Grabb’s Encyclopedia of Flaps Head and Neck

Chapter 182
Nasolabial Flaps to Anterior Floor of Mouth
I. A. McGREGOR
D. SOUTAR
The functional integrity of the anterior floor of the mouth is probably more important in maintaining tongue
mobility and consequent normality of articulation and deglutition and control and disposal of saliva than any other
part of the oral cavity. Even minor loss of tongue mobility results in a serious disturbance of function. As a result,
small defects of this area that elsewhere in the mouth might be suitably managed by direct suture require a
formal reconstruction.
For the small defect, a suitably matching small flap reconstruction is required, and it is in this situation that the
nasolabial flap provides a simple, safe, and effective method of reconstruction. The reconstruction involves the
raising of an inferiorly based nasolabial flap on one side (1) or, much more frequently, both sides (2), depending
on the site and size of the intraoral defect. The flap or flaps are tunneled through the cheek and brought into the
mouth. There the single flap is sutured to the defect or, in the case of bilateral flaps, inter-digitated and sutured
to the defect. Division of the pedicle and insetting are carried out 3 weeks later.
INDICATIONS
Defects of the anterior floor of the mouth that are most suitable for a bilateral nasolabial flap reconstruction
often involve the floor itself and part of the ventral aspect of the tongue. Frequently, it is found that one flap
covers the defect of the floor while the other covers the defect of the tongue, the combined flaps forming a
rectangle. The method works best in the edentulous mouth where the loss of the teeth and the alveolar
resorption that follows leave a shallow floor of the mouth.
Certain virtues of the technique are obvious: the good cosmetic result on the face because of the scar line
in the nasolabial fold and the fact that most adults can spare tissue in the nasolabial site. Less obvious, but
possibly more important, is the direction of any pull of the bridge segment. This is upward and laterally and
has the effect of holding the tongue up and preventing it from sinking down into the mouth during healing.
This plays a significant role in maintaining tongue mobility.
Nearly all the defects in the anterior floor that are potential candidates for the method require bilateral flaps,
and it is this technique that will be described.
FLAP DESIGN AND DIMENSIONS
Inferiorly based nasolabial flaps are outlined on each cheek and raised with sufficient subcutaneous tissue to
ensure a good blood supply, although remaining superficial to the facial muscles. The base of the flap should be
maintained at just above the level of the angle of the mouth (Fig. 182.1). It is desirable to place the base of the
flap at this point because just below this level several branches from the facial artery and inferior labial artery
pass into the nasolabial skin and subcutaneous tissue (3). The flap relies on the subcutaneous and dermal
vascular system, augmented by these vessels in the base of the flap. Placing the base of the flap at this level
also ensures that the flaps enter the oral cavity from well above the “sump” area and so minimize any tendency
to fistula formation.
OPERATIVE TECHNIQUE

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The tunnel is made through the soft tissue of the cheek near the base of the flap, gaining entrance to the mouth
through previously intact buccal mucosa, and sited to take the most direct route to the defect. The passage must
be made wide enough to accommodate the flap easily. There is no tendency to strangulation of the flap unless
the tunnel is made unduly narrow or the secondary defect on the cheek is closed too tightly in the vicinity of the
tunnel. Each flap is led into the oral cavity and interdigitated with its fellow. It is surprising how often the two
flaps, adapting to a natural position, lie with one flap anterior to the other (Fig. 182.2).
The secondary defect is closed, taking care (as previously stressed) to leave a small triangular area inferiorly
unsutured to avoid constricting the base of the flap. The flaps are sutured to the margins of the intraoral defect
and finally to each other. The flaps are divided, and insetting is completed at the end of 3 weeks, with the bridge
segment usually discarded. The flaps at this stage look bulky, and the appearance before division is made worse
by the presence of the bridge segment of each flap passing laterally and the natural tendency of each flap to
tube itself. The bulky appearance should be ignored because the appearance of pin-cushioning settles quite
quickly to complete flatness (Fig. 182.3).
The technique described is two-stage; although there is no doubt that it could be made into a single-stage
procedure by raising the flaps as skin islands relying on a pedicle of subcutaneous tissue, this is unwise. In the
area of the base of the flap, the pilosebaceous follicles extend deeply in the subcutis, and the pedicle of an
island would be a somewhat tenuous structure with a dubious blood supply. We consider that to jeopardize the
blood supply of the flap in this way is not justified. A further reason for using a two-stage technique concerns the
presence in males of hair-bearing skin in the flap, particularly at its base. The 3-week interval between the two
stages allows hair to grow
on the flap in its intraoral site. When the bridge segment is divided, it is a simple matter to ensure that no hairs
remain on the part of the flap that is to be left in the mouth permanently.
FIGURE 182.1 A,B: The principle of bilateral inferiorly based nasolabial flaps brought into the mouth through a
cheek tunnel, interdigitated, and sutured to the defect of the anterior floor of the mouth.
CLINICAL RESULTS
The presence of teeth in the symphyseal region makes the flap technically much more difficult. The
distance required to reach the defect is considerably increased, and the area of inset tends to be smaller.
The possibility of biting through the flap pedicle is also a deterrent to using the flap, and the use of bite
blocks to prevent this makes the transfer, if anything, technically even more difficult. All in all, it is best

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restricted to the edentulous patient.
FIGURE 182.2 The steps in transfer of bilateral nasolabial flaps in a patient following resection of a small
squamous cell carcinoma of the anterior floor of the mouth. A: The left nasolabial flap raised, and the right
flap tunneled through into the mouth, with the secondary defect sutured. B: The flaps interdigitated and
sutured in position.
Dental state aside, the main restriction to use of the flap concerns the lateral extent of the defect. The
length of each flap raised on the face is strictly limited above by the presence of the eye and the need to
avoid ectropion when the secondary defect is closed. It is equally limited below in males by the
commencement of beard area skin at approximately the level of the angle of the mouth. This limitation of
length means that the defects these flaps can fill in the mouth are correspondingly limited in width.
FIGURE 182.3 Subsequent stages of the transfer. A: The flap just prior to division of the pedicles with
obvious pin-cushioning. B: Late result showing how the pin-cushioning corrects as the flaps flatten out.
The nasolabial flap has proved reliable in intraoral reconstruction. Necrosis is not common and, in our
experience, has been the result of technical error. Although the flaps may appear bulky at the time of
division (Fig. 182.3A), the temptation to thin at this stage should be resisted because the flaps flatten out
rapidly (Fig. 182.3B); this is particularly evident when excision of tumor also has involved resection of the
alveolar rim of mandible.

SUMMARY
Only by reconstruction with flaps such as bilateral nasolabial flaps can the anterior free segment of the
tongue, where so much of the function of that organ resides, be kept in its normal position and state,
untethered, freely mobile, and separate from the anterior floor of the mouth.
References
1. Zarem HA. Current concepts in reconstructive surgery in patients with cancer of the head and neck. Surg
Clin North Am 1971;51:149.
2. Cohen IK, Edgerton MT. Transbuccal flaps for reconstruction of the floor of the mouth. Plast Reconstr
Surg 1971;48:8.
3. Herbert DC, Harrison RG. Naso-labial subcutaneous pedicle flaps. Br J Plast Surg 1975;28:85.

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Chapter 183
One-Stage Nasolabial Skin Flaps for Oral and Oropharyngeal
Defects
R. A. ELLIOTT
The nasolabial region is a well-known donor site for a variety of flaps. In most older patients, this area can yield a
sizeable flap without significant distortion. When the flap is based inferiorly, the beard usually can be avoided,
and when the flap is carried on a subcutaneous pedicle, one-stage repair of many oral and oropharyngeal
defects is feasible.
INDICATIONS
The nasolabial skin flap is quite versatile. Numerous authors have extolled its virtues for repair of ipsilateral
surgical defects of the palate and a variety of other intraoral defects. Until the 1970s, most employed two-
stage procedures and protected the
flap with a bite block (1, 2, 3, 4). Development of a safe one-stage technique enhanced its value
significantly, particularly in the edentulous patient. The repair of antral fistulae, prompt rehabilitation of
elderly and poor-risk patients, and combination with radical neck dissection became more routine, and
bilateral flaps were interdigitated to repair defects of the anterior floor of the mouth and liberate the tongue
(5).
ANATOMY
The facial artery enters the face lateral to the mandible at the anterior border of the masseter and passes
upward and forward on a tortuous course to the corner of the mouth, giving off the inferior labial artery branches,
which supply the base of the flap and adjacent muscles. Although not dissected in this operation, the facial artery
can be mobilized readily until it becomes fixed beneath the risorious and zygomaticus major muscles near the
mouth. After giving off the superior labial artery deep to the latter muscle, a smaller main trunk passes on and
through facial muscles to reach the inner canthus. No vessels enter the deep surface of the distal portion of the
flap superiorly.
All named arteries are accompanied by one or more veins; most drain into the facial vein. The terminal branches
of the facial nerve lie deep in the facial muscles and are not endangered by flap elevation superficial to the
muscle, as recommended [see Operative Technique section]. Rich anastomoses between the facial vessels and
the deep perforators of the infraorbital and transverse facial vessels further assure an abundant blood supply to
and from the flap. Division of the facial artery at the level of the mandible, for example, during radical neck
surgery, is not a limiting factor, primarily because of similar rich anastomoses between the facial, masseteric, and
buccal vessels (6).
FLAP DESIGN AND DIMENSIONS
The skin and subcutaneous flap is based inferiorly near the angle of the mouth and may extend to the inner
canthus. The medial border lies in the paranasal sulcus above and in the nasolabial fold below (Fig. 183.1A).
The flap width and length are judged to fill the defect without tension and permit safe closure of the donor site.
The full width is maintained for most of the length. Flap width has varied from 1.5 to 3.0 cm, and narrower flaps

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have never been used.
FIGURE 183.1 A-C: Flap design and technique. (From Elliott, ref. 5, with permission.)
The design proximal to the skin-bearing triangle is held at full width for at least 1.5 cm to define a subcutaneous
pedicle to tunnel through the cheek. The remainder of the inferior pattern then tapers sharply to facilitate donor
site closure without a dog-ear (Fig. 183.1B).
A liberal arc of rotation similar to that of the arterialized flap (7) delivers this flap to most points in the oral cavity
and lateral pharynx with ease. The point of entry into the mouth can be varied slightly to bring the skin-bearing
tissue directly to the defect (Fig. 183.1C) but should remain above the angle of the mouth to assure the best flap
circulation (6).
OPERATIVE TECHNIQUE
The entire design pattern is outlined sharply through the dermis. Then the flap is elevated superficial to the facial
muscles, from superior to inferior, until the selected point for passage of the subcutaneous pedicle through the
cheek is reached.
A liberal tunnel is created through the cheek to avoid constriction of the pedicle. Blunt dissection minimizes the
threat of damage to the facial nerves and vessels as the flap is delivered into the defect beneath its nearest
border. After testing briefly for position and adequacy, the flap is marked to define the near border of the defect
and withdrawn.
The pattern is deepithelialized inferior to the mark, any hair follicles are removed conservatively, and the flap is
returned to the defect and inset with a single layer of nonabsorbable sutures. Tension must be avoided,
especially along the long axis of the flap. The donor site is closed superiorly by advancement or direct suture
and inferiorly by undermining and advancing the lateral cheek over the base of the pedicle to avoid distortion or
compression of the pedicle.

