Geoffrey 3 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery-Craniofacial, Head and Neck Surgery-Pediatric Plastic Surgery. 3-Elsevier (2018)

236
SECTION II
CHAPTER 9.2 • Computerized surgical planning in orthognathic surgery
Three-dimensional identification of
hard and soft tissue landmarks
The 3D CT provides a greater understanding of the craniofa-
cial deformity, which cannot be visualized on 2D films,
particularly in patients with facial asymmetry. 3D images
eliminate any magnification distortion observed in 2D images,
and the right and left sides of the craniofacial skeleton can be
examined and measured independently. The mirroring effect
on the non-affected side can also be used to define the skeletal
discrepancy.
Three-dimensional surgical simulations
for skeletal correction
3D surgical simulation takes the guesswork out of 2D surgical
planning. Surgical simulation was traditionally performed
using 2D lateral cephalograms and photographs, and the
surgical plan was later transferred to study models that were
mounted on a semi-adjustable articulator using facebow
transfer. The model surgery was then performed to create
surgical splints. This multistep transfer left many opportuni-
ties for errors in splint construction and in transferring the
surgical plan to the operating room.
In a 3D surgical simulation, there is no need to perform a
facebow transfer, which eliminates the step of transferring the
surgical plan from the lateral cephalogram to the study
models. As the dental occlusion and CT are superimposed as
one unit, the changes performed on the skeleton are trans-
ferred directly to the dental occlusion. CAD/CAM technology
can generate the intermediate and final surgical splints by 3D
printing.
In two-jaw surgery, an additional advantage of 3D simula-
tion software is that the surgeon has the freedom to perform
either the maxillary or mandibular surgery first. This does not
affect the final outcome of surgery. The software can also
generate surgical cutting guides and splints to make precise
osteotomy cuts and place rigid internal fixation accurately.
Fig. 9.2.10  A 3D virtual patient created by the registration of a 3D cone beam
computed tomography (CBCT) image, 3D dental scan, and 3D photographs.
position or in a Frankfort horizontal plane parallel to the floor,
3D medical-grade CT images are acquired with the patient
lying in the supine position. The orientation of the 3D volume
in the virtual space becomes a challenge because improper
head orientation will adversely affect the surgical outcome.
For a patient with facial asymmetry (including orbital dysto-
pia) or torticollis, transferring a natural head posture to the
digital world is critical. Xia et al. have described a novel
method of recording head posture with a help of a gyroscope
and transferring the registration to the 3D digital volume to
orient the patient’s head in space if the CT was obtained with
the patient in the supine position.6 Another method is obtain-
ing a 3D facial photograph in a natural head position and then
registering the 3D CT volume to a 3D soft tissue facial
photograph.7
Head orientation is not an issue with CBCT technology
because CBCT images are obtained with the patient standing
or sitting upright. At the time the CBCT image is obtained,
the patient can be asked to look straight ahead to document
the patient’s NHP (natural head position) or to use a Frankfort
horizontal plane parallel to floor, depending upon user prefer-
ence. This process will eliminate the need for the external
registration methods that are required for medical-grade
CT. Before confirming the head position in the virtual space,
clinical findings, such as the skeletal midline, dental midline,
and occlusal cant, need to corroborate with the patient
CT in virtual space. The skeletal midline and the patient’s
horizontal plane will be the primary reference planes to
perform all skeletal movements during computerized surgical
planning.
Processing and registering 3D data
to create a virtual patient for
surgical simulation
The next step involves processing and registering all 3D CT
data. The 3D images need to be processed to remove artifacts
and scatter. Once the images are processed and cleaned, the
registration between the patient’s 3D scan and the study
models is initiated. The superimposition can be performed
manually by selecting corresponding anatomical points on
the CT and the dental study models, or the automatic super-
imposition feature in the software program can be used in
some cases. Registration may need fine tuning by manual
manipulation for the best final fit. The final superimposition
for a 3D photograph can be accomplished by importing the
3D patient photographs and superimposing the 3D CT volume
(Fig. 9.2.10).
Generation of 2-dimensional images
The 3D CT scan allows one to generate traditional radio-
graphs, such as a panoramic radiograph, lateral cephalogram,
postero-anterior cephalogram, and TMJ sections. Generating
2D images from 3D images may sound redundant; however,
2D images may need to be generated because of a lack of
age-based 3D cephalometric norms. Using traditional cepha-
lometric measurements is a good way to start.

237
Step-by-step surgical simulation planning for two-jaw surgery
bilateral sagittal split osteotomy, inverted L osteotomy, and
vertical ramus osteotomy. Once the osteotomy is completed,
the mandibular distal segment can be moved. The mandibular
skeletal component is coordinated with the maxilla based on
the preset final dental occlusion. This is accomplished by
importing the preset, hand-articulated final occlusion models
and superimposing them on the maxillary dentition and by
superimposing the mandibular skeleton on the mandibular
dental cast dentition.
Once the maxillary and mandibular skeletal components
are coordinated in the final occlusion, the next step involves
moving the maxillary and mandibular skeletal components as
one unit to the final desired position. In this step, two additional
variables that need to be corrected are the amount of maxil-
lary impaction and the amount of maxillary and mandibular
advancement. These will be determined by the initial skeletal
deformity and the desired final facial aesthetic results. The last
skeletal correction that can be accomplished is the correction
of the occlusal plane (pitch). The normal occlusal plane angle
to the Frankfort horizontal plane is approximately 9°, with a
range of 2° to 17°. The patient’s occlusal plane can be corrected
by moving the maxillary and mandibular skeletal components
in a clockwise (steeping occlusal plane) or counterclockwise
(flattening occlusal plane) movement. This will have a significant
impact on the chin projection and ANS (anterior nasal spine)
position. Clockwise changes in the occlusal plane will increase
maxillary projection and decrease mandibular projection, and
counterclockwise changes will have the opposite effect.
After completion of the desired skeletal movements based
on the treatment plan, bony overlaps or bony gaps need to be
evaluated. This will inform the surgeon whether bone needs
to be removed or whether the patient will need a bone graft
to augment the bone in the area of the large bony defect. In
the mandible, the relationship of the proximal and distal seg-
ments can be evaluated. As the maxillary and mandibular
skeletal components are moved, the x, y, and z coordinates of
displacement for each identified skeletal landmark can be
viewed in real time and modified as needed. If soft tissue was
added to the CT data, soft tissue changes can also be evalu-
ated (Figs. 9.2.11 & 9.2.12).
For single-jaw surgery, virtual surgical planning is not of great
benefit regardless of whether the maxilla or mandible is to be
operated on. Once the surgeon determines which jaw is in the
normal position, the abnormal jaw can be corrected to the
normal jaw position.
Step-by-step surgical simulation
planning for two-jaw surgery
After completion of a thorough diagnosis and a tentative
surgical treatment plan, the next step is to simulate the treat-
ment plan on the virtual patient using a personal computer.
The orientation of the virtual patient should match the
patient’s natural head position. The skeletal facial midline has
to be established before any skeletal movement is performed.
The condyle needs to be confirmed to be in the correct relation
to the condylar fossa. The next step involves making appro-
priate osteotomies to simulate the surgical treatment plan.
The surgeon can define the path of the osteotomy for an
individual patient. For maxillary surgery, there are multiple
options, from a single-piece Le Fort I osteotomy to a four-
piece asymmetric osteotomy. The specific path of the osteotomy
can be user-defined. Once the osteotomy is defined based on
the needs of the patient, the segments can then be moved to
the desired end position. The first step is to correct all maxil-
lary asymmetry. This will involve correcting the maxillary
dental midline to coincide with the patient’s skeletal facial
midline in the transverse plane. This step should be followed
by the correction of the maxillary occlusal cant (roll). Depend-
ing on the severity of the occlusal cant, this can be achieved
by differentially impacting one side and disimpacting the
opposite side or by unilateral disimpaction or impaction to
level the canted occlusal plane. Finally, the maxillary arch
rotation (yaw) is corrected to make the maxilla more sym-
metric. As these movements are carried out, the actual changes
can be recorded in millimeters by the software.
After correction of maxillary asymmetry, the mandible is
then brought into occlusion with the maxilla. For a mandibu-
lar osteotomy, several options are available, including a
Fig. 9.2.11  Pre- and post-surgical simulation
prediction of a patient who will undergo two-jaw
surgery.

238
SECTION II
CHAPTER 9.2 • Computerized surgical planning in orthognathic surgery
Fig. 9.2.12  Pre- and post-surgical simulation
prediction for a patient who will to undergo two-jaw
surgery. In this image, the 3D photograph’s opacity
has been changed, and the cone beam computed
tomography (CBCT) data and 3D dental scan are
invisible. This is simulation is used for patient
education and for understanding the patient’s
expectations from surgery.
Fig. 9.2.13  (A) The displacement of the mandible
inferiorly when the maxillary surgical plan involved
correction of the occlusal cant by moving the left
side of the maxilla down and the right side
superiorly. The patient’s clinical exam had
demonstrated that the path of the opening of the
mandible was deviated to the left side from
habitual occlusion to the maximum opening. This
would have been difficult to simulate, and it would
have been a challenge to accurately position the
maxilla with the intermediate splint. (B) The design
of the intermediate splint if the mandible was
operated on first. This would provide a more
predictable postsurgical result.
A
B
Decision of whether to perform maxillary or
mandibular surgery first
Virtual surgical planning technology allows surgeons to easily
plan mandibular surgery first, followed by maxillary surgery.
This was very difficult with traditional facebow transfer and
model surgery. Mandibular surgery may be performed first if
the patient exhibits a significant mandibular deviation from
rest position to habitual occlusion. This is most commonly
seen in patients with asymmetrical mandibular morphology
and facial asymmetry. If maxillary surgery is performed first
with planned cant correction, the mandible has to be opened
for splint construction, and it would be difficult to predict the
path of the opening of the mandible in the virtual patient. This
may lead to an improper position of the maxilla. In such situ-
ations, performing mandibular surgery first makes more
sense (Figs. 9.2.13A & 9.2.13B). An alternate option would be
to use skeletal-based positioning guides to position the maxilla

239
Conclusion
used to establish the register of the unoperated maxilla to the
rest of the skeleton with a drill hole, and the second is used
to reposition the maxilla at the time of fixation.
For genioplasty surgery for asymmetric chin position, the
guide becomes very important to accurately position the chin
during fixation. There have been many designs of chin posi-
tioning guides. Some are tooth borne and some are bone
borne, and they may be connected to the dental splint. For
patients who will receive autogenous bone grafts, virtual
surgical planning helps to design a template for the harvest
that will fit perfectly in the bony defect. The template saves
significant time in the operating room.
A recently completed prospective study using a computer-
aided surgical simulation protocol showed that a computerized
plan can be transferred accurately and consistently to the patient
to position the maxilla and mandible at the time of surgery.10
Conclusion
Virtual surgical planning has significant benefits for patient
needing orthognathic surgery. With the acceptance and
advancement of new in-office CBCT machines, user-friendly
surgical treatment planning software, and in-office 3D print-
ers, the technology will become more accessible as the benefits
become more apparent to the growing number of surgeons
performing orthognathic surgery using 3D virtual surgical
planning. In addition, many new technologies continue to be
developed to assist surgeons in planning orthognathic sur-
gery more accurately. CAD/CAM-designed surgical cutting
guides, positioning guides, and splints allow for clinically
significant improvements in accuracy and efficiency and
a reduction in surgical error, all of which benefit both the
patient and the surgeon. Prediction of surgical outcome can
only be enhanced by better pre-surgical diagnosis and treat-
ment planning using the information from a clinical exam.
Continued improvements in state-of-the-art software applica-
tions that enable enhanced planning give orthodontists and
surgeons the vision necessary to deliver the desired results
while providing excellent communication between clinicians
as well as with the patient.
during skeletal fixation. There are several designs of the posi-
tion guides, and each guide can be customized based on the
surgeon’s preference.
Cutting guides, positioning guides, bone graft
templates, and splints
Guides, templates, and splints are key armamentaria for 3D
computerized surgical planning. The guides help the surgeon
to precisely transfer the surgical plan from the virtual patient
on a personal computer (PC) to the operating table. Significant
improvements have been made over the years to develop
more sophisticated guides to accurately transfer the surgical
plan to the operating table. Guides can be divided into two
types: bone borne and tooth borne.
In most patients, an intermediate split to position the
maxilla and a final splint to position the mandible is a very
efficient process. During maxillary fixation with the interme-
diate splint after intermaxillary fixation, the variables that the
surgeon has to control are the vertical position of the maxilla
and the proper position of condyles in the condylar fossa
(Fig. 9.2.14 A-I).
Cutting guides help to make osteotomies in the planned
locations. They also help to remove overlapping bony inter-
ference more accurately while maintaining good bone-to-bone
contact for bone plating during fixation. Position guides are
helpful for repositioning the osteotomized Le Fort I bone to
the desired final position independent of the mandible. This
eliminates the concern of a CR–CO discrepancy affecting the
final position of the Le Fort I segment. It also takes the guess-
work out of the position of the condyle in the condylar fossa
at the time of Le Fort I fixation. Position guides can be custom
designed based on the surgeon’s need. One important factor
that needs to be considered in designing positioning guides
is that they must be rigid enough to allow the position of the
osteotomized bony segment and at the same time allow
enough room for plate fixation. One such design is the
Orthognathic Positioning System (OPS), which is used to
transfer the virtual surgical plan to the operating table during
orthognathic surgery.9 The system comes with a maxillary
splint with two sets of removal attachments. The first set is
A
B
Fig. 9.2.14  (A–F) Pre- and post- frontal, profile, and
smiling photographs after the patient underwent
two-jaw surgery using virtual surgical planning and
simulation.
Continued

240
SECTION II
CHAPTER 9.2 • Computerized surgical planning in orthognathic surgery
D
E
F
G
(G–I) Pretreatment computed
tomography (CT) and after completion of maxillary
surgery and mandibular surgery simulation.
Fig. 9.2.14, cont’d
C

241
Conclusion
H
I
Fig. 9.2.14, cont’d
References
1. Ellis EIII. The accuracy of model surgery: evaluation of an old
technique and introduction of a new one. J Oral Maxillofac Surg.
1990;48(11):1161–1167.
2. Kwon TG, Choi JW, Kyung HM, Park H-S. Accuracy of maxillary
repositioning in two-jaw surgery with conventional articulator
model surgery versus virtual model surgery. Int J Oral Maxillofac
Surg. 2014;43(6):732–738.
3. Proffit WR, White RP Jr. Combined surgical-orthodontic treatment:
How did it evolve and what are the best practices now? Am J
Orthod Dentofacial Orthop. 2015;147(5 sup):S205–S215.
4. Liou EJ, Chen PH, Wang YC, et al. Surgery-first accelerated
orthognathic surgery: orthodontic guidelines and setup for model
surgery. J Oral Maxillofac Surg. 2011;69(3):771–780.
5. Mah J, Sachdeva R. Computer-assisted orthodontic treatment: the
SureSmile process. Am J Orthod Dentofacial Orthop.
2001;120(1):85–87.
6. Xia JJ, McGrory JK, Gateno J, et al. A new method to orient
3-dimensional computed tomography models to the natural head
position: a clinical feasibility study. J Oral Maxillofac Surg.
2011;69(3):584–591.
7. Xia JJ, Gateno J, Teichgraeber JF. New clinical protocol to evaluate
craniomaxillofacial deformity and plan surgical correction. J Oral
Maxillofac Surg. 2009;67(10):2093–2106.
8. Cordray FE. Three-dimensional analysis of models articulated in
the seated condylar position from a deprogrammed asymptomatic
population: a prospective study. Part 1. Am J Orthod Dentofacial
Orthop. 2006;129(5):619–630.
9. Polley JW, Figueroa AA. Orthognathic positioning system:
intraoperative system to transfer virtual surgical plan to operating
field during orthognathic surgery. J Oral Maxillofac Surg.
2013;71(5):911–920.
10. Hsu SS, Gateno J, Bell RB, Hirsch DL, Markiewicz MR, Teichgraeber
JF, Zhou X, Xia JJ. Accuracy of a computer-aided surgical
simulation protocol for orthognathic surgery: a prospective
multicenter study. J Oral Maxillofac Surg. 2013;71(1):128–142.

