Reoperative Aesthetic & Reconstructive Plastic Surgery

The left lateral nasal defect was reconstructed with a median forehead ap. The
pedicle was divided after 3 weeks and inset into the donor site, restoring the brow
line.
826
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The cheek defect was reconstructed with a cervicofacial advancement. The plane
of dissection was subcutaneous in the face and subplatysmal in the neck. The ap
was inset along the nasolabial fold.

827
Chapter 24
Surgery for Recurrent Cutaneous Malignancies of the Head and Neck
The forehead ap remained bulky in this postoperative photograph, but the facial
edema has resolved. The nasal reconstruction was revised 2 months later, improv-
ing the nasal contour.
References—With Key Annotated References
1. Miller SR. CCN Practice guidelines for nonmelanoma skin cancer. Oncology 13:529-549,
1999.
2. Swanson NA. Mohs surgery. Technique, indications, applications, and the future. Arch Derma-
tol 119:761-773, 1983.
In this review, the history and evolution of Mohs surgery and the technique itself is brie y outlined.
The indications for Mohs’ surgery, together with methods of handling the postoperative wound and
future applications of the technique, are discussed in detail.
3. Balch CM, Soong SJ, Gershenwald JE, et al. Prognostic factors analysis of 17,600 melanoma pa-
tients:Validation of the American Joint Committee on Cancer melanoma staging system. J Clin
Oncol 19:3622-3634, 2001.
The American Joint Committee on Cancer (AJCC) proposed major revisions of the tumor-node-
metastases (TNM) categories and stage groupings for cutaneous melanoma.This analysis demon-
strated that large and complex data sets could be used effectively to examine prognosis and survival
outcome in patients with melanoma.The results of this evidence-based methodology were incorporated
into the AJCC melanoma staging as described in the companion publication.
4. McMasters KM,Wong SL, Edwards MJ, et al. Factors that predict the presence of sentinel lymph
node metastasis in patients with melanoma. Surgery 130:151-156, 2001.
This analysis was performed to identify prognostic factors that are predictive of sentinel lymph node
(SLN) metastasis in melanoma. Increasing Breslow thickness, Clark level of more than III, the pres-
ence of ulceration, and patient age of 60 years or less are the most important independent prognostic
factors associated with the nding of positive SLN in patients with melanoma.

828
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
1. Predisposing factors for local recurrence in nonmelanoma skin cancer include:
a. Morpheaform BCC
b. Lesions located in the H zone of the face
c. Immunosuppressed patients
d. Tumors greater than 2 cm in diameter
e. All of the above
2. All the following are the predisposing factors for local recurrence of malignant
melanoma except:
a. Primary tumor thickness
b. Nodular histologic subtype
c. Presence of ulceration
d. Desmoplastic histologic subtype
e. Lentigo maligna
3. The indications for Mohs micrographic surgery include:
a. Recurrent nonmelanoma skin cancer
b. Lesions in the H zone of the face
c. Morpheaform BCC
d. Lesions with perineural invasion
e. All of the above
4. All of the following are indications for delayed reconstruction after resection of
recurrent head and neck skin cancer except:
a. Uncertainty of pathologic margins
b. Large tumors requiring a total rhinectomy
c. Concerns about tumor surveillance
d. Exposure of intracranial contents
e. Poor performance status
5. Which of the following applies to the surgical excision of SCC of the skin?
a. Width of the margins and depth of excision are the same as those used for
BCC
b. Width of the margins and depth of excision are greater for SCC than for
BCC
c. Super cial parotidectomy is often necessary in the treatment of SCC of
the external ear
d. Frozen section control is useful in both SCC and BCC
e. Mohs surgery is indicated in the management of SCC
R EVIEW QUESTIONS

829
Reoperative Issues Following
Flap Reconstruction in the Head
Julian J. Pribaz and Helena O.B.Taylor
C ha pter 2 5
Reoperative Problems
Types of problems
Patient features
Goals of therapy
Osteoradionecrosis
Age
Soft tissue coverage
Bony nonunion
Comorbidity
Oral continence
Exposed hardware
Radiation
Orbital coverage
Infection
Nutrition
Speech
Orocutaneous stula
Prognosis
Deglutition
Exposed vasculature
Dentition
Aesthetics
Education is when you
read the ne print. Experience is what
you get when you don’t.
Pete Seeger

830
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
PLANNING A PATH
There are few areas of plastic surgery in which reoperation is as anticipated as in
head and neck reconstruction.The lofty goal of reconstructing form and function
in these complex defects, and in patients with multiple medical conditions, requires
careful planning from the outset. Return trips to the operating room may re ect
predicted steps along a well-laid reconstructive path, or, not infrequently, a detour
imposed by an unforeseen complication.
Typical disease processes mandating head and neck reconstruction include tumors,
congenital or acquired soft tissue anomalies, vascular malformations, and trauma.
Until these problems are answered more satisfactorily with transplant or tissue en-
gineering, we are left with reconstruction, an inherently limited tool. In this arena,
where published complication rates are in the 30% range and reoperation rates not
signi cantly lower, the reconstructive surgeon must be well equipped with all the
possible tools available along the reconstructive ladder.This is particularly true in an
era when delayed reconstruction is no longer the accepted standard of care,1 and
when free tissue transfer has obviated much of the staged procedures used in the
past.
Careful planning may minimize the number of steps to achieve the best result.This
requires a thorough evaluation of the patient and the defect, as well as coordination
between the various surgical teams, including oral and maxillofacial surgeons, oto-
laryngologists, and plastic surgeons. Frequently these patients are elderly, have a his-
tory of heavy alcohol and tobacco use, poor nutritional status and delayed diagno-
sis of now progressive local and distant neoplasm. An overall prognostic picture for
the patient helps set realistic goals for therapy. The defects are often complex in
their components—lacking bone, skin, musculature, innervation and mucosa. In
the chapter that follows we hope to review the kinds of problems frequently en-
countered in reoperative head and neck reconstruction, and provide some tools
with which to tackle it.
TYPES OF PROBLEMS
In most series of head and neck reconstructions, nonoperative complications are as
common as operative complications, with cardiopulmonary morbidity arising most
frequently. Operative complications may be divided into donor site versus recipi-
ent site problems. Donor site morbidity is largely secondary to infection, delayed
wound healing, or, more rarely, loss of function. Recipient site complications in-
clude wound dehiscence, orocutaneous stula, exposed vasculature or hardware,
bony nonunion, and poor deglutition, speech, or cosmetic outcome. A large per-
centage of both donor and recipient site complications may be managed nonoper-
atively with meticulous wound care. The following table summarizes some of the
larger series of head and neck reconstructions and the most common complica-
tions.

831
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head
Retrospective Reviews of Complications in Head and Neck Reconstruction
Number
Overall
Flap
Flap-Related
Medical
Study
of Patients
Complications
Survival
Complications
Complications
Shasta et al6
74 free aps
55%
99%
21 surgical
21 medical
(1992)
in 72 patients
CONCLUSION: ASA, age, and radiation therapy did not affect surgical complication rates, but ASA, not age alone, does
correlate with postoperative medical morbidity.
Schusterman et al1
308 free aps
36%
94.5%
Hematoma 6%
Not measured
(1994)
in 265 patients
Infection 6%
Fistula 11%
Seroma 2%
Donor site 8%
CONCLUSION: Only prior surgery and use of vein grafts increased ap loss.
Bhuvanesh et al4
200 free aps
28%
98%
Overall 20%
14%
(1999)
in 200 patients
Recipient site 15%
Donor site 5%
CONCLUSION: Univariate analysis of radiation therapy, anesthesia 10 hours, and advanced comorbidity score versus
complications. Only the comorbidity score was signi cantly correlated on multivariate analysis.
Ryan and Hochman30
100 free aps
31%
91%
17%
13%
(2000)
in 97 patients
CONCLUSION: Early discharge does not cause complications.
Beausang et al3
288 free aps
41%
94%
Minor 19%
12%
(2003)
in 288 patients
Reoperative 10%
CONCLUSION: Free tissue transfer is safe in elderly patients, although medical complications occur more frequently when
preoperative comorbidities exist.
Borggreven et al5
100 free aps
32% severe
96%
16 (50% of severe)
16 (50% of severe)
(2003)
in 100 patients
19% minor
3 (20% of minor)
16 (84% of minor)
CONCLUSION: Comorbidity score alone, not age, gender,TN stage, preoperative radiation therapy or long operative times,
correlates with complications.
Both the patient and practitioner prefer reoperations that are a planned component
of a predicted treatment plan. In an effort to prevent infection of hardware, soft tis-
sue coverage is often achieved before reparation of the bony structure. Or the soft
tissues and skeletal structure may be tackled simultaneously, with free osteomyocu-
taneous flaps, or with serial expansion, as with distraction osteogenesis.2 Multi-
staged reconstructions are often used to achieve facial nerve function, dental reha-
bilitation, and the best aesthetic outcome (such as the use of multiple local aps
with a better color match rather than a single distant ap). Unplanned reopera-
tions may be divided into those required to treat the complications of the initial
surgery, complications of adjuvant therapy, or progression of disease.

