The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

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916
•• Prefabrication and prelamination of osseous grafts for
the reconstruction of large alveolar defects15
•• Complex prefabricated grafts for microsurgical
reconstruction of the maxilla and midface6,12,16,17
Reconstruction with Prefabricated
Grafts
From the point of view of functional anatomy, there are
four problems that need to be overcome:
1. Reconstruction of a pneumatized, lightweight skeletal
structure with mechanical stability
2. Establishment of a stable inner lining of cavities
3. Establishment of gingiva that is resistant to masticatory
loading
4. Prevention of graft inflammation, especially at the
implant site
Before the development of prefabricated composite grafts,
the inner lining of the oral cavity was reconstructed using
full- or split-thickness skin grafts, intestinal grafts, and
mucosal grafts.4,18,19 However, hair growth, maceration,
persistent peristalsis, and excessive mucous secretion have
diminished the acceptability of these grafts for the replace­
ment of the oral lining. Furthermore, a high rate of implant
loss was observed with these grafts because of deep and
persistently inflamed pockets around the site where the
dental implant penetrated the gingiva.
Moreover, attempts at reconstruction with mucosal pre­
lamination of fasciocutaneous flaps failed because of severe
clinical outcomes, but only in the case of mandibular re­
constructions6 (Fig. 50.2).
For the reconstruction of a pneumatized midface, these
free flap techniques are inappropriate, which has led to the
trend of patient-specific implants and full-face transplan­
tation.8–10
There is a flowing transition between tissue deficiency
and defect, and if these persist long enough, they are usu­
ally combined with facial disfigurement; therefore complex
surgical protocols, rather than simple free flap techniques,
are necessary to avoid unfavorable results.
The surgical concept of like-with-like restoration in the
case of the oral and maxillofacial anatomy includes both the
reconstruction of missing tissues and the rearrangement of
the skeletal architecture of the face to achieve acceptable
aesthetic and functional results, which can be best illus­
trated in cleft patients.
Two aspects must be taken into account during the
treatment of maxillofacial deficiencies or defects:
1. Like-with-like reconstruction based on the three “iden­
tities,” namely, identical size, identical shape, and iden­
tical tissue structure to those of the recipient site.6,11,12
2. Correction of facial disfigurement using grafts and/or
surgical orthognathic procedures.13,14
Depending on the extent of the tissue deficiency, a series of
surgical methods have been described for different indica­
tions in maxillofacial surgery:
•• Osteoplastic reconstruction (e.g., “stack plasty”) of the
alveolus and osteoplasty of tertiary clefts14
a
b
Fig. 50.2 Stepwise aesthetic and functional rehabilitation by trimming bulky flaps and integrating implant restoration. (From Holle J, Vinzenz
K, Würinger E, Kulenkampff KJ, Saidi M. The prefabricated combined scapula flap for bony and soft-tissue reconstruction in maxillofacial
defects—a new method. Plast Reconstr 1996;98(3):542 -552.)

917
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
Fig. 50.3 The surgical procedure for prefabricating composite flaps from the scapula (a) and iliac crest (b). PTFE, Polytetrafluoroethylene.
Anatomy cross section
Osteotomy
1. Preformation
2. Implant
installation
3. Dermis
prelamination
Dermis
Coverage/
envelope
with PTFE
membrane
Bone
Dermis
PTFE
membrane
Titanium
osseo-integrated
implant
Posterior
Anterior
4. Composite flap reinstated
A
B
C
a
1. Preformation
2. Implant installation
3. Dermis prelamination
Dermis
Coverage/
envelope
with PTFE
membrane
Iliac crest
bone graft
4. Composite flap rotated
and reinstated
Bone graft
rotated
b

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
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•• Accurate postoperative control using computer-assisted
design systems
•• Critical scientific analysis of the clinical results
If these criteria are not met or if a multistage surgery is re­
quired at the recipient site, the clinical effort of transplant
prefabrication and the physical as well as psychological
stress to the patient are difficult to justify.18,24-28
Most of the cited surgical protocols for graft prefabrica­
tion have been abandoned because of unfavorable results
and complications.
Prefabricated Composite Mandibular
Grafts in Orofacial Reconstruction
Essential in orofacial reconstruction is the prefabrication
of an artificial periodontal unit, consisting of the alveolar
bone, gingiva, and dental implants, as an integrated com­
ponent of the entire graft (Fig. 50.4). Thus full oral func­
tion is available immediately after the completion of dental
restoration.13
Only by inflammation-free periointegration of the den­
tal implants will the implant site be sealed against the oral
environment, allowing a stable and successful long-term re­
sult.22,23,29
Surgery for Midface Defects
While the alveolar crest of the maxilla can be restored us­
ing block-graft techniques,14,15 the pneumatized skeletal
anatomy of the midface should preferably be reconstructed
using prefabricated composite grafts6 (Fig. 50.5). Midface
defects affect all tissue structures and require treatment
before disfigurement is caused by the tendency of the tis­
sues to close the defects by shrinking.
scarring of the lining combined with further loss of oral mo­
bility, particularly in the case of reconstructions of the floor
of the mouth.18
Dermal prelamination of the bone, which was first
cited in 1996,6,12 is a complex prefabricated composite
graft that allows the restoration of the pneumatized, light­
weight skeletal architecture of the face by replacing like
with like.6,12,16
As illustrated in Fig. 50.3, the prefabrication of complex
composite grafts includes the following:
•• Preformation of the bony graft
•• Dermal prelamination of the bony graft
•• Installation of dental implants
The transplant is enveloped in an expanded polytetrafluo­
roethylene (ePTFE) membrane and allowed to mature at
the donor site for several months. After maturation, a graft
with a “perfect fit” can be harvested and used for recon­
struction. Prefabricated grafts from the scapula are best
suited to midface reconstructions, whereas those from the
iliac crest are best suited to mandibular reconstructions
(see Fig. 50.3) Revascularization is only required for trans­
plants exceeding 4 cm in diameter (Video 50.1).20
A prerequisite for the use of prefabricated grafts is con­
cept surgery, which is defined as surgery that follows a pre­
defined objective and a detailed, preoperatively prepared,
stepwise plan, as opposed to routine surgery, which does not
involve or strictly follow such plans and may involve a wide
variety of perioperative protocols with unknown effects on
the surgical outcome.21
Concept surgery requires12,22,23:
•• A clear definition of the aspired clinical result
•• Computer-assisted operation planning to transform the
surgical concept into clinical reality
Fig. 50.4 Reconstruction of the mandible with a prefabricated iliac composite graft with a periodontal unit consisting of the bony alveolus,
gingiva, and implant restoration in a 57-year-old man who had undergone mandibulectomy. (Reproduced from Vinzenz K, Schaudy C. Osteo­
plastic surgery of the face—state of the art and future aspects. Eur Surg 2011;43(5):270-283, with permission from Springer-Verlag Wien.)

919
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
field of soft tissue and bony reconstructions and into that of
tissue engineering and “inductive surgery.” Shortly thereaf­
ter, the first scientific studies on tissue induction in prefab­
ricated composite grafts were published.22,23
The main novelty of this procedure is the placement of a
dermal graft over the bone to create a substitute for the oral
mucosa and avoid the unfavorable results obtained with skin
and intestinal grafts.
Induction of Tissues in Prefabricated
Grafts
Induction of an “Osseomucosal Unit”
A stable attachment to the bone is essential for the restora­
tion of the inner oral lining (Fig. 50.8). Histomorphologic
evaluation of prefabricated composite grafts has shown
that the dermis is attached in a periosteum-like manner to
the extensively remodeled bone, which osseointegrates the
inserted titanium implants, and that the basal parts of the
dermis are attached to a papillary connective tissue layer.12
Furthermore, the graft must fit perfectly into the defect
(“click in place”), which can be achieved using accurate pre­
operative computer-assisted planning.12,13,16,17
In complex midface reconstruction, the prefabricated
graft is “suspended” into the defect using osteosynthesis
titanium miniplates connected to already-osseointegrated
dental implants17 (Figs. 50.6 and 50.7) This new method
ensures fast restoration of oral function, pneumatized nasal
and paranasal cavities, and high graft stability for several
years. Therefore this method is preferred in diseases with
severe scarring, such as noma.17
Regenerative, Inductive Maxillofacial
Surgery
Regenerative medicine is the “process of replacing, engi­
neering or regenerating human cells, tissues or organs to
restore or establish normal function via stimulating the
body’s own repair mechanisms.”30
McCarthy et al,31 who established distraction osteogen­
esis in maxillofacial surgery before the turn of the millen­
nium, were the first to take craniofacial surgery out of the
a
b
c
Fig. 50.5 (a) Three-dimensional computed tomography after surgery to verify the correct fit of a prefabricated composite graft. Note in
particular the exact intersection at the palate. (b) Reconstruction of the maxillary sinus as a pneumatized paranasal cavity. (c) Reconstruc­
tion of the alveolus and palate in the second quadrant with an attached masticatory gingiva and integrated implant restoration at 6 weeks
postoperatively. (From Holle J, Vinzenz K, Würinger E, Kulenkampff KJ, Saidi M. The prefabricated combined scapula flap for bony and soft-
tissue reconstruction in maxillofacial defects—a new method. Plast Reconstr Surg 1996;98(3):542–552.)

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
920
a
b
Fig. 50.7 Lateral radiographic studies before
(a) and after (b) reconstruction of the entire
midface, including the maxilla, palate, and
nose, in a patient with severe noma. (From
Vinzenz K, Holle J, Würinger E. Reconstruc­
tion of the maxilla with prefabricated scapu­
lar flaps in noma patients. Plast Reconstr Surg
2008;121(6):1964–1973.)
Fig. 50.6 (a–c) An osteosynthesis plate is attached to additional dental implants (yellow arrows) in the graft, and the graft is suspended in
the defect (clicked in place). (c From Vinzenz K, Holle J, Würinger E. Reconstruction of the maxilla with prefabricated scapular flaps in noma
patients. Plast Reconstr Surg 2008;121(6):1964–1973.)
Titanium
miniplates
Nasal septum
Alveolus and
hard palate
Dental
implants
a
b
c

921
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
Distraction osteogenesis is an inductive surgery that
combines reconstructive surgery with aesthetic surgery
of the face, depending on the distraction distance. In dis­
traction osteogenesis, the gradual advancement of a bone
segment leads to the formation of new bone behind it, and
distraction histogenesis is the biologic process of soft tissue
adaptation to the resultant gradual stretching.32
Bone transport represents an alternative to microsurgi­
cal midface reconstruction. Similar to prefabricated compos­
ite grafts, this method provides a new lining via expansion
of the attached gingival tissue, which aids in the perioin­
tegration of dental implants and resists functional loading
during mastication.29
In orthognathic surgery, distraction osteogenesis is best
suited for the three-dimensional rearrangement of the face
to optimize the facial proportions in various indications,
including complex surgical protocols such as those in cleft
surgery.
Moreover, the muscles adherent to the distracted bone
are stimulated to create new cells at the origins and inser­
tions of the muscles as well as within the muscle mass. In
addition, the bone–muscle crosstalk, which is the interac­
tion between the regenerating muscles and the remodeling
bone, improves the musculoskeletal balance of the face, lead­
ing to a better aesthetic appearance, as shown in a 28-year-
old patient who had undergone unsuccessful orthognathic
treatment for 7 years (Fig. 50.10).
However, it must be noted that bone transport related
to distraction osteogenesis across large distances may cause
injury of the skeletal muscles.33
Bone Transport
Based on the principles described previously, bone trans­
port can be used as an alternative to microsurgical recon­
struction using prefabricated composite grafts in patients
with noma (see Fig. 50.9, 7). The main advantages in this
setting are the requirement of fewer and cheaper surgi­
cal instruments, the shorter operation time, and the lack
Complete Restitution of the Inner Mucosal
Lining
The quality of the epithelium of the inducted bone and the
attached lining can be ascertained via immunohistochemi­
cal analysis. Most importantly, the prefabricated grafts are
covered by an almost normal epithelium within 4 weeks
after flap transfer.
The epithelium is fixed to the underlining connective
tissue by rete ridges. The observation of keratin expression
by the epithelial cells indicates a clinically verified complete
restitution of the mucosa.23
Attachment of the Gingiva to Resist
Masticatory Load
Because a prefabricated composite graft consists of bone
and dental implants, it provides an excellent surface for
the development of a keratinized, attached epithelium that
withstands masticatory forces because of the increasing
number and size of the connective tissue parts within it af­
ter the reconstruction surgery. The attached epithelium re­
sembles the normal mucosa and seals the implants against
the oral environment.22,29
Anti-inflammatory Immune Response of the
Neomucosa
The mucosal covering becomes rapidly populated by den­
dritic cells, which are major players in the initiation of
specific immune responses, and this may additionally con­
tribute to a low periimplant infection rate.22
Distraction Osteogenesis and Histogenesis
In both reconstructive and aesthetic surgery, the facial pro­
portions represent the gold standard of aesthetic appear­
ance1 (Fig. 50.9, Video 50.2).
Fig. 50.8 Characteristics of a prefabricated composite graft.
(1) Remodeling activity of the bone. (2) An osseomucosal unit with
periosteum-like attachment of the lining. (3) Epithelium fixed to
the underlying connective tissue by rete ridges. (Reproduced from
Vinzenz K, Schaudy C. Osteoplastic surgery of the face–state of the
art and future aspects. Eur Surg 2011;43(5):270–283, with permis­
sion from Springer-Verlag Wien.)

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
922
3
4
5
7
6
1
2
Fig. 50.9 Possible osteotomies and regions of distraction osteogenesis (DO), with various indications for distraction in the maxillofacial
region. (1) Advancement of the entire face, mostly used in syndromic patients. (2) Midface distraction in high Le Fort II or Le Fort III oste­
otomy. (3 and 5) Distraction of an alveolar bone block to increase the height of the alveolus. (4) Lengthening of the mandible in the sagittal
dimension. (6) Distraction of the ascending branch of the mandible. (7) Bone transport. The schema should further illustrate the facial soft
tissue envelope being supported by the underlying bone structure of the face. This functional musculoskeletal interaction, the “bone–muscle
crosstalk,” in the face is best described as sectorial architectonic shoring (see Fig. 50.11).
a
b
Fig. 50.10 Managing unfavorable results. This 28-year-old patient was treated with a comprehensive orthognathic surgical protocol in­
cluding distraction osteogenesis after failure of orthodontic treatment for 7 years. (a) Disrupted facial proportions, tension on the facial
soft tissue envelope with pronounced nasolabial and mentolabial folds, and “chubby cheeks” caused by displaced retaining ligaments and
a loss of the alveolar bone in the piriform region and lateral maxillary segments. (b) Aesthetic appearance after skeletal rearrangement
with bimaxillary orthognathic surgery including distraction osteogenesis, maxillary reconstruction by stack plasty, and restoration of
musculoskeletal balance. (Reproduced from Vinzenz K, Schaudy C. Osteoplastic surgery of the face–state of the art and future aspects.
Eur Surg 2011;43(5):270–283, with permission from Springer-Verlag Wien.)

923
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
Musculoskeletal Balance in Distraction
Osteogenesis
The superficial facial fascia is cranially elongated in the neck
and has deep attachments in the temporal and periorbital
regions.34 This surgical anatomy of the fascia is the key to
understanding the functional changes in the aesthetic ap­
pearance of the face during distraction osteogenesis.
In the fat compartments of the face, the deep and su­
perficial fascial planes are separated by areolar tissue that
is adherent to both planes through a series of dense fibrous
attachments.35
The fascia with its viscoelastic properties is normally
considered a passive structure that transmits mechanical
tension generated by muscular activities.36
Advanced bone relocation surgery changes the tension
on the fascia and the superficial musculoaponeurotic system
(SMAS) via retaining ligaments, which function as sectorial
architectonic shoring over the fat compartments (Fig. 50.11).
As a consequence, this leads to greater primary tension
on the SMAS and fixed mimic muscles.
of a need for admission into an intensive care unit, which
makes this technique applicable in developing countries,
for instance, in Africa.13,17
Distraction Osteogenesis in Orthognathic
Surgery
Distraction osteogenesis has three major advantages over
conventional orthognathic surgery:
1. It is possible to move segments over a longer distance,
thereby reducing the need for further bone grafts.
2. It provides stable, long-term outcomes.
3. It enables the three-dimensional rearrangement of the
face in the case of facial disfigurement, especially in the
transverse dimension, as is needed in cleft patients.6,13
For these reasons, distraction is useful in the complex sur­
gical protocols of cleft surgery. Moreover, a close functional
relationship between the bone and soft tissue facial enve­
lope can be achieved using distraction osteogenesis.
Fig. 50.11 Olympic Stadium, Munich (by architect Frei Otto), as an example of sectorial architectonic shoring. (2014 M(e)ister Eiskalt—Pic­
ture used under Creative Commons License.)

