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SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
966
separate study that ileocolon flaps may be raised safely
using up to 30 cm of terminal ileum without requiring
supplemental oral vitamin B12.16 Thus, with a meticu­
lous technique and appropriate prophylactic measures,
most donor site complications are preventable, are tem­
porary, and should not deter surgeons from employing
this valuable alternative.
Future Directions
Lately, to take advantage of the multiple benefits, we
have started harvesting the ileocolic flap laparoscopi­
cally. The initial results are favorable, with no compro­
mise of the flap. Based on critical review of our results,
we have concluded that for optimum voice quality,
the ideal Vt construct should have the following three
characteristics: ileocecal valve opening of 5 mm, ileal
length of 10 cm, and distance between the Vt-T junc­
tion and the tracheostomy of 1.5 cm.17 Another modi­
fication, which could prove beneficial, is increasing the
firmness of the ileal wall. Further research is required
to substantiate these clinical impressions.
Avoiding and Managing
Complications in Voice Tube
Reconstruction
Redundancy of the Voice Tube
Sometimes, substantial intraoperative swelling of the
flap after revascularization may make it difficult to
judge the appropriate length of the Vt. Excessive lateral
bulging accompanied with straining during phonation
is an indication for correction of the redundancy. A cen­
tral portion of the ileal segment is removed, followed
by two-layer anastomosis.
Regurgitation through the Ileocecal
Valve
We have found that decreasing the ileocecal valve ap­
erture to 0.5 cm eliminates aspiration.8 However, if a
patient presents with persistent respiratory symptoms,
inadequate plication or loosening should be suspected.
Revision plication through an anterior transcolonic ap­
proach provides prompt relief.
Leakage or Stricture at the
Coloesophageal Anastomosis
Persistent leakage, despite conservative measures, is
best addressed with regional pedicled flaps such as del­
topectoral or pectoralis major flaps. Surgical revision
of the anastomosis will provide definitive resolution of
the dysphagia.
Tips and Tricks in Oropharyngeal
Reconstruction
Treating Oral Incontinence After Lower Lip
Reconstruction
Oral incontinence after free flap reconstruction of major
or total defects of the lower lip can be treated with sling
suspension using a tendon graft (palmaris, plantaris, or
extensor tendon of the second or third toe). The tendon
is threaded through a subcutaneous tunnel in the re­
constructed lower lip. Each end is then placed through a
tunnel connecting the oral commissure with the plane
between the deep temporal fascia and the temporalis
muscle. After appropriate adjustment of the tension,
each end is anchored to the anterior third of the tempo­
ralis muscle with 3–0 Prolene Pulvertaft sutures.18
Treating Swallowing Dysfunction with a
Free Jejunal Diversionary Conduit Flap
Chronic radiation damage, corrosive injury of the epi­
glottis, and stroke can sometimes result in swallow­
ing difficulties, aspiration, and choking. When con­
servative therapeutic strategies fail, the patient has to
choose between permanent feeding tubes to preserve
voice or tracheostomy to preserve oral feeding. Even if
voice preservation is chosen, the patient may still suffer
from aspirations of saliva and refluxed gastric content.
We have developed a technique to allow preservation
of both functions. The cervical esophagus is transected
below the thyroid gland. The superior stump of the
transected esophagus is connected to a tubularized
deltopectoral flap to create a permanent pharyngos­
tomy and drain saliva and food residue from the base of
the tongue. The distal stump of the esophagus is con­
nected to the anterior gingivobuccal sulcus via a free
jejunal flap placed subcutaneously over the mandible.
This is the new inlet for food passage. With training, the
patients quickly learn how to direct the food toward
the jejunal opening and regain the ability to eat with a
minimal risk of aspiration.19
Anatomic Variations in Head and Neck
Reconstruction
The variations and interdependence of the perforator
anatomy of the anterolateral and anteromedial flaps
have already been covered. This section addresses sev­
eral other anatomic variations of the most commonly
used flaps in this area.
Anatomic variations are important to keep in mind
during dissections of flaps in the upper limb. A high ori­
gin of the radial artery above the intercondylar line of
the humerus in 10 to 25% of extremities puts a laterally

967
Chapter 51 Oral and Pharyngeal Reconstruction
positioned median nerve at risk. Therefore, if the bra­
chial artery bifurcation is not seen in the cubital fossa,
more cephalad dissection of the radial artery should be
avoided. On the other hand, a superficial ulnar artery,
present in 2% of upper extremities, may initially run me­
dially superficial to the flexors in the cubital fossa be­
fore acquiring a more lateral position toward the wrist.
Thus any thick-walled vessel located under the fascia
should be regarded with suspicion and not mistaken for
the basilic vein. Preoperative palpation, limiting dissec­
tion to the superficial fascia, and deflation of the tour­
niquet to check for pulsation will prevent transection
of the artery.
The anatomy of the jejunal flap has been described
as being consistent without any emphasis on anatomic
variations. In our own series of 120 jejunal flaps over a
5-year period, we encountered 3 patients (2.5%) with
double-vessel anatomy. Two had double jejunal arteries
and one had double jejunal veins. In the double artery
variants, revascularization using just one artery in the
first patient resulted in partial flap necrosis, whereas
double arterial anastomosis in the second patient en­
sured complete survival. Single-vein anastomosis in the
third patient with double jejunal veins caused initial
congestion that improved without a need for a second
venous anastomosis. Unlike cutaneous flaps, jejunum
has unreliable collateral circulation within the bowel
wall, which may be inadequate to sustain its high met­
abolic needs.20
Conclusion
Undoubtedly, pharyngoesophageal and voice recon­
struction with a free ileocolon flap is a technically chal­
lenging procedure. Nevertheless, it is a method that
uses autologous tissue to restore not only swallowing
but a good quality voice in the overwhelming major­
ity of the patients. Attention to technical details and
awareness of anatomic variations will minimize unfa­
vorable results and complications.
References
1. Chen HC, Tang YB, Mardini S, Chen SH. Transfer of
Intra-Abdominal Organs for Advanced Reconstruc­
tions. Taichung: Elsevier Taiwan; 2013:213–40
2. Yang CW. The psychosocial impact of laryngectomy
and voice reconstruction. In: Chen HC, Tang YB, Mar­
dini S, Chen SH, eds. Transfer of Intra-Abdominal Or­
gans for Advanced Reconstructions. 1st ed. Taichung:
Elsevier Taiwan; 2013:4–11
3. Messing BP, Kim M, Hirata R, et al. Evaluation of pro­
phylaxis treatment of Candida in alaryngeal patients
with tracheoesophageal voice prostheses. Laryngo­
scope 2015;125(5):1118–1123
4. Chaturvedi P, Syed S, Pawar PV, et al. Microbial colo­
nization of Provox voice prosthesis in the Indian sce­
nario. Indian J Cancer 2014;51(2):184–188
5. Chen HC, Gharb BB, Rampazzo A, Perrone F, Chen SH,
Trignano E. Simultaneous restoration of voice func­
tion and digestive tract continuity in patients with
synchronous primaries of hypopharynx and thoracic
esophagus with pedicled ileocolon flap. Surgery 2011;
149(5):662–671
6. Mardini S, Chen HC, Salgado CJ, Hsu CM, Chen KT,
Feng GM. Bowel preparation before microvascular
free colon transfer for head and neck reconstruction:
is it necessary? Plast Reconstr Surg 2004;113(7):
1916–1922
7. Tsao CK, Chen HC, Chuang CC, Chen HT, Mardini S,
Coskunfirat K. Adequate venous drainage: the most
critical factor for a successful free jejunal transfer.
Ann Plast Surg 2004;53(3):229–234
8. Rampazzo A, Gharb BB, Spanio di Spilimber­
go S, Chung KP, Chen HC. Voice reconstruction
with free ileocolon flap transfer: implications for
the lower respiratory tract. Plast Reconstr Surg
2011;127(5):1916–1924
9. Karri V, Yang MC, Chung KP, Chen SH, Mardini S, Chen
HC. Total pharyngolaryngectomy and voice recon­
struction with ileocolon free flap: functional out­
come and quality of life. J Plast Reconstr Aesthet Surg
2011;64(7):911–920
10. Chen SH, Tang YB, Chen HC. Survival of transferred il­
eum after ischemia time longer than 1 hour: a clinical
result different from animal studies. J Am Coll Surg
2013;217(2):300–305
11. Yu P, Hanasono MM, Skoracki RJ, et al. Pharyngoeso­
phageal reconstruction with the anterolateral thigh
flap after total laryngopharyngectomy. Cancer 2010;
116(7):1718–1724
12. Chen WF, Chang KP, Chen CH, Shyu VBH, Kao HK. Out­
comes of anterolateral thigh flap reconstruction for
salvage laryngopharyngectomy for hypopharyngeal
cancer after concurrent chemoradiotherapy. PLoS One
2013;8(1):e53985
13. Motoyama S, Saito R, Maruyama K, et al. Sound spec­
trogram analysis in patients receiving Kawahara’s
surgical voice restoration for advanced carcinoma of
the hypopharynx and cervical esophagus. Dis Esoph­
agus 2007;20(1):42–46
14. Chen HC, Mardini S, Yang CW. Voice reconstruction
using the free ileocolon flap versus the pneumatic
artificial larynx: a comparison of patients’ preference
and experience following laryngectomy. J Plast Re­
constr Aesthet Surg 2006;59(12):1269–1275
15. Rampazzo A, Salgado CJ, Gharb BB, Mardini S, Spanio
di Spilimbergo S, Chen HC. Donor-site morbid­
ity after free ileocolon flap transfer for esophageal

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
968
and voice reconstruction. Plast Reconstr Surg
2008;122(6):186e-194e
16. Rampazzo A, Salgado CJ, Gharb BB, Chung TT, Mardini
S, Chen HC. Necessity of Vitamin B12 replacement
following free ileocolon flap transfer. Plast Reconstr
Surg 2008;122(5):153e–154e
17. Tsou YA, Li TS, Tsai MH, Chen HC, Belafsky P. Opti­
mal ileocolic flap length for a reconstructed voice
tube after laryngopharyngectomy. J Laryngol Otol
2016;130(2):190–193
18. Huang TC, Li TS, Weng HC, et al. Sling suspension us­
ing the anterior third of the temporalis muscle ex­
tended with tendon graft to correct oral incontinence
after free flap reconstruction in cases of a major de­
fect of the lower lip muscle. Head Neck 2016;38(5):
683–688
19. Atsushi Imaizumi AI, Anitaa Liem AL, Quand Ngo QN,
Hung-Chi Chen HC. Free jejunal diversionary conduit
flaps following radiation damage to the pharynx: a
technique for regaining oral feeding while preserv­
ing vocal function. J Plast Reconstr Aesthet Surg
2012;65(5):620–628
20. Tan BK, Wong CH, Chen HC. Anatomic variations
in head and neck reconstruction. Semin Plast Surg
2010;24(2):155–170

969
Reconstruction of the Mandible
and Maxilla
Matthew M. Hanasono
Restoration of the mandible and maxilla are among the
most challenging and arduous procedures performed by
reconstructive surgeons. Accuracy is paramount to restor­
ing facial appearance and function, including airway main­
tenance, mastication, swallowing, speech, and, in the case
of the maxilla, vision. This chapter focuses on reconstruc­
tion of segmental defects of the mandible and maxilla that
require grafts and flaps for reconstruction rather than rigid
fixation alone. An understanding of the nuances of recon­
struction of this region of the body can help the surgeon
achieve success in accurate reconstruction and minimize
the chances for complications. Because microvascular free
flaps play a huge role in contemporary mandibular and
maxillary reconstruction, this chapter focuses on avoiding
and treating complications related to free tissue transfer in
addition to addressing other nonmicrovascular complica­
tions that are specific to these structures.
Reconstructive Techniques to
Minimize Complications
Mandibular, and occasionally maxillary, reconstruction
with a reconstruction plate that spans a segmental bony
mandibular defect was a more popular technique before
the development of microvascular free bone flaps. Some
centers still rely, at least occasionally, on reconstructive
plates when a patient is deemed unsuitable for a prolonged
operative procedure involving free tissue transfer or when
a surgeon with microvascular expertise is not available.
However, experience has shown that such reconstructions
are at high risk for complications, including plate fracture
and exposure, either intraorally or through the skin of the
cheek or chin.
To help decrease the rate of exposure, many surgeons
have attempted to combine reconstruction plates with a
pectoralis major muscle or myocutaneous pedicled flap or
a soft tissue free flap. However, Wei et al1 still reported a
complication rate of 69% in patients undergoing mandibu­
lar reconstruction with a titanium plate and soft tissue free
flap in a series of 80 patients. Plate exposure was the most
common complication, followed by soft tissue deficiency,
deformity of the lateral face, intraoral contracture, trismus,
and osteoradionecrosis.
Overall, complication rates associated with a reconstruc­
tive plate and soft tissue flap are reported to be between 21
and 87%.2 Anterior defects are associated with a higher rate
of plate extrusion than lateral defects, as are defects in pa­
tients undergoing radiation treatment or with a history of
prior irradiation. In addition, larger defects result in signifi­
cantly higher failure rates than smaller defects.
Even when patients are reasonable candidates for a free
flap, some surgeons advocate plate or plate and soft tis­
sue flap reconstruction in patients with advanced cancers
and a limited life expectancy, because the surgery is usu­
ally shorter and recovery is usually faster. However, this ap­
proach must be carefully considered on a case-by-case basis,
because the incidence of plate-related complications is high.
In addition, the results are rarely ideal because of persistent
contour deformity and malocclusion. Secondary salvage of
such complications with vascularized bone flaps can be per­
formed but tends to be more difficult than if it is performed
at the time of the surgical resection. Additional difficulties at
the secondary surgery include more challenging dissection
of recipient vessels and greater difficulty restoring accurate
occlusion because of postoperative and radiation therapy–
associated scar contracture.
Autologous Bone Grafts
Autologous bone grafts can be used for mandibular and max­
illary reconstruction. The bone is revascularized by a pro­
cess of creeping substitution. Sources of cortical bone graft
include iliac crest, split calvarium, and rib. Nonvascularized
CHAPTER
52

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
970
viation toward the side of the defect when reconstructed
with a soft tissue flap alone that can be mitigated by slightly
overcorrecting the volume of the defect with the flap. There
is also a tendency toward flap atrophy, especially after radia­
tion therapy, so a bulky flap can help improve the aesthetic
result as well.
Edentulous patients tend to have more deviation of the
mandible, because they do not have teeth to guide their
mandible into proper occlusion, which is another factor to
consider when opting for a soft tissue free flap over an os­
teocutaneous free flap in posterior mandible reconstruction.
In summary, osteocutaneous free flap reconstruction will
tend to have better occlusal outcomes, but bulky soft tissue
free flap reconstructions may be acceptable for patients who
are not good candidates for an osteocutaneous free flap be­
cause of poor functional status, donor site unavailability, or
limited life expectancy.
For the maxilla, soft tissue free flaps or prosthetic obtu­
rators can be considered for defects posterior to the canine
tooth.6,8–10 Defects of the posterior hard palate and alveolus
can usually be reconstructed with soft tissue free flaps, such
as the ALT or RAM free flaps (or the radial forearm fasciocu­
taneous free flap for obese individuals) with good functional
and aesthetic results. It is important to make sure the flap
is inset such that it is not ptotic into the oral cavity, because
this makes concurrent use of a prosthetic for dental restora­
tion difficult or impossible. For anterior defects, bony recon­
struction is necessary to maintain midfacial height, width,
and projection.11
Soft tissue free flaps can be combined with titanium
mesh or bone grafts to reconstruct the orbital floor when
the maxillary defect includes the orbital floor.6 In a review
of orbital floor reconstruction for trauma, Kirby et al12 found
that autologous bone reconstructions were more likely to be
complicated by orbital dystopia and enophthalmos compared
with titanium mesh and porous polyethylene, possibly related
to increased difficulty in shaping the reconstructed orbital
floor, irregular thickness, and unpredictable resorption. Be­
cause accurate reconstruction is very important to prevent
these complications, as well as decreased vision or even blind­
ness related to excessive pressure on the globe or the optic
nerve, the orbit should be preplated with mesh before making
osteotomies whenever possible. This mesh can then be used
for the reconstruction or serves as a template for reconstruc­
tion with bone grafts. Alternatively, I am increasingly using
three-dimensionally printed models to guide titanium mesh
or bone graft reconstruction (Fig. 52.1).
If the orbit is exenterated in combination with a super­
structure maxillectomy that spares the alveolus and pal­
ate, soft tissue free flaps are usually indicated to obliterate
the orbital cavity and close the orbito-sino-nasocutaneous
wound.13 If the palate is also resected with the orbit and rest
of the maxilla, a multipaddled soft tissue free flap is used
to close both the intraoral wound and the orbital wound.
Rarely, the defect is so extensive that the orbit and the an­
terior palate and alveolus are both resected. In such cases,
our reconstructive algorithm would call for a soft tissue free
flap to fill the orbital cavity and an osteocutaneous free flap
bone grafts may be used in defects shorter than 5 cm. High
failure rates are common in longer segments and in anterior
defects. Preoperative or postoperative radiation therapy is
usually considered a contraindication for mandibular recon­
struction with bone grafts regardless of the size of the defect
because of the heavy torque forces on the mandible asso­
ciated with mastication. Therefore use of nonvascularized
bone grafts for mandible reconstruction is usually restricted
to patients with benign disease or who require mandibular
surgery for posttraumatic or orthognathic rather than on­
cologic indications. Bone grafts can be used successfully in
non–load-bearing parts of the maxilla and midface, such as
in orbital reconstruction, but should be supported by well-
vascularized tissues, such a pedicled temporalis or free flap,
especially in the setting of irradiation.
Microvascular Free Flaps
Microvascular free flaps are the preferred method of re­
construction for most segmental mandibular and maxil­
lary oncologic defects. In particular, bone free flaps allow
for restoration of facial contour, provide a stable surface for
mastication, and, as long as there is adequate bone height
and thickness, accommodate osseointegrated implants for
dental restoration. Osteocutaneous free flaps not only re­
place mandibular or maxillary bone, but also are accompa­
nied by a skin paddle that can be used to close soft tissue
defects of the oral cavity and/or of the cheek and neck in
the case of through-and-through defects. The most com­
monly used bony or osteocutaneous free flaps include the
fibula, iliac crest (deep circumflex iliac artery), scapula,
and radial forearm free flaps. Of these, the fibula osseous–
osteocutaneous free flap is probably the most commonly
used at most reconstructive centers.
Soft Tissue Free Flap
For specific defects, soft tissue free flap reconstruction
alone without a reconstruction plate can give acceptable
results for mandibular and maxillary reconstruction. An
osteocutaneous free flap is necessary to maintain facial
symmetry when there is an anterior defect of the mandible
or maxilla.3–6 When there is an isolated posterior defect
of the mandible or maxilla, a soft tissue free flap, such as
the anterolateral thigh (ALT) or rectus abdominis myocuta­
neous (RAM) free flaps, can be used if the patient is not a
good candidate for an osteocutaneous free flap (because of
poor medical condition or peripheral vascular disease, for
example).4,5
For the mandible, posterior defects that encompass the
condyle, ramus, and as far anterior as the parasymphysis can
be reconstructed with a soft tissue free flap. For such defects,
the benefits of osteocutaneous free flap reconstruction are
arguably less, because the aesthetic appearance is less af­
fected by loss of bony structure, the muscles of mastication
cannot generally be reattached in a functional manner, and
there is no perfect substitute for the resected temporoman­
dibular joint.7 There will be a tendency for mandibular de­

