neural compromise. It has
sufficient bulk to substitute for the lower face and can yield adequate excursion in the needed directions of
pull. If the hilus of the muscle is placed over the zygomatic arch, its slips of origin can be separated and
fashioned to substitute not only for the zygomatic major muscle, but also for the elevators of the upper lip
and for the retractors of the commissure. A multidirectional pull can be obtained that is ideal if the patient
has a “canine” type of smile in the contralateral normal face.
Possibly, the most important advantage of the pectoralis minor is its dual innervation, a proof of its
segmental origin during development. The upper third of the muscle is innervated by a branch of the lateral
pectoral nerve, while the lower two thirds receive nerve supply from the medial pectoral nerve, an offshoot
from the medial cord of the brachial plexus. This dual innervation allows for independent movements of the
upper part quite separately from the lower part of the muscle. These separately moving muscle subunits
can be used to address the separate needs of animation of the eye and mouth, a quality not present in
previously described muscle units.
ANATOMY
The pectoralis minor is a flat, thin, triangular muscle situated beneath the pectoralis major. The muscle arises
from the outer surfaces of the third, fourth, and fifth ribs near their costochondral junctions and from the fasciae
covering the intercostal muscles. The fibers ascend upward and laterally and converge to form a flat tendon that

inserts in the upper surface of the coracoid process of the scapula. Frequently, there is an additional slip that
originates from the second rib.
The normal action of the muscle is pulling the scapula forward and downward, assisting simultaneously in
adduction of the arm by rotating the scapula. If the scapula is maintained in a fixed position by the levator
scapulae, the pectoralis minor raises the corresponding ribs in forced inspiration.
Blood Supply
There is great variability in the arterial supply of the pectoralis minor, with contributions received from three main
sources: the lateral thoracic artery, the thoracoacromial artery, or directly from a branch of the axillary artery.
Infrequently, the latter arterial source is present when contributions to the muscle from the other two arterial
trunks are minimal. I call this direct artery the “lateral thoracic artery” because, in the few clinical encounters in
which a direct artery from the axillary to the pectoralis minor occurred, there was no visible contribution to the
muscle from other arterial sources more inferiorly. In the original ten dissections, a separate branch from the
axillary artery was never encountered.
By far the predominant vascular pattern is from branches of the lateral thoracic or thoracoacromial arteries. The
former passes around the lateral margin of the muscle after it has supplied it with a branch, while the latter
passes around the medial margin of the muscle after it has issued an arterial branch, usually to the superior part
of the muscle. One or the other branch is dominant, but in a clinical series, the dominant branch came more
frequently from the lateral thoracic artery. When the two branches share the blood supply to the pectoralis minor,
harvesting the muscle on the lateral thoracic contribution has been the choice, but in these patients, the superior
portion of the muscle was not as well perfused and appeared duskier.
There is also extensive variability in the venous drainage of this muscle. More often than not, there is a separate
vein that will drain the muscle adequately; however, in many cases, one of the venae comitantes must be used
because the direct vein is absent. If there is some doubt about dominant venous drainage, it is best to harvest all
the available veins and to observe under magnification which one best drains the muscle unit after microvascular
transfer.
Nerve Supply
The nerve supply to the muscle has minimal variations. The majority of the pectoralis minor (four fifths) receives
innervation from the medial pectoral nerve, while the most superior part of the muscle receives a tiny branch from
the lateral pectoral nerve. Another substantial branch of the lateral pectoral nerve destined to innervate the
pectoralis major uses the pectoralis minor only as a passway; thus harvesting the pectoralis minor necessitates
taking of that nerve. However, these axons need not be lost, and if time is taken to redirect these fibers back to
the pectoralis minor, additional innervation can be obtained through a process of direct neurotization.
The nerve supply to the pectoralis minor is multisegmental, receiving contributions from all five spinal nerves
contributing to the brachial plexus, namely, C5, C6, C7, C8, and T1. Motor fibers from these spinal nerves reach
the pectoralis minor through branches of two nerves, the lateral and medial pectoral nerves. The dominant
innervation to the pectoralis minor is through the medial pectoral nerve, with contributions from C8 and T1. A
major branch from this nerve is responsible in all cases for three fourths or two thirds of the muscle, depending
on whether the muscle has three or four slips. Also constant is the innervation of the superior part of the
pectoralis minor, which, in all cases, comes through a tiny branch from the lateral pectoral nerve. A larger lateral
pectoral branch also penetrates the muscle, but it usually does not supply the muscle; instead, it courses through
it on its way to the pectoralis major.
Contrary to reported variability in the nerve supply of the pectoralis major, the innervation of the pectoralis minor
is relatively constant. Variations are limited to the presence or absence of the communicating loop, with fiber

