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

HEAD AND NECK CANCER • 383
defi ned or irregular borders to nodal masses, and groups
of three or more nodes, each in the range of 6 to 15 mm
in diameter.
Nuclear Magnetic Resonance Imaging . Magnetic
resonance imaging appears to be superior to CT in sev-
eral respects. Techniques for MRI allow for a better defi -
nition of soft tissue and the extent of tumor invasion
into the various tissue planes. As such, MRI is superior
to CT scanning for soft tissue delineation. The use of
MRI of the posterior fossa was fi rst reported by Young
et al. 25 to illustrate these advantages. In a subsequent
study, Randell et al. 26 compared MRI with CT in a series
of 26 patients with tumors in the posterior fossa. While
CT was better for demonstrating calcifi cation or bony
invasion by tumor, MRI was shown overall to be more
much more sensitive for the demonstration of mass
effects ( Figure 35-5 ); even identifying some tumors that
were not visualized at all by CT. MRI is also excellent for
evaluating the neck for large metastatic nodes and deter-
mining the extent of tumor invasion of adjacent muscles,
vessels and nerves. 27
MRI has also been helpful in the diagnostic workup of
salivary gland tumors. Because the intensity of the signal
of the parotid gland is slightly less than that of the sur-
rounding subcutaneous fat, and greater relative to mus-
cle, it can enhance the difference between these adjacent
structures. Additionally, the submandibular gland has a
slightly lower signal intensity than the sublingual gland,
which may permit the delineation of the deep segment
of the submandibular gland from the adjacent sublingual
gland. Any tumor within the salivary glands would then
be differentiated from the glandular structures.
Technetium Scan . The ability of salivary glands to con-
centrate technetium-99m pertechnetate (Tc 99m) forms
the basis of the use of this nuclear medicine technique
in imaging salivary glands. The increased metabolic activ-
ity of the cells comprising Warthin tumor produces the
characteristic image of increased uptake. Oncocytomas
are other lesions that may take up this tracer in excess of
surrounding gland. Rarely, oncocytic rests in pleomorphic
adenomas, and oncocytic tumor metastases might also
mimic this picture. However, aside from Warthin tumor,
Tc 99m scans are not very useful in other salivary gland
imaging, or in oropharyngeal carcinomas.
INTRAORAL CANCERS
Although the oral cavity and oropharynx are anatomi-
cally distinct regions for classifi cation, their management
is discussed together because of the many similarities in
their diagnostic workup and treatment options. Whereas
the oral cavity is defi ned as the area extending from the
FIGURE 35-3. A lymphocintigram of a melanoma located in the midline of the
vertex of the scalp (A), shows drainage toright neck only, while a lateral view (B) shows
drainage to a small node of the parotid gland, a hotter node at the angle of the mandible,
and two additional nodes in the middle and lower neck.
A
B

384 • CHAPTER 35
vermilion border of the lips to an imaginary plane between
the junction of the hard and soft palates above, and the cir-
cumvallate papillae of the tongue below, the oropharynx
extends from this plane posteriorly and includes the soft
palate, tonsils, tonsillar pillars, base of tongue, and pharynx
( Figure 35-6 ).
The most common sites of cancers of the oral cavity are
the tongue (36%), fl oor of mouth (35%), gingiva (16%),
buccal mucosa (10%), and hard palate (3%) ( Figure 35-7 ).
The overall 5-year survival rates at these sites range from
31% to 66%, but two thirds of these cancers are already in
stage III or IV by the time they are fi rst seen by a physi-
cian. This delay in treatment has many causes, including
minimal symptoms, inadequate routine oral examinations,
and reluctance by the patient to acknowledge its presence
because of fear of a diagnosis of cancer. 28
The order of frequency for sites of oropharyngeal
cancers are the tonsillar fossa (43%), soft palate (26%),
base of tongue (20%), and the pharyngeal walls (11%)
( Figure 35-8 ). The overall 5-year survival rates at these
sites range from 17% to 57%. In the past, the differences
FIGURE 35-4. A recurrent tumor of the maxillofacial
area (A) can be evaluated by CT scan (B) to determine if
the tumor ( single arrows ) invades bone ( double arrow is at
infraorbital foramen). A CT scan of the neck (C) of another
patient shows an enlarged node with central necrosis ( arrow ).
A
B
C
FIGURE 35-5. MRI scan of same patient as in Figure
35-4A,B shows the extent of the tumor ( single arrows ) much
better, and can evaluate the bony wall of the maxillary sinus,
and the posterior wall of the sinus ( double arrows ).

HEAD AND NECK CANCER • 385
in survival statistics between oral cavity and oropharyn-
geal lesions was believed to be due to the biologically
more aggressive nature of cancers of the oropharyngeal
area. This is not quite correct. The difference is the delay
in the detection of the cancer which leads to the more
advanced stage of the oropharyngeal tumors at the time
of diagnosis. This delay can account for as much as 20%
to 30% of the advanced lesions of the pharynx not being
diagnosed until metