Operative Technique in Plastic Surgery – Kevin C.Chung

■ Leaks that cause neck infection (redness, drainage from the incision, etc.)
require wide incision and drainage of the wound and may require additional
intervention. However, in most cases, small leaks seal spontaneously with
local wound care.
FIG 2 • Postoperative esophagogram after free jejunum
reconstruction (denoted by bracketed section). Note the
flow of contrast proximally and distally without evidence
of leak.
OUTCOMES
■ Swallowing is the primary end point to judge the success of
pharyngoesophageal reconstruction. Most patients have some degree of
dysphagia after reconstruction, but this improves over time with decreased
mucus production.
■ The most important determinant of dysphagia, however, may be the amount
of tongue that is resected or defunctionalized.

■ A recent review of our patients over the past 20 years showed that 86.5% of
patients were discharged from the hospital on an oral diet.8
■ Speech rehabilitation after a total laryngectomy is usually obtained with a
tracheoesophageal puncture (TEP). This consists of the creation of a fistula
between the neopharynx and tracheostoma and placement of a one-way valve.
To speak, the patient occludes the tracheostoma and forces air through the
valve from the trachea to the neopharynx. Vibration of the tubular pharyngeal
walls produces sound, which is then articulated in the mouth to produce
speech.
■ Another method of speech rehabilitation is with the creation of a voice tube at
the time of pharyngoesophageal reconstruction. The description of this
technique is beyond the scope of this chapter, but essentially, it consists of
creating two loops of the jejunum, one for reconstruction of the
pharyngoesophagus and the other for creation of a tube that passes air from the
trachea to the pharyngoesophagus.
COMPLICATIONS
■ The overall flap success rate is 91% to 100%.9,10
■ Pedicle thrombosis occurs most commonly in the first few days
postoperatively.
■ However, late thrombosis also occurs in patients who have a leak or
infection. Unfortunately, flap salvage in these circumstances is rarely possible
because this flap has poor ischemic tolerance. Most patients require a second
flap.
■ Fistulas occur more commonly at the proximal pharyngoesophageal
anastomosis. The reported fistula rate is 5% to 18%.7,9–12 They are more
common in patients who have previously been treated with radiation therapy.
■ Most fistulas close spontaneously with local wound care.
■ The rest require surgical closure and sometimes secondary flaps to bring in
well-vascularized tissue for coverage.
■ Strictures occur more commonly at the distal esophageal anastomosis. The
reported stricture rate is 7.5% to 14%.7,9,11
■ Strictures occur because of fibrosis of the distal anastomosis, flap redundancy
resulting in kinking, or circumferential scarring in the distal pharynx. They
are diagnosed with endoscopy or radiography.
■ Endoscopic dilation is the first-line treatment. Refractory cases are managed

surgically, with reanastomosis or excision of redundant segment.
■ Abdominal donor-site complications include ileus, bowel obstruction,
cellulitis, and wound dehiscence.
■ A recent review of our patients over the past 20 years revealed an overall
abdominal complication rate of 4.5%.8
REFERENCES
1. Ascioti AJ, Hofstetter WL, Miller MJ, et al. Long-segment, supercharged,
pedicled jejunal flap for total esophageal reconstruction. J Thorac Cardiovasc
Surg. 2005;130(5):1391-1398.
2. Wadsworth JT, Futran N, Eubanks TR. Laparoscopic harvest of the jejunal
free flap for reconstruction of hypopharyngeal and cervical esophageal defects.
Arch Otolaryngol Head Neck Surg. 2002;128(12):1384-1387.
3. Lillehei RC, Goott B, Miller FA. The physiological response of the small
bowel of the dog to ischemia including prolonged in vitro preservation of the
bowel with successful replacement and survival. Ann Surg. 1959;150:543-560.
4. McGill CW, Taylor BH, Flynn MB, et al. Effects of cooling and intraluminally
administered antiseptics on surgically induced ischemia of the intestine in
dogs. Surg Gynecol Obstet. 1979;149(3):377-379.
5. Shumrick DA, Savoury LW. Recent advances in laryngo, pharyngo,
esophageal reconstruction. Acta Otolaryngol Suppl. 1988;458:190-193.
6. Reuther JF, Steinau HU, Wagner R. Reconstruction of large defects in the
oropharynx with a revascularized intestinal graft: an experimental and clinical
report. Plast Reconstr Surg. 1984;73(3):345-358.
7. Schusterman MA, Shestak K, de Vries EJ, et al. Reconstruction of the cervical
esophagus: free jejunal transfer vs gastric pull-up. Plast Reconstr Surg.
1990;85(1):16-21.
8. Razdan SN, Albornoz CR, Matros E, et al. Free jejunal flap for
pharyngoesophageal reconstruction in head and neck cancer patients: an
evaluation of donor-site complications. J Reconstr Microsurg. 2015;31(9):643-
646.
9. Moradi P, Glass GE, Atherton DD, et al. Reconstruction of
pharyngolaryngectomy defects using the jejunal free flap: a 10-year experience
from a single reconstructive center. Plast Reconstr Surg. 2010;126(6):1960-
1966.
10. Shangold LM, Urken ML, Lawson W. Jejunal transplantation for
pharyngoesophageal reconstruction. Otolaryngol Clin North Am.

1991;24(6):1321-1342.
11. Theile DR, Robinson DW, Theile DE, et al. Free jejunal interposition
reconstruction after pharyngolaryngectomy: 201 consecutive cases. Head
Neck. 1995;17(2):83-88.
12. Walker RJ, Parmar S, Praveen P, et al. Jejunal free flap for reconstruction of
pharyngeal defects in patients with head and neck cancer—the Birmingham
experience. Br J Oral Maxillofac Surg. 2014;52(2):106-110.

46
CHAPTER
Anterolateral Thigh Flap for
Pharyngoesophageal
Reconstruction
Edward I. Chang and Matthew M. Hanasono
DEFINITION
■ Pharyngeal defects can commonly result after resection of laryngeal
malignancy or, less commonly, a pharyngeal or esophageal primary tumor.1,2
■ Pharyngeal defects, either partial or circumferential, can be reconstructed with
anterolateral thigh (ALT) free flaps to restore swallowing and potential for
voice rehabilitation (FIG 1).1–5
■ Given the high incidence of preoperative radiation in this patient population,
reconstruction of the pharyngeal defect using a free flap should also facilitate
simultaneous neck wound reconstruction if necessary.
■ Complications following pharyngeal reconstruction must be considered and
include flap loss, infection, fistula, stricture, and neck wound dehiscence.
ANATOMY
■ The arterial supply to the ALT flap is derived from branches of the lateral
descending circumflex femoral artery arising from the profunda femoris artery.
■ The lateral descending circumflex vessels are located between the rectus
femoris and vastus lateralis muscles and have a variable intramuscular course.
■ Venous drainage of the flap occurs via paired venae comitantes that
terminate in the profunda femoris vein.6–8
■ The ALT flap can be harvested as a perforator-based fasciocutaneous flap, a
myocutaneous flap including some or all of the vastus lateralis muscle, or as a
chimeric flap by including portions of the vastus lateralis muscle supplied by a
separate branch of the main pedicle.
■ One or more perforators are usually found along an imaginary line connecting

the anterior superior iliac spine (ASIS) to the lateral patella.
■ The perforators are typically located at the midpoint of this line and 5 cm
proximally and distally, the so-called A, B, and C perforators named in a
proximal to distal orientation.9
■ The perforators typically arise from the main pedicle and can pass through the
vastus lateralis muscle (musculocutaneous) or pass through the septum
between the vastus lateralis and rectus femoris (septocutaneous).
■ Occasionally, the perforators may originate from either the transverse branch
or an oblique branch of the lateral circumflex artery.
■ If multiple perforators are present, the flap can be divided into separate skin
paddles to reconstruct the primary pharyngeal defect and to resurface the neck.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The quality of the neck skin and soft tissues should be carefully examined to
determine the need for external coverage following tumor resection and
reconstruction.
■ This is particularly important in patients with a prior history of surgery and/or
radiation.
■ Neck dissection and severe radiation fibrosis may limit the availability of
recipient blood vessels.
■ In addition, many patients with head and neck cancer and those with a history
of prior neck radiation have carotid vascular disease further challenging
reconstruction in this setting. In these cases, preoperative imaging may be
useful in select cases, and reconstructive surgeons should be prepared to use
alternate recipient vessels with or without vein grafting. Patients should be
counseled of this possibility as well as the potential for additional surgical
incisions for recipient vessel exposure.
■ The donor site should be examined also for prior surgical scars as well as the
thickness of the soft tissue.
■ Patients with excessive adipose tissue thickness in the thighs may not be
good candidates for an ALT flap. In obese patients with thick thigh tissue,
reconstruction of a circumferential defect is best performed with a jejunum
flap or a thinner flap that can be tubed more easily.
■ Harvesting the flap and sacrificing the lateral descending circumflex femoral
artery have not been found to exacerbate peripheral vascular disease or
precipitate limb ischemia; however, signs of vascular insufficiency should alert