FIGURE 183.2 Squamous cell carcinoma excision of alveolus and palate in 85-year-old man. A: Lesion for full-
thickness excision through lining of maxillary antrum. B: Design of usable flap. C: Inset flap after 5 months. D:
Donor site at 33 months. (From Elliott, ref. 5, with permission.)
CLINICAL RESULTS
Over the past 20 years, I have used this flap for the one-stage repair of significant surgical defects of
anterior and posterior palate, including the uvula; tonsil and base of tongue; lateral tongue; oropharyngeal
wall; and floor of mouth, both lateral and anterior. It provided one-stage repair of alveolar and palatal
defects involving the maxillary sinus for three elderly, edentulous patients, one of whom is illustrated in
Figure 183.2.
My first candidate, a hearty 85-year-old man, was spared an antral fistula, had full rehabilitation after radical
neck surgery for metastatic disease, and remained free of clinical disease to his death at age 92. Other
operated patients had emphysema, heart failure, renal disease, obesity, diabetes, and alcoholism. Three
had a radical neck dissection as part of the procedure.
There have been no complications with this flap. Hair delivered into the oral cavity on one flap remained a
curiosity without clinical significance. No cysts have been seen; except for some flattening of facial contour
and a permanent scar, there is little evidence of surgery. Most facial scars become barely noticeable in
elderly patients, especially those following normal skin lines.
This flap design obviates the need for more complicated and risky techniques in the repair of a variety of
significant intraoral defects. It is my closure technique of choice whenever an adequate nasolabial donor
site can be matched with a significant intraoral defect, especially in the edentulous patient.
SUMMARY
An inferiorly based nasolabial skin flap, transposed on a subcutaneous pedicle buried in an ipsilateral cheek

tunnel, is proposed for the safe, one-stage repair of a variety of significant intraoral defects. This technique
has many advantages for elderly and high-risk patients and can be combined with radical neck dissection.
References
1. Rosenthal W. Verschluss traumatischer Gaumendefekte durch Weichteile des Gesichts. Zentralbl Chir
1868;43:596.
2. Esser JFS. Deckung von Gaumendefekten mittels Geslielter Naso-labial Haclappon. Dtsch Z Chir
1918;147:128.
3. Wallace AF. Esser's skin flap for closing large palatal fistulae. Br J Plast Surg 1966;19:322.
4. Georgiade N, Mladick R, Thome F. The nasolabial tunnel flap. Plast Reconstr Surg 1969;43:463.
5. Elliott RA. Use of nasolabial skin to cover intraoral defects. Plast Reconstr Surg 1976;58:201.
6. Herbert D, Harrison R. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg 1975;28:85.
7. Rose EH. One-stage arterialized nasolabial island flap for floor of mouth reconstruction. Ann Plast Surg
1981;6:71.

Chapter 184
Buccal Fat Pad Flap Plus Skin Graft to Oroantral and Oronasal
Defects
P. EGYEDI
H. MÜLLER
EDITORIAL COMMENT
The buccal fat pad is not readily considered as a potential flap. The cases illustrated here demonstrate its
usefulness in the closure of palatal defects.
The buccal fat pad can be used for closure of oroantral and oronasal defects in an area between the second
premolar anteriorly and a point approximately 1 cm dorsal to the pterygoid process in the soft palate (1). The
medial limit is about 0.5 cm from the midline, although the flap also has been used in defects just crossing the
midline of the palate (Fig. 184.1A).
INDICATIONS
Defects after resection for a mixed tumor of the lesser salivary glands in the posterior palatal region are
typical and most common indications for this procedure (Fig. 184.1B). Another indication for the procedure
is an oroantral fistula produced in the posterior region of the alveolar process after exodontia. The average
case can be closed easily with local flaps; however, bone loss may occur. If, in addition, soft tissues are
traumatized and scarred and tissue loss has occurred, it can be very difficult to close the oroantral
communication. In such cases, the buccal fat pad can be advantageously used.
Orthodontic surgery in the upper jaw is a further indication, especially in cleft palate patients, in whom an
irregular dental arch necessitates displacement of the anterior part of the alveolar process, leaving the
second or third molar in place. If advancement of the anterior fragment is necessary, a gap results. In this
situation, the buccal fat pad is a great help in obtaining primary closure.
ANATOMY
The anatomic label of the buccal fat pad is corpus adiposum buccae. It is a biconvex structure surrounded by a
thin but distinctive capsule, and it is situated in the buccal space between the buccinator muscle and the
masseter muscle (2, 3, 4) (Fig. 184.2). The fat pad attains its greatest volume in this buccal space, and it is this
part that should be used for the buccal fat pad flap.
The anterior aspect of the buccal fat pad protrudes into the oral cavity ventral to the anterior border of the
masseter muscle. From here it extends between the masseter and buccinator muscles to continue posteriorly
and superiorly into the fatty tissue that occupies the space between the masticatory muscles.
At the anterior border of the temporalis muscle, the fat pad extends upward into the temporal fossa between the
anterior border of the temporalis muscle and the temporal surface of the zygomatic bone. Around the tendon of
the temporalis muscle, an extension of the buccal fat pad communicates with the pterygomandibular space (Fig.
184.2). The main blood supply courses through this pedicle. It is derived from branches of the buccinator artery,

a branch of the internal maxillary artery. The buccinator artery communicates with the external maxillary and
transverse facial arteries.
OPERATIVE TECHNIQUE
An incision through the mucosa on the buccal aspect of the vestibulum in the molar region will readily expose the
buccal fat pad. A vertical mucosal incision slightly lateral to the anterior margin of the ascending ramus also will
result in a forward bulging of the fat pad. A third approach to the fat pad is elevation of a mucoperiosteal flap in
the molar region on the lateral aspect of the maxillary alveolar process and then incision of the periosteum at the
level of the buccal sulcus. The choice of exposure depends on the requirements of the specific situation in which
the flap is used.
After exposure of the buccal fat pad, it can be grasped with tissue forceps and carefully mobilized from its
anterior and caudal aspects. Care should be taken not to sever the pedicle from which the blood supply is
derived. The buccal fat pad then is drawn into the defect and sutured in place, avoiding rupture of this rather
friable fatty tissue (Fig. 184.3).
FIGURE 184.1 A: The oblique lines on the palate and alveolus delineate the “inner area” that can be closed by
the fat pad without additional flaps and where the success rate is 90% or higher. The more horizontal lines are in
the “outer area,” where residual fistulas may be expected in 50% or more of cases. Additional flaps may be
necessary to close defects in this outer area. B: Scheme of closure after partial maxillary resection along the
dotted lines. B, buccal fat pad; S.S.G., split-thickness skin graft.
A split-thickness skin graft is used to cover the flap on the oral side. The graft is sutured to the wound margins
and covered with iodoform gauze, held in place by crossing sutures. Alternatively, a denture can be made to
adapt the skin to the underlying fat by fixing the denture to the maxilla.
Depending on the width of the defect and the functional requirements in the area, additional flaps can be used to
provide coverage in an area beyond reach of the buccal fat pad. The authors have used the cheek flap (5), a
palatal island flap from the opposite side (6), and a cranially based pharyngeal flap for this purpose.

FIGURE 184.2 Illustration from Ranke's article describing dissection in an infant (4). Point 6 is connected by a
line to the pedicle of the buccal fat pad (5). 4, masseter muscle; 3, parotid gland; 7, zygomatic arch; 2, temporalis
muscle.
CLINICAL RESULTS
We used the buccal fat pad flap in 17 patients, 10 of whom had tumor surgery. It was used twice to close a
gap in the alveolar process during orthognathic surgery in cleft palate patients, twice to close a large, long-
standing defect in the premolar-molar region after dental extractions, and three times to fill a depression in
the canine fossa.
FIGURE 184.3 A: Mixed tumor of the palate. B: Defect after excision. C: The fat pad was moved over the
floor of the maxillary sinus into the defect. D: After healing of the skin graft, there was a minimal residual
fistula, which was closed later. This defect was almost beyond the reach of the fat pad.

Partial failure occurred in three patients after tumor surgery, resulting twice in a residual fistula that
measured 2 mm and could be closed by turnover flaps from adjacent tissue. In the third patient, a residual
fistula of 15 mm resulted that could be closed by a palatal island flap (6).
In five patients, additional local flaps were used in combination with the buccal fat pad to cover the entire
defect. None of the patients had any visible or functional deficit of the cheek caused by the use of this flap,
and so far the flap has not resulted in any complications.
SUMMARY
The buccal fat pad flap can be used advantageously in many unilateral defects in the posterior palate and
alveolus.
References
1. Egyedi P. Utilization of the buccal fat pad for closure of oro-antral and/or oro-nasal communications. J
Maxillofac Surg 1977;5:241.
2. van der Broek AJP. Leerboek der bijzondere ontleedkunde voor tandartsen, 2d Ed. Utrecht: Oosthoek's
uitgeversmij, 1946;76.
3. Merkel F. Handbuch der Topographischen Anatomie. Druck and Verlag von Friedrich Vieweg and Sohn,
1885-1890;460.
4. Ranke H. Ein Saugpolster in der Menschlichen Backe. Virchows Arch 1884;97:527.
5. Kaplan EN. Soft palate repair by levator muscle reconstruction and a buccal mucosal flap. Plast Reconstr
Surg 1975;56:129.
6. Worthington P. The management of the palatal pleomorphic adenoma. Br J Oral Surg 1974;12:132.