SECTION II • Head and Neck Reconstruction
9.3 
Computerized surgical planning in head
and neck reconstruction
Jamie P. Levine and David L. Hirsch
SYNOPSIS
■ When planning a resection, the computed tomography (CT) scan
should be relatively close in time to the planning session and the
surgery. The modeling team should outline the tumor and generous
margins should be planned. It is best to do this with the ablative team
directly to avoid any discrepancy in the plan. If there is a question
about margin safety and need for further intraoperative resection, an
alternate guide can be made to accommodate for these potential
changes.
■ Take into account your soft tissue needs when planning these
procedures. Take as much skin as you need from your primary flap or
plan in alternative flaps, especially if a complex resection is planned
and there is a large intra- and extra-oral soft tissue demand.
■ In cases with significant tissue loss or lack of tissue flexibility, such as
in radiation injury, the bony reconstruction can be designed to
minimize the strain on the remaining soft tissue and decrease the
complexity of the reconstruction.
■ All specialties involved in the surgical and peri-operative treatment
should be invited and try to attend the virtual planning session. The
involvement of the team will allow for fewer critical errors in the
planning process. Also, each team should evaluate the plan that is
reconstructed by the engineers after this meeting and sign off before
the plans are considered final.
■ As the reconstruction becomes more complex and may have multiple
segments, predesigned plates can play an important role in obtaining
very precise reconstruction results.
■ Consider primary osteointegrated implants in benign cases.
■ In free flap reconstruction, plan bone segments to remain at least
2 cm in length to maintain appropriate circulation.
■ Use virtual planning to appropriately position your bone segments.
With appropriate scanning, perforators can even be noted in which to
assist in the soft tissue design. Make sure to maintain a sufficient
proximal and distal osteotomy so that knee and ankle stability is not
affected.
■ When bone loss or malposition is part of the deformity, reposition the
bone with the assistance of imaging technology. This can be planned
using mirror-imaging techniques, etc. Plan the repositioning of the
bone segments along with any grafts or flaps that will be taken.
■ When using multi-segmental repositioning, or complex rotational
segments where alignment is critical such as in implant placement,
make intermediary splint devices to help confirm the position of the
reconstruction as you advance through each step.
Introduction
Craniofacial, maxillofacial, and head and neck surgery started
long before the advent of three-dimensional (3D) imaging.
Historically, the field of head and neck reconstruction did not
exist. This lack of head and neck reconstruction truly limited
the surgeon’s ability to perform any type of head and neck
ablative, trauma, and congenital surgery. The advances first
in pedicled flap surgery and then in microsurgery techniques
forever changed the field of head and neck oncologic surgery.
The ability to now reconstruct larger and larger composite
defects gave significant freedom to the ablative surgeon.
Similarly, over the last generation, advances made in imaging
technology have been a quantum advance for the reconstruc-
tive surgeon. Radiographic techniques, such as computed
tomography (CT) imaging, suddenly allowed the surgeon to
assess a defect or injury and helped them to plan a more
precise and strategic reconstruction. New approaches and
operative techniques were developed because of these
advances. Even with this advancement in imaging technol-
ogy, the surgeon still only had a two-dimensional (2D) repre-
sentation of a 3D problem. There was no physical translation
that could be made between the images and the patient. The
information obtained from imaging was best translated
through anatomic knowledge and increased experience from
the surgeon. Teaching of these reconstructive techniques is
also difficult. In repairing the three dimensional bony archi-
tecture of the craniofacial skeleton, one is visually limited by
access and the inability to gain complete 3D exposure of the
desired surgical sites. Also, because of the very 3D nature
of the craniofacial skeleton, even small degrees of error can
lead to poor outcomes. Traditional reconstructive techniques

243
Techniques
planning has been the standard in architectural design and
biomedical fabrication. In all aspects of surgery, proper plan-
ning facilitates more predictable operative results, but prior
to the use of virtual planning, much of this relied on 2D
imaging and surgical trial-and-error. It has been our goal to
make all forms of reconstructive surgical procedures, includ-
ing oncologic, traumatic, congenital, and aesthetic, treatable
with this methodology. These techniques are teachable, have
a shallow learning curve, allow for precise and anatomic bony
reconstruction, and ultimately decrease surgical time. In
specific cases, we have married the virtual planning with
navigation guidance technology to allow for even more accu-
racy in both ablative and reconstructive procedures when
indicated (Fig. 9.3.2).
The goal of this chapter is to illustrate how virtual surgery
and computer assisted design can be utilized by the surgeon
to decrease operative time and create accurate postoperative
results when compared to traditional craniomaxillofacial
surgical treatment planning. We will review our methodol-
ogy in approaching some of these problems and illustrate
application of these techniques. This will only be a small
representation of the types of cases to which we have applied
these techniques and we feel the applications will broaden
as surgeons find the ease in which their operations can be
planned and executed. We have reliably achieved excellent
results in both malignant and benign head and neck oncologic
surgery and reconstruction, orthognathic surgery, maxillofa-
cial trauma, temporomandibular joint reconstruction (TMJ),
and skull base surgery. These techniques have become our
preferred method for complex craniomaxillofacial surgery
and reconstruction.
Techniques
The evolution of our current technique initially involved the
use of stereolithographic models as templates (Fig. 9.3.3).
These models were printed directly from the CT scan, and
we would use them to preoperatively bend plates around
the presumed bony resection, to develop plates to work
around exophytic lesions, and for intraoperative reference to
help us to navigate these operations. We first utilized this
technique and these models for mandibular reconstruction
after tumor resection. This was an area where we felt there
was great variability in outcome based off of how well all
the bony segments were reconstructed. Although helpful, this
technique was still quite labor intensive, and there was still
often “guesswork” and room for error both in performing
osteotomies of the mandible and fibula correctly, aligning
the released jaw segments, and in setting of the fibula into
the resection site. The current evolution of our technique
involves preplanning each phase of the operation including
the osteotomies on the mandible and the lower extremity by
using staged cutting guides. Currently, these techniques allow
for surgically efficient and highly predictable outcomes as
far as bone and soft tissue positioning. We continue to refine
these techniques as far as cutting guide design and surgi-
cal planning, including placement of permanent implants,
dentures, and ideal bone positioning. We will describe the
basic process of planning and using computer-aided design/
computer-aided manufacturing (CAD-CAM) technology for
reconstruction.
require a large learning curve and can lead to inconsistent
results, especially with less experienced surgeons. Surgical
experience and an innate sense of 3D anatomy has been
important in obtaining better outcomes, but not all surgeons
have the same skill set or experience, so outcomes become
more variable. With advances made over the last decade in
computer modeling and virtual surgery, we are now able to
translate the information received from radiographic imaging
studies to actual intraoperative tools that can help us over-
come the complex 3D anatomy of the head and neck (Fig.
9.3.1). This has led to more predictable and, we believe, more
functional outcomes for the patient. As these techniques
improve along with guidance technology, the accuracy and
outcomes should continue to improve. It also allows the less
experienced surgeon to potentially obtain similar outcomes to
the more experienced ones.
At our institution, we have been utilizing 3D facial analysis
and virtual surgical planning (VSP) in all of our craniomaxil-
lofacial reconstructive and ablative cases. Over the past 8
years, many cases have been planned, modeled, and executed
in this manner and have led to more reliable and predictable
outcomes. Over this time, we have been continuously refining
these techniques, and this approach has truly revolutionized
the way we diagnose, treat, and reconstruct head and neck
diseases and defects. In our modern computer era, digital
A
Fig. 9.3.1  (A) A stereolithographic model of the skull with the tumor and virtual
cuts colored. (B) The cutting guide specific to the patient’s fibula and mandible are
noted along with an occlusal splint.
B

244
SECTION II
CHAPTER 9.3 • Computerized surgical planning in head and neck reconstruction
ultimately evolved into the gold standard for mandible
reconstruction.3
Today, the free fibula flap is almost universally the first
choice for oromandibular reconstruction in patients with both
benign and malignant disease. The introduction of key tech-
nologies has refined the surgery. Initially, the reconstruction
relied on intraoperative evaluation of the post-ablative defect.
The surgeon would then employ any number of imperfect
and tedious manipulations to re-sculpt the bony gap. This
increased operative times with often imperfect results.
The introduction of CT-based stereolithographic models
allowed for an element of pre-operative planning. The ability
to simulate defects on these printed 3D models allowed us to
pre-operatively plan the reconstruction and contour of the
reconstruction plate, etc. This was catapulted to the next level
with software using the CT data for 3D virtual surgery.4
Computer-aided surgical modeling
Head and neck reconstruction
Evolution:
Hidalgo first published the use of the free fibula flap for
mandibular reconstruction in 1989.1 The advantages of this
flap for mandibular reconstruction soon became apparent.
It has the ability to provide a long segment of bone (up to
25 cm), along with the surrounding soft tissue, and has a
donor site with a relatively low morbidity. Perhaps the
most important aspect of the fibula is the unmatched ability
for 3D contouring permitted by a reliable periosteal blood
supply and multiple osteotomies.2 The free fibula flap has
Fig. 9.3.2  Guidance technology showing intraoperative positioning of the reconstructed segments; in this case, checking the desired fibula positioning near the glenoid
fossa.

245
Computer-aided surgical modeling
Computer- aided design technology uses this information to
recreate a virtual representation of the diseased mandible and
donor fibula. In this virtual environment, 3D resection of the
mandible can be simulated on the computer model. The
computer generated fibula is then transposed to the virtual
mandible and recontoured with simulated osteotomies in
multiple orthogonal planes. Complimentary osteotomies are
virtually created to ensure bony apposition (Fig. 9.3.4). The
simulated osteotomies are then translated to pre-manufactured
cutting guides. This ensures that the VSP is precisely trans-
lated to the intraoperative environment.5
The anatomic recreation of the bony mandible is unmatched
using this technique. Bony apposition is maximized with a
superior aesthetic result. From an orthognathic perspective it
has also revolutionized function. Optimal restoration of oro-
mandibular function involves mastication, deglutition, and
the management of oral secretions. A critical component of
re-introducing these functions is dental rehabilitation. VSP
has revolutionized the reconstructive surgeons ability to
accomplish this (Fig. 9.3.5).6
While this technology has been extensively reported in the
literature, we have continued to add technical refinements
that are unique.7 Today, we routinely perform complex recon-
structions that involve several of these elements in each
surgery. Some of these technical improvements include precise
placement of primary endosteal implants, double barreling
techniques to improve the bony contour, customized recon-
struction plate fabrication, implants with a dental prosthesis
Fig. 9.3.3  Stereolithographic model used as a template for plate bending. The
plate can then be used for the intraoperative reconstruction and bone alignment.
Fig. 9.3.4  Planning session that is showing the computer generated fibula transposed to the virtual mandible, after the resection, and recontoured with simulated
osteotomies in multiple orthogonal planes. Complimentary osteotomies are virtually created to ensure bony apposition.

246
SECTION II
CHAPTER 9.3 • Computerized surgical planning in head and neck reconstruction
desired modeling company (we have primarily worked with
and evolved our techniques with 3D Systems Medical Model-
ing Inc., Golden, CO, USA). The scans are converted into 3D
reconstructions of the craniomaxillofacial skeleton and the
donor site. The donor site is not always required, but we
normally obtain this since our reconstructions have become
more complex and precise over time. It is helpful for us to see
the 3D variability in the donor site, which can be important,
especially when planning implants and multiple segments,
and the associated vasculature and perforator anatomy. We
will obtain this using CT angiography. A web meeting is then
held with biomedical engineers from the modeling company
and the surgical team. The key parameters of the planning
phase for mandibular reconstruction (or any type of head and
neck surgery) are the margins of resection, repositioning of
any malpositioned tissue, and the location of fibula placement
in relation to the remaining mandible and craniofacial skeleton
(Fig. 9.3.7). For traumatic injuries the goal is relocation of the
displaced bony fragments and planning of bone grafts and/
or permanent implants. In orthognathic surgery, the staged
movement of the jaws for the desired endpoint is also planned.
These inputs are determined by the surgeon and marked
during the web meeting by the modeling engineer on the 3D
reconstruction image (Fig. 9.3.8). Control of the mouse pointer
can be transitioned between both teams, and real-time cepha-
lometric, volumetric, and linear analysis can be extrapolated
as bony segments are being virtually manipulated.
A good example of the power and precision of virtual
planning is for fibula reconstruction of mandibular and
maxillary defects. These were the first reconstructions that
we approached with complete virtual planning. We were able
to overcome many of the challenges that we faced in utilizing
traditional fibula free flap reconstructive methods once we
began fully utilizing CAD-CAM technology. Communication
between the ablative, reconstructive, and engineering teams is
necessary in maximally translating the surgical resection and
reconstruction into a virtual model that can then be used to
create personalized cutting guides and templates that allow us
to create seamless fibula–mandible continuity. By incorporat-
ing the engineers into the surgical planning, they understand
the importance and reality of tissue positioning, including
bone segments, soft tissue, and vascular pedicles. The virtual
resection of the mandible is completed first. The cutting paths
are chosen at the desired margins of the diseased mandible,
and the segment is virtually removed. The 3D reconstructed
fibula image is then superimposed on the mandibular defect
in its desired vascular and soft tissue orientation (Fig. 9.3.7).
Virtual fibular osteotomies are created to fit the idealized
reconstruction. The first osteotomy is designed to precisely
fit the proximal angle of resection on the native mandible.
Additional osteotomies are created, as needed, to recreate the
shape of the resected portion of the native mandible. Although
any shape and bend can be created using this technique, it is
the reconstructive surgeons job to keep the reconstruction
realistic with appropriate sized segments (usually 2 cm or
greater) and to respect the limits of the blood supply. Simple is
sometimes better, even with virtual modeling. The engineers
can use the geometry of the virtually resected mandible or
mirror the contralateral disease-free mandible and orient this
to the overlying maxilla in order to create ideal orthognathic
relationships. The shape of the plate and the number and
lengths of fibula segments can be modified to optimize the
Fig. 9.3.5  Virtual planning for dental reconstruction. The osteointegrated implant
position is optimally planned as well as the precisely positioned denture.
in a single stage, and free flap placement along with complex
orthognathic repositioning (Fig. 9.3.6).8 Anecdotally, these
technical refinements have allowed for even more efficient
and predictable reconstructive outcomes.
Technical aspects:
Computer-aided mandibular ablation and reconstruction
involves four distinct phases: planning, modeling, surgical,
and evaluative. It has only been with the evaluative phase that
we have been able to continually refine our techniques and
improve our surgical outcomes. Planning begins with a high-
resolution CT scan of the patient’s craniofacial skeleton
according to standard scanning protocols. Scans of the lower
extremities or other donor sites (iliac, scapula, etc.), if needed,
are obtained to have an exact understanding of the vascular
and bony anatomy. These images are then forwarded to the
Fig. 9.3.6  Virtual plan for a customized reconstruction plate. Double blue circles
represent predictive holes that will be placed into the mandibular cutting guides.
These predictive holes are placed in the mandibular cutting guides and will
correspond exactly to holes in the customized reconstruction plate. This allows for a
very precise reconstructive outcome overall.

