Grabb’s Encyclopedia of Flaps Head and Neck

the upper aerodigestive tract. Am J Surg 1986;152:43.
5. Carstens MH, Stofman GM, Hurwitz DJ, et al. A new approach for repair of oro-antral-nasal fistulae: the
anteriorly based buccinator myomucosal island flap. J Craniomaxillofac Surg 1991;19:64.
6. Carstens MH, Stofman GM, Hurwitz DJ, et al. The buccinator myomucosal island pedicle flap: anatomic
study and case report. Plast Reconstr Surg 1991;88:39.
7. Niranjan NS. An anatomical study of the facial artery. Ann Plast Surg 1988;21:14.

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Chapter 194
Sternocleidomastoid Muscle and Musculocutaneous Flap
S. ARIYAN
EDITORIAL COMMENT
The designs and clinical applications are anatomically possible but have limited use with intraoral cancer,
particularly if they have been irradiated. Even if a neck dissection is not necessary, the space of potential
spread of intraoral cancer would be violated. The sternocleidomastoid muscle alone is quite helpful in
covering the traumatically exposed or infected mandible. The limiting factor for its arc of rotation is the
eleventh nerve that innervates it.
The sternocleidomastoid muscle and musculocutaneous flap can be used for reconstruction of the tongue, floor
of the mouth, tonsillar fossa, and cheek (1, 2, 3, 4, 5, 6, 7). It also can be used for pharyngoesophageal defects
(see Chapter 223). There are several advantages to the sternocleidomastoid flap. It uses local tissue for one-
stage reconstruction of oropharyngeal defects of moderate size, with donor sites that may be closed primarily
without the necessity of skin grafts. The flap can be
used successfully in patients who have had previous radiation to the neck if the skin is soft and supple over the
muscle and there is no clinical evidence of radiation fibrosis or induration.
ANATOMY
The sternocleidomastoid muscle is a round muscle that arises by two tendinous fascicles from the sternum and
the medial third of the clavicle, passes obliquely across the side of the neck, and inserts on the lateral surface of
the mastoid process. Fresh and preserved cadaver dissections have demonstrated that the sternocleidomastoid
has three blood supplies (7, 8) (Fig. 194.1). These vessels enter the muscle at various sites as nutrient vessels
to circulate within the muscle and provide musculocutaneous branches to the overlying skin. Although sonic
small branches may travel for a centimeter or two along the undersurface of the muscle, there is no axial
distribution of vessels along the length of the undersurface of the muscle.
The blood supply to the superior portion of the sternocleidomastoid is a branch from the occipital artery that
enters the muscle just below the mastoid region (Fig. 194.1). The blood supply to the inferior portion is from a
branch of the thyrocervical trunk. Midway between its origin and insertion, the sternocleidomastoid is supplied by
a branch of the superior thyroid artery as well as by smaller vessels from the adjacent strap muscles.
FLAP DESIGN AND DIMENSIONS
Flaps can be designed with only a “paddle” of skin attached over one end of a pedicle of the sternocleidomastoid
muscle, which then is used to transport this skin (7, 9). The muscle pedicle may be based on either the superior
or inferior blood supply (Fig. 194.2), the choice being made according to the ease with which the flap may be
transported to the defect. In each case, the donor site can be closed either by local advancement of the neck
skin or by local transposition flaps.

FIGURE 194.1 The three blood supplies to the sternocleidomastoid are the occipital artery superiorly, superior
thyroid artery midway, and thyrocervical trunk inferiorly. (From Ariyan, ref. 7, with permission.)
Surgical defects from resections in the oral cavity may be reconstructed with a 6 × 8-cm paddle of skin
transported on a pedicle of sternocleidomastoid muscle based on its superior blood supply (Fig. 194.3). The skin
paddle should be kept overlying the muscle above the level of the clavicle. Although large paddles of skin may
have sufficient circulation to the portion that is extended over the clavicle or below, the blood supply to this
extended portion is tenuous and unreliable.
Tongue and Floor of Mouth
Resection of lesions in the anterior or lateral floor of the mouth resulting in wounds of moderate size may be
reconstructed with a single paddle of skin based over the inferior portion of the sternocleidomastoid transported
on its superior blood supply. This allows for coverage of the wound and preserves the free motion of the tongue.
Larger resections of the floor of the mouth that may require resection of a portion of the tongue, with or without a
rim mandibulectomy, may require two sternocleidomastoid flaps (Fig. 194.5). The required resection may result in
a defect too large for these flaps, however, and it may be necessary to reconstruct the area with a large flap,
such as the pectoralis major musculocutaneous flap.
Tonsillar Fossa and Posterior Floor of Mouth
Surgical defects of moderate size may be covered with a 6 × 8-cm paddle of skin transported on a pedicle of
sternocleidomastoid muscle. This area is particularly suited for an inferiorly based sternocleidomastoid flap
because the flap can be pivoted on its longitudinal axis and passed under the mandible for a more direct
approach to the area (Fig. 194.6). A superiorly based sternocleidomastoid flap may be used, but it often results
in a bulky mass under the mandible as a result of the muscle folding on itself to reach the tonsillar area.
Cheek
Large through-and-through defects of the cheek need inner lining as well as outer covering. These may be
reconstructed with a large superiorly based sternocleidomastoid muscle flap for inner lining that is closed in two
layers to provide a watertight seal. The outer covering can be provided with a skin graft, a cervical skin flap, or a
musculocutaneous flap, such as the trapezius or pectoralis major muscle. Another alternative is to reconstruct
with two skin paddles on an axial (flat muscle) musculocutaneous flap such as the pectoralis major or latissimus
dorsi muscle.
OPERATIVE TECHNIQUE

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The skin paddle is incised down to the muscle fascia, and it is “tacked down” to the muscle with several
interrupted sutures from the dermis to the muscle fascia. Traction must not be placed on the skin paddle
because the attachments to the underlying muscle are loose and areolar and the musculocutaneous vessels
within this tissue will be damaged. One or two traction sutures are placed through the muscle fascia at the distal
end of the muscle pedicle to help elevate the sternocleidomastoid during its dissection.
FIGURE 194.2 A: A paddle of skin outlined on the inferior portion of the sternocleidomastoid above the clavicle
may be elevated on its superior blood supply and transported under the mandible to the oral cavity. B: A paddle
of skin outlined on the superior portion of the sternocleidomastoid may be elevated on its inferior blood supply
and transported under the mandible.

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FIGURE 194.3 A: The skin paddle is outlined over the lower portion of the sternocleidomastoid but kept above
the level of the clavicle. B: The sternocleidomastoid muscle is dissected as high as necessary to allow this
muscle pedicle to be rotated under the mandible to reach the area of the surgical defect.
FIGURE 194.4 A: A prophylactic neck dissection may be performed by preservation of the spinal accessory
nerve and jugular vein. B: The fascia of the posterior triangle is incised at the border of the trapezius muscle to
dissect and preserve the spinal accessory nerve. C: Once the spinal accessory nerve is freed to the
sternocleidomastoid, the remainder of the neck contents may be dissected as one specimen from the vessels
and nerves in the carotid sheath. (From Ariyan, ref. 10, with permission.)
FIGURE 194.5 A: A large tumor of the floor of mouth may require two sternocleidomastoid flaps based on the
superior blood supplies. B,C: Following resection of the tumor and a rim mandibulectomy, the two
sternocleidomastoid flaps may be sutured to each other in the midline, to the tongue posteriorly, and to the labial
sulcus anteriorly.

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FIGURE 194.6 A,B: A paddle of skin over the superior portion of the sternocleidomastoid muscle may be pivoted
180 degrees on its longitudinal axis to reach a defect in the tonsillar fossa.
The muscle may be dissected and elevated by incising the fascia along the anterior and posterior borders of the
sternocleidomastoid muscle belly. This separates the muscle from the cervical fascia of the anterior and posterior
triangles as they split to cover the two surfaces of the sternocleidomastoid muscle. The dissection then is
continued by scissors to free and elevate the muscle pedicle from the deeper half of the split cervical fascia. Only
the amount of dissection necessary to transport the skin paddle under the body of the mandible to reach the oral
cavity is needed. The middle blood supply from the superior thyroid can often be preserved, but it may be cut
and tied if necessary to provide the mobility to reach the defect. Care must be taken to avoid damaging the
spinal accessory nerve passing through or under the sternocleidomastoid.
If a prophylactic neck dissection is to be performed concurrently, the dissection is carried further cephalad (Fig.
194.4). The spinal accessory nerve will need to be cut to elevate the sternocleidomastoid sufficiently to reach the
inframastoid area. Occasionally, this nerve passes under the sternocleidomastoid rather than through the muscle
and gives a motor branch to the muscle. In such a case, the branch to the sternocleidomastoid may be cut and
the main trunk of the spinal accessory nerve may be preserved if the patient is a proper candidate for a
“functional” radical neck dissection (10); however, if it is necessary to carry the dissection to the inframastoid
area, care must be taken to avoid damage to the occipital artery supplying this muscle.
Once the flap is dissected sufficiently to allow it to pass under the mandible and reach the surgical defect, the
tension on the flap is placed on the muscle by suturing from the deeper portion of the wound margins to the
muscle pedicle. This not only permits the skin paddle to be sutured to the mucosal margin without tension but
also provides a second layer of closure to protect the deeper wound from the salivary products and bacteria.
CLINICAL RESULTS
Despite its many advantages, the sternocleidomastoid flap has significant limitations. The
musculocutaneous blood supply from the muscle to the overlying skin is delicate and can be damaged
easily through the loose areolar tissue attaching the skin to the underlying muscle. This makes the
sternocleidomastoid musculocutaneous flap technically one of the most delicate and tenuous for survival of
the skin paddle.
In flaps with compromised circulation, ischemia was manifested by early venous congestion, ecchymosis,
and blistering of the skin paddle within 48 hours. These paddles resulted in loss of the epithelium in 10 of
the 24 flaps. Nevertheless, each of these flaps healed with intact wound margins and survival of the dermis
of the skin paddle. In each case, the dermis resurfaced with epithelium without requiring surgery. Histologic

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examination of these flaps demonstrated squamous epithelium of the surface and survival of the deeper
dermis, even though there was absence of the keratin layer and absence of the glandular elements,
indicating loss of the upper dermis.
In two patients, a small pharyngocutaneous fistula was noted in the first few postoperative days. These
fistulas closed by contraction of the wound within 2 weeks despite oral intake of a liquid diet by each
patient.
One potential objection to the use of a sternocleidomastoid musculocutaneous flap might be that it violates
the general principles of cancer surgery. For many years, this muscle has been removed as part of the
specimen in the classic radical neck dissection, even if it did not contain invasive tumor; however, the safety
of preserving the sternocleidomastoid muscle in patients treated with prophylactic neck dissections and in
selected patients with clinically positive necks has been demonstrated (11, 12). As mentioned earlier in this
chapter, the investing layer of the cervical fascia over the anterior cervical triangle splits into anterior and
posterior sheets to envelop the sternocleidomastoid and converges again to cover the posterior triangle.
Therefore, if the muscle is dissected out of this enveloping sheet, the posterior layer of this split cervical
fascia may be left intact, leaving the underlying neck contents undisturbed and permitting the resection of
the entire remaining neck contents (10).
SUMMARY
Sternocleidomastoid muscle and musculocutaneous flaps can be used successfully either alone or with
other flaps to reconstruct various cheek, neck, and intraoral defects.
References
1. Owens NA. A compound neck pedicle designed for the repair of massive facial defects: formation,
development and application. Plast Reconstr Surg 1955;15:369.
2. Bakamjian VY. A technique for primary reconstruction of the palate after radical maxillectomy for cancer.
Plast Reconstr Surg 1963;31:103.
3. Littlewood AHM. Compound skin and sternomastoid flaps for repair in extensive carcinoma of the head
and neck. Br J Plast Surg 1967;20:403.
4. Jabaley ME. Reconstruction of patients with oral and pharyngeal cancer. Curr Probl Surg 1977;14:1.
5. McCraw JB, Magee WP, Kalwaic H. Uses of the trapezius and sternomastoid myocutaneous flaps in head
and neck reconstruction. Plast Reconstr Surg 1979;63:49.
6. O'Brien BM. A muscle-skin pedicle for the total reconstruction of the lower lip. Plast Reconstr Surg
1970;45:395.
7. Ariyan S. One-stage reconstruction for defects of the mouth using a sternocleidomastoid myocutaneous
flap. Plast Reconstr Surg 1979;63:618.