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exchange between the medial and lateral pectoral nerves. It is worth mentioning that in two clinical cases of
severe brachial plexopathy, with documented neuroradiologic and electrical findings of C8 and T1 avulsion, the
inferior segment of the pectoralis minor responded to intraoperative electrical stimulation, raising the possibility
that some motor fibers from T2 may contribute to the innervation of this muscle.
The dual innervation of the pectoralis minor makes it a unique muscle for facial reanimation procedures because
the upper leaves can be motored separately from the lower portion of the muscle. This characteristic opens
possibilities for independent eye and mouth movements, one of the greatest advantages of using this muscle for
facial-muscle substitution (Figs. 157.1, 157.2, 157.3, 157.4).
FLAP DESIGN AND DIMENSIONS
In the adult, the individual slips of the muscle measure 10 to 14 cm long. The upper leaves are shorter, and the
lower leaves are longer. In a child or baby, pectoralis minor leaflets are only 6 to 10 cm long, making it ideal for
facial reanimation procedures, since the muscle can be used in toto without any trimming. The width of the
muscle is less than 0.5 cm in very young patients, but it can be up to 2 or 3 cm in athletic adults, a situation that
would require extensive debulking.
FIGURE 157.1 A: The location of the pectoralis minor on the anterior thorax showing the four slips of origin near
the costal cartilages and the coracoid tendinous insertion. Note the heavy line over the anterior axillary fold,
which signifies the incision for microsurgical harvesting of this muscle. B: Corresponding fresh dissection
specimen showing the pectoralis minor exposed after removal of the pectoralis major muscle. (From Terzis, ref.
7, with permission.)

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FIGURE 157.2 A: The left pectoralis minor in situ showing the two vascular pedicles, namely, the
thoracoacromial and the lateral thoracic, as they emerge around the muscle medially and laterally after they have
contributed their branches. Note the lateral pectoral branch that uses the pectoralis minor as a passageway in
its journey to the undersurface of the pectoralis major. B: Fresh specimen showing the left pectoralis minor in
situ. The pectoralis major is elevated with the retractor. Note the two arterial branches (black arrows), one
emerging medially and one laterally, that contribute to the blood supply of this muscle. The superior branch from
the thoracoacromial trunk is a small arterial twig, and in this case, as in most cases, one has to transfer the
muscle on the branch from the lateral thoracic artery. Note also the branch from the lateral pectoral nerve (white
arrow) as it pierces through the pectoralis minor to reach the undersurface of the pectoralis major. (From Terzis,
ref. 7, with permission).
FIGURE 157.3 A: The exemplary vascular and neural pattern that supplies the pectoralis minor muscle. Note
that the arterial branch from the lateral thoracic artery is larger and enters the muscle more centrally. This artery
is closely accompanied by the medial pectoral nerve, which is in all cases the predominant nerve supply to this

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muscle. The superior portion of the muscle, however, more frequently than not, receives its innervation from
contributions of the lateral pectoral nerve. Note the communicating loop between medial and lateral pectoral
nerves, which is a common occurrence. B: The right pectoralis minor is reflected toward its origin showing the
hilar structures. Note the extensive vascular variability. In this specimen, the thoracoacromial and lateral thoracic
arteries contribute two branches each to the pectoralis minor, a small and larger branch, for a total of four. Two
are tiny twigs and enter the muscle at its margins (small white arrows). The other two branches are of larger
caliber (large white arrows). Clinically, this muscle would have been transferred on the dominant artery (upper
large arrow), which in this case is a branch of the thoracoacromial trunk. (From Terzis, ref. 7, with permission.)
FIGURE 157.4 The inferior margin of the pectoralis major is visualized superiorly. Note the lateral thoracic artery
as it ascends from the axillary artery and after supplying the pectoralis minor passes over the lateral margin of
the pectoralis minor to enter the inferior margin of the pectoralis major. This is an important surgical landmark
because identification of the lateral thoracic vessels at the lower border of the pectoralis major allows easy
isolation by following these vessels in a distoproximal fashion. This invariably leads to isolation of the branch of
the lateral thoracic to the pectoralis minor muscle. (From Terzis, ref. 7, with permission.)
Flap design is carried out by precise preoperative measurements of the patient's face in repose and during
extremes of facial movement. A mold is made of the exact shape needed for a particular reanimation procedure.
Before harvesting, the tension of the muscle is measured, and 6-0 silk sutures are placed over its inferior margin
1 to 2 cm apart. Once the muscle is harvested from the anterior thorax, it is placed on a wet sponge.
There is a 30% to 50% shrinkage of the muscle following harvesting because of the elastic recoil of its fibers. By
placing holding sutures along its origins and insertion, an attempt is made to reexpand the muscle to its previous
dimensions. Then the mold is placed on the stretched muscle, and appropriate trimming and debulking are
carried out.
It is important to allow for more muscle length than merely the length-width measurements of the facial mold.
Supported by experience in facial reanimation procedures and contrasting to extremity free-muscle
transplantation, it proved to be a poor idea to reproduce in situ length in the face. In a few patients in whom the
muscle was placed under too much tension, the muscle force generated was too great for the requirements of
the recipient site. Subsequently, the muscle had to be weakened. Thus, during a revisional stage, the
transplanted muscle was loosened by advancing it medially; this invariably corrected the deformity.
In children between 4 and 5 years of age, no trimming or debulking is necessary, since the muscle usually fits the
facial dimensions of children perfectly.

