Plastic and Reconstructive Surgery Board Review Pearls of Wisdom 3th

CHAPTER 80 Mandibular Reconstruction
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When might so t-tissue aps be considered or mandibular reconstruction?
1. Posterior/lateral de ects.
2. Sick or elderly patients who cannot tolerate a lengthy operation.
3. No bony options because o previous surgery/trauma or medical comorbidities.

What are the typical pedicle lengths or the bula, iliac crest, and scapula aps?
1. Fibula: 6 to 8 cm, but can be lengthened i bula is removed rom proximal pedicle.
2. Iliac crest: 6 to 8 cm.
3. Scapula: 4 cm, up to 14 cm i subscapular artery is included.
4. Radial orearm: up to 20 cm.

How are the bony aps xed to the native mandible?
With a reconstruction plate or miniplates. Studies have not shown any dif erence in rates o malunion or other
complications.

What are the advantages and disadvantages o use o miniplates?
Advantages:
1. More precise application o hardware to bone ap.
2. Low pro le and, there ore, avoids adding bulk to external sur ace o the bone.
3. Ease o selective removal should the need arise (e.g., extrusion).
4. Provides adequate stability.
Disadvantage:
1. Requires steeper learning curve to shape bone ap.

What are the advantages and disadvantages o use o a reconstruction plate or ap xation?
Advantages:
1. Can be used as a template to help shape the bone ap.
2. Strong rigid xation.
Disadvantages:
1. Plate can be bulky and hence palpable in patients with minimal so t-tissue coverage.
2. Stress shielding can lead to load bearing and subsequent bony resorption and osteopenia.

What is the minimal length o an osteotomized segment?
Ideally at least 1.5 cm to ensure an adequate periosteal blood supply to the segment.

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What is osteoradionecrosis (ORN) o the mandible?
A necrotic wound in irradiated bone that persists or 3 to 6 months without healing. T e period o highest risk or
ORN is the rst 3 years a ter radiation therapy and most cases occur at radiation doses greater than 60 Gy.

What are the indications o resection and reconstruction o ORN?
1. Pain.
2. Fistula.
3. Fracture.
4. Exposed bone.

What must be excluded prior to diagnosing ORN?
Recurrent cancer.

What is the optimal method o treatment or ORN o the mandible that has ailed conservative treatment?
Resection o necrotic mandible and reconstruction with a ree ap to bring well-vascularized tissue into the
irradiated area.

What is the role o hyperbaric oxygen in the treatment o ORN?
T e use o hyperbaric oxygen is controversial. It is requently used to treat ORN; however, the practice is not
supported by randomized clinical trials. It may be help ul or small lesions, ollowing surgical debridement.

What is bisphosphonate related osteonecrosis o the jaws (BRONJ)?
Similar to ORN, patients who receive intravenous bisphosphonate or cancer or, much less commonly, oral
bisphosphonates or osteoporosis, are at risk or developing necrosis o the mandible and maxilla.

What is the pathophysiology o BRONJ?
Although not completely understood, bisphosphonates are known to cause apoptosis o mature osteoclasts and
osteoclast progenitor cells as well as strongly inhibit osteoblastic activity and cause a reduction in bone vascularity.
T e net ef ect appears to be an overall reduction in bone resorption and turnover, but also a reduced ability to
heal, possibly resulting in osteonecrosis in some patients.

How is BRONJ treated?
Early-stage BRONJ is treated with oral hygiene care, antibiotic mouthwash, and oral antibiotics. Many patients
respond to this treatment. Once BRONJ becomes advanced, with pathologic racture, stula, or osteolysis
extending to the in erior mandibular border, surgical debridement or mandibular resection is indicated.

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What are some options or reconstructing composite mandibular de ects that include a through-and-
through cheek de ect (see Figs. 80-1 to 80-3)?
Figure 80-1 Right bula osteocutaneous ree- ap skin markings (A), and completed harvest (B) showing preservation o 7 cm o proximal and
distal bone and design o skin paddle centered over the posterior border o the bula, where the per orating blood vessel emerges rom the posterior
intermuscular septum. Fibula ree ap a ter osteotomies, inset, and xation with a titanium reconstruction plate or a mandibular de ect (C).
C
A
B

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Plastic & Reconstructive Surgery Board Review
B
A
Figure 80-2 Iliac crest osteocutaneous ree- ap skin markings (A), and completed harvest (B) showing outline o skin paddle over rst per orator
and harvest o bone beginning at or just lateral to the anterior superior iliac spine (ASIS).
Figure 80-3 A chimeric ree ap including scapular bone, latissimus dorsi muscle, and parascapular skin aps all based on the subscapular
artery and vein.
1. Combine a bula osteocutaneous ree ap with a pectoralis major myocutaneous pedicled ap (PMC).
2. Combine a bula osteocutaneous ree ap with a second so t-tissue ree ap, such as the anterolateral thigh
(AL ) ree ap.
3. Use a 2-skin paddle bula ree ap based on separate cutaneous per orators arising rom the peroneal artery.
4. Use a chimeric bula ree ap and soleus muscle ree ap, both based on the peroneal artery (the soleus muscle
can be skin gra ted or allowed to mucosalize spontaneously i used to close the intraoral de ect).
5. Use o a chimeric ree ap based on the subscapular system (e.g., scapular bone–parascapular cutaneous–
latissimus dorsi myocutaneous chimeric ree ap) or the deep circum ex iliac artery system (e.g., iliac crest
osteocutaneous–internal oblique muscle ree ap).

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What are the options o condylar reconstruction?
1. Excise and reinsert the native condyle as a nonvascularized gra t as long as the condyle is disease ree.
2. Shape the end o bular segment, cover it with excess periosteum or ascia, and insert it into the joint.
3. Free medial emoral condyle ap.
4. Use a costochondral gra t.
5. Prosthetic condyle.
6. No reconstruction.

What is the risk o condylar implants?
1. Erosion into the middle cranial ossa.
2. Joint dislocation.
3. Sensorineural hearing loss due to migration o the prosthesis into the epitympanum, resulting in destruction o
the cochlea.

Who is a candidate or primary osseointegration?
Patients who undergo vascularized bony reconstruction or trauma, benign tumors, osteomyelitis, ORN or
low-malignancy tumors that do not require postoperative radiation.

What is the minimum width o bone required or dental implants?
6 mm. At least 1 mm o healthy bone must surround the implant to ensure adequate osseointegration.

What is the minimum vertical bone height or dental implants?
7 to 10 mm.

Which bony aps can be used or osseointegrated implants?
Fibula, iliac crest, and scapula.

How are computer-aided design and computer-generated models use ul in mandibular reconstruction?
T ese technologies, which involve planning bony ree- ap reconstructions on a computer, then creating accurate
physical models using three-dimensional printers, can help to guide the surgery. Computer-generated cutting
guides can also be used to assist with osteotomy placement and custom-made titanium reconstruction plates
can be manu actured, eliminating the need or plate bending. All o these technologies contribute to improving
accuracy and reducing operative time in mandibular reconstruction.
FIBULA

What is the blood supply to the bula?
Peroneal vessels, which branch of the tibioperoneal trunk.

What length o bone can harvested?
Generally, between 22 and 26 cm in an adult patient.

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What is the blood supply to the cutaneous portion o the osteocutaneous bula gra t?
Per orators rom the peroneal artery that travel at least partially within the posterior intermuscular septum, which
separates the deep and super cial posterior compartments.

Where are per orators typically located on the leg?
Most commonly they arise within the middle third o the lower leg, though they may be located more proximal or
distal.

What muscles are dissected of o the bula during harvest?
T e peroneus brevis and longus, extensor digitorum longus, extensor hallucis longus, tibialis posterior, and exor
hallucis longus muscles.

What nerve can be included to provide sensation to the skin paddle o the osteocutaneous bula ap?
Lateral sural cutaneous nerve.

What muscle can be harvested with the bula or use in composite mandibular reconstruction?
Soleus or exor hallucis longus muscles.

How much proximal and distal bula should be preserved?
1. Approximately 4 to 6 cm rom the bular head to protect the common peroneal nerve wrapping around the
bular head.
2. Approximately 6 to 8 cm proximal to the lateral malleolus to avoid ankle joint instability (Fig. 80-1).

What are the contraindications to using a ree bula ap or mandibular reconstruction?
Nonpalpable pulses in oot or other evidence on physical examination o arterial insu ciency (e.g., nonhealing
ulcers, hairless, shiny skin, symptoms o claudication) and/or venous stasis (e.g., edema, purplish discoloration).
I there is any question to the adequacy o blood ow to the oot, then a C angiogram, MR angiogram, or
conventional arteriogram should be obtained.

Is routine preoperative angiography o the lower extremity necessary prior to harvesting a ree bula ap?
No. Several studies demonstrate that i the patient has a normal physical examination then angiography adds
no bene t and is unnecessary. However, i the patient has abnormal examination or a history o lower extremity
vascular trauma, then an angiogram or C A is justi ed.

What is the average width o the lateral sur ace o the bula?
About 18 mm in males and 13 mm in emales.

What is a double-barreled bula?
o more closely approximate the height o the mandible (mean height o 34 mm in males and 31 mm in emales),
an osteotomy can be per ormed where the distal hal is turned 180 degrees to be stacked on the proximal hal .

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What is the donor morbidity or a bular osteocutaneous ap?
1. Prolonged leg swelling.
2. Paresthesias.
3. Pain a ter prolonged walking.
4. Di culty in squatting.
5. Great toe stif ness or contractures.

What is peronea arteria magna and what is the incidence?
A single dominant arterial in ow to the distal lower extremity that comes rom the peroneal artery. T e incidence
is up to 5%.
ILIAC CREST

What is the blood supply to the iliac crest bone ap?
Deep circum ex iliac vessels.

What is the length o bone that can be harvested rom the iliac crest?
Approximately 14 to 16 cm.

What muscle can be harvested with the iliac crest?
T e internal oblique muscle supplied by the ascending branch o the DCIA. It is important to repair the muscle
de ect to minimize risk or postoperative hernia/bulge.

What are the disadvantages to using the iliac crest or mandibular reconstruction?
1. Relatively short pedicle length, which may necessitate use o vein gra ts.
2. T e skin paddle can be bulky and unreliable.
3. Donor-site morbidity including pain with ambulation, gait disturbance, lateral emoral cutaneous nerve injury,
and abdominal bulges/hernia ormation.

How can donor site morbidity be reduced?
Harvest a split-thickness iliac bone, taking just the inner table. Per orming a per orator dissection o the blood
vessels supplying the skin paddle, to minimize the amount o muscle harvested with the ap (Fig. 80-2).
SCAPULA

What is the blood supply to the scapula?
Circum ex scapular artery, which branches rom the subscapular artery, and supplies the lateral and medial
borders o the scapula. Some authors have also described using the angular branch o the thoracodorsal artery,
which supplies the scapular angle or tip.

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How do you nd the circum ex scapular artery?
T e circum ex scapular artery travels through the triangular space, which is ormed by the teres major, teres minor
and the long head o the triceps muscle, and is located about two- ths o the distance rom the scapular spine
to the scapular tip. It curves around the lateral scapular border, giving of several branches that supply the lateral
scapular bone, be ore dividing into horizontal and vertical branches, which supply the scapular and parascapular
cutaneous aps. T e horizontal branch also supplies the medial scapular bone, although the primary blood supply
to this part o the scapula is the dorsal scapular artery.

How do you nd the angular artery?
T e angular artery arises rom the thoracodorsal artery, usually the latissimus dorsi branch, but occasionally rom
the serratus anterior branch or more proximal to the branching o the thoracodorsal into these branches. It travels
deep to the latissimus dorsi muscle within a at pad to supply the scapular angle or tip.

What is the bone length that can be harvested rom the scapula?
Up to 14 cm o bone can be harvested rom either the lateral or the medial edge o the scapula. T e lateral bone
ap, which is based on the vertical branch of o the circum ex scapular artery, has a shorter pedicle but provides
thick, corticocancellous bone that may be usable or dental implants. T e medial bone ap, which is thinner, is
based on the horizontally oriented cutaneous branch o the circum ex scapular artery and is associated with less
postoperative shoulder stif ness.

What is the advantage o the scapular ap?
T e ability to design several aps based on a single vascular axis (also known as chimeric aps). Because the
subscapular artery ultimately supplies the latissimus dorsi and serratus anterior muscles (via the thoracodorsal
artery) and the parascapular skin paddle and the scapular skin and bone (by the circum ex scapular artery),
reconstructions using several tissue types can be per ormed with a chimeric ap, requiring only a single arterial
and venous anastomosis (Fig. 80-3).

What are the disadvantages o the scapular ap?
T e need to reposition the patient or harvest and closure o donor site prior to per orming the anastomosis.
Some patients may note a degree o shoulder stif ness and rotator cuf weakness.
RADIAL FOREARM

What is the blood supply to the radial orearm ap?
Radial artery.

What preoperative test is absolutely necessary i a radial orearm ap is planned?
Allen’s test.

Between the insertions o what two muscles on the radius, should the osteotomies be made when harvesting
the bone?
T e brachioradialis and the pronator teres muscles.

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What is the length o bone that can be harvested rom the radius?
Up to 10 cm and 40% o the cross section o the radius.

What is the racture rate with using the osteocutaneous radial orearm ap?
12% to 20%. T is rate has decreased to with the use o prophylactic plating o the radius a ter the bony ap is
harvested.

What nerve needs to be preserved during the ap harvest?
Super cial radial nerve, which is a sensory nerve to the dorsal thumb and rst nger.

Where is the super cial radial nerve located?
T e super cial radial nerve is located lateral to the radial artery, beneath the brachioradialis muscle. It pierces the
deep ascia about 7 cm proximal to the wrist and divides into lateral and medial branches.

