Chẩn Đoán Và Điều Trị Phẫu Thuật Tái Tạo Hiện Đại (CURRENT Reconstructive Surgery)

INTRAORAL RECONSTRUCTION • 433
( Figure 37-4 ). To ensure that the length of the musculo-
vascular bundle will be adequate to reach into the oral
cavity, one should fabricate a template of the fl ap with a
surgical towel cut to the anticipated size and length. The
point of rotation of the fl ap can be designed as superior as
the point of exit under the inferior edge of the clavicle of
the pectoral branch of the thoracoacromial artery. If the
PMMC fl ap is to be mobilized this far superiorly, the lat-
eral thoracic artery must be divided. This may compro-
mise the blood supply of the fl ap in some patients. Under
most circumstances, the PMMC fl ap begins at the level of
the nipple and is carried inferiorly to the lower borders of
the rib. The skin paddle may be extended over the rectus
sheath, but these portions of skin are supplied by a ran-
dom vascular pattern and are less reliable. After the skin
incisions around the skin paddle are carried through the
subcutaneous tissue, the muscle is incised medially from
its sternal attachments and elevated from the chest wall.
The neurovascular bundle is identifi ed by direct visualiza-
tion and palpation. For further mobilization, the humeral
attachments of the muscle are divided. An oblique inci-
sion from the superior lateral edge of the skin paddle to
A
C
D
B
FIGURE 37-2. (A) A patient with an anterior palatal fi stula with markings for
turnover fl aps of oral mucosa to be used for nasal closure. (B) The design for an anteriorly
based dorsal tongue fl ap. (C) The tongue fl ap being raised. (D) The fl ap after inset. Note
that the fl ap still maintains a connection to the tongue.

434 • CHAPTER 37
F
E
FIGURE 37-2. (continued) (E) The tongue fl ap after division with closure of the
palatal fi stula. (F) The tongue donor site after fl ap division and inset.
FIGURE 37-3. Reconstruction of a marginal mandibulectomy defect with a split-
thickness skin graft. (A) A patient with a T2 carcinoma of the fl oor of mouth. (B) The
marginal mandibulectomy defect, including resection of the fl oor of mouth and ventral
tongue. (C) Split-thickness skin graft (0.018 inch) used to resurface the defect. (D) The
Xeroform bolster and tie-over sutures used to secure the skin graft.
A
B
C
D

INTRAORAL RECONSTRUCTION • 435
A
B
C
E
D
FIGURE 37-4. (A) Photograph
demonstrating resection of the lateral mandible
and fl oor of mouth. (B) The resection of the skin
overlying the mandibular body. (C) The design of
a pectoralis fl ap utilizing two skin paddles (one
for the fl oor of mouth, and one for the skin). The
area to be de-epitheliazed (including the nipple)
is marked. The superior incision is designed to
preserve the blood supply and the possibility of
raising a deltopectoral fl ap. (D) The inset of the
cutaneous paddle of the fl ap. (E) The inset of
the intraoral paddle of the fl ap. The lateral bony
mandible has not been reconstructed.

436 • CHAPTER 37
A
B
FIGURE 37-5. (A) Photograph demonstrating the
design of an anterior lateral thigh fl ap for coverage of a near-
total glossectomy defect. (B) The anterior lateral thigh fl ap
harvested with isolation of its pedicle.
the axillae can be used to improve exposure. This incision
should be located approximately at the sight of a lower
transverse incision that would be used if a deltopectoral
fl ap were designed. By not dividing the second and third
intercostals perforators when raising the PPMC fl aps and
by not incising the skin supplied by the second and third
intercostals perforators, one still has the future option of
designing an ipsilateral deltopectoral fl ap. The donor area
from the PMMC fl ap can be closed primarily, leaving little
chest deformity.
Multiple modifi cations of the PMMC fl ap have been
described. The skin paddle can be modifi ed to resurface
two epithelial defects (ie, skin and mucosa, when a through-
and-through defect has been created) ( Figure 37-4 ). The
pectoralis muscle can be employed without the cutaneous
portion of the paddle. In this way the fl ap is far less bulky.
If an epithelial surface is required, a split-thickness skin
graft can be applied directly to the muscle. When the mus-
cle is used intraorally, it will re-epithelialize with mucosa
if allowed to heal by secondary intention.
Several other pedicled fl aps have been used for oral
cavity reconstruction, most notably the latissimus dorsi
fl ap. The latissimus dorsi shares many of the advantages
of a pectoralis myocutaneous fl ap, including a large arc of
rotation, reliable vascularity and possibility of inclusion of
muscle with or without a skin island. However, it neces-
sitates turning the patient to harvest the fl ap, and is gener-
ally second to the pectoralis myocutaneous fl ap for oral
cavity reconstruction.
Soft Tissue Reconstruction With Free Flaps
Free fl aps are often the ideal reconstructive modality for
defects involving large resections of the soft tissues of the
oral cavity. The most common free fl aps for soft tissue
reconstruction are the anterolateral thigh fl ap, the radial
forearm free fl ap, and the rectus abdominis fl ap.
The anterolateral thigh fl ap is a perforator fl ap, derived
from the descending branch of the lateral circumfl ex
femoral artery. Its advantages include a long pedicle
( Figure 37-5 ) with a suitable vessel diameter and the pos-
sibility of harvesting the fl ap with thigh musculature (the
vastus lateralis muscle, rectus femoris muscle, and/or the
tensor fasciae lata) or as a sensate fl ap (by incorporat-
ing the anterior branch of the lateral cutaneous nerve of
the thigh). Because of its distance to the head and neck,
its harvest can be performed simultaneously with tumor
extirpation. Flap elevation begins by mapping the cutane-
ous perforators with a pencil Doppler probe. These perfo-
rators are located by fi rst marking the midpoint between
the anterior superior iliac spine and superolateral corner
of the patella ( Figure 37-5 ). A circle centered at this mid-
point is then drawn with a radius of 3 cm. The majority of
the cutaneous perforators are located in the inferolateral
quadrant of this circle. The fl ap is then harvested with its
center over these perforators and its long axis parallel to
that of the thigh. The fl ap can be elevated with or without
the fascia lata (suprafascial dissection). The fl ap’s skin
and subcutaneous tissue are raised until the perforator(s)
to the skin is defi ned. Once the skin vessel(s) is seen, it
is dissected until the main pedicle is reached. If the skin
vessel(s) is a musculocutaneous perforator(s) (the major-
ity of patients), then the harvest includes an intramuscular
dissection through the vastus lateralis muscle. If the skin
vessel is a septocutaneous perforator, then the dissection
is simpler and proceeds between the vastus lateralis and
rectus femoris muscles. The length of the pedicle is 8 to
16 cm, with a vessel diameter of larger than 2 mm. A skin
defect of less than 9 cm in width can be closed primarily
without any reported evidence of compartment syndrome.
Larger defects require skin grafting. A distinct disadvan-
tage is the thickness of the fl ap in overweight individuals.
However, the fl ap can be trimmed to the subdermal fat
level for use as a thinner fl ap (4 mm).
The radial forearm free fl ap is a fasciocutaneous free
fl ap deriving its blood supply from branches of the radial
artery that run in the intermuscular septum between the
brachioradialis and fl exor carpi radialis muscle. The major
advantage of the radial forearm free fl ap is the large amount
of thin forearm skin that can be harvested for reconstruc-
tion. The main disadvantage of the radial forearm free fl ap
is the potential poor cosmesis at the donor forearm site.

INTRAORAL RECONSTRUCTION • 437
For through-and-through cheek defects, the radial forearm
free fl ap can be folded to create separate skin paddles for
cutaneous and oral mucosa reconstruction. A segment of
radius vascularized by vessels passing from the radial artery
through the lateral intermuscular septum and perforating
vessels through the muscle belly of the fl exor pollicus lon-
gus may be transferred with the radial forearm fl ap and be
used for mandible bony reconstruction. The antebrachial
cutaneous nerves of the forearm can be incorporated into
the fl ap to make the radial forearm free fl ap a sensate fl ap.
However, spontaneous return of fl ap sensation has been
documented in patients who underwent reconstruction of
the oral cavity with noninnervated fl aps. Compared with
an anterolateral thigh fl ap, a radial forearm free fl ap is often
thinner, but has similar indications for reconstruction. 5 By
harvesting additional subcutaneous tissue extensions and
folding these extensions under the cutaneous portions of
the radial forearm free fl ap, additional bulk can be added to
the reconstruction of the mobile tongue or base of tongue.
The bulk of vascularized fat does not diminish with time,
as is the case with vascularized muscle that undergoes den-
ervation atrophy.
The rectus abdominis musculocutaneous free fl ap is based
on periumbilical perforators from the deep inferior epi-
gastric arteries. Incorporation of the periumbilical perfora-
tors permits an orientation of the skin paddle virtually in
any direction from the midline. After the perforators are
identifi ed, the anterior rectus sheath is incised medial to
the linea semilunaris and lateral to the linea alba. To pre-
serve the strength of the abdominal wall, the anterior rec-
tus sheath should not be harvested below the arcuate line.
Inferiorly, the anterior rectus sheath is incised vertically
to completely expose the rectus muscle. The deep infe-
rior epigastric pedicle is identifi ed after the rectus muscle
is bluntly dissected free from the posterior rectus sheath.
The vascular pedicle, up to 15 cm in length, is exposed
all the way to the origin of the vessels from the external
iliac artery and vein. The intercostals nerves that supply
the rectus muscle and overlying skin are mixed sensory
and motor nerves, but microanastomosis to a sensory nerve
in the head and neck has not yet resulted in a report of
restoration of sensation. Closure of the abdominal wall can
be accomplished with direct approximation of the residual
anterior fascial margins. Most surgeons would agree that
unless patients are engaged in vigorous physical activities,
harvest of a unilateral rectus muscle has little functional
impact. Probably the biggest disadvantage of using the rec-
tus abdominis fl ap is its bulky nature. However, for near-
total and total glossectomy defects, the rectus abdominis
can be a useful option ( Figures 37-6 and 37-7 ).
COMPLICATIONS
Complications are defect-specifi c and vary according to the
type of reconstruction. In some circumstances, there are
clear advantages to be realized through the use of regional
fl aps to replace extirpated tissue. Conversely, however, the
use of a bulky, adynamic fl ap may severely compromise
the function of the residual innervated and mobile tissue.
A small fi nger of residual tongue may perform its duties of
mastication and speech quite well unless it is tethered to
the alveolus by primary closure or immobilized through
attachment to an adynamic myocutaneous fl ap.
The most common source of skin graft failure in the
oral cavity is inadequate immobilization. This results in
shearing, which prevents successful revascularization by
the capillary buds. A collection of fl uid, either hematoma
or seroma, under the graft also will lead to skin necrosis
because the distance through which the capillary buds
must grow prevents reestablishment of a vascular sup-
ply within the critical time period. Placement of the graft
over an avascular recipient bed will also result in graft
failure. Infection and residual cancer are other causes of
graft failure. When circumstances require that the graft
replace gingiva or extend onto the defect created by a
marginal mandibulectomy, immobilization may be facili-
tated by the preoperative construction of a surgical stent.
Split-thickness skin graft reconstruction is contraindicated
in patients who have received prior radiation therapy if
the graft is to be placed over exposed bone to prevent
osteoradionecrosis. 3
An Allen test should be preformed prior to harvesting a
radial forearm free fl ap to ensure the postoperative viabil-
ity of the hand. During a radial forearm free fl ap harvest
the paratenon of the fl exor tendons should be preserved
to minimize the risk of tendon exposure and of skin graft
failure. After a rectus free fl ap, the greater the amount of
fascia and muscle removed, the higher the risk of develop-
ing a hernia or bulge. Both complications can be avoided
by proper repair of the abdominal wall. To repair the fascia
after fl ap removal and to prevent the formation of a her-
nia or bulge, some surgeons use nonabsorbable mesh to
replace the anterior rectus sheath that has been harvested.
Success rates for free tissue transfer should exceed 95% in
experienced hands.
OUTCOMES
Repair of Glossectomy Defects
Restoration of tongue function after ablative surgery
remains a major challenge for the reconstructive surgeon.
The ultimate goal is to restore form and function, but the
complex set of intrinsic and extrinsic muscle that provide
coordinated motor activity cannot be duplicated by rein-
nervated muscle fl aps. It is unrealistic to expect a unidirec-
tional, reinnervated muscle, such as the rectus abdominis,
to mimic the complex, pattern of muscle contraction in
the native tongue. The attainable goals of tongue recon-
struction are to preserve the mobility of the remaining
tongue, to restore bulk so that the neotongue can contact
with the palate to assist in articulation and swallowing, and
to restore sensation.

438 • CHAPTER 37
FIGURE 37-6. (A) A near-total glossectomy
specimen. (B) A glossectomy defect. (C) The
design of a myocutaneous rectus abdominis free
fl ap. (D) The rectus fl ap inset into the vallecula
for reconstruction of the base of tongue. (E)
The rectus inset into the fl oor of mouth for
reconstruction of the anterior tongue.
A
B
C
D
E

INTRAORAL RECONSTRUCTION • 439
The extent of the glossectomy and the presence or
absence of an associated mandibulectomy defect deter-
mine the surgeon’s approach to reconstruction. Because
of the different functions of the two regions, the tongue
is divided into the mobile anterior part and the tongue
base. The mobility of the anterior tongue is critical for
articulation, mastication, and the oral phase of swallowing.
The tongue base is critical in completing the pharyngeal
phase of swallowing. The approach to reconstructing the
mobile tongue should involve the use of thin, sensate, pli-
able tissues that maintain maximum mobility and poten-
tially restore sensation. Defects of the tongue base present
a separate problem. Volume of the tongue base must be
restored so that the tongue base can contact the pharyn-
geal walls and generate a driving force to drive the food
bolus through the pharynx.
To help prevent aspiration and improve swallowing, a
number of additional surgical measures should be consid-
ered at the time of reconstruction. According to the two
pump theory of swallowing, the tongue base acts fi rst as
a piston driving the food bolus into the oropharynx. The
second pump is the negative pressure in the hypopharynx
generated by the anterior elevation of the larynx caused
by contraction of the hyomandibular musculature. A
glossectomy often involves disruption of the hyoman-
dibular muscle complex. Therefore, to help restore laryn-
geal elevation, the hyoid should be anteriorly suspended
from mandible. This can be accomplished by passing two
large prolene sutures around the body of the hyoid and
through drill holes created in the anterior, inferior border
of the mandible. In patients who are at the greatest risk
for aspiration because of the amount of tongue resected,
FIGURE 37-7. A total tongue reconstruction with a
myocutaneous rectus abdominis free fl ap.
a tubed epiglottic laryngoplasty may be employed. This
involves incising the interarytenoid mucosa and the lower
portion of the aryepiglottic folds bilaterally and sewing
the sides together to create a tube. This procedure will
preserve speech but will also require the use of a tra-
cheotomy. In patients who have undergone an exten-
sive tongue resection, in particular a total glossectomy,
management must be individualized on the basis of the
patient’s pulmonary reserve and general health. Because
of the concerns of aspiration some patients may require a
total laryngectomy.
Partial Glossectomy Defects
Defects following excision of small lesions of the oral
tongue and tongue base may be satisfactorily closed pri-
marily. In 1998, in a prospective study McConnel et al.
compared three methods of reconstruction with respect
to speech and swallowing function: primary closure, dis-
tal myocutaneous fl ap, and microvascular free fl ap. 6 The
results demonstrated that patients with relatively small
resections of the oral tongue (,30%) and tongue base
(,60%) who underwent primary closure had better swal-
lowing outcomes and speech intelligibility than patients
who underwent distal or free fl ap closure. Flap reconstruc-
tion usually is needed if greater than 50% of the tongue is
resected. Hemiglossectomy defects can be closed primar-
ily, but fl ap reconstruction for hemiglossectomy defects
may improve swallowing function. In 2002, Hsiao et al.
compared the swallowing and speech of six patients who
underwent hemiglossectomy and were closed primarily to
six patients who were reconstructed with a radial forearm
free fl ap. 7 Patients who had fl ap reconstruction had bet-
ter swallowing but poorer speech. The authors speculated
that a fl ap adds bulk, thus improving pharyngeal clear-
ance by maintaining the tongue-to-mouth roof contact
that is necessary for swallowing, but that a nonfunctional
fl ap hinders articulation by restricting the mobility of the
remaining portion of the tongue.
When small mobile tongue defects are combined
with segmental mandible defects, primary consider-
ation is given to maintaining the mobility of the tongue.
Composite skin-bone free fl aps, such as the osteocutane-
ous radial forearm or fi bula free fl ap, can be contoured
to replace the soft tissue defect and restore mandibular
continuity; but if the position of the skin paddle leads to
tethering of the tongue, one should consider reconstruct-
ing the fl oor of mouth and tongue separately from the
mandible.
The combination of a segmental mandibulectomy
defect with hemiglossectomy defect involving the mobile
tongue or both the mobile tongue and base of tongue is
a more challenging reconstruction. The reconstructive
options begin with fi rst choosing the optimal fl ap for
tongue reconstruction and then considering the options
for the mandible. Two free fl aps, in particular a forearm
fl ap or an anterolateral thigh with a fi bular fl ap, may be
necessary for complex composite defects.

