Operative Technique in Plastic Surgery – Kevin C.Chung

■ The donor site is then closed in a layered fashion, and a split-thickness skin
graft is applied.
Flap Inset
■ The flap vessels are marked with methylene blue or a marking pen to
maintain correct orientation and ligated (TECH FIG 3A).
■ The flap is transferred to the head and neck area, and the pedicle vessels are
passed through the FOM defect (or tunnel) to the recipient vessels taking care
to avoid twisting or kinking of the pedicle.
■ This may be facilitated by using a Penrose drain passed through the tunnel
to transfer the pedicle to the recipient site.
■ The flap skin is inset into the defect using 2.0 Vicryl sutures in an interrupted
fashion sutured to the remaining FOM mucosa. The inset begins at the
deepest/least accessible portion of the FOM and proceeds toward the most
accessible area (TECH FIG 3B).
■ In some cases, there is insufficient mucosa available to suture to the flap.
■ In these cases, it important to make sure that the flap is securely inset;
otherwise, postoperative dehiscence and leak may occur. This is best
accomplished by suturing the flap using a U-shaped stitch around the teeth.
■ The needle is passed through the gingiva distal (ie, behind) a tooth toward
the intraoral defect. The suture is then passed through the skin entering the
subcutaneous layer (ie, from deep to superficial). The needle is then passed
through the flap skin through the skin in a U-shaped manner and then
passed through the gingiva mesial to the tooth. The suture is tied around the
tooth securely holding the flap in place (TECH FIG 3C,D).
■ In most cases, most/all of the inset is performed prior to microsurgical
anastomosis to ensure that the position of the pedicle does not change after
inset.
■ In some cases, the flap is partially inset, microsurgery is performed, and
the flap is then cut to final size and inset. However, usually with careful
planning, minimal alteration of the flap is necessary.

TECH FIG 2 • A. Preoperative markings of a radial
forearm flap. B. Radial forearm flap elevated on radial
artery/vein and cephalic vein.
TECH FIG 3 • A. Radial forearm flap ligated and
pedicle marked with blue ink to prevent
kinking/twisting. Lateral antebrachial cutaneous nerve
is shown (arrow). B. Final inset of the flap achieving a

watertight closure. C,D. Sequence of tying U-shaped
suture around teeth to secure flaps in cases with
inadequate remaining mucosa for flap suturing so that
the knot is on the mandible side.
PEARLS AND PITFALLS
Indications
■ When reconstructing FOM defects, the goals of reconstruction are to
maximize tongue mobility and maintain a watertight closure to
prevent leaks.
Advantage
■ Microvascular free flaps are the preferred reconstructive options for
patients with floor of mouth defects after tumor extirpation due to a
more robust blood supply, flexibility in donor site harvest, and
positional customization.
Approach
■ The defect should be carefully analyzed such that the right flap is
selected. This decision is influenced by the volume of the defect,
concomitant structures that may be involved, recipient vessels, and
patient factors.
■ Care should be taken in flap design so that minimal alteration of the
flap is necessary during inset if possible.
■ The flap should be securely inset to avoid dehiscence. If there is
insufficient mucosa available to suture the flap, then sutures should be
placed around the teeth.
POSTOPERATIVE CARE
■ Patients are typically kept on bed rest for 12 to 24 hours postoperatively with
the head of bed elevated to 30 degrees to minimize postoperative edema.
■ Patients who undergo free flap reconstruction are monitored closely in the
postoperative period using physical exam, use of transcutaneous Doppler
probe, implantable Doppler probe, or combination thereof.
■ Patients are treated with aspirin and/or Lovenox or subcutaneous heparin for
deep venous thrombosis prophylaxis (unless otherwise contraindicated).
Sequential compression devices are also utilized while the patients are on bed
rest.

■ Perioperative antibiotics targeted against intraoral microbial flora are
maintained for 72 hours.
■ Antibiotics may be necessary for longer periods of time in patients with
contaminated wounds or those with severe tissue damage (eg, extensive
surgery with or without radiation) or those with comorbid conditions (eg, poor
dentition, obesity, uncontrolled diabetes, history of alcohol use).
■ Enteral nutrition via feeding tube is started 24 hours postoperatively, and a
speech and swallow evaluation is typically obtained by 7 to 14 days
postoperatively.
■ Patients are evaluated by physical therapy while in the hospital and are
transitioned to either home or a rehabilitation facility upon discharge.
COMPLICATIONS
■ Short-term postoperative complications may include bleeding, dehiscence, or
flap failure from arterial/venous thrombosis.
■ Long-term complications may include flap failure, salivary fistulas, wound
dehiscence, or radiation-induced fibrosis yielding insufficient soft tissue to
accomplish reconstructive goals.
REFERENCES
1. Kademani D, Bell RB, Bagheri S, et al. Prognostic factors in intraoral
squamous cell carcinoma: the influence of histologic grade. J Oral Maxillofac
Surg. 2005;63:1599-1605.
2. Evans GRD, Schusterman MA, Kroll SS, et al. The radial forearm free-flap
for head and neck reconstruction—a review. Am J Surg. 1994;168:446-450.
3. Sabesan T, Ramchandani PL, Ilankovan V. Sensory recovery of noninnervated
free flap in oral and oropharyngeal reconstruction. Int J Oral Maxillofac Surg.
2008;37:819.
4. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept
based on the septocutaneous artery. Br J Plast Surg. 1984;37:149.
5. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft tissue flap? an
experience with 672 anterolateral thigh flaps. Plast Reconstr Surg.
2002;109:2219.
6. Cavadas PC, Sanz-Giménez-Rico JR, Gutierrez-de la Cámara A, et al. The
medial sural artery perforator free flap. Plast Reconstr Surg. 2001;108:1609-
1615.
7. Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for

reconstruction in the head and neck. Plast Reconstr Surg. 1979;63:73-81.

43
CHAPTER
Reconstruction of Total
Glossectomy Defects
Mark Sisco and Mihir Bhayani
DEFINITION
■ Total glossectomy defects occur most commonly in patients with malignancies
of the tongue or floor of mouth.
■ These complex defects require reconstruction with moderate to large volume
flaps to restore the bulk of the tongue.
■ Because the muscular action of the tongue is not restored by this procedure,
the bulk of the reconstructed tissue is necessary for swallowing (by pushing the
food to the back of the mouth). However, restoration of swallowing is not
always feasible and depends on the amount of residual normal tongue base and
floor of mouth that is preserved.
ANATOMY
■ The oral cavity comprises the floor of mouth, oral tongue, alveolar ridge,
buccal mucosa, and hard palate.
■ The tongue itself is composed of intrinsic striated muscles that affect its shape.
Extrinsic muscles, including genioglossus, hyoglossus, palatoglossus, and
styloglossus, insert into the tongue and affect its position in the oral cavity.
■ The blood supply to the tongue is almost entirely derived from the lingual
arteries, which arise from the external carotid arteries.
■ The base of tongue, which represents the posterior third of the tongue, is
attached to the hyoid bone and represents the anterior-most portion of the
oropharynx.
■ The floor of mouth is the U-shaped mucosal reflection that spans the region
between the mandibular alveolus and ventral tongue.
■ The tongue has distinct functions to support mastication, deglutition,

sensation, and speech.
■ For mastication, it moves food into position for chewing.
■ During deglutition, the tongue propels the food bolus posteriorly into the
oropharynx by progressively pressing against the hard palate in a retrograde
fashion. This is followed by contraction of the palatoglossus muscles and
elevation of the base of tongue. From this point onward, coordinated
contraction of muscles in the pharynx and hypopharynx moves the bolus into
the esophagus.
■ The tongue is the most important articulator of speech and is critical to the
production of all vowels and several consonants.
PATHOGENESIS
■ Over 95% of tongue cancers are squamous cell carcinomas.
■ It is more common in males and often presents in the fifth and sixth decades
of life.
■ The most common etiology is smoking and chewing tobacco.
■ Human papillomavirus has emerged as a new cause of base of tongue
malignancies that arise from the lingual tonsils.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Most patients with tongue cancer who present to the plastic surgeon have been
determined to need resection of at least 25% of the tongue.
■ Total glossectomy generally refers to removal of at least 75% of the tongue.
■ Patients should be queried about a history of carotid disease, smoking, prior
surgery, or radiation therapy.
IMAGING
■ Patients who have a history of prior neck lymph node dissection or known
carotid disease may benefit from angiography to determine optimal
management.
SURGICAL MANAGEMENT
■ The goals for reconstruction are as follows:
■ To enable complete resection of the tumor with wide margins
■ To achieve wound closure
■ To minimize donor morbidity
■ To restore function
■ In the case of the total or subtotal glossectomy, these goals are best