What is the limitation to the radial osteocutaneous orearm ap in mandibular reconstruction?
T e bone harvested is thin and cannot usually tolerate osteotomies or accept dental implants.

What nerve can be included in the harvest to provide a sensate ap?
Lateral antebrachial cutaneous nerve, which is a branch rom the musculocutaneous nerve.

What is the most common complication related to the donor site?
Failure o the skin gra t to take over the tendons, which can be minimized by per orming a supra ascial dissection
and preserving paratenon over the tendons.
REFERENCES
Ang E, Black C, Irish J, et al. Reconstructive options in the treatment o osteoradionecrosis o the craniomaxillo acial skeleton. Br J
Plast Surg. 2003;56:92–99.
Bahr W. Blood supply o small bula segments: an experimental study on human cadavers. J Craniomaxillofac Surg. 1998;26:148–152.
Boyd JB, Mulholland RS, Davidson J, et al. T e ree ap and plate in oromandibular reconstruction: long-term review and indications.
Plast Reconstr Surg. 1995;95:1018–1028.
Celik N, Wei FC, Chen HC, et al. Osteoradionecrosis o the mandible a ter oromandibular cancer surgery. Plast Reconstr Surg.
2002;109:1875–1881.
Chang EI, Clemens MW, Garvey PB, Skoracki RJ, Hanasono MM. Cephalometric analysis or microvascular head and neck
reconstruction. Head Neck. 2012;34:1607–1614.
Chang YM, Santamaria E, Wei FC, et al. Primary insertion o osseointegrated dental implants into bula osteoseptocutaneous ree ap
or mandibular reconstruction. Plast Reconstr Surg. 1998;102:680–688.
Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Reconstruction o the mandible with osseous ree aps: a 10-year experience with 150
consecutive patients. Plast Reconstr Surg. 1999;104:1314–1320.
Disa JJ, Cordeiro PG. T e current role o preoperative arteriography in ree bula aps. Plast Reconstr Surg. 1998;102:1083–1088.
Forrest C, Boyd B, Manktelow R, Zuker R, Bowen V. T e ree vascularized iliac crest tissue trans er: donor site complications associated
with eighty-two cases. Br J Plast Surg. 1992;45:89–93.
Frodel JL Jr, Funk GF, Capper D , et al. Osseointegrated implants: a comparative study o bone thickness in our vascularized bone
aps. Plast Reconstr Surg. 1993;92:449–455; discussion 456–458.

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Gurlek A, Miller MJ, Jacob RF, Lively JA, Schusterman MA. Functional results o dental restoration with osseointegrated implants a ter
mandible reconstruction. Plast Reconstr Surg. 1998;101:650–655; discussion 656–659.
Hanasono MM, Militsakh ON, Richmon JD, Rosenthal EL, Wax MK. Mandibulectomy and ree ap reconstruction or bisphosphonate-
related osteonecrosis o the jaws. JAMA Otolaryngol Head Neck Surg. 2013;139:1135–1142.
Hanasono MM, Skoracki RJ. Computer-assisted design and rapid prototype modeling in microvascular mandible reconstruction.
Laryngoscope. 2013;123:597–604.
Hanasono MM, Skoracki RJ. T e scapular tip osseous ree ap as an alternative or anterior mandibular reconstruction. Plast Reconstr
Surg. 2010;125:164e–166e.
Hidalgo DA, Pusic AL. Free ap mandibular reconstruction: a 10-year ollow-up study. Plast Reconstr Surg. 2002;110:438–449;
discussion 450–451.
Hidalgo DA. Condyle transplantation in ree ap mandible reconstruction. Plast Reconstr Surg. 1994;93:770–781; discussion 782–783.
Horiuchi K, Hattori A, Inada I, et al. Mandibular reconstruction using the double barrel bular gra t. Microsurgery. 1995;16:450–454.
Kroll SS, Robb GL, Miller MJ, Reese GP, Evans GR. Reconstruction o posterior mandibular de ects with so t tissue using the rectus
abdominis ree ap. Br J Plast Surg. 1998;51:503–507.
Lutz BS, Wei FC, Ng SH, Chen IH, Chen SH. Routine donor leg angiography be ore vascularized ree bula transplantation is not
necessary: a prospective study o 120 clinical cases. Plast Reconstr Surg. 1999;103:121–127.
Mariani PB, Kowalski LP, Magrin J. Reconstruction o large de ects postmandibulectomy or oral cancer using plates and myocutaneous
aps: a long-term ollow-up. Int J Oral Maxillofac Surg. 2006;35:427–432.
Militsakh ON, Werle A, Mohyuddin N, et al. Comparison o radial orearm with bula and scapula osseocutaneous ree aps or
oromandibular reconstruction. Arch Otolaryngol Head Neck Surg. 2005;131:571–575.
Nahabedian MY, u aro A, Manson PN. Improved mandible unction a ter hemimandibulectomy, condylar head preservation, and
vascularized bular reconstruction. Ann Plast Surg. 2001;46:506–510.
Ohsaki M, Maruyama Y. Anatomical investigations o the cutaneous branches o the circum ex scapular artery and their communications.
Br J Plast Surg. 1993;46:160–163.
Patel A, Maisel R. Condylar prostheses in head and neck cancer reconstruction. Arch Otolaryngol Head Neck Surg. 2001;127:842–846.
Robey AB, Spann ML, McAulif M, Meza JL, Hollins RR, Johnson PJ. Comparison o miniplates and reconstruction plates in bular
ap reconstruction o the mandible. Plast Reconstr Surg. 2008;122:1733–1738.
Rosson GD, Singh NK. Devascularizing complications o ree bula harvest: peronea arteria magna. J Reconstr Microsurg. 2005;21:
533–538.
Seikaly H, Chau J, Li F, et al. Bone that best matches the properties o the mandible. J Otolaryngol. 2003;32:262–265.
Shpitzer , Gullane PJ, Neligan PC, et al. T e ree vascularized ap and the ap plate options: comparative results o reconstruction o
lateral mandibular de ects. Laryngoscope. 2000;110:2056–2060.
T oma A, Levis C, Young JE. Oromandibular reconstruction a ter cancer resection. Clin Plast Surg. 2005;32:361–375.
Urken ML, Buchbinder D, Costantino PD, et al. Oromandibular reconstruction using microvascular composite aps: a report o 210
cases. Arch Otolaryngol Head Neck Surg. 1998;124:46–55.
Urken ML, Buchbinder D, Weinberg H, Vickery C, Sheiner A, Biller HF. Primary placement o osseointegrated implants in microvascular
mandibular reconstruction. Otolaryngol Head Neck Surg. 1989;101:56–73.
Villaret DB, Futran NA. T e indications and outcomes in the use o osseocutaneous radial orearm ree ap. Head Neck. 2003;25:
475–481.
Waits CA, oby EB, Girod DA, sue . Osteocutaneous radial orearm ree ap: long-term radiographic evaluation o donor site
morbidity a ter prophylactic plating o radius. J Reconstr Microsurg. 2007;23:367–372.
Wax MK, Winslow CP, Hansen J, et al. A retrospective analysis o temporomandibular joint reconstruction with ree bula microvascular
ap. Laryngoscope. 2000;110:977–981.
Wei FC, Celik N, Yang WG, Chen IH, Chang YM, Chen HC. Complications a ter reconstruction by plate and so t tissue ree ap in
composite mandibular de ects and secondary salvage with osseocutaneous ap. Plast Reconstr Surg. 2003;112:37–42.
Wei FC, Chen HC, Chuang CC, Noordhof MS. Fibular osteoseptocutaneous ap: anatomic study and clinical application. Plast
Reconstr Surg. 1986;78:191–200.
Yu P, Chang EI, Hanasono MM. Design o a reliable skin paddle or the bula osteocutaneous ap: per orator anatomy revisited. Plast
Reconstr Surg. 2011;128:440–446.
Zoumalan RA, Hirsch DL, Levine JP, Saadeh PB. Plating in microvascular reconstruction o the mandible: can xation be too rigid?
J Craniofac Surg. 2009;20:1451–1454.

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David M. Adelman, MD, PhD, FACS and
Matthew M. Hanasono, MD

What are the ve layers o the scalp?
Skin, subcutaneous at, galea aponeurotica, loose areolar tissue, and pericranium (remembered by the mnemonic:
SCALP).

What ascial structure connects the rontalis muscle anteriorly to the occipitalis muscle posteriorly?
T e galea aponeurotica.

What is the signi cance o the temporal line o the calvarium?
It is the line along which the deep temporal ascia uses with the pericranium.

What is the pericranium?
T e pericranium is the periosteum o the calvarial bones.

Which region o the scalp o ers the greatest mobility?
T e parietal region, located over the temporoparietal ascia.

What blood vessels supply the scalp?
T e paired supratrochlear, supraorbital, super cial temporal, posterior auricular, and occipital blood vessels.

Which arteries are branches o the internal carotid artery? Which are branches o the external carotid artery?
T e supratrochlear and supraorbital arteries arise rom the ophthalmic artery, which is the rst branch o the
internal carotid artery. T e others are branches o the external carotid artery.

What is the sensory innervation o the scalp?
T e paired supratrochlear (V1) and supraorbital (V1) nerves, which supply orehead and rontoparietal scalp;
the zygomaticotemporal (V2) nerve, which supplies the region lateral to the brow and the temporal region; the
auriculotemporal (V3) nerve, which supplies the lateral scalp; and the greater occipital (C2) and lesser occipital
(C2–3) nerves, which supply the occipital region.
Scalp and Calvarial
Reconstruction
CHAPTER 81

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Plastic & Reconstructive Surgery Board Review

Where are the temporal branches o the acial nerve located?
On the deep sur ace o the temporoparietal ascia within the loose areolar tissue, along an imaginary line that
connects the ear lobe to a point 1.5 cm above the lateral eyebrow (Pitanguy line).

What are the three layers o the calvarium?
Outer table, diploic space, and inner table.

What are the bones o the calvarium, and by which process are they ormed during development?
T e rontal, parietal, and temporal bones are ormed by intramembranous ossi cation. T e occipital and sphenoid
bones are ormed by endochondral ossi cation.

By what age is calvarial growth complete?
Calvarial growth is generally complete by 7 years o age.

What is aplasia cutis congenita?
Aplasia cutis congenita is a rare congenital disorder characterized by a localized absence o skin, dermal
appendages, and, in some cases, subcutaneous tissues. Although it may occur anywhere on the body, the majority
occurs on the scalp. In 15% to 30% o cases, aplasia cutis congenita may be associated with de ects o the
underlying skull or dura, exposing the brain and sagittal sinus, which can be li e threatening.

How is aplasia cutis congenita treated?
T e best treatment strategy remains a subject o debate. Small wounds that do not involve dura, brain, or sagittal
sinus exposure can be managed conservatively with moist dressings. When the dura with enlarged veins, the brain,
or the sagittal sinus are exposed, emergency coverage with skin gra ts, allogra ts, or ap reconstruction may be
indicated to prevent bleeding and in ection. Many calvarial de ects exhibit spontaneous bone growth, while others
may need delayed cranioplasty.

Do all scalp de ects require reconstruction?
No. Some partial-thickness de ects may be le t to heal by secondary intention. However, contracture may result,
and the scar may have limited or no hair growth.

What actors may preclude use o local f aps or scalp reconstruction?
Wounds in which tension- ree, broadly based aps cannot be created. Also, prior radiation, surgery or in ection, as
well as tobacco use, corticosteroid use, or diabetes mellitus may result in ap loss or impaired wound healing and
are relative contraindications.

Which scalp wounds are most amenable to primary closure?
Small scalp de ects, usually less than 3 cm in diameter. Wide undermining is usually required since the scalp
tissues have limited elasticity. Galeal scoring may be a use ul adjunct.

Which scalp wounds are most amenable to skin gra ting?
T ose with a well-vascularized base or accepting the gra t, such as those with intact ascia or pericranium.

CHAPTER 81 Scalp and Calvarial Reconstruction
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How can skin gra t survival onto calvarial bone be improved?
Burring o the outer table until the vascularized diploic space is reached. Galeal, temporoparietal ascia, or
pericranial aps may also be rotated over calvarial bone prior to skin gra t placement and will improve gra t
survival.

What are the drawbacks o skin gra ting or scalp reconstruction?
Potential gra t loss, especially when radiation is given, alopecia, poor color and thickness match, shiny appearance,
and breakdown ollowing even relatively minor trauma.

What are the potential bene ts o acellular biologic matrices or scalp reconstruction?
Unlimited supply, no donor site morbidity, can be placed on minimally per used sur aces, and may decrease need
or ap reconstruction.

What are the potential downsides to using an acellular biologic matrix or scalp reconstruction?
May require skin gra ting as a second procedure, requires a vascularized wound bed, alopecia, and prone to
in ection prior to becoming vascularized.

What are the bene ts o tissue expansion in scalp reconstruction?
issue expansion can acilitate closure o wounds involving up to 50% o the scalp with hair-bearing tissue.

What are the drawbacks o tissue expansion in scalp reconstruction?
Frequent complications (up to 25%), including expander extrusion and in ection, particularly in previously
radiated tissues. Several weeks may be needed or healing and expansion a ter initial placement, making this a
suboptimal technique or primary reconstruction when adjuvant therapy is indicated. A noticeable decrease in hair
density may also occur.

In what situations might tissue expansion o the scalp be contraindicated?
When there is inadequate time to per orm expansion and nal reconstruction be ore giving adjuvant therapy.
issue expansion is also contraindicated in wounds that are open, in ected, or irradiated, or do not have stable
calvarial coverage, as well as in patients who cannot tolerate staged reconstruction.

In what plane are tissue expanders placed when used in scalp reconstruction?
In the subgaleal space.