8. Jabaley ME, Hedder FR, Wallace WH, et al. Sternocleidomastoid regional flaps: a new look at an old
concept. Br J Plast Surg 1979;32:106.
9. Ariyan S. The sternocleidomastoid myocutaneous flap. Laryngoscope 1980;90:676.
10. Ariyan S. Functional radical neck dissection. Plast Reconstr Surg 1980;65:768.
11. Bocca E, Pignataro O. A conservative technique in radical neck dissection. Ann Otol Rhinol Laryngol
1967;76:975.
12. Bocca E. Conservative neck dissection. Laryngoscope 1975;85:1511.

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Chapter 195
Trapezius Osteomusculocutaneous Island Flap for Reconstruction
of The Anterior Floor of The Mouth and Mandible
W. R. PANJE
The trapezius osteomusculocutaneous island flap can be successfully used in the reconstruction of the anterior
floor of the mouth and the mandibular arch (1, 2).
INDICATIONS
Indications for use of the trapezius osteomusculocutaneous island flap are (a) anterior mandibular defects,
(b) compound defects (i.e., floor of mouth, tongue, or buccal area) in addition to bone (mandibular defect),
(c) osteoradionecrosis, and (d) facial contouring in which bone is necessary.
This flap offers the following advantages over previous approaches: (a) it has the potential of a one-stage
immediate reconstruction; (b) it offers the alternative of available skin, muscle, or bone for reconstruction of
defects of the lower two thirds of the face and oral cavity; and (c) it eliminates the need for microsurgical
transplantation of tissue. In addition, in patients in whom oncologic surgery has resulted in denervation of
the trapezius muscle, the trapezius osteomusculocutaneos island flap has the advantage of using the
already paralyzed trapezius muscle without the need for damaging additional muscles (such as the chest
muscle in the pectoralis bone flap).
ANATOMY
Multiple arteries supply the trapezius muscle, but the major blood supply is provided by the transverse cervical
artery arising from the thyrocervical trunk (3). The transverse cervical artery begins deep to the sternal head of
the sternocleidomastoid muscle, crosses the posterior triangle, and enters the trapezius muscle on its deep
surface about 4 cm medial to the acromion. The artery is identified easily as it passes deep to the posterior belly
of the omohyoid muscle (Fig. 195.1).
The transverse cervical vein usually travels in the same fascial plane as the artery; however, the vein can travel
superficial to the omohyoid muscle. If it is seen in this area, it should be preserved. It usually empties into the
subclavian vein 2 to 3 cm lateral to where the thyrocervical trunk originates from the subclavian artery. The vein
is usually the limiting factor in extending the arc of rotation of this flap.
The accessory nerve generally enters the trapezius muscle in the area of the vascular pedicle. Because of its
multiple innervations of the muscle, the nerve usually can be preserved if properly dissected.
To use the scapular spine as part of this compound flap, the trapezius muscle attachment to the scapular spine
must be preserved. Accessory nutrient arteries penetrate the scapular spine at the fascial attachment of the
trapezius muscle to the spine (4).
OPERATIVE TECHNIQUE
The first step in the formation of the trapezius osteomusculocutaneous island flap is the harvesting of a
composite flap of the trapezius muscle based on the transverse cervical artery and vein, overlying skin, and all or
a portion of the scapular

spine. The flap can be developed once the transverse cervical artery and vein supply has been identified
entering the deep surface of the trapezius muscle (Fig. 195.1).
FIGURE 195.1 Major branches of the transverse cervical artery and associated structures, with patient lying
prone.
To preserve the attachment of the trapezius muscle to the bone, an incision should be made inferior to the
scapular spine. This incision will detach the infraspinatus muscle from the bone. The inferior side of the spine
should be bluntly dissected free of any muscle attachments. By bringing the dissection laterally along the spine,
the fossa will be identified just deep to the acromial part of the spine. This part of the scapular bone should be
palpated, and the arch covering the fossa must be maintained.
The scapular spine that is to be used to reconstruct the anterior mandibular defect is removed from the body of
the scapula by a sharp chisel or osteotome, proceeding from a lateral to a medial direction (Fig. 195.2). The
acromial attachment to the clavicle should be maintained to preserve normal shoulder joint function. By this
method, approximately 12 × 2 cm of spine can be obtained without compromising shoulder girdle stability. Once
the scapular spine has been delivered, the surgeon will proceed in a manner similar to the procedure used in the
development of the trapezius musculocutaneous island flap.
FIGURE 195.2 Line of chisel cut when removing scapular spine for mandible reconstruction is indicated.
In reconstructing the mandible, the scapular spine can be fractured in a green-stick manner at its midpoint to
conform to the mentum of the mandible. The scapula is attached to the remaining mandibular segments by wire.
External fixation is also needed (Morris biphase). The mentum area of the newly reconstructed mandible also
needs anterior support. This can be accomplished by attaching wire between the biphase and the mandible or by
neck bandage support, in which a bulky dressing is applied beneath the chin and maintained in place for at least
2 weeks. A 4- to 6-week period of stabilization is needed for bony union to occur (Fig. 195.3).

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The scapular spine also can be used simply based on the trapezius muscle by means of occipital artery vascular
nutrition only (5), that is, if the transverse cervical artery and vein have been interrupted, as with a previous
radical neck dissection, the occipital artery perforators usually will take over the blood supply to the trapezius
muscle. By maintaining the integrity of the muscle attachments to the scapular spine as well as by carrying the
muscle back to the region of the occipital artery, a pedicled flap based on the occipital artery and paraspinous
artery perforators attached to the scapular spine then can be used to reconstruct the anterior mandibular defect.
Skin also can be used in a nondelayed manner in reconstructing the anterior floor of the mouth at the same time
as when the mandible is reconstructed, as long as it is not extended caudal to the scapular spine. The skin of the
superior-based unipedicle compound trapezius osteomusculocutaneous flap does not survive as well as that of
the island flap.
CLINICAL RESULTS
When using the trapezius osteomusculocutaneous island flap for reconstruction of the anterior floor of the
mouth and the mandible, a 90% success rate may be expected, even when used in irradiated fields. There
is a 70% success rate in restoring osteoradionecrotic bone loss and in preventing the spread of
osteoradionecrosis.
SUMMARY
The trapezius osteomusculocutaneous flap can be used to reconstruct the anterior floor of the mouth and
the mandible.

FIGURE 195.3 A: Five days after trapezius osteomusculocutaneous island flap primary restoration of an
anterior mandibular and floor of mouth defect. B: Orthopantomogram radiograph demonstrating scapular
spine replacement of an anterior mandibular defect. C: Two months after restoration of the anterior
mandible and floor of the mouth. D: Three years after restoration of the anterior mandible and floor of the
mouth. Note that dentures have been fitted to the reconstructed mandible.
References
1. Panje WR, Cutting C. Trapezius osteomyocutaneous island flap for the reconstruction of the anterior floor
of the mouth and the mandible. Head Neck Surg 1980;3:66.
2. Panje WR. Mandible reconstruction with the trapezius osteomusculocutaneous flap. Arch Otolaryngol
1985;111:223.
3. Huelke D. A study of the transverse cervical and dorsal scapular arteries. Anat Rec 1958;132:233.
4. Lexer E, Kuliga B, Turk W. Untersuchungen über Knochenarterien. Berlin: Hirschwald, 1904;15-16.
5. McCraw JB, Magee WR, Kalwaic H. Uses of the trapezius and sternomastoid myocutaneous flaps in head
and neck reconstruction. Plast Reconstr Surg 1979;63:49.

Chapter 196
Rib-Pectoralis Major Osteomusculocutaneous Flap
M. S. G. BELL
EDITORIAL COMMENT
Both this and the preceding chapter indicate the interest and study given to the vascularization of the ribs. It
is clear that when muscle is attached to bone, it also provides blood supply. The bone will bleed from its
edges if there is enough vascularized muscle attached to it; however, anatomic studies do indicate that
there is more muscle attached if one takes the fifth rib with the pectoralis major muscle in contrast to the
sixth one. When taking the fifth rib, however, the arc of rotation will not extend beyond the central portion of
the mandible.
The rib-pectoralis major osteomusculocutaneous flap has been used to provide replacement for mandibular
defects and lining tissue in the oral cavity, especially for reconstruction of the soft palate, floor of the mouth, and
lateral pharyngeal wall (1). It may be used as a pedicle flap or as a free flap.
ANATOMY
Both the fifth and sixth ribs have been used, and each seems to obtain sufficient blood supply from the overlying
pectoralis major muscle to allow flap transfer and survival to provide a reasonably reliable composite flap for
complicated reconstructions (2, 3). (For details of the muscle anatomy, see Chapter 135.)
FLAP DESIGN AND DIMENSIONS
I have taken a portion of skin up to 15 cm2 for reconstruction of the soft palate, floor of the mouth, and lateral
pharyngeal wall. The inferior margin of the cutaneous portion of the pectoralis major flap may be extended below
the costal margin by at least 5 cm.
The skin flap should be cut larger than necessary because the bulk of muscle and fat beneath the skin must be
accommodated in closure of the mouth defect, and underestimating this area is easy. Because the rib does
provide some degree of rigidity, swelling in the area may increase skin tension on the suture line, and a rather
redundant flap will minimize this degree of tension. (I believe that development of fistulas in my series of patients
may have been, in part, a result of this problem.)
The cutaneous portion of the flap always should be planned so that the superior margin begins as high as
possible to include the perforating musculocutaneous arteries along the lower margin of the pectoralis major
muscle. In female patients in whom the inframammary fold must be taken as the upper margin of the skin flap,
dissection may be beveled upward, just beneath the breast tissue, preserving cutaneous perforating vessels that
may be seen running obliquely downward. This factor may be critical in preserving the cutaneous blood supply.
Either the fifth or sixth rib can be used. In 21 of my 22 patients, the sixth rib was taken. In the reconstruction in
which the fifth rib was used, the muscle pedicle was under a little greater tension than with sixth-rib flaps. The
fifth-rib flap is useful when an external skin and lip defect also must be covered because a longer skin
component can be used.
Access to the base of the pectoralis major flap may be achieved in several ways. A vertical incision is used by
many surgeons, with the incision running downward from the mid-portion of the clavicle to the point at which the

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cutaneous portion of the pectoralis major flap is raised. Access to the flap also may be gained by raising a
standard deltopectoral flap. This procedure displays the entire clavicular origin of the muscle and the
musculotendinous junction in the axilla, which is subsequently divided.
Access to the sternal origin of the pectoralis major flap is gained by raising a laterally based flap about 10 cm
wide at the level of the anterior axillary line that extends medially to the sternum. This flap usually contains the
nipple and is designated so that its inferior limb runs right along the proposed skin flap to be carried into the
mouth (Fig. 196.1A and B). The amount of skin undermining with this technique is greater than in the vertical
incision technique; however, the standard Bakamjian flap is preserved and may be used for help in closure of the
chest defect when a large flap is taken. It also may be used for closure of the neck skin should a defect be
present there or should a subsequent complication require use of a local flap.
FIGURE 196.1 A: The pectoralis major osteomusculocutaneous flap using a vertical incision for access (see text
for details). B: Variation in design to preserve a deltopectoral flap for either immediate or later use. (From Bell,
Barron, ref. 1, with permission.)
OPERATIVE TECHNIQUE
The pectoralis major muscle is raised from the chest wall along its lateral margin. There is a discrete fascial
plane allowing blunt dissection. The sternal and clavicular origins of the pectoralis major muscle are separated,
and the vessels entering the deep surface of the muscle are easily seen and preserved. The sternal portion of
the muscle that will carry the skin and bone is defined laterally to its musculotendinous junction in the axilla.
The muscle is divided at this point (Fig. 196.1). The sternal origin of the muscle then is divided with the cutting
cautery. At this point, the rib with the largest muscular attachment can be chosen The skin flap overlying the rib
is incised, and the intercostal muscles above and below the rib that are to be taken are divided with the cutting
cautery. Periosteum of the rib is preserved to ensure maximum blood supply. The costal cartilage is
disarticulated at the sternum, and the rib is divided laterally according to the bone length required. The angle of
the costochondral junction, especially in the sixth rib, corresponds well to the angle between the body and
vertical ramus of the mandible. The intercostal artery is ligated where it leaves the internal mammary artery,
anterior to the thoracis internus muscle.