440 • CHAPTER 37
Tongue base defects may be diffi cult to close primarily
if a large portion of the oropharynx has also been resected.
The anterior mobile tongue can be advanced posteriorly to
assist in closure of posterior defects, but additional tissue
must be introduced if closure causes signifi cant distortion
of the mobile tongue. A sensate forearm fl ap is the most
useful fl ap to reconstruct such defects. If the patient is not
a good candidate for a free fl ap, a pedicled pectoralis myo-
cutaneous fl ap is a good alternative.
Total Glossectomy Defects
Total tongue reconstruction involves creating bulk for the
neotongue and positioning the neotongue so that the verti-
cal height is suffi cient to achieve contact with the palate.
Free musculocutaneous fl aps, in particular the rectus abdo-
minis free fl ap ( Figure 37-7 ), have the advantage that the
muscle of the fl ap can be used as a platform for positioning
the overlying fat and skin component. Drill holes placed in
the mandible can be used to secure the muscle. The tendi-
nous inscriptions in the rectus abdominis fl ap offer a better
purchase for sutures than those directly placed in muscle.
Fasciocutaneous free fl aps, such as radial forearm, ALT,
scapular, or parascapular fl aps, can also be de-epitheliazed
and folded on themselves to create additional bulk and to
help maintain the position of the neotongue.
Prosthetics After Tongue Reconstruction
In some circumstances the reconstructed tongue may have
insuffi cient bulk. Speech and swallowing can be improved
in some patients through the use of a fabricated prosthetic
tongue to be attached to a dental prosthesis. Residual den-
tition facilitates retention of the prosthesis. The prosthetic
tongue is modifi ed with a central groove for swallowing,
while a fuller model is employed for speech.
An alternative way to address the abnormally large oral
cavity resulting from a glossectomy is to employ a pala-
tal-drop prosthesis. This prosthesis is constructed for the
maxillary arch. The palatal aspect of the prosthesis is built
up gradually until the patient achieves the best possible
speech and swallowing ability. Dropping the level of the
palate compensates for the lack of tongue volume.
Hard Palate Defects
Mucosal defects of the hard palate do not require any form
of reconstruction; they will heal by secondary intention.
Patient comfort may be increased by the use of a surgical
obturator constructed preoperatively and inserted at the
time of surgery. Use of a surgical obturator allows return
to oral feeding in the immediate postoperative period. The
surgical obturator is removed 5 days postoperatively and is
converted into an interim obturate, which may be removed
periodically for oral hygiene.
Defects that extend through the palatal bone into the
overlying antrum or nasal cavity require either a prosthesis
or reconstructive surgery. A number of surgical techniques
have been described. Small defects frequently can be closed
using a turnover fl ap for nasal lining and a palatal fl ap
based on the greater palatine artery for oral closure. These
techniques are similar to those described for closure of a
palatal fi stula after repair of a cleft palate. Recent reports
suggest that the placement of acellular dermis (alloderm)
between the nasal and oral closure may help the closure
of palatal fi stulas by acting as a scaffold for soft tissue in-
growth. Basic reconstructive principles would suggest that
palatal closure requires a two-layer closure of the oral
and nasal mucosa. Palatal defects may also be closed with
tongue fl aps ( Figure 37-2 ). Palatal defects combined with
alveolar defects may be closed with the temporalis muscle.
However, when the alveolar ridge is intact, one must pass
the muscle through a fenestration in the maxillary sinus or
advance or remove the maxillary tuberosity.
When local fl aps or regional fl aps are insuffi cient, recon-
struction of hard palate defects may require free tissue
transfer. Large palatal defects often involve resection of the
alveolus, maxilla, and the soft tissues of the face and orbit.
Radial forearm, rectus abdominis, fi bula, scapular, and iliac
crest free fl aps have been used for successful reconstruc-
tion. When the hard palate has been resected without the
loss of tooth-bearing segments, a soft tissue fl ap, such as
a radial forearm fasciocutaneous fl ap, is a good option of
reconstruction. When the hard palate has been resected
with signifi cant portions of the alveolus, adequate teeth
and/or retentive surfaces may not be available to provide
stability to a conventional denture. Soft tissue reconstruc-
tion alone leaves a blunted buccal sulcus and palatal arch
which may not be able to retain a prosthesis or denture.
Functional dental rehabilitation in some patients can best
be achieved by reconstructing the defect with vascularized
bone. The bone from an osteocutaneous radial forearm free
fl ap or from an osteocutaneous fi bular free fl ap can be used
to reconstruct the alveolus with the skin paddle used for
palatal reconstruction. Futran et al. reported their experi-
ence with 27 patients who underwent midface reconstruc-
tion with the fi bula free fl ap. 8 Osteotomies were made in
the fi bula to create the missing tooth-bearing segments.
Eighteen patients received secondary osseointegrated
implants, and 14 patients were using implant-borne pros-
theses. The authors noted that in more extensive resec-
tions where there was also a need for reconstruction of the
zygomatic complex, infraorbital rim, and fl oor, the utility
of fi bula free fl ap was limited.
Recently, Cordeiro and Santamaria proposed a classifi -
cation system and algorithm for reconstruction of maxil-
lectomy and midfacial structures. 9 The temporalis muscle,
soft tissue free fl aps (rectus abdominis and radial forearm),
nonvascularized bone (rib or calvarium), and vascularized
bone fl aps (osteocutaneous radial forearm free fl ap) was
used to construct a variety of maxillectomy defects. Palatal
defects were closed only with soft tissue ( Figure 37-8 ).
The nonvascularized and vascularized bone was used for
the osseous reconstruction of the zygoma and orbit.
Defects in the bony hard palate or maxillary alveolus
are suited to prosthetic rehabilitation. The prosthodontist

INTRAORAL RECONSTRUCTION • 441
should be consulted prior to surgical treatment. Dental
records including casts, roentgenograms, and jaw relation-
ship records are obtained. The surgeon can indicate to the
prosthodontist preoperatively the tissue to be resected. In
this way, it is possible to construct a surgical obturator prior
to the operation. Restoration of residual dentition should
be done preoperatively whenever possible. When resection
of the alveolus is necessary, bone cuts should be planned to
allow a margin of good alveolus adjacent to the teeth that
are retained. When intact dentition remains, the bone cuts
should be placed through the socket of an adjacent tooth
and not in the interdental space. Failure to observe this
precaution frequently results in the subsequent loss of the
residual tooth.
Soft Palate Defects
Reconstruction of soft palate defects has traditionally relied
on prosthetic rehabilitation. However, a number of surgical
options may be entertained. Palatal island fl aps alone or in
combination with a pharyngeal fl ap, buccal mucosal fl aps,
and free fl aps have been used to reconstruct soft palate
FIGURE 37-8. (A) Photograph demonstrating
a total orbitomaxillectomy defect. (B) The fl ap design
utilizing two cutaneous skin paddles—one for orbit
and cheek skin reconstruction and one for the palate
reconstruction. (C) Postoperative the patient in (A).
(D) Postoperative the palatal reconstruction.
A
B
D
C

442 • CHAPTER 37
defects. Both inferiorly and superiorly based pharyngeal
fl aps have been described. These fl aps have in common
the ability to afford the patient acceptable velopharyngeal
competence without creating complete nasal obstruction.
Brown et al. utilized speech and swallowing domains of
the University of Washington Quality of Life question-
naire to assess outcomes of two different forms of pala-
tal reconstruction after resection for cancer. 10 They were
able to document better outcomes when a pharyngeal fl ap
was used to supplement radial forearm fl ap reconstruction
( Figure 37-9 ). The authors proposed that the pharyngeal
fl ap decreases the level of velopharyngeal incompetence by
maintaining the radial forearm fl ap in a posterior position.
Resection of the lateral soft palate is the most com-
monly encountered defect of the soft palate. They are
usually the result of a composite resection of a primary
cancer of the retromolar trigone or tonsillar fossa that
extends to the soft palate ( Figure 37-9 ). In addition to or
instead of soft tissue reconstruction, rehabilitation of the
lateral palatal defect can be achieved with a speech pros-
thesis. The prosthesis is connected to a maxillary plate so
that it extends through the palatal defect and is superior
to the residual palate. Upon function, the remaining pal-
atal tissue makes contact with the prosthesis, achieving
oral-nasal separation.
Most patients, following soft palate resection, have long-
standing middle ear abnormalities secondary to Eustachian
tube dysfunction. The condition of the tympanic mem-
brane and middle ear should be examined regularly.
Myringotomy tubes may be indicated.
FIGURE 37-9. (A) The exposure and resection
of the hemi-soft palate through a lip splitting
approach and midline mandibulotomy. (B) A radial
artery free forearm fl ap inset into the soft palate
defect. A superiorly based pharyngeal fl ap has also
been inset for nasal lining and to help suspend the
radial artery fl ap. (C) Postoperative the patient in (A)
at 1 year.
A
B
C

INTRAORAL RECONSTRUCTION • 443
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algorithm for reconstruction of maxillectomy and midfacial
defects. Plast Reconstr Surg. 2000;105:2331–2346.
10. Brown JS, Zuydam AC, Jones DC, Rogers SN, Vaughan
ED. Functional outcome in soft palate reconstruction using
a radial forearm free fl ap in conjunction with a superiorly
based pharyngeal fl ap. Head Neck. 1997;19:524–534.

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38
Mandibular Reconstruction
Joseph J. Disa, MD, FACS
INTRODUCTION
The mandible defi nes the profi le and appearance of the
lower third of the face. It is essential for proper occlu-
sion, mastication, deglutition, and speech. The ultimate
outcome of segmental mandibular resection depends on
the location and amount of mandible removed. Segmental
defects of the mandible can result from the extirpation of
benign and malignant tumors and from trauma.
Segmental defects that are traumatic in nature generally
result from penetrating trauma. High-velocity gunshot or
shotguns wounds or injuries occurring in a combat envi-
ronment typically are associated with contamination and a
large zone of injury. Immediate reconstruction with vascu-
larized or nonvascularized bone grafts in this setting is not
likely to be successful; therefore, wound stabilization with
serial debridement is necessary to optimize the chances
for a successful outcome. In this setting of a surgically cre-
ated mandibular defect (after tumor removal), immediate
reconstruction is ideal. This will eliminate the problems
with soft tissue contracture that inevitably occur in the
setting of delayed reconstruction.
They can be broadly classifi ed into central, lateral, or
hemimandibular. Central defects involve the anterior arch
of the mandible, lateral defects involve the mandibular body
and ramus to varying degrees, and hemimandibular defects
involve the body, ramus, and condyle. Removing the central
segment of the mandible without reconstruction will result
in loss of lip support, chin projection, and potentially oral
competence (the so-called Andy Gump deformity). Lateral
mandible resection does not result in a defect of the same
severity, there will be a loss of lower lateral facial projection
and potential malocclusion due to the unopposed action of
the contralateral muscles of mastication. In general, seg-
mental defects of the mandible should be reconstructed if
the patient’s medical condition permits.
PATIENT EVALUATION
Preoperative evaluation of the patient undergoing man-
dible reconstruction is based on a multidisciplinary team
approach. This includes head and neck surgeons, recon-
structive surgeons, pathologists, medical and radiation
oncologists, maxillofacial prosthodontists, speech and
occupational therapists, internists, psychologists, and
social workers. A careful preoperative medical evaluation
is necessary because of the frequent associated comor-
bidities seen in this patient population. Close communi-
cation with the extirpative surgeon will help to anticipate
the extent of resection and allow for proper fl ap selection.
Potential donor and recipient sites need to be assessed
for suitability. The fi bula donor site is evaluated for the
skin quality and the presence of arterial or venous insuf-
fi ciency. In the absence of normal pedal pulses on clini-
cal examination, a conventional or magnetic resonance
arteriogram or other suitable study should be obtained to
determine the patency of the vascular system. The radial
forearm donor site is evaluated with an Allen test to
determine the patency of the palmar arches. Preoperative
dental evaluation is done to establish premorbid occlu-
sion, manage diseased dentition, and begin the planning
of dental rehabilitation 1
PATIENT PREPARATION
In addition to standard preoperative radiography used by
the surgical oncologist, a lateral cephalogram and 1:1 CT
scan of the mandible are obtained. These studies are used
to create templates used intraoperatively. Direct measure-
ments from the surgical specimen determine mandibular
segment length while the templates will determine the
angles of the osteotomies necessary for accurate graft shap-
ing ( Figure 38-1 ).
c h a p t e r