OPERATIVE TECHNIQUE
The patient is placed on his or her back, and the face and neck areas, as well as the contralateral upper
extremity and upper thorax, are prepped and draped. One surgical team prepares the recipient site. The
following tasks need to be addressed: (a) face-lift incision, (b) undermining a cheek flap extending from the
preauricular area to the upper and lower lip up to the philtrum—the superior margin of the cheek flap is the
infraorbital rim and the inferior margin is the submandibular area, (c) identification of the facial artery and vein
and microsurgical isolation of this vascular pedicle from 2 cm below the mandible to the level of the alar base,
and (d) identification and microsurgical isolation of the distal ends of the cross-facial nerve grafts up to the region
of the upper lip.
A separate team harvests the pectoralis minor muscle simultaneously by working on the opposite side of the
operating table; this shortens operating time appreciably. The following procedures are followed:
1. Placement of the incision over the posterior border of the anterior axillary fold, so that it is not easily visualized
2. Identification of the inferior margin of the pectoralis major muscle
3. Identification and isolation of the lateral thoracic vascular pedicle as it enters the inferior margin of the
pectoralis major
4. Microsurgical pursuit of the lateral thoracic pedicle to the undersurface of the pectoralis minor muscle and
isolation of the dominant arterial trunk that supplies the pectoralis minor
5. Identification of the inferior margin of the pectoralis minor and demarcation of the outer surface over the thorax
by blunt dissection
6. Distal dissection freeing the undersurface of the pectoralis minor muscle from the intercostals, investing
fasciae, and outer costal surface
7. Proximal exploration clearly defining the outer and inner surfaces of the origin of the muscle up to the cora-
coid process
8. Placement of two holding sutures over the inferior margin of the muscle and averting the muscle so that the
hilar structures become apparent
9. Identification of the medial and lateral pectoral nerves and communicating loop, tracing the pectoral nerves to
gain as much length as possible, and marking with 8-0 microsutures and subsequent severance of the nerves
0. Identification and clarification of the dominant arterial supply and dominant venous drainage
1. Marking of muscle tension in situ by placing black 6-0 sutures every 1 cm along its inferior margin
2. Separating the origin of the muscle from the thoracic wall and freeing it completely (An attempt is made to
incorporate as much fascia as possible in the terminal portion of the individual slips.)
3. Severance of the coracoid insertion
4. Keeping the muscle warm until the recipient site in the face is completely prepared to receive the transfer
Before microsurgical transfer, the previously prepared facial mold is placed on the face and measurements are
rechecked. Then, with a preoperative videotape on a TV terminal in the operating room that shows the patient
talking or smiling, 4-0 and 5-0 Mersilene sutures are placed to the alar base, upper lip, nasolabial fold, oral
commissure, and lower lip. Each suture is tested to see if pulling on the suture reproduces the exact pull needed
to match the animation of the contralateral normal face. Then the vascular pedicle of the muscle is severed, and
the muscle is photographed as a free unit. It is brought to the face after appropriate trimming and/or debulking.

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Both surgical teams are working together at this critical point in a methodical fashion with minimal ischemia time
to inset the muscle in the cheek using the previously placed sutures. This usually takes from 20 to 40 minutes.
The diameter of the branch of the lateral thoracic artery that supplies the pectoralis minor ranges from 0.5 to 0.9
mm, depending on the age and vascular variability of the patient. Such a caliber is not too dissimilar to the distal
end of the facial artery. If there is a question about the condition of venous drainage, the arterial clamps are
released and the hilar structure is carefully observed. The vein that bleeds most profusely is the one chosen for
microvascular reconnection with the facial vein.
Once the vascular anastomoses are completed, the insetting of the muscle is checked and the final tension is
adjusted. If additional sutures are needed, they are provided at this point. Depending on the preoperative
videotapes and the facial mold measurements, facial tension is adjusted, not to exceed the tension in situ. In
most cases, 60% to 70% of in situ tension is recommended, depending on the strength of desired pull.
At completion of muscle placement, the operating microscope is brought back to the field and microneural
coaptations
are carried out. Usually, two cross-facial nerve grafts are placed for smile substitution. The upper graft is
coapted with the lateral pectoral nerve, and the lower graft is sutured to the medial pectoral nerve.
FIGURE 157.5 The pectoralis minor after it has been transferred to the face. The placement of the muscle is
such that the coracoid insertion is anchored at the zygomatic arch and preauricular area. The lower slip of the
muscle is directed to the commissure or lower lip depending on the preoperative measurements. The central
slips are dedicated for the upper lip and nasolabial folds. The upper slip usually ends at the alar base and is also
anchored in the medial region of the infraorbital rim about 1 cm below the medial canthus. This slip is placed for
nasalis substitution if the patient has a strong nasalis function in the contralateral normal face. The
microneurovascular repairs are always done on the external surface of the muscle to facilitate their execution.
(From Terzis, ref. 7, with permission.)
At completion of the microneural repairs, the medial and lateral pectoral nerves are stimulated, and intraoperative
videotapes of the resulting facial movements are obtained. Finally, the cheek flap is closed, and a tiny stitch is
placed as a marker over the cheek to facilitate postoperative Doppler monitoring of the arterial pulse. Usually, no
dressing or drains are necessary. The face lift incision is covered with antibiotic ointment, and the face is left
open for direct inspection. Extubation of the patient is carried out carefully to ensure that no structures are
disrupted (Figs. 157.5 and 157.6).