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FIGURE 196.2 A,B: The flap elevated and passed beneath the skin bridge over the clavicle. Note the large
muscle attachment to the rib. (From Bell, Barron, ref. 1, with permission.)
Because the perichondrium is taken with the rib, entry into the pleural space may occur as dissection proceeds
laterally. If care is taken, using the wide end of the Howarth elevator, the rib usually can be elevated without
damaging the pleura.
The rib-pectoralis major osteomyocutaneous flap then is raised on its neurovascular bundle and tunneled
beneath the skin in the supraclavicular area into the neck and mouth (Fig. 196.2). The bone is tailored to the
appropriate length and may be bent by kerfing to conform to the desired contour of the new mandible. Fixation
with intramedullary Compere wires and wire loops has been satisfactory. The rib and the costal cartilage are
soft, and I have found that plates and screws are less secure than intramedullary fixation (see Fig. 196.3).
The vascularity of the bone and cartilage appears to be adequate for healing. Bleeding will be observed from the
perichondrium and periosteum of the rib after the flap has been elevated. I considered performing a
microvascular anastomosis of the intercostal artery and vein to suitable vessels in the neck, but this effort was
judged unnecessary because there was visible bleeding.
FIGURE 196.3 A-C: Postoperative views of a patient who had a postradiation recurrent squamous cell
carcinoma on his right tonsil extending onto his soft palate and pharyngeal wall and anteriorly onto the floor of
his mouth. He required an en bloc resection of his entire soft palate, the right third of his oral pharynx and
hypopharynx, and the entire vertical and horizontal half of his right mandible. A right radical neck dissection was
performed in continuity with this. Reconstruction was done with a sixth-rib composite pectoralis major
musculocutaneous flap. The nasal lining of the soft palate was created by a mucosal flap from the hard palate;
the oral right half of the soft palate was reconstructed from the musculocutaneous flap. The flap also lined the
oral and hypopharyngeal defects and replaced the floor of the mouth and mandible. Healing of both the donor

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and recipient areas was uneventful. The threaded Kirschner wires were removed from the mandible at 3 months,
and the patient has clinical union of the mandible. His speech is hypernasal but clear. He eats without difficulty,
although he did have problems initially with swallowing. The cosmetic result is excellent. (From Bell, Barron, ref.
1, with permission.)
If the pleural space has been entered, the defect is narrowed by using a rib approximator and wiring the adjacent
ribs with 25-gauge wire loops. The chest wall skin defect is closed with a combination of the lateral chest wall
flap and the deltopectoral flap as required. Figure 196.1B shows the lateral chest flap bearing the nipple used to
close the chest defect. A free skin graft to the donor bed of one of these flaps may be required.
FIGURE 196.4 A: This 22-year-old man had an extensive composite resection for mucormycosis. Two thirds of
his hard and soft palate were removed, along with his left maxilla, eye, floor of orbit, nasal septum, cribriform
plate, and floor of his anterior cranial fossa. After a 6-week course of amphotericin B and dressing changes, a
delayed composite free-flap reconstruction was performed using the pectoralis major rib flap. B,C: This free flap
was anastomosed to the facial vessels in the neck, and it healed without difficulty. Portions of this flap were
deepithelialized where the bulk of the flap was in contact with the inner surface of the cheek and along the lining
of the nose. A nasopharyngeal tube was left in place to stent this area for a period of 3 weeks. The patient now
has excellent air entry through both nostrils. The skin was left on the flap to line the eye socket, and the patient
wears a plastic prosthesis to give some bulk to his eyelid. The nipple is located in the center of his palate. It is
now 2 years since surgery, and the patient has had no problems with this flap, aside from a small abscess that
developed after it was perforated with a lamb bone. The abscess was drained and healed without difficulty. The
cosmetic result is excellent, and the patient's speech is mildly hypernasal.
In one patient, I used this flap as a free composite flap to repair a large soft-tissue defect in the face. The patient
had had mucormycosis and required removal of two thirds of his hard and soft palate, his left maxilla, his ethmoid
sinus and left eye, and the cribriform plate and floor of his left anterior cranial fossa (Fig. 196.4). The pectoralis
major flap was easily revascularized by means of the facial vessels.
CLINICAL RESULTS
I have used this osteomyocutaneous flap on 22 occasions to reconstruct mandibular defects. One free flap
for reconstruction of the hard and soft palate and left maxillary defect has been done. The skin portion of
the flaps replaced the floor of the mouth and the pharyngeal wall in four patients and the soft palate as well
in two others (see Fig. 196.3). All patients, with the exception of the free-flap patient, have had a full course
of radiation therapy preoperatively.

The pectoralis major muscle pedicle appears to allow excellent protection for the great vessels in the neck,
and its bulk gives a cosmetically satisfying contour to the neck. I have lost two flaps because of
compression of the vascular pedicle within the arch of the rib. This was a technical error, and the encircling
rib evidently constricted the pedicle. Seven ribs became exposed with delayed healing, requiring total
removal of the bone in five. I have thus had major complications in seven of 22 patients.
The chest wall defects have healed without complication. Persistent pleural effusions in two patients
necessitated maintenance of the chest tube for 10 days. I have noted no appreciable loss of shoulder
function as a result of using this muscle flap.
Hospitalization varied from 2 to 4 weeks in the patients who did not develop complications with local wound
healing. Two patients with extensive pharyngeal wall reconstructions had prolonged deglutition problems.
With time, they have managed to take oral nourishment. Cosmetically, the results are equal to currently
described reconstructive techniques (4, 5, 6, 7). Bony union was firm in all my patients at pin removal 3
months postoperatively. A bone biopsy taken from two patients at 4 and 12 weeks after surgery showed
viable, architecturally normal bone. The rib appears to have been adequately vascularized in my group of
15 patients, and it has evidently not resorbed. Bony union has been painless and clinically firm (fibrous
union). Despite the advantages of the rib in providing a more total replacement of tissue loss, there was a
significant rate of complications detracting from its advantages.
In contrast, a musculocutaneous flap has a much lower incidence of complications (8, 9), with no flaps lost
in my ongoing series. While the stability of the mandible is not restored and the cosmetic appearance may
be less pleasing, the reliability is evidently much higher. Therefore, the osteomusculocutaneous flap should
be restricted in use because of its high complication rate. The proportion of breakdowns was higher in
midline reconstructions, with only one of four flaps healing uneventfully. The success rate of this procedure
would likely be greater in nonirradiated patients, but there were none in my series of mandible
reconstructions.
SUMMARY
The osteomusculocutaneous flap should be restricted in use probably to fairly large defects of the lateral
mandible where there is concern about instability and rotation of the opposite hemimandible.
References
1. Bell MSG, Barron PT. The rib-pectoralis major osteomyocutaneous flap. Ann Plast Surg 1980;6:347.
2. Ariyan S, Finseth FJ. The anterior chest approach for obtaining free osteocutaneous rib. Plast Reconstr
Surg 1978;62:676.
3. Hendel PM, Huttner RS, Rodrigo J, Buncke HJ. The functional vascular anatomy of the rib. Plast Reconstr
Surg 1982;70:578.
4. Cuono CB, Ariyan S. Immediate reconstruction of a composite mandibular defect with a regional
osteomusculocutaneous flap. Plast Reconstr Surg 1980;65:477.
5. Daniel RK. Mandibular reconstruction with free tissue transfers. Ann Plast Surg 1978;1:346.

6. McKee DM. Microvascular bone transplantation. Clin Plast Surg 1978;5:283.
7. Rosen IB, Bell MSG, Barron PT, et al. Use of microvascular flaps including free osteocutaneous flaps in
reconstruction after composite resection for radiation and recurrent oral cancer. Am J Surg 1979;138:544.
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. Ariyan S. Further experiences with the pectoralis major myocutaneous flap for the immediate repair of
defects from excisions of head and neck cancers. Plast Reconstr Surg 1979;64:605.

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Chapter 197
Lateral Pectoral Osteomusculocutaneous Flap
J. W. LITTLE III
J. R. LYONS
An obvious further extension of the pectoralis musculocutaneous flap is the inclusion of skeletal tissue deep to
the muscle as a composite flap to allow one-stage immediate reconstruction of the mandible (1).
Others have included rib (2, 3, 4, 5, 6), but because the costal origins of the pectoralis major muscle arise only
from the cartilaginous portions of the second through sixth ribs (7), we contend that these flaps represent
essentially chondromusculocutaneous flaps with bony rib extensions. Certainly, exclusion or resection of the
cartilage component would render the bony parts little more than free grafts. While cartilaginous rib serves,
perhaps, as an effective mandibular spacer, it surely cannot allow the solid
reconstruction through bony interposition and union that is preferred in mandibular repair.
A component of the pectoral muscle system does have its origin from the true bony rib cage: the pectoralis minor
muscle arising from the third through fifth bony ribs lateral to the costochondral junction. We recommend,
therefore, a composite system that incorporates a key portion of this muscle in a lateral pectoral flap—formally, a
pectoralis major-pectoralis minor osteomusculocutaneous flap.
INDICATIONS
Such a composite transfer is indicated whenever mandibulectomy is performed, whether or not
accompanied by neck dissection. Although conventional secondary bone grafting remains a satisfactory
alternative for mandibular restoration in the nonirradiated patient without undue scarring, we consider
vascularized bony transfer mandatory in unfavorable situations.
Osteomusculocutaneous flaps based on the sternocleidomastoid system are negated by surgical and
radiation therapy to the neck (8). Sternal transfer on the pectoralis system is useful (9), but we prefer our
bony component and donor site. Although dissection of the lateral pectoral composite flap is demanding and
practiced elevation requires 2 hours, it offers obvious advantages compared with free bony transfer by
microvascular techniques.
ANATOMY
The blood supply of the pectoral muscles by way of the thoracoacromial artery is well described (10, 11, 12, 13,
14). The pectoral branch sends a significant vessel to the pectoralis minor muscle before continuing on the deep
surface of the pectoralis major as its dominant vascular supply. The descending portion of the vessel, while
closely applied to the undersurface of the pectoralis major muscle, remains free from the muscle in a distinct
fibroareolar layer that is further protected on its deep surface by a significant fascial sheet.
A secondary supply to the pectoralis comes by way of the lateral thoracic artery. After a highly variable origin
from the second part of the axillary artery, the subscapular trunk, or the thoracoacromial artery, the vessel
follows the lateral border of the pectoralis minor, supplying this muscle and the serratus anterior before reaching
the undersurface of the pectoralis major. It anastomoses freely with the pectoral branch of the thoracoacromial
artery, the thoracodorsal artery of the subscapular trunk, and the intercostal arteries of the lateral thoracic wall.

