Grabb’s Encyclopedia of Flaps Head and Neck

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ANATOMY
The DCIA and DCIV arise from the external iliac artery and vein within 1 to 2 cm above the inguinal ligament.
Although the DCIV may run either deep or superficial to the external iliac artery, it always takes a cephalad turn,
to enter the external iliac vein up to 3 cm above the junction of the DCIA and the external iliac artery. The DCIA
and DCIV travel in a linear course toward the anterior superior iliac spine (ASIS), where they then assume a
more curvilinear course along the inner table of the ilium. The pedicle is easily identified at the junction of the
transversus abdominis and iliacus muscles, lying from 0.5 to 2.5 cm beneath the lip of the iliac crest (4). During
its course, the deep circumflex pedicle gives rise to the ascending
branch, perforators to the ilium and the inner periosteum, and an array of cutaneous perforators that traverse the
three muscles of the abdominal wall. These latter perforators exit the external oblique muscle in a zone that
extends from the ASIS to a point about 9 cm lateral, where the DCIA terminates as a large cutaneous perforator.
The key to ensuring the blood supply to the skin is to be certain to design the skin paddle over this zone of
perforators and to harvest a cuff of the three muscle layers to maintain the integrity of these delicate vessels.
The ascending branch(es) of the DCIA and DCIV, which supply the internal oblique muscle, arise at any point
from the external iliac vessels to the ASIS. Through cadaver dissections, it has been shown that the ascending
branch arises within 1 cm medial to the ASIS in 65% of cases but has a more medial takeoff, from 2 to 4 cm
medial to the ASIS, in 15% of cases. In the remaining cases, there is no single dominant ascending branch but
rather an array of branches that supply the internal oblique muscle. Therefore, in roughly 80% of cases, the
internal oblique muscle has an axial-pattern blood supply with a single dominant ascending branch (1, 5, 6, 7).
Because of this axial pattern, the muscle can be maneuvered safely in virtually any direction relative to the bone
to restore the anatomy of this region (6, 7).
FLAP DESIGN AND DIMENSIONS
The bone of the ilium can be harvested with an excellent vascular supply for up to 14 cm lateral to the ASIS. The
ilium can be harvested either as a unicortical or, more commonly, as a bicortical vascularized bone flap. In the
former case, the inner table is harvested while maintaining the muscle attachments to the outer table.
Preservation of the muscle insertions of the upper thigh muscles leads to an easier postoperative course of
rehabilitation. The disadvantage of harvesting a unicortical segment of bone is that it often leads to insufficient
bone width for placement of dental implants.
The skin paddle is designed along an axis that can be drawn from the ASIS to the inferior border of the scapula.
As long as the skin paddle is centered over this axis, the zone of perforators is almost certainly incorporated. The
maximum dimensions of the skin flap have not been determined; the limiting factor is more often the ability to
achieve primary closure of the abdominal wall rather than pushing the limits of the vascular supply.
The internal oblique muscle arises from the thoracolumbar fascia, the iliac crest, and the inguinal ligament. It
inserts into the linea semilunaris of the rectus sheath and the lower three ribs. This muscle usually is harvested
in its entirety to ensure adequate tissue for achieving the reconstruction and because harvesting only the lower
extent of the muscle does little to maintain the integrity of the abdominal wall (Fig. 210.1). The patient's body
habitus determines the thickness and dimensions of the internal oblique muscle. In all cases, the muscle shrinks
in size once its attachments are cut, and it must be stretched during insetting to take advantage of the full extent
of tissue harvested. Although any one of the three major components of this tripartite flap can be harvested
independently, based on the DCIA and DCIV, the three components are usually harvested together when
reconstructing oromandibular defects.

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OPERATIVE TECHNIQUE
The skin incision provides exposure of the external oblique muscle and aponeurosis, which, in turn, is incised in
the direction of its fibers, leaving a 3-cm cuff of muscle attached to the inner table of the ilium (Fig. 210.1). The
plane between the internal and external oblique muscles is defined, and exposure of the entire span of the
internal oblique muscle is obtained, from the ilium to the costal margin, by blunt dissection. Although the internal
oblique muscle can be cut at any point to begin dissection of the muscle off the transversus abdominis, it is
started most easily in the region just caudal to the twelfth rib.
FIGURE 210.1 Exposure of the internal oblique muscle is achieved by incising the skin paddle as well as the
external oblique muscle and aponeurosis. The external oblique is incised while preserving a cuff attached to the
inner table of the iliac crest. The internal oblique muscle is exposed by blunt dissection to the level of the costal
margin, where it is then incised along its medial, lateral, and cephalad margins to reflect it caudally off the
transversus abdominis muscle. (From Urken et al., ref. 6, with permission.)
The internal oblique muscle then is carefully elevated in a cephalad to caudad direction, stopping within 2 cm of
the inner table of the ilium. On the deep surface of the muscle, the ascending branch is identified and preserved.
This vascular arcade is followed as it courses through the transversus abdominis muscle to its junction with the
DCIA and DCIV. With the exposure afforded by transecting the transversus abdominis muscle, leaving a cuff
attached to the inner table of the ilium, the DCIA and DCIV can be traced to their takeoff from the external iliac
vessels. The DCIA and DCIV must be isolated from the surrounding fascial envelope composed of the
condensation of the transversalis and iliacus fasciae while leaving the course of these vessels undisturbed
lateral to the ASIS. Complete exposure of the inner table of the ilium is achieved by transecting the iliacus muscle
approximately 2 cm deep to the palpable pulse of the DCIA. The lateral aspect of the ilium is exposed by sharp
dissection throughout the full extent of the bone to be harvested. The bone flap then is cut from the lateral aspect
of the ilium while carefully
retracting the abdominal contents. In the region medial to the ASIS, the lateral femoral cutaneous nerve can be
identified and preserved in most cases. This nerve may run a course either superficial or deep to the DCIA and
DCIV.

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FIGURE 210.2 Internal oblique iliac-crest osteomyocutaneous flap has been harvested from the abdominal wall.
The defect must be closed in three layers. The first involves approximation of the transverse abdominis to the
iliacus muscle. The external oblique muscle then is sutured to the upper thigh muscles. The skin and
subcutaneous tissues are closed to complete the donor-site repair. The flap shown here is unicortical, preserving
the external table of the ilium with the attachments of the upper-thigh muscles. (From Urken et al., ref. 6, with
permission.)
Closure of the iliac donor site must be done in a meticulous fashion to prevent weakness or frank herniation of
the abdominal contents (Fig. 210.2). This is accomplished by approximating the transversus abdominis muscle to
the iliacus muscle. It is often helpful to drill holes in the cut margin of the ilium to allow greater purchase of these
sutures and to ensure a secure inner closure. In select cases, where the strength of the transversus abdominis
muscle is questionable, a synthetic mesh can be placed. The second layer of the closure is achieved by suturing
the external oblique muscle to the upper thigh muscles and tendons. Flexion of the ipsilateral knee is helpful to
relieve tension on the closure. During the postoperative period, assisted ambulation, beginning with a walker and
then progressing to a cane, is instituted starting on day 5 or 6 after surgery.
The iliac crest-internal oblique composite flap, consisting of the iliac bone, the broad sheet of the internal oblique
muscle, and the skin overlying the iliac crest (Fig. 210.3), is inset into the oral cavity. The internal oblique muscle
is used to resurface the ilium, achieving a thin cover over the neomandible that is ideally suited for dental
rehabilitation (Fig. 210.4). The muscle can achieve maximum mobility relative to the bone by performing a
backcut along the muscle to isolate a narrow soft-tissue pedicle surrounding the vascular supply. Although the
initial description of the use of this flap in the oral cavity included a primary vestibuloplasty using a split-thickness
skin graft, this technique is rarely used currently, except in select
situations (6, 8) (Fig. 210.5). These latter cases include patients with a significant loss of either the floor of the
mouth or the buccal/labial mucosa. In these cases, mucosalization of the bare muscle may lead to obliteration of
the buccal or lingual sulci, which otherwise could be preserved with the application of a skin graft. The internal
oblique muscle undergoes significant atrophy as a result of denervation, producing a desirable lining of the oral
cavity.

FIGURE 210.3 Various components of the tripartite iliac-crest osteomyocutaneous flap have been labeled: ilium,
which may be unicortical or bicortical, A; skin paddle, B; internal oblique muscle, C; cuff of external oblique
muscle, D; transversus abdominis muscle, E; iliacus muscle, F. (From Urken et al., ref. 6, with permission.)
FIGURE 210.4 The iliac crest is usually fixed to the native mandible, using a three-dimensional reconstruction
plate. The internal oblique muscle may be transposed over the neomandible and used for coverage of defects of
the oropharynx, hypopharynx, as well as the infrastructure of the maxilla. Greater freedom can be obtained in the
mobility of the internal oblique muscle relative to the bone by performing a backcut to narrow the soft-tissue
attachments surrounding the ascending branch of the DCIA. (From Urken et al., ref. 6, with permission.)