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FIGURE 157.6 A: The right pectoralis minor muscle was harvested using the technique described in the text.
The outer surface of the muscle is shown. Note the sutures placed every 2 cm to mark the tension of the muscle
in situ. B: The right pectoralis minor muscle has been transferred to the left cheek. The microvascular
anastomoses have been completed (note white arrow). The final tension of the muscle will be adjusted prior to
the execution of the microneural coaptations. (From Terzis, ref. 7, with permission.)
CLINICAL RESULTS
One disadvantage of the pectoralis minor flap is that because of its deep position underneath the pectoralis
major, debulking cannot be done easily in situ. Thus the muscle must be debulked after harvesting and
before reestablishment of its blood supply through microvascular anastomoses with recipient vessels. This
increases ischemic time substantially and can have functional repercussions. A further disadvantage is the
short and complex neurovascular pedicle, which makes familiarity with the vascular and inaccessible neural
networks of the infraclavicular region mandatory if this flap is to be safely used.
Another disadvantage is that the vascular supply of the muscle can vary, and the surgeon should be
prepared to make judgments intraoperatively about whether the lateral thoracic artery is of sufficient caliber
to carry the whole muscle. If the contributing branch from the thoracoacromial trunk is of large caliber, its
severance may lead to duskiness of the upper portion of the pectoralis minor (Figs. 157.7, 157.8, 157.9,
157.10).
SUMMARY
The pectoralis minor is a highly versatile muscle that should be included in the armamentarium of surgeons
who treat patients with developmental or late acquired facial paralysis. It is not a substitute for the highly
specialized and densely innervated normal facial musculature, but its dual innervation, multileaf origin, and
flat, thin shape make it a second-best choice for use in restoration of facial symmetry and coordinated
function in cases of chronic or developmental facial paralysis.

FIGURE 157.7 A: A 6-year-old boy with developmental left facial paralysis. Note the absence of left
nasolabial fold, lowering of left alar base, lack of left lower lip depressor, and weak buccinator. He also was
unable to close the left eye completely and presented with 4-mm scleral show. Note small degree of
“puckering” around left commissure, implying a partial paralysis. B: Patient is shown here 1 year after three
cross-facial (sural) nerve grafts were placed in his face and just prior to the free pectoralis minor transfer to
the left face. Direct neurotization through the cross-facial nerves accounts for the increased animation
present in the left face. However, this is never enough to restore symmetry. (In 1982, I used to make a
nasolabial fold incision to facilitate placement of the cross-facial nerve graft. I have stopped using this
incision because the resulting nasolabial scar was not acceptable to me. This has made preparation of the
recipient site somewhat more difficult and lengthy, but I think it has paid off now, because there are no
visible scars on the anterior face.) (From Terzis, ref. 7, with permission.)
FIGURE 157.8 A-C: Patient is seen here at 10 years of age and 3 years after microneurovascular transfer
of the right pectoralis minor to the left cheek. As is the case with most developmental facial paralysis
patients, he has completely synchronous and coordinated animation of the left paralyzed face with the right
normal face (B). In addition, the patient is demonstrating a phenomenon that depicts an intriguing degree of
plasticity, since he is able to voluntarily move the right (A) or the left side of his face independently (C)
despite the fact that both sides of his face are controlled by his right cerebral cortex (i.e., peripheral fibers of
the right facial nucleus innervate the right facial musculature as well as cross through the cross-facial nerve
grafts to supply innervation to the free pectoralis minor transplanted to the left face). (From Terzis, ref. 7,

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with permission.)
FIGURE 157.9 Patient is shown here in 1988 at age 13 (i.e., 5 years following microneurovascular transfer
of the right pectoralis minor to the left face). A: In repose, (B) showing a small grin, and (C) a broader smile.
(From Terzis, ref. 7, with permission.)
FIGURE 157.10 A,B: The upper slip of the pectoralis minor, elongated with the incorporation of fascia from
its costal origin, was split and placed in a preseptal position to substitute for the paralyzed left eye
sphincter. This segment of the muscle was innervated by a separate cross-facial nerve graft to the lateral
pectoral nerve. The patient has independent eye movements that are synchronized only with his
contralateral eye as well as complete restoration of his blink reflex in the left eye, which was previously
delayed and incomplete. There is no evidence of synkinesis with the left lower face. Patient is shown here
in close-up with the eyes open (A) and closed (B). Minimal revisions are planned to correct the excess skin
that is shown in the medial aspect of the left upper eyelid. (From Terzis, ref. 7, with permission.)
References
1. Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation with microneurovascular anastomoses for
the treatment of facial paralysis. Plast Reconstr Surg 1976;57:133.
2. Terzis JK, Sweet RC, Dykes RW, Williams HB. Recovery of function in free muscle transplants using
microneurovascular anastomoses. J Hand Surg 1978;3:37.
3. O'Brien BMcC, Franklin JD, Morrison WA. Cross-facial nerve grafts and microneurovascular free muscle