971
Chapter 52 Reconstruction of the Mandible and Maxilla
then transferred to a flap-monitoring floor when they are
deemed stable. The advantage of having patients sedated
overnight is it prevents unnecessary agitation and vomit­
ing, which may result in an increased risk of hematoma
or flap compromise. The disadvantage of keeping patients
sedated and on a ventilator overnight is the need for high
to reconstruct the palate and alveolar arch to maintain mid­
facial projection.
Pectoralis Major Myocutaneous
Pedicled Flap
In patients who are poor candidates for a microvascular
free flap reconstruction, the pectoralis major myocutane­
ous (PMMC) pedicled flap is sometimes used to reconstruct
mandibular and maxillary defects.14 Use of this flap, alone
or in combination with a titanium plate as described pre­
viously, should be considered a secondary option. Func­
tional and aesthetic results are rarely optimal. Complica­
tions associated with using this flap include tethering by
the proximal flap and vascular pedicle, restriction of neck
movement and pulling of the bulk of the flap downward,
an unsightly bulge in the neck, and, if adequate cutaneous
perforators are not incorporated into the flap design, partial
skin-paddle necrosis that can lead to a fistula (Fig. 52.2).
If the PMMC flap is used, the skin paddle should be de­
signed so that it is centered over the fourth intercostal space
to provide adequate reach, and the proximal flap should be
debulked as much as possible15 (Fig. 52.3). A long neck and
short torso should be considered a potential contraindica­
tion for maxillary and even some mandibular reconstruc­
tions because of the inadequate reach of this flap.
Postoperative Care
After major head and neck reconstruction, patients are
usually kept sedated and on a ventilator overnight; they are
weaned off the ventilator the next morning as tolerated,
Fig. 52.1 A computer-generated model manufactured using three-
dimensional printing technology assists the surgeon to reconstruct
the left bony orbit by allowing complete visualization of the surgical
defect in the absence of soft tissue structures that limit exposure so
that hardware or bone grafts can be accurately shaped.
Fig. 52.2 A pectoralis major myocutaneous flap used for cheek
reconstruction. The flap has contracted inferiorly, causing a large
wound dehiscence and, subsequently, a fistula. A palatal obturator
is visible through the fistula. The base of the flap is bulky, and neck
movement is limited.
Fig. 52.3 Maximal length of the pectoralis major myocutaneous flap
can be obtained by centering the skin paddle over the interspace
between the fourth and fifth ribs, where there are a number of myo­
cutaneous perforators. Bulk in the neck and contracture of the flap
can be minimized by making the base of the flap narrow, so that a
minimum of muscle is included.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
972
Management of Complications
Associated with Mandible and
Maxilla Reconstruction
Summary Box
Complications Associated with Mandible and
Maxilla Reconstruction
Microvascular
•• Flap loss
•• Pedicle thrombosis
•• Venous thromboembolism
Nonmicrovascular
•• Infection
•• Would dehiscence
•• Fistula
Donor Site
•• Infection
•• Wound dehiscence
•• Skin graft loss (flap loss)
•• Lack of mobility and stability
Management of Microvascular
Complications
At our institution, trained nursing staff in a dedicated free
flap unit perform hourly flap checks for the initial 48 hours
and then every 2 hours for the next 48 hours, and finally
every 4 hours until discharge. Any concern for a microvas­
cular complication mandates immediate evaluation by a
microsurgeon with a low threshold for operative explora­
tion. The use of prophylactic anticoagulants such as hepa­
rin, dextran, aspirin, or low-molecular-weight heparin (i.e.,
enoxaparin) has not been demonstrated to improve flap
survival or decrease pedicle thrombosis, and therefore the
use of anticoagulants is not routine at our institution ex­
cept as prophylaxis against venous thromboembolism.16
Signs of flap compromise such as increased swelling and
bruising, change in color, or loss of the Doppler signal should
prompt an immediate return to the operating room as long
as the patient is medically stable. Early intervention remains
the single most significant predictor of flap salvage, and, as
such, a low threshold should exist for reoperation even at
the slightest suspicion for thrombosis.17–19 A negative ex­
ploration is far preferable to a lost free flap.
Every effort should be made to diagnose the cause of the
flap compromise during reoperation (Fig. 52.4). Making the
volumes of intravenous fluids because of the sedation and
paralysis. Sedation and paralysis often cause hypotension
and require intravenous fluid resuscitation, because va­
sopressors are generally considered contraindicated after
free flap surgery. Therefore patients may become fluid
overloaded, which can cause significant cardiopulmonary
complications in patients with minimal cardiopulmonary
reserve. In recent years, we have opted to allow some pa­
tients to breathe spontaneously without ventilator support
and avoid sedation after surgery in our institution. These
patients seem to recover faster and develop less cardiopul­
monary complications with a shorter hospital stay. Venous
thromboembolism, infection, and delirium tremens pro­
phylaxis are given as indicated.
Patients routinely receive tracheostomy and nasogastric
feeding tube placement at the time of surgery. They then
receive tube feedings for 2 weeks, while intraoral incisions
are allowed to heal. For uncomplicated intraoral defects, a
pureed diet is allowed after 2 weeks if all incisions appear
to have healed without a fistula. For more complex defects,
such those with a concurrent glossectomy, a modified bar­
ium swallow study is obtained to assess swallowing and
to rule out a leak in areas that are not easily visualized by
physical examination. Tracheostomy decannulation can usu­
ally be performed early, around postoperative day 5, when
the immediate postoperative swelling has subsided. In se­
lect cases of maxillary reconstruction where the flap is not
bulky and does not obstruct the airway, a tracheostomy is
not performed, but the airway is closely monitored postop­
eratively in case the flap swells more than expected.
Patients who undergo fibula free flap reconstruction
are allowed to ambulate as early as postoperative day 2,
even in a splint, with weight-bearing as tolerated on the
affected limb.16 Early ambulation is important to prevent
deep venous thrombosis and pulmonary complications.
When not ambulating, the patient is instructed to keep
the donor limb elevated at all times, whether in bed or in
a chair, to facilitate wound and skin graft healing. We usu­
ally allow about 15 to 20 minutes of ambulation or dan­
gling and advance gradually based on the amount of lower
extremity swelling observed.
When the orbit has been reconstructed, a forced duction
test is performed at the end of surgery to rule out entrap­
ment. Corticosteroids are given during surgery and again
postoperatively if there is swelling to prevent pressure on
the globe. If possible, the patient is woken up immediately
after surgery rather than kept sedated so that the vision can
be assessed. Visual checks are performed regularly in the
postoperative period. Any decrease in vision is an indication
for prompt ophthalmologic evaluation. Traumatic optic neu­
ropathy secondary to traction injury is usually treated with
high-dose steroids, and any impingement on the optic nerve
or pressure on the globe should be relieved by emergent
return to the operating room. Diplopia should be followed
with computed tomography (CT) to rule out entrapment or
suboptimal positioning of grafts and hardware used to re­
construct the orbit.

973
Chapter 52 Reconstruction of the Mandible and Maxilla
poor flap design, or injury to the distal circulation during flap
harvest. These usually represent unsalvageable conditions.
Although anticoagulant and antiplatelet medications are
not routinely used as prophylactic agents, I do use them in
select cases after a pedicle thrombosis not only if hyperco­
agulability is suspected but also if we are concerned about
a residual clot in the distal microcirculation of the flap that
could not be extracted during revision surgery. If return to
the operating room is delayed or evidence of thrombosis
of the distal flap circulation exists, I also use small doses of
thrombolytics, such as tissue plasminogen activator (2–6 mg
injected into the recipient artery with a 30-gauge needle or
into a vessel side branch while the vein is clamped for sev­
eral minutes to prevent dilution by release into the systemic
circulation).16 However, in general, many of these interven­
tions have not been demonstrated to have a significant im­
pact on flap salvage.17
correct diagnosis is critical for salvage and prevention of fu­
ture thrombotic events. Causes of flap compromise that can
be corrected by clot removal and anastomotic revision per­
formed in a timely manner include pedicle compression, kink­
ing, or twisting; focal pedicle injury (e.g., those resulting from
intimal injury near the anastomosis); and anastomotic error.
Vein grafts are used as needed to replace sections of damaged
pedicle or recipient vessel and relieve excess tension on the
pedicle and anastomoses. Hypercoagulable conditions may
also result in flap compromise and need to be addressed with
anticoagulants after thrombectomy and anastomotic revision.
Prolonged vasospasm or hypotension resulting in flap com­
promise are extremely rare and should be considered diag­
noses of exclusion. They can be treated with topical vasodi­
lators and by intravascular volume restoration, respectively.
More problematic are thromboses related to purulent infec­
tion, traction injuries to the perforator(s) or distal pedicle,
Yes
No
Flap compromise
Urgent reexploration
Pedicle thrombosis?
Continued close observa­
tion and consider aspirin
and/or systemic heparin
to prevent recurrent
thrombosis
Give thrombotic (e.g.,
tissue plasminogen activa­
tor 2–4 mg into pedicle
artery with vein clamped)
for presumptive distal flap
thrombosis
Continued close observa­
tion and consider aspirin
and/or systemic heparin
to prevent recurrent
thrombosis
Abort and consider second
flap or other reconstructive
options
Yes
No
Restoration of flow?
Yes
No
Restoration of flow?
Diagnosis of flap or recipient vessel arterial throm­bosis,
venous thrombosis, or both
•• Open clotted blood vessel and perform thrombectomy
•• Irrigate with heparin saline
•• Revise anastomoses
•• Utilize alternate recipient blood vessels if compromised
inflow/outflow diagnosed
•• Possible vein graft(s)
Abort and
consider second
flap or other
reconstructive
options
Continued close
observation
Yes
No
Restoration of flow?
Continued close
observation
Treat vasospasm by
removing adventitia,
applying papaverine and/or
lidocaine, and warming flap
Yes
No
Restoration of flow?
Release kinks, twists, sources of compression, or tension
(revise anastomosis or vein graft if need)
Fig. 52.4 Algorithm for evaluating and treating a compromised microvascular free flap.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
974
to undergo another free tissue transfer. For many mandib­
ular and maxillary defects, if a free flap was indicated for
the initial reconstruction, a free flap is still the best option
in the setting of a flap loss and should be considered as
the primary option if there are no definitive contraindica­
tions.22,23 Although a pedicled pectoralis major muscle or
myocutaneous flap, with or without a titanium plate, rep­
resents a potential option in the setting of a free flap loss,
Management of a Flap Loss
In most circumstances, reviving a free flap requires a
lengthy operation, potentially additional donor site mor­
bidity for harvest of vein grafts, added blood loss, need
for blood transfusions, and a prolonged hospital stay and
recovery. In certain circumstances, consideration should
be given to abandoning a flap, immediately or after a
judicious salvage attempt, and performing a second re­
construction rather than putting the patient through an
extensive flap salvage operation, which may ultimately
prove futile. We have demonstrated that delayed flap
thromboses occurring later than 3 days after reconstruc­
tion and late recognition of flap compromise in which
both the artery and vein are thrombosed are associated
with significantly lower salvage rates. Similarly, compro­
mised muscle-only flaps are also associated with worse
salvage outcomes compared with fasciocutaneous and os­
teocutaneous free flaps. Multiple attempts at salvaging a
failing free flap result in the most dismal prognosis and
are not recommended.20 Before every attempt at salvaging
a failing free flap, I discuss the possibility of abandoning
the flap and performing an alternate reconstruction, ei­
ther in the same setting or after a delay to wait for more
optimal conditions in terms of the patient’s medical con­
dition and the freshness of the surgical team.
Ultimately, in the setting of a flap loss, the reconstruc­
tive microsurgeon is faced with a dilemma of whether to
proceed with another free flap or pursue another option
such as a pedicle flap or a prosthetic obturator (in the case
of maxillectomy defects).6,21 In my experience, the loss of
a free flap does not preclude the patient from another free
flap provided that the patient is stable and medically able
Fig. 52.6 Coronal view of a computed tomography angiogram show­
ing patent external iliac and deep circumflex iliac arteries bilaterally
(arrows).
Fig. 52.5 (a) Computed tomography (axial view) of a right hemimandibulectomy performed for a mandibular ameloblastoma reconstructed
with a titanium plate and pectoralis major muscle flap. (b) Intraoral exposure of the titanium plate that occurred several months after surgery.
a
b

975
Chapter 52 Reconstruction of the Mandible and Maxilla
at least for mandibular reconstruction, I usually prefer to
use a second free flap, which has proven to be equally suc­
cessful and demonstrates superior aesthetic and functional
outcomes.21
Patient management after a flap loss is to some extent
dependent on identifying the cause of the flap, if possible,
and taking the necessary steps to avoid the same conditions
when performing a second flap. For example, if there is a
suspicion for a hypercoagulable state, consideration should
be given toward a hematology consult.21 The loss of a free
flap used to reconstruct the mandible or maxilla because
of infection or fistula (see later discussion) results in an in­
flamed, infected wound that may require antibiotics and se­
rial débridement and washouts before another free flap re­
construction is done. When performing a second free flap,
the surgeon and patient should be prepared for the use of
alternate recipient vessels such as the transverse cervical
vessels, contralateral neck vessels, internal mammary ves­
sels, thoracoacromial vessels, or the cephalic vein and for the
use of vein grafts.21,24
Anterior superior iliac spine
(ASIS) replaces the angle
of the mandible.
a
b
Fig. 52.7 (a) Three-dimensional reconstruction of the iliac bone.
Using computer-aided design (CAD) software, a right mandibu­
lar reconstruction has been planned. The planned iliac crest bone
free flap is shown in light blue. The portion of the bone colored
green will be removed and discarded. Use of CAD can be especially
helpful when a prior resection has been performed and the original
mandible is not present to use as a template for reconstruction.
(b) A computer-generated cutting guide is used to help make oste­
otomies that duplicate the plan.
Fig. 52.8 An iliac crest bone free flap used for right mandibular re­
construction.
Fig. 52.9 Postoperative appearance after iliac crest bone free flap
reconstruction that demonstrated good facial symmetry.
Particularly when a patient who is referred for recon­
struction has lost a flap performed by another surgeon, I have
found it useful to perform preoperative CT angiography of the
potential flap vasculature to identify any abnormalities that
may have caused the flap loss25–28 (Figs. 52.5 and 52.6). CT an­
giography of the neck may also be helpful in identifying avail­
able recipient blood vessels, especially when the prior surgery
was performed by a different surgeon. Finally, in the setting
of a delayed secondary reconstruction in which the original
architecture of the mandible or maxilla is unknown, com­
puter-aided design (CAD) of the reconstruction can be used to
produce three-dimensional medical models, and computer-
generated cutting guides can be invaluable in performing an
accurate restoration27,28 (Figs. 52.7–52.9). In such cases, the
fibula or other bony free flap can be shaped on the computer
“virtually” so as to best restore facial shape and dental occlu­
sion. Computer-generated cutting guides help the surgeon
to make osteotomies such that the bony segments of the flap
have the precise lengths and angles needed to replicate the
preoperative plan made on the computer.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
976
cated prevention with mouth-opening exercises is critical to
maintaining long-term function. Cicatricial trismus is often
more easily treated with scar release and intraoral z-plasty
or, when severe, an additional cutaneous free flap, such as
the radial forearm flap. Hardware failure is very rare because
of excellent bony healing of free flap tissues, but radiated
bone may necessitate a new free flap (Figs. 52.12–52.14).
Another promising development is the availability of com­
puter-planned, custom-made titanium plates. Such plates
are milled from a solid block of titanium and, because they
have never been bent, are much stronger than traditional
plates, but they also have a very low profile, which helps
prevent plate exposure through radiated skin.
Management of Fistula
The development of an orocutaneous fistula is often a ma­
jor complication that can potentially lead to flap failure or
death if a patient suffers a carotid blowout. A high index of
suspicion should be exercised in all patients who have re­
ceived preoperative radiation, chemotherapy, and surgery.
Prolonged swelling, increasing erythema, malodorous or
purulent discharge, or changes in drain output should all
prompt further evaluation. Patients may or may not exhibit
leukocytosis and fever. CT or a barium swallow may be in­
dicated to evaluate for the possibility of a fistula but are not
required for an obvious fistula. Early exploration is almost
always warranted, because free flap pedicle thrombosis
secondary to infection is almost never salvageable. A so-
called “herald bleed” should be considered an emergency
that warrants urgent exploration to prevent a life-threat­
ening complication. Before neck exploration, irrigation,
and débridement, the potential risks for multiple surgeries,
prolonged wound care, and a flap loss should be explained
to the patient.
Empiric antibiotics are given and wound cultures are
obtained at the time of neck exploration. Antibiotics are
adjusted as indicated by the results of the wound culture.
Based on experience, I manage fistulas with repeated op­
erative or bedside irrigation and débridement procedures
Management of Nonmicrovascular
Complications
Aside from complications associated with the microvascu­
lar anastomosis, patients undergoing free flap reconstruc­
tion are potentially at risk for a number of other compli­
cations. Often, patients undergoing major resections and
reconstructive operations for extensive tumors are mal­
nourished, have had prior radiation and chemotherapy, and
have had a history of or may be actively using tobacco prod­
ucts. Consequently, these patients are potentially at risk for
infection, wound dehiscence, and fistula formation during
the perioperative recovery period.
Although superficial infections can be managed with
antibiotics, purulent deep space infections warrant prompt
operative intervention. Early, aggressive drainage and irri­
gation of a neck abscess is critical to minimize the risk of a
vascular rupture or flap loss. Infection can cause flap pedicle
thrombosis, and, as mentioned previously, such cases of flap
compromise are rarely, if ever, salvageable.
Although minor wound separation can be managed con­
servatively, exposure of blood vessels, bone, or hardware
warrants further surgery. In the setting of prior radiation
and surgery, preemptive replacement of damaged neck skin
with external flap coverage should be considered. Designing
a flap with two independent skin paddles based on inde­
pendent perforating blood vessels, or a chimeric flap with a
skin and muscle component in which the muscle can be skin
grafted, to separately close intraoral and extraoral defects
obviates suturing radiated tissue together and may minimize
the risk of wound dehiscence (Fig. 52.10). When this is not
possible, a second free flap or a pedicled PMMC can be used
for neck coverage (Fig. 52.11).
Late complications include trismus and hardware fail­
ure. Trismus may be related to fibrosis of the temporoman­
dibular joint (TMJ) secondary to radiation therapy or to cic­
atricial contracture of the skin paddle in some cases. TMJ
fibrosis is usually treated conservatively with physiother­
apy but is unfortunately often recalcitrant and may interfere
with eating and dental care and restoration. Early and dedi­
Fig. 52.10 A fibula osteomyocutaneous free flap to be used in a
mandibular reconstruction. A skin-grafted hemisoleus muscle sup­
plied by a proximal branch of the peroneal artery can be used to
close a small neck defect. A skin paddle based on a separate perfo­
rator arising from a distal peroneal artery is used to reconstruct the
intraoral defect.