accomplished by providing a reconstruction that minimizes dead space and
provides bulk.
• This will reduce the likelihood of aspiration and provide a platform for food
boluses during swallowing.
■ If patients present with aspiration, the surgeon should plan for total
laryngectomy at the time of total glossectomy.
■ In general, the above goals are best met with microvascular transfer of a
vertical rectus abdominis myocutaneous (VRAM) or anterolateral thigh (ALT)
perforator flap. Pedicle flaps, such as the pectoralis myocutaneous flap, may be
used but do not provide as much bulk or freedom in inset.
Preoperative Planning
■ Potential donor sites should be examined, including the ALT and abdomen.
■ A determination of the donor site should be based on surgeon preference as
well as the body habitus of the patient.
■ Patients who have had previous abdominal surgery or who have a large
abdominal pannus may not be good candidates for a rectus-based flap.
■ Patients should generally have gastrostomy tubes placed preoperatively or at
the time of surgery.
■ If laryngectomy is not planned, patients should also have tracheostomy tube
placed to secure the airway.
Positioning
■ A shoulder roll should be used to extend the neck.
T E C H N I Q U E S
■ Anesthesia and Assessment of the Defect
■ After anesthesia is initiated, the oral cavity and oropharynx are examined to
assess the anticipated defect (TECH FIG 1).
■ Tracheostomy is usually performed first, followed by glossectomy and then
neck dissection as indicated.
■ In cases in which a total glossectomy is known to be required, a two-team
approach can be used to reduce surgery time.

■ For total glossectomy defects, the primary goal is to create enough bulk
anteriorly to allow contact between the flap and the hard palate when the
mandible is closed.
TECH FIG 1 • Total glossectomy defect with
preservation of a small portion of the right floor of
mouth using a visor incision.
■ If necessary, the flap may be folded upon itself to increase its bulk.
■ Flap Selection and Harvest
■ A soft tissue flap with sufficient bulk and volume is selected. Most
commonly, the VRAM flap or the ALT flaps are used since these flaps
provide both skin and healthy muscle with sufficient bulk to reconstruct the
missing tongue. In general, thinner fasciocutaneous flaps such as the radial
forearm are less useful due to insufficient volume.
■ In this example, a musculocutaneous ALT flap was selected (TECH FIG
2A,B).
■ Other myocutaneous flaps or fasciocutaneous flaps such as the gracilis or
parascapular flap (with or without latissimus muscle), latissimus flap, etc. are

used less frequently.
■ Recipient vessels are dissected in the head and neck area and made ready for
microanastomosis.
■ The flap is transferred to the head and neck area and inset into the defect
using interrupted 2-0 braided absorbable sutures. This ensures tension-free
inset and minimizes the risk of inadvertent flap avulsion of the anastomosis
(TECH FIG 2C; Videos 1 and 2).
Video p3-c043_01
Video p3-c043_02
■ The flap may also be neurotized by connecting the remnant of the lingual
nerve (if preserved) to a cutaneous branch of the ALT flap (TECH FIG 2D).
This is usually easiest to do before insetting the skin paddle for the flap.
00:00 / 00:00
00:00 / 00:00

TECH FIG 2 • A. Skin markings for anterolateral thigh
myocutaneous flap. B. Harvested flap showing the
skin and muscle portion. In these cases, it is best to
keep the muscle and skin connected. C. Flap insetting
begins in the deepest portion of the defect with
interrupted Vicryl sutures. D. Anastomosis of the
lingual nerve to the cutaneous nerve of the flap can be
performed if this nerve is preserved during the
resection. This is most easily accomplished prior to
insetting of the skin paddle.
■ Flap Inset
■ Flap inset begins by passing the flap vessels into the neck and insetting the
deepest/most dependent portion of the flap. The inset then progresses
proximally, rolling the tissue inward to increase the bulk of the flap in the
oral cavity.
■ The vascular anastomoses are performed to high-flow vessels. These are
most commonly the facial artery and common facial vein; however, the
lingual or other arteries may be used.

■ The venous anastomosis should be under sufficient tension to prevent
kinking with neck motion. I prefer to use a microvascular coupler to a short
branch from the internal jugular vein.
■ Alternatively, an end-to-side anastomosis may be performed to the internal
jugular vein. This requires the use of a small Satinsky clamp.
■ Completion of the inset is performed, again using interrupted 2-0 braided
absorbable sutures (TECH FIG 3A; Video 3).
Video p3-c043_03
■ The muscle from the flap can be used to reconstruct the floor of mouth and
sutured loosely to the mandible on each side (TECH FIG 3B). This is
helpful to prevent leaks (or to contain them if they occur).
■ A 10 Fr Blake drain is placed in the neck.
■ The neck is closed in layers.
■ The flap donor site is closed.
00:00 / 00:00

TECH FIG 3 • A. Inset flap demonstrating bulk of the
flap (rounded appearance) intraorally. This bulk is
necessary to propel food to the back of the mouth. B.
Muscle inset in the floor of mouth to contain leaks.
Microanastomosis is also shown.
PEARLS AND PITFALLS
Patient
education
and
planning
■ Patients requiring total glossectomy are at high risk for complications
given that they are nutritionally compromised, they have advanced
malignancies, they often smoke, and many have had prior surgery or
radiation.
Surgical
planning
■ A successful reconstruction is most often achieved during the primary
operation. It is significantly more difficult to achieve a successful
reconstruction after a flap has necrosed, a fistula has formed, or a
dehiscence has occurred.
Flap
design
■ A variety of flap designs have been proposed to allow various three-
dimensional configurations. More complex shaping and folding of flaps
may result in a greater risk of ischemia and partial flap loss, especially
among smokers.
■ Generally, the flap dimensions should be at least 30% larger than the
floor of mouth defect for sufficient bulk. If an ALT flap is used and the
patient is thin, a portion of the vastus lateralis can be used or the flap

can be partially de-epithelialized and folded upon itself.
POSTOPERATIVE CARE
■ The patient is kept sedated and ventilated by tracheostomy overnight.
■ Flap monitoring can be performed with clinical exam, handheld Doppler, or
implantable Doppler.
■ Oral hygiene is started 2 to 3 days postop with Peridex.
■ Swallowing function is assessed before attempts at feeding.
■ Drains are removed from the neck at 15 mL/d.
■ Drains are removed from donor sites at 30 mL/d.
OUTCOMES
■ Although most patients are able to verbally communicate with laryngeal
preservation, 85% of patients are found to have intelligible speech.1,2
■ In patients who have simultaneous total laryngectomy, about 50% of patients
regain the ability to phonate.
■ Only 30% of those patients have intelligible speech. Reconstruction using
free tissue transfer has been independently associated with improved speech
outcomes when compared to pedicled reconstruction flaps.
■ Most patients recover the ability to swallow after reconstruction of a total
glossectomy defect.
■ Feeding tube dependence at 1 year postsurgery has been found to be
anywhere from 50% to 75%.1,2
■ At least 75% of patients are able to maintain some type of oral intake with
one-third of patients able to be feeding tube independent. Flap choice has not
been shown to have any effect on swallowing function.
■ Maintenance of the flap bulk and volume is important for speech and
swallowing (FIG 1).
COMPLICATIONS
■ Patients are subject to the usual complications that may afflict any patients
with locally advanced head and neck cancer.
■ These include pneumonia, deep vein thrombosis (DVT) or pulmonary
embolus, and myocardial infarction.
■ Wound healing complications are common, especially in smokers or patients
with a history of prior radiation therapy.