By how much should the scalp be expanded?
T e expanded scalp should be at least 20% larger than size o de ect to allow or tissue recoil. Multiple tissue
expanders are sometimes needed to achieve this degree o expansion.

What is the bene t o galeal scoring when using local f aps or scalp reconstruction?
Although galeal scoring results in only modest improvements in ap length (1.67 mm per galeal incision according
to a study by Raposio et al.), it signi cantly decreases wound tension (up to 40% according to the same study).

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Plastic & Reconstructive Surgery Board Review

How is galeal scoring per ormed?
Galeal scoring is per ormed perpendicular to the line o maximal tension. Incisions are made through the galea but
not deeper to avoid blood vessel transection and vascular compromise o ap.

What are the principles o local f ap design or scalp reconstruction?
Flaps should try to incorporate at least one major scalp vessel and need to be 3 to 5× the diameter o the de ect to
close without tension. Skin gra ts can be used to cover the ap donor site provided there is intact periosteum but
will result in an area o alopecia (Fig. 81-1).
C
A

B
Figure 81-1 Small- to moderate-sized scalp de ect (A), closed with broadly based local scalp aps (B), and nal result (C).

What regional f aps are used in scalp reconstruction?
emporoparietal ascia aps and temporalis muscle aps may be used or de ects in the temporal region; trapezius
and latissimus dorsi muscle or myocutaneous aps may be used or de ects in the occipital region.

CHAPTER 81 Scalp and Calvarial Reconstruction
781

What are pericranial f aps typically used or?
Anterior pericranial aps supplied by the deep branches o the supraorbital and supratrochlear blood vessels are
o ten used in skull base surgery when a de ect has been created between the paranasal sinuses and the anterior
cranial ossa. T e ap is delivered through a calvarial de ect, such as one created during a rontal craniotomy, and
placed along the anterior cranial oor. T e nasal side o the ap usually mucosalizes spontaneously. In other cases,
pericranial aps are elevated and rotated over exposed calvarial bone a ter scalp resection and used as a vascularized
bed or skin gra t coverage.

What is the blood supply to the pericranium?
T e blood supply to the pericranium is via the middle meningeal and intracranial circulation to the calvarial bone.
As a result, disruption o blood supply to the scalp does not result in calvarial bone necrosis.

What are the common indications or ree f ap reconstruction o the scalp?
Large size, ull-thickness scalp de ects, and prior surgery or radiation treatment, which limits vascularity and
pliability o local aps (Fig. 81-2).
C
A

B
Figure 81-2 Large size ull-thickness scalp de ect including a ull-thickness calvarial de ect reconstructed with titanium mesh (A), latissimus
dorsi muscle ree ap anastomosed to the super cial temporal vessels (B), and nal result a ter coverage with an unmeshed split-thickness skin
gra t (C).

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Plastic & Reconstructive Surgery Board Review

What actors are important in selecting a ree f ap or scalp reconstruction?
De ect size, vascular pedicle length, ap size, thickness and tissue type, donor site morbidity, and surgeon
pre erence.

What ree f aps are commonly used in scalp reconstruction?
1. Latissimus dorsi muscle/myocutaneous ap: thin, broad ap or large de ects; the muscle ap may be covered
with an unmeshed skin gra t with good aesthetic outcomes, particularly in bald patients.
2. Serratus anterior muscle ap: thin, small muscle with a long vascular pedicle; lower three slips o muscle may
be harvested without signi cant scapular winging.
3. Radial orearm asciocutaneous ap: small ap with a long vascular pedicle; may be more durable than a
muscle ap with skin gra t; relatively poor donor site appearance.
4. Omental ap: can cover a large sur ace area; irregular contour; requires laparotomy.
5. Rectus abdominis muscle/myocutaneous ap: long but narrower than the latissimus dorsi muscle ap; can be
harvested with two-team approach; myocutaneous ap is usually overly thick.
6. Anterolateral thigh ap: can be a asciocutaneous or myocutaneous ap; may be overly thick in some patients;
has potential to cover a large de ect, but will require skin gra ting o the donor site.

Which recipient vessels are commonly used in ree f ap scalp reconstruction?
T e super cial temporal vessels are pre erred by many surgeons. T e acial vessels are o ten second choices, but
their use o ten requires interpositional vein gra ts.

What are the key points o postoperative care ollowing ree f ap scalp reconstruction?
Besides ap monitoring, elevation o the head to minimize edema, patient positioning to minimize pressure and
shear orces on the ap or skin gra t, use o closed suction drains to prevent seromas, and head positioning to
prevent compression or kinking o the vascular pedicle.

What steps are necessary to prepare or scalp replantation?
T e avulsed scalp must be cleansed, shaved, and debrided; arteries and veins must be ound in the avulsed scalp,
as well as sensory nerves, i possible; recipient vessels and nerves must be prepared; vein gra ts are harvested; and
broad-spectrum antibiotics are given.

How many microvascular anastomoses are necessary or success ul scalp replantation?
T is is controversial. However, anastomoses o one artery and two veins are usually recommended. Medicinal
leeches may help in cases o venous congestion.

What are the indications or calvarial reconstruction?
o provide protective coverage o intracranial contents and to restore contour.

What are the advantages o autologous bone in calvarial reconstruction?
No oreign-body reaction, lower incidence o gra t loss, and exposure and in ection can sometimes be managed
without gra t removal.

What are the disadvantages o autologous bone in calvarial reconstruction?
Limited amount o available gra t material, and donor site morbidity.

CHAPTER 81 Scalp and Calvarial Reconstruction
783

What are the common sources o autologous bone or calvarial reconstruction and their advantages/
disadvantages?
Split calvarial bone: may be harvested rom same operative eld as de ect, usually rom the parietal region where
skull is thickest and not over midline to avoid injury to the sagittal sinus; limited size o available gra t; risk o
violating the dura during harvest.
Iliac crest bone: larger quantity o bone than the calvarium; donor site pain, impaired gait, high rate o
hematomas, and de ormity or hernia i ull-thickness bone is used.
Rib: large de ects may be reconstructed by harvesting multiple ribs and splitting them; may destabilize the chest
wall, especially i adjacent ribs are harvested; risk or pneumothorax during harvest; may result in undesirable
washboard-like contour.

What are the advantages o alloplastic calvarial reconstruction?
Unlimited amount o material, may be sized and contoured as needed, and no donor site morbidity.

What are the disadvantages o alloplastic calvarial reconstruction?
Requires well-vascularized coverage, usually requires removal a ter exposure or in ection, some materials result in
heat or cold intolerance, and some cause radiographic arti acts.

What are some common materials used or alloplastic calvarial reconstruction?
1. itanium: durable with minimal oreign body reaction, may experience cold intolerance, radiopaque, and
causes arti acts on radiographic imaging.
2. Methyl methacrylate: durable, easily contoured; radiolucent; hardening process is exothermic.
3. Calcium hydroxyapatite: o ten used in combination with titanium mesh, may allow or some osteoconduction
(bone ingrowth), hardening process is isothermic, and can be brittle.
4. Polyetheretherketone: highly durable, radiolucent, and must be custom made.

How are in ected calvarial reconstructions best managed?
Usually by a two-staged approach. T e rst stage consists o debridement or removal o the in ected bone or
implant, antibiotic treatment, and scalp reconstruction with well-vascularized tissue. Reconstructive ap is
re-elevated and calvarial reconstruction is per ormed at a second stage. Without rigid protection o the brain, care
must be taken to avoid injury between stages.
REFERENCES
Antonyshyn O, Gruss JS, Zuker R, Mackinnon SE. issue expansion in head and neck reconstruction. Plast Reconstr Surg. 1988;82:
58–68.
Arnold PG, Rangarathnam CS. Multiple- ap scalp reconstruction: orticochea revisited. Plast Reconstr Surg. 1982;69:605–613.
Bilkay U, Kerem H, Ozek C, Erdem O, Songur E. Alopecia treatment with scalp expansion: some surgical ne points and a simple
modi cation to improve the results. J Craniofac Surg. 2004;15:758–765.
Blake GB, MacFarlane MR, Hinton JW. itanium in reconstructive surgery o the skull and ace. Br J Plast Surg. 1990;43:528–535.
Chao AH, Yu P, Skoracki RJ, DeMonte F, Hanasono MM. Microsurgical reconstruction o composite scalp and calvarial de ects in
cancer: a 10-year experience. Head Neck. 2012;34:1759–1764.
Chicarilli ZN, Ariyan S, Cuono CB. Single-stage repair o complex scalp and cranial de ects with the ree radial orearm ap. Plast
Reconstr Surg. 1986;77:577–585.

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Plastic & Reconstructive Surgery Board Review
Grigg R. Forehead and temple reconstruction. Otolaryngol Clin North Am. 2001;34:583–600.
Gurlek A, Alaybeyoglu N, Demir CY, Aydoğan H, Bilen B , Oztürk A. Aesthetic reconstruction o large scalp de ects by sequential
tissue expansion without interval. Aesthetic Plast Surg. 2004;28:245–250.
Hanasono MM, Goel N, DeMonte F. Calvarial reconstruction with polyetheretherketone implants. Ann Plast Surg. 2009;62(6):
653–655.
Hof man JF. Management o scalp de ects. Otolaryngol Clin North Am. 2001;34:571–582.
Hudson DA, Arasteh E. Serial tissue expansion or reconstruction o burns o the head and neck. Burns. 2001;27:481–487.
Hussussian CJ, Reece GP. Microsurgical scalp reconstruction in the patient with cancer. Plast Reconstr Surg. 2002;109:1828–1834.
Ioannides C, Fossion E, McGrouther AD. Reconstruction or large de ects o the scalp and cranium. J Craniomaxillofac Surg. 1999;
27:145–152.
Lee EI, Chao AH, Skoracki RJ, Yu P, DeMonte F, Hanasono MM. Outcomes o calvarial reconstruction in cancer patients. Plast Reconstr
Surg. 2014;133:675–682.
Leedey JE, Janis JE, Rohrich RJ. Reconstruction o acquired scalp de ects: an algorithmic approach. Plast Reconstr Surg. 2005;116:
54e–72e.
Lesavoy MA, Dubrow J, Schwartz RJ, Wackym PA, Eisenhauer DM, McGuire M. Management o large scalp de ects with local
pedicle aps. Plast Reconstr Surg. 1993;91:783–790.
Lipa JE, Butler CE. Enhancing the outcome o ree latissimus dorsi muscle ap reconstruction o scalp de ects. Head Neck. 2004;26:
46–53.
Losken A, Carlson GW, Culbertson JH, et al. Omental ree ap reconstruction in complex head and neck de ormities. Head Neck.
2002;24:326–331.
Lutz BS, Wei FC, Chen HC, Lin CH, Wei CY. Reconstruction o scalp de ects with ree aps in 30 cases. Br J Plast Surg. 1998;51:
186–190.
Manson PN, Crawley WA, Hoopes JE. Frontal cranioplasty: risk actors and choice o cranial vault reconstructive material. Plast Reconstr
Surg. 1986;77:888–904.
McCarthy JG, Zide BM. T e spectrum o calvarial bone gra ting: introduction o the vascularized calvarial bone ap. Plast Reconstr
Surg. 1984;74:10–18.
Menders EK, Schenden MJ, Furrey JA, Hetzler P , Davis S, Graham WP 3rd. Skin expansion to eliminate large scalp de ects. Plast
Reconstr Surg. 1984;74:493–507.
Newman MI, Hanasono MM, Disa JJ, Cordeiro PG, Mehrara BJ. Scalp reconstruction: a 15-year experience. Ann Plast Surg.
2004;52:501–506.
Orticochea M. New three- ap scalp reconstruction technique. Br J Plast Surg. 1971;124:184–188.
Ozkan O, Coskun rat OK, Ozgentas HE, Derin A. Rationale or reconstruction o large scalp de ects using the anterolateral thigh ap:
structural and aesthetic outcomes. J Reconstr Microsurg. 2005;21:539–545.
Pinar YA, Govsa F. Anatomy o the super cial temporal artery and its branches: its importance or surgery. Surg Radiol Anat.
2006;28:248–253.
Raposio E, Nordstrom RE, Santi PL. Undermining o the scalp: quantitative ef ects. Plast Reconstr Surg. 1998;101:1218–1222.
Seery GE. Surgical anatomy o the scalp. Dermatol Surg. 2002;28:581–587.
Silberstein E, Vasileios P, Landau D, et al. Aplasia cuts congenita: clinical management and a new classi cation system. Plast Reconstr
Surg. 2014;134:766e–774e.
emple CL, Ross DC. Scalp and orehead reconstruction. Clin Plast Surg. 2005;32:377–390.
erkonda RP, Sykes JM. Concepts in scalp and orehead reconstruction. Otolaryngol Clin North Am. 1997;30:519–539.
olhurst DE, Carstens MH, Greco RS, Hurwitz DJ. T e surgical anatomy o the scalp. Plast Reconstr Surg. 1991;87:603–612.
Ueda K, Harashina , Inoue , anaka I, Harada . Microsurgical scalp and skull reconstruction using a serratus anterior myo-osseous
ap. Ann Plast Surg. 1993;31:1014.
Van Rappard JH, Molenaar J, Van Doorn D, Sonneveld GJ, Borghouts JM. Sur ace-area increase in tissue expansion. Plast Reconstr
Surg. 1988;82:833–839.

785
Scott L. Hansen, MD, FACS and
Hani Sbitany, MD, FACS

What is the unction o the lips?
Establishment o oral competence ( unction o orbicularis oris muscle), modulation o the spoken word, acial
expression, as well as a role in social relationships.

What is cheiloscopy?
T e study o lip prints. Lip prints have a unique topographic pattern, just like a ngerprint pattern.