446 • CHAPTER 38
HISTORICAL PERSPECTIVE
Mandible reconstruction techniques were developed in
the early twentieth century. Over the past century signifi -
cant developments have occurred. Initial attempts at man-
dible reconstruction utilized nonvascularized bone grafts.
Cortical bone from the rib and tibia were initially used
with limited success. Later, cancellous bone from the iliac
crest proved more useful as this graft material is more cel-
lular and more easily revascularized. External fi xation of
bone grafts was described during World War I; and internal
wire fi xation of the grafts and the use of antibiotics were
major developments during World War II. With the passage
of time, more aggressive surgical resections and the use of
postoperative radiation therapy led to problems with bone
graft absorption and infection.
FIGURE 38-1. (A) The preoperative lateral cephalogram
and 1:1 CT scan of the mandible are used to create templates
which will aid in graft shaping. (B) Diagram demonstrating how
the template (T) is used to design a wedge (W) osteotomy in
the fi bula free fl ap (F). The result is an osteotomy which will
allow the fi bula to have the same basic shape as the patient’s
native mandible.
A
B
Following the initial use of bone grafts, the era of pros-
thetic and allograft mandible reconstruction followed.
This 40-year period utilized various prosthetic materi-
als, including metallic trays, Silastic, Dacron, and Tefl on.
Although these materials offered good restoration of man-
dibular contour and continuity, long-term outcome was
largely unsuccessful with a high incidence of exposure,
fracture, and infection of the materials. In the 1980s, stain-
less steel and titanium mandibular reconstruction plates
were developed and used with some success, particularly
in lateral mandibular defects. Plate fracture and exposure
remained a problem, and long-term success approximated
50% for anterior arch reconstruction and up to 85% for
lateral reconstruction.
The use of regional, pedicled osseocutaneous fl aps was
the next major advancement. The ability to transfer liv-
ing bone attached to its muscular pedicle into the defect
was felt to be a major advancement. Various fl ap–bone
combinations included pectoralis major with rib, sterno-
cleidomastoid with clavicle, trapezius with scapula, and
temporalis with parietal bone from the skull. These tech-
niques suffered from the poor quality of the transferred
bone, unreliable blood supply to the bone segments, and
less than ideal bone–soft tissue orientation, resulting in
suboptimal function and aesthetics.
The greatest development and current gold standard
for mandible reconstruction involves the use of micro-
vascular free tissue transfer. Microvascular technique has
allowed for the transfer of vascularized bone grafts with
or without associated soft tissue to the mandibular defect.
These techniques allow for the selection of the ideal bone
and soft tissue replacement depending on the needs of the
defect. The initial development of the vascularized iliac
crest graft, and later vascularized fi bula, radial forearm, and
scapula grafts have improved both the functional and aes-
thetic outcome in mandible reconstruction. Refi nements
in these techniques over the past three decades have led
these techniques to be the standard of care in most major
centers.
With the exception of traumatic mandible defects, the
best time to reconstruct the mandible is at the time of
segmental resection. Delaying reconstruction will result in
scarring and fi brosis in the remaining bone and soft tissue
envelope. This may severely impact the functional out-
come of the reconstruction particularly if reconstruction
occurs after radiotherapy. Trismus of the remaining man-
dible is possible further complicating the reconstruction.
Immediate reconstruction with well vascularized hard and
soft tissue will augment primary wound healing, and opti-
mize functional outcome.
Reconstructive Goals
Segmental resection of the mandible can lead to a bony
defect (as in benign disease) or a composite defect con-
sisting of bone, oral cavity mucosa, tongue and supporting
structures, and even external skin. The use of osteocuta-
neous free fl aps is a source of composite tissue for these

MANDIBULAR RECONSTRUCTION • 447
complex reconstructions. Usually one well-planned fl ap
can provide adequate composite tissue for the recon-
struction. Vascularized bone will replace the missing
mandibular segment; proper alignment of the bone will
optimize occlusion and minimize trismus. Reconstruction
of intraoral soft tissues needs to maximize mobility of the
tongue and buccal mucosa in order to optimize speech and
swallowing. An adequate buccal sulcus will allow for den-
tal rehabilitation, and in the instance where a large amount
of intraoral soft tissue and/or external skin replacement
is required, a second fl ap either pedicled or free may be
required. External skin replacement results in a color mis-
match with the native facial skin and will detract from the
aesthetic result.
TECHNIQUE
Non–Free Flap Mandible Reconstruction
The vast majority of segmental mandibular defects are
reconstructed with free tissue transfer. The non–free fl ap
options, which are occasionally employed, include nonvas-
cularized bone grafts, prosthetic plates and soft tissue fl aps,
and regional osteomusculocutaneous fl aps.
Nonvascularized Bone Grafts. A requirement for con-
sidering nonvascularized bone grafts for mandible recon-
struction is the presence of adequate blood supply in the
surrounding soft tissues. Therefore, pathologic conditions,
including prior irradiation, extensive scar tissue from prior
surgery, trauma or infection, or inadequate soft tissues will
not likely support healing of a nonvascularized bone graft.
The main indication for nonvascularized grafts include,
small bone-only defects of the ramus and body resulting
from the treatment of benign tumors or mandibular frac-
ture nonunion.
Corticocancellous iliac crest or rib grafts are typically
used and these are rigidly fi xed with mandibular recon-
struction plates. The use of particulate cancellous grafts
packed into alloplastic or allograft trays with or without
the use of concomitant hyperbaric oxygen has also been
described. 2 Although nonvascularized techniques have
been successful, in an era when vascularized grafts are
readily available and reliable, the role of nonvascularized
reconstruction is limited.
Prosthetic Plates and Soft Tissue Flaps. Typically, tita-
nium reconstruction plates (.2 mm) are used. They are
shaped against the native mandible whenever possible.
Placing drill holes through the plate into the native man-
dible prior to resection will allow for accurate fi xation and
retention of the position of the remaining mandible. The
plate should be placed along the inferior border of the
mandible to maintain facial height, avoid tooth roots, and
keep it away from the oral mucosa.
If there is not adequate soft tissue to cover the recon-
struction plate, the use of a regional or distant soft tissue
fl ap is indicated. Regional soft tissue fl aps include the
pectoralis major, latissimus dorsi, trapezius, sternocleido-
mastoid, or platysma. In general, these fl aps are hampered
by their excess or bulk, limited arc of rotation, donor site
morbidity, and lack of reliability of the skin island. Perhaps
the best soft tissue fl ap for covering a reconstruction plate
in the lateral or posterior position is the radial forearm free
fl ap. Boyd et al. have reported a 96% success rate. 3 The
advantages of this technique include excellent aesthetic
and functional outcomes in debilitated elderly patients and
poor prognosis patients with lateral and posterior low vol-
ume defects. The major downside is the tendency toward
plate exposure, fracture, and loosening.
Regional
Osteomusculocutaneous
Flaps. Several
regional osteomusculocutaneous fl aps have been described
for mandible reconstruction, including fl aps based on
the pectoralis major, sternocleidomastoid, and trapezius.
Realistically, the best fl aps are the pectoralis major with an
associated portion of the fi fth or sixth rib used for anterior
mandible reconstruction, or the trapezius with a portion of
the scapula spine used for short lateral mandibular defects.
The limited amount of bone with its inherent poor blood
supply due to it being attached to the distal portion of the
fl ap, limited insetting fl exibility, and excessive soft tissue
bulk make these fl aps a poor second choice when com-
pared with free tissue transfer.
Free Flap Mandible Reconstruction
The advantages of free fl ap mandible reconstruction com-
pared with other methods are numerous. Vascularized
bone allows for the replacement of living bone with living
bone. Bone healing resulting in a stable union between the
fl ap and the native mandible can be expected within 2 to
3 months for the majority of patients, regardless of preop-
erative or postoperative radiation therapy. Various free fl ap
donor sites allow for fl ap selection based on the require-
ments of the defect. As a result, a single fl ap is adequate
in the majority of situations. Depending on the fl ap used,
vascularized bone will provided adequate stock for the
placement of osteointegrated dental implants.
There are four donor sites used most commonly for
free fl ap mandible reconstruction: fi bula, iliac crest, radial
forearm, and scapula ( Figure 38-2 ). Each donor site dif-
fers with respect to quality and quantity of the bone and
skin island, length of the vascular pedicle, and the ability to
support osteointegrated dental implants. Additionally, the
location of the donor site may or may not facilitate a two-
team approach. The anatomic requirements of the defect
coupled with donor site factors determine fl ap selection
( Table 38-1 ).
Fibula Flap. The fi bula is the fl ap of choice for most
segmental mandible defects due to its versatility. The
fl ap is based upon the peroneal artery and associated
veins ( Figure 38-3 ). The fl exor hallicus longus muscle
can be harvested with the fl ap to provide extra bulk. The
skin island is supplied by perforating vessels traveling

448 • CHAPTER 38
within the posterior crural septum. The skin island can
be positioned either in the oral cavity or externally. The
fi bula has two distinct qualities that allow it to be used
for lateral, anterior, or hemimandibular defects. First, it
has the greatest amount of bone available of any osseous
free fl ap. Depending on the length of the donor leg,
the fl ap can provide more than 20 cm of useable bone.
Secondly, the fi bula has both an intraosseus and seg-
mental blood supply. Therefore, multiple osteotomies
can be accomplished to facilitate shaping without fear
of devascularizing the bone. 4 Another advantage of the
fi bula fl ap is the quality of the bone is general adequate
to allow for the placement of osteointegrated dental
implants.
The position on the leg is remote from the recipient
site; therefore, a two-team approach with simultaneous
fl ap harvest and tumor ablation can be accomplished.
Depending on surgeon preference, the fi bula osteotomies
and graft shaping can be accomplished in situ while the
fl ap is being perfused, or after the fl ap has been detached.
Donor site morbidity is minimized by preserving 5 to 7 cm
of distal fi bula at the ankle and 4 to 6 cm of proximal
fi bula at the knee ( Figure 38-4 ).
The main disadvantage of the fi bula is the skin island.
With careful preservation of the posterior crural septum
and the perforating vessels to the skin island, it is reliable
in more than 90% of patients. Incorporation of the fl exor
hallicus longus with the fl ap may enhance the reliability
of the skin island as well as providing extra bulk for the
reconstruction. The anatomy of the posterior crural sep-
tum limits the amount of fl exibility for positioning of the
skin island relative to the bone. Therefore, careful design
of the skin island is necessary not only to ensure it has
adequate blood supply, but also that it can be positioned
properly to meet the needs of the defect.
Iliac Crest. The shape of the iliac crest makes it use-
ful for reconstruction of hemimandibular defects. The
thickness makes it acceptable for osteointegrated dental
implants. The blood supply to the iliac crest free fl ap is
via the deep circumfl ex iliac artery and vein. The vascular
pedicle is short, thus limiting placement options with-
out vein grafting, and the bone lacks a segmental blood
supply, thus limiting the opportunity for graft shaping
with osteotomies. The skin island is relatively thick and
immobile limiting its utility for intraoral reconstruc-
tion. Donor site morbidity is signifi cant with the poten-
tial for numbness in the hip region, bulging, and hernia
formation. Modifi cations of this fl ap include using only
the inner table of the iliac crest. This reduces donor site
morbidity, but also reduces the quality of the bone avail-
able for osteointegration. 5 The versatility of the fi bula
fl ap has led the diminished use of the iliac crest in most
situations ( Figure 38-5 ).
TABLE 38-1. Comparison of Donor Sitesa
Bone
Skin
Pedicle
Locationb
Osteointegration
Fibula
111
11
11
111
111
Iliac Crest
111
1
1
11
111
Radius
1
111
111
11
2
Scapula
11
11
11
2
1
aComparison of donor sites with respect to quality of bone, skin, and pedicle; location of donor site allowing for a two-team approach; and ability to
receive dental implants. Donor site characteristics are rated as excellent (111), good (11), poor (1), and negative (2).
bLocation refers to the ability for simultaneous tumor ablation and fl ap harvest.
FIGURE 38-2. Diagrammatic representation of the four
basic free fl aps used in mandible reconstruction; (A) scapula,
(B) iliac crest, (C) radius, and (D) fi bula.
A
B
C
D

MANDIBULAR RECONSTRUCTION • 449
Radial Forearm. The radial forearm osteocutaneous fl ap
is based on the radial artery associated venae comitantes
and cephalic vein. Harvest of the lateral antebrachial cuta-
neous nerve allows for this fl ap to be reinnervated. This
FIGURE 38-3. (A) Planning the fi bula free fl ap. Care is
taken to avoid injuring the superfi cial peroneal nerve which
crosses in the region of the neck of the fi bula. The skin
island is centered over the posterior border of the fi bula so
the perforating vessels nourishing the skin island can be
captured. (B, C) The bone used for the fi bula fl ap can be
harvested either proximally or distally on the leg. This allows
for lengthening the vascular pedicle based on the distance
from the fl ap to the recipient vessels which will be used for the
microvascular anastomoses. (D) Miniplate rigid fi xation of the
bone segments after osteotomy.
A
D
B
C
FIGURE 38-4. Shaping the fi bula free fl ap while it is still
being perfused in the leg.
fl ap has the best donor site vessels and skin island quality
of all of the free fl aps used for mandible reconstruction.
The vascular pedicle has excellent length and vessel cali-
ber, the skin island can be large, thin, and pliable (ideal for
intraoral resurfacing). The major drawback of the forearm
is the poor quality of available bone. Up to approximately
10 cm of unicortical radius can be harvested with the soft
tissue component of the fl ap. Osteotomies cannot be reli-
able performed in the unicortical segment of radius due to
the risk of devascularizing the bone. The amount of bone
available is typically not suffi cient for the placement of
dental implants ( Figure 38-6 ). 6
The major drawback of the radial forearm donor site is
the risk of radius fracture after removing a segment of the
radius. Techniques to reduce this risk include adjustments
in the size and shape of the radial osteotomies, immediate
bone grafting, and the use of rigid fi xation. The forearm
fl ap is best suited to lateral or ramus defects where bone
requirements are secondary to soft tissue requirements. 6

450 • CHAPTER 38
Scapula. The scapula fl ap is based on the circumfl ex scap-
ular vessels. Vessel length and caliber are good and can be
extended by proximal dissection. The circumfl ex scapular
vascular axis is versatile because a single blood supply can
supply not only bone form the scapula, but also a large
quantity of soft tissue. Scapular bone, serratus anterior
FIGURE 38-5. Design of the iliac crest fl ap.
muscle, latissimus dorsi muscle with or without a skin
island, and either a transverse (scapular) or axial (paras-
capular) skin paddle can all be harvested off the same ves-
sels. This allows for the correction of large and complex
defects (particularly those requiring massive soft tissue
corrections) with a single fl ap ( Figure 38-7 ).
The major disadvantages of the scapular fl ap are the
limited amount and poor quality of available bone. The
bone does not tolerate osteotomies well and typically is
insuffi cient for the placement of dental implants. Also the
location of the donor site precludes a two-team approach
toward fl ap harvest and tumor ablation. The major indi-
cation for the scapula fl ap is a posterior defect with a
minimal bone requirement (not requiring an osteotomy)
and massive soft tissue requirement (both intraoral and
external skin). 7
Condyle Reconstruction
Due to the unreliability of prosthetic condyles, condyle
reconstruction is generally accomplished in one of two
ways. Either the native condyle is autotransplanted into
the glenoid fossa, or the end of the vascularized bone fl ap
FIGURE 38-6. Radial forearm fl ap. Note the poor quality
bone, but excellent soft tissue and vascular pedicle.
FIGURE 38-7. The scapular vascular axis allows for
harvest of bone, muscle, and skin all from the same pedicle.