832
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
TYPES OF PATIENTS AND PATIENT
EVALUATION
There have been a multitude of studies searching for prognosticators in head and
neck reconstruction. As with much of the surgical literature, randomized controlled
data are sparse. Most series demonstrate complications in the 30% to 40% range,
with a wide distribution between ap-related complications and medical morbid-
ity. Consistently, series have shown that preoperative comorbidities are the strongest
predictors of postoperative medical complications.3-5
Age has been linked to longer hospitalizations and increased medical complica-
tions postoperatively, but age alone has not been consistently shown to raise ap-
related complications. A single institution series from Toronto of patients who un-
derwent free tissue transfer for head and neck reconstruction demonstrated that
length of stay rose in line with age.2 Patients less than 50 years of age had a mean
length of stay of 15 days, whereas patients older than 70 years had a mean length of
stay of 22 days. Overall mortality was less than 1%, and ap survival was 94%.The
reoperation rate was 10%, and medical complications were 12%. Although reoper-
ation did not correlate with age, the medical morbidity was signi cantly more com-
mon in elderly persons, particularly cardiac and pulmonary complications.
A second series from M.D. Anderson Cancer Center reviewed 308 free aps over
4 years, one of the largest free ap series.1 These investigators replicated the 94%
ap survival rate and had a 36% complication rate. They looked at free ap loss
and its correlation with tobacco and alcohol use, prior radiation therapy, age, Amer-
ican Society of Anesthesiologists (ASA) score, prior surgery and use of vein grafts.
Only the last two variables, prior surgery and use of vein grafts, showed signi cant
correlation with ap loss. A similar review of 200 patients who underwent free tis-
sue transfer found a 98% ap survival rate, with a 16-day median length of stay.4 In
this series, prior radiation therapy, prolonged anesthesia (greater than 10 hours),
age older than 70 years, and advanced comorbidity score all correlated with in-
creased postoperative complications, but only the latter was signi cant on multivari-
ate analysis. Age older than 70 years increased the systemic complication rate from
a mean of 14% to a mean of 76%.
Conversely, a retrospective review of 72 patients after free tissue transfer found that
ASA score rather than age alone increased the risk for postoperative medical com-
plications.6 Similarly, Borggreven et al5 found that the Adult Comorbidity Evalua-
tion-27 index (ACE-27), a validated comorbidity scoring tool for head and neck
cancer, was a strong predictor of complications. Age, gender, tobacco use, TNM
stage, prior radiation therapy, and prolonged operating time did not predict com-
plications. More recently, a series of 197 free aps in septuagenarians and octoge-
narians, of which 95% were for head and neck reconstruction, con rmed that age
did not alter the rate of surgical complications or ap survival.7 However, octoge-

833
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head
narians had a much higher overall complication rate in comparison with septuage-
narians (59% and 35%, respectively), and an almost prohibitively high perioperative
mortality rate (18.5% versus 7.7%).
In summary, age and comorbidity score may predict postoperative medical compli-
cations in this patient population, but ap related complications are hard to predict.
Before embarking on a lengthy course of reconstruction an honest discussion must
take place with the patient. Comorbidities, alcohol and tobacco use, nutritional sta-
tus, radiation therapy, and overall functional status should factor into surgical plan-
ning. The goals of reconstruction must be weighed against the risks of systemic
complications. Some patients may choose suboptimal reconstruction to avoid a
lengthy hospital stay.The best reconstruction is of little use in a moribund patient.
DEFECT EVALUATION
Optimal surgical planning requires careful evaluation of the defect.The primary de-
fect is often larger than it may originally appear after it has been excised to nega-
tive tumor margins, or debrided to viable tissue. Exposure or proximity of critical
structures, including major vessels or nerves, must be taken into consideration, as
well as the overall con guration of the defect.
ASSESSMENT OF MISSING TISSUE
The surface area (both surface and lining) as well as volume must be measured.
Coverage of various surfaces may be required, particularly in the head and neck,
where oral mucosa, nasal lining, and skin are often missing. Models of the defect can
be made preoperatively or intraoperatively to optimize the design of the flap.8
Modeling not only enables surface area and volume measurements, but also may fa-
cilitate appropriate orientation of epithelial surfaces, and folding of a single ap to
cover a complicated defect. The patient examples on pp. 838-842 and 847-853
demonstrate use of such models.
ASSESSMENT OF R ECIPIENT VESSELS
Free tissue transfer has become the standard of care for many complex head and
neck reconstructions. Nevertheless, the ideal ap is only as good as its new blood
supply. Recipient vessels should be outside the zone of injury, yet they must be ac-
cessible and of adequate caliber.Vein grafts may be required for both arterial and ve-
nous anastomoses.This should be determined before detaching the ap, and if both
are required, an arteriovenous loop graft may be inserted. “Flow-through” flaps
may be used to vascularize a tandem free ap. Appropriate ow-through aps in-
clude those based on the radial, ulnar, peroneal, or descending branch of the cir-
cum ex femoral arteries. In patients who have undergone multiple prior proce-
dures, with a resulting “frozen neck,” the transverse cervical vessels may represent a
suitable alternative for recipient vessels.9

834
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
ASSESSMENT OF THE OPTIMAL DONOR SITE
Ongoing innovation of new aps offers the reconstructive surgeon a growing list of
donor sites from which to choose (see box below).The ideal donor site optimizes
the reconstructive outcome without imposing morbidity or complicating the logis-
tics of the operation. Positional changes for ap harvest and inset not only lengthen
the procedure, but may also jeopardize ap viability.
Systemic Therapies
Hyperbaric oxygen
Nutritional optimization
Antibiotics
Tools for Bony Surgical Fixation
Free osseous tissue transfer
Bone grafts
Miniplates
Distraction osteogenesis
Prosthetics
Some Common Tools in the Armamentarium of Head and Neck
Reconstructive Surgeons
Tools for Soft Tissue Coverage
Local aps
Distant aps
Pectoralis
Radial forearm
Sternocleidomastoid
Free bula
Platysma
Iliac crest
Deltopectoral
Scapula
Temporoparietal
Latissimus
Nasolabial
Rectus
Cheek advancement
Tensor fascia lata
FAMM
Anterolateral thigh
Submental
Jejunum
Supraclavicular
Techniques
Delay
Prelamination
Prefabrication
Flap folding
FAMM, Facial artery musculomucosal ap.
Initially attention should be paid to establishing a stable support.This may require
bony framework, cartilage, muscle (functional or denervated), dermis, or fat. The
patient example on pp. 843-847 demonstrates complications that may be predicted
if this approach is neglected. Subsequently, consideration should be given to skin
match, including color, thickness and texture. Some areas may require skin grafting.
Careful planning may enable skin discarded from one part of the ap to be used to
graft a different area. Lining may be built from skin, skin graft or mucosa. Finally the
ap pedicle must be assessed for length, caliber, and branching pattern.T-junctions
in the pedicle may allow for larger and safer anastomoses.
CLINICAL PROBLEM SOLVING
The goals of head and neck reconstruction include soft tissue coverage, oral conti-
nence, maintenance of speech, deglutition, dental rehabilitation, and reasonable aes-
thetic outcome.

835
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head
SOFT TISSUE COVERAGE: FREE TISSUE VERSUS
LOCAL TISSUE TRANSFER
The advent of free tissue transfer in the 1970s transformed the management of
head and neck defects. Multiple papers have argued that immediate reconstruction
with free tissue, despite longer operative times, is superior to local or regional ap
reconstruction in diminishing postoperative wound complications.10,11 It has also
been argued from a resource utilization perspective that free tissue transfer may be
more cost effective. An M.D. Anderson series compared 89 radial forearm free aps,
56 rectus abdominis free flaps, and 33 pectoralis major myocutaneous flaps for
oropharyngeal reconstruction after cancer resection.12 They found no major differ-
ences in complication rates. Operative times were longer for free ap reconstruc-
tions than for pedicled aps, but hospitalizations were signi cantly longer in the pa-
tients undergoing pectoralis flap reconstructions. They concluded that despite
longer operative times, free tissue transfer provided a more cost-effective means of
head and neck reconstruction.
Nevertheless, soft tissue reconstruction with local tissues in many circumstances
makes good sense. Options include not only pectoralis myocutaneous aps, but also
platysma,13 submental island aps,14 supraclavicular island aps, and so on15 (see box
on p. 834).
BONY R ECONSTRUCTION
Free ap options for bony reconstruction have historically included rib, metatarsal,
scapula, radius, ilium and bula. Rib and metatarsal have largely been abandoned. A
retrospective review of 59 iliac grafts and 58 bula grafts showed no signi cant dif-
ferences in ap complications, oral continence, speech, facial contour, but oral de-
glutition was better in the free bula group, and there were fewer intraoral suture
line complications.16 The patients undergoing iliac aps had more systemic compli-
cations, which was postulated to be secondary to delayed mobilization. The au-
thors of this series, Shpitzer et al16 suggest that the bula should be the rst choice
for mandibular reconstruction, with the ilium as a good second option for patients
with lower-extremity edema, varicosities, prior vein stripping, prior lower extrem-
ity trauma, arterial insuf ciency, or C-shaped defects.
Recent technologic advances have increased the array of surgical tools. Options for
use of non-native tissue are also expanding. Porous polyethylene (Medpor, Porex
Products, Newnan, GA) and other synthetic materials are being used to finesse
bony contours.17 Custom-designed mandibular prostheses may obviate free bular
mandibular reconstruction. Miniplates and distraction osteogenesis devices maxi-
mize the utility of native bony tissues.