977
Chapter 52 Reconstruction of the Mandible and Maxilla
are usually unsuccessful. In some cases, small fistulas that
do not come in contact with the carotid artery or internal
jugular vein, as well as a free flap pedicle or hardware, can be
managed conservatively and allowed to heal on their own.
In maxillary reconstruction, a nasopalatal or nasocu­
taneous (including sino-nasocutaneous and orbito-sino-­
nasocutaneous) fistula may also occur. Such fistulas, though
rarely, if ever, life-threatening, can result in permanent func­
tional impairments, such as nasal regurgitation in the case
of a nasopalatal fistula. Small fistulas can sometimes be
reclosed primarily if they occur early, before wound con­
tracture and scar tissue formation, provided they are not
until the wound is clean. If the free flap has been lost, a sec­
ond free flap is performed only when the wound is clean,
because performing a free flap in a grossly infected field is
associated with an increased risk of failure. Orocutaneous
fistula reconstruction is usually performed with a pectora­
lis major muscle or myocutaneous flap, because attempts to
close the fistula in the acute stage when tissues are inflamed
a
b
c
Fig. 52.11 (a) A fibula osteocutaneous free flap is used to reconstruct the right mandibular body and lower ramus. (b) The radiated neck
skin has retracted and cannot be closed primarily without a substantial amount of tension, increasing the risk for a wound dehiscence.
Also, as the forceps demonstrate, there is a cutaneous “buttonhole” wound resulting from resection of the mandible and overlying soft
tissues directly beneath. (c) Therefore, an anterolateral thigh perforator flap was used to replace the neck skin. A portion of the flap was
­deepithelialized and placed beneath the buttonhole wound.
Fig. 52.12 A fractured titanium reconstruction plate (arrow) in a
patient who had a fibula free flap reconstruction after a right seg­
mental mandibulectomy for cancer.
Fig 52.13 Excision of a previously irradiated fibula free flap and frac­
tured titanium reconstruction plate.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
978
associated with gross infection. Late fistulas in irradiated
patients, regardless of size, can rarely be reclosed with local
tissues or flaps in my experience (Figs. 52.15 and 52.16).
Nasopalatal fistulas can often be treated with a palatal pros­
thesis that clasps to the remaining teeth to cover the hole.
Nasocutaneous fistulas, though unsightly and associated
with chronic mucous crust formation, can be left alone pro­
vided there is no hardware exposure and the orbit remains
well supported. Difficulties with primary or local tissue flap
closure probably stem from the constant pressure of air dur­
ing breathing and nose blowing as well as chronic bacterial
contamination.
Tissue closure of a nasopalatal or nasocutaneous fistula
usually requires another free flap. In such cases, complete
débridement of poorly vascularized tissues at the margins,
sometimes including removal of the prior free flap, as well
as necrotic bone should be performed. In some cases, dé­
bridement of the skull base in collaboration with a neuro­
a
b
c
Fig. 52.14 (a) Three-dimensional rapid prototype model of a patient’s mandible and planned second fibula free flap reconstruction and the
computer-planned custom-made titanium reconstruction plate. (b) Screw holes are placed in locations and angles specified by the surgeon.
Although lower profile, a milled titanium plate is substantially stronger than one that is bent by the surgeon. (c) The second fibula free flap
is fixed to the remaining left mandible with the custom-made titanium reconstruction plate.
surgeon is indicated. When possible, suture lines should be
placed over bone rather than over an air-filled cavity. Dead
space should be obliterated with the new flap. Because pa­
tients who have had maxillectomy and radiation treatment
often have chronic nasal crusting and sinusitis, periopera­
tive antibiotics and meticulous postoperative nasal hygiene
in coordination with an otolaryngologist or head and neck
surgeon is helpful. Treatment of these fistulas in the setting
of prior surgery and irradiation with the ongoing challenges
of air pressure from nasal breathing and chronic bacterial
contamination can be very challenging.
Donor Site Complications
Although donor site availability, body habitus, and surgeon
preference determine free flap selection, like other sur­
geons I rely greatly on the fibula and ALT free flaps for their
reliability, appropriateness for the majority of mandibular

979
Chapter 52 Reconstruction of the Mandible and Maxilla
a
b
c
d
e
f
Fig. 52.16 (a) Right orbitomaxillectomy performed for squamous cell carcinoma originating in the right cheek and invading the orbit and
maxilla. (b) The right orbitomaxillectomy was reconstructed with an anterolateral thigh free flap anastomosed to the right facial artery and
vein. (c) After right orbitomaxillectomy and anterolateral thigh free flap reconstruction with postoperative radiation therapy, the patient
underwent flap debulking and placement of an orbital prosthesis. Unfortunately, she developed a small nasocutaneous fistula. (d) The
fistula gradually enlarged over several months. (e) A second anterolateral thigh free flap was performed, débriding nonviable bone at the
margins and completely removing the prior free flap. (f) Postoperative appearance after a second anterolateral thigh free flap reconstruc­
tion to close a nasocutaneous fistula.
Fig. 52.15 Postoperative appearance showing good facial symmetry after a computer-
planned second fibula free flap performed after removal of a fractured fibula and titanium
reconstruction plate. Note that the lips were previously reconstructed with Karapandzic flaps
during the original surgery.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
980
roma, 2% incidence of wound dehiscence, and 1% incidence
of infection.30 Eight percent of patients reported weak­
ness or instability at their initial postoperative visit, but
this resolved in all patients within 6 months. Regardless of
whether the flap was harvested as a pure perforator flap or
a myocutaneous flap, all patients returned to their preop­
erative level of activity. When primary closure of the thigh
donor site cannot be achieved, a split-thickness skin graft is
applied. Loss of the graft occurs if the knee is not immobi­
lized during healing. However, such losses are usually par­
tial and heal spontaneously with conservative nonsurgical
treatment.
Conclusion
Substantial preoperative planning, attention to detail during
surgery, and close monitoring after surgery are especially
important in mandibular and maxillary reconstruction, not
only for flap survival but for good ­postoperative function
and aesthetics. Emergent return to the operating room is
essential for flap salvage. Flap salvage requires accurate
­diagnosis of the cause for flap compromise so measures can
be taken to correct the inciting event and prevent it from
recurring. Purulent infections and fistulas should be ­readily
irrigated and débrided in the operating room, ­because
­infections can lead to pedicle thrombosis and/or vascular
rupture and systemic illness. Under the appropriate con­
ditions, a second free flap after loss of an initial free flap
can be performed with high success rates and is usually the
best reconstructive option.
and maxillary reconstructions, and acceptable donor site
morbidity. Prospective studies regarding donor site mor­
bidity with these flaps have demonstrated a low risk of
major complications with good long-term functional out­
comes.29,30 In general, most infections, wound dehiscences,
and superficial complications can be avoided with careful
tissue handling, meticulous technique, tension-free clo­
sure, and appropriate care of skin grafts.
Analysis of 157 consecutive patients undergoing a fib­
ula free flap reconstruction demonstrated approximately one
third of patients experienced a complication in the periopera­
tive period, including skin graft loss (15%), infection (11%), and
wound dehiscence (8%).29 Furthermore, 8% reported weakness,
9% noted issues with contracture of the great toe, 12% reported
reduced ankle mobility, and 4% complained of decreased ankle
stability. Nonetheless, 96% of patients returned to their preop­
erative functional status after reconstruction.29
Although not observed in my series, the greatest risk in
fibula free flap harvest is devascularization of the lower ex­
tremity. This dreaded complication can be avoided by care­
ful preoperative history and physical examination for lower
extremity vascular disease and conventional, CT, or MRI an­
giography when a concern arises, with selection of another
flap donor site if circulation is found to be compromised.
The patient’s lower leg should always be examined, check­
ing for pedal pulses and distal perfusion. If there are signs
of vascular insufficiency, a reversed vein graft can be used
to rebuild the peroneal artery.
Analysis of 220 consecutive patients undergoing ALT
free flap reconstruction demonstrated a 5% incidence of se­
References
1. Wei FC, Celik N, Yang WG, Chen IH, Chang YM, Chen HC.
Complications after reconstruction by plate and soft-
tissue free flap in composite mandibular defects and sec­
ondary salvage reconstruction with osteocutaneous flap.
Plast Reconstr Surg 2003;112(1):37–42
2. Mariani PB, Kowalski LP, Magrin J. Reconstruction of large
defects postmandibulectomy for oral cancer using plates
and myocutaneous flaps: a long-term follow-up. Int J Oral
Maxillofac Surg 2006;35(5):427–432
3. Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Reconstruction of
the mandible with osseous free flaps: a 10-year experi­
ence with 150 consecutive patients. Plast Reconstr Surg
1999;104(5):1314–1320
4. Mosahebi A, Chaudhry A, McCarthy CM, et al. Reconstruc­
tion of extensive composite posterolateral mandibular
defects using nonosseous free tissue transfer. Plast Recon­
str Surg 2009;124(5):1571–1577
5. Hanasono MM, Zevallos JP, Skoracki RJ, Yu P. A prospec­
tive analysis of bony versus soft-tissue reconstruction
for posterior mandibular defects. Plast Reconstr Surg
2010;125(5):1413–1421
6. Wax MK, Winslow CP, Hansen J, et al. A retrospec­
tive analysis of temporomandibular joint reconstruc­
tion with free fibula microvascular flap. Laryngoscope
2000;110(6):977–981
7. Hanasono MM, Silva AK, Yu P, Skoracki RJ. A comprehen­
sive algorithm for oncologic maxillary reconstruction.
Plast Reconstr Surg 2013;131(1):47–60
8. Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodon­
tic guidelines for surgical reconstruction of the max­
illa: a classification system of defects. J Prosthet Dent
2001;86(4):352–363
9. Cordeiro PG, Santamaria E. A classification system and al­
gorithm for reconstruction of maxillectomy and midfacial
defects. Plast Reconstr Surg 2000;105(7):2331–2346, dis­
cussion 2347–2348
10. Brown JS, Shaw RJ. Reconstruction of the maxilla and
midface: introducing a new classification. Lancet Oncol
2010;11(10):1001–1008
11. Hanasono MM, Skoracki RJ. The omega-shaped fib­
ula osteocutaneous free flap for reconstruction of
extensive
midfacial
defects.
Plast
Reconstr
Surg
2010;125(4):160e–162e
12. Kirby EJ, Turner JB, Davenport DL, Vasconez HC. Orbital
floor fractures: outcomes of reconstruction. Ann Plast
Surg 2011;66(5):508–512
13. Hanasono MM, Lee JC, Yang JS, Skoracki RJ, Reece GP,
Esmaeli B. An algorithmic approach to reconstructive
surgery and prosthetic rehabilitation after orbital exen­
teration. Plast Reconstr Surg 2009;123(1):98–105

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23. Wei FC, Demirkan F, Chen HC, et al. The outcome of failed
free flaps in head and neck and extremity reconstruction:
what is next in the reconstructive ladder? Plast Reconstr
Surg 2001;108(5):1154–1160, discussion 1161–1162
24. Hanasono MM, Barnea Y, Skoracki RJ. Microvascular sur­
gery in the previously operated and irradiated neck. Mi­
crosurgery 2009;29(1):1–7
25. Garvey PB, Selber JC, Madewell JE, Bidaut L, Feng L, Yu
P. A prospective study of preoperative computed to­
mographic angiography for head and neck reconstruc­
tion with anterolateral thigh flaps. Plast Reconstr Surg
2011;127(4):1505–1514
26. Garvey PB, Chang EI, Selber JC, et al. A prospective
study of preoperative computed tomographic angio­
graphic mapping of free fibula osteocutaneous flaps
for head and neck reconstruction. Plast Reconstr Surg
2012;130(4):541e–549e
27. Hanasono MM, Jacob RF, Bidaut L, Robb GL, Skoracki RJ.
Midfacial reconstruction using virtual planning, rapid
prototype modeling, and stereotactic navigation. Plast Re­
constr Surg 2010;126(6):2002–2006
28. Hanasono MM, Skoracki RJ. Computer-assisted design and
rapid prototype modeling in microvascular mandible re­
construction. Laryngoscope 2013;123(3):597–604
29. Momoh AO, Yu P, Skoracki RJ, Liu S, Feng L, Hanasono MM.
A prospective cohort study of fibula free flap donor-site
morbidity in 157 consecutive patients. Plast Reconstr
Surg 2011;128(3):714–720
30. Hanasono MM, Skoracki RJ, Yu P. A prospective study of
donor-site morbidity after anterolateral thigh fasciocu­
taneous and myocutaneous free flap harvest in 220 pa­
tients. Plast Reconstr Surg 2010;125(1):209–214
14. Schneider DS, Wu V, Wax MK. Indications for pedicled
pectoralis major flap in a free tissue transfer practice.
Head Neck 2012;34(8):1106–1110
15. Rikimaru H, Kiyokawa K, Inoue Y, Tai Y. Three-
dimensional anatomical vascular distribution in the
pectoralis major myocutaneous flap. Plast Reconstr Surg
2005;115(5):1342–1352, discussion 1353–1354
16. Hanasono MM, Butler CE. Prevention and treatment of
thrombosis in microvascular surgery. J Reconstr Micro­
surg 2008;24(5):305–314
17. Chang EI, Zhang H, Liu J, Yu P, Skoracki RJ, Hanasono MM.
Analysis of risk factors for flap loss and salvage in free flap
head and neck reconstruction. Head Neck 2016;38(Suppl
1):E771–E775
18. Chen KT, Mardini S, Chuang DC, et al. Timing of presenta­
tion of the first signs of vascular compromise dictates the
salvage outcome of free flap transfers. Plast Reconstr Surg
2007;120(1):187–195
19. Yu P, Chang DW, Miller MJ, Reece G, Robb GL. Analysis of
49 cases of flap compromise in 1310 free flaps for head
and neck reconstruction. Head Neck 2009;31(1):45–51
20. Selber JC, Angel Soto-Miranda M, Liu J, Robb G. The sur­
vival curve: factors impacting the outcome of free flap
take-backs. Plast Reconstr Surg 2012;130(1):105–113
21. Corbitt C, Skoracki RJ, Yu P, Hanasono MM. Free flap
failure in head and neck reconstruction. Head Neck
2014;36(10):1440–1445
22. Moreno MA, Skoracki RJ, Hanna EY, Hanasono MM.
Microvascular free flap reconstruction versus pala­
tal obturation for maxillectomy defects. Head Neck
2010;32(7):860–868
Discussion by Giorgio De Santis and Alessio Baccarani
Head and neck reconstruction is mainly performed af­
ter oncologic resections. Functionally head and neck
reconstructions address several regions of interest;
namely, the scalp and cranium, the midface, the skull
base, the mandible, and the pharyngoesophagus. The
goals of head and neck reconstruction are to restore
form, function, and aesthetics by selecting appropri­
ate and safe techniques. To achieve this, good wound
healing has to be accomplished in frequently hostile
environments. Use of the reconstructive ladder as
a guide for reconstruction is appropriate, because
most small defects can be successfully managed with
local flaps or nonvascularized grafts. However, when
large composite defects are to be restored, free flaps
are required.1,2 The importance of a free flap is high­
lighted by the fact that a failed free flap in head and
neck jaw reconstruction may necessitate reconstruc­
tion with a second or even third free flap.3 Success
rates for free flaps in the head and neck and upper
extremities are high, at around 97 to 98%.3,4 Only
slightly lower success rates may be achieved even
in the elderly population.5,6 Complete functional re­
habilitation, however, involves not only skeletal and
soft tissue reconstruction, but also implant insertion,
peri-implant soft tissue management, and eventually
prosthetic restoration.
In general terms, complications may occur in each
of the aforementioned phases, and these are classified
by location, timing, and pathogenesis (Table 52D.1).
For simplicity, this discussion considers general com­
plications first that occur regardless of the specific
reconstruction performed. Next, more specific regional
complications with respect to the midface and mandible
are briefly analyzed.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
982
General Complications
Total Free Flap Failure
Common causes of free flap failure include arterial and
venous thrombosis, infection, anatomic variations, and
flap dissection technical errors (e.g., vascular pedicle
anomalies and flap elevation problems).2,3,7
Arterial Failure
In the head and neck region, there are three common
causes of thrombosis resulting in flap failure:
1. Bleeding
2. Extrinsic compression and kinking of the vessel
3. Avulsion of the anastomosis related to uncontrolled
physical movement or coughing bouts
Arterial spasm is an uncommon cause, unlike in the ex­
tremities, where the recipient arteries are more mus­
cular and prone to spasm. Bleeding can occur at any
point along the anastomosis where vessel apposition
is poor, which could be related to vessel mismatch or
a faulty suturing technique. Platelets aggregate at the
gap in an attempt to seal the leak, and this promotes
thrombosis. Aside from the anastomotic line, bleeding
may originate from small arterial branches because of
slipped ligatures or hemoclips. A hematoma that ac­
cumulates around the pedicle is a potent stimulus of
vessel spasm.
Potential bleeding points may not be immediately
apparent because of the hypotensive state the patient
is in during anesthesia. Thus bleeding usually manifests
during reversal from anesthesia or in the intensive care
unit when blood pressure has normalized. Hemodilution
is yet another factor that creates a bleeding tendency;
this is easily avoided by using blood products instead of
crystalloids to correct for hypovolemia.
Bleeding is an indication for reexploration. A leak­
ing point at the anastomosis can be sealed by placing
additional sutures. Sometimes an adventitial stitch is
all that is necessary to avoid new needle punctures. If a
thrombus is seen, it should be extracted and the anas­
tomosis revised, because the segment of vessel has be­
come thrombogenic. If the vessel has been joined to the
carotid artery and is leaking, additional sutures would
be necessary to stem the bleed. If possible, the surgeon
should avoid end-to-side anastomosis to the carotid
artery. Kinking of the pedicle happens when there is
vessel redundancy. The lay of the vessels is checked
before closing the wound, and adjustments are made
by anchoring sutures to create a smooth curve if there
Table 52D.1 Complications for mandible reconstruction with
vascularized fibular flap
Skeletal reconstruction
Implantology
Soft tissues management
Recipient site
Early
Vascular
Neurologic
Instability
Mucosal dehiscence
Infection
Late
Nonunion or delayed union
Fistulas, sequestrectomy
defects, plate exposure
Failure to establish
osseointegration
Peri-implant inflammatory hyperplasia
Donor site
Early
Vascular
Neurologic
Dehiscence
Late
Ankle instability
1–2-degree toe stiffness
Perimalleolar edema
Poor scarring
Cutaneous dyschromia