the surgeon to potentially calcified vessels that may make the microvascular
anastomosis more challenging.
FIG 1 • Circumferential defect after
laryngopharyngectomy, extending from the base of
tongue to the cervical esophagus.
IMAGING
■ Head and neck computed tomography (CT) with intravascular contrast is
critical for evaluating the extent of the disease and planning the resection.
■ The preoperative imaging can often decipher whether partial pharyngectomy
will be performed or whether a segment involving the entire circumference of
the pharynx will be resected.
■ CT angiography can also guide recipient vessel selection. In the previously
operated and/or irradiated neck, identification of alternate recipient vessels
such as the transverse cervical vessels may be necessary.3,10

■ In certain circumstances, even more distant recipient vessels, such as the
internal mammary vessels, are needed.
■ No specific imaging studies are needed for the donor site. Although a CT
angiogram can be performed in anticipation that a second skin paddle is
needed, we do not routinely obtain them.
SURGICAL MANAGEMENT
Preoperative Planning
■ Optimizing the patient to undergo a lengthy operation is critical and includes
adequate nutrition via tube feeding, if necessary because many patients may
have had difficulty swallowing and subsequent weight loss.
■ Smoking cessation should be encouraged although, realistically, this is
challenging to achieve in a short period of time.
■ Preoperative consultation and medical clearance are also important in at-risk
patients.
■ Many patients with head and neck malignancies have a history of smoking
and alcohol use and are therefore at risk for cardiovascular or hepatic
complications.
■ Preoperative imaging and optimization of cardiac function are important to
prevent postoperative medical complications.
Positioning
■ The patient is prepped in the supine position with the neck extended to
facilitate neck dissection and recipient vessel exposure.
■ The bed is typically turned 180 degrees with the foot of the bed facing the
anesthetist, allowing the surgical teams complete access to the head and neck
region.
■ Both thighs should be prepped into the field to access harvesting the flap from
either thigh.
■ This is because in a small percentage of cases, there is a paucity of skin
perforators in one thigh, in which case the other thigh can be used instead.
■ The entire head and neck as well as the chest to the level of the xiphoid should
also be prepped into the field, in case a pectoralis major myocutaneous flap is
needed for neck wound coverage.
Approach

■ The approach to reconstructing a pharyngeal defect should also take into
account alternate flaps to reconstruct the defect.
■ In general, free tissue transfer results in the most optimal outcomes, and other
flaps such as the radial or ulnar forearm flap are also useful for partial
pharyngectomy defects when the thigh flap is not available or in obese
patients with thick thigh tissues.
■ The lateral arm flap as well as other thigh-based flaps such as the profunda
artery perforator (PAP) flap may also be good options.
■ Our preference is to reconstruct circumferential defects with a thigh-based
flap whenever possible; however, a free jejunal flap can also be considered.11
■ In patients who are not candidates for a free tissue transfer (ie, major
comorbidities that preclude a long operation or lack of recipient vessels),
pedicled flaps such as the pectoralis major myocutaneous flap, supraclavicular
flap, or an internal mammary artery perforator flap can be considered.1
T E C H N I Q U E S
ALT Flap Harvest
Video p3-c046
■ The ASIS and lateral patella are marked, and a line is drawn connecting
these two points.
■ The line is divided in half and a point 5 cm proximal and distal are marked,
which identifies the approximate location of the A, B, and C perforators
00:00 / 00:00

(TECH FIG 1A).9
■ The exact dimensions of the skin flap depend on the size of the defect (see
Reconstruction of Partial vs Circumferential Defects, later).
■ The medial incision is made first and the dissection proceeds through the
skin, subcutaneous tissues, and fascia.
■ A subfascial dissection is performed from medial to lateral to identify the
cutaneous perforators.
■ The flap outline can be adjusted after the perforator location has been
confirmed so that the perforator is near the center or slightly superior to the
center of the flap, if maximal pedicle length is critical.
■ The cutaneous perforators can take an intramuscular path through the vastus
lateralis muscle, or they may traverse through the septum between the vastus
lateralis and rectus femoris muscles.
■ Selection of the perforator depends on the length of pedicle that is needed
(the more distal perforators will provide a longer pedicle) as well as the size
of the perforators.
■ The larger the perforator (0.5-mm artery and 1-mm vein are commonly
seen), the easier and safer the dissection.

TECH FIG 1 • A. To anticipate the location of the
cutaneous perforating blood vessels, a line is drawn
between the ASIS and the upper lateral corner of the
patella, as shown in this right thigh image. Most
commonly, perforators are located at the midpoint of
this line (labeled B) and 5 cm above and below the
midpoint (labeled A and C, respectively). B. Markings
for a two–skin paddle anterolateral thigh (ALT) free

flap. One skin paddle will be used to create a
pharyngeal conduit, and one skin paddle will be used
to close the cutaneous defect that occurs in many
patients due to contracture of a radiated neck skin. C.
Completed dissection of the two–skin paddle ALT free
flap. The skin paddle that will be used to reconstruct
the pharyngeal conduit is 9.5-cm wide so that the
diameter of the lumen will be 3 cm once the flap is
tubed. D. Completed dissection of the two–skin paddle
ALT free flap showing the dual perforator anatomy of
the flap. The main lateral descending circumflex
femoral pedicle can be visualized clearly with the
dissection completed to maximize the length of the
pedicle.
■ Typically, one or two perforators are selected for dissection.
■ If separate skin paddles are necessary, these skin paddles can be based on
their own perforator (TECH FIG 1B,C).
■ If separate perforators are not available for each skin paddle, the skin
between these areas can simply be de-epithelialized; however, this does
increase the bulk of the tissues in the region where the flap is folded on
itself.
■ The perforators are dissected and exposed until the main pedicle vessels
(descending branches of the lateral circumflex femoral blood vessels) are
visualized between the vastus lateralis and rectus femoris muscles.
■ The main pedicle is then dissected proximally toward the takeoff of the
vessels from the profunda femoris muscle.
■ Occasionally, the perforators may arise from the transverse branch or oblique
branches of the lateral femoral circumflex vessels.3,6,7,10 This is typically not
problematic (though it may limit the length of the pedicle), and the main
pedicle vessels are dissected to their source to maximize vessel caliber and
pedicle length.
■ Once the medial (anterior) dissection is completed, the lateral (posterior)
incision can be made based on the size of the flap that is needed, and
dissection again proceeds down to the fascia.