247
Computer-aided surgical modeling
Fig. 9.3.8  This shows margins of resection around the tumor and the location that
the fibula will ultimately be placed into.
Fig. 9.3.9  This figure shows the mandible resection with the fibula segments in
place. Fibula segments can be modified to optimize the shape of the neomandible,
including a central double barrel segment. The planning provides seamless bony
approximation and maintains a perfect occlusal arrangement. The planned dental
prosthesis is also noted in appropriate occlusal position.
A
Fig. 9.3.7  Figure shows a complete virtual planning session prior to plate
placement. (A) The margins of resection are noted around the tumor, and within
this area the fibula is planned. You can also see the positioning of implants in red.
These are being aligned to the overlying dentition and arranged within the fibula
placement. The location of fibula placement in relation to the remaining mandible is
shown (B).
B
shape of the neomandible, maintain well-vascularized seg-
ments of fibula, provide appropriate bone-to-plate relation-
ships for positioning of implants, provide seamless bony
approximation, and maintain a perfect occlusal arrangement.
The virtual osteotomies in both the mandible and fibula are
planned to optimize bone apposition for subsequent bony
union and to ease positioning and placement intraopera-
tively. Bone positioning is seamless between the osteotomies
created on the mandible for the resection and the osteotomies
created on the fibula for the reconstruction. Currently, for
most benign cases, we will also plan precise dental endos-
seous implant placement by choosing the desired position
to obtain appropriate postoperative prosthetic occlusion
(Fig. 9.3.9).
The modeling phase involves stereolithographic manufac-
turing of the planned components. This includes a model of
the native craniofacial skeleton for intraoperative reference
and to augment the education of residents, surgeons, and the
patient. Next, sterilizable cutting guides are produced that fit
flush onto the native mandible and fibula and allow the
osteotomies to precisely match those created during the plan-
ning phase. A reconstruction plate template is then designed
that facilitates pre-bending of the titanium plate preopera-
tively and is made to match the plate design of the desired
plating company. The challenge of determining the fibula

248
SECTION II
CHAPTER 9.3 • Computerized surgical planning in head and neck reconstruction
to recreate the desired shape without any intraoperative
measuring. The learning curve that is required to perform the
appropriate osteotomies is removed, and we believe the
results obtained from using these techniques are consistently
better than any other.
Next is the surgical phase of the reconstruction.6,9 Access to
the mandible is based on location and severity of tumor or
pathology. After access to the mandible is obtained, we use
the techniques described by Marchetti et al. for maintenance
of maxillomandibular relationships.10 The mandibular cutting
guides, after sterilization, are then introduced into the field
and secured to the mandible with bone screws. The cutting
guides enable an exact duplication of the angles of osteotomy
that were planned during the web meeting (Fig. 9.3.12). A saw
is introduced into the slots of the cutting guides, and the
osteotomies are performed. Once the mandible is resected, the
definitive reconstruction plate is placed on the mandible in
the predetermined position and holes drilled at the appropri-
ate locations. The mandibular cutting guides are often
designed with predictive holes so that we use the same screw
holes as the reconstruction plate to provide a precise anatomic
reference in hardware positioning. With these predictive
holes, precise plate placement and exacting bone orientation
is always maintained. We prefer to do the fibula shaping with
the pedicle intact and perfusion uninterrupted (Fig. 9.3.13).
The fibula cutting guide is used to replicate the cuts for both
the end and closing wedge osteotomies that were planned
previously. We now take the fibula segment straight up to the
mandible, never losing control of the mandibular segments
(Fig. 9.3.14). This has also allowed us to perform minimal
incision approaches for even very large resections (Fig. 9.3.15).
The evaluation phase usually includes a CT scan and/or
X-rays along with standard postoperative follow up. The CT
scan is used as the ultimate comparison to the operative plan
that was virtually generated. This allows critical analysis of
accuracy and can help refine the techniques for the future. In
lengths and intersection angles is made simple and reliable.
These cutting guides facilitate the osteotomy process and
provide seamless integration between the mandibular and
fibular portions of the reconstruction (Figs. 9.3.10 & 9.3.11). A
linearized cutting guide is fabricated from the cut pieces of
the virtual fibula, with cutting slots that are located at the
appropriate lengths along the fibula and at the proper angles
Fig. 9.3.10  The fibula lengths and intersection angles are made simple and
reliable with the fibula cutting guides which are created to fit on the fibula precisely
and create seamless ostomies. These cutting guides facilitate the osteotomy
process and provide precise integration between the mandibular and fibular portions
of the reconstruction.
Fig. 9.3.11  This figure shows the mandibular cutting guides in place. These
cutting guides facilitate the osteotomy process and provide precise integration
between the mandibular and fibular portions of the reconstruction.
Fig. 9.3.12  Mandibular cutting guides in place. The cutting guides enable an exact
duplication of the angles of osteotomy that were planned during the web meeting.

249
Computer-aided surgical modeling
general, accuracy is excellent and is within 1–5 mm (Fig.
9.3.16). The main source of error is probably due to the hand
bending of the reconstruction plate. With the newer types of
modeled plates even this has been significantly improved
allowing us greater accuracy in the reconstruction. These pre-
modeled titanium plates not only help the accuracy of the
outcome but shorten the length of the case.
For most benign pathology cases, we virtually plan and
then place dental implants and, in some cases, the dental
prosthesis intraoperatively (Figs. 9.3.17 & 9.3.18). Most
Fig. 9.3.14  The fibula segment is brought straight up to the mandible defect and
is placed directly into position below the prepositioned plate. Control of the
mandibular segments is never lost during the procedure. The double barrel segment
in this patient is plated with a separate miniplate and lag screw. New preplanned
plates can be designed to engage all of these segments with a single plate.
Fig. 9.3.15  Postoperative X-ray showing precise position of the fibula segments
and osteo-integrated implants are also noted to be in the appropriate position.
A
Fig. 9.3.16  (A,B) Images show the preplanned reconstruction along with
predictive holes for the plate placement. The 3D CT scan is noted with the
postoperative result showing a very close appearance to the operative plan that was
virtually generated. Also note the plate design which was preplanned and is placed
around the mental foramen and incorporates a screw hole to also engage the
double barrel segment.
B
Fig. 9.3.13  Fibula after the osteotomies are completed and the device is removed.
Fibula shaping we perform with the pedicle intact and perfusion uninterrupted. This
can also be done off the field but this will increase the ischemic time accordingly.
Note in the picture a beveled double barrel osteotomy segment and planned skin
paddle for intraoral lining.

250
SECTION II
CHAPTER 9.3 • Computerized surgical planning in head and neck reconstruction
Unfortunately, many complex traumatic injuries involve
avulsion of teeth and bony comminution making accurate
reduction of these fractures technically difficult intraopera-
tively. This is where computer-assisted virtual surgery is
extremely beneficial. A CT scan of the facial skeleton is
acquired, along with dental casts of the maxilla and mandible
if possible. These techniques are also utilized in virtual
orthognathic surgery. The casts are laser scanned by the
modeling company and virtually integrated into the image
data. The use of CAD-CAM based occlusal splints has gained
popularity in recent years, and we have also found similar
benefit in using them for these cases of complex facial trauma,
particularly where tooth-bearing bony segments are commi-
nuted, or there is loss of dentoalveolar hard tissue.19–22
Planning of the surgery always starts with a virtual web
meeting. In the meeting, the fractured segments are virtually
reduced to optimize bony alignment (Figs. 9.3.19 & 9.3.20).
This “virtual reduction” reduces the trial and error that is
normally required for open reduction. The bony injuries are
analyzed in all planes and virtual reduction of the fractures is
carried out to the surgeon’s preference depending on the
planned surgical approach. Volumetric analysis of the reduced
segments can be easily computed by the virtual software to
aid in establishing symmetry. Occlusal splints are fabricated
for the tooth-bearing segments based on the desired maxillary
and mandibular reduction. Templates for non-tooth-bearing
facial bones can also be created to allow for proper restoration
of facial width and projection. Although virtual surgery helps
the surgeon determine how to best restore anatomic align-
ment preoperatively, the true benefit of this technology has
been its intraoperative application and the personalized
device design (Fig. 9.3.21). Using the 3D models finalized
from the VSP, surgical guides are then designed and
manufactured and used intraoperatively for more accurate
Fig. 9.3.17  Noted in this figure is immediate implant and denture placement. For
most benign pathology cases, we virtually plan and then place dental implants and,
in some cases, the dental prosthesis.
Fig. 9.3.18  Another example of a dental prosthesis for immediate placement.
Fig. 9.3.19  This figure shows a reformatted 3D CT scan of a pan-facial fracture.
Different colors represent the larger fracture segments.
patients advance to complete dental rehabilitation within the
first year postoperatively. We believe, even if not placed
intraoperatively, placement of dental implants and prosthetic
dental reconstruction is facilitated by the precise alignment
and positioning of the fibula we obtain from virtual
planning.
Maxillofacial trauma
Treating complex multi-segment maxillofacial trauma is a
challenge even to the most experienced surgeons because of
anatomic distortion, bony displacement, etc. When treatment
planning surgical correction of a traumatic injury, many
factors must be considered including status of the dentition
and pre-existing occlusal relationship, facial widths, facial
heights, and bone segment continuity. Restoration of normal
facial width, facial height, and antero-posterior projection is
not only difficult to achieve but is extremely difficult to teach.
Historically, no single approach guarantees a satisfactory
outcome.11–16 Post-operative deformities from these injuries is
common and often impossible to correct.17 We have success-
fully and very accurately utilized 3D virtual surgery and
modeling techniques for the treatment of these type of complex
injuries.18 Each injury is approached individually. The model-
ing allows us to optimally reposition the craniofacial skeletal
fragments, provide splints to assist in and confirm alignment,
and provides templates for bone replacement or augmenta-
tion if necessary.

251
Maxillofacial trauma
model to guarantee appropriate bone position and facial
width. The guide can be used at the time of surgery to help
reduce these segments relative to the non-injured cranial
region. The fragments can be built off each other and the
position checked and confirmed with each bone segment that
is reduced and plated.
In addition to the intraoperative guides that allow for
optimal reduction, virtual surgery affords the opportunity for
the design of precise permanent implants. This can be either
autologous tissue (bone graft) or alloplastic implants (titanium
mesh, acrylic, reconstruction plates, customized poly-
etheretherketone (PEEK)) depending on the operative need.
Virtual 3D surgery can be used to create a template of the
defect to guide preoperative or intraoperative creation of the
graft or plate as well as creating custom milled prefabricated
facial implants.
In the surgical phase, all of the fractures are exposed and
the operation is carried out as planned, using the prefabricated
templates and guides to ensure correct positioning of the
fracture segments (Fig. 9.3.21). The guides are secured with
screws and are designed to not interfere with placement of
osteosynthesis plates. We have also utilized guidance technol-
ogy, in very complex and multifragment cases, that integrates
between our preoperative scan and our desired reconstruction
to help guarantee bony repositioning.
Frontal sinus
A representative area where modeling has significant benefit
is the frontal sinus.23 In either tumors or fractures, this tech-
nique allows an elegant and safe approach to this hidden area
(Fig. 9.3.22). The frontal sinus represents an area that is some-
what hidden anatomically, and the approach to it usually
requires a much larger surgical dissection than the problem
may warrant. Because of potential injury to the dura and the
brain, traditional approaches usually require a craniotomy for
a direct anterior approach. In very select problems in this area,
alignment of the bony segments. The guides are fixated to the
maxillofacial bones with bone screws and provide precise
reference points for bony reduction and reconstruction and
prove to be very useful for re-establishing proper facial width.
In cases where there is significant comminution and associ-
ated facial widening, guides can be manufactured from the
Fig. 9.3.22  The frontal sinus represents an area that is hidden anatomically from
an anterior approach. This figure shows a planning session where the frontal sinus
position is precisely shown anteriorly.
Fig. 9.3.20  Planning for the surgery starts with a virtual web meeting. In the
meeting, the fractured segments (colored) are virtually reduced to optimize bony
alignment.
Fig. 9.3.21  Printed stereolithographic skull model showing the desired bony
reduction. There are individualized surgical devices which are noted in white on the
zygoma and help to precisely guide the fracture reduction intraoperatively. Also
noted in white in the right supraorbital region is a template to help create a bone
graft intraoperatively for missing bone. In the surgical phase, all of the fractures are
exposed and reduced and the prefabricated templates and guides are used to
ensure correct positioning of the fracture segments.

252
SECTION II
CHAPTER 9.3 • Computerized surgical planning in head and neck reconstruction
Fig. 9.3.23  On the anterior table of the frontal
sinus a planned cutting guide is shown which will
allow for the widest possible access to the sinus
with minimal risk of injury. Options for the cutting
guide can be customized to fit very precisely for
the planned exposure and help minimize the
incision for access.
screws into the frontal bone. These are designed not to inter-
fere with the placement of osteosynthesis plates. This use of
guidance technology, which integrates between the preopera-
tive scan and the desired reconstruction, helps to guarantee
bony alignment by preplanning plate and osteotomy position-
ing. The planning and guide fabrication allows for a safe
osteotomy and access directly into the frontal sinus for frac-
ture repair, tumor removal, etc.
Temporomandibular joint/skull base
The key to a successful operation involving the TMJs or base
of skull is exposure and access. Because of the density of vital
structures in this area, care must be taken to avoid inadver-
tently damaging these when manipulating the area of interest.
Precise positioning of autograft or allografts in reconstructing
the TMJ is essential to restoring mandibular and occlusal
function. Traditionally, reconstructing a TMJ has been carried
out as a two-stage operation. Initially, a gap arthroplasty is
performed and postoperative CT is acquired to aid in the
custom fabrication of a TMJ prosthesis. Once fabricated, a
second operation is required for adaptation of the custom
joint prosthesis. Recently, intraoperative navigation has been
utilized to prevent injury in the middle cranial fossa.26 By
combining techniques of virtual planning and intraoperative
navigation, this can be a safe single-stage operation, and the
virtual plan can be confirmed intraoperatively.
The CT scan and the maxillomandibular dental casts are
sent to the modeling company and uploaded into the virtual
software. 3D rendering is completed and stereolithographic
models are fabricated. Surgical resections are designed via
web meeting, and reconstruction of the joint can be virtually
created using a stock TMJ prosthesis or any other desired
methodology and merged into the virtual 3D rendering. By
manipulating the osteotomies and ramal and glenoid fossa
components in the software, ideal positioning of the joint
replacement is possible. This allows for a one-stage ablative
and reconstructive operation without compromising the
functional outcome. These techniques have also been used in
microvascular free flap reconstruction of the TMJs. Just as
previously described in reconstruction of head and neck
defects with microvascular free fibula flaps, imaging of the
proposed donor site is sent to the modeling company in order
to properly plan the reconstruction.
or even in other confined locations, the surgery can be planned
virtually and guides can be created to position the surgeon
safely and directly into the area of the defect without a full
intracranial dissection (Fig. 9.3.23).
The incidence of frontal sinus fractures ranges from 10% to
15% of all facial fractures, and they often occur in combination
with other facial fractures, such as orbital walls and nasal
bones.24 Diagnosis can be made clinically in cases where the
frontal table is severely involved; however, CT scanning has
become the standard for both diagnosis and planning of
surgery.25 Uniquely, the frontal bone has both an anterior and
posterior table, which, in addition to the nasofrontal duct, can
be variably involved in the injury pattern. Fracture of the
anterior wall poses mostly a cosmetic concern. The involve-
ment of the nasofrontal duct or posterior table is another
important factor in determining treatment of frontal sinus
factures.
It has been shown that surgical planning and using
CAD-CAM technology for craniofacial reconstruction allow
for surgically efficient and highly predictable outcomes in
both bony and soft tissue reconstructions.9 Planning begins
with a high-resolution CT scan of the patient’s craniofacial
skeleton according to standard scanning protocols. A web
meeting is then held. During this meeting, the surgeons can
precisely outline where the borders of the frontal sinus are
located. In cases of fractures, bony segments are being virtu-
ally manipulated. A cutting guide for the surgeon can be
designed and created that allows for safe and rapid access to
the entire frontal sinus while maximizing the size of the avail-
able bone segments and minimizing further fracture disloca-
tion. Most importantly, in cases of minimal or no fracture of
the anterior table of the frontal sinus, the guide allows the
widest possible access to the sinus with minimal risk of injury
(Fig. 9.3.23).
The modeling phase involves stereolithographic manufac-
turing of the planned guides and a model of the involved
craniofacial skeleton for intraoperative reference. The cutting
guides facilitate the osteotomy process and provide seamless
transition between the frontal bone and entrance through the
bone of the anterior table.
The precision and speed in performing these complex
osteotomies are greatly improved by utilizing this technique.
During the surgical phase, the cutting guide is placed and
secured to the craniofacial skeleton with monocortical depth