983
Chapter 52 Reconstruction of the Mandible and Maxilla
is redundancy. Alternatively, the redundant segment
may be shortened.
Compression of the pedicle can be a consequence
of tunneling. A tunnel that is too narrow gives no allow­
ance for swelling. An adequate tunnel is one that allows
the easy passage of two fingers. During reexploration
for a case of tight tunneling, the pedicle should ideally
be rerouted, and this may entail use of vein grafts if the
pedicle is short. If this is not possible, a simple measure
is to lay the subcutaneous tunnel open with a skin flap
incision. The pedicle remains covered by the skin flap,
and the secondary defect is skin grafted. Naturally, the
aesthetic outcome is far from ideal, but its expense is
justified if the flap is salvaged. Subsequently, the scars
may require revision at a later date.
Occasionally, the pedicle may be compressed against
bone, such as the osteotomized edges of the mandi­
ble and maxilla. If the vessel is abutting against bone,
the surgeon should ensure that the point of contact is
smoothed or, better still, recessed and soft tissue intro­
duced to cushion the pedicle.
Venous Failure
Veins, being low-pressure systems, are more suscep­
tible to compression, twisting, and kinking. Spasm is
uncommon. The same measures for preventing and
rectifying vessel occlusion in the previous section ap­
ply, with one additional measure, which is to anasto­
mose an extra vessel. Most pedicles have paired veins.
In the radial forearm flap, for example, the venae co­
mitantes and cephalic vein can be joined to the inter­
nal jugular and external jugular veins, respectively. An
extra outflow channel means that venous drainage is
safeguarded even when one system is obstructed.
In the event of venous congestion, reexploration
should be undertaken urgently. Any clot formed in the
vessel lumen is expelled by gently squeezing the ves­
sels and manually extracting the clots with a jeweler’s
forceps (Fig. 52D.1). Depending on the microvascular
flap used, flushing saline into the vein may be avoided,
because this propels the clots deeper toward the micro­
circulatory system.
a
b
c
d
Fig. 52D.1 (a) A fibula flap revision after thrombosis. (b) The clot is removed from the vein. (c) The flap is reinset after washout.
(d) Postoperative view showing muscle reepithelialization.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
984
Second Flap After Total Flap Failure
When faced with total flap failure, one salvage option
is to use a pedicled flap such as the pectoralis major
myocutaneous flap, the deltopectoral flap, or the lower
trapezius flap. Recent literature,2 however, advocates a
second free flap for the following reasons:
•• To cover exposed critical structures such as the brain
and neck vessels that are out of the reach of pedicled
flaps
•• To facilitate early adjuvant treatment, because free
flaps have better vascularity and heal more quickly
•• To obtain specialized tissue such as bone for
mandible reconstruction
•• To reduce complications related to delayed wound
healing
The only contraindication is a deteriorating and unfit
patient. Severe infection is a relative contraindication
that can be treated with adequate débridement.
Virgin recipient vessels should be used for revascu­
larization of the second free flap, because the original
recipient vessels may be inflamed. The most common
primary arterial recipient vessels are the facial and su­
perior thyroid arteries. Therefore, in the event of flap
failure, alternative vessels include the ipsilateral super­
ficial temporal vessels, the transverse cervical vessels,
or the contralateral superior thyroid artery. Regarding
venous drainage, if the ipsilateral neck is to be reused,
then the cephalic vein can be transposed up to the neck
when the external or internal jugular veins are not avail­
able.7,8 Alternatively, the surgeon may use contralateral
neck vessels, but this would entail the use of vein grafts.
Partial Free Flap Failure
In some instances vascular impairment may occur at the
distal pedicle only, thus inducing partial flap ischemia.
This event is usually related to extrinsic compression
or trauma. If evidence exists early in the postop­
erative period, pedicle reexploration and an attempt
to salvage is recommended, before retrograde clot­
ting occurs. If partial flap sufferance develops late in
the postoperative period (after day 5 or 6), a salvage
procedure and pedicle reexploration may not be use­
ful. In the case of a microvascular reconstruction with
a bone flap, such as the fibula, the ischemic segment
may be débrided and still used for reconstruction as a
nonvascularized graft (Fig. 52D.2) if local conditions
are permissive.
Carotid Blowout
Sudden massive bleeding in a previously irradiated
neck suggests a blowout of the carotid artery. This con­
dition can occur as a complication of head and neck sur­
gery in which the carotid arteries have been stripped
bare, manipulated, or used as a recipient vessel for free
flaps. Urgent repair of the blowout often involves use
of a vein patch or an interpositional vessel graft.9 The
entire vessel must be covered with well-vascularized
soft tissue to prevent further blowouts. An emergency
flap such as a pedicled pectoralis major muscle flap is a
good option for this purpose.
Plate Exposure
Plates, screws, and titanium meshes used in head
and neck reconstruction may become exposed in an
early or late setting. Causes of early exposure include
wound dehiscence related to tension, infection, or
flap necrosis. If the exposed area is small and located
over a noncritical area such as the external surface of
the mandible, then the wound can be dressed and al­
lowed to granulate before secondary closure is consid­
ered. New implant materials such as titanium are inert
and seldom incite a foreign body response even in the
presence of infection. Nevertheless, the surgeon needs
to plan for rapid closure, because the implant might
loosen and allow the underlying skeletal fixation to lose
its stability. The wound could be closed secondarily by
skin advancement or by a flap such as the deltopec­
toral flap if skin is deficient. Intraorally, exposed plates
above the salivary line can often be left in situ until
the bone has healed. This is sometimes the case for a
fibula-reconstructed upper alveolus in which skin is
not included because of excessive bulk. Exposed mini­
plates will gradually become overgrown with granula­
tion tissue and mucosa over 6 to 9 months, as long as
the bone is well vascularized. Below the salivary line, a
wound with an exposed plate heals poorly because it
is constantly bathed in saliva. A common scenario is a
patient with mandibular reconstruction experiencing a
suture line breakdown at the lower buccal or labial sul­
cus and developing a salivary fistula. In such situations,
fresh soft tissue must be imported to close the defect. A
tongue flap may be useful for this purpose. Secondary
sutures will break down if the wound is under tension.
Late exposure of the implant is usually related to
thinning of the skin over the implant, which may oc­
cur as a result of radiation therapy. This can be avoided
by interposing a layer of soft tissue between the skin
and the implant. In fibula flaps used for mandibular re­
construction, a deepithelialized portion of the intra­
oral skin paddle is routinely used to provide an extra
soft tissue layer over the reconstruction plate. Initially,
the added bulk may appear excessive, but this eventu­
ally subsides with radiotherapy. An exposed implant is
simply removed if the bone has united, and the exist­
ing wound will usually heal spontaneously. If there is

985
Chapter 52 Reconstruction of the Mandible and Maxilla
non-union, it should be bone grafted, refixed, and cov­
ered with a flap.
Ectropion
Ectropion is defined as eversion of the lid margin from
the globe. The condition is graded as mild, moderate, or
severe. Chronic ectropion results in exposure keratitis
of the conjunctiva, which contributes to ocular irrita­
tion and may lead to blindness.10
This complication is commonly seen after flap re­
construction of through-and-through maxillectomy de­
fects. Resection of maxillary tumors may result in the
loss of cheek skin, oronasal lining, and the underlying
maxilla and zygoma. Such defects with requirements for
skin, bone, and mucosa are reconstructed using compos­
ite osteocutaneous free flaps such as the scapular flap
or fibular flap or with bone grafts in combination with
a soft tissue free flap such as an anterolateral thigh flap.
Ectropion may develop because of the pull exerted by
the flap on the lower eyelid. Osteotomized osteocutane­
ous flaps allow less free play between bone and skin and
make it harder to achieve the dual goal of eyelid support
and contour restoration. An accurately reconstructed
a
b
c
d
e
f
Fig. 52D.2 (a) Partial flap necrosis after maxilla reconstruction with a fibula flap. (b) The distal devascularized bony segment is
removed and débrided. (c) The bony segment is reinset as a nonvascularized graft and (d) covered with well-perfused soft tissues.
(e) Mucosal healing. (f) The bone graft appears viable and vascularized at implant insertion.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
986
orbitozygomatic framework is critical to correct ocular
and eyelid positioning, because the rigid framework pro­
vides anchor points for soft tissue.
Specific Complications by Region
Maxilla
Complications occur when the function and anatomy
of the resected maxilla are unrestored. There are three
main goals of reconstruction11:
1. Support the orbital contents.
2. Separate the sinus and nasal cavities from the orbit
and obliterate the sinus cavity.
3. Reconstruct the shape of the anterior cheek wall.
Failure to achieve these goals may result in complica­
tions that manifest, respectively, as enophthalmos and
diplopia, speech, swallowing and occlusal derange­
ments, and facial asymmetry and deformity.
Diplopia can often be resolved by correction of en­
ophthalmos. Fine-cut computed tomography (CT) and
volumetric three-dimensional reconstruction are es­
sential to delineate and calculate the abnormality in
orbital volume. This information is useful for the sur­
geon during reconstruction to predict the size of the
bone graft to use and to determine the best location to
place it intraorbitally. A triangular bone graft is usu­
ally harvested from split calvarial grafts because of
its favorable curve, which fits on the orbital floor. The
graft is placed with its concave surface facing up and its
apex directed toward the cone of the orbit. A very slight
overcorrection is necessary to offset the volume loss
from bone graft resorption. Oronasal fistulas occurring
in the hard and soft palate are common. The complica­
tions associated with fistulas include passage of food
into the nasal cavity and hypernasal speech. Closure of
these fistulas is commonly made more difficult by tris­
mus and postirradiation fibrosis. Small fistulas can be
closed with a tongue flap or by a facial artery myomu­
cous (FAMM) flap. Larger defects are closed with a free
radial forearm flap or locally by a transverse-FAMM
flap as recently described by our group.8
A dental obturator worn as a denture is also an al­
ternative option. To correct facial asymmetry, it is nec­
essary to evaluate the deformity using CT. This will aid
the surgeon in deciding the relative extents of hard and
soft tissue correction necessary. Autologous bone is the
preferred method of repairing bony deformities. Choices
for soft tissue augmentation include dermal fat grafts
in conjunction with fat injections for minor defects and
vascularized soft tissue flaps for major defects.
Mandible
Radical resection of oral cancers commonly results in
major defects of the mandible. The goals of mandibu­
lar reconstruction include functional restoration of
the bony and dental arches, as well as good aesthet­
ics. Functional restoration requires the close coopera­
tion of the plastic, oral, and oncologic surgeons and the
prosthodontist. Careful presurgical planning is critical
for a successful result. Common complications of man­
dibular reconstruction with bone flaps include non­
union, fistula, malocclusion, and jaw asymmetry.
Bone Nonunion
Nonunion is defined as failure of consolidation after
6 months, with clinical and radiological evidence of
impaired healing. If the jaw has been irradiated, heal­
ing takes longer, and the bone may take up to a year to
consolidate. Nonunion may occur between the osteoto­
mized segments of the bone flap or at the junction be­
tween the bone flap and the mandible. These typically
manifest as pain, instability, or plate fractures. Causes
of impaired healing include devascularization of the
graft by periosteal stripping and functionally unstable
fixation with miniplates.
Osteotomized bone segments lack endosteal blood
supply and are dependent on periosteal blood supply
for survival. Consequently, bone flaps should never be
stripped of periosteum during miniplate fixation, be­
cause removing the periosteum will devitalize the
grafts. The plates are placed directly over muscle and
periosteum without regard for exposing bone.12
To ensure adequate fixation with miniplates, Hi­
dalgo advocates placement of plates in two perpendic­
ular planes at each osteotomy site (i.e., on the buccal
surface and along the inferior border of the graft and
mandible).12 When a reconstruction plate is used, a
minimum of three screws should be used at each end
of the plate for adequate stability. Because it is a “load-
bearing” construct, only one or two screws are needed
for each bone segment.
Nonunion can be managed by reconstruction plat­
ing, which provides greater stability than miniplates.
First, the plate is applied without tightening the screws,
and the nonunited bone ends are freshened. A block of
corticocancellous bone graft is then wedged tightly
between the bone stumps. The screws are driven
home, compressing the bone graft between the bone
ends. Some caveats for successful outcome include
well-vascularized soft tissue enveloping the graft and
­sufficient soft tissue to afford tensionless closure over

987
Chapter 52 Reconstruction of the Mandible and Maxilla
the construct, without which the graft will be exposed
and resorbed rapidly.
A free, vascularized, corticoperiosteal bone graft can
also be used to treat nonunion, particularly if it is radia­
tion-induced.13,14 To achieve this, the bone ends are first
freshened and stabilized with strong plating. The bone–
periosteal flap is then harvested from the medial femoral
condyle, based on the descending genicular arteriovenous
pedicle. It is subsequently wrapped around the defect and
revascularized by microvascular anastomoses to suitable
recipient vessels. Nonvascularized cancellous bone grafts
may also be used in conjunction with this technique.
Fistula
The incidence of fistula formation is between 13 and
50%. Predisposing factors of fistula formation include
the following:
•• Slow skin-to-mucosa union
•• Chronic coughing and gagging, as violent throat
movements can tear the suture line
•• Old age and debilitation
Typically, a fistula presents as erythema of the cervical
skin flap that develops into a draining abscess. Treat­
ment consists of drainage, dressings, and antibiotics.
Most fistulas will heal with conservative management,
provided the flap is viable and there is no distal obstruc­
tion. Oral intake is withheld to allow healing. Nutrition is
maintained by nasogastric tube feeding or jejunostomy
feeding. If such means of feeding are temporarily un­
available, the patient is given total parenteral nutrition.
A fistula that worsens warrants repair with a flap.
Persistent leakage can lead to carotid artery exposure
and blowout. In addition, a leak at the distal suture line
can cause aspiration pneumonia because of its proxim­
ity to the tracheotomy. Local flaps such as the deltopec­
toral flap or the pectoralis major myocutaneous flap are
used to seal such fistulas. The pectoralis major flap is
ideal, because the skin island can be turned inward to
form the pharyngeal lining and the muscle portion used
to cover the neck vessels. If neck skin is deficient, a skin
graft is applied over the muscle.
Asymmetry and Impaired Occlusion
Malocclusion and jaw asymmetry are potential prob­
lems when the surgical effort is focused solely on “fill­
ing” a defect without regard for dentition and occlusal
relationships. Such problems may be avoided by the
early involvement of dental and maxillofacial surgeons,
who can aid with planning, the surgery itself, and post­
operative rehabilitation.
The classic approach is to place the patient in maxil­
lomandibular fixation (MMF) before mandibular resec­
tion, thus maintaining normal occlusion of the residual
dentition. After resection and reconstruction, the MMF
is released.
In a patient who has full dentition and class 1 occlu­
sion, minimal dental preparation is required. MMF is ap­
plied, without the need for a dental splint. A dental splint
is useful in individuals who have malocclusion or partial
dentition, because it may be difficult to determine the
correct occlusion intraoperatively. Such splints are fab­
ricated with dental models, and this process is aided by
studying the patient’s photographs, plain radiographs,
and orthopantomogram. In an edentulous patient, den­
tures are used to establish the correct anteroposterior and
vertical occlusal relationships. Intraoperatively, the upper
denture is secured by screws to the palate, and the lower
one by circum-mandibular wiring. The patient is placed
in MMF once the dentures are in place.
In our experience, reconstruction plating is pre­
ferred for fixation of the bone flap. The advantages in­
clude strength; speed, because a less-than-perfect fit
between bone segments is acceptable; and better pres­
ervation of the periosteum, because fewer screws are
needed than for miniplating. The plate is preadapted
once the mandible is exposed, before the tumor is re­
sected. This is accomplished by a template, which is
contoured by pressing it against the outer surface of
the mandible. The plate is then shaped according to the
template and applied to the mandible. The plate should
span the diseased portion and overlap normal bone by at
least three screw holes at each end. The plate is then re­
moved and resection continued. This technique ensures
that the proximal and distal bone ends of the mandible
retain their original spatial relationship. In the final as­
sembly of the plate and bone flap, the condyle is checked
to ensure that it is seated correctly in the glenoid fossa.
Early presentation of malocclusion and jaw asym­
metry usually relate to errors in estimating graft length.
Such errors can result in retrognathia, prognathism, or a
midline shift. However, there are instances in which it is
not possible to achieve an accurate reproduction of the
bony arch because of constraints of graft length (result­
ing in retrognathia) or space constraints related to floor
of mouth swelling (resulting in prognathism).
Corrective osteotomies may be performed to rec­
tify malocclusion or jaw asymmetry, but this should be
done after bone healing has taken place, because there
is a risk of devitalizing the flap. Dental casts, simulation
surgery, and orthodontics are critical for a successful