■ The fascia is incised, and the subfascial dissection is performed until the
perforators are visualized.
■ The perforators are then freed from the posterior approach, and the entire
flap should now be perfused on the main pedicle (TECH FIG 1D).
■ Once the resection has been completed, and adequate recipient vessels
identified, the flap is harvested.
■ Ideally, branches of the external carotid artery are preferred along with
branches of the internal jugular vein. However, the external jugular vein
can also serve as a recipient vein if needed.
■ If no suitable branches of the external carotid are available, the transverse
cervical vessels can serve as possible recipients. Vein grafting to more
distant vessels such as the internal mammary vessels is also a potential
option.3
■ The flap is partially inset into the defect using absorbable sutures in a simple
interrupted manner by paying careful attention to evert the skin and mucosa.
■ Insetting the flap in this manner sets the length and position of the pedicle
and simplifies microsurgical anastomosis.
■ In some cases, it is simpler to perform the anastomosis prior to inset;
however, this approach risks twisting or stretching the pedicle and should
be done carefully.
■ Once the flap inset is completed, the microvascular anastomosis is
performed. The perfusion to the flap is assessed, and the flap is monitored
either via the second skin paddle (if one is used for neck reconstruction) or an
implantable Doppler ultrasound.
■ The neck should be irrigated copiously, and the mouth should be flushed to
assess for any leak in the flap inset that can result in a fistula.
■ The pedicle should be inspected prior to closure of the neck to make
certain there are no twists or kinks in the pedicle.
■ Closed suction drains are placed prior to closure taking care to avoid direct
suction or pressure on the pedicle.
Reconstruction of Partial vs Circumferential Defects
■ Circumferential defects require a 9-cm-wide flap in order to tube the flap to
create a 3-cm-diameter tube, according to the formula: circumference = π ×
diameter.
■ An additional 2- to 3-cm cuff of the thigh fascia can be harvested with the
flap that will allow for a second layer closure of the defect. This second layer

may help to contain any small leaks and prevent the formation of a fistula.
■ We recommend completing the proximal (base of tongue) and distal
(cervical esophagus) suture closure first, then the vertical suture closure last.
■ This gives the best visualization of the proximal and distal closures, which
are the most technically challenging and where leaks most commonly
occur.
■ The flap is inset such that the vertical suture line comes to lie 180 degrees
away from the side of the microvascular anastomosis (TECH FIG 2A).
■ The distal portion of the flap that will be inset into the cervical esophagus is
designed with a dart that is then inset into a longitudinal cut made in the
cervical esophagus.
■ This dart inset will break up the circumferential scar distally, thereby
widening the distal anastomosis and will minimize or prevent cicatricial
stricture (TECH FIG 2B).
■ For partial defects, in which the posterior wall of the pharynx is preserved,
the width of the remaining pharynx is measured and subtracted from 9 cm.
This is the width of the ALT flap needed to create a 3-cm lumen for the
pharyngeal reconstruction.
■ One of the vertical suture closures is performed first, along the remaining
posterior pharyngeal wall, and then the proximal and distal suture closures
are performed.
■ The other vertical suture line is performed last.
Neck Skin Reconstruction
■ In some cases, a second skin paddle can be used to reconstruct the neck skin
in patients with poor skin viability or skin fibrosis from radiation therapy.
This is performed most easily with a flap that has two cutaneous perforators
by creating a second skin paddle to reconstruct the neck defect.
■ Either the proximal or distal perforator can be used for the neck
reconstruction.
■ Poorly vascularized neck skin is debrided, and the skin paddle is interposed
between the superior neck skin flap and the tracheal stoma, inferior neck,
and chest skin (TECH FIG 3).

TECH FIG 2 • A. Partial inset of the ALT free flap
pharyngeal conduit. The cervical esophagus and base
of tongue suture lines are closed first, and the flap is
then closed to itself to form a tube on the side that is
contralateral to the microvascular anastomoses. B.
Close-up of the inset of the ALT free flap to the
spatulated cervical esophagus. The arrow points to a
dart created in the flap to help minimize cicatricial
stricture.
TECH FIG 3 • A. Nearly completed inset of the tubed

ALT free flap pharyngeal conduit showing the still
open lateral suture line (forceps placed into the lumen)
and the second skin paddle that will be used to close
the neck defect. B. Completed neck closure. The
second skin paddle of the ALT free flap allows for
resection and replacement of poorly vascularized,
fibrotic, and contracted neck skin, which minimizes the
risk for wound dehiscence. C. Postoperative
appearance, approximately 1 year after surgery.
■ When there is only one cutaneous perforator, a portion of the vastus lateralis
muscle can be harvested with the skin paddle (TECH FIG 4A).
■ This muscle is skin grafted, and in our experience, dehiscence is rare, even
along the tracheal stomal suture line.
■ Alternatively, in partial-thickness defects, the skin flap can be folded upon
itself with a de-epithelialized area in between to facilitate neck skin
closure.
■ A pectoralis muscle or myocutaneous pedicled flap can also be used to
reconstruct the neck skin (TECH FIG 4B).
■ The muscle can also be placed over the ALT flap suture lines, to help
decrease the chance for leakage.
Donor-Site Closure
■ The donor site should be inspected for hemostasis and the incision closed in
layers over closed suction drains.
■ Most donor sites 9 cm or less in width can be closed primarily depending on
the degree of laxity in the patient’s soft tissue.
■ If the donor site cannot be closed primarily, a skin graft can be placed over
the exposed vastus lateralis and rectus femoris muscles.
■ A VAC dressing is often the simplest way to bolster the skin graft and
precludes the need for closed suction drains.

TECH FIG 4 • A. In cases in which there is only one
cutaneous perforator available and the neck skin
requires reconstruction as well, a portion of the vastus
lateralis muscle can be harvested with the flap and
skin grafted. B. A second option is use of a pectoralis
major myocutaneous pedicled flap. In this case, the
flap has been “islanded” to minimize bulk proximally.
The muscle portion of the flap provides a loose
second layer of closure over the pharyngeal
reconstruction. C. Completed neck closure.
PEARLS AND PITFALLS
Flap design
■ Wait for clear margins by frozen section pathology before
committing to the width of the flap.
■ If two cutaneous perforators are available, one can be used to
create a second skin paddle for neck skin reconstruction, if needed.
■ In the setting of a single perforator, a portion of the vastus lateralis
muscle covered with a skin graft can be used for neck resurfacing.
Microvascular
anastomosis
■ Meticulous technique and careful handling of the vessels are
critical particularly in the previously radiated neck.
■ Make certain there are no kinks or twists in the vessels.
Flap inset
■ The inset should be a watertight closure.
■ Irrigate in the mouth prior to and after completing the flap inset to

assess for any leak.
■ Consider using the fascia for a second layered closure of the flap
inset.
Flap
monitoring
■ Clinical examination of an external skin paddle or portion of the
vastus lateralis muscle is ideally used for monitoring.
■ In a completely buried flap, an implantable Doppler ultrasound
can be used for monitoring.
Postoperative
care
■ Patients should be maintained on prophylactic antibiotics for
several days following reconstruction. Oftentimes, removal of the
neck drains is a useful guide when antibiotics can be discontinued.
The length of antibiotic treatment is also dependent on the quality
of the neck skin, history of radiation therapy, and comorbid
conditions that increase the risk of infections (eg, obesity,
hypertension, diabetes mellitus).
■ A modified barium swallow (MBS) is performed to rule out leaks
and confirm flap conduit patency prior to resumption of an oral
diet. The MBS is performed approximately 2 weeks
postoperatively in nonradiated patients and 6 weeks
postoperatively in radiated patients.
POSTOPERATIVE CARE
■ Patients ideally should be off the ventilator and should not need to be
monitored in the intensive care unit unless that is the policy for flap
monitoring.
■ Flap monitoring includes physical examination of the flap by a trained
professional (nurse, physician assistant, or surgeon) to assess for color,
warmth, turgor, capillary refill, and a percutaneous Doppler signal.
■ If the flap is entirely buried, an implantable Doppler is often placed and can
be monitored according to protocol.
■ The flap should be monitored at a minimum on an hourly basis for the first 2
days and then changed to every 2 hours for the next 2 days and then every 4
hours until discharge.
■ The patient should be encouraged to keep the head midline and elevation to
minimize any risk of traction or kinking of the pedicle when the patient turns
his/her head.
■ Patients may start increasing movement of their neck 2 weeks following the
operation and potentially may need physical therapy for range-of-motion
exercises.

■ Elevation will help minimize postoperative swelling.
■ Most patients will also have a new, permanent tracheostomy, which should be
cleaned and suctioned frequently to prevent a mucous plug that can block the
airway.
■ Care should be taken to avoid external pressure on the neck to avoid venous
obstruction and thrombosis. This includes tracheostomy ties, large pillows that
may wrap around the neck, or other potential sources of pressure.
■ Patients are encouraged to mobilize on postoperative day 1 and to begin
ambulation on day 2.
■ A physical therapy consult may be necessary to facilitate mobilization.
■ Low molecular weight heparin should be started on postoperative day 1 for
venous thromboembolism (VTE) prophylaxis.
■ Patients should be maintained and continued on antibiotics for a minimum of 1
week, and drains should be monitored for any signs of bleeding, infection, or
fistula. Removal of the neck drains is often a useful guide for when antibiotics
can be discontinued.
■ The length of antibiotic treatment also depends on the quality of the neck
skin, history of radiation therapy, and comorbid conditions that increase the
risk of infections (eg, obesity, hypertension, diabetes mellitus).
OUTCOMES
■ Free flap success rates at high volume institutions are generally well over
95%, approaching 99% success rates.
■ Compared with jejunal flap reconstructions, ALT free flap reconstructions
have been found to result in superior voice quality when a tracheoesophageal
puncture (TEP) is performed with placement of a one-way valve voice
prosthesis.4,5,8,12
■ Stricture and fistula rates are not significantly greater with the ALT free flap.
■ The ALT free flap is also preferable because it avoids the need for a
laparotomy.
COMPLICATIONS
■ As with any surgery, there are risks of bleeding and infection following this
operation that may require operative exploration to correct the complication.
■ A leak or fistula may heal spontaneously if the fistula is small; however, larger
fistulae often require surgery and potentially a pedicle pectoralis major muscle
flap to close the fistula.