What are the critical and unique anatomic landmarks o the lip?
Philtral columns, philtral groove, Cupid’s bow and tubercle or the upper lip; the vermilion (white roll or
mucocutaneous junction); and oral commissures.

Where is Cupid’s bow located?
Found on the upper lip, Cupid’s bow is the area o vermilion border at the base o the two philtral columns.

When do the lips begin to develop embryologically?
At 4 to 5 weeks o gestation.

What are the important processes that occur during embryologic development o the lips?
T e two medial nasal prominences use with the maxillary prominences to orm the upper lip. T e mandibular
prominence contributes to lower lip development. Failure o neural crest cell migration (as early as day 22) results
in variable cle ting o the upper lip.

Discuss the perioral subunit principle o the lips.
Burget and Menick described the lateral subunit, bordered by the philtral column, nasal sill, alar base and
nasolabial old, as well as the medial subunit, which represents one-hal o the philtrum.
Lip Reconstruction
CHAPTER 82

786
Plastic & Reconstructive Surgery Board Review

What is the subunit principle?
When the majority o a subunit has been lost, replacement o the entire subunit with like tissue yields the best
aesthetic reconstruction.

What is the blood supply to the lip?
Is derived rom the acial artery, branching into both the in erior and superior labial artery.

What muscle planes does the acial artery travel within?
Deep to the platysma, risorius, and zygomaticus major and minor muscles and super cial to the buccinator and
levator anguli oris.

Where does the in erior labial artery branch rom the acial artery?
2.6 cm lateral and 1.5 cm in erior to the oral commissure.

T e acial artery terminates into what artery in the mid ace?
It becomes the angular artery, orming branches to the nasal ala and anastomosing with the dorsal nasal artery. T e
acial and labial arteries communicate with the subdermal plexus through a dense population o musculocutaneous
per orators.

What is the lymphatic drainage pattern o the lips?
T e upper lip and lateral lower lip drain primarily to the submandibular lymph nodes. T e remaining lower lip
drains to the submental nodes.

What is the motor innervation to the lips?
T e acial nerve, whose buccal and marginal mandibular branches supply the perioral musculature on their
undersur ace.

What muscles o acial expression are innervated on their super cial sur ace?
T e buccinator, levator anguli oris, and mentalis.

What is the sensory innervation to the lips? What innervates the upper lip?
Maxillary and mandibular divisions o the th cranial nerve. T e in raorbital nerve, which is a terminal branch o
the maxillary nerve, innervates the upper lip. T e lower lip and chin receive sensory innervation rom branches o
the mandibular nerve (mental nerve).

Where does the in erior alveolar nerve travel?
T e in erior alveolar nerve, a branch o the mandibular nerve, travels through the body o the mandible and exits
rom the mental oramen.

What landmarks are used or an in raorbital nerve block?
T e nerve exits the in raorbital oramen 4 to 7 mm below the in erior orbital rim on a vertical line that descends
rom the medal limbus o the iris.

CHAPTER 82 Lip Reconstruction
787

What is the course o the in raorbital nerve and what does it supply?
It travels beneath the levator labii superioris and super cial to the levator anguli oris to supply the lateral nasal
sidewall, ala, columella, medial cheek, and upper lip.

What landmarks are used to nd the mental oramen?
It is located below the apex o the second mandibular bicuspid but has 6 to 10 mm o lateral variability.

What territory does the mental nerve supply?
T e lower lip skin down to the labiomental old. T e nerve is located in the submucosa as it exits the oramen and
requently is visible in this location.

What are the steps or per orming a mental nerve block?
T e lower lip is pulled out, and with tension, the mental nerve can be visualized on stretch in the mucosa on each
side. It is just lateral to the canine, using this technique. It is injected with local anesthetic in the mucosa, and not
at the mental oramen.

Which nerve block anesthetizes the central chin?
In erior alveolar nerve block.

What are the goals o lip reconstruction?
Reconstruction o skin and oral mucosa, re-establishment o the vermilion, maintenance o an adequate stomal
diameter, maintenance o sensation, and to restore normal oral sphincter unction (competence).

What are the limits o primary closure o the lower lip in terms o tissue loss? What about the upper lip?
Up to one-third o lower lip loss may be tolerated with primary closure be ore microstomia and oral incompetence
become a concern. Up to 25% tissue loss o the upper lip allows or reasonable primary closure.

What is the minimal unctional diameter o the oral stoma?
3 cm.

What is the di erence between primary closure o the upper lip as opposed to the lower lip?
T e unique anatomic landmarks o the upper lip (Cupid’s bow, philtral columns) make the upper lip less amenable
than the lower lip or primary closure.

How is primary closure per ormed?
Precise layered closure should be suture speci c. Fast-absorbing material (4-0 or 5-0 chromic gut) in the buccal
mucosa (which heals rapidly). T e orbicularis oris is repaired with large bites o a long-absorbing (vicryl or PDS)
suture or permanent suture (clear nylon). Interrupted, buried sutures o ne vicryl (5-0) may be used or dermal
approximation, ollowed by a running or interrupted mono lament suture (e.g., 6-0 nylon) in the skin.

788
Plastic & Reconstructive Surgery Board Review

How does one treat vermilion lesions?
T e vermilion should be handled with care. Discrepancies o 1 mm can be detected at a conversational distance.
Lesions near the vermilion border must be excised with a vertical ellipse.

In what direction are horizontal lesions o the vermilion excised?
ransversely.

At what angle should incisions o the vermilion cross the mucocutaneous line?
90-degree angle.

What technique may be used when incising across the vermilion?
When crossing the vermilion with an incision, the ne anatomic borders o the uninvolved, marginal vermilion
should be tattooed with dye prior to local in ltration. T is allows or proper alignment when closing. Again, the
incision should cross the vermilion border at a 90-degree angle.

Where are sutures placed when closing a vermilion lesion?
Sutures are placed on the surrounding lip skin, and never on the vermilion directly. In ammation rom sutures on
the vermilion border may distort this line.

Where are the majority o malignancies o the lip—the upper or lower?
95% o lip cancers involve the lower lip (more sun-exposed).

What histologic types are most lip malignancies?
90% o all lip cancers are squamous cell carcinoma (SCC). Other, rarer subtypes (sebaceous carcinoma, adenoid
cystic carcinoma, acinic cell carcinoma, and Merkel cell carcinoma) may also occur.

Which lesion represents a precursor to SCC?
Keratoacanthoma, which looks clinically similar to SCC.

Lip cancers make up what percentage o all oral carcinomas?
25%.

What margins should one take when excising lip malignancies?
In one prospective study (72 consecutive patients with primary stage I/II SCC o the lower lip), ull-thickness
excision with 3-mm margins yielded a 89.9% tumor- ree specimen rate with a 2.8% recurrence rate a ter a 5-year
median ollow-up. 3- to 5-mm margins appear to be su cient in most series.

What techniques may be used when excising an SCC rom the lower lip?
A ared W-plasty, single-barrel, or double-barrel incision (in contrast to conventional V-excisions) aid in wider
margins and avoidance o crossing the labiomental old.

CHAPTER 82 Lip Reconstruction
789

What general principles apply in lip reconstruction?
A wide variety o aps are available or reconstitution o the upper and lower lips. wo main strategies are
available: rotation-advancement o remaining uninvolved lip peripheral to the de ect and lip-switch aps.

What is the reconstructive technique o lip-switching?
T e concept is based on the dual blood supply to the lips rom the acial artery and using tissue rom one lip to
reconstruct the other lip.

What is an Abbé f ap based upon and what is it used or?
More commonly rom the lower lip, it is based upon the coronal branch o the in erior labial artery, and is used to
close a paramedian or philtral de ect.

How is an Abbé f ap designed?
Designed so that it measures one-hal the width o the upper lip de ect. A secondary division o the pedicle is
per ormed at 3 weeks postelevation.

How does the Estander f ap di er rom the Abbé f ap?
T e Estlander’s derivation o the Abbé ap involves a triangular designed ap, based on the superior labial artery.
It provides coverage or lateral lower lip de ects involving the commissure.

What is the Gillies an f ap used or?
As a rotational advancement ap, the Gillies an ap donates upper lip and cheek tissue to close large central lower
lip tissue losses (> 50%). Several modi cations o this original concept have been established. McGregor (1983)
initially described a rectangular-shaped musculocutaneous ap similar to Gillies, but with a more narrow base and
thus without the distortion at the oral commissure present in its predecessor. ypically, the width o the ap is the
same as the vertical de ect height and the length o the ap is equivalent to the width o the de ect in addition to
the width o the ap.

What is unique about the Karapandzic f ap?
Originally described in 1974, this is an innervated orbicularis oris (composite) ap. Used to repair midline upper
and lower lip de ects, this ap is elevated by semicircular incisions camou aged within the nasolabial olds, and
mobilized based on neurovascular pedicles consisting o trigeminal and acial motor and sensory supply. T is ap
provides a unctionally competent oral sphincter. Other innervated composite aps incorporate levator anguli oris
or depressor anguli oris or muscle units. Each o these aps can restore up to 50% de ects unilaterally and may be
raised bilaterally to restore total lip de ects.

What type o de ect is reconstructed with a Webster–Bernard f ap?
Very large (> 80%) de ects o the lower lip can be reconstructed with the Webster–Bernard ap. T is involves
medial advancement o cheek tissue to recreate the lower lip. T e vermilion is then reconstructed with a mucosal
ap.

What is the pre erred reconstructive technique ollowing a ull-thickness excision o the central 75% o the
upper lip?
Bilateral Karapandzic aps with an Abbé ap. T e Karapandzic aps allow or trans er o innervated upper lip skin
and musculature, while the Abbé ap allows or reconstruction o the central philtrum.

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Plastic & Reconstructive Surgery Board Review

Which f ap is pre erred or reconstruction o a ull-thickness tumor resection rom the le t lateral lower lip
and le t commissure?
Estlander ap.

T e acial artery myomucosal (FAMM) f ap consists o what layers o tissue and structures?
Oral mucosa, submucosa, buccinator muscle, acial artery, and venous plexus. As such, this ap is idea or
reconstructing de ects o the wet vermillion. T is ap is not used or large, ull-thickness de ects o the lower lip.

When local or regional f aps are not available, what is the next step in lip reconstruction?
Free ap options are available or total lip reconstitution, but are plagued by bulky reconstruction, the ailure to
restore a competent oral sphincter, and aesthetic limitations.

For each f ap (Abbé, Bernard–Burow, Estlander, Gillies, Karapandzic) describe the advantages and
disadvantages.
Abbé f ap: Ideal or central de ects o the upper lip (philtral). Color match and rapid reinnervation are well
described. Pedicled ap con guration (requiring secondary division), minor secondary vermilion discrepancies,
and upper lip asymmetries are all negative characteristics.
Modi ed Bernard–Burow f ap: Postoperative scars are camou aged with natural creases along alar base and sill.
Displacement o philtral columns and distortion o nasolabial old contribute to dis avor o this ap.
Estlander f ap: Optimal or reconstruction o lateral lower commissural de ects. Adverse ef ect o microstomia and
ablation o the natural old o the oral commissure are potential outcomes.
Gillies an f ap: Designed or large lower lip de ects (> 50%), it has a generous arc o rotation. Similar to the
Estlander ap, this ap may reduce the aperture o the mouth. It also disrupts and displaces the modiolus. Finally,
distortion o the lip and lack o neural supply can lead to severe aesthetic de ormities and oral incompetence.
Karapandzic f ap: Neurovascular rotational ap provides reconstruction with a competent oral sphincter. Similar
to the Gillies and Estlander aps, distortion and displacement o the modiolus occurs.

What is the primary di erence between the Karapandzic and Gillies f aps?
Both are advancement aps o the lower lip tissue, used to reconstruct lower lip central de ects. However, the
Karapandzic ap involves dissection and preservation o acial nerve branches, thus resulting in a unctional
reconstruction.

What are the potential complications o lip reconstruction?
T e main complication post lip reconstruction is microstomia. Other complications, such as philtral or
commissural obliteration, nerve injury, and oral incompetence can also occur.

What are the major muscles which elevate the upper lip?
T e levator labii superioris, zygomaticus major, and levator angulii oris.

What muscles depress the lower lip and angle o the mouth?
T e depressor labii in erioris and depressor anguli oris.

What muscle elevates the central lower lip?
Mentalis muscle.

CHAPTER 82 Lip Reconstruction
791

What is the most common etiology o commissure wounds?
Electrical burns. Frequently observed in children between the ages 1 and 4 years.

What is the early management o commissure electrical burns?
While some believe in immediate excision and closure is warranted, most proceed with conservative therapy,
including topical antibiotics, and allowing the wound to demarcate.

What is the most common complication in the acute phase o commissure healing?
Bleeding rom the labial artery, which usually occurs 24 to 48 hours a ter the injury.

What regional f ap can be used to reconstruct a hair-bearing, complete upper lip de ect?
emporal rontal scalp ap based on the super cial temporal vessels or a submental ap based on the submental
artery, a branch o the acial artery.