FIG 1 • Long-term follow-up view demonstrating good
height and bulk of the flap. Also note that the flap has
re-epithelialized.
■ Small fistulas may be managed conservatively with local care.
■ Larger fistulas or those near the vascular pedicle may require operative
intervention and closure with a secondary pedicle flap (eg, pectoralis or
supraclavicular) as appropriate.
■ Total flap loss generally requires a second free flap or possibly a pectoralis
myocutaneous flap, depending on the etiology of the flap loss.3–6
REFERENCES
1. Kiyokawa K, Tai Y, Inoue Y, et al. Functional reconstruction of swallowing
and articulation after total glossectomy without laryngectomy: money pouch-
like reconstruction method using rectus abdominis myocutaneous flap. Plast
Reconstr Surg. 1999;104(7):2015-2020.
2. Salibian AH, Allison GR, Rappaport I, et al. Total and subtotal glossectomy:
function after microvascular reconstruction. Plast Reconstr Surg.
1990;85(4):513-524.
3. Paydarfar JA, Freed GL, Gosselin BJ. The anterolateral thigh fold-over flap
for total and subtotal glossectomy reconstruction. Microsurgery.
2016;36(4):297-302.
4. Lyos AT, Evans GR, Perez D, Schusterman MA. Tongue reconstruction:
outcomes with the rectus abdominis flap. Plast Reconstr Surg.
1999;103(2):442-447.
5. Lin DT, Yarlagadda BB, Sethi RK, et al. Long-term functional outcomes of

total glossectomy with or without total laryngectomy. JAMA Otolaryngol Head
Neck Surg. 2015;141(9):797-803.
6. Rigby MH, Hayden RE. Total glossectomy without laryngectomy: a review of
functional outcomes and reconstructive principles. Curr Opin Otolaryngol
Head Neck Surg. 2014;22(5):414-418.

44
CHAPTER
Reconstruction of Buccal
Mucosal Defects
Imran Ratanshi and Colleen M. McCarthy
DEFINITION
■ Carcinoma can involve the buccal mucosa of the oral cavity.
■ The treatment of buccal mucosa cancer is typically surgical resection.
ANATOMY
■ The buccal mucosa lines the inner aspect of the cheek and the lip.
■ Blood supply to the buccal mucosa is derived from buccal branches of the
facial artery, superficial temporal artery, and internal maxillary artery.
■ Sensory innervation to the buccal mucosa is provided by the trigeminal nerve.
■ Anatomic borders (FIG 1A)
■ Superiorly border—attachments to the maxillary alveoli
■ Inferior border—attachments to the mandibular alveoli
■ Anterior border—lateral lip commissure
■ Posterior border—pterygomandibular raphe
■ Relevant layers of the cheek from external to internal (FIG 1B)
■ Skin
■ Subcutaneous fat
■ Superficial musculoaponeurotic system (SMAS)/platysma
■ Parotid fascia/capsule
■ Parotid gland
■ Parotidomasseteric fascia
■ Masseter muscle
■ Buccal fat pad (within buccal space)
■ Buccinator
■ Buccal mucosa

■ There are three important spaces in the buccal region. These are potential sites
for fluid collection, infection, or tumor spread.
■ Buccal space
• Anterior border—oral commissure
• Posterior border—anterior border of masseter
• Superior border—zygomatic process of maxilla, zygomaticus muscles
• Inferior border—depressor anguli oris and attachment of deep fascia to
mandible
• Medial border—buccinator muscle (space is superficial to the muscle)
• Lateral border—platysma, subcutaneous tissue, skin
■ Pterygomandibular space
• Anterior border—posterior border of buccal space (anterior border of
masseter)
• Posterior border—parotid gland
• Superior border—lateral pterygoid muscle
• Inferior border—inferior border of mandible (lingual surface)
FIG 1 • A. Surface anatomy of the intraoral cheek
surface. B. Anatomic layers of the cheek illustrated from
external to internal. SMAS, superficial
musculoaponeurotic system.

• Lateral border—ascending ramus of mandible (space is deep to mandible)
• Medial border—medial pterygoid muscle (space is superficial to this
muscle)
■ Masseteric (or submasseteric) space
• Anterior border—anterior margin of masseter
• Posterior border—parotid gland
• Superior border—zygomatic arch
• Inferior border—mandible
• Lateral border—masseter
• Medial border—lateral surface of mandibular ramus
■ The buccal fat pad (of Bichat) occupies the buccal space. Contents of the
buccal fat pad include
■ Motor buccal nerve
■ Sensory buccal nerve (V3)
■ Facial artery and vein
■ Buccal branch of maxillary artery
■ Terminal buccal branches of facial nerve
■ Parotid (Stensen) duct
PATHOGENESIS
■ Buccal cancer originates in the mucosal lining of the cheeks inside the mouth.
■ Squamous cell carcinoma is the most common type of pathology.
■ No single risk factor causes buccal cancer.
■ Risk factors for buccal cancer include a history of:
■ Premalignant conditions1
• Oral lichen planus and leukoplakia are common premalignant lesions.
■ Malignant conditions
• Previous aerodigestive cancer
■ Modifiable risk factors1,2
• Tobacco (particularly chewing tobacco)
• Alcohol abuse
• Betel nut [or areca nut] (common in a South Asian chewed delicacy called
“paan”)
• Poor nutrition
• Poor dentition

• Oral denture wear
■ Viruses: HPV-16, HPV-18, HPV-31, HPV-33, and HPV-35; HHV-4 and
HHV-8; HIV; EBV1
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Risk factors for buccal cancer should be identified, particularly smoking
status. In a patient who is an active smoker, the risk of partial or complete flap
loss is greater.
■ A history of any prior surgeries or vascular line placement may limit the use of
specific reconstructive options.
■ For example, a prior neck dissection may preclude the use of the facial artery
musculomucosal (FAMM) flap if the facial artery has been previously ligated.
■ If level 1 (submental) nodes have been previously resected, use of the
submental island flap or platysmal island flap is contraindicated.
■ Placement of a radial artery line for invasive blood pressure monitoring is a
relative contraindication for use of a radial forearm free flap.
■ History and clinical findings of prior irradiation may also be a relative
contraindication to a locoregional flap reconstruction, depending on the
condition of the tissues.
■ A handheld pencil Doppler or duplex ultrasound can be used in the
preoperative setting and/or in the operating room to determine the location of
arterial perforating vessels.
SURGICAL MANAGEMENT
Preoperative Planning
■ Potential donor sites must be considered preoperatively.
■ Discussion with the resecting surgeon is helpful to estimate the defect size and
potential for close or positive margins. If positive margins are anticipated,
other nonsurgical treatment strategies should be explored.
■ Need for adjuvant radiation therapy should influence the reconstructive
modality.
■ It is imperative that patency of the ulnar artery is confirmed with an Allen test
in the preoperative period. Use of a bedside pulse oximeter can be a useful
adjunct to objectively identify collateral flow in this setting.
■ Intravenous and intra-arterial lines must also be avoided in the ipsilateral
upper forearm if a radial forearm free flap is to be harvested.