MANDIBULAR RECONSTRUCTION • 451
is fashioned into a condyle. Tumors involving the man-
dibular ramus or angle may necessitate condyle removal
with the surgical specimen. If the condyle is not involved
with the disease process as judged by the clinical impres-
sion of the oncologic surgeon and frozen section patho-
logic evaluation of the marrow space, then the condyle
and condylar neck can be resected from the specimen
and transplanted back to the end of the reconstructed
mandible using rigid fi xation. Surgical oncologists fi nd
disarticulation of the condyle and removal with the spec-
imen less likely to injure the facial nerve in resection of
tumors high on the ascending ramus of the mandible.
The possible exception to this is the pediatric patient
where the mandibular condyle is a growth center of the
mandible that does not close until late in the teenage
years ( Figure 38-8 ).
If transplantation of the condyle is considered to be
unwise from an oncologic perspective, the proximal end
of the reconstructed mandible can be rounded to mimic
the condyle. It can then be covered with fascia, left alone,
and anchored into the glenoid fossa. Leaving a small gap
(~1 cm) between the ends of the reconstructed mandi-
ble and the roof of the glenoid fossa will reduce the risk
of ankylosis. Patients generally function well with only
one intact temporomandibular joint. There is a slightly
higher risk of trismus and malocclusion in this setting
compared with condyle preservation or transplantation.
As mentioned, prosthetic condyles are typically avoided
due to the risk of infection, extrusion, or erosion into the
temporal fossa. 8
Flap Selection
Each of the fl aps described have characteristics that make
them useful for mandible reconstruction. Depending on
the location and type of defect, one fl ap may be more or
less useful than another. In general, the characteristics of
the fi bula make it the fi rst choice for the majority of defects.
The selection of the appropriate donor site is based on the
bone and soft tissue requirement of the defect. Short lat-
eral segment, long segment, or anterior bone defects, with
or without a soft tissue requirement, are best treated with
a fi bula free fl ap ( Figure 38-9 ). In the setting of a massive
soft tissue requirement, the fi bula free fl ap in conjunction
with a soft tissue fl ap such as the radial forearm fl ap may be
the best choice. Short segment defects involving the ramus
with or without the condyle, associated with large soft tis-
sue and external skin defects, benefi t from reconstruction
FIGURE 38-8. (A) Hemimandibular defect after
segmental resection. (B) Hemimandible reconstruction
with fi bula free fl ap. Note skin island and condyle
autotransplantation onto the fl ap. The fl ap is still connected
to the donor site in the leg. (C) The fi bula free fl ap is rigidly
fi xed to the native mandible and the condyle transplant is
seated into the glenoid fossa. Microvascular anastomoses are
accomplished prior to inset of the fl ap skin island.
B
C
A

452 • CHAPTER 38
with a scapular fl ap. Short segment ramus defects with or
without the condyle with a large intraoral lining require-
ment are best treated with the radial forearm osteocutane-
ous fl ap. The ilium has no advantages that make it useful
for anterior defects. It is also a second choice for lateral
defects due to the poor quality skin and donor site mor-
bidity. Its best use is for lateral or hemimandibular defects
when the fi bula is not available ( Figure 38-10 ). 7
Dental Rehabilitation
Mandible reconstruction with vascularized bone is the
best method of achieving a stable reconstruction that can
tolerate the load created by mastication. The two main
methods of dental rehabilitation include simple dental
prosthesis and osteointegrated dental implants. After seg-
mental mandibulectomy, the vascularized free fl ap can
restore incisal opening and occlusion. Soft tissue from the
fl ap can replace the intraoral soft tissues thus creating a
stable base for the prosthesis. A simple dental prosthesis is
useful to provide lip support and replace dentition. Dental
prostheses are typically anchored to remaining dentition.
They provide aesthetic correction, but in general are not
stable enough to support the load generated by mastica-
tion. The best functional and aesthetic results are seen
with the use of osteointegrated dental implants. The fi bula
and iliac crest provide the best bone stock for the use of
dental implants ( Figure 38-11 ). 9 Although the placement
FIGURE 38-9. (A) Anterior arch resection and fi bula free fl ap after osteotomies and
rigid fi xation. Note preservation of mandible shape. (B) Lateral mandible reconstruction
with fi bula free fl ap. Individual segments are rigidly fi xed to each other and the native
mandible.
A
B
FIGURE 38-10. Algorithm for fl ap selection based on the requirements of the
defect.
Bone
defect
Short lateral
segment
Skin
soft tissue
defect
+Extensive
intraoral
and
external
skin
Algorithm for Mandible Reconstruction
with Osseous Free Flaps
Flap
Scapula
Radius
Fibula
Fibula +
forearm
Long segment or multiple
osteotomies (Hemimandible,
central segment)
Short, ascending
ramus±condyle
+Large
soft tissue
+external
skin
+Large
intraoral
lining
+Small-
moderate
intraoral or
external skin

MANDIBULAR RECONSTRUCTION • 453
of dental implants at the time of the mandible reconstruc-
tion has been described, most surgeons favor delaying
placement until adequate bone healing. Implants placed
at the time of reconstruction will lengthen the procedure,
potentially compromise bone viability, and may result in
implant malposition. Placing dental implants in patients
who have been irradiated is controversial due to the high
risk of failure of osteointegration and the potential to
fracture the reconstructed mandible. In the nonirradiated
patient, any hardware in the way of the implant will need
to be removed prior to implantation.
COMPLICATIONS
General complications following mandible reconstruction
include wound healing problems, leakage of saliva, and
hardware exposure, and partial or complete fl ap necrosis
if used in the reconstruction. Use of a prosthetic plate and
a soft tissue fl ap either regional or free has been shown to
have a higher overall failure rate of 20%. When used to
replace the central segment of the mandible, the failure rate
approaches 40%, as compared with approximately 5% for a
lateral defect. 3 However, given the overall success with free
tissue transfer, prosthetic plate reconstruction of the mandi-
ble should be limited to lateral or ramus defects in patients
who are not candidates for a vascularized bone fl ap.
A signifi cantly higher rate of complications has been
reported in patients receiving postoperative radiation. 10
These include orocutaneous fi stula, osteoradionecrosis,
hardware exposure, and/or cervical contracture. The use
of a vascularized fl ap in the form of free tissue transfer
has been shown to reduce the rate and/or severity of some
of these complications following reconstruction of the
mandible. 11 , 12
OUTCOMES
The outcome of mandible reconstruction is evaluated
by bone retention, speech and swallowing, and aesthetic
appearance. Bone retention has been evaluated in mandible
reconstruction. Preservation of bone height over time is an
indicator of bone mass retention. It has been shown that
fi bula free fl aps maintain bone height in more than 90% of
patients with follow up ranging from 2.5 to 10 years. 13 This
seems to be independent of irradiation, dental implanta-
tion, and the location of the reconstruction. In a series of
more than 150 patients during a 10-year period, speech,
swallowing, and aesthetics were evaluated. 7 Speech was
found to be normal (36%), near normal (27%), intelligible
(28%), and unintelligible (9%). The best speech results
were seen in lateral and hemimandibular reconstructions
and the worse in anterior reconstructions.
In general, the more intraoral soft tissue required, the
worse the speech, particularly if the tongue is involved.
The skin island from the fi bula fl ap is much less mobile
than normal intraoral soft tissues. The fi ndings with diet
were similar, 45% of patients returned to an unrestricted
diet, 45% soft diet, and 5% each required a liquid diet or
tube feeding. Like speech outcome, the best results were
seen in the later and hemimandibular reconstructions and
the worst with anterior reconstruction particularly if there
is tongue involvement. Aesthetic assessment in this same
group of patients revealed an excellent aesthetic result in
32% of patients, 27% good, 27% fair, and 14% poor results.
The best results were lateral and hemimandibular recon-
structions, and the worse anterior and those requiring an
external skin island either from the native fl ap or a second
fl ap. The color and texture mismatch from an external skin
paddle greatly detracts from the overall aesthetic result
( Figure 38-12 ).
A
B
FIGURE 38-11. (A) Anterior mandible reconstruction
with removable dental prosthesis sitting on fl ap skin island
and anchored to remaining dentition. (B) Hemimandibular
reconstruction with fi bula free fl ap (above) and 10 years later
after removal of hardware and placement of osseointegrated
dental implants.

454 • CHAPTER 38
FIGURE 38-12. (A–C) Functional
and aesthetic outcome in 150 consecutive
mandible reconstructions with vascularized
free fl aps.
Tube feed
Tube feed
Soft
Soft
Unrestricted
Unrestricted
Classification
Central
Hemimandibular
Lateral
Conceptual Considerations in Mandible Reconstruction
Central
Hemimandibular
Lateral
15%
48%
50%
70%
38%
34%
5%
14%
8%
10%
0%
8%
Liquids
Liquids
Diet
(n = 133)
A
Unintelligible
Unintelligible
Near normal
Near normal
Normal
Normal
Classification
Central
Hemimandibular
Lateral
Central
Hemimandibular
Lateral
10%
38%
42%
35%
29%
42%
50%
33%
4%
5%
0%
4%
Intelligible
Intelligible
Speech
(n = 133)
Conceptual Considerations in Mandible Reconstruction
B
Poor
Poor
Good
Good
Excellent
Excellent
Classification
Central
Hemimandibular
Lateral
Central
Hemimandibular
Lateral
15%
43%
67%
35%
33%
8%
25%
14%
25%
25%
14%
0%
Fair
Fair
Aesthetic Results
(n = 140)
Conceptual Considerations in Mandible Reconstruction
C

MANDIBULAR RECONSTRUCTION • 455
1. Hidalgo DA. Aesthetic improvements in free-fl ap mandible
reconstruction. Plast Reconstr Surg . 1991;97:707.
2. Marx RE, Ames JR. The use of hyperbaric oxygen therapy
in bony reconstruction of the irradiated and tissue-defi cient
patient. J Oral Surg . 1982;40:412.
3. Boyd JB, Mulholland RS, Davidson J, et al. The free fl ap and
plate in oromandibular reconstruction: long term review and
indications. Plast Reconstr Surg . 1995;95:1018.
4. Hidalgo DA. Fibula free fl ap: a new method of mandible
reconstruction. Plast Reconstr Surg . 1989;84:71.
5. Shenaq SM, Klebuc MJ. The iliac crest microsurgical free fl ap
in mandibular reconstruction. Clin Plast Surg . 1994;21:37.
6. Zenn MR, Hidalgo DA, Cordeiro PG, et al. Current role of
the radial forearm fl ap in mandibular reconstruction. Plast
Reconstr Surg . 1997;99:1012.
7. Cordeiro PG, Disa JJ, Hidalgo DA, et al. Reconstruction
of the mandible with osseous free fl aps: a 10-year experi-
ence with 150 consecutive patients. Plast Reconstr Surg .
1999;104:1314.
8. Hidalgo DA. Condyle transplantation in free fl ap mandible
reconstruction. Plast Reconstr Surg. 1994;93:770.
9. Frodel JL Jr, Funk GF, Caper DT, et al. Osseointigrated
implants: a comparative study of bone thickness in four vas-
cularized bone fl aps. Plast Reconstr Surg . 1993;92:449.
10. Deutsch M, Kroll SS, Ainsle N, et al. Infl uence of radiation
on late complications in patients with free fi bular fl aps for
mandibular reconstruction. Ann Plast Surg . 1999;42:662.
11. Celik N, Wei FC, Chen HC, et al. Osteoradionecrosis of the
mandible after oromandibular cancer surgery. Plast Reconstr
Surg . 2002;109:1875.
12. Cannady SB, Dean N, Kroeker A, et al. Free fl ap reconstruc-
tion for osteoradionecrosis of the jaws–outcomes and predic-
tive factors for success. Head Neck . 2011;33(3):424.
13. Disa JJ, Hidalgo DA, Cordeiro PG, et al. Evaluation of
bone height in osseous free fl ap mandible reconstruc-
tion: an indirect measure of bone mass. Plast Reconstr Surg .
1999;103:1371.
REFERENCES

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39
Reconstruction of the
Paralyzed Face
Christopher A. Derderian, MD / Oksana Jackson, MD
c h a p t e r
PATIENT EVALUATION AND SELECTION
There are 17 paired and one unpaired facial muscles that
serve two critical roles ( Figure 39-1 ). From a functional
standpoint they protect the eye, maintain patency of the
nasal airway and preserve oral continence. Their integral
role in the complex nuances of communication through
articulation of speech and facial expression are underscored
by the frustration patients with facial paralysis convey when
seen in consultation. To best serve these patients, the sur-
geon must possess an advanced appreciation of the anatomy
of the facial nerve ( Figure 39-2 ) and the facial musculature
and its function ( Table 39-1 ). Likewise, knowledge of the
common etiologies and presentations of facial paralysis
( Table 39-2 ) and an arsenal of surgical techniques to effec-
tively address the patient’s concerns are needed.
Obtaining a detailed history of the paralysis is critical.
The time and rapidity of onset, related injury or illness,
treatments attempted and diagnostic tests performed prior
to presentation should be determined. A standard facial
nerve examination noting symmetry, muscle tone, twitch-
ing/spasms, and the absence or presence of synkinesis can
usually pinpoint the location of nerve injury. Several facial
nerve grading scales are commonly used today, including
the House-Brackmann and Sunnybrook scales, and can be
particularly useful in documenting recovery after acquired
facial nerve injury and Bell palsy.
The etiology of facial nerve paralysis can be broadly
divided into congenital and acquired forms. The vast
majority is acquired; however, many of the patients seen
by plastic surgeons have a congenital cause. Hemifacial
microsomia is the most common cause of unilateral con-
genital facial paralysis, and Möbius syndrome is the most
common bilateral cause. First described by the German
neurologist Paul Julius Möbius in 1888, Möbius syn-
drome consists of congenital bilateral CN VI and VII
paralysis, and is associated with trunk and limb anoma-
lies in one-third of patients. Its etiology is unknown, and
it is rare, occurring in 1:200,000 births. Bell palsy is the
most common acquired cause, and it is believed to have
some association with viral illness, specifi cally herpes
simplex virus infection. The distinguishing characteristics
of Bell palsy are: acute onset of paralysis (24–72 hours),
ipsilateral periauricular numbness and pain, altered taste,
decreased tear production, and hyperacusis.
The management of the patient with facial paralysis
depends on whether or not the integrity of the nerve can
be reestablished, if spontaneous recovery may occur, and
the duration of the paralysis. For example, in the setting
of Bell palsy, it may take up to a year for the patient to
recover function and no surgical intervention would be
recommended during this time, whereas with tumor abla-
tion or trauma patients, no waiting period is entertained
if the nerve has knowingly been injured or sacrifi ced and
repair or grafting would be employed acutely. The limit-
ing temporal factor to be considered is the time to loss of
motor endplates and fi brosis of the facial musculature that
generally occurs 1 to 2 years after denervation. However,
the time for nerve growth through reestablished branches
or grafts must be taken into account; therefore, the gen-
eral treatment algorithm is divided into two groups: those
with paralysis for less than 1 year (early) and more than
1 year (late) ( Table 39-3 ).
In addition to these objective data, a critical component
of the evaluation is a detailed discussion with the patient
regarding the most troublesome aspects of their paralysis.
Practical considerations are the patient’s occupation, dura-
tion of the treatment, number of stages, and commitment

458 • CHAPTER 39
to any rehabilitation or learning programs required to max-
imize results. In selecting the procedures the surgeon must
also consider the patient’s age, comorbidities, length of
operation, soft tissue quality, and nerve and muscle donor
site availability. Each region of the face should be treated
separately and the most concerning areas addressed fi rst.
PATIENT PREPARATION
In the time leading up to defi nitive surgical treatment,
conservative measures must be instituted to minimize per-
manent functional losses. These are largely related to eye
protection. Maintenance of eye moisture using drops, oint-
ments, lid taping, contact lenses, moisture chambers, eye
patches, or temporary tarsorrhaphy sutures may be used to
protect the eye and improve patient comfort.
The procedures described below typically require gen-
eral anesthesia. When performing facial nerve mapping or
functional muscle transfer, clear communication with the
anesthesia team regarding the need to hold paralysis is crit-
ical. For cross-facial nerve graft harvest or gracilis harvest
for functional muscle transfer, a two-team approach is ideal
with separate setups to minimize the operative time and
the risk of infection in the donor sites. Microvascular anas-
tomosis can be performed under loupe magnifi cation or
using an operating microscope. Microvascular instruments
and suture and experienced surgical and nursing teams are
required.
TREATMENTS
Conservative Treatment
For many patients, despite a thorough workup, there is
no known etiology of their facial palsy, and a period of
observation is warranted to see if spontaneous resolution
occurs. These patients may fall under the diagnosis of
exclusion: idiopathic facial paralysis or Bell palsy. There is
strong data indicating effi cacy in the early use of steroids
in the treatment of Bell palsy. The recovery is signifi cantly
more rapid and complete when the patient is treated with
steroids within 72 hours of onset of symptoms. The use
FIGURE 39-1. Anatomy of the facial musculature. (Adapted from McCarthy JG, Galiano
RD, Boutros SG, eds. Current Therapy in Plastic Surgery. Philadelphia: Elsevier/Mosby; 2005:195.)
Frontalis m.
Corrugator m.
Procerus m.
Nasalis m.
Orbicularis oris m.
Mentalis m.
Depressor labii
inferioris m.
Depressor
anguli oris m.
Zygomaticus
major m.
Risorius m.
Levator labii superioris
alaeque nasi m.
Levator labii
superioris m.
Zygomaticus
minor m.
Orbicularis oculi m.