What ree f ap would be most appropriate to reconstruct a complete lower lip de ect?
T e radial orearm ap which is thin, pliable, and has a long, reliable vascular pedicle. T e palmaris longus tendon
can be incorporated into the ap to provide a sling.
REFERENCES
Anvar BA, Evans BC, Evans GR. Lip reconstruction. Plast Reconstr Surg. 2007;120(4):57e–64e.
Baumann D, Robb G. Lip reconstruction. Semin Plast Surg. 2008;22(4):269–280.
Burget GC, Menick FJ. Aesthetic restoration o one-hal o the upper lip. Plast Reconstr Surg. 1986;78(5):583–593.
Campbell JP. Surgical management o lip carcinoma. J Oral Maxillofac Surg. 1998;56:955–961.
Canady JW, T ompson SA, Bardach J. Oral commissure burns in children. Plast Reconstr Surg. 1996;97:738–744; discussion 745;
746–755.
de Visscher JG, Gooris PJ, Vermey A, Roodenberg JL. Surgical margins or resection o squamous cell carcinoma o the lower lip. Int
J Oral Maxillofac Surg. 2002;31:154–157.
de Visscher JG, van der Waal I. Etiology o cancer o the lip. A review. Int J Oral Maxillofac Surg. 1998;27:199–203.
Dupin C, Metzinger S, Rizzuto R. Lip reconstruction a ter ablation or skin malignancies. Clin Plast Surg. 2004;31(1):69–85.
Godek CP. Weinzweig J. Bartlett SP. Lip reconstruction ollowing Mohs’ surgery: the role or composite resection and primary closure.
Plast Reconstr Surg. 2000;106(4):798–804.
Langstein HN, Robb GL. Lip and perioral reconstruction. Clin Plast Surg. 2005;32(3):431–445.
Lesavoy MA, Smith AD. Lower third ace and lip reconstruction. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia, PA: W. B.
Saunders; 2006:799–858.
McGregor IA. Reconstruction o the lower lip. Br J Plast Surg. 1983;36:40–47.
Schulte DL, Sherris DA, Kasperbauer JL. T e anatomical basis o the Abbé ap. T e Laryngoscope. 2001;111:382–386.
obin GR, O’Daniel G. Lip reconstruction with motor and sensory innervated composite aps. Clin Plast Surg. 1990;17(4):623–632.
Wei FC, an BK, Chen IH, Hau SP, Liau C . Mimicking lip eatures in ree- ap reconstruction o lip de ects. Br J Plast Surg. 2001;
54:8–11.
Zide BM. De ormities o the lips and cheeks. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, PA: W. B. Saunders; 1990:2009–2037.

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793
Pieter G. L. Koolen, MD and
Samuel J. Lin, MD, MBA, FACS

How much o the tongue lies within the oral cavity?
T e anterior two-thirds o the tongue. T e posterior limit o the oral cavity superiorly is the junction o the hard
and so t palates and in eriorly the sulcus terminalis o the tongue.

What are other terms or the posterior third o the tongue?
T e pharyngeal tongue or tongue base.

Where are the circumvallate papillae and the ungi orm papillae located?
T e circumvallate papillae lie immediately anterior to the sulcus terminalis. T e ungi orm papillae are scattered on
the upper sur ace o the tongue anterior to the circumvallate papillae.

What separates the oral and pharyngeal portions o the tongue?
T e sulcus terminalis.

Where on the tongue is the oramen cecum?
T e apex o the sulcus terminalis.

Which structure migrates through the oramen cecum o the tongue during embryological development?
T e thyroid.

Which embryological structures use to orm the tongue?
T e median tongue bud (tuberculum impar) and two distal tongue buds orm the oral tongue. T e hypobranchial
eminence becomes the pharyngeal tongue.
Tongue Reconstruction
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Describe the sur ace anatomy o the tongue.
T e oral tongue has an apex, which touches the incisors, a dorsum (the upper sur ace), and a smooth ventral
sur ace, which is contiguous with the oral oor and gingiva. T e tongue base is more vertical in orientation and
contiguous with the glossoepiglottic olds.

What nerves provide general sensation to the tongue?
Oral: lingual nerve. Pharyngeal: glossopharyngeal nerve.

Which cranial nerves transmit taste sensation?
Cranial nerves (CN) VII, IX, and X; all contain special sensory taste a erent bers.

What is the course o the chorda tympani nerve?
aste bers leave the lingual nerve and are conveyed via the chorda tympani. It carries taste sensory bers rom the
anterior two-thirds o the tongue to the intratemporal acial nerve. With the lingual nerve, the chorda tympani
travels rom the ventral sur ace o the tongue to the lingual sulcus, where it is caudal to the submandibular duct;
then superiorly, to the lingual border o the mandible near the third molar. T e chorda tympani leaves the lingual
nerve at the medial border o the lateral pterygoid and traverses the middle ear, joining CN VII in the acial canal.

Where are taste buds located?
ongue, so t palate, palatoglossal arches, posterior sur ace o the epiglottis (CN X), and posterior oropharynx.

How many taste buds are there on each papilla?
Approximately 3, 250 and 1,200 taste buds are ound on the ungi orm, vallate, and oliate papillae, respectively.
Fili orm papillae have no taste buds.

What are the our types o taste?
Salty, sweet, sour, and bitter.

Where on the tongue is salty taste sensed?
T e entire tongue sur ace can sense salty taste. T ere is a strong misconception that there is a “taste map.” In act
every taste can be sensed in all regions o the tongue.

What other sensation is important in recognizing avors?
Ol action. Patients who cannot smell may complain o lack o taste sensation.

Describe the musculature o the tongue.
T e musculature o the tongue is divided into two unctional halves by a brous septum. T e extrinsic muscles,
styloglossus, hyoglossus, and genioglossus together control the position o the tongue. T ey connect the tongue to
the hyoid, mandible, and styloid processes. T e palatoglossus assists in tongue elevation but is usually considered
primarily to be a muscle o the palate. T e intrinsic muscles shape the tongue by controlled contractions o
transverse, longitudinal, and vertical bers either side o the midline septum.

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What provides motor supply to the muscles o the tongue?
T e hypoglossal nerve.

What is the unction o the genioglossus muscle?
T e anterior bers o genioglossus retract the tongue tip. T e bulk action o genioglossus is to protrude the tongue
anteriorly and in eriorly.

What is the blood supply o the tongue?
T e lingual artery, arising rom the external carotid artery, provides in ow. Drainage is via venae comitantes into
the internal jugular vein.

What is the lymphatic drainage o the tongue?
T e oral tongue lymphatics drain into the respective cervical nodal basin bilaterally. T e level II nodes are most
commonly a ected by tongue cancer metastases, but levels I and III are also at high risk. Hence, the most
commonly per ormed elective neck dissection or tongue cancer is a selective neck dissection o levels I, II, and III
(also re erred to as a supraomohyoid neck dissection).

What are the most important unctions o the tongue?
Airway protection, swallowing (deglutition), tasting, articulating speech, and tongue nger unction. Additionally,
the tongue assists chewing by repeatedly presenting the ood bolus to the teeth.

What use is the “ nger unction” o the tongue?
T e ability o the tongue to orm a rm tip that is use ul or clearing the oral sulci, manipulating a ood bolus, and
cleaning the lips and dentition.

What are the phases o swallowing?
T ere are voluntary and involuntary phases o swallowing. First, in the voluntary (oral) phase o swallowing, the
apex o the tongue is pressed against the palate. T e intrinsic muscles move ood posteriorly into the oropharynx
by elevating sequential portions o the tongue to the palate. T e tongue base is positioned superiorly and
posteriorly, orming a ood plat orm in readiness or the involuntary phase. Concurrently the hyoid bone is moved
superiorly.
During the involuntary (pharyngeal), phase the palatopharyngeal sphincter seals the nasopharynx, while the larynx
and pharynx are elevated. T e tongue base and pharyngeal constrictors orce the ood bolus in eriorly over the
posteriorly arched epiglottis and closed laryngeal inlet.

What is the most common tongue malignancy?
Squamous cell carcinoma o the tongue.

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Plastic & Reconstructive Surgery Board Review

How are lingual cancers staged?
T e American Joint Committee on Cancer method or planning treatment, estimating prognosis, and comparing
research o oral cavity and oropharyngeal cancers involves categorizing tumors according to the tumor size ( is,
1, 2, 3, or 4), nodal metastases (N0, N1, N2, N3), and presence o distant metastases (Mx, M0, M1). Once
the three tumor characteristics ( NM) are known, the tumor can be given a stage I to IV. Oral tongue cancer
staging di ers rom pharyngeal tongue only with respect to the 4 de nitions, because the adjacent structures that
might be invaded vary.
1: tumor less than 2 cm in maximum dimension.
2: tumor 2 to 4 cm.
3: tumor more than 4 cm.
4: tumor invades adjacent structures.

What are the relative survival rates or various stages o tongue cancer?
According to the National Cancer Institute o the United States National Institutes o Health, the 5-year relative
survival rate or cancers localized to the primary site (tongue) is approximately 77%, or those that have spread
to regional lymph nodes or extended directly beyond the primary site is approximately 55%, and or cancers that
have already metastasized at diagnosis is approximately 29%. T e relative survival rate measures the survival o the
cancer patients in comparison to the general population to estimate the e ect o cancer.

What part o the tongue is most requently af ected rst by malignancy?
T e midlateral aspect o the tongue.

What is an oral glossectomy?
T e resection o the tongue tip and up to hal o the tongue base is called an oral glossectomy. Other de ects
include subtotal hemiglossectomy (a wide local excision that is smaller than a hemiglossectomy), hemiglossectomy
(divided into either an oral or extended hemiglossectomy), and total glossectomy.

What are the priorities in lingual reconstruction?
Immediate wound closure, prevention o orocervical stula, obliteration o dead space lingual to the mandible,
maintenance/restoration o tongue unction, coverage o major vessels, and uncomplicated wound healing.

How much o the tongue is required to maintain tongue unction?
A portion o at least 20% to 30% o the lateral tongue is required or some residual tongue unction. It is critical
that the chosen reconstruction does not tether residual tongue unction.

How is residual tongue unction maintained with reconstruction?
T e most important actor in preserving unction is maintaining residual tongue mobility by avoiding tethering.
Reconstruction methods that may lead to tethering o the residual tongue include primary closure, skin gra ting,
or poorly designed regional or distant aps. Correctly planned reconstruction provides suf cient ap size or
coverage o the de ect with the tongue in all ranges o movement. In addition, the ap should cover adjacent oor
o mouth, pharyngeal, or palate de ects as required.

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Why is the volume o a ree ap important in reconstructing subtotal or total tongue de ects?
T e presence o bulk in a ap supports the ventral tongue, preventing prolapse or contralateral shi ting o the
residual tongue. Bulk helps direct oral contents and secretions laterally toward the oropharynx and allows the
neotongue to contact the palate, which is important or speech and swallowing.

What are the options or reconstructing lingual de ects?
Primary closure, skin gra ts, and local, regional, or distant aps. Common ree aps or tongue reconstruction
include radial orearm, lateral arm, rectus abdominis myocutaneous, and anterolateral thigh.

Which ree aps can be used to provide general sensation to the reconstructed tongue?
Radial orearm, anterolateral thigh, and lateral arm are three commonly used aps or tongue reconstruction,
which may be innervated to provide sensation.

Do noninnervated aps used or tongue reconstruction regain sensation?
Yes. Ninety percent o noninnervated asciocutaneous ree aps placed on an unscarred bed in the oral cavity
regained at least some sensory modalities, likely the result o axonal sprouting into the ap. Sensory upgrading o
the ap may occur secondary to the large cortical representation o the tongue in the sensory homunculus.

Do innervated ree aps or tongue reconstruction regain normal sensation?
No. Flaps are unable to taste because they lack taste buds. However, patients rarely complain about loss o
taste (likely because taste buds are almost ubiquitous within the buccal cavity). General sensory unction o an
innervated ree ap approaches that o the normal tongue and is superior to the donor site sensation.

Do innervated aps unction better than noninnervated aps?
No studies to date have compared tongue unction in innervated versus noninnervated aps. Innervated aps gain
general sensation sooner postoperatively than noninnervated aps. However, sensation may not be important or
tongue unction.

What actors af ect sensory recovery in aps used or tongue reconstruction?
Postoperative radiation and the use o a recipient nerve other than the lingual or in erior alveolar nerve negatively
impact the sensory recovery o innervated ree aps or tongue reconstruction. Age, smoking, and the size o the
de ect do not seem to in uence the return o sensation.

How does the provision o radiation therapy af ect the choice o reconstruction?
While radiation therapy un ortunately diminishes the wound-healing capabilities o tissues, it does, however,
improve the survival o patients. T e choice o reconstruction, there ore, needs to withstand the e ects o radiation
as much as possible. Prior irradiation not only adversely a ects wound healing but also makes the dissection o
tissue planes and o recipient vessels or microvascular trans er signi cantly more dif cult than in a nonirradiated
eld. Postoperative radiation increases scarring, may cause xerostomia, and may a ect the swallowing
mechanism, making a reely (untethered) mobile reconstruction even more critical to success ul tongue unction.
Chemotherapy compounds the e ects o radiation. In general, the presence o radiation changes or o a plan to
deliver postoperative radiotherapy should strongly encourage the use o a microvascular reconstruction, which can
import liberal volumes o nonirradiated tissue with its own blood supply. It should also be remembered that tissues
subjected to postoperative irradiation would invariably shrink, meaning that a reconstruction must overcorrect
tongue volume to compensate.

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What is the ef ect o a palatal build-down prosthesis on tongue unction?
A prosthesis placed over the palate in an attempt to achieve tongue–palate contact has a negative impact on
unction because the patient will lose important sensory eedback rom the palate. (Palatal sensation might explain
how noninnervated aps are able to unction similar to reinnervated aps.)

What are the important determinates o unctional outcome ollowing tongue reconstruction?
T e primary predictor o postoperative unction is de ect size, with larger de ects associated with poorer outcomes.
Postoperative radiotherapy and midline de ects correlate with worse unctional results. Reconstructions that
maintain tongue mobility and bulk give patients better speech and swallowing.

What are the advantages o the radial orearm ree ap or tongue reconstruction?
Large sur ace area available; thin, pliable tissue; long pedicle i required; technically easy to harvest; several use ul
variants: neuro asciocutaneous, osseo asciocutaneous, and tendo asciocutaneous.

What are the disadvantages o the radial orearm ree ap?
Lack o bulk or large tongue de ects and the donor site morbidity, which includes sensory changes and poor
cosmesis.