■ Donor-site complications are rare, but some numbness in the distribution of
lateral femoral cutaneous nerve is not uncommon.2
■ Almost all patients return to their preoperative level of ambulatory activity in 3
months or less.
REFERENCES
1. Chiu ES, Liu PH, Baratelli R, et al. Circumferential pharyngoesophageal
reconstruction with a supraclavicular artery island flap. Plast Reconstr Surg.
2010;125(1):161-166.
2. Hanasono MM, Skoracki RJ, Yu P. A prospective study of donor-site
morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap
harvest in 220 patients. Plast Reconstr Surg. 2010;125(1):209-214.
3. Hanasono MM, Barnea Y, Skoracki RJ. Microvascular surgery in the
previously operated and irradiated neck. Microsurgery. 2009;29:1-7.
4. Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolateral
thigh flap: a clinical and functional outcomes study. Plast Reconstr Surg.
2005;116(7):1845-1855.
5. Yu P, Hanasono MM, Skoracki RJ, et al. Pharyngoesophageal reconstruction
with the anterolateral thigh flap after total laryngopharyngectomy. Cancer.
2010;116(7):1718-1724.
6. Lakhiani C, Lee MR, Saint-Cyr M. Vascular anatomy of the anterolateral
thigh flap: a systematic review. Plast Reconstr Surg. 2012;130(6):1254-1268.
7. Lee YC, Chen WC, Chou TM, Shieh SJ. Anatomical variability of the
anterolateral thigh flap perforators: vascular anatomy and its clinical
implications. Plast Reconstr Surg. 2015;135(4):1097-1107.
8. Lewin JS, Barringer DA, May AH, et al. Functional outcomes after
circumferential pharyngoesophageal reconstruction. Laryngoscope.
2005;115(7):1266-1271.
9. Lin SJ, Rabie A, Yu P. Designing the anterolateral thigh flap without
preoperative Doppler or imaging. J Reconstr Microsurg. 2010;26(1):67-72.
10. Yu P. The transverse cervical vessels as recipient vessels for previously
treated head and neck cancer patients. Plast Reconstr Surg. 2005;115(5):1253-
1258.
11. Moradi P, Glass GE, Atherton DD, et al. Reconstruction of
pharyngolaryngectomy defects using the jejunal free flap: a 10-year experience
from a single reconstructive center. Plast Reconstr Surg. 2010;126(6):1960-
1966.

12. Selber JC, Xue A, Liu J, et al. Pharyngoesophageal reconstruction outcomes
following 349 cases. J Reconstr Microsurg. 2014;30(9):641-654.

47
CHAPTER
Pectoralis Major Flap for
Pharyngeal Reconstruction
Michael A. Howard and Babak J. Mehrara
DEFINITION
■ The pectoralis major muscle flap was first reported by Pickrell in 19471 and
popularized for head and neck reconstruction by Ariyanas a myocutaneous flap
in 1979.2,3
■ While free tissue transfer remains the standard for many head and neck
defects, this pedicled flap is useful for reconstruction of partial pharyngeal
defects due to the proximity of the donor site to the recipient area as well as the
fact that this flap is usually not in the radiation field in patients with recurrent
tumors.
■ The pectoralis flap is also useful in cases in which microsurgery is not
feasible or if coverage of the neck is required in complex reconstructions.
■ The flap has the advantages of a healthy robust muscle with reliable vascular
anatomy, simple harvest technique, and a wide arc of rotation.
■ Goals of pharyngeal reconstruction:
■ Achieve primary wound healing
■ Maintain oral continence and facilitate swallowing while avoiding redundant
pouches along food path
■ Prevent aspiration
■ Protect vital neck structures
ANATOMY
■ The pectoralis major is a fan-shaped muscle of the anterior chest which
functions to adduct and medially rotate the arm (FIG 1).

FIG 1 • Anatomy of the pectoralis major myocutaneous
flap.
■ The pectoralis muscle inserts into the medial one-third of the clavicle as well
as the sternum and cartilaginous portions of ribs 1 to 6.
■ The muscle originates as a tendinous insertion into greater tubercle of the
humerus. The muscle in this area runs deep to the deltoid muscle, and the cleft
that is formed between these two structures is referred to as the deltopectoral
groove.
■ The pectoralis muscle has a Mathes and Nahai type 5 blood supply, composed
of a dominant pedicle (the thoracoacromial artery and vein) as well as
secondary minor pedicles arising from parasternal perforators arising from the
internal mammary artery and vein.
■ The motor nerve supply of the pectoralis muscle is derived from the medial
and lateral pectoral nerves.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A number of factors should be considered during flap selection and design.
■ Defect location. The arc of rotation of the pectoralis flap can be estimated by

locating the pedicle of the flap and using a lap pad or suture that is held to the
tip of the designed flap. The location of the pedicle can be marked by drawing
a line from the acromioclavicular joint to the xiphoid. In most patients, a
vertically drawn pectoralis myocutaneous flap can easily the upper portion of
the hypopharynx.
■ Size of defect. The pectoralis flap is not easily tubularized due to the thickness
of the skin flap and muscle, as well as donor site complications arising from
harvesting very wide skin flaps, and as a result, is not in most cases useful for
circumferential defects.
■ Prior chest surgery is also an important consideration since this may have
resulted in scars that may decrease the utility of the flap or, less commonly,
have injured the blood supply.
■ The use of this flap in women for pharyngeal reconstruction is also
complicated by the presence of breast tissue, and a history of breast cancer
(and screening) should be elicited in these patients.
■ This is not a good option in patients with large breasts as the thickness of the
flap complicates wound closure and may result in an unsightly donor defect.
■ Smoking history does increase the risk of complications, and if possible,
smoking should be stopped as long as possible prior to surgery (however, this
may not always be feasible in patients with active tumors).
IMAGING
■ Imaging is rarely necessary for the planning or design of a pectoralis major
flap.
SURGICAL MANAGEMENT
Preoperative Planning
■ Patients who are referred for pharyngeal reconstruction have primary tumors
of the hypopharynx/pharynx or suffer from aggressive or recurrent tumors of
the surrounding structures (eg thyroid or larynx).
■ In many cases, the planned procedure involves laryngectomy and end
tracheostomy and repair of the pharyngeal defect.
■ Because the posterior wall of the larynx is closely adhered to the anterior wall
of the pharynx, a strip of the pharyngeal wall is commonly resected with the
laryngeal specimen.
■ These patients are good candidates for pectoralis myocutaneous flap

reconstruction.
■ Similarly, the pectoralis flap is a good option in patients with small tumors of
the pharynx in which a partial pharyngeal resection is performed.
■ Patients with more extensive defects of the pharynx that require tubularization
of a flap or reconstruction of nearly the entire circumference of the pharynx are
better served with a free flap (tubularized anterolateral thigh or jejunum).
■ Defects of the pharynx extending below the clavicle are most commonly
reconstructed with a gastric pull-up or colon interposition flap.
■ Once a suitable surgical candidate for a pectoralis flap is identified (usually
after preoperative consultation with the head and neck oncologist), the patient
is examined to assess the quality of the neck skin and subcutaneous tissues.
■ Many patients who present for reconstruction of pharyngeal defects have
previously undergone chemoradiation for laryngeal organ preservation and, as
a result, have radiation damage to the skin. In these cases, plans should be
discussed not just for reconstruction of the pharyngeal defect but also the
overlying skin.
Positioning
■ The patient is positioned supine, and the bed may be rotated 90 degrees to
allow easy access to the head and neck area.
■ Surgery is performed under general anesthesia often after end tracheostomy
has been placed.
T E C H N I Q U E S
■ Flap Design
■ The defect is assessed for viability of the mucosal edges (TECH FIG 1A).
■ The size of the defect is carefully measured, and the arch of rotation of the
flap is assessed as discussed above to ensure tension-free closure.
■ The flap pedicle is marked by drawing a line connecting the
acromioclavicular joint to the xiphoid.4
■ TECH FIG 1B shows the defect in the right pharyngeal wall (marked with
blue ink) and overlying skin after tumor resection.
■ The flap skin paddle can be designed vertically or horizontally on the chest.

