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

RECONSTRUCTION OF THE NOSE • 333
sculpted through these new incisions. Contour is created
with buried and quilting sutures.
Maintaining the shape of the skin covering the soft
triangles and columella is crucial to repairing defects in
this area. Superfi cial defects can be reconstructed using a
composite graft from the antihelix of the ear. A second-
ary deformity of the ear is sacrifi ced for quality aesthetic
results in the nasal reconstruction. The donor site closure
often requires a full-thickness skin graft. Deeper, more
complex defects of the columellar region may require uni-
lateral or paired nasolabial fold fl aps over an anchored car-
tilage strut graft.
Free Tissue Transfer
Microvascular free fl aps play a role in nasal reconstruc-
tion in cases of large defects where tissue loss prevents the
use of all other local fl aps for nasal lining. Free fl aps are
transferred with multiple skin islands based on musculo-
cutaneous perforators and used to recreate the nasal lining
and columella, as well as any adjacent defects of the nasal
fl oor. Commonly used free fl aps are the radial forearm
fl ap, groin fl ap, and anterolateral thigh fl ap. These fl aps
are often bulky and require multiple thinning procedures
to maintain a patent airway. The free fl aps are frequently
anastamosed to the facial vessels. Ideally, cartilage grafts
are used for support over the free fl ap, and a paramedian
forehead fl ap is used for skin covering. In cases of burns
and signifi cant facial trauma, a free fl ap may be used to
supply the skin covering, but the aesthetic results are sub-
optimal. On account of the fi ne defi nition and relatively
thin soft tissue covering the nose, free tissue transfer is
less commonly used to reconstruct the nose. In addition,
the forehead fl ap is usually available and provides a more
aesthetic reconstructive option.
COMPLICATIONS
Because certain areas of the nose require full-thickness
skin, there is the potential for a higher rate of graft loss.
Should graft loss occur, a search for possible offending
causes should be made. In the case of a forehead fl ap, the
distal skin in the region of the hairline is often tenuous due
to the random nature of the distal blood supply. This may
be minimized by a primary delay procedure. At the time
of the delay, the distal skin pattern—either a heminasal
outline or full nasal outline—may be incised and partially
elevated. A thin skin graft, with or without a cartilage graft
for alar rim support, may be fi xed to the underside of the
fl ap as a means of prefabrication.
OUTCOMES ASSESSMENT
Any reconstructive endeavor will ultimately be judged on
how closely it recreates the natural appearance of the nose.
Minimal incisions, placed along the aesthetic lines of the
nose, with minimal subcutaneous tissue is the goal. For
large defects, the nasolabial fl ap usually fulfi lls these needs
well. The reconstruction, however, must not compromise
the ultimate survival of the patient. As such, the survival
rate among cancer cases must be examined.
REFERENCES
1. Chang JS, Becker SS, Park SS. Nasal reconstruction: the
state of the art. Curr Opin Otolaryngol Head Neck Surg .
2004;12(4):336–343.
2. Kindwall EP, Gottlieb LJ, Larson DL. Hyperbaric oxygen
therapy in plastic surgery: a review article. Plast Reconstr
Surg . 1991;88(5):898–908.
3. Rohrich RJ, Griffi n JR, Ansari M, Beran SJ, Potter JK. Nasal
reconstruction–beyond aesthetic subunits: a 15-year review
of 1334 cases. Plast Reconstr Surg. 2004;114(6):1405–1416;
discussion 1417–1419.
4. Millard DR Jr. Various uses of the septum in rhinoplasty.
Plast Reconstr Surg . 1988;81(1):112–128.
5. Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate
fl ap for repair of nasal septal perforation. Laryngoscope .
2003;113(8):1425–1428.
6. Burget GC. Aesthetic reconstruction of the nose. In: Mathes
SJ, Hentz VR, eds. Plastic Surgery . Philadelphia: W.B. Saun-
ders; 2005.
7. Tessier P, Kawamoto H, Posnick J, Roulo Y, Tulasne JF, Wolfe
SA. Complications of harvesting autogenous bone grafts:
a group experience of 20,000 cases. Plast Reconstr Surg.
2005;116(5 suppl):72S.
8. Byrd HS, Hobar PC. Alloplastic nasal and perialar augmenta-
tion. Clin Plast Surg . 1996;23(2):315–326.
9. Gryskiewicz JM, Rohrich RJ, Reagan BJ. The use of alloderm
for the correction of nasal contour deformities. PlastReconstr
Surg. 2001;107(2):561–570; discussion 571.
10. Anderer U, Libera J. In vitro engineering of human
autogenous cartilage. J Bone Miner Res . 2002;17(8):
1420–1429.
11. Kita M, Hanasono MM, Mikulec AA, Pollard JD, Kadleck
JM, Koch RJ. Growth and growth factor production by hu-
man nasal septal chondrocytes in serum-free media. Am J
Rhinol . 2006;20(5):489–495.
12. Chang CH, Kuo TF, Lin CC, et al. Tissue engineering-based
cartilage repair with allogenous chondrocytes and gelatin-
chondroitin-hyaluronan tri-copolymer scaffold: a porcine
model assessed at 18, 24, and 36 weeks. Biomaterials . 2006;
27(9):1876–1888.
13. Hubbard TJ. Leave the fat, skip the bolster: thinking outside
the box in lower third nasal reconstruction. Plast Reconstr
Surg . 2004;114(6):1427–1435.
14. Cook JL. A review of the bilobed fl ap’s design with particu-
lar emphasis on the minimization of alar displacement. Der-
matol Surg . 2000;26(4):354–362.
15. Menick, Frederick J. Nasal Reconstruction: Forehead Flap.
Plast Reconstr Surg. 113(6):100e–111e, May 2004.

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31
Lip Reconstruction
Naveen K. Ahuja, MD / Robert J. Morin, MD / Mark S. Granick, MD
INTRODUCTION
The importance of functional and aesthetically pleasing
lips transcends their ability to maintain oral competence.
In addition to providing a role in mastication, the lips are
an essential part of communication, facial expression, and
beauty. Phonation of many sounds requires the advanced
function of the lips and their surrounding musculature.
The same is true for the ability to create a vast number of
human expressions, including smiling and pouting. Finally,
the role of lips in facial beauty and human sensuality can-
not be underestimated. The ability to restore both the form
and function required to perform these advance tasks is an
integral skill required of all reconstructive surgeons.
Defects of the lips are most often acquired secondarily.
Traumatic injuries do occur; however, defects secondary to
oncologic excision are much more common. Squamous cell
carcinoma is the most common malignancy and the lower
lip is involved approximately 90% of the time. Regardless
of the etiology, form must be restored carefully and meticu-
lously. Many techniques have been described and modifi ed
over time, but the ultimate goal has remained the same:
sensate, functional, and aesthetically pleasing lips. This
chapter highlights the essential features and techniques
involved in the reconstruction of this complex anatomic
structure.
PATIENT SELECTION
It is important to identify the structures of the lip that
are defi cient and will require either direct repair or recon-
struction. Some defects may be simply superfi cial and not
require reconstruction of the deeper structures. An accu-
rate understanding of the anatomy of the lips is the foun-
dation necessary for a successful reconstruction. The lips
exist between the subnasal superiorly, the mental crease
inferiorly, and the modioli laterally. They are covered by
skin, mucosa, and a unique, keratinized, stratifi ed squamous
epithelium known as the vermilion. There is a well-defi ned
border between the skin and the vermilion. If not care-
fully repaired, the vermilion border is unforgiving when
violated. Just above the vermilion border is the white roll,
which is prominent because of the underlying orbicularis
muscle. The red line is located a few millimeters poste-
rior to where the lips meet during normal closure. This
line separates the dry portion of the vermilion from the
intraoral mucosa. The central portion of the upper lip
forms two philtral peaks that encompass a soft depression
known as the philtral groove. The shape of the superior
border of the upper lip (which begins laterally at the com-
missure, rises to a peak at the base of the philtral column,
descends to a point in the midline, rises again to the base
of the contralateral philtral column, and then descends to
the contralateral commissure) is often referred to as the
Cupid’s bow.
The musculature of the lip is as complex as the func-
tion it provides. The orbicularis oris is the dominant mus-
cle that encircles the mouth. It originates at the modiolus:
a fi brous structure adherent to the skin just lateral to
the commissures bilaterally. The primary function of the
orbicularis is to provide the sphincter tone necessary for
oral competency. It is also responsible for the ability to
pout and to evert the lips. The mentalis muscle originates
from the mandibular periosteum and inserts into the chin
pad. Contraction of this muscle results in the elevation of
the lower lip. The depressor anguli oris, the depressor labii
inferioris, and the platysma all contribute to lip depression.
The levator anguli oris, the zygomaticus and the levator
labii superioris contribute to lip elevation.
The lips have a robust blood supply as demonstrated
by both their unique coloration and their impressive abil-
ity to avoid infection when injured. The dominant supply
comes from the superior and inferior labial arteries that
c h a p t e r

336 • CHAPTER 31
run below the vermilion in a plane between the orbicu-
laris oris and the oral mucosa. These small arteries branch
off the facial artery just lateral to the commissures. Most
fl aps are designed based on the location of these arteries.
Due to the extensive collateral network, however, certain
fl aps can also survive on a random blood supply.
Lip sensation is provided by both the mental and the
infraorbital nerves. The mental nerve is a branch of the
mandibular division of the trigeminal nerve. The infraor-
bital nerve is a branch of the maxillary division of the
trigeminal nerve. Motor innervation of the lips is provided
by the buccal and marginal mandibular branches of the
facial nerve. Most of the motor innervation occurs on the
posterior surface of the muscles; however, the mentalis
muscle is innervated on its anterior surface.
Any patient with a lip defect is in theory a candidate
for reconstruction. However, patient comorbidities may
often delay or prevent surgery. The ideal patient is either
a young, healthy trauma patient or a patient who recently
had a resection of a lip cancer with negative margins and
no metastatic disease. Unfortunately, the situation is
usually more complex. Trauma patients may have other
potentially life-threatening injuries, and oncology patients
may have inadequately resected disease or adverse effects
secondary to other treatment modalities. Major recon-
structive lip surgery, especially procedures that irre-
versibly alter the surrounding normal tissue, should be
delayed until the patient can safely tolerate what usually
amounts to an elective operation. In addition, the sur-
geon should be reasonably sure a proper cancer resection
has been performed based on a tissue diagnosis and the
current recommendations for surgical margins.
PATIENT PREPARATION
Prior to performing any reconstructive procedure, it is
essential to discuss the risks, benefi ts, common complica-
tions, alternative options, and postoperative care with the
patient in as much detail as possible. Discussions about
postoperative feeding should take place prior to any proce-
dure that may temporarily interfere with mouth opening
(eg, Abbe fl ap) due to pedicled blood supply.
From a technical perspective, patients undergoing lip
surgery should be prepped with some form of antisep-
tic, although the utility of this is questionable due to the
nonsterile nature of the mouth. Perioperative antibiot-
ics are usually recommended. Nasotracheal intubation
is the preferred method of maintaining an airway, as it
allows the lips to be completely accessible and it prevents
distortion of the perioral anatomy. If this is not possible,
oral intubation is usually tolerated fairly well by placing
the tube on the contralateral side. Performing some pro-
cedures under local anesthesia with sedation is another
option. Finally, the endotracheal tube must be secured
in a manner that does not interfere with the operation.
Wiring the tube to a maxillary tooth avoids the excessive
use of tape and can decrease the incidence of accidental
intraoperative extubation.
TECHNIQUE
Superfi cial Defects
Small superfi cial defects of the vermilion or the surrounding
lip often heal well by secondary intention. Minimal distor-
tion should be expected, however, as a degree of contraction
will occur in all healing wounds. This contraction can be
reduced by closing the defect primarily; alternatively, some
surgeons advocate using a full-thickness skin graft. In our
experience, however, full-thickness skin grafts result in an
aesthetically unacceptable result. These techniques should
only be used with defects superfi cial to the orbicularis oris
muscle. Deeper defects require a more complicated repair.
Vermilion Defects
Lip vermilion is specialized tissue that is unlike any other
soft tissue in the body. It has unique properties of color
and texture that result in a suboptimal aesthetic result if
reconstructed with any other type of tissue. Additionally,
lip vermilion overlies muscle that is essential to maintain-
ing proper sphincteric function of the lip. If at all possible,
vermilion should be reconstructed with vermilion.
Small, lateral, superfi cial defects of the vermilion will
usually heal by secondary intention with acceptable
results. Similar defects located more medially can often
be closed primarily. The skin edges should be approxi-
mated carefully and everted in order to prevent lip notch-
ing. Anatomic landmarks, particularly the white roll and
the vermilion border, should be marked prior to injecting
local anesthetic solution, as injection will distort the nor-
mal lip anatomy. Alignment sutures can be used in place
of marking to assure accurate approximation; even small
discrepancies are noticeable at conversational distance.
Three-layer closure of the buccal mucosa, orbicularis oris,
and skin can then be performed. Mucosal closure should
be accomplished with a fast absorbable suture, while the
muscle layer is closed with a slowly absorbable suture.
Accurate re-approximation of the orbicularis oris muscle
will help prevent stomal incompetency. A secure deep
closure also minimizes tension on the cutaneous closure,
which should be performed using small, permanent suture
that is usually removed after 5 days.
Larger defects of the vermilion require more advanced
reconstructive procedures, including vermilion advance-
ment fl aps or vermilion switch fl aps. Vermilion advance-
ment fl aps are most useful when repairing midline
vermilion defects. 1 After extraoral and intraoral incisions
are made, tissue fl aps are then created. These fl aps include
vermilion and are based on the labial artery. The fl aps are
advanced into the defect and sutured in place. The extraoral
incision is extremely important cosmetically; it should be
made precisely at the vermilion border and it should be
meticulously repaired.
A bipedicled contralateral labial mucosal fl ap is often
used to repair vermilion defects when additional soft tis-
sue bulk is required. Labial mucosa fl aps from the opposite
lip are raised on a pedicles and rotated 180 degrees to fi ll

LIP RECONSTRUCTION • 337
the defect. The fl ap can be divided 10 to 14 days later, at
which time the donor defects can be repaired with a ver-
milion advancement fl ap. Patient compliance is important
for this procedure as lip motion prior to fl ap division, and
inset can compromise the reconstructive result.
When the remaining vermilion is inadequate for a com-
plete reconstruction, tongue fl aps can be used in an attempt
to reconstruct vermilion. The ventral portion of the tongue
is used because it provides a closer tissue match than the
dorsal portion. The leading edge of the fl ap is sutured to
the most anterior aspect of the defect, and the pedicle is
divided after 2 weeks. Again, patient compliance and a
previously discussed nutrition plan are essential. Although
these fl aps close the defect and provide adequate bulk,
reconstruction with tongue tissue provides an aesthetically
suboptimal result. In addition, tongue fl aps often require
moisturizing regimens, as constant exposure to an unnatu-
ral environment leads to desiccation and fl aking.
Lower Lip Defects Less Than
One Third the Width
Reconstruction of defects that involve less than one
third of the total width of the lower lip can usually be
closed primarily. The three layers involved in the closure
are fairly compliant and can usually be brought together
without causing microstomia or creating an obvious
size discrepancy between lips. When dealing with these
defects one of the most important anatomic landmarks
is the mental crease. The mental crease marks the infe-
rior border of the gingivo-buccal sulcus, and incisions
through this crease result in suboptimal aesthetic result.
Wedge excision of the lower lip is a relatively straight-
forward way to remove either cancerous or damaged
soft tissue in a manner that facilitates primary closure.
Two essential rules should be followed: incisions should
not cross the mental crease and the vertex of the wedge
should not exceed 30 degrees. If an excision requires
either a vertex angle greater than 30 degrees, or an inci-
sion through the mental crease, a w-plasty may be per-
formed. The w-plasty is a modifi ed wedge excision which
employs a W-shaped excision. The apices of the W are
directed inferiorly, and again the vertex angles should not
exceed 30 degrees or cross the mental crease. This mod-
ifi cation permits the excision of wider defects without
compromising aesthetic outcome.
Another option is a rectangular or barrel excision. This
procedure can be used when a wedge excision would
result in an incision that crosses the mental crease. A
rectangular segment of tissue is excised, and a crescent-
shaped incision is created around the mental prominence.
The incision creates bilateral fl aps that are then advanced
medially ( Figures 31-1A–C and 31-2A, B ) to close the
defect. Excision of crescent-shaped areas of normal skin
FIGURE 31-1. (A) A pediatric patient with a large lower
lip lesion. (B) The patient following excision of the lesion with
markings for bilateral advancement fl aps. (C) The patient
following closure of the reconstructed lower lip.
A
B
C