It is the arborized bed of the lateral thoracic artery that we consider the collateral bridge between the
thoracoacromial supply of the pectoralis major free border and, through pectoralis minor and serratus anterior
attachments, the lateral bony fifth rib. It is perhaps surprising that the lower half of the pectoralis minor muscle
alone can serve this function without the need to include the entire unit with its proximal blood supply, but such
has consistently been the case.
The lateral pectoral osteomusculocutaneous flap includes a lateral segment of vascularized fifth rib that is carried
within a soft-tissue bloc that contains the entire musculature of the chest wall from the superior border of the
fourth rib to the inferior border of the sixth between the costochondral and anterior axillary lines. This muscle bloc
includes a segment of free-border pectoralis major, the lower half of pectoralis minor, and portions of serratus
anterior, external oblique, and external and internal intercostal muscles.
FLAP DESIGN AND DIMENSIONS
The major part of the pectoralis major muscle can be spared, minimizing both functional and aesthetic deformities
to the chest wall. The resulting narrow, flat pedicle is far more appropriate for passage through most necks. If
muscle bulk is truly required throughout the neck, we suggest including the entire pectoralis minor muscle with its
proximal blood supply, detaching the muscle from the coracoid while continuing to preserve the pectoralis major
span intact. Incidentally, we have found the thin pedicle as effective as the bulky muscular one in protecting an
irradiated carotid where overlying neck flaps have failed.
The pectoralis major-pectoralis minor osteomusculocutaneous flap differs from previous flaps in three respects:
(a) the attached rib is lateral and therefore bony, (b) the accompanying skin paddle is lateral and therefore
hairless even in relatively hirsute patients, and (c) the pedicle is muscle free and therefore thin.
We prefer a lateral inframammary location for the skin island, even in cases not involving rib transfer. Not only is
the subcutaneous tissue of this region frequently scant, but so also is the hair production. Although others
advocating fascial-cutaneous extensions beyond the muscle have selected more medial sites for their paddles,
recent in vivo injection studies suggest that a lateral distribution of the thoracoacromial axis may predominate, at
least under the influence of competing hemodynamic territories.
Inframammary skin islands have measured up to 12 × 12 cm. The pivot point of this island flap occurs
immediately below the midclavicle. The arc of rotation allows the skin island to reach the posterior pharynx and
the rib to reach the contralateral mandibular angle.
Following extirpation or preparation of the defect, the course of the pectoral branch of the thoracoacromial artery
is outlined on the chest wall (see Chapter 135). If neck dissection has been performed, the lower limb of the
preferred parallel incisions of McFee will have been adjusted downward to the level of the clavicle. The skin
island is marked according to the requirements of the defect. If both lining and cover are missing, a sizable
paddle is required to replace both and to include an intervening deepithelialized zone for passage from extraoral
to intraoral sites.
The island is routinely ovoid in configuration, with specific tailoring to await the stage of “fitting in.” It extends
from just below the nipple-areola in men (just above the inframammary fold in women) to as far inferior as
necessary (approaching the costal margin), and from the costochondral line medially (slightly medial to the nipple
line in men) to as far lateral as necessary (approaching the anterior axillary line). The fifth rib is palpated
precisely and indicated beneath the upper third of the skin island. If there has been no incision at the level of the
clavicle, one is marked (Fig. 197.1).
OPERATIVE TECHNIQUE
The skin island is incised on all margins down to underlying muscle. Beginning at the superior margin, where the

P.541
pectoralis major muscle is now exposed some brief distance above its free border, the skin and subcutaneous
tissues of the upper pectoral region are rapidly elevated from the muscle as a broad bipedicle flap to the level of
the clavicular incision.
Dissection of the flap proper then is begun, starting at the inferior margin, raising skin, subcutaneous tissue, and
investing muscle fascia from the underlying muscle slips of external oblique and serratus anterior, until the lower
border of the sixth rib is reached. If this dissection is not “bloody,” sufficient
muscle fascia is not being retained with the flap and portions of the distal skin island may be jeopardized (15).
FIGURE 197.1 Planned incisions. (From Little et al., ref. 1, with permission.)
Over the sixth rib, dissection is deepened onto periosteum, exposing this layer until the superior border of that rib
is reached. Dissection is now further deepened through the intercostal musculature of the fifth intercostal space
onto pleura. Here a few protective fibers of internal intercostal muscle may be retained on the endothoracic
fascia overlying the pleural surface as the dissection approaches the inferior margin of the key fifth rib.
The medial flap margin is deepened through remaining soft tissues onto the fifth rib at the costochondral
junction. The rib is freed circumferentially over a short subperiosteal zone and divided just lateral to the junction
so that no cartilage will be included in the future osteosynthesis. The cut end of the rib then is lifted with a prying
motion, and superior and lateral dissection is resumed between the periosteum and pleura. With practice, a
somewhat forceful yet blunt technique allows rapid performance of an otherwise tedious step, sparing an intact
pleura. This is continued from medial to lateral, progressively lifting the rib away from pleura, until the necessary
length has been freed.
FIGURE 197.2 Staggered cross section of composite bloc. (From Little et al., ref. 1, with permission.)

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If the resected portion of mandible has been measured with a curved wire at the time of extirpation, precise
determination of required rib length is possible. Of course, an additional 2 to 3 cm is included to allow mortised
unions. When the determined length is freed, the rib is divided laterally, along with its intercostal bundle.
This same level of dissection, immediately above the pleura, is continued superiorly another centimeter, clearing
the fourth intercostal space up to the inferior border of the fourth rib, which can be palpated from beneath as the
flap is folded upward. Because this rib will be left with the chest wall, its inferior edge is sharply incised through
the soft tissue and periosteum of the flap superficial to its intercostal bundle.
The dissection now proceeds, lifting periosteum from denuded fourth rib, until its superior border is reached.
Until this point, dissection has proceeded en bloc with easily defined peripheral and deep margins to the bloc
(Fig. 197.2). No attention to specific anatomic particulars has been required.
Now a finger is insinuated around and behind the free border of the pectoralis major muscle just above the
hinged attachment of the flap at the superior border of the fourth rib, entering the space between the pectoralis
major and the remaining upper portion of pectoralis minor muscle. A sweep of the finger superiorly clears this
space to the clavicle, leaving the upper portion of the pectoralis minor muscle against the chest wall.
It would be possible to include within the flap the entire pectoralis minor muscle with its major vascular supply
from above, but this has not been necessary to ensure rib survival and would otherwise increase the bulk of the
pedicle beyond the aesthetic requirements of most patients.
The remaining narrow attachment of the flap to the bony wall—consisting of fourth-rib periosteum, intercostal
fascia, and a few pectoralis minor fibers—is now divided flush with the superior border of the fourth rib, leaving
the entire composite bloc attached only along the free lateral border of the pectoralis major muscle. Now that the
composite paddle has been raised, attention must be directed to dissection of the vascular paddle.
The bipedicle skin flap is retracted superiorly to expose the pectoralis major muscle. A site is selected some 2 to
3 cm above the superior margin of the skin island (three to four fingerbreadths above the free-muscle border) for
complete division of the muscle down to the submuscular fatty layer with its pectoral vessels. This division of
muscle is performed with care over a semilunar arc that, when completed, will leave a defect in the free border of
the pectoralis major muscle that has a serrated edge (Fig. 197.3).
This step is aided by lifting the pectoralis major and attached composite bloc to determine the course of the
pectoral branch underneath the muscle, thereby predicting the
precise zone of the arc under which they will be encountered. Once the vessels themselves are found, dissection
proceeds rapidly as the vessels are freed within their fatty compartment from the deep muscular surface.
FIGURE 197.3 The lateral pectoral composite flap and secondary defect. (From Little et al., ref. 1, with
permission.)

Perforating branches into the overlying muscle are divided between microclips, and the submuscular fascia is
progressively divided on either side of the vessels until the clavicle is reached. Here the vessels can be freed
totally from the muscle and allowed to drop away, rendering a true vascular island of the composite bloc. The
clavicular origin of the muscle then is sharply divided along the clavicle, creating a bipedicle flap of muscle
paralleling the overlying bipedicle flap of skin and fat. The muscle rent need be only large enough to allow
passage of the entire compound paddle up through the muscle and skin onto the chest.
If neck dissection has not been done, the skin and platysma of the neck also are elevated as a broad bipedicle
flap to the level of the defect, and the flap again is passed through. A half-twist of the ribbon-like pedicle is
necessary to bring the curve of the rib into accord with that of the mandible, or the rib can be rolled down one-
half turn to accomplish the same alignment.
If, on bringing the rib and skin island to their respective defects, there is tension on the pedicle as it crosses the
clavicle, a broad half-thickness notch in that structure will bring relief (as we have added on two occasions).
Assuming proper elevation and handling of the flap, bleeding can be elicited from the muscle cuff about the rib
and from the rib ends.
If symphysis replacement is required, burred grooves through the concave cortical rib surface will cause free flow
of blood and allow appropriate bending for chin contour, which is maintained by wires. For such symphysis
replacement, the rib ends are freed of soft tissue, burred of outermost cortex, and inserted within the cleared
cancellous portions of the cut mandibular ends, where they are transfixed. For horizontal and ascending ramus
replacement, overlapping mortised joints are fashioned and wired. In all cases, prolonged external biphasic
splinting is added, allowing full jaw motion throughout the postoperative period.
Skin islands have replaced lining from the levels of the hypopharynx and contralateral posterior pharyngeal wall
to the anterior floor of the mouth, tongue, and cheek. When concomitant cover is required, an intervening buried
deepithelialized strip is necessary between intraoral and extraoral portions of the flap.
Small defects of the pleura are closed directly, while larger ones require a chest tube. When direct closure of the
skin defect is possible without tension, such as when the skin island is needed for lining alone, an anterior
border strap flap of latissimus dorsi muscle is transposed to cover the pleura and fill out the muscle defect of the
chest wall. When defects are closed in the wake of skin islands needed to replace both lining and cover, a
latissimus dorsi musculocutaneous flap allows secure closure without displacement of chest wall landmarks (Fig.
197.4).
CLINICAL RESULTS
The bony fifth rib within a composite bloc based on a non-muscular pedicle has been transferred to the
mandible of six patients. All had massive (T3 or T4) or recurrent cancers, and all had received prior
irradiation to the jaw and neck (two with added interstitial dosage). Half required replacement of cover, as
well as lining, during their jaw reconstructions. All flaps survived and healed under these unfavorable
conditions.
One patient suffered a minor partial-thickness marginal loss to a portion of the chest paddle extended
beyond the anterior axillary line. This healed spontaneously without treatment. Three patients died within 4
months of surgery (two from tumor and one of postoperative stroke), all with satisfactory reconstructions
essentially intact. The remaining three patients demonstrate a solid mandible with good range of motion and
residual occlusion. Speech and oral function have been good.
One patient developed a minor anterior separation of lining and required a chest tube for 1 week because