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Chapter 185
Intraoral R Econstruction With Tongue Musculomucosal Flaps
J. GUERREROSANTOS
EDITORIAL COMMENT
A good study of the vascular anatomy of the tongue and its relevance in the design of tongue flaps can be
found in Bracka, A. The blood supply of dorsal tongue flaps. Br J Plast Surg 34;379, 1981.
The tongue musculomucosal flap provides the most dependable means of reconstructing the lining of the oral
cavity. The tongue flap is especially useful in the surgical correction of palatal perforations that are large or
surrounded by thickened fibrous tissue. Using tongue flaps, a surgeon can be more aggressive in removing
tumors and still give the patient the opportunity for successful rehabilitation through immediate reconstruction.
INDICATIONS
Palatal Reconstruction
The tongue flap is particularly useful in heavily irradiated patients by providing additional muscle coverage
of the bones. It plays an important role in the treatment of large fistulas (1, 2, 3, 4, 5, 6, 7, 8, 9). The closure
of perforations in the soft palate is preferably done with the use of the palatal tissues themselves, and in
extensive perforations, we can use a combined reconstructive method that uses a tongue flap and a
pharyngeal flap.
Buccal Reconstruction
In the buccal area, tissue losses that include the mucosa alone or some or all of the anatomic layers can be
reconstructed with a tongue flap (10, 11). The flap can be designed to vary the amount of muscle that is
considered necessary for reconstructing the defect (see Fig. 185.5). For full-thickness cheek losses, the
tongue musculomucosal flap can be used for the inner lining, and the outer covering can be provided by
either a forehead flap or a large pectoralis major musculocutaneous flap.
Floor of the Mouth and Tonsillar Area Reconstruction
The tongue flap can be used for reconstructing either a primary or a secondary defect in both the floor of
the mouth (12, 13, 14, 15) and the tonsillar area (16, 17).
ANATOMY
A thorough appreciation of the anatomy of tongue flaps and their clinical applications is given in Chapter 177.
FLAP DESIGN AND DIMENSIONS
Palate
Proper planning of a tongue flap is essential to the success of the operation to ensure that the orientation of the
flap will be correct at each stage and that it will fit the defect without tension, kinking, or torsion. All possible sites
and orientations for the flap should be considered to ensure that the most suitable one is selected. Planning of

the tongue flap in reverse is probably the most important phase of the operation. Using a pattern of the defect,
the steps in the operative procedure are carried out in reverse order until the donor site is reached. The final
pattern should be larger than needed, particularly in length.
For reconstructing the palatal lining, it is advisable to use an anteriorly based tongue musculomucosal flap (Fig.
185.1). On the basis of my experience and that of some other authors, incisions should be made following the
longitudinal direction of the blood circulation of the tongue, always avoiding crossing the midlingual raphe. The
following dimensions should be used: 5 cm long, 3.5 cm wide, and two thirds of the thickness of the lingual
dorsum.
Buccal Area
To succeed in cheek reconstruction using a tongue flap, the following rules should be observed. Flaps should be
planned with a minimum width of 2 cm and a minimum thickness of 5 mm. I prefer dorsal or marginal flaps whose
pedicles are near the lingual apex. The pedicle should be long enough to permit mobility of the tongue without
allowing traction on the tip of the flap. If the loss of cheek mucosa is very extensive a large direct flap may be
used, taking care that the pedicle does not cross the median lingual raphe.
FIGURE 185.1 Anteriorly based tongue musculomucous flap used for the closure of perforation in the hard
palate. The flap should be 5 cm long, 3.5 cm wide, and quite thick. It is sutured into the fistula, and the pedicle is
sectioned 2 or 3 weeks later. (From Guerrerosantos, ref. 5, with permission.)
OPERATIVE TECHNIQUE
Palatal Reconstruction
The margins of the palatal fistula are first pared. About a 2-cm layer of tongue muscle is raised with the flap to
ensure that a full quota of blood vessels remains. Elevation of the flap is done in the direction of the pedicle as
far as necessary, checking at intervals to see at which point the flap is capable of reaching its destination without
tension.
The donor site is easily closed in two or three layers, leaving a small area open next to the flap pedicle to avoid
tension at the base of the pedicle and disturbance of the blood supply. The tip of the flap is sutured to the
margins of the fistula. The palatal closure of these wounds is critical to prevent added morbidity from small fistula
formation. Simple running sutures or simple interrupted palatal sutures often fail to evert the mucosa. I have used
a separate horizontal mattress suture to ensure the close approximation of tissues with minimal chance of
inversion of the epithelium (Fig. 185.2).

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After 3 weeks, the flap can be divided and sutured along the line 1.5 cm behind the posterior margin of the
defect. The bridge segment of the flap is turned upward to its original site, and insetting of the distal transferred
segment is completed. The bridge segment often tends to entube, and this must be undone by scoring and, if
necessary, by excising contracted scar tissue (Figs. 185.3 and 185.4).
Floor of the Mouth and Tonsillar Area Reconstruction, Buccal Area
The technique used in palatal reconstruction can be adapted to reconstruction of other intraoral areas (Figs.
185.3, 185.4, 185.5)
FIGURE 185.2 A: Palatal-alveolar fistula after noma. B: Closure of the fistula with tongue flap. C: Result is
shown 18 months after repair. (From Guerrerosantos and Altamirano, ref. 17, with permission.)
CLINICAL RESULTS
Like any other flap, the tongue musculomucosal flap is subject to complications if it is not used with
judicious care. All general flap principles should be observed faithfully. Complications have been generally
associated with local wound problems, such as localized infections and limited wound dehiscence. Tension
and distortion are the main enemies of successful tongue musculomucosal flap repair. Good arterial and
venous blood supply and gentle handling of tissue are its only allies.

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FIGURE 185.3 Tongue and floor of the mouth reconstruction. A: Defect on the lower aspect of the tongue
and floor of the mouth. B: An anteriorly based tongue flap is outlined, and a median window is made on the
midlingual line near the tip. C: Raising of the tongue flap. D: Suture of the flap into the defect. The flap
passes through a median window, its pedicle being buried. (From Guerrerosantos, ref. 5, with permission.)
Using the technique correctly, I have achieved success in 90% of my tongue flap patients, as far as flap
integration and healing are concerned. I caution that the surgeon should never design a transverse flap
across the lingual raphe because the distal portion of the flap will necrose. Also, the tongue flap
can fail in oral reconstruction if a short, thin flap is designed, if the flap is sutured under tension, if the
circulation is deficient, and if there is danger of the tongue separating the flap from the palate.
FIGURE 185.4 A: Intraoral photographs showing a patient with squamous cell carcinoma of the ventral
surface of the tongue and floor of the mouth. B: This patient was treated surgically using the technique
shown in Figure 185.3.
FIGURE 185.5 Cheek area reconstruction. A: A flap is planned on the lingual apex. B: Elevation of the
tongue flap. C: Suture of the flap into the defect. Three weeks later, the pedicle is sectioned. (From
Guerrerosantos, ref. 5, with permission.)

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SUMMARY
The tongue musculomucosal flap can be used to close various intraoral defects.
References
1. Conley JJ, De Amesti F, Pierce MK. Use of tongue flaps in head and neck surgery Surgery 1957;41:745.
2. Conley JJ. The use of lingual flaps in repair of fistulas of the hard palate. Plast Reconstr Surg
1966;38:123.
3. Guerrerosantos J, Garay J, Tones A, Altamirano JT. Tongue flap with triple fixation in secondary cleft
palate surgery. In: Transactions of the Fourth International Congress of Plastic Surgeons. Amsterdam:
Excerpta Medica, 1969;369.
4. Guerrerosantos J, Fernandez JM. Further experience with the tongue flap in cleft palate repair. Cleft
Palate J 1973;10:192.
5. Guerrerosantos J. Tongue flaps. In: Grabb WC, Myers MB, eds. Skin flaps. Boston: Little, Brown,
1975;216.
6. Jackson IT. Use of tongue flaps to resurface lip defects and close palatal fistulas in children. Plast
Reconstr Surg 1972;49:537.
7. Jackson IT. Closure of secondary palatal fistulas with intraoral tissue and bone grafting. Br J Plast Surg
1972;25:73.
8. Klopp CT, Schurter M. Reconstruction of palate with tongue flap and repair of tongue. Cancer 1956;9:1.
9. Quetglas J. Perforaciones del paladar. Rev Esp Cir Plast 1973;6:131.
10. Kleinschmidt O. Operaciones en las partes blandas y esqueleto de la cara. In: Kirschner M., ed. Tratado
de tecnica operatoria general y especial. Barcelona: Editorial Labor, 1948;378.
11. Schultz RC. Regional considerations in repairing soft tissue. In: Schultz RC ed., Facial injuries. Chicago:
Year Book Medical Publishers, 1970;118.
12. Oneal RN. Oronasal fistulas. In: Grabb WC, Rosenstein SW, Bzoch KR, eds. Cleft lip and palate.
Boston: Little, Brown, 1971;490.
13. Papaioannou A, Farr H. Reconstruction of the floor of the mouth by a pedicle tongue flap. Surg Gynecol
Obstet 1966;122:807.

14. Pilhew FR. Tongue flap in oral surgery. Boll Soc Cirug (Buenos Aires) 1964;48:442.
15. Som ML. Marginal resection of the mandible with reconstruction by tongue flap, for carcinoma of the floor
of the mouth. Am J Surg 1971;121:679.
16. Fernandez-Villoria JM. Tonsillar area reconstruction. Plast Reconstr Surg 1967;40:220.
17. Guerrerosantos J, Altamirano JT. The use of lingual flaps in repair of fistulas of the hard palate. Plast
Reconstr Surg 1966;38:123.

Chapter 186
Bucket-Handle Vestibular Mucosal Flap to Anterior Palate
P. EGYEDI
H. MÜLLER
EDITORIAL COMMENT
This technique certainly accomplishes its task; however, the buccal sulcus, which is very difficult to recreate
at a later time, is sacrificed unless the patient is committed to an Abbé flap.
The problem of minor residual fistulas and clefts adjacent to the premaxilla or in the palate has received little
attention in the literature compared with other aspects of clefting. The reason may be that these fistulas are often
symptomless, and surgical correction may be difficult and disappointing. Also, prosthetic covering of these
fistulas is sometimes successful, although the long-term effect of any partial prosthetic appliance on the
remaining dentition must be taken into account.
INDICATIONS
Some indications for closure of palatal fistulas are (a) escape of liquids through the nose, (b) escape of air
through the nose during speech, (c) impaction of solid food particles in the fistula, and (d) the need to
immobilize the premaxilla with a bone graft for prosthetic purposes.
ANATOMY
As Figure 186.1 demonstrates, the pedicle of the flap is situated laterally, and the base is well vascularized (1),
unlike the base of the vestibular flap, which can be used most successfully in unilateral clefts and is situated
medially in the region of the cleft. The vessels involved are branches of the labial and infraorbital arteries. The
midpart of the flap, however, is composed partly of scar tissue, a condition that must be noted.
FLAP DESIGN AND DIMENSIONS
In unilateral clefts, the average fistula can be closed with a vestibular flap (2). In major openings, the tongue flap
(see Chapter 185) can be used advantageously (3). In bilateral cleft patients in whom a Y-shaped opening
around the premaxilla exists, bilateral vestibular flaps can be used, but the failure rate seems fairly high. Because
the base of the vestibular pedicle is usually scarred by previous operations, the blood supply must be assumed
to be marginal, and where the two flaps meet, tip necrosis occurs frequently.
OPERATIVE TECHNIQUE
Two parallel incisions are made in the vestibulum (Fig. 186.1A). The width of the flap is between 0.4 and 1 cm,
depending largely on the local anatomy and the depth of the vestibular sulcus. Exact measurements cannot be
given, because irregularities in the scarred area are considerable. If the vestibulum is quite shallow, the surgeon
should be careful not to remove too much tissue from the inner aspect of the lip unless correction with an Abbé
flap is planned.
The inner of the two incisions is carried to the alveolar bone. The periosteum can be raised over a small distance