338 • CHAPTER 31
around the mental prominence may be necessary in order
to advance the lateral tissue without distorting the normal
lower face architecture.
The most important principle to consider when clos-
ing these lip defects is the need for a meticulous three-
layer closure, including a careful approximation of the
muscular layer. Additionally, if these techniques are used
to repair traumatic lip defects where the damaged margins
are excised, the principles of contaminated wound closure
must be applied. These principles include copious irriga-
tion, debridement of nonviable tissue, removal of foreign
bodies, and meticulous hemostasis.
Lower Lip Defects Between
One Third and Two Thirds the Width
Larger defects, involving one third to two thirds the total
width of the lower lip, demand a more complex recon-
struction. Previously mentioned techniques inevitably
lead to microstomia and occasionally sphincter incompe-
tence when applied to more moderately sized defects. As a
result, procedures that recruit tissue from uninvolved parts
of the lip can be employed. Lip-switch procedures are the
most commonly used methods for the reconstruction of
medium-sized defects.
The Abbe fl ap is one of the most consistent and reli-
able methods of lip reconstruction ( Figure 31-3A–D ). The
Abbe fl ap provides healthy lip tissue, including vermilion,
from the opposite lip and successfully replaces “like with
like.” This fl ap also allows for the transposition of hair-
bearing skin, which is an important consideration when
operating on men. From a technical perspective, a full-
thickness lip fl ap based on the labial artery is raised from
the donor lip. Extreme care is taken to protect the arte-
rial pedicle, as damage to the sole blood supply will likely
result in fl ap loss. The fl ap is then rotated 180 degrees and
sutured into the original defect. While this fl ap has been
described as a free composite graft, its use as a rotational
fl ap gives predictable results. The pedicle is divided after
14 to 21 days and the fl ap is inset. It is important to note
that ideally, only tissue lateral to the philtrum should be
used; violating the anatomic boundaries of the philtrum
results in an undesirable cosmetic deformity. Additionally,
Abbe fl aps should be designed so that the width of the fl ap
is approximately half the width of the defect. This impor-
tant principle ensures that each lip is shortened by the
same amount and prevents aesthetically unpleasing asym-
metry. Finally, bilateral Abbe fl aps can be used in patients
with large, centrally located, lower lip defects. The fl aps are
raised laterally to the philtral column and rotated medially
into place. Surgical scars can usually be hidden in the bor-
ders of the aesthetic subunits.
The staircase or stepladder advancement fl ap is another
reconstruction option. Both unilateral and bilateral ver-
sions have been described and their use depends on
whether the defect is medial or lateral. “Stairs” are created
on either one or both sides of the defect; the width of the
each stair is approximately half the width of the defect.
The height of each stair is approximately 8 mm. Usually
two to four stairs are required for closure. This method
unfortunately leads to more noticeable scarring than most
other procedures.
The Estlander fl ap is another form of cross lip recon-
struction. It differs from the Abbe fl ap; in that it can be
used to reconstruct defects that involve the lateral com-
missure. An ipsilateral, triangular-shaped fl ap with curvi-
linear borders is raised from the upper lip. This fl ap is then
rotated 180 degrees into the defect. Closure is completed
in one stage, however, and the modiolus is displaced and
the commissure is obliterated. Frequently, the result is a
FIGURE 31-2. (A) A patient with a lower lip defect after oncologic resection with
markings for bilateral rotation-advancement fl aps. (B) The patient following fl ap inset.
A
B

LIP RECONSTRUCTION • 339
new, unnaturally round commissure. Depending on the
clinical situation and the patient’s preference, this can
often be corrected with a secondary procedure.
The Gillies fan fl ap is a rotation advancement fl ap that
reconstructs lateral defects by recruiting tissue from the
mesolabial fold in addition to advancing ipsilateral lip
and rotating the opposing lip. 2 When using a Gillies fl ap,
a fan-shaped area of tissue is raised from the ipsilateral
upper lip, which is then rotated around a point adjacent
to the oral commissure to close a lateral lower lip defect.
FIGURE 31-3. (A) A patient with a large upper lip defect following resection of recurrent basal cell carcinoma. (B) The patient
undergoing harvest of an Abbe fl ap from the lower lip based on the inferior labial artery. (C) The patient following inset of the
Abbe fl ap into upper lip and primary closure of the lower lip donor site. (D) The fi nal result of the patient several months after the
division and inset of the Abbe fl ap.
A
B
C
D

340 • CHAPTER 31
The Gillies modifi cation allows for the mobilization
of greater amounts of tissue, but suffers from the same
rounded commissure seen in the Estlander fl ap.
Karapandzic further modifi ed the Gillies fl ap by design-
ing a fl ap that preserves both neurovascular supply and
motor function. Large circumoral incisions are made in
the melolabial crease that extend inferiorly to the lower
lip ( Figure 31-4A–C ). Flaps are rotated inferomedially in
order to close the defect ( Figure 31-5A, B ). This procedure,
similar to the previous designs from which it was modifi ed,
often results in a rounded commissure and microsomia.
Lower Lip Defects Greater Than
Two Thirds the Width
Subtotal or total defects of the lower lip often require the
most advanced reconstructive techniques. Attempts to use
local tissue for near-complete defects have been described.
However, there is usually insuffi cient local tissue to recre-
ate a lower lip without compromising function and cre-
ating unacceptable aesthetic results. With that caveat in
mind, several local techniques are available. A modifi cation
of the Gillies fan fl ap that entails rotating the fl ap about
the oral commissure can be used to reconstruct extensive
defects of the lower lip. Based on the labial vessels, this
fl ap may be raised bilaterally to reconstruct the lower lip.
The orbicularis fi bers are also rotated with the fl ap, how-
ever, and altered sphincteric function or sphincter incom-
petence may result.
The Bernard-Burrow-Webster fl ap is a horizontal, cheek
advancement musculocutaneous fl ap that, if raised bilater-
ally, can be used to reconstruct the entire lower lip. The
creation of a Bernard-Burrow-Webster fl ap involves creat-
ing a horizontal incision lateral to the oral commissure, fol-
lowed by excising a cutaneous triangle (Burrow’s triangle)
lateral to the philtral column to allow medial advance-
ment of the fl ap without otherwise distorting the cheek. 3
Neovermilion creation is then undertaken to complete the
reconstruction.
Another well-described method of total lower lip
reconstruction with local tissues is the gate fl ap, originally
described by Fujimori et al. in 1968. This fl ap utilizes
FIGURE 31-4. (A) A patient with a large lower lip soft
tissue defect secondary to oncologic resection. (B) The
patient demonstrating modifi cation of a unilateral Bernard-
Burrow-Webster fl ap to close the defect. Soft tissue triangles
are excised to allow medial advancement without distortion of
the cheek. (C) The patient demonstrating inset of the Bernard-
Burrow-Webster fl ap.
A
B
C

LIP RECONSTRUCTION • 341
FIGURE 31-5. (A) A patient with a lower lip defect
secondary to post-traumatic deformity. (B) The patient
demonstrating use of a Karapandzic fl ap to rotate and
advance lateral tissue to fi ll medial lower lip defect.
(C) The patient following closure of the defect demonstrating
a moderate amount of microstomia.
A
B
C
bilateral wedges of tissue extending along the nasola-
bial folds to the inferior border of the mandible that are
rotated medially. These two fl aps are then sutured together
and come together somewhat like a gate, giving this fl ap its
descriptive name. A secondary z-plasty after an appropri-
ate interval improves the cosmesis and overall function of
the reconstruction.
Many methods of distant tissue transfer have also been
described. All options unfortunately share the need to
create a new vermilion with either tongue or mucosal
advancement fl aps. As stated previously, use of distant tis-
sues in an attempt to accomplish this task is suboptimal. 4
In the event that distant tissue is the only option, several
pedicled and free fl aps have been described. The deltopec-
toral and pectoralis major fl aps are particularly useful for
reconstructing the entire lower lip but primarily provide
adynamic bulk. The radial forearm, gracilis, and anterolat-
eral thigh fl aps are among the most popular options for
free tissue transfer.
The radial forearm free fl ap is the most commonly per-
formed free tissue reconstruction of the lip. 5 It can be com-
bined with palmaris longus tendon in order to improve
sphincter function. Anastomosing the lateral antebrachial
cutaneous nerve to the mental nerve can provide sensa-
tion. The fl ap is usually folded over the palmaris tendon,
which is sutured to periosteum, to provide support for the
lower lip. The tendon may also be sutured to remaining
orbicularis fi bers to provide a more dynamic appearance.
Vermilion reconstruction is performed and hair transplan-
tation can be used to improve skin texture and to help
camoufl age the scars.
The free gracilis fl ap, often harvested with a branch
of the obturator nerve, has also been successfully used to
reconstruct subtotal or total lip defects. 6 The facial artery
and vein are used as recipient vessels. The marginal branch
of the facial nerve can be anastomosed to the obturator
branch of the gracilis fl ap, allowing for fl ap innervation. If
any orbicularis muscle remains, the remnant fi bers can be
sutured to the gracilis, which helps provide some sphincter
function. Skin grafting and vermilion reconstruction com-
plete the procedure.
Upper Lip Defects
Upper lip reconstruction can usually be accomplished by
following the same principles and techniques described
for lower lip reconstruction with a few additional consid-
erations. While the upper lip is not as important from a
functional perspective, it contains most of the anatomic
landmarks and aesthetic subunits responsible for the

342 • CHAPTER 31
appearance of the lips. The philtral columns, philtrum,
upper vermilion border, and nasolabial folds are all very
important in terms of aesthetics. In the event that a large
percentage of an anatomic subunit must be violated, it is
often better to resect the subunit en bloc and to replace it
in its entirety. Additionally, the proximity of the upper lip
to the nose makes any scar contracture more noticeable.
Distortion of the nasal anatomy can be quite obvious, even
to the casual observer.
Upper lip reconstruction is often required as a second-
ary procedure in patients who previously underwent the
repair of a bilateral cleft lip. These patients are often miss-
ing bulk in the upper lip and the soft tissue that is pres-
ent is often scarred and contracted. Use of an Abbe fl ap
in this situation to create a new philtrum usually yields
excellent results.
The patient’s gender must be taken into consideration
during upper lip reconstruction. While the use of hair-
bearing skin in men will allow for postreconstruction scar
camoufl age, transposing hair-bearing skin to the lip in
women is less than ideal. For example, the delayed tempo-
ral frontal scalp fl ap is a good option for upper lip recon-
struction in men. This fl ap recruits hair-bearing skin and
subsequently produces a better result.
COMPLICATIONS
Due to the important aesthetic and functional character-
istics of the lips, successful reconstruction is both essential
and technically diffi cult. In addition to standard complica-
tions including bleeding, infection, and abnormal scarring,
there are several well-described complications specifi c to
lip reconstruction. Often, secondary procedures are needed
to correct these problems.
Microstomia results when too large a percentage of lip
tissue is excised and the defect is closed without introduc-
ing new tissue ( Figure 31-5C ). This may occur following
the reconstruction of large defects with local advance-
ment fl aps. Microsomia is functionally compromising as
it limits the patient’s ability to eat, wear dentures, or be
orally intubated. It can also be emotionally disturbing to
the patient, especially in social situations. Surgical correc-
tion of this complication is usually necessary. A procedure
that either rearranges or recruits tissue in the defi cient
area is often employed.
Loss of sphincteric function or oral competency is
most commonly seen when dealing with defects that
involve large portions of the muscular lower lip. This
can result in drooling, impaired phonation, and diffi culty
eating. Loss of sensation secondary to nerve transection
is a well-described complication of any procedure that
uses incisions designed to divide tissue in the vicinity of
sensory nerves.
A rounded commissure may result if rotational proce-
dures near the commissure are used. Displacement of the
modiolus results in the distortion of the normal lateral lip
features and can be aesthetically unpleasing. A secondary
commissure-plasty is often required to restore the normal
appearance. Scar contractures and hypertrophic scarring
can distort the anatomy as well. Scar management tech-
niques as well as early scar release are employed to correct
this distortion.
Careful planning, extensive knowledge of the anatomy,
and meticulous technique are essential when attempting
to prevent these complications.
OUTCOME
Lip reconstruction is a diffi cult task due to the complex
anatomy as well as the high functional and aesthetic
demands. Postoperatively, patients should be followed
to assess their overall function, especially their abil-
ity to maintain oral competence, as well as their natu-
ral appearance. An acceptable aesthetic and functional
outcome will be achieved if several fundamental prin-
ciples apply regardless of whether a defect is the result
of trauma or oncologic resection. By respecting the
concepts of aesthetic subunits, recruiting additional tis-
sue when necessary, and meticulously re-approximating
vital structures, both form and function can be restored.
When defects cannot be closed primarily, transposition,
rotation advancement, and occasionally free fl aps may
be employed. The anatomic reconstruction of a carefully
evaluated lip defect in a properly prepared patient can
produce excellent results with a low risk of functionally
and aesthetically devastating complications.
1. Boutros S. Reconstruction of the lips. In: Thorne CH, Bartlett
SB, Beasley RW, et al., eds. Grabb and Smith’s Plastic Surgery.
6th ed. Philadelphia: Lippincott, Williams & Wilkins; 2006.
2. Lesavoy M, Smith A. Lower third face and lip recon-
struction. In Mathes SJ, ed. Plastic Surgery . Vol. 2. 2nd ed.
Philadelphia: Saunders; 2005.
3. McCarn K, Park S. Lip reconstruction. Otolaryngol Clin
North Am. 2007;(40):361–380.
4. Sarukawa S, Kashiwaya G, Sakuraba M. A new fl ap design
for reconstruction full-thickness defects of the lower lip:
The extended upper lip island (EULI) fl ap. J Plast Reconstr
Aesthet Surg . 2006(59):1436–1441.
5. Lee J, Fernandes R. Microvascular reconstruction of extend-
ed total lip defects . Oral Surg Oral Med Oral Pathol Oral
Radiol Endod . 2007;104(2):170–176.
6. Ninkovic M, Spanio di Spilimbergo S, Nincovic M. Lower
lip reconstruction: introduction of a new procedure using
a functioning gracilis muscle free fl ap. Plast Reconstr Surg .
2007;119(5):1472–1480.
REFERENCES

32
Cheek Reconstruction
Richard A. Hopper, MD, MS / Scott D. Imahara, MD /
Jon P. Ver Halen, MD / Joseph S. Gruss, MD, FRCS[C]
nasolabial groove and lateral nasal unit, and laterally by
a line from the lateral canthus to the lateral oral com-
missure. In triangle I, the close relationship of the cheek
to the inferior eyelid and external nasal valve pose chal-
lenges to reconstruction due to the risk of distorting these
two important areas to function and symmetry. Although
the lower eyelid is not formally part of the cheek, it is
often involved in cheek defects. Since this is a vital com-
ponent in fl ap design in this region, we designate cheek
defects involving the lower lid as triangle Ia.
The lateral preauricular triangle (triangle II) comprises
the region encompassed medially by a line drawn from the
lateral canthus to the angle of the mandible, laterally by
following the pretragal fold, and superiorly by a line join-
ing the lateral canthus to the hairline. The middle bucco-
mandibular triangle (triangle III) is inverted compared to
the other two triangles, with its base inferior. It is bounded
by the margin of the mandible inferiorly and triangles I
and II medially and laterally, respectively.
Each triangular zone has its own particular characteris-
tics which must be taken into consideration in the recon-
struction of cheek defects, including superfi cial differences
in skin color and texture, adjacent functional structures,
and underlying vascular, nerve, and muscular anatomy. The
landmark boundaries of each zone are not rigid, but rather
should serve as an anatomic outline of the principles and
techniques of cheek reconstruction. The rest of this chap-
ter uses the interdigitated triangular subunit classifi cation
of defects to describe a useful approach to skin and soft
tissue reconstruction.
The cheek is composed of the overlying skin envelope,
subcutaneous fat, the superfi cial musculoaponeurotic sys-
tem (SMAS), muscles of mastication and facial expression,
and underlying bone support. There is considerable interin-
dividual variability in the quality and characteristics of the
c h a p t e r
INTRODUCTION
The functional facial areas of the eyelid, nose, mouth, and
ear border the cheek region. Although it does not have
the same intrinsic functional properties as these adjacent
structures, inappropriate cheek reconstruction will reliably
disrupt facial function, resulting in debilitating patient
morbidity. Reconstruction of cheek defects requires metic-
ulous preoperative planning, consideration of the effect of
scar contracture on the adjacent soft tissue, and precise
surgical technique. Successful cheek reconstruction relies
on an intimate understanding of the skin quality of the dif-
ferent areas of the face by age, the vascular supply of the
tissues, and the optimum orientation and location of scar
placement. Despite these challenges, unlike other areas
of the face, the cheek has a laxity and compliance that
permits a variety of reconstructive options ranging from
primary closure to extensive local and regional fl aps. The
focus of this chapter is reconstruction of the skin and sub-
cutaneous tissues of the cheek. Facial nerve, parotid duct,
and bone injuries are covered elsewhere in this text.
PATIENT EVALUATION
Key to the assessment of patients with cheek defects is
their precise location because different areas of the cheek
require different reconstructive options. Gonzalez-Ulloa
and colleagues 1 provided an original description of the
regional esthetic units of the cheek which was later subdi-
vided into three overlapping regions by Zide 2 ( Figure 32-1 ).
A modifi ed demarcation of these subunits into three, inter-
digitated triangular zones has been adopted that aligns
with our approach to regional fl ap selection and rotation
( Figure 32-2 ).
The medial infraorbital triangle (triangle I) is the area
bounded superiorly by the lower eyelid, medially by the

344 • CHAPTER 32
FIGURE 32-3. Facial relaxed skin tension lines. (From
Leach J. Proper handling of soft tissue in the acute phase. Facial Plast
Surg. 2001;17(4):227–238.)
FIGURE 32-2. Reconstructive triangle classifi cation of
the cheek.
cheek skin. In older patients, the skin envelope is lax, has
a paucity of subcutaneous fat, possesses multiple rhytids,
and is compliant to stretch. Younger patients in contrast
will have more subcutaneous fat and smooth elastic skin. 3
The cheek has a complex pattern of relaxed skin tension
lines. 4 Orienting incisions along these lines will optimize
the fi nal scar, regardless of age, by minimizing perpendicu-
lar stretch ( Figure 32-3 ).
In addition to interindividual variability of the skin,
there are also differences in skin quality between different
regions of the same patient. Skin within the infraorbital
triangle (triangle I; Figure 32-2 ), including the malar emi-
nence, tends to be relatively thicker, more pigmented, and
shiny. Preauricular skin (triangle II) is paler and thinner,
with a matte surface texture. Finally, lower cheek skin in
triangle III is of intermediate texture, color, and thickness
in relation to the other two zones. The terminal hair-bear-
ing skin of the cheek within all three triangles must be
carefully observed, including future hair growth in pre-
pubescent males. Patient dissatisfaction will result from
reconstruction of a hairless region with skin containing
terminal follicles. The transition zone between the lower
eyelid and triangle I of the cheek is marked by a change in
skin quality (thinner skin in the eyelid), the delicate ani-
mation and support provided by the underlying orbicularis
oculi muscle, and the attachment of the orbital septum to
the arcus marginalis at the inferior orbital rim. Skin and
subcutaneous cheek injuries that violate this transition
increase the complexity of the reconstruction.
Beneath the skin lies the SMAS, the investing fascial
layer of the head and neck. 5 , 6 This layer is continuous
with the platysma in the neck, the temporoparietal fas-
cia in the lateral temporal region, the fascia of the fronta-
lis muscle in the forehead, and galea aponeurotica of the
FIGURE 32-1. The aesthetic subunits of the cheek.