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
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ization of the mimic muscles and tightening of the mus­
cles of the floor of the mouth and pharynx produces the
effect.37,38
In contrast to studies on apnea therapy and the mas­
ticatory system,33 there are very few publications on the
changes in the musculoskeletal balance resulting from the
crosstalk between the bone and the mimic muscles. Our own
constant observations are now being cephalometrically and
optoelectronically recorded and analyzed.6
The rearrangement and dynamization of the facial en­
velope usually occur after a latent period of 12 to 16 weeks
during which the mimic muscles regenerate, triggered
by the resultant increase in the exercise to the muscles
(Fig. 50.12).
A similar process occurs in the deeper tissue struc­
tures in the skull and can therefore be used in sleep apnea
therapy as well. In this context, a combination of dynam­
a
b
c
d
Fig. 50.12 A 25-year-old patient before and after distraction osteogenesis of the mandible. (a,b) Although the retaining ligaments were
already in their new position at the end of the mandibular advancement, and although regular frontal occlusion was achieved, the typical
“chubby cheek” appearance persisted, though it was reduced, for some weeks. (c,d) The newly achieved musculoskeletal balance resulted
in the loss of the “chubby cheek” appearance and flattening of the nasolabial and mentolabial folds by regeneration and dynamization of
the mimic muscles because of the bone–muscle crosstalk. As a result of the high bone-remodeling activity in the area of distraction, ac­
celerated orthodontic treatment was possible, in a short time of 14 to 16 weeks.

925
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
Concept Surgery for Facial Restoration
In the case of loss or aplasia of facial parts, facial disfigure­
ment increases in parallel with the extent of the maxillofa­
cial deficiency or defect. In such cases, only like-with-like
reconstruction combined with skeletal rearrangement can
restore the anatomic form. To ensure complete restoration,
aesthetics and function must be considered as an insepa­
rable unit.
Distraction in Complex Protocols
Patients with cleft lip and palate syndromes require both
surgical restoration of the maxillary arch and skeletal rear­
rangement to cope with the facial disfigurement. Therefore
regenerative surgical methods like distraction osteogenesis
need to be included in the treatment protocol for bilateral
clefts (see the next section).
Blood flow to
jugular vein
Facial artery
Facial vein
2a
2b
1
a
b
c
d
Fig. 50.13 Tertiary bilateral osteoplasty in a 17-year-old boy after several unsuccessful operations elsewhere. (a) Microsurgical transfer of a
prefabricated scapular flap to reconstruct the frontal nasomaxillary defect combined with orthognathic surgery that included expansion of
the highly compressed maxilla by distraction osteogenesis (1) and correction of mandibular prognathism by orthognathic surgery, which
involved submarginal mandibular osteotomy (2a) and subapical horizontal osteotomy (2b). (b) Osseomucosal scapular graft immediately
before microvascular anastomosis. (c) Plaster model illustrating the highly compressed dental arch with a circular cross-bite before treatment
and (d) the reconstructed model with regular occlusion with an implant after dental restoration. (b–d From Holle J, Vinzenz K, Würinger E,
Kulenkampff KJ, Saidi M. The prefabricated combined scapula flap for bony and soft-tissue reconstruction in maxillofacial defects—a new
method. Plast Reconstr Surg 1996;98(3):542–552.)

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
926
1. Reconstruction of the nasomaxillary complex with a
prefabricated composite graft from the scapula
2. Conventional orthognathic surgery to improve the
facial profile
3. Distraction osteogenesis in the transverse dimension to
rearrange the maxillary arch
Restorative Surgery in Cleft Patients
Three surgical methods were combined in an advanced
surgical concept to rehabilitate a 17-year-old patient with
bilateral cleft lip and palate syndrome after several un­
successful surgical attempts at rehabilitation elsewhere6
(Fig. 50.14):
a
b
c
d
e
f
Fig. 50.14 The same patient before (a–c) and after (d–f) surgery with cephalometric analysis. The entire nasomaxillary complex was re­
constructed to treat severe midface deficiency. The piriform region was restored with an implant-bearing alveolus in combination with re­
arrangement of the facial proportions. (From Holle J, Vinzenz K, Würinger E, Kulenkampff KJ, Saidi M. The prefabricated combined scapula
flap for bony and soft-tissue reconstruction in maxillofacial defects—a new method. Plast Reconstr Surg 1996;98(3):542 -552.)

927
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
Restorative Surgery in the Aging Face
Dermatocosmetic surgery fails to accomplish facial rejuve­
nation in patients with skeletal aging.
Quite understandably, dermatocosmetic treatment
alone caused an unfavorable result in a patient with acceler­
ated skeletal aging resulting from unsuccessful surgical and
prosthetic treatments for severe periodontal disease for 30
years (Fig. 50.16a,c).
In the literature, there are few case reports on the reha­
bilitation of patients treated with combined cosmetic and
reconstructive surgery. These reports advise the surgeon
about what is feasible and reveal the current state of patient
selection in cosmetic surgery: Patients with difficult to treat
conditions are currently not eligible for cosmetic surgery.
The correction of the skeletal framework is garnering in­
creasing research attention and becoming the new frontier
in facial rejuvenation.
Both the facial aesthetics and oral function were re­
stored by this comprehensive surgical protocol6 (see Fig.
50.13a). The reconstruction of the anterior maxilla and the
hard palate was achieved using the osseomucosal scapular
graft6 (see Fig. 50.13b), which was integrated with the rear­
ranged skeletal architecture. The surgical result in this pa­
tient was stable, even after 15 years6 (see Figs. 50.13d–f).
The aesthetic and functional reconstruction of the
piriform nasal aperture together with three-dimensional
skeletal rearrangement is a prerequisite for the success­
ful correction of the nose in patients with cleft lip and
palate syndrome. This is because the nasomaxillary ana­
tomic shape correlates very closely with a symmetrical
maxillary arch, as demonstrated in a cleft patient with an
unfavorable aesthetic outcome after septorhinoplasty with­
out correcting the three-dimensional facial proportions
(Fig. 50.15).
a
b
c
d
Fig. 50.15 A 20-year-old patient with cleft lip and palate syndrome on the right side after multiple attempts to correct the profile solely by
nose correction. An aesthetic restoration of the nose in a patient with a cleft lip and palate syndrome requires reconstruction of the piriform
region and the corresponding maxillary arch as well as three-dimensional skeletal rearrangement of the entire midface.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
928
During the aging process, areas with a strong predis­
position to resorption, including the midface skeleton and
particularly the piriform nasal apertures, alveolus, and in­
ferolateral portion of the orbital rim, atrophy in a specific
and predictable manner and contribute to the stigmata of
the aging face.41
To achieve complete rehabilitation, the current ran­
domly drawn borders between aesthetic and reconstructive
plastic surgery, which broadly disregard medical diagnoses,
need to be adjusted.
A surgical procedure similar to the surgical protocol de­
scribed in the treatment of patients with cleft lip and palate
During aging, characteristic changes occur in the skin,
soft tissue envelope, and bony skeleton of the face, which
result in the “aging face syndrome.” An understanding of the
relevant biomechanical and histologic changes is a prerequi­
site for developing an appropriate treatment plan.39
Traditionally, soft tissue lifting and redraping have
constituted the cornerstone of most facial rejuvenation
procedures.40 Unfortunately, age-related changes in the
facial skeleton and their effect on facial appearance have
not been well appreciated, because sculptural manipu­
lation of the facial soft tissues is successful in midface
rejuvenation.39,41
a
b
c
d
Fig. 50.16 A 68-year-old woman with severe aging underwent several unsuccessful attempts at oral surgery that accelerated the aging pro­
cess and resulted in a haggard appearance after resorption of the midface skeleton, especially the piriform region of the nose, and severe
atrophy of the mandible, which had to be treated because of a high risk of fracture.

929
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
a superficial SMAS lift can be used as a cosmetic surgical
procedure, as described by Ullmann and Levy.42
As illustrated in Fig. 50.17, the reconstruction of the al­
veolus was accomplished using a prefabricated iliac graft15
together with midface advancement by distraction osteo­
genesis and eye surgery to prevent any further necessity of
glasses (Fig. 50.16b,d).
Conclusion
Established surgical methods in reconstructive maxil­
lofacial surgery do not have any obligatory concepts and
standards, as seen in previously published case reports.
With the development of prefabricated composite grafts,
on the other hand, concept surgery has become reality and
involves the induction of functional tissue as an essential
part of complex surgical protocols.
The evolution of reconstructive maxillofacial surgical
techniques to avoid or correct unfavorable results described
in this chapter represents the improved higher standard of
restorative surgery, in which aesthetics and function are
considered as an inseparable unit in all cases, regardless of
the indication for surgery.
In this context, aesthetic surgery itself constitutes a part
of reconstructive surgery and is differentiated from cosmetic
facial surgery by the inclusion of functional aspects.
syndrome has been used for the restoration of the aging face.
The physiological anatomy can be restored by osseomucosal
grafts and skeletal rearrangement. In addition, a deep mask
lift can be performed to redrape the facial soft tissues, and
Fig. 50.17 Radiographic examination indicates the surgical proto­
col executed to cope with the unfavorable outcome resulting from
severe mandibular atrophy and facial deformity related to previous
insufficient surgical interventions making prosthetic rehabilitation
impossible: mandibular alveolar reconstruction with an iliac prefabri­
cated composite graft in combination with midface advancement by
distraction osteogenesis. The facial soft tissue envelope was treated
using a mask lift to redrape the facial soft tissues and a superficial
musculoaponeurotic system lift for cosmetic correction.
References
1. Pallett PM, Link S, Lee K. New “golden” ratios for facial
beauty. Vision Res 2010;50(2):149–154
2. Cohen M. Craniofacial surgery: the first 25 years. Where
do we come from? Who are we? Where are we going? J
Craniofac Surg 2014;25(1):14–16
3. Wei FC, Tay SKL. Principles and techniques of microvascu­
lar surgery. In: Neligan PC, ed. Plastic Surgery: Vol 1. 3rd
ed. Elsevier Health Sciences; 2012:587–620
4. Ariyan S. The pectoralis major myocutaneous flap. A ver­
satile flap for reconstruction in the head and neck. Plast
Reconstr Surg 1979;63(1):73–81
5. Zimpfer M. Performance report of the Department of
Anaesthesiology and General Intensive Care, University
of Vienna–General Hospital Vienna (Austria) University
Clinic for Oral and Maxillofacial Surgery, 2001; 139–142
6. Holle J, Vinzenz K, Würinger E, Kulenkampff KJ, Saidi M.
The prefabricated combined scapula flap for bony and
soft-tissue reconstruction in maxillofacial defects—a new
method. Plast Reconstr Surg 1996;98(3):542–552
7. Kuzbari R, Worseg A, Burggasser G, et al. The ex­
ternal oblique muscle free flap. Plast Reconstr Surg
1997;99(5):1338–1345
8. Gerbino G, Zavattero E, Zenga F, Bianchi FA, Garzino-De­
mo P, Berrone S. Primary and secondary reconstruction
of complex craniofacial defects using polyetheretherk­
etone custom-made implants. J Craniomaxillofac Surg
2015;43(8):1356–1363
9. Siemionow MZ, Papay F, Djohan R, et al. First U.S. near-total
human face transplantation: a paradigm shift for massive
complex injuries. Plast Reconstr Surg 2010;125(1):111–122
10. Pomahac B, Pribaz JJ, Bueno EM, et al. Novel surgical tech­
nique for full face transplantation. Plast Reconstr Surg
2012;130(3):549–555
11. Ortiz Monasterio F, Santamaría E, Morales D, Morales C,
Yudovich M, Sanchez Ramos F. Reconstruction of the pre­
maxilla: an option for mutilated bilateral clefts. J Cranio­
fac Surg 2009;20(Suppl 2):1768–1770
12. Vinzenz KG, Holle J, Würinger E, Kulenkampff KJ, Plenk
H Jr. Revascularized composite grafts with inserted im­
plants for reconstructing the maxilla—improved flap
design and flap prefabrication. Br J Oral Maxillofac Surg
1998;36(5):346–352
13. Vinzenz K, Schaudy C. Osteoplastic surgery of the
face—state of the art and future aspects. Eur Surg
2011;43(5):270–283
14. Schaudy C, Vinzenz K. Osteoplastic reconstruction of se­
verely resorbed maxilla by stack plasty: combining sinus

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osteomuscular transplant for reconstruction of distant
defects in the head and neck region: a new method of
transforming two island flaps to one longer island flap. J
Craniomaxillofac Surg 2014;42(8):2056–2063
29. Schlenz I, Korak KJ, Kunstfeld R, Vinzenz K, Plenk H Jr,
Holle J. The dermis-prelaminated scapula flap for re­
constructions of the hard palate and the alveolar ridge:
a clinical and histologic evaluation. Plast Reconstr Surg
2001;108(6):1519–1524, discussion 1525–1526
30. Mason C, Dunnill P. A brief definition of regenerative
medicine. Regen Med 2008;3(1):1–5
31. McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH.
Lengthening the human mandible by gradual distraction.
Plast Reconstr Surg 1992;89(1):1–8, discussion 9–10
32. Bell WH, Guerrero CA, eds. Distraction Osteogenesis of
the Facial Skeleton. Lewiston, NY: BC Decker, 2007
33. Makarov MR, Samchukov ML, Cope JB, Murihead DE. The
effect of gradual traction on skeletal muscles. In: Sam­
chukov ML, Cope JB, Cherkashin AM, eds. Craniofacial
Distraction Osteogenesis. St Louis, MO: Mosby; 2001:75
34. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the
ligamentous attachments in the temple and periorbital
regions. Plast Reconstr Surg 2000;105(4):1475–1490, dis­
cussion 1491–1498
35. Stuzin JM, Baker TJ, Baker TM. Refinements in face lift­
ing: enhanced facial contour using vicryl mesh in­
corporated into SMAS fixation. Plast Reconstr Surg
2000;105(1):290–301
36. Guerrero CA, Bell WH, Gonzalez M, Rojas A. Intraoral
mandibular bone transport—a case report. In: Samchukov
ML, Cope JB, Cherkashin AM, eds. Craniofacial Distraction
Osteogenesis. St Louis, MO: Mosby; 2001:372–375
37. Zinser MJ, Zachow S, Sailer HF. Bimaxillary ‘rotation ad­
vancement’ procedures in patients with obstructive sleep
apnea: a 3-dimensional airway analysis of morphological
changes. Int J Oral Maxillofac Surg 2013;42(5):569–578
38. Maglicca K, Helman JI. Distraction osteogenesis in the
management of obstructive sleep apnoe syndrome. In:
Bell WH, Guerrero CA, eds. Distraction Osteogenesis of
the Facial Skeleton. Lewiston, NY: BC Decker; 2007:431
39. Mendelson B, Wong CH. Changes in the facial skeleton
with aging: implications and clinical applications in facial
rejuvenation. Aesthetic Plast Surg 2012;36(4):753–760
40. Little JW. Volumetric perceptions in midfacial aging with
altered priorities for rejuvenation. Plast Reconstr Surg
2000;105(1):252–266, discussion 286–289
41. Wong CH, Mendelson B. Midcheek lift using facial soft-
tissue spaces of the midcheek. Plast Reconstr Surg
2015;136(6):1155–1165
42. Ullmann Y, Levy Y. Superextended facelift: our experience
with 3,580 patients. Ann Plast Surg 2004;52(1):8–14
augmentation with lateral and vertical onlay bone graft­
ing. Br J Oral Maxillofac Surg 2014;52(7):647–651
15. Vinzenz K, Schaudy C, Würinger E. The iliac prefabri­
cated composite graft for dentoalveolar reconstruc­
tion: a clinical procedure. Int J Oral Maxillofac Implants
2006;21(1):117–123
16. Vinzenz KG, Holle J, Würinger E, Kulenkampff KJ. Prefab­
rication of combined scapula flaps for microsurgical re­
construction in oro-maxillofacial defects: a new method.
J Craniomaxillofac Surg 1996;24(4):214–223
17. Vinzenz K, Holle J, Würinger E. Reconstruction of the
maxilla with prefabricated scapular flaps in noma pa­
tients. Plast Reconstr Surg 2008;121(6):1964–1973
18. Millesi W, Rath T, Millesi-Schobel G, Glaser C. Reconstruc­
tion of the floor of the mouth with a fascial radial fore­
arm flap, prelaminated with autologous mucosa. Int J Oral
Maxillofac Surg 1998;27(2):106–110
19. Neligan PC, ed. Plastic Surgery: Vol 3, 3rd ed. Elsevier
Health Sciences; 2012
20. Marx RE. Clinical application of bone biology to man­
dibular and maxillary reconstruction. Clin Plast Surg
1994;21(3):377–392
21. Kansy K, Mueller AA, Mücke T, et al. Microsurgical recon­
struction of the head and neck region: Current concepts
of maxillofacial surgery units worldwide. J Craniomaxil­
lofac Surg 2015;43(8):1364–1368
22. Schlenz I, Korak KJ, Kunstfeld R, Vinzenz K, Plenk H Jr,
Holle J. The dermis-prelaminated scapula flap for re­
constructions of the hard palate and the alveolar ridge:
a clinical and histologic evaluation. Plast Reconstr Surg
2001;108(6):1519–1524, discussion 1525–1526
23. Kunstfeld R, Petzelbauer P, Wickenhauser G, et al. The
prefabricated scapula flap consists of syngeneic bone,
connective tissue, and a self-assembled epithelial coating.
Plast Reconstr Surg 2001;108(7):1908–1914
24. Rohner D, Jaquiéry C, Kunz C, Bucher P, Maas H, Hammer
B. Maxillofacial reconstruction with prefabricated osse­
ous free flaps: a 3-year experience with 24 patients. Plast
Reconstr Surg 2003;112(3):748–757
25. Holle J, Vinzenz K. Maxillofacial reconstruction with pre­
fabricated osseous free flaps: a 3-year experience with 24
patients. Plast Reconstr Surg 2004;114(2):607–609, au­
thor reply 609–610
26. Warnke PH, Springer ING, Wiltfang J, et al. Growth and
transplantation of a custom vascularised bone graft in a
man. Lancet 2004;364(9436):766–770
27. Nkenke E, Eitner S. Complex hemimaxillary rehabili­
tation with a prefabricated fibula flap and cast-based
vacuum-formed surgical template. J Prosthet Dent
2014;111(6):521–524
28. Kärcher H, Feichtinger M. Transformation of a vas­
cularised iliac crest or scapula bone to a pedicled