836
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
MANIPULATION OF DONOR TISSUE
Manipulation of the donor tissue may improve reconstructive outcome while min-
imizing donor site morbidity. Preoperative tissue expansion provides greater soft
tissue for coverage, a thinner more pliable ap, and facilitates donor site closure.18
Multiple aps may be designed off a single pedicle (as in the patient example on pp.
838-842) or multiple pedicles may be harvested for a single extensive ap. Folding
of the skin, muscle or bone may enable a single ap to reconstruct what would
otherwise require multiple aps.
Patience in the short term may prevent future complications. Flap delay may extend
the vascular territory of a given ap, or make a tenuous ap more robust. Prelam-
ination—implanting tissue or other materials into a vascular territory—can be used
to preassemble a ap before transfer.19 Prefabrication—transferring a vascular pedi-
cle to a new area for neovascularization—enables the reconstructive surgeon to
build an ideal ap not found in normal anatomy.20
The patient examples that follow highlight some of these reconstructive surgical
techniques and complications that can be avoided by careful planning.
SURGICAL TECHNIQUE
TUMOR, R ADIATION, EXPOSED HARDWARE
Patient Example
A 42-year-old patient presented with a radiation-induced leiomyosarcoma in the
left cheek that also involved the mandible. The patient had previously undergone
radiation therapy for Hodgkins’disease. She had a radical excision of the tumor, in-
cluding the left hemimandible and an immediate reconstruction with a free bula
osteomyocutaneous ap.The skin island of this ap was used for intraoral lining.

837
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head
Additionally, a sural nerve graft was used to repair the left mental nerve (left). Post-
operatively, she healed well, but because of the high grade of the tumor, additional
postoperative irradiation and chemotherapy were administered. This resulted in a
marked inflammatory reaction of the skin and mucosa that persisted for several
months. Approximately 7 months postoperatively, she developed an intraoral wound
breakdown, infection, and orocutaneous stula (right).
First Reoperation
The patient underwent debridement of the infected orocu-
taneous fistula. The tissues most affected were the native mucosa and skin. The
bula osteocutaneous ap remained viable.The reconstruction plate became widely
exposed and the patient underwent treatment with hyperbaric oxygen therapy.
Once the surrounding tissue recovered, she was ready for closure of the stula and
resurfacing of the external defect.
Secondary Reoperation
She underwent removal of the reconstruction plate
and repair of the defect with a free anterolateral thigh ap. This healed well with
resolution of her orocutaneous stula, and adequate soft tissue coverage of the hard-
ware.

838
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Commentary
This case highlights the difficulty created by irradiation in the
management of patients with head and neck cancer. Although irradiation is used to
control local disease, in this particular case, it predisposed to the development of the
sarcoma.Then the oncologists’concerns about local control and the recommenda-
tion for additional radiation and chemotherapy further complicated the situation.
The tissue response depends on the radiation dose. When the dosage is high, the
possibility of complications and the need for reoperation is very high. In this pa-
tient, the free bula osteocutaneous ap survived, because it was well perfused and
had only encountered one cycle of radiation. The surrounding tissues, however,
eventually succumbed to the cumulative effects of the radiation leading to break-
down and stula formation.
Another common problem in patients with soft tissue intraoral cancer is osteora-
dionecrosis of the mandible.This sets in motion a prolonged series of therapies that
include hyperbaric oxygen treatment21 and reoperation to remove the necrotic
bone, bony reconstruction, and often further ap repair.
ARTERIOVENOUS MALFORMATION: INFECTION,
TISSUE EXPANSION,THREE-DIMENSIONAL MODELING,
AND FOLDED FLAPS
Patient Example
A 5-year-old patient presented with an extensive arteriovenous malformation
(AVM) of the right cheek, maxilla, and upper and lower lips.This was a high- ow
lesion, which had ulcerated, producing very painful, troublesome ulcers that would
often bleed excessively requiring repeat transfusions.The patient was malnourished
and had dif culty eating. Minor interventions, such as ligation of bleeding points,
sclerosing injections, and steroids, were unsuccessful in stemming the growth of
this malformation.

We felt that only a complete extirpation of the
AVM would resolve the problem.To prepare for
the extensive defect that would result, a tissue ex-
pander was placed in the back to preexpand the
scapular and parascapular territory to allow for
eventual harvest of a folded composite ap from
the back. After adequate expansion had been
achieved, the patient was taken to the operating
room and the very vascular tumor was radically
excised.The blood loss was massive and immedi-
ate reconstruction was not possible, because the
wound had to be pressure packed to control he-
mostasis. Postoperatively, she also developed a
pulmonary complication that prevented a return
to the operating room for 5 days.
839
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head
First Reoperation
Once the patient was stabilized, she was returned to the op-
erating room and the packing was removed to reveal a slightly malodorous wound
with a greenish exudate. This was debrided and copiously irrigated and the deci-
sion made to proceed with the reconstruction.
An alginate model was made of the defect and a fairly accurate ap design made by
wrapping a piece of Esmark bandage around the alginate model.

840
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This pattern was then transferred to the expanded back and a tailored scapular-
parascapular and latissimus dorsi ap was harvested on the subscapular vessels.
As predicted by the Esmark, the ap was folded and sutured while still in situ sur-
rounding the latissimus dorsi muscle between the scapular and parascapular aps.
The composite ap was then detached and transferred to the defect on the right
face. A branch of the facial nerve stump was coapted to the thoracodorsal nerve
supply to the latissimus dorsi muscle. At the end of the procedure, the ap was well
perfused with a very satisfactory appearance.

841
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head
Second,Third, and Fourth Reoperations
Unfortunately, at postoperative day
3, purulent drainage appeared in the neck near the site of the vascular repair and the
circulation in the ap deteriorated.The patient was returned to the operating room
emergently to irrigate and redo the thrombosed arterial and venous repairs. The
ap was salvaged initially, but infection persisted and thrombosis recurred despite
anticoagulation therapy and further exploration within the next 12 hours.The aps
nally could not be salvaged, and complete ap necrosis resulted requiring debride-
ment.The resulting defect was subsequently skin-grafted and allowed to heal.
Fifth and Subsequent Reoperations
Once the wound had stabilized and the
patient improved nutritionally, she was returned to the operating room for a further
free ap to reconstruct the complex defect as no local options existed in this young
child. A similar model and pattern were used for ap design, but this time the rec-
tus abdominis myocutaneous ap was planned, again utilizing a similar folding pat-
tern of skin containing a segment of rectus muscle between the folded skin aps.
The segmental nerves to the muscles were coapted to the facial nerve branches
and the ap was inset to ll the defect.

842
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Fortunately, this ap healed well. However, with better nutrition, the initially thin
abdominal ap became more bulky as a result of a thicker adipose layer and re-
quired thinning and debulking over the next few years. The color match was also
suboptimal, and 6 years later, an expanded submental ap was transferred to resur-
face the cheek and to provide skin with better color and texture match.
Commentary
This case illustrates the need for careful planning in patients that
will require a complex multilayered reconstruction. Preoperatively there had been
some purulent drainage at the sites of ulceration. The heavy intraoperative blood
loss and the need for prolonged wound tamponade with packing almost certainly
compounded the problem creating an infected wound. Free tissue transfer should
be avoided in an infected wound, because there is an increased risk of infection
around the pedicle and anastomotic sites, which can lead to thrombosis.
We believe that free aps cannot be salvaged once there is thrombo-
sis associated with infection and purulent drainage.
After debridement and subsequent skin grafting to obtain wound control, further
reconstruction can be safely undertaken. In less extensive defects, local options and
regional aps are commonly used.The pectoralis major myocutaneous ap is an ex-
cellent choice in many patients and is often used to salvage head and neck problems
in adults after failed free aps. However, in this child, with such an extensive defect,
a second free ap was mandatory.
The initial preexpanded back donor site had been closed primarily, but the back
was too tight to be considered for a second extensive free ap;therefore a free tai-
lored TRAM ap was used to solve the reconstructive dilemma. Abdominal skin,
however, is always a poor match to surrounding facial skin and local aps from the
submental area can help restore a better color and texture match.