CHEEK RECONSTRUCTION • 345
scalp. In the face, the SMAS is located between the sub-
cutaneous fat and deeper structures, including the facial
nerve branches, the muscles of the face, the parotid gland,
Stensen duct, and the buccal fat pad. Terminal branches
of the facial nerve (CN VII) supply all the superfi cial
muscles of facial expression. Freilinger et al. grouped the
muscles of facial expression into four layers, with muscles
in the three most superfi cial layers being innervated on
their deep surfaces. 7 The muscles in the fourth, or deep-
est, layer (ie, mentalis, levator anguli oris, and buccinator
muscles) are innervated through their lateral or superfi -
cial surfaces. The masseter muscle, as well as sensation to
the upper lip, infraorbital region, and malar eminence, is
innervated by the second division of the trigeminal nerve,
the maxillary nerve (CN V2). The infraorbital foramen is
located approximately 1 cm below the infraorbital rim,
in a line perpendicular to the pupil. The third division of
the mandibular nerve (CN V3) provides sensation to the
lower lip, mandibular region, and preauricular skin.
The branches of the external carotid artery, and associ-
ated minor contributions from the internal carotid artery
tree, provide the dominant arterial blood supply to the skin
and muscles of the cheek. The facial artery is a branch of
the external carotid artery, and enters the cheek by cross-
ing mandible border at 2 to 3 cm anterior to the angle.
It then traverses the face obliquely, and provides superior
and inferior labial branches below the ala, and the lateral
nasal artery above the alar crease before terminating as the
angular artery along the side of the nose. The transverse
facial artery arises from the superfi cial temporal artery and
crosses the face parallel to the zygoma below the orbit,
meeting the angular artery. The dorsal nasal artery emerges
along the superior medial surface of the orbit, is a terminal
branch of the ophthalmic artery from the internal carotid
artery system, and anastomoses with the superior end of the
angular artery. These interconnected external and internal
carotid artery-supplied systems provide a rich, redundant
blood supply to the cheek. Respect for these reliable arte-
rial systems permits the safe elevation and transfer of large
local and regional fl aps for cheek reconstruction.
The venous drainage from the cheek is predominantly
into the external jugular system via the anterior facial vein.
A secondary system is via the ophthalmic, infraorbital, and
deep facial veins which eventually drain into the intracra-
nial cavernous sinus. Uncontrolled cheek infections there-
fore have the potential for intracranial extension via the
latter route.
PATIENT PREPARATION
Initial interaction with the patient with a cheek defect
does not always require immediate, defi nitive closure. An
adequate margin of clean tissue either following trauma
or cancer ablation should be confi rmed. The planned and
potential reconstructive options should be thoroughly dis-
cussed with the patient beforehand. Necrotic skin edges
can be excised to healthy tissue. A staged or combination
approach may be preferable with questionable resection
margins or large defects that cross multiple zones. Closure
in the emergent setting can usually be accomplished
with at least a sterile dressing or skin graft for temporary
wound coverage until defi nitive reconstruction is appro-
priate. Staged options include the use of tissue expand-
ers to pre-expand local fl aps prior to elevation at a second
operation.
TECHNIQUES OF CHEEK
RECONSTRUCTION BY
TRIANGULAR SUBUNIT
Infraorbital Triangle (Triangle I)
Due to the thicker underlying subcutaneous fat and lack of
strong retaining ligaments, the medial aspect of triangle I is
relatively mobile, and subunit defects can usually be closed
primarily at the nasojugal and nasolabial folds with mini-
mal lateral undermining. Care must be taken, however,
to avoid tenting of the nasojugal junction as described in
the design of local fl aps below. Even small defects, such
as benign skin lesion excisions, have the potential to dis-
tort the lower eyelid upon primary closure. To avoid this,
lesions should be excised as a circular defect and then
closed primarily in an orientation that does not distort the
eyelid margin. Any residual dog-ear deformities may be
excised as needed.
As with most cheek defects, if primary closure is not pos-
sible, skin grafting is appropriate in select cases. Examples
include defects when tumor surveillance is required after
primary ablation, if there are contraindications to a large
regional fl ap such as heavy smoking or poor health, and
if a temporizing measure is required prior to planning
staged defi nitive reconstruction. Split-thickness skin grafts
in triangle I defects must be used with care, since there is
a considerable risk of causing lower eyelid retraction and
ectropion, even if the defect does not involve the eyelid
itself. Full-thickness skin grafts, which are less prone to con-
traction, are better suited for skin replacement of superfi -
cial defects in this region, but even these grafts can distort
the lower eyelid if the defect crosses the cheek–lower
lid junction. Appropriate harvest sites for color match
include preauricular, postauricular, and supraclavicular
skin. Multiple full-thickness skin grafts patching should be
avoided, but if necessary, the grafts edges should align with
the esthetic subunit borders and be oriented along relaxed
skin tension lines ( Figure 32-3 ).
The use of small transposition local fl aps within trian-
gle I is restricted by the limited laxity of the adjacent nose
and lower eyelid. For medium-sized defects inappropriate
for primary closure, wide lateral undermining of the cheek
skin in a subcutaneous plane can often close defects in this
zone by taking advantage of lateral laxity to advance the
skin. These local advancement fl aps can easily “tent” in the
region of the line of closure at the nasojugal groove. To
avoid this potentially diffi cult secondary deformity, it is
extremely important to secure the dermis at the edge of
the fl ap to the periosteum of the nasal bone or piriform

346 • CHAPTER 32
aperture with long-lasting or permanent sutures. All ten-
sion on the fl ap should be on these retaining sutures, such
that the nasojugal groove is reformed, and there is no ten-
sion on the skin closure line just medial to the groove.
For complete triangle I defects ( Figure 32-4 ), a posteri-
orly based cervicofacial fl ap can be employed. When per-
formed correctly, these large fl aps are perfused by the facial
artery and can provide enough tissue for coverage of the
entire triangle I, transferring primary closure of the donor
site to the supraclavicular region. The posterior cervico-
facial fl ap can be raised in a plane deep to the SMAS in
the face with subplatysmal extension into the neck for
improved fl ap viability, but with increased risk of damage
to the branches of the facial nerve. 8 More commonly, the
fl ap is raised in a subcutaneous plane.
When planning the cervicofacial fl ap, the desired
arc of rotation needs to be determined. For defects not
involving the lower eyelid, the fl ap should be based pos-
teriorly, and can be rotated upward along the nasolabial
and mentojugal grooves, limiting the scars to this line as
it extends into the supraclavicular region. For triangle Ia
defects involving the lower eyelid, the cervicofacial fl ap
FIGURE 32-4. Reconstruction of complete triangle I
defects. (A) A large residual defect within triangle I is shown
after lesion excision. (B) A posteriorly based cervicofacial fl ap
was elevated in the subcutaneous plane and perfused by
branches of the facial artery. (C) Final fl ap inset is shown with
fl ap edges created along margins of the aesthetic triangles,
including along the nasolabial fold and lateral nasal unit. The
fl ap must be secured to underlying periosteum near the piriform
rim and malar eminence to avoid inferior traction on the eyelid.
(D) Final result is shown more than 1 year after reconstruction.
C
B
D
A

CHEEK RECONSTRUCTION • 347
is instead based anteriorly, and is rotated in an oppo-
site arc of rotation, superiorly and then medially along
the lower eyelid. In these cases, the superior margin of
the fl ap should extend laterally and superiorly above the
lateral canthus and into the non–hair-bearing temple
region before it heads inferiorly toward the neck via the
preauricular crease. The donor site tension is therefore
placed either behind the ear or in the lateral neck. This
is the Juri 9 modifi cation of Beare’s 10 initial description of
the fl ap. By suspending the cervicofacial fl ap from the
temporal region, and again from the infraorbital perios-
teum, the surgeon can avoid inferior traction on the fl ap
and subsequent eyelid ectropion.
In all cervicofacial fl aps for triangle I defects (whether
anteriorly or posteriorly based), the distal edge of the fl ap
must be anchored to the periosteum of the malar promi-
nence of the zygoma, the infraorbital rim, the nasal bone,
and the piriform aperture. We prefer a series of delayed ties
of 3-0 PDS (monofi lament polydioxanone) but a Vicryl
(polyglactin) suture is also appropriate. Without this detail,
the fl ap will “tent” in this region and distort the shadow
of the nasojugal groove and pull inferiorly on the lower
eyelid. It must be emphasized that these deep anchor-
ing sutures are not a substitute for full fl ap dissection and
elevation. The tension of closure must be transferred to
the donor site in the neck, not placed on the distal fl ap.
The deep anchoring sutures should not provide radial trac-
tion on the distal fl ap which would compromise perfusion;
instead, they are used to contour the deep surface of the
fl ap and counter the inferior pull of gravity after the fl ap
has been rotated into the defect.
Preauricular Triangle (Triangle II)
Reconstruction and closure of defects in the preauricu-
lar triangle follow principles that are similar to those
described for the infraorbital triangle. Skin overlying
the preauricular triangle is inherently lax, resulting in
an excess of skin and enabling its use as a donor site
more often than as a recipient. Moderate-sized defects in
zone 2 can often be closed with advancement of anteri-
orly or inferiorly based undermined subcutaneous fl aps,
similar to a subcutaneous facelift dissection. Anteriorly
based cheek fl aps are limited by secondary distortion of
the nasofacial groove and oral commissure. The inferiorly
based advancement fl aps in this zone can be extended
well into the neck, as a truncated version of a cervicofa-
cial fl ap ( Figure 32-5 ).
Defects in the inferior portion of triangle II can be
closed with a local transposition fl ap or a V-Y advance-
ment fl ap. In both these fl aps, the donor site scar should be
planned inferior to the defect. This will avoid scarring of
the anterior central face, which is visible on frontal view,
as well as to minimize edema of the fl ap and a secondary
trap-door deformity. An inferiorly based transposition fl ap
from the postauricular skin can be a reasonable option for
inferior preauricular defects, but the patient needs to be
aware that the fl ap will be non-hair bearing.
Two remaining options for reconstruction of triangle II
defects are serial excision and tissue expansion, particu-
larly if there are no time constraints such as benign lesions,
old defects, or scars.
Buccomandibular Triangle (Triangle III)
Deep defects in triangle III can involve the facial artery,
preventing the design of inferiorly based axial cervicofacial
fl aps, such as those described above. An additional consid-
eration is that reconstruction of full-thickness defects in
this zone requires not only skin and soft tissue coverage,
but also intraoral buccal lining. Reconstruction of defects
involving the orbicularis oris muscle or the lateral com-
missure of the mouth should fi rst recreate a functional
sphincter with labial based dissected muscle slips similar
to a macrostomia repair.
Small, partial-thickness triangle III defects may be
repaired using local transposition fl aps or posteriorly
based cervicofacial fl ap if the facial artery is preserved.
Care must be taken to orient incisions along relaxed skin
tension lines, in particularly the mentolabial fold when-
ever possible. Prophylactic w-plasty or z-plasty should
be considered for incisions, which cross the mandibular
border to minimize linear contracture. Local fl ap options
for intraoral closure that have been described include
tongue fl aps, turnover or hinge fl aps, buccal fat pad
fl aps, galeal fl aps with periosteum, or masseter crossover
fl aps. 11 – 17 All of these fl aps are then covered by a sepa-
rate, cutaneous fl ap. For large full-thickness defects, a
variety of regional myocutaneous and composite fl aps
have been described that enable folding, splitting or
paddling, including the deltopectoral fasciocutaneous
fl ap, and the pectoralis major, or trapezius myocutane-
ous fl aps. 18 , 19
Combination Zone Defects
Large defects involving both triangles I and II with or
without zone 3 pose a particular challenge. A traditional
cervicofacial fl ap in these cases often does not reach the
superomedial aspect of the defect adjacent to the lateral
nasal unit. In order to advance suffi cient tissue from the
lower cheek, a well-vascularized robust fl ap is required.
The platysma should be incorporated into the superior
portion of the fl ap, and the pectoral fascia below. This
allows elevation of a large inferomedial cervicopectoral
fl ap to be raised based on the anterior thoracic perfora-
tors of the internal mammary artery. To avoid vertical
banding across the neck, the posterior incision should
follow a course under the ear lobule, behind the bor-
der of the trapezius, across the acromioclavicular joint
and along the lateral pectoralis border. The chest donor
defect in these cases typically requires skin grafting.
Other options include the medially based deltopectoral
fl ap, the cervicohumoral fl ap, the trapezius fl ap, the pec-
toralis major myocutaneous fl ap, and the latissimus dorsi
myocutaneous fl aps.

348 • CHAPTER 32
A
B
D
C
FIGURE 32-5. Reconstruction of a large triangle II defect. (A) Defect appearance
after lesion excision. (B) The elevation of an inferiorly based cervicofacial fl ap in the
subcutaneous plane with extension into the neck. (C) Final fl ap inset with fl ap margins
along the borders the aesthetic triangles. (D) Final result more than 1 year after
reconstruction.
Microvascular transfer fl aps have largely replaced
these large pedicled regional fl aps for large defects due to
decreased donor site morbidity. For malignant lesions that
have undergone or will undergo irradiation, microvascular
free fl aps have become the mainstay of treatment of com-
plex full-thickness defects. Well-vascularized tissue distant
from an irradiated fi eld, with unlimited three-dimensional
movement, conformability, and the ability to transfer com-
posite tissue such as bone, have made free fl aps particu-
larly attractive in this application. The radial forearm free
fl ap (RFFF) is often utilized as a reconstructive option.
The RFFF can be harvested with palmaris longus tendon
to enable resuspension of the lateral lip if it is involved,
and it can be folded to enable combined inner lining and

CHEEK RECONSTRUCTION • 349
FIGURE 32-6. Microvascular reconstruction
of a large combination zone defect. (A) Preoperative
view of a 62-year-old man with a large angiosarcoma
involving triangle I and Ia (ie, the lower eyelid) and
triangle III. (B) Intraoperative result after lesion
extirpation and reconstruction with a parascapular
free fl ap. (C) Early result several weeks after cheek
reconstruction. (D, E) Final result more than 1 year
after fi nal lower eyelid reconstruction using a Hughes
tarsoconjunctival fl ap.
C
D
E
A
B

350 • CHAPTER 32
skin coverage. In addition, thinning of the RFFF can allow
cheek reconstruction with satisfactory facial contour.
Other microvascular fl aps available for application in full-
thickness buccal defects include the tensor fascia lata free
fl ap 20 and the parascapular free fl ap 21 ( Figure 32-6 ).
As stated earlier, staged reconstructive options include
the use of tissue expanders to pre-expand local fl aps prior
to elevation at a second operation. The tissue expanders
are placed subcutaneously under the cheek via scalp or
facelift approaches, with a remote reservoir placed over
the mastoid or under the scalp to allow gradual expan-
sion ( Figure 32-7 ). A combination of fl aps or approaches
is also possible. A cervicofacial fl ap can be used to recon-
struct the zone 2 and 3 components of the defect, while
a delayed two-stage forehead fl ap could be used to recon-
struct the zone 1 component ( Figure 32-8 ).
FIGURE 32-7. Staged cheek reconstruction using
tissue expansion. (A) An adolescent girl who underwent
excision of a congenital nevus involving triangle I, triangle III,
and upper lip as an infant. The cheek had been resurfaced
with gluteal full-thickness skin and the upper lip with
supraclavicular full-thickness skin. These distant donor sites
demonstrate the limitations of poorly matched skin graft in
cheek reconstruction. (B) Prior to placement of a cheek tissue
expander to pre-expand a posteriorly based cervicofacial
fl ap. The tissue expander fi ll port is placed distant to the
device over the mastoid. (C) Final result after elevation and
reconstruction using a pre-expanded cerviofacial fl ap.
A
C
B