253
Conclusion/future directions
integration of various technologic elements will continue to
evolve. For now, the greatest utility of this technology has
been for bone reconstruction and repositioning, but in the
future we will be able to accurately plan and predict the soft
tissue outcome as well. Lastly, and most importantly, the
learning curve associated with these techniques is less steep.
A surgeon’s experience will not be the major obstacle in
obtaining the desired outcome. Based on our experiences and
results, virtual planning for correction of all forms of acquired
and congenital craniofacial deformities has great benefit and
can produce more desirable results than traditional methods.
Operative time and operative access can often be minimized
due to preoperative planning and the accuracy inherent in
these techniques. We have been able to increase the complex-
ity of our reconstructions adding multiple elements into a
single reconstruction. We commonly have multiple bone
segment reconstructions including layered double barrel seg-
ments and very precise endosseous implant placement. We
have also had success in placing implant-retained dental
prostheses intraoperatively to provide an unparalled single
stage reconstruction. The options and opportunities created
by VSP are only limited by the surgeons imagination and
desired outcome.
Conclusion/future directions
VSP and model design has given us the ability to visualize the
surgery before it happens, design the desired outcome,
provide guides for performing the surgery, and furnish tools
for confirming the match between the planned and desired
outcome. The techniques we describe in this chapter have
been evolving and represent a portion of the type of cases that
this technology can be used for. This has become a team
project between the ablative surgeons, reconstructive sur-
geons, and the engineers.27 As the software improves and
surgeon’s experience with it increases, communication with
the engineer may not always be necessary, but currently, they
play an integral role in VSP and creating the stereolithographic
models, guides, and templates. With the recent addition of
customized plate fabrication, another potential source of error
has been addressed and optimized. Our results and creativity
have improved because of this addition.
Intraoperative guidance will likely be utilized more com-
monly in the future to help double-check bone position
against the virtual plan in very complex cases. As the
software improves and techniques are further developed,
1. Hidalgo D. Fibula free flap: a new method of mandible
reconstruction. Plast Reconstr Surg. 1989;84:71–79.
2. Wallace C, Chang Y, Tsai C, Wei FC. Harnessing the potential of the
free fibula osteoseptocutaneous flap in mandible reconstruction.
Plast Reconstr Surg. 2010;125:305–314.
3. Hidalgo D, Rekow A. A review of 60 consecutive fibula free flap
mandible reconstructions. Plast Reconstr Surg. 1995;96:585–596.
4. Hidalgo D. Aesthetic improvements in free-flap mandible
reconstruction. Plast Reconstr Surg. 1991;88(4):574–585.
5. Tepper O, Hirsch DL, Levine JP, Garfein ES. The new age of
three-dimensional virtual surgical planning in reconstructive plastic
surgery. Plast Reconstr Surg. 2012;130:192e–194e, author reply
194e–195e.
6. Hirsch DL, Garfein ES, Christensen AM, et al. Use of computer-
aided design and computer-aided manufacturing to produce
orthognathically ideal surgical outcomes: a paradigm shift in head
and neck reconstruction. J Oral Maxillofac Surg. 2009;67:2115–2122.
7. Haddock N, Monaco C, Weimer K, et al. Increasing bony contact
and overlap with computer-designed offset cuts in free fibula
mandible reconstruction. J Craniofac Surg. 2012;23(6):1592–1595.
8. Levine JP, Bae JS, Soares M, et al. Jaw in a day: total maxillofacial
reconstruction using digital technology. Plast Reconstr Surg.
2013;131(6):1386–1391.
9. Sharaf B, Levine JP, Hirsch DL, et al. Importance of computer-aided
design and manufacturing technology in the multidisciplinary
approach to head and neck reconstruction. J Craniofac Surg.
2010;21:1277–1280.
10. Marchetti C, Bianchi A, Mazzoni S, et al. Oromandibular
reconstruction using a fibula osteocutaneous free flap: four different
“preplating” techniques. Plast Reconstr Surg. 2006;118:643–651.
Access the complete reference list online at

253.e1
References
References
1. Hidalgo D. Fibula free flap: a new method of mandible
reconstruction. Plast Reconstr Surg. 1989;84:71–79.
2. Wallace C, Chang Y, Tsai C, Wei FC. Harnessing the potential of the
free fibula osteoseptocutaneous flap in mandible reconstruction.
Plast Reconstr Surg. 2010;125:305–314.
3. Hidalgo D, Rekow A. A review of 60 consecutive fibula free flap
mandible reconstructions. Plast Reconstr Surg. 1995;96:585–596.
4. Hidalgo D. Aesthetic improvements in free-flap mandible
reconstruction. Plast Reconstr Surg. 1991;88(4):574–585.
5. Tepper O, Hirsch DL, Levine JP, Garfein ES. The new age of
three-dimensional virtual surgical planning in reconstructive plastic
surgery. Plast Reconstr Surg. 2012;130:192e–194e, author reply
194e–195e.
6. Hirsch DL, Garfein ES, Christensen AM, et al. Use of computer-
aided design and computer-aided manufacturing to produce
orthognathically ideal surgical outcomes: a paradigm shift in head
and neck reconstruction. J Oral Maxillofac Surg. 2009;67:2115–2122.
7. Haddock N, Monaco C, Weimer K, et al. Increasing bony contact
and overlap with computer-designed offset cuts in free fibula
mandible reconstruction. J Craniofac Surg. 2012;23(6):1592–1595.
8. Levine JP, Bae JS, Soares M, et al. Jaw in a day: total maxillofacial
reconstruction using digital technology. Plast Reconstr Surg.
2013;131(6):1386–1391.
9. Sharaf B, Levine JP, Hirsch DL, et al. Importance of computer-aided
design and manufacturing technology in the multidisciplinary
approach to head and neck reconstruction. J Craniofac Surg.
2010;21:1277–1280.
10. Marchetti C, Bianchi A, Mazzoni S, et al. Oromandibular
reconstruction using a fibula osteocutaneous free flap: four different
“preplating” techniques. Plast Reconstr Surg. 2006;118:643–651.
11. Kelly KJ, Manson PN, Vander Kolk CA, et al. Sequencing Le Fort
fracture treatment (Organization of treatment for a panfacial
fracture). J Craniofac Surg. 1990;1:168–178.
12. Markowitz BL, Manson PN. Panfacial fractures: organization of
treatment. Clin Plast Surg. 1989;16:105–114.
13. Gruss JS. Fronto-naso-orbital trauma. Clin Plast Surg. 1982;9:
577–589.
14. Gruss JS, Whelan MF, Rand RP, et al. Lessons learnt from the
management of 1500 complex facial fractures. Ann Acad Med
Singapore. 1999;28:677–686.
15. Gruss JS, Bubak PJ, Egbert MA. Craniofacial fractures. An algorithm
to optimize results. Clin Plast Surg. 1992;19:195–206.
16. Gruss JS, Pollock RA, Phillips JH, et al. Combined injuries of the
cranium and face. Br J Plast Surg. 1989;42:385–398.
17. Tessier P. Complications of facial trauma: principles of late
reconstruction. Ann Plast Surg. 1986;17:411–420.
18. Tepper OM, Sorice S, Hershman GN, et al. Use of virtual three-
dimensional surgery in posttraumatic craniomaxillofacial
reconstruction. J Oral Maxillofac Surg. 2011;69:733–741.
19. Fernandes R, DiPasquale J. Computer-aided surgery using 3D
rendering of maxillofacial pathology and trauma. Int J Med Robot.
2007;3:203–206.
20. Papadopoulos MA, Christou PK, Athanasiou AE, et al. Three-
dimensional craniofacial reconstruction imaging. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2002;93:382–393.
21. Treil J, Braga J, Ait Ameur A. [3D representation of skull and soft
tissues. Usefulness in orthodontic and orthognathic surgery]. J
Radiol. 2009;90:634–641.
22. Alves PV, Bolognese AM, Zhao L. Three-dimensional computerized
orthognathic surgical treatment planning. Clin Plast Surg.
2007;34:427–436.
23. Broer PN, Levine SM, Tanna N, et al. A novel approach to frontal
sinus surgery: treatment algorithm revisited. J Craniofac Surg.
2013;24(3):992–995.
24. Manolidis S, Hollier LH Jr. Management of frontal sinus fractures.
Plast Reconstr Surg. 2007;120:S32–S48.
25. Nahser HC, Lohr E. Possibilities of high resolution computer
tomography in the diagnosis of injuries of the facial skull. Radiologe.
1986;26:412.
26. Bell RB. Computer Planning and Intraoperative Navigation in
Cranio-Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am.
2010;22:135–156.
27. Avraham T, Franco P, Brecht LE, et al. Functional outcomes of
virtually planned free fibula flap reconstruction of the mandible.
Plast Reconstr Surg. 2014;134(4):628e–634e.

SECTION II • Head and Neck Reconstruction
10.1 
Introduction to midface reconstruction
The reconstruction of composite midface defects remains a
challenge to even the most experienced surgeons. Advances
in microsurgery and craniofacial surgery have transformed
the approach to midface reconstruction by increasing sur-
gical options, which have improved functional outcomes
and aesthetic results. The list of available techniques and
applicable flaps for complex head and neck reconstruction
continues to expand, and without convincing evidence
that a single reconstructive option is superior to another,
surgeon preference remains the dominant factor determin-
ing treatment choice for craniofacial defects. Harnessing
and implementing technological advances has enhanced
surgical planning and precision in execution of surgical
plans. Ultimately, this precision creates optimal condi-
tions for long-term oral rehabilitation. Interestingly, these
innovations have served to reinforce the age-old surgical
principles that have guided facial reconstruction for the
past century.
A new feature of this fourth edition of Plastic Surgery are
two chapters dedicated to midface reconstruction. For the first
time, the reconstructive approaches at the M.D. Anderson
Cancer Center and the Memorial Sloan Kettering Cancer
Center are showcased side by side to provide readers with
successful yet different philosophies adopted at two world-
renowned academic oncologic healthcare institutions. In
addition to their vast operative experience, the scholarly
contributions of the participating authors have helped define
these institutions as the core of reconstructive innovation and
education. Therefore, it is with enthusiasm and academic
fervor that the new chapters of this new edition be released
to serve a discerning audience in nuanced perspectives on
such a complex reconstructive problem.
Eduardo D. Rodriguez

SECTION II • Head and Neck Reconstruction
10.2 
Midface and cheek reconstruction: The
Memorial Sloan Kettering approach
Leila Jazayeri, Constance M. Chen and Peter G. Cordeiro
SYNOPSIS
Reconstructive goals for midface and maxillary defects:
■ Wound closure
■ Obliterate the maxillectomy defect
■ Restore barrier between sinonasal cavity and anterior cranial fossa
■ Separate oral and sinonasal cavities
■ Support orbital contents/maintenance of ocular globe position
■ Speech
■ Mastication
■ Maintain patent nasal airway
■ Facial contour
Reconstructive goals for cheek defects:
■ Wound closure
■ Obtain good color and texture match
■ Use local and regional flaps when possible
■ Avoid ectropion and complications secondary to undue tension
Midface and maxillary reconstruction
Introduction/general principles
Reconstruction of the midface starts through a clear under-
standing of the complex three-dimensional (3D) anatomy
of the maxilla.1 In the most basic terms, the maxilla may
be thought of as a six-walled geometric box that includes
the roof, which is made up by the orbital floor; the floor
of the box, which is made up by each half of the anterior
hard palate and alveolar ridge; and the medial wall of the
box, which forms the lateral walls of the nasal passage
(Fig. 10.2.1). The maxillary antrum is contained within the
central portion of the maxilla. The cranial base overlies the
posterior pterygoid region of the maxilla. The two horizontal
and three vertical buttresses produce facial width, height,
and projection. The overlying soft tissues, including the
muscles of facial expression and mastication, insert on the
maxilla and are responsible for individual facial appearance
and function.
The goals of reconstruction are functional and aesthetic.
Most extensive midface defects require free flaps for recon-
struction, with the flap selection dependent on the amount of
resected skin, soft tissue, and bone.2–7 Complex structures
such as lips, eyelids, and the nose should be reconstructed
separately, usually with local flaps, without incorporating free
tissue transfer.8–12 By following an algorithm based on a clearly
delineated classification system of midfacial defects, even
patients with very large, complex defects can be restored to
good function. The author’s algorithm is described below
(Fig. 10.2.2).1,13
The goal of midface reconstruction is not necessarily to
reconstruct all the walls of the maxilla that have been resected.
Rather, successful midface reconstruction should:
1. Close the wound.
2. Obliterate the maxillectomy defect.
3. Support the globe if preserved or fill the orbital cavity if
the globe is exenterated.
4. Maintain a barrier between the nasal sinuses and the
anterior cranial fossa.
5. Restore facial shape.
6. Reconstruct the palate.
Diagnosis and treatment
The algorithm we use to reconstruct complex midface defects
is based on the extent to which the maxillary bone has been
resected. Once the bony defect is assessed, we address the soft
tissue defects, including skin, muscle, palate, and mucosal
lining of the cheek. Finally, important structures such as the
palate, oral commissure, nasal airway, and eyelids are dealt
with in an attempt to restore function.