P.543
of a pleural tear that was otherwise without consequence. No chest tube was required in the remaining five
patients.
In a prior patient in whom a full-thickness muscular pedicle was used, total flap loss followed efforts to
reduce the muscular element to allow passage through an undissected neck. We consider the
recommended nonmuscular technique safer in achieving a truly narrower pedicle.
In using the skeletonized, nonmuscular pedicle, functional pectoral loss is minimized. We do not suggest
that total function is preserved by this maneuver, however, because the remaining muscle must be
denervated to a greater or lesser degree when the nutrient pathways with their inevitable neural
components are freed from the muscle. Some muscle wasting results, producing a deformity, but the
deformity is mild and subtle compared with the alternative of complete muscle division with retraction of
medial and lateral parts.
SUMMARY
One-stage reconstruction of the mandible, including both cover and lining, with the lateral pectoral
(pectoralis major-pectoralis minor) osteomusculocutaneous flap is well worth the extra surgical effort
involved.
FIGURE 197.4 A: A 44-year-old man with osteoradionecrosis of the mandible and recurrent
mucoepidermoid carcinoma treated by composite excision, including lining, mandibular body, and skin.
Extirpation and reconstruction marked. B: Flap elevated and laid over chest, showing thin pedicle,
pectoralis muscle, and skin paddle. C: Flap elevated and laid over neck showing bleeding fifth rib. D: Early
postoperative view with mandibular splint in place. E: Postoperative Panorex of jaw at 14 months. F:

Postoperative occlusion. G: Postoperative donor site; note latissimus dorsi musculocutaneous patch. H,I:
Postoperative views at 14 months. (From Little et al., ref. 1, with permission.)
References
1. Little JW III, McCulloch DT, Lyons JR. The lateral pectoral composite flap in one-stage reconstruction of
the irradiated mandible. Plast Reconstr Surg 1983;71:326.
2. Ariyan S. Pectoralis major, sternomastoid, and other musculocutaneous flaps for head and neck
reconstruction. Clin Plast Surg 1980;7:89.
3. Ariyan S, Cuono CB. Myocutaneous flaps for head and neck reconstruction. Head Neck Surg 1980;2:321.
4. Cuono CB, Ariyan S. Immediate reconstruction of a composite mandibular defect with a regional
osteomusculocutaneous flap. Plast Reconstr Surg 1980;65:477.
5. Landra AP. One-stage reconstruction of a massive gunshot wound of the lower face with a local
compound osteomusculocutaneous flap. Br J Plast Surg 1981;34:395.
6. Biller HF, Baek S, Lawson W, et al. Pectoralis major myocutaneous island flap in head and neck surgery:
analysis of complications in 42 cases. Arch Otolaryngol 1981;107:23.
7. Williams PL, Warwick R, eds. Gray's anatomy, 36th Ed. Philadelphia: Saunders, 1980.
8. Siemssen SO, Kirkby B, O'Connor TPF. Immediate reconstruction of a resected segment of the lower jaw
using a compound flap of clavicle and sternomastoid muscle. Plast Reconstr Surg 1978;61:724.
9. Green MF, Gibson JR, Bryson JR, Thomson E. A one-stage correction of mandibular defects using a split
sternum pectoralis major osteomusculocutaneous transfer. Br J Plast Surg 1981;34:11.
10. Ariyan S, Finseth FJ. The anterior chest approach for obtaining free osteocutaneous rib grafts. Plast
Reconstr Surg 1978;62:67.
11. Ariyan S. The viability of rib grafts transplanted with periosteal blood supply. Plast Reconstr Surg
1980;65:140.
12. Manktelow RT, McKee NH, Vettese T. An anatomical study of the pectoralis major muscle as related to
functioning free muscle transplantation. Plast Reconstr Surg 1980;65:610.
13. Freeman JL, Walker EP, Wilson JSP, Shaw HJ. The vascular anatomy of the pectoralis major
myocutaneous flap. Br J Plast Surg 1981;34:3.
14. Nakajima H, Maruyama Y, Kocla E. The definition of vascular skin territories with prostaglandin E1: the
anterior chest, abdomen and thigh-inguinal region. Br J Plast Surg 1981;34:258.

15. Magee WP, Gilbert DA, McInnis WD. Extended muscle and musculocutaneous flaps. Clin Plast Surg
1980;7:57.

Chapter 198
Vascularized Outer Table Calvarial Bone Flap
J. M. PSILLAKIS
EDITORIAL COMMENT
This is a relatively new flap, and as such, there is considerable controversy about the correct anatomy and
operative approach. The reader is cautioned to read the references and the current literature.
The outer table of the calvarium has become an increasingly important donor site for bone grafts in craniofacial
surgery (1, 2, 3, 4, 5). It is close to the operative field, it has a membranous origin similar to that of the facial
skeleton, there is an inconspicuous donor-site scar, and there is relatively little postoperative pain.
The vascularized outer table calvarial bone flap can be taken from any part of the skull, but in most cases I use
the parietal region as the donor area, and the blood supply is carried by the periosteum in continuity with the
deep fascial layer of the temporal aponeurosis.
INDICATIONS
This flap is useful for bone loss in the frontal area, supraorbital region, zygomatic region up to the level of
the nose, maxillary area in the middle third of the face, and the mandibular area up to the level of the chin.
ANATOMY
The superficial temporal artery continues cranially anterior to the ear at the level of the superficial fascia of the
head, more commonly known as the SMAS, and gives off large branches to the parietal and frontal areas.
Relatively large perforators of the superficial temporal artery are given off that penetrate into the calvarium
primarily at suture lines. There are multiple anastomoses between the superficial temporal system and the middle
meningeal arterial arcade within the diploic space.
The periosteum over the frontal parietal region continues with a thin layer over the deep temporal fascia. At the
level of the zygomatic arch, proximal branches from the superficial temporal vessels anastomose within the deep
temporal muscle. This system irrigates the periosteum even in the absence of large perforating branches from
the distal superficial temporal artery. The outer table of the calvarial bone in the frontal parietal region receives
numerous small perforators from the vascular network within the periosteum. These perforators do not
significantly contribute to the blood supply of the inner table. The inner table is more vascularized by the
meningeal vessels. Because of the existence of this random system of anastomosing vessels from the superficial
and deep arteries through the temporalis fascia and periosteum, a periosteal flap can be designed using this
layer as a pedicle carrying a segment of the outer table of the calvarium (Fig. 198.1). If only the outer table is to
be used, it is unnecessary to include the galea and the superficial temporal artery to maintain the blood supply to
the bone. If the full thickness of the bone is to be used, it is important to include the galea and the superficial
temporal vessels in the flap. The thickness of the calvarium is variable from one region to the other, but a special
study performed in 100 cadavers showed that the thickness of the parietal area is 5 mm, with a range of 4 to 6
mm.

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FLAP DESIGN AND DIMENSIONS
With a pivot point in the zygomatic arch, the vascularized outer table calvarial bone flap can reach the forehead,
the zygomatic region, and the mandible up to the level of the chin. The bone can be as long as needed to go
from one temporal region to the other. The width can be variable, but it is easier to take bone flaps from a
maximum width of 5 cm. If larger areas are necessary, a more careful cut of the bone is necessary to avoid
damage to the inner table. I was able to take up to 10 cm in width without creating a lesion in the
inner table. The pedicle must include the deep temporal fascia and the loose tissue that is found over it. If a long
pedicle is needed, the temporal fascia must be cut in a curved shape with the pivot point more posteriorly on the
zygomatic arch. The width of the fascia at the level of the zygomatic arch may range from 5 to 8 cm.
FIGURE 198.1 Scheme of the technique to obtain the vascularized outer table calvarial bone. (From Psillakis et
al, ref. 3, with permission.)
OPERATIVE TECHNIQUE
The skull is exposed through a coronal incision and subgaleal dissection. Care is taken to avoid injury to the
proximal branches of the superficial temporal artery within 2 cm of the zygomatic arch. The size and shape of the
bone graft are determined, and an appropriate pattern of the graft is marked in the periosteum of the parietal or
frontal bone behind the hairline. This pattern is at least 2 to 3 mm larger than the actual graft needed.
The periosteum along the perimeter of the pattern is cut, except inferiorly, where the bone is to be pedicled. With
a pneumatic saw, the bone then is cut through the outer cortex into the diploic space. The groove created by the
pneumatic saw then is used to insert the pediatric Gigli saw into the distal extremity of the flap to cut through the
diploic space. As the saw approaches the pedicle proximally, gentle upward pressure will cut the inferior bony
margin without disrupting the delicate fascial pedicle. This method can be used to elevate bone flaps up to 5 cm
in width. If a larger bone flap is necessary, long, flexible, thin saw blades can be used. For segments of bone up
to 3 cm, the thin and flexible pneumatic saw can be used for cutting through the diploe. The chisel also can be
used for narrow segments, and specific designs of chisels have been published, but I think the chisel is much

P.546
more risky to take bone from the skull than the method just described.
CLINICAL RESULTS
The results of this operation have been very satisfactory (Fig. 198.2). The outer table calvarial bone has
almost no resorption, and it retains volume well. It is also quite hard, and its curvature is ideal for modeling
the bone and creating projection where necessary.
FIGURE 198.2 A: Partial loss of the mandible from a gunshot wound. B: Intraoperative view of the
technique described. C: Postoperative appearance.
SUMMARY
The outer table of the skull can be brought down as a vascularized bone flap for various facial defects.
References
1. McCarthy JG. Zide BM. The spectrum of calvarial bone grafting: introduction of the vascularized calvarial
bone flap. Plast Reconstr Surg 1984;74:10.
2. Pensler J, McCarthy JG. The calvarial donor site: an anatomic study in cadavers. Plast Reconstr Surg
1985;75:648.
3. Psillakis JM, Grotting JC, Casanova R, et al. Vascularized outer table calvarial bone flaps. Plast Reconstr
Surg 1986;78:309.
4. Casanova R, Cavalcante D, Grotting JC, et al. Anatomic basis for vascularized outer-table calvarial bone
flaps. Plast Reconstr Surg 1986;78:300.
5. McCarthy JG. Vascularized outer-table calvarial bone flaps (Discussion). Plast Reconstr Surg
1986;78:318.