FIGURE 210.5 Coronal section through the reconstructed oral cavity reveals the internal oblique muscle, A,
transposed over the iliac bone, which is rigidly fixed to the native mandible. A split-thickness skin graft is shown
sutured over the muscle to achieve restoration of sulcular anatomy, B. The skin paddle of the tripartite flap is
sutured into the neck to serve either as a monitor or for closure of an associated cutaneous defect, C. (From
Urken et al., ref. 6, with permission.)
CLINICAL RESULTS
In a series of 180 vascularized bone-containing free flaps used exclusively in oromandibular reconstruction
(including ilium, scapula, and fibula donor sites), the soft-tissue flaps transferred with the ilium (n = 123)
included 66 internal oblique flaps and 57 osteocutaneous flaps. The tripartite flap, consisting of bone, skin,
and muscle, is ideally suited for reconstructing composite defects that include mandible, mucosa, and
overlying skin (8). It is critical to respect the relationship of the skin paddle to the bone so as not to
compromise the vascular supply to the skin. In most cases where the skin is used for external cover, it is
usually limited in its cephalad extent to defects that do not extend above the level of the oral commissure.
Careful attention to this important parameter will result in a high success rate, with a minimum of
complications related to skin ischemia.
SUMMARY
The iliac donor site is a valuable source of vascularized bone that can be transferred with two separate soft-
tissue flaps. The internal oblique muscle flap provides greater versatility to this donor site, thus expanding
its use in oromandibular reconstruction.
References
1. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps. Plast Reconstr Surg 1979;64:595.
2. Moscoso J, Keller J, Genden E, et al. Vascularized bone flaps in oromandibular reconstruction: a
comparative anatomic study of bone stock from various donor sites to assess suitability for enosseous dental

implants. Arch Otolaryngol Head Neck Surg 1984;120:36.
3. Salibian A, Rappaport I, Allison G. Functional oromandibular reconstruction with the microvascular
composite groin flap. Plast Reconstr Surg 1985;76:819.
4. Frederickson JM, Man SC, Hayden RE. Revascularized iliac bone graft for mandibular reconstruction.
Acta Otolaryngol (Stockh) 1985;99:214.
5. Ramasastry SS, Tucker JB, Swartz WM, Hurwitz DJ. The internal oblique muscle flap: an anatomic and
clinical study. Plast Reconstr Surg 1984;73:721.
6. Urken ML, Vickery C, Weinberg H, et al. The internal oblique-iliac crest osseomyocutaneous
microvascular free flap in head and neck reconstruction. J Reconstr Microsurg 1989;5:203.
7. Urken ML, Vickery C, Weinberg H, et at. The internal oblique-iliac crest osseomyocutaneous free flap in
oromandibular reconstruction: report of 20 cases. Arch Otolaryngol Head Neck Surg 1984;120:36.
8. Urken ML, Weinberg H, Vickery C, et al. The internal oblique-iliac crest free flap in composite defects of
the oral cavity involving bone, skin and mucosa. Laryngoscope 1991;101:257.

Chapter 211
Thoracodorsal (Serratus Anterior) Compound Flap
A. M. GODFREY
B. N. BAILEY
Musculocutaneous cover and rib can be prepared as two separately oriented components vascularized by a
single long pedicle with large vessels. This double flap may be used as an island or free flap.
INDICATIONS
The component parts of the flap may be used in different combinations and can be used as a free flap
wherever skin, bone, and muscle may be required. This includes defects of the limb bones as well as
defects of the mandible and maxilla. This flap also can be used as an island flap to reach some head and
neck defects as well as the arm and chest wall.
ANATOMY
Muscle
The serratus anterior muscle arises as eight digitations from the upper eight ribs. The first digitation is the
largest, and it inserts into the upper costal surface of the vertebral border of the scapula. The next three
digitations insert into the whole of the vertebral border, and the lower four digitations insert into the scapular
angle. Denervation or removal of the lower four digitations does not produce winging of the scapula if the upper
four digitations are intact.
Nerve Supply (Long Thoracic Nerve)
The long thoracic nerve is not at risk during surgery because the supply to the upper four digitations of the
serratus anterior lie slightly deeper on the chest wall, separated from the vascular pedicle of the flap by a definite
fascial layer.
Vascular Supply (Lateral Thoracic and Thoracodorsal Arteries)
The upper four digitations are supplied mainly by branches of the lateral thoracic artery. The lower four
digitations are supplied by a single branch (72%), two branches (24%), and multiple branches (4%) of the
thoracodorsal pedicle as well as the lateral thoracic and intercostal vessels (1). The branch(es) pierces the
fascia over the serratus anterior superficial to the nerve supply (approximately in the midaxillary line) and runs
with it to the lower four digitations. The vascular and nerve supplies to the latissimus dorsi muscle have been
described in detail elsewhere (2, 3, 4).
There is a rich communication between the intercostal vessels and the thoracodorsal branches supplying the
serratus anterior. This has been confirmed by the authors using standard cadaver injection techniques.
The presence of endosteal as well as periosteal blood supply is shown at operation by the bleeding from the rib
marrow. This provides a block of serratus anterior muscle, rib(s), and intercostal muscles and vessels for
reconstruction, supplied only by the thoracodorsal pedicle. This block may be used alone or with a latissimus
dorsi muscle or musculocutaneous flap, all supplied by the thoracodorsal pedicle (Fig. 211.1).

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OPERATIVE TECHNIQUE
The patient is placed in the lateral position with the upper arms supported and abducted to allow access to the
axilla. The skin incision is made along the lateral border of the latissimus dorsi muscle from the axilla to
approximately the eighth rib. It is made convex anteriorly if skin is to be taken with the latissimus dorsi. The
lateral margin of the latissimus dorsi muscle is elevated in the lower half of the wound, and its vascular bundle is
traced proximally to the bifurcation of the thoracodorsal trunk, about 10 cm from the origin of the subscapular
artery. The branch(es) to the serratus anterior runs from the thoracodorsal pedicle downward and a little
anteriorly before piercing the fascia over the serratus anterior and supplying its distal half.
Delineation of the Serratus Anterior-Rib Tissue Block
For single-rib reconstructions (e.g., jaw), the fifth rib is used. When two ribs are required, the fifth and sixth ribs
are used (Fig. 211.2).
Muscle is incised along the inferior margins of the fourth and sixth interspaces to preserve two intercostal
bundles. The incision is deepened to the pleura, which is freed from the deep surface of the ribs by digital and
scissor dissection.
It is important to include the maximum costal insertion of the serratus anterior, and so the anterior rib division is
made just lateral to the costochondral junction. The scapular insertion of the serratus anterior is divided, and the
muscle is sutured to the ribs posteriorly to prevent separation during manipulation.
FIGURE 211.1 A: The thoracodorsal trunk (T.D.T.) is shown branching to the serratus anterior (S.A.) muscle
and the latissimus dorsi (L.D.) muscle. R., rib; S.S.A., subscapular artery; C.S.A., circumflex scapular artery;
L.T.N., long thoracic nerve. B: Cadaver dissection.
The required length of rib(s) is measured from anteriorly, and the rib is divided posteriorly so that the serratus
anterior tissue block is now attached only by its vascular pedicle. The rib curvature may be altered by careful
sawcuts through the inner cortex. To straighten the rib(s), greenstick outfractures are made. To increase rib
curvature, inner cortical wedges are excised and greenstick infractures are made.
The intercostal bundles and muscle insertions must be protected. When the curvature of two ribs is altered, the
sawcuts should be staggered to retain more stability of the bone unit.

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The latissimus dorsi muscle or musculocutaneous flap is raised in the usual way, and its vascular pedicle is
traced proximally to obtain the required length. The entire bifid composite flap is left attached to the subscapular
vessels during closure of the defect to allow recovery and to maintain perfusion until transfer.
FIGURE 211.2 Possible variations of the thoracodorsal compound flap. A: Two ribs plus muscle cover for major
limb reconstruction. B: One rib plus serratus anterior muscle and skin for jaw reconstruction. C: Innervated
muscle.
Closure of the Secondary Defect
Pleural tears are closed with fine catgut sutures. A chest tube drain is inserted through a distal intact intercostal
space and is brought out through the anterior skin.
The rib defect is covered posteriorly by the scapula. Laterally, the serratus anterior is sutured together from
above and below the wound. Direct closure of the skin is possible when latissimus dorsi muscle or
musculocutaneous flaps of up to 12 to 14 cm have been raised. Wider defects may be covered with split-
thickness skin grafts. Mesh reinforcement of the interspace could be carried out, but so far we have not found it
necessary. A single-rib defect is closed by pulling together the adjacent ribs with heavy sutures, and, if possible,
the skin defect is closed directly. The scar is concealed mostly by the resting arm.
CLINICAL RESULTS
The following variations have been used in 21 patients: ten patients with lower leg defects of skin and bone,
ranging from 8 to 28 cm; one patient with an upper humeral defect of 14 cm; and ten patients with
mandibular/facial reconstruction for congenital abnormalities, defects following tumor resection, traumatic
defects, and facial palsy.
SUMMARY
The thoracodorsal compound flap can be used either as a free flap or as an island flap. It can be tailored
easily to fit many defects, as the amount of bone, muscle, and skin to be included in the flap can be varied
in a number of ways.
References
1. Rowsell AR. Personal communication concerning 100 cadaver axillary dissections, Oxford, 1980.

2. Olivari N. The latissimus flap. Br J Plast Surg 1976;29:126.
3. Bostwick J, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus dorsi flaps. Plast Reconstr Surg
1979;63:31.
4. Bailey BN. Latissimus dorsi flaps: a practical approach. Ann Acad Med (Singapore) 1979;8:445.

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Chapter 212
Microvascular Free Transfer of A Partial Fibula for Mandibular
Reconstruction
M. A. SCHUSTERMAN
EDITORIAL COMMENT
This is an excellent chapter describing the procedure that is most commonly known for restoration of
continuity of the mandible.
Reconstruction of the mandible, particularly when the defect involves the anterior mandible, is a formidable
challenge to the reconstructive surgeon. Most defects consist not only of bone, but also of soft tissue, thus
necessitating use of a composite reconstructive modality. Vascularized bone has been well accepted for use in
reconstruction of the mandible. Of all the flaps currently available, the fibula has become the flap of choice at
many centers.
INDICATIONS
Benign and malignant neoplasms account for about 80% of mandibular resections. Most of these tumors
are squamous cell carcinomas that require composite reconstructions wherein both the mandible and the
affected extraoral and intraoral soft tissues are replaced. This type of restoration also may be indicated for
severe trauma to the lower face.
The advantages of the fibula free flap include (a) ease of flap harvest; (b) excellent quality and quantity of
bone, suitable for placement of dental implants; (c) a segmental periosteal blood supply that provides good
flow to multiple osteotomy sections, allowing shaping of the bone to match the original mandible; (d) a
reliable skin paddle that can be derived from the lateral leg skin; (e) a remote location in relation to the
tumor site, which permits a two-team approach that reduces operating time; and (f) less donor-site morbidity
(1, 2, 3).
If no skin paddle is required, the fibula is harvested from the ipsilateral leg. If skin tissue is needed in the
reconstruction, the contralateral leg is selected, allowing for placement of the skin paddle intraorally (Fig.
212.1).
ANATOMY
The fibula bone lies in the deep posterior compartment, just lateral to the tibia (Fig. 212.2). The upper end of the
fibula
does not comprise any part of the knee joint but articulates with the undersurface of the tibial plateau. The lower
end of the fibula is the lateral malleous and is involved in ankle-joint articulation. There are four muscles
surrounding the fibula: the extensor digitorum longus superiorly, the posterior tibialis medially, the peroneal
muscles laterally, and the flexor hallucis longus inferiorly. The blood supply to the fibula comes from the peroneal
vessels, which are one of three terminal branches of the popliteal artery; the others are the anterior tibial vessel
and the posterior tibial, which branches with the peroneal vessels.