What are the advantages o the supra ascial dissection or a radial orearm ree ap?
Fewer donor site complications: decreased rate o skin gra t loss, less delayed healing, decreased incidence o
tendon exposure.

What options exist or reconstructing total or subtotal tongue de ects?
Primarily ree aps: anterolateral thigh, rectus abdominis myocutaneous, latissimus dorsi, jejunum.

For total tongue de ects, can the tongue muscles be reconstructed?
No. Currently, the tongue muscles are too complex to reconstruct. Functioning gracilis may be trans erred in
either a longitudinal or a transverse orientation, with the goal o providing only elevation o the neotongue when
required. oo ew studies exist to comment on the utility o unctioning muscle trans ers in tongue reconstruction.

Are there problems associated with using muscle aps or tongue reconstruction?
Noninnervated muscle aps undergo atrophy and over time may not provide enough bulk in reconstruction o
large de ects. T e reinnervation o musculocutaneous aps is worse than that o noninnervated asciocutaneous
aps.

Can the tongue be transplanted rom a cadaveric donor?
Yes. In 1999, tongue transplantation was demonstrated as technically easible in a canine model. In 2003,
the rst tongue transplantation in humans was per ormed in Vienna to reconstruct an oncological de ect
involving the total tongue with in ltration o the mandible and oor o mouth ( 4N2bM0). T e patient was
immunosuppressed immediately postoperatively and therea ter. Resection margins were ree o tumor but
recurrence occurred a ter 12 months and the patient died 1 month later. At 10 months, the patient had regained
sensation to the le t tongue but not independent motor unction; however, the patient was able to swallow saliva
and small amounts o pulpy oods, and speak intelligibly. Since then, a composite transplantation o tongue with
mandible and oor o mouth has been achieved in late 2009 in Spain. Composite tissue allotransplantation or
oncological de ect reconstruction remains highly controversial.

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REFERENCES
Avery CM, Pereira J, Brown AE. Supra ascial dissection o the radial orearm ap and donor site morbidity. Int J Oral Maxillofac Surg.
2001;30:37–41.
Bannister LH. Alimentary system. In: Williams PL, ed. Gray’s Anatomy. 38th ed. oronto, ON, Canada: Churchill-Livingstone; 1999:
1683–1733.
Bastian RW, Riggs LC. Role o sensation in swallowing unction. Laryngoscope. 1999;109:1974–1977.
Berry M, Bannister LH, Standring SM. Nervous system. In: Williams PL, ed. Gray’s Anatomy. 38th ed. oronto, ON, Canada: Churchill-
Livingstone; 1999:901–1397.
Boyd B, Mulholland S, Gullane P, et al. Reinnervated lateral antebrachial cutaneous neurosome aps in oral reconstruction: are we
making sense? Plast Reconstr Surg. 1994;93:1350–1359; discussion 1360–1362.
Chang SC, Miller G, Halbert CF, Yang KH, Chao WC, Wei FC. Limiting donor site morbidity by supra ascial dissection o the radial
orearm ap. Microsurgery. 1996;17:136–140.
Collins P. Embryology and development. In: Williams PL, ed. Gray’s Anatomy. 38th ed. oronto, ON, Canada: Churchill-Livingstone;
1999:91–341.
de Bree R, Hartley C, Smeele LE, Kuik DJ, Quak JJ, Leemans CR. Evaluation o donor site unction and morbidity o the asciocutaneous
radial orearm ap. Laryngoscope. 2004;114(11):1973–1976.
Evans GRD, Kroll SS. Intraoral so t tissue reconstruction. In: Schusterman MA, ed. Microsurgical Reconstruction of the Cancer Patient.
Philadelphia, PA: Lippincott-Raven; 1997:13–23.
Greene FL, Balch CM, Page DL, et al. AJCC Cancer Staging Handbook. 6th ed. New York, NY: Springer-Verlag; 2002.
Haughey BH. ongue reconstruction: concepts and practice. Laryngoscope. 1993;103:1132–1141.
Haughey BH, Beggs JC, Bong J, Genden EM, Buckner A. Microneurovascular allotransplantation o the canine tongue. Laryngoscope.
1999;109:1461–1470.
Horner MJ, Ries LA, Krapcho M, et al. SEER Cancer Statistics Review, 1975–2006. Bethesda, MD: National Cancer Institute; 2009,
based on November 2008 SEER data submission, posted to the SEER web site
Huang CH, Chen HC, Huang YL, Mardini S, Feng GM. Comparison o the radial orearm ap and the thinned anterolateral thigh
cutaneous ap or reconstruction o tongue de ects: an evaluation o donor-site morbidity. Plast Reconstr Surg. 2004;114(7):
1704–1710.
Imanishi Y, Isobe K, Nameki H, et al. Extended sigmoid-shaped ree jejunal patch or reconstruction o the oral base and pharynx a ter
total glossectomy with laryngectomy. Br J Plast Surg. 2004;57:195–202.
Kermer C, Watzinger F, Oeckher M. ongue transplantation: 10-month ollow-up. Transplantation. 2008;85:654–655.
Kimata Y, Sakuraba M, Hishinuma S, et al. Analysis o the relations between the shape o the reconstructed tongue and the postoperative
unctions a ter subtotal or total glossectomy. Laryngoscope. 2003;113:905–909.
Kuriakose MA, Loree R, Spies A, Meyers S, Hicks WL Jr. Sensate radial orearm ree aps in tongue reconstruction. Arch Otolaryngol
Head Neck Surg. 2001;127:1463–1466.
Kveton JF, Bartoshuk LM. aste. In: Bailey BJ, Calhoun KH, eds. Head and Neck Surgery—Otolaryngology. 2nd ed. Philadelphia, PA:
Lippincott-Raven, 1998:609–626.
McConnell FM. Analysis o pressure generation and bolus transit during pharyngeal swallowing. Laryngoscope. 1988;98:71–78.
Murakami R, anaka K, Kobayashi K, et al. Free groin ap or reconstruction o the tongue and oral oor. J Reconstr Microsurg.
1998;14:49–55.
Nicoletti G, Soutar DS, Jackson MS, Wrench AA, Robertson G. Chewing and swallowing a ter surgical treatment or oral cancer:
unctional evaluation in 196 selected cases. Plast Reconstr Surg. 2004;114:329–338.
Nicoletti G, Soutar DS, Jackson MS, Wrench AA, Robertson G, Robertson C. Objective assessment o speech a ter surgical treatment
or oral cancer: experience rom 196 selected cases. Plast Reconstr Surg. 2004;113:114–125.
Salibian AH, Allison GR, Armstrong WB, et al. Functional hemitongue reconstruction with the microvascular ulnar orearm ap. Plast
Reconstr Surg. 1999;104:654–660.
Salibian AH, Allison GR, Rappaport I, Krugman ME, McMicken BL, Etchepare L. otal and subtotal glossectomy: unction a ter
microvascular reconstruction. Plast Reconstr Surg. 1990;85(4):513–524; discussion 525–526.
Santamaria E, Wei FC, Chen IH, Chuang DC. Sensation recovery on innervated radial orearm ap or hemiglossectomy reconstruction
by using di erent recipient nerves. Plast Reconstr Surg. 1999;103:450–457.
Soutar DS, McGregor IA. T e radial orearm ap in intraoral reconstruction: the experience o 60 consecutive cases. Plast Reconstr Surg.
1986;78:1–8.

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Swartz WM, Banis JC. Intraoral reconstruction. Head and Neck Microsurgery. Baltimore, MD: Williams & Wilkins; 1992.
Urken ML, Moscoso JF, Lawson W, Biller HF. A systematic approach to unctional reconstruction o the oral cavity ollowing partial
and total glossectomy. Arch Otolaryngol Head Neck Surg. 1994;120:589–601.
Vriens JP, Acosta R, Soutar DS, Webster MH. Recovery o sensation in the radial orearm ree ap in oral reconstruction. Plast Reconstr
Surg. 1996;98:649–656.
Yoleri L, Mavioglu H. otal tongue reconstruction with ree unctional gracilis muscle transplantation: a technical note and review o
the literature. Ann Plast Surg. 2000;45:181–186.
Yousi NJ, Dzwierzynski WW, Sanger JR, Matloub HS, Campbell BH. T e innervated gracilis musculocutaneous ap or total tongue
reconstruction. Plast Reconstr Surg. 1999;104(4):916–921.

801
Eugene Y. Fukudome, MD and
Donald J. Morris, MD, FACS
THORACIC RECONSTRUCTION

What is the most common intrathoracic problem that requires intervention by a plastic surgeon?
Empyema (collection o pus within the pleural space). T is can be secondary to problems such as bronchopleural
stula or esophageal per oration, and a thoracic surgeon may enlist the help o a plastic surgeon in managing these
di cult problems.

What is a bronchopleural stula, and what is the cause?
A bronchopleural stula is a communication between a bronchus and the pleural cavity that is usually caused by
postoperative necrosis o the bronchial stump ollowing lung resection. A bronchopleural stula can also result
rom necrotizing pneumonia or necrosis o the bronchial wall secondary to radiation.

What are the important principles in the success ul management o an empyema resulting rom a
bronchopleural stula or esophageal per oration?
1. Assessment and optimization o the patient’s overall medical condition and nutrition status.
2. Appropriate antibiotics based on culture and sensitivity data.
3. Resection and/or debridement o the bronchopleural stula or esophageal per oration back to healthy tissue,
and closure.
4. Obliteration o dead space and rein orcement o any bronchial or esophageal repairs with well-vascularized
tissue. ypically a ap is required.
5. Adequate drainage a ter reconstruction.

How do you obliterate intrathoracic dead space?
Larger, bulkier muscle aps (pectoralis major, latissimus dorsi) or omentum is used to ll the hemithorax. O ten,
an intercostal muscle ap is used to bolster a bronchial or esophageal repair, and a muscle ap can be transposed
into the chest through the intercostal muscle ap donor site. Alternatively, a rib resection can be per ormed to
allow transposition o the muscle into the chest.
Chest and Abdominal
Wall Reconstruction
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What are the common acquired chest wall problems that require intervention by a plastic surgeon?
Chest wall de ects resulting rom tumor resection, trauma, or wounds resulting rom radiation, severe in ection,
and surgical complications.

What are the important goals and principles in the success ul management o these chest wall problems?
1. Resection o the tumor with adequate margins.
2. Debridement o all devitalized/damaged issue.
3. Optimization o respiratory mechanics by the creation o an airtight pleural space with a stable chest wall such
that negative intrathoracic pressure can be generated during inspiration.
4. Protect intrathoracic organs and prevent problems such as lung hernia and diaphragmatic hernia.
5. Recruitment o well-vascularized so t-tissue coverage o the de ect that will allow or adjuvant radiation therapy
i indicated.
6. Re-establish a cosmetically acceptable chest wall contour.

Describe the di erences between nonrigid, semirigid, and rigid reconstruction o the chest wall.
Nonrigid methods o reconstruction include so t-tissue aps such as muscle and musculocutaneous aps. While
this method does recruit well-vascularized tissue, there is minimal contribution to the structural integrity o the
chest wall. Paradoxical chest wall motion may be a signi cant problem to these patients postreconstruction.
Semirigid methods typically re er to a situation where mesh is used to span a skeletal de ect, and the mesh is
sutured in place under tension. Synthetic (polypropylene and polytetra uoroethylene [P FE]) or bioprosthetic
mesh can be used depending on the clinical situation.
Rigid xation involves the use o oreign bodies such as polymethylmethacrylate “sandwiched” between synthetic
mesh such as polypropylene. Autologous orms o rigid xation can include rib and ascia gra ts, but these
have largely been replaced by synthetic products. Absence o bacterial contamination, and well-vascularized,
nonradiated so t-tissue coverage is critical when using oreign material or rigid xation o the chest wall because
in ection will require removal o the construct with loss o the entire reconstruction.

When is rigid reconstruction o the chest wall indicated, and when is nonrigid reconstruction su cient?
Universally accepted guidelines based on high-quality data do not exist, but various authors have provided the
ollowing guidelines:
Size-based criteria: chest wall de ects larger than 5 cm, or de ects involving 4 or more ribs should undergo rigid
reconstruction.
Location-based criteria: chest wall de ects involving the apex and posterior chest wall do not require rigid xation,
except when the tip o the scapula may become impacted in the de ect. In this case, semirigid xation should be
considered. Anterior and lateral de ect should be considered or rigid reconstruction.

What are the problems associated with rigid reconstruction o the chest wall?
Rigid xation is associated with higher rates o surgical site in ection. When in ection occurs, reoperation and
removal o oreign material are indicated, either acutely, or a ter a delay period to rst allow or brosis. In either
case, this may lead to a delay in any planned chemotherapy or radiation therapy. Rigid reconstruction may also
result in more chronic pain. T e risks and bene ts o rigid xation o the chest wall must be care ully considered
or each individual patient.

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How does radiation therapy impact reconstruction o the chest wall?
Radiation-induced brosis may result in enough stif ening o the chest wall to prevent paradoxical respiratory
movement so that rigid reconstruction may be unnecessary. It is also prudent to avoid placement o a oreign body
in a radiated eld. Radiation therapy also mandates the use o well-vascularized healthy tissue or reconstruction.

What are the common f aps used or thoracic reconstruction?
T e latissimus dorsi, pectoralis major, rectus abdominis, and serratus anterior muscles are commonly used. T e
omental ap also has several applications. Intercostal muscle aps play a role in re-en orcement o bronchial,
tracheal, and esophageal repairs. Free tissue trans ers are less commonly used, but may be required.