Positioning
■ The patient is placed in a supine position with neck in slight extension.
■ General anesthesia with nasotracheal intubation will typically be employed.
■ Tumor ablation will proceed by the ablative surgeon.
■ The reconstructive surgeon may undertake simultaneous harvest of a
microvascular flap if the surgical teams are certain that a free tissue transfer is
indicated. Partial elevation of a flap may be employed, including pedicle
dissection, and may be performed to optimize efficiency.
Approach
■ The pliable nature of buccal mucosa allows for full mandible excursion.
Therefore, primary closure of small to moderate-sized defects can lead to soft
tissue restriction, ultimately resulting in trismus.
■ Superficial mucosa-only defects can be reconstructed with a split-thickness
skin graft or palatal graft.
■ Alternatively, acellular dermis may be used in this setting and can serve as a
scaffolding in which vascular ingrowth can occur with minimal scar
contraction.
■ Flap reconstruction may be indicated in circumstances where more bulk is
desired than can be achieved with skin or dermal grafting alone.
■ Many local and locoregional flap options have been described. Workhorse
flaps utilized in restoring buccal mucosal lining include
■ Pedicled flap options:
• Buccal fat transposition flap—for small buccal defects
• Facial artery myomucosal flap—small to moderate-sized buccal defects that
involve the alveoli and/or lips
• Submental artery island flap—moderate-sized buccal defects
• Platysmal island flap—moderate-sized buccal defects
• Pectoralis major flap—moderate- to large-sized buccal defects in patients
who are poor candidates for free flap reconstruction or in salvage cases
■ Microvascular free flap options—offer additional tissue bulk and the ability
to contour donor tissue to fit a defect without restriction
• Radial forearm fasciocutaneous flap
• Thin, pliable soft tissue
• Consistent blood supply with long vascular pedicle
• Donor-site morbidity includes tendon exposure, injury to the dorsal radial

sensory nerve branch, and inferior appearance.
• Anterolateral thigh fasciocutaneous flap
• Can often close donor site primarily
• Best used in very thin patients or those in whom a radial forearm flap is not
an option
• Can be performed as adipofascial flap if more bulky donor site
T E C H N I Q U E S
■ Autogenous Grafts
■ For mucosa-only defects, very small defects may be repaired with primary
closure. Small defects may be repaired with palatal mucosal grafts. For
moderate-sized defects, a split-thickness skin graft can be employed to
resurface the intraoral buccal lining.
■ Skin grafts should be fenestrated to prevent accumulation of serous fluid and
fixed with resorbable suture (eg, cat gut).3
■ A tie-over bolster dressing using petroleum-impregnated gauze and
nonresorbable suture (eg, silk) should be used to minimize shear and prevent
saliva from entering below the skin graft surface.4 The bolster can also be
tied extraorally.3
■ A bite block may be considered if there is concern about dislodging the
bolster dressing.
■ Grafts should not be considered in the setting of anticipated radiation.
■ Acellular Dermal Matrix
■ Human acellular dermal matrix (ADM) is a biomaterial derived from
cadaveric skin that has been processed to remove cells and immunogenic
antigens.
■ ADM may be used in a similar manner to a skin graft.
■ The ADM is sutured into place and a bolster applied similar to a skin graft.
■ The bolster should be kept in place for 3 to 7 days.5
■ Failure presents as a pale graft that easily sloughs from its wound base.

■ Mild contraction can occur that is maximal at 3 to 5 weeks.5
■ Buccal Fat Pad Flap
■ The body of the buccal fat pad is centrally located over the parotid duct.
■ The blood supply includes branches of the facial artery, internal maxillary
artery, superficial temporal artery, and maxillary artery.
■ The buccal fat pad can be mobilized to resurface a defect.
■ Suitable for moderate-sized defects up to 5 cm. Cheek depression can occur
in larger defects.6
■ The flap can be mobilized through a 1-cm horizontal incision in the molar
region, 5 mm above the second molar, and halfway between the Stensen duct
and the upper gingivobuccal sulcus.
■ An incision is then made in the buccinator muscle, and the capsule
surrounding the fat pad is entered bluntly so as not to disrupt the buccal
branches of the facial artery.
■ Gentle extraoral pressure will help deliver the fat pad.
■ The fat pad is mobilized and fixated into the adjacent defect with resorbable
suture.
■ The flap will be resurfaced by via re-epithelialization over 4 to 6 weeks.
■ A bite block or splint should be considered for 12 to 14 days to avoid
chewing through the pedicle or causing trauma to the flap.7,8
■ Submental Island Flap
■ The submental artery island flap is an axial fasciocutaneous flap.
■ The vascular pedicle is based off the submental artery and vein and has a
length of up to 5 cm. The submental artery takes origin from the facial artery
5 cm anterior the mandibular angle. It runs a tortuous course and supplies the
submandibular gland and level 1 (submandibular) lymph nodes. The
submental artery runs deep to the digastric muscle in 70% of cases.
Therefore, the digastric muscle may be included in the flap.9
■ The skin paddle of the submental artery extends from one angle of the
mandible to the other. A pinch test determines the flap width. The flap
comprises the skin, subcutaneous fat, platysma muscle, submental fat, and

lymph nodes.
■ A handheld Doppler is used to identify cutaneous perforators just posterior
to the mandibular arch and adjacent to the anterior belly of digastric.
■ The upper border of the flap is drawn approximately one to two
fingerbreadths below the lower border of the mandible to protect the
marginal mandibular nerve and to reduce the risk of visible scar.8,10
■ The skin markings are incised down to and through the platysma muscle,
taking care to preserve the common or anterior facial veins and the marginal
mandibular nerve deep to platysma.
■ Starting on the contralateral side to the pedicle, a subplatysmal dissection is
then performed from lateral to medial.
■ Next, the ipsilateral side is elevated. The skin is incised down to and through
the platysma muscle similar to the contralateral side. The submental arteries
are identified deep to the submandibular gland superiorly and are
skeletonized with the subplatysmal skin island. Use of a handheld Doppler at
this stage can be useful to identify and protect the pedicle.
■ The anterior digastric muscle overlying the pedicle is harvested and included
with the flap to protect the blood supply (TECH FIG 1).
■ A tunnel is then made through the ipsilateral mylohyoid muscle to facilitate
transfer into the oral cavity. A strip of mylohyoid muscle may be included
with the pedicle to improve ease of transfer.
■ The neck is then primarily closed. This can be aided by slight neck flexion.
■ Tension on the pedicle may be minimized in the early postoperative period
by turning the head toward the pedicle.

TECH FIG 1 • Elevation of the submental island flap.
■ Platysmal Myocutaneous Island Flap
■ The platysma is a paired Mathes and Nahai type II muscle that originates
from the superficial fascia of pectoralis major and inserts over the angle of
the mouth and caudal cheek.
■ The dominant pedicle is the submental artery and venae comitantes. The
minor blood supply is a branch of the suprasternal artery, which in turn is a
branch of the suprascapular artery and vein.
■ The skin island in a platysmal flap should be designed in the hairless region
of the neck overlying the insertion of the sternocleidomastoid. A pinch test
can be performed to estimate the flap width, but it should not exceed more
than 5 × 7 cm.
■ Flap dissection should be undertaken prior to tumor extirpation and neck
dissection to avoid injury to the pedicle.
■ The distal border of the flap is incised to and through the platysma muscle.
■ The proximal border of the flap is incised through the skin only, preserving
platysma muscle.
■ The flap is then elevated from distal to proximal in a subplatysmal plane.
Care should be taken to identify the marginal mandibular nerve.

Consideration should also be given to include the anterior belly of digastric
muscle.8,11
■ The pivot point is about the lower border of the ipsilateral mandible.
■ This flap may be at risk for venous congestion from compression over the
mandible and can result in flap tip necrosis.
■ FAMM Flap
■ The FAMM flap is an axial flap based on the facial artery.
■ The course of the artery should be mapped extraorally and intraorally. The
facial artery takes origin from the external carotid artery. The location of the
facial artery can be identified along the lower border of the mandible, three
fingerbreaths from the mandibular angle at the anterior border of the masseter
muscle. The artery follows a tortuous course between the buccinator muscles
and the muscles of facial expression toward the alar base. It is approximately
one-half of an inch lateral to the oral commissure and one-quarter of an inch
from the alar base. It continues as the angular artery and travels toward the
medial canthus. This can be confirmed using a handheld Doppler.
■ The FAMM flap is designed along the course of the facial artery just anterior
to the parotid (Stensen) duct and consists of the buccal mucosa, a small
amount of buccinator muscle, the facial artery, and a venous plexus (TECH
FIG 2A). It can be approximately 1.5- to 2-cm wide.
■ Both superiorly and inferiorly based flaps can be used depending on the
defect location and arc of rotation required.
■ To aid in the dissection, stay sutures can be placed above and below the
commissure to create a taut buccal mucosa.
■ Sharp dissection is used to dissect through the buccinator muscle to identify
the artery.
■ The artery is ligated distally, and dissection is then carried from distal to
proximal to identify the artery near the oral commissure. Attachments of the
facial artery to the overlying buccinators can be tenuous and must be kept
intact.
■ Once the flap is harvested, it is transposed and inset (TECH FIG 2B). The
donor site may be closed primarily or grafting may be undertaken.12