931
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
Discussion by J. Rodrigo Diaz-Siso and Eduardo D. Rodriguez
The reconstruction of complex maxillofacial defects
is a formidable challenge for novice and experienced
surgeons alike. Historically, advances in the repair of
the craniofacial skeleton have arrived separately and
in parallel to the development of techniques used to
rearrange and replace facial soft tissues. Whereas the
structural pillars of the craniofacial skeleton were de­
fined and successfully applied to the treatment of facial
trauma, flap-based reconstruction consisted of pack­
ing adjacent or distant soft tissues in areas where bone
was also missing. Gradually, skeletal repair and soft
tissue reconstruction have overlapped and resulted in
unprecedented symbiosis. The techniques developed
from this overdue partnership have allowed the im­
portant improvement and maintenance of respiratory,
masticatory, and speech functions in addition to pro­
viding aesthetic restoration of facial contour, projec­
tion, and soft tissue harmony.
The list of available techniques for complex head and
neck reconstruction is nearly endless, and without clear
evidence that any reconstructive option is superior to an­
other, surgeon preference remains the main factor deter­
mining treatment choice for craniofacial defects. However,
reconstructive principles developed over the past century
continue to guide reconstructive efforts. Adherence to
these principles, which allow a degree of surgeon prefer­
ence regarding choice of skeletal repair and microvascular
flap, will help avoid unfavorable results when undertak­
ing the reconstruction of complex craniofacial defects. In
this discussion, we describe these surgical principles1 and
briefly discuss preferred treatment options to optimize
long-term functional and aesthetic outcomes.
Surgical Planning
The importance of detailed planning has been a guid­
ing principle of reconstructive surgery since the spe­
cialty’s inception. To quote Gillies, “The architect would
never dare build without a blueprint—and his bricks
are cheaper than ours!”2 Facial anthropometrics should
be assessed to determine the required steps to achieve
reconstructive goals3,4:
•• Restoration of malar, maxillary, or mandibular
projection
•• Maxillary or mandibular projection
•• Correction of enophthalmos or vertical dystopias by
ensuring proper positioning of the globe
•• Separation of the upper respiratory and alimentary
tracts
•• Creation of a platform for orbital or dental implants
Horizontal facial thirds, vertical fifths, and facial and
dental midlines can be analyzed using digital photog­
raphy of preinjury and preoperative states.5 Dental
impressions and radiological studies like computed
tomography (CT) are also helpful; three-dimensional
reconstructions of the latter can allow a global view of
the current defect’s dimensions and influence on the
patient’s skeletal proportions, along with the location
of fistulas, if applicable. Bite and occlusion analysis is
critical to operative success, and maxillomandibular
relationships must be recorded and modeled to aid the
bending of plates, if applicable.
Computerized surgical planning allows precise
two-dimensional (lateral cephalograms) and three-
dimensional defect analysis and osteotomy design.
The ability to 3D-print custom cutting guides based
on patient-specific CT data yields unprecedented lev­
els of accuracy during the elevation and inset of distant
osseocutaneous free flaps. Furthermore, stereolitho­
graphic models can be created from this data, maintain­
ing the ability to bend plates preoperatively. Although
future computational advances will likely be exponen­
tial, the exact role of virtual surgical planning in cranio­
facial reconstruction is yet to be determined.
Preoperative assessment of commonly used vessels,
like the superficial temporal, facial, and external carotid,
can be performed clinically. In areas of excessive scar
tissue and/or previous surgeries, CT angiography may
be indicated to determine the best possible donor ves­
sel for the incoming flap. Evaluation of the chosen flap
location is also warranted, but angiographic studies are
not routinely performed.5
Critical Concepts of Composite Facial
Reconstruction
Aesthetic Unit
Gonzalez-Ulloa’s detailed study6 of the physical and
physiological characteristics of the skin resulted in the

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
932
division of the face into nine aesthetic units and sub­
units containing distinct skin texture, color, thickness,
and histologic structures:
1. Forehead
6.  Lower lip
2. Nose
7.  Chin
3. Eyelids
8.  Ears
4. Cheeks
9.  Neck
5. Upper lip
Each of these is further subdivided based on subtle
differences in the aforementioned criteria. With this
knowledge, reconstructive strategies for cutaneous fa­
cial defects were developed, consisting of taking skin
grafts from donor sites with the most similar charac­
teristics to the recipient region to ensure the best pos­
sible aesthetic result (Fig. 50D.1).
Decades later, experience in facial trauma re­
construction helped define the structural buttresses
a
b
c
d
Fig. 50D.1 Scleroderma affecting the soft tissues and skeleton of the left face, exemplifying the reconstructive critical concepts
of the aesthetic unit. (a) Defect boundaries and tissue requirements. (b) Soft tissue volume. (c) Secondary revisions. (d) The final
result.

933
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
responsible for the height, width, and projection of the
facial skeleton (Box 50D.1). Thus the importance of the
reconstruction of these structural pillars to the mainte­
nance and recovery of adequate facial proportions was
established.3,7
Box 50D.1
Main Vertical Buttresses of the Upper Face
•• Nasomaxillary
•• Zygomatic
•• Pterygomaxillary
•• Posterior mandibular buttress, the major
vertical pillar of the lower facial third
Principal Horizontal Buttresses
•• The frontal bar/superior orbital rims
•• Inferior orbital rims
•• Maxillary alveolar rim/piriform aperture
•• Mandibular alveolar rim
•• The inferior border of the mandible
Facial Structural
Buttresses
The integration of these methods begets the no­
tion that the aesthetic subunits of the face are not “skin
deep;” they also include subcutaneous tissues and the
underlying bone. Therefore the overall appearance of
each aesthetic unit will ultimately depend on the thick­
ness and texture of the skin, the depth and contour of
the soft tissues and, critically, the skeletal support that
lies underneath (or lack thereof).1 In light of this, the re­
construction of a complex defect with soft tissue alone
will undoubtedly close the wound, but failure to address
the bony deficit will result in inadequate structural sup­
port and suboptimal long-term results.
Defect Boundaries
Among the early reconstructive principles champi­
oned by Gillies2 is the convention that one must retain
“what is normal . . . in its normal position and so de­
fine the defect to be filled.” This belief was a sensible
one; removal of perfectly healthy tissues was not con­
sidered sound surgical judgment given the high re­
constructive failure rates.1 Yet advances in the gamut
of options encompassing the reconstructive ladder
have resulted in much higher success rates, particu­
larly in microsurgery.
This has therefore allowed surgeons to fully em­
brace the aesthetic unit principle, in which some large
defects can be extended to the next unit boundary,
leading to a better result. Thus when a defect involves
60 percent or more of a unit or subunit, the resection
can and should be extended (in thickness and surface
area) to the nearest border.8 This is particularly help­
ful in areas where the surrounding tissues are not
easily advanced or rotated. Indeed, this larger defect
will require a larger flap for adequate wound cover­
age, but the scars will encompass the unit or subunit
borders. Thus a more harmonious aesthetic result is
achieved, because some scars can be somewhat con­
cealed. In addition, the newly reconstructed aesthetic
unit will present uniform skin thickness, texture, and
color throughout.
This principle may not apply to all aesthetic units,
however. Reconstruction of the lips and eyelids has pre­
sented much difficulty, notably in the case of total-lip or
total-eyelid defects. Autologous reconstructive solutions
of these specialized structures have yet to produce opti­
mal results; a conservative approach may be warranted
in these cases, and maximal preservation of local tissues
is encouraged.
Tissue Requirements
The choice of autologous tissue donor site (or multiple
donor sites) for craniofacial reconstruction should be
determined by each defect’s skin color and thickness,
volume deficiency, and specific composite tissue re­
quirements. Early lessons in facial reconstruction em­
phasized the need for adequate lining, support, and
coverage of the renovated structure,2 and each of these
components, when applicable, should be included in
the reconstructive strategy.
The requirement for mucosal lining, be it conjunc­
tiva, nasal, sinus, or oral mucosa, should not be under­
appreciated, because inadequate reconstruction of the
lining may result in fibrosis, contracture, or chronic in­
fection.1 Although skin provides functional lining for the
reconstructed nose, muscle or fascia is the preferred tis­
sue to cover all intraoral bone because of its ability to
mucosalize over time.9 If there is no exposed intraoral
bone, skin can be used to line the inner surface of the
cheek, because contracture is minimal.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
934
Bone and Soft Tissue Support
Another seminal reconstructive principle is that losses
must be replaced in kind.2 Again, when bone and soft
tissue are missing, reconstruction with soft tissues
alone is insufficient, regardless of how bulky the cho­
sen flap may be. With this in mind, replacement of
the skeletal buttresses is fundamental to a successful
result. Not only should the reconstructed bone restore
facial dimensions and proportions, it should also pro­
vide a solid foundation for osseointegrated implant-
based dental prostheses.3 Nonvascularized bone grafts,
although useful to manage small bone defects in the
presence of adequately perfused soft tissues, undergo
unpredictable degrees of resorption. Hence, composite
vascularized bone flaps are the preferred method of
skeletal buttress restoration. For periorbital, maxillary,
and mandibular reconstruction, the fibula and iliac
crest can be ideal donor sites; each flap has advantages
and limitations.
The fibula’s considerable length allows the procure­
ment of up to 26 cm of vascularized bone strong enough
to withstand osseointegrated orbital or dental implants
and the subsequent forces applied during mastication.
Moreover, multiple, predictable osteotomies can be
performed to tailor the incoming flap to a variety of
craniofacial defects, often replacing several missing but­
tresses at once. In addition to a predictably long vascular
pedicle that can reach the neck vessels, the fibula can
be inset with a large skin paddle or as a chimeric flap
including the soleus muscle. Depending on the vertical
dimensions of the maxillary or mandibular defect, the
fibula may not offer sufficient height, resulting in inad­
equate support.
The free iliac crest flap offers ample height for dental
implants and cheek projection and is also strong enough
to withstand masticatory effort. The internal oblique
muscle can be included for mucosal lining, and the iliac
crest flap’s variable orientation adds to its versatility. Its
accompanying vascular pedicle, although predictable,
can easily reach the facial vessels; however, should these
vessels be inadequate, vein grafts may be necessary to
comfortably reach the cervical vasculature. Moreover,
the subcutaneous layer may be considerably thick in
Western populations.
The free fibular and iliac crest flaps have compara­
ble morbidity,10 and both can be harvested using a two-
team approach, because the patient remains supine. The
scapular flap is another possible flap choice for maxil­
lary reconstruction; however, the need to reposition the
patient to access the scapula precludes a two-team ap­
proach, increasing operative time. Other limitations of
the free scapular flap include limited bone stock and a
short vascular pedicle.
Soft Tissue Volume
The initial choice of flap for the reconstruction of com­
plex craniofacial defects must provide adequate soft
tissue shape, with proper consistency and abundant
volume, in slight excess. The secondary debulking of
excess soft tissue is simpler and more predictable than
subsequent increases in flap volume to obtain adequate
contour. Vascularized fat should be included to mini­
mize the likelihood of resorption or fat necrosis. This
will ensure stable coverage for the underlying bone, in
addition to satisfactory long-term aesthetic outcomes.
Flap selection is determined by the approximation
of flap characteristics to the tissues comprising the de­
fect’s aesthetic unit. The ulnar forearm flap yields a thin
soft tissue envelope with relatively hairless skin and a
long vascular pedicle, making it the preferred option for
the reconstruction of forehead and periorbital defects
with adequate underlying skeletal support.9 The ulnar
forearm flap also provides sufficient coverage for lip re­
construction without the microstomia that may result
from local flap rearrangement; the radial forearm flap is
also useful for lip reconstruction, and when innervated,
it may result in a more functional reconstruction. For
soft tissue cheek defects, the lateral circumflex femo­
ral artery flap is an excellent option because of its long
vascular pedicle and ample soft tissue that, though often
bulky, can be secondarily trimmed for contour. Scapular
and parascapular flaps are also viable options in patients
with darker skin and less noticeable color variations.
Timing
Acute reconstruction of a facial defect will limit fi­
brosis and contracture by merging the original injury
and the reparative surgical injury into a single period
of wound healing.1 In facial trauma, early fracture re­
pair will support the natural repositioning of the soft
tissue envelope.11 Similarly, when faced with missing
skeletal structures, early reconstruction of the facial
buttresses with vascularized bone flaps will provide
adequate support for local tissues and for transferred
myocutaneous or fasciocutaneous flaps, which in turn
prevents excessive contracture, scarring, and bone mis­
alignment or resorption5 (Fig. 50D.2).

935
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
a
b
c
d
e
Fig. 50D.2 (a) Osteonecrosis of the body of the left mandible, exemplifying the reconstructive critical concepts of the aesthetic
unit. (b) Tissue requirements, bone and soft tissue support, soft tissue volume, and timing. (c) Bone and soft tissue support, soft
tissue volume, and timing. (d) Soft tissue volume and timing. (e) The final result.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
936
Secondary Revisions
Early reconstruction is not equal to single-stage re­
construction. Complex and extensive craniofacial
defects often require multiple surgical stages and sec­
ondary revisions, which should be a part of the initial
reconstructive plan. This requires adept recognition
and preservation of the available local tissues for ad­
vancement in later stages. Once skeletal and soft tis­
sue support are achieved, efforts are directed toward
replacing the cutaneous components of the transferred
free flap with local skin, providing uniform skin color,
thickness, and contour.1 This can be achieved through
dermabrasion, local rearrangement, or direct excision
of originally distant skin with subsequent full-thick­
ness skin grafts from areas with more desirable skin
characteristics, like the postauricular or supraclavicu­
lar regions. Revision procedures may also include suc­
tion lipectomy or debulking of subcutaneous tissues.
Secondary revisions are key to obtaining superior re­
sults in craniofacial reconstruction; understanding the
range of available techniques allows the surgeon to
create a detailed plan that initially takes full advantage
of free tissue transfer and later offsets its limitations
(Figs. 50D.3 and 50D.4).
a
b
c
d
Fig. 50D.3 Application of the reconstructive critical concepts to total face, double jaw, and tongue transplantation. (a,b) Preop­
erative. (c,d) At postoperative day 510.