GUNSHOT W OUND TO THE FACE, COMPLEX DEFECTS:
ESTABLISHING A FRAMEWORK
Patient Example
A 17-year-old male sustained a gunshot wound
to the face with loss of the central third of his
face, including part of the maxilla and left
mandible. At another institution, he underwent
multiple operative procedures, including de-
bridement, and ORIF of the fractured maxilla
and mandible with primary bone grafting using
rib. He also had two radial forearm free aps,
which were used for palatal reconstruction and
nasal lining. Additionally, the patient had a can-
tilevered bone graft for nasal support and fore-
head ap for nasal reconstruction. Also, an Abbé
flap was used to reconstruct his upper lip. He
had a partial loss of the forehead ap nasal re-
construction and loss of some of the bone
grafts, which resulted in contractions and defor-
mities of the soft tissue.
843
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head
He presented to our institution approximately 12 months after his injury with sig-
ni cant extensive deformity despite his multiple reconstructive operations and re-
operations. Examination revealed that there was extensive de ciency of appropri-
ate supporting and lining tissue to his central face and mandible as well as
contractures and deformity to his nose, lips, and circumoral region.

844
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
First Reoperation at Our Institution
The rst step was to release all the con-
tractures and to recreate the defect to fully assess the defect in the skeletal founda-
tion. The bony beds in the maxilla and mandible were prepared, and a large free
bular osteocutaneous ap was harvested and tailored by excising the central part
of the bone, but leaving the covering periosteal and muscular cuff. The residual
bone was appropriately reosteotomized to reconstruct the maxilla with the distal
end of the bula. An intervening segment of bone was removed, leaving the peri-
osteal cuff, and the proximal end of the bone ap was used to reconstruct the seg-
mental mandibular defect. The cutaneous part of the ap provided coverage and
lining over the palate and left buccal and oor of the mouth regions. Additionally,
a superiorly based facial artery musculomucosal (FAMM) ap22 was raised from the
right cheek and used to provide lining to the contracted upper lip.

845
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head
Fourth and Fifth Reoperations at Our Institution
Once all the wounds had
healed, it was apparent that a suboptimal result persisted.
Second and Third Reoperative Procedures at Our Institution
The patient
had lost the left ala from the original forehead ap.To reconstruct this and the de-
cient left nostril sill, a free ap using the ascending helix and root of the right ear
was used. Although the ap survived, a suboptimal result was obtained and revision
was performed. At this time a commissureplasty was also performed on the left cor-
ner of the mouth.

846
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Approximately 5 years after his initial injury, the patient agreed to another opera-
tive procedure using a second forehead ap, this time from the left side of his fore-
head, since the right side had already been used at the previous institution early in
his care (top). Additionally, re nements to the nasal lining and supporting cartilage
grafts to the tip were used.The forehead ap was divided and inset about 6 weeks
later. No further surgery has been performed; the patient is shown 3 years later
(bottom).
Commentary
This unfortunate case demonstrates a number of principles that
were not adhered to that resulted in multiple additional operative procedures.
It is imperative in these types of injuries, where there is extensive dam-
age to both soft tissue and supporting tissue, that an adequate founda-
tion be built rst.
This should be supported by appropriate lining tissue to allow healing.The tissues
being replaced are very specialized. Until the era of transplantation becomes a re-
ality, these tissues cannot be reconstructed in a single step with similar types of tis-
sue.This, of necessity, means that multiple reoperative procedures are to be antici-
pated.

Better initial planning can reduce the number of additional proce-
dures.
Thus, after an adequate foundation is built and the tissues thinned and modi ed as
required, re nements of the external structures such as the nose can then be ad-
dressed.The reconstructive surgeon should avoid the premature use of the forehead
ap, as this is too valuable a resource to lose when the foundation has not been ad-
equately built, and has not had time to stabilize. Additionally, although the use of an
auricular free ap has been successful for distal heminasal reconstruction and can
provide good symmetry with an opposite uninjured heminose,23 it is too dissimi-
lar if a forehead ap reconstruction has been previously used. This case also illus-
trates that for the best uniform and aesthetic result, a second forehead ap from
the opposite side of the forehead is required.
This case highlights the problems encountered with patients sustaining major
trauma, such as gunshot wounds to the central face. They all require multiple op-
erations to remove damaged tissues and multiple reconstructive procedures, each of
which have potential complications necessitating further surgical intervention.
However, with experience, the number of reoperative procedures can be reduced.
ARTERIOVENOUS MALFORMATION—
COMBINING DISTANT AND LOCAL TISSUES
Patient Example
847
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head
First Operation
This 39-year-old man with extensive arteriovenous malforma-
tion (AVM) of his left cheek, lips, and maxilla presented for treatment. Following
preoperative embolization, the AVM was radically excised, creating a complex de-
fect with full-thickness loss of the left cheek, the left upper and lower lips, and the
left hemimaxilla.

848
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
To facilitate reconstruction, an intraoperative alginate model was made of the de-
fect.8 This simple three-dimensional model could be visualized from different an-
gles and the dimensions of the missing lining ap, the cutaneous coverage required
as well as the intervening buried part of the ap could be appreciated. The three-
dimensional model can be converted into a three-dimensional pattern by wrap-
ping a piece of Esmark bandage around and recording the locations of the internal
and external coverage requirements.This can then be transferred to the donor site
(which in this case was the forearm), allowing a well-tailored radial forearm free ap
to be designed. The parts to be buried are deepithelialized allowing the ap to be
folded (as predicted by the Esmark) to reconstruct this complex defect.

Additionally, at the recipient site, a contralateral facial artery musculomucosal
(FAMM) ap22 is raised for use in vermilion reconstruction (top). A palmaris longus
tendon graft is inserted as a circumferential sling to support the lower lip. Once
this is secured to the zygomatic arch, the tailored radial forearm ap is brought
to the face, the internal lining part of the ap is inset into the palate and buccal de-
fect, then the ap is folded, revascularized, and inset into the cheek and upper lip.
The area of the ap at the lip margin is deepithelialized and the FAMM ap inset
(bottom).
Commentary
With such a complex defect, a decision was made preoperatively
to address only the soft tissue component of the defect with a plan to address the
bony loss of the maxilla at a second, reoperative procedure. The simple measures
taken to carefully plan the rst reconstructive stage minimized the need for addi-
tional secondary procedures.
849
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head

850
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Second Reoperative Elective Procedure
Approximately 6 months later, a re-
construction of the left hemimaxilla was undertaken. A bular free ap was used
and osteointegrated implants inserted into the bula ap for later dental rehabili-
tation. Postoperatively the patient developed a hematoma and wound breakdown
over the cheek, exposing the reconstruction plate.

Third Emergency Unplanned Procedure
Reoperation to evacuate the hema-
toma and wound debridement was required. To cover the open wound and ex-
posed plate, a forehead ap was planned.The patient additionally requested a hair-
bearing ap to reconstruct his moustache;thus the reconstructive ap was designed
to address both problems. An extended forehead ap with an intervening deep-
ithelialized segment was designed and transferred to the left cheek and upper lip.
Commentary
After considering all treatment options, a procedure was chosen
that was capable of addressing two problems:an emergent need to cover the recon-
struction plate and an elective need to provide a moustache. If this ap, based on the
supratrochlear vessels, were used just to cover the defect, however, it could not be
subsequently used for moustache reconstruction. It is important to think expan-
sively and not to “burn bridges,” especially in complex, multistaged reconstruc-
tions.
851
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head
Fourth and Fifth Reoperative Procedures
Although the patient had a well-healed cheek
flap, moustache, and lip vermilion, he had no
movement or animation of the left side of his
face as a result of removal of all the muscles of
facial expression from his left lips and cheek.
Also, the color match of the radial forearm ap
was not ideal.

852
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
To deal with these problems, a functional platysma submental ap was designed.
The platysma was still innervated by the cervical branches of the facial nerve.This
myocutaneous ap was raised on the submental branch of the facial artery, preserv-
ing the cervical branch of the facial nerve to the platysma. It was tunneled into the
left cheek after excision of the cutaneous part of the radial forearm flap. The
platysma muscle was rotated through approximately 75 degrees so that its vector of
pull would be up and laterally.
Dental rehabilitation of his left maxilla was also completed by his oral surgeon at a
subsequent operation.