(e.g., 0.2 cm), but then the flap leaves the bone to enter the vestibular tissue to meet the outer incision just labial
to the vestibular “crest.” At this stage, after the bucket-handle flap has been raised, an attempt is made to obtain
a nasal layer of epithelial tissue on both sides of the premaxilla.
A “circumcision” of the Y-shaped area is done, the periosteum of the premaxilla and the lateral alveolar segments
are raised, and the nasal layer is closed with inverted sutures. Access may be extremely difficult in these
patients, and if a reliable closure is not possible, one sometimes must resort to deepithelialization of the fistula
and to closing it with a single layer of tissue on the oral surface. In this latter case, however, introduction of a
bone graft into the cleft cannot be done in the same operation. As a rule, the bulk of the bucket-handle flap is
such that the alveolar gap can be plugged over a considerable area. Whenever a more or less reliable nasal
layer closure can be obtained, introduction of autogenous bone is usually indicated, since the success rate of
closure is greatly increased (4). Suturing should be done with fine atraumatic sutures (Fig. 186.2).
FIGURE 186.1 A: Schematic drawing of the bucket-handle vestibular mucosal flap. At X, the extension
mentioned in the text could be made to cover the dorsal part of a Y-shaped fistula. In the situation depicted here,
this would be useless. B: The flap was sutured into the anterior part of the fistula. The defect dorsal to the flap
sometimes can be closed by mobilizing the palatal mucoperiostea (arrows) and suturing them together. C:
Alternative method of closure of the dorsal part of the defect using one end of the bucket-handle flap at a second
operation (see text). (From Egyedi, ref. 1, with permission.)
After treatment, a petrolatum-impregnated iodoform gauze is lightly applied over the whole area and kept in place
with sutures fixed to adjacent teeth, forming a network over the area. Sutures and pack are covered by cold-cure
acrylic. Additionally, 600,000 units of penicillin G are administered for 2 days.
CLINICAL RESULTS
Eighteen patients have been treated with this flap. In one patient, necrosis of the area of the flap behind the
premaxilla resulted, and this should be considered a failure. In all other patients, flap survival was
satisfactory, although in a few patients, superficial necrosis with loss of epithelium was seen; however,
these patients had reepithelialization within a few weeks, and the desired closure in the alveolar area was
invariably obtained. In three patients, the most distal part of the fistula of the anterior palate remained
patent. In two patients, persistent fistulas were closed at a second operation because of subjective
complaints. Significant bone loss in this area was observed in two of seven patients in whom bone was
inserted. Total loss of the bone graft occurred in the patient in whom there was necrosis of the flap.

FIGURE 186.2 Typical end result after stabilization of the premaxilla and closure of the residual cleft with
the bucket-handle vestibular mucosal flap. The pedicles and the slight bulging immediately dorsal to the
incisors can be seen clearly.
A significant disadvantage is the unavoidable reduction of the vestibulum oris, especially anterior to the
premaxilla. Correction with a vestibuloplasty in a second operation is possible, or if indicated, an Abbé flap
can be done.
Sometimes it is necessary to displace the premaxilla to get a satisfactory occlusion. In such instances, the
bucket-handle flap, unlike two vestibular flaps, cannot be used in the same operation. In vestibular flaps, the
soft-tissue pedicle to the premaxilla serves also as the blood supply; however, the difficulty of getting a
proper nasal layer makes this combined operation rather risky anyway.
The pedicle of the bucket-handle flap sometimes presents an obstacle for construction of an anterior bridge;
also, the pedicles may produce a sensation of restricted movement of the lip for the patient. In such
instances, the pedicles should be divided at the height of the alveolar process and replaced in their original
position.
In Y-shaped fistulas, the dorsal leg of the Y cannot, as a rule, be covered properly by the bucket-handle flap
unless the leg is very short. In this instance, the bucket-handle flap can be provided with an extension to
cover this part of the fistula also (Fig. 186.1A). If the latter procedure is not possible, one can secondarily
dissect half the palatal part of the bucket-handle flap and swing it over to the dorsal leg of the Y (Fig.
186.1C), with the blood supply provided by the opposite part of the flap. Alternatively, one can try to obtain
closure of this part of the gap by approximating two palatal flaps (Fig. 186.1B), but the results are often
disappointing.
SUMMARY
The bucket-handle vestibular mucosal flap can be used to close small anterior palatal fistulas.
References
1. Egyedi P. The bucket-handle flap for closing fistulas around the premaxilla. J Maxillofac Surg 1976;4:212.
2. Burian F. Chirurgie der Lippen- and Gaumenspalten. Berlin: Verlag, 1963.
3. Guerrerosantos J, Altamirano JT. The use of lingual flaps in repair of fistulas of the hard palate. Plast

Reconstr Surg 1966;38:123.
4. Perko M. Gleichzeitige Osteotomie des Zwischenkiefers, Restspaltenverschluss and
Zwischenkieferversteifung durch sekundare Osteoplastik bei Spatfallen von beidseitigen Lippen-, Kiefer, and
Gaumenspalten. Dtsch Zahn Mund Kieferheilk 1966;47:1.

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Chapter 187
Palatal Mucoperiosteal Island Flap
P. J. GULLANE
S. ARENA
EDITORIAL COMMENT
This procedure appears to provide adequate coverage in the adult after tumor resection or trauma. The
editors believe it should not be used in the growing child because of possibly severe secondary effects on
the dentition and palatal growth.
The palatal mucoperiosteal island flap serves to resurface defects of the soft palate, retromolar trigone, buccal
region, tonsillar fossa, and posterior third of the floor of the mouth. Palatal flaps have been used for some time in
palate-lengthening procedures, in closure of oroantral fistulas, and in resurfacing intraoral defects (1, 2, 3, 4, 5,
6, 7). The success of this flap depends on the external carotid system and an intact palate.
INDICATIONS
Soft Palate Reconstruction
This flap provides adequate local tissue to reconstruct the soft palate after tumor ablation. The periosteal
surface that faces cephalically does not require coverage (see Fig. 187.2). Alternatively, two separate
mucoperiosteal island flaps can be used and tailored to fit the defect (see Fig. 187.3).
Tonsil and Retromolar Trigone Defects
Ablation of cancer in the tonsillar and retromolar trigone areas frequently leaves a defect that is too small for
a regional flap but is suitable for local flap reconstruction. Various reconstructive techniques include skin
grafts and local tongue flaps. The palatal mucoperiosteal island flap provides adequate tissue, good
reliability, and excellent healing, even when used over exposed bone.
Buccogingival Sulcus Relining
Many benign tumors and occasionally low-grade cancers (verrucous carcinoma) occur in the region of the
buccogingival sulcus. Wide surgical extirpation leaves a defect that, if it is lined with a skin graft, leads to
cheek contracture. The palatal flap with a “free up” procedure in the greater palatine foramen will provide
adequate tissue coverage in a one-stage operation without the disadvantages inherent in the use of skin
grafts.
The many advantages of the palatal mucoperiosteal island flap include a local source of tissue, a strong
flap with good blood supply, excellent mobility (it can be positioned anywhere through an arc of 180
degrees), adequate bulk and length, a limited impairment of speech, and a success rate of 96%. These
many advantages compensate for the relatively prolonged 2 to 3 months required for epithelialization of the
donor site over the hard palate.

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FIGURE 187.1 A: Outline and elevation of mucoperiosteal island flap. B: Flap elevated and rotated through
180 degrees into the operative defect.
ANATOMY
The hard palate is composed of the premaxilla, maxilla, and palatine bones. The main mass of the hard palate is
made up of the palatal processes of the maxilla, and posteriorly, the horizontal plate of the palatine bones
completes the bony shelf. The greater palatine foramen lies between the palatine bone and the maxilla. The
lesser palatine foramina perforate the palatine bone itself.
The mucous membrane of the anterior hard palate is strongly united with the periosteum, forming the
mucoperiosteum, which can be readily stripped from the bone. The attachment of the periosteum to the bone is
secured by multiple fibrous tissue pegs (Sharpey's fibers).
The blood supply to the hard palate is provided by the greater palatine artery, which emerges from the greater
palatine foramen and courses anteriorly along the lateral margin of the palate to enter the incisive foramen.
Venous drainage accompanies the artery back to the pterygoid plexus.
OPERATIVE TECHNIQUE
Approximately 85% of the soft tissue over the hard palate may be elevated on one greater palatine artery and
rotated through 180 degrees to resurface an intraoral defect. The incisions are carried through the periosteum,
and the opposite greater palatine artery is ligated. At the junction of the soft and hard palates, 0.5 to 1.0 cm of
overlap should be provided to prevent a nasopalatine fistula (Fig. 187.1).
The vascular bundle then is carefully identified, and if further length to the pedicle is necessary, a greater
palatine
foramen “free up” procedure can be accomplished with a fine burr and a fracture of the hook of the hamulus. In
freeing up the neurovascular bundle from its foramen by this maneuver, a further 1.0 cm of length can be
provided to the flap. This flap now will provide 8 cm2 of tissue. The palatal defect is left to epithelialize
spontaneously. By 3 months, there is complete healing of the denuded donor site (Figs. 187.2 and 187.3).

FIGURE 187.2 Palatal flap reconstructs half the soft palate. Note the good epithelialization of the donor site.
FIGURE 187.3 A: Two separate mucoperiosteal island flaps used to reconstruct the total soft palate. B: Flaps
sutured in position.
CLINICAL RESULTS
This flap has been used in 52 patients over an 8-year period. No fistulas of the palate have occurred;
however, flap necrosis developed on two occasions. The high success rate is attributable to excellent blood
supply and careful identification and preservation of the vascular pedicle. The greater palatine foramen
“free-up” provides an extra 1.0 cm of length to the flap, but extreme caution should be exercised to prevent
damage to the neurovascular bundle.

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SUMMARY
The palatal mucoperiosteal island flap can be used to cover defects in the soft palate, the tonsil area, and
the retromolar trigone regions as well as to provide lining for the buccogingival sulcus.
References
1. Millard DR. The island flap in cleft palate surgery. Surg Gynecol Obstet 1963;116:197.
2. Wilson JSP. The application of the two-centimeter pedicle flap in plastic surgery. Br J Plast Surg
1967;20:278.
3. Henderson D. Palatal island flap in closure of oroantral fistula. Br J Oral Surg 1974;12:141.
4. Herbert DC. Closure of a palatal fistula using mucoperiosteal island flap. Br J Plast Surg 1974;37:332.
5. Millard DR, Seider HA. The versatile palatal island flap: its use in soft palate reconstruction and
nasopharyngeal and choanal atresia. Br J Plast Surg 1977;30:300.
6. Gullane PJ, Arena S. Palatal island flap for reconstruction of oral defects. Arch Otolaryngol 1977;103:598.
7. Montandon D, Lehmann W. An island palatal flap for velum reconstruction. Chir Plast 1980;5:257.