TECH FIG 2 • Elevation (A) and transposition (B)
options for the facial artery myomucosal (FAMM) flap.
■ Pectoralis Major Myocutaneous Flap
■ The pectoralis major flap is a useful flap in patients with large buccal defects
who have medical comorbidities that preclude free flap reconstruction or in
salvage circumstances.13
■ The pectoralis major is a Mathes and Nahai type V muscle whose dominant
pedicle is the thoracoacromial artery and venae comitantes. Minor pedicles
arise from the lateral thoracic artery and anterior perforators from the internal
mammary artery between the second and fifth ribs. The sternocostal portion
originates from the anterior chest wall from the second to sixth ribs.
■ The pivot point is just below the clavicle. The surface landmark of the
thoracoacromial pedicle the intersection of a line from the acromion process
to the xiphoid notch, and a plumb line from the midclavicle. The pedicle can
be found within a 2-cm radius of this point.
■ Using reverse planning, a vertical or horizontal skin paddle can be designed

centered on the pectoralis major.
■ The lateral flap is incised to anterior pectoralis muscle fascia. Skin and soft
tissue lateral to the flap are then widely undermined.
■ Next, the medial flap is incised to pectoralis muscle fascia, providing
complete exposure of the muscle.
■ The muscle is then elevated from distal to proximal, ligating the intercostal
and lateral thoracic perforators.
■ If an ipsilateral deltopectoral flap may be required, preservation of the
second and third internal mammary perforators should be considered.
■ During the lateral dissection, the pectoralis major is disinserted to facilitate
mobilization. Ligation of the lateral pectoral nerve can also be considered for
further reach.
■ A subcutaneous tunnel overlying the clavicle is then developed to facilitate
flap transfer toward the neck.
■ The medial half of the clavicle can also be divided to provide additional
length and minimize compression on the venae comitantes.
■ This flap is limited by additional bulk and may not be suitable for obese
patients.
■ A bulge will be observable on the ipsilateral neck where the flap has been
turned over.
■ Radial Forearm Fasciocutaneous Free Flap
■ The flap is harvested from the nondominant forearm (TECH FIG 3).
■ The course of the radial artery and superficial veins, including the cephalic
vein, is marked.
■ Proximal venous compression can aid in identifying the superficial venous
system.
■ The approximate course of the medial and lateral antebrachial cutaneous
nerves can also be marked.
■ The radial forearm flap is usually centered so that the midpoint of the flap
follows a line halfway between the radial artery and the cephalic vein.
■ The limb is exsanguinated and tourniquet is inflated.
■ The distal flap margin is incised.
■ Blunt dissection is used to identify three main structures:
■ Distal branches of the superficial radial nerve

■ The radial artery and venae comitantes between the flexor carpi radialis
and brachioradialis tendons
■ The cephalic vein on the distal radial edge of the flap
■ The radial artery, venae comitantes, and cephalic vein are ligated distally.
■ When results of an Allen test are in doubt, an Acland clamp can be placed
on the radial artery to definitively assess hand perfusion prior to ligating
the radial artery.
■ An incision is made on the ulnar flap margin through the skin and fascia.
■ Flap elevation proceeds from an ulnar to a radial direction deep to the volar
antebrachial fascia, carefully protecting the paratenon overlying the wrist
flexor tendons.
■ The flexor carpi radialis muscle is identified, as is the lateral intermuscular
septum on the lateral aspect of the muscle. Traction of the muscle in an ulnar
direction will reveal the radial artery and its venae comitantes.
■ An incision is made along the radial margin of the flap through the skin and
underlying volar antebrachial fascia, and the flap is elevated from radial to
ulnar, again preserving paratenon overlying the wrist flexor tendons, until the
brachioradialis tendon is identified. Care must be taken to preserve the
superficial sensory branches of the radial nerve.
■ As dissection proceeds from the radial margin of the flap, the fascia is lifted
off of the brachioradialis. The further proximal the dissection, the more the
brachioradialis muscle conceals the artery beneath its volar medial border.
■ The proximal flap margin is then incised, avoiding injury to the cephalic and
basilic veins, as well as to the medial and lateral antebrachial cutaneous
nerves.
■ The lateral intermuscular septum and associated radial artery and venae
comitantes and perforators are then elevated in a distal to a proximal
direction. Deep branches to the volar surface of the distal radius and to
adjacent muscle bellies are ligated.
■ At the approximate junction of the middle and distal thirds of the arm, the
superficial branch of the radial nerve penetrates the deep fascia to course
superficial to this fascia. From this point of penetration distally, the deep
fascia is incised longitudinally, freeing the nerve.
■ A longitudinal incision proximally toward the antecubital fossa allows
elevation of the proximal radial artery and any subcutaneous veins all the
way to the bifurcation of the brachial artery as is necessary. A Weitlaner or

other retractor is useful to expose the pedicle deep to the brachioradialis and
flexor carpi radialis muscle bellies. The proximal length of the cephalic vein
can be dissected to be as long as required.
■ The tourniquet is deflated, and immediate reperfusion of the flap and of the
hand is revealed.
■ A split-thickness skin graft is needed to close the donor site. The wrist
should be immobilized for 2 weeks to avoid graft shear from the underlying
wrist flexors.
TECH FIG 3 • Anatomic structures encountered during
elevation of the radial forearm flap.
■ Anterolateral Thigh Fasciocutaneous Flap
■ The anterolateral thigh flap is useful for moderate- to large-sized buccal
defects in circumstances where the radial forearm is not an available donor

site (TECH FIG 4A,B).14
■ A line is drawn between the anterior superior iliac spine to the superolateral
border of the patella. This line represents the muscular septum between the
rectus femoris and the vastus lateralis muscles (TECH FIG 4C).
■ The cutaneous vessels are mapped by a Doppler probe centered over the
midpoint of this line. Most skin perforators are located within a circle of 3-
cm radius centered at this midpoint. The flap is centered over the location
of these vessels, and its long axis is designed parallel to that of the thigh.
■ Additional perforators can often be found 5 cm distal and 5 cm proximal to
this point. If perforators cannot be readily identified, a Duplex ultrasound is
useful in definitively identifying perforators. If none can be found, the
opposite thigh should be considered.
■ An incision is made along the distal 10 to 15 cm of the medial aspect of the
flap down to and through the deep fascia on to the rectus femoris muscle
belly.
■ The rectus femoris muscle is identified based on its bipennate muscle
fibers and a flat, stout tendon spanning its entire undersurface. A fat plane
exists superficial to the lateral intermuscular septum between the rectus
femoris and vastus lateralis.
■ Once the septum is identified, the remaining medial skin and fascia incision
is completed from distal to proximal.
■ The rectus femoris muscle is retracted medially to expose the entire septum.
■ The septocutaneous vessel can be clearly observed. An appropriate
perforator can be selected. A pure septocutaneous course is less common. In
most cases, the perforator follows a varied intramuscular course and typically
gives off many small branches to the vastus lateralis muscle from the lateral
and posterior sides of the vessel.

ASIS Lateral femoral cutaneous nerve Lateral circumflex femoral artery Descending branch of LCFA Circle of 3cm radius Vastus lateralis Septum between rectus femoris and vastus lateralis Lateral superior C border of the patella Pubic tubercle - Profunda femoris artery - Rectus femoris

TECH FIG 4 • Use of an ALT free flap to reconstruct a
full-thickness buccal defect from resection of an
invasive squamous cell carcinoma. A. Planned
resection with margin. B. Final defect. C. Surface
landmarks for perforators and perforator anatomy for
anterolateral thigh flap based on the lateral circumflex
femoral system. D. Elevated ALT flap with vascular
pedicle marked in ink on one side to identify twisting.
E. The flap was folded to provide both intraoral lining
and external skin. The interposing segment
connecting the two surfaces was de-epithelialized. F.
Final inset showing external skin paddle (internal
paddle not shown).