RECONSTRUCTION OF THE PARALYZED FACE • 459
of antivirals is not indicated unless a concurrent viral syn-
drome is noted at onset. 1 The remainder of the treatment
is conservative: protection of the eye as listed above and
physical therapy. Bell palsy is typically self-limiting with
spontaneous resolution within 6 months; however, 5% to
10% of patients are left with some degree of severe paraly-
sis that may require intervention.
Physical therapy may be benefi cial in many patients
recovering from acute facial nerve injuries or postrecon-
struction, and techniques such as electrostimulation, sur-
face electromyograph biofeedback, and various exercise
regimens may augment recovery. Neuromuscular retrain-
ing can improve the outcome after Bell palsy, by speeding
and strengthening muscle recovery and overcoming synki-
nesis. Patients with partial paralysis can learn to strengthen
alternative muscles on the weakened side and damped
forceful normal motions, thus improving facial balance
and symmetry. Botox injections are a useful adjunctive
treatment to physical therapy for patients who develop
synkinesis during facial nerve recovery. They can also be
used in unilateral forehead or lower lip palsies to achieve
better symmetry. They need to be repeated approximately
every 3 to 6 months; but if the result is favorable, neurec-
tomy or myectomy can be performed surgically for a per-
manent result.
Surgical Treatment
The goals of reconstruction are divided into regions—brow,
eyes, cheek, and lips. The ultimate goals are to restore static
and dynamic symmetry and function. The patient’s con-
cerns should be addressed and her expectations should be
T
Z
B
M
C
T
Z
B
B
M
C
T
Z
B
M
C
T
Z
B
M
C
T
Z
B
M
C
T
Z
B
M
C
Type I, 13%
Type II, 20%
Type III, 28%
Type IV, 24%
Type V, 9%
Type VI, 6%
FIGURE 39-2. The considerable variability seen in facial nerve branching patterns
is depicted above. (Adapted from Davis RA, Anson BJ, Budinger JM, Kurth LR. Surgical anatomy
of the facial nerve and parotid gland based upon a study of 350 cervicofacial halves. Surg Gynecol
Obstet. 1956;102(4):385–412.)

460 • CHAPTER 39
tempered so that well-defi ned, achievable outcomes will
result in patient satisfaction.
The Brow
Paralysis in the distribution of the temporal branch of the
facial nerve results in inability to elevate the eyebrows and
wrinkle the forehead, and eventual brow ptosis. The options
for treatment include direct, coronal, or endoscopic brow lift
to the affected side, and frontal branch neurectomy, frontalis
myectomy, and Botox injection to the unaffected side.
TABLE 39-1. Action of the Facial Musculature
Scalp
Frontalis: raises brows and wrinkles forehead as in surprise
Eye
Orbicularis oculi: sphincter of eyes, closes lids, compresses lacrimal sac
Corrugator: draws eyebrows downward and medially as in frowning or suffering
Nose
Procerus: draws medial angel of eyebrow downward
Anterior and posterior dilator naris: enlarge nares in hard breathing and anger
Depressor septi: constricts nares
Nasalis: draws alar wings toward septum and depresses cartilage
Mouth
Levator labii superioris: raises upper lip
Levator labii superioris alaeque nasi: raises lip and dilates nares
Zygomaticus minor: with the 2 levator labii muscles, forms nasolabial furrow; deepened when in sorrow
Levator anguli oris: with the 2 levator labii muscles and the zygomaticus minor, expresses contempt or disdain
Zygomaticus major: draws angle of mouth up and back as in laughing
Risorius: retracts angel of mouth
Depressor labii inferioris: draws lip down and back as in irony
Depressor anguli oris: depresses angle of mouth
Mentalis: elevates and protrudes lower lip
Orbicularis oris: a complex muscle with layers, some parts intrinsic to the lips, the others derived from the
following facial muscles: buccinator, levator anguli oris, depressor anguli oris, and zygomaticus major and
minor: closes lips, protrudes lips, and pressure lips to teeth
Buccinator: compresses cheek, hold food under teeth in mastication, important in blowing when the cheeks are
distended with air
Adapted from Pansky B, House EL. Review of Gross Anatomy. New York: Macmillan; 1964:2246.
TABLE 39-2. Etiology of Facial Palsy and
Respective Incidences
Etiology
Percent of Cases
Bell palsy
Trauma
Herpes zoster
Tumor
Birth (congenital and acquired)
Infection
Other
51%
23%
7%
5%
4%
3.5%
6%
Adapted from May M, Schaitkin BM. The Facial Nerve. 2nd ed.
New York: Thieme; 2000:181.
Unilateral frontalis muscle paralysis can cause over a
10 mm difference in brow height. Larger discrepancies
in brow height tend to occur in older patients who also
tend to have deep creases within the brow. Excision of
a segment of skin and frontalis above and parallel to the
affected brow with placement of the scar in a preexisting
skin crease is the most powerful method of brow eleva-
tion. Important aspects of this technique are to overcor-
rect slightly, repair the frontalis muscle and suspend the
soft tissue from the underlying periosteum, and mini-
mize the visible scar with appropriate positioning in a
preexisting crease.
Coronal endoscopic brow lift has the advantage of an
inconspicuous scar but provides limited lift, rarely greater
than 5 mm change. 2 It is best used in younger patients
with minor asymmetry and in whom the scar from a
direct brow lift may be more conspicuous. The use of
selective frontal branch neurectomy, frontalis or corruga-
tor myectomy, or Botox injections to the unaffected side
are adjuncts to supplement coronal or endoscopic lifts
that have some application in select patients. 3
The Eye
Eyelid closure is controlled by the orbicularis occuli
muscle which has palpebral (involuntary blink), presep-
tal (voluntary blink), and orbital (forceful closure) por-
tions. Paralysis of this muscle results in incomplete eyelid

RECONSTRUCTION OF THE PARALYZED FACE • 461
closure, referred to as lagophthalmos. This is caused by
inability to close the upper eyelid due to the unopposed
action of the levator palpebrae superioris and from
paralytic ectropion of the lower eyelid, and it results
in discomfort from dry eye, corneal irritation, exposure
kerititis, and epiphora. Initial conservative treatments
address symptom relief and protection of the cornea,
but chronic impairment requires surgical intervention
to restore anatomic relationships, protect the globe,
and restore function. Lagophthalmos may be surgically
treated by a variety of procedures including lid loading,
palpebral springs, temporalis muscle transfer, fascial or
tendon slings, or tarsorrhaphy, and multiple techniques
used in combination are often required.
Eyelid loading consists of the placement of a gold or
platinum weight between the orbicularis and tarsus in
the upper lid to facilitate upper eyelid closure while
preserving the normal levator palpebrae superioris func-
tion in eye opening ( Figure 39-3 ). Gold weights signifi -
cantly decrease ocular care needs long term, although
replacement of the weight is occasionally required.
Commonly, a lower eyelid procedure is required to aug-
ment eyelid loading and achieve complete closure. The
mass of the gold weight is determined preoperatively by
taping sample weights to the upper lid and testing open-
ing and closure in the upright position. In the patient
with an intact Bell’s refl ex, the goal is to use the lightest
possible weight that will bring the upper eyelid within
2 to 4 mm of the lower eyelid. If too large a weight is
selected, ptosis can occur and there is an increased likeli-
hood of detachment or erosion of the weight. 4 Palpebral
springs are an alternative technique to assist in upper
eyelid closure, but are fraught with technical compli-
cations, including ptosis, spring breakage, malposition,
and extrusion. While several groups have reported suc-
cess with this technique, it should only be attempted by
those with experience in its use.
Lower eyelid support procedures to treat paralytic
ectropion and aid in eye closure include static sling sus-
pension, temporalis transfer, tarsal strip, and tarsorrhaphy.
During normal eyelid closure, the lower lid moves very
little in the vertical dimension, and forced closure of the
lower lid raises it only 2 to 3 mm. Thus, a static support
procedure such as a fascial or tendon sling can provide a
good aesthetic and functional result. The sling is tunneled
through the lower lid near the lash margin and secured
medially to the medial canthal ligament and laterally
to the orbital rim near Whitnall tubercle ( Figure 39-4 ).
When selecting the lateral position for anchoring, the
vector should adhere to the same principles for negative
and positive vector selection adhered to in lateral can-
thopexy, and slight over correction is preferred. 5
Temporalis muscle transfer uses autologous tissue to
create a dynamic support system. A 1.5- to 2.0-cm strip of
TABLE 39-3. Treatment Algorithm for Treatment of Facial Palsy by Duration of Paralysis
Facial palsy
Dynamic
Brow
Eye
Temporalis transfer
Botox
Selective denervation
Fascial/tendon sling
Lower lid sling
Gold weight
Tarsorrhaphy
Brow lift –
Direct
Coronal
Endoscopic
Temporalis transfer –
Turnover
Advancement
Lip and cheek
Late (>12 months)
Early (<12 months)
Observation
Nerve repair or
CFNG
Static
Conservative measures
Microneurovascular transfer
1. Stage – gracilis/MNTM
2. Stage – CFNG/gracilis

462 • CHAPTER 39
FIGURE 39-3. Sequence for placement of gold weight loading of the upper lid to
aid in eye closure. (Adapted from May M, Schaitkin BM. The Facial Nerve. 2nd ed. New York:
Thieme; 2000:709.)
Orbital fat
Skin
Orbital septum
Muscle of Muller
Levator
aponeurosis
Tarsus
Muscle of Riolan
Combined
fascia
Orbicularis
oculi fascia
temporalis fascia and muscle is elevated and split into two
limbs that are tunneled into the upper and lower lids. This
procedure has the advantage of providing an architectural
and functional mechanism with restoration of lid position,
lid support, and spread of tear fi lm. The disadvantages are
a lateral temporal bulge, lid movement with mastication,
and distortion of the palpebral aperture with contraction.
Lateral tarsorrhaphy uses excision of skin, conjunctiva, and
muscle from the lateral canthal region to create raw sur-
faces that are sutured to one another. The result is a tighter
lid with a shorter palpebral aperture. This is typically held
in reserve for patients with signifi cant corneal exposure
after more conservative procedures have failed.
The Cheek and Lips
Inability to smile and lack of oral competence are typically
the most problematic and socially stigmatizing symptoms
for the facial paralysis patient. There are many techniques
to improve appearance and function of the midface, and
they range in complexity from static slings to functional
muscle transfer. Again, the patient’s anatomy, tissue qual-
ity, comorbidities, and functional and aesthetic goals are
weighted in considering reconstructive options. An under-
standing of the anatomy of the smile as described by Rubin
is critical to achieving a symmetric, dynamic, and natural
appearing smile reconstruction ( Figure 39-5A ). 6 In muscle
transfer procedures, critical evaluation of each patient’s
unique smile features is essential in planning muscle inser-
tion points and muscle orientation, in order to achieve
a successful outcome with motion that best mirrors the
unaffected side ( Figure 39-5B ).
Static Reconstructions
The traditional and least complex reconstructions are those
utilizing a static sling with the goal of improving symme-
try at rest and oral competence. Many tissues have been
used for slings, including tensor fascia lata, tendon grafts,
and more recently, acellular dermal allograft. Establishing
solid anchor points on both the proximal and distal ends of
the graft to prevent recurrence, appropriate vector selec-
tion, and over correction are the key technical elements.
Typically, the sling is sutured at the oral commissure at the
site of insertion of the zygomaticus major and minor, and
levator labii superioris muscles. Bone-anchored sutures to
the body of the zygoma or permanent sutures to the tem-
poral fascia may be used to anchor the superior end of the
sling. The critical maneuver is overcorrection to account
for future lengthening of the graft and descent of the com-
missure over time.
Dynamic Procedures
Temporalis Transfer . Temporalis muscle transfer, as either
a turnover fl ap or an advancement fl ap, is the most popular
local fl ap option in use today ( Figure 39-6 ). When used as a
turnover fl ap, the central portion of the temporalis muscle
is dissected away from the midtemporal fossa, rotated
over the zygomatic arch, and tunneled to the commissure,
typically using the deep temporal fascia as an extension of
the muscle. The fascia is dissected away from the muscle
and permanent sutures are placed at the fascial fusion point
to bolster the strength of its attachment to the muscle.
The fascia is then sutured around the oral commissure. As

RECONSTRUCTION OF THE PARALYZED FACE • 463
in static slings, the key aspects of this reconstruction are
correct vector and insertion points and overcorrection of
the commissure at rest because descent of the commissure
is expected. The temporalis advancement fl ap consists of
an intraoral approach to the coronoid process which is
removed with insertion of the temporalis muscle. Once
the muscle is completely mobilized, it is advanced toward
the commissure, and a back cut along the posterior
part of the origin of the temporalis is often needed to
accommodate the advancement. The inferior end of the
muscle is then sutured to the commissure directly or using
a bridging piece of tendon or tensor fascia lata. A variation
of this technique, the lengthening temporalis myoplasty
described by Labbé, removes a section of the zygomatic
arch to access the coronoid process and preserves the
temporalis tendon for insertion into the oral commissure
( Figure 39-6 ). 7 The advantages of temporalis muscle fl aps
are a single-stage procedure, shorter operative time, and a
less technically demanding procedure. The disadvantages
include the need for masticatory effort to animate the
reconstruction and involuntary facial movement with
mastication, and in the case of the muscle turnover fl ap,
a conspicuous soft tissue bulge at the arch that increases
facial width, and temporal hollowing from loss of
temporalis muscle bulk.
Microneurovascular Muscle Transfer. The current gold
standard for dynamic reconstruction is microneurovas-
cular muscle transfer in which a segment of muscle from
elsewhere in the body brought to the face with its vas-
cular and neural supply. The muscle is attached medially
at the corner of the mouth and upper lip and laterally to
the parotid fascia just below the malar prominence; thus
its orientation and subsequent vector of motion can be
more precisely controlled than a local muscle transfer.
The advantages, therefore, are a greater ability to simulate
the motion on the unaffected side of the face and create a
symmetric smile.
This modality may be used for patients who have
either unilateral or bilateral facial paralysis. When cases
FIGURE 39-4. Lower lid support using a fascial or tendinous sling. (Adapted from
Zuker R, Manktelow R, Hussain G. Facial paralysis. In: Mathes SJ, ed. Plastic Surgery. Vol 3. 2nd ed.
Philadelphia: Saunders-Elsevier; 2006.)