937
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
Face Transplantation: Ultimate
Application of the Same Principles
Severe craniofacial defects that are considerably exten­
sive or include the total aesthetic units of the central
face (eyelids, nose, upper and lower lips) may prove
nonreconstructible using conventional autologous
techniques. For these rare and unique cases, face trans­
plantation has become a feasible reconstructive option,
resulting in excellent functional and aesthetic out­
comes and manageable complications.12 Furthermore,
it has proven to be effective for defects resulting from a
range of mechanisms of injury, including burns, animal
attacks, benign tumors, and ballistic trauma.13 How­
ever, the requirement of lifelong immunosuppression
has limited the applicability of allotransplantation to
craniofacial defects resulting from the resection of ma­
lignant tumors. The inherent risks of cancer recurrence
and de novo malignancy, as highlighted by isolated
cases,12 offset the potential reconstructive benefits.
Nevertheless, face transplantation may be the ultimate
representation of the reconstructive principles dis­
cussed previously.
Surgical Planning
Perhaps because of face transplantation’s new and
(currently) experimental nature, extensive surgical
planning has been a staple of the procedure. In addition
to extensive skeletal and vascular imaging studies, ca­
daver dissections have been performed in preparation
for surgery.14 Furthermore, institutional review board
protocols currently require that a backup plan consist­
ing of autologous reconstructive techniques must be in
place as a contingency should the recipient develop al­
lograft failure. Virtual surgical planning has also been
used to guide osteotomies during procurement and in­
set of bone-containing facial allografts.
Aesthetic Units
At least 17 transplanted facial allografts have included
a bony component, most commonly the maxilla or
mandible.12 This accentuates the understanding that,
when presented with complex skeletal and soft tissue
defects, the transplant-surgical plan aims to restore
normal anatomy to the highest possible degree. The
superior aesthetic result is a result of the replacement
of aesthetic units of the facial skin in combination with
the underlying skeletal structures providing support.
Defect Boundaries
There is considerable debate surrounding the facial
aesthetic unit principle in the setting of transplanta­
tion. Healthy tissues are precious in patients with such
a
b
Fig. 50D.4 Application of the reconstructive critical concepts to total face, scalp, ear, eyelid, and skeletal subunit transplantation.
(a) Preoperative. (b) At postoperative day 70.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
938
severe facial defects, and should allograft failure occur,
the transplant team has an ethical obligation to return
the patient to his or her pretransplant state of func­
tion and appearance, if not better. Thus if the defect is
restricted to the central face, the replacement of the
affected aesthetic units alone via partial face transplan­
tation should provide adequate functional and aes­
thetic results. If a patient’s defect involves 60 percent
of every single facial aesthetic unit, it is likely that the
severe functional and aesthetic deficits merit full-face
transplantation. In these cases, the principle applies:
each unit’s normal tissue, comprising less than 40%, is
removed along with the damaged tissue majority, and
these are subsequently replaced with a complete and
healthy unit that is part of a full-face allograft.
In other words, although the entire face can be con­
sidered a unit, it is important to keep in mind that the
principle applies to individual facial units and subunits,
and removing an entire healthy unit to obtain superior
aesthetic results with a full-face allograft severely re­
duces the surgical team’s chances to restore the patient’s
pretransplant state if allograft resection is ever required.
Tissue Requirements, Bone and Soft
Tissue Support, and Soft Tissue Volume
The principles of tissue requirements, bone and soft
tissue support, and soft tissue volume remain as fun­
damental to obtaining favorable results in face trans­
plantation as they are in autologous reconstruction.
However, these principles focus on the necessary com­
ponents to be reconstructed and the thought process
of free flap selection from several applicable options.
In the setting of face transplantation, flap selection is
a moot point: the goal is to replace missing structures
with identical ones procured from a healthy donor.
Nonetheless, there are important parameters to con­
sider when selecting the donor, which have a strong
influence on the quality of the result; immunologic
parameters aside, the skin color and texture match are
key, as are anthropometric and cephalometric relation­
ships. Soft tissues, whenever possible, are transplanted
in slight excess during transplantation in the form of
excess neck skin or scalp; debulking or contouring
these redundant tissues at a later date is considerably
simpler than autologous reconstruction.
Timing
Only one face transplant has been performed sub­
acutely, without having first attempted to reconstruct
the defect using autologous techniques.12 Although fur­
ther study and longer follow-up are necessary to deter­
mine the best possible timing for face transplantation,
the logistical difficulties of donor-recipient matching
make early transplantation (immediately after injury or
creation of the defect) very unlikely. This is particularly
relevant given the overwhelming donor shortage most
nations currently face. For this reason, at present, early
conventional reconstruction remains indicated regard­
less of whether the defect may require transplantation
at a future time-point. However, transplantation is per­
formed immediately after the surgical re-creation of
the facial defect on the recipient, thus reducing the risk
of excessive scarring and contracture and promoting an
anatomic restoration of the facial structures.
Secondary Revisions
Because of the previously described donor shortage, it
is not always possible to match a recipient with a do­
nor of similar age, dimensions, and skin texture and
color; “donor selectivity” takes a back seat to “donor
suitability.” Hence, these differences in cephalometric
and anthropometric criteria may result in the need for
secondary revisions. The entire arsenal of plastic sur­
gery techniques and aesthetic surgical procedures is
available to the reconstructive surgeon for the new goal
of enhancing the aesthetic result of a face transplant
recipient.15
Transplantation is not without surgical complica­
tions, and revisions have played and will play a role in
overcoming some expected and unexpected hurdles
when performing this novel procedure. In a patient who
developed class III malocclusion over the first 6 months
posttransplantation, a Le Fort III osteotomy was per­
formed after conservative orthodontic treatment failed
to restore normal occlusion.15 It is important to note that
these revision surgeries should also adhere to the prin­
ciples described here to ensure success and avoid unfa­
vorable results.
Conclusion
The reconstruction of complex craniofacial defects
cannot follow a generalized formula or series of in­
structions, because patient presentations widely vary.
Rather, despite—or precisely because of—the unique­
ness of each individual case, the surgical approach
should be guided by time-tested and data-driven re­
constructive principles. There are endless surgical
techniques currently available to the reconstructive
surgeon to apply these concepts, and to an extent, sur­
geon preference will ultimately guide the details of
each surgical plan. However, these principles form the
basis of sound reconstructive decision-making and set
the stage not only for the avoidance of the unfavorable
result, but the achievement of superior outcomes.

939
Chapter 50 Complex Soft Tissue and Bony Maxillofacial Reconstruction
References
1. Fisher M, Dorafshar A, Bojovic B, Manson PN, Rodri­
guez ED. The evolution of critical concepts in aes­
thetic craniofacial microsurgical reconstruction. Plast
Reconstr Surg 2012;130(2):389–398
2. Gillies HD, Millard DR. The Principles and Art of Plas­
tic Surgery. Boston: Little; 1957
3. Rodriguez ED, Bluebond-Langner R, Park JE, Manson
PN. Preservation of contour in periorbital and midfa­
cial craniofacial microsurgery: reconstruction of the
soft-tissue elements and skeletal buttresses. Plast
Reconstr Surg 2008;121(5):1738–1747, discussion
1748–1749
4. Bak M, Jacobson AS, Buchbinder D, Urken ML. Con­
temporary reconstruction of the mandible. Oral On­
col 2010;46(2):71–76
5. Rodriguez ED, Martin M, Bluebond-Langner R, Khal­
ifeh M, Singh N, Manson PN. Microsurgical recon­
struction of posttraumatic high-energy maxillary
defects: establishing the effectiveness of early re­
construction. Plast Reconstr Surg 2007; 120(7, Suppl
2)103S–117S
6. Gonzalez-Ulloa M. Restoration of the face covering by
means of selected skin in regional aesthetic units. Br J
Plast Surg 1956;9(3):212–221
7. Manson PN, Hoopes JE, Su CT. Structural pillars of the
facial skeleton: an approach to the management of Le
Fort fractures. Plast Reconstr Surg 1980;66(1):54–62
8. Muresan C, Hui-Chou HG, Dorafshar AH, Manson PN,
Rodriguez ED. Forehead reconstruction with micro­
vascular flaps: utility of aesthetic subunits. J Reconstr
Microsurg 2012;28(5):319–326
9. Broyles JM, Abt NB, Shridharani SM, Bojovic B,
Rodriguez ED, Dorafshar AH. The fusion of cranio­
facial reconstruction and microsurgery: a func­
tional and aesthetic approach. Plast Reconstr Surg
2014;134(4):760–769
10. Rogers SN, Lakshmiah SR, Narayan B, et al. A compari­
son of the long-term morbidity following deep cir­
cumflex iliac and fibula free flaps for reconstruction
following head and neck cancer. Plast Reconstr Surg
2003;112(6):1517–1525, discussion 1526–1527
11. Robertson BC, Manson PN. High-energy ballistic and
avulsive injuries. A management protocol for the next
millennium. Surg Clin North Am 1999;79(6):1489–
1502, xi
12. Khalifian S, Brazio PS, Mohan R, et al. Fa­
cial transplantation: the first 9 years. Lancet
2014;384(9960):2153–2163
13. Dorafshar AH, Bojovic B, Christy MR, et al. To­
tal face, double jaw, and tongue transplanta­
tion: an evolutionary concept. Plast Reconstr Surg
2013;131(2):241–251
14. Brown EN, Dorafshar AH, Bojovic B, et al. Total face,
double jaw, and tongue transplant simulation: a ca­
daveric study using computer-assisted techniques.
Plast Reconstr Surg 2012;130(4):815–823
15. Mohan R, Fisher M, Dorafshar A, et al. Principles of
face transplant revision: beyond primary repair. Plast
Reconstr Surg 2014;134(6):1295–1304

(Trang không có chữ)

S E C T I O N V I I
Reconstructive Surgery
for the Head and
Neck, Body, and Lower
Extremity

Statue of a fighting Gaul. From Agora of Italians in Delos, Greece. c. 100 BC.
(National Archaeological Museum, Athens, Greece. © Hellenic Ministry of Culture and Sports/Archeological Receipts Fund.
Photo: Yiannis Patrikianos.)

943

Oral and Pharyngeal Reconstruction
Peirong Yu
The oral cavity consists of the following structures: the lips,
buccal mucosa, mandibular and maxillary alveolar ridge,
retromolar trigone, hard palate, floor of the mouth, and an­
terior (oral or mobile) tongue. The pharynx is anatomically
divided into the oropharynx, nasopharynx, and hypophar­
ynx. The oropharynx is bounded by the nasopharynx supe­
riorly, the oral cavity anteriorly, and the hypopharynx and
larynx inferiorly. The main structures in the oropharynx
are the base of tongue, tonsillar pillars, lateral and poste­
rior oropharyngeal walls, and soft palate. The hypopharynx
extends from the level of the hyoid bone to the lower bor­
der of the cricoid cartilage, which is congruous with the
cervical esophagus below. This is a critical area that is re­
sponsible for airway protection and swallowing and speech
functions.
Common malignancies in the oral and pharyngeal re­
gions include those of the lip, buccal area, floor of mouth,
tongue, tonsils, hypopharynx, and larynx. The treatment of
these lesions often results in surgical defects that can sig­
nificantly affect the appearance and function of these vital
structures. Providing basic tissue coverage for these defects
without considering the functional and aesthetic outcomes
is no longer acceptable in modern-day practice. Unfavor­
able outcomes are common in these complex reconstruc­
tions. Proper reconstruction of such defects may prevent
life-threatening complications, restore essential functions
such as swallowing and speech, and improve patients’ qual­
ity of life and self-image.
Avoiding Unfavorable Results
and Complications in Oral and
Pharyngeal Reconstruction
Preoperative Planning
Medical Evaluation
Major head and neck surgery and free flap reconstruction
pose significant perioperative risks for patients. Medi­
cal complications, not surgical complications, have been
proven responsible for slow recovery, prolonged hospital
stay, and poor outcomes.1 A thorough medical evaluation
and consultation to the medical services before surgery are
often required. Many head and neck cancer patients have a
long history of tobacco and alcohol abuse. Pulmonary func­
tion should be evaluated in those with chronic obstructive
pulmonary disease, and cardiovascular workup should
be performed as indicated. Preoperative optimization of
heart and lung functions is essential to reduce periopera­
tive mobility and mortality. A history of peripheral vascu­
lar disease and carotid artery disease has a great impact
on the flap selection, recipient vessel selection, and risks
for perioperative cerebrovascular accidents. Carotid artery
diseases can also be identified on head and neck CT images,
which may demonstrate calcification and stenosis. Vascular
specialists should be consulted when significant peripheral
CHAPTER
51

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
944
Common donor sites such as the forearm, anterolateral
thigh (ALT), abdomen, and anterior chest should be eval­
uated for skin quality and thickness, history of surgery or
trauma, and vascular disease. Hand dominance should also
be documented. A bracelet with the words “NO IV” is placed
on the potential donor site arm, typically the one with the
nondominant hand.
Surgical Goals and Intraoperative
Considerations for Specific Defects
Floor-of-Mouth Defects
Defects in the floor of mouth may vary from a small mu­
cosal defect to a large defect involving the musculature
with exposed bone. The latter often require postoperative
radiotherapy, which significantly influences the methods of
reconstruction. Isolated floor-of-mouth defects that do not
include the suprahyoid musculature may be skin grafted or
reconstructed with a facial artery musculomucosal (FAMM)
flap.2,3 However, ligating and dividing the facial artery is
common practice during a neck dissection. Therefore re­
construction using the FAMM flap may not be possible for
patients who have had a neck dissection.
When the floor-of-mouth defect extends to the up­
per neck, with resection of part of the suprahyoid muscu­
lature and exposure of the mandible, more extensive flap
vascular diseases and carotid stenosis are present. Diabetes
is also prevalent in this patient population and increases
the risk of surgical site infection. Proper glucose control is
essential.
Flap Choices
Choice of flaps is extremely important for oral and pharyn­
geal reconstruction. Specific defects require several consid­
erations:
•• Specific flaps with appropriate thickness
•• Pedicle length
•• Ability to carry both skin and muscle
•• Possibility of two skin islands
•• Skin color match
•• Donor site morbidity
The thickness of the flap affects not only postoperative
function, but aesthetic outcomes as well. The paucity of
recipient vessels may demand a flap with a long vascular
pedicle to obviate vein grafting in an already-complex set­
ting. Therefore, depending on the defects, surgical goals,
and availability of recipient vessels, the choice of flap
should be carefully evaluated in the preoperative planning
session. The patient and family should be made fully aware
of potential functional deficits, including the possibility of
long-term tube feeding and tracheostomy dependency.
Summary Box
Complications After Glossectomy and Pharyngoesophageal Reconstruction
Complication
Partial
glossectomy
(%)
Total
glossectomy
(%)
Pharyngoesophageal
reconstruction
(%)
Neck wound infection
9
11
4
Leak or fistula
7
10
9
Stricture
—
—
6
Dehiscence or delayed healing
6
7
3
Neck hematoma
2
5
3
Partial flap necrosis
2
5
1
Vessel thrombosis
3
4
3
Flap loss
1
1
2
Cardiopulmonary
8
10
9
Stroke
1
1
1
Ischemic bowel
0
0
2