What is the blood supply o the latissimus dorsi muscle?
T e thoracodorsal artery, arising rom the subscapular artery, is the primary blood supply o the latissimus dorsi
muscle. T e latissimus dorsi ap can also be based on posterior intercostal per orators and used as a turnover
ap to address de ects in the mid-back region. For thoracic surgery patients who have previously undergone a
posterolateral thoracotomy, the latissimus dorsi muscle is o ten divided, making the distal portion o the muscle
unusable or reconstruction unless a muscle-sparing thoracotomy was used.

What is the blood supply o the serratus anterior muscle?
T e serratus branch of the thoracodorsal artery rom the subscapular system supplies the serratus anterior muscle.

What is the blood supply o the pectoralis major muscle?
T e pectoral branch o the thoracoacrominal artery is the primary blood supply o the pectoralis major muscle.
T e pectoralis major muscle can also be based on internal mammary artery (IMA) per orators and used as a
turnover ap or sternal wound closure.

What is the blood supply o the rectus abdominis muscle?
Although the primary blood supply o the rectus abdominis muscle is the deep in erior epigastric artery, or chest
wall reconstruction, this ap is typically based on the superior epigastric artery, originating rom the IMA. In cases
where the IMA has been divided, a rectus abdominis muscle ap can be raised based on intercostal and subcostal
vessels. A previous subcostal incision, however, is a contraindication to a superiorly based rectus abdominis ap.

What is the blood supply o the greater omentum?
T e right and le t gastroepiploic arteries supply the greater omentum. T e omental ap can be based on either the
right or le t gastroepiploic artery.
STERNAL RECONSTRUCTION

How requently does dehiscence o median sternotomy wounds occur?
1% to 5% o median sternotomy wounds will dehisce.

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What are the common sternal and mediastinal problems that require intervention by a plastic surgeon?
In ection: Postoperative complications such as poststernotomy in ections and mediastinitis. In addition, the
sternoclavicular joint may become in ected rom hematogenous seeding rom a distant source.
Exposures: Major vessels, pericardium and its contents, vascular gra ts, and other critical hardware such as
ventricular assist devices may become exposed and require coverage.

What are some risk actors or sternal wound in ection?
Diabetes, COPD, obesity, smoking, renal ailure, peripheral vascular disease, IMA harvest (bilateral harvest is
higher risk than unilateral harvest), prolonged hospital course, ICU course or ventilator support, and use o intra-
aortic balloon pump.

What are the di erent presentations o sternal wound in ections?
Sternal wound in ections can present in three relatively distinct ways as categorized by Pairolero.
ype I in ections occur within several days and present with serosanguineous drainage.
ype II in ections occur a ew weeks postoperatively and present with cellulitis, osteomyelitis, mediastinitis, and
drainage o pus.
ype III in ections occur months later and present with osteomyelitis, chondritis, and a chronically draining sinus
tract.

How are sternal wound in ections managed?
Sternal wounds must be managed in conjunction with the cardiac surgeon, and any operative debridement should
occur in a cardiac surgery suite with cardiac anesthesia in an event that any mediastinal structures are injured.
ype I in ections typically are handled by irrigation, minimal debridement, and re-closure, and are usually handled
by the cardiac surgeon.
ype II and III in ections are managed by ollowing the principles o chest wall reconstruction. Irrigation
and drainage o the in ection is critical, and devitalized tissue must be debrided. Cartilage is relatively poorly
vascularized, and when in ected, must be debrided as well. When the patient is medically as optimized as possible,
reconstruction is undertaken using healthy well-vascularized tissue to obliterate the dead space and close the
wound. Care ully selected patients who have a low bacterial burden, well-vascularized bone, and no dead space
may be candidates or sternal osteosynthesis.

What is the main cause o ailure o reconstruction o a dehisced/in ected median sternotomy wound?
Inadequate debridement.

Are sternal in ections typically managed as a single-stage operation consisting o thorough debridement with
immediate coverage, or in a multi-staged manner?
Single-stage debridement and closure has been reported, but the debridement must be aggressive to ensure all
devitalized so t tissue, bone, and cartilage is removed. More commonly, a staged approach is used. A staged
approach allows or repeated assessment o the wound and tissue, and allows culture and sensitivity data to be
nalized to ensure proper antibiotic choice. Negative pressure wound therapy, such as the VAC device, acilitates
a staged approach because the VAC device can promote the ormation o healthy granulation tissue, protect the
mediastinal contents, and stabilize the sternum and allow or extubation prior to de nitive reconstruction.

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Is there a role or rigid sternal xation in the management o sternal reconstruction?
Many surgeons are reluctant to place any hardware or rigid sternal xation in the setting o recent sternal
in ection; there ore, so t-tissue-only reconstruction is typical. Although rigid sternal xation is not necessary, an
unstable sternum may result in chronic pain, paradoxical movement, and respiratory impairment. o address these
problems related to sternal instability, some authors have success ully per ormed rigid internal xation in care ully
selected patients with an adequately debrided wound, low bacterial burden, and well-vascularized bone. T is
approach requires urther study, but may represent a uture approach to this problem. In addition, primary sternal
plating at the time o cardiac surgery (rather than traditional wire cerclage) may be indicated in patients that are
high risk or wound complications (diabetes, COPD, obesity, renal ailure, immunosuppression, etc.).

What are the common f ap choices or sternal reconstruction?
Pectoralis major, omentum, and rectus abdominis.

Describe the multiple ways in which the pectoralis major muscle can be used or sternal reconstruction?
One or both pectoralis major muscles can be used.
When the internal mammary artery was used or CABG (usually the le t IMA), this muscle can be used as an
advancement or transposition ap, based on the thoracoacromial artery. T e muscle can be dissected ree rom the
chest wall as well as the overlying skin, can be released rom the humerus to increase mobility, and can also be split
to cover superior and in erior de ects. T e muscle can also be le t attached to the skin as a musculocutaneous ap,
and this is o ten the better option as it avoids devascularizing the anterior chest skin. I the IMA is preserved, the
muscle can be used as a turnover ap, based on the IMA per orators.

Describe the various ways an omental f ap can be harvested or sternal reconstruction?
T e omental ap can be harvested through a transdiaphragmatic approach and brought up into the mediastinum.
Alternatively, the omentum can be harvested through an upper midline laparotomy incision, but should be placed
into the mediastinum using a transdiaphragmatic course to avoid an upper midline ventral hernia. Laparoscopic
harvest o the omentum is also described as a minimally invasive approach.

Is there a f ap which is “best” or sternal reconstruction?
T e pectoralis muscle is probably the most commonly used ap and is o ten considered to be the “ rst-line.”
However, a recent meta-analysis o the topic ailed to show that a muscle ap was superior to an omental ap.

Describe f ap selection in upper, middle, and lower third back wound reconstruction.
rapezius muscle ap (upper), latissimus muscle ap (middle), gluteus muscle ap, and superior or in erior gluteal
artery per orator aps (lower). Paraspinous muscle should be considered or advancement or turnover to cover
exposed spinal hardware.

What is the most common organism identi ed in sternal in ections/mediastinitis?
Staphylococcus species.

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Should debridement and f ap coverage be per ormed in one stage, or should f ap coverage be per ormed in a
delayed ashion a ter debridement and dressing changes or closed drainage?
Studies indicate that aggressive debridement and immediate ap coverage has a very high success rate
(approximately 95%) and avoids the drawbacks o delayed closure, such as multiple operations and prolonged
exposure o mediastinal contents.

What are other advantages o f ap closure o in ected/dehisced sternal wounds?
Decreased hospital stay and cost.
RECONSTRUCTION OF THE ABDOMINAL WALL

Describe the anatomy o the musculo ascial layers o the abdominal wall, including the lineal alba, arcuate
line, and semilunar lines.
T e anterior abdominal wall is made up o paired rectus abdominis muscles, and pyramidalis muscles. Lateral
to the rectus abdominis muscles, the abdominal wall has three muscle layers: (1) external oblique, (2) internal
oblique, and (3) transversus abdominis. T e aponeurosis o these muscles use lateral to the rectus abdominis
muscles to create the semilunar lines. Above the arcuate line, the rectus abdominis muscle has an anterior sheath
(composed o the external oblique and part o the internal oblique aponeurosis) and a posterior sheath (composed
o part o the internal oblique and transversus abdominis aponeurosis). Below the arcuate line, there is only an
anterior sheath composed o the aponeurosis rom the three muscles. Finally, the muscular aponeuroses orm the
midline linea alba that separate the le t and right rectus muscles.

Describe the blood supply o the abdominal wall.
T e abdomen is supplied by the superior epigastric artery, the deep in erior epigastric artery (zone 1), super cial
branches o the circum ex iliac and external pudendal vessels (zone II), and intercostal, subcostal and lumbar
arteries (zone III o Huger’s classi cation). T e laterally based vessels are ound between the internal oblique and
transverse abdominis muscles along with the nerves.

What are the common abdominal wall problems that require intervention by a plastic surgeon?
Most commonly, midline abdominal wall de ects due to incisional hernias with retraction o the muscles laterally.
T ere may actually not be any tissue loss per se, but the de ect is due to loss o domain. T ere may be loss o
healthy skin due to multiple operations complicated by in ection or stulae. Signi cant abdominal wall de ects
can also result rom tumor resection.

What are the goals o abdominal wall reconstruction?
Protect intra-abdominal organs, restore musculo ascial integrity and unction, prevent recurrent herniation, and
provide stable so t-tissue coverage with an acceptable contour.

What are the critical components to assess when evaluating abdominal wall de ects?
While the size o the de ect is important, it is also critical to accurately assess the skin, musculo ascial layer, and
intra-abdominal domain. In addition, the location o the de ect will impact reconstructive options, and must be
assessed.

CHAPTER 84 Chest and Abdominal Wall Reconstruction
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What are some options or management o skin and so t-tissue de ects o the abdominal wall?
Closure, typically with undermining, healing by secondary intention (with dressing changes or negative-pressure
wound therapy), skin gra ting, local or regional aps, tissue expansion, or in rare cases, ree tissue trans er.

What are some options or management o abdominal wall de ects involving the musculo ascial layers?
Closure, typically with component separation, ascia gra ts, aps containing ascia, or with the use o implanted
mesh (this should only be considered when there is adequate skin coverage overlying the mesh).

Describe the components separation technique.
In an anterior component separation, the external oblique aponeurosis is incised lateral to the semilunar line,
and the avascular plane between the external oblique and internal oblique muscle is dissected to allow medial
advancement o the complex consisting o the rectus abdominis muscle with its surrounding sheath and the
internal oblique and transversus abdominis muscles. A posterior component separation deep to the transversus
abdominis muscles can also be utilized including the posterior rectus sheath.

What distances are gained by per orming a components separation?
On each side, an estimated length gain is 3 to 5 cm at the epigastrium, 7 to 10 cm at the umbilical region, and
1 to 3 cm at the suprapubic region.

Describe some modi cations o a standard components separation?
Minimally invasive techniques can be used to limit undermining, and preserve per orating vessels to the skin.
T ese modi cations may reduce dead space and ischemia, and may reduce postoperative wound complications.

What role can tissue expansion play in abdominal wall reconstruction?
issue expanders can be placed subcutaneously to increase the amount o skin available. T ey can also be placed in
the avascular plane between the external and internal oblique muscles to acilitate ascial expansion and closure.

Describe the di erent types o mesh, and how these can be used to reconstruct the abdominal wall.
Implantable mesh is either synthetic or biologic. Biologic mesh is derived rom either human or animal material
(dermis or other), while synthetic material can be manu actured rom various materials, and has been classi ed
as macroporous (polypropylene), microporus (expanded polytetra uoroethylene or eP FE), or composite.
Polypropylene’s macroporous structure allows or tissue in-growth, but may cause adhesions o the mesh to bowel,
whereas eP FE’s microporus structure does not allow in-growth. While adhesions are minimized, the mesh is
never incorporated, but heals with capsule ormation, and has no resistance to in ection. Once contaminated,
this type o mesh must be removed. Composite meshes combine more than one material and are designed or
intraperitoneal use with less risk o bowel adhesion ormation. Mesh can be placed as either an overlay or underlay
to bolster the primary ascial closure (with or without component separation), or as a bridged repair where the
mesh spans a gap in the ascia.

What are the characteristics o an optimal abdominal wall reconstruction?
Hernia recurrence rates are lowest when ascial closure is achieved, and mesh is used to bolster the repair as an
underlay. Wrinkles in the mesh should be avoided, and the mesh should underlap the musculo ascial layer. Dead
space must be obliterated, and drains should be placed. A bridged repair is in erior, and is associated with a high
ailure rate. Mesh underlay appears to be superior to mesh overlay. ypical recommendations are to avoid synthetic
mesh in contaminated elds and to avoid placing polypropylene in an intraperitoneal location; however, high-
quality studies to address these issues are lacking, and the optimal use or each type o mesh is yet to be determined.

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What are the reconstructive options or the ventral hernia repair in a heavily contaminated case?
Fascia closure should be strived or usually by addition o bilateral external oblique component separation. Many
surgeons eel that in heavily contaminated cases, synthetic mesh is contraindicated, and that it may be necessary
to use a bridging biologic mesh i the ascia cannot be closed; however, there is a high rate o postoperative seroma
ormation and a high ailure rate, and uture operations are likely. Further studies are needed to determine an
optimal reconstructive strategy.

What are the challenges in per orming abdominal wall reconstruction in patients who also have an
enterocutaneous stula?
T e presence o an enterocutaneous stula predisposes these patients to malnutrition as well as electrolyte
abnormalities. T ese patients will require a bowel resection and anastomosis in addition to abdominal wall
reconstruction, and an anastomotic leak in the early postoperative period may result in early stula recurrence, or
may also present as li e-threatening abdominal sepsis. T e clinician must maintain vigilance when caring or these
complex patients.