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FIGURE 212.1 Use of the contralateral osteocutaneous fibula facilitates intraoral placement of the skin paddle.
The peroneal vessels lie between the tibialis posterior muscle and the flexor hallucis longus. The posterolateral
intermuscular septum is the terminal end of the transverse crural septum; it is through this septum that the
cutaneous perforators run. It is therefore important to harvest as much of this septum as possible when
harvesting the skin paddle (see Fig. 212.2).
FIGURE 212.2 Cross-sectional anatomy of the leg; dotted line denotes tissue harvest for osteocutaneous fibula.
FLAP DESIGN AND DIMENSIONS
The fibular head at the knee, the peroneal nerve just below the fibular head, and the lateral malleolus at the
ankle are marked (Fig. 212.3). Hash marks are drawn at 10, 15, 20, and 25 cm from the fibular head. The skin
paddle is centered between the hash marks, taking into account the mandibular area being
resected: this determines whether the proximal or distal part of the fibula is used.

FIGURE 212.3 Design of flap on the leg; note position of peroneal nerve. Distances are millimeters from fibular
head.
In the anteroposterior plane, the paddle is centered along the posterior border of the fibula. A posterior
mandibular reconstruction entails the creation (by osteotomy) of a ramus and neoangle; use of the proximal fibula
allows pedicle placement at the neoangle, and thus adjacent to the recipient vessels in the neck (Fig. 212.4). For
an anterior mandibular reconstruction, the distal fibula is used to provide long donor vessels from the end of the
flap (Fig. 212.5).
OPERATIVE TECHNIQUE
The designated leg is elevated and a tourniquet inflated. Because the peroneal artery and vein course along the
medial side of the fibula, a lateral approach is used in beginning the dissection. An anterior incision down
through the deep muscle fascia is made; inclusion of this fascia is crucial. As the dissection continues posteriorly
to the posterolateral intermuscular septum, the peroneal muscles are exposed. The anterior surface of the
septum then is followed down the fibula, and the peroneal muscles are elevated from the lateral and anterior
surfaces of the bone. The anterolateral intermuscular septum is divided close to the fibula to prevent injury to the
anterior tibial neurovascular bundle, and the dissection continues down through the interosseous membrane.
FIGURE 212.4 Posterior reconstruction requires pedicle take off at neoangle, and thus a proximal bone harvest.
Next a posterior incision is made down through the deep muscle fascia, and the skin paddle is elevated to the
edge of the soleus muscle. An incision about 1 cm deep is made in the soleus muscle 1 cm from its lateral
border. The bone is now cut to the required length with an oscillating saw. The bone should not be cut within 8
cm of the lateral malleolus because the tibiofibular ligaments may be injured, causing ankle-joint instability. The
proximal cut in the fibula should be made as high as possible without damaging the peroneal nerve. Even if the

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proximal fibula will not be used, it should be harvested to expose the trifurcation of the leg vessels, facilitating the
pedicle dissection.
Once the fibula is cut, it is retracted laterally, and the dissection proceeds from distal to proximal and from medial
to lateral. Medially, the peroneal vessels are located, followed down to their distal aspect, ligated, and divided.
With knowledge of their location, flap dissection continues (medially to laterally), with less risk of harming the
perforating vessels to the skin paddle.
FIGURE 212.5 Anterior reconstruction requires a long pedicle and thus a distal bone harvest.
After elevating the flap, the tourniquet is released and any residual bleeding controlled. By this time, the ablative
team should have the mandible exposed and ready for resection. Before osteotomies are undertaken, the
reconstruction team bends a reconstruction plate over the native mandible, stabilizes the plate with screws
posterior to the planned mandibulectomy cuts, and then removes the plate and screws. Thus, the original shape
of the mandible will be reestablished and the condyles correctly positioned relative to the neomandible.
The ablative team now completes the resection while the reconstruction team uses the shaped reconstruction
plate (as a template) to cut the fibula with closing wedge osteotomies; during this sequence, the fibula is
perfused in situ. Bone fragments are fixed before transfer to limit ischemia time. As soon as the resection is
finished and tumor-free margins have been confirmed by frozen sections, the pedicle is divided and the flap is
transferred to the recipient site.
First, the skin paddle is inset along the tongue because this is technically easier to do before the bone is in
place. Next the bony ends of the fibula/reconstruction-plate complex are trimmed (while being moderately
compressed) to make a good fit, and then the plate is fastened to the native mandible with the screws and holes
used previously. Microsurgical anastomoses are performed last. The external carotid artery and internal jugular
vein used in an end-to-side configuration are the recipient vessels of choice. After the anastomoses are
completed, the flap is checked for adequate revascularization, flap insetting is completed, and the wound is
closed over suction drains. The leg incision is also closed over suction drains, and a bulky dressing and
posterior leg splint are applied.

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FIGURE 212.6 A: Preoperative appearance of patient with recurrent squamous-cell carcinoma. B: Preoperative
marking of leg; note the position of the peroneal nerve, which should be avoided, and the location of skin in
relation to hash marks, measured in millimeters from fibular head. C: Prebent plate is taken to the leg, where
harvested fibula is osteotomized and fixed to the plate in situ to limit ischemia time. D: Postoperative
appearance, frontal view.
Postoperatively, the patient is managed and monitored in the surgical intensive care unit. If the patient is stable
after 24 to 48 hours and transferred to a regular nursing floor, activity is slowly increased, as tolerated. A feeding
tube is used in all patients who have a mandibular, floor-of-the-mouth, or oropharyngeal reconstruction. During
the first postoperative week, most patients are seen for physical therapy to initiate walking and range-of-motion
exercises, particularly in the donor area.
Following a fibular harvest, the posterior leg splint is removed on the third or fourth day, and the patient begins
cautious ambulation in physical therapy. If there is a skin graft to the donor site, walking is postponed for 7 days,
and the leg is wrapped with an elastic bandage when it is dependent. In uncomplicated cases without a skin
graft, the patient is discharged 10 to 14 days after surgery.
CLINICAL RESULTS
Excellent results have been achieved with this flap (Fig. 212.6) for immediate and delayed reconstruction
defects due to trauma, osteoradionecrosis, and salvage cases after previous flap failure. Flap losses have
resulted from the difficult nature of the cases, not from any inherent flaws of the fibula flap. Two main areas
of concern involve the vascular supply of the flap.

The first vascular condition of concern is atherosclerosis. Many patients requiring free fibulas are elderly
and have a significant history of tobacco use; they are therefore also strong candidates for development of
arterial occlusive disease of the lower-extremity vessels. Each candidate for this flap needs to have a
detailed history and examination of the cardiovascular system. If there are clinical indications of arterial
insufficiency, angiograms are indicated before the procedure to assess the integrity of the peroneal artery
and the vascular supply to the leg.
A second issue of concern is the peroneal magnus artery, especially a situation in which the entire lower
extremity is fed by a dominant or solitary peroneal artery, so that vessel sacrifice would devascularize the
lower extremity. Although this condition has an estimated incidence of 10% in the normal population, we
have not seen its occurrence in more than 120 free fibula flaps. We do not perform routine angiography in
all patients to rule out the occurrence of this condition; again, the main indications for angiography are
clinical symptoms and signs of vascular insufficiency.
The gravest complication is total flap loss because of thrombosis, which usually occurs during the first 24
hours after surgery. In addition to frequent clinical assessments by experienced personnel, monitoring
devices are used for direct imaging of the blood vessels or for measuring tissue perfusion. When a flap is
judged to have questionable blood inflow or outflow, the only acceptable action is immediate surgical
exploration. Early thrombectomy may salvage a flap if the ischemic interval has been less than 2 or 3 hours.
Donor-site complications with the free fibular flap have tended to be minor and brief; usually, edema and
pain are not significant.
SUMMARY
In the past few years, advances in free-flap composite reconstructions have resulted in reliable methods for
quality restoration of the mandible. The fibula is a choice donor, with major advantages and few deterrents.
References
1. Schusterman MD, Reece GP, Miller MJ, Harris S. The osteocutaneous free fibula flap: is the skin paddle
reliable? Plast Reconstr Surg 1992;90:787.
2. Hidalgo DA. Free fibula flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84:71.
3. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Fibular osteoseptocutaneous flap: anatomic study and
clinical application. Plast Reconstr Surg 1986;78:191.

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Chapter 213
Mandible Reconstruction With Free Fibula Flap
JOHN BRADLEY TURNER
HENRY C. VASCONEZ
EDITORIAL COMMENT
The way to go in bony mandibular reconstruction. Soft tissue coverage is a must.
INDICATIONS
The free fibula flap has become the gold standard for reconstruction of the mandible in several clinical
scenarios (1). It has been demonstrated that for defects greater than 6 cm, the flap has a significantly higher
rate of success than nonvascularized bone grafts, especially in hostile environments (2). In patients
undergoing either neoadjuvant or postoperative radiation
therapy, the most successful mandible reconstruction includes vascularized bone with the greatest
advantage from the free fibula (3, 4). Other less common indications for mandibular reconstruction include
congenitally or acquired mandibular hypoplasia, infected nonunions or chronic osteomyelitis of mandibular
fractures, osteoradionecrosis or bisphosphonate-related osteonecrosis of the jaw (BRONJ), high-velocity
penetrating injuries, and salvage reconstruction in instances of failed plate/soft-tissue reconstructions.
The advantages of the free fibula include (1, 5) the following:
Versatility in flap design including the ability to capture muscle and fascia for bulk and resurface intra-
and extraoral lining defects with skin
Excellent length (22 to 24 cm) and strength of bone
Dual blood supply to the bone allowing multiple osteotomies for contouring
Excellent pedicle length
Two-team approach to reconstruction
Minimal long-term morbidity of the donor site in low-demand patients