256
SECTION II
CHAPTER 10.2 • Midface and cheek reconstruction: The Memorial Sloan Kettering approach
lips, nose, and eyelids. Occasionally, the orbital rim will be
resected and non-vascularized bone grafts will be necessary
for reconstruction. Type I maxillectomy defects are small-
volume deficiencies with large surface area requirements,
often needing one or two skin islands. Our flap of choice
is the radial forearm free flap, as it provides good external
skin coverage and minimal bulk while allowing multiple
skin islands that can be de-epithelialized to improve contour,
wraparound bone grafts, and supply lining for the nasal cavity
(Fig. 10.2.4).
Type II: subtotal maxillectomy defects
Type II, or subtotal, maxillectomies are those that involve
resection of the lower five walls of the maxilla, including the
palate, but leave the orbital floor intact (Fig. 10.2.5). These
defects may be further subdivided into type IIA defects,
which include <50% of the transverse palate, or type IIB
defects, which include >50% of the transverse palate and/
or the anterior arch of the maxilla. Both type IIA and type
IIB maxillectomy defects are moderate-volume deficiencies
with large surface area requirements, which usually need one
skin island.
For type IIA defects, which involve <50% of the trans-
verse palate, reconstruction may proceed with either a
microvascular free flap or a skin graft and an obturator,
depending on patient and surgeon preference. If a free flap
is selected to avoid the inconvenience and maintenance of
a palatal obturator, our flap of choice is the radial forearm
fasciocutaneous free flap (Fig. 10.2.6). The skin inset is critical,
and the skin paddle must be equal to or smaller than the
original defect to keep the soft palate taut and recreate the
buccal sulcus. Without a taut inset, the skin paddle can
prolapse into the oral cavity. If adequate teeth or bone stock
remain, dentures or even osseointegrated dental implants
may be used.
For type IIB defects, which involve >50% of the transverse
palate or a significant portion of the anterior arch, an osteo-
cutaneous free flap is needed. These defects require bone
for structural support as well as skin lining of the neopalate
Type I: limited maxillectomy defects
Type I, or partial, maxillectomy defects are those that
involve one or two walls of the maxilla, most commonly
the anterior and medial walls (Fig. 10.2.3). Both the palate
and the orbital floor are intact. The resection will often
include the soft tissue and skin of the cheek, and even the
Fig. 10.2.1  The maxilla may be thought of as a six-walled geometric box that
includes the roof, which is made up by the orbital floor; the floor of the box, which
is made up by each half of the anterior hard palate and alveolar ridge; and the
medial wall of the box, which forms the lateral walls of the nasal passage.
Roof (orbital floor)
Medial wall
Lateral wall
Floor (anterior hard palate
and alveolar ridge)
Fig. 10.2.2  By following an algorithm based on a clearly delineated classification system of midfacial defects, even patients with very large, complex defects can be
restored to good function.
Reconstruction
of the midface
TYPE I -
Limited Maxillectomy:
Large SA
Small Vol
TYPE II -
Subtotal Maxillectomy:
Large SA
Medium Vol
IIA
Palatal defect <50%
Orbital floor intact
Palate intact
Orbital floor intact
IIB
Palatal defect >50%
or
Anterior arch defect
Orbital floor intact
TYPE III -
Total Maxillectomy:
Large SA
Medium/large Vol
TYPE IV -
Orbitomaxillectomy:
Large SA
Large Vol
IIIA
Palatal defect
Orbital floor defect;
Preservation
Orbital contents
IIIB
Palatal defect
Orbital exenteration
Palate intact
Orbital exenteration

257
Midface and maxillary reconstruction
or conventional dentures may also be used to recreate
teeth.
Type III: total maxillectomy defects
Type III defects are total maxillectomies that involve resection
of all six walls of the maxilla. Type III defects can be further
subdivided into resections that exclude (type IIIA) or include
(type IIIB) the orbital contents. Both type IIIA and type IIIB
maxillectomy defects are moderate-to-large-volume deficien-
cies with large surface area requirements, which usually need
at least one skin island.
For type IIIA defects, which involve resection of all six
walls of the maxilla, including the palate and orbital floor,
but preserve the orbital contents (Fig. 10.2.8), a bone graft is
needed to reconstruct the orbital floor and a free flap with
one or more skin paddles is needed to recreate the palate,
nasal lining, and/or the cheek. The goals are to support the
globe, obliterate any communication between the orbit and
nasopharynx, and reconstruct the palatal surface. For bony
support, we have used split calvarium, iliac crest, or less
commonly, split ribs to reconstruct both the maxillary prom-
inence and the orbital floor. For mucosal and skin lining,
our flap of choice is the rectus abdominis myocutaneous
flap, which may be wrapped around the bone graft to sepa-
rate the orbital contents from the oral cavity (Fig. 10.2.9A).
The bulk of the rectus can also fill the dead space of the
antrum and use of this can provide a water-tight closure
of the palate. In patients who are not candidates for free
tissue transfer, a temporalis flap may be used to cover the
orbital floor bone graft and provide some volume to fill the
midfacial defect (Fig. 10.2.9B). Reconstruction with a tempo-
ralis flap, however, requires simultaneous use of a palatal
obturator.
The type IIIB defect, which involves resection of the entire
maxilla including the orbital contents, is also known as an
extended maxillectomy (Fig. 10.2.10). The reconstructive goals
for these extensive, large-volume defects are to close the
and nasal floor. A prosthesis is inadequate, because bone
is needed to provide support to the upper lip. Our flap of
choice is the radial forearm osteocutaneous “sandwich” flap
(Fig. 10.2.7).14 The bone segment can be shaped to recreate
the maxillary alveolar arch and support the upper lip, and
the thin pliable skin can be wrapped around the bone like
a sandwich to replace the lining of the palate and nose. If
adequate bone is harvested, osseointegrated dental implants
Fig. 10.2.3  Type I, or partial, maxillectomy defects are those that involve one or
two walls of the maxilla, most commonly the anterior and medial walls.
Fig. 10.2.4  For type I defects, our flap of choice is the radial forearm free flap, as it provides good external skin coverage and minimal bulk allowing multiple skin islands
to be de-epithelialized to improve contour, wraparound bone grafts, and supply lining for the nasal cavity.

258
SECTION II
CHAPTER 10.2 • Midface and cheek reconstruction: The Memorial Sloan Kettering approach
Type IV: orbitomaxillectomy defects
Type IV defects involve resection of the upper five walls of
the maxilla and will usually include resection of the orbital
contents, leaving the dura and brain exposed; the palate is
usually left intact (Fig. 10.2.13). These are large-volume defects
with large surface area requirements. Our flap of choice is the
rectus abdominis flap, with one or more skin islands used for
external skin and/or nasal lining (Fig. 10.2.14).
Functional and aesthetic outcomes
Speech
In 44 patients who underwent resection of the palate, speech
was rated as normal in 22 patients (50%), near normal in 15
patients (34.1%), intelligible in six patients (13.6%), and unin-
telligible in one patient (2.3%). Speech results by maxillectomy
classification are presented in Table 10.2.1.
Diet
After midface reconstruction with palatal resection, 26 patients
(52%) were able to eat an unrestricted diet, 21 patients (42%)
could manage a soft diet, three patients (6%) were only able
to tolerate liquids, and one patient (2%) required tube feeding
(Table 10.2.1).
Globe position and function
Of the 42 patients who underwent resection of the orbital floor
with preservation of the orbital contents, 21 patients were
assessed. All patients maintained vision. Mild vertical dysto-
pia developed in one patient (4.8%), but no treatment was
necessary. Mild horizontal diplopia developed in four patients
(19%), which did not cause functional problems. Enophthal-
mos developed in one patient (4.8%). Lower eyelid ectropion
developed in 10 patients (47.6%), which was rated as mild in
four patients (19%), moderate in three patients (14.3%), and
palate, restore the nasal lining, and reconstruct the eyelids,
cheek, and lip as necessary. If the anterior cranial base is
exposed, the brain must also be covered. Our flap of choice is
a rectus abdominis myocutaneous free flap with one or more
skin islands used to recreate the palate, lateral nasal wall, and
any cutaneous deficits (Figs. 10.2.11 & 10.2.12). The latissimus
dorsi flap may also provide adequate soft tissue bulk and
pedicle length, but it is not as versatile with regard to provid-
ing multiple skin island coverage.
Fig. 10.2.6  (A) For Type IIA defects, which involve <50% of the transverse palate, reconstruction may proceed with either a microvascular free flap or a skin graft and an
obturator, depending on patient and surgeon preference. If a free flap is selected to avoid the inconvenience and maintenance of a palatal obturator, our flap of choice is the
radial forearm fasciocutaneous free flap. (B) Radial forearm free flap is prepared. (C) Inset of the free flap.
A
B
C
Fig. 10.2.5  Type II, or subtotal, maxillectomies are those that involve resection of
the lower five walls of the maxilla, including the palate, but leave the orbital floor
intact.

259
Midface and maxillary reconstruction
Table 10.2.1  Functional and aesthetic outcomes
Maxillectomy defect
Type I
(n = 20)
Type IIA
(n = 8)
Type IIB
(n = 8)
Type IIIA
(n = 22)
Type IIIB
(n = 23)
Type IV
(n = 19)
Total
(n = 100)
Speech
N/A = 18
N/A = 2
N/A = 3
N/A = 8
N/A = 8
N/A = 17
n = 44
  Normal
2
3
2
8
5
2
22 (50%)
  Near normal
2
1
5
7
15 (34.1%)
  Intelligible
1
2
1
2
6 (13.6%)
  Unintelligible
1
1 (2.3%)
Diet
N/A = 18
N/A = 1
N/A = 6
N/A = 7
N/A = 17
n = 50
  Unrestricted
1
4
3
9
7
2
26 (52%)
  Soft
3
4
7
7
21 (42%)
  Liquids
1
2
3 (6%)
  Feeding tube
1
1 (2%)
Eyeglobe position and function
N/A = 16
N/A = 8
N/A = 8
N/A = 4
N/A = 23
N/A = 19
n = 21
  Normal
1
4
5 (23.8%)
  Dystopia
1
1 (4.8%)
  Diplopia
4
4 (19%)
  Enophthalmos
1
1 (4.8%)
  Ectropion
1
9
10 (47.6%)
    Mild
4
4 (19%)
    Moderate
3
3 (14.3%)
    Severe
1
2
3 (14.3%)
Oral competence
N/A = 20
N/A = 6
N/A = 6
N/A = 21
N/A = 17
N/A = 18
n = 12
  Yes
2
2
1
5
1
11 (91.7%)
  No
1
1 (8.3%)
Microstomia
N/A = 20
N/A = 6
N/A = 6
N/A = 21
N/A = 21
N/A = 14
n = 12
  Yes
1
1
1
3 (25%)
  No
2
1
1
1
4
9 (75%)
Aesthetic result
N/A = 8
N/A = 1
N/A = 5
N/A = 9
N/A = 7
n = 70
  Excellent
6
6
5
12
5
7
41 (58.6%)
  Good
5
1
1
4
9
5
25 (35.7%)
  Fair
1
2
1
4 (5.7%)
  Poor
0 (0%)
Fig. 10.2.7  For type IIB defects, which involve >50% of the transverse palate or a significant portion of the anterior arch, an osteocutaneous free flap is needed. These
defects require bone for structural support as well as skin lining of the neopalate and nasal floor. A prosthesis is inadequate, because bone is needed to provide support to
the upper lip. Our flap of choice is the radial forearm osteocutaneous “sandwich” flap.

260
SECTION II
CHAPTER 10.2 • Midface and cheek reconstruction: The Memorial Sloan Kettering approach
microstomia. No treatment was needed. Oral competence is
described in Table 10.2.1.
Aesthetic results
Out of 70 patients who underwent evaluation of aesthetic
outcomes, 41 patients had aesthetic results that were judged
as excellent (58.6%), 25 patients had results judged as good
(35.7%), and four patients had results judged as fair (5.7%).
Although none of the patients were rated with poor results,
it was most difficult to obtain a positive aesthetic result in
patients who underwent skin, eyelid, or lip resections. Aes-
thetic results by maxillectomy classification are detailed in
Table 10.2.1.
Cheek reconstruction
Introduction/general principles
The reconstructive goals and algorithm associated with maxil-
lectomy defects should be prioritized in midface reconstruc-
tion. Once these have been addressed, or in isolated cheek
reconstruction, the principles associated with cheek recon-
struction should be considered. The cheek is composed of an
external skin layer, muscles of facial expression, fat, and oral
mucosa. The cheek is a relatively flat and expansive surface.
As a peripheral unit of the face, the cheek cannot be fully
compared to the contralateral cheek in any one view. As such,
exact symmetry and precise subunit reconstruction will opti-
mize the aesthetic results; however, it is not critical, especially
compared to reconstruction of central subunits (nose, lip, and
eyelid).15,16 The more critical concept in cheek reconstruction
is restoring the skin color and texture. Local tissues provide
tissue of like texture, color, and hair growth. Thus, whenever
possible, local tissue is the first choice in reconstructing the
cheek.
Many cheek defects can be closed primarily. The best
results are achieved by hiding the final scar along resting skin
tension or contour lines. When treating subtotal facial defects
Fig. 10.2.8  For type IIIA defects, which involve resection of all six walls of the
maxilla including the palate and orbital floor, but preserve the orbital contents, a
bone graft is needed to reconstruct the orbital floor and a free flap with one or more
skin paddles is needed to recreate the palate, nasal lining and/or the cheek.
A
Fig. 10.2.9  Type IIIA defect reconstructed with bone graft for floor of orbit. (A) Rectus abdominus free flap for closure of palate and coverage of bone graft.
severe in three patients (14.3%). None of the patients with
ectropion underwent additional procedures (Table 10.2.1).
Oral competence
Of the 12 patients who underwent resection and reconstruc-
tion of the oral commissure, 11 patients (91.7%) had good to
excellent oral competence within 1 month postoperatively.
After radiation therapy, three patients (25%) developed mild

261
Cheek reconstruction
cheek defects. Any described local flaps can be used in the
cheek with two principles in mind: (1) incisions should be
kept parallel to relaxed skin tension lines, and (2) avoid any
tension on other facial structures to prevent secondary defor-
mities such as ectropion on the lower eyelid or distortion of
the nose or lip.
Cheek rotation advancement flap
Mobilized cervicofacial flaps and myocutaneous flaps from
the chest are workhorse options for reconstruction of external
defects of the cheek and, at times, can be used for full-thickness
defects. These flaps can be based anteriorly or posteriorly (Fig.
10.2.15). Anterior based flaps, described by Juri and Juri,18,19
are useful for posterior and large anterior defects. The author’s
preferred flap is the anteriorly based cervicofacial flap (Fig.
10.2.16). The flap is based on the facial and submental arteries
and elevated in the subcutaneous plane to the clavicle. The
residual cheek skin is shifted forward and the neck upward
to close the donor site. The dog-ear is then removed, ideally
in the nasolabial fold, immediately or in a delayed fashion,
depending on the vascular supply after elevation and inset.
For larger defects, the anterior based cheek rotation flap can
be extended down to the chest to move neck and chest skin
to the face.20–22 The flap incision should be carried down into
the neck behind the trapezius, lateral to the acromioclavicular
joint and deltopectoral groove, crossing the chest medially in
the third to fourth intercostal space in a male with a back-cut,
if needed in the parasternal area. Inferiorly, the flap is elevated
with the platysmal muscle and with the deltoid and pectoral
fasciae.
Posteriorly based flaps, described by Stark and Kaplan, are
used for small and moderate-sized anterior cheek defects or
larger posterior defects.23 These flaps allow for transfer of the
jowls and submental area into the face. Posteriorly based flaps
can also be extended into the neck and chest for increased
reach.24–26
Ectropion is an important complication to consider in the
use of cervicofacial flaps. These flaps are designed to abut the
lower eyelid and thus pull down on the delicate lower eyelid
skin. To avoid this, the flap should be designed to avoid any
tension in this region and should be suspended to the
B
(B) Temporalis flap for coverage of bone graft.
Fig. 10.2.9, cont’d
of the cheek skin, split- and full-thickness skin grafts should
be avoided. Their unpredictable color and shiny texture vio-
lates the important principle of restoring cheek color and
texture and creates a patch-like effect in the cheek.17 Skin
grafts are suitable for the reconstruction of the lower eyelid
or the preauricular/temporal region.
Diagnosis and treatment
Local flaps
Local flaps provide skin that is similar to that of the face in
terms of color and texture and are used for medium-sized
Fig. 10.2.10  The type IIIB defect, which involves resection of the entire maxilla
including the orbital contents, is also known as an extended maxillectomy.

262
SECTION II
CHAPTER 10.2 • Midface and cheek reconstruction: The Memorial Sloan Kettering approach
A
Fig. 10.2.11  Type IIIB defects involve
resection of the upper five walls of the
maxilla and will usually include resection of
the orbital contents, leaving the dura and
brain exposed. The palate is usually left
intact. (A) Intraoperative photograph of type
IIIB maxillectomy defect. (B) Postoperative
photograph of type IIIB maxillectomy defect.
B
Fig. 10.2.12  For type IIIB defects, our flap of choice is a rectus abdominis myocutaneous free flap with one or more skin islands used to recreate the palate, lateral nasal
wall, and any cutaneous deficits.
underlying periosteum or bone.27,28 Another drawback of this
flap is its unpredictable blood supply. The risk of ischemic
complications is high in radiated patients, smokers, and flaps
placed under tension.
Free tissue transfer
There are disadvantages to regional flaps that should be
considered. The main disadvantage of regional flaps is a
vascular supply that is not always reliable. When turned over
on its self for full-thickness defects, regional flaps can get too
bulky, leading to the creation of a cheek that has poor func-
tional and aesthetic results. Skin grafts are usually necessary
to address the donor site. Finally, regional flaps are occasion-
ally not able to reliably reach the midface. For large defects
involving the external skin, intraoral lining, or both, micro-
vascular free flaps are generally indicated; however, color and
texture match is more difficult to achieve.