CHEEK RECONSTRUCTION • 351
FIGURE 32-8. Combination fl ap reconstruction. (A) Operative view of a
squamous cell cancer involving triangle I, the medial canthus, and the lateral nose.
(B, C) Intraoperative view after cancer extirpation demonstrating a large defect including
triangle I, Ia (the lower eyelid), triangle III, full-thickness lateral nose and alar rim.
(D) Final fl ap reconstruction using a posteriorly based cervicofacial fl ap for reconstruction
of the cheek elements and a fi rst-stage forehead fl ap. Note the junction of the two fl aps
is placed along the margin of the nasal and cheek aesthetic subunits.
A
B
C
D

352 • CHAPTER 32
COMPLICATIONS
Because of the intricate anatomy of the face, numerous
complications can occur following reconstruction. Certainly,
scars should be placed in the least conspicuous locations. For
defects of triangle I, closure of even small defects by primary
approximation has the potential to displace the lower eyelid
inferiorly, resulting in either eyelid retraction or ectropion. To
avoid this, lesions should be excised as a circular defect and
then closed primarily in an orientation that does not distort
the margin of the lower eyelid. Any residual dog-ear defor-
mities may be excised as needed. Widening of the nasal base
can occur with reconstruction of zone 2 defects. Care should
be taken to not release the soft tissue attachment of the base
of the fl ap to the piriform rim to avoid this complication.
For defects in triangle III, appropriate intraoral, water-tight
closure needs to be achieved prior to addressing skin closure.
If the oral closure is inadequate, orofacial fi stula, fl ap break-
down, severe contraction, or infection will result.
OUTCOMES ASSESSMENT
Conceptualizing cheek defects as three interconnected
triangular zones facilitates creation of a reconstruction
plan that will preserve both form and function. Basic
plastic surgery principles must be followed, such as ori-
enting scars along the relaxed skin tension lines or natural
esthetic subunit junctions, reconstructing like tissue with
like, and transferring the tension of closure to the lax-
ity of the donor site. Variations of the cervicofacial fl ap
with different arcs of rotation based on the location of the
defect are the work horses of cheek reconstruction. More
complex defects require multiple regional fl aps, a staged
approach, or microvascular transfer of tissue. Care must be
taken in fl ap planning to avoid distortion of the adjacent
lower eyelid, the nasojugal groove, and the oral commis-
sure by tension-free insetting of the fl ap into the defect
with adequate suspension and anchoring the fl ap to the
deep tissues.
FIGURE 32-8. (continued) (E, F) Final result after second stage division of the
forehead fl ap.
F
E
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CHEEK RECONSTRUCTION • 353
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importance for reconstructive and aesthetic surgery. P last
Reconstr Surg . 1987;80(5):686–690.
8. Kroll SS, Reece GP, Robb G, Black J. Deep-plane cervico-
facial rotation-advancement fl ap for reconstruction of large
cheek defects. Plast Reconstr Surg . 1994;94(1):88–93.
9. Juri J, Juri C. Advancement and rotation of a large cervico-
facial fl ap for cheek repairs. Plast Reconstr Surg. 1979;64(5):
692–696.
10. Beare R. Flap repair following exenteration of the orbit. Proc
R Soc Med . 1969;62(11 Part 1):1087–1090.
11. Chambers RG, Jaques LD, Mahoney WD. Tongue fl aps for
intraoral reconstruction. Am J Surg . 1969;118(5):783–786.
12. Chicarilli ZN. Sliding posterior tongue fl ap. Plast Reconstr
Surg . 1987;79(5):697–700.
13. Kim YK, Yeo HH, Kim SG. Use of the tongue fl ap for
intraoral reconstruction: a report of 16 cases. J Oral Maxil-
lofac Surg. 1998;56(6):716–719; discussion 720–721.
14. Samman N, Cheung LK, Tideman H. The buccal fat pad in
oral reconstruction. Int J Oral Maxillofac Surg . 1993;22(1):
2–6.
15. Dean A, Alamillos F, García-López A, Sánchez J, Peñalba M.
The buccal fat pad fl ap in oral reconstruction. Head Neck .
2001;23(5):383–388.
16. Stefanovic P, Nikolic Z, Stajcic Z. Reconstruction of full-
thickness cheek defect affecting the oral commissure by gal-
eal skin island fl ap: a case report. J Craniomaxillofac Surg .
1992;20(7):317–319.
17. Langdon JD, Ord RA. The surgical management of lip can-
cer. J Craniomaxillofac Surg . 1987;15(5):281–287.
18. Sharzer LA, Kalisman M, Silver CE, Strauch B. The paraster-
nal paddle: a modifi cation of the pectoralis major myocuta-
neous fl ap. Plast Reconstr Surg . 1981;67(6):753–762.
19. Nakatsuka T, Harii K, Asato H, et al. Analytic review of
2372 free fl ap transfers for head and neck reconstruction
following cancer resection. J Reconstr Microsurg . 2003;19(6):
363–368; discussion 369.
20. Endo T, Nakayama Y, Soeda S. Reconstruction of the cheek
and palate using a three-paddle tensor fasciae latae free fl ap.
Br J Plast Surg . 1991;44(3):234–235.
21. Upton J, Albin RE, Mulliken JB, Murray JE. The use of scap-
ular and parascapular fl aps for cheek reconstruction. Plast
Reconstr Surg . 1992;90(6):959–971.

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33
Eyelid Reconstruction
and Ptosis Repair
Lisa R. David, MD, FACS / Claire Sanger, DO
INTRODUCTION
The primary importance of the eyelid is functional, spe-
cifi cally protection of the cornea. Reconstruction of the
upper and lower eyelids is challenging because of the
complex anatomy and specialized function of the struc-
tures. The goal of any type of eyelid defect reconstruc-
tion, regardless of the size and layers involved, is globe
protection without visual disruption and restoration of
the area to an appearance as close to normal as possible.
Surgical technique must include repair of all the miss-
ing layers of the defect. The etiology of the defect may
often impact the choice of reconstructive techniques.
Eyelid defects are usually secondary to trauma, congeni-
tal abnormalities, or after cancer treatment. There are
a signifi cant number of techniques described for eyelid
reconstruction that increases the complexity of the sur-
gical decision making process. Many of these techniques
are simply variations of the same principle. General prin-
ciples include replacing like with like, therefore eyelid
skin should be the fi rst choice if it is available. If it is
not an option then use skin grafts or regional fl aps. If
nothing else is available, the fi nal option should be a
free fl ap. Reconstruction of the eyelid can be addressed
in a straightforward algorithmic approach based on the
depth, location, and size of the defect. 1
PATIENT EVALUATION
The etiology of the defect needs to be determined and
a history of previous treatment to the region must be
obtained. In addition, it is important to identify other fac-
tors that will affect the repair including previous surgery,
radiation, and skin damage in the area of the planned
donor site. A detailed history and physical exam of the
eyelids is crucial for treatment planning. On physical
examination, the horizontal and vertical extent of the
defect should be measured and photographed. The con-
dition of the eye itself must be assessed for symptoms of
dry eye, chronic irritation, tear production, visual acuity,
and muscle function. Timing of the repair depends on
the risk that delay will have on the structures the eye-
lids protect, specifi cally the cornea. If this is a secondary
reconstruction, obtaining pictures and medical records of
the previous defect is essential. The depth of the original
injury can often be underestimated when evaluating the
secondary defect. As a result, secondary defects once rec-
reated intraoperatively may require more extensive surgi-
cal intervention.
Additional Studies
Ancillary testing for eyelid reconstruction depends upon
the etiology of the defect. Traumatic and congenital
defects require radiographic analysis of the orbital bones.
Any bony defect will need to be addressed in addition
to the soft tissue defect. If the etiology is postoncologic
resection then fi nal pathologic diagnosis with confi rmed
clear margins is necessary. This is sometimes problematic
for patients where there is no access to Mohs microscopic
surgery. Choices for management of cancer in this region
include Mohs surgery versus frozen section versus perma-
nent histology with delayed reconstruction. However, it is
in the patient’s best interest to be sure there is no residual
cancer prior to starting the reconstruction; otherwise some
of the reconstructive options may be lost.
c h a p t e r

356 • CHAPTER 33
PATIENT PREPARATION
Reconstruction of the eyelid is a complex process often
requiring a staged approach. It is important to discuss
with the patient the possible need for multiple proce-
dures. The patient’s ability to tolerate more than one
procedure may impact your choice of reconstructive
options. Even with a planned one-stage procedure, sec-
ondary work is often indicated. In addition, a discussion
of the type of anesthesia is warranted. The patient’s abil-
ity to have a local rather than a general anesthesia must
be considered in surgical planning. Some patients will
have signifi cant medical comorbidities and are unable to
undergo general anesthesia. Local anesthesia is often a
viable option but it may impact the selection of surgical
technique. The postoperative course must be discussed,
including a possible period of eye irritation and redness
requiring eye drops or patching. Once the patient and his
or her family are aware of what the surgery will involve,
it is appropriate to proceed with the surgical repair.
TECHNIQUE
An algorithmic approach incorporating defect size, thick-
ness, and location is the easiest approach ( Figure 33-1 ).
Many techniques have been described for all types of
eyelid defects. Rather than explain each procedure in
detail, this chapter will focus on technique choice. To
understand the choice of surgical techniques that fol-
low, it is imperative to understand the complex eyelid
anatomy ( Figure 33-2 ).The skin of the eyelid is the thin-
nest in the body. Deep to the skin is a very thin layer
of subcutaneous tissue and deep to that the orbicularis
oculi muscle. The tarsal plate is deep to the orbicularis
oculi muscle. In the upper eyelid, the levator palpebrae
superioris is attached to the superior margin of the tar-
sus. The ends of the tarsal plates are attached to the
medial and lateral orbital margins by the medial and
lateral palpebral ligaments. The conjunctiva, the inner
lining of the eyelid, runs over the sclera to the cornea
and joins it at the limbus. The orbicularis oculi muscle
is responsible for opening and closing the eyelids. The
levator palpebrae superioris muscle, in conjunction with
Muller muscle, elevates the upper lid. The eyelid sensory
innervation is from the trigeminal nerve, both the oph-
thalmic and maxillary division. The motor innervation
to the orbicularis oculi muscle is from the facial nerve.
The motor innervation to the levator palpebrae superio-
ris is from the oculomotor nerve. The blood supply to
the eyelid comes from the medial palpebral branches of
the ophthalmic artery and the lateral palpebral branches
of the lacrimal artery. The medial canthus is a complex
structure attached to the nasal bones and contains the
caruncle and the puncta for the upper and lower canali-
culi. The lacrimal duct and sac lie medial and caudal to
the canaliculus. The lateral canthus is a two-layered liga-
ment attached to the lateral orbital rim that holds the
eyelid in place. Technique selection for reconstruction
is based on this anatomy and assessment for treatment
planning and includes the depth, location, and size of
the defect. Procedure selection will be discussed based
on these characteristics.
Partial-thickness Loss of
the Upper or Lower Eyelid
Partial-thickness defects include loss of a portion of the
anterior or posterior lamellae. The anterior lamella con-
sists of the skin and the underlying orbicularis oculi mus-
cle. Reconstruction options include full-thickness skin
grafts harvested from the contralateral upper eyelid, post-
auricular, or neck donor sites. This option is a valuable one
especially in an older patient who may only be able to tol-
erate a procedure that can be done with a local anesthetic
( Figure 33-3A, B ). Skin grafts are not ideal for all patients
because of associated pigmentation, scarring, and cosme-
sis. For those patients, local skin fl aps and myocutaneous
fl aps are a better option. The horizontal V-Y advancement
fl ap recently described by Marchac is a good example of a
local fl ap for the reconstruction of partial-thickness defects
of the anterior lamellae. 2 The Tripier fl ap is especially use-
ful for congenital defi ciencies ( Figure 33-4A–C ).
The posterior lamella consists of the conjunctiva and
tarsus. Defects in this region often result in loss of sup-
port to the eyelid and can be very problematic. If the
defect is an isolated lining problem, which is rare, then
the options for mucosal reconstruction include hard pal-
ate mucosa, buccal mucosa, acellular dermis, and skin
grafts. If the tarsus is involved, reconstruction with
skin, mucosa, cartilage or composite grafts is needed. If
enough lower lid support is lost, then a fascial sling is
indicated. Key points for the reconstruction of partial-
thickness defects are to resurface the cutaneous defect,
to put the incisions within natural skin tension lines, and
to minimize tension on the eyelid margin.
Full-thickness Loss of the
Upper or Lower Eyelid
In cases with full-thickness loss of either of the eyelids,
the size and location of the defect dictates what surgical
reconstructive options are available as long as there is no
history of radiation or previous fl aps in the area. If there
is a full-thickness defect with less than one third of the
eyelid involved and the canthus is spared, then the options
include primary closure with or without the release of a
portion of the lateral canthal ligament, a local myocutane-
ous transposition fl ap, composite grafts, and a sliding fl ap. 3
If the resection was not performed in a pentagonal pat-
tern, then revision of the defect should be undertaken to
create two sides perpendicular to the eyelid margin that
turn obliquely to meet at the inferior aspect of the defect.
Primary closure is often an option in the elderly patient
because of skin laxity in the area. In the patient with less
skin laxity, the release of a portion of the lateral canthal
ligament can allow the skin to move together with less

EYELID RECONSTRUCTION AND PTOSIS REPAIR • 357
FIGURE 33-1. Treatment algorithm for defects of the eyelid.
Canthus involved
Thickness
of defect
No
Yes
Partial
thickness
Size of defect
Full
thickness
Medial
Lateral
Local
transposition
from temporal
region
Quality of
wound bed
<1/3 of lid
1/3 to 1/2
of lid
1/2 to 3/4
of lid
Lid
involvement
1. Temporal
extension with
advancement
2. Unipedicled or
bipedicled (myo)
cutaneous flap
from opposing
eyelid with
mucosal graft
3. Mustarde cheek
flap
4. Hughes/reverse
Hughes
procedure
1. Myocutaneous
or cutaneous
flap bed with
mucosa
2. Cutler beard
flap
3. Switch flap
1. Primary closure
2. Local
myocutaneous
transposition flap
with or without
release of part of
lateral canthal
tendon
3. Composite
graft
4. Sliding flap
1. Bipedicled
upper lid
myocutaneous
flap with
mucosal graft
2. Cheek flap
3. Nasolabial
flap with lining
1. Bipedicled
cutaneous
flap from
the lower
eyelid and
donor site
is closed
with a skin
graft
2. Myocutaneous
flap from
above the
eyebrow and
donor site is
closed with
a skin graft
Upper only
Both lids
Lower only
Vascularized
1. Superficial
temporal
artery
fascial flap
with skin
grafts to
both sides
2. Forehead flap
3. Free flap ie,
tarsoconjunctival
flap from
contra lateral
eye
Non-Vascularized
Full thickness
skin graft
Pedicled cutaneous
flap ± canthal
tendon insertion
with Mitek screw

358 • CHAPTER 33
tension and is safe as long as only a portion of the ligament
is released. 4 A full-thickness defect necessitates repair of
the lining as well as the overlying structures. Local V-Y
or rhomboid myocutaneous transposition fl aps therefore
must be lined either with buccal or hard palate mucosa.
Composite grafts are an option only if the defect is small
enough to ensure its viability.
If there is a full-thickness defect with one third to
one half of the eyelid involved and the canthus is spared,
the reconstruction usually can be done with eyelid skin,
avoiding the use of a remote donor site. Local transpo-
sition or advancement fl aps within the eyelid are use-
ful here. Lateral defects can be closed using temporal
rotation fl aps. Local fl aps that have been successful
with this size defect include a myocutaneous fl ap lined
with mucosa, the Cutler-Beard technique, and the eye-
lid switch fl ap ( Figure 33-5A–D ). The Cutler-Beard fl ap
uses a full-thickness rectangular segment from the lower
eyelid and is done in two stages. The eyelid switch fl ap
rotates a small full-thickness fl ap from the opposite eye-
lid based on the marginal artery ( Figure 33-6A–D ). It is
also a two-stage procedure.
A full-thickness defect with one half to three quar-
ters of the eyelid involved and the canthus spared usu-
ally necessitates utilizing tissue from donor sites outside
the eyelid. The options include temporal extension of the
defect and advancement, a uni- or bipedicled myocuta-
neous fl ap from the opposing eyelid with a mucosal graft
for lining, a Mustarde rotational cheek fl ap, and a reverse
Hughes or a Hughes procedure, depending on the eyelid
FIGURE 33-2. Cross-section anatomy of the upper eyelid. (Redrawn from a fi gure
WFUSM Plastic Surgery Collection.)
UPPER LID
Mueller’s muscle (MM); Whitnall’s ligament (WL); Levator palpebrae superioris (LPS);
intermuscular transverse ligament (ITL); lamina propria mucosae (LPM); muscle of Riolan
(MR); anterior aspect of the tarsus (Ta); levator aponeurosis - posterior layer (PL); levator
aponeurosis - anterior layer (AL); orbital septum (OS); orbicularis oculi muscle (OOM);
submuscular fi broadipose tissue (SMFAT).
LOWER LID
Smooth muscle fi ber (SMF); Lockwood ligament (LL); inferior rectus muscle (IRM);
capsulopalpebral head (CPH); inferior oblique muscle (IOM); capsulopalpebral fascia
(CPF); submuscular fi broadipose tissue (SMFAT); obricularis oculi muscle (OOM);
orbital septum (OS); lower eyelid retractor - anterior layer (LERA); lower eyelid retractor -
posterior layer (LERP); muscle of Riolan (MR).