Chapter 199
Microvascular Free Transfer of A Dorsalis Pedis Flap for Intraoral
Lining
L. A. SHARZER
The oral cavity, it was thought, had certain characteristics that rendered it unsuitable as a free-flap recipient site
(1, 2). Subsequent reports (3, 4, 5, 6, 7) indicated that it is possible to transfer free flaps safely to the oral cavity,
and although this mode of reconstruction has not become the first-line treatment of choice, it is nevertheless an
essential part of the reconstructive surgeon's armamentarium.
INDICATIONS
Of the available free-flap donor sites for intraoral reconstruction, the dorsum of the foot has several distinct
advantages. Its thinness and pliability make it especially suitable to replace oral lining. The free dorsalis
pedis flap is of suitable size, and it has a long vascular pedicle. It is also possible to transfer it as an
osteocutaneous flap by including the second metatarsus (see Chapter 207). Finally, the distance between
the foot and the mouth makes a two-team approach very practical, without increased operating time.
ANATOMY
The vascular anatomy and technique of elevation of the dorsalis pedis flap are described in Chapter 548.
FLAP DESIGN AND DIMENSIONS
Arteriography of the dorsum of the foot is routine prior to dorsalis pedis flap elevation. It is necessary to assess
the patency, location, and source of the dorsalis pedis artery as well as the adequacy of the posterior tibial
circulation. Two views are necessary, particularly the lateral view, if an augmented flap is required, and a
decision must be made regarding the need for delay.
A reasonable approximation of size and shape, however, can be made from preoperative evaluation of the lesion.
The flap then should be designed slightly larger than the anticipated need. The vascular pedicle should be taken
long enough to allow for sufficient leeway in choice of recipient vessel. This is particularly important in the
irradiated patient, because it is best to choose a recipient artery outside the area of irradiation. Venous drainage
of the flap is by means of the greater saphenous vein and the venae comitantes of the dorsalis pedis artery;
therefore, both should be taken long enough to allow freedom in choosing a recipient vein. Either one will
provide adequate venous drainage.
It is important to remember that because free-flap reconstruction is planned, possible recipient vessels should
not be sacrificed unnecessarily. It is, of course, axiomatic that the choice of this method of reconstruction must
not compromise the adequacy of the resection for cure of the cancer. Unlike free-flap transfer to other sites,
where a specific recipient artery is planned, the surgeon must be well versed in the vascular anatomy of the
head and neck area and have in mind a variety of possible recipient vessels. Frequent choices are the facial
artery and vein (retrograde from the face), lingual or superior thyroid artery (if end-to-end arterial anastomosis is
desired), or the external carotid artery (if end-to-side anastomosis is preferred).
OPERATIVE TECHNIQUE
Delay is rarely necessary before intraoral transfer of a dorsalis pedis flap. The only indication for delay is the

requirement for a large flap that includes the “random” portion of the dorsal foot skin. This is the portion of skin
distal to the perforating branch of the dorsalis pedis artery in those patients in whom the first dorsal metatarsal
artery is of a type II configuration. In these patients, my method of delay is to elevate the distal portion of the flap
as far proximally as the perforating branch and to ligate this branch. The flap then is replaced in situ and
reelevated 7 to 10 days later. Most oral cancers, even large ones, have a small enough mucosal presentation
that an undelayed flap will suffice.
For details of flap elevation see Chapter 548. If marginal circulation is in question, it can be tested with
fluorescein. The flap is transferred to the oral cavity and held in place with a few sutures, and the vascular
anastomoses are carried out (Fig. 199.1). It is my preference to perform the arterial anastomosis first; however,
the order of vascular connections is probably not important. Once circulation is established, a watertight intraoral
closure is performed, followed by routine wound closure. Monitoring of the flap in the postoperative period is by
hourly observation of color and capillary refill as well as by palpation or Doppler examination of the dorsalis pedis
artery.
FIGURE 199.1 A: Large intraoral wound following composite resection for mandibular sarcoma. B: Dorsalis
pedis flap being inset. Flap has been sutured to base of tongue; anterior border is free. C: Postoperative
appearance of flap.
CLINICAL RESULTS
There are two disadvantages to this type of intraoral reconstruction. Free flaps are generally an all-or-
nothing procedure. Early vascular thrombosis leads to complete flap necrosis, in contrast to pedicle flap
reconstruction, where partial necrosis or fistula formation is the most common complication, but complete
flap loss is rare. Specific disadvantages of the dorsalis pedis flap relate to donor-site morbidity; however,
because these flaps are relatively small, donor-site complications are unusual.
SUMMARY
Free dorsalis pedis flap transfer for intraoral lining is not the usual first-line treatment. Nevertheless, it is a
reliable, safe alternative and a valuable addition to our choice of reconstructive procedures.

References
1. Kaplan EN, Buncke HJ, Murray DE. Distal transfer of cutaneous island flaps in humans by microvascular
anastomoses. Plast Reconstr Surg 1973;52:301.
2. Finseth F, Kavarana N, Antia N. Complications of free-flap transfers to the mouth region. Plast Reconstr
Surg 1975;56:562.
3. Leek D, Ben-Hur N, Mazzarella L. Reconstruction of the floor of the mouth with a free dorsalis pedis flap.
Plast Reconstr Surg 1977;59:379.
4. Sharzer LA, Horton CE, Adamson JE, et al. Intraoral reconstruction in head and neck cancer surgery. Clin
Plast Surg 1976;3:495.
5. Panje WR, Bardach J, Krause CJ. Reconstruction of the oral cavity with a free flap. Plast Reconstr Surg
1976;58:415.
6. Franklin JD, Withers EH, Madden JJ, Lynch JB. Use of the free dorsalis pedis flap in head and neck
repairs. Plast Reconstr Surg 1979;63:195.
7. Schlenker JD, Robson MC, Parsons RW. Methods and results of reconstruction with free flaps following
resection of squamous cell carcinoma of the head and neck. Ann Plast Surg 1981;6:362.

Chapter 200
Innervated Gracilis Musculocutaneous Flap for Total Tongue
Reconstruction
N. J. YOUSIF
W. W. DZWIERZYNSKI
EDITORIAL COMMENT
A number of flaps for reconstruction of the total tongue have been described, and they include— besides
the innervated gracilis—the radial forearm, the lateral arm flap, as well as the rectus abdominis. One should
not forget that possibly the most important factors for deglutition are the remaining muscles in the
undersurface of the resected tongue. Restoration of sensibility should also be an important objective and
can be achieved by performing an anastomosis either end-to-end or end-to-side to the lingual nerve.
Reconstruction after total glossectomy is a difficult problem in head and neck reconstructive surgery. The tongue
is essential in swallowing, speech, and airway protection (1). Tongue function is achieved by the complex
interactions of the intrinsic and extrinsic musculature and their nerve innervation (2, 3). To obtain active muscle
function for a neo-tongue, we utilize an innervated transverse gracilis myocutaneous flap. Recreating all the
complex motions of the tongue is currently impossible, but the innervated gracilis flap is used in an attempt to
recreate one of these functions—elevation (4). Elevation of the neo-tongue can potentially help the glossectomy
patient achieve airway protection and improved propulsion of the food bolus.
INDICATIONS
Innervated tongue reconstruction is indicated for total glossectomy defects after cancer extirpation surgery
(5, 6). Most conventional tongue reconstructions provide only bulk (7, 8). For partial glossectomy defects, in
which some muscle innervation remains, addition of bulk may be sufficient (9). For patients undergoing total
glossectomy, innervated gracilis reconstruction offers the cancer patient hope of restoration of some
aspects of tongue function.
ANATOMY
The dominant vascular pedicle from the profunda femoris artery to the gracilis enters the muscle 10 cm below the
pubic tubercle. The artery at its origin is 1.5 to 2 mm in diameter. It is accompanied by two venae comitantes.
The main arterial pedicle divides into three to six vessels, ranging in length between 1 and 2 cm, before entering
the muscle. In the upper third of the gracilis muscle, three to six musculocutaneous perforators supply the
overlying skin. A septocutaneous perforator can sometimes be found running between the gracilis and the
adductor longus muscle. The middle and distal thirds of the skin overlying the gracilis muscle are supplied by
vessels from the superficial femoral and saphenous arteries. The unreliability of this distal skin component of the
traditional longitudinally designed gracilis myocutaneous free flap has limited its usefulness in the treatment of
larger defects (10). Vertical orientation of the skin paddle allows a more robust and reliable blood supply to the
cutaneous paddle (11).
The motor-nerve supply to the gracilis muscle is the anterior branch of the obturator nerve, which is located

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between the abductor magnus and the abductor longus muscles. The nerve enters the muscle immediately
superior to the dominant vascular pedicle, on its deep medial surface.
FLAP DESIGN AND DIMENSIONS
The skin paddle is designed to reconstruct the bulk of the resected tongue and pharynx. Skin paddles as large
as 10 × 20 cm can be harvested for tongue reconstruction. With the patient in the supine position, the knee and
hip are flexed, and the lower extremity is abducted. A line is drawn 10 cm inferior to the pubic tubercle,
perpendicular to the axis of the gracilis muscle. This line marks the center of the cutaneous paddle of the
transverse gracilis flap. A crescent-shaped skin paddle is designed; the width of the cutaneous segment is
determined by the amount of skin in the upper medial thigh that can be removed, while allowing direct closure
(Fig. 200.1). An incision is made along the anterior margin of the flap down to, and including, the fascia lata. Flap
dissection continues from anterior-to-posterior in a subfascial plane until the intermuscular septum.
FIGURE 200.1 Drawing of donor site (left) and shin paddle (right).
The septofasciocutaneous and myofasciocutaneous perforators from the dominant pedicle are identified,
protected, and included in the flap. The adductor longus muscle is retracted anteriorly, to gain better exposure of
the flap pedicle. Dissection of the pedicle continues to the profunda femoris artery and vein. A pedicle length of 6
to 8 cm can be achieved. The nerve to the gracilis lies immediately superior to the vessels; it is dissected to its
branching point. A posterior incision is made along the flap margin, including the deep fascia of the thigh, and
dissection proceeds anteriorly to the posterior border of the gracilis. The gracilis muscle is then separated from
the adductor longus and adductor magnus muscles. The entire gracilis muscle is included with the flap for
fabrication of a dynamic sling. The donor site is reliable and well known to most microsurgeons.
OPERATIVE TECHNIQUE
The initial flap dissection can be started simultaneously with the cancer extirpative surgery. The width of the
gracilis skin paddle is chosen to allow direct closure of the donor site; this is usually 6 to 10 cm. After cancer
extirpation, the recipient vessels are identified in the neck. For the recipient vessel, the external carotid artery
can be used in an end-to-side fashion; or one of its branches, the lingual or superior thyroid artery, can be used
with an end-to-end anastomosis. The external jugular vein or one of its branches is usually chosen for the
venous outflow. The hypoglossal nerve stump is preserved for neurotization of the neo-tongue (4).
The orientation of the gracilis muscle is critical. The muscle is oriented transversely to form a sling, achieving
elevation of the neo-tongue with active muscle contraction. The ends of the muscle are fastened laterally to the
mandibular arch. This is achieved with a Mitek suture anchor (DePuy Mitek, Raynham, MA) inserted into the
mandible body or its remnant (Fig. 200.2). If a mandible reconstruction is required, the gracilis muscle is
suspended to the periosteum of the remaining mandible or by using direct suture fixation to the reconstruction
plate on the fibula flap. The muscle is centrally secured to the hyoid bones. The skin pedicle, which is oriented
perpendicularly to the muscle, is used to close the intraoral defect and is folded to produce a neo-tongue (12).

Sufficient bulk must be available to allow palatoglossal contact. After the gracilis is suspended, the vascular
anastomoses are performed. The motor nerve to the gracilis is coapted to the hypoglossal nerve on one side.
FIGURE 200.2 Attachment of gracilis muscle to mandible transversely as seen from below.
CLINICAL RESULTS
Surgical difficulties encountered in creating a neo-tongue with the transverse gracilis technique are minimal.
Because of the abundant subcutaneous tissue on the flap, attachment of the gracilis to the mandible is the
greatest challenge. In all patients, bulk was maintained during postoperative follow-up; however, decreased
bulk in the flap may occur following radiation therapy. Excessive bulk may also pose a problem: in one
patient, a suction lipectomy was required to achieve tracheostomy decannulization. Prognosis in patients
requiring a total glossectomy is generally poor. The innervated gracilis musculocutaneous flap offers
palliation and, in the occasional survivor, long-term improved reconstruction (13).
SUMMARY
The innervated gracilis musculocutaneous flap is currently our preferred method of reconstruction of large
total glossectomy defects. The bulk of the cutaneous pedicle and muscle is superior to other methods of
static reconstruction. The donor site is reliable and well known to most microsurgeons. With the addition of
a single-nerve anastomosis, the innervated gracilis flap offers a reconstructive option that can replace bulk
and can offer the potential for improved physiologic motion.
References
1. Yu P, Robb GL. Reconstruction for total and near-total glossectomy defects. Clin Plast Surg 2005;32:411.
2. McConnell FMS. Analysis of pressure generation and bolus transit during pharyngeal swallowing.
Laryngoscope 1988;98:71.
3. Urken ML, Moscoso J, Lawson W, Biller HF. A systematic approach to functional reconstruction of the oral
cavity following partial and total glossectomy. Arch Otolaryngol Head Neck Surg 1994;120:589.