Chapter 188
Cervical Skin Flap for Intraoral Lining
V. Y. BAKAMJIAN
Before the post-World War II era of advances in reconstructive surgery, most repairs after cancer surgery of the
head and neck involved direct suturing of oral wound edges. Reconstruction was often postponed for an
arbitrary 6 or 12 months to rule out recurring cancer before embarking on a protracted plan of reconstruction with
flaps migrated from distant sites.
The next reconstructive advance—choosing cervical skin to replace losses of oral lining—seemed a natural
choice (1, 2, 3, 4). A skin flap could be outlined on the neck in either a transverse, oblique, or vertically
downward direction from a superolateral base below the mastoid process and angle of the mandible (Fig.
188.1A). This location was chosen for its proximity to oral sites as well as for the blood supply from branches of
the external carotid artery.
In view of the limitations imposed on the use of cervical skin following radical neck dissection, however, it is not
at all surprising that cervical neck flaps have been almost completely abandoned for intraoral lining in favor of
later more versatile techniques that followed the introduction of deltopectoral (5, 6), musculocutaneous (7, 8),
and free flaps (9, 10).
INDICATIONS
Advantages of the cervical skin flap are (a) proximity for direct transfer to intraoral common defects, (b)
thinness and pliability of the flap, (c) better than average random-pattern vascularity than in skin on the
torso or extremities, and (d) the laxity of aging cervical skin from which it is convenient to borrow flap
material. In the form described herein, it is capable of lining moderate-sized oral defects fairly well, leaving
only an inconspicuous linear scar on the neck.
If a cervical flap is to be used, it is important that this option not be destroyed by the routine incisions
habitually employed for radical neck dissection (5). Instead, by accurately anticipating reconstructive
requirements before the recipient defect is created by resection, the surgeon should tailor neck incisions for
each patient to meet the requirements for the formation of an appropriate flap for reconstruction.
FLAP DESIGN AND DIMENSIONS
Generally, only the transverse variant of the flap for use in elderly female patients remains a practical option (Fig.
188.1B). This is only possible with no more than a supraomohyoid neck dissection. In this form, the flap is
outlined so that its maximal width permits direct closure of the donor wound. The safe length of the flap may be
to the anterior border of the contralateral sternocleidomastoid muscle.
OPERATIVE TECHNIQUE
Raising the flap may or may not include the thin platysma layer of muscle with the skin, as the surgeon chooses.
Either choice cannot significantly influence the success or failure of the flap because the platysma does not
extend to the base area of the flap over the upper third of the sternocleidomastoid muscle (Fig. 188.1D).
Depending on the location of the recipient defect, the flap will pass to its destination either buccally or lingually in
relation to the mandible through a portal generally in the vicinity of its angle (Figs. 188.2 and 188.3). The

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passage is treated with the caution that is usual for avoiding injury to the marginal mandibular branch of the
facial nerve. After the flap is sutured distally into the defect, its basilar segment within the short tunnel is entubed,
skin side inward, forming a skin-lined fistula, and the donor neck wound is closed by direct suturing of its edges.
A minor second-stage procedure some 2 to 3 weeks later will divide the pedicle and close the fistula.
FIGURE 188.1 A: Varying projections for a cervical skin flap from a more or less superolateral common base
under the mastoid process and angle of the mandible. B-E: Varying incisional patterns that may provide good
exposure for neck dissection simultaneously with the formation of a flap for intraoral lining. Absence of the layer
of platysma muscle from the base area that is common for cervical flaps.
FIGURE 188.2 An obsolete example of the oblique variant of cervical flap that could be used in male patients to
obtain hairless supraclavicular skin, if it were available, for the intraoral defect. A: A faucial and soft palatine
lesion. B: The raised flap and the defect viewed from below. (Continued)

FIGURE 188.2 Continued C: The fistula of flap entry. D: Oral view of the reconstruction.
CLINICAL RESULTS
In an early series of 20 patients in whom a cervical skin flap was used for intraoral lining, 18 had had radical
neck dissection and two had had supraomohyoid neck dissection. Four of the 20 flaps failed, all the failures
occurring in patients with radical neck dissection and with flaps of an oblique or vertically downward
orientation.
FIGURE 188.3 A bilobed version of the transverse cervical flap to a glossal and glossopalatine area defect.
A: The defect. B: Outline of the flap. C: Intraoral view of the repair. D: The fistula. E: Division of the
pedicle and closure of the fistula.
SUMMARY
Cervical skin flaps once were used extensively for intraoral lining. They recently were supplanted by the
more versatile and reliable techniques introduced by deltopectoral, musculocutaneous, and free flaps. The
transverse cervical flap still has some value for the elderly female patient in whom node dissection is limited
to the supraomohyoid area.

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References
1. Edgerton MT. Replacement of lining to oral cavity following surgery. Cancer 1951;4:110.
2. Edgerton MT, DesPrez JD. Reconstruction of the oral cavity in the treatment of cancer. Plast Reconstr
Surg 1957;19:89.
3. DesPrez JD, Kiehn CL. Methods of reconstruction of anterior oral cavity and mandible malignancy. Plast
Reconstr Surg 1959;24:238.
4. Bakamjian VY, Littlewood M. Cervical skin flaps for intraoral and pharyngeal repair following cancer
surgery. Br J Plast Surg 1964;17:191.
5. Bakamjian VY, Marshall D. Plastic and reconstructive considerations in selecting incisions used for radical
neck dissection. Aust N Z J Surg 1967;36:184.
6. Bakamjian VY. The reconstructive use of flaps in cancer surgery of the head and neck. In: Saad MN,
Lichtveld P, eds. Reviews in plastic surgery: general plastic and reconstructive surgery. Amsterdam:
Excerpta Medica, 1974.
7. Brown RG, Fleming WH, Jurkiewicz MJ. An island flap of the pectoralis major muscle. Br J Plast Surg
1977;30:161.
8. Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck.
Plast Reconstr Surg 1979;63:73.
9. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomosis. Plast Reconstr Surg
1973;52:111.
10. Harii K, Ohmori K, Ohmori S. Hair transplantation with free scalp flaps. Plast Reconstr Surg 1974;53:410.

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Chapter 189
Submental Skin Flap for Intraoral Lining
M. SOUSSALINE
A submental skin flap for the reconstruction of mucosal cheek defects after cancer resection is described (1, 2,
3). Mucosal cheek defects up to 6 × 6 cm with overlying intact cheek skin can be closed with this flap.
INDICATIONS
Women with an excess of skin in the submental area yield the best results. The quality and flexibility of the
skin are quite close to those of the mucosa. Male bearded skin is less desirable. Reconstructions following
the primary resection of small T1-T2 cheek cancers, where the cheek skin is in good condition, are most
satisfactory. Radiation therapy to the submental skin is a contraindication to the use of this flap.
ANATOMY
The flap includes the underlying muscular fascia. Blood supply is from the anterior and inferior branches of the
facial artery, and venous drainage is provided by the anterior jugular vein, which must be preserved. The
dissection is started at the distal end of the flap to preserve venous drainage.
FLAP DESIGN AND DIMENSIONS
This flap is based on a 6- to 7-cm-wide pedicle in the submental region. The flap is 10 to 12 cm long, and its long
axis is horizontal. The posterior side of the flap lies in the fold between the submental anterior cervical areas
(Fig. 189.1A).
OPERATIVE TECHNIQUE
After the flap is raised, a tunnel is made along the buccal surface of the lateral anterior mandible to reach the
buccal sulcus and the inferior margin of the cheek resection. The flap then is turned into the mouth (Fig. 189.1B).
The tunneled portion of the flap is deepithelialized, and the flap is then sutured to the mucosal defect with 3-0
nylon.
The flap donor area is closed by approximation of the wound edges. A dressing to provide soft compression on
the flap is sutured in place (Fig. 189.1C). The dressing is removed after 5 days. A feeding tube is used until
healing has taken place.
CLINICAL RESULTS
I have used this technique in three patients with good results. There has been no flap necrosis, and healing
was complete in 3 weeks. The cosmetic result at the flap donor site was acceptable.
SUMMARY
The submental skin flap can be used in one stage for intraoral lining of cheek defects.

FIGURE 189.1 A: Dashed line (a) outlines the submental skin flap. Arrow (b) is at the base of the flap.
Dotted line (c) indicates the intraoral portion of the flap. B: Mucosal cheek defect is at (a). Tunnel between
the pedicle of the flap and the cheek is at (b). Pivot point of the flap is at (c). The deepithelialized portion of
the flap is at (d). The portion of the flap used for lining is at (e). C: Deepithelialized portion of the flap has
been tunneled at (a). Dressing (b) is sutured in place.
References
1. Hadjistamoff B. Restoration of cheek by using the skin of the jaw-neck region. Plast Reconstr Surg
1947;2:127.
2. De Cholnoky T. Cheek repair of extensive soft-tissue losses. Plant Reconstr Surg 1955;16:288.
3. Soussaline M, Senechal G, Cachin M, et al. La chirurgie reparatrice en carcinologie cervico-faciale.
Paris: Ste. Franc ORL et path cervico-faciale, 1977.

Chapter 190
Anterior Cervical and Lateral Cervical Apron Skin Flaps
B. W. EDGERTON
EDITORIAL COMMENT
This clever way of obtaining thin skin to resurface the floor of the mouth has the disadvantage that it cannot
be used in postradiation neck dissections, particularly if the carotid vessels are exposed. The temporary
fistula would be a serious disadvantage if radiation were contemplated postoperatively. The fistula can be
avoided (see text). The author continues to believe that the safest and simplest techniques should be used
when the results are comparable; regional flaps do sometimes get neglected.
Following World War II, the need for a method of immediate reconstruction of the lining of the oral cavity following
surgical resection of large malignant tumors stimulated the design of a variety of new pedicle skin flaps about the
head and neck (1, 2, 3). One of the most useful of these new regional flaps proved to be the cervical apron flap.
Even in the 1990s this method offers certain advantages over the use of free flaps in cancer reconstruction.
INDICATIONS
The reconstruction of large lining defects in the oral cavity continues to be one of the (if not the most)
important features in satisfactory functional rehabilitation of speech, eating, and appearance after the
removal of large cancers of the head and neck. Resected lining of the oropharynx may be satisfactorily
replaced by free skin grafts, but if good functional results are to be expected following resections of the
anterior cavity, with or without removal of the symphysis of the mandible, a pedicle flap must be used.
Bilateral nasolabial fold flaps will provide lining for the oral cavity in modest amounts (up to 2 inches), but
usually the defects following adequate cancer resections are too large. The surgeon should consider the
use of an apron cervical pedicle flap.
There are several advantages to the use of this particular flap in the treatment of oral cavity malignancy.
The flap allows transfer of non-hair-bearing skin from the anterior or lateral neck region into the oral cavity
by means of a transverse superior pedicle that is based along the lower border of the mandible. This apron
of skin is used to provide needed lining for the floor of the mouth or the alveolar and buccal regions. It also
will serve to replace resected tongue or to line the lower lip.
Elevation of the flap exposes the underlying deep contents of the neck, thus facilitating neck dissection and
the removal of cervical lymph nodes that so often accompany the surgical excision of squamous cancer of
the oral cavity. The apron cervical flap may be elevated, folded, and transferred at the time of tumor
resection without prior delay procedures. It may be transferred, along with closure of the orocutaneous
fistula, as a one-step procedure if desired (4).
I have continued to find the apron flap to be the most reliable and dependable “workhorse” for anterior oral
cavity lining reconstruction. This flap also has proved to be of significant value in the repair of certain
congenital defects, such as aglossia-adactylia, and in the repair of gunshot wounds with major losses of the
floor of the mouth and mandible.