EYELID RECONSTRUCTION AND PTOSIS REPAIR • 359
FIGURE 33-4. (A–C) Unilateral Tripier fl ap using
skin and muscle to reconstruct a lower lid defect.
(Redrawn from a fi gure WFUSM Plastic Surgery Collection.)
A
C
B
FIGURE 33-3. (A) Partial-thickness lower eyelid reconstruction utilizing a
full-thickness skin graft; and (B) 3-month follow up result. (WFUSM Plastic Surgery Collection.)
A
B
involved. 5 A Mustarde fl ap can be useful for both upper
and lower eyelid defects ( Figure 33-7A–C ). For upper
eyelid defects, the fi rst stage uses a full-thickness fl ap from
the lower eyelid to reconstruct the upper eyelid based on
a pedicle. In the second stage, the pedicle is divided and
a rotational cheek fl ap is used to close the lower eyelid
defect. Lower eyelid defects can be reconstructed with a
single-stage Mustarde cheek fl ap ( Figure 33-8A–E ). The
Hughes procedure originally described for lower eyelid
defects is a tarsoconjunctival lining fl ap from the upper
lid to the lower lid covered with a skin graft that is staged
with pedicle division a few weeks later.
Complete upper or lower eyelid loss is a diffi cult prob-
lem, which is fortunately uncommon. For complete loss
of the lower eyelid, surgical options include a bipedicled
upper lid myocutaneous fl ap with mucosal graft for lining.

360 • CHAPTER 33
FIGURE 33-5. Eyelid switch fl ap: a two-stage procedure. (Redrawn from a fi gure
WFUSM Plastic Surgery Collection.)
A
B
C
D
This must be situated above the canthus to prevent ectro-
pion. Other options include a cheek fl ap with a medial
and lateral z-plasty and a graft for lining or a nasolabial
fl ap with lining. 6 Treatment options for complete loss of
the upper eyelid include a bipedicled cutaneous fl ap from
the lower eyelid and a mucosal graft for lining. Closure
of the donor site can be accomplished with a Mustarde
cheek fl ap for the best results. Other donor site treat-
ment options include a skin graft, composite graft, or a
myocutaneous fl ap from above the eyebrow and skin graft
to the donor site. The repairs described below for loss of
both eyelids can be used for one eyelid as well.
Complete upper and lower eyelid loss requires a
combination of reconstruction techniques, and choice is
usually dependent on donor site availability. Treatment
options usually include more remote donor sites such as
a superfi cial temporal artery fascial fl ap with skin grafts
on both sides, and a forehead fl ap. In cases when nothing

EYELID RECONSTRUCTION AND PTOSIS REPAIR • 361
is available regionally, then a free fl ap such as a tarsocon-
junctival fl ap from the contralateral eye is an option.
The medial and lateral canthi are critical structures to
the support and integrity of the eyelid. Medial canthal
reconstruction options are dependent on the extent of
the defect. If there is a good bed, then a full-thickness
skin graft from the upper eyelid is adequate. If there is no
vascularized bed, then a unipedicled cutaneous fl ap from
the upper eyelid will be needed. Onishi recently described
the use of glabellar combined Rintala fl aps with good suc-
cess in this region. 6,7 If the medial canthal tendon needs
to be reinserted, then a screw should be used. The lateral
canthus is easier to reconstruct, and a local transposition
fl ap from the temporal area is usually suffi cient.
Eyebrow and Eyelash Reconstruction
Cosmesis and a reconstruction that recreates the normal
appearance of the eyelid necessitate the reconstruction
of the eyebrow and eyelashes if involved. 8 Conservative
treatment includes tattooing, but most would agree this
is suboptimal. Current techniques include the transplan-
tation of hair follicles, strip grafts, or pedicled fl aps that
are hair bearing. Follicular grafting can be done for the
eyelashes as well, but this is a little more labor intensive.
Often repeat grafting is necessitated to get an adequate
density of hair follicles.
COMPLICATIONS
For reconstruction of the eyelid, as with any surgical pro-
cedure, complications are better avoided than managed.
The key to preventing complications is to remember the
anatomy of the eyelid and to replace all of the missing
structures. In addition, a tension-free repair is an absolute
requirement in this region both because the eyelid skin
is thin and because the protection of the globe itself is so
critical. Unlike other areas of the face, waiting until the
scar has settled 9 to 12 months later before reoperation is
often a luxury we do not have in this area because of the
associated risk. The globe itself must be protected either
with a temporary Frost suture or lateral tarsorrhaphy.
Major complications in this area include ectropion with
scleral show and entropion. Ectropion, an eversion of the
eyelid margin, most often involves the lower eyelid. It can
be best prevented by avoiding tension on the lower eye-
lid and by adequately supporting the lower lid. Once it
occurs, treatment is surgical and may include a z-plasty,
a skin graft, or a fascial sling. Entropion is an inversion of
the eyelid margin causing corneal irritation by the lashes.
In eyelid reconstruction entropion is best prevented with
adequate lining as a component of the reconstruction.
Once it occurs, treatment is surgical and, in the case of a
postreconstruction complication, recreation of the lining
defect along with a mucosal graft is usually successful in
correcting this secondary deformity.
FIGURE 33-6. (A–D) Clinical case of an eyelid switch procedure in a child.
(WFUSM Plastic Surgery Collection.)
A
C
D
B

362 • CHAPTER 33
A
B
C
FIGURE 33-7. (A–C) Mustarde rotational cheek fl ap for reconstruction of a lower
eyelid defect. (Redrawn from a fi gure WFUSM Plastic Surgery Collection.)

EYELID RECONSTRUCTION AND PTOSIS REPAIR • 363
FIGURE 33-8. (A–E) Clinical example of the Mustarde
rotational cheek fl ap closure of an eyelid defect. (WFUSM
Plastic Surgery Collection.)
A
C
E
D
B

364 • CHAPTER 33
Ptosis
The healthy eyelid in primary gaze should be located half
way between the pupillary aperture and the corneoscleral
junction. The major muscle involved in eyelid elevation
is the levator palpebrae superioris and, to a lesser extent,
Mueller’s muscle. If the eyelid is caudal or inferior to the
half way point, it is likely a case of eyelid ptosis (bleph-
aroptosis). 8 In true ptosis one or more of these muscles
is affected. A diagnosis of pseudoptosis is made when
the eyelid is inferiorly displaced, but the cause is not
attributed to the levator complex. It is often a result of
enophthalmos due to the displacement of the globe pos-
teriorly into the orbital space.
The etiology of ptosis may be congenital or acquired.
In congenital cases, the levator muscle is either fi bro-
sed, not functioning properly, or absent. This can be
determined clinically by having the patient look down
(downward gaze). If lagophthalmos is present, then con-
genital ptosis is likely the etiology. Improved long-term
results have been achieved when the repair is accom-
plished within the fi rst year of life, as documented with
improved aesthetic outcomes and decreased physiologi-
cal and developmental side effects.
The most common etiological factor that leads to
acquired ptosis is a stretching of the aponeurosis supe-
rior to the tarsus but it can result from any injury to the
levator aponeurosis. This can be due to traumatic injury,
surgical injury, tumor, syndromes such as Horner, myas-
thenia gravis, third nerve palsy, and mechanical changes
with anophthalmos. It is estimated that 40% to 50% of
causes are involutional, while approximately 40% are a
result of trauma. Depending on the severity of ptosis,
severe visual obstruction and even gait disturbances can
result and thus necessitate surgical intervention .
PATIENT SELECTION
Identifying the underlying cause of a patient’s ptosis is
essential to selecting the most appropriate surgical pro-
cedure to correct the condition, to prevent recurrence,
and to minimize the risk of postoperative complications.
A detailed history should include onset of symptoms,
history of trauma, contact lens use, coexisting systemic
conditions, previous surgery, and any recent use of botu-
linum toxin. It is important to determine if there is any
fl uctuation in the degree or severity of ptosis during the
day that may require further work up to rule out the
presence of myasthenia gravis. Any use of anticoagula-
tion medications should be documented as well.
Extraocular movement and visual acuity should
always be examined and documented prior to any perior-
bital surgical intervention. A thorough clinical examina-
tion can help identify the etiology of the ptosis and guide
the surgeon to the most effective surgical treatment.
Irregularities in the pupil size or in response to light may
indicate a neurological condition. A motility examina-
tion may reveal a coexisting Horner syndrome (Mueller
FIGURE 33-9. Technique for measurement of marginal
refl ex distance which measures the distance between the
upper lid margin and the corneal refl ex. (Redrawn from a fi gure
WFUSM Plastic Surgery Collection.)
2
mm
4
mm
muscle) or Bell phenomenon (third cranial nerve palsy),
which can be either a congenital or an acquired condi-
tion. Symmetry should be examined and reviewed with
the patient. The severity of the ptosis should be quanti-
fi ed by measuring the interpalpebral fi ssure height, upper
lid margin to corneal refl ex distance, levator function,
and upper lid crease position.
• The interpalpebral fi ssure height is obtained by mea-
suring the height from the lower eyelid to the upper
eyelid centrally. This determines the vertical aperture,
which is between 8 and 12 mm (average 10 mm) in
adults.
• The upper lid margin to corneal refl ex distance is
referred to as the marginal refl ex distance (MRD-
1) ( Figure 33-9 ). It is measured from the corneal
light refl ex to the upper central lid margin with the
patient in the primary gaze position. The normal
upper eyelid in the primary position will rest at
or just below the superior corneal limbus with a
MRD-1 between 4.0 and 4.5 mm. If the corneal
light refl ex is obstructed by the upper lid, then the
degree of ptosis is severe, and the measurement is
obtained by lifting the eyelid until the corneal light
refl ex is visualized. The MRD-1 is then recorded
as a negative value. The MRD-1 is a very impor-
tant value as it is independent of the position of the
lower lid.
• The levator function is assessed by measuring the
upper eyelid excursion from maximal downward
gaze to maximal upward gaze while eliminating any
interference from the frontalis muscle by placing
pressure on the forehead during the examination.
Normal levator function is considered greater than
12 mm excursion. It is classifi ed as good at 10 to
15 mm, fair between 6 and 9 mm, and poor if it is
less than 5 mm.
• The upper lid crease position is described as the mar-
gin crease distance (MCD). The eyebrow is lifted
and the patient asked to look down. The measure-
ment is made from the lid crease centrally to the
lash line while in downward gaze. A normal MCD
should be between 9 and 11 mm. A separation of
the levator aponeurosis from the orbicularis muscle

EYELID RECONSTRUCTION AND PTOSIS REPAIR • 365
is suspected if the MCD is greater than 9 mm.
Separation of the levator aponeurosis from the tar-
sus is suspected if the fold is excessively deep. An
absent fold may indicate congenital ptosis.
PATIENT PREPARATION
Clear and detailed documentation will assist in commu-
nication with the patients and their families concern-
ing their condition and the treatment options. It is very
helpful to take preoperative photographs of the patient
(primary gaze, upward gaze, downward gaze, and eyes
closed) to compliment the discussion and for documenta-
tion. Photographs help patients to express their concerns,
likes, and dislikes concerning the form and function they
anticipate postoperatively.
There are several different ways to classify ptosis.
To meet the objective of choosing the best surgical inter-
vention, we will classify according to true ptosis and
pseudoptosis.
1. True ptosis is characterized by an upper eyelid margin
in primary gaze below the normal anatomic position
as described above. It can result from dysfunction in
one or more of the components of the levator com-
plex (levator palpebrae superioris muscle, levator
aponeurosis, and the Mueller muscle). Patients may
compensate by using the frontalis muscle to lift the
upper lid. The etiologic factors can be isolated or be
part of a syndrome, and within these two categories
it can be congenital or acquired.
2. Pseudoptosis is used to describe a condition that
appears to give an inferiorly displaced eyelid but in
which the etiology is unrelated to the levator com-
plex. Intervention focuses on treating the underlying
disorder, which can improve the effect on the eyes. It
is often related to conditions that effect orbital vol-
ume such as enophthalmos, anophthalmos, phthisis
bulbi, microphthalmos, and fat atrophy. In these con-
ditions, the eyelid is usually normal. It is the globe that
is incorrectly positioned. Treatment is therefore best
focused on addressing the orbital volume and not the
levator muscle. Dermatochalasis, redundant upper
eyelid skin, can be corrected by blepharoplasty.
SURGICAL TECHNIQUE
In order to select the correct operation, it is imperative
that the anatomical structures directly contributing to the
ptosis are identifi ed. The two most important factors for
selecting an appropriate surgical technique are the degree
of ptosis that is present and the quality of levator mus-
cle function remaining. When a patient has a mild ptosis
(2–3 mm) and good levator excursion (10–15 mm) cor-
rection can be achieved by plicating, shortening or advanc-
ing the levator muscle. For a patient with moderate ptosis
(3–5 mm) and good levator excursion the levator muscle
can still be plicated or advanced. For a patient with severe
ptosis (.5 mm) and normal levator excursion, levator
advancement remains the technique of choice. If the leva-
tor excursion is moderate (6–9 mm) in combination with
any amount of ptosis, advancing the levator muscle will
give the strength and durability needed to correct the pto-
sis. In the case of a poorly functioning levator muscle, a
frontalis sling is required. In summary, if levator function
is present, then the levator can be used to correct the pto-
sis. These procedures can be combined with an upper lid
blepharoplasty; however, for purposes of this chapter we
will focus on the procedure done for ptosis correction.
Levator Aponeurosis
Repair and Advancement
This procedure can be used in varied severity of levator
dysfunction and thus is a very important technique to mas-
ter. The patient should be positioned supine in a comfort-
able position, tetracaine drops applied, and a sclera shield
placed for corneal protection. The intended site for the
incision should be marked and then the skin infi ltrated
with a local anesthetic. The incision should be located
approximately 9 to 12 mm above the lid margin centrally
as in blepharoplasty cases. The incision is made through
the skin and orbicularis muscle to identify the levator
aponeurosis. A fi ne-tipped electrocautery device or teno-
tomy scissors can be used to dissect the aponeurosis from
the orbital septum superiorly and then inferiorly to expose
the edge of the tarsal plate where the aponeurosis may still
have attachments.
1. In cases when a levator advancement is planned
(levator excursion .6 mm): The levator aponeuro-
sis is released from the superior edge of the tarsus
carefully to limit disruption of the vascular arcade
which will increase the risk of bleeding. Just deep to
the levator is the Mueller muscle, which should be
preserved in the deep layer overlying the conjunc-
tiva. Once lifted off the deep layer and freed medi-
ally and laterally, the levator is advanced inferiorly
toward and over the tarsal plate. Generally, one can
expect a 1:1 result of correction (1 mm of advance-
ment 5 1 mm of elevation). For more severe cases,
additional advancement will be needed; this should
be tested with a cooperative patient after the fi rst
stitch is centrally placed securing the levator to the
tarsal plate. Many surgeons have a strong prefer-
ence regarding the type of suture material selected.
Absorbable sutures can be used either in a running
or interrupted fashion. Care should be exercised in
order to maintain inclusion of the tarsus and levator
while avoiding full-thickness bites which include
the conjunctiva. Excess aponeurosis should be
excised after the placement and elevation has been
confi rmed to be correct. It is acceptable to overcor-
rect by 1 to 1.5 mm. 9 Excision of the skin should
be done very cautiously, as aggressive resection can
lead to eyelid entropion and distortion. If recreation