transfer for long-established facial palsy. Br J Plast Surg 1980;33:202.
4. Manktelow RT, McKee NH, Vettese T. An anatomic study of the pectoralis major muscle as related to
functioning free muscle transplantation. Plast Reconstr Surg 1980;6:610.
5. Mayou BJ, Watson JSD, Harrison DH. Free microvascular and microneurovascular transfer of the extensor
digitorum brevis muscle for the treatment of unilateral facial paralysis. Br J Plast Surg 1981; 34:362.
6. Terzis JK, Manktelow RT. Pectoralis minor: A new concept in facial reanimation. Plast Surg Forum
1982;5:106.
7. Teris JK. Pectoralis minor: A unique muscle for correction of facial palsy. Plast Reconstr Surg
1989;83:767.

Chapter 158
Lip-Switch Abbé Flap for Philtrum
D. R. MILLARD JR.
EDITORIAL COMMENT
Chapters 158 and 159 are modifications of the crossed-lip-flap principle.
The lip-switch flap is popularly known as the Abbé flap (1). The technique involves a composite flap of lip tissue,
including skin, muscle, and mucosa, based on one coronary vessel. It has been found to live on a narrow
mucosal pedicle (2).
INDICATIONS
In unilateral cleft lip, when the initial surgery has destroyed natural landmarks and the discarding of tissue
has tightened the upper lip, not only is there a lack of soft tissue, but the constricting effect on growth of
underlying structures compounds the defect. It will be noted that the unrestrained lower lip will show a
relatively severe protrusion. The lip-switch flap will, of course, reduce the lower lip slack as it releases the
upper lip tightness.
FLAP DESIGN AND DIMENSIONS
The flap can be taken from either lip, but it is most commonly switched from the lower to the upper lip (3, 4, 5). Its
shape has been varied in form from triangular to rectangular to square to even more odd and irregular
configurations. The shape and size of the flap depend, of course, on the defect to which the flap is to be
transposed, bearing in mind that it need not necessarily be the exact size of the apparent defect. When the flap
is taken out of one lip to be inserted into the other, the donor lip is reduced. This may lessen the amount needed
for the opposite lip if normal lip proportions are to be maintained.
It was the previous routine of reconstructive surgeons to insert the lip-switch flap into the upper lip scar. This
improved the tissue deficit, but it did not take aesthetic landmarks into consideration, and it resulted in a
patchwork effect that seemed to fall short of possibilities.
In postoperative unilateral cleft lip patients in whom the philtrum and cupid's bow had been violated or destroyed,
it seemed more logical to ignore the unilateral scar and to use the lip-switch flap to create a new philtrum.
Accomplishing this means using a midline releasing incision in the upper lip and transposing a philtrum-shaped
flap from the lower lip (Fig. 158.1A). To be truly philtrum-shaped, the flap should be formed somewhat like a
shield, and if it is fashioned slightly narrower at the mucocutaneous ridge before it swells into a shield, it also will
help to effect a cupid's bow. It should be taken from the middle of the lower lip, where often a dimple is present.
This can be spared in the lower lip, but it is most desirable as a philtrum dimple in the upper lip. The flap is
transposed 180 degrees (Fig. 158.1B).
The same aesthetic shape of flap is applicable in secondary bilateral clefts when the scarred prolabium must be
shifted into the columella to release the depressed nasal tip. Obviously, a midline shield-shaped lower lip flap is
an ideal replacement for the upper lip philtrum.

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OPERATIVE TECHNIQUE
Both the donor area and the flap insertion in the upper lip are closed in three layers: mucosa, muscle, and skin.
After 7 to 10 days, the pedicle is divided and the upper and lower lip are revised at the division area (Fig.
158.1C).
CLINICAL RESULTS
Of course, three new scars have been added, but remarkably enough, they are not noticeable because they
form the boundaries of the philtrum of the upper lip and only a midline seam of the lower lip. The
reconstruction of the philtrum reduces the dominance of the old unilateral cleft scar, rendering it less
noticeable. Because it has been relaxed, it can be better revised or even excised totally up to one side of
the philtrum flap.
SUMMARY
A midline shield-shaped lower lip flap is an ideal replacement for the upper lip philtrum.
FIGURE 158.1 A: When no philtrum or cupid's bow is present in a postoperative unilateral cleft, then ignore
the unilateral scar and divide the upper lip in the midline. Take a shield-shaped lower lip flap from the
midline to carry whatever dimple is present to the upper philtrum. B: Composite flap based on coronary
vessel and small amount of mucosa is being transposed 180 degrees. C: Construction of a midline philtrum
camouflages the unilateral deformity and scar.
References
1. Abbé R. A new plastic operation for the relief of deformity due to double harelip. Med Rec 1898;53:477.
2. Millard DR Jr., McLaughlin, CA. Abbé flap on mucosal pedicle. Ann Plast Surg 1979;3:544.
3. Blair VP, Letterman GS. The role of the switched lower lip flap in upper lip reconstruction. Plast Reconstr
Surg 1950;5:1.
4. Millard DR Jr., Composite lip flaps and grafts in secondary cleft deformities. Br J Plast Surg 1964;17:1.