■ Vertical skin paddles have excellent skin perfusion, close easily due to
alignment with the relaxed skin tension lines, and have a suitable arch or
rotation to repair defects of the anterior wall of the pharynx.
TECH FIG 1 • A. Markings for anticipated resection of
recurrent squamous cell cancer of the right pharynx
involving the skin. B. Defect in the lateral pharyngeal

wall (marked with blue ink) and overlying neck skin
after resection. Arrow indicates the carotid artery and
jugular vein. Design of (C) and markings for (D) a
vertical pectoralis major myocutaneous flap. Note
position of the flap medial to the nipple where the best
perforators are usually found. SN, sternal notch; X,
xiphoid.
■ The most reliable skin perforators are located medial to the nipple;
therefore, a vertical flap is usually drawn just medial to the areola (TECH
FIG 1C,D).
■ The flap width is based on the size of the defect, and a “pinch test” to
ensure that the donor site can be closed primarily.
■ In rare cases, when a wide flap is needed, the nipple may be included in
the flap design.
■ A horizontal skin paddle is also possible and, if placed more distally on the
flap, has greater arch of rotation. In addition, the horizontal skin paddle can
provide greater flap width and cover nearly circumferential defects of the
pharynx.
■ Care should be taken with flap design to capture skin perforators, and
design of the flap below the inframammary crease should be avoided.
■ In some cases, a crescent-shaped flap can be drawn to capture parasternal
perforators; however, this flap design is rarely useful in practice.
■ A handheld Doppler may be used to define skin perforators, but this can be
tricky since the perforators may be in the muscle rather than entering the
overlying skin.
■ In the example provided, the right pectoralis flap is marked in a vertical
manner with the skin paddle located just medial to the areola.
■ Flap Elevation
■ The skin paddle is incised, and the muscle is identified.
■ The skin medial to the flap is elevated to expose the sternal insertion of the
muscle, and the pectoralis muscle is incised while perforating branches
from the internal mammary vessels are ligated.

■ The dissection continues from distal to proximal elevating the muscle above
its chest wall insertion at the inframammary fold.
■ The dissection is continued proximally in the loose areolar plane, and the
pedicle is visualized by reflecting the muscle.
■ At this point, one must decide how much muscle he or she will include with
the flap.
■ Generally, most of the width of the pectoralis muscle is included in the flap
to enable coverage of the exposed vascular structures after closure of the
pharyngeal defect. In this case, the required width is marked on the muscle,
and the muscle is incised from distal to proximal to excise the humeral
insertion (this portion is not necessary in most cases and results simply in
creating extra bulk).
■ The medial and lateral pectoral nerves entering this portion of the muscle
are transected. This will allow the muscle to atrophy postop, thereby
improving aesthetic outcome.
■ If possible, it is best to preserve the clavicular head of the pectoralis muscle
since transection of this portion can cause additional morbidity and postop
pain due to changes in the mechanical forces exerted on the humeral head.
■ In these cases, the thoracoacromial vessels are dissected as they enter into
the flap just below the clavicular head of the muscle.
■ The muscle harvested in this area is narrowed to approximately 1 to 2 cm on
each side of the pedicle to avoid bulkiness and postoperative neck
contracture.
■ Flap Inset
■ A subcutaneous tunnel is created over the clavicle with sufficient width to
accommodate passage of the flap (TECH FIG 2A). Care should be taken to
avoid injuring the external jugular vein.
■ The edges of the defect can be marked with methylene blue to facilitate
creation of a template for the skin paddle.
■ This is marked on the skin with some room for error, and the excess skin
paddle is de-epithelialized since this step is easier to perform prior to
passing the flap into the subcutaneous tunnel.
■ The flap can be passed above the clavicular portion of the pectoralis muscle.
If addition pedicle length is required, the flap can be tunneled below the

clavicular head of the pectoralis muscle or the clavicular portion of the
muscle can simply be transected.
■ Some surgeons describe passing the flap below the clavicle bone by
resecting the medial portion of the bone to achieve greater length. This is
rarely necessary in practice, however, and may result in injury to the
brachial plexus, brachial artery, or brachial vein.
■ The flap is folded backward on itself (ie, the skin paddle is facing posteriorly
and toward the pharyngeal wall while the muscle is facing anteriorly).
■ Inset flap ensuring minimal tension and no constriction on the vascular
pedicle (TECH FIG 2B).
■ A feeding tube is passed into the stomach under direct vision.
■ The flap is sutured to the pharyngeal defect using interrupted 2.0 Vicryl
sutures (TECH FIG 2C). Care should be taken to achieve a watertight
closure. The knots may be placed on the inside and a second layer closure to
ensure a tight seal is performed with a running 4.0 PDS suture. All sutures
should be with tapered needles.
■ The muscle is draped over the defect and used to cover the carotid artery and
internal jugular vein on both sides.
■ The wound is copiously irrigated, and drains are placed lateral to the
sternocleidomastoid muscles (ie, not crossing the flap or its pedicle).

TECH FIG 2 • A. Pectoralis flap rotation and inset. B.
Flap has been de-epithelialized and is ready for inset
after having been passed under the neck skin. C.
Inset of the flap with interrupted 2.0 Vicryl sutures.
The pharynx with nasogastric tube is indicated by the
short arrow and the posterolateral inset by the long
arrow.
■ Closure
■ The neck skin is closed in layers to reapproximate the platysma with 2.0
Vicryl and the skin with 4.0 nylon sutures.
■ Neck skin closure can be facilitated by bringing the patients head out of
extension as it is usually done to facilitate tumor extirpation.
■ If the skin cannot be closed, a split-thickness skin graft can be applied to the

muscle and sutured into place.
■ A Xeroform gauze is used to protect the skin graft and stapled into place.
■ No bolster is necessary, and the skin graft should not be meshed if possible.
■ The chest is closed after the placement of a drain.
PEARLS AND PITFALLS
Indications
and
assessment
■ The pectoralis major myocutaneous flap is ideal for partial defects
of the pharynx following laryngectomy.
■ This flap is less useful for near circumferential or circumferential
defects.
■ The use of the flap may be limited in women due to intervening
breast tissues.
Technique
■ Vertical flaps have the best perfusion. The flap is drawn medial to
the areola and designed to capture as many perforators as possible.
■ Horizontal flaps are also possible but should not be designed
below the IMF.
■ Transection of the medial and lateral pectoral nerves results in
muscle atrophy and decreased bulk.
■ Preservation of the clavicular head of the pectoralis muscle is
feasible in most cases and decreases postoperative morbidity.
■ Partial de-epithelialization of the flap prior to tunneling in the neck
is helpful.
■ Avoid tension and achieve a watertight closure with absorbable
sutures on taper needles. A two-layer closure is helpful for
reducing leaks.
POSTOPERATIVE CARE
■ The chest drain is removed when the output is less than 30 cc/24 hours. In
patients with prolonged drain output, compression may be helpful but should
be done with care to avoid compression of the pedicle.
■ Ipsilateral arm activity:
■ Passive range of motion allowed 1 to 2 days after surgery
■ Progressive increase in active motion at 7 to 10 days
■ Unrestricted arm activity beginning 4 to 6 weeks after surgery