945
Chapter 51 Oral and Pharyngeal Reconstruction
sulcus, causing drooling, oral incompetence, and inability to
eat and drink. Therefore the flap edge should be sutured to
the labial tissue at the base of the labial sulcus. The remain­
ing labial mucosal defect can be left to remucosalize or can
be skin grafted. The remucosalization process takes approxi­
mately 1 week. The same principle applies to mandibular
reconstruction with a fibular osteocutaneous flap when the
labial mucosa defect extends to the vermilion (Fig. 51.4).
Floor-of-mouth defects commonly involve the ventral
tongue. A common practice is to close the tongue to itself by
folding the lateral edges of the tongue ventrally and to re­
construct the floor of the mouth with a flap. This technique
creates a small “snake tongue” (see Fig. 51.3a) that often
causes impairment of speech and swallowing functions. A
better approach is to resurface the ventral tongue and the
floor of the mouth simultaneously with a thin forearm flap
(Fig. 51.5) to preserve the bulk and mobility of the tongue.
Partial or Hemiglossectomy Defects
The tongue is a highly functional organ. A common problem
after partial tongue reconstruction is the tethering of the
remaining tongue, limiting tongue mobility and function.
The most important goal for partial or hemiglossectomy
reconstruction is, therefore, to preserve the remaining
tongue function. Small defects of up to one quarter or even
one third of the tongue, with minimal resection of the floor
reconstruction is indicated. In high-risk patients, the pec­
toralis major flap is a viable option to fill the dead space in
the floor of the mouth and upper neck. In young and more
functional patients, however, a free flap is preferred to mini­
mize neck deformity and maximize function.
The common problems after this type of reconstruc­
tion may include a bulky flap that limits tongue mobility
and function or inadequate filling of dead space causing
infection, fistula, and subsequent bone exposure that may
delay adjuvant therapy and cause osteoradionecrosis. The
goals are to effectively obliterate the dead space and pro­
tect the mandible from postoperative radiotherapy with­
out unwanted bulk that may impede tongue mobility and
oral function. A radial forearm flap or ulnar artery perforator
(UAP) flap is ideal because they provide a thin and supple
lining (Fig. 51.1). A thin ALT flap can also be used to recon­
struct the floor of the mouth, with a segment of the vastus
lateralis muscle used to fill the dead space (Fig. 51.2). This
flap is particularly useful for large defects involving the en­
tire suprahyoid musculature, especially after previous radia­
tion. A shallow floor-of-mouth defect should not be covered
with a bulky flap, because it may restrict tongue mobility
and obliterate the lingual sulcus, causing drooling (Fig. 51.3).
When the resection involves the mandibular gingiva and
labial mucosa up to the vermilion border, a common mistake
is to suture the flap all the way to the vermilion. This will
push the lip downward and completely obliterate the labial
Fig. 51.3 (a) A bulky flap in the floor of mouth can interfere with tongue and lip function. (b) Flap thinning is possible with suction-assisted
lipectomy and direct excision at the end of debulking. (c) One year later.
a
b
c
Fig. 51.1 A forearm flap can provide a thin and pliable skin for floor-
of-mouth reconstruction that allows full mobility of the tongue.
Fig. 51.2 When there is a large soft tissue defect in the floor of
mouth, an anterolateral thigh flap with a segment of vastus lateralis
muscle can provide reliable coverage and dead space filling.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
946
other corner to the gingiva. The rest of the flap is sutured to
the dorsal tongue medially and gingiva laterally. Such inset­
ting re-creates a nice ventral sulcus and lateral gutter (Fig.
51.9). When there is no gingiva left to attach the flap to, it
can be sewn to the teeth by tying the suture knots around
the teeth. A single layer of interrupted 3–0 Vicryl sutures
usually suffices, although some surgeons prefer horizon­
tal mattress sutures. It is important, however, not to tie the
of the mouth and no communication to the neck, may be
closed primarily or with a skin graft (Fig. 51.6). Resection
of the floor of the mouth combined with a neck dissection
creates a connection between the oral cavity and the neck
along the lingual cortex of the mandible. These defects are
best reconstructed with a flap to eliminate the dead space,
minimizing the risk of infection and fistula formation. The
remaining tongue has the ability to move intelligibly as
long as it is not tethered. A bulky flap will push the remain­
ing tongue to the side and obstruct its mobility. Therefore
a thin and pliable flap should be chosen. The radial forearm
flap or UAP flap is usually the first choice. Some adipose
tissue in the upper forearm may be included to obliterate
the submandibular dead space (Fig. 51.7). A thin ALT flap
with a strip of the vastus lateralis muscle can be a good
option as well.
To avoid tethering of the remaining tongue, careful flap
insetting is important. The length of the ventral tongue, de­
fined as the distance from the tip of tongue to its junction
with the floor of mouth and gingiva, is approximately 5 to
6 cm. The distal end of the flap is oriented toward the tip of
the remaining tongue. The distal flap width, usually 6 cm,
matches the ventral tongue length (Fig. 51.8). Thus one cor­
ner of the distal flap is sutured to the tip of tongue, and the
Fig. 51.4 (a) When resection of labial mucosa approaches the vermilion border, suturing the flap to the mucosal margin may obliterate the
labial sulcus and push the lower lip down, causing drooling. (b) A better approach is to inset the flap to the bottom of the labial sulcus and
leave the raw surface on the lip to remucosalize. This will preserve the labial sulcus and prevent drooling.
a
b
Fig. 51.5 (a) After resection of the ventral tongue, closure of the remaining mobile tongue to itself may result in a “snake tongue,” with
significant volume loss. (b) An alternative approach to reconstructing the ventral tongue defect is to use a thin forearm flap, part of which
is also used to reconstruct the floor of the mouth.
a
b
Fig. 51.6 For partial tongue defects without bone exposure or com­
munication to the neck, full-thickness skin grafts can provide excel­
lent coverage with preservation of tongue mobility.

947
Chapter 51 Oral and Pharyngeal Reconstruction
Total or Subtotal Glossectomy Defects
Unlike hemiglossectomy, a total or subtotal glossectomy
leaves no meaningful tongue muscle. Functional outcomes
are poor, and aspiration can be a serious complication ne­
cessitating a total laryngectomy in some patients. Common
problems after total and subtotal glossectomy reconstruc­
tion include inadequate bulk resulting in a “funnel tongue,”
inadequate vascularized tissue filling resulting in infection
and fistula formation, and risks of aspiration related to re­
section of all floor-of-mouth musculature (Fig. 51.10).
Funnel Tongue
The goal of reconstruction is to create enough bulk for
the neotongue. Tissue bulk is important for reconstruct­
ing large defects of the tongue for two reasons. First, it is
needed to help the neotongue touch the palate to produce
better speech and push food toward the hypopharynx. Sec­
ond, the tissue bulk diverts saliva and food to the lateral
gutters during swallowing to minimize aspiration.10 With
these goals, a bulky flap should be chosen. Some muscle
is also needed to obliterate the dead space in the floor of
mouth and upper neck. This makes the ALT flap the ideal
horizontal mattress sutures too tight, which may lead to
flap–mucosa edge necrosis and fistula formation.
Sensory reinnervation can improve swallowing function
and patient satisfaction. This can be achieved by coapting
the sensory nerve of the flap to the divided lingual nerve.
Sensory recovery of the flap with this technique has been
well documented. The radial forearm flap, UAP flap, ALT flap,
and lateral arm flap can all potentially provide sensory re­
innervation.4–9
Fig. 51.7 (a) Partial glossectomy with neck dissection often leaves a submandibular or upper neck dead space. A conventional radial fore­
arm flap may not have extra tissue to obliterate the dead space. (b,c) A portion of the adipofascial tissue from the upper forearm based on
a proximal perforator can be included in the radial forearm for this purpose.
a
b
c
a
b
Fig. 51.8 For hemiglossectomy reconstruction, the goal is to preserve the remaining tongue mobility without tethering. Adequate ventral
sulcus and lateral gutter should be re-created with a 6 to 7 cm wide flap. The distal width of the radial forearm flap is used to re-create the
ventral sulcus of the mobile tongue to prevent tethering.
Fig. 51.9 With proper flap insetting, the ventral sulcus and lateral
gutter of the tongue can be re-created to achieve tongue mobility.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
948
sides of the midline.11 The distance between the hyoid bone
and the mentum is approximately 4.5 to 5 cm (Fig. 51.13).
Care should be taken to avoid compression of the vascular
pedicle by these suspension sutures.
Motor Reinnervation
Functional muscle transfer has been successfully used to
restore upper extremity functions and for facial reanima­
tion. However, it is rarely used in tongue reconstruction
choice. It also has the advantages of providing sensory and
motor reinnervation (Fig. 51.11). The rectus abdominis
myocutaneous (RAM) is another good option. Obese men
often have more adipose tissue in the abdomen than in the
thighs. The opposite may be true for women. It has been
suggested by some surgeons to remove the thick cutaneous
portion of the flap and use the muscle only. Muscle flaps
with or without skin grafts are, however, prone to atrophy
and will lose significant bulk, especially after radiotherapy,
resulting in a funnel shape that allows food to pour into the
hypopharynx and larynx, causing aspiration. A forearm flap
is usually too thin for total or subtotal glossectomy defects.
During flap insetting, a dome of neotongue is created
so that it can touch the palate easily (Fig. 51.12). Flap inset­
ting can be difficult in a narrow jaw, particularly when no
mandibular gingiva is left. It is helpful to inset the flap before
revascularization while the flap is still “empty.”
Aspiration
In addition to a funnel tongue, drop of the larynx can cause
aspiration, which often occurs during a total glossectomy
because the suprahyoid musculature is removed. The risk
can be reduced with laryngeal suspension. Laryngeal sus­
pension is often performed with circumhyoid sutures (0–0
Prolene) placed through drill holes in the mentum on both
Fig. 51.10 A total glossectomy with resection of all floor-of-mouth
musculature leaves no tongue muscle to function and increases the
risk of aspiration because of the drop of the larynx.
Fig. 51.11 Both sensory and motor reinnervation is possible with the anterolateral thigh flap with a segment of the vastus lateralis muscle
for total glossectomy reconstruction. (a) The lingua nerve is used for sensory reinnervation. (b) The hypoglossal nerve is used for motor
reinnervation.
a
b
Fig. 51.12 Volume is necessary for total glossectomy reconstruc­
tion to reduce the risk of aspiration and improve swallowing and
speech functions.

949
Chapter 51 Oral and Pharyngeal Reconstruction
Flap Choices for Pharyngoesophageal
Reconstruction
The choice of flaps for pharyngoesophageal reconstruction
is important. The flap has a great impact on defect coverage,
restoration of speech and swallowing functions, simultane­
ous neck resurfacing and tracheostoma reconstruction, and
donor site morbidity. Commonly used flaps include the ALT
flap, jejunal flap, radial forearm flap, and pectoralis major
myocutaneous flap.14–20 The pectoralis flap gained popular­
ity in the early 1980s but is used less now because of ad­
vances in free flap reconstruction. In general, enteric flaps
heal fast but tracheoesophageal (TE) speech is poor and
donor site morbidity is higher. Conversely, fasciocutane­
ous flaps heal slower but TE speech is superior and donor
site morbidity is minor.21,22 ALT flaps have largely replaced
jejunal and radial forearm flaps in the last decade. If the
ALT flap is unavailable because of a lack of perforators or
is deemed too bulky, a radial forearm flap or ulnar artery
perforator flap is the next choice. In otherwise healthy pa­
tients with a circumferential defect, the jejunal flap is an­
other good choice. Contraindications of the jejunal flap in­
clude significant comorbid diseases, obesity, and a history
of abdominal or gastrointestinal surgeries. The pectoralis
major flap can be used for partial defects in male patients,
for salvage after failed free flap reconstruction, or in very
high-risk patients who cannot tolerate a free flap surgery.
The advantage of ALT flaps over forearm flaps is that an am­
ple amount of fascia, the vastus lateralis muscle, and a large
second skin paddle can be included for better coverage of
the soft tissue defect in the neck, thus potentially reducing
the risk of fistula formation.
Flap Insetting
The flap is usually partially inset before revascularization.
Recipient vessel choices include the branches of the exter­
nal carotid artery and facial vein. In a previously radiated
and operated neck, using the transverse cervical vessels
may avoid difficult and risky dissection around the carotid
artery.23,24 Before closure of the neck incision, the neck is
slightly flexed with the head in a neutral position. This re­
positioning may cause kinking or twisting of the vascular
pedicle. Therefore the vascular pedicle should be carefully
inspected again before closing the neck incision. The sec­
ond skin paddle is then turned outward to resurface the
neck, to reconstruct the tracheal defect, or for flap moni­
toring. To monitor a buried flap without an external skin
island, I prefer externalizing a small skin island based on
a second cutaneous perforator or externalizing a small
amount of the vastus lateralis muscle based on a muscular
branch.25 This technique is highly reliable, because three-
dimensional assessment of the entire skin or muscle is
possible. This second skin island or muscle is then brought
out through the neck incision and covered with petroleum
and produces uncertain results. My experience and that of
others12,13 have shown minimal muscle movements after a
functional muscle flap such as a gracilis flap or ALT flap with
the vastus lateralis muscle by coapting the motor nerve of
the flap to the hypoglossal nerve. My current approach is
to use the ALT flap with vastus lateralis muscle with both
sensory and motor reinnervation, because these additional
procedures are easy to perform and add little extra time.
Without postoperative radiotherapy, reinnervation of the
muscle may prevent muscle atrophy. Postoperative radio­
therapy, however, may destroy the motor end plates before
reinnervation occurs. As with partial glossectomy recon­
struction, sensory reinnervation may improve swallowing
functions and patient satisfaction.8
Postlaryngopharyngectomy Defects
The difficulties of postlaryngopharyngectomy reconstruc­
tion are mainly the results of previous radiotherapy and
neck surgery. This increases the risk for delayed wound
healing, fistula formation, infection, carotid artery rupture,
lack of recipient vessels, a combined pharyngoesophageal
and neck skin defect, and tracheoesophageal puncture
(TEP) complications. Functional outcomes such as speech
and swallowing can be disappointing as well. In addition to
being nonvocal after a total laryngopharyngectomy, postre­
construction complications such as pharyngocutaneous
fistulas and anastomotic strictures may render patients
dependent on tube feeding. Radiotherapy has become the
primary treatment for early stages of squamous cell carci­
noma in the larynx and hypopharynx. Therefore the major­
ity of laryngopharyngectomy cases are recurrent cancers
that have failed radiotherapy and, in some cases, previous
neck dissection. These defects are among the most difficult
to repair in head and neck reconstruction. The reconstruc­
tive goals are to provide alimentary tract continuity, pro­
tect great vessels, maximize TEP speech and swallowing
functions, reduce the risk of fistula formation, and mini­
mize neck deformity and donor site morbidity.
Fig. 51.13 After a total glossectomy, static laryngeal elevation can
be achieved with circumhyoid sutures to suspend the larynx to the
mandible.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
950
flap failure (Fig. 51.14). During flap insetting, the proxi­
mal anastomosis between the flap and the base of tongue
is usually performed first. The longitudinal seam is posi­
tioned posterolaterally at the 4 or 8 o’clock position for easy
suturing of the T junction. It can be positioned at 6 o’clock
if the flap is tubed first. Anastomosis starts with two corner
sutures at the 3 and 9 o’clock positions. The posterior wall
is then completed, followed by the anterior wall. The tubed
flap is slightly twisted so that the longitudinal seam at the
distal anastomosis is facing posteriorly at the 6 o’clock posi­
tion. Such positioning of the tubed flap places the perforator
vessels anteriorly between the 11 and 1 o’clock positions to
avoid compression of the perforators against the preverte­
bral fascia. The entire vascular pedicle can be placed anteri­
orly across the flap to avoid sharp kinking (Fig. 51.15).
Stricture
Anastomotic strictures can result from a circular scar for­
mation, inadequate diameter, a thick flap, postoperative ra­
diation, or fistula. To obtain a sufficient lumen, a flap width
of 9.4 cm is required to achieve a 3 cm diameter (3π) for
the tubed neopharynx or esophagus.19 For partial defects,
the width of the flap is calculated by subtracting the width
of the remaining pharyngeal mucosa from 9.4 cm. The flap
can be thinned as needed by direct excision of subcutane­
ous fat at the periphery of the flap. Ample subcutaneous
tissue should be left around the cutaneous perforators, and
2 to 3 mm of subcutaneous tissue is left on the dermis to
protect the subdermal plexus. The anterior wall of the cer­
vical esophagus is split longitudinally for approximately 1.5
cm to spatulate the distal anastomosis (Fig. 51.16). This is
important to enlarge the distal anastomosis and minimize
the risk of ring stricture.
On the flap side, a triangular lip is created and inserted
into the longitudinal split of the esophagus to complete the
spatulation (Fig. 51.17). A Montgomery salivary bypass tube
with a diameter of 14 mm can be placed inside the tubed
flap during circumferential reconstruction in some patients.
This technique may further reduce stricture and fistula for­
mation.
The indications for the use of the Montgomery tube in­
clude a thick flap, difficult flap insetting, very low location
jelly–impregnated gauze to prevent desiccation. A 2–0 silk
tie may be placed around the perforator at the skin level
so that the pedicle can be easily tied when it is time to
remove the monitor segment. The monitor is removed 5
to 7 days later, before the patient is discharged from the
hospital. Alternatively, a handheld Doppler device can be
used to monitor the perforator or the main vascular pedicle
through the neck skin. The Flow Coupler (Synovis) provides
an additional method of flap monitoring. With the jejunal
flap, a 3 to 4 cm long monitor segment is created from the
remaining jejunum based on branches of the pedicle ves­
sels. Both ends of the bowel segment are left open to avoid
distention. At the time of neck closure, the tracheostoma
is sutured to the surrounding neck and anterior chest skin,
and a No. 8 Shiley tracheostomy tube is placed in the tra­
cheostoma and secured to the chest skin.
Perforator Compression or Kinking
When the ALT flap is tubed to reconstruct a circumferen­
tial defect, the perforators need to be carefully positioned.
If they are positioned posteriorly against the prevertebral
fascia, the swelling of the flap can easily compress the per­
forators against the hard surface of the vertebrae, causing
Fig. 51.14 During flap insetting for circumferential pharyngoesophageal reconstruction, positioning the perforators of the anterolateral
thigh flap posteriorly may cause perforator compression against the vertebrae and flap failure.
Fig. 51.15 The longitudinal seam of the tubed anterolateral thigh
flap is positioned more posteriorly with the perforators in the ante­
rior location to avoid compression and kinking.