5. Millard DR Jr. Cleft craft: the evolution of its surgery, Vol. 2. Boston: Little, Brown, 1977;636-653, 684-
710.

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Chapter 159
Lower-Lip Sandwich Abé Skin Flap to Upper Lip
I. T. JACKSON
EDITORIAL COMMENT
The results that the author shows are outstanding. We wonder whether contraction of the upper lip also
occurs when a small Abbé flap is transferred to the upper lip and the orbicularis is sutured to the Abbé flap
on either side.
The aim of the cross-lip operation is to improve the appearance of the lip by releasing the tightness, establishing
lip balance, and restoring the cupid's bow. In addition, the function of the upper lip should not be compromised;
ideally, it should be improved.
INDICATIONS
If there has been a poor primary lip repair with sacrifice of much tissue, the upper lip is tight. This condition
can vary
from being slight and acceptable to severe, with gross lip imbalance and an unacceptable deformity. There
may be central shortness with a whistling deformity and incisor show. The lip imbalance is accentuated by
redundancy of the lower lip and, in some cases, maxillary retrusion. This condition is due entirely to skin
sacrifice and not to muscle deficiency.
FIGURE 159.1 A: The midline incision in the upper lip is shown. The junction of skin and vermilion is
tattooed with Bonney's blue. B: The upper lip is divided completely. C: The orbicularis muscles have been

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widely dissected and can now be comfortably approximated in the midline. The design of the Abbé flap is
shown in the lower lip. D: The sandwich flap is elevated from the lower lip, leaving the orbicularis of the
lower lip intact. E: The flap is swung round in such a way that the mucosa is positioned behind the
orbicularis and the skin in front of the reconstructed orbicularis. F: The flap is sutured in position, and the
lower lip defect is closed in layers.
To achieve good upper lip function, orbicularis continuity is essential. A lip may be aesthetically acceptable
at rest but not when functioning if that continuity is not established. From personal experience, and
according to the literature, it has been noted that the prolabium has no muscle fibers in the complete
bilateral cleft. Similarly, in the unilateral cleft, the orbicularis is abnormally inserted (1, 2). If the muscle is not
correctly dissected out and reconstructed, the coordinated upper lip function is poor.
In severely mutilated lips requiring a cross-lip flap, one can be sure that the level of sophistication in the
original repair was low, and it is unlikely that any muscle reconstruction was performed. That being so, the
orbicularis is probably intact and can be used to reconstruct muscular continuity in the upper lip. The
requirements for cover of the reconstructed muscle are skin, vermilion, and mucosa; this is the sandwich
cross-lip flap (3).
In the past, cross-lip flaps were lifeless curtains that moved in a secondary fashion when the lateral
segments moved. The sandwich cross-lip flap is a functional flap, allowing one to sidestep the question of
function in cross-lip flaps, which has its proponents (4, 5) and its antagonists (6, 7). Other advantages of
this procedure are early pedicle division, a clinical impression of an improved lower lip scar, and the
flexibility of having the mucosa and the skin separated, allowing for variation in design in the two layers.
FLAP DESIGN AND DIMENSIONS
The three main faults seen in Abbé flap designs are that they are too large, too long, and too square. The flap
should be triangular like the philtrum, and it should be as wide and as long as a normal philtrum. It should end in
the lip and not be introduced into the nasal floor or columella, as has been suggested (8), except in very
exceptional circumstances. The flap always must be inserted into the midline of the upper lip, even if it means
disregarding old scars. In some cases, where bulk is required in the lower half of the lip and a cupid's bow is to
be established, one should not hesitate to insert a flap of half the lip height.
OPERATIVE TECHNIQUE
Preoperatively, the discontinuity of the orbicularis is demonstrated by asking the patient to purse his or her lips.
In the unilateral case, the upper lip is divided completely in the midline. In the bilateral case, the old scars are
excised and the prolabium and underlying subcutaneous tissue are used to effect columellar lengthening (Figs.
159.1 and 159.2).

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FIGURE 159.2 A-D: The operative steps as shown in Figure 159.1. (From Jackson and Soutar, ref. 3, with
permission.)
The orbicularis muscle bellies are dissected out from the skin and from their periosteal attachments at the alar
base and columellar areas. These now can be rotated downward and advanced. It should be noted that there is
often brisk bleeding just lateral to the alar base, and attention must be paid to this. The muscles are then sutured
together with nonabsorbable suture material. The complex anatomy of the orbicularis (9) cannot be duplicated,
but a secure anastomosis is desirable. The muscular sphincter has now been reconstituted, and the skin and
mucosal deficiency can be measured.
The dimensions are transferred onto the lower lip. It is helpful to tattoo the mucocutaneous junction on both sides
of every incision; this makes for easier approximation later in the procedure. The skin and mucosa are incised
down to the orbicularis; on the nonpedicle side, the labial vessels are cut through. This indicates their position,
and thus on the side of the pedicle these vessels are virtually skeletonized. The skin and mucosa are now
elevated from the orbicularis, the vermilion is divided from it transversely, and the flap is now free on its pedicle.
Rotation is accomplished with facility, and the skin and mucosa are sutured in position. The lower lip is closed in
layers.
Division of the flap can safely be performed at 3 to 5 days under local anesthesia.