263
Cheek reconstruction
Large external defects require a significant amount of
pliable skin with minimal underlying soft tissue. The radial
forearm fasciocutaneous flap is ideal for these situations
because it provides an adequate quantity of skin with minimal
bulk (Fig. 10.2.17). Depending on the amount of soft tissue
bulk required, the lateral arm flap, anterolateral thigh flap,
and scapular flap are satisfactory options.
Intraoral lining defects that span the maxillary and man-
dibular sulci require a microvascular free flap. A radial forearm
free flap provides thin pliable skin to resurface this area. The
flap may also be neurotized to enhance recovery of sensation
in this tissue by anastomosing the lateral antebrachial cutane-
ous nerve to a sensory nerve in the recipient area.
Full-thickness defects of the cheek require at least two skin
islands to resurface the inner lining and provide external
coverage. The folded radial forearm fasciocutaneous flap is
the first choice for small through-and-through defects. Larger
resections of the cheek associated with segmental mandibu-
lectomy, as well as partial maxillectomy/orbitectomy, are best
reconstructed by using the rectus abdominis free flap with
multiple skin islands. If the commissure is resected, it should
be reconstructed with a local switch procedure from the intact
opposite lip and not with a portion of the free flap. The free
flap should be reserved for reconstruction of the intraoral and
external skin defects.
Fig. 10.2.14  For type IV defects, our flap of choice is the rectus abdominis flap, with one or more skin islands used for external skin and/or nasal lining.
Fig. 10.2.13  A type IV or orbitomaxillectomy defect involves loss of the orbital
contents and upper walls of the maxilla, leaving the palate intact.

264
SECTION II
CHAPTER 10.2 • Midface and cheek reconstruction: The Memorial Sloan Kettering approach
Fig. 10.2.15  The cheek rotation advancement flap. (A) Anteriorly based cheek
rotation advancement flap is the local flap of choice for partial thickness cheek
defects. (B) Posteriorly based cheek rotation advancement flap is an alternative
design for coverage of posterior or small anterior cheek defects.
A
B
A
B
Fig. 10.2.16  The cheek rotation advancement flap is our local flap of choice for partial thickness cheek defects. (A) Preoperative view of anterior cheek lesion. (B) Partial
thickness moderate sized anterior cheek defect.

265
Cheek reconstruction
C
D
E
F
(C) Cheek rotation advancement flap design. (D) Cheek rotation advancement flap inset with suspending periosteal sutures to avoid ectropion and
skin grafting of preauricular donor site. (E,F) Postoperative view showing good color and texture match as well as lack of ectropion.
Fig. 10.2.16, cont’d

266
SECTION II
CHAPTER 10.2 • Midface and cheek reconstruction: The Memorial Sloan Kettering approach
A
B
C
D
E
F
Fig. 10.2.17  For large partial and full thickness cheek defects free tissue transfer is often needed. Our flap of choice is the radial forearm fasciocutaneous flap. (A–C) Large
anterior cheek lesion. (D) Large partial thickness anterior cheek defect. (E) Reconstruction with radial forearm fasciocutaneous flap to facial artery and vein. (F) Postoperative
view of large partial thickness cheek reconstruction with radial forearm flap; color match is acceptable, yet inferior to that obtained using local/regional tissue.

267
Cheek reconstruction
3. Dalgorf D, Higgins K. Reconstruction of the midface and maxilla.
Curr Opin Otolaryngol Head Neck Surg. 2008;16(4):303–311.
4. Foster RD, Anthony JP, Singer MI, Kaplan MJ, Pogrel MA, Mathes
SJ. Reconstruction of complex midfacial defects. Plast Reconstr Surg.
1997;99(6):1555–1565. A series of 26 consecutive midface reconstructions
over 5 years was assessed. An algorithm for free flap selection in this
setting is advanced based on this experience.
6. Wells MD, Luce EA. Reconstruction of midfacial defects after
surgical resection of malignancies. Clin Plast Surg. 1995;22(1):79–89.
Oncologic resections of the midface generate devastating deformities. Local
reconstructions are preferred when sufficient support is available for
osseointegrated implants; otherwise, osteocutaneous tissue transfer should
be considered.
7. Zhang B, Li DZ, Xu ZG, Tang PZ. Deep inferior epigastric artery
perforator free flaps in head and neck reconstruction. Oral Oncol.
2009;45(2):116–120. The DIEP flap is described as a reliable means of
head and neck reconstruction with reduced donor site morbidity.
8. Cordeiro PG, Disa JJ. Challenges in midface reconstruction. Semin
Surg Oncol. 2000;19(3):218–225.
9. Herford AS, Cicciu M, Clark A. Traumatic eyelid defects: a review
of reconstructive options. J Oral Maxillofac Surg. 2009;67(1):3–9.
10. Kakudo N, Ogawa Y, Kusumoto K. Success of the orbicularis oculi
myocutaneous vertical V-Y advancement flap for upper eyelid
reconstruction. Plast Reconstr Surg. 2009;123(3):107e.
13. Cordeiro PG, Santamaria E. A classification system and algorithm
for reconstruction of maxillectomy and midfacial defects. Plast
Reconstr Surg. 2000;105(7):2331–2346, discussion 47-8. Maxillary
defects are classified, based on a series of 60 patients presenting for
reconstruction after oncologic resection. Free flap selection is discussed in
this context.
14. Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm
osteocutaneous “sandwich” free flap for reconstruction of the
bilateral subtotal maxillectomy defect. Ann Plast Surg. 1998;
40(4):397–402. Advantages of the osteocutaneous radial forearm free flap
in maxillary reconstruction are discussed. “Sandwiching” the osseous
component between the skin paddles provides for nasal and palatal lining
as well as support for osteointegrated implants.
16. Menick FJ. Reconstruction of the cheek. Plast Reconstr Surg.
2001;108(2):496–505.
Access the complete reference list online at

267.e1
References
References
1. McCarthy CM, Cordeiro PG. Microvascular reconstruction of
oncologic defects of the midface. Plast Reconstr Surg.
2010;126(6):1947–1959.
2. Andrades P, Rosenthal EL, Carroll WR, Baranano CF, Peters GE.
Zygomatic-maxillary buttress reconstruction of midface defects
with the osteocutaneous radial forearm free flap. Head Neck.
2008;30(10):1295–1302.
3. Dalgorf D, Higgins K. Reconstruction of the midface and maxilla.
Curr Opin Otolaryngol Head Neck Surg. 2008;16(4):303–311.
4. Foster RD, Anthony JP, Singer MI, Kaplan MJ, Pogrel MA, Mathes
SJ. Reconstruction of complex midfacial defects. Plast Reconstr Surg.
1997;99(6):1555–1565. A series of 26 consecutive midface reconstructions
over 5 years was assessed. An algorithm for free flap selection in this
setting is advanced based on this experience.
5. Konno A, Togawa K, Iizuka K. Primary reconstruction after total or
extended total maxillectomy for maxillary cancer. Plast Reconstr
Surg. 1981;67(4):440–448.
6. Wells MD, Luce EA. Reconstruction of midfacial defects after
surgical resection of malignancies. Clin Plast Surg. 1995;22(1):79–89.
Oncologic resections of the midface generate devastating deformities. Local
reconstructions are preferred when sufficient support is available for
osseointegrated implants; otherwise, osteocutaneous tissue transfer should
be considered.
7. Zhang B, Li DZ, Xu ZG, Tang PZ. Deep inferior epigastric artery
perforator free flaps in head and neck reconstruction. Oral Oncol.
2009;45(2):116–120. The DIEP flap is described as a reliable means of
head and neck reconstruction with reduced donor site morbidity.
8. Cordeiro PG, Disa JJ. Challenges in midface reconstruction. Semin
Surg Oncol. 2000;19(3):218–225.
9. Herford AS, Cicciu M, Clark A. Traumatic eyelid defects: a review
of reconstructive options. J Oral Maxillofac Surg. 2009;67(1):3–9.
10. Kakudo N, Ogawa Y, Kusumoto K. Success of the orbicularis oculi
myocutaneous vertical V-Y advancement flap for upper eyelid
reconstruction. Plast Reconstr Surg. 2009;123(3):107e.
11. Naugle TC Jr, Levine MR. Lid reconstruction. Ophthalmology.
2008;115(9):1643–1644, author reply 4.
12. Robotti E, Righi B, Carminati M, Ortelli L, Bonfirraro PP, Devalle L,
et al. Oral commissure reconstruction with orbicularis oris elastic
musculomucosal flaps. J Plast Reconstr Aesthet Surg. 2010;63(3):
431–439.
13. Cordeiro PG, Santamaria E. A classification system and algorithm
for reconstruction of maxillectomy and midfacial defects. Plast
Reconstr Surg. 2000;105(7):2331–2346, discussion 47-8. Maxillary
defects are classified, based on a series of 60 patients presenting for
reconstruction after oncologic resection. Free flap selection is discussed in
this context.
14. Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm
osteocutaneous “sandwich” free flap for reconstruction of the
bilateral subtotal maxillectomy defect. Ann Plast Surg.
1998;40(4):397–402. Advantages of the osteocutaneous radial forearm free
flap in maxillary reconstruction are discussed. “Sandwiching” the osseous
component between the skin paddles provides for nasal and palatal lining
as well as support for osteointegrated implants.
15. Chandawarkar RY, Cervino AL. Subunits of the cheek: an algorithm
for the reconstruction of partial-thickness defects. Br J Plast Surg.
2003;56(2):135–139.
16. Menick FJ. Reconstruction of the cheek. Plast Reconstr Surg.
2001;108(2):496–505.
17. Georgiade RSaN, ed. J. F. Reconstruction of the burned face in children.
St. Louis: Mosby; 1984.
18. Juri J, Juri C. Advancement and rotation of a large cervicofacial flap
for cheek repairs. Plast Reconstr Surg. 1979;64(5):692–696.
19. Juri J, Juri C. Cheek reconstruction with advancement-rotation
flaps. Clin Plast Surg. 1981;8(2):223–226.
20. Becker DW Jr. A cervicopectoral rotation flap for cheek coverage.
Plast Reconstr Surg. 1978;61(6):868–870.
21. Crow ML, Crow FJ. Resurfacing large cheek defects with rotation
flaps from the neck. Plast Reconstr Surg. 1976;58(2):196–200.
22. Shestak KC, Roth AG, Jones NF, Myers EN. The cervicopectoral
rotation flap–a valuable technique for facial reconstruction. Br J
Plast Surg. 1993;46(5):375–377.
23. Stark RB, Kaplan JM. Rotation flaps, neck to cheek. Plast Reconstr
Surg. 1972;50(3):230–233.
24. Beare R. Flap repair following exenteration of the orbit. Proc R Soc
Med. 1969;62(11 Pt 1):1087–1090.
25. Garrett WS Jr, Giblin TR, Hoffman GW. Closure of skin defects of
the face and neck by rotation and advancement of cervicopectoral
flaps. Plast Reconstr Surg. 1966;38(4):342–346.
26. Kaplan I, Goldwyn RM. The versatility of the laterally based
cervicofacial flap for cheek repairs. Plast Reconstr Surg.
1978;61(3):390–393.
27. Harris GJ, Perez N. Anchored flaps in post-Mohs reconstruction of
the lower eyelid, cheek, and lateral canthus: avoiding eyelid
distortion. Ophthal Plast Reconstr Surg. 2003;19(1):5–13.
28. Okazaki M, Haramoto U, Akizuki T, Kurakata M, Ohura N, Ohmori
K. Avoiding ectropion by using the Mitek Anchor System for flap
fixation to the facial bones. Ann Plast Surg. 1998;40(2):169–173.

SECTION II • Head and Neck Reconstruction
10.3 
Midface reconstruction: The M. D.
Anderson approach
Matthew M. Hanasono and Roman Skoracki
Introduction
Options for treating oncologic midfacial defects include use
of prosthetic obturators, pedicled flaps, and free flaps, some-
times combined with grafts or alloplasts. While the popularity
of pedicled flaps has declined due to limited reach and
volume, prosthetic obturators remain a good solution for
patients with limited palatal defects. However, for extensive
defects, obturators may be difficult or impossible to retain,
particularly in edentulous patients. Furthermore, obturators
are usually inappropriate for defects that involve resection of
the skull base and orbital floor. Finally, some patients may not
like the inconvenience of an obturator, which must be removed
and cleaned regularly and periodically adjusted or replaced
for fit.
For midfacial reconstructions in which obturators are not
an option or not desired by the patient, a variety of bony
and soft tissue free flaps have been utilized and flap selec-
tion is a subject of debate. The challenge of reconstructing
the midface is that resections are highly variable and patient
specific, and no one technique is ideal for every defect.1,2 Suc-
cessful outcomes in midfacial reconstruction require mastery
of a range of soft tissue and bony free flaps as well familiar-
ity with traditional craniofacial techniques such as plating
and grafting.
Reconstructive approach
Although there are several important considerations in
midface reconstruction, the palate should be considered first
(Fig. 10.3.1).3 The extent of hard and soft palate resected, if
any, as well as the defect location and plans for dental restora-
tion, will dictate whether a prosthetic obturator is indicated
or a bony or soft tissue free flap should be performed. Accu-
rate reconstruction of the orbital floor, if resected, is manda-
tory for proper orbital position and eye function (Fig. 10.3.2).
Following orbital exenteration (removal of orbital contents), a
pedicled or free flap may serve to line the orbit. If an extended
orbital exenteration (removal of orbital contents and one or
more orbital walls) or orbitomaxillectomy (orbital exentera-
tion combined with a maxillectomy) is performed, a free flap
is indicated to separate the orbit from the nasal cavity and
sinuses. Our reconstructive algorithm4 is presented in Fig.
10.3.3, and a detailed explanation follows.
Unilateral posterior palatomaxillectomy
While any number of palatoalveolar defects are possible,
Okay et al.3 recommend distinguishing defects based on
whether function can be satisfactorily restored with an obtu-
rator or if a flap is required. Palatoalveolar defects that spare
both canine teeth can often be successfully treated with an
obturator. In these cases, cantilever forces resulting in unstable
prosthetic retention are minimized because of the favorable
root morphology of the canine adjacent to the obturator and
the generous arch length provided by the remaining alveolus.
Thus, defects including unilateral posterior palatomaxillary
defects can usually be obturated and should be considered
separately from those that cannot, including defects that
involve half the palate and those that involve the entire ante-
rior arch or whole palate.
As mentioned above, some patients even with unilateral
posterior defects will still prefer or require autologous recon-
struction. In these patients, we reconstruct posterior palato-
maxillary defects with soft tissue rather than bony free flaps.
Restoration of posterior maxillary dentition, which is not
easily visible even when smiling, is not a priority to many
patients.
The anterolateral thigh (ALT) or rectus abdominis myocu-
taneous (RAM) free flaps are usually well suited to providing
the appropriate amount of tissue for posterior palatomaxillary
reconstruction (Fig. 10.3.4). These flaps tend to be thicker in
Western patients and will fill the maxillary sinus. The radial
forearm fasciocutaneous (RFF) free flap can be used on more
obese individuals or for small defects in which bulk is not
needed to provide cheek projection.
Access video lecture content for this chapter online at expertconsult.com