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4. Yousif NJ, Dzwierzynski WW, Sanger JR, et al. The innervated gracilis musculocutaneous flap for total
tongue reconstruction. Plast Reconstr Surg 1999;104:916.
5. Urken ML, Turk JB, Weinberg H, et al. The rectus abdominis free flap in head and neck reconstruction.
Arch Otolaryngol Head Neck Surg 1991;117:857.
6. Sultan MR, Coleman JJ III. Oncologic and functional considerations of total glossectomy. Am J Surg
1989;158:297.
7. Matloub H, Larson D, Kuhn J, et al. Lateral arm free flap in oral cavity reconstruction: a functional
evaluation. Head Neck 1989;11:205.
8. Sanger JR, Campbell BH, Ye Z, et al. Tongue reconstruction with a combined brachioradialis-radial
forearm flap. J Reconstr Microsurg 2000;16:7.
9. Cheng N, Shou B, Zheng M, Huang A. Microneurovascular transfer of the tensor fasciae latae
musculocutaneous flap for reconstruction of the tongue. Ann Plast Surg 1994;33:136.
10. Whetzel TP, Lechtman AN. The gracilis myofasciocutaneous flap: vascular anatomy and clinical
application. Plast Reconstr Surg 1997;99:1642.
11. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis musculocutaneous flap. Ann Plast
Surg 1992;29:482.
12. Yoleri L. Total tongue reconstruction with free functional gracilis muscle transplantation: a technical note
and review of the literature. Ann Plast Surg 2000;45:181.
13. Wechselberger G, Schoeller T, Bauer T, et al. Surgical technique and clinical application of the
transverse gracilis myocutaneous free flap. Br J Plast Surg 2001;54:423.

Chapter 201
Scapular Osteocutaneous Flap
W. M. SWARTZ
EDITORIAL COMMENT
This is an excellent technique for reconstruction of the mandible and either overlying skin or intraoral lining.
The major drawback of the procedure is the need to reposition the patient, while in iliac-crest or fibula
harvesting, the patient may remain supine for the entire procedure.
Scapular and parascapular cutaneous flaps of the back (1, 2, 3, 4, 5, 6) may be combined with the osseous
territory of the lateral border of the scapula to provide versatile osteocutaneous free flaps based on the
circumflex scapular artery. A wide variety of tissue combinations have been used extensively for head and neck
reconstruction of both the mandible and maxilla (7) and also for reconstruction of tibial osseous defects (8).
INDICATIONS
The principal indication for the scapular osteocutaneous flap in head and neck surgery has been
mandibular reconstruction. Osseous defects of the mandible of up to 14 cm, in conjunction with large
cutaneous or intraoral mucosal defects, are well suited for this application. Great freedom in spatial
orientation of skin and bone is allowed. Through-and-through defects of the cheek, combined with sagittal
mandibular defects, also can be reconstructed with this flap, as can anterior mandible defects (9). The
length of the vascular pedicle easily reaches the external carotid system under most conditions. In addition,
the scapular bone can be used for the maxilla and the infraorbital rim in maxillectomy defects. A great
amount and variety of soft tissues are available for restoring cheek skin, palatal tissue, or obliteration of the
maxillary sinuses.
ANATOMY
The blood supply to the lateral border of the scapula is derived from a descending branch of the circumflex
scapular artery just before its emergence through the triangular space, where it then arborizes to supply the
cutaneous circulation. The distal third of the scapula is supplied additionally by the terminal branches of the
thoracodorsal artery (Fig. 201.1). This anatomic relationship is important when planning osteotomies of the distal
third of the scapula: If the thoracodorsal circulatory system is not included in the flap, osteotomies in the distal
third risk necrosis of the bone. The entire border of the scapula, including the tip, may be well served by the
proximal blood supply, provided that osteotomies in the distal third are not performed.
After giving off branches to the muscles surrounding the lateral border of the scapula, the circumflex scapular
artery emerges through the triangular space, bound by the long head of the triceps and the teres major and teres
minor muscles. The skin circulation then arborizes into a transverse branch and a descending branch, which
provide the directional basis for the parascapular flap and transverse scapular flap. The skin flap also can be
oriented toward the margin of the breast into the axilla.
The vascular pedicle is derived from the subscapular artery and, as such, derives a length about 4 to 5 cm to the
lateral border of the scapula. Should a skin-only flap be used, a longer pedicle of 6 to 9 cm is possible. The

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diameter of the
subscapular artery is 2.0 to 2.5 mm. Paired venae comitantes accompany the circumflex artery; they join into a
single large vein near the axillary vein.
FIGURE 201.1 Diagrammatic rendition of blood supply to the lateral border of the scapula.
FLAP DESIGN AND DIMENSIONS
The osseous portion of the flap extends from just below the glenoid fossa to the tip of the scapula and may
include the entire tip should reconstructive needs require. Up to 14 cm of bone length are available in the adult
male. The cutaneous flap can be designed either transversely or obliquely, depending on soft-tissue
requirements. Additionally, multiple skin paddles can be developed with separation of the skin, leaving
connections in the subdermal plexus. This kind of arrangement is helpful for providing intraoral and extraoral skin
requirements.
OPERATIVE TECHNIQUE
The surgical procedure is carried out in either the prone or lateral positions, depending on recipient-site
requirements. The proximal portion of the skin paddle is centered over the triangular space, which, in turn, lies
along the upper border of the scapula. Preoperatively, the cutaneous distribution of the lateral and descending
branches of the circumflex scapular artery is identified using transcutaneous ultrasonic Doppler evaluation. The
arm is draped with a stockinette, allowing freedom of arm motion during the dissection. The skin then is incised
down to the loose areolar plane directly above the infraspinatus muscle.
I prefer to elevate the skin island from medial to lateral, identifying the vessels in the subcutaneous plane on the
underside of thy, flap. The subscapular artery then is followed into the triangular space at the lateral border of
the scapula. It is important not to separate the circumflex scapular artery from the lateral border of the scapula in
this dissection. The dissection is carried on the lateral border of the circumflex scapular artery through the
triangular space. Several branches to the teres major and subscapular muscles are ligated to accomplish the
vascular preparation.
If the latissimus dorsi muscle or the angular branch of the thoracodorsal vessels is required for a complex,

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multitissue reconstruction, an additional incision is made in the axilla and the thoracodorsal system is dissected.
This maneuver is not necessary unless the latissimus or the terminal branch of the thoracodorsal vessel is
required.
At this time, the lateral border of the scapular bone is palpated as it joins the thinner central portion, and this is
the site of the longitudinal osteotomy. Using a periosteal elevator, the teres major muscle is divided sharply along
with the branches of the serratus muscle toward the tip of the scapula. Then, using an oscillating saw, the bone
is cut through, either angulating toward the tip, if desired, or straight along the border (Fig. 201.2). A second cut
is made transversely across the lateral border of the scapula about one finger breadth below the glenoid fossa.
This portion of the dissection is somewhat bloody, and periosteal bleeders will require coagulation. An osteotome
is used to complete the saw cuts, if necessary. Muscular attachments of the scapular border to the serratus
muscle and teres muscle are sharply divided, and the bone then is elevated completely on its vascular pedicle.
Vessels that contribute to the blood supply of the scapula will be identified at the time of cutting through these
muscles.
When large flaps that need both the circumflex scapular artery and the thoracodorsal systems are required with
an osteotomy in the central portion of the scapula, both the thoracodorsal and circumflex scapular systems are
dissected. The teres major muscle straddles these two blood supplies. Either the teres major can be divided from
its origin and resutured, or a portion of the flap can be passed through the triangular space to complete the
dissection. With adequate retraction and a bit of a stretch, all but the largest flaps can be delivered into the
axilla to join with the latissimus dissection and the thoracodorsal pedicle, thus avoiding division of the teres major
muscle.

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FIGURE 201.2 Diagram illustrating anatomic landmarks involved in sharp division of teres major along with the
branches of the serratus muscle. The bone is then cut through.
The scapular osteocutaneous donor site requires reattachment of the serratus and the teres muscle to the
border of the scapula. These muscles are reapproximated with 2-0 Vicryl or Dexon sutures, without needing to
drill holes in the border of the scapula. A drain is placed in the axilla, and the skin is closed primarily.
Postoperatively, the shoulder is kept immobilized for 1 week, and gradual stretching exercises are begun. An
example of the scapular osteocutaneous flap used for complex three-dimensional reconstruction requiring bone
and soft tissue is presented (Fig. 201.3).
CLINICAL RESULTS
Our experience using this flap for a wide variety of mandibular and maxillary defects has encouraged us to
recommend the flap without reservation. Donor-site morbidity is low, and shoulder motion is regained in
most patients through a course of physical therapy commencing 1 week postoperatively.
SUMMARY
This flap provides a segment of corticocancellous bone up to 14 cm long that is well perfused on a vascular
pedicle separate from the overlying skin island. Because of the rich subdermal plexus of the scapular and
parascapular systems, extremely large multilobulated flaps can be fabricated for a wide variety of bone and
soft-tissue defects. The rich blood supply to the scapular bone contributes to early bone union.

FIGURE 201.3 An 86-year-old woman, following radical maxillectomy for squamous-cell carcinoma. A:
Preoperative condition showing missing septum of nose, left nasal side wall, orbital floor, hard palate, and
external cheek skin. B: Proposed surgical plan. Lateral border of scapula was designed to become new
alveolar bone, stretching from the midline of the maxilla to the zygomatic arch. The thickest portion of the
scapula was suitable for osteointegrated implants for later dental restoration; the thinner scapular blade
formed the hard palate. A skin graft was used on the palatal surface over periosteum and muscle that
accompanied the scapular bone. A large double-paddle scapular skin flap then formed the basis of the soft-
tissue restoration, which included the nasal lining and external cheek skin. C: Early postoperative result.
References
1. Dos Santos LF. The scapular flap: a new microsurgical free flap. Rev Bras Cir 1980;70:133.
2. Dos Santos LF. The vascular anatomy and dissection of the free scapular flap. Plast Reconstr Surg
1984;73:599.
3. Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular flap: a new cutaneous microsurgical free flap.
Plast Reconstr Surg 1982;69:591.

4. Rowsell AR, Davis DM, Eisenberg N, et al. The anatomy of the subscapular-thoracodorsal arterial system:
a study of 100 cadaver dissections. Br J Plast Surg 1984;37:574.
5. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg 1982;69:6011.
6. Teot L, Bosse JP, Monfarrege R, et al. The scapular crest pedicled bone grafts. Br J Microsurg
1981;3:257.
7. Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap for mandibular and maxillary
reconstruction. Plast Reconstr Surg 1986;77:530.
8. Sekeguchi J, Kobaygashi S, Ohmori K. Use of the osteocutaneous free scapular flap on the lower
extremities. Plast Reconstr Surg 1993;91:1103.
9. Coleman JJ, Sultan MR. The bipedicled osteocutaneous scapular flap: a new subscapular system free
flap. Plast Reconstr Surg 1991;87:682.