Commentary
This case illustrates many issues that the reconstructive surgeon
faces when dealing with complex problems, which of necessity will require multi-
ple operations and reoperations, both of an elective and emergency nature to deal
with complications. Careful planning at every stage can reduce the number of un-
planned procedures. It also illustrates that fact that complex problems may require
a combination of free tissue transfers to deal with the large complex defect and
then subsequent smaller procedures using local tissues and aps to maximize a -
nal aesthetic and functional outcome.
SPECIAL CONSIDERATIONS
Although head and neck reconstruction follows many of the paradigms for recon-
struction elsewhere in the body, there are several features that make it unique. More
important than the speci cs of any particular operation is the overall planning and
coordination with other aspects of the patient’s care. Head and neck reconstruction
is mandated for a complex array of pathologies, many of which are life threatening.
Reconstruction of head and neck defects may be only a small part of a patient’s
overall treatment plan. Often adjuvant therapies such as chemotherapy and radiation
may, by necessity, begin before completion of wound healing. Anticipation of pos-
sible complications facilitates an appropriate response.
The patient and surgeon must be aware that back up “lifeboat” plans
must be in place before initiation of any reconstruction.
For example, radiation appears to increase the risk of orocutaneous stula, which
predisposes the patient to two potentially life-threatening complications:aspiration
and carotid artery blowout.
Carotid artery exposure carries a morbidity of 13% to 33%.24 Although microsur-
gical reconstruction of head and neck defects appears to have lowered the rate of
orocutaneous stula formation, it is still in the 6% to 18% range.25,26 In a series of
494 microvascular head and neck reconstructions, Salgado et al27 attempted to clas-
sify orocutaneous stulas, which occurred in 7.1% of their patients. Critical stu-
las were considered to be those that were peristomal (in the vicinity of the sternal
notch), or midneck, which occurred in only 1.8% of all their patients. Submandibu-
lar or submental orocutaneous stulas were more common and were considered
more benign, and all healed with conservative management. Medical management
of orocutaneous stulas includes systemic antibiotics, meticulous wound care to
minimize maceration from salivary secretions, and nutrition with enteral feedings
by nasogastric or gastrostomy tube, or, less optimally, parenteral nutrition. Critical
stulas were treated with debridement and interposition of pectoralis or deltopec-
toral aps as a “tissue plug.” Although biopsies are not routinely performed in these
cases, the surgeon must be aware that local recurrence may be the culprit in persis-
tent stulas.
853
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head

854
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Carotid artery rupture or blowout is one of the true surgical emergen-
cies in plastic surgery.
Although in theory a shunt from the common carotid artery to the internal carotid
artery may be placed while a plan for repair is formulated, more frequently ligation
of the vessels is mandated. Of the patients who survive this catastrophic event, 40%
may develop neurologic de cits.28
POSTOPERATIVE CARE
Preoperative planning greatly facilitates postoperative care. For example, the need
for tracheostomy or enteral feeding tube should be assessed in advance, and po-
tentially performed concurrently, if not before the reconstruction. In this patient
population, with comorbidities and preoperative debilitation, there is no room for
error. Frequently patients spend the rst night in an intensive care setting for care-
ful airway management, pulmonary toilet, and monitoring.
Nutritional status must be thoroughly evaluated, and means for resumption of en-
teral feeding must be established.We routinely resume gastrostomy feedings within
1 or 2 days of reconstruction.Where available, consultation with a nutritionist is ad-
vised.
Systemic antibiotics are standard in postoperative care. Broad-spectrum antibiotic
therapy, including gram-positive, gram-negative, and anaerobic coverage, is usually
instituted for at least 48 hours.29 Often gram-positive coverage is maintained until
the drains are removed and the skin is well healed.
As with other kinds of surgery, hospitalization after head and neck reconstruction
is getting shorter and shorter. An analysis of length of stay after microvascular head
and neck reconstruction concluded that early hospital discharge did not adversely
affect outcomes.30 Although in the past patients were hospitalized until tra-
cheostomy decannulation and resumption of oral intake, now patients are dis-
charged with tracheostomies and enteral feeding tubes in place.When possible, pa-
tients are discharged home with suitable services, or to an interim care facility,
which can assist in their transition home.
Oral rehabilitation with dental implants is usually delayed for months after recov-
ery from surgery.This is a multistep procedure implemented by the oral surgeons.
Outcomes for these osteointegrated implants have been good, though implantation
into native mandible has higher success rates than into free osseous aps or bone
grafts. Radiation and hyperbaric oxygen therapy do not appear to affect outcomes
of these implants.31

ANTICIPATED OUTCOMES
As with all of plastic surgery, patient and physician satisfaction are a function not
only of eventual outcomes, but also of their correlation with expectations.Whether
occurring as a result of congenital malformation, trauma, or cancer, these defects
present a formidable challenge in restoration of form and function. First attention
must be turned to stable coverage of critical structures, and aesthetics follow. But
with careful planning, and with a series of backup plans, the two can be accom-
plished with the least angst to patient and practitioner.
Transplantation, which was once a distant goal in head and neck reconstruction, is
now a looming reality. Although facial transplantation may provide single-stage re-
construction of complex defects with ideal tissue, a host of new problems are intro-
duced with the need for lifelong immunosuppression. A paper from the Royal Col-
lege of Surgeons in England reviewed the science, technical aspects, and ethics
involved in facial transplantation, and concluded that:“until there is further research
and the prospect of better control of [possible] complications, it would be unwise
to proceed with human facial transplantation.”32 Nevertheless, science has marched
on, and the first partial face transplant was performed in November 2005 in
Amiens, France.
Advances in science and technology will doubtless provide a cornucopia of new
tools with which to tackle head and neck reconstruction. But each will come with
its own risks and limitations. The wise practitioner will draw from the new and
old alike, to customize a course for each patient.
References—With Key Annotated References
1. Schusterman MA, Miller MJ, Reece GP, et al. A single center’s experience with 308 free aps
for repair of head and neck cancer defects. Plast Reconstr Surg 93:472-480, 1994.
This is one of the larger series of free ap reconstructions for head and neck cancer. It con rmed a high
success rate for ap survival (95%) and analyzed causes of potential ap failure. Only prior surgery
and use of vein grafts (not tobacco, alcohol use, or radiation) portended a worse ap survival.
2. Kuriakose MA, Shnayder Y, DeLacure MD. Reconstruction of segmental mandibular defects by
distraction osteogenesis for mandibular reconstruction. Head Neck 25:816-824, 2003.
3. Beausang ES, Ang EE, Lipa JE, et al. Microvascular free tissue transfer in elderly patients:The
Toronto experience. Head Neck 25:549-553, 2003.
4. Bhuvanesh S, Cordeiro PG, Santamaria E. Factors associated with complications in microvas-
cular reconstruction of head and neck defects. Plast Reconstr Surg 103:403-411, 1999.
5. Borggreven PA, Kuik DJ, Quak JJ, et al. Comorbid condition as a prognostic factor for com-
plications in major surgery of the oral cavity and oropharynx with microvascular soft tissue re-
construction. Head Neck 25:808-815, 2003.
6. Shasta KC, Jones NF,Wu W, et al. Effect of advanced age and medical disease on the outcome
of microvascular reconstruction for head and neck defects. Head Neck 14:14-18, 1992.
855
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head