What are some intraoperative maneuvers that could be use ul during a di cult case?
Preoperative mechanical bowel preparation, gastric decompression, paralysis, and avoidance o nitrous oxide
are essential. Some surgeons advocate monitoring peak inspiratory pressure and bladder pressure to avoid
postoperative abdominal compartment syndrome or similar problems. Abdominal compartment syndrome can be
lethal and there ore must be avoided. With peak inspiratory pressures increasing more than 10 mm rom baseline,
one must consider a bridging mesh to avoid this complication.

What is the role or f aps in abdominal wall reconstruction?
While component separation is very ef ective or central midline musculo ascial de ects, it is much less use ul or
superior or in erior midline de ects, or lateral de ects. In these cases, regional aps may provide a reconstructive
solution.

Name some f aps that can be used or abdominal reconstruction?
Lower abdominal de ects can be repaired with a tensor ascia lata ap, rectus emoris ap, or anterolateral thigh
ap. T ese aps have been reported to reach the supraumbilical position. Vastus lateralis, or gracilis aps can also
be used or lower de ects. A subtotal thigh ap can provide a signi cant amount o tissue or large de ects. T e
latissimus dorsi muscle can be used or upper lateral de ects. O ten, these de ects are reconstructed with mesh and
the ap is used to cover the mesh with well-vascularized tissue.

How do you manage an abdominal wall desmoid tumor?
Abdominal wall desmoid tumors should be managed in conjunction with a general surgeon. Recent studies
have shown that many o these can be treated with oral agents such as non steriodal antiin ammatories, thereby
avoiding surgery in some patients. While these are benign tumors that do not metastasize, they are locally
aggressive and have a tendency to recur. An en bloc ull-thickness wide local excision should be per ormed with
negative pathological margins to minimize the risk o recurrence. Due to the large de ect size resulting rom an
aggressive resection, abdominal wall reconstruction can be a challenge, but should ollow the principles outlined
above. Abdominal wall desmoid tumors do not require chemotherapy or radiation.

CHAPTER 84 Chest and Abdominal Wall Reconstruction
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REFERENCES
Albino FP, Patel KM, Nahabedian MY, Sosin M, Attinger CE, Bhanot P. Does mesh location matter in abdominal wall reconstruction?
A systematic review o the literature and a summary o recommendations. Plast Reconstr Surg. 2013;132(5):1295–1304.
Althubaiti G, Butler CE. Abdominal wall and chest wall reconstruction. Plast Reconstr Surg. 2014;133(5):688e–701e.
Arnold PG, Pairolero PC. Chest-wall reconstruction: an account o 500 consecutive patients. Plast Reconstr Surg. 1996;98(5):804–810.
Arnold PG, Pairolero PC. Intrathoracic muscle aps: a 10-year experience in the management o li e-threatening in ections. Plast
Reconstr Surg. 1989;84(1):92–98; discussion 99.
Bakri K, Mardini S, Evans KK, Carlsen B , Arnold PG. Workhorse aps in chest wall reconstruction: the pectoralis major, latissimus
dorsi, and rectus abdominis aps. Semin Plast Surg. 2011;25(1):43–54.
Berri RN, Baumann DP, Madewell JE, Lazar A, Pollock RE. Desmoid tumor: current multidisciplinary approaches. Ann Plast Surg.
2011;67(5):551–564.
Cicilioni OJ Jr, Stieg FH 3rd, Papanicolaou G. Sternal wound reconstruction with transverse plate xation. Plast Reconstr Surg.
2005;115(5):1297–1303.
Cohen M. Reconstruction o the chest wall. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Boston, MA: Little, Brown
and Company; 1994:1248–1267.
Gottlieb LJ, Pielet RW, Karp RB, Krieger LM, Smith DJ Jr, Deeb GM.. Rigid internal xation o the sternum in postoperative
mediastinitis. Arch Surg. 1994;129(5):489–493.
Hanna WC, Ferri LE, McKendy KM, urcotte R, Sirois C, Mulder DS. Reconstruction a ter major chest wall resection: can rigid
xation be avoided?. Surgery. 2011;150(4):590–597.
Hawn M , Snyder CW, Graham LA, Gray SH, Finan KR, Vick CC. Long-term ollow-up o technical outcomes or incisional hernia
repair. J Am Coll Surg. 2010;210(5):648–655.
Huger WE Jr. T e anatomic rationale or abdominal lipectomy. Am Surg. 1979;45(9):612–617.
Itani KM, Rosen M, Vargo D, et al. Prospective study o single-stage repair o contaminated hernias using a biologic porcine tissue
matrix: the RICH Study. Surgery. 2012;152(3):498–505.
Ko JH, Wang EC, Salay DM, Paul BC, Dumanian GA. Abdominal wall reconstruction: lessons learned rom 200 “components
separation” procedures. Arch Surg. 2009;144(11):1047–1055.
Krpata DM, Stein SL, Eston M, et al. Outcomes o simultaneous large complex abdominal wall reconstruction and enterocutaneous
stula takedown. Am J Surg. 2013;205(3):354–358; discussion 358–359.
Mahabir RC, Butler CE. Stabilization o the chest wall: autologous and alloplastic reconstructions. Semin Plast Surg. 2011;25(1):34–42.
Mathes SJ, Steinwald PM, Foster RD, Hof man WY, Anthony JP. Complex abdominal wall reconstruction: a comparison o ap and
mesh closure. Ann Surg. 2000;232(4):586–596.
Montgomery A. T e battle between biological and synthetic meshes in ventral hernia repair. Hernia. 2013;17(1):3–11.
Pairolero PC, Arnold PG, Harris JB. Long-term results o pectoralis major muscle transposition or in ected sternotomy wounds. Ann
Surg. 1991;213(6):583–589; discussion 589–590.
Ramirez OM, Ruas E, Dellon AL. “Components separation” method or closure o abdominal-wall de ects: an anatomic and clinical
study. Plast Reconstr Surg. 1990;86(3):519–526.
Raman J, Lehmann S, Zehr K, et al. Sternal closure with rigid plate xation versus wire closure: a randomized controlled multicenter
trial. Ann T orac Surg. 2012;94(6):1854–1861.
Roche NA, Van Landuyt K, Blondeel PN, Matton G, Monstrey SJ. T e use o pedicled per orator aps or reconstruction o lumbosacral
de ects. Ann Plast Surg. 2000;45(1):7–14.
Rohrich RJ, Lowe JB, Hackney FL, Bowman JL, Hobar PC. An algorithm or abdominal wall reconstruction. Plast Reconstr Surg.
2000;105(1):202–216.
Rosenthal AH. T oracic and abdominal reconstruction. In: Brown DL, Borschel GH, eds. Michigan Manual of Plastic Surgery.
Philadelphia, PA: Lippincott Williams & Wilkins; 2004:344–348.
Roth DA. T oracic and abdominal wall reconstruction. In: Aston SJ, Beasley RW, T orne CH, eds. Grabb and Smith’s Plastic Surgery.
5th ed. Philadelphia, PA: Lippincott-Raven; 1997:1023–1029.
Saulis AS, Dumanian GA. Periumbilical rectus abdominis per orator preservation signi cantly reduces super cial wound complications
in “separation o parts” hernia repairs. Plast Reconstr Surg. 2002;109(7):2275–2280; discussion 2281–2282.
Sey er AE. Chest wall reconstruction. In: Achauer BM, Eriksson E, eds. Plastic Surgery Indications, Operations, and Outcomes. St Louis,
MO: Mosby; 2000:547–562.

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Singh K, Anderson E, Harper JG. Overview and management o sternal wound in ection. Semin Plast Surg. 2011;25(1):25–33.
Souza JM, Dumanian GA. An evidence-based approach to abdominal wall reconstruction. Plast Reconstr Surg. 2012;130(1):116–124.
sukushi S, Nishida Y, Sugiura H, et al. Non-rigid reconstruction o chest wall de ects a ter resection o musculoskeletal tumors. Surg
oday. 2015;45(2):150–155.
van Wingerden JJ, Lapid O, Boonstra PW, de Mol BA. Muscle aps or omental ap in the management o deep sternal wound
in ection. Interact Cardiovasc T orac Surg. 2011;13(2):179–187.
Ventral Hernia Working Group, Breuing K, Butler CE, et al. Incisional ventral hernias: review o the literature and recommendations
regarding the grading and technique o repair. Surgery. 2010;148(3):544–558.
Vyas RM, Prsic A, Orgill DP. ransdiaphragmatic omental harvest: a simple method or sternal wound coverage. Plast Reconstr Surg.
2013;131(3):544–552.

811
Arin K. Greene, MD, MMSc and
Sumner A. Slavin, MD

What is lymphedema?
Accumulation o protein-rich uid in the interstitial space due to lymphatic dys unction.

How common is lymphedema?
Approximately 150 million people are a ected worldwide.

What structures are most commonly involved?
T e extremities, ollowed by the genitalia.

Does lymphedema a ect the superf cial or deep areas o the extremity?
Only the subcutaneous tissues are involved.

What is the natural history o lymphedema?
Adipose and brous tissues are produced which cause enlargement o the limb.
Lymphedema
CHAPTER 85

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How is lymphedema classif ed?
Primary or secondary.
ypes o lymphedema. (Le t) A 24-year-old emale developed primary lymphedema o the lower extremity during adolescence. (Right) A
70-year-old emale with upper extremity lymphedema ollowing mastectomy, axillary lymphadenectomy, and radiation or breast cancer.

What is primary lymphedema?
Lymphedema that results rom a congenital mal ormation o the lymphatic system.

How common is primary lymphedema?
Rare. T e prevalence is approximately 1:100,000.

When does primary lymphedema present?
Males usually present in in ancy, emales typically develop swelling in adolescence.

What structures are most commonly a ected by primary lymphedema?
Lower extremities (90%), genitalia (16%), and upper extremities (10%).

Is there a genetic cause o primary lymphedema?
Yes, mutations in VEGFR3, FOXC2, SOX18, and CCBE1 cause some amilial/syndromic orms o
lymphedema.

CHAPTER 85 Lymphedema
813

What is Milroy disease?
Lymphedema o one or both lower extremities present at birth, with either a amily history o disease or a
mutation in VEGFR3.

What is Meige disease?
Lymphedema o one or both lower extremities presenting in adolescence with a amily history o the disease; a
genetic mutation has not been identi ed.

What is secondary lymphedema?
Lymphedema that results rom injury to the lymphatic system.

What is the most common cause o lymphedema worldwide?
Parasitic in ection ( lariasis), causing lower extremity lymphedema.

What is the most common cause o lymphedema in developed countries?
Upper extremity lymphedema secondary to axillary lymphadenectomy and radiation treatment or breast cancer.

What percentage o women with breast cancer who have axillary lymphadenectomy and radiation develop
lymphedema?
Approximately 33%.

How long a ter axillary lymphadenectomy and radiation does it take or lymphedema to become clinically
evident?
3 to 24 months.

How is lymphedema diagnosed?
More than 90% o patients are diagnosed by history and physical examination.

What conditions are most commonly con used with lymphedema?
Lipedema, venous stasis, systemic causes o edema (cardiac, renal, hepatic disease), posttraumatic swelling,
Klippel– renanuay syndrome, Parkes–Weber syndrome, and hemihypertrophy.

Can obesity cause lymphedema?
Yes, when a patient’s body mass index exceeds 60 kg/m2 lower extremity lymphatic dys unction occurs
(obesity-induced lymphedema).

What test can conf rm the diagnosis o lymphedema?
Lymphoscintigraphy is 92% sensitive and 100% speci c or lymphedema.

Is CT or MRI use ul to diagnose lymphedema?
No, they are less accurate than lymphoscintigraphy and have nonspeci c ndings.

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Can a biopsy diagnose lymphedema?
No, histopathology shows nonspeci c in ammation.

What is the most common complication o lymphedema?
Cellulitis.

What other problems result rom lymphedema?
Dif culty with daily activities, inability to wear proper- tting clothing, and psychosocial morbidity.

Is lymphedema curable?
No, it is a chronic, progressive condition.

What is the f rst-line treatment or lymphedema?
Compression using either elastic stockings, a pneumatic pump, or bandaging.

Are there drugs available to treat lymphedema?
No.

Is blood pressure monitoring and venepuncture harm ul to a lymphedematous limb?
No, but the nona ected extremity should be used i possible.

When is operative intervention or lymphedema indicated?
Signi cant morbidity despite maximal conservative treatment.

What are the two categories o operative intervention or lymphedema?
Excisional or physiological procedures.

What are excisional procedures?
Operations that remove lymphedematous tissue.

What are physiological procedures?
Operations that attempt to restore lymph drainage.

Which is superior, excisional, or physiological procedures?
Excisional procedures are more e ective and predictable. T ey can also be used or moderate and severe disease.

What is the f rst-line excisional procedure or extremity lymphedema?
Suction-assisted lipectomy.

CHAPTER 85 Lymphedema
815

What is the second-line operative procedure or severe extremity lymphedema with signif cant skin excess?
Staged skin and subcutaneous excision.

What is the Charles procedure?
Circum erential removal o skin, subcutaneous tissue, and ascia ollowed by skin gra ting o the underlying
muscle.

Is the Charles procedure e ective?
Yes, but it is rarely used because it has signi cant postoperative morbidity.

What are the most common physiological procedures per ormed?
Lymphaticovenous anastomosis and vascularized lymph node trans er.

What are the advantages and disadvantages o lymphaticovenous anastomosis?
T e procedure generally is reserved or patients with early disease be ore subcutaneous bro-adipose tissue
develops. Improvement is variable and patients usually require the continued use o compression garments.

What are the advantages and disadvantages o vascularized lymph node trans er?
T e procedure generally is reserved or individuals with early lymphedema be ore bro-adipose hypertrophy
occurs. Improvement is variable. Patients are at risk or lymphedema at the site where lymph nodes are harvested;
the rate has been reported to be as high as 23%.
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