Chapter 202
Radial Forearm Free Flap in Intraoral Reconstruction
D. S. SOUTAR
I. A. McGREGOR
EDITORIAL COMMENT
Postoperatively, the radius must be protected from undue stress because the incidence of fracture can be
significant when a segment of the radius has been removed with the flap. The ulnar artery version of the
forearm flap has not been included in the Encyclopedia because the safety of this flap is still being debated.
The radial forearm flap is a fasciocutaneous flap based on the radial artery and venae comitantes, together with
the subcutaneous forearm veins. Several reports (1, 2, 3, 4, 5) already have demonstrated the versatility,
usefulness, and reliability of this flap both as a pedicled flap in reconstructive surgery of the hand and as a free
flap in the expanding field of free tissue transfer. This flap can be used as either a fasciocutaneous flap or as an
osteofasciocutaneous flap (6, 7) for reconstructing defects resulting from excision of intraoral malignancies.
INDICATIONS
Resection techniques that preserve all or part of the mandible and reconstructive techniques that aim to
restore mandibular continuity result in smaller intraoral defects. Such defects do not readily accommodate
large bulky flaps without distorting the oral cavity and disturbing oral function and competence.
The radial forearm flap offers thin, pliable predominantly hairless skin that is well suited to replace oral
mucosa following tumor excision. The flap readily conforms to the varying contours within the oral cavity
and subsequently settles remarkably quickly, showing little or no evidence of contracture or “pin-
cushioning” (Fig. 202.8). This may be related to the presence of the deep fascia on the undersurface of the
flap that, perhaps, does not contract to the same degree as subcutaneous fat.
Bone may be included as an osteocutaneous flap to reconstruct the mandible and oral mucosa in a single
stage (see Fig. 202.9). The fascial attachment of skin to bone allows a mobility of the skin that simplifies
closure of the oral mucosa.
The donor defect is relatively painless, even in patients from whom bone has been removed. This causes
the patient minimal discomfort in the early postoperative period, thus facilitating recovery and early
mobilization. In the longer term, skin grafts on the forearm appear to give a satisfactory cosmetic result,
particularly in elderly patients.
ANATOMY
Much of the skin of the forearm is supplied by the radial artery, which is covered proximally by the fleshy belly of
the brachioradialis. It soon emerges distally between the brachioradialis and the flexor carpi radialis to lie
superficially, covered only by skin, subcutaneous tissue, and the deep fascia.
The artery, together with its two venae comitantes, is invested in a condensation of the deep fascia known as the
lateral intermuscular septum (Fig. 202.1). This septum separates the flexor and extensor compartments of the

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forearm and is attached to the periosteum of the radius distal to the insertion of pronator teres.
The artery gives off branches that pass through the deep fascia to supply the underlying flexor muscles and
branches that spread out on the deep fascia to form a fascial plexus and
supply the overlying skin. By means of this vascular network, the radial artery can supply the skin of the palmar
and radial aspects of the forearm and provide a periosteal blood supply to the distal radius.
FIGURE 202.1 Fasciocutaneous flap. Cross section through the forearm distal to pronator teres showing the
position of the radial artery and the plane of dissection for elevation of the fasciocutaneous flap. (From Soutar et
al., ref. 7, with permission.)
Venous drainage of the forearm flap is provided by two venae comitantes that accompany the artery and a
variable pattern of subcutaneous forearm veins that drain into the cephalic, basilic, and median cubital veins.
Routinely, both venous systems communicate by means of a constant branch from the venae comitantes, which
drains into the median cubital vein.
The forearm flap is ideally suited for free-tissue transfer because the artery can be readily palpated for much of
its length and the superficial subcutaneous veins of the forearm are easily identified. The diameter of the artery,
usually in excess of 3 mm, remains relatively constant from its origin to the wrist joint, making anastomosis of
either proximal or distal ends equally straightforward. Furthermore, the absence of significant arterial disease,
particularly atheroma in elderly patients, has been most remarkable.
FLAP DESIGN AND DIMENSIONS
Using a template, a radial forearm flap can be designed to replace the amount of resected tissue accurately,
thereby minimizing distortion and functional disturbance within the oral cavity. The radial artery, which is
subcutaneous for much of its length in the forearm, can be palpated and its course marked on the skin surface.
The superficial subcutaneous forearm veins are similarly marked, and the appropriately designed flap is outlined.
The arteriovenous system on which the forearm flap is based is capable of supplying all the skin of the forearm
from above the elbow to the wrist, except for a narrow strip overlying the ulna posteriorly. In practice, such large
flaps are not required in intraoral reconstruction.
The quality of the skin and the length of the vascular pedicle required for easy anastomosis most often influence
the choice of donor site. The presence and distribution of hair on the forearm may influence site selection (Fig.
202.2), although such hairs tend to be short and fine and cause little trouble following flap transfer.
Distally designed flaps are thinner than proximal flaps, and this is most evident in woman and obese patients. In
addition, the distal design is chosen when bone is to be included (as an osteocutaneous flap) or when a long
vessel pedicle is required. The advantages of the distal flap have to be balanced against the donor defect. In
practice, the mid-forearm flap has proved to be most useful. It combines the advantages of ease of elevation and

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donor defect found in proximal flaps with the skin quality of distal flaps.
FIGURE 202.2 Proximal fasciocutaneous flap. The radial artery and superficial veins were marked on the skin
surface and a flap was designed on the non-hair-bearing skin. A distal arterial pedicle was raised and
subsequently anastomosed to provide a retrograde arterial flow. (From Soutar et al., ref. 7, with permission.)
An added bonus of the midforearm flap lies in the possibility of raising both a proximal and distal vascular
pedicle, allowing a certain freedom with regard to subsequent anastomosis because either end of the artery can
be anastomosed in an antegrade or retrograde fashion and the free end ligated. Alternatively, the artery can be
used as an interpositional graft. In this situation, the arterial flow appears to be more physiologic, matching more
closely the preexisting conditions in the forearm.
OPERATIVE TECHNIQUE
Elevation of the forearm flap is straightforward and can be performed simultaneously with the intraoral resection
without altering the patient's position on the operating table. Also, the vessels that supply this flap can be
assessed accurately preoperatively and are fairly large and constant. This greatly simplifies the technical
aspects of this free-tissue transfer and may explain, in part, the reliability of the technique.
It can be difficult to determine which vein to use for anastomosis in free-tissue transfer, and on occasions, it has
seemed prudent to anastomose both a superficial vein and a deep vena comitans. In other cases, useful
information can be gained by selective clamping of the veins prior to transferring the flap. Where doubt exists, it
is safer to perform the arterial anastomosis first, and following release of the arterial clamps, the pattern of
venous outflow can be accurately determined and the appropriate vein then chosen for anastomosis.
The length of venous pedicle should never be a problem, since this can be extended well above the elbow, and
in this situation, a single venous anastomosis obviously will provide drainage for both superficial and
accompanying venous systems.
Donor Site
After outlining an appropriately designed flap, dissection proceeds under tourniquet control following elevation
exsanguination. This technique is preferred to more complete exsanguination methods, since it permits easier
identification of vessels that still contain some blood. This aids the dissection and preservation of superficial
veins and, in addition, facilitates the identification of the numerous vessels on the undersurface of the fascia that
require ligation and division.
The margins of the flap are incised down to the deep fascia, preserving subcutaneous veins as required. It is
easier to incise the fascia overlying muscle rather than that which overlies tendon, and for this reason, elevation
of the flap commences proximally, most often at the posterior ulnar border, where the fascia is thickest and most
readily identified.

FIGURE 202.3 Distal fasciocutaneous flap. The radial artery and subcutaneous veins are dissected out
proximally. Note the exposed tendons distally. (From Soutar et al., ref. 7, with permission.)
The flap is raised in a subfascial plane, exposing muscle bellies proximally and tendons distally (Fig. 202.3).
Intermuscular septa passing deeply are divided, as are the vessels that pass through the deep fascia to supply
the underlying flexor muscles. More distally, care must be taken to preserve the paratenon covering the flexor
tendons to retain a defect suitable for skin grafting. The plane of dissection on the undersurface of the deep
fascia ensures that the radial artery, lying in the lateral intermuscular septum, is included in the flap (see Fig.
202.1).
When raising a fasciocutaneous flap, the attachment of the lateral intermuscular septum to the periosteum of the
radius must be divided to allow elevation of the radial artery and venae comitantes. With the vascular pedicle
thus secured in the flap, the radial margin incision can be completed, again dissecting in a subfascial plane.
Retraction of the brachioradialis allows identification of the radial nerve, which may be isolated and preserved.
The fasciocutaneous flap is now separated from the underlying musculature, but it remains attached by the radial
artery and venae comitantes proximally and distally and by the previously isolated subcutaneous veins
proximally. Longitudinal incisions can be made, as required, in a proximal or distal direction to dissect out
sufficient length of vascular pedicle.
When bone is to be included as an osteocutaneous flap, the attachment of the lateral intermuscular septum to
the periosteum of the radius must be preserved intact (Fig. 202.4). To reach the medial border of the radius, the
plane of dissection passes deeply through the muscle bellies of the flexor pollicis longus and pronator quadratus.
The lateral border of the radius has no such muscle attachments, but here the attachment of the lateral
intermuscular septum, as it passes into the lateral periosteum of the radius, can be identified and preserved
intact.
FIGURE 202.4 Osteofasciocutaneous flap. Cross section through the forearm distal to pronator teres showing
the plane of dissection for elevation of the osteocutaneous flap. (From Soutar et al., ref. 7, with permission.)
The length of bone that can be removed is limited by the muscle attachments to the radius and is restricted to

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that part which is attached to the lateral intermuscular septum (Fig. 202.5). This extends distally from the
insertion of the pronator teres, and a length of up to 10 cm of bone extending to the insertion of brachioradialis
can be obtained. The thickness
of radius that can be removed safely is often difficult to determine in practice.
FIGURE 202.5 The muscle attachments to the radius limit the length of bone available for transfer. (From Soutar
et al., ref. 7, with permission.)

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FIGURE 202.6 Donor defect. A: Proximal defect at 6 months. B: Distal defect at 6 months. C: Distal defect
extending over radial border at 9 months. (From Soutar et al., ref. 7, with permission.)
It is advisable to obtain preoperative radiographs of the forearm to exclude disease or deformity and to assess
the thickness of the radius and cortices. Certainly, no more than half the cross section of the radius should be
removed, and it is safer to err on the side of conservatism rather than to weaken the radius and risk subsequent
fracture.
Occasionally, small defects in the forearm can be closed directly, but by far the majority require a split-thickness
skin graft. Both graft survival and the late cosmetic result are often better in the proximal defect overlying muscle
than on the paratenon of the distal defect. Confining the donor area to the palmar aspect of the forearm and
avoiding the radial border also result in a more favorable cosmetic result (Fig. 202.6).
When bone is removed, immobilization in protective plaster is mandatory to limit use of the limb in the immediate
postoperative period. Fracture of the radius has been reported in patients in whom such protective measures
have not been carried out. Postoperative radiographs of the forearm can be used to monitor progress and to
determine the degree and extent of immobilization required (Fig. 202.7).
An Allen test is performed routinely preoperatively to ensure viability of the hand devoid of a radial arterial input,
and repair of the radial artery is therefore not essential. In practice, repair of the radial artery is performed when it
is technically straightforward, and a segment of the cephalic vein that lies adjacent to the defect and has a
caliber similar to the radial artery is a convenient donor for a reverse vein graft (Figs. 202.8 and 202.9).

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FIGURE 202.7 Defect in radius at 3 weeks (A) and at 9 months (B) following removal of a 7-cm length of bone in
a 72-year-old patient. (From Soutar et al., ref. 7, with permission.)
FIGURE 202.8 The forearm flap as a fasciocutaneous flap. A: Squamous carcinoma involving the right lower
alveolus, floor of mouth, and retromolar trigone in a 64-year-old patient. B: Postoperative appearance at 8
months following excision that included a rim resection of mandible. C: Intraoral appearance 8 months after
operation. (From Soutar et al., ref. 7, with permission.)