■ The patient is maintained nothing-by-mouth (NPO) for 7 to 10 days and is
maintained on feeding tubes for nutrition during this time period.
■ Oral hygiene is maintained with dilute saline or chlorhexidine mouth rinses
to reduce oral bacterial load.
■ Although there is a paucity of literature or data on antibiotic use, we routinely
keep patients treated in this manner on broad-spectrum antibiotic coverage
(Gram negative, Gram positive, anaerobic) for 7 to 10 days.
■ This is based on the fact that the procedure is contaminated and most patients
are nutritionally compromised, and have a history of radiation, smoking, or
alcohol use.
■ A hypaque swallow (or dilute barium) is performed to ensure that there is no
leak or aspiration. If clear, feeds are started with liquids and progressed to a
soft diet.
■ Swallow therapy is usually helpful for these patients.
■ Neck drains are removed when output is less than 30 cc/
24 hours.
■ Neck sutures are removed in 2 to 4 weeks (longer period for patients with a
history of radiation).
OUTCOMES
■ The pectoralis flap is highly reliable with a low reported total flap loss rate
(2%).5
■ However, a high overall complication rate ranging between 20% and 50% has
been reported and is related, in most cases to patient comorbidities.
■ Fortunately, most of these complications are minor and heal without major
intervention.
COMPLICATIONS
■ Salivary leak and fistula formation is relatively common occurring in 5% to
35% of cases.
■ These leaks are particularly common in patients with a history of radiation
therapy and smokers.
■ The most common area where leaks occur is the proximal anastomosis likely
due to traction on this area due to the weight of the flap. Suturing the soft
tissues of the flap to a solid area (ie, the inferior edge of the mandible
periosteum) may be helpful but not always possible.
■ Sixty to seventy percent of these fistulas heal spontaneously with wound care

over a 6- to 8-week period of time. During this time period, patients are
maintained NPO and evaluated frequently. The wound should be opened
widely to facilitate packing and wound care.
■ Fistulas that do not heal spontaneously may require operative intervention for
debridement and, rarely, a second flap.
■ Strictures are also possible and occur most frequently in patients with a history
of radiation. These are usually managed conservatively with dilatation.
■ The most dreaded complication of pharyngeal reconstruction is exposure and
infection of large vessels with blow out. Fortunately, this occurs rarely and
often present with a “herald” bleed.
■ The surgeon should not hesitate to evaluate a patient with angiography or in
the operating room in these cases. Blowouts can be avoided by meticulous
wound care and, if necessary, a second flap to cover the exposed vessels.
REFERENCES
1. Pickrell KL, Baker HM, Collins JP. Reconstructive surgery of the chest wall.
Surg Gynecol Obstet. 1947;84(4 suppl):465-476.
2. Ariyan S. Further experiences with the pectoralis major myocutaneous flap for
the immediate repair of defects from excisions of head and neck cancers. Plast
Reconstr Surg. 1979;64(5 suppl):605-612.
3. Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for
reconstruction in the head and neck. Plast Reconstr Surg. 1979;63 (1
suppl):73-81.
4. Hanasono MM, Matros E, Disa JJ. Important aspects of head and neck
reconstruction. Plast Reconstr Surg. 2014;134(6 suppl):968e-980e.
5. Bussu F, Gallus R, Navach V, et al. Contemporary role of pectoralis major
regional flaps in head and neck surgery. Acta Otorhinolaryngol Ital. 2014;34(5
suppl):327-341.

48
CHAPTER
Supraclavicular Island Flap
for Oropharyngeal
Reconstruction
Michael W. Chu and Ernest S. Chiu
DEFINITION
■ The oropharynx is the middle part of the pharynx from the level of the soft
palate to the epiglottis and is bordered superiorly by the nasopharynx and the
hypopharynx inferiorly.
■ The supraclavicular artery island flap (SCAIF) is a fasciocutaneous, axial
pattern, local rotational flap based on the supraclavicular artery.
ANATOMY
■ The oropharynx is a musculomucosal tube that connects the nasal cavity and
mouth to the upper aerodigestive tract and serves as a conduit for air and food.
■ The arterial supply of the SCAIF flap is derived from the supraclavicular
artery, a branch of the transverse cervical artery. The transverse cervical artery
originates from the thyrocervical trunk which arises from the first portion of
the subclavian artery.
■ Rarely, the supraclavicular artery arises from the suprascapular artery.1
■ The average length of the supraclavicular artery is 4 cm long (range 1–7 cm),2
and its diameter is 1 to 1.5 mm2 (FIG 1).
■ The supraclavicular artery can be reliably found in the supraclavicular triangle,
between the sternocleidomastoid, clavicle, and trapezius.
■ The venous supply of the SCAIF flap is derived from vena comitantes
accompanying the supraclavicular artery draining to the internal jugular vein.
In addition, the SCAIF drains laterally to branches of the external jugular vein.
These lateral branches are typically ligated during flap elevation.
■ Sensory innervation of the SCAIF flap is derived from the supraclavicular

nerve arising from cervical roots C3 to C4. These nerves emerge from the deep
fascia 1 to 2 cm anterior to the vascular pedicle, underneath the
sternocleidomastoid muscle near the midpoint of the muscle belly.
■ The nerve branches proximal to the pedicle with one branch exiting anterior
to the flap and the other coursing axially along the length of the flap. This
provides potential for the SCAIF to be a sensate flap (Sands, 2012).
■ The average dimension of the skin paddle for the SCAIF flap is a length of
24.2 cm and width of 8.7 cm.3
■ Contrary to initial reports,4 the SCAIF flap can be harvested beyond the
deltoid muscle.3
■ Flap delay or tissue expansion can increase the size of the flap to as large as
12 × 35 cm.5
■ The arc of rotation for the supraclavicular flap has been reported up to be up to
180 degrees.1 However, caution should be used when rotating flaps greater
than 90 degrees to avoid venous obstruction.6
■ The SCIAF flap has many advantages.
■ Thin, pliable, hairless flap with good color match for head and neck
reconstruction
■ Harvest and reconstruction are in the same surgical field.
■ Consistent vascular anatomy with a large arc of rotation

FIG 1 • Anatomy of the supraclavicular artery.
■ Reliable flap blood supply that is preserved in most cases, even after neck
dissection and previous radiation therapy7
■ Does not require microsurgical expertise and decreased operative duration
compared to microsurgical reconstruction8
■ Primary closure of donor site if width is less than 8 cm
■ Disadvantages
■ Risk of vascular pedicle compromise secondary to torsion or kinking
particularly with increased arc of rotation6
■ Shoulder scar is visible with certain clothing choices.
■ Obese patients with thick supraclavicular tissues may not be good
candidates.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The most common cause of oropharyngeal defects is head and neck cancer. As
a result, history of prior treatments (surgery, radiation) and risk factors for
wound healing complications (ie, history of tobacco use, ethanol abuse,
malnutrition) common in this patient population should be elicited.
■ If reconstruction is performed at the time of tumor extirpation, then
discussions with the ablative surgeon are important to delineate flap dissection
and preservation of the flap pedicle.
■ Physical exam should evaluate the pliability of the neck and shoulder skin,
extent of prior surgery (if any), carotid pulse, lymphadenopathy, and, if
possible, size and nature of the primary tumor.
IMAGING
■ Routine preoperative radiographic imaging is not necessary in patients with no
history of prior neck dissection.
■ In patients who have previously undergone neck dissection (ipsilateral to the
proposed flap site), angiography (CTA or MRA) can be done to confirm
patency and characterize anatomy, vessel length, patency, and diameter of the
supraclavicular artery.
■ Handheld Doppler can also be used to confirm location and patency of the
supraclavicular artery preoperatively and intraoperatively.
■ Indocyanine green laser angiography is occasionally useful to evaluate

perfusion of the SCAIF after the flap has been elevated.
SURGICAL MANAGEMENT
■ Reconstructive goals of oropharyngeal reconstruction are to promote rapid
healing, re-establish the aerodigestive tract, and prevent wound complications
and infection.
FIG 2 • Design of a supraclavicular arterial island flap
measuring 10 × 7 cm. The asterisk represents the
supraclavicular artery vascular pedicle found in the
triangle delineated by the clavicle, sternocleidomastoid,
and trapezius muscle.
■ The main steps of the procedure are as follows:
■ Measure defect dimensions.
■ Design skin paddle centered over the axial course of the vascular pedicle.
■ Raise fasciocutaneous flap from lateral to medial.
■ Mobilize flap into defect.
■ Inset the flap by tunneling or interpolating the flap, or transpose the flap by
islandizing the flap (propeller flap).