ANATOMY
The circulation to the flap is highly reliable in the absence of preoperative intensive radiation therapy to that
portion of the neck. The blood supply of this flap is so vigorous that it has proved to be one of the few regional
flaps in the head and neck region that will support an immediate free bone graft to a defect in the mandible—
providing a high probability of bone graft osteosynthesis. Pedicle flaps of less vigor, such as those from the chest
or shoulders, often are associated with slow bone graft absorption when used to cover an immediate bone graft.
Although this is treated as a random pedicle flap, it does in fact receive descending branches from the labial
vessels and from vessels reaching the flap from each lower cheek region.
In most instances, the flap is elevated so that it includes the platysma muscle underlying the entire apron flap.
This muscle provides a vigorous layer of blood vessels to nourish the flap, analogous to the additional circulation
provided through the deep fascia in modern fasciocutaneous flaps.
FLAP DESIGN AND DIMENSIONS
This flap must be planned from the outset of treatment because it is not possible to use it once a neck dissection
has been performed through the usual neck incisions. It is a flap that should be used with caution even in a
nonoperated neck if that patient's neck has been exposed to a heavy dose of preoperative radiation.
Certain anatomic points need to be considered in the design and planning of an apron cervical flap. In female
patients, the absence of hair-bearing skin in the neck gives one the latitude to design the flap so that the apron
lies at a somewhat higher level on the neck than in male patients. With men, that portion of the flap destined for
permanent intraoral replacement should be marked carefully to lie inferior to the normal beard line in the lower
neck (Figs. 190.1 and 190.2). The width of the expected lining defect within the oral cavity should be estimated
carefully. The width of the apron part of the flap need not exceed that measurement.
There is essentially no limit to the width of this flap. The pedicle will easily carry sufficient non-hair-bearing skin
from the lower neck to replace the entire width of the anterior oral cavity. I have moved flaps with aprons up to 14
cm wide and 10 cm long. It is unusual to require this much flap tissue for oral cavity repair.
FIGURE 190.1 In the first stage, a primary cancer of the right floor of the mouth was removed in continuity with a
right radical neck dissection. The contents of the deep neck were exposed by the design and shape of the apron
flap. The lower part of this flap, or the “apron,” must be raised from a part of the neck below the hairline in men.
In most instances, the chin and lower lip-splitting incision used here for exposure is unnecessary. I currently
extend this medial incision at the hyoid level toward the mastoid process on the contralateral side. A deliberate
dart is created along the anterior border of the skin graft to avoid any later linear contracture.

FIGURE 190.2 The second stage is carried out 3 to 4 weeks later. The upper margin of the previous skin graft is
slightly elevated and sutured to the divided margin of the skin flap just above. The non-hair-bearing portion of the
apron flap then is drawn into the oral cavity and fitted to the remaining defect, with the excess being trimmed.
When desired, a portion of this flap can be carried across the floor of the mouth and used to replace tongue that
may have been resected with the primary tumor.
OPERATIVE TECHNIQUE
After designing the flap to meet width requirements for the lining defect within the oral cavity, the incisions in the
neck above the apron are allowed to widen out toward the tip of the mastoid process on the ipsilateral side and
laterally toward the angle of the mandible on the contralateral side of the neck. This gives an extremely wide
pedicle that receives circulation from both sides of the skin of the upper neck (Fig. 190.3A). The platysma muscle
is usually left on the deep surface of the apron flap and elevated with the skin and subcutaneous tissue.
The facial artery and vein may be sacrificed on both sides of the neck at the lower border of the mandible along
with the removal of the tumor without serious jeopardy to the blood supply of this flap. When one reaches the
level of the cervical branch of each facial nerve to the lower lip, that nerve is identified and lifted upward with the
pedicle, thus preserving good lower lip function bilaterally.
The elevated flap then is reflected upward onto the patient's face. The neck dissection is carried out on one or
both sides of the neck along with the indicated removal of mandible, floor of mouth, and a margin of normal oral
cavity mucosa around the tumor. When a segment of the mandible has been resected, a bone graft from the iliac
crest is fashioned and fit to the defect. A small steel bar below the bone graft provides additional fixation by
wiring to the mandibular fragments (bone and bar technique).

FIGURE 190.3 A: This patient had a large cancer of the floor of the mouth penetrating the lingual cortex of the
mandible. A single 1.5-cm-diameter lymph node in the left carotid triangle was positive for squamous cell
carcinoma. At the outset of stage 1, the incision shown was used to elevate a large apron flap from the lower left
neck region with a wide pedicle extending from one mastoid tip to the other. (The incision for this flap must be
planned before the neck dissection is undertaken.) The platysma muscle is lifted with the skin flap. The tumor
then was removed in continuity with a complete left neck dissection and a supraomohyoid neck dissection on the
right side. The involved mandible was resected with the specimen over a 12-cm-wide central area. The floor of
the mouth and a small portion of the anterior tongue were included for good tumor margin. B: The mandible has
been replaced with an iliac bone graft and small transosseous steel bar. The apron flap has been folded about
the bone graft and may be seen with its margin sutured to the remaining mucosa on the deep surface of the
lower lip. The tongue thus remains free for the important functions of talking and eating. C: At the end of the first
stage, the patient's mandible has been satisfactorily reconstructed. A narrow fistula extends from the neck up into
the oral cavity along the pedicle of the flap and is left for several weeks until stage 2 is performed. D,E: The
postoperative appearance of the patient following the second stage of the apron flap procedure. At that
operation, the pedicle of the flap was divided and its intraoral portion was attached to the underside of the
tongue tip. The neck fistula then was closed by suturing the skin in the left submaxillary region to the upper
margin of the previously applied skin graft. At 11 years after surgery, there was no recurrence of the squamous
cell carcinoma. (A, B, and C from Edgerton, DesPrez, ref. 4, pp. 100-101, with permission.)
The apron then is folded inward and around the lower border of the bone graft and bar so that the skin from the
lowest margin of the apron flap is brought up into the oral cavity (Fig. 190.3B). This edge is sutured to the
remaining mucosa on the deep surface of the lower lip at the anterior border of the mucosal defect created by
resection of the cancer. The lap thus surrounds the bone graft, covering its anterior, inferior, and posterior
surfaces. The lower neck is closed with a split-thickness skin graft so that a deliberate fistula is left leading from
the oral cavity outward along the pedicle of the apron flap to the surface of the neck (Fig. 190.3C). The
orocutaneous fistula is closed at a second operation 3 to 4 weeks later (Fig. 190.3D). It is of interest that very
few mechanical problems are experienced by the patient during the 4-week interval, and minimal salivary
discharge occurs through the fistula. This is important because many patients also will have a tracheostomy

during that period.
Variations in Operative Techniques
The cervical apron flap may be transferred along with closure of the orocutaneous fistula as a one-step
procedure, if desired, by removing the epidermis over that portion of the pedicle that transverses the submaxillary
and submental spaces of the neck (4). This method will leave a permanent blood-bearing pedicle supplying the
apron portion of the flap that constitutes the new lining of the oral cavity. The donor site in the lower neck causes
minimal deformity and may be closed either by a simple split-thickness skin graft or by rotation of an adjacent
regional flap.
I have used the cervical apron flap as a one-stage island flap technique by removing the epidermis of the folded
pedicle and closing the cervical skin and fistula at the primary operation. There are two disadvantages to this
one-stage method: (a) unless the tongue remnant is mobile, the approximation of the lining portion of the flap to
the posterior part of the oral cavity defect (usually along the residual resected body of the tongue) is more
difficult and less ideal; and (b) the closure of the neck incision is likely to be dimpled or puckered at the point of
the pedicle. For these reasons, I usually carry out the apron flap as a two-stage technique.
At times, the skin of the lower lip or chin may be involved in a malignant process that also extends into the oral
cavity. When this is the case, the apron flap technique still may be used, but it is designed as a double-pedicle
flap. The involved skin of the chin and lip is resected, but a pedicle base is left on either side of the chin defect.
Each lateral pedicle may extend to the lobe of the ear. These two lateral pedicles appear to be quite adequate to
allow an apron of skin from the lower neck to be brought upward and folded in a similar fashion to the standard
cervical apron flap. The central upper border of the flap is advanced up into the chin and lip area to close the
defect in that region. The apron then is turned under the reconstructed mandible to line the cavity in the fashion
described above.
In a few instances, I have included a segment of the clavicle in the soft tissue beneath the apron of the flap,
using this as a bone graft for the mandible. Because free bone grafts do well when placed within the standard
apron flap, it is difficult to know whether inclusion of the clavicle adds significantly to the technique (5). The blood
supply that this segment of clavicle receives from the undersurface of the apron flap must be relatively small, but
the bone ends do bleed modestly at the time of transfer.
CLINICAL RESULTS
The vigorous blood supply to the cervical apron flap has made flap necrosis an uncommon occurrence. In
approximately 3% of the elevated flaps, some degree of full-thickness necrosis occurs postoperatively along
the lining portion of the apron flap. In most instances, these are small areas of demarcation along the
sutured edges of the flap only a few millimeters in width. In no instance have I experienced a major loss of a
flap requiring an additional flap from another source.
Vilray Blair et al. (6) pointed out years ago that the blood supply about the head and neck of males, even
those of advanced age, was so satisfactory that age was little or no contraindication to the design and
transfer of flaps in that region. I have found this to be the case. The exception occurs in elderly men who
also are severely malnourished or dehydrated. Appropriate preoperative nutrition and hydration are, of
course, essential for consistent flap success. Women have more delicate circulation to the skin of the head
and neck. This must be taken into consideration in planning their cervical apron flaps. In a few instances,
the vertical straight-line portions of residual scar in the apron donor site of the lower neck required later Z-
plasty. This problem can be avoided by appropriate design of the skin graft (including triangular darts) used
to replace the apron of skin (see Fig. 190.1).