856
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
7. Howard MA, Cordeiro PG, Disa J, et al. Free tissue transfer in the elderly: Incidence of peri-
operative complications following microsurgical reconstruction of 197 septuagenarians and
octogenarians. Plast Reconstr Surg 116:1659-1667, 2005.
8. Pribaz JJ, Morris DJ, Mulliken JB.Three-dimensional folded free- ap reconstruction of com-
plex facial defects using intra-operative modeling. Plast Reconstr Surg 93:285-292, 1994.
A methods paper describing the use of intraoperative alginate models to provide accurate three-dimen-
sional measurements of head and neck defects.The three-dimensional model is then converted into a
two-dimensional pattern by wrapping the model with a piece of Esmark bandage.Appropriate fold-
ing of the ap tailors the ap to the defect, maximizing use of the epithelial surfaces.
9. Yu P. The transverse cervical vessels as recipient vessels for previously treated head and neck
cancer patients. Plast Reconstr Surg 115:1253-1258, 2005.
10. Kroll SS, Reece GP, Miller MJ, et al. A comparison of the rectus abdominis free ap with the
pectoralis major myocutaneous flap for reconstruction in the head and neck. Am J Surg
164:615-618, 1992.
11. Schusterman MA, Kroll SS,Weber RS, et al. Intraoral soft tissue reconstruction after cancer ab-
lation: A comparison of the pectoralis major ap and the free radial forearm ap. Am J Surg
162:397-399, 1991.
12. Kroll SS, Evans GR, Goldberg D, et al. A comparison of resource costs for head and neck re-
construction with free and pectoralis major aps. Plast Reconstr Surg 99:1282-1286, 1997.
13. Verschuur HP, Dassonville O, Santini J, et al. Complications of the myocutaneous platysma ap
in intraoral reconstruction. Head Neck 20:623-629, 1998.
14. Vural E, Suen JY. The submental island flap in head and neck reconstruction. Head Neck
22:572-578, 2000.
15. Di Benedetto G, Aquinati A, Pierangeli M, et al. From the “charretera” to the supraclavicular
fascial island ap:Revisitation and further evolution of a controversial ap. Plast Reconstr Surg
115:70-76, 2005.
16. Shpitzer T, Neligan PC,Gullane PJ, et al.The free iliac crest and bula aps in vascularized oro-
mandibular reconstruction: Comparison and long-term evaluation. Head Neck 21:639-647,
1999.
17. Cenzi R, Farina A, Zuccarino L, et al. Clinical outcome of 285 Medpor grafts used for cra-
niofacial reconstruction. J Craniofac Surg 16:526-530, 2005.
18. Pallua N, von Heimburg D. Pre-expanded ultra-thin supraclavicular aps for full-face recon-
struction with reduced donor-site morbidity and without the need for microsurgery. Plast
Reconstr Surg 115:1837-1844, 2005.
19. Pribaz JJ,Weiss DD, Mulliken JB, et al. Prelaminated free ap reconstruction of complex cen-
tral facial defects. Plast Reconstr Surg 104:357-365, 1999.
This article describes the technique of prelamination: assembling a ap with its various components
before transfer. It reviews ve patients who underwent reconstruction of nasal and paranasal facial de-
fects with prelaminated forearm free aps. Flaps were assembled on the arm with skin and cartilage
grafts, and subsequently transferred to the face.
20. Pribaz JJ, Fine N, Orgill DP. Flap prefabrication in the head and neck: A 10-year experience.
Plast Reconstr Surg 103:808-820, 1999.
This paper describes the technique of ap prefabrication, whereby any volume of tissue may be vas-
cularized by insertion of a pedicle in anticipation of future transfer. Seventeen aps were created and
transferred, either as free aps or pedicled island aps. Some pitfalls are described and clinical tips are
provided for performing these procedures.
21. Neobius EB, Lind MG, Lind FG. Hyperbaric oxygen therapy for wound complications after
surgery in the irradiated head and neck: A review of the literature and a report of 15 consec-
utive patients. Head Neck 19:315-322, 1997.
22. Pribaz J, Stephens W, Crespo L, et al. A new intraoral flap: Facial artery musculomucosal
(FAMM) ap. Plast Reconstr Surg 90:421-429, 1992.
23. Pribaz JJ, Falco N. Nasal reconstruction with auricular microvascular transplant. Ann Plast Surg
31:289-297, 1993.

24. Coleman JJ. Treatment of the ruptured or exposed carotid artery: A rational approach. South
Med J 78:262-267, 1985.
25. Deutsch M, Kroll SS, Ainsle N, et al. In uence of radiation on late complications in patients
with free bular aps for mandibular reconstruction. Ann Plast Surg 42:662-664, 1999.
26. Nakatsuka T, Harii K,Yamada A, et al. Dual free ap transfer using forearm ap for mandibu-
lar reconstruction. Head Neck 14:452-458, 1992.
27. Salgado CJ, Mardini S, Chen H-C, Chen S. Critical oropharyngeal stulas after microsurgical
head and neck reconstruction: Indications for management using the tissue plug technique.
Plast Reconstr Surg 112:957-963, 2003.
28. Porto DP, Adams GL, Foster C. Emergency management of carotid artery rupture. Am J Oto-
laryngol 7:213-217, 1986.
29. Carrau RL, Snyderman C, Janecka IP, et al. Antibiotic prophylaxis in cranial base surgery. Head
Neck 13:311-317, 1991.
30. Ryan MW, Hochman M. Length of stay after free ap reconstruction of the head and neck.
Laryngoscope 110:210-216, 2000.
31. Shaw RJ, Sutton AF, Cawood JI, et al. Oral rehabilitation after treatment for head and neck ma-
lignancy. Head Neck 27:459-470, 2005.
32. Morris PJ, Bradley JA, Doyal L, et al. Facial transplantation: A working party report from the
Royal College of Surgeons of England.Transplantation 77:330-338, 2004.
This report detailed the technical, immunologic, psychological, and societal issues surrounding facial
transplantation.They concluded that facial transplantation, although desirable in its ability to achieve
a single-stage, elegant reconstruction, is premature.This paper was followed 9 months later by the rst
partial face transplant, performed in France.
857
Chapter 25
Reoperative Issues Following Flap Reconstruction in the Head

858
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
1. All of the following statements regarding orocutaneous stula and carotid artery
exposure in head and neck surgery are true except:
a. Poor nutritional status and radiation therapy predispose to orocutaneous
stulas and carotid artery exposure
b. Orocutaneous stulas may precipitate rupture of exposed great vessels
c. The location of an orocutaneous stula does not impact prognosis
d. Careful dressing changes, treatment of infection, and attention to nutri-
tional status may diminish the chances of carotid artery rupture
e. Most orocutaneous stulas do not result in carotid artery rupture
2. In most series of free tissue transfer for head and neck reconstruction, patient age
and comorbidities contribute to:
a. Flap-related complications but not medical complications
b. Medical complications but not ap-related complications
c. Neither ap-related complications nor medical complications
d. Donor site but not recipient site complications
3. Treatment of gunshot wounds to the face epitomizes the careful surgical plan-
ning required for complex composite head and neck reconstructions. After sta-
bilization of the patient, the best way to proceed with a staged reconstruction af-
ter gunshot wound to the face is to:
a. Obtain immediate coverage with the use of local tissue, such as cheek ad-
vancement and forehead aps
b. Await wound contracture to minimize the use of distant and local tissues
c. Perform a single-stage free tissue transfer
d. Analyze the defect and reestablish a bony framework
4. All of the following are potential bene ts of facial transplantation except:
a. Decreased medical morbidity
b. Single-stage reconstruction
c. No donor site morbidity
d. Improved cosmesis
5. In patients who require free tissue transfer for head and neck reconstruction but
have undergone multiple prior procedures, with a resulting “frozen neck,” a
good solution for recipient vessels is to:
a. Place the anastomosis within the zone of injury
b. Use the transverse cervical vessels
c. Avoid vein grafts
d. Perform preoperative angiography
R EVIEW QUESTIONS

859
Secondary Procedures
in Facial Reanimation
Fausto Viterbo and Adel Hussein Amr
C ha pter 2 6
Reoperative Problems
Hollowness in the temporal region
after using classical temporalis
muscle
Insuf cient movement after using
small terminal branches of buccal
nerve for cross-face grafting
Over-and-under action of ortho-
dromic temporalis transposition
Slippage of the attachment of
fascia lata graft to the lower lip
Facial expressions and body gestures are a living language
which we all have learned to read as a clue to,
and use as a revelation of, the inner person, and character.
Paul Zucker
Overaction of the muscle on the
normal side of face
Apparent frontal wrinkles on the
normal side
Horizontal direction of the smile
after using masseter muscle
transposition
Persistent relaxation of the lower
eyelid after a tarsal strip procedure
Persistent attening in the nasolabial
fold after muscle transposition

860
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Facial paralysis resulting from a congenital deformity or from traumatic injury to
the facial nerves has serious physical and emotional rami cations. Patients who have
suffered varying degrees of facial paralysis are often unable to express emotion;they
feel isolated and may be depressed and withdrawn. Facial paralysis may even have a
negative impact on a person’s professional life,depending on the individual’s need for
public interaction.1 Physical problems can also be a concern.The lack of eyelid oc-
clusion can lead to dryness of the eye,corneal ulceration,and even perforation of the
globe. When the mouth is affected, facial paralysis may impede the patient’s ability
to smile or may cause an asymmetrical smile. Drooling may result, causing further
embarrassment for the patient during eating. The very act of chewing may cause
trauma to the mucosa. Furthermore, the absence of frontal muscle movement will
depress the eyebrow position on the paralyzed side, producing asymmetrical wrin-
kling in this region.1,2 Treatment may necessitate a staged procedure to permit time
for nerve regeneration. Reoperation is often necessary to obtain symmetry, to en-
hance functional and aesthetic results, and to address complications.
CLINICAL PROBLEM-SOLVING
SURGICAL OPTIONS
Dynamic treatment using nerve grafts and/or muscle transposition is the preferred
approach for restoring innervation to the paralyzed facial muscles. Static treatment
is used only in special cases, where there is no possibility of a dynamic solution.
FACIAL PALSY
Chronic
Acute
Additional procedures in late cases:
ß Myectomy of the zygomaticus and orbicularis oculi mucles of normal side.
ß Neurectomy of the frontal branch of the normal side.
Trauma
Direct
repair
No
improvement
Cross face
nerve graft
with ETS
No
improvement
Orthodromic
temporalis
Bell’s palsy or
post rhytidoplasty
EMG after
30 days and
repeat 120 days
Improvement
Wait
No improvement
Cross face nerve graft
with ETS (Bell’s palsy)
or nerve graft and
muscle neurotization
(post rhytidoplasty)
Mild to moderate
(there is some action)
Cross face nerve with
ETS. In some cases
combined with
orthodromic
temporalis
Severe
(very little or no action)
Orthodromic
temporalis and
cross face
nerve with ETS