366 • CHAPTER 33
of the lid crease is needed, the skin closure should
include intermittent portions of the levator aponeu-
rosis within the stitch.
2. In cases when a levator plication is planned (ptosis
,5 mm and good levator function): This approach
is very similar to that of the levator advancement.
The medial and lateral fi bers are released, but the
attachment to the superior tarsal plate is left intact.
Instead of separating the levator from the tarsus, it
is plicated on itself at the superior margin of the
tarsus. If the bulk of the levator creates a distor-
tion of the overlying skin, it should be trimmed.
The degree of plication should be evaluated with a
cooperative patient as described previously.
Tarsal Conjunctival Mullerectomy
This technique, also referred to as the Fasanella-Servat
procedure, is a reconstructive option when a patient has a
mild amount of ptosis (¯2 mm) with good levator func-
tion and a positive response to phenylephrine eye drops.
The MRD-1 should be measured both before and during
the phenylephrine test to determine the severity of ptosis
(normal MRD-1 5 4.5 mm). Phenylephrine 2.5% is rec-
ommended as it has less propensity for cardiac side effects
and has been shown to be equally effective as 10% phe-
nylephrine. 10 , 11 Systemic absorption can be decreased by
occluding the canaliculi during insertion of the drops by
pressing on the opening with the index fi nger. Tetracaine
drops and local anesthetic are recommended and should
be injected carefully so as not to distort the upper lid
margins. A frontal nerve block is another good option.
Once the anesthetic has taken effect, the eyelid is
everted to expose the conjunctiva overlying the tarsal plate.
Either a resection-ptosis clamp or two identical size mos-
quitoes are used to clamp the posterior lamella at the level
of the superior margin of the tarsal plate ( Figure 33-10 ).
Special care is used to be sure the clamps are in line with
the curve of the upper lid to prevent distortion. A mono-
fi lament suture is placed through the skin under the clamp.
The tissue is then excised between the suture and the
clamp. After waiting several minutes to assure hemostasis
the clamps are removed and the eyelid reverted to its nor-
mal position. 12 The suture is removed 1 to 2 weeks later
according to the clinical signs of correction.
Frontalis Sling
For patients who have a poorly functioning levator
(,5 mm), upper lid function will need to come from
periorbital muscles linked to the upper lid, regardless of
the amount of ptosis ( Figure 33-11 ). This is a common
situation for congenital cases of ptosis ( Figure 33-12 ). The
procedure is performed by connecting the tarsus to the
frontalis muscle. 13 Several materials, each with benefi ts
and potential risks, have been used. Autologous material
can be harvested from the fascia lata and has a low risk
of infection, but it requires a second operative site and
scar. Donated fascia lata eliminates a donor site scar in the
patient but carries a small risk of transmission of disease.
Silicone rods have been used successfully, but they have
a slightly higher rate of infection, exposure and material
failure. The material is generally connected to the frontalis
muscle at the level just superior to the eyebrow and then
to the tarsus just above the lash line. The intraoperative
level of the corrected eyelid should be 1 mm or so above
the desired level as the material will relax in the postoper-
ative period. Regardless of the material chosen, the tension
must be adequate to correct the ptosis and not to create
compensatory entropion of the upper lid.
COMPLICATIONS
Complications from upper lid ptosis surgery can be cat-
egorized as follows: contour irregularities, under correc-
tion, overcorrection, and keratitis. Levator aponeurosis
under correction is seen with inadequate advancement,
under resection, or dehiscence or loosening of the sutures.
This can be salvaged with re-advancement, resection, or
replacement of the sutures. A frontalis sling may be needed
if the levator is injured or not functioning properly. In the
case of overcorrection, conservative treatment with mas-
sage and lubricants should be instituted upon detection of
FIGURE 33-10. Fasanella-Servat procedure (tarsal conjunctival muellerectomy).
(Redrawn from a fi gure WFUSM Plastic Surgery Collection.)
Running suture (full thickness)
behind clamps, lateral to medial
A
Trim excess
clamped tissue
B

EYELID RECONSTRUCTION AND PTOSIS REPAIR • 367
the problem to decrease the likelihood of having to do a
resection of the levator for correction. Complications with
the tarsal conjunctival Mullerectomy often involve eyelid
contour abnormalities that can be created if the clamp
or mosquitoes are not placed complimentary to the con-
tour of the lid. If this is noted in the postoperative period,
the stitch should be loosened and the eyelid smoothed to
improve the contour. If that does not solve the problem,
then the excess tarsus, usually located centrally, can be
excised to achieve the correct contour. Under correction
will result if there is not enough tissue removed from the
posterior lamella or if there is dehiscence of the incision
site. Correction can be achieved by repeating the proce-
dure or by addressing the levator. Over or under correction
with the frontalis sling correction can be done by opening
the brow incision and tightening or loosening the sling as
needed. Keratitis can occur with any of these procedures
from exacerbating a dry eye state, lagophthalmos, suture
keratopathy, or granuloma formation. Artifi cial tears and
lubricating ointments will provide relief of the symptoms
and stimulate repair. If the irritation is from the suture,
it should be removed but can be avoided if the suture is
buried during the initial operation.
OUTCOMES ASSESSMENT
A good aesthetic and functional result is the goal of any
reconstructive procedure of the eyelid. The best results
come from adhering to the following principles:
1. Avoid tension and reconstruct the defect whenever
distortion occurs with primary closure.
2. Full-thickness defects require adequate reconstruc-
tion of all the involved layers.
3. Reconstruct with like tissues if available. Use the
upper eyelid to replace the lower if needed but avoid
the reverse as much as possible.
4. Avoid staged procedures if possible. Flaps with a
large base should be utilized in preference to a nar-
row pedicle.
FIGURE 33-11. (A, B) Frontalis sling procedure used for ptosis repair with history of
poor levator function. (Redrawn from a fi gure WFUSM Plastic Surgery Collection.)
A
B
FIGURE 33-12. Clinical example of congenital ptosis before (A) and after (B) the
repair. (WFUSM Plastic Surgery Collection.)
A
B

368 • CHAPTER 33
REFERENCES
1. Mathijssen I, van der Meulen JC. Guidelines for reconstruc-
tion of the eyelids and canthal regions. J Plast Reconstr Aes-
thet Surg . 2010;63(9):1420–1433.
2. Marchac D, de Lange A, Bine-bine H. A horizontal V-Y
advancement lower eyelid fl ap. Plast Reconstr Surg . 2009;
124:1133–1141.
3. Demir Z, Yüce S, Karamürsel S, Çelebio ğ lu S. Orbicularis
oculi myocutaneous advancement fl ap for upper eyelid
reconstruction. Plast Reconstr Surg . 2008;121(2):443–450.
4. Lewis CD, Perry JD. Transconjunctival lateral cantholysis for
closure of full-thickness eyelid defects. Ophthal Plast Recon-
str Surg . 2009;25(6):469–471.
5. Morley A, deSousa J, Selva D, Malhotra R. Techniques of
upper eyelid reconstruction. Surg Ophthalmol . 2010;55(3):
256–271.
6. Onishi K, Maruyama Y, Okada E, Ogino A. Medial canthal
reconstruction with glabellar combined rintala fl aps. Plast
Reconstr Surg . 2007;119:537–541.
7. Stein J, Antonyshyn O. Aesthetic eyelid reconstruction. Clin
Plastic Surg . 2009;36(3):379–397.
8. Ahmad SM, Della Rocca RC. Blepharoptosis: evaluation,
techniques, and complications. Facial Plast Surg . 2007;
23(3):203–215.
9. Newman M, Spinelli H. Reconstruction of the eyelid, cor-
rection of ptosis, and canthoplasty. In: Grabb and Smith’s
Plastic Surgery. 6th ed. Philadelphia: Lippincott Williams &
Wilkins; 2006;39:397–416.
10. Fraunfelder FT, Scafi di A. Possible adverse effect from
topical ocular 10% phenylephrine. Am J Ophthalmol .
1978;85:447–453.
11. Glatt HJ, Fett DR, Putterman AM. Comparison of 2.5%
and 10% phenylephrine in the elevation of upper eyelids
with ptosis. Ophthalmic Surg . 1990;21:173–176.
12. McLeish WM, Anderson RL. Cosmetic Oculoplastic Surgery:
Eyelid, Forehead, and Facial techniques . 3rd ed. Philadelphia:
W.B. Saunders; 1999.
13. Saunders RA, Grice CM. Early correction of severe con-
genital ptosis. J Pediatr Ophthalmol Strabismus . 1991;28:
271–273.
5. Attention to the contour intraoperatively will
improve the postoperative results.
6. Perform a thorough preoperative examination so as
to address the underlying cause of ptosis in order to
select the proper technique for repair.
7. Protection of the globe is your primary respon-
sibility.
It should be remembered that the more obvious the
residual deformity or reconstruction, the less likely the
patient will be happy with the result. The most com-
plex techniques do not always give the best results and
a forehead fl ap or free fl ap are good examples of such.
The more remote the donor site (eg, forehead) the less
it will be like the original tissue, and the more obvious it
becomes to the patient.

34
Scalp, Calvarial, and
Forehead Reconstruction
Matthew R. Swelstad, MD / Michael L. Bentz, MD, FACS, FAAP
INTRODUCTION
Scalp, forehead, and cranial defects occur from a variety
of congenital and acquired processes. Lacerations, burns,
and tissue avulsions may require emergent treatment.
Tissue defects are also the result of the medical and sur-
gical management of neoplastic conditions of the scalp,
including basal cell carcinoma, squamous cell carcinoma,
melanoma, dermatofi brosarcoma protuberans, soft tis-
sue sarcomas, and vascular malformations. Excision of
premalignant lesions such as giant congenital melano-
cytic nevi and nevi sebaceous may also require complex
closure. Infectious complications from leprosy, herpes,
fungi, lupus vulgaris, and lichen planus may also lead to
scalp and calvarial defects. External beam radiation used
in the medical management of neoplastic and other scalp
disorders may lead to scalp ulceration or osteoradion-
ecrosis. A variety of congenital anomalies, such as cutis
aplasia, may be associated with defects in the scalp and
cranium exposing the underlying bone or dura. The role
of the plastic surgeon is to safely and reliably reconstruct
these defects while preserving function, maximizing aes-
thetics, and minimizing risk and morbidity.
Vascular Supply
The vascular supply of the scalp is excellent. It consists
of several axial arterial vessels connected by an intricate
vascular plexus. Scalp vessels originate from the internal
and external carotid arteries. In the forehead, the supraor-
bital and supratrochlear arteries (branches of the internal
carotid) exit their respective foramina in the supraorbital
ridge and travel superiorly toward the vertex of the cra-
nium. The external carotid artery branches into four main
scalp vessels. The fi rst of these branches is the occipital
artery, which is the predominant blood supply to the pos-
terior scalp. The posterior auricular artery provides blood
supply to the scalp over the mastoid and temporal areas
behind the ear. The internal maxillary artery courses ante-
riorly toward the midface and sends off the anterior and
posterior deep temporal arteries which supply the tem-
poralis muscle. The superfi cial temporal artery, which is
the terminal branch of the external carotid artery, divides
into the frontal branch and the parietal branch. The fron-
tal branch supplies the anterior temporal region and lat-
eral forehead. The parietal branch supplies the posterior
temporal and parietal regions. 1 Figure 34-1 illustrates the
vascular supply to the forehead and scalp.
Innervation
The forehead is innervated by the supraorbital nerve
and the supratrochlear nerve, both branches of the oph-
thalmic division of the trigeminal nerve (CN V1). The
supraorbital nerve exits its foramen in the supraorbital
ridge, and divides into a superfi cial branch and a deep
branch. The superfi cial branch penetrates the fronta-
lis muscle and courses toward the scalp vertex in the
subcutaneous plane. It supplies sensation to the overly-
ing forehead skin. The deep branch of the supraorbital
nerve travels between the periosteum and deep margin
of the frontalis muscle. It provides sensation to the tem-
poroparietal scalp. Innervation to the skin over the lat-
eral orbit and temporal area of the forehead is supplied
by the zygomaticofacial and zygomaticotemporal nerves,
branches of the maxillary division of the trigeminal nerve
(CN V2). The temporal scalp, innervated by the auricu-
lotemporal nerve, is a branch of the mandibular division
of the trigeminal nerve (CN V3). The great auricular and
c h a p t e r

370 • CHAPTER 34
the lesser occipital nerves, both branches of the cervical
plexus, exit immediately posterior to the sternocloid-
mastoid muscle providing sensation to the soft tissue of
the ear and post auricular region of the scalp. The greater
occipital nerve, which is a branch of the cervical spinal
nerve, provides posterior scalp sensation. 1
Motor innervation of scalp muscles is supplied by
branches of cranial nerve VII (facial nerve). The most
Supraorbital nerve
Supratrochlear nerve
Zygomaticotemporal
branch of trigeminal
nerve
Temporal branches
of facial nerves
Facial nerve
Posterior auricular
branch of facial nerve
Auriculotemporal nerve
Greater occipital nerve
Lesser occipital nerve
Great auricular nerve
Supratrochlear artery
Supraorbital artery
Front branch of
superficial temporal artery
Deep temporal artery
Internal maxillary artery
External carotid artery
Occipital artery
Posterior auricular artery
Superficial temporal artery
Parietal branch of superficial
temporal artery
FIGURE 34-1. Schematic drawing of the neurovascular anatomy of the scalp. A
thorough understanding of this anatomy allows the surgeon to design fl aps with optimal
vascularity while minimizing the morbidity of damaging important nerves.

SCALP, CALVARIAL, AND FOREHEAD RECONSTRUCTION • 371
important of these branches in scalp reconstruction is the
frontal branch of the facial nerve. The facial nerve exits
the cranial base through the stylomastoid foramen. The
frontal branch then courses through the parotid gland
and eventually into the temporal parietal fascia. Once in
the temporoparietal fascia, the frontal branch crosses the
middle third of the zygomatic arch in a plane superfi cial
to the deep leaf of the temporal fascia and innervates the
frontalis muscle ( Figure 34-2 ). 2 The path of the nerve
lies along a straight line between the lobule of the ear
and a point 1.5 cm lateral to the upper lateral eyebrow.
Damage to the frontal branch of the facial nerve will
result in paresis of the ipsilateral frontalis muscle and
the inability to elevate the eyebrow. Dissection in the
lateral orbital region places this nerve at risk of either
transection or traction injury. 3 Command of the anatomy
and careful dissection allows the surgeon to navigate this
complex anatomical region with success. Figure 34-1
illustrates the nervous supply to the forehead and scalp.
Lymphatic System
The lymphatic system of the scalp is composed of the
highly variable nodal basins of the parotid, preauricular,
postauricular, mastoid, and occipital regions. More pre-
dictable nodal regions exist in the neck as well. Because
of the variable lymphatic drainage of the scalp, nodal
mapping is performed simultaneously with surgical man-
agement of some scalp neoplasms (melanoma) to identify
sentinel lymph nodes.
Muscles of the Scalp and Forehead
The scalp and forehead consist of 10 paired muscles, the
frontalis, occipitalis, temporalis, procerus, corrugator,
depressor supercilii, and the three auricular muscles, the
auricularis anterior, posterior, and superior. Each of these
muscles is innervated by branches of the facial nerve with
the exception of the temporalis. The temporalis muscle
is a muscle of mastication, and is innervated by the man-
dibular division of the trigeminal nerve (CN V3). All
of these muscles except for the temporalis muscle lie
within the galea aponeurosis layer. 3
Cranium
The major bones of the cranium include the fron-
tal, occipital, temporal, and parietal bones. Each bone
is separated by a suture line, which normally fuses at
Temporo-Parietal Fascia
Loose Areolar Tissue
Temporalis Muscle
Deep Temporal Fascia
Path of Dissection
Line of Fusion
Deep Layer
Superficial Layer
Superficial Temporal Fat Pad
Frontal Branch of Facial Nerve
Buccal Fat Pad
Zygomatic Arch
Masseter Muscle
Posterior Masseteric Fascia
Parotid-Massesteric Fascia
SMAS
FIGURE 34-2. Schematic drawing of the course of the temporal branch of
the facial nerve (CN VII). The temporal branch is vulnerable to injury on account of it
superfi cial location. To prevent damaging the nerve, it is recommended to dissect in a
plane immediately superfi cial to the deep temporal fascia until two centimeters above
the zygomatic arch. At this point, one should drop below the superfi cial leaf of the deep
temporal fascia into the temporal fat pad. (From: Stuzin, JM, Wagstrom L, Kawamoto HK, Wolfe
SA. Anatomy of the frontal branch of the facial nerve. Plast Reconstr Surg. 1989;83:265–271.)