269
Reconstructive approach
not prolapse into the oral cavity. Creating a concave palatal
reconstruction with soft tissue flaps can be technically chal-
lenging. This may be possible by ensuring the flap is not
redundant and, if necessary, suspending the flap to the zygo-
matic periosteum with sutures.
We favor the use of osteocutaneous free flaps for hemipala-
tomaxillectomy defects in highly functional patients with a
reasonable oncologic prognosis (Fig. 10.3.5). Besides provid-
ing better anterior projection, osteocutaneous free flaps offer
the possibility of osseointegrated implants for dental restora-
tion. Postoperative radiation therapy increases the risk of
failed implant osseointegration, which should play a role in
Unilateral hemipalatomaxillectomy
Unlike unilateral posterior palatomaxillary defects, defects of
the palate and alveolus extending anterior to the canine tooth
defects are difficult to obturate because of the greater cantile-
ver forces acting on the prosthesis.5 Free flap selection for
these defects is somewhat controversial. Soft tissue free flaps
are more straightforward surgically. However, they do not
provide a rigid skeletal framework, which can result in a loss
of anterior maxillary projection on the side of the defect, and
cannot accept osseointegrated implants for dental restoration.
To accommodate a dental prosthesis, the soft tissue flap must
Fig. 10.3.1  Reconstructive classification of palatomaxillary defects based on ability to accommodate an obturator and need for bony or soft tissue reconstruction.
Maxillectomy types include (A) superstructure maxillectomy (orbital floor removed, palate intact), (B) posterior palatomaxillectomy (hard palate and alveolus posterior to the
canine tooth removed), (C) hemipalatomaxillectomy, (D) premaxillary resection, and (E) bilateral palatomaxillectomy (hard palate and anterior alveolus, including at least
the canine teeth removed).
A
B
C
D
E

270
SECTION II
CHAPTER 10.3 • Midface reconstruction: The M. D. Anderson approach
complete bilateral defects, a shorter segment of bone is used
and one or more segments can be omitted.
Orbital floor defects
Our experience suggests that, when supported by a soft tissue
free flap, the orbital floor can be successfully reconstructed
with bone grafts or alloplasts, such as titanium mesh (Fig.
10.3.8).3 Many surgeons, however, feel that bone grafts are
more resistant to radiation-associated complications than
alloplasts are. On the other hand, bone grafts are more difficult
to shape accurately, which may result in malpositioning of the
globe. When using the fibula free flap for reconstructing
hemipalatomaxillectomy and bilateral palatomaxillectomy
defects that include resection of the orbital floor, we include
some flexor hallucis longus muscle to support the bone graft
or alloplastic orbital floor reconstruction.
Orbital exenteration defects
The primary goal of reconstruction following orbital exentera-
tion is to line the orbital cavity with durable tissue. The
patient’s desire for an orbital prosthetic should also be con-
sidered when planning the reconstruction. A deep orbital
cavity facilitates prosthetic fit while a shallow orbital cavity,
or an orbital reconstruction that sits flush with the face,
may not securely hold a prosthesis without osseointegrated
implants. This also causes unsightly and unnatural appearing
protrusion of the prosthesis.10
When postoperative radiation is able to be avoided, healing
by secondary intention or split-thickness skin grafting, even
on bare bone, are usually successful methods for addressing
the standard orbital exenteration wound. If the orbital cavity
is to be irradiated after surgery, better vascularized recon-
struction of the orbital cavity with a soft tissue flap, such as
the timing of osseous-containing free flap reconstruction.
Recommendations for free flap selection and shaping with
osteotomies are discussed below.
Bilateral (anterior) palatomaxillectomy
Because both canine teeth are preserved, premaxillary defects
may be amenable to obturation or reconstruction with a soft
tissue free flap combined with a dental prosthesis that clasps
to the remaining teeth to maintain midfacial projection and
support the upper lip and nose. Otherwise, for these and more
extensive anterior palatomaxillectomy defects, bony recon-
struction is indicated to maintain midfacial height, width,
and projection.6,7 Extensive bilateral defects cannot usually be
obturated due to the lack of teeth to support a heavy prosthesis.
The fibula free flap is our preferred flap for bony hemi- and
bilateral palatomaxillectomy reconstruction.8,9 The lateral
surface of the fibula is used to restore the vertical maxillary
height, measured from the orbital rim to the occlusal plane of
the hard palate, by orienting it to face anteriorly (Figs. 10.3.6
& 10.3.7). The leg that is ipsilateral to the side of the planned
microvascular anastomosis is selected for fibula osteocutane-
ous free flap harvest so that the skin paddle can be used to
restore the palate. Vein grafts are used when pedicle length is
inadequate to reach the recipient vessels.
After the resection is complete, osteotomies are made in the
fibula such that the flap takes on a shape similar to the Greek
letter “omega” in the transverse plane. We have found the use
of CAD-CAM and three-dimensional (3D) models, when
available, useful for shaping the fibula flap in maxillary
reconstruction. The fibula is rigidly fixed to the zygomatic
bones laterally. When reconstructing bilateral maxillectomy
defects, the lateral portions of the “omega” recreate the malar
regions. The central portion of the fibula free flap restores the
maxillary alveolus. A slight downward angulation of the
portion of the fibula used to recreate the anterior maxillae is
usually needed to fully restore vertical facial height. For
unilateral (see hemipalatomaxillectomy, above) or less than
Fig. 10.3.2  (A) Maxillectomy with orbital floor resection.
In this case, a hemipalatomaxillectomy is performed with
resection of the orbital floor, termed a “total maxillectomy”
by some, although others use this term to include defects
in which the orbital floor is spared. To avoid confusion, the
status of the orbital floor should be mentioned separately.
(B) Maxillectomy with orbital exenteration. In this case,
orbital exenteration is combined with a superstructure
maxillectomy, termed an orbitomaxillectomy by some
authors.
A
B
Text continued on p. 276

271
Orbital exenteration defects
Fig. 10.3.3  Midfacial reconstructive algorithm. ALT,
anterolateral thigh; FOC, fibula osteocutaneous; RAM,
rectus abdominis myocutaneous; RFF, radial forearm
fasciocutaneous; RFOC, radial forearm
osteocutaneous; TM, temporalis muscle; TPF,
temporoparietal fascia. *We favor osteocutaneous free
flap reconstruction for hemipalatal defects (i.e., entire
left or right palate) in suitable candidates with a good
functional status and favorable prognosis.
Soft tissue flap
(e.g., ALT or RAM)
vs. osteocutaneous
flap (e.g., FOC)
Obturator vs.
osteocutaneous flap
(e.g., FOC or RFOC)
Osteocutaneous
flap (e.g., FOC)
Thick flap
(e.g., ALT or RAM)
Thick flap and
osteocutaneous flap
(e.g., ALT or RAM
combined with FOC)
Multi-skin
paddle flap
(e.g., ALT or RAM)
Extended orbital
exenteration
Combined with
posterior palatal or
hemipalatal defect*
Combined with
hemipalatal or
bilateral palatal
defect*
Anterior
(premaxilla only)
Anterior/bilateral
Palatal defect
Midface defect
Orbital exenteration defect
Orbital floor defect
Hemipalate
Obturator vs.
soft tissue flap
(e.g., ALT or RAM)
Isolated orbital
exenteration
Thin flap
(e.g., TM or TPF
flaps, or RFF)
See “extended
orbital exenteration”
above
With orbital
exenteration
Orbital contents
preserved
Alloplast or
bone graft
Posterior only
None
None

272
SECTION II
CHAPTER 10.3 • Midface reconstruction: The M. D. Anderson approach
Fig. 10.3.4  (A) Patient with a posterior
palatomaxillectomy defect sparing the orbital floor and
orbital contents (B) undergoing an anterolateral thigh
free flap reconstruction. (C) The maxillary sinus is
obliterated after complete removal of the mucosa with
a diamond burr drill. The flap is inset so that it does
not hang into the oral cavity. (D–E) Postoperative
external and intraoral appearance.
A
B
C
D
E

273
Orbital exenteration defects
Fig. 10.3.5  (A) Patient with a unilateral
hemipalatomaxillectomy defect sparing the orbital
floor and orbital contents. (B) A fibula osteocutaneous
free flap was performed with two skin paddles. (C) One
skin paddle was used to reconstruct the palatal defect
and the other was de-epithelialized to give soft tissue
bulk to the cheek. (D) Postoperative appearance.
A
B
C
D
Fig. 10.3.6  (A,B) “Omega-shaped” fibula free flap configuration. The fibula is osteotomized to resemble the Greek letter omega in the horizontal plane.
A
B

274
SECTION II
CHAPTER 10.3 • Midface reconstruction: The M. D. Anderson approach
A
B
C
D
E
Fig. 10.3.7  (A) Patient with a bilateral palatomaxillectomy defect sparing the orbital floors and orbital
contents. (B) An “omega-shaped” fibula osteocutaneous free flap was used to restore midfacial height, width, and
projection. (C) Flap inset. (D) Osseointegrated implants were placed approximately 6 months after the initial
reconstruction for dental restoration. (E) Postoperative appearance with a dental prosthesis.

275
Orbital exenteration defects
Fig. 10.3.8  (A) Patient with a palatomaxillectomy
with an orbital floor defect. (B) An orbital floor
reconstruction with titanium mesh was performed.  
(C) An anterolateral thigh free flap was harvested for
reconstruction. Two skin paddles were dissected,
based on separate perforator blood vessels. (D) One
skin paddle was used to reconstruct the palatal defect.
The other was de-epithelialized and placed between
the titanium mesh and cheek skin, to minimize the risk
for hardware exposure. (E) Postoperative appearance
with slight intentional volume overcorrection in
anticipation of shrinkage following adjuvant radiation
therapy.
A
B
C
D
E

276
SECTION II
CHAPTER 10.3 • Midface reconstruction: The M. D. Anderson approach
Fig. 10.3.9  (A) Patient with an extended orbital exenteration defect, including resection of the roof of the orbit and frontal dura. (B) An anterolateral thigh myocutaneous
free flap was used to reconstruct the defect, with a portion of the vastus lateralis muscle placed against the dural repair and also used to obliterate the frontal sinus.  
(C) Immediate postoperative appearance.
A
B
C
Fig. 10.3.10  (A) Patient with an orbitomaxillectomy
defect, including resection of the posterior hard palate.
(B) A rectus abdominis myocutaneous free flap was
designed to close the orbital, nasal lining, and palatal
defects with separate skin paddles based on separate
perforating blood vessels.
A
B
the temporalis muscle or temporoparietal fascia flaps (com-
bined with a skin graft), is necessary to avoid chronic bone
exposure.
In extended orbital exenterations and orbitomaxillectomies,
the reconstructive goals are also to separate the orbit from the
nasal or sinus cavities and from the dura and brain if the
orbital roof has been removed. In extended orbital exentera-
tion, our preference is to reconstruct the cavity with an RFF
free flap in cases where the bony resection is limited. This flap
is usually thin, which helps to retain an orbital prosthetic.
When the bony resection is more extensive, such as in orbito-
maxillectomy, a larger volume flap is preferred. RAM or ALT
free flaps are good choices in this situation, although creating
a concave orbit needed for a prosthesis may be more difficult
to achieve (Fig. 10.3.9). When there is also a palatal defect, the
RAM and ALT free flaps can be designed with multiple skin
paddles to reconstruct both the orbit and the palate (Fig.
10.3.10).

277
Orbital exenteration defects
C
D
(C) Insetting of the flap.
(D) Completed reconstruction.
Fig. 10.3.10, cont’d
References
1. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface:
introducing a new classification. Lancet Oncol. 2010;11:1001–1008.
2. Cordeiro PG, Santamaria E. A classification system and algorithm
for reconstruction of maxillectomy and midfacial defects. Plast
Reconstr Surg. 2000;105:2331–2346.
3. Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic
guideline for surgical reconstruction of the maxilla: a classification
system of defects. J Prosthet Dent. 2001;86:352–363.
4. Hanasono MM, Silva AK, Yu P, Skoracki RJ. A comprehensive
algorithm for oncologic maxillary reconstruction. Plast Reconstr
Surg. 2013;131:47–60.
5. Moreno MA, Skoracki RJ, Hanna EY, Hanasono MM. Microvascular
free flap reconstruction versus palatal obturation for maxillectomy
defects. Head Neck. 2010;32:860–868.
6. Hanasono MM, Skoracki RJ. The omega-shaped fibula
osteocutaneous free flap for reconstruction of extensive midfacial
defects. Plast Reconstr Surg. 2010;125(4):160e–162e.
7. Hanasono MM, Jacob RF, Bidaut L, Robb GL, Skoracki RJ. Midfacial
reconstruction using virtual planning, rapid prototype modeling,
and stereotactic navigation. Plast Reconstr Surg. 2010;126:2002–2006.
8. Chang YM, Coskunfirat OK, Wei FC, Tsai CY, Lin HN. Maxillary
reconstruction with fibula osteoseptocutaneous free flap and
simultaneous insertion of osseointegrated dental implants. Plast
Reconstr Surg. 2004;113(4):1140–1145.
9. Rodriguez ED, Martin M, Bluebond-Langner R, et al. Microsurgical
reconstruction of posttraumatic high-energy maxillary defects:
establishing the effectiveness of early reconstruction. Plast Reconstr
Surg. 2007;120:103S–117S.
10. Hanasono MM, Lee JC, Yang JS, et al. An algorithmic approach to
reconstructive surgery and prosthetic rehabilitation after orbital
exenteration. Plast Reconstr Surg. 2009;123:98–105.