In one instance, the apron flap separated completely from its line of attachment to the inner surface of the
lower lip 8 days following surgery. The underlying large bone graft to the mandible was exposed. To my
surprise, conservative management over a period of 8 weeks produced spontaneous healing within the oral
cavity and a successful take of the bone graft. The skin pedicle to the apron flap was not divided until this
healing was complete.
SUMMARY
The anterior and lateral cervical apron flap technique is a reliable method of immediate reconstruction of
large defects of the anterior oral cavity. The proximity of this tissue to the oral cavity and the vigorous blood
supply of the tissue make it the most reliable of all of the regional flaps for reconstruction of this part of the
body. It may be combined with immediate bone grafting of the mandible (bone and bar technique). Although
today the use of a free flap may be considered an alternative reconstructive technique for these defects, the
added operative time and greater risk of circulatory failure make this a somewhat dubious choice. The
apron flap should be considered whenever there has been no prior major neck surgery or irradiation.
References
1. Brown JB. Rehabilitation of patients with head and neck tumors. In: Symposium on cancer of the head and
neck. Chicago: American Cancer Society, 1957;263.
2. Edgerton MT, McKee DM. Reconstruction with loss of the hyomandibular complex in excision of large
cancer. Arch Surg 1959;78:425.
3. Ward G, Edgerton MT. Recent improvements in resection of the maxilla. Am J Surg 1950.
4. Edgerton MT, DesPrez JD. Reconstruction of the oral cavity in the treatment of cancer. Plast Reconstr
Surg 1957;19:89.
5. Davis JS. Plastic surgery. Philadelphia: Blakiston, 1919;504.
6. Blair VP, Moore S, Byars LT. Cancer of the face and mouth. St. Louis: Mosby, 1941.

Chapter 191
Omental Flap for Cheek, Neck, and Intraoral Reconstruction
S. K. DAS
M. A. LESAVOY
The good vascularity, unique arrangement of blood vessels, and ability to accept skin grafts with ease allow the
omentum, which is dispensable, to be an excellent salvage flap.
INDICATIONS
Typical indications for use of the omentum are (a) to protect the exposed, irradiated carotid vessels
following block dissection of the neck as well as to prevent carotid blowout (1) (see Chapter 140); (b) to
reconstruct the pharyngostome; (c) to reconstruct full-thickness cheek defects (2); (d) to contour the face,
and (e) to use as cover for the face with the addition of split-thickness skin grafting following massive tissue
loss (3, 4).
ANATOMY
See Chapter 140.
FLAP DESIGN AND DIMENSIONS
For pedicle transfer of the omentum from within the abdominal cavity to distal targets, such as the neck or face,
various lengthening procedures are mandatory (5, 6, 7, 8). Following omentocololysis (6), there is a gain in
omental length of 2 to 12 cm. For the omentum to reach the neck, however, omentogastrolysis (freeing of the
omentum from the greater curvature of the stomach, based on a right or left gastroepiploic pedicle) is necessary.
Usually, the right gastroepiploic vessels are larger than the left, and at least one other major artery should be
preserved and left attached to the stomach. The gastroepiploic arch is maintained with the omentum (Fig. 191.1).
It is now possible to mobilize the omentum superiorly to the root of the neck in 88% of patients and to the ear in
79% of patients. If the omentum does not reach the target area of the neck or face after this stage, it is almost
certain that a definitive omental lengthening is needed.
Planning the incisions (5, 6) for elongation of the omentum and preserving the continuity of the vascular arcades
will allow the omentum to reach to the vault of the skull. The only deficiency in lengthening the omentum for distal
target areas is the reduction in the quantity of omentum available for use. Thus, when the quantity of the
omentum limits the lengthening procedure, transfer of the omentum by microvascular anastomoses is
appropriate, provided healthy recipient vessels are available. This will allow a large piece of the omentum to be
transferred to distal areas without losing bulk.
OPERATIVE TECHNIQUE
For pedicle transfer of the omentum from the abdomen to the face or neck, the best route is subcutaneous. After
the omentum is harvested and lengthened, it is brought out of the abdomen through the upper end of the
laparotomy wound and tunneled subcutaneously along the presternal area to the target area over the neck or
face. Care should be taken to make the tunnel big enough that the pedicle of the omentum is not strangulated
(Fig. 191.2).

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FIGURE 191.1 Route of the omentum for pedicle transplantation to the neck through a subcutaneous tunnel.
(From Das, ref. 6, with permission.)
FIGURE 191.2 A: Craniofacial area before reconstruction with omentum. Massive craniofacial resection of left
frontal bone, orbit, globe, maxilla, left half of the mandible, and left radical neck dissection. Pectoralis major,
latissimus dorsi, multiple random, scalp, and other flaps had failed. The patient originally had a carcinoma of the
maxillary antrum and had refused surgery. B: Omentum in place over the scalp and face. The right
gastroepiploic vessels were anastomosed to the contralateral right facial vessels, so that the omentum could
span the skull to arrive at left side of the face. Ipsilateral recipient vessels were nonexistent. The omentum was
covered with a meshed split-thickness skin graft. The omentum and graft did well, and later the unit was elevated
without compromise to drain a brain abscess.
CLINICAL RESULTS
The success rate with omental flaps, both on a pedicle and with microvascular free transfer, in
reconstructing difficult defects over face, neck and head, is extremely high. An interesting reported finding is
that overall increase in body weight is reflected in the transplanted omentum. Because of the size of the
donor and recipient vessels in vascularized omental transfer (1.5 mm and greater), the procedure is not
difficult. Any complications related to this procedure are due mostly to omental harvesting.

SUMMARY
The omentum, either pedicled or as a free-tissue transfer, is an excellent salvage flap for defects of the
head and neck.
References
1. Goldsmith HS, Beattie EJ. Carotid artery protection by pedicled omental wrapping. Surg Gynecol Obstet
1970;130:57.
2. Harashina T, Imai T, Wada M. The omental sandwich reconstruction for full-thickness cheek defect. Plast
Reconstr Surg 1979;64:411.
3. Arnold PG, Irons GB. One stage reconstruction of massive craniofacial defect with gastroomental free flap.
Ann Plast Surg 1981;6:26.
4. Brown RG, Nahai F, Silverton JA. The omentum in facial reconstruction. Br J Plast Surg 1978;31:58.
5. Alday ES, Goldsmith HS. Surgical technique for omental lengthening based on arterial anatomy. Surg
Gynecol Obstet 1972;135:103.
6. Das SK. The size of the human omentum and methods of lengthening it for transplantation. Br J Plast Surg
1976;29:170.
7. Das SK. Use of the omentum in reconstructive surgery. In: Barron J, Saad MN, eds. Operative manual of
plastic and reconstructive surgery. Edinburgh: Churchill-Livingstone, 1980; Chap. 5.
8. Das SK. Assessment of the size of the human omentum. Acta Anat (Basel) 1981;110:108.

Chapter 192
Cervical Musculocutaneous Flap for Intraoral Lining
H. SAITO
EDITORIAL COMMENT
In effect, this is a variation of the platysmal myocutaneous flap. Because the blood supply to the platysma
usually comes from branches along the facial artery, the flap must be designed in order not to jeopardize
the blood supply.
The lateral and median cervical skin flap (1), a modified version of previously reported methods (2, 3), is suitable
for a reconstruction of intraoral defects smaller than 6 × 6 cm.
INDICATIONS
The lateral cervical musculocutaneous flap is used for reconstruction of lateral defects in the mouth and
pharynx (Fig. 192.1). The median cervical musculocutaneous flap is used for reconstruction of the anterior
median floor of the mouth (Fig. 192.2).
FLAP DESIGN AND DIMENSIONS
For the lateral cervical musculocutaneous flap, a vertical rectangular flap, usually 6 × 5 cm, is outlined on the
lateral neck and is designed to be large enough to cover the defect. The tip can extend to just above the clavicle.
The location of the base is usually 2 cm below the posterior half of the mandible and is 8 cm wide.
The procedure for the median cervical musculocutaneous flap is essentially the same as for the lateral flap,
except the pedicle is based on the median submental region and is about 7 cm wide.
FIGURE 192.1 Schematic drawing of the lateral cervical musculocutaneous flap. A: To make the subcutaneous
tissue-platysma muscle pedicle of this flap, a laterally based epidermal-dermal flap was raised and turned back
on itself (arrow). The thick line indicates the incision line of the vertical lateral cervical flap. B: The flap is rotated
as the arrow indicates and sutured to the mucosal defect. C: Final external appearance. (From Saito et al., ref. 1,
with permission.)
OPERATIVE TECHNIQUE
The subcutaneous tissue-platysma muscle pedicle of both the lateral and median cervical musculocutaneous
flaps is developed on the bearded portion of the flap, adjacent to its base. This is done by first raising a laterally

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based epidermal-dermal rectangular skin flap, which is temporarily turned back on itself, until it can be used at
the end of the operation to close the upper neck wound (see Figs. 192.1 and 192.2). Then the lateral or median
cervical flap can be raised to include the platysma muscle. Intravenous fluorescein is used to assess the viability
of the flap.
The lateral flap is used to cover the intraoral defect and can be turned upward to the tonsillar region or half
rotated and extended horizontally to the region of the tongue and oral floor. The flap is sutured in place and
usually fixed with a tie-over dressing. The neck is easily closed by using all or part of the laterally based
epidermal-dermal skin flap and by advancing the anterior and posterior neck skin.
FIGURE 192.2 Schematic drawing of the median cervical musculocutaneous flap. A: Incision lines. B: The flap
and laterally based epidermal-dermal flap. C: The flap (AB) is rotated into the floor of the mouth as the arrow
indicates and sutured into the defect. D: Final external appearance. (From Saito et al., ref. 1, with permission.)
The median flap is sutured into the anteromedian floor of the mouth after the appropriate neck dissection.
Excision of the lower lip should be avoided, and suspension of the hyoid bone is unnecessary (Fig. 192.3).
CLINICAL RESULTS
Lateral cervical musculocutaneous flaps were used in 37 patients and the median flap was used in three.
The primary tumors involved the floor of the mouth, tongue, tonsil, gingiva, buccal mucosa, root of the
tongue, and mandible. All but three of the tumors were squamous cell carcinomas. Either conservative or
radical neck dissections were performed on one or both sides in 36 of 40 patients. Mandibular resection,
marginal or sectional, was used in 16 patients. Combination therapy with radiation was carried out in 28
patients.