951
Chapter 51 Oral and Pharyngeal Reconstruction
well-vascularized cervical esophagus compared with the
base of the tongue. In fact, proximal fistulas are rare with
the ALT flap unless there is a dehiscence from poor tissue
quality. It has been speculated that the longitudinal seam
of a tubed fasciocutaneous flap or two longitudinal suture
lines in a partial defect might have contributed to a higher
incidence of fistula formation with the radial forearm flap.
However, in my experience, the fistula rate with the ALT
flap is no higher than with the jejunal flap, and no fistulas
have occurred through the longitudinal suture lines.
Fistulas usually develop between 1 and 4 weeks post­
operatively and manifest as leakage of saliva or liquids or, in
some patients, as a neck infection. Therefore any neck infec­
tion or abscess that occurs after a pharyngoesophageal re­
construction should raise suspicion for anastomotic leakage.
Risk factors for fistula formation include improper suturing
techniques, poor tissue quality at the anastomosis site, pre­
vious radiotherapy, lack of well-vascularized tissue protec­
tion of the anastomosis, and turbulent postoperative course.
At the time of surgery, any questionable tissue in the
proximal pharynx and cervical esophagus should be trimmed
until well-vascularized tissue is seen. Although a watertight
seal using a horizontal mattress suturing technique is advo­
cated by some, I believe that such tight horizontal mattress
suturing may actually cause necrosis of the mucosal edges
and thus increase the risk for fistula. I prefer single-layer,
of the transected cervical esophageal end, small cervical
esophagus, or poor tissue quality because of radiation injury.
The tube is inserted through the mouth before the longitudi­
nal seam of the flap is completed. The proximal flange of the
bypass tube is placed above the proximal anastomosis, and
the distal end is placed in the esophagus below the distal
anastomosis. A 1–0 Prolene suture is attached to the flange
of the tube, brought out through the mouth, and taped to the
cheek to prevent distal migration and facilitate easy removal
of the tube. A 10 Fr red rubber catheter is placed over the
Prolene suture to protect the oral commissure (Fig. 51.18).
If a feeding tube has not yet been placed, a Dobbhoff
feeding tube is placed through the nose and flap or inside
the Montgomery salivary bypass tube, and through the cer­
vical esophagus to the stomach. The Montgomery tube is
usually removed 4 to 6 weeks after reconstruction. This can
be done in the clinic without sedation by pulling out the
previously placed Prolene suture.
Pharyngocutaneous Fistula Formation
In my experience, pharyngocutaneous fistulas occur in 6%
of patients.19,20 Fistula rates are similar in partial and cir­
cumferential reconstructions. Pharyngocutaneous fistulas
occur more commonly at the distal anastomosis than at the
proximal anastomosis, most likely related to the thin, less
Fig. 51.16 To spatulate the distal anastomosis to minimize ring stric­
tures, the anterior cervical esophagus is incised longitudinally for
approximately 1.5 cm.
Fig. 51.17 A triangular lip of flap is created to be inset to the longitu­
dinal opening of the cervical esophagus to complete the spatulation.
a
b
Fig. 51.18 For some patients, a Montgomery salivary bypass tube can be placed in the reconstructed esophagus to minimize the risks of
leakage and stenosis. (a) A Prolene suture is placed on the flange of the tube and taped to the cheek. (b) A small red rubber catheter is
placed over the Prolene suture to prevent the suture cutting through the oral commissure.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
952
modified barium swallowing study is repeated in two weeks.
Most leaks heal within 2 weeks.
Tracheostoma Problems
In a previously irradiated patient, the tracheostoma is at
risk for necrosis and dehiscence. This could be the result of
an ischemic tracheostoma itself or ischemic neck and chest
skin or tight closure. The blood supply to the trachea arises
laterally. Extensive lateral dissection on both sides to skel­
etonize the trachea should be avoided. When the tracheal
stoma is short, excessive undermining of the previously
irradiated anterior chest skin to reach a low tracheostoma
under tension can easily cause skin necrosis, because it is
compressed over the clavicular heads. An alternative ap­
proach to mature the anterior wall of the tracheostoma
is to use a pedicle internal mammary artery perforator
(IMAP) flap.26 Questionable neck skin around the tracheos­
toma should be débrided, and well-vascularized skin from
the flap should be used instead. Full-thickness skin graft­
ing over the vastus lateralis muscle to mature the posterior
tracheostoma and anterior neck can provide very stable
coverage.
Another common problem with the tracheostoma is
partial obstruction related to a bulky second skin paddle
for external coverage. The skin paddle should be thinned as
much as possible at the time of reconstruction. Alternatively,
muscle and skin grafting can provide excellent results. When
a Shiley tube is placed in the tracheostoma with a bulky skin
paddle, the flange of the Shiley tube can cause compression
and necrosis of the skin around the tracheostoma. To avoid
this, the superior flange of the Shiley tube is trimmed and
a longer tube should be used (Fig. 51.20). The flap can also
be thinned using suction-assisted lipectomy several months
after surgery; this method works extremely well.
For tracheoesophageal voice rehabilitation, patients
commonly wear a hands-free stoma button. This button
needs to sit inside the tracheostoma securely. Ideally, the
tracheostoma should have a circumferential flange to secure
the voice button without the bowstring of the neighboring
sternocleidomastoid (SCM) muscles. This can be achieved
by dividing the medial edges of the SCM before neck clo­
sure and maturing the tracheostoma using a semivertical
mattress suturing technique to create a flange (Fig. 51.21).
Managing a Frozen Neck
A frozen or woody neck, defined as severe fibrosis in the
neck without tissue planes, is the result of neck surgery
(such as neck dissection) combined with radiotherapy.24
Long-standing pharyngocutaneous fistulas usually result
in the worst cases of frozen neck. There are three major
problems associated with managing a frozen neck during
reconstruction:
1. Risk of carotid artery rupture
2. Lack of recipient vessels
3. Concomitant neck skin or tracheal defects
simple interrupted 3–0 Vicryl sutures for flap insetting, tak­
ing relatively big bites, inverting the skin and mucosal edges
into the lumen, spacing each suture 5 to 7 mm apart, and
avoiding tight knots. To further protect the suture lines, a
second layer of fascial closure is recommended.
During ALT flap harvesting, a wider amount of fascia
than skin is included in the flap. When making the anterior
incision, the fascial incision is made 1 to 2 cm more medi­
ally than the skin incision. Likewise, an additional 1 to 2 cm
of fascia is recruited posteriorly.
After completion of flap insetting, the extra fascia of the
flap is wrapped around the flap to reinforce the suture lines
and cover the anastomoses. Placement of the Montgomery
salivary bypass tube inside the flap may also reduce the risk
of fistula in high-risk patients by protecting the anastomosis
from constantly soaking in saliva.
If neck resurfacing is needed but only one cutaneous
perforator remains, an attempt might be made to external­
ize a portion of the distal flap by deepithelializing a strip of
skin around the distal anastomosis (Fig. 51.19). This, how­
ever, results in a high fistula rate.19 Even with a minor leak­
age, the deepithelialized portion will reepithelialize, causing
a nonhealing fistula.
The timing for resuming an oral diet after surgery may
also have an effect on fistula formation. The radial forearm
flap has a reputation of having high fistula rates and having
delayed fistulas that occur 4 to 5 weeks after surgery.14,15 A
fasciocutaneous flap does not heal as quickly as a jejunal flap
once it is immersed in saliva 24 hours a day. This may ex­
plain the high incidence of delayed fistula formation. In fact,
the anastomosis may experience secondary healing, which
could take 4 to 6 weeks. If an oral diet is started early, for
instance 7 days after surgery, as with the jejunal flap, fistu­
las will likely develop with the unhealed fasciocutaneous
flap. After fasciocutaneous flap reconstruction, I routinely
delay oral intake for 2 weeks in nonirradiated patients and
for 4 to 6 weeks in patients who have undergone radiother­
apy. Before oral intake, a modified barium swallowing study
is performed. If no leaks or fistulas are identified, a liquid
diet is started and then advanced to a regular diet as toler­
ated. In the presence of a leak, oral intake is delayed, and the
Fig. 51.19 A novice mistake is to deepithelialize a strip of skin and
externalize a portion of the flap for neck coverage. This results in
a high fistula rate. Once a leakage occurred in this patient, the de-
epithelialized portion reepithelialized quickly because of the lack of
contact inhibition, resulting in a nonhealing fistula.

953
Chapter 51 Oral and Pharyngeal Reconstruction
The use of the transverse cervical vessels solves the first
two problems associated with a frozen neck. Elevating an an­
terior neck skin flap from an area that has been previously
irradiated and operated on often causes skin necrosis. Re­
leasing the contractured neck and removing the scar tissue
further creates a large neck skin defect.
Successful management of this problem can be easily
achieved with the ALT flap without the need for a second
flap. Seventy-eight percent of patients have more than one
cutaneous perforator in the ALT flap.27–29 Therefore the ALT
flap can be divided into two independent skin islands based
on separate perforators. One skin island is used for pharyn­
goesophageal reconstruction and the other for neck resur­
facing. If only one cutaneous perforator is present, various
amounts of vastus lateralis muscle can be included in the
flap to support skin grafting to resurface the neck. The su­
perficial half of the vastus lateralis muscle can be harvested
immediately below the descending branch to obtain a thin
and broad flap. Alternatively, a second skin paddle from the
anteromedial thigh (AMT) flap can be used for neck resur­
facing.30–32
The vascular pedicle of the AMT flap is the rectus femo­
ris branch that often originates from the proximal descend­
ing branch. The rectus femoris branch travels underneath
the rectus femoris muscle, then descends along the medial
edge of the muscle, sending cutaneous perforators to the
medial thigh skin. Although overall the AMT perforators are
In a frozen neck, the carotid artery and internal jugular
vein are usually encased in fibrotic tissue. Surgical dissec­
tion around these great vessels during fistula and scar tis­
sue excision and preparation for recipient vessels can easily
cause these already damaged vessels to rupture, resulting
in high rates of morbidity and mortality. The best approach
to avoiding carotid artery rupture is to stay away from it.
My preference is to use the transverse cervical vessels as
recipient vessels. The transverse cervical vessels are avail­
able in 92% of patients and are very similar in size to those
of the flap vascular pedicle.23
The supraclavicular area (posterior triangle) is usually
spared during modern neck dissections and is rarely radi­
ated. Therefore exposure of the transverse cervical vessels in
the supraclavicular area lateral to the sternocleidomastoid
muscle is relatively easy and risk-free.
On the left side of the neck, particular attention should
be paid to avoiding injury to the thoracic duct. Dissection
should start high, above the supraclavicular fat pad, and
proceed deep to it. The external jugular vein usually joins
the transverse cervical vein before entering the subclavian
vein. This part of the external jugular vein is more deeply
located and of good quality. If both veins are unavailable,
such as in patients who have undergone a radical neck dis­
section, the internal jugular vein stump immediately above
the subclavian vein is usually long enough for an end-to-
side anastomosis.
Fig. 51.20 To prevent the Shiley tube from cutting through the
bulky flap, a longer Shiley tube is used and the upper flange is
trimmed. The Shiley tube is loosely fixed to the chest skin.
Fig. 51.21 (a) The tracheostoma is matured with semivertical mattress sutures to create a circumferential rim to retain the hands-free
speech button (b).
a
b

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
954
bilized circumferentially, thus reducing the blood supply to
the trachea. The tracheostoma is also often under tension.
Tracheostoma necrosis is not uncommon, which can lead to a
fatal airway disaster. These patients often have simultaneous
total laryngopharyngectomy or even total esophagectomy.
My current approach is to reconstruct the trachea with
a flap so that the airway can be secured in the lower neck
to avoid a risky mediastinal tracheostomy that skeletonizes
the trachea. If the esophageal resection is limited to the cer­
vical esophagus, simultaneous cervical esophageal and tra­
cheal reconstruction can be accomplished with a two-skin
island ALT flap. One skin paddle is used for esophageal re­
construction and the other for tracheal reconstruction (Fig.
51.24a). The human trachea is approximately 11 to 12 cm
long. A tubed ALT flap with a length of 5 to 6 cm is adequate
to bring the airway to the lower neck (Fig. 51.24b). The ma­
nubrium, clavicular heads, and sometimes the first ribs are
also resected, providing good exposure for flap insetting to
the tracheal remnant. Then 3–0 Vicryl or PDS sutures are
used for the flap–tracheal anastomosis, with the knots out­
side the lumen. The cuff of the endotracheal tube can be
positioned immediately below the anastomosis for ventila­
tion during surgery.
At the end of surgery, the endotracheal tube is changed
to a long Shiley tube and the patient is awakened breath­
only present in half of patients, their presence has a recipro­
cal relationship to the ALT perforators. When there is only
one or no ALT perforator, AMT perforators can usually be
found. Thus, taking the descending branch as the main ped­
icle, both the ALT and AMT flaps can be carried (Fig. 51.22).
In summary, the use of the transverse cervical vessels and
multi-island ALT flap or ALT–AMT chimeric flap can convert
an extremely difficult case with a frozen neck into a rela­
tively straightforward one, reducing surgical risks and donor
site morbidities and improving quality of life.
Avoiding a Risky Mediastinal
Tracheostomy
When a head and neck cancer, such as an extensive laryn­
geal cancer or thyroid cancer, involves the cervical and up­
per thoracic trachea, tracheal resection can be performed
extending down to 4 to 5 cm above the carina. The tradi­
tional method of securing the airway is a mediastinal tra­
cheostomy, which involves mobilizing the tracheal stump
below the subclavian vessels and maturing it to the chest
skin (Fig. 51.23).
This technique carries high mortality rate, especially in
patients who had been previously irradiated. To bring the
tracheal stump down to the chest, the trachea has to be mo­
a
b
Fig. 51.22 (a) When two skin paddles are needed and only one anterolateral thigh flap perforator is present, the anteromedial thigh flap
can be used as a second skin paddle (b) based on the rectus femoris branch vessels that usually arise from the descending branch.
Fig. 51.23 When a significant portion of the trachea is resected, the tracheal stump is usually mobilized (a) and brought under the innomi­
nate artery (b) to create a mediastinal tracheostomy (c). Such procedures carry a high risk for life-threatening tracheal necrosis in previ­
ously irradiated patients.
a
b
c