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FIGURE 213.1 A: Cross-sectional anatomy of the extremity including free fibula flap outline. B: Schematic
of a free fibula osteocutaneous flap. C: Schematic of subtotal mandibular reconstruction with extraoral skin
paddle placement.
Reported disadvantages are few but include:
Lack of vertical height leading some to attempt “double barrel” approach
Unsightly lower leg donor scar
Occasional vascular variability
ANATOMY
The fibula is the lateral, non-weight-bearing bone of the leg. The proximal and distal segments contribute to
translational stability of the knee and ankle joints. The fibula flap is vascularized by the peroneal vessels, which
bifurcate from the tibi-operoneal trunk (Fig. 213.1). This occurs 3 to 4 cm below the bifurcation of the popliteal
and anterior tibial arteries. The pedicle remains within the deep posterior compartment of the leg until the distal
third. The pedicle resides between the flexor hallucis longus posteriorly and the tibialis posterior anteriorly, with
the fibula lateral to the vessels. As the vessels descend to
the fibula, they provide four to six segmental perforators to the bone, periosteum, and surrounding musculature
allowing flexibility in tissue harvest and bony osteotomies. A nutrient branch of the peroneal artery, which enters
the posteromedial fibula in the mid-diaphysis, provides endosteal circulation. The surgeon should be aware of
the bifurcation of the common peroneal nerve at the fibular head proximally. Vascular abnormalities including
arteriosclerotic disease and peroneal arteria magna are contraindications to this flap. Up to 15% of the

population possess a peroneal arteria magna anomaly in which the blood supply to the foot is derived solely from
the peroneal artery (6).
FIGURE 213.2 Example of preoperative surgical planning facilitated with computer-aided design. Note the
planned resection, reconstruction, and osteotomy design on the patient's own fibula.
Preoperative imaging is indicated in the absence of either dorsalis pedis or posterior tibial pulses at the level of
the ankle or an inconclusive foot Allen test. Ideal imaging indicates both patency of the limb vasculature as well
as direction of flow. The authors favor duplex ultrasound or CT angiography given the level of information
rendered with low morbidity.
Computer-aided design and virtual surgical planning have added another element to the operation (Fig. 213.2).
Often, the anticipated resection, models, plates, and cutting guides can be fabricated from the preoperative CT
scan to improve osteotomy alignment and reduce ischemia times (Fig. 213.3). This reduces operative time, which
often offsets the cost of the initial planning (7, 8).
OPERATIVE TECHNIQUE
A two-team approach is facilitated in most clinical scenarios. The patient is positioned in the supine or lateral
decubitus position. The limb is placed with the hip flexed and the knee bent to 90 degrees with a bump under the
ipsilateral hip. A towel roll can be used to facilitate a “door stop” effect under the foot allowing dorsiflexion,
freeing the assistant to aid in surgery. The dissection is usually begun with a tourniquet. When needed, a skin
paddle is centered on the posterior border of the fibula of desired length and width. A Doppler probe can identify
perforators from the intermuscular septum. The anterior incision is initially made through the level of the investing

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fascia of the leg. The flap is then elevated as a fasciocutaneous flap to the level of the posterior intermuscular
septum. Dissection is then taken deeply along the septum to the level of the fibula, reflecting the peroneus
muscles anteriorly along the length of the fibula. The posterior skin incision is then taken to the level of the
septum and the soleus is dissected away from the deep posterior compartment. Often, a small cuff of flexor
hallucis longus and soleus is retained to preserve perforators
The dissection then proceeds circumferentially, first around the anterior fibula, through the anterior intermuscular
septum, and lastly the interosseus membrane. The distal peroneal vasculature is identified and ligated, and then,
osteotomies are executed. A 6-cm stump of fibula should be preserved proximally and distally to avoid joint and
nerve injury. The bone can then be distracted out of the wound, allowing dissection in the posterior compartment
to proceed in a distal to proximal manner.
Suitable recipient vessels in the neck should be identified and appropriate for size and pedicle orientation. Other
considerations are location of the desired skin paddle and number of osteotomies. Without the use of computer-
aided design, which usually includes a preformed plate, the plate can be bent on the native mandible prior to
removal of the diseased segment.
Osteotomies can be performed in situ prior to pedicle division or at the neomandible site before or after
microvascular transfer (Fig. 213.3). Advantages of in situ plating include less ischemia time and risk of
anastomotic avulsion but necessitate confidences in the fabrication of the plate and generous pedicle length.
Flap monitoring can be facilitated as the surgeon prefers but the authors use clinical and Doppler examinations
or internal Doppler in instances without a skin paddle. Donor site closure is dependent upon skin paddle size
with up to 6 cm being closed primarily. Liberal use of partial closure and split-thickness skin grafting often limits
complications, as compartment
syndrome has been reported after aggressive primary closures. The foot is maintained with a short leg splint and
allowed only toe-touch weight bearing for 2 to 3 weeks to allow coaptation of the lateral/anterior/posterior
compartment musculature.
FIGURE 213.3 A: Preoperative model with prebent plate for hemimandibular reconstruction. B: Cutting guide
fastened to the fibula. C: Hemimandible with prebent plate prior to pedicle division and microvascular transfer.

FIGURE 213.4 Postoperative 3D CT scan of a hemimandible reconstruction.
CLINICAL RESULTS
For large bone and soft-tissue deficits of the mandible and perioral tissue, the fibula has become the gold
standard for reconstruction (Fig. 213.4). Large series have demonstrated most optimal reconstructions with
regard to aesthetics, functionality, and donor site morbidity relative to other flaps such as the iliac crest,
radius, rib, or scapula.
SUMMARY
The free fibula flap is a proven option for mandible reconstruction when indicated. The importance of
preoperative planning with regard to size of the defect, location of bone placement, minimizing donor site
morbidity, osteotomy location/number/angles, skin paddle, and pedicle orientation cannot be overstated.
References
1. Cordeiro P, Disa J, Hidalgo D, et al. Reconstruction of the mandible with osseous free flaps: a 10-year
experience with 150 consecutive patients. Plast Reconstr Surg 1999;104(5):1314.
2. Foster R, Anthony J, Sharma A, et al. Vascularized bone flaps versus non-vascularized bone flaps for
mandibular reconstruction: an outcome analysis of primary bone union and endosseous implant success.
Head Neck 1999;21:66.
3. Seikaly H, Chau J, Li F, et al. Bone that best matches the properties of the mandible. J Otolaryngol
2003;32(4):262.
4. Takushima A, Harii K, Asato H, et al. Mandibular reconstruction using microvascular free flaps: a statistical
analysis of 178 cases. Plast Reconstr Surg 2001;108(6):1555.
5. Ling X, Peng X. What is the price to pay for a free fibula flap? A systematic review of donor-site morbidity
following free fibula flap surgery. Plast Reconstr Surg 2012;129(3):657.
6. Seres L, Csaszar J, Voros E, et al. Donor site angiography before mandibular reconstruction with free
fibula flap. J Craniofac Surg 2001;12(6):608.
7. Wolff KD, Hölzle F. (2005). Latissimus Dorsi Flap. In Wolff KD, Hölzle F (Eds.) Raising of microvascular

flaps: a systematic approach(pp. 65-82). Berlin, Heidelberg, New York: Springer.
8. Stirling C, Yuhasz M, Shah A, et al. Simulated surgery and cutting guides enhance spatial positioning in
free fibular mandibular reconstruction. Microsurgery 2015;35(1):29-33.

Chapter 214
Endocultivation: Computer-Aided Tissue Engineering of
Customized, Vascularized Bone Grafts for Mandibular
Reconstruction
P. H. WARNKE
EDITORIAL COMMENT
At present, the standard for mandibular reconstruction, either segmental or, at times, complete, is the use of
vascularized fibula, scapula, or iliac crest. The failures are often due to poor lining, particularly in cases of
prior irradiation.
The method here described, as the author indicates, is still experimental, but it brings together two
principles that are fairly well established. One is the use of the prefabricated flap introduced by Shintomi,
from Japan, and the second is the use of computerized technology for preoperative planning. It is still
unclear what type of bone regeneration occurs with bone morphogenetic protein-7 in a scaffold made of
titanium.
Currently, major bone discontinuity defects of more than 6 cm are repaired with an autologous vascularized
fibula, scapula, iliac crest, or rib transplant. Recent advances in the emerging field of regenerative medicine, that
is, repairing damaged tissue through growing it anew by means of tissue engineering, may offer new solutions
for reconstructive surgeons. “Regeneration” means that one repairs the damaged tissue by growing it anew with
methods of tissue engineering, thus circumventing the issue of immunologic rejection, as the patient's own cells
are used to cultivate the required tissue. I describe a technique of endocultivation, which involves the growing of
customized, computer-designed, vascularized replacements for subsequent transfer, to reconstruct previously
resected bone. It should be emphasized that endocultivation techniques are still at a basic stage of development
and are currently more suited to homogenous tissue like bone. However, they may offer the potential to grow
more complex organ replacements in the future.
INDICATIONS
The repair of bony defects from congenital malformations, trauma, infection, or tumor resection remains a
challenge in modern orthopaedic and maxillofacial surgical practice (1). The reconstruction of the long
bones, the spine, and the skull must meet high mechanical and aesthetic demands. However, a major
disadvantage of autologous vascularized bone is that harvesting the required bone graft creates another
skeletal defect, which is associated with significant morbidity (2). In vitro tissue engineering has been a
focus of many research groups; however, in vivo endocultivation techniques currently offer greater potential
(3, 4). Patients serve as their own bioreactors, and the required tissue is cultivated inside the patient's own
body on an individualized matrix. In vitro bioreactors are not required (4, 5, 6).
In 2004, we began using endocultivation techniques to grow customized, computer-designed, vascularized,
jaw replacements in the latissimus dorsi muscle of patients, for subsequent transplantation to reconstruct
their previously resected jaws (4, 5). The latissimus dorsi flap has accrued a broad spectrum of applications
in the field of reconstructive surgery. This is due to the large area of tissue available, thereby allowing
flexibility in flap design, as well as its long and high-capacity vascular pedicle that permits relatively