FIGURE 159.3 A: The lip, having been augmented with a sandwich Abbé switch flap. B: The functional integrity
of the upper lip is illustrated. (From Jackson and Soutar, ref. 3, with permission.)
CLINICAL RESULTS
Since using this technique in most patients requiring a cross-lip flap, the results have been satisfactory from
an aesthetic and functional point of view (Fig. 159.3).
SUMMARY
The cross-lip-sandwich flap can be effectively used to improve both the cosmetic and functional aspects of
an upper lip deformity.
References
1. Estlander JA. En ny operationsmetod att atersrall en forstord lapp ellek-kind. Finsak Lak-Sall SK Handl
1872;14:1.
2. Fara MD, Smahel J. Postoperative follow-up of restitution procedures in the orbicularis oris muscle after
operation for complete bilateral cleft of the lip. Plast Reconstr Surg 1967;40:13.
3. Jackson IT, Soutar DS. The sandwich Abbé flap in secondary cleft lip deformity. Plast Reconstr Surg
1980;66:38.
4. Smith JW. The anatomical and physiological acclimation of tissue transplanted by the lip switch technique.
Plast Reconstr Surg 1960;26:40.
5. Thompson N, Pollard AC. Motor function in Abbé flaps. Br J Plast Surg 1961;14:66.
6. Isaksson I, Johanson B, Peterson I, Sellden U. Electromyographic study of the Abbé and fan flaps. Acta
Chir Scand 1962;123:343.
7. Schuh FD, Crikelair GF, Cosman B. A critical appraisal of the Abbé flap in secondary cleft lip deformity. Br
J Plast Surg 1970;23:142.

8. McGregor IA. The Abbé flap: its use in single and double lip clefts. Br J Plast Surg 1963;16:46.
9. Briedis J, Jackson IT. The anatomy of the philtrum: observations made on dissection in the normal lip. Br J
Plast Surg 1980;34:128.

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Chapter 160
Lip Fleur-De-Lis Flap
D. R. MILLARD JR.
EDITORIAL COMMENT
This is a classic technique that attempted to replace the lost central portion of the lip. Such substantial
deformities were created when the premaxilla or the columella was sacrificed as part of a cleft-lip repair, a
sacrifice that fortunately is no longer made.
Through cancer ablation, radiation, or secondary congenital cleft lip deformities, a relative side-to-side tightness
of a lip often occurs. There also may be deficiency in the free border vermilion. One lip may be tight and thin,
with only a minimum of vermilion visible. The opposite lip may be loose, with voluminous vermilion in view (Fig.
160.1). In such circumstances, the lip fleur-de-lis flap has been found to be effective in two planes (1).
INDICATIONS
By extending the standard lip-switch flap with lateral mucosal flaps, it is possible to double its dimension of
effectiveness. The standard lip-switch portion of the flap will reduce the relative slack of the donor lip while
it releases the tightness of the opposite lip.
FIGURE 160.1 A: Tight, thin upper lip. B: Loose, full lower lip.
Simultaneously, the mucosal extensions on the lip-switch flap, taken out of the voluminous vermilion of one
lip, are transported and inserted behind the thin free-border vermilion of the other lip. This has a balancing
effect because the excessive vermilion is reduced while simultaneously bolstering the deficient vermilion of
the opposite lip.
FLAP DESIGN AND DIMENSIONS
The design of this double-dimension flap depends on the coronary vessels. The composite vertical lip-switch flap
is marked, with its horizontal mucosal extensions placed along the coronary vessel just posterior to the free
border of the lip. This places the horizontal scar just out of sight (Fig. 160.2A).

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OPERATIVE TECHNIQUE
The order of progression in the cutting of this flap is vital. The mucosal extension away from the future coronary
vessel pedicle can pick up the coronary vessel in its body. Then the standard lip-switch flap is cut through and
through on that side. The through-and-through incision on the other side of the lip-switch flap is carried up near
the coronary vessel, crossing the mucocutaneous junction in front, but preserving the coronary vessel and
cutting the other mucosal extension superficial to the coronary vessel (Fig. 160.2B). This completes the
development of the fleur-de-lis, which, with its mucosal limbs, will pivot 180 degrees on the coronary vessel to be
transposed into two axes of the opposite lip.
FIGURE 160.2 A: Fleur-de-lis flap marked on the lower lip along the coronary vessel. Upper lip marked for scar
excision and posterior mucosal release along the free border. B: Fleur-de-lis flap cut, based on coronary vessel
on the left.
The opposite lip is prepared for the fleur-de-lis by releasing it vertically at the chosen position and by incising the
vermilion horizontally, just posterior to its free border, to allow turndown of mucosa (Fig. 160.3A). Into this double
release, the fleur-de-lis is transposed with a rather flamboyant fit. The lip-switch flap fills the vertical defect, as
the mucosal limbs slide in behind the mucosal turndown flaps (Fig. 160.3B).
SUMMARY
The lip fleur-de-lis flap can release and thicken a thin, tight lip while tightening and thinning the opposite
loose, thick lip to the mutual benefit of both (Fig. 160.4).
FIGURE 160.3 A: Thin vermilion of the upper lip released by a posterior mucosal incision. B: Fleurde-lis
flap transposed into the upper lip with mucosal wings fitting into posterior releasing incisions in the mucosa.