■ Close the donor site (primarily or with skin grafts).
Patient Positioning
■ The patient is positioned supine, and a shoulder roll is placed for neck
extension.
■ The head is supported by a small donut to prevent neck hyperextension.
Preoperative Planning
■ The position of the pedicle is estimated by marking the triangle formed by the
clavicle inferiorly, sternocleidomastoid muscle anteriorly, and the trapezius
muscle posteriorly (FIG 2).
■ The position and patency of the supraclavicular artery can be confirmed
using a handheld Doppler, and the axial direction of the pedicle can be traced
onto the flap.
■ Manual pinch test can confirm ability to primary close the donor site.
■ Arc of rotation is used to mark the distal aspect of the flap. Using a lap pad
held at the level of the pedicle and marking the length of the flap is useful in
this step.
T E C H N I Q U E S
■ Markings
■ The oropharyngeal defect is measured (TECH FIG 1A), and the
supraclavicular skin is marked based on the arc of rotation and defect needs.
■ Generally speaking, the flap should be at least 1 to 2 cm wider than the
defect to avoid closure of the defect in the pharynx under tension (TECH
FIG 1B).
■ Flaps designed distal to the anterior deltoid muscle may become ischemic
without a delay procedure. Distal flap necrosis will result in
pharyngocutaneous fistulas and wound healing complications.
■ A manual pinch test is used to confirm ability to close the donor site
primarily.
■ If primary closure of the defect is not feasible, a split-thickness skin graft
can be harvested and applied with a VAC sponge bolster.

TECH FIG 1 • A. A 74-year-old woman with history of
squamous cell carcinoma of right tonsil underwent
composite resection including tonsillectomy, lateral
pharyngeal wall, and soft palate (circle) through a lip-
split incision. B. The oropharyngeal defect has been
measured, and the flap has been marked out,
measuring 7 × 23 cm. Manual pinch test confirmed
laxity of the skin to allow primary closure.
■ Flap Harvest
■ The skin over the deltoid muscle is incised, and the incision is carried down
through the fascia of the anterior deltoid muscle.
■ Flap dissection then proceeds rapidly in a subfascial plane from distal to
proximal until the sternocleidomastoid muscle is exposed.
■ At this point, the dissection proceeds proximally more carefully with blunt
dissection and bipolar electrocautery to a point within 2 cm of the vascular
pedicle.
■ The vascular pedicle is not routinely skeletonized to avoid unnecessary
trauma.
■ A Doppler can be used to confirm vascular flow and the position of the
pedicle on the undersurface of the flap as the dissection proceeds proximally.
■ The SCAIF flap can be transferred as an island flap (ie, circumferential skin
incisions around the marked flap; TECH FIG 2A) or as a
transposed/interpolated flap maintaining the skin incisions around the
proximal portion of the flap (TECH FIG 2B).

■ The primary determinant of the type of flap is the arc of rotation that is
required to reach the defect.
■ Defects that can be easily reached by the transposed or interpolated flaps (ie,
arc of rotation is less than 90 degrees, and there is no tension on flap inset)
can be repaired with flaps that do not need incising the proximal skin
markings.
TECH FIG 2 • A. The supraclavicular flap has been
completely dissected and made into an island. The
proximal portion is de-epithelialized (arrowheads) and
ready to inset. B. The supraclavicular artery flap has
been dissected from lateral to medial, and the
neurovascular pedicle (*) has been skeletonized.
■ The skin in these areas can be de-epithelialized and buried.
■ This flap design maintains the best blood supply for the skin flap since the
flap is supplied by both its axial blood supply as well as random branches
through the proximal skin.
■ If the flap is tunneled, however, care should be taken to prevent kinking or
compression of the pedicle.
■ In addition, if the flap is rotated at least 180 degrees, dissection of the
vascular pedicle proximally should be considered to avoid compromise (see
TECH FIG 2B).
■ This type of flap is useful for defects that involve the middle or lower
portions of the pharynx in which the SCAIF is turned over, tubed, or
tunneled easily into the defect and the skin is inset into the defect in the
correct orientation (ie, into the lumen of the pharynx).
■ Defects of the oropharynx that are located above the tongue base or extend
to the soft palate, as shown in this case example, are usually treated with

island flaps because this approach has increased flap reach and increased flap
arc of rotation.
■ In these cases, the flap dissection can be continued bluntly proximally to
identify the flap pedicle, and the vessels can be dissected to avoid kinking
the pedicle.
■ The pedicle usually does not need to be skeletonized, however, and care
should be taken to avoid injury to the venous drainage of the flap, thus
avoiding venous congestion.
■ Flap Inset and Completion
■ Once the flap is made into an island (TECH FIG 3A), it is inset into the
pharyngeal defect by turning the patient’s head away from the flap donor site
(to set the maximum tension) and suturing the flap under no tension to the
defect with interrupted 2.0 Vicryl sutures.
■ Care must be taken to achieve a watertight closure.
■ The proximal portion of the flap is de-epithelialized and used to fill dead
space created by the resection (TECH FIG 3B).
■ In rare cases, the flap can be thinned if it is excessively bulky; however,
thinning within a 2-cm radius of the pedicle should be avoided (TECH FIG
3C).

TECH FIG 3 • A. The supraclavicular artery flap is
made into an island, and the harvest is complete. B. It
is rotated into the oropharynx. The proximal flap has
been de-epithelialized (arrowheads), and the distal
flap (*) is inset to cover the defect. C. The flap can be
thinned primarily, with care to avoid thinning the flap
within a 2-cm radius of the perforator.
■ The neck skin is closed in layers by reapproximating the platysma with 2-0
Vicryl sutures and the skin with 4-0 nylon sutures.
■ The donor site is closed by undermining the surrounding skin and closing in
a layered fashion.
■ If the donor site cannot be closed primarily, a split-thickness skin graft is
harvested, sutured into place with chromic sutures or staples, and bolstered
with a VAC dressing.
■ A single large Jackson-Pratt type drain is placed in the neck. Drains are not
usually necessary in the donor site but may be used at the surgeon’s

discretion.
■ Tracheostomy ties and pressure around the donor site and vascular pedicle
should be avoided.
■ The position of the pedicle is usually marked on the neck to avoid
postoperative pressure.
■ Dry dressings may be used if desired. Alternatively, bacitracin ointment can
be applied to the donor site and neck wound for 24 hours until the skin is
sealed.
PEARLS AND PITFALLS
Indications
and
assessment
■ The SCAIF flap is an excellent choice for reconstruction of
oropharyngeal defects.
■ The flap is simple to harvest, has reliable anatomy, and is versatile.
■ The donor site is relatively inconspicuous and well tolerated.
Flap design
■ A lap pad may be used to estimate the length of flap and arc of
rotation.
■ Making an island of the flap with dissection of the pedicle
increases the arc of rotation and flap reach without tension.
However, pedicle dissection should be performed carefully to
avoid venous congestion
■ Avoid marking flaps distal to the anterior deltoid (high risk for
distal tip necrosis). Flap delay may be helpful in these cases.
Technique
■ Handheld Doppler or flap transillumination can be performed to
localize the pedicle from the undersurface of the flap and avoid
injury.
■ Leaving a cuff of fascia and subcutaneous fat around the pedicle,
even in cases where the flap is made into an island, is useful for
avoiding injury to the vessels during flap dissection.
Postoperative
care
■ Avoid compression of the pedicle with trach ties.
POSTOPERATIVE CARE
■ The patient is maintained nil per os (NPO) for 5 to 7 days with standard mouth
care.

■ Antibiotics with Gram-positive, Gram-negative, and anaerobic coverage are
maintained for 24 to 48 hours in uncomplicated cases.
■ In patients with contaminated wounds (ie, fistulas), history of radiation
therapy, or factors that increase wound healing complications (eg, long
smoking history, diabetes, obesity), antibiotic coverage may be maintained for
a longer period of time at the surgeon’s discretion.
■ A swallow study is performed on POD 5 to 10, either a clinical bedside or a
formal study with contrast dye, to confirm that the wound is water tight.
■ In patients with a history of radiation, contaminated wounds, or history of
salivary fistulas, longer periods of time may be required for healing (often 10–
14 days prior to swallow).
■ Physical therapy and rehabilitation for upper extremity range of motion and
strengthening can begin 2 to 3 weeks postoperatively.
■ Long-term outcomes are excellent with rapid healing, return to function, and
acceptable donor site scarring in most patients (FIG 3).
OUTCOMES
■ The success rate of SCAIF is very high, and total flap loss is rare.
■ Functional deficits from the donor site are rare. But patients who have had
previous neck dissections and radiation therapy may have decreased range of
motion and strength that can be exacerbated by the SCAIF harvest. These
patients should be referred for physical therapy as early as possible.
COMPLICATIONS
■ Distal flap ischemia and necrosis may occur if the flap is marked beyond the
vascular territory of the supraclavicular artery (distal to the anterior deltoid).
■ This may be avoided in some cases with a preoperative delay of the flap
performed 2 to 3 weeks prior to the anticipated extirpative procedure.