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technically easy microvascular anastomoses (7, 8).
The anatomic proximity of the latissimus dorsi to the thoracodorsal artery is fortuitous, as it allows for
significant spontaneous neovascularization (9). This subsequently permits free-flap transfer into the desired
recipient region. This independent vascular supply makes it possible to grow constructs of the size of a
mandible or, in the future (4, 5), possibly even a complex organ. For example, the latissimus dorsi is a more
suitable incubation site to grow a bone replacement, such as a neomandible, than the site to which it will
subsequently be transplanted, as the area containing the bone defect is often compromised by prior
radiation therapy. Irradiated tissue demonstrates poor regenerative properties and even soft-tissue injury
heals poorly. The choice of a prepared muscle pouch inside the latissimus dorsi has proven
to be a highly successful site as a bioreactor in early clinical studies, with substantial evidence of
heterotopic bone growth and remodeling within the graft (5).
The special feature of the endocultivation procedure is that the flap can be prefabricated with an
individualized bone replacement. Computer-aided design (CAD) provides a practical and exacting method of
customizing replacement scaffolds, to produce a perfect fit for each individual defect. Two major
advantages of this technique are the production of an optimal three-dimensional aesthetic outcome and the
prevention of creating a secondary skeletal defect. It should be emphasized that the endocultivation
technique is still very new, and such prefabricated flaps are currently indicated only for patients who have
poor potential skeletal donor sites.
ANATOMY
The latissimus dorsi is a flat, fanlike muscle that arises directly from the spinal processes of the lower six thoracic
vertebrae, the lumbar and sacral vertebrae, and the dorsal iliac crest via the thoracolumbar fascia. The muscle
inserts between the teres and pectoralis muscles at the humerus, and together with the teres major, it forms the
posterior axillary fold (7). The main nutrient vessel is the thoracodorsal artery, which regularly gives off a strong
branch to the serratus anterior muscle. The length of the extramuscular part of the vessel course varies from 6 to
16 cm and is about 9 cm, on average (8). The extramuscular part gives off several minor branches (7). At the
point of origin from the subscapularis vessels, the thoracodorsal vessels have diameters of 1.5 to 4 mm (artery)
and 3 to 5 mm (vein after unification of the two concomitant veins) (7, 8). Whereas the thoracodorsal artery
provides blood mainly to the proximal and lateral two-thirds of the muscle, the distal parts of the muscle are
reached by perforating branches of the intercostal arteries (7, 8).
FLAP DESIGN AND DIMENSIONS
The flap design is similar to a regular latissimus dorsi flap. The flap can be combined with a skin paddle.
Because of its good vascular supply and the size of the latissimus dorsi, the muscle can be surgically divided to
form a pouch to insert the replacement scaffold. The pouch is the site of cultivation, and acts as an in vivo
bioreactor. The dimensions of the replacement determine the size of the pouch. As the thoracodorsal vessel
pedicle is intended to provide the vascular supply of the transplant, the pouch should be located near the lateral
rim of the muscle. Therefore, the cultivated-bone replacement will have sufficient blood supply after both
transplantation and microsurgical anastomosis of the vessel pedicle.
OPERATIVE TECHNIQUE
The endocultivation procedure has one presurgical step for custom scaffold design and two different surgical
steps. These are described for the cultivation of a mandible replacement.
Step 1

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Preoperative Planning
The aim is to grow a subtotal replacement mandible inside the latissimus dorsi muscle, with an adequate
vascular pedicle to allow for subsequent transplantation of a viable graft into the defect. Furthermore, the
replacement should be individually shaped to fit the defect perfectly, thus improving the chances of adequate
postoperative function and a satisfactory aesthetic result.
Initially, a three-dimensional computed tomography (CT) scan of the head must be performed, to identify the
mandibular defect and to design an ideal virtual replacement of the missing part/s, using CAD-planning
techniques (Fig. 214.1). The data describing the mandible replacement are then directed to a CAD-operated
three-axes milling machine, and a Teflon mandible model is created, matching exactly the virtual dimensions of
the replacement mandible.
FIGURE 214.1 Top: Three-dimensional computed tomography (CT) scan of a 56-year-old patient after ablative
surgery for squamous-cell cancer 8 years previously. The mandible was resected from the paramedian left
region to the retromolar right region. This critical-sized defect of more than 7 cm was bridged with a titanium
reconstruction plate since the initial surgery. Bottom: The CT data of the mandible with defect region is
separated. Using computer-aided design (CAD)-planning techniques, an ideal virtual mandibular transplant is
designed, that would fit exactly into the defect. The data of this virtual transplant are forwarded to a CAD-
operated 3-axes milling machine, to form an identical Teflon model (compare with Fig. 214.2) (4).
Step 2
Scaffold Loading and Implantation
The Teflon mandible is then used as a mold from which a titanium mesh scaffold is created (Fig. 214.2). The
Teflon mandible is subsequently set aside, and the titanium mesh cage (now serving as an external scaffold) is

filled with an internal scaffold— bovine hydroxyapatite matrix. This internal scaffold is then coated with bone
morphogenetic protein-7 (BMP-7). Subsequently, 10 to 20 mL of bone marrow is aspirated from the iliac crest
and added to the hydroxyapatite matrix, with the intention of providing undifferentiated precursor cells as a target
for rhBMP-7.
The loaded titanium mesh cage (Fig. 214.3) is then implanted into a surgically created pouch of the right or left
latissimus dorsi muscle. The pouch serves as an in vivo bioreactor. A 7- to 10-week cultivation phase is required,
to allow for both the growth of heterotopic bone and for ingrowth of new vessels from the thoracodorsal artery
(Fig. 214.4).
Computed tomography after implantation and prior to transplantation is helpful to detect heterotopic bone growth
or any increase in mineralization (Fig. 214.5). In addition, bone scintigraphy (600 MBq technetium-99m-
oxydronate-tracer) may be used to demonstrate extraskeletal osteoblast activity inside the replacement. This is
useful in demonstrating the successful induction of new bone formation.
Step 3
Transplantation
After a cultivation period of a minimum of 7 weeks, the mandible replacement is transplanted to repair a
significant mandibular defect. The replacement is harvested with the surrounding muscular tissue and the
adjacent vessel pedicle from the thoracodorsal artery and vein (Fig. 214.6). Transplantation into the defect
region is performed via an extraoral approach. Minor bone overgrowth on the ends of the replacement can be
curetted, so that the transplant fits easily into the defect. As the replacement has been customized using CAD
design, no further correction of the shape or form of the graft should be required. When a titanium mesh cage is
being used as the external scaffold, it is helpful to have overlapping edges at the docking points to the original
mandible stumps. Thus, the replacement can be easily fixed onto the stumps with mini-screws (Fig. 214.7). The
transplant's vascular pedicle is then anastomosed onto the neck vessels, utilizing standard microsurgical
techniques.
FIGURE 214.2 A Teflon mandible model (right) was prepared with a CAD-operated 3-axes milling machine. The
model has identical dimensions to the virtually designed transplant (compare with Fig. 214.1). A titanium mesh
scaffold was then formed onto the Teflon model. After removing the Teflon model, the remaining titanium mesh
cage ( left) has dimensions similar to those of the ideal virtual transplant. The cage is loaded with hydroxyapatite
blocks serving as internal scaffold. The blocks will be later coated with bone morphogenetic protein-7 and
autologous bone marrow (4).

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FIGURE 214.3 The loaded titanium mesh cage is implanted into a pouch of the right latissimus dorsi muscle of
the patient. The surrounding muscle tissue is fixed on the cage with resorbable sutures, to allow for maximum
soft-tissue contact for neovascularization inside the graft (4).
CLINICAL RESULTS
Experience in humans with this computer-assisted endo-cultivation technique is currently very limited (4, 10,
11). The method is still experimental and, at the time of publication of this chapter, still requires ethics
approval, as the use of BMPs at this anatomic site is an off-label use. As
such, mandibular reconstructions using vascularized fibula, scapula, or iliac-crest grafts remain the gold
standard. Preoperative planning requires experience in CAD planning and rapid prototype development, to
allow for the exact fit of the replacement.
FIGURE 214.4 View on the lateral side of a female patient, where a mandibular replacement (arrow) is
growing inside her lateral right latissimus dorsi muscle. The shoulder range of motion is not significantly
reduced.

FIGURE 214.5 Three-dimensional (3D) CT scanning of the thorax. The mandible replacement is cultivated
without contact to the skeleton laterally anterior to the tip of the scapula. New bone formation is even seen
to be occurring through the titanium scaffold around the mandibular replacement (arrow) (4).
To date, patients undergoing this procedure have not complained of pain or sleep disturbance and have
relayed only minor concerns regarding the range of motion of the affected shoulder. Wound closure can be
a problem after transplantation of a massive replacement, particularly if the skin is nonelastic in the defect
region, with previous irradiation therapy and fibrosis. Although not ideal, a split-thickness skin graft covering
the adjacent muscle tissue of the graft may be employed if this proves to be particularly problematic (4).
This type of mandible replacement allows for masticatory function, when the external scaffold is properly
fixed onto the mandible stumps. Patients are provided with a significantly superior quality of life, given their
improved aesthetic appearance and enhanced ability to speak. To date, there has been no experience in
the insertion of dental implants into such neomandibles.
FIGURE 214.6 The mandible replacement is harvested with the surrounding muscle tissue and the adjacent
thoracodorsal vessel pedicle (arrow) (4).