372 • CHAPTER 34
predetermined ages. The bone itself is composed of an
outer cortex and an inner cortex separated by the dip-
loic space. This space is not clinically developed in young
children, so reconstructive strategies which utilize the
diploic space, such as split calvarial bone grafts, cannot be
as easily performed until the space is adequately devel-
oped. Several venous channels course within the diploic
space. Emissary veins connect the venous system of the
scalp to the intracranial venous systems by traversing all
three layers of the cranium. 1 , 2
PATIENT EVALUATION
When evaluating the patient with trauma to the scalp, it
is important to identify the depth of the injury and the
tissues involved. The scalp consists of the hair-bearing and
non–hair-bearing tissue between the supraorbital rims
and the posterior nuchal line of the occiput. The forehead
is the non–hair-bearing area of the scalp extending from
the temporal hairline laterally, to the anterior hairline
superiorly, and to the supraorbital rims inferiorly. The fore-
head can be divided into fi ve subunits: one central area,
two lateral areas, and two eyebrow areas.
The scalp is composed of fi ve basic layers that can be
remembered by using the mnemonic SCALP . SCALP
stands for S kin, sub C utaneous tissue, galea A poneurosis,
L oose areolar tissue, and P eriosteum. 4 , 5 The skin of the
scalp is one of the thickest on the body. It is fi rmly adhered
to the underlying subcutaneous layer and galea aponeu-
rosis. Because no natural surgical plane exists between
these layers, fl aps such as the temporal parietal fascia fl ap
(which is contiguous with the galea aponeurosis), require
sharp dissection during elevation. If the dissection is too
superfi cial, damage to hair follicles in the subcutane-
ous tissue will result in alopecia. If the dissection is too
deep, the temporoparietal fascia vascular supply may be
compromised. Excellent surgical planes exist between
the galea, the subgaleal fascia and the periosteum. The
loose attachments between these layers allows for scalp
mobility. With careful technique it is possible to elevate
the subgaleal areolar tissue in the interval between the
periosteum and galea, creating a thin, translucent, well-
vascularized fascia layer that is easily rotated into small
local defects to cover exposed bone. The periosteal layer,
also known as the pericranium, may also be elevated as a
fl ap. The periosteum is fi rmly fi xed to the underlying cra-
nium. It is very strong and fi rm and it too may be rotated
into adjacent tissue defects.
PATIENT PREPARATION
The patient should be positioned supine on the operating
table with the head propped up on a circle of foam small
enough to allow maximal exposure of the head but large
enough to provide adequate support. Reconstruction may
be performed under different types of anesthesia depend-
ing upon the patient and the size and location of the
defect. Reconstruction of the scalp frequently requires
constant turning of the head to visualize more lateral
areas of the scalp to facilitate fl ap elevation and ultimate
closure. If an endotracheal tube or laryngeal mask airway
is used, special care must be taken to ensure that it is well-
secured. The hair does not necessarily need to be shaved
and is usually left intact. It should however be thoroughly
prepped with an aqueous solution to ensure coverage.
The excellent vascular supply of the scalp may lead to
brisk bleeding at the time of the surgery. Electrocautery
can be effective in controlling this bleeding, but places
hair follicles at risk for thermal injury and subsequent
alopecia. To limit bleeding, lidocaine with epinephrine
can be injected preoperatively, where epinephrine acts to
vasoconstrict the blood vessels. With various concentra-
tions of lidocaine with epinephrine available, one needs
to be careful not to exceed the maximum recommended
dose particularly in children. Some surgeons also use
metal clips applied along the edge of the scalp fl aps to
temporarily compress the tissue to limit bleeding, while
others use sutures placed several millimeters from the
wound edge to compress vessels.
TECHNIQUE
Several factors infl uence scar visibility. First, proper
placement and design of incisions may help to conceal
alopecia associated with scars. Scars located at the hair-
line, adjacent to the ear, or within rhytids are usually
inconspicuous. In addition, avoidance of hair follicles
and minimization of tension at the suture line will help
to reduce scar width, alopecia, and visibility. Incisions
made within the hair-bearing regions of the scalp should
be parallel to the angle of the hair follicles. This will
help minimize hair follicle damage. Finally, fl ap design
needs to consider fi nal hair orientation after rotation or
transposition. Flaps that surgically alter the natural ori-
entation of the hair follicles will make the reconstruc-
tion less aesthetic and may require altering the patient’s
hairstyle.
Reconstructive Strategies
Plastic surgeons have several reconstructive strategies
available to repair defects of scalp soft tissue. Ideally, the
soft tissue defect is closed with similar tissue from the
adjacent scalp in such a way that the aesthetics and func-
tion of the region are preserved. When the defect is not
able to be primarily closed using local tissues, the wound
may be closed by secondary intention (with/without skin
grafts), tissue expansion, pedicled fl aps, and microsurgi-
cal free fl aps. 4 , 5
Simple wound closure is the technique of choice for
small defects. It involves re-approximating the wound
edges with minimal adjacent subgaleal undermining.
Advancement fl aps may be used to close moderate-sized
defects. This may involve signifi cant undermining of adja-
cent tissue (as well as galeal scoring) with care not to dis-
turb the overlying blood supply. When advancement fl aps

SCALP, CALVARIAL, AND FOREHEAD RECONSTRUCTION • 373
do not suffi ce, or if advancement fl aps create a signifi cant
amount of aesthetic or functional distortion, then rota-
tion fl aps or transposition fl aps are the next consideration.
These local fl aps come in a variety of sizes and shapes.
For example, hair-bearing transposition fl aps work well to
reconstruct defects involving the sideburns. The resulting
scars are well hidden along the hairlines and the orientation
of the hair follicles is similar to normal. Another example
is the more technically challenging use of the Orticochea
three-fl ap reconstruction for moderate-sized scalp defects.
The Orticochea scalp fl aps are large fl aps based on axial
blood fl ow from large axial vessels (ie, superfi cial tempo-
ral, occipital, posterior auricular, supraorbital, and supra-
trochlear vessels). 3
The galea is an inelastic layer of the scalp that resists
stretching. Therefore, scoring of the galea at approximately
one centimeter intervals, starting at the edge of the fl ap
and parallel to the defect, may dramatically improve tis-
sue mobility. 4 , 5 When scoring the galea, care needs to be
exercised to release only the galea, and not injure the
subcutaneous tissue. Too deep of an incision may damage
the vascular supply to the fl ap or hair follicles leading to
scalp necrosis or alopecia. Some surgeons prefer to also
score the galea perpendicular to the direction of desired
advancement. This can be effective in achieving additional
expansion and advancement, but may lead to an increase
in fl ap tip necrosis. All techniques are facilitated by use of a
needle tip bovie to minimize secondary scalp bleeding.
When closing defects of the forehead, the surgeon
should attempt to reconstruct the anterior hairline.
Rotation (and occasionally transposition) fl aps are usu-
ally the best means to do this. If the defect is large, then
back grafting may be necessary in the donor area of the
occiput. Other fl ap options to reconstruct the anterior
hairline include the bipedicled Juri fl ap or pedicled hair
bearing island fl aps.
Final position of the eyebrow needs to be monitored
during forehead reconstruction. 5 Often, some displace-
ment of the eyebrow is necessary to achieve an adequate
closure. In the case of glabellar defects, medial displace-
ment of the eyebrows is infrequently permanent. Vertical
elevation of the eyebrow commonly improves with time.
With experience, the surgeon will be able to determine
which changes are temporary and therefore acceptable,
and which changes are likely permanent but possibly
unavoidable.
Finally, when designing scalp fl aps it is important to
consider both motor and sensory innervation. 1 , 5 Cutting
across motor nerves, such as the frontal branch of the
facial nerve, will result in brow paralysis and potential
signifi cant facial asymmetry. Damaging a sensory nerve
such as the greater auricular nerve or the deep branch
of the supraorbital nerve will result in paresthesia and
potentially a painful neuroma. It is not always possible
to spare these nerves as part of the primary or recon-
structive efforts. When sacrifi ce of one of these nerves is
planned or possible, a discussion with the patient regard-
ing postoperative changes is useful.
Healing by Secondary Intention. Not all scalp soft tis-
sue defects are able to be closed using full-thickness local
tissue rearrangement. In these situations, alternative man-
agement strategies are employed. One option is to per-
form local wound care, allowing it to close by secondary
intention. Healing by secondary intention is often the
treatment of choice in patients where either the risk of
surgical reconstruction is too high, or the morbidity of the
reconstruction unacceptable. With proper care and time,
these wounds will ultimately contract and re-epithelialize.
In the hair-bearing scalp, this results in alopecia. In the
forehead, healing by secondary intention may produce an
excellent result. For this reason, secondary intention heal-
ing of small- to moderate-sized forehead wounds is often
the treatment of choice.
Skin Grafts. Skin grafting is the process of remov-
ing skin from one area of the body and applying it to
another. Skin grafts may be harvested remotely as either
full-thickness skin grafts or as split-thickness skin grafts.
Full-thickness skin grafts are composed of all the layers
of the skin, while split-thickness grafts are only com-
posed of the epidermis and a portion of the dermis.
Split-thickness skin grafts contract more during the
long-term healing phase than full-thickness skin grafts.
Split-thickness grafts may also be meshed (multiple
small holes are placed in the graft), which allows a given
graft to expand over a greater surface area. Meshed grafts
also contract more during the healing phase compared to
non-meshed grafts. The ability of meshed split-thickness
skin grafts to shrink a wound during the healing pro-
cess can be exploited by the reconstructive surgeon to
decrease the fi nal size of the wound.
Skin grafts do not have their own blood supply.
They receive nutrition from the underlying wound bed.
Therefore, before a skin graft may be used, a healthy vas-
cularized wound base must exist. An example of a good
wound base would be the presence of viable periosteum,
subgaleal fascia, muscle, or granulation tissue. Denuded
bone in the absence of periosteum is not a healthy wound
base. To improve the chances of optimal skin graft “take”
on exposed bone, the outer cortex of the bone can be
removed to facilitate granulation tissue formation.
Burring of the outer cortex of the bone followed by sev-
eral weeks of wound care will accelerate creation of a
graftable granular wound base. 6 Figure 34-3 illustrates
a case where a scalp rotation fl ap was used to decrease
the size of a large forehead defect. However, exposed
bone was still present at the wound base. A subgaleal
fascia fl ap was mobilized and rotated over the exposed
bone and immediately skin grafted with good long-term
results. Figure 34-4 demonstrates bilateral scalp rotation
fl aps with galeal scoring for closure of a vertex defect.
Since skin grafts do not usually have viable growth of
hair follicles, areas of hair-bearing scalp reconstructed
with skin grafts will have noticeable alopecia. The areas of
alopecia can occasionally be camoufl aged with hair trans-
plantation, serially excised, or closed by local tissue fl aps.

374 • CHAPTER 34
FIGURE 34-3. (A) Intraoperative photographs of a
patient with a large forehead defect and exposed bone
following Mohs micrographic surgery for a basal cell
carcinoma. (B) Elevation of subgaleal fascia fl aps and a
large posterior scalp rotation fl ap. (C) Subgaleal fascia fl ap
anteriorly rotated to cover exposed forehead bone. (D) The
scalp rotation fl ap decreased the size of the forehead defect;
a skin graft was applied immediately over the subgaleal
fascia fl ap. (E) Six months after surgery.
A
B
C
D
E

SCALP, CALVARIAL, AND FOREHEAD RECONSTRUCTION • 375
FIGURE 34-4. (A) Intraoperative photographs of a patient with a scalp defect
located at the vertex of the cranium following basal carcinoma excision. (B) Two scalp
rotation fl aps were elevated and the galea scored. (C) Immediate postoperative result.
A
B
C
If these options are insuffi cient, tissue expansion of adja-
cent areas is often quite effective.
Tissue Expansion. Tissue expansion allows the recon-
structive surgeon to increase the surface area of donor
“normal” tissue to be used in the primary or secondary
reconstruction process. Infl atable silicone expanders are
placed under the adjacent normal galea and scalp. Each
expander is injected weekly or biweekly with saline until
the amount of expanded tissue is greater than perceived
necessary to close the scalp defect. Expanders are then
removed, and fl aps of appropriate geometry are created
with the expanded scalp to close the defect. Expansion
is most commonly used in this area to increase available
forehead skin for contralateral defects, or to increase
hair-bearing scalp, which is then mobilized over areas
of scarring and alopecia. 7 Dog ears are often created in
the process of expanded tissue rearrangement. These will
usually resolve over weeks to months. Aggressive trim-
ming of dog ears is discouraged, however, as this may nar-
row the fl ap base and decrease fl ap perfusion. 4 The most
common complications associated with tissue expansion
include infection, extrusion or rupture of the expanders.
In addition, patients need to understand and accept their
progressively abnormal appearance during the expansion
process. Figure 34-5 demonstrates the effi cacy of tissue
expansion in complex scalp reconstructions.
Cranial Vault Reconstruction. It is important to estab-
lish, prior to cranial reconstruction, that overlying soft
tissue of the scalp is healthy and is present in adequate
supply. Proceeding with cranial reconstruction before a
stable soft tissue envelop is created will lead to wound
breakdown, infection, and failure of the cranial recon-
struction. In addition, patients with a history of prior
infections in the surgical fi eld need to be warned of
the increased risk of subsequent infections during
reconstruction.
The cranium may be reconstructed in a variety of
ways. Alloy, titanium, or resorbable plates and screws
are used when the cranial bones are present but mala-
ligned or fractured. When defi ciencies of the cranial

376 • CHAPTER 34
bone are present, many authors utilize the adjacent cra-
nial bone as a graft source, exploiting that the cranium
is composed of an outer and inner cortex separated by
a diploic space. Defects up to one half the size of the
cranium can be reconstructed by separating the contral-
ateral inner and outer cortex. The outer cortex is then
returned to its anatomic position and fi xated, while the
inner cortex is used to reconstruct the skeletal defect.
Transposed bone is then secured in place using resorb-
able plates in children, and titanium plates in adults. If
the defect is larger than one half the size of the cranium,
or if the patient does not have a well-developed diploic
space, then demineralized cadaveric donor bone may be
used. Demineralized bone promotes both osteoconduc-
tion and osteoinduction. Sources for additional bone in
large reconstructions include autologous split-rib grafts
( Figure 34-6 ) and ilium.
Synthetic materials such as methylmethacrylate,
porous polyethylene, and hard tissue replacement are
also used. Methylmethacrylate is a nonporous acrylic
FIGURE 34-6. Intraoperative photograph demonstrating
the use of split-rib grafts for the reconstruction of a large
cranial defect.
FIGURE 34-5. (A) Intraoperative photographs of a patient with a large scalp
and cranial defect following Mohs micrographic surgery for dermatofi brosarcoma
protuberans. A skin graft was applied acutely to cover the defect. (B) After maturation
of the skin graft, two tissue expanders were used to increase the amount of adjacent
scalp tissue. (C) Postoperative result following removal of the tissue expanders and
advancement of scalp fl aps.
A
B
C

SCALP, CALVARIAL, AND FOREHEAD RECONSTRUCTION • 377
monomer that is easily molded in the operating room
but has a high rate of infection and extrusion. Porous
polyethylene (Medpor) and hard tissue replacement
polymers (hard tissue replacement) are both synthetic
implants with lower rates of extrusion because each
allows for vascular ingrowth into the material. These
synthetic constructs are computer generated to fi t the
exact size of the calvarial defect according to preopera-
tive computed axial tomographic imaging. Because they
are synthetic, extrusion and infection are still possible.
Long-term data assessing these outcomes is still some-
what limited.
Hydroxyapatite cement is also extensively used in
cranial reconstructions. Hydroxyapatite cement is com-
posed of calcium phosphate and is easily molded in the
operating room. Early studies suggested that hydroxy-
apatite cement was converted to bone. However, more
recent studies suggest that only the outer layers of the
hydroxyapatite cement become revascularized while the
inner portions remain avascular. The most common form
of hydroxyapatite cement used in cranioplasties comes
in a paste form. The paste is mixed in the operating
room and applied to the defect. When applied to a full-
thickness calvarial defect, hydroxyapatite cement may
develop microfractures. The signifi cance of these microf-
ractures remains unclear. Some surgeons use hydroxy-
apatite cement as an onlay for bone augmentation and
recontouring.
Flap Reconstruction. Traditionally, large scalp defects
have been managed with pedicled fl aps or microvascular
free fl aps. These large fl aps are based on axial blood ves-
sels. Flaps are often composed of fascia, muscle, skin, or a
combination of all three. In addition to the combined use
of local fl aps (pericranial fl ap, subgaleal fascia fl ap, tem-
poroparietal fascia fl ap) other useful regional fl aps include
the temporalis muscle fl ap, as well as rotational fl aps based
on the splenius capitus, frontalis, and occipitalis muscles.
Examples of distant pedicled fl aps used for scalp recon-
struction include the extended deltopectoral fl ap, trapezius
fl ap, latissimus dorsi fl ap, lateral arm fl ap, and pectoralis
major fl ap. With the advent of microsurgical techniques,
new and more acceptable tissue donor sites evolved.
Common free fl aps used in scalp reconstruction include
the latissimus dorsi, anterior lateral thigh, omentum, radial
forearm, rectus abdominus, and the dorsal thoracic fascia
fl aps. Microsurgical free fl aps offer not only reliable soft
tissue coverage, but also greater fl exibility with fl ap inset-
ting, positioning, and in selecting donor sites with an opti-
mal match for the given defect. 4 , 5
Microsurgical techniques also provide the potential for
large pieces of avulsed scalp to be revascularized. This can
help avoid the need for more complex secondary scalp
reconstructions, with hair growth in the avulsed tissue pro-
viding an acceptable reconstruction. 8 , 9 It may ultimately
be possible to perform large scalp and facial reconstruc-
tions with transplant allografts, following improvements
in the safety of long-term immunosuppression. 5 , 10
Cutis Aplasia Congenita. Cutis aplasia manifests as a tis-
sue defect of the scalp (and possibly underlying cranium)
ranging from a minor anomaly to a massive defi ciency
of scalp and cranium that leads to exposed dura. Several
management strategies have been employed. In defects
with exposed dura, it is important to keep the dura moist
at all times to prevent desiccation and cracking. If the
dura is not damaged, then spontaneous re-ossifi cation of
the cranium may occur over several months based on the
osteogenic potential of the dura. Cranioplasty may other-
wise be performed after a stable soft tissue envelope has
been reconstructed. Healing by secondary intention and
re-epithelialization of the wound from the margin is safe.
Critical to the success of treatment plans is the need for
consistent and meticulous care to protect the integrity of
dura during the healing process. In addition, the newly
formed skin is often friable and of poor quality. Local
fl aps may be a good option in some cases, but are more
challenging in the neonatal age group. Scalp tissue expan-
sion is usually avoided in neonates since the pressure of
the expanders will signifi cantly deform the underlying
cranial bone. More recently, dermal substitutes have been
used for exposed scalp coverage. Dermal substitutes are
easy to apply at bedside, and keep the dura moist. In addi-
tion, newly formed skin is more supple and durable when
compared with secondary intention healing. Finally, assess-
ment of the underlying intracranial structures should be
organized in conjunction with the neonatologist caring for
these pediatric patients.
COMPLICATIONS
The more common complications seen with any surgical
procedure, namely bleeding and infection, are certainly
seen with scalp reconstruction but may take on more sig-
nifi cant weight. Superfi cial infections are less common in
the scalp on account of its robust blood supply. With the
need for calvarial bone reconstruction, however, infection
that may involve the meninges can be potentially life-
threatening. Similarly, bleeding inside the cranial vault
has little room for expansion and can produce either a
closed-space epidural or subdural hematoma. Thus, care-
ful inspection and hemostasis is critical during recon-
struction. If a large area of dura is exposed, it is probably
benefi cial to place circumferential tie-up sutures from the
dura to the surrounding edge of bone to minimize tracking
of blood laterally.
Injury to the dura is a potential complication with
skull reconstruction. Care should be taken to dissect cau-
tiously when bone is absent. Should a dural injury be dis-
covered, adequate exposure of the entire defect should
be achieved. This may require removal of more bone
around the area of injury so that sutures can be placed
with safety. If the edges can be approximated without
undue tension, the wound should be closed with inter-
rupted braided nylon. If the edges remain apart, a patch
of either autogenous pericranium or alloplast can be
used as an inlay material and sutured to the edges of the