FIG 3 • One-year postoperative follow-up shows a
healed, well-mucosalized supraclavicular flap in the
oropharynx (A) and a well-healed, primarily closed,
donor site scar (B).
■ Venous insufficiency can occur due to excessive rotation, tension on insetting,
compression from flap tunneling (especially in radiated skin), and
tracheostomy ties.
■ If the flap shows vascular compromise, inset stitches can be removed, leech
therapy, nitroglycerin paste, or supercharging the flap with an additional
venous anastomosis or derotating the flap and delaying definitive
reconstruction. However, these techniques are often not feasible in oral cavity
reconstruction.
■ Donor site wound dehiscence may occur in excessively wide flaps. Therefore,
if closure is too tight, then consider tissue expansion or skin grafting.
■ Hematoma can cause airway compromise, wound healing complications, and
flap loss.
■ Ensure adequate hemostasis at end of case and intervene as quickly as
possible to avoid flap compression and airway compromise.
■ Orocutaneous fistula formation is a relatively common complication of
oropharyngeal reconstruction occurring in 5% to 35% of patients.
■ The risk of this complication increases significantly with preoperative
radiation therapy. This risk can be mitigated with the use of meticulous
technique for flap inset. Using the de-epithelialized component of the flap to
bolster the repair and obliterate dead space is also useful.
■ Most orocutaneous fistulas heal spontaneously with good local wound care

and bypass of the oropharynx with a gastric tube for feeding.
■ Fistulas that do not heal or close spontaneously within 3 months of surgery
may require additional surgery.
■ Strictures are also a frequent complication following oropharyngeal
reconstruction particularly in patients treated with preoperative or
postoperative radiation.
■ Most of these cases can be treated with endoscopic dilatation; however, in
rare cases, additional surgical intervention is necessary.
■ Referred shoulder sensation and dysesthesia with swallowing can occur
particularly if the flap is neurotized for oropharyngeal or oral cavity
reconstruction.2
REFERENCES
1. Vinh VQ, Van Anh T, Ogawa R, Hyakusoku H. Anatomical and clinical
studies of the supraclavicular flap: analysis of 103 flaps used to reconstruct
neck scar contractures. Plast Reconstr Surg. 2009;123:1471-1480.
2. Abe M, Murakami G, Abe S, et al. Supraclavicular artery in Japanese: an
anatomical basis for the flap using a pedicle containing a cervical, non-
perforating cutaneous branch of the superficial cervical artery. Okajimas Folia
Anat Jpn. 2000;77:149-154.
3. Chan JWH, Wong C, Ward K, et al. Three- and four-dimensional computed
tomographic angiography studies of the supraclavicular artery island flap.
Plast Reconstr Surg. 2010;125:525-531.
4. Blevins PK, Luce EA. Limitations of the cervicohumeral flap in head and
neck reconstruction. Plast Reconstr Surg. 1980;66:220-224.
5. Di Benedetto G, Aquinati A, Pierangeli M, et al. From the “charretera” to the
supraclavicular fascial island flap: revisitation and further evolution of a
controversial flap. Plast Reconstr Surg. 2005;115:70-76.
6. Salgarello M, Lahoud P, Selvaggi G, et al. The effect of twisting on
microanastomotic patency of arteries and veins in a rat model. Ann Plast Surg.
2001;47:643-646.
7. Yu P. The transverse cervical vessels as recipient vessels for previously treated
head and neck cancer patients. Plast Reconstr Surg. 2005;115:1253-1258.
8. Liu PH, Chiu ES. Supraclavicular artery flap: a new option for pharyngeal
reconstruction. Ann Plast Surg. 2009;62:497-501.

49
CHAPTER
Section XII: Facial Nerves
Facial Reanimation in the
Oncologic Patient Using
Nerve Grafts and Nerve
Transfers
Joseph H. Dayan
DEFINITION
■ Facial reanimation in the setting of parotid tumors can be challenging,
sometimes with unpredictable functional and aesthetic outcomes.
■ Additionally, patients with locally advanced disease may not be ideal for
multiple stage procedures over the course of several years.
■ A rapid and reliable functional result with the least number of procedures
becomes a priority.
■ This chapter focuses on reanimation strategies mainly using nerve grafts and
nerve transfers depending on the clinical scenario.
■ Dynamic panfacial reanimation is the goal.
■ The reanimation procedures presented in this chapter are ideally performed at
the time of tumor ablation if possible.
ANATOMY
■ The masseter muscle is one of the muscles of mastication.
■ It arises from the lower border and medial surface of the zygomatic arch and
inserts into the lateral surface of the mandible (FIG 1).
■ The muscle consists of three layers—superficial, middle, and deep.

FIG 1 • Topography of the motor nerve to masseter. The
main trunk typically divides into a long posterior branch
and a shorter anterior superior branch.
■ The superficial muscle fibers pass backward and downward; the deeper
fibers are more vertical. The motor nerve to the masseter is derived from the
mandibular division of the trigeminal nerve. It leaves the infratemporal fossa
by passing over the lateral pterygoid muscle and mandibular notch. It enters
the masseter muscle from its deep surface and courses down between its deep
and middle layers by having a diameter of 1 to 2 mm. It becomes more
superficial distally toward the anterior inferior part of the muscle and runs
alongside the (friable) vascular pedicle that arises from the inferior alveolar
artery.
■ The facial nerve exits the stylomastoid foramen, turns superficially, and
immediately enters the substance of the parotid gland where it is classically
described as dividing into five branches—temporal (frontal), zygomatic,
buccal, mandibular, and cervical.
■ The nerve usually divides into upper (temporal) and lower (cervical) trunks at
first, from which these branches arise. In practice, they constitute five
variably interconnected groups of branches hereafter referred to as divisions.
■ Despite the various studies of facial nerve anatomy, it may be more useful to
envision the facial nerve as consisting of physiological and functional

divisions that do not necessarily correlate to the anatomic distribution of
branches but instead relate to muscular groups and actions.
■ The temporal branch of the facial nerve exits from the upper pole of the
parotid gland at the level of the zygomatic arch and becomes superficial being
plastered onto the underside of the temporoparietal fascia.
■ The course of the nerve follows a line drawn from 0.5 cm below the tragus to
1.5 cm above the eyebrow, but 3D modeling demonstrates the branches cover
a triangular area bordered between a line through the palpable
zygomaticofrontal and zygomaticotemporal sutures and a vertical line 1 cm in
front of the auditory meatus.
■ At the lateral margin of the frontalis, these branches run deep to frontalis and
orbicularis oculi (which it innervates), eventually reaching the glabella region
to supply the depressors of the brow.
■ The zygomatic division leaves the parotid gland to run just inferior the
zygomatic arch immediately deep to the superficial musculoaponeurotic
system (SMAS) to innervate the elevators of the upper lip and lower portion of
orbicularis oculi.
■ Distally, it runs on the undersurface of the zygomaticus muscle complex
before ramifying more medially in the face. The buccal branches exit the
anterior border of the parotid gland and run inferior to the parotid duct and on
the surface of the buccal fat pad deep to the SMAS layer to supply the
muscles of the mouth and cheek.
■ Both zygomatic and buccal divisions have a highly overlapping distribution
of innervation that allows transection of one or more branches without
weakness; this is the basis of cross-facial nerve grafting.
■ The mandibular branch leaves the lower portion of the parotid gland and
swings down below the ramus of the mandible to supply the muscles of the lip
and chin.
■ Cadaveric dissections demonstrate that the nerve always comprises at least
three major branches that run on the undersurface of the platysma and
superficial to the facial vessels.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Unlike the nononcologic patient population, many of these patients receive
adjuvant radiotherapy, with resulting volume loss and tissue contracture, and
potentially negative effects on neurotization.
■ While smile is often the most visually impressive feature to reanimate, the