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FIGURE 214.7 Three-dimensional CT scan of the patient after transplantation of the endocultivated
mandible replacement. The overlapping titanium-mesh wings of the replacement are fixed in the correct
position, thus returning the contour of the patient's jaw-line to approximately that present premorbidly (4).
The amount of bone that can be induced with BMP is limited. Follow-up CT studies have shown that bone
density inside the replacements subsequently enhances, due to masticatory functional loading. It is likely
that, with the technique described previously, it may not exceed the density of regular cancellous bone (12).
Future studies are focused on improvement of bone induction.
SUMMARY
Endocultivation is a pioneering technique used to grow individually shaped bone replacements within the
latissimus dorsi muscle of patients with severe skeletal defects. The goal is to use the patient as the
bioreactor, to prevent the common problems of engineering tissue in vitro in the laboratory. The
replacement scaffolds are designed prior to surgery, using CAD, to enable a perfect fit. The site of
cultivation is a surgically created pouch in the lateral latissimus dorsi, which allows for neovascularization,
courtesy of the thoracodorsal artery and vein, thereby allowing subsequent free-flap transfer into the
desired recipient region. This independent vascular supply makes it possible to grow constructs of the size
of a mandible or, in the future, possibly even a complex organ.
References
1. MacArthur BD, Oreffo ROC. Bridging the gap. Nature 2005;433:19.
2. Takushima A, Harii K, Asato H, et al. Mandibular reconstruction using microvascular free flaps: a statistical
analysis of 178 cases. Plast Reconstr Surg 2001;108:1555.
3. Spector M. Basic principles of tissue engineering. Chicago: Quintessence Publishing Co., Inc.,
1999:Chap. 1, Tissue engineering.
4. Warnke PH, Springer IN, Wiltfang J, et al. Growth and transplantation of a custom vascularised bone graft
in a man. Lancet 2004;28:766
5. Warnke PH, Wiltfang J, Springe, IN, et al. Man as living bioreactor: fate of an exogenously-prepared
customized tissue-engineered mandible. Biomaterials 2006;27:3163.
6. Warnke PH. Repair of a human face by allotransplantation. Lancet 2006;15:368:181.
7. Wolff KD, Hölzle F. Raising of microvascular flaps: a systematic approach. Berlin, Heidelberg, New York:
Springer, 2005.
8. Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary
neurovascular pedicle. Plast Reconstr Surg 1981;67:631.

9. Terheyden H, Warnke P, Dunsche A, et al. Mandibular reconstruction with prefabricated vascularized
bone grafts using recombinant human osteogenic protein-1: an experimental study in miniature pigs. Part 2:
transplantation. Int J Oral Maxillofac Surg 2001;30:469.
10. Heliotis M, Lavery KM, Ripamonti U, et al. Transformation of a prefabricated hydroxyapatite/osteogenic
protein-1 implant into a vascularised pedicled bone flap in the human chest. Int J Oral Maxillofac Surg
2006;35:265.
11. Arnander C, Westermark A, Veltheim R, et al. Three-dimensional technology and bone morphogenetic
protein in frontal bone reconstruction. J Craniofac Surg 2006;17:275.
12. Warnke PH, Springer IN, Acil Y, et al. The mechanical integrity of in vivo engineered heterotopic bone.
Biomaterials 2006;27:1081. [Epub 2005 Aug 22]

Chapter 215
Reconstruction of The Cervical Esophagus With Skin Flaps
C. E. SILVER
R. J. BRAUER
EDITORIAL COMMENT
These adjacent skin flaps are of historical significance only.
Tumors of the hypopharynx and cervical esophagus are often treated by total pharyngolaryngectomy with partial
or total esophagectomy. Repair of the surgical defect is a complex task. Reconstructions have been performed
using many variations and combinations of local tissues, skin grafts, stents, regional flaps, free flaps, and
transpositions or free transplantations of abdominal viscera. The ideal reconstruction would entail a single-stage
operation, employ nonirradiated tissues, require no thoracic or abdominal surgery, and have minimal morbidity
and mortality. Although marked improvements in reconstructive procedures have occurred, there is still no single
procedure that can be applied to all patients with uniformly reliable results. Various methods of
pharyngoesophageal reconstruction using skin flaps have the advantage of not requiring abdominal or thoracic
operations, but they have other limitations.
INDICATIONS
Many of the standard cervical skin flaps have been replaced by either the deltopectoral flap (see Chapter
216) or the pectoralis major musculocutaneous flap (see Chapter 218) or a combination of these flaps.
When these flaps are unavailable or contraindicated for some reason, the cervical skin flap (Wookey) (1, 2)
or its modifications can be used.
FLAP DESIGN AND DIMENSIONS
The procedure described by Wookey (2) employed a laterally based rectangular cervical skin flap for
reconstruction following pharyngolaryngectomy. The upper edge of the flap was sutured to the cut edge of the
pharynx and the lower edge to the esophagus. The flap was then folded back onto itself, creating a lateral
fissure in the neck. All the pharyngeal and esophageal anastomoses were completed at the first stage. The
opposite cervical skin was mobilized to resurface the neck, or if necessary, a skin graft was used. At a second
stage, the lateral fissure was closed. In most cases, this could be accomplished by simple incision and direct
suture along the edges of the defect (3).
In a modified procedure (4, 5, 6, 7), the cephalocaudal length of the flap was increased by including the
submental skin. This allowed a greater length of esophagus to be resected. The pharyngeal and esophageal
anastomoses were only partially completed at the first stage in order to simplify the procedure. At the second
stage, the neoesophagus was completed and the cervical defect was resurfaced by transfer of a thoracoacromial
skin flap.
The reconstruction with cervical skin was further modified by others. A U-shaped superiorly based flap with
separate incisions for the pharyngostoma and esophagostoma has been described (8). Bilateral skin flaps have
been used, where one flap is lined with a skin graft (9). One flap formed the posterior wall, and the skin-lined flap

provided the anterior esophageal wall and external surface.
OPERATIVE TECHNIQUE
The modified Wookey reconstruction uses a laterally based skin flap for the initial resection, which can include a
radical neck dissection. The superior incision includes the submental skin by following the contour of the
mandible (Fig. 215.1A). The inferior incision parallels the clavicle. The flap extends to the angle of the mandible
on both sides. At the conclusion of the resection, the operative site includes the stumps of the trachea,
esophagus, and oropharynx (Fig. 215.1B). The flap is sutured to the posterior edges of the oropharynx and the
esophagus, creating two temporary stomata (Fig. 215.1C). A tracheostoma is constructed through a separate
incision in the skin below the flap. The submental area is covered with a split-thickness skin graft. At the second
stage, a new gullet is created by tubing the flap (Fig. 215.1D-F). A previously delayed thoracic skin flap is used
to cover the cervical cutaneous defect (Fig. 215.1G).
FIGURE 215.1 Modified Wookey operation. A: Outline of laterally based flap. B: Operative field after resection.
Note stumps of oropharynx, esophagus, and trachea. C: Completion of first stage. Exteriorization of pharynx and
esophagus. Submental skin graft. D: Second stage. Incision outlining pharyngoesophageal segment. E,F:
Closure of skin-lined tube. G: Rotation of thoracoacromial flap to resurface neck. (From Silver, ref. 7, with
permission.)
CLINICAL RESULTS
The Wookey procedure has several inherent shortcomings. The laterally based flap tends to have marginal
circulation at the tip, associated with frequent partial loss. The flap is often in the field of prior radiotherapy.
Necrosis may delay completion of reconstruction by several weeks, and several additional procedures often
are required to replace the lost tissue. In addition, the wide open pharyngostoma results in constant
aspiration of saliva into the dependent tracheostoma, causing the patient to be most uncomfortable until
reconstruction is finally completed.
In 1960 Mustard (3) reported the results of 44 patients operated on by himself and Wookey. Twenty-four

percent of their patients survived 5 years, and six (14%) died before surgery was completed. The average
length of hospitalization was not reported, but Mustard recommended 6 to 12 weeks between the primary
resection and closure of the lateral sinus.
In eight modified Wookey reconstructions performed by the senior author (4), there was one operative
death. All patients developed temporary fistulas after the second stage. Hospitalizations ranged from 6
weeks to 3 months.
In another series of 13 patients (10), an average of three procedures was required to complete
reconstruction; hospitalizations ranged from 25 to 210 days. Twelve patients were ultimately able to
swallow. One operative death occurred.
SUMMARY
Cervical skin flaps were the standard flaps used to reconstruct the pharyngoesophageal area. They are still
useful in some patients, but they have been largely supplanted by the hardier deltopectoral and pectoralis
major flaps.
References
1. Mikulicz J. Ein Fall von Resektion des Carcinomatosen Oesophagus mit Plastichen Ersatz des excidirten
Stuckes. Prager Med Wochenschr 1886; 11:93.
2. Wookey H. The surgical treatment of carcinoma of the pharynx and upper esophagus. Surg Gynecol
Obstet 1942;75:499.
3. Mustard RA. The use of the Wookey operation for cancer of the hypopharynx and cervical esophagus.
Surg Gynecol Obstet 1960;111:577.
4. Silver CE, Som ML. Reconstruction of the cervical esophagus after total pharyngolaryngectomy: a
modified Wookey operation. Ann Surg 1967;165: 239.
5. Silver CE. Surgical treatment of hypopharyngeal and cervical esophageal cancer. World J Surg
1981;5:499.
6. Silver CE. Surgery for cancer of the larynx and related structures. New York: Churchill-Livingstone, 1981.
7. Silver CE. Reconstruction after pharyngolaryngectomy-esophagectomy. Am J Surg 1976;132:428.
8. Montgomery WM. Surgery of the upper respiratory tract, Vol. 2. Philadelphia: Lea & Febiger, 1973;300-
301.
9. Litton WB. Reconstruction of the hypopharynx and cervical esophagus: local flap technique after planned
preoperative irradiation. Trans Am Acad Ophthalmol Otol 1968;72:85.
10. Demergasso F, Piazza MV. Trapezius myocutaneous flap in reconstructive surgery for head and neck

cancer: an original technique. Am J Surg 1979; 138:533.