CROSS-FACIAL NERVE GRAFTING
861
Chapter 26
Secondary Procedures in Facial Reanimation
The cross-facial nerve graft, a technique described by Scaramella3 and Smith,4 con-
sists of a sural nerve graft that relies on end-to-end neurorrhaphy to connect the fa-
cial nerve network on the paralyzed side with the distal buccal branches on the
normal side. Although this technique is used by many surgeons, results are often
limited. Disadvantages include the limited availability of graft material, the inabil-
ity to divide several branches on the normal side without causing injury, and the in-
ability to use this approach for early treatment because of the need to delay division
of the facial nerve network until regeneration has occurred.1
In cases of late paralysis with de nitive atrophy of the facial muscles, sural nerve
grafts with gracilis, latissimus dorsi, pectoralis minor, or rectus abdominis muscle free
aps can be used.5,6 With this approach the graft is sutured to one of the terminal
buccal branches across the face and under the nose or the chin;its other limb is su-
tured to the nerve of the transplanted muscle. The pedicle of the muscle ap is
anastomosed to the facial or superficial temporal vessels. This procedure can be
performed in one or two stages.When done in one stage, it may cause temporary
muscle atrophy until regeneration of the axons through the sural nerve graft is
complete, which may take up to 1 year. When this procedure is executed in two
stages, the surgeon must wait for the axons to travel the length of the sural nerve
graft, as indicated by Tinel’s sign, before free muscle ap transfer is initiated. With
this second option, the time for muscle denervation is greatly diminished. Another
option is muscle transfer with a long nerve pedicle, which can be sutured to the
buccal branches on the normal side. In this way the procedure can be performed in
one stage.The latissimus dorsi muscle, accompanied by the thoracodorsal nerve, is
one good option.7,8 Other recent options include the rectus abdominis muscle, rec-
tus femoris muscle, and serratus anterior muscle aps as whole muscles or as mus-
cular subunits.9-11

862
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
CROSS-FACIAL NERVE GRAFTING W ITH END-TO-SIDE
ANASTOMOSIS
In 1992, with the introduction of the end-to-side neurorrhaphy without injury to
the donor nerve,12-15 an important modi cation was made to the cross-facial nerve
grafting technique. Instead of dividing the buccal branch on the normal side and
the trunk of the paralyzed facial nerve, we transferred the sural nerve graft, connect-
ing both buccal branches, right and left, and temporal zygomaticus branches, right
and left, without dividing them or removing their epineurium, thereby preventing
any injury to these nerves (see p. 861).This technique has two advantages. First, it
permits early intervention, preventing muscular atrophy without harm to the facial
nerves;second, it allows the possibility of spontaneous nerve regeneration. Another
advantage is the possibility of doing numerous cross-facial grafts, thus enhancing the
potential for segmental facial reinnervation.The only limitation to this approach is
the availability of donor nerve material. Recent progress in research has been made
on arti cial nerves, nerve guides with veins and absorbable materials, and reduced
morbidity through the use of modern immunosuppressive drugs, coupled with the
use of grafts from cadavers. In the near future it is likely that we will have numer-
ous grafts available for use in cross-facial grafting.16-18

HYPOGLOSSAL TO FACIAL GRAFTS
With this technique, the trunk of the facial nerve is divided as proximally as possi-
ble, and the hypoglossal nerve, or the ansa of the hypoglossal nerve, is also divided
as distally as possible.The proximal hypoglossal nerve is sutured end-to-end to the
distal end of the facial nerve. In this way the muscles of the face are reinnervated by
the bers of the hypoglossal nerve. Because this nerve has a great number of bers,
the potential reinnervation is dramatic.19,20 However, the improvement is primarily
in relation to the resting muscle tone, but they are not as good functionally. To
move the face, a person must attempt to press the tongue in one direction or an-
other, making the learning of spontaneous movement quite dif cult. The com-
plaints associated with the tongue sequelae are frequent, including hemilingual im-
mobility, which makes it dif cult to remove food from the gingival buccal sulcus.21
To avoid these unpleasant sequelae, May et al22 recommend the use of a nerve graft
between the hypoglossal nerve and the facial nerve without doing a complete tran-
section of the hypoglossal nerve, thereby decreasing potential problems. Other au-
thors have used end-to-side neurorrhaphies in the hypoglossus with good results.23,24
THE “BABYSITTER” TECHNIQUE
Although cross-facial nerve grafting is often used, this procedure requires a period
of approximately 1year for regeneration of the axons through the nerve graft. This
long delay before surgical intervention could result in a compromised result because
of muscular atrophy. To offset these problems, Terzis25 proposed transferring an-
other nerve graft to connect the homolateral hypoglossal nerve to the facial nerve
at the same time that the cross-facial nerve graft was being placed. By using the
hypoglossal nerve, the distance traveled by the axons is reduced, and the muscles of
the face become innervated sooner. After some time has elapsed, when the axons
from the cross-facial nerve graft reach the end of the sural nerve graft across the face
and the junction with the facial nerve trunk, these axons will replace the action of
the axons coming from the hypoglossal nerve.
FREE MUSCLE FLAPS
Late paralysis accompanied by de nitive facial muscle atrophy can be treated with
free muscle transposition. In 1976 Harii et al5 were the rst to relate a successful
transfer of the gracilis muscle with cross-facial nerve grafting.
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Since then, other muscles such as pectoralis minor, latissimus dorsi, serratus, and
rectus abdominis have been used for free ap reconstruction for facial reanimation.
The gracilis muscle is preferred for free ap transfer because of its anatomic con-
sistency, the length of its pedicle, and the fact that subdivision does not decrease the
functional quality of tissue available for transfer.1 The muscle is shown above on the
left, and the position where the muscle is to be xed is shown on the right.
Several nerves can be used for reanimation of the transferred muscles.We prefer the
contralateral facial nerve branches through sural nerve grafts placed at the same
time or in a rst-stage procedure.The hypoglossal or the accessory nerves are also
available as donor nerves.1
In the Moebius syndrome, the masseter muscle nerve is the most frequently used
donor nerve, because it is rarely affected by this syndrome.26
TEMPORAL MUSCLE FLAPS
In instances of late paralysis, when the muscles are atrophied with no possibility of
reinnervation, the muscles of mastication, the masseter or temporalis, can be trans-
ferred to the corner of the mouth.To smile, then, the patient must clench his or her
teeth, contracting the masseter or the temporalis. Although the smile obtained is not
spontaneous, the results are well accepted by patients.27,28
The masseter can be used totally or partially. Its disadvantage is its horizontal direc-
tion of pull, which may lead to an asymmetrical, unnatural smile.1

The temporalis muscle ap, introduced by Gilles,29 allows traction in a more oblique
direction, similar to the direction of the zygomaticus muscles, which are princi-
pally responsible for the smile.
The temporalis muscle originates from the temporal fossa and inserts in the cora-
coid process of the mandible.Vascularity is through the anterior and deep tempo-
ral arteries and branches of the maxillary artery. It is innervated by branches of the
mandibular division of the trigeminal nerve.29,30
Because this muscle is short, it cannot reach the medial canthus of the eye and the
buccal rim. Many approaches for elongating the muscle have been described, in-
cluding fascia lata grafts (Gilles29), muscle grafts (Millesi31), incorporated strips of
periosteum attached to the tendon of the muscle (Baker and Conley27), silicone
lamina, and Gore-Tex.28
Temporalis muscle transfer is commonly used for facial reanimation because of its
extended reach, enabling it to reanimate the eyelid as well as the face.29
A disadvantage of the temporalis muscle transposition ap is the depression of the
anterior temporal fossa that results, as well as the increased volume over the zy-
goma, causing aesthetic complaints, especially in the case of unilateral paralysis.To
minimize this problem, some have suggested using the posterior portion of the
temporalis muscle, which keeps it a little more hidden.28
ORTHODROMIC TEMPORAL MUSCLE FLAPS
McLaughlin32 introduced the use of the temporal muscle ap without changing its
direction. He cut the coronoid process of the mandible intraorally, at the temporalis
muscle insertion, and xed a silicone sling to the bone fragment and to the orbicu-
laris oris muscle on the paralyzed side. The aesthetic results were very good, but
function improvement was minimal.This technique provides good resting position
of the corner of the mouth, especially in cases of facial paralysis of long duration.
Breidahl et al33 suggested a similar technique.They used an extraoral approach with
resection of the zygomatic arch and detachment of the tendon of the temporalis
muscle from the coronoid process, with placement of a fascia lata graft between
this tendon and the orbicularis oris muscle.
Viterbo34 and Viterbo and Faleiros35 modi ed the technique of Breidahl et al33 by
preserving the zygomatic arch, thus producing a better aesthetic result. This ap-
proach was even used in cases in which removal of arch was required for better
exposure of the temporalis tendon;in these situations, they replaced the arch at the
end of the procedure and xed it with plates or acrylic glue.
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In this modi ed technique, the temporalis muscle tendon is grasped with a Kocher
forceps. The fascia lata graft is sutured to the temporalis tendon and passed under
the SMAS, or more recently, under the zygomatic arch, through Bichat’s fat pad, and
exiting through an incision in the nasolabial fold. Nylon sutures are then applied to
the orbicularis muscle at the lower lip, commissure, and upper lip.
The aesthetic results achieved with this technique are very good, as seen in this
18-year-old patient with congenital facial paralysis, seen preoperatively and 2 years