■ The superficial (anterior) course of the perforator is then exposed by
dividing the overlying muscle, and the perforator is traced back to the main
descending branch of the lateral circumflex femoral artery. The perforator
can then be freed on its lateral, medial, and deep surfaces to free it
completely to its origin.
■ Once the perforator is freed, the lateral skin marking is incised down to and
through the deep fascia.
■ The flap is elevated from a distal to proximal and lateral to medial
direction, with care being taken to preserve the perforator (TECH FIG
4D).
■ Once the flap is harvested, it is transposed and inset (TECH FIG 4E,F).
■ Primary closure of the donor site can often be achieved. For larger skin
paddles, a split-thickness skin graft may be required.
■ In circumstances in which there is extensive subcutaneous tissue in the thigh,
an adipofascial flap may be considered. This allows better tailoring to fit the
defect thickness. The fascial surface that does not stretch is allowed to
remucosalize.15 Therefore, it must be fitted to size or trismus will result.
■ Cutaneous Paddles of Chimeric Flaps
■ Loss of buccal and additional oral cavity mucosa may be part of a composite
defect involving bone, floor of mouth, and tongue.
■ Chimeric flap designs can offer a skin cover for mucosal lining defects in
conjunction with bone for segmental defects or muscle for dead space
obliteration if required.
■ Buccal resurfacing can be achieved using skin paddles of chimeric flaps.
■ Common examples include fibula osteocutaneous flap, scapula
osteocutaneous flap, anterolateral thigh myocutaneous flap, and iliac crest
osteocutaneous flap.
PEARLS AND PITFALLS
Complication
Pearls for Management
Iatrogenic
injury to the
■ When harvesting a submental island flap, the patient should not
be paralyzed until after the mandibular branch of the facial nerve

marginal
mandibular
nerve during
submental flap
harvest
is identified.
Poor skin graft
take
■ A bolster dressing of Xeroform and silk sutures may be applied
to protect the skin graft from sheer and saliva. This should be
maintained for 7 days.
Wound
dehiscence
■ When insetting the flap, care should be taken to ensure a
watertight closure. Horizontal mattress sutures can be helpful.
However, sutures should not be overtight so as not to cause flap
tip necrosis and poor healing. Where watertight closure is not
possible, consideration of placing additional muscle to obliterate
the dead space between the cheek and neck.
Fistula tract
formation
■ Acute fistulas are best managed with regular irrigation and
through-and-through intraoral and extraoral packing. Intraoral
packing with Vaseline-impregnated gauze or Xeroform helps to
form a plug to minimize saliva entry into the neck. Extraoral
packing with saline-soaked or dry gauze helps to remove necrotic
or infected debris.
Vascular
compromise
■ Care should be taken to avoid excess pressure on the neck at the
site of a vascular pedicle and/or anastomosis.
POSTOPERATIVE CARE
■ A nasogastric tube or similar device should be employed until graft or flap
take is established and intraoral wounds are sealed, usually around
postoperative day 7.
■ Pressure avoidance at the microvascular site is essential to reduce the risk of
venous thrombosis, particularly if the external jugular system is used for
venous anastomosis. If utilized, tracheostomy ties should not cause any neck
compression whatsoever (while equally preventing the tracheostomy from
dislodging).
■ Securing the tracheostomy with sutures should be considered in
circumstances in which this is not possible.
■ Position restrictions that prevent a patient from turning toward the side of
venous anastomosis can reduce the risk of twisting the venous pedicle and
subsequent thrombosis.

■ Routine monitoring of microvascular free tissue transfer should include an
evaluation of both arterial and venous systems.
■ For flaps whose skin paddles are difficult to visualize, a Cook-Swartz
Doppler probe or equivalent device should be considered.
OUTCOMES
■ The buccal region is important in speech, oral preparatory phase of
swallowing, oral competence, and generating suction.16
■ Loss of function results more from tumor extirpation, reconstruction, and
radiation than the inciting tumor.
■ If the donor tissue chosen appropriately meets the defect requirements,
excellent functional outcomes can be achieved.
■ Wound dehiscence can lead to fistula and abscess formation. This can delay
adjuvant treatments such as radiation or chemotherapy. Therefore, efforts
should be undertaken to avoid this complication where possible.
COMPLICATIONS
■ Partial or complete graft loss
■ Partial or complete flap loss
■ Delayed wound healing
■ Motor or sensory nerve injury
■ Fistula formation
■ Abscess formation
■ Scar contracture
■ Trismus
■ Altered speech
■ Loss of oral competence
REFERENCES
1. McDowell JD. An overview of epidemiology and common risk factors for
oral squamous cell carcinoma. Otolaryngol Clin North Am. 2006;39(2):277-
294.
2. Yan L, Chen F, Liu F, et al. Differences in modifiable factors of oral squamous
cell carcinoma in the upper and lower of oral fissure. Oncotarget.
2017;24(8):75094-75101.
3. Chaturvedi P, Pai PS, DeCruz AK, et al. Extra-oral knotting of tie-over
sutures: a novel technique to bolster the split thickness skin graft for buccal

mucosal defect. J Surg Oncol. 2003;84:103-104.
4. Qureshi SS, Chaukar DA, DeCruz AK. Simple technique of securing intraoral
skin grafts. J Surg Oncol. 2005;89:102-103.
5. Shi L-J, Want Y, Yang C, et al. Application of acellular dermal matrix in
reconstruction of oral mucosal defects in 36 cases. J Oral Maxillofac Surg.
2012;70(11):e586-e591.
6. Chien C-Y, Chung-Feng H, Chuang H-C, et al. Comparison of radial forearm
free flap, pedicled buccal fat pad flap, and split thickness skin graft in
reconstruction of buccal mucosal defect. Oral Oncol. 2015;41(7):694-697.
7. Chaudary B, Gong Z, Lin Z, et al. Reconstruction of intraoral maxillary defect
with buccal fat pad. J Craniofac Surg. 2014;2174-2177.
8. Squaquara R, Evan KF, di Spilimbergo SS, Mardini S. Intraoral reconstruction
using local and regional flaps. Semin Plast Surg. 2010;24(2):198-211.
9. Szudek J, Taylor SM. Systematic review of the platysma myocutaneous flap
for head and neck reconstruction. Arch Otolaryngol Head Neck Surg.
2007;133:655-661.
10. Martin D, Pascal JF, Baudet J, et al. The submental island flap: a new donor
site. Anatomy and clinical applications as a free or pedicled flap. Plast
Reconstr Surg. 1993;92:867-873.
11. Thakkur RK, Pandya SR. The posterosuperiorly based platysmal
myocutaneous flap: the underutilized reconstructive option. J Maxillofac Oral
Surg. 2015;14(2):476-480.
12. Pribaz JJ, Stephens W, Crespo L, Gifford G. A new intraoral flap: facial
artery myomucosal (FAMM) flap. Plast Reconstr Surg. 1992;90:421-429.
13. Milenovic A, Virag M, Uglesic V, Aljinovic-Ratkovic N. The pectoralis
major flap in head and neck reconstruction: first 500 patients. J
Craniomaxillofac Surg. 2006;34:340-343.
14. Chuang HC, Su CY, Jeng SF, Chien CY. Anterior lateral thigh flap for buccal
mucosal defect after resection of buccal cancer. Otolaryngol Head Neck Surg.
2007;137(4):632-635.
15. Agostini T, Agostini V. Further experience with adipofascial ALT flap for oral
cavity reconstruction. J Plast Reconstr Aesthet Surg. 2008;61(10):1164-1169.
16. John S, Hassuji RM, Rajashekhar B. Speech and swallowing outcomes in
buccal mucosa carcinoma. Indian J Palliat Car. 2011;17(3):238-240.