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Chapter 216
Deltopectoral Skin Flap: Pharyngoesophageal Reconstruction
V. Y. BAKAMJIAN
Reconstruction of the pharynx and cervical esophagus was the initial purpose for which the deltopectoral flap
was devised in 1962 to overcome the considerable difficulties and shortcomings of earlier methods, mainly the
two-stage technique with a cervical flap (see Chapter 215) and other one-stage techniques with skin grafts (1, 2,
3, 4, 5, 6, 7).
ANATOMY
See Chapter 127.
OPERATIVE TECHNIQUE
Radical neck dissection with laryngopharyngectomy that precedes reconstruction with a deltopectoral flap is best
served by a transverse pair of parallel neck incisions, modified after MacFee. Contrary to commonly voiced
opinions, these incisions amply provide needed exposure for accomplishing the ablative objective adequately
(Fig. 216.1A) while also serving the interest of the reconstruction. The upper incision is placed at hyoid or just
below hyoid level in a natural skin crease, and the lower is placed at clavicular level, in common with the upper
margin of the deltopectoral flap (Fig. 216.1B).
The flap is introduced to the midline of the neck, passing beneath the bipedicle flap of cervical skin raised
between the incisions of the neck dissection (Fig. 216.1C). With its raw side facing the prevertebral fascia,
suturing begins between the tip of the flap and the excision line in the posterior wall of the oropharynx or
epipharynx, as the case may be. The process continues to the sides bilaterally and reflects forward to meet at a
point at the base of the tongue, a bit off-center and away from the side of the radical neck dissection. Starting
from this point, the longitudinal seam that entubes the flap veers gently backward in its descent to meet the
stump of the esophagus behind the transected trachea. Here the lips of the seam part to encircle the esophageal
end opening, establishing an end-to-side anastomosis to the skin tube (Fig. 216.1D). Before this anastomosis is
completed, however, a nasally introduced feeding tube is passed down the skin tube and into the esophagus
and stomach, after which the seam is continued a short distance more to a fistulous exit over the medial head of
the clavicle. The neck wounds are closed, and the donor wound on the chest and shoulder is covered with a skin
graft (Fig. 216.1E).
The saliva-draining fistula, lying to one side and a little below the level of the tracheostoma (Fig. 216.1F), poses
no aspiration problems in the interim of some 3 weeks before the second stage. This procedure consists of
reentering the anastomosis site through the scar of the previous clavicular incision, opening the lowermost
portion of the skin tube and dividing it, adjusting the disparity in caliber of the tubes, and reconnecting them in
more of an end-to-end type of anastomosis (Fig. 216.1G).
A nearly identical technique is applicable in cases of oropharyngeal high resection without loss of the larynx and
cervical portion of the gullet. Here the hollow tube of inverted skin, lying alongside the retained larynx and
cervical gullet, serves only as a carrier for the distally used portion of the flap in the recipient defect (Fig.
216.2A), and it needs to be returned to the chest wall in a later stage. Division of the tube is done by reopening
the upper scar of the previous neck incision, through which the oropharyngeal reconstruction is also
completed. The remainder of the tube then is dissected downward in the neck and delivered to the outside

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through the scar of the lower neck incision, where it is untubed and returned to the chest wall (Fig. 216.2B).
There is also the possibility of rotating the end of the flap into the thoracic inlet instead of upward into the
oropharynx (Fig. 216.3A). This maneuver was found useful in a case of low obstruction of the cervical
esophagus with a heavily irradiated recurrent cancer. The resection, including larynx, thyroid gland, and cervical
esophagus, extended to approximately 1½ inches below the level of the sternal notch. The mode of entubing and
anastomosis is demonstrated by the diagrams in Figure 216.3B. A minor complication ensued, with dehiscence
and radionecrosis of the damaged cervical skin from around the tracheostoma (Fig. 216.3C) but was easily
corrected at a second stage, when the divided pedicle of the deltopectoral flap was used to replace the
unhealthy skin around the tracheostoma (8, 9) (Fig. 216.3D).
FIGURE 216.1 A: Typical exposure obtained through a transverse pair of parallel incisions for
laryngopharyngectomy and radical neck dissection. B: Outline of the incisions in conjunction with those to be
used for raising the deltopectoral flap. C: Passage of the deltopectoral flap into the neck, beneath the bipedicle
cervical flap of neck dissection. (Continued)

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FIGURE 216.1 Continued. D: Manner of forming the new gullet and its upper and lower anastomoses. E: First
stage completed, with closure of neck wounds and skin grafts on donor area. F: Demonstration of the fistulous
outlet that remains over the medial head of the clavicle. G: Steps in the second stage for completion of the
reconstruction. (From Bakamjian, Calamel, ref. 5, with permission.)

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FIGURE 216.2 A: The same basic technique employed for an oropharyngeal high defect not involving a loss of
the larynx and cervical esophagus. B: Steps in the second-stage division of the entubed pedicle and its return to
the chest.
FIGURE 216.3 A: Rotation of the tip of the flap to a low-lying esophageal stump in the thoracic inlet. (Continued)

FIGURE 216.3 (Continued) B: Diagram of the first-stage repair, the width of the flap end forming the length of
the new gullet. C: The patient ready for the second stage. D: Final result. Note that the base of the deltopectoral
flap has been used to replace the radiation-damaged skin around the tracheostoma. (From Bakamjian, Calamel,
ref. 5, with permission.)
SUMMARY
The deltopectoral flap can be adapted to reconstruct either high or low defects of the cervical esophagus.
References
1. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin
flap. Plast Reconstr Surg 1965; 36:173.
2. Bakamjian VY. Reconstruction of the pharynx and cervical esophagus. In: Gaisford JC, ed. Symposium on
cancer of the head and neck: total treatment and reconstructive rehabilitation. St. Louis: Mosby, 1969.
3. Bakamjian VY. Surgery for cancers of the hypopharynx and cervical esophagus. In: Cooper P, ed. The
craft of surgery, 2nd ed. Boston: Little, Brown, 1971.
4. Bakamjian VY. Methods for pharyngoesophageal reconstruction. In: Grabb WC, Smith JW, eds. Plastic
surgery: concise guide to clinical practice, 2nd ed. Boston: Little, Brown, 1973.
5. Bakamjian VY, Calamel PM. Oropharyngoesophageal surgery. In: Converse JM, ed. Reconstructive
plastic surgery, 2nd ed. Philadelphia: Saunders, 1977; 2697-2756.

6. Bakamjian VY, Holbrook LA. Prefabrication techniques in cervical pharyngoesophageal reconstruction. Br
J Plast Surg 1973;26:214.
7. Jackson IT, Lang W. Secondary esophagoplasty after pharyngolaryngectomy, using a modified
deltopectoral flap. Plast Reconstr Surg 1971;48:155.
8. Selfe RW, Conley JJ. Tracheostoma construction with a deltopectoral flap. Arch Otolaryngol
1979;105:290.
9. Virkkula L, Eerola S, Appelqvist P. Repair of stricture and fistula of antethoracic oesophagogastrostoma
using reversed pectoralis skin pedicle flap. Scand J Thorac Cardiovasc Surg 1977;11:67.

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Chapter 217
The Superior and Inferior Thyroid Artery Perforator (Stap) Flap
WARREN M. ROZEN
JEREMY L. WILSON
EDITORIAL COMMENT
A reliable pedicled flap in the head and neck region. Similar to the submental flap. The use of these flaps
should be severely limited in patients with previous radiotherapy.
INDICATIONS
The superior and inferior thyroid artery perforator (STAP and ITAP) flaps can be used for a range of defects
of the head and neck—we have used them for preauricular, postauricular, cheek, and perioral defects (1).
They are suitable for harvest as free flaps.
ANATOMY
Published cadaveric injection studies have identified the external carotid and subclavian arteries as the main
sources of blood supply to the anterior neck with a proposed watershed area between these territories running
horizontally in the lower neck (2). The same studies have also suggested that there is little or no vascular
communication across the midline. As a result of these findings, it has been suggested that anterior neck skin
flaps should not be raised across the midline and should not incorporate the watershed area between the two
parent vascular territories. This approach has limited the usefulness, size, and reach of anterior neck flaps.
However, a recent description by Behan et al. (2010) of the cervicosubmental island flap brought into question
the validity of these previous studies (3), with the skin of the anterior neck used with reliability.
In our anatomical studies, we have found a dominant thyroid artery perforator greater than 0.5 mm in diameter in
every case (90/90 cases) on computed tomographic angiography (CTA) with a diameter range of 0.5 to 1.3 mm
with a mean of 0.9 mm (Fig. 217.1). At least one such perforator was consistently shown to arise from its source
vessel deep to the investing layer of deep cervical fascia, and to emerge from this layer at the anterior border of
the sternocleidomastoid (SCM) muscle, at its caudocranial midpoint (within 2 cm of this point in all 90 cases).
Other smaller thyroid artery perforators were shown to perforate the SCM. The dominant perforators arose from
the superior thyroid artery (STA) in 89 of 90 cases and from the inferior thyroid artery (ITA) in 1 case. The
dominant perforator consistently emerged between the investing layers of fascia forming the epimysium of the
SCM, and traversed a variable subplatysmal course, before consistently perforating the platysma within the
ipsilateral neck. After perforating the platysma, the STA perforator traversed an axial (transverse) subcutaneous
course up to the midline, adjoining the axial
course of the STA perforator of the contralateral side of the neck. A long flap between the medial borders of each
SCM could thus be planned as an axial pattern flap. These imaging findings have been confirmed operatively
(Fig. 217.2).

FIGURE 217.1 Preoperative computed tomographic angiogram of a patient undergoing periauricular
reconstruction with a superior thyroid artery perforator (STAP) flap. Skin surface rendered view on the left, and
cropped view demonstrating the STAP (arrow) on the right, with the perforator seen to emerge between the
layers of the investing layer of fascia forming the epimysium of the SCM, and traverse a short subplatysmal
course, before perforating the platysma within the ipsilateral neck and traversing an axial (transverse)
subcutaneous course up to the midline, adjoining the axial course of the STAP of the contralateral side of the
neck. (Reproduced with permission from Wilson JL, Rozen WM, Ross R, et al. The superior thyroid artery
perforator flap: anatomical study and clinical series. Plast Reconstr Surg 2012;129(3):641-646.)
FIGURE 217.2 A: Intraoperative identification of the same superior thyroid artery perforator (STAP) as shown in
Figure 217.2, confirming the position, course, and use of the axial course of this perforator as the vascular basis
of the STAP flap. B: Another patient, undergoing a neck lift, with endoscopic identification of a STAP. Arrow
depicts location of STAP. (Reproduced with permission from Wilson JL, Rozen WM, Ross R, et al. The superior
thyroid artery perforator flap: anatomical study and clinical series. Plast Reconstr Surg 2012;129(3):641-646.)