378 • CHAPTER 34
defect. Similarly, a patch of pericranium may be used as
an overlay even if the edges can be approximated. Sterile
sealant can also be used on top of the repair to further
minimize cerebrospinal fl uid leak.
The use of hydroxyapatite cement in the pediatric
population remains controversial, with a concern that
hydroxyapatite cement may alter cranial growth, thus
creating cranial asymmetries. In cases when hydroxyapa-
tite cement is used as an onlay for augmentation, it may
become internalized within the cranial vault as the sur-
rounding cranium grows. To understand why hydroxyapa-
tite onlays become internalized within the cranium, one
has to reexamine the mechanisms of calvarial growth. In
a child, the cranium grows by deposition of new bone at
the outer cortex with simultaneous resorption of the inner
cortex. Hydroxyapatite used as an onlay graft prevents new
bone formation on the outer cortex but does not prevent
resorption of the inner cotex. Over time, the underlying
bone is completely resorbed, and a full-thickness cranial
defect is created. Therefore, the use of hydroxyapatite
as an onlay for cranial augmentation and recontouring
should be delayed until cranial skeletal maturity. This pro-
cess of internalization is also one of the reasons temporary
resorbable plates and screws are used in children, while
permanent titanium plates and screws are used in adults.
OUTCOMES
Success or failure of scalp reconstruction is usually known
within the fi rst several days following the reconstruction.
A successful outcome results if the fl aps remain viable and
the wound remains closed and stable. Scars that area able
to be hidden further contribute to an aesthetic appearance
and an excellent result. Occasionally, the reconstruction
is adequate yet the underlying problem recurs, either due
to regrowth of tumor or inadequate eradication of infec-
tion. A well-designed fl ap that accurately restructures the
soft tissue is of little benefi t if the patient continues to
have leakage of cerebrospinal fl uid from the edges of the
wound. Carefully cataloguing the injured tissues within
the defect and adequately reconstructing each will go a
long way toward a successful outcome.
REFERENCES
1. Knize DM. Forehead and Temporal Fossa: Anatomy and
Technique. Philadelphia: Lippincott Williams & Wilkins;
2001.
2. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy
of the frontal branch of the facial nerve. Plast. Reconstr. Surg.
1989;83:265–271.
3. Orticochea M. New three-fl ap scalp reconstruction tech-
nique. Br J Plast Surg. 1971;24:184–188.
4. Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired
scalp defects: an algorithmic approach. Plast Reconstr Surg.
2005;116:54e–72e.
5. Temple CLF, Ross DC. Scalp and forehead reconstruction.
Clin Plastic Surg. 2005;32:377–390.
6. Seline PC, Siegle RJ. Scalp reconstruction. Dermatol Clin.
2005;23:13–21.
7. Zuker RM. The use of tissue expansion in pediatric scalp
burn reconstruction. J Burn Care Rehabil. 1987;8:103–106.
8. Thomas A, Obed V, Murarka A, Malhotra G. Total face and
scalp replantation. Plast Reconstr Surg. 1998;102:285–287.
9. Sabapathy SR, Venkatramani H, Bharathi RR, D’Silva J.
Technical considerations in replantation of total scalp avul-
sions. J Plast Reconstr Aesthet Surg. 2006;59:2–10.
10. Siemionow M, Agaoglu G. Allotransplantation of the face:
how close are we? Clin Plast Surg. 2005;32:401–409.

INTRODUCTION
In the early part of the twentieth century, George Crile 1
noted that most patients with cancer of the upper aerodi-
gestive tract would die as a result of regional metasta-
ses to the cervical lymph nodes rather than metastases
to distant organs. He therefore recommended the radi-
cal resection of the cervical lymph nodes in an attempt
to cure these patients. The advances of anesthesia, and
the establishment of blood transfusions paved the way
for major improvements in the survival of these patients.
Further developments in medicine continued into the late
1930s and 1940s that permitted safer extensions of the
operations to achieve better cure rates from cancer treat-
ment. The advent of intravenous thiopental (Pentothal)
facilitated the induction of anesthesia and permitted the
routine use of endotracheal tubes, as originally reported
by Crile, for inhalation anesthetics. Once blood could be
controlled from entering the tracheobronchial airway,
these operations became safer. The further developments
of blood-typing techniques and the establishment of
blood banks permitted the replacement of blood loss and
controlled the incidence of postoperative shock. Finally,
early development of antibacterial drugs such as sulfa
(and later the antibiotics) allowed control of the wound
infections that followed these operations.
These landmark advances in medicine led to the
improvement and the safety of major surgical proce-
dures and permitted even more aggressive resections to
treat more extensive cancers. Hayes Martin 2 advocated
the radical resection of oral cancer together with the
underlying mandible, popularizing the “commando pro-
cedure,” to improve the chances of cure or local control.
Subsequently, major advances by plastic surgery permit-
ted early reconstruction, and eventually one-stage opera-
tions for the resection of the cancer and the repair of the
regional anatomy.
Soon after the discovery of x-ray by Roentgen, 3 there
were parallel improvements in the treatment of cancers
with radiation therapy. In the early 1920s, orthovoltage
machines with 200 kV radiation were developed and used
in the treatment of these cancers, but there were many
local complications from the radiation damage. Coutard 4
replaced single-dose radiation treatment with that of
divided doses over 3 weeks, and the time-dose relation-
ships that were elaborated by Strandqvist 5 led to the wide-
spread acceptance of divided daily doses of radiation over
4 to 6 weeks. Towards the latter half of that century, there
were advances in the development of various radioisotopes
which led to the use of interstitial implantation to deliver
additional radiation when the patient had already had pre-
vious external beam treatments. In a further evolution of
these techniques, it was possible to add radioactive seeds
in the periphery of the surgical resection site to further
decrease local recurrence.
Similar advances occurred in chemotherapy subsequent
to the discovery of methotrexate in the 1940s. The addi-
tion of new drugs and chemical agents have been shown
to improve the results of surgery alone or radiation alone.
Several successful trials have led to the advocacy of chemo-
therapeutic agents in the adjuvant setting, thereby permit-
ting the preservation of vital organs, such as the larynx.
The development of these various therapeutic modali-
ties mandates a close communication among the various
specialists managing these cancer patients. Most medical
centers have developed multidisciplinary tumor boards
to evaluate these patients and to recommend appropriate
treatment plans. It is the author’s belief that these tumor
boards should not recommend any one “decision” on man-
agement, because cancer is different in each patient and
the possible combinations of primary site, lymph node
involvement, and ancillary medical problems lead to
innumerable possibilities of outcome. Furthermore, most
Head and Neck Cancer
Stephan Ariyan, MD, MBA
35
c h a p t e r

380 • CHAPTER 35
studies of head and neck cancers have been retrospec-
tive because no single institution can generate signifi cant
numbers of comparable patients in a short period of time
to make valid comparisons between different modalities
for any given tumor site and stage. Tumor boards should
therefore be advisory, providing a consensus of opinion
and permitting minority opinions as well. The ultimate
decision should still rest with the physician who has the
primary responsibility for the individual care of that spe-
cifi c patient.
It is expected that there will be more than 40,000 new
cases of cancer of the oral cavity, pharynx, and larynx in
2006. 6 Although we will be able to cure many of these
patients, we must also remember that there will be many
patients who come to see us when their cancers are too
advanced for any hope of cure. In spite of this, some of
these patients may be candidates for resections, for adju-
vant radiotherapy, or chemotherapy, if only to achieve
local control. On occasion, aggressive treatments, such
as with intraoperative adjuvant radiation with radioac-
tive seeds implanted following surgical resection of recur-
rence, have permitted long-term, disease-free survivals.
These successes have opened up new avenues in treating
patients with advanced cancer. As physicians, our goal is
to “cure” patients; whenever we cannot accomplish this,
our goal should be to “care” for them. We have a respon-
sibility to provide our patients with comfort from their
disability and their pain, and to provide them the oppor-
tunity to die with dignity in the company of their families
and loved ones. Even though such palliation does not lead
to increased survival in these patients with advanced can-
cer, these treatment modalities may allow the patients to
return to their homes and spend the rest of their time in
their chosen environment, rather than to spend it in a hos-
pital or nursing home.
GENERAL PRINCIPLES
OF INTRAORAL CANCERS
Leukoplakia is a hyperkeratosis which appears as a white
patch on the oral mucosa as a result of chronic irritation.
For a number of years, leukoplakia was believed to be a
precancerous lesion of the oral cavity. However, Pindborg 7
reported that in one third of the patients who harbor this
lesion are cleared of the disorder within 15 years of follow-
up. On the other hand, erythroplakia or erythroleukoplakia
(white patches of leukoplakia within an area of erythropla-
kia) has been reported to show a higher risk of malignant
transformation. Shafer and Waldron 8 reported that biop-
sies of erythroplakia were found to represent invasive car-
cinoma, carcinoma in situ, or severe dysplasia. Therefore,
while leukoplakia can be treated conservatively, all lesions
of erythroplakia should be biopsied and treated according
to the histologic diagnosis.
Epidermoid carcinoma of the oropharynx grows with
local invasion, and as it progresses, the cancer cells may
spread along the lymphatics to the regional cervical lymph
nodes. The various sites of the primary cancer have a
propensity to spread through these lymphatic channels to
different chains of cervical lymph nodes ( Figure 35-1 ). An
understanding of this course of events is important because
the treatment of these cancers is predicated on decisions
based on the location and extent of the primary tumor,
regional nodal involvement, and distant organ involve-
ment, all of which result in the staging classifi cation, which
will be illustrated later.
Lymphatic Spread
Tumor cells may travel along lymphatic channels to reach
the cervical nodes. These nodes may become enlarged
either because of a reactive response to the bacteria in
the oral cavity, which invade the tumor mass to cause
a local infection, or because of tumor replacement of
the node. Generally, lymph nodes need to enlarge to at
least 1 cm in diameter before they can become clinically
detectable.
On examination of the neck, the clinical impression
of a “fi xed” lymph node (ie, a lymph node that cannot be
moved around by the examining fi ngers) is believed to
represent the growth of tumor through the capsule of the
lymph node and into the adjacent structures. However,
this fi xation may, in fact, also result from infl ammation
of the node as a response either to the tumor cells, or to
bacterial invasion of the primary tumor. Although preop-
erative radiation may convert a “fi xed” lymph node to a
“freely movable” one, this change can also be observed in a
number of patients treated with systemic antibiotics alone,
and is not diagnostic.
II
III
I
IV
V
FIGURE 35-1. Sites of cervical metastases to the
various nodal groups: I—submandibular, II—jugulodigasrtic,
III—midjugular, IV—supraclavicular, V—posterior cervical.

HEAD AND NECK CANCER • 381
Unknown Primary
Sometimes a metastatic lymph node may be diagnosed in
the neck, but the site of the primary tumor cannot be iden-
tifi ed. A complete and thorough examination with direct
endoscopy and random biopsies will reveal the primary
tumor in 60% of the initial cases; among the remaining
patients, one third (15%) are identifi ed later, while two
thirds (25%) will remain undiagnosed even at autopsy.
These unknown primary tumors are often the result of
a very small primary lesion that metastasized early from
a region of the pharynx that is rich with lymphatics. The
most common sites of these are along the Waldeyer ring:
nasopharynx, base of tongue, tonsils, and pyriform sinus.
In a smaller number of patients, it may actually represent
a regression of the primary tumor after some cells have
already metastasized to the lymph nodes. Regardless of the
true etiology, the consensus is to treat these patients with
cervical lymphadenectomy, or with radiation therapy to
the neck, since such treatments result in 25% to 30% of
the patients remaining disease-free at 5 years.
Hematogenous Spread
Metastases in lymph nodes do not cause distant organ
spread, but are indicators of the potential for distant metas-
tases having already occurred. Although tumor cells may
be spread into the bloodstream as a result of biopsies or
surgical removal, there is no correlation between positive
blood samples or wound washings and subsequent recur-
rences or distant metastases. 9 , 10 It is more likely that the
primary tumor is shedding malignant cells in the blood-
stream continuously throughout its growth for some time
before the diagnosis of malignancy is even made. When
lymph nodes are found to be harboring cancer cells, it
implies that this cancer is aggressive enough to overcome
the immunologic defense of the lymph nodes. Therefore,
this would represent a greater likelihood that any other
cancer cells that may have entered the bloodstream, and
traveled to distant organs, are more likely to be as aggres-
sive and have the same potential to survive in these distant
sites as well—presenting at a later date as distant metas-
tases. The most frequent sites of distant organ spread by
epidermoid carcinoma of the head and neck are the lungs,
bones, and liver. Although distant metastases are detected
clinically in 5% to 25% of the patients with oropharyn-
geal cancers, 11 10% to 50% of the autopsy specimens have
demonstrated such distant metastases. 12 – 14 Thus, the initial
workup should include CT scans of the neck (for evalua-
tion of the lymph nodes) or any painful boney areas (for
metastases to bones), chest x-ray, and liver function tests
in order to stage the patient according to the TNM (tumor,
node, metastasis) system.
DIAGNOSTIC WORKUP
The proper workup of the patient with a tumor of the
head and neck must include a thorough clinical examina-
tion together with proper biopsies to determine the extent
of the cancer, in order to classify and stage the disease.
The occurrence of benign lesions, such as necrotizing sia-
lometaplasia, 15 that resemble malignancies, and the pre-
sentation of some early malignancies that look like benign
lesions, both serve to preclude accurate assessment of
oral and pharyngeal lesions by clinical examination alone.
Regardless of the clinical experience and expertise of the
treating physician, the use of tissue biopsy remains the
essential defi nitive diagnostic tool.
Biopsy
The biopsy of the tumor may be either incisional or exci-
sional. Incisional biopsy of a representative portion of the
lesion should include a small segment of adjacent normal
tissue in order to differentiate a malignancy from tissue
damage due to chronic irritation, previous interventions,
or previous radiation therapy. Excisional biopsy should be
reserved for solitary lesions that are small, easily accessible,
and superfi cial. In all excisional biopsies, attention must be
paid to both the peripheral and the deep margins to ensure
adequate and complete removal for microscopic examina-
tion of extent of invasion.
Fine-Needle Aspiration . It is absolutely essential to defer
any open biopsy of a suspicious neck node or of any mass
in the head and neck region until a full and comprehensive
diagnostic workup has been completed in an effort to fi nd
the primary lesion. Since the primary cancer can be dis-
covered in most of the patients who are initially seen with
such masses, this policy of a thorough workup avoids treat-
ment delays, inappropriate incisions, and local recurrences
as a result of seeding of tumor cells.
While open biopsy as a fi rst step in diagnosis are to be
condemned, the technique of thin- or fi ne-needle aspira-
tion (FNA) biopsy has been fi rmly established in the diag-
nostic workup. FNA defi nes the disorder as a malignancy or
infl ammation, can identify the cell type or tissue of origin,
has been found to be a reliable technique for diagnosis, and
is virtually free of needle tract recurrences in malignant
tumors in the neck. This is a simple technique that can
be performed readily in the offi ce with a 22-gauge needle
( Figure 35-2 ), and can provide the pathologist with glass
slide smears for cytologic examination, and samples for a
paraffi n block. 16
Sentinel Node Biopsies . The principle of this tech-
nique is based on three tenets: (1) that each anatomic
site has specifi c lymph nodes that fi lter the efferent lym-
phatic vessels leading from the tumor; (2) that these
lymph nodes can be identifi ed; and (3) that the absence
of tumor cells in those lymph nodes is a reliable indicator
that there are no other lymph nodes in that group harbor-
ing cancer. This technique of localization of the lymph
nodes has been employed successfully for the detection
of metastatic nodes in the workup of melanomas. 17 – 20 This
has been particularly helpful in tumors located near the
anatomic midline, to locate the draining lymph nodes, and