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
988
outcome. The surgeon should ensure that both intra­
oral and extraoral soft tissue is sufficiently pliable for
osteotomies and movement of the underlying bone. If
present, soft tissue deficiencies or contractures should
be addressed first (Figs. 52D.3 and 52D.4).
Conclusion
Late presentation of the complications addressed here
usually relates to radiotherapy, which causes fibrosis.
Thus any minor displacement of the reconstructed jaw
will become more pronounced with time as soft tis­
sue contracture worsens. The best way to counteract
this process is to mobilize the jaw, maintain mastica­
tion, and preserve occlusion. If good dentition is pres­
ent, continued use of the patient’s jaw will maintain
occlusion. In partially edentulous patients, dentures,
orthodontic appliances, and guiding elastics are used
to preserve occlusion.
Fig. 52D.3 (a) Iliac crest grafting after mandible reconstruction with a vascularized fibula flap to restore adequate occlusion.
(b) After implant insertion.
a
b
Fig. 52D.4 Vertical discrepancy between the fibula and mandible stumps may be treated by longitudinal osteotomy and distrac­
tion osteogenesis.
a
b
References
1. Mardini S, Wei FC, Salgado CJ, Chen HC. Reconstruc­
tion of the reconstructive ladder. Plast Reconstr Surg
2005;115(7):2174
2. Wei FC, Demirkan F, Chen HC, et al. The outcome of
failed free flaps in head and neck and extremity re­
construction: what is next in the reconstructive lad­
der? Plast Reconstr Surg 2001;108(5):1154–1160,
discussion 1161–1162
3. Baccarani A, De Santis G. Mandible reconstruction: a
review article. J Surg 2015;S(1):7–10
4. Singh B, Cordeiro PG, Santamaria E, Shaha AR, Pfister
DG, Shah JP. Factors associated with complications in
microvascular reconstruction of head and neck de­
fects. Plast Reconstr Surg 1999;103(2):403–411
5. Coskunfirat OK, Chen HC, Spanio S, Tang YB. The safe­
ty of microvascular free tissue transfer in the elderly
population. Plast Reconstr Surg 2005;115(3):771–775
6. Harii K. Technical advances of plastic and recon­
structive surgery in cancer surgery. Int J Clin Oncol
2005;10(4):215–217
7. Novakovic D, Patel RS, Goldstein DP, Gullane PJ. Sal­
vage of failed free flaps used in head and neck recon­
struction. Head Neck Oncol 2009;1:33
8. Pompei B, Pollastri G, Molteni G, De Santis G, Bac­
carani A. The new transverse-facial artery musculo­

989
Chapter 52 Reconstruction of the Mandible and Maxilla
mucosal flap for intraoral reconstructions. Plast Re­
constr Surg Glob Open 2016;4(3):e652
9. Vasilakis V, Patel HD, Chen HC. Head and neck recon­
struction using cephalic vein transposition in the ves­
sel-depleted neck. Microsurgery 2009;29(8):598–602
10. Jelks GW, Jelks EB. Prevention of ectropion in re­
construction of facial defects. Clin Plast Surg
2001;28(2):297–302, viii
11. Rohner D, Tan BK, Song C, Yeow V, Hammer B. Repair
of composite zygomatico-maxillary defects with free
bone grafts and free vascularized tissue transfer. J
Craniomaxillofac Surg 2001;29(6):337–343
12. Schmoker RR. Management of infected ­fractures
and nonunions of the mandible. In: Yaremchuk
MJ, Gruss J, Manson PN, eds. Rigid Fixation of
the
­Craniomaxillofacial
Skeleton.
Boston,
MA:
­Butterworth-Heinemann; 1992:233–244
13. Sakai K, Doi K, Kawai S. Free vascularized thin
­corticoperiosteal
graft.
Plast
Reconstr
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1991;87(2): 290–298
14. Celik N, Wei FC, Chen HC, et al. Osteoradionecrosis
of the mandible after oromandibular cancer surgery.
Plast Reconstr Surg 2002;109(6):1875–1881

990
CHAPTER
53

Reconstruction of the Lip and Cheek
Peter C. Neligan
Although an unfavorable outcome is something we strive
to avoid, the reason for suboptimal results can be multifac­
torial. Sometimes, despite the best of intentions, the most
fastidious technique, and the most careful planning, things
go wrong. In cases such as this, there is really nothing the
surgeon can do; the patient may pick at a wound, hema­
tomas happen, infection is always a threat. Generally, the
surgeon cannot control these things. The purpose of this
chapter is to address issues that surgeons can control and
to point out pitfalls that can trip up even the best surgeon.
This chapter addresses why results of lip and cheek recon­
struction may disappoint and what the surgeon can do to
either avoid these problems or manage them.
The face is how individuals present themselves and
how others know and recognize them. Both the lips and the
cheeks play an important role in this region of anatomy, and
reconstructing them predictably is the reconstructive sur­
geon’s goal. Injury, disease, or surgical trauma can result in
significant changes to the face that can profoundly affect
the patient, not only in terms of appearance but even more
importantly, in terms of function. This can have a ­significant
effect on self-perception and quality of life. As far as the
lip is concerned, subtle changes in the appearance of the
­vermilion border, oral commissures, or Cupid’s bow are eas­
ily ­detected by even the most casual observer. Loss of ­labial
competence may interfere with the ability to ­articulate,
whistle, suck, kiss, control salivary secretions, and eat. In
fact, many patients who have problems with lip function
and lip continence avoid eating in public because they are
“awkward,” drool, and embarrass themselves and others.
Neuromuscular injury can lead to facial asymmetry at rest
and, even more particularly, during facial animation, and
distressing functional disabilities are common.
Lip reconstruction is not new. Surgeons have been
­trying to functionally and cosmetically reconstruct lips for
­centuries. For smaller defects, reconstruction can be very
effective. However, where larger defects are ­concerned,
­reconstructing an aesthetically pleasing as well as a
­functional lip becomes increasingly difficult.
The cheek, on the other hand, although it occupies a
very prominent position in the face, is often thought of as
a fairly innocuous part of the facial anatomy and is not af­
forded the same attention to detail in terms of reconstruc­
tion as, for example, the nose, the ear, the eyelid, or the lip.
Plastic surgeons are often called on to reconstruct the cheek,
and although it does not compare in intricacy and visual im­
pact with the eyelid, nose, or lip, skillful restoration is nev­
ertheless imperative. It is a less intricate piece of anatomy
than other areas, but it is nevertheless a major contributor
to facial appearance. Several aspects of the cheek are im­
portant. These include skin color, contour, and movement.
It is also important that the cheek be symmetrical with the
other side of the face, because asymmetry is a feature that
catches the eye and bestows a sense of the abnormal, wher­
ever it is encountered.
One aspect of the cheek is that, unlike the central facial
structures (the nose and lips), the cheeks are often viewed
separately if, for example, the head is turned to one side
or the other, as frequently happens in normal social inter­
actions. So all aspects of both cheeks, in this situation, are
not seen together. This is in contrast, for example, to the
nose, where the right and left alae are instantly comparable.
Thus a reasonably accurate replica of the intact contralat­
eral cheek will result in a very satisfactory reconstruction,
whereas a less than accurate alar reconstruction will provide
a less than satisfactory result.

991
Chapter 53 Reconstruction of the Lip and Cheek
struction that commonly has a poor result is in skin color
(Fig. 53.1a). In fact, skin color can be the cause of a poor
result in any area of facial reconstruction. Skin color that is
totally different from the native skin in an otherwise excel­
lent reconstruction will stand out as a poor result. However,
there are ways to address this. Choosing local tissue for the
reconstruction brings in tissue of the same characteristics
in terms of texture and color and is the best solution if it is
possible. However, sometimes distant tissue must be used
that brings its own characteristics with it. In terms of color
disparity, deepithelializing any flap and replacing the skin
cover with a split calvarial graft from the parietal scalp will
alter the color of a nonmatching flap to match the facial skin
color1,2 (Fig. 53.1b). This results in a major improvement in
the perception of the reconstruction.
Under normal circumstances reconstructive options are
selected based on tissue availability and often size. In the
head and neck in general and in the face in particular the
fact that the reconstruction is going to be the visual evidence
of what surgery the patient has undergone also must be con­
sidered. The surgeon can think of the cheek as a separate
aesthetic unit, but reconstruction of the cheek typically af­
fects nearby units—for example, the pull on the lower eyelid
from a cheek advancement flap.
Also, reconstruction may include an adjacent structure
such as part of the nose or an eyelid. Disease and trauma
do not respect aesthetic subunits! Reconstruction of the
underlying bony skeleton is obviously an important part of
cheek reconstruction and is an area that, in the past, was
neglected. When reconstructing any body part it is impor­
tant to take stock of what tissue is missing and what needs
to be reconstructed. In most cases it is necessary to replace
what is missing, and this includes bone. This chapter does
not discuss maxillary reconstruction, but this may form part
of the reconstruction requirements of the cheek, and failure
to reconstruct a bony defect will result in major problems
when combined with postoperative and postradiotherapy
scarring (Fig. 53.2).
Avoiding and Managing
Unfavorable Results and
Complications
Summary Box
Common Problems with Lip and Cheek
Reconstruction
Lip
•• Notching of the lip
•• Blunting of the oral commissure
•• Microstomia resulting from large resections
•• Loss of oral continence
Cheek
•• Ectropion of the lower eyelid
•• Excessive bulk of the flap reconstruction
•• Poor color match of regional or free flaps
As with all reconstructions, it is important to consider what
tissue is being replaced. In the case of the cheek, this is easy
to see on first impression. The cheek consists of a soft tissue
envelope of skin, subcutaneous tissue, muscle, and buccal
mucosa draped over a bony framework, the most project­
ing part of which is the zygomatic prominence. Within this
soft tissue is embedded the parotid gland and duct, the fa­
cial nerve, and the buccal fat pad.
Furthermore, the texture of the cheek must be consid­
ered. On a woman it is smooth and soft. On a man it is par­
tially hair-bearing and less smooth. Although contour and
shape are important features, the aspect of cheek recon­
Fig. 53.1 (a) This cheek was reconstructed with a free parascapular flap. Despite the fact that the defect was adequately covered, the dif­
ference in color between the flap and the native skin would never resolve and would render this an unfavorable outcome. (b) The flap has
been deepithelialized and resurfaced with a split-thickness skin graft from the parietal scalp. This vastly improves the appearance of the
reconstruction.
a
b

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velop extensive dental caries, cavities, root exposure, gingi­
vitis, and other conditions (Fig. 53.3).
Also important is maintenance of an adequate oral ap­
erture to facilitate oral hygiene and to accommodate remov­
able dentures. The labial vestibule is an important feature
of labial anatomy, and its preservation or re-creation is im­
portant for oral hygiene, dental care, and denture fitting. To
achieve these functions, preservation of labial sensation is
important, and because of the vital role of the lips in facial
aesthetics, maximizing cosmesis is one of the key goals of
reconstruction.5,6
If the orbicularis oris muscle has been disrupted it is
vitally important to restore continuity of that muscle if at
all possible. Failure to do so can result in notching or, at the
very least, an unsightly scar7 (Fig. 53.4). Careful reapproxi­
mation of muscle edges with intact motor innervation usu­
ally results in complete restoration of dynamic orbicularis
function. Although some authors contend that the upper lip
functions primarily as a curtain that could be replaced with
a static flap reconstruction, there is no doubt that a com­
pletely intact sphincter with active function and sensation
yields the best functional result.8,9
Lip Reconstruction
Many procedures have been described to reconstruct vari­
ous lip defects, and some of the oldest remain effective and
in use today. In fact, most of the reconstructive techniques
in present use are modifications or refinements of tech­
niques that were described in the medical literature over
the past two centuries. As already mentioned, the lips not
only have unique functional requirements but also occupy
the central aesthetic unit of the face so that any irregularity
of the lips, even if function is not affected, is instantly rec­
ognizable. A detailed description of the various techniques
used in lip reconstruction is beyond the scope of this chap­
ter. Rather, this chapter focuses on areas where mistakes
are commonly made that can adversely affect outcome.
Lip Function
As already mentioned, the lips are an important aesthetic
feature of the lower face, and any deformity of the lips is
instantly recognizable. Even minor deformities are easily
noticed. More important, however, are the functional char­
acteristics of the lips. The lips play a very important part in
speech articulation, as anyone who has tried to speak after
extensive local anesthesia at the dentist can attest. The lips
are also vital for the maintenance of oral competence.3,4
Sensation allows the lips to monitor the texture and tem­
perature of substances before oral intake.
Goals of Lip Reconstruction
The goals of lip reconstruction are many. The most im­
portant of these is function. No matter how good a recon­
structed lip looks, if it cannot maintain oral competence,
the reconstruction is a failure. Maintenance of oral compe­
tence is vital. It is important that the lips close, not only to
maintain oral competence but also to protect the dentition.
Teeth degenerate if exposed, and as a result patients de­
Fig. 53.2 This patient has had a maxillectomy defect reconstructed
with a muscle flap. The soft tissues, including the muscle, have re­
tracted after radiation, and the patient has lost facial projection and
facial height. Without a bony foundation, such a deformity will al­
ways ensue and is very difficult to rectify.
Fig. 53.3 This 37-year-old woman has sustained facial burns. Her
lips do not close and her teeth are exposed, making dental hygiene
impossible and rendering the patient susceptible to caries.
Fig. 53.4 This patient has had his lip cancer resected. The recon­
struction was made with a Karapandzic flap. However, failure to
properly repair the orbicularis oris muscle has resulted in a very vis­
ible scar that could have been avoided.

993
Chapter 53 Reconstruction of the Lip and Cheek
ance and can sustain a loss of one third of its breadth before
tightness or asymmetry begins to show.
Early lip reconstruction techniques focused primarily
on primary closure of the surgical defect, whereas more
contemporary techniques attempt to address the impor­
tance of an aesthetic, functional result. Reconstruction of
the ­aesthetic subunits as described by Burget and Menick8
is helpful, and aesthetic features such as Cupid’s bow and
the philtral columns must be carefully restored. Failure to
restore these landmarks results in an abnormal appearance
that is instantly detectable.
One of the features that is readily picked up by the hu­
man eye is asymmetry. Surgery that results in asymmetry is
typically more noticeable than symmetrical alterations. As
an example, rounding of both commissures is less obvious
than rounding of one side. Whenever possible, the height,
projection, and relationship between the upper and lower
lips should also be preserved or replicated. This is most eas­
ily achieved by using tissue from the adjacent or opposing
lip.12,13
Preoperative Planning
Reconstructive choice is important when considering the
lip. In the case of trauma, the damage is already done, and
the surgeon’s task is to repair and reconstruct the lip so that
it is as functional and aesthetically pleasing as possible. For
patients facing lip resection for disease, the task is no dif­
ferent; the surgeon must reconstruct the lip to be as func­
tional and aesthetically pleasing as possible. However, in
the latter case the surgeon has the luxury of planning what
reconstruction will best suit the patient. The choice de­
pends on multiple factors, such as prognosis, general medi­
cal condition, availability of local tissue, history of prior ra­
diation, and comorbidities. The lips are somewhat unique,
however, in that the need to reconstruct the lips is very dif­
ferent from, for example, the need to reconstruct a breast.
Oral competence is vital for normal eating, ­articulation, and
If reconstruction of the sphincter is not feasible, an ady­
namic reconstruction must be pursued that provides some
degree of oral competence, as in the case, for example, of
free flap reconstruction. In free flap lip reconstruction it is
important to use a tendon (usually the palmaris) to drape
the flap over and to maintain tension in the palmaris by
weaving it through the intact orbicularis on either side of
the resection so that when the orbicularis contracts, it also
pulls on the tendon and tenses the reconstructed lip.
In repairing or reconstructing the lips, one of the main
dangers is resulting microstomia. Although patients can
function reasonably well with a small degree of microsto­
mia, it is very important to minimize it, because not only
may it interfere with function but, as already mentioned, it
can also hamper oral hygiene. Patients should be counseled
before surgery that denture insertion and removal may be
difficult, or, quite simply, not possible (Fig. 53.5). Decreases
in the shape or depth of the labial vestibule can exacerbate
oral incompetence and drooling and may preclude patients
from wearing a removable prosthesis. Preservation of labial
sensation is vitally important to maximize oral competence
and to fulfill its other sensory roles.10,11
Because of the anatomic configuration of the upper lip
and, specifically, because of its aesthetic subunit structure,
its reconstruction presents certain aesthetic challenges that
are not of concern during lower lip reconstruction. Loss of
the philtral columns and Cupid’s bow creates a noticeable
cosmetic deformity that presents a significant reconstructive
challenge. In profile, the upper lip should protrude in front
of the lower lip, so a reconstruction that results in excisional
tightness with reduction or elimination of this relationship
not only is undesirable, but will certainly result in an inferior
aesthetic outcome. Thus although it may not be necessary to
insert extra tissue, such as a cross-lip flap, to close the de­
fect, it may be necessary to preserve the normal relationship
of the upper to lower lip and thereby to preserve aesthetic
balance. In contrast, the lower lip is better able to withstand
tissue loss without significant changes in its profile appear­
Fig. 53.5 (a) A patient with extreme microstomia after a burn injury. This extent of microstomia needs to be released. (b) The release was
maintained with splinting. (c) At 15-year follow-up showing maintenance of commissuroplasty.
a
b
c

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
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that would otherwise not be noticed. Notching, for example,
can be the result of scar contracture; a straight-line repair
that looks great initially may contract and produce a notch,
a situation that can be avoided if a z-plasty is incorporated
into the repair.
Lip-switch (cross-lip) flaps fulfill the requirement of
providing tissue of like composition and appearance. These
are axial flaps based on the labial arteries. They replace
like tissue with like, replacing the trilaminar defect in one
lip with trilaminar tissue from the other. The classic Abbé
flap can reconstruct medial or lateral lip defects with a full-
thickness composite flap that reconstructs all three layers
and restores continuity of the vermilion, whereas the Est­
lander flap is essentially a circumcommisural lip-switch flap
similarly supplied by the labial artery.16
Surgical Considerations
Surgical technique is important, and there are a few techni­
cal principles that are important to follow to achieve opti­
mal results. My personal approach is as follows:
1. The width of the flap does not need to be as big as
the width of the defect. This technical trick allows for
repair of the defect by taking advantage of the inher­
ent elasticity of the lip tissues while, at the same time,
reducing the amount of tissue that has to be sacrificed
from the donor lip, thereby making closure of the
secondary defect easier. Thus both lips end up a little
smaller, but by taking some tissue from both lips, better
balance between the two lips is maintained.
2. The height of the flap needs to match that of the defect.
Although less width may be acceptable, less height will
result in some element of notching and will produce a
significantly inferior result.
3. The position of the flap relative to the opposite lip is
an important technical point to appreciate. This refers
particularly to the Abbé flap and is important because
the position of the flap determines the position of
the pedicle. Essentially the pedicle should be placed
roughly opposite the midposition of the defect, because
the flap will be half the width of the defect, so when
the secondary defect is closed, the pedicle ends up
being in precise alignment with one end of the defect
(Fig. 53.7).
Pedicle division is performed 14 to 21 days later. With the
Abbé flap, it is also important not to overly skeletonize
the pedicle or the labial artery. This can result in injury to
the pedicle and possible avulsion. Leaving a cuff of tissue
around the vessel will mitigate this problem.
A useful trick to determine the position of the pedicle
is to note the position of the labial artery when cutting the
nonpedicle side of the flap. Adhering to the aesthetic sub­
unit principle, Burget and Menick8 suggested that defects
constituting more than half of a topographic subunit of the
communication, so the option to not reconstruct the lip is
essentially nonexistent.
After injury or after surgical resection for disease, there
are several options for reconstruction of the lips.14,15 The first
choice, of course, is to use the remaining lip segment if the
defect size allows. This is by far the best option. This choice
assumes that there is enough lip to effect the repair without
creating microstomia. Another consideration is whether the
defect is full thickness and whether all three elements, skin,
muscle and mucosa, need to be replaced. Regardless of what
the defect is, local tissue is the best option, because it re­
places what has been lost and is the perfect match in terms
of color, thickness, and composition.
Defects of the upper lip of less than 25% can be closed
by direct approximation. However, if this resection includes
the philtrum, then that structure needs to be reconstructed
and, as already alluded, the relationship between upper and
lower lips needs to be maintained.
For the lower lip, a slightly larger defect, up to 30%, can
be closed directly. Once again, care must be taken to ensure
accurate closure of all layers. Repair of the orbicularis oris
and reconstitution of the circumoral sphincter are the most
important aspects of a functional repair. Failure to properly
repair all of these structures will result in an unfavorable
outcome. As already mentioned, failure to repair the orbi­
cularis can result in an obvious scar that is easily seen on
animation.
It is also important to plan the scars. A V-shaped wedge
design usually permits closure of smaller defects, whereas
a W-shaped excision facilitates the closure of larger defects.
Furthermore, this modification will generally allow for the
scar to be kept above the mental crease. This improves the
cosmetic appearance of the repair, because it preserves the
integrity of the chin aesthetic subunit (Fig. 53.6). Failure to
align the vermilion properly can result in a very visible scar
Fig. 53.6 The difference between a V-shaped wedge and a
W-shaped wedge is depicted. If this patient had a V-shaped wedge,
the scar would extend into the chin subunit, whereas use of a
W-shaped design prevents that extension of the scar and results in
a better outcome.