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FIGURE 217.3 Operative series of the same patient in Figures 217.2 and 217.3A. A: The lesion for excision is
marked and perforators marked. B: The defect is created and the superior thyroid artery perforator (STAP) flap
marked. C: The flap is transposed and inset. Note a rotation flap is also performed above the external auditory
meatus (EAM) to maintain patency of the EAM. (Reproduced with permission from Wilson JL, Rozen WM, Ross
R, et al. The superior thyroid artery perforator flap: anatomical study and clinical series. Plast Reconstr Surg
2012;129(3):641-646.)
FLAP DESIGN AND DIMENSIONS
The flap is raised as a locoregional, pedicled island flap. The flap is planned around the location of the dominant
perforator, at the anterior border of the SCM, and planned to be raised deep to platysma proximally, to include
the course of the perforator toward the skin. Flap length can safely reach 22 cm, up to the anterior border of the
contralateral SCM. Length-to-width ratio is greater than 4:1 and is based largely on perforator diameter.
The cervical skin has thus been explored as the basis for regional flaps (4, 5). Extensive dissection studies by
Hurwitz et al. helped to clarify the arterial supply to the cervical skin and platysma (5). Hurwitz et al. (5) described
a direct cutaneous branch of the STA in 80% of dissections, found passing over the anterior border of SCM at
the point where the omohyoid is crossed by the SCM. This vessel alone has found to be sufficient for supply of
the platysma flap. Majouffre-Lefebvre et al. (6), in an extensive clinical series supplemented by cadaveric
dissection, demonstrated the cutaneous distribution of the STA, showing ink staining medially to the midline.
OPERATIVE TECHNIQUE
The surgical technique comprises raising the flap from distal to proximal, with thinning of the flap in the deep
subcutaneous plane only performed to the midline, and subplatysmal harvest from the midline to the anterior
border of the SCM. The flap is usually islanded, with arterial inflow solely by the STA perforator and venous
drainage through concomitant veins. The flap is then transposed into the regional defect, with dogear excision
performed as required (Fig. 217.3). Preoperative imaging can aid templating and flap design (Fig. 217.4).
CLINICAL RESULTS
We have had no flap losses, and no reoperations in any of the cases. Tip perfusion was uniformly tested
intraoperatively, and all cases were well-perfused (see Figs. 217.3 and 217.5).
In one early case (the only case in which a CTA was not performed preoperatively), there were two
dominant perforators, and inadvertent damage to the more anterior perforator led to some venous
congestion of the tip that healed without complication.

FIGURE 217.4 Axial maximum-intensity projection (MIP) reconstruction of a computed tomographic
angiogram (CTA) of the vasculature of the neck, highlighting a superior thyroid artery (STA) perforator (red
arrow) adjacent to a periauricular defect. Flap design for an STA perforator flap is highlighted (white
ellipse). (Reproduced with permission from Wilson JL, Rozen WM, Ross R, et al. The superior thyroid
artery perforator flap: anatomical study and clinical series. Plast Reconstr Surg 2012;129(3):641-646.)
SUMMARY
The use of the STA as the basis for anterior neck skin flaps has been described previously, but a targeted
approach combining preoperative identification of the dominant vascular pedicle and flap planning based
upon its course have permitted further refinement as a true axial perforator flap. The STAP flap can provide
an extremely long skin paddle extending well across the contralateral neck, with a flap width as little as 2 to
3 cm. These dimensions clearly highlight this as an axial pattern fasciocutaneous flap and are supported by
existing angiosome studies demonstrating capture of the contralateral STA perforator territory (2). The
application of this locoregional flap for defects of the neck and face may be further enhanced in any future
use as a free flap. As a thin, sensate, color-matched, and robust flap, we feel the application of the STAP
flap may reduce the need for free tissue transfer in many clinical scenarios and may become a workhorse
flap in head and neck reconstruction.
FIGURE 217.5 Operative sequence during harvest of the superior thyroid artery (STA) perforator flap
planned in Figure 217.5, with the lesion, defect, and flap design, and postoperative view of the harvest and
flap inset shown from left to right. (Reproduced with permission from Wilson JL, Rozen WM, Ross R, et al.

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The superior thyroid artery perforator flap: anatomical study and clinical series. Plast Reconstr Surg
2012;129(3):641-646.)
References
1. Wilson JL, Rozen WM, Ross R, et al. The superior thyroid artery perforator flap: anatomical study and
clinical series. Plast Reconstr Surg 2012;129(3):641-646.
2. Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck: anatomic study and clinical
applications. Plast Reconstr Surg 2000;105:2287-2313.
3. Behan F, Sizeland A, Gilmour F, et al. Use of the keystone island flap for advanced head and neck cancer
in the elderly--a principle of amelioration. J Plast Reconstr Aesthet Surg 2010;63:739-745.
4. Imanishi N, Nakajima H, Kishi K, et al. Is the platysma flap musculocutaneous? Angiographic study of the
platysma. Plast Reconstr Surg 2005;115:1018-1024.
5. Hurwitz DJ, Rabson JA, Futrell JW. The anatomic basis for the platysma skin flap. Plast Reconstr Surg
1983;72:302-314.
6. Majoufre-Lefebvre C, Laurentjoye M, Faucher A, et al. The horizontal infrahyoid myocutaneous flap:
surgical technique. Rev Stomatol Chir Maxillofac 2008;109:106-109.

Chapter 218
Use of The Pectoralis Major Musculocutaneous Flap for One-Stage
Cervical, Esophageal, and Pharyngeal Reconstruction
R. F. RYAN
Reconstruction of the cervical esophagus has challenged surgeons for many years (1). Until 15 years ago, it was
not unusual for patients needing esophageal replacement to undergo 20 or 30 operations. The two major
developments in solving the problem of cervical esophageal replacement were the deltopectoral flap (2) and the
development of free microvascular flaps of jejunum (3). The disadvantage of the Bakamjian flap was that it
required two or three stages if it required a delay. The jejunal flap required an abdominal procedure and the risk
of microvascular failure.
The next step was using a cutaneous flap vascularized by its underlying muscle for partial replacement of the
esophagus (4, 5, 6, 7). This was a one-stage procedure with the flap buried, and it did not require delay, division
of the pedicle, or invasion of the abdominal cavity.
INDICATIONS
The pectoralis major musculocutaneous flap can be used to replace the cervical esophagus and lower
pharynx.
OPERATIVE TECHNIQUE
The following is a description of the procedure as performed on the first patient: Preoperative examination of the
cervical esophagus in this female patient showed only a small linear lesion about 1 cm wide and 2.5 cm long.
The patient had previously undergone extensive radiation over the neck, a left radical neck resection, a right
modified neck resection, and a laryngectomy. The oncologic surgeon planned to open the old midline T incision
from the laryngectomy radical neck incision and resect the anterior portion of the esophagus. Unfortunately, the
tumor extended submucosally and required resection of the entire esophagus from the level of the tracheostomy
up to the posterior pharyngeal wall and resection of the gullet after a previous glossectomy and laryngectomy.
I was aware of previous failures in which musculocutaneous flaps had been sutured in a straight line along the
borders of the skin to make a skin-lined tube. I also was aware that a hollow tube can be made by a narrow
pedicle if it is sutured in a spiral manner, as is done with the cardboard core for a roll of toilet tissue. Moreover,
muscular contractions would tend to seal a spiral tube of skin rather than distract the edges and form fistulas.
A long pectoralis major muscle cutaneous flap was therefore elevated (7), as shown in Figures 218.1, 218.2,
218.3, 218.4. Because this was the first time I had done such a procedure, the pedicle was first tacked to one
side. This would not work, so it was sutured to the other side of the oral cavity and then sutured in a spiral
fashion. Because the new esophagus was of a much greater diameter than the remaining esophagus, the distal
esophagus was split, as when anastomosing vessels of different diameters (Figs. 218.5 and 218.6).
CLINICAL RESULTS
The patient did well, but she refused to have the nasogastric tube removed. She did drink and swallow
around the tube; however, several weeks postoperatively, the patient accidentally dislodged her
nasogastric tube and was unable to swallow. In observing the patient, I noticed that she used her left arm to

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lift the glass to her mouth and was unable to swallow
liquid. I then had the patient use her right hand, and she was able to swallow without difficulty. Thus, I
would recommend that the nerve to the flap be divided.
FIGURE 218.1 A: The principal blood supply to the left pectoralis major muscle. B: The pectoralis major
musculocutaneous flap, permanent tracheostomy, and old T incision from laryngectomy and right radical
neck dissection. (From Ryan et al., ref. 7, with permission.)
FIGURE 218.2 A: The elevated left pectoralis major musculocutaneous flap. A nasogastric tube is shown
entering the distal esophagus and lying on the bare prevertebral fascia after resection of the esophagus. B:
Drawing shows passage of the musculocutaneous flap up into the neck wound. (From Ryan et al., ref. 7,
with permission.)

FIGURE 218.3 A: Suturing of the distomedial edge of the left pectoralis major musculocutaneous pedicle
flap to the nasal pharynx with the distal tip at the right side. A nasogastric tube enters the distal esophagus,
which has been split to give a large anastomotic suture line. B: The flap is sutured on its distolateral side to
the remaining floor of the mouth. The suturing then was continued in a spiral manner, sewing pedicle edge
to pedicle edge to form a new esophagus around the nasogastric tube. Not shown is the bulk of the
pectoralis muscle that covered the suture lines. C: Drawing shows the completed esophageal tube or gullet
from nasopharynx to distal cervical esophagus. The muscle is not shown as it overlaps the tube. (From
Ryan et al., ref. 7, with permission.)
FIGURE 218.4 Lateral drawing to show the total amount of pharynx and esophagus replacing the single-
stage reconstruction by a left pectoralis major musculocutaneous flap. (From Ryan et al., ref. 7, with
permission.)

FIGURE 218.5 Radiographs showing contrast media flowing down around the large nasogastric tube still in
place in the reconstructed gullet. (From Ryan et al., ref. 7, with permission.)
FIGURE 218.6 Photograph showing the skin incisions of the neck and chest wall that healed primarily.
(From Ryan et al., ref. 7, with permission.)
This patient is now 2 years postoperative, still has a patent esophagus, and is maintaining her nutrition. She
has had a subcutaneous recurrence of the squamous cell carcinoma, however. The patient is still smoking
through her tracheostomy.
SUMMARY
The pectoralis major musculocutaneous flap can be used in a spiral fashion to reconstruct the cervical
esophagus and lower pharynx.
References
1. Capozzi A, Feierabend TC, Davenport F, Bernard FD. Cervical esophageal reconstruction. Plast Reconstr
Surg 1966;38:347.
2. Bakamjian VY, Holbrook LA. Prefabrication techniques in cervical pharyngoesophageal reconstruction. Br
J Plast Surg 1973;26:214.