postoperatively. Patients are instructed to do daily exercises, smiling in front of the
mirror, chewing on the operated side, and seeking to achieve better symmetry with
the smile on the normal side. After intensive treatment and exercise, some patients
recover spontaneous smiles without clenching their teeth.
CROSS-FACIAL NERVE GRAFTING W ITH END-TO-SIDE
ANASTOMOSIS PLUS TEMPORAL MUSCLE ORTHODROMIC
TRANSPOSITION
In recent cases of facial palsy of 1 year or less, we combine the two techniques:the
cross-facial graft with end-to-side (ETS) anastomosis and the temporal orthodromic
muscle transposition. The patient’s smile is restored in 30 days through clenching
the teeth;in most cases, after 1 or 2 years, spontaneous smile regeneration occurs as
a result of the cross-facial graft.1
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This patient had Bell’s palsy; her condition was treated with an orthodromic
temporalis ap with a fascia lata graft and cross-facial nerve graft with sural nerve
and end-to-side neurorrhaphies. The preoperative and 5-year postoperative
views are shown.

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R EOPERATIVE SURGERY OF THE HEAD AND NECK
This Bell’s palsy patient was treated with an orthodromic temporalis ap and fas-
cia lata graft. A cross-facial nerve graft with sural nerve ETS neurorrhaphies and an
upper eyelid gold weight was also performed.The preoperative and 1-year postop-
erative views are shown.

This patient had facial palsy on the right side following resection of an acoustic
neuroma 18 months earlier.The patient was treated with an orthodromic tempo-
ralis muscle ap with a fascia lata graft and a cross-facial nerve graft with sural nerve
and ETS neurorrhaphies. A gold weight was inserted in the right upper eyelid.The
patient is shown preoperatively and 3 months postoperatively.
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LENGTHENING TEMPORALIS MYOPLASTY
Labbé and Huault36 published an interesting technique, detaching the temporalis
muscle from its origin and from the coronoid process and reinserting it anteriorly
in the temporal crest and tunneling beneath the orbicularis oris, passing under the
zygomatic arch and through Bichat’s fat pad. With this approach, there is no need
for grafts.The aesthetic and functional results are acceptable.
TIMING OF TREATMENT
The timing of surgery for congenital paralysis, Bell’s palsy, and palsy following face
lift is controversial.Very early surgery may be not necessary because many patients
will show spontaneous recovery. On the other hand, waiting too long may lead to
de nitive muscle atrophy, losing the opportunity for reinnervation.
In congenital paralysis, we believe we should not wait more than 1 year. For Bell’s
palsy and palsy following a face lift, we do two electromyographic examinations,
one after 1 month and the second at 4 months. If no clinical or electromyographic
improvement is observed, we recommend surgery.
Speci c Problems
CONGENITAL FACIAL PARALYSIS
The incidence of congenital facial paralysis is approximately 2:1000 births.21 Con-
genital facial paralysis can have two causes:
1. Malformation in the facial nerve or the facial muscle. In general, this pathol-
ogy is genetically based, with a strong familial tendency.
2. Acquired causes, such as trauma subsequent to birth. Congenital paralysis
caused by malformation is often associated with deformities in the auricular
canal, hearing de cits, mandibular alterations, and hemifacial microsomia.
Although this is controversial, we think treatment should be done as soon as possi-
ble, with nerve grafts done before the child reaches 1 year of age to prevent muscle
atrophy. Some patients who are not too old can show considerable improvement.
Late cases receive orthodromic temporalis muscle transposition.1 It is important to
analyze the state of the temporal muscle in congenital facial paralysis. In some cases
this muscle can also be affected and will not be useful for transposition.1

Congenital facial paralysis in this 5-year-old patient was treated with a cross-facial
nerve graft and two sural nerve grafts with end-to-side neurorrhaphies. Her preop-
erative and 3 years postoperative views are shown.
MOEBIUS SYNDROME
A frequent type of bilateral congenital facial paralysis is Moebius syndrome; pa-
tients with this condition often experience severe emotional problems. These pa-
tients have great dif culty with social integration, primarily because of the inabil-
ity to smile and the absence of facial expression.
The deformities can be obvious at birth, and there is no tendency to progress with
age.The deformities can be asymmetrical, in various degrees among the partial fa-
cial and superior and inferior parts of the face. It can occur unilaterally or bilater-
ally. Any cranial nerve can be affected with the VI and VII cranial nerve involve-
ment, although the most frequently affected are cranial nerves III,V, IX and XII.37
The mouth appears to have a smaller aperture and the commissures are displaced
inferiorly.
To restore the smile some authors use platysma and temporalis muscle transfers.38
We prefer orthodromic temporal aps with fascia lata grafts, unilateral or bilateral,
depending on the case. Especially in Moebius syndrome patients we recommend
suturing the fascia lata in the orbicular oris muscle only in the inferior lip, because
the commissures of the mouth are very inferior and must be adequately elevated.1
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This 6-year-old patient had bilateral Moebius syndrome that was treated with an
orthodromic temporalis ap and fascia lata grafts. Preoperative and 1 year postop-
erative views are shown.
Some authors use free gracilis muscle aps reinnervated with the motor nerve to
the masseter.26 The problem with this method is that chewing causes contraction of
the gracilis muscle and the resultant smile.These procedures are done in two stages
and the surgery is complex; each gracilis is transferred in a separate stage which
takes approximately 6 to 8 hours. Our preference is to perform an orthodromic
transposition of the temporalis because we can do both sides in 2 to 3 hours, in a
single surgery stage, without any risk of vascular thrombosis and just one day of
hospitalization.
DENERVATION OF THE ORBICULARIS
OCULI MUSCLE
SUPERIOR EYELID
Facial palsy frequently compromises innervation of the orbicularis oculi muscle,
affecting the occlusion of the upper eyelid.
Upper eyelid
Lower eyelid
Gold
weights
Elongation
of lid elevator
Severe
Blepharoplasty or
lateral tarsorrhaphy
Horizontal shorting
of tarsal plate or
tarsal strip or
cartilage graft
Mild

INFERIOR EYELID
Denervation of the orbicularis oculi muscle also affects lower eyelid position, fre-
quently causes ectropion and scleral show, accompanied by dry eye.There are a va-
riety of options for correction. Mild cases are treated by blepharoplasty with eleva-
tion of the SOOF, or by lateral tarsorrhaphy. More pronounced cases are treated by
horizontal shortening of the tarsal plate or by tarsal strip.40 Severe cases require
conchal cartilage graft xed to the periosteum of the orbital border and the tarsal
plate, elevating and maintaining the lid in an adequate position1 (see Chapter 18).
REOPERATION
PARALYSIS AFTER FACE LIFTING
Facial palsy after face lifting is not uncommon. Sometimes it is caused directly by
scissors or scalpel or even by electrocautery. Fortunately the majority of these cases
improve spontaneously. Some cases, however, do not show the same improvement,
resulting in problems with closing the eyelids or an asymmetrical smile. In these
cases we recommend early intervention before muscular atrophy occurs. Our goal
is to locate the anatomic interruption of the facial nerve branch, and when there is
no tension, to directly repair it with end-to-end neurorrhaphy.When there is ten-
sion, we do a sural nerve graft.
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To obtain lid closure we use gold
weights.These can be placed with
local anesthesia, are reversible and
can be removed at any time. The
exposure of the tarsus after xing
the gold weight with sutures is
shown above. The result of the
correction is immediate.39

874
PART III
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In some cases we cannot locate the anatomical lesion in the nerve. In these cases we
put a sural nerve graft with one limb sutured lateral to the affected branch. The
other end of the graft is put into the paralyzed muscle, making a direct muscular
neurotization, as was done in this patient who had right facial paralysis that affected
the buccal branch following a face lift.41
SYMMETRY
In facial paralysis, reoperations are very common. The majority of the cases need
complementary treatment to obtain better symmetry in facial movements.
In a great number of cases after a certain time, the fascia lata graft xed to the tem-
poral muscle relaxes, which in uences the diminished activity of the paralyzed lip
during smiling. To correct this, under local anesthesia and sedation, an incision is
made in the nasolabial sulcus or the lower lip matching the incision used in the rst
procedure. We dissect the fascia lata graft and plicate it with 2 stitches using 2-0
mono lament nylon as seen in this patient who had right facial palsy after resection