995
Chapter 53 Reconstruction of the Lip and Cheek
upper lip necessitate removal of the remaining portions of
the subunit. This will allow reconstruction of the entire sub­
unit to be performed by using a foil template of the defect
to design the Abbé flap in the lower lip so that exactly the
amount of tissue resected from one lip is transferred from
the other. However, this approach may have some limita­
tions in terms of the amount of tissue available to recon­
struct a given defect, and a combination of both methods is
probably the most expedient approach.
Sometimes, however, there simply is not enough lip tis­
sue to achieve reconstruction, in which case it may become
necessary to use tissue from the adjacent cheek, nasolabial
region, or neck. For extreme defects, however, there is no
other option but to use regional tissue or even more distant
tissue as a free flap.
Thus, for all the reasons already described, local flaps are
the best option for reconstructing larger defects involving
up to two thirds of the width of either the upper or lower
lip. These flaps involve either a lip-switching maneuver, ro­
tation of tissue from one lip to another, or recruitment and
advancement of adjacent tissue, such as cheek tissue, to
achieve the reconstruction.
Microstomia has already been addressed. In addition,
rotational flaps can cause rounding or blunting of the com­
missures. The Karapandzic flap results in blunting of both
commissures, which is usually less noticeable than altera­
tion of only one commissure, as is sometimes seen with the
Estlander flap (Fig. 53.8). Some degree of microstomia is also
inevitable, which may preclude the use of dentures.
In free flap reconstruction it is important to note that
the height of the mucosal element of the lip will usually be
shorter than the skin element. Thus these two elements of
the defect need to be carefully measured so that the flap can
be properly designed (Fig. 53.9). The same rules that apply
to free flaps also apply to lip-switch flaps (i.e., the width of
the flap is less than the width of the defect); however, the
height of the flap needs to be the same as that of the defect,
Fig. 53.7 The dimensions of a lip-switch flap and placement of the pedicle. For an Abbé flap, the pedicle is positioned opposite the mid­
point of the resection on the other lip. The width of the flap is no less than half the width of the excision, but it is important to maintain
the height of the excision by using a flap of the same height. (Reproduced from Bentz ML, Bauer BS, Zuker RM. Principles and Practice of
Pediatric Plastic Surgery. 2nd ed. New York: Thieme; 2016.)
Vermilion-mucosal
junction
Labial artery
Fig. 53.8 Blunting of the oral commissure after an Estlander flap.
Most patients are accepting of the defect, which may be minimally
noticeable. However, when large flaps are used, such as in this pa­
tient, both microstomia and commissure blunting require a com­
missuroplasty.
Fig. 53.9 This resection demonstrates that the mucosal excision is
commonly less than the skin excision, and this needs to be reflected
in the design of the reconstruction.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
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Similarly with trauma, immediate reconstruction may
be the lesser of two evils to avoid the long-term results of
extensive open wounds and subsequent scarring and de­
formity. In many cases, it is reasonable to do a temporizing
reconstruction with a plan to return for a more definitive
and functionally better and aesthetically more pleasing re­
construction secondarily. Only if local tissue is not available
should distant tissue be considered; in that situation, donor
tissue choice is important.
Local Flaps for Cheek Reconstruction
The amount of local tissue available for reconstruction de­
pends on several factors. The size of the defect is obviously
important in determining the amount of tissue left. How­
ever, the age of the patient is also important. Older patients
in general have more laxity. Defects that can be recon­
structed in older patients with relative ease will demand
more complex repair in a young patient. Cheek wounds can
commonly be converted to an ellipse and closed directly.
It is important to be cognizant of the relaxed skin tension
lines and to keep all scars parallel to these lines if possible.
In an elderly patient, these lines are usually easily visual­
ized because of natural wrinkling, and incisions can thus
be appropriately planned. Failure to do so will result in an
unacceptable scar (Fig. 53.11).
All manner of local flaps can be used for defect closure.
Two principles apply:
1. Keep incisions parallel to relaxed skin tension lines.
2. Avoid traction on vital structures that may cause sec­
ondary deformity.
As far as the cheek is concerned, the most common ana­
tomic unit affected is the lower eyelid. It is very easy to pro­
duce an extrinsic ectropion from nonjudicious use of local
flaps. It is just as easy to avoid such complications through
careful planning.
even overcompensating a little to allow for subsequent scar
contracture.
The ultimate free flap reconstructive technique of the
lip, which would also incorporate muscle between the in­
ner and outer layers and restore the vermilion component,
has not been described. Nevertheless, the composite radial
forearm–palmaris longus tendon free flap has several ad­
vantages over pedicled flaps. This reconstruction allows for
a single-stage procedure that results in complete skin cover­
age and intraoral lining. The large amount of skin that can
be used with the radial forearm flap usually results in an
adequate stomal size, minimizing the risk of microstomia.
Although the color match between the radial forearm flap
and surrounding facial tissue is commonly suboptimal, ac­
ceptable cosmetic results are attainable by respecting the
borders of the aesthetic subunits during surgical resection
and reconstructive planning (Fig. 53.10).
Cheek Reconstruction
General Principles
Bony reconstruction of the cheek, though not discussed
here, is very important if it is required. In terms of soft tis­
sue reconstruction of the cheek, local tissue works best in
terms of replacing like with like for the same reasons dis­
cussed earlier. It provides tissue of like texture, of similar
color, and with identical characteristics in terms of dermal
appendages, hair growth, skin characteristics, and other
factors. Where possible, this is the tissue of choice.
If sufficient tissue is not available locally and the nature
of the disease process allows it, tissue expansion becomes
an alternative method of providing sufficient local tissue to
cover the defect. However, most cancer reconstructions can­
not afford the luxury of expanding adjacent tissue to assist
in the reconstruction. The nature of the disease in this case
demands simultaneous ablation and reconstruction.
Fig. 53.10 This patient has had a lip and chin defect reconstructed
with a pectoralis flap, breaking all the rules of lip reconstruction.
The lip is notched, oral competence is lost, there is no attempt at
continuity of the oral sphincter, and color mismatch, the least of the
problems, is obvious.
Fig. 53.11 This patient is marked for excision of a basal cell carci­
noma using the relaxed skin tension lines to optimize her result.

997
Chapter 53 Reconstruction of the Lip and Cheek
be based anteriorly as described by Juri and Juri.17 They can
also be based posteriorly as described by Stark and Kaplan.18
One of the most important pitfalls to avoid in using this flap
is producing an ectropion. To avoid this, the flap should be
suspended from the underlying bony skeleton. This can be
achieved either with the aid of periosteal sutures (Fig. 53.12)
or with an anchoring device such as a Mitek anchor.19
Cheek rotation flaps can cover surprisingly large defects
with excellent cosmetic results. Nevertheless, a free flap is
still sometimes required to close extremely large defects,
as with the patient in Fig. 53.1. The same color match is­
sues apply; color match can often turn a mediocre result
into an excellent one, and the opposite is true for poor color
match. Surgeons must be cognizant of the pull of such a flap
on ­adjacent structures; the lower eyelids are particularly
­vulnerable. Thus suspension of the flap continues to be an
important consideration.
Conclusion
As with any type of reconstruction anywhere in the body,
careful planning is the key to success. This is particularly
the case in reconstruction of any part of the face, because
it is unique in its equally important requirement for aes­
thetic perfection and distinctive function. The lips are the
epitome of this requirement, but the cheek has its own dis­
tinctive role.
The cheek rotation or cervicofacial flap is the most com­
mon approach to cheek reconstruction and remains the ba­
sis for most successful cheek reconstructions. It is impor­
tant to remember some basic principles. Although there is
some laxity in the cheek, particularly in older patients, the
amount of this laxity is limited. For that reason the rota­
tional element of the flap is also important. These flaps can
Fig. 53.12 Placement of periosteal suspension sutures to suspend
a cheek rotation flap.
References
1. Lannon DA, Novak CB, Neligan PC. Resurfacing of colour-
mismatched free flaps on the face with split-thickness skin
grafts from the scalp. J Plast Reconstr Aesthet Surg 2009;
62(11):1363–1366
2. Walton RL, Cohn AB, Beahm EK. Epidermal overgrafting
improves coloration in remote flaps and grafts applied
to the face for reconstruction. Plast Reconstr Surg 2008;
121(5):1606–1613
3. Langstein HN, Robb GL. Lip and perioral reconstruction.
Clin Plast Surg 2005;32(3):431–445, viii
4. Sun G, Lu M, Hu Q. Reconstruction of extensive lip and peri­
oral defects after tumor excision. J Craniofac Surg 2013;
24(2):360–362
5. Coppit GL, Lin DT, Burkey BB. Current concepts in lip recon­
struction. Curr Opin Otolaryngol Head Neck Surg 2004;
12(4):281–287
6. Fang QG, Shi S, Zhang X, Li ZN, Liu FY, Sun CF. Total lower
lip reconstruction with a double mental neurovascular
V-Y island advancement flap. J Oral Maxillofac Surg 2014;
72(4):834.e1–834.e6
7. Jan SN, Khan FA, Ansari HH, Hanif A, Bajwa A. Reducing
the vermilion notch in primary lip repairs: Z-plasty ver­
sus the Noordhoff triangular flap. J Coll Physicians Surg
Pak 2012;22(5):307–310
8. Burget GC, Menick FJ. Aesthetic restoration of one-half
the upper lip. Plast Reconstr Surg 1986;78(5):583–593
9. Cordeiro PG, Santamaria E. Primary reconstruction of
complex midfacial defects with combined lip-switch pro­
cedures and free flaps. Plast Reconstr Surg 1999;103(7):
1850–1856
10. Ayhan Oral M, Zeynep Sevim K, Görgü M, Yücel Öztan
H. Sensory recovery with innervated and noninnervated
flaps after total lower lip reconstruction: a comparative
study. Plast Surg Int 2013;2013:643061
11. Chang YM, Rodriguez ED, Chu YM, Tsai CY, Wei FC. Inferi­
or alveolar nerve reconstruction with interpositional su­
ral nerve graft: a sensible addition to one-stage mandibu­
lar reconstruction. J Plast Reconstr Aesthet Surg 2012;
65(6):757–762
12. Williams EF III, Setzen G, Mulvaney MJ. Modified Ber­
nard-Burow cheek advancement and cross-lip flap for to­
tal lip reconstruction. Arch Otolaryngol Head Neck Surg
1996;122(11):1253–1258
13. Williams E, Hove C. Lip reconstruction. In: Papel ID,
ed. Facial Plastic and Reconstructive Surgery. 2nd ed.
New York: Thieme; 2002
14. Ducic Y, Athre R, Cochran CS. The split orbicularis myo­
mucosal flap for lower lip reconstruction. Arch Facial Plast
Surg 2005;7(5):347–352
15. Wilson JS, Walker EP. Reconstruction of the lower lip.
Head Neck Surg 1981;4(1):29–44
16. Abbe R. A new plastic operation for the relief of deformity
due to double harelip. Plast Reconstr Surg 1968;42(5):
481–483
17. Juri J, Juri C. Cheek reconstruction with advancement-
rotation flaps. Clin Plast Surg 1981;8(2):223–226
18. Stark RB, Kaplan JM. Rotation flaps, neck to cheek. Plast
Reconstr Surg 1972;50(3):230–233
19. Yu K, Kim AJ, Tadros M, Costantino PD. Mitek anchor-
augmented static facial suspension. Arch Facial Plast Surg
2010;12(3):159–165

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Discussion by Lawrence J. Gottlieb
The function of the face is to look normal in both re­
pose and animation and to express the spectrum of
emotions, allowing for successful interpersonal inter­
action. Whereas symmetry is the norm for centrofacial
features, asymmetry is the norm in the shape of most
faces because of slight differences in fat and muscle of
the cheeks, with one side of the face curved and the
other more straight. Most people do not notice this
asymmetry and, if they do, are not particularly both­
ered or concerned about it. In contradistinction, many
patients are distressed by postoperative asymmetry—
even if it is the same as the preoperative state. There­
fore, to avoid the perception of an unfavorable result, it
is helpful to point out to the patient and the family the
“normal” preexisting asymmetries preoperatively.
The idealized goal in facial reconstruction is for a
casual observer to not be able to notice the scars (or the
reconstruction) in normal social interactions. The lead­
ing constraints in obtaining these goals are the age of
the patient, the size of the defect including any three-
dimensional loss of tissue volume, the quality of remain­
ing skin surrounding the defect, and the tissue chosen
for closure or reconstruction. Scars are less noticeable
when incisions are closed without tension, when they
are made parallel to relaxed skin tension lines (RSTL),
and on patients with coarse, ruddy skin. Imperceptible
scars are attainable if they look like normal skin lines
and/or are hidden by shadows, folds, or hair.1 Because
younger patients are less likely to have coarse skin with
prominent skin lines, shadows, or folds, they are more
likely to have unfavorable scars. In addition, younger
skin has more elasticity, which commonly leads to wid­
ened scars and distortion of adjacent mobile parts.
Lip and cheek reconstruction are discussed together
because they are intimately connected functional units.
Functional units of the face are three-dimensional con­
siderations of aesthetic units. Each individual compo­
nent of a functional unit includes its overlying skin,
underlying soft tissue, musculature, and/or structural
support and lining. Each component has specialized
functions, and dysfunction may affect that unit but may
impact the function of an adjacent unit. This is partic­
ularly evident when dealing with the aesthetics and
function of the lips with loss or dysfunction of the fa­
cial muscles of expression located in the adjacent cheek.
Reconstructive options for lip and cheek defects in­
clude the usual array of available techniques including
healing by secondary intention; primary closure; skin
grafts; local, regional, or distant flaps; and free tissue
transfers.
Lip Reconstruction
Restoration of the lips is complicated by the fact that
they are mobile structures and need to function (aes­
thetically and mechanically) differently when in repose
and when animated, because function and aesthet­
ics are inextricably linked in these functional units.
In ­addition, as mobile structures, they are subject to
­distortion by gravity, scars, and possibly radiation,
­denervation, and muscular dysfunction.
Lip reconstruction may be indicated for loss or ab­
normality of the mucosa, vermilion, skin, subcutaneous
tissue, muscle, or a combination of some or all of these
components. The most common circumstance requiring
lip reconstruction is related to partial- or full-thickness
loss from trauma or tumor extirpation.
Small partial-thickness defects can generally be
closed primarily, or with a skin graft or flap (if too
large to close primarily.) In most situations, skin
grafts provide a less than optimal aesthetic result
with ­discrepancies of color, texture, composition, and
­elasticity (Fig. 53D.1). When dealing with a ­partial or
complete loss of a portion of the lip, adjacent “like”
­tissue will usually provide the best replacement,
­particularly when considering the qualities of skin cover.
Fig. 53D.1 A patient with recurrent basal cell carcinoma. (a) The original resection was closed with a skin graft. Although the
contour is good and the edges of the graft are parallel to the relaxed skin tension lines, the discrepancy of color and texture are
obvious in repose. (b) The lack of elasticity is obvious with animation.
a
b

999
Chapter 53 Reconstruction of the Lip and Cheek
Closure of the lip, whether from trauma or excision of a
tumor, requires meticulous approximation of each layer,
paying particular attention to lining up the vermilion
border and white roll on the surface and repairing any
muscle disruption. It is imperative to mark, ideally with
a temporary tattoo, the vermilion border and other land­
marks before the infiltration of local anesthesia with
epinephrine and the onset of intraoperative swelling.
Epinephrine will obliterate the color differences, mak­
ing meticulous approximation of the vermilion border
impossible. In addition, breaking up the closure below
the white roll by adding a small z-plasty or other inter­
digitations helps restore the gentle curve of the lip and
avoids notching of the incision line.
Although a common notion is that 25% of the upper
lip can be closed primarily, this cannot be done without
distortion of the philtrum in upper lateral defects, espe­
cially when dealing with younger patients. Therefore,
to minimize distortion, the surgeon should consider re­
constructing aesthetic subunits with local flaps for de­
fects larger than 10 to 15% of the upper lip (Fig. 53D.2).
For central upper lip defects or when lateral lip defects
are too large to close with “like” adjacent tissue, a lip-
switch–type procedure (Abbé or Estlander) or circum­
oral rotation–advancement (Karapandzic) flap should
be considered. These procedures are the embodiment
of the restoration of the functional unit concept in that
they have the potential to restore some or all the compo­
nents (skin, muscle, and mucosa) of the missing portion
of the lip. Although denervated when transferred, the
transferred muscle within these “switched” lip segments
generally regains some function through direct neuroti­
cization. Men should be warned that after a lip-switch
procedure, the hair in the segment that was “switched”
will grow in the wrong direction. When closing larger
defects with these techniques, the surgeon must balance
the advantages of having “like” tissue and competent
lips with the disadvantages of creating microstomia, po­
tential distortion seen on animation, and the significant
amount of additional scarring added to the face.
When the defect is too large to close with “like” tis­
sue, regional or distant tissue is required. Invariably if
distant skin is used for reconstruction, color mismatch
leads to unfavorable results. Even skin from different
parts of the head and neck that have better color match
have different qualities of texture, composition, pliabil­
ity, and elasticity, as well as different attachments to
deeper tissue, whether they are subcutaneous fat or
muscle fibers. It is these different attachments that lead
to discrepancies in how reconstructed lips look in ani­
mation versus repose.
Free tissue transfer is generally required to success­
fully reconstruct more than 80% of the lip. For a suc­
cessful functional reconstruction of the lower lip, the
orbicularis sphincter needs to be reconstructed and
the lip needs to be suspended. Suspending a tendon to
fixed points merely allows the skin to drape over the
tendon like a clothesline and produces an adynamic lip.
The best functional reconstruction using free flaps sus­
pends the reconstructed lip skin independent of orbi­
cularis sphincter restoration.2 An alternative method of
bridging orbicularis muscle loss includes transferring
Fig. 53D.2 (a,b) This 69-year-old woman had a defect of her upper lip after excision of a melanoma. Important landmarks and a
crescent V-Y flap are marked. The incision on the neck is for sentinel lymph node biopsy. (c) The cheek flap was advanced to the
border of the aesthetic unit and the residual defect was closed with a crescent V-Y flap based on perforators off of the facial artery.
(d,e) At 2 years postoperatively, she required no revisions. (f) Minimal distortion is noted with smiling.
a
b
c
d
e
f