464 • CHAPTER 39
B
A
Mona Lisa:
67%
Corners of mouth pulled up and outward
Dominant zygomaticus major
Canine:
31%
Exposure of the canines
Dominant levator labii superioris
Full Denture:
2%
Strong action of all upper lip
elevators and lower lip depressors
are unilateral, the cross-facial nerve graft technique of
innervation of the free muscle transfer is preferred. The
advantages of utilizing the cross-facial nerve graft are
primarily that contraction of the transplanted muscle is
spontaneous and emotionally driven, and although physi-
cal therapy can greatly improve the outcome by strength-
ening muscle activity, a lengthy period of relearning is not
necessary to initiate motion or coordinate this motion
with smiling on the unaffected side of the face. When the
neural input is supplied by the cross-facial nerve graft,
the procedure is usually done is two stages, spaced 6 to
12 months apart.
When paralysis is bilateral, the motor nerve to the
masseter muscle may be used bilaterally to innervate
the muscle transfer in separate single-stage procedures
to power muscle contraction and animation of each oral
commissure. When compared with the cross-facial nerve
graft, the use of the motor nerve to the masseter to power
a gracilis free fl ap results in much greater excursion of
the oral commissure and a more symmetric smile, but
FIGURE 39-5. (A) Anatomy of the smile (B) Preoperative markings to establish the
vector of smile on the unparalyzed side prestage 1 cross-facial nerve graft (left ), and
to project the nasolabial fold and smile vector onto the paralyzed side prestage 2 free
muscle transfer (right ). (Part A: Adapted from Rubin LR. The anatomy of a smile: its importance in
the treatment of facial paralysis. Plast Reconstr Surg. 1974;53(4):384–387.)

RECONSTRUCTION OF THE PARALYZED FACE • 465
FIGURE 39-6. Temporalis muscle transfer. (A) The incision design for access to the
temporalis muscle. Access for the Labbé procedure is gained by refl ecting the zygomatic
arch inferiorly to expose the coronoid process of the mandible. (B) Advancement of the
temporalis insertion to the oral commissure. (C) Muscle fl ap alternative to the Labbé
advancement technique. (D) Position of the turned over and not advanced temporalis
muscle, repositioned zygomatic arch, and closed access incisions at the end of the
procedure. (Adapted from Byrne PJ, Kim M, Boahene K, Millar J, Moe K. Temporalis tendon
transfer as part of a comprehensive approach to facial reanimation. Arch Facial Plast Surg.
2007;9(4):234–241.)
A
B
C
D

466 • CHAPTER 39
spontaneity is compromised. There are some instances
where a patient with a unilateral paralysis may be better
served by use of the motor nerve to the masseter and these
include patients who frequently smile (eg, salesperson),
those with heavy faces that require greater force to ani-
mate, advanced age, and those who prefer a single-stage
procedure. Otherwise, the utility of a spontaneous smile
achieved through a cross-facial nerve graft is thought to
outweigh the benefi t of greater excursion with motor
nerve to the masseter. 7 – 8
Two-Stage Free Muscle Transfer. In the fi rst stage of
a two-stage free muscle transfer, a midfacial branch of
the facial nerve on the unaffected side of the face that
creates the desired smiling motion upon stimulation is
selected and anastomosed to a nerve graft harvested from
elsewhere in the body. The patient is marked preopera-
tively, noting the vector of the normal smile and posi-
tion of the nasolabial fold. The facial nerve is approached
through a preauricular incision with a submandibular
extension in a neck crease. Subcutaneous dissection is
performed to the anterior border of the parotid gland,
and then the midfacial branches of the facial nerve are
dissected and mapped with the assistance of electrostim-
ulation. A zygomaticobuccal branch is chosen that opti-
mally elevates the oral commissure and upper lip along
the pre-marked vector, creating a pleasing smile without
any other facial muscle contraction. It is important to
identify a second nerve branch to be preserved that pro-
duces a similar motion.
Typically the sural nerve in the lower extremity is
chosen as the donor nerve due to its predictable course,
available length, and ease of harvest. The nerve can be rap-
idly and easily harvested with a tendon stripper through
two to three small transverse incisions. Alternatively, an
open approach can be used, fi rst identifying the nerve
just above the lateral malleolus, and then tracing its
course up the posterior leg and between the gastrocne-
mius muscles either via a single longitudinal incision or
multiple stair step incisions up the leg. The nerve graft
is tunneled from the midcheek across the upper lip and
banked in the contralateral upper buccal sulcus in the
supraperiosteal plane ( Figure 39-7 ). The end is marked
with a colored suture or staple to assist with identifi -
cation during the second stage. The nerve can also be
brought below the chin and banked in the contralateral
preauricular region, although this requires a longer nerve
graft and subsequently, a longer time for reinnervation.
A meticulous epineural repair is then performed with
the assistance of an operating microscope to the chosen
facial nerve branch.
A Tinel sign is followed clinically in the offi ce to moni-
tor fascicular advancement through the graft, and the sec-
ond stage is planned when the Tinel sign has reached the
distal end of the nerve graft, usually 6 to 9 months after
the fi rst procedure. A critical part of planning the second
stage is again assessing the characteristics of the smile on
the unaffected side of the face, specifi cally the vector of
FIGURE 39-7. (A) Position of cross-facial nerve graft in
the gingivobuccal sulcus of the upper lip. (B) Inset position of
the gracilis microneurovascular free muscle transfer.
A
B
motion, strength of motion, relative movement of the
upper lip and oral commissure, and the position and
depth of the nasolabial fold. Preoperatively, these fea-
tures are marked on the unaffected side of the face and
transposed to the affected side to guide muscle position-
ing ( Figure 39-5 ).
The gracilis muscle is the preferred donor muscle for
reanimation. It can be harvested in the supine position

RECONSTRUCTION OF THE PARALYZED FACE • 467
and is distant from the facial site such that two teams
can work simultaneously. In addition, its pedicle is a good
size match for the facial vessels, it has a reliable pat-
tern of innervation, and its harvest causes no functional
defi cit. Many other donor muscles, however, have been
used successfully for reanimation, including the pectora-
lis minor, latissimus, serratus anterior, rectus abdominus,
and extensor carpi radialis brevis. The gracilis muscle is
approached through a longitudinal incision on the inner
thigh, and a segment of the muscle is harvested based on
the location of the pedicle. The length of this segment is
determined by measuring the distance from the oral com-
missure to the root of the helix. The muscle is also split
longitudinally and only 50% to 75% harvested to dimin-
ish bulkiness in the cheek. The edge of the muscle to be
sewn to the mouth is reinforced with mattress sutures
as described by Zuker et al. to minimize tearing of the
delicate muscle fi bers, dehiscence, or malposition of the
muscle at the insertion site. 5 , 8
Exposure in the face is again achieved through a
preauricular incision with a submandibular extension,
and the cheek fl ap is elevated above the parotid fascia.
The facial vessels are identifi ed and isolated at the ante-
rior border of the masseter muscle, and the dissection is
continued to the oral commissure and into the upper lip.
Three to four inset sutures are then placed in the lower
lip, oral commissure, and upper lip sequentially to recre-
ate a pleasing smiling motion that matches the vector
and creases of the contralateral smile when traction is
placed on these sutures. The inset sutures are brought
through the muscle and tied and then the arterial and
venous anastomoses are completed, followed by coapta-
tion of the cross facial nerve graft to the gracilis motor
nerve in the upper buccal sulcus. Lastly, the muscle inset
is completed by sutures in the preauricular region to the
parotid fascia; the muscle origin is spread out to avoid
bulkiness in the lateral cheek and some tension, enough
only to slightly elevate the commissure, is placed on the
muscle ( Figure 39-7 ).
Postoperative management includes close monitoring
of fl ap perfusion in an ICU setting for 2 days and a soft
diet for several weeks. Muscle activity is seen approxi-
mately 6 to 8 months postoperatively, although electrical
activity can be detected earlier with a surface electromyo-
graph device. Therapy is begun at this time and helps to
strengthen and tailor the muscle activity over the follow-
ing year. When successful, this procedure can produce a
pleasing, spontaneous, and emotionally driven smile, and
can have a profound impact on the psychological well-
being of patients ( Figure 39-8 ). The disadvantages include
a lengthy time period and two procedures to complete the
reconstruction, and there is often great variability in out-
comes between patients.
The asymmetry of the lower lip seen in unilateral
facial paralysis is primarily caused by the depressor labii
inferioris on the unaffected side. This is typically not
noticeable at rest, but can be quite striking with smile
and speech. Even patients with successful reanimation
procedures for smile can look quite asymmetric due to
the unopposed depressor function. It is usually easier
to ablate the function of the unaffected side than to
restore the affected depressor function. Resection of the
depressor labii inferioris on the normal side or selec-
tive denervation of this muscle are effective treatment
methods. Use of local anesthetic in the depressor prior
to ablation is an easy and useful tool to evaluate if a
desirable smile will be produced from selective ablation
of depressor function. 9 Botox can similarly provide a
temporary cessation in depressor function to determine
if the desired affect will be achieved by a permanent
ablative procedure.
COMPLICATIONS
Complications after reconstruction for facial paralysis
range from acute postoperative problems such as facial
hematoma, infections, and arterial or venous thrombosis
after free muscle transfer, to a variety of delayed com-
plications relating to muscle or tendon malposition or
malfunction that result in less than optimal aesthetic or
functional results. Gold weights and palpebral springs
of the upper eyelid are subject to exposure and may
require replacement. Static slings of the eyelid or cheek
may stretch and lengthen with time requiring secondary
tightening procedures. Late complications of free muscle
transfer are challenging to correct and include excess
muscle bulk in the cheek, disruption of the muscle inser-
tion from its perioral attachment, scarring of the muscle
to the overlying skin causing irregular dimpling with
motion, and the most concerning, inadequate motion
after reconstruction. The fi rst three complications can
be improved by revisional procedures. The last compli-
cation of inadequate motion may be related to muscle
viability or neural input and requires either a second
muscle transfer, repeat cross-facial nerve graft, or trans-
fer of the gracilis nerve from the cross-facial nerve graft
to the motor nerve to masseter to achieve greater power
for the reconstruction.
OUTCOMES ASSESSMENT
Successful outcomes and high patient satisfaction after
facial paralysis reconstruction are dependent on a realis-
tic reconstructive plan, careful preoperative planning, and
good surgical technique. A multispecialty approach is often
benefi cial and coordinated care by plastic surgeons, oph-
thalmologists, oculoplastic surgeons, neurologists, physical
therapists, and psychologists can improve patient outcomes
in complex cases. In dynamic reconstructions, patient moti-
vation and compliance with therapy regimens are critical
in maximizing and optimizing motion. Reconstruction of
the paralyzed face can successfully improve function, and
also can have signifi cant effects on the psychological, emo-
tional, and social well-being of patients affected with this
disorder.

468 • CHAPTER 39
FIGURE 39-8. Before (A) and after (B) photos of a representative patient with
unilateral facial paralysis. This patient was treated with a two-staged cross-facial
nerve graft and gracilis microneurovascular free muscle transfer. Note the symmetry in
excursion of the oral commissure and vector of smile.
A
B

RECONSTRUCTION OF THE PARALYZED FACE • 469
REFERENCES
1. Sullivan FM, Swan IR, Donnan PT, et al. Early treatment
with prednisolone or acyclovir in Bell’s palsy. N Engl J Med.
2007;357(16):1598–1607.
2. Takushima A, Harii K, Sugawara Y, Asato H. Anthro-
pometric measurements of the endoscopic eyebrow lift
in the treatment of facial paralysis. Plast Reconstr Surg.
2003;111(7):2157–2165.
3. Moody FP, Losken A, Bostwick J 3rd, Trinei FA, Eaves FF
3rd. Endoscopic frontal branch neurectomy, corrugator my-
ectomy, and brow lift for forehead asymmetry after facial
nerve palsy. Plast Reconstr Surg. 2001;108(1):218–223.
4. Rofagha S, Seiff SR. Long-term results for the use of gold
eyelid load weights in the management of facial paralysis.
Plast Reconstr Surg. 2010;125(1):142–149.
5. Zuker R, Manktelow R, Hussain G. Facial paralysis. In:
Mathes SJ, ed. Plastic Surgery. Vol 3. 2nd ed. Philadelphia:
Saunders-Elsevier; 2006:883–916.
6. Rubin LR. The anatomy of a smile: its importance in
the treatment of facial paralysis. Plast Reconstr Surg.
1974;53(4):384–387.
7. Labbé D, Huault M. Lengthening temporalis myoplasty
and lip reanimation. Plast Reconstr Surg. 2000;105(4):
1289–1297; discussion 1298.
8. Marcus J, Borschel G, Zuker R. Facial paralysis and facial
reanimation. In: Bentz M, Bauer B, Zuker R, eds. Principles
and Practice of Pediatric Plastic Surgery. Vol 2. St. Louis, MO:
QMP, Inc; 2008:1001–1028.
9. Godwin Y, Tomat L, Manktelow R. The use of local anes-
thetic motor block to demonstrate the potential outcome
of depressor labii inferioris resection in patients with facial
paralysis. Plast Reconstr Surg. Sep 15 2005;116(4):957–961.

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40
Alopecia
Edward H. Davidson, MA (Cantab), MBBS / Keith Jeffords, MD, DDS / Ernest K. Manders, MD
INTRODUCTION
Hair, especially that of the scalp, is an important compo-
nent of body image. Perception of age, well-being, and
psyche are in part conveyed by the presence and style
of the hair. Furthermore, the hair of the eyebrows and
eyelashes provides a role in maintenance of ocular health
that goes beyond solely appearance. As such, hair loss
can represent a distressing cosmetic and functional prob-
lem. Alopecia, or hair loss, may be partial or complete,
affecting any part or all of the nonglabrous skin, and has
a multitude of causes.
The history of alopecia addressed as a medical prob-
lem dates to classical times. Grafting of hair has since
evolved in technique and grown in popularity for cor-
rection of hair loss along with the emergence of tissue
expansion and the use of local soft tissue fl aps across the
spectrum of alopecia etiologies. Male pattern baldness as
well as the deformities of burns, trauma, and congenital
hair absence may often be treated effectively with mod-
ern surgical techniques.
PATIENT EVALUATION AND SELECTION
The role of the plastic or reconstructive surgeon embark-
ing on hair restoration surgery must fi rst be to evaluate
the hair loss. It is crucially important for the surgeon to
know why hair is being lost. If a medical treatment is
indicated, then it will surely be more effi cacious than any
attempt at a surgical solution. Moreover, attempts at res-
toration surgery may very well fail if an underlying con-
tinuing medical condition is not, at least fi rst, adequately
treated. This tenet is particularly pertinent to scarring, or
cicatricial, forms of alopecia in which there is a potentially
permanent and irreversible destruction of hair follicles
and their replacement with scar tissue. A classifi cation of
alopecia etiopathogenesis and recommended treatments
is presented in Table 40-1 .
As well as the cause, the extent of the hair loss is a
fundamental consideration. Presently, all hair restoration
surgery techniques rely on autotransplantation or transpo-
sition of the patients’ preexisting hair. Tissue-engineered
hair and cadaveric allografts are yet to become a surgical
reality. Identifi cation of adequate donor hair is therefore
a prerequisite to restoration both by grafting and tis-
sue expansion. In the case of male pattern baldness, for
example, in which hair is most commonly fi rst lost at the
temporal sides of the hairline and at the vertex, correc-
tion requires suffi cient area of donor hair. Fortunately for
both patient and surgeon, an area of scalp may be doubled
without any observable diminution of hair density. Since
treatment of this patient group is complicated by the pro-
gressive nature of balding, it is important for the surgeon
to counsel any patient that their relationship will be ongo-
ing, possibly for the lifetime of the patient. Today the tim-
ing of surgical intervention should depend on the needs
of the patient, and the techniques employed should be
chosen with consideration of possible progression of hair
loss in male patients. For example, hair restoration early
can, for example, create a “donut” deformity as the native
hair continues to be lost around an island of transplanted
hair. Similarly, the “plugged” look is the result of thinning
of native hair surrounding foci of grafted follicles. Hence,
age and patient expectations along with the natural history
of male pattern hair loss are also important factors in the
patient evaluation and selection process.
If medical treatment is not indicated, or there is medi-
cal resolution of any ongoing pathologic process, and the
extent of hair loss is amenable to improvement without
unacceptable compromise of the existing healthy tissue,
then the patient may be considered a worthy surgical
candidate.
c h a p t e r