45
CHAPTER
Jejunum Flap for
Pharyngeal Reconstruction
Farooq Shahzad and Babak J. Mehrara
DEFINITION
■ The free jejunal flap is a workhorse for reconstruction of the hypopharynx and
cervical esophagus.
■ A flap of up to 20 cm can be harvested on a single jejunal vessel and its
vascular arcade. This length limits the use of this flap for reconstruction of
subtotal or total esophageal defects.
■ For subtotal or total esophageal reconstruction, pedicled colon or gastric pull-
up procedures are more appropriate in most cases.
■ However, both of these options have limited reach cephalad and may not
extend all the way to the pharynx. In this situation, they can be combined with
a free jejunal flap for the pharyngeal and cervical esophageal part of the
reconstruction.
■ Alternatively, total esophageal reconstruction can also be performed with a
pedicled jejunal flap (pedicled in the abdominal donor site) with
supercharging the distal flap arcade in the neck or chest.1
ANATOMY
■ The jejunum is the second part of the small intestine. It starts from the
ligament of Treitz and extends to the ileum.
■ The lumen of the jejunum contains circular mucosal folds called plicae
circulares.
■ These folds slow down the passage of food and increase the surface area for
absorption.
■ They decrease in size and number distally along the small bowel.
■ The blood supply of the small bowel is via the superior mesenteric artery. It

gives rise to multiple jejunal and ileal branches (FIG 1).
■ These branches divide and form vascular loops called arcades.
■ These arcades further divide to form secondary and tertiary arcades.
■ The terminal vessels that supply the small bowel area are called the vasa
recta.
■ The veins accompany the arteries.
■ A jejunal flap can be based on any jejunal artery and its accompanying
vascular arcade. Free jejunal flaps are typically based on the ideal vascular
arcade as defined by the recipient site needs (see below).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The history and physical exam should identify those patients who are not
eligible for the operation.
■ Contraindications include chronic intestinal disease (eg, Crohn disease),
ascites, and grave medical condition precluding a long operation.

FIG 1 • Anatomy of the jejunum and intestines.
■ Relative contraindications include multiple previous abdominal surgeries and
limited pulmonary reserve.
■ Other donor sites are assessed for potential backup options, including the
pectoralis flap, internal mammary artery perforator (IMAP) flap, deltopectoral
flap, supraclavicular flap, radial or ulnar forearm flaps, and anterolateral thigh
(ALT) flap.
■ Patients with thrombotic tendencies should be identified. This includes a
history of deep vein thrombosis (DVT) or miscarriages or family history of
thromboembolism.
■ A hypercoagulability workup and hematology consult can be obtained if
necessary.
IMAGING
■ In general, no specific imaging is needed.
■ A mesenteric angiogram can be performed to evaluate the patency of the
vascular pedicle in patients suspected of having atherosclerotic occlusive
disease. However, this is rarely done as the superior mesenteric artery is
typically spared from atherosclerosis.
SURGICAL MANAGEMENT
■ Jejunal free flap is most commonly used for circumferential defects of the
cervical esophagus.
■ It can also be used to patch smaller defects or repair incomplete defects, but in
these situations, we prefer the radial forearm or ALT flaps.
■ The ALT free flap is also a good option for circumferential
pharyngoesophageal defects.
■ The donor site for this flap usually requires a split-thickness skin graft,
however, and is, in our opinion, more morbid than a jejunum flap. In addition,
tubing an ALT flap results in an extra suture line (in addition to the proximal
and distal pharyngeal anastomosis) requiring more surgical time and
potentially increasing the risk of leak.
■ As a result, we use this flap as a second-line option when the jejunum cannot
be used. However, this idea is heavily debated.
■ In patients who are not free flap candidates (medical condition necessitating a
short operation or no available recipient neck vessels), regional pedicled flaps

like the pectoralis major myocutaneous flap or supraclavicular flap are more
commonly used.
Preoperative Planning
■ The plan for resection and neck dissection should be discussed with the
ablative head and neck surgeon. This allows for a better understanding of the
anticipated surgical defect so that a reconstructive plan can be developed.
Furthermore, an informed discussion can be held with the patient, and
appropriate consent can be obtained.
■ It is also important to discuss the need for preservation of recipient vessels
with the ablative surgeon.
■ Preoperative bowel preparation can be performed. Often, a simplified bowel
prep with clear liquid diet for 24 hours and a bottle of magnesium citrate the
day before surgery is all that is necessary.
Positioning
■ The patient is placed in the supine position for the duration of the case.
■ Perioperative antibiotic prophylaxis is performed. We use cefazolin and
metronidazole for head and neck cases.
■ Sequential compression devices are used for DVT prophylaxis. Underbody
warming device is used to prevent hypothermia during the case.
■ The face and neck are prepped with an iodine-based solution.
■ The chest and abdomen are prepped with a chlorhexidine-based or iodine-
based solution.
■ The entire field is draped as one for convenience.
■ The chest can be covered with a drape or towel to prevent heat loss.
Approach
■ The jejunal flap can be harvested via an open or a laparoscopic approach.
■ Open harvest of the jejunal flap is our preferred method. It is performed via a
midline epigastric incision. Generally, we make an 8-cm incision above the
umbilicus.
■ This technique is technically easier and expeditious and allows direct
visualization of the flap and pedicle.
■ Moreover, the pedicle can be separated in situ prior to flap harvest, which is
easier to perform than after pedicle division and cuts down on ischemia time.
■ Laparoscopic-assisted harvest of the jejunal flap is performed via multiple

small laparoscopic incisions.2 It requires expertise in minimally invasive
techniques.
■ This usually means that the assistance of a general surgeon is required for
flap harvest.
■ The advantage is decreased abdominal wall morbidity.
■ The jejunum tolerates ischemia for approximately 2 to 2.5 hours. Thus,
meticulous planning and expeditious execution are critical for a successful
outcome.
■ Hypothermia increases the ischemic tolerance of jejunal flaps, and some
experts have described improved ischemic tolerance with cooling the flaps to
5°C,3 6oC to 12°C,4 and 10°C.5 This is generally not necessary, as ischemia
times are kept less than 2 hours if the recipient vessels are prepared and the
team is ready to perform microsurgical anastomosis when the flap is
harvested. In fact, some suggest that 2 hours of euthermic ischemia time is
beneficial for postoperative outcomes as this approach may decrease mucous
production.6
T E C H N I Q U E S
■ Free Jejunum Reconstruction After
Laryngopharyngectomy
Preparation of Recipient Area
■ The extirpative defect is analyzed.
■ The length of the hypopharyngeal/esophageal defect is measured, and a
determination is made whether it is amenable to reconstruction with free
jejunal flap (TECH FIG 1).
■ If not, an alternate method of reconstruction is chosen.
■ Recipient vessels in the neck are dissected and prepared.
■ The recipient artery and vein should be located close to each other because
the donor vessels in a jejunal flap cannot be very widely separated.
■ The recipient artery is usually the superior thyroid, facial, or lingual artery.
■ The recipient vein is usually a branch of the internal jugular vein, the main
trunk of the internal jugular vein (end to side), or the external jugular vein.