FIGURE 160.4 After division of the pedicle, the upper and lower lip relationship has been improved in two
planes.
Reference
1. Millard DR Jr. A lip fleur-de-lis flap. Plast Reconstr Surg 1964;34:34.

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Chapter 161
One-Stage Lip-Switch
H. OHTSUKA
EDITORIAL COMMENT
Although this technique avoids the 1- or 2-week period of attachment, there is significant risk of loss of the
flap, especially from venous congestion.
By modifying the Abbé lip-switch procedure for repair of full-thickness defects or deformities of the upper lip (1), a
one-stage lip-switch technique was developed (2). This modification obviates the 1- to 2-week waiting period
required for separation of the vascular pedicle.
FIGURE 161.1 Diagram of operative procedure. A: Preoperative design. Facial and lower labial arteries are
illustrated. B: Mucosal closure of the transferred flap and pedicle. Modification of closure is shown in B'. C:
Completion of the procedure.
INDICATIONS
The one-stage procedure shortens the time required, thus ameliorating communication problems and
discomfort in patients with significant disproportion between the upper and lower lip, especially in unilateral
or bilateral cleft-lip deformities. An arterialized one-stage lip-switch operation can be rather risky compared
to the traditional Abbé flap. Indications should be limited to properly selected patients. Various degrees of
venous congestion or even necrosis in the traditional flap are not rare (3). Therefore, a sufficient quantity of
submucosal tissue must be preserved for the long pedicle of a one-stage lip-switch flap.
ANATOMY
Asymmetries or variations in lower-vermilion vascularization have been described (3, 4), including cases with an
equal distribution of the bilateral inferior labial arteries; predominant inferior artery of one side; the inferior labial
artery present only on one side; or the inferior labial artery present as the terminal branch of the sublabial artery.
The inferior labial artery may arise from a common trunk at the level of the labial commissure or directly from the
superior labial artery (4, 5). In any case, numerous branches and terminals of the inferior labial, sublabial,

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mental, and submental arteries constitute an abundant labial network.
The facial artery and inferior and superior labial arteries run close to the oral mucous membrane. The main
routes of these arteries can be palpated manually between the fingers. A Doppler evaluation is also of value for
the precise determination of vessel location both preoperatively and intraoperatively. The venae comitantes do
not always parallel the arterial routes and are sometimes absent despite the rich venous network in the
submucosa concentrating near the arteries (2, 3). In addition, the proper arteries and veins may meander,
especially in older people.
FLAP DESIGN AND DIMENSIONS
The most significant point in the success of this procedure lies in the route of venous drainage. If the inferior
labial vein runs exactly along the labial artery as a vena comitans, the procedure is not risky; however, the vein
does not always parallel the artery (3), and it is difficult to identify and isolate without damage in some instances.
A 7- to 10-mm-wide (or more) mucous pedicle flap, including the inferior labial artery, is recommended as the
vascular pedicle for flap survival.
About a quarter to a half of the lower lip is used, depending on assessment of the defect volume in the upper lip.
To obtain a good quantity of submucosal tissue and to avoid shortness of the pedicle from the lower lip, the flap
must be designed to the side, with the requirements of the upper-lip defect in mind, instead of merely opposing
the defect (3).
OPERATIVE TECHNIQUE
An inverted M-shaped lower-lip flap is raised as usual, except for the long pedicle side (Fig. 161.1); a V-shaped
mucosal incision is sometimes recommended (Fig. 161.1B'). The flap pedicle is extended to the commissure
along the inferior labial artery, including a thin layer of orbicularis oris muscle about 6 to 8 mm wide. A small
amount of tissue in the upper lip, especially near the commissure, may be excised to accommodate the pedicle.
Deepithelialization of mucosal tissue may be performed in half of the vascular pedicle on the lip flap side. In this
situation, the distal portion of the flap is incised a little closer to the mucous membrane to pass the
deepithelialized vascular pedicle through it.
Three-layer fine sutures in the upper lip and loose fixation of the flap pedicle are carried out, followed by primary
closure of the flap donor site and the incised site of the vascular pedicle (Fig. 161.1C). Most cases of venous
stasis are reversible with drainage if a nourishing labial artery (or labial coronary arterial arch) is not injured (3).
Several dressing changes per day with wet gauze are used (2). Thermographic evaluation may help in
postoperative assessment of flap circulation.
CLINICAL RESULTS
Postoperative results were excellent in the case illustrated (Fig. 161.2). The elderly patient presented with
many
accompanying cardiovascular and mental problems. During the first 9 postoperative days, mild pulmonary
congestion, slight anemia, hypokalemia, arrhythmia, and an unsettled mental state were present.
Postoperative venous congestion was treated by removal of several sutures and insertion of drains.
Marginal bleeding was controlled by frequent dressing changes with wet gauze.