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1000
innervated muscle flaps.3,4 Although many authors ad­
vocate neurorrhaphy of the sensory nerves of cutaneous
free flaps, this is not absolutely necessary, because these
flaps generally regain sensation with time from sponta­
neous neurotization.
Reconstructing large defects of the upper lip with its
gentle curves and delicate lines in an aesthetically pleas­
ing way is difficult, especially in women and children.
Burget and Menick5 have successfully reconstructed
large unilateral lateral defects with a large aesthetic sub­
unit Abbé cross-lip flap. The best techniques for total or
subtotal central upper lip reconstruction use bilateral
lip or cheek advancement flaps complemented with an
Abbé cross-lip flap to create a semblance of a philtrum.
Full-thickness reconstruction of the upper lip tends
to fair better in men if they are willing to wear a mus­
tache. Hair-bearing fasciocutaneous flaps based on the
superficial temporal vessels to resurface skin defects
have been described, as have composite osteocutane­
ous flaps for more complex reconstructive needs1,2 (Fig.
53D.3). Although hair-bearing flaps successfully camou­
flage any irregularities of upper lip aesthetic unit recon­
struction, if it is shaved, the lip looks like a “blob” and
needs multistage revisions to look natural.
Fig. 53D.3 (a) Indolent basal cell carcinoma of the upper lip in a 72-year-old male. (b) The defect after resection of the upper lip
(extending into the cheeks), a portion of the lower lip, the anterior surface of maxilla, the nasal floor, and the columella. (c,d) The
lateral view demonstrates the volume of tissue missing. An alginate mold was made for a three-dimensional perspective to aid in
planning the reconstruction. (e) A hair-bearing temporoparietal osteofasciocutaneous composite free flap based on the superficial
temporal vessels was created. A vascularized outer table of cranium (straight arrow) replaced the anterior surface of the maxilla,
various layers of temporoparietal fascia (asterisks) were used to create the buccal sulcus and line the nasal floor, deep temporal
fascia (curved arrow) was used to bring in the orbicularis muscle defect in an attempt to re-create a sphincter, and hair-bearing skin
was used to re-create a mustache. (f,g) At the completion of surgery. The buccal lining was created with a skin graft, held in place
with the patient’s denture, which was attached with K-wired to the hard palate (g). The upper lip functional unit was re-created in
three dimensions (f). (h) Result 6 months postoperatively of the single-stage reconstruction with no revisions. (Reproduced from
Gottlieb LJ, Agarwal S. Autologous alternatives to face transplant. J Reconstr Microsurg 2012;28:49–61.)
a
b
h
f
g
c
*
*
*
*
*
*
*
*
e
d

1001
Chapter 53 Reconstruction of the Lip and Cheek
Regardless of what tissue is used to reconstruct
the lip, the surgeon should try to hide scars along the
borders of the aesthetic units or subunits of the lip or
within (or parallel to) natural skin lines. In addition, al­
though the lips may not be perfectly symmetrical, ob­
taining relative symmetry, avoiding distortion in repose,
and minimizing distortion with animation is essential to
a successful reconstruction.
Cheek Reconstruction
The cheek is generally considered to be a single aes­
thetic unit, and this is particularly true in younger peo­
ple who have few if any skin lines, creases, or rhytids.
With aging, skin lines of facial expression and rhytids
invariably develop (Fig. 53D.4). These lines are gener­
ally parallel to the RSTL, are slightly curved, and gen­
erally come together in the jowl or neck area in a V
shape (Fig. 53D.5). These lines can define subunits and
should be guides to the direction of incisions for wound
closure or the design of flaps. Patients without rhytids
or obvious skin lines on their cheeks are best served
with one of the variations of a cervical facial flap.6–10
Although these flaps hide scars at the borders of the
aesthetic units and tend to be aesthetically pleasing,
they are not perfect. Several potential issues with cer­
vical facial flaps exist:
1. An altering hairline and beard pattern in men (par­
ticularly below the sideburn)2 (Fig. 53D.6)
2. Asymmetry of loose neck skin (Fig. 53D.7)
3. Blunting of the nasolabial fold (Fig. 53D.8)
Patients who have prominent rhytids and skin lines on
their cheeks may be candidates for local flaps or adjacent
tissue rearrangement. Because of the direction of the
rhytids and RSTL, V-Y designs with incisions in or paral­
lel to RSTL leads to the most favorable scars (Fig. 53D.9).
Fig. 53D.4 Skin lines and potential subunits that develop with aging. (a) A 30-year-old. (b) A 60-year-old. (c) An 80-year-old.
(d) A 90-year-old.
a
b
c
d
Fig. 53D.5 The relaxed skin tension lines and rhytids of the
cheek are slightly curved and generally come together in the
jowl or neck area in a V shape.
Fig. 53D.6 An altered hair pattern after a Schrudde angle-­
rotation flap in which hairless postauricular skin was transferred
in front of the ear.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
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Fig. 53D.7 Asymmetrical neck skin draping after a left cervi­
cal facial flap.
Fig. 53D.8 (a) Schrudde angle-rotation flap planned for closure of a cheek defect. (b) Flap transfer. (c) The reconstruction ap­
pears nearly perfect, with imperceptible scars, on the oblique view. (d) On frontal view, however, asymmetry of the nasolabial
folds produces an unfavorable result.
a
b
c
d
Fig. 53D.9 (a) Preoperative markings of the skin lines and rhytids on an 83-year-old woman. (b) Markings for a large, crescent
V-Y flap to be used to close the defect of the upper cheek. (c) The flap has been elevated, advanced, and rotated. Deepithelialized
corners were used to suspend the flap to bone and fascia periorbitally. (d) Flap inset. (e) One-month postoperative result demon­
strating scars in or parallel to skin lines and rhytids and symmetry of the facial features.
d
e
a
b
c

1003
Chapter 53 Reconstruction of the Lip and Cheek
Regardless of the reconstruction technique, main­
taining vascularity of the transferred tissue is impera­
tive. Although conventional wisdom suggests that deep
plane–composite elevation will have a better blood sup­
ply than elevation in the subcutaneous plane, there are
reports of marginal necrosis with deep plane (sub–su­
perficial musculoaponeurotic system [SMAS]) elevation
and others finding almost no necrosis with subcutane­
ous elevation.11–14 Clinical experience, corroborated by
experimental work, demonstrates that preservation of
critical perforating vessels, particularly perforators off
the transverse facial vessels, whether dissection is above
or below the SMAS, is key for maintaining a robust blood
supply (Fig. 53D.10).
When a large surface area of tissue is missing or
needs to be replaced, especially when associated with
a three-dimensional volume defect, distant or free tis­
sue transfer may be required. Invariably this distant
tissue will have less-favorable skin color, texture, and
composition than local or regional skin. Because of this,
it is rare to obtain a great result in one step using skin
from distant locations. Achieving the ideal goals may
only be possible in a staged fashion, with the initial
steps aimed at closing the wound and reestablishing
structural support if needed. Subsequent surgical steps
in restoring the face toward normal should be consid­
ered and planned at the initial step. The goals of subse­
quent steps would generally be to refine contour and/or
Fig. 53D.10 A transverse facial artery perforator preserved
in a cervical facial flap.
Fig. 53D.11 (a,b) One year after a complex defect was closed with a thoracodorsal-scapular osteocutaneous chimeric flap. Ruddy
skin changes are evident surrounding the flap from postoperative radiation. (c) A compound deep plane cervicofacial flap was el­
evated. (d,e) Result 4 months postoperatively after the cervicofacial flap procedure.
d
e
a
b
c

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
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improve color discrepancies. Although stark color mis­
matches may be improved with deepithelization and
resurfacing with split-thickness skin grafting from the
scalp, this technique is not perfect, particularly when
the native cheek skin surrounding the flap has a ruddier
color and texture than the scalp. Alternatively, the patch
of abnormal-looking skin can be secondarily removed
and replaced with local or regional tissue (Fig. 53D.11).
Conclusion
The ideal goal in lip and cheek reconstruction is for a
casual observer to not notice the reconstruction in nor­
mal social interactions. This requires not only hidden
scars without distortion or patches but competent lips
and cheeks allowing for eating, intelligible speech, and
expression of emotions.
References
1. Borges AF, Alexander JE. Relaxed skin tension lines, Z-
plasties on scars, and fusiform excision of lesions. Br J
Plast Surg 1962;15:242–254
2. Gottlieb L, Agarwal S. Autologous alternatives
to facial transplantation. J Reconstr Microsurg
2012;28(1):49–61
3. Ninkovic M, Spanio di Spilimbergo S, Ninkovic M.
Lower lip reconstruction: introduction of a new pro­
cedure using a functioning gracilis muscle free flap.
Plast Reconstr Surg 2007;119(5):1472–1480
4. Bauer T, Schoeller T, Rhomberg M, Piza-Katzer H,
Wechselberger G. Myocutaneous platysma flap for
full-thickness reconstruction of the upper and lower
lip and commissura. Plast Reconstr Surg 2001;108(6):
1700–1703
5. Burget GC, Menick FJ. Aesthetic restoration of one-
half the upper lip. Plast Reconstr Surg 1986;78(5):­
583–593
6. Mustardé JC. The use of flaps in the orbital region.
Plast Reconstr Surg 1970;45(2):146–150
7. Stark RB, Kaplan JM. Rotation flaps, neck to cheek.
Plast Reconstr Surg 1972;50(3):230–233
8. Juri J, Juri C. Advancement and rotation of a large cer­
vicofacial flap for cheek repairs. Plast Reconstr Surg
1979;64(5):692–696
9. Schrudde J, Beinhoff U. Reconstruction of the face by
means of the angle-rotation flap. Aesthetic Plast Surg
1987;11(1):15–22
10. Kroll SS, Reece GP, Robb G, Black J. Deep-plane cer­
vicofacial rotation-advancement flap for reconstruc­
tion of large cheek defects. Plast Reconstr Surg 1994;
94(1):88–93
11. Austen WG Jr, Parrett BM, Taghinia A, Wolfort SF, Up­
ton J. The subcutaneous cervicofacial flap revisited.
Ann Plast Surg 2009;62(2):149–153
12. Whetzel TP, Mathes SJ. The arterial supply of the face
lift flap. Plast Reconstr Surg 1997;100(2):480–486,
discussion 487–488
13. Whetzel TP, Stevenson TR. The contribution of the
SMAS to the blood supply in the lateral face lift flap.
Plast Reconstr Surg 1997;100(4):1011–1018
14. Schaverien MV, Pessa JE, Saint-Cyr M, Rohrich RJ.
The arterial and venous anatomies of the lateral face
lift flap and the SMAS. Plast Reconstr Surg 2009;
123(5):1581–1587

1005

Reconstruction of the Scalp and Cranium
Russell R. Reid and Lawrence J. Gottlieb
Reconstruction of the scalp and cranium can entail some
of the most challenging, sophisticated, and rewarding sur­
gical procedures that comprise a reconstructive surgeon’s
practice. Much of the challenge lies in the task of replacing
like tissues with like, protecting vital structures, and the
myriad options that exist. With any reconstructive proce­
dure, planning entails a precise determination of the tissue
components that are or will be missing, the size of the de­
fect, and any anticipated exposure of vital tissues. The sur­
gical goals may vary from closing a wound to reconstruct­
ing a part. These goals are modulated by consideration of
the patient’s age, existing comorbidities, and wound heal­
ing deterrents (e.g., smoking, radiation, infection, previous
cranioplasties, and persistent tumor).
Successful reconstruction of the scalp demands a de­
tailed knowledge of the unique anatomy that is inherent
in this region. For example, the hirsute quality of the scalp
with its characteristic quality and density of hair places
the remaining, neighboring scalp and its associated proce­
dures (local flaps, tissue expansion) at a premium and vice
versa for treatment of alopecia. In the majority of cases, the
inelasticity of the scalp prevents primary closure of most
wounds, and in such cases, the healing by secondary inten­
tion, tissue expansion, skin graft or substitute coverage, lo­
coregional flaps, or free tissue transfer may be indicated to
close the wound or defect. However, when the defect is mas­
sive, or composite in nature (i.e., with concomitant cranial
bone loss), the treatment goals shift toward safe, reliable
closure of the defect to protect vital structures with a sec­
ondary objective of reconstructing the scalp by restoring a
hair-bearing surface in a staged fashion. In the latter sce­
nario of a composite defect, a multidisciplinary approach,
with a neurosurgeon and on occasion other specialists, is
absolutely necessary.
Unfavorable results of scalp and cranial reconstruction
can be divided into two broad categories: (1) aesthetic and
(2) functional or protective. Unfavorable aesthetics include
unsightly scars, contour irregularities, and abnormal quali­
ties of skin, including color, texture, composition, and hair
patterns. The function of the scalp and cranium, in addition
to appearance, is generally related to protection of underly­
ing structures, and unfavorable results occur when the in­
tegrity of the scalp or cranium is compromised. Addition­
ally, the cranium serves to help regulate cerebral spinal fluid
and venous pressures of the brain and meninges, and loss
of large portions of the cranium may predispose to the syn­
drome of the trephined.
Avoiding Unfavorable
Results and Complications
in Reconstruction of the Scalp
and Cranium
Preoperative Planning and Patient
Selection
Proper preoperative planning is essential to avoid unfavor­
able results. When planning reconstruction of any scalp
defect, several factors must be considered:
•• Location and three-dimensional size of the defect
•• Components of the defect (skin, pericranium or
cranium, dura)
•• Surrounding tissue quality
•• Age and health of patient
•• Status of disease (control or palliation)
If wound closure is the primary goal, following the sequen­
tial steps of the ‘‘wound closure’’ ladder is appropriate (e.g.,
secondary intention, primary closure, skin graft, locore­
gional flap, free flap). If the main goal is to reconstruct the
CHAPTER
54

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1006
pericranium, cranium, devascularized bone flaps, pros­
thetic material, dura, brain parenchyma, or vessels. In ad­
dition, the quality of the surrounding tissue (scarring, in­
fection, radiation) and aesthetic concerns such as contour,
skin  color match, hairline, brow position, and subunits
(e.g., forehead) must be considered.3
After assessing the size and location of the defect (or
anticipated defect), the structures involved, the surround­
ing tissue quality, and the patient’s comorbidities, the next
step in preoperative planning is to define the operative goal.
Is the goal to close the wound or reconstruct the defect?
Sometimes these two goals are in sync.
If aesthetic reconstruction is the goal, then multiple
staged procedures may be needed to obtain the best result.
Frequently, wounds are initially closed in the most straight­
forward way, with the anticipation that secondary recon­
struction with tissue expansion or other reconstructive
technique will be performed secondarily.
In the case of terminal disease, one may adjust the re­
constructive approach depending on whether the goal is
control or palliation. If tissue quality is poor due to ­scarring,
radiation, or infection and if local options are unavailable or
unreliable, then distant tissue is indicated. Sometimes, even
if local, less complicated options are technically feasible,
they are more likely to have an unfavorable result, because
distant tissue is safer and more reliable in ensuring uncom­
plicated healing.4–6 This approach is especially important if
there is exposure of vital structures.
Patient Selection
It is critical for the surgeon to not only determine the eti­
ology of the defect, but also to identify patients at high
risk who therefore have a higher chance of a detrimental
defect or deformity, especially in aesthetic reconstruction,
the process should not be sequential; instead the best op­
tion should be used, even if a more straightforward proce­
dure would work to close the wound.1
The next consideration is determining the limitations
that may preclude obtaining the initial goals and ensuring
that the patient, family, and surgeon have realistic expec­
tations.
Etiology and Analysis of Defects
The magnitude and complexity of a scalp defect depends
upon a variety of causative factors. They may be full-thick­
ness or partial-thickness in depth and can be classified as
congenital or acquired. Congenital defects may include2
cutis aplasia or defects arising from other congenital le­
sions (congenital nevi, congenital vascular malformations,
and congenital tumors). Acquired scalp defects have several
possible causes:
•• Injuries, such as burns
•• Blunt or penetrating trauma
•• Avulsion injuries leading to ‘‘degloving’’ of the scalp
•• Tumor invasion
•• Infection
•• Oncologic resection
•• Radiation
•• Wound-healing difficulties
Preoperative anticipation of potential difficulty with di­
rect closure when the scalp has been compromised by one
of these circumstances or conditions is crucial to success.
The initial evaluation of the defect is based on its size and
location, tissue involved, and structures exposed, such as
Summary Box
Unfavorable Results of Scalp and Cranial ­Reconstruction
Aesthetic
•• Unsightly scars
•• Qualitative difference of skin
○
○Color
○
○Texture
○
○Composition: hair (alopecia)
•• Contour irregularities
○
○Soft tissue
–
– Too thick
–
– Too thin
–
– Shrink-wrap
○
○Cranium
–
– Denting (loss or thinning of bone)
–
– Protruding (excess or malpositioned bone)
Functional/Protective
•• Wound-healing issues
○
○Marginal necrosis
○
○Unstable skin/scar
○
○Wound breakdown
–
– Exposure of hardware, prosthetics, tissue
expander, bone grafts or flaps, and dura
○
○Infection
–
– Wound
▪
▪Superficial
▪
▪Deep
–
– Meningitis
–
– Epidural, subdural, or brain abscess
•• Cranial defect
○
○Loss of brain protection
○
○Syndrome of trephined