SECTION II • Head and Neck Reconstruction
11 
Oral cavity, tongue, and mandibular
reconstructions
Ming-Huei Cheng and Jung-Ju Huang
SYNOPSIS
■ A comprehensive review of the oral cavity, tongue, and mandibular
defect, the patient’s disease status, and prognosis are equally
important to achieve optimal reconstruction and minimize
complications. Evaluation of the defect size, shape, geometry and
relationship to the adjacent structures should be performed. A
strategic approach to flap selection and flap design restores the defect
in the best way possible.
■ Patient risk factors, defect characteristics, donor flap selection, and
surgical technique should be considered in mandibular reconstruction.
The use of different tissue components to achieve composite
reconstruction is essential for successful functional reconstruction. An
understanding of the anatomical characteristics of all the available
osteocutaneous flaps may increase the likelihood of selecting the
appropriate donor flap for mandibular reconstruction.
■ For reconstruction of type III mandibular defects, several options exist,
including the use of a soft-tissue flap with a reconstruction plate, one
osteocutaneous flap with one pedicled flap, double free flaps, chimeric
flaps such as a composite scapular flap, and a composite
osteomusculocutaneous peroneal artery combined (OPAC) flap. The
evolution of the fibular flap from a bone-only flap to an
osteoseptocutaneous (OSC) flap and an OPAC flap may increase the
clinical applications of this flap for type III mandibular defects. Due to
the triangular profile of the fibula, the placement of plates and screws
on the lateral aspect of the fibula reduces the incidence of injury to its
pedicle and septocutaneous perforators.
■ Recently, the idea of computer-assisted 3D simulation is emerging.
The use of 3D plating and guidance of osteotomy can be applied to
ease the surgery and enhance the reconstructive result.
Introduction
Reconstruction of the oral cavity and mandible can be chal-
lenging with regard to both functional and aesthetic outcomes.
The oral cavity is composed of different structures that inte-
grate with each other to serve with their best functions in
speech, swallowing, and facial expression. Any defect involv-
ing one of the functional unit can destroy the function of
others. An ideal reconstruction should mimic the missing
tissue with regard to structure, geometry, and tissue character.
A three-dimensional consideration of the defect is required to
facilitate the best reconstruction.
The tongue is the most commonly involved organ of
primary oral cavity squamous cell carcinoma in the US, while
the buccal mucosa is the number one involved structure in
Asia where betel nut chewing presents as the most prevalent
cause of buccal cancer. Tongue reconstruction may be chal-
lenging and deserves special attention as its role in articula-
tion, deglutition, and airway protection makes it irreplaceable.
Reconstruction attempts fall into restoring the mobility of the
tongue after partial resection and providing bulk when free
tongue movement will not be possible after total tongue resec-
tion. A well-performed buccal mucosa reconstruction main-
tains limitless mouth opening, maximizes quality of life, and
preserves cosmesis of the facial profile.
When the resection of cancer inevitably involves the man-
dible, bony reconstruction should be carefully planned or
converted to plating and soft-tissue coverage depending on
the patient’s general and disease status. The cause of man-
dibulectomy can be for oncologic etiology, treatment of
osteoradionecrosis, or a traumatic result from gunshot. Typi-
cally a very advanced cancer stage or gunshot trauma can
result in severe tissue defects, involving not only the mandible
itself but also the surrounding soft tissues like the oral mucosa,
oral lining, floor of the mouth, tongue, and external cheek
skin. These defects require delicate reconstruction to restore
function, cosmesis, and dead space left from resection of the
masticator muscle, buccal fat pad, and parotid gland, which
indicates soft-tissue obliteration to prevent fluid accumula-
tion and infection.1
Basic anatomy/disease process
The oral cavity is bounded by the lip anteriorly, the orophar-
ynx posteriorly, the hard and soft palates superiorly, the

279
Patient selection and decision-making
floor.16 A thorough physical examination, radiographic study
of the tumor, and histology with TNM staging should be
performed by both surgical oncologists and reconstructive
surgeons prior to surgery. Any history of gunshot trauma,
X-rays, and three-dimensional computed tomography (CT)
scans of the defect should also be considered during preop-
erative planning. In soft-tissue-involved cancer, such as buccal
or lingual, MRI provides better images for soft-tissue evalua-
tion. Whole body PET scan provides an opportunity to
identify distant metastasis in patients with more advanced
cancer staging. In addition to classical TNM staging,17 gene
expression18–20 and profiling provide a subclassification based
on DNA repair genes. This subclassification plays a role in
predicting the clinical outcome after radiotherapy.18 Liao et al.
addressed that upregulation of centromere protein H is cor-
related with poor prognosis and progression in tongue cancer
patients.21 Chronic ulcer, leukoplakia, and tumor growth are
regularly seen at specialized centers.22 Visual-loss as an initial
symptom of squamous cell carcinoma of the tongue had been
published by Foroozan.23 It is important to keep in mind that
rare constellations of symptoms may require differential
diagnosis: a tumor or abscess of the tongue could also be
a sign of atypical metastasis of lung cancer.24,25 Recently, a
rare schwannoma of the tongue was reported by Cohen and
Wang.26 Malignant fibrous histiocytoma of the tongue was
reported by Rapidis et al.27
Patient selection and decision-making
A comprehensive assessment of the defects, the patient’s
general condition, and the availability of donor tissue are
important before reconstruction. A thorough understand-
ing of the missing tissue, including its geometrical relation
to each structure inside the oral cavity, will elucidate the
functional and aesthetic requirements of reconstruction and
facilitate the selection of an optimal reconstructive method
(Tables 11.1–11.3).
Patient factors (Table 11.4)
Many oral cavity cancer patients have a history of smoking
and alcohol consumption, which increases the risk of periop-
erative pulmonary and overall complications. These factors
also affect the patency of microvascular anastomoses in a
free-flap transfer.28,29 Diabetes mellitus is a risk factor for
peripheral vasculopathy and is associated with a higher
incidence of postoperative infection. A patient with end-stage
renal disease undergoing a prolonged operation is at greater
risk of developing postoperative fluid overload and other
associated complications. Patients with Child’s class B or
C cirrhosis had more complications, including pulmonary
complications, acute renal failure, and sepsis, than those with
class A cirrhosis (80% versus 19.1%).30 Advanced age is not an
absolute contraindication for microsurgery. However, medical
problems associated with chronological age, such as cardio-
pulmonary disease, atherosclerosis, and previous stroke,
indicate a higher incidence of postoperative medical compli-
cations.28 These advanced oromandibular cancer patients are
often malnourished, which has an impact on normal wound
healing, pulmonary function, and postoperative recovery.31
Smoking should be ceased 2 weeks before a long operation to
tongue and mouth floor inferiorly and the cheeks laterally.
Between the cheek skin and oral mucosa lie muscles that act
to facilitate facial expression, mouth movement, and oral
competence. The skeletal structures, namely the mandible and
maxilla, maintain the appearance of the lower and middle
face.
Squamous cell carcinoma is the most common cancer of the
oral cavity, accounting for 86% oral cavity malignancy. The
other pathological causes include verrucous carcinoma,
sarcoma, melanoma, lymphoma, and other rare cancers.
Trauma, complications from cancer treatment, and benign
causes, such as submucosal fibrosis, account for a few recon-
struction demands. The mean age-adjusted incidence of oral
cavity and pharyngeal cancer is 11.9 per 100 000 from 1975 to
2008 in the US. The incidence is even higher in countries
where betel nut chewing is a social problem.2 In 2008, head
and neck cancers comprised 2–3% of all cancers and accounted
for 1–2% of all cancer deaths in the US.3–4 Most patients with
head and neck cancer have metastatic disease at the time of
diagnosis (with regional nodal involvement in 43% and
distant metastasis in 10%). Moreover, patients with head and
neck cancer often develop second primary tumors at an
annual rate of 3–7%.4–6 The male-to-female ratio is currently
3 : 1 for the incidence of oral cavity and pharyngeal cancers.3
Statistical analysis of a 10-year period revealed a trend
toward earlier diagnosis of head and neck cancer. Surgical
treatment with or without radiation and chemotherapy
remains the standard of care.5 Early diagnosis, however,
provides a better tissue/organ-preserving surgery and better
postoperative cosmesis and functional preservation with a
better prognosis. Since the first introduction of the free intes-
tinal flap in 19597 and the first fasciocutaneous free flap for
head and neck reconstruction in 1976, free-flap transfer has
become the gold standard for reconstruction due to its high
flap survival rate, improved cosmetic and functional results,
and acceptable level of donor site morbidity.8–9 These tech-
niques also facilitate resection of even more advanced but
localized tumors.
Inadequate oral hygiene and contamination may increase
the risk of infection and also compromise the survival of
any inadequately vascularized tissue.10–14 Irradiation produces
detrimental acute and chronic effects not only in the perios-
teum and the marrow of the mandible but also in the oral
mucosa and surrounding soft tissue.11–14 With chronic hypoxia,
cellular and vascular damage lead to skin atrophy and increase
the susceptibility to wound breakdown and decreased healing
potential following minor trauma. Vascular changes initially
occur in the microcirculation; however, with progression,
larger blood vessels can be affected as well. Many of these
issues are addressed by the transplantation of well-vascular-
ized tissue with bone and skin components. Vascularized
bone resists infection well, does not resorb, and is not depen-
dent on the recipient bed vascularity for survival.15
Diagnosis/patient presentation
The most common first sign of the oral cavity is an unhealed
ulceration or a growing mass with touch bleeding. Most of
the patients experience pain to a variable degree. Cuffari and
colleagues demonstrated a positive correlation between the
pain character and TNM staging of the tongue and mouth

280
SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
Table 11.2  Selection of soft-tissue flaps for buccal mucosa reconstruction
Flap character
Flap type
Small
mucosa
defect
Large
mucosa
defect
Mucosa
trigon
Through
and through
Mucosa and
partial maxilla
Mucosa and
marginal
mandibulectomy
Local/regional flap
Nasolabial flap
+
–
–
–
–
–
Buccal fat pad flap
++
++
–
–
–
–
Submental flap
++
++
–
–
–
–
Facial artery musculomucosal flap
++
–
–
–
–
–
Deltopectoral flap
–
+++
++
+++
++
+++
Pectoralis major myocutaneous flap
–
++++
++
+++
++
++++
Free flap
Radial forearm flap
–
++++
++
+
+
+
Ulnar forearm flap
–
++++
++
+
+
+
Lateral arm flap
–
++
++
+
+
+
Rectus abdominis musculocutaneous flap
–
++
++
+++
++++
++++
Anterolateral thigh
  fasciocutaneous flap
–
+++
+++
+++
++
+++
  musculocutaneous flap
–
++
+++
++++
++++
++++
Thoracodorsal artery perforator flap
–
++++
++++
++
++
+++
Medial sural artery perforator
–
+++
++
+
+
+
Recommendation rates as follows: ++++, excellent; +++, good; ++, fair; +, poor; –, not applicable.
Table 11.1  Comparisons of soft-tissue flaps for buccal mucosa and tongue reconstruction
Flap character
Flap type
Skin or
mucosa
Flap
dimension
Flap
thickness
Pedicle
size
Pedicle
length
Dissection
difficulty
Local/regional flap
Nasolabial flap
++
+
++
–
–
–
Buccal fat pad flap
–
+
+
–
–
–
Facial artery musculomucosal flap
++
+
++
–
–
–
Submental flap
+++
+++
++
–
–
–
Deltopectoral flap
++
+++
+++
–
–
–
Pectoralis major myocutaneous flap
++++
++++
++++
–
–
–
Free flap
Radial forearm flap
++++
++++
++
+++
++++
++++
Ulnar forearm flap
++++
++++
++
+++
++++
++++
Lateral arm flap
+++
++
++
++
+
+++
Rectus abdominis musculocutaneous flap
++++
+++
++++
++++
+++
++++
Anterolateral thigh
  fasciocutaneous flap
++++
++++
+++
++++
++++
+
  musculocutaneous flap
++++
++++
++++
++++
+++
+
Thoracodorsal artery perforator flap
++++
+++
+++
+++
+++
++
Medial sural artery perforator
++++
+++
++
+++
++++
++
Flap character rates as follows: ++++, excellent; +++, good; ++, fair; +, poor; –, not applicable. Dissection difficulty rates as follows: ++++, not difficult; +++, mild difficulty;
++, moderate difficulty; +, most difficult.

281
Patient selection and decision-making
reduce pulmonary complications. For a malnourished patient,
a short period of tube feeding before surgery improves mal-
nutrition in an effort to optimize wound healing and general
recovery after surgery.
Defect factors (see Table 11.4)
As dictated by the principles of reconstruction, it is necessary
to replace tissue with like tissue. A complete assessment of the
defect is just as important as a careful evaluation of the
patient’s medical history. However, when a severe medical
comorbidity precludes advanced reconstruction, the surgeon
should not hesitate to downgrade along the reconstruction
ladder. The assessment of the defects should include the size,
volume, and components of the involved soft tissue, the
length and location of the mandible defect, the available
recipient vessels, and the quality of the external skin.
Skin graft
The environment of the oral cavity is not conducive to survival
of the skin graft. Its clinical application here has largely been
replaced by the use of pedicled and free flaps. The progression
of scar contracture from a skin graft often limits the mobility
of the oral mucosa and tongue, which worsens the postopera-
tive oral cavity function.
Local/regional flap
Before the development of free tissue transfer, local and
regional flaps were the treatment of choice. Today, the appli-
cations of pedicled flaps are limited to the reconstruction of
small defects or in patients where free tissue transfer is not
indicated.
Free tissue transfer
The advent of microsurgical free tissue transfer has signifi-
cantly increased reconstructive alternatives through the ability
to use larger flaps and the increased versatility to ensure a
better fit of the defect. The use of free tissue transfer for
composite reconstruction has allowed restoration of increas-
ingly complex defects in a single stage with better functional
and aesthetic outcomes.
Different decision-making processes for the most common
oral conditions will be discussed below.
Table 11.3  Tongue defects and available reconstructive options
Class
Tongue defect
Considerations
Preferred options
Alternatives
I
Hemi or less
Thin, pliable skin flap, motility
Radial forearm flap/ulnar
forearm flap
Medial sural artery perforator flap
Anterolateral thigh fasciocutaneous flap
IIa
Two-thirds
Bulky skin flap
Anterolateral thigh perforator flap
Profunda artery perforator flap, Rectus
abdominis musculocutaneous flap
IIb
Three-quarters
Bulky musculocutaneous flap
Anterolateral thigh
musculocutaneous flap
Tensor fascia lata musculocutaneous flap
Rectus abdominis musculocutaneous flap
III
Total
Large musculocutaneous flap
with adequate volume for
swallowing
Pentagonal anterolateral thigh
musculocutaneous flap
Tensor fascia lata musculocutaneous flap
Rectus abdominis musculocutaneous flap
Table 11.4  Considerations in mandibular reconstruction.
Consideration
Details
1
Patient’s risk
factors
• Smoking, old age, diabetes,
malnutrition, cardiovascular disease,
liver cirrhosis, nutrition
• Local advanced disease, distal
metastasis, recurrent or second
primary cancer, postoperative
radiation
2
Defects
• Length and location of bone defects
• Size, volume, and components of soft
tissue
• Radiated skin and vessels, previous
scarring, cosmesis
3
Recipient vessels
• Ipsilateral or contralateral
4
Selection of donor
flaps
• See Table 11.6.
5
Technique
considerations
Plating
• Reconstruction plate or miniplates,
preoperative 3D CT plating before or
after pedicle division
• Occlusion with intermaxillary wiring
Osteotomy
• Lengths and number of segments
• Before or after pedicle division
Flap inset
• Before vs. after anastomosis
• Bone inset first, then mucosa or
external skin
Microsurgical
anastomosis
• Artery first or vein first
Osseointegration
• Immediate/delayed
• Number of dental implants
Requirement of tracheostomy
Making the decision to perform a tracheostomy should not be
delayed in elderly patients that will undergo total tongue
resection or advanced tongue resection involving the base of
the tongue or pre-epiglottis area, small defects involving the
base of the tongue or extending to the pre-epiglottis area,
resection of mouth floor cancer and involving the genioglos-
sus muscles that may cause tongue drop, and large flap

282
SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
The sulcus should be carefully recreated if the buccal–
gingival sulcus is involved in the resection. The sulcus func-
tions as a food reservoir during mastication and helps in
directing the saliva and food toward the oropharynx during
deglutition. In such cases, a slight folding of the flap is required
reconstruction that subsequently with swelling may acciden-
tally obstruct the airway and require an elective tracheostomy.
The tracheostomy can be kept in place for one week or longer
and removed whenever the patient’s general status becomes
stable and the wound heals without the requirement for
debridement (requirement for anesthesia).
Decision-making for buccal reconstruction
(see Table 11.2)
Reconstruction is relatively straightforward if the defect
involves only the buccal mucosa. The size/shape of the defect
should be measured with the mouth open at maximum. A
retractor can be applied between the upper and lower teeth
to facilitate maximal exposure. A sizeable flap for adequate
resurfacing is necessary to prevent irreversible trismus and
facilitate satisfactory result. The pliability of a soft-tissue flap
allows for easier flap inset to fit the contour of the defect. A
better functional restoration with regard to postoperative
mouth movement, eating, speech, and facial expression can
be provided (Figs. 11.1–11.5).
Fig. 11.1  A 55- year-old male patient sustained of left buccal carcinoma, stage 2.
A left buccal mucosa defect remained after tumor resection with a left modified
radical neck dissection.
Fig. 11.2  A radial forearm flap sized 10 × 7 cm was harvested from his
non-dominant left hand.
Fig. 11.3  At the 3-year follow-up, the patient was satisfied with the donor site with
split-thickness skin graft.
Fig. 11.4  Result of the radial forearm flap for buccal reconstruction showed good
functional recovery with flap color match and appropriate thickness and with
adequate mouth opening.
Fig. 11.5  The face looks symmetric after surgery at 3-year follow-up.