955
Chapter 51 Oral and Pharyngeal Reconstruction
standard practice after microvascular head and neck re­
construction.35–41 Common justifications for such practice
include long operative times, patients with multiple medi­
cal comorbidities, lack of adequate non–intensive care unit
(ICU) nursing, and the deep sedation required to “protect”
the microvascular anastamoses. However, these purported
benefits are largely unproven and must be weighed against
the increased risk of medical complications and high costs.
I began to consider the idea of immediate extubation
and weaning off ventilation after witnessing several elderly
patients with limited cardiopulmonary reserve progress to
cardiopulmonary failure in the ICU because of fluid overload.
Adequate sedation is required for patients under mechanical
ventilation. It is not uncommon for these patients to develop
hypotension secondary to sedation. Because vasopressors
are generally considered contraindicated after a free flap re­
construction, large amounts of fluid resuscitation are often
required to maintain blood pressure. Although this practice
is well tolerated for young and otherwise healthy patients,
those with limited cardiopulmonary reserve, such as hap­
pens with chronic obstructive pulmonary disease, conges­
tive heart failure, and other significant cardiopulmonary co­
morbid diseases, and elderly patients can have major issues.
Because of fluid overload, these patients are unable to be
weaned from the ventilator for several days, causing a sig­
nificantly increased incidence of pneumonia and respiratory
ing spontaneously to avoid positive ventilation, which could
cause stress and air leak at the flap–tracheal anastomosis.
The Shiley tube is changed to a Lary tube after 3 days, as in
regular postlaryngectomy patients. A layer of the vastus late­
ralis muscle is also included in the flap to cover the radiated
great vessels. In patients with extensive mediastinal expo­
sure, an additional pectoralis major muscle flap is needed to
cover the great vessels on the contralateral side.
When a total esophagectomy is performed in addition
to a total laryngopharyngectomy, gastric pull-up for esopha­
geal reconstruction is no longer an option in most patients.
My preferred approach for esophageal reconstruction is a
supercharged jejunal flap.33,34 The second and third mes­
entery vessels are usually divided, and the fourth serves as
the pedicle. The jejunal flap is then pulled up to the neck
through the retrosternal route. The jejunum is then anasto­
mosed to the oropharynx, and the second mesentery vessels
are supercharged to the transverse cervical or the internal
mammary vessels.
The trachea is reconstructed with a free ALT or radial
forearm flap.34 Flap insetting can be tricky. If the jejunal flap
is pulled up first, it will obstruct the visualization of the
tracheal stump. If the tracheal reconstruction is done first,
pulling up the jejunum can be difficult and may disrupt tra­
cheal reconstruction. The following sequence may help solve
this problem34:
1. The ALT flap is harvested, and parachuting sutures are
placed for the flap–tracheal anastomosis without tying
the flap down to the trachea.
2. Vascular anastomosis for the ALT flap is completed.
3. The jejunal flap is pulled up to the neck and revascular­
ized.
4. The parachuting sutures are tied down to complete ALT
flap insetting to the trachea (Fig. 51.25).
Minimizing Severe Medical
Complications: The Rapid Awakening
Protocol
Traditionally, postoperative admission to an intensive care
setting with maintenance on mechanical ventilation is
Fig. 51.24 Reconstructing the trachea with the second skin paddle of the anterolateral thigh flap (a) to extend the airway (b) above the
sternal notch. This technique eliminates risky paratracheal dissection for a mediastinal tracheostomy.
a
b
Fig. 51.25 When a total esophagectomy and tracheal resection is
performed, the esophagus is reconstructed with a supercharged je­
junal flap while the trachea is reconstructed with a free anterolateral
thigh flap (a). (b) The anterolateral thigh flap extends the airway
to the neck.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
956
ment. Larger or infected fistulas should be evaluated with
computed tomography to rule out abscess and assess the
proximity of the fistula or abscess to the carotid artery. Any
dead space or abscess around the carotid artery, especially
in patients who have undergone previous radiotherapy or
chemoradiation, should be thoroughly but carefully dé­
brided without jeopardizing the carotid artery and filled
with a muscle flap such as a pectoralis major muscle flap.
This should be done as soon as possible to prevent rupture
of the carotid artery. Attempting to repair the leak or de­
hiscence at this stage will not be successful and may cause
more tissue damage. The muscle flap is adequate to oblit­
erate the fistula track and will remucosalize quickly. It is
extremely important not to delay the débridement when
infection or abscess is identified. Early intervention may
achieve rapid healing and prevent life-threatening compli­
cations.
Persistent fistulas are rare in the absence of tumor re­
currence or distal obstruction or stricture. Long-standing
fistulas will eventually cause stricture because of scar tis­
sue formation, which in return results in nonhealing of the
fistula. In these cases, reconstruction with a radial forearm
flap or a pedicled supraclavicular flap may be indicated in
certain patients.
Postlaryngectomy fistulas should also be managed
promptly. Although the overall incidence of postlaryngec­
tomy pharyngocutaneous fistulas has decreased significantly
in the past decade, it remains very high in previously irradi­
ated patients, up to 40%.43–46 Once fistulas develop, the ra­
diation effects are compounded by salivary contamination
of the neck, leading to chronic inflammation and hypoxia of
the neck skin and vasculature and putting the patient at risk
for loss of neck skin and the remaining pharynx, for trache­
ostoma compromise, and even for carotid artery rupture.
Conservative management is often ineffective. Delaying de­
finitive reconstruction will only cause severe frozen neck,
thus increasing the difficulty of later reconstruction. Early
surgical intervention within 6 weeks, before severe fibrosis
sets in, is much easier technically, and results are superior.47
Anastomotic Strictures
With the ALT flap, anastomotic strictures rarely occur at
the proximal anastomosis site unless the flap was com­
promised at the time of reconstruction. Distal anastomotic
strictures usually occur several months or years after re­
construction. Patients usually present with dysphagia
symptoms. A modified barium swallowing study should be
performed to confirm the diagnosis (Fig. 51.26). Manage­
ment of strictures involves endoscopic balloon dilation;
repeated dilations may be required. Surgical dilation under
general anesthesia may cause esophageal perforation and
is rarely used today. In refractory cases, surgical repair can
be achieved with a radial forearm free flap or a pedicled
supraclavicular flap.
failure. In some cases, this may even include multiple organ
failure. Their ICU stays, medical cost, and length of hospital
stay increase significantly.
My colleagues and I therefore developed a Rapid Awak­
ening Protocol (RAP) for patients to be extubated or weaned
off the ventilator immediately at the conclusion of surgery.42
This protocol effectively avoided this “vicious cycle.” Most
patients are able to proceed to regular recovery and do not
require an ICU setting. RAP patients tend to ambulate sooner
and develop fewer cardiopulmonary complications, and by
transferring to the floor, their recovery is expedited with an
overall shorter hospital stay. Effective communication with
anesthesiologists and ablative surgeons regarding this ap­
proach should be maintained throughout the case to ensure
that patients meet the criteria of the RAP.
Managing Unfavorable Results
and Complications in Oral and
Pharyngeal Reconstruction
Neck Wound Infection
Neck wound infection is the result of prolonged wound
exposure and oral contamination during surgery. Many
patients with tongue cancer have poor oral hygiene be­
cause of pain. Prior chemoradiation therapy and diabetes
can also increase the risk of infection. Copious irrigation
and obliteration of submandibular dead spaces are impor­
tant for preventing postoperative wound infection. Wound
infection usually develops 5 to 7 days after surgery. Early
drainage and thorough débridement and irrigation may en­
able primary wound closure over a drain to prevent delay of
adjuvant therapy. Pulsevac irrigation or irrigation directly
on the vascular pedicle should be avoided, because it may
cause vessel thrombosis in an already hypercoagulatory
state during infection. If adequate vascularized tissue re­
mains in the upper neck after débridement, no additional
procedure is needed. However, any dead space in the upper
neck should be obliterated with a muscle flap. The pecto­
ralis major muscle flap is commonly used for this purpose
and to protect the carotid artery, which is particularly im­
portant in patients who have had prior chemoradiation
therapy.
Pharyngocutaneous Fistula
Pharyngocutaneous fistula after pharyngoesophageal re­
construction is more difficult to manage because of ra­
diation damage and a paucity of well-vascularized tissue.
Once a fistula is identified, oral intake is withheld and lo­
cal wound care is initiated. Small fistulas, in the absence
of tumor recurrence or distal obstruction, usually heal
spontaneously within 2 weeks with conservative manage­

957
Chapter 51 Oral and Pharyngeal Reconstruction
the way to the axillary vessels. The humerus insertion of
the pectoralis major muscle is partially divided to increase
the reach. Compared with the pectoralis major muscle, the
latissimus muscle flap is thin, broad, and more malleable
to manipulations for flap insetting. The skin paddle can be
used for external coverage, and a skin graft is used for lu­
minal coverage over a Montgomery salivary bypass tube,
which serves as a stent to support the skin grafts (Fig.
51.27). The Montgomery tube is removed 6 weeks later.
If the patient is not considered a good candidate for re­
construction, a spit fistula is created in the upper neck to
drain the saliva, the cervical esophagus is closed and covered
with a pectoralis major muscle flap, and a permanent feed­
ing gastrostomy or jejunostomy is performed.
Managing a Failed Reconstruction
A failed free flap reconstruction in an otherwise straight­
forward case can be managed with another free flap. Often,
however, the neck environment is hostile because of infec­
tion and radiation with the lack of recipient vessels. A sec­
ond free flap in this setting is usually futile. Salvage with a
pedicled pectoralis major flap for glossectomy reconstruc­
tion is a viable option. The outcomes for pharyngoesopha­
geal reconstruction with the pectoralis major are less op­
timal, particularly in female patients and circumferential
defects. A less commonly used flap that I find very useful is
the pedicled latissimus dorsi flap.48 This flap can reach the
pharynx easily without tension. The pedicle is dissected all
Fig. 51.26 Pharyngoesophageal stricture at the flap–esophageal anastomosis.
Fig. 51.27 The latissimus flap is another option to salvage a failed free flap reconstruction of the pharyngoesophageal defect. (a) The lumen
is lined with skin grafts over the Montgomery salivary bypass tube to serve as a stent. The latissimus muscle is placed over the skin grafts
and covers the great vessels. (b) The skin paddle is used to cover the external defect.
a
b
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38. Halfpenny W, McGurk M. Analysis of tracheostomy-
associated morbidity after operations for head and neck
cancer. Br J Oral Maxillofac Surg 2000;38(5):509–512
39. Allak A, Nguyen TN, Shonka DC Jr, Reibel JF, Levine PA,
Jameson MJ. Immediate postoperative extubation in pa­
tients undergoing free tissue transfer. Laryngoscope 2011;
121(4):763–768
4. Boyd B, Mulholland S, Gullane P, et al. Reinnervated lat­
eral antebrachial cutaneous neurosome flaps in oral re­
construction: are we making sense? Plast Reconstr Surg
1994;93(7):1350–1359, discussion 1360–1362
5. Santamaria E, Wei FC, Chen IH, Chuang DCC. Sensation re­
covery on innervated radial forearm flap for hemiglossec­
tomy reconstruction by using different recipient nerves.
Plast Reconstr Surg 1999;103(2):450–457
6. Vriens JPM, Acosta R, Soutar DS, Webster MHC. Recovery
of sensation in the radial forearm free flap in oral recon­
struction. Plast Reconstr Surg 1996;98(4):649–656
7. Matloub HS, Larson DL, Kuhn JC, Yousif NJ, Sanger JR. Lat­
eral arm free flap in oral cavity reconstruction: a func­
tional evaluation. Head Neck 1989;11(3):205–211
8. Yu P. Reinnervated anterolateral thigh flap for tongue re­
construction. Head Neck 2004;26(12):1038–1044
9. Yu P, Chang EI, Selber JC, Hanasono MM. Perforator pat­
terns of the ulnar artery perforator flap. Plast Reconstr
Surg 2012;129(1):213–220
10. Urken ML, Moscoso JF, Lawson W, Biller HF. A systematic
approach to functional reconstruction of the oral cavity
following partial and total glossectomy. Arch Otolaryngol
Head Neck Surg 1994;120(6):589–601
11. Weber RS, Ohlms L, Bowman J, Jacob R, Goepfert H. Func­
tional results after total or near total glossectomy with
laryngeal preservation. Arch Otolaryngol Head Neck Surg
1991;117(5):512–515
12. Yousif NJ, Dzwierzynski WW, Sanger JR, Matloub HS,
Campbell BH. The innervated gracilis musculocutaneous
flap for total tongue reconstruction. Plast Reconstr Surg
1999;104(4):916–921
13. Yamamoto Y, Sugihara T, Furuta Y, Fukuda S. Functional
reconstruction of the tongue and deglutition muscles fol­
lowing extensive resection of tongue cancer. Plast Recon­
str Surg 1998;102(4):993–998, discussion 999–1000
14. Scharpf J, Esclamado RM. Reconstruction with radial fore­
arm flaps after ablative surgery for hypopharyngeal can­
cer. Head Neck 2003;25(4):261–266
15. Anthony JP, Singer MI, Mathes SJ. Pharyngoesophageal re­
construction using the tubed free radial forearm flap. Clin
Plast Surg 1994;21(1):137–147
16. Azizzadeh B, Yafai S, Rawnsley JD, et al. Radial forearm free
flap pharyngoesophageal reconstruction. Laryngoscope
2001;111(5):807–810
17. Reece GP, Bengtson BP, Schusterman MA. Reconstruction
of the pharynx and cervical esophagus using free jejunal
transfer. Clin Plast Surg 1994;21(1):125–136
18. Disa JJ, Cordeiro PG. Reconstruction of the hypo­
pharynx and cervical esophagus. Clin Plast Surg
2001;28(2):349–360
19. Yu P, Robb GL. Pharyngoesophageal reconstruction with
the anterolateral thigh flap: a clinical and functional
outcomes study. Plast Reconstr Surg 2005;116(7):
1845–1855
20. Yu P, Hanasono MM, Skoracki RJ, et al. Pharyngo­
esophageal
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with
the
anterolateral
thigh flap after total laryngopharyngectomy. Cancer
2010;116(7):1718–1724
21. Nakatsuka T, Harii K, Asato H, Ebihara S, Yoshizumi T,
Saikawa M. Comparative evaluation in pharyngo-oesoph­
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44. McCombe AW, Jones AS. Radiotherapy and complications
of laryngectomy. J Laryngol Otol 1993;107(2):130–132
45. Hier M, Black MJ, Lafond G. Pharyngo-cutaneous fistulas
after total laryngectomy: incidence, etiology and out­
come analysis. J Otolaryngol 1993;22(3):164–166
46. Natvig K, Boysen M, Tausjø J. Fistulae following laryngec­
tomy in patients treated with irradiation. J Laryngol Otol
1993;107(12):1136–1139
47. Iteld L, Yu P. Pharyngocutaneous fistula repair after radio­
therapy and salvage total laryngectomy. J Reconstr Micro­
surg 2007;23(6):339–345
48. Hsu P, Yu P. Complex salvage of a failed pharyngoesopha­
geal reconstruction with impending airway disaster. Plast
Reconstr Surg 2010;125(5):208e–210e
40. Bradley PJ. Should all head and neck cancer patients be
nursed in intensive therapy units following major sur­
gery? Curr Opin Otolaryngol Head Neck Surg 2007;15(2):
63–67
41. Godden DRP, Patel M, Baldwin A, Woodwards RTM. Need
for intensive care after operations for head and neck
cancer surgery. Br J Oral Maxillofac Surg 1999;37(6):
502–505
42. Clemens MW, Hanson SE, Rao S, Truong A, Liu J, Yu P.
Rapid awakening protocol in complex head and neck re­
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43. Genden EM, Rinaldo A, Shaha AR, Bradley PJ, Rhys-Evans
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gectomy. Acta Otolaryngol 2004;124(2):117–120
Discussion by Mouchammed Agko and Hung Chi Chen
Cancer is the leading cause of death in Taiwan, with
oral cancer being the fourth most common.1 As a result,
surgeons have amassed extensive experience in both
ablation and reconstruction of this group of debilitat­
ing maladies. We would like to share our experience
by focusing our discussion primarily on surgical voice
reconstruction with or without simultaneous pharyn­
goesophageal reconstruction. Additional tips and tricks
of oropharyngeal reconstruction are discussed briefly.
Surgical Voice Reconstruction
Background
Laryngeal and hypopharyngeal cancers are among the
most common indications for laryngectomy. Because
of the combination of betel nut chewing and alcohol
consumption and smoking, hypopharyngeal cancer is
3.3 times more common in Taiwan than in the Western
population, especially among males.1 Thus voice recon­
struction in postlaryngectomy patients has become a
large focus of our efforts. A multidisciplinary team ded­
icated to this mission has been assembled to diagnose,
treat, and fully rehabilitate patients who are motivated
to regain speech after laryngectomy. This team consists
of experts in a wide range of areas:
•• Medical and radiation oncology
•• Otolaryngology
•• Psychiatry
•• Anesthesiology
•• Intensive care medicine
•• Speech pathology
•• Nursing
•• Reconstructive plastic surgery
Close cooperation between the members of the team
is of utmost importance in providing optimal results.
Laryngectomy with resultant loss of voice has dev­
astating psychosocial consequences. Deprivation of the
most effective method of communication and inability
to express emotions and opinions verbally disrupts in­
teraction with others and results in social withdrawal
and a decrease in quality of life. The reported incidence
of depression after laryngectomy is 30 to 40%.1 Voca­
tional problems are common, as well. In one study, 50%
of laryngectomy patients reported forced retirement and
75% reported a limited social life.2 The profound benefit
of voice restoration is therefore easy to imagine.
Speech Physiology
A detailed exploration of the process of speech produc­
tion is beyond the scope of this discussion. However,
a basic understanding of the physiology is required
to grasp the concept of surgical voice reconstruction.
Sound production requires two elements: a power
source and a vibrating element. When it comes to
speech production, the power source is air that comes
from the lungs, and the vibration occurs in the vocal
cords of the larynx. Respiration, phonation, articula­
tion, and resonance are four processes that interact to
produce intelligible speech. The airstream originating
from the lungs during exhalation passes through the
glottis. The vocal folds open and close in rapid cycles,
allowing the air to exit into the supraglottic vocal tract
as periodic sound waves. Various resonating chambers
above and below the larynx modify this fundamental
tone produced in the larynx. The sound is then con­
verted to speech by the action of articulators: tongue,
lips, palate, pharynx, teeth, and related structures.