1007
Chapter 54 Reconstruction of the Scalp and Cranium
Intraoperative Considerations
Due to its unique nature, the ideal tissue for scalp defect
coverage would be adjacent scalp tissue, thereby following
the classic tenet to replace like tissue with like. If there is
significant damage to surrounding tissue due to trauma,
multiple surgeries, infection, or radiation, defect coverage
with local tissue may not be the ideal option to obtain re­
liable, stable wound closure. The goal of wound coverage
from a functional and protective standpoint should be
combined with the goal of achieving a cosmetically pleas­
ing (or acceptable) result. Often, this goal requires a com­
bination of different procedures and several surgical stages.
In order to achieve an optimal aesthetic result, frequently
the final revisions (using locoregional flaps, tissue expan­
sion, hair transplantation, flap thinning, or excision of skin
paddles or grafts) must be delayed until stable wound cov­
erage is obtained.
Scalp Reconstruction Options
Primary Closure
Classically, the reconstructive surgeon can resort to pri­
mary closure with undermining of isolated scalp defects if
the defect is less than 3 cm in diameter, especially if the
defect is posteriorly located10 (Fig. 54.1). Frequently, post­
traumatic wounds have the appearance of tissue loss but,
on careful inspection, are found to not be missing any tis­
sue. These wounds can usually be closed directly if minimal
tissue needs to be débrided. Limitations of that approach
may exist based on the surrounding tissue quality or expo­
sure of vital structures. Maneuvers that facilitate closure,
such as local advancement flaps, undermining the tissue,
and scoring of the galea11 helps in reducing tension and in­
creases the chances of stable wound coverage. However, the
surgeon must be careful to not score too deeply or close un­
der too much tension, both of which will compromise the
blood supply and lead to marginal necrosis, wound break­
down, or alopecia.
Secondary Intention
Dr. Frederic Mohs’ initial approach12 of healing small forehead
and scalp defects with secondary intention by granulation,
contraction, and reepithelialization, can be used and is often
applied in the case of paramedian forehead flap donor sites.
In the congenital case of cutis aplasia, simple defects can be
allowed to close by secondary intention with the applica­
tion of a topical antimicrobial, and no surgical intervention is
needed.13 Although healing by secondary intention frequently
leads to acceptable results in patients of Western European de­
scent (Fig. 54.2), patients with darker skin frequently heal with
more noticeable hypopigmented or hyperpigmented scars. In
the scalp area, the healed defect will be alopecic but will have
also reduced in size significantly because of the contraction
component of secondary healing.14
­outcome. In this regard, it has been our overwhelming ex­
perience that previous radiation, previous or concurrent in­
fection, exposed hardware, concurrent cerebrospinal fluid
(CSF) leak, previous multiple cranioplasties, and cigarette
smoking are deterrents to successful reconstruction of the
complex scalp defect.7 In these cases, the complication rate
has been noted to escalate to 59% in one study.8 To help
guide reconstructive choices in these difficult scenarios
and minimize major complications as well as unfavorable
results, we have developed a severity scoring system: The
University of Chicago CRAnial Severity Score of Hostility
(CRASSH)9 (Table 54.1), which serves as a tool for decision-
making in the reconstruction of composite scalp–cranial
defects.
Procedure and Technique Selection
If there is a large cranial defect with reliable soft tissue
coverage and a CRASSH score of 0, almost any cranioplasty
technique, alloplastic or autologous, will have a low mor­
bidity rate. Similarly, if a patient with unreliable soft tis­
sue coverage has a low CRASSH score, particularly without
having a previous or concurrent infection, then a regional,
distant, or free flap should be used to provide reliable soft
tissue coverage over the cranial reconstruction (alloplastic
or autologous). The more complicated the patient’s his­
tory regarding high risk for wound-healing issues (i.e., the
higher the CRASSH score), the more likely more reliable
soft tissue coverage should be used, the less likely alloplas­
tic material is acceptable as a bony substitute, and the more
likely autologous bone is the best choice. Patients with the
most hostile wounds (CRASSH of more than 3) do best with
vascularized autologous bone.
Table 54.1 University of Chicago
CRAnial Score of Severity of
Hostility (CRASSH)
Preoperative factor
Score
Current or history of infection
1 point
Previous radiation
1 point
Previous failed reconstruction
1 point for every event
Large cranial defect (> 60 cm2)
1 point
Previous CSF leak
1 point
Open wound
1 point
History of tobacco use
1 point
Source: From Fong AJ, Lemelman BT, Lam S, et al. Reconstructive ap­
proach to hostile cranioplasty: a review of the University of Chicago
experience. J Plast Reconstr Aesthet Surg 2015;68:1036–1043.

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Another method to be considered when the outer table of
the cranium is exposed is to drill burr holes into the diploe,
await granulation tissue to cover the bone, then skin graft
the granulation tissue. Alternatively, the outer table of the
skull can be removed or burred down and a skin graft can
be placed directly on the well-vascularized diploe.16 With­
out the gliding capacity of the pericranium, however, these
grafts are often prone to minor wound breakdown. This is
also the case in wounds devoid of pericranium that are cov­
ered initially with a bilayer wound matrix or acellular der­
mal matrix, which has gained popularity for scalp wounds
of this nature17,18 (Fig. 54.4).
Tissue expansion is certainly an ideal reconstructive
option of choice for hair-bearing scalp defects, because
no other technique can provide ‘‘like tissue’’ for large de­
fects.19,20 Temporary skin grafting with the anticipation of
subsequent removal after tissue expansion of adjacent lo­
cal tissue from the same aesthetic unit provides a superior
cosmetic outcome (Fig. 54.5). The main disadvantages of
tissue expansion are the need for multiple procedures, the
temporary aesthetic deformity of having expanders, and the
lengthy treatment period of several months during expan­
sion, necessitating optimal compliance from the patient and/
or caregivers.19,21 The major complications associated with
tissue expansion are wound breakdown, extrusion, and in­
fection. Wound breakdown and extrusion can be minimized
by placing the incisions perpendicular rather than parallel
Skin Grafting and Tissue Expansion
Skin grafting of the scalp is a relatively straightforward pro­
cedure that provides reliable wound closure. Skin grafting
of the scalp has several disadvantages:
•• Difficulty in matching the color, texture, and thickness
of skin
•• Suboptimal restoration of the contour
•• Lack of hair if used in hair-bearing regions
Patients who are bald and have defects in these non–
hair-bearing areas are often best served with a skin graft,
whereas defects within the hair-bearing portion are typi­
cally aesthetically unacceptable. Color differences can be
minimized by harvesting from the scalp. Using hair-bear­
ing scalp has the added advantage of hiding the donor site
under hair (when it grows back) (Fig. 54.3). Split-thickness
skin grafts typically do not tolerate radiation very well,
especially if a significant amount of desquamation oc­
curs from the radiation.3 If adjunctive radiation is antici­
pated, the surgeon should consider using a fasciocutane­
ous flap instead; if it desquamates, it has the capacity to
­reepithelialize.
Robinson (1908)15 was the first to describe that a skin
graft can take directly on pericranium rather than wait­
ing for the wound to be covered by granulation tissue first.
Fig. 54.1 Primary closure. Posterior scalp wound (a) facilitated by loose skin from the neck (b).
a
b
Fig. 54.2 Healing by secondary intention. (a) A patient with an open scalp wound referred for closure. (b) One month after treatment with
a topical antimicrobial. (c) After 3 months.
a
b
c

1009
Chapter 54 Reconstruction of the Scalp and Cranium
Fig. 54.3 (a) Melanoma of the left anterior scalp. (b) Wide excision. (c) Wound temporized with bilayer wound matrix. (d) Split-thickness
skin graft harvested from hair-bearing scalp. (e) Aesthetic deformity of the recipient site and hidden donor site 1 year later. (f) The patient
uses a “comb-over” technique in an attempt to hide the aesthetic deformity.
a
b
c
d
e
f
Fig. 54.4 (a) Wide excision of skin cancer with removal of outer table of calvarium. (b) After placement of bilayer wound matrix. (c) Fourteen
months after split-thickness skin graft. (d) Minor trauma to adherent skin graft 3 years after placement. Atrophic changes occurred over time.
a
b
c
d

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1010
Fig. 54.5 (a) A burn injury to the scalp of a 2-year-old patient. (b) After tangential excision of burn eschar. (c) The wound was closed with
a split-thickness skin graft with significant burn alopecia. (d) Incisions for the expander placement, placed perpendicular to the expander.
(e) Hair-bearing scalp was expanded for 4 months. (f) The anterior hairline was marked using a template from the contralateral side.
(g) A left transposition flap was incised and the expander removed. (h) The area was “resurface-tested” before excision of the alopecic
area. (i) Bone molding was noted under the expander. (j) After resurfacing of the entire alopecic area with expanded hair-bearing flaps.
a
b
c
d
e
f
g
h
i
j
to the direction of expansion (see Fig. 54.5d), avoiding folds
in the expander and avoiding having any incisions overlying
the expander, its tubing, and port.19 Another consequence
of tissue expansion is the molding or erosion of the skull
from the pressure of the expander (see Fig. 54.5i). Although
this can potentially lead to disastrous consequences,22 bony
contour irregularities caused by tissue expansion generally
spontaneously improve with time. To minimize unfavorable
results, not only do the previously mentioned issues need to
be considered, but the plan of how the expanded flaps will
be moved needs to be determined at the time of insertion.
Axial transposition flaps will more likely accomplish the goal
rather than direct advancement flaps. In addition, because
whether expanded flaps will totally cover the defect to be
resurfaced cannot be easily predicted, it is prudent to only
excise the lesion or scar after ensuring the expanded flap
will indeed cover the defect. Otherwise, the surgeon might
be tempted to “push” the limits of the flap and compromise
its circulation, or areas that cannot be resurfaced with the
expanded flap may need repeat grafting.

1011
Chapter 54 Reconstruction of the Scalp and Cranium
avoid this, when large local flaps are performed, the donor
sites frequently need to be skin grafted to minimize tension
(Fig. 54.6). Rotation, transposition, or geometric flaps can
provide acceptable cosmetic results if the defect is small to
moderate size.23,24
Multiple locoregional flaps have been described.25,26 For
example, Raposio et al27 described the use of three adjacent
rhomboid flaps in the vertex area to reconstruct the natural
whorl pattern of the hair in that region. A combination of ro­
tation and advancement is often used to cover larger defects
requiring a long curvilinear incision, which incorporates at
least one of the named scalp vessels, allowing for maximal
excursion while maintaining vascularity.
In geometric terms, the length of the rotation flap
should exceed five times the diameter of the defect to get
adequate tension-free closure28 (Fig. 54.7). Galeal scoring,
back-cutting, and undermining of the scalp in the subgaleal
plane can help minimize tension as well. The results of these
Locoregional Flap Reconstruction
When considering local flap reconstruction of the head and
neck, the surgeon must think in two broad categories: aes­
thetic subunit reconstruction or nonsubunit reconstruc­
tion. There are no separate aesthetic units of the scalp, but
there is a clear distinction between the hair-bearing scalp
and the aesthetic unit of the forehead. When using scalp
flaps, the surgeon must be cognizant of the hairline and
avoid distortion of the brow. In addition, the reconstruc­
tive surgeon must respect the direction of hair growth. A
swatch of hair growing in the wrong direction can nega­
tively affect an otherwise excellent reconstruction. The
thick, inelastic nature of the scalp can make local tissue
rearrangements (with direct closure of the donor site) dif­
ficult. Closure under tension often leads to loss of hair in
a widened scar, marginal necrosis, and wound breakdown,
which is devastating when underlying hardware is used. To
Fig. 54.7 (a) A soft tissue tumor just behind the hairline. (b) After excision. (c) Closure with a large rotation flap to avoid distortion of the
hairline or brow. (d) Final result 3 weeks postoperatively.
a
b
c
d
Fig. 54.6 Local transposition flaps that could not be closed primarily because
of tension; a skin graft was placed to close the wound without tension.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1012
Free Tissue Transfer
Although seemingly more complex, free flaps are often the
most straightforward solution to complicated defects of the
scalp, because free tissue transfers provide the most robust
vascular supply of the flap to the wound compared with the
distal portion of a pedicled flap (which may have marginal
vascularity). This is particularly important in the presence
of infection, preoperative, and postoperative radiation and
a history of previous surgery. In addition, it is usually easier
to inset and tailor free tissue transfers than pedicle flaps,
thereby making free flaps not only the best option but, in
many cases, the easiest.
Although the general principle of “replacing like with
like tissue” is an important concept, specifically in scalp
reconstruction, sometimes the conditions of the wound or
simply the size of the defect precludes using local or re­
gional reconstructive options. In those cases, a more ad­
vanced approach using free tissue transfer with different
tissue components—depending on the complexity of the
defect—is indicated. This is applicable in the setting of ag­
gressive malignancies when expedient wide excision, of­
ten resulting in exposed bone, dura, or even brain paren­
flaps appear better in hirsute scalps than bald heads, which
do not have hair or skin lines to hide the scars (Fig. 54.8).
Reconstruction of defects with flaps extraneous to the
aesthetic unit in which the defect is located may be required
if there is not enough quantity or laxity of tissue within the
same aesthetic unit. This is pertinent in defects that often
border the forehead and hair-bearing scalp. On occasion,
male pattern baldness helps by providing non–hair-bear­
ing skin otherwise not available (Fig. 54.9).
Distant Pedicle Flaps
When surrounding tissue is affected by prior trauma, scar­
ring, infection, or radiation injury, the surgeon must rely
on tissue outside the “zone of injury” in the form of distant
flaps. Defects in the occipital area can be reliably closed with
a pedicle trapezius myocutaneous flap based on the deep
branch of the transverse cervical artery.29 The latissimus
dorsi pedicle flap can also be used to cover select areas of
the scalp.30 Alternatively, free-style perforator-based flaps
may be used to close these defects (Fig. 54.10). If regional or
distant pedicle flaps are not available or adequate for wound
coverage, free tissue transfer should be considered.
Fig. 54.8 Obvious scars on a bald head from a large rotation flap. (a) View from top. (b) The lateral view accentuates the effects of scar
contracture with a double-bubble deformity.
a
b
Fig. 54.9 (a) Squamous cell carcinoma of the right temple area. (b) A defect was created by excision, with a planned rotation flap design
taking advantage of the hairless temporal skin from male pattern baldness. (c) One year postoperative result.
a
b
c

1013
Chapter 54 Reconstruction of the Scalp and Cranium
dorsi is a suitable muscle flap with a long vascular pedicle
and adequate surface area, thickness, and contour to cover
the convex surface of the scalp. Although the latissimus
dorsi flap has the option of including a skin paddle for post­
operative monitoring, the skin is usually excluded in obese
patients because of the significant deformity that would be
caused by the skin with its underlying subcutaneous tissue
(Fig. 54.11). If a bony defect is present, the latissimus dorsi
flap may include the option of incorporating ­vascularized
rib based on the intercostal perforators connected to the
thoracodorsal system, and a portion of vascularized scapula
based on the angular artery with the flap33–36 (Fig. 54.12).
If more tissue is required than the latissimus dorsi free flap
can provide, it can be combined with the serratus muscle
chyma, requires immediate reliable coverage. Beasley and
colleagues4 developed a staging system based on defect size
and surrounding tissue quality indicating free flap coverage
for defects of the forehead and scalp with heavy trauma,
infection, radiation damage, and previous local flap failure,
as well as for forehead defects larger than 50 cm2 and scalp
larger than 200 cm2. Those numbers are merely guidelines;
every case must be carefully analyzed with an individual­
ized treatment plan. The decision regarding the type of free
flap indicated depends also on multiple factors, including
defect size, location, wound condition, tissue types needed,
tissue availability, donor site morbidity, and surgeon and
patient preference. If there is previous infection, a muscle
free flap is believed to be to be beneficial.31,32 The latissimus
a
b
Fig. 54.10 (a) Wide excision of a recurrent squamous
cell carcinoma. (b) Free-style perforator-based pro­
peller flap design. (c) Wound closed with an adipose–­
cutaneous free-style perforator-based propeller flap.
c
Fig. 54.11 The unfavorable result of including a skin component of
a latissimus flap in an obese patient.
Fig. 54.12 A chimeric flap, including two ribs, scapula tip, latissimus
muscle, and skin paddle (not visible).

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1014
cial—specifically in areas of prior severe radiation damage,
infection, or cerebrospinal fluid leak. Although the vascu­
lar pedicle can be lengthened significantly up to more than
90 cm,40 when it is lengthened, the amount of surface area
available for coverage is decreased. The main disadvantage is
the need for laparotomy and potential associated complica­
tions,41 although it may be harvested laparoscopically, which
limits scars and donor site morbidity (Fig. 54.14).
Whereas fasciocutaneous flaps work well to reconstruct
defects, the paucity of hair makes them less optimal in scalp
reconstruction. The scapular and parascapular, radial fore­
arm, and anterior lateral thigh free flap are common options.
The radial forearm free flap has a thinner dermis than the
back or thigh skin and thus may be less suitable to match
the thick dermis of the scalp. The color match of all these
flaps is suboptimal, as is the amount of subcutaneous tissue.
The excess subcutaneous tissue may be secondarily thinned
and the color mismatch may be minimized by overgrafting
with split-thickness skin grafts harvested from remaining
scalp (Fig. 54.15).
flap and the scapular–parascapular free flap—all of which
are based off the subscapular vascular system37 (Videos
54.1 and 54.2).
One of the most versatile flaps frequently used for small
to moderate-sized defects is the rectus abdominis muscle
flap. It is relatively thin with a long pedicle and can be rap­
idly harvested in the supine position, thereby facilitating si­
multaneous harvest and tumor resection or recipient site
preparation.38 Although it can be raised as a myocutaneous
flap, because of overall obesity in the Western population,
skin is usually not included in this flap when used for scalp
coverage. It should be noted that muscle flaps will atrophy
and thin with time; frequently, this adds to the aesthetic
outcome, but if there is an underlying contour irregularity or
hardware, it will be an unfavorable outcome after the muscle
atrophies (Fig. 54.13).
An omental flap was the first successful free flap used
for scalp reconstruction.39 The advantages of the omental
flap are its pliability, long vascular pedicle, thin contour, rich
vascularity, and immunologic potency, which can be benefi­
Fig. 54.13 Hardware visible after atrophy of a muscle flap.
Fig. 54.14 The limited number of scars (four small scars from lapa­
roscopic port sites and one from the Pfannenstiel incision) from a
laparoscopically harvested omentum.
Fig. 54.15 (a) An anterior lateral thigh flap to the right side of the face (performed by Ed Rodriguez, MD, DDS). (b) After thinning. (c) Af­
ter reduction in the size of the flap with cervical facial advancement and resurfacing with split-thickness skin graft from native scalp. The
change in skin tone is notable. The orbital area was not treated and still has the yellow hue of thigh skin.
a
b
c