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FIGURE 192.3 A: The median cervical musculocutaneous flap prepared. The forceps hold the end of the
epidermal-dermal flap. B: The tongue is seen through the defect left after resection of the floor of the
mouth. C: Marginal resection of the mandible. D: Reconstructed floor of the mouth. A tie-over dressing is
usually employed.
The flap survived without complications in 38 of 40 patients (95%). One patient who received a
preoperative full dose of radiation for gingival cancer had an oral fistula that was, however, easily repaired
by fistulectomy. Another patient with carcinoma of the oral floor developed a fistula that healed
spontaneously. Preoperative radiation of less than 3,000 rads and postoperative full-dose radiation did not
interfere with wound healing. The intraoral tissue looked like skin (histologically, dermis) in 112 patients and
like mucous membrane (histologically, connective tissue or scar) in 28 patients.
The epidermal-dermal flap used to close the donor site became necrotic in a few patients; however, enough
connective tissue to protect the carotid artery survived. When the neck wound could be closed easily by
advancing the skin, the epidermal-dermal flap was excised.
SUMMARY
A median or lateral cervical musculocutaneous flap can be used to cover many of the smaller (up to 6 × 6
cm) intraoral defects.
References
1. Saito H, Nishimura H, Matsui T, et al. Primary reconstruction by modified cervical island skin flap following
resection of oral and pharyngeal cancer. Arch Otorhinolaryngol 1978;221:203.
2. DesPrez JD, Kiehn CD. Methods of reconstruction following resection of anterior oral cavity and mandible
for malignancy. Plast Reconstr Surg 1959;24:238.

3. Farr HW, Jean-Gillies B, Die A. Cervical island skin flap repair of oral and pharyngeal defects in the
composite operation for cancer. Am J Surg 1969;118:759.

Chapter 193
Buccinator Myomucosal Island Pedicle Flap
D. J. HURWITZ
EDITORIAL COMMENT
This is a most useful flap for the repair of multiply recurrent palatal fistulas when one is faced with a paucity
of tissue that is usually very scarred. It is also applicable for coverage of palatal defects after tumor
resection in the soft or hard palate.
Complex anatomy and confined space make closure of large intraoral wounds and oronasal fistulae a formidable
undertaking. To solve the problems of distant donor sites, multistaged procedures, and the sequelae of failed
cleft-palate repairs, a well-vascularized, single-staged, buccal mucosal flap was developed (1, 2, 3, 4, 5, 6).
INDICATIONS
The anteriorly based buccinator mucosal island flap (BMIF) yields up to a 5 × 7-cm patch of oral mucosa
and muscle that can reach most regions of the oral cavity with minimal donor-site morbidity. Bilateral flaps
can reconstruct both nasal and oral surfaces.
ANATOMY (1)
The buccinator muscle joins the orbicularis oris sphincteric complex. The deepest muscle of facial expression, it
forms a quadralateral canopy from maxillary to mandibular alveoli, and from oral commissure to
pterygomandibular raphe. The buccinator forces food against the teeth during chewing and permits forceful
blowing of air through the lips.
The muscle is innervated by the buccal branch of the facial nerve, which crosses the masseter along the parotid
duct, branches to the superficial surface of the muscle, and continues through the buccal fat pad to innervated
medial upper lip musculature, The buccal branch of the mandibular division of the trigeminal nerve provides
sensation to mucosa via a deeper traverse across the medial pterygoid muscle.
The buccal fat pad separates the buccinator from the masseter. Beyond the anterior border of the masseter, the
buccomasseteric fascia covers the fat pad. The parotid duct crosses the masseter, enters the buccal fat pad,
and then perforates the superior midportion of the buccinator to empty into the oral cavity. The deep surface of
the buccinator is adherent to mucosa. If approached through a nasolabial incision, the buccinator lies
immediately lateral to the orbicularis oris muscle. It is deep to the orbicular, the zygomaticus major, and levator
anguli oris muscles (Fig. 193.1). The surgeon also encounters the masseter muscle, buccal fat pad, and
buccomasseteric fascia. Between the buccomasseteric fascia and the buccinator are an areolar connective
tissue plane and fat pad that facilitate blunt separation of the muscle.
The facial artery forms the blood supply of the BMIF (4, 7). It originates from the external carotid and ascends the
neck, sprouting submandibular gland, platysma, and submental branches. After the artery crosses the antegonial
notch of the mandible, it gives off twigs to the masseter and depressor anguli oris muscles (Figs. 193.1 and
193.2). Under cover of the lip depressors, the facial artery branches into the inferior labial artery that encircles

the lower lip. Between the mandible and maxilla, the artery obliquely crosses and supplies two or three branches
to the anterior portion of the buccinator (5). After it courses between and supplies twigs to the zygomaticus and
levator anguli oris, the facial artery branches into the superior labial artery which runs across the upper lip. After
sprouting the lateral nasal artery, the facial artery usually terminates through the levator labii superioris alaeque
nasi as the angular artery.
FIGURE 193.1 Diagrammatic frontal composite view of anatomy relevant to the buccinator muscle and facial
artery.
FIGURE 193.2 Sagittal composite intraoral view, schematically illustrating T-shaped flap (in gray). Note its
relationship to the buccal mucosa and facial artery.
Generous anastomoses to the infraorbital (from the internal maxillary), to the transverse fascial (from the
superficial temporal), and to the dorsal branch of the ophthalmic (from the internal carotid) allow the option of a
distally based flap. The marked tortuousity of the facial artery in the face can be unraveled for additional
centimeters of pedicle length. The anterior racial vein takes a more direct and posterior course to drain into the
jugular vein. Small venae comitantes travel with the artery.
There is an independent and anastomotic deep posterior blood supply to the buccinator throughout the buccal
branch of the internal maxillary artery and venous drainage through the pterygoid plexus. This system forms the
basis of posteriorly based buccinator mucosal flaps (5, 6).
FLAP DESIGN AND DIMENSIONS
Flaps for fistulas of the hard palate that do not involve the alveolus are pedicled on the proximal facial artery for a
direct intermaxillary course and greater vascular length. The flap crosses the dental arch through an edentulous
segment or may have to be divided later. Both proximally and distally based facial artery pedicles can repair

fistulas that include the aveolus as well as the palate or when the approach to the palatal fistula is through an
opening in the maxillary sinus. Up to a third of the vertical buccal sulcus span can be harvested, with only
temporary oral opening restriction. Wider flaps require skin grafting of the donor site.
In moderate-sized, cleft-related fistulas (Fig. 193.3A), turnover marginal oral flaps are developed to close the
nasal side, leaving a larger but exclusively oral wound to close. If the enormity of the fistula prevents this
approach or this is a fresh cancer resection, then bilateral buccal flaps repair both the oral and nasal sides.
A myomucosal island flap is most often designed as a transverse ellipse originating near the oral commissure
(Fig. 193.3B). The upper margin of the flap is inferior to the parotid duct, and the lower margin approaches the
mandibular buccal sulcus. In addition to the midsulcus transversely oriented ellipse, a vertically oriented flap
anterior to the parotid duct or a combined T-shaped flap is designed (see Fig. 193.2).
OPERATIVE TECHNIQUE
The recipient site is created; the buccal flap is drawn with methylene blue as the labial commissure is pulled
medially. Bimanual cheek palpation locates the oblique course of the facial artery across the cheek. Good
retraction, magnification, and lighting are essential. The Dingman cleft-palate gag is useful if the upper tongs are
positioned in the buccal sulcus instead of under the incisors. Several 2-0 silk sutures pull the labial commissure
toward the mouth gag. The parotid duct orifice may be cannulated for extra safety. Because the facial artery is
superficial to the buccinator and takes a sinuous pathway through the cheek, a nasolabial counterincision aids
the dissection (see Flap Design and Dimensions section).
Intraoral Start
With marked stretch on the buccal mucosa, the outline of the flap is incised with a scalpel through to the
buccinator muscle (Fig. 193.3B). The transversely oriented fibers are seen easily, and the minimal bleeding is
stopped by electrocautery. Excessive penetration threatens injury to the facial artery anteriorly and premature
entry into the buccal fat pad posteriorly. If extraoral accessory exposure is elected, a gauze sponge can be
placed in the buccal sulcus and the cutaneous incision done.
Extraoral Exposure
The nasolabial fold is incised through subdermal fat and the superficial fascia and fat dissected to identify the
facial artery just inferior to the labial commissure, where it is most superficial. The vessel is followed up to the
alar base and inferiorly toward the mandible by teasing away overlying facial muscles. The artery is intertwined
with terminal twigs from the buccal and zygomatic branches of the facial nerve as well as the infraorbital nerve.
Dissection should be done superficial and anterior to the vessel, leaving the branches to the buccinator
undisturbed. Using microhemoclips, the inferior labial, superior labial, and lateral nasal branches are ligated,
leaving most of the blood flow through the facial artery to the buccinator muscle. The artery defines the anterior
margin of the buccinator muscle. When a proximally vascularized flap is chosen, the distal end is ligated near the
nasal branches.
Next, dissection is done medial to the buccal fat pad, and the muscle is freed from the buccomasseteric fascia.
Once into the fat pad, dissection is easier as one hugs the muscle. It is important to stay deep to the buccal
motor branches and end posteriorly at the anterior border of the masseter muscle. With distally based flaps, the
facial artery is ligated inferior to the labial commissure. After the superficial surface of the muscle is exposed, the
mouth is reentered.

FIGURE 193.3 A 43-year-old man with previously repaired bilateral complete cleft lip and palate who suffered
from large anterior oronasal fistulas on either side of the premaxilla. After uneventful healing of bilateral T-
shaped buccinator mucosal island flaps (BMIFs), an alveolar iliac crest bone graft was performed 4 months
postoperatively, to create a continuous alveolus for functional dental reconstruction. A: In this mirror view of the
anterior palate, the isolated premaxilla is demonstrated by the arrow and is surrounded by fistula. B: After the
fistula margins were opened, bilateral T-shaped BMIFs were harvested. On the left side, a turnover, distally
based flap resurfaced the nasal side. Elevation of the left flap, with forceps holding the facial artery. C: On the
right side, a proximally based advancement flap repaired the oral surface of the anterior hard palate.
Intraoral Return
To conserve the buccinator muscle, the posterior 40% of the mucosa in dissected off the muscle. The mucosa
also may be raised from the portion of the flap that lies anterior to the facial artery. After hemostasis is obtained,
an incision is made through the small segment of buccinator muscle to the buccal fat pad, preserving the facial
vein with the flap, if possible. The anterior mucosal dissection places the facial artery at risk; so the nasolabial
exposure is referred to as often as necessary. The remaining attachments are cut and the flap is delivered to the
fistula without twisting the pedicle.
An extraoral counterincision maintains the recognizable orientation of the pertinent anatomy, allows direct
visualization of the facial arterial system, and is the safest way to avoid inadvertent vascular injury to the small
branches to the buccinator. The choice of proximally or distally based flaps depends on the proximity of the
defect.