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960
Current Methods of Voice
Rehabilitation
The three most commonly used voice production and
rehabilitation mechanisms after laryngectomy include
the following:
1. Esophageal speech
2. Artificial larynx (electronic or pneumatic)
3. Tracheoesophageal puncture with prosthesis (TEP)
Compressing air into the esophagus and then releasing
it causes the pharyngoesophageal segment to vibrate
and produce the esophageal tone that is used for speech
production by the articulators. This method does not
require an operation, but fewer than half of patients
can acquire this skill. Even when successful, the qual­
ity of voice is poor, and attempts at speech after eating
often result in vomiting and choking.
The electrolarynx is a handheld device that trans­
mits a vibration noise to either the pharynx or mouth.
This noise is then formed into words by the articulators.
The sound produced is understandable but machine-like
and monotonous. In countries where the language re­
quires particular intonation (pitch), such as in Taiwan,
Hong Kong, and mainland China, the pneumatic artifi­
cial larynx (Taiwan tube) is preferred. A cup placed over
the tracheostomy directs the air to the mouth through
a plastic tube that contains a membrane vibrator. The
air vibrations are transformed into speech by the ar­
ticulators. The device is difficult to conceal, is prone to
mechanical malfunction, and requires maintenance be­
cause it is often occluded by secretions. This frequently
puts patients in an awkward position, because it forces
them to stop talking during a conversation to clean up
the tube before they can resume talking. As with the
electrolarynx, the voice produced is mechanical.
Finally, tracheoesophageal puncture allows a small,
silicone-valve prosthesis to be inserted into a surgically
created, midline fistula between the trachea and the
esophagus or neoesophagus. Upon occlusion of the tra­
cheostomy, the air is diverted from the trachea through
the one-way prosthesis, thereby creating pharyngo­
esophageal vibrations that allow voice production. It
provides easy and successful acquisition of speech with
good fluency and intelligibility in patients who are eli­
gible for the procedure. However, several disadvantages
do exist:
•• Meticulous maintenance is required to keep the
device clean and functional.
•• There is a potential for obstruction by secretions and
food particles.
•• Microbial colonization with Candida biofilm
formation is a significant issue that requires oral
chemoprophylaxis and limits the life span of the
prosthesis to around 4 to 8 months.3,4
•• Tissue maceration around the prosthesis results
in dilation of the tracheoesophageal fistula with
consequent leak around the device. This may
dislodge the device, which will cause aspiration
if it falls into the trachea and requires emergency
treatment.
•• Enlarging fistulas necessitate repeated changes of
the prosthesis to larger sizes. Once the largest size
has been used, the fistula has to be closed.
•• The device may cause stenosis of the tracheostomy.
Although the most common reconstruction involves
creation of a tracheoesophageal fistula and placement
of a prosthesis, reconstruction of voice with intestinal
transfers can provide equal, if not better, voice quality,
with fewer long-term complications and requirements
for maintenance and secondary procedures. We have
performed more than 136 intestinal transfers over the
last 17 years with the goal of creating a natural mecha­
nism for voice restoration using autogenous tissue.
The Concept of the Voice Tube
A voice tube (Vt) is a conduit that is created to shunt
air from the trachea to the pharynx/esophagus or
neopharynx/neoesophagus. It provides for an autog­
enous tube to divert airstream from the trachea to the
esophagus upon digital occlusion of the tracheostomy.
The pharyngoesophageal vibrations create a tone that
is formed into speech by the articulators. The tube can
be constructed from skin, jejunum, or ileum; each has
advantages and disadvantages. The Vt has three basic
components, each of which can be made of different
tissue types and serves a special function1 (Fig. 51D.1):
1. The Vt–trachea (Vt-T) junction serves as the inlet of
airflow from the trachea.
2. The (Vt) body transfers air from the trachea to the
esophagus and aids in creation of sound by creating
vibratory movements of air.
3. The Vt–esophagus (Vt-E) junction is the outlet and
functions as a one-way valve that allows air outflow
into the esophagus while preventing regurgitation
of food and saliva. This valvelike mechanism also
aids in creating air turbulence that affects phona­
tion.
Each component of the Vt can be manipulated surgi­
cally to fine-tune the end result of voice production.

961
Chapter 51 Oral and Pharyngeal Reconstruction
Fig. 51D.1 The voice tube (Vt) construct consists of
three components: the inlet (Vt–tracheal junction),
the Vt body, and the outlet (Vt–esophageal junc­
tion). (Reproduced from Chen HC, Tang YB, Mardini
S, et al. Transfer of Intra-Abdominal Organs for Ad­
vanced Reconstructions. Taichung: Elsevier Taiwan;
2013.)
Conduction of air
Vibration of air
Inlet
(voice tube-trachea junction)
Oulet
(voice tube-esophagus junction)
Inflow of air
Outflow of air
One-way mechanism
Different ways of insetting the Vt-T and Vt-E junctions
are discussed in the following sections.
Voice Tube Construct in Different
Clinical Scenarios of Laryngectomy
Patients
Total Pharyngolaryngectomy
The reconstruction of the defect in a total pharyngo­
laryngectomy requires simultaneous restoration of
gastrointestinal continuity and voice. A free ileocolon
flap based on the ileocolic artery is transferred to the
neck. The colonic segment is fashioned as an isoperi­
staltic or antiperistaltic interposition flap fashioned to
match the pharyngoesophageal defect, whereas the il­
eum serves as the Vt. This is our preferred method and
is described in detail later in this discussion.
Total Laryngectomy with a
Pharyngoesophageal Stricture or Partial
Defect
For a total laryngectomy with a pharyngoesophageal
stricture or partial defect (less than one third of the cir­
cumference), a free ileocecal flap with a short colonic
segment is harvested. The cecum is designed as a patch
that fits the defect in the esophagus, and the ileum is
the Vt.
Total Laryngectomy without a
Pharyngoesophageal Stricture or Defect
The appendix vermiformis with or without a patch of
cecum can be used a free flap based on the appendi­
ceal artery and ileocolic vein to repair a total laryn­
gectomy without a pharyngoesophageal stricture or
defect. The distal aspect of the appendix is connected
to the trachea (Vt-T junction), and the cecal end is inset
in a two-layered fashion into a fissure created in the
anterolateral aspect of the esophagus (Vt-E junction).
A gentle curve is created at the cephalad end to form
an antigravity loop that prevents regurgitation of saliva
and food into the appendiceal lumen.
Alternatives
A similar construct can be created from jejunum. For
simultaneous pharyngoesophageal and voice recon­
struction, a free jejunum flap of sufficient length is har­
vested and split into two segments while maintaining
blood supply on the same portion of mesentery. The
first segment is used for esophageal reconstruction in
an isoperistaltic fashion. The second segment is used
as a Vt. The proximal part of the second segment is at­
tached to the trachea, forming the Vt-T junction. The
distal part is attached to the proximal neoesophagus
(first segment of jejunum), forming the Vt-E junction.
In this case, because there is no intrinsic valve mech­
anism, the Vt-E junction end of the jejunum Vt is ta­
pered and an antigravity loop curve is maintained to
prevent regurgitation. A shorter free jejunum flap can
be used in a similar fashion if only voice reconstruction
is necessary.
Both the pharyngoesophagus and the Vt can be re­
constructed using two fasciocutaneous flaps (i.e., an­
terolateral thigh and forearm flap) built into a similar
design. However, it is rarely used in our practice because
of the increased risk of leak and fistula formation and
the lack of pliability, which precludes the creation of an
antigravity loop. In addition, secretions from sebaceous
and sweat glands and lack of peristalsis commonly lead
to occlusion of the Vt-E junction.
Indications, Contraindications, and
Timing
The indications for reconstruction with an ileocolon
flap are tumor excision, radiation damage, a failed re­
constructive effort, corrosive injury, or congenital dis­
ease that affects the larynx along with partial (less than
one third) or total circumferential defect of the alimen­
tary tract. The alimentary tract defect can be short or
extend from the pharynx to the pylorus. For defects

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
962
extending into the thoracic esophagus, a pedicled il­
eocolon flap is redirected to the neck in a retrosternal
or subcutaneous plane. However, the Vt (ileum) is ar­
ranged in the same way as the free flap.5
Patients with previous gastrointestinal procedures
that involved resection of the target ileocolic segment
or may have compromised the mesenteric vasculature
thereof are offered alternative flaps. Otherwise, any pa­
tient considered fit to undergo a microvascular proce­
dure is a candidate. Previous laparotomies and advanced
age are not contraindications by themselves.
There are four possible scenarios regarding the tim­
ing of surgical voice reconstruction with an ileocolon
flap:
1. Immediately after primary surgical ablation
2. Immediately after salvage resection for failed organ
preservation–intended radiation therapy with or
without chemotherapy
3. In a delayed fashion after resection in another insti­
tution
4. In a delayed fashion after previously failed recon­
struction
Preoperative Preparation
Preoperative evaluation, preparation, and optimiza­
tion of medical and nutritional status is paramount.
A special preoperative consideration in this group of
patients is confirmation of optimum thyroid and para­
thyroid hormone levels. The training to produce an
audible voice has high energy requirements. We have
found a remarkable improvement in voice production
in patients who had low hormone levels and received
appropriate replacement. Even though transfer of un­
prepared bowel has not led to increased complication
rates, bowel preparation is still administered before
surgery, because it shortens the time taken to prepare
the bowel after harvest and thus the ischemia time.6
Surgical Technique
Incisions and Exposure of Structures
in the Neck
In the immediate reconstruction scenario, the ablative
surgeons determine the incisions and exposure. When
delayed reconstruction is performed, the incisions are
designed to expose the pharynx and cervical esopha­
gus, the tracheal stump, and the recipient vessels. We
prefer to raise a laterally based platysma myocutaneous
flap, which is later used to safely cover the microvas­
cular anastomosis and most of the pedicle. Depending
on the existing scars, the anterior border of the flap is
placed somewhere between the anterior border of the
sternocleidomastoid muscle and the native esophagus1
(Fig. 51D.2).
The target structures in the neck are identified be­
fore flap transfer. In patients in whom a segment of pha­
ryngoesophagus was resected, the proximal and distal
stumps are located and tagged. In patients who have an
esophageal stricture, it is opened and released in prepa­
ration for transfer. A skin flap is raised, leaving a cuff of
skin around the tracheostomy. Three or four cartilagi­
nous rings are exposed on the lateral aspect of the tra­
chea, ipsilateral to the lateral platysma myocutaneous
flap, for later inset of the Vt. Finally, the recipient ves­
sels, usually the transverse cervical artery and external
jugular vein, are located and dissected.
Flap Harvesting
A median laparotomy is used as an access to expose the
ileocolon. The peritoneum lateral to the ascending co­
lon is incised to allow mobilization up to the midtrans­
verse colon. Transillumination is then used to precisely
visualize the mesenteric vascular pattern before iso­
lation of a maximum-length ileocolic pedicle while
preserving optimal blood supply to the ends of ileum
Fig. 51D.2 Proposed incisions for exposures of the struc­
tures in the neck. The laterally based platysma myocutane­
ous flap is used to cover the vascular pedicle. (Reproduced
from Chen HC, Tang YB, Mardini S, et al. Transfer of Intra-
Abdominal Organs for Advanced Reconstructions. Taichung:
Elsevier Taiwan; 2013.)

963
Chapter 51 Oral and Pharyngeal Reconstruction
and colon to be reanastomosed. An appendectomy is
performed in the standard fashion. Noncrushing bowel
clamps are applied proximal and distal to the ileocolic
flap. The bowel segment is isolated from the rest of the
abdominal cavity with abdominal pads before division.
Both intestinal stumps are cleaned with cotton-tipped
applicators, and an ileocolic anastomosis is performed.
The mesenteric defect is closed with a running locked
suture. A feeding jejunostomy is placed in the left upper
quadrant before closure of the abdomen in three layers.
Flap Preparation
In the meantime, both antegrade and retrograde ir­
rigation of the flap with copious amounts of 10% po­
vidone iodine is performed on the back table before
revascularization. Cotton-tipped applicators soaked in
povidone iodine are used to mechanically remove any
residual stool.
Inset of the Flap and Ileocecal Valve
Plication
The ileocolon flap can be inset in either an isoperistal­
tic (cecum cephalad) or antiperistaltic (cecum caudad)
position. The antiperistaltic inset has the advantage of
a shorter ileal Vt, which decreases the force required
to produce voice. In addition, the cecal opening can be
adjusted for a better size match with the distal esopha­
geal stump. On the other hand, the isoperistaltic design
allows for a slight advantage with swallowing. Also, the
high position of the ileocecal valve in the pharynx po­
tentially reduces the risk of aspiration. Finally, a longer
ileal conduit (close to 10 cm) can be inset without kink­
ing of the pedicle. We have determined that this partic­
ular length of the Vt is ideal for optimal voice outcome
in terms of loudness, maximum phonation time, and
sound pressure level. As a result, this configuration has
become our preferred method1 (Fig. 51D.3).
Fig. 51D.3 Isoperistaltic inset of a free ileocolon
flap. (a) The defect before reconstruction. (b) The
ileocolon flap has been exteriorized and the ileo­
colic artery skeletonized. (c) The cecum is anas­
tomosed to the pharynx; the ileum (voice tube) is
shown before connection with the trachea, as de­
picted in the illustration. (Reproduced from Chen
HC, Tang YB, Mardini S, et al. Transfer of Intra-
Abdominal Organs for Advanced Reconstructions.
Taichung: Elsevier Taiwan; 2013.)
a
b
c

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
964
After the flap has been prepared on the back ta­
ble, prompt revascularization is achieved. For intesti­
nal transfers, proper selection of the recipient veins is
a critical factor in providing adequate venous outflow
and minimizing venous congestion.7 For this reason, we
make a special effort to provide double venous drain­
age, if possible.
We have found that only 5% of patients have sig­
nificant incompetence of the ileocecal valve during ir­
rigation of the flap. Nevertheless, we routinely perform
internal plication of all ileocecal valves with interrupted
sutures to decrease the lumen of the valve to 5 mm to
minimize regurgitation, and we pay special attention in
those found to have an incompetent valve.8 This is cou­
pled with external plication using serosal sutures that
suspend the ileum superiorly to the adjacent colon to
push the valve into the cecal lumen and further decrease
the risk of regurgitation.
To determine the appropriate length of the colonic
interposition segment, the shoulder roll is used to keep
the neck in a hyperextended position. The intestinal flap
should fit exactly into the defect without any redun­
dancy. During the suturing process, some length is lost,
particularly while placing the second layer. This will ac­
count for the extra length that will be seen when the
neck is placed back in neutral position.
After placing a nasogastric tube through each nos­
tril, the flap, and the distal stump of the esophagus, the
proximal end of the flap is anastomosed to the phar­
ynx in two layers, using absorbable sutures for the first
full-thickness layer and nonabsorbable for the second.
In circumferential defects, the back wall is sutured first.
During the placement of the second seromuscular layer,
the flap is attached to the prevertebral fascia and the
mesentery is used to patch the first layer.
The distal end of the flap is also sutured to the
esophageal stump in two layers. To better distribute
the size mismatch between the colon and the esopha­
gus, a 1.5 cm vertical incision is made on the anterior
esophageal wall to allow for spatulation.9 It is essential
to ensure that there is no tension on this anastomosis.
After placing the first layer, the shoulder roll is removed.
The second layer is performed, with the surgeon paying
special attention to avoid narrowing the esophageal lu­
men during the imbrication.
After completion of the pharyngoesophageal recon­
struction, the Vt is sutured to the trachea. The Vt-T junc­
tion can be created in one of three ways: (1) end-to-end,
(2) end-to-side, or (3) partial approximation of the Vt to
the tracheostomy1 (Fig. 51D.4).
We prefer the end-to-end method, because it allows
flow of large volumes of air into the Vt without the risk
of compression during occlusion of the tracheostomy.
It requires the stump of the trachea to be long enough
to allow for creation of a tracheostomy at the anterior
wall of the remaining trachea, ideally 1.5 cm from the
ileotracheal anastomosis. The secretions from the Vt are
minimal, especially with ileal voice conduits, and actu­
ally decrease to very low levels over time.8
Debulking the mucosa before inset can decrease the
occurrence of mucosal prolapse into the tracheal lumen.
During the end-to-side placement, a 1 cm diameter hole
is created on the side of the trachea deep to the orifice of
the tracheostomy. The goal is to benefit from the stent­
ing effect of the tracheal rings at the periphery of the
anastomosis to prevent compression during occlusion
of the tracheostomy. When the tracheal stump is short,
c
a
b
Fig. 51D.4 The three different configurations of the voice tube–
trachea (Vt-T) junction. (a) End-to-side. (b) Partial approxima­
tion. (c) End-to-end. (Reproduced from Chen HC, Tang YB,
Mardini S, Chen SH. Transfer of Intra-Abdominal Organs for
Advanced Reconstructions. Taichung: Elsevier Taiwan; 2013.)