472 • CHAPTER 40
HAIR REPLACEMENT
THERAPY WITH ADDITIONS
All patients should be counseled about the use of hair-
pieces and additions. For many patients, these are a prac-
tical and satisfactory alternative to surgical therapy. That
said, there are drawbacks to the use of this alternative.
Expense is an important consideration. Hair replacement
organizations have estimated in the recent past that a
customer would be worth $40,000 or more over his
lifetime use of their products. Hairpieces cost from sev-
eral hundred dollars each to more than $2000 each. The
user must purchase two at the same time, so that his or
her appearance is not altered if one is damaged or being
cleaned. Hairpieces are typically styled when in place
on the wearer and then must be cared for appropriately.
Depending on the use and the ambient temperature and
humidity where worn, hairpieces are typically cleaned at
least every 5 months for a fee. They last for 3 to 5 years
and must then be replaced.
Attachment has been provided by several means.
Rings through the scalp are not popular now. Most addi-
tions depend on adhesives or on their being woven into
the native hair at the edge of the area of alopecia. Both
systems of attachment require continuing care. Adhesive
methods often employ a skin adhesive applied to the skin
and a double-sided sticky tape applied to the underside
of the hairpiece. Meticulous cleansing and preparation can
consume 3 to 4 hours once a week. The wearer still lives
with fear of dislodgement.
The weave attachment is an attractive product because
it allows patients to participate in physical activities, such as
waterskiing, without concern for dislodgement. However,
the weave must be tightened as the hair grows, so every
6 weeks or so, a visit to the provider is required to maintain
the proper adherence and appearance. There is typically an
appreciable charge for this service.
It should be obvious from this discussion that surgical
treatment can be cost-effective and relatively trouble free
once accomplished. Even given the limitations and costs
enumerated above, wearing a hairpiece is a good alterna-
tive for many patients.
Special mention should be made of the condition
seen in some older women in whom there is a global
thinning of the hair. There is a special prosthesis that is
custom created for this problem and which is very effec-
tive. The hair addition prosthesis is a net with strands
TABLE 40-1. Etiopathogenesis and Treatment
Diagnosis
Medical Treatment
Surgical Treatment
Scarring (cicatricial)
Hereditary or developmental
Trauma (including traction)
Burns
Neoplastic
Infl ammation of dermis
(eg, syphilis, tuberculosis, herpes
zoster, sarcoidosis, pyoderma,
gangrenosum, pemphigoid cicatrical
pemphigoid, and morphea)
Nonscarring
Autoimmune alopecia areata
(may be areata , in patches; totalis ,
affecting all of the scalp; or
universalis , affecting the entire body)
Androgenic (male pattern baldness)
Stress-induced (emotional stress,
starvation, crash diets, malaria,
tuberculosis, typhoid etc, after
surgery, hepatic, or renal failure)
Iron and zinc defi ciency
Postpartum
Thyroid or pituitary disorder
Collagen vascular disease
Drug-induced (anticancer
chemotherapy, antithyroid drugs,
cholesterol-lowering agents,
warfarin)

—
—
—
Appropriate treatment of
underlying neoplasia
Appropriate treatment of
underlying infl ammatory
process
Triamcenalone or hydrocortisone
Adjuvant minoxidil, and/or
fi nasteride; consider addition
Remove stressor; hair addition
Treat defi ciency
Watchful waiting
Treat underlying cause
Steroids, disease modifying
agents, immunosuppressant
monoclonal antibodies
Await spontaneous resolution at
termination of therapy; wigs

Yes
Yes
Yes (upon resolution of neoplastic process)
Yes (upon resolution of infl ammatory process)
Yes (if medical treatment fails)
Yes
Yes (if conservative therapy fails)
Not usually indicated
Yes (if conservative therapy fails)
Not usually indicated
Not usually indicated
Only if resolution does not occur following
cessation of treatment

ALOPECIA • 473
of hair attached. The hair is matched to the wearer. It is
laid down over the patient’s scalp and the native hair is
combed up through the interstices in the net. Together
with the hair attached to the net strands, a very nice aug-
mentation is achieved. After fi tting the hair net prosthe-
sis, a stylist then cuts the hair appropriately. This can be
worn for extended periods and cleaned with a regular
shampoo in the shower.
PATIENT PREPARATION
Preoperative workup might well include a biopsy of the
skin at the site of which there is hair loss as well as appro-
priate laboratory blood tests to rule out medically treat-
able conditions as detailed in Table 40-1.
The role of topical agents, such as minoxidil, and anti-
androgenic therapies, such as fi nasteride, remain contro-
versial because of concerns for cost, effort in use, and
limited effectiveness for many patients. They may be use-
ful adjuncts, especially in the treatment of male pattern
baldness where they may delay surgical intervention until
the degree of progression and patient concerns dictate an
intervention.
A preoperative assessment, including clinical history
and physical examination, is vital to assess the patient’s fi t-
ness for surgery. Adequate counseling is essential to ensure
patient expectations are realistic and that consent is appro-
priately informed. Clinical examination for delineation of
the affected areas to be treated and selection of donor sites
is important for gaining informed consent as well as for
preoperative planning. Demonstrating the operative plan
and the anticipated result for the patient in front of a mir-
ror is probably the best way to gain a realistic understand-
ing of the results of surgery in the patient’s mind. In terms
of reconstructive goals in male pattern baldness hair res-
toration procedures, framing the face by reinvigoration of
the anterior hairline should be prioritized over reconstruc-
tion of the vertex density.
Prior to surgery, as well as postoperatively, it is prudent
to encourage the patient in lifestyle practices that promote
hair health. Namely, the use of a good shampoo appro-
priate to their hair type; diet rich in proteins, iron, zinc
and water; avoidance of psychological stress, anxiety, and
trichotillomania; avoidance of vigorous combing, excessive
shampooing, drying, bleaching, dying, perming or straight-
ening; and avoiding the use of rubber bands, buns, and
braids.
TECHNIQUE
When surgical intervention is warranted, the options
available to the reconstructive surgeon for hair rejuve-
nation are outlined below. Tissue expansion is the pre-
ferred technique for large areas requiring repopulation
with hair while follicular unit grafts are better suited for
more focused, smaller areas. The combination of these
two techniques may be indicated; for example, the use
of tissue expansion of the scalp in male pattern baldness
with adjuvant follicular unit grafts to shape the anterior
hairline. The use of pedicled hair-bearing tissue fl aps is
now a less commonly employed strategy.
Hair Transplantation
Hair transplantation began with the demonstration by
Orentreich that hair follicles show donor dominance
when transferred to a different site in the scalp. Donor
dominance means that the dermis and hair follicle within
it display the hair growth characteristic of the donor area
rather than the recipient area after transfer. This is to
be expected in view of more modern knowledge that
has mapped higher levels of distribution of the enzyme
5-alpha reductase to the areas of characteristic male pat-
tern hair loss. Simply put, the transferred hair follicles
are programmed differently than those of the area of
normal androgenic baldness. For all hair transplantation,
the patient should be told that only one session of graft-
ing is unlikely to achieve the desired results, especially if
treating area of total hair loss. Many hair transplant sur-
geons have routinely counseled patients that up to four
sessions of transplantation would be necessary to get an
attractive result. Typically, the procedures can be carried
out using a combination of local nerve blocks and infi l-
tration of local anesthesia to donor and recipient tissues.
Inpatient admission is usually unnecessary and upon
completion of the procedure grafts are dressed with
an antibacterial ointment and a dressing. Patients may
shower the next day. Manipulation of the scalp should
be minimal at this juncture in recovery. Patients should
be counseled that after hair transplantation, hair growth
will not be obvious to them until 3 to 6 months after
transplantation and that the hair may not be long enough
for styling in the way they want until 6 to 9 months after
transplantation.
For male pattern baldness, the patient is prepared
before operation with a marking of the intended hair-
line, with the patient’s input and understanding. It should
be stressed to the patient that in the case of a mature
man, the hairline is expected to be fairly high on the
forehead. Pre-pubertal hairlines are unnatural and are to
be avoided. When designing the anterior hairline, grafts
should be placed at least 8 to 9 cm above the glabella, no
farther forward than the preexisting hairline and rather
than being straight, a feathered pattern creating an irreg-
ular 1 cm hairline transition zone should be used with
preservation of some temporal recession.
Follicular Unit Micrografts and Minigrafts (Strip
Method). Hair transplantation potentially allows for hair
to be transplanted from and placed in any area of the non-
glabrous skin without any visible scar ( Figures 40-1A, B
and 40-2A, B ). Whilst usually necessitating a scar, albeit
one that is hidden if the hair of the donor region is suffi -
ciently long and dense (ie, if worn .1 cm long in the scalp),

474 • CHAPTER 40
A
B
FIGURE 40-1. (A) Photographs before and after of patient requesting hair
restoration surgery at the anterior hairline. (B) After patient seeking restoration of the
anterior hairline.
A
B
FIGURE 40-2. (A) A patient seeking hair restoration for the vertex scalp. (B) After
micrograft transfer to the vertex scalp.

ALOPECIA • 475
micrografts and minigrafts have become the standard for
hair transplantation. This technique, though time consum-
ing and labor intensive, allows for much more effi cient har-
vesting of donor hair with minimal transaction compared
with traditional “punch” excision techniques. Typically, a
donor ellipse of hair is harvested, hence the resultant scar
from which follicles are dissected. An ellipse or longer strip
is harvested from the region between the occipital pro-
tuberance and 1 cm above the top of the ears (the area
above the ear and below the occipital protuberance may
thin over time). An alternative to the ellipse method uses
a multiblade scalpel that will cut several strips about 2 mm
thick from the occipital scalp with one pass of the knife.
The multiblade knife must be oriented so that the con-
tinuity of the hair shafts and their respective follicles is
maintained in each strip of tissue.
Following excision from the posterior scalp micro-
grafts (one or two hairs) or minigrafts (three or four
hairs) are then dissected in 1.5- to 3-mm slices from the
donor ellipse or strips. Grafts are held by the perifol-
licular fatty tissue under the hair bulbs or surrounding
tissue and must remain moistened with saline as well as
ideally being kept at 4°C until insertion. Slits are created
1.5 mm apart using an 18- to 20-gauge needle or thin
blade (eg, 22.5 Sharpoint blade or Ziering SP88 and the
Ziering SP89) down to the subcutaneous fat (4–6 mm)
at an angle of 30 to 60 degrees facing forward at the
anterior hairline and toward the center of the scalp to
mimic natural hair growth. As a slit is made, the graft is
immediately inserted by sliding the graft along the side
of the blade with the help of a jeweler’s forceps. The
application of pressure can also help with the placement
process and prevent “popping,” extrusion of the newly
placed grafts. The process is time consuming and labori-
ous. It is typical for a committed hair transplant surgeon
to have from three to fi ve assistants who prepare and
place grafts under his or her direction. 1 – 3
Follicular Unit Extraction. Follicular unit extraction has
become the method of choice for primary grafting for male
pattern baldness. Sometimes called a “scalpel-less hair
transplant,” grafts are obtained using small, round punches
(1–2 mm) harvesting 1 to 2 hair units. The donor sites are
shaved close to the scalp. For larger sessions, the posterior
hair is trimmed with a military-type haircut. For smaller
sessions, the long hair of the occipital scalp is retracted
with hair clips and a small portion of the scalp is trimmed.
Then the donor area is concealed by covered hair.
The donor area is infi ltrated with local anesthesia.
Then these small punches are used to harvest follicle
directing the punch toward of the visible hair down the
hair shaft ( Figure 40-3A–C ). Hair is harvested every 4 to
A
B
FIGURE 40-3. (A) Recovery of unit follicular grafts with a
punch. (B) Appearance of the donor site after harvest. (C) The
follicular units awaiting implantation.
C

476 • CHAPTER 40
5 hair units. No sutures are required. The donor areas are
covered with antibiotic ointment. Each donor site con-
tracts and granulates, resulting in a favorable donor fi eld.
The follicular units are then trimmed of excessive
fat and readied for transplantation. As with micrograft-
ing techniques, the grafts are inserted into the recipient
sites using jeweler’s forceps. Hair growth takes weeks to
months.
This technique can be used for small grafting ses-
sions as in grafting for eyebrows. Larger sessions are used
for male pattern baldness. There is no linear scar in the
occipital scalp, and patients have minimal postoperative
pain. This technique is more expensive than the strip
method because of the lengthy time of harvesting indi-
vidual hair units. However, the patient benefi ts from no
visible scar and reduced recovery time. 4
Pedicled Hair-bearing Tissue Flaps
The use of pedicled fl aps for the reconstruction of areas
of alopecia has become increasingly less common, except
in clinical situations that require urgent coverage. Flaps
used in urgent situations are usually local advancement
or transposition fl aps. These have been described in
detail in multiple sources in the plastic surgery literature.
Generally, these fl aps do not require delay, but the sur-
geon should be wary of creating a fl ap whose tip crosses
the midline, especially in an elderly patient. Vascular
anastomoses across the midline in aged patients may not
support distal tissues.
A variety of pedicled fl aps have been described for
treatment of male pattern hair loss. Now largely obso-
lete and out of popular favor due to the stigma of leav-
ing sometimes visible scars, these include local temporal
area fl aps to more complex fl aps like the Juri temporo-
parietal-occipital fl ap that benefi ts from routine delay.
Many an unwary surgeon has been confronted with a dif-
fi cult donor site closure when using scalp fl aps for alo-
pecia reconstruction. This is particularly true of the Juri
fl ap when designed by an overly ambitious surgeon.
Today, fl aps for aesthetic reconstruction are used less
often. They can still achieve excellent results but do
present the problem of moving a limited amount of hair-
bearing scalp while imposing a donor site defect which
may be diffi cult to close and which may leave an undesir-
able scar. In addition, the angle of exit of the hair shafts
from the skin of the fl ap may be the complete opposite
of the native angle of exit, as in the case of the Juri fl ap.
Today, if fl aps are used for aesthetic reconstructions, their
use can be signifi cantly enhanced by prior expansion.
Tissue Expansion
Tissue expansion has been extremely valuable in the
treatment of soft tissue defects. Physiologically this pro-
cess is more sophisticated than a simple stretching of the
tissue; expansion is the result of formation of new cell
growth and increase tissue mass. This requires time and
both patient and surgeon must be ready to commit to the
time it takes. Hair follicles are preserved in expansion of
the skin and, although new follicles are not thought to be
created, this may not be true in the case of scalp expan-
sion in children. An area of scalp may be doubled with-
out producing a visible thinning of hair density.
The fundamental principles of tissue expansion have
been described previously; briefl y, tissue expansion
involves at least three stages: insertion, expansion, and
reconstruction. Preoperative planning specifi cally with
reference to expander selection, design of the place-
ment, and timing of surgery is the lynch pin of successful
outcome. Among the fi rst questions the surgeon should
ask are where he and the patient wish the fi nal scars to
lie. The limitations of surgery in this regard should be
discussed with the patient. Expanders are almost always
placed beneath the galea and above the fascia of under-
lying muscle. In the area of the anterior scalp and fore-
head, expanders may be place on top of the frontalis so
that innervated motion of the reconstructed forehead
is preserved. The dissection between the subcutaneous
fat and the underlying frontalis is easier in a child than
in an adult. Once the incision has been made and car-
ried to the preferred depth, a pocket is created to allow
implant insertion. Infl ation of the expander generally
begins 7 days after insertion and proceeds at weekly or
twice a week intervals. For patient convenience, expan-
sion can usually be performed at home by the patient
and his family and friends. Implant expansion should
proceed until adequate soft tissue has been generated to
accomplish the reconstructive goal. Any type of rotation,
advancement, or transposition fl ap may be designed with
the expanded tissue.
After completion of expansion, incision in the line
of the previous insertion site will permit removal of the
defl ated expander. At this time, the bald scalp at the
temple areas is surgically removed and the expanded
hair-bearing scalp surrounding each of the defect sites
is advanced as indicated generally by the arrows to form
advanced temple hairlines. The anterior-posterior width
of expander assures that with expansion of the hair-
bearing scalp surrounding and behind the defect areas
suffi cient additional hair-bearing scalp is formed to be
brought forward and completely cover the defects. The
expanded tissue is easily bunched along the new hair-
line and sutured to the remaining skin at the top of the
forehead. In time, the expanded tissue grows fl at on
the skull with a minimum scar at the hairline. If desired,
the expanded forelock may be advanced anteriorly a
slight distance.
The precise technique will obviously vary in terms
of geometry, expander selection, and expansion course
dependent on anatomic location. Three common patterns
of expansion for male pattern baldness are detailed here.
Expanded Juri Flap. Use of the Juri fl ap is made more
diffi cult by the need for several steps for delay and by the