■ However, any suitable artery or vein situated close together may be used.
■ It is important to dissect the recipient vessels first (ie, prior to flap
dissection) because the location of the vessels in relation to the defect
determines flap design (see below).
■ If there is pedicle bleeding or other problems during flap harvest, the flap
can be immediately harvested, inset, and revascularized without additional
increases in ischemia time.
TECH FIG 1 • Defect after laryngopharyngectomy.
Note wide skin excision and resection of the pharynx.
■ Jejunal Flap Harvest
■ A midline abdominal incision is made, from the xiphoid to above the
umbilicus. The deep fascia and peritoneum are opened up to get access to the
celiac cavity.
■ The greater omentum and transverse colon are retracted cephalad.
■ The small bowel is run back till the ligament of Treitz is identified. From
here, the small bowel is run for approximately 30 to 40 cm distally.
■ In this location, a suitable segment of jejunum is chosen for the flap. This

is because the vascular arcades are longest in this area, thus allowing longer
pedicle length. Bowel reanastomosis is also easy here. Moreover, in the
unfortunate event of flap pedicle thrombosis, another segment of bowel can
be harvested more distally.
■ The bowel is transilluminated to identify a suitable vascular arcade to base
the flap on (TECH FIG 2A).
■ Dimming the operating room lights and then shining the overhead lights or
the headlight along an angle is used to illuminate the flap pedicle against a
dark background.
■ In choosing an optimal segment of bowel, important considerations are the
length of bowel needed and the position of the recipient vessels in the neck in
relation to the proximal jejunal anastomosis with the pharynx (TECH FIG
2B,C).
■ The distance along a diagonal line from the proximal cervical defect to the
position of the recipient vessels in the neck is measured and is used to
design the flap with a vascular pattern that will minimize kinking,
stretching, or compression of the anastomosis.
■ The bowel and the accompanying fan-shaped piece of mesentery to be
harvested are marked with a marker or methylene blue.
■ The proximal bowel end is marked with a stitch to maintain orientation.
■ The mesentery is ligated as a fan shape with the apex toward the pedicle.
■ Dissection is begun by opening the mesentery adjacent to the bowel ends.
■ A Penrose drain is placed through this opening on each side around the
bowel for retraction.
■ The mesentery is then ligated sequentially between two hemostats, tying off
the small mesenteric vessels with 4-0 silk ties (alternatively, a LigaSure may
be used to rapidly dissect and isolate the flap).
■ Small mesenteric bites should be taken, as large bites result in bunching of
the mesentery and thus effective shortening of the pedicle.
■ Pedicle dissection is left to the end; this is done so that if there is
troublesome pedicle bleeding, the vessels can be ligated and the flap can be
transferred to the neck expeditiously.
■ The proximal and distal ends of the jejunal flap are divided with an intestinal
stapling device. We use a GIA 90 or 100 Ethicon Proximate Linear Cutter.
■ The pedicle dissection is completed by incising the peritoneum over the
vessels and carefully dissecting the vessels for a distance of approximately 1

to 2 cm.
■ The vessels are then separated over a distance of approximately 1 cm to
facilitate microsurgical anastomosis.
■ Great care is taken during handling of the pedicle vein as it is very delicate
and an injury can result in a mesenteric hematoma.
■ The pedicle is then ligated with silk ties and the flap is transferred to the
neck.
TECH FIG 2 • A. Transillumination of the jejunum flap
is used to evaluate the vascular anatomy. Note length
and position of the flap artery (arrow). B. The length of
the bowel segment and the relationship of the pedicle
length are determined. The length of the bowel
segment is shown between the arrowheads. The
position of the pedicle (and its length) is measured
from the cervical margin of resection to the area
where the vessels are located (bracketed area). C.
Flap length and pedicle position are marked in the
abdomen, and the pedicle vessels that most closely

match the location of the vessels are selected. For
example, if the recipient vessels are located roughly
midway along the length of the jejunum, the same
position (ie, middle marking) is selected for flap
design.
■ Flap Inset
■ The flap is inset in an isoperistaltic manner.
■ The proximal bowel anastomosis is performed to the pharynx or proximal
esophageal remnant.
■ There is usually a size mismatch between the larger pharyngeal segment and
smaller jejunal lumen.
■ The jejunum can be widened by opening it at the proximal end
longitudinally along the antimesenteric border as needed (TECH FIG
3A,B).
■ Another method is to fold the end of the jejunum and suture to itself, thus
doubling the size of the lumen.
■ Alternatively, the proximal end of the flap can be stapled closed, and the
anastomosis to the pharynx can be performed in an end-to-side manner.
■ Anastomosis is performed with interrupted 2-0 Vicryl sutures in an airtight
manner.
■ The anterior anastomosis is then reinforced with interrupted 4.0 PDS sutures
from the pharyngeal muscles to the serosa of the jejunum.
■ We usually perform the microvascular anastomosis after completion of the
proximal bowel anastomosis to the pharynx. This is done under the
microscope or loupe magnification.
■ Upon completion of revascularization, flap perfusion is assessed by color
and bowel peristalsis, and the distal anastomosis is completed.
■ This operative sequence decreases the ischemic time and, more
importantly, enables the surgeon to judge the precise length of jejunum
necessary to span the defect as the bowel elongates following restoration of
perfusion.
■ The distal pharyngeal anastomosis is performed by placing the patient’s neck
in neutral or slightly flexed position to avoid redundancy.

■ Full-thickness bites of the jejunum are sewn to the distal pharynx using
interrupted 2-0 Vicryl sutures.
■ A second layer can be done by oversewing the serosa on both sides with
4.0 PDS, thus reinforcing the repair and more precisely adjusting the
tension on the jejunal segment.
■ There is evidence to suggest that use of stapling devices is associated with
a higher incidence of stricture formation.7
■ In patients who are high risk for leak (eg, radiation and very proximal
resection), a salivary bypass tube (we use Hood Salivary tubes) can be passed
intraorally to span the proximal and distal anastomosis.
■ These tubes come in a variety of sizes and are usually sutured to the distal
tongue (although the flange at the proximal portion usually maintains the
tube in normal position).
■ This is tolerated only in patients who have undergone laryngectomy
because the irritation from the tube in a patient with an intact larynx would
be troublesome.
■ A nasoenteric feeding tube is placed under direct vision to prevent disruption
of the anastomosis. The feeding tube is guided through the flap and into the
stomach.
■ If the abdomen is still open, the placement of the tube in the stomach can
be verified by palpation.
■ Flap monitoring is performed with an implantable Doppler device. A
segment of bowel can also be exteriorized and used for direct flap
monitoring. However, we have not found this technique useful. It has been
argued that these flaps tolerate ischemia so poorly that salvage is unlikely in
the event of flap vessel thrombosis.
■ Drains are placed in the neck. They should not be close to blood vessels.
■ Closure is performed, taking great care to prevent tight closure that could
potentially compress the pedicle (TECH FIG 3D,E).

TECH FIG 3 • Jejunal flap inset. A. The proximal width
of the jejunum can be increased by cutting the flap
along the antimesenteric border for 2 to 3 cm. This
widens the proximal lumen and can be used to match
the size mismatch between the luminal diameter of the
jejunum and the proximal pharynx. B. An alternative
method to increase the width of the jejunum is to
double the flap upon itself and anastomose the

jejunum in an end-to-side fashion. C. Jejunum flap
inset into the defect with anastomosis to the right neck
vessels. D. Pectoralis major myocutaneous flap is
used to cover the flap and neck. E. Split-thickness
skin graft is used for the skin defect in the upper neck.
■ Donor-Site Closure
■ If two teams are available, the second team can perform this part of the
procedure, while the other team is performing flap inset. This cuts down on
patient time under anesthesia, in an already lengthy operation.
■ Otherwise, a moist lap is placed in the abdomen and this part is done in the
end.
■ The small bowel is reanastomosed. This can be performed in a handsewn
manner with sutures or with an intestinal stapling device.
■ The mesentery is reapproximated with a running suture to prevent internal
bowel herniation.
■ The fascia and skin are closed.
PEARLS AND PITFALLS
Planning
■ This operation requires meticulous planning and expeditious
execution, as the ischemia time is only 2–2.5 hours.
■ A backup plan for a free or pedicled flap should be in place.
Recipient site
preparation
■ It is critical to communicate with the ablative surgeon to preserve
recipient vessels in the neck.
■ The recipient vessels should be prepared prior to flap harvest.
Flap inset
■ The flap should be inset in isoperistaltic orientation, and flap
redundancy should be minimized. Otherwise, the patient will have
long-term dysphagia.
■ The proximal pharyngoesophageal anastomosis should be
performed meticulously to avoid fistulas.
■ The distal esophageal anastomosis is performed with interrupted
sutures with the neck in a neutral or slightly flexed position to
avoid redundancy.