ALOPECIA • 477
diffi culty in closing the donor site. It is this latter problem
that limits the width of the hair-bearing fl ap that the sur-
geon can use. The alternative to these problems lies in the
use of a tissue expander prior to fashioning and rotating
the Juri fl ap. Placed under the temporo-parietal-occipital
area of the Juri fl ap (best accomplished with an expander
with a slight bend or dogleg), the expansion begins in a
week and is continued until the difference of the mea-
surement of the arc over the expander, minus the width
of the base of the expander at the level of the skull, equals
the width of the desired fl ap for transfer. With the scalp
fl ap width is achieved by the expansion, this calculation
ensures that the surgeon will be able to close the defect
without and tension or struggle.
The fl ap does not require delay for rotation. Its capsule
should not be incised at the base, because laboratory stud-
ies using radioactive microspheres have demonstrated that
the blood fl ow to an expanded fl ap is doubled if the cap-
sule is left intact. The rotation is easy and the inset rapid.
The result is most gratifying with placement of a broad,
hair shaft–dense fl ap at the anterior hairline. 5
Temporal Recession. Temporal recession results in a
central projecting area of hair bearing scalp with alope-
cia on each side. In the case of this form of male pattern
hair loss, a specialized soft tissue expander having three
spaced arms extending from one side of the base with
concave recesses between the arms and a single interior
cavity may be used ( Figures 40-4 and 40-5A–C ). 6 The
tissue expander is implanted by forming an incision (as
indicated) along the patient scalpline at the depths of
the recessed hairline, lifting the hair bearing scalp from
the skull to form a subgaleal pocket having the shape
of the expander and then inserting the expander into
the pocket so that the fi ngers and recesses are positioned
to conform closely to the anterior hairline. The hairline
incision is then sutured closed to confi ne the defl ated
expander within the pocket.
30
30
34
32
32
42
36
26
28
42
36
26
10
FIGURE 40-4. The double-croissant expander for the
anterior hairline.
After an appropriate interval, saline solution is injected
into the single interior cavity of the expander through the
port so that expander and overlying hairy soft tissue are
expanded above the base which is supported on the skull.
Repeated injection of saline solution into the expander
lifts the cover and expands the overlying tissue, thereby
increasing the area of the hair-bearing scalp around the
two temple bald recess defects.
Expansion is continued until the measured arc length
of the expanded scalp indicates suffi cient expansion has
occurred to cover the temple recesses. Generally, the dif-
ference of the measurement of the arc over the expander,
minus the width of the base of the expander at the level
of the skull, should equal the width of the desired fl ap for
transfer of the width of the advancement needed. Almost
any degree of scalp expansion can be easily concealed by
wearing a hat, such as a baseball cap, to lessen patient
embarrassment during the period of expansion. Only fore-
head expansion is harder to conceal, but even this altered
appearance can be minimized with the use of bouffant
caps like those commonly worn in the operating room.
At the time of advancement, the central hairline is
reconstructed fi rst and the closure is conducted from cen-
tral to lateral. There will be dog ears laterally. These may
be neglected and will generally go fl at. The surgeon should
not discard scalp-bearing hair. Allow time for contraction
and the dog-ear will shrink. Avoid scars that are perpendic-
ular to the hairline as these will always widen and present
a problem in the long term.
Reconstruction of Hippocratic Baldness. Sculpture
depicts Hippocrates, the father of medicine, as being bald
across the top of his head. The term “Hippocratic baldness”
has come to signify complete vertex hair loss. It can now
be addressed with micrografts, but the mathematics of fol-
licular transplantation work against obtaining a result that
closely approximates a normal expected density of hair
across the top of the head. Tissue expansion can accom-
plish a normal-appearing distribution of hair across the top
of most patients’ heads. This is because an area of scalp
can be expanded to twice its normal area with no visible
diminution of hair density. By expanding the remaining
privileged areas of the temporal, and lower parietal and
occipital scalp, the surgeon can usually create enough scalp
with normal-appearing hair density to cover the entire top
of the head ( Figures 40-6A–C ).
The tradeoff for the patient is 2.5 months of visible
deformity after the fi rst 6 weeks of expansion, when
change is usually not apparent. Not much is visible dur-
ing the fi rst 6 weeks of expansion while the patient is
instructed to simply let his hair grow long. After this he
may wish to wear bouffant-type hats or hats of another
design to disguise the expansion. This can be accom-
plished so that the only unusual feature is that of wear-
ing a hat indoors. At about 4 months after expander
placement in the typical patient, the expanders can be
removed with total reconstruction of the vertex scalp

478 • CHAPTER 40
and fashioning of a new anterior hairline. Because this
scalp is privileged and spared complete androgenetic
hair loss, the result should be lifelong. Any further hair
loss in a patient reconstructed as described here can be
treated with a simple midline excision of a thinning area
in the outpatient clinic under local anesthesia.
Initially the patient is counseled and the process of
expansion explained. The hairline should be set in front
of a mirror, recalling the admonition that it should be a
mature hairline. Two differentially expanding expanders
are placed through a transverse incision centered on the
midline at the occipital hairline. Using male Van Buren
urethral sounds, the pockets in the subgaleal space are
created and the expanders placed with the aid of Scudder
bowel clamps with rubber catheter segments placed over
their arms. The incision is closed securely and infl ation
FIGURE 40-5. (A) A patient with a double-croissant
expander, as pictured in Figure 40-3, expanded and ready
for advancement. (B) The patient after advancement.
(C) A close-up view of the anterior hairline scar.
C
B
A

ALOPECIA • 479
begun in a week. The classic measurements described
above are made and when they indicate that enough tis-
sue is generated, then the advancement is made in the
operating room.
The advancement incisions begin with an extension
of the insertion incision and removal of the expanders. A
midline incision across the vertex to the intended anterior
hairline is created. The incision posteriorly is extended
along the hair-bearing edge of the expanded scalp to a
point of incision on the temporal hairline. This point is
determined by projecting a 7 cm line perpendicular to
the midline of the scalp to the most anterior point of
contact with this line on the temporal hairline. At this
point the surgeon directs a straight line incision extend-
ing obliquely caudally and slightly posteriorly over the
greatest height of the expander in the area of the tem-
poral scalp. The temporal scalp posterior to this incision
will then advance upward and to the midline to create
a new anterior hairline. The extent of expansion and the
placement of this incision allow creation of the desired
anterior hairline, even permitting major advancement.
Resection of the two “rabbit ears” of bare scalp based at
A
FIGURE 40-6. (A) A differential tissue expander in
place with more temporal expansion and the method of
treating male temple baldness. (B). After advancement
as described in the text and in reference 5. (C) Showing
the anterior hairline and the method of closure.
B
C

480 • CHAPTER 40
the anterior hairline and closure in the midline over a
drain complete the operation. The patient should shower
the next day. Patients are typically thrilled at the result,
both immediately and in the long term. 7 , 8
COMPLICATIONS
Regardless of the reconstructive technique chosen, post-
operative complications in the practice of hair restoration
are few. Avoidance of specifi c complications including
the plugged look and so-called donut formation (follow-
ing transplantation of a vertex in a continuingly balding
patient) has been discussed above. Donor site hair sparse-
ness may result from mathematical error. The scalp of the
majority of Caucasian patients has 60 to 100 follicular
units/cm 2 ; and if this is reduced by more than 50% (in tis-
sue expansion or by harvest of isolated punch grafts), the
hair density of the donor area will be visibly affected. Those
with poor donor site density (,40 follicular units/cm 2 )
are therefore poor candidates. This potential complica-
tion is avoided in micrograft and minigraft transplan-
tation as the donor site is, by the very nature of the
technique, removed. Overly deep insertion of grafts has
been reported to result in the formation of ingrown hairs
and cysts hence technical vigilance is a must. Assuming a
good sterile operative technique, hair restoration surgery
is rarely complicated by infection and, though there are
some advocates for their use, prophylactic antibiotics
are not generally required. Retraction of expanded tis-
sue has been described but with adequate expansion, this
should be negligible and not problematic. Scar widening
is a potential complication whenever the skin barrier is
breached, and these procedures are no different. As part
of preoperative counseling, patients should be consented
for possible complications pertaining to scaring, infection
hematoma formation where appropriate, as well as for
the potential need for revision procedures.
OUTCOME ASSESSMENT
In practice, assessment of operative outcomes of hair res-
toration surgery is largely subjective. Patient satisfaction
comes fi rst. Independent of that, qualitative comparison of
pre-and postoperative photography is currently the main-
stay of outcomes documentation. More objective quantita-
tive is truly diffi cult.
ACKNOWLEDGMENT
The authors wish to thank Ms. Kathy Smith of the Nu/
Hart Hair Clinics, Inc. 200 Fleet Street, Penthouse Suite,
Pittsburgh, PA 15220.
REFERENCES
1. Uebel CO. Micrografts and minigrafts: a new approach for
baldness surgery. Ann Plast Surg. 1991;27(5):476–487.
2. Barrera A. Advances in aesthetic hair restoration. Aesthet
Surg J . 2003;23(4):259–264.
3. Avram M, Rogers N. Contemporary hair transplantation.
Dermatol Surg . 2009;35(11):1705–1719.
4. Rassman WR, Bernstein RM, McClellan R, et al. Follicular
unit extraction: minimally invasive surgery for hair trans-
plantation. Dermatol Surg . 2002;28(8):720–728.
5. Sajjadian A, Manders EK. Surgical and medical treatment
for male pattern hair loss. In: Peled I, Manders EK, eds.
Aesthetic Surgery of the Face . London: Martin Dunitz;
2004.
6. Manders EK. Tissue Expander and Method of Treating Male
Temple Baldness. U.S. Patent No. 4,955,395.
7. Manders EK, Graham WP 3rd, Schenden MJ, Davis TS. Skin
expansion to eliminate large scalp defects. Ann Plast Surg .
1984;12(4):305–312.
8. Manders EK, Mottaleb M, Hetzler PT. Soft tissue expan-
sion. In: Marsh JL, ed. Current Therapy in Plastic and Recon-
structive Surgery: Head and Neck . Philadelphia: B.C. Decker;
1989:88–98.

c h a p t e r 41
Breast Cancer
Gretchen Ahrendt, MD, FACS
BACKGROUND
Breast cancer remains the most commonly diagnosed
cancer in women, with an estimated 212,920 new cases
for 2006. 1 The widespread application and improve-
ments in screening mammography have contributed to
an increase in the diagnosis of nonpalpable early-stage
breast cancer, and ductal carcinoma in situ (DCIS)
accounts for 28% of all new breast cancer diagnoses.
Although breast cancer mortality has declined in recent
years, more than 41,000 women are expected to die
annually of their disease. Early diagnosis and multimo-
dality treatment, including appropriate use of surgery,
adjuvant systemic therapy, and radiation therapy, have
contributed to the recent declines in mortality. Emerging
molecular profi ling of breast cancer subtypes has dem-
onstrated that breast cancer is a heterogeneous group of
diseases with variable clinical outcomes. Although addi-
tional research is needed to fully appreciate the complex-
ity of the molecular subtypes of breast cancer, current
treatment strategies can be more individually tailored
to improve outcomes by identifying patients who maxi-
mally benefi t from systemic treatment.
BREAST CANCER RISK FACTORS
Most recognized breast cancer risk factors are related to
prolonged estrogen exposure ( Table 41-1 ). Nonmodifi able
estrogen exposure risk factors include early onset of menar-
che, late onset of menopause, nulliparity, and delayed
onset of fi rst childbirth. The average age at fi rst childbirth
has been increasing, particularly among women in higher
socioeconomic classes who are already at increased risk
of developing breast cancer. 2 The use of exogenous estro-
gen, alone or in combination with progesterone, for the
management of menopausal symptoms is a modifi able
breast cancer risk factor. Results of the Women’s Health
Initiative demonstrated that the prolonged use of estro-
gen or combined estrogen plus progesterone hormone
replacement therapy (HRT) increased breast cancer risk
over never-users. 3 Cessation of HRT resulted in a return of
breast cancer risk to baseline levels after 5 years. The use
of HRT in postmenopausal women to manage menopausal
symptoms needs to be balanced with the increased rela-
tive risk of breast cancer. The long-term use of HRT solely
for the management of perimenopausal symptoms is no
longer advised.
There is mounting evidence that postmenopausal
obesity contributes to breast cancer risk. 4 The excess
risk appears to be limited to never-users of HRT.
Postmenopausal women with a body mass index greater
than 30 who have never used hormone therapy have a
1.7- to 2.3-fold increased risk of ductal estrogen receptor
positive and progesterone receptor positive (ER1/PR1)
tumors compared with lean women. Body mass index
was not found to relate to breast cancer risk among cur-
rent HRT users. Premenopausal women with increased
dietary fat intake, particularly animal fat and high-fat
dairy foods, have an increased breast cancer risk. 5 Alcohol
consumption of more than 10 g per day is also associated
with increased risk of ER1 breast cancer. 6 There appears
to be an interaction between alcohol consumption and
use of HRT on breast cancer risk. Diet, weight gain, hor-
mone use, and alcohol intake are potentially modifi able
risk factors that should be discussed with patients as
additional breast cancer risk factors.
Women with a fi rst-degree relative with a history of
breast cancer are at increased risk for developing the
disease. Most women, however, overestimate the magni-
tude of this risk. 7 A family history of sporadic postmeno-
pausal breast cancer in a fi rst-degree relative modestly
increases breast cancer risk, and many women with a
family history of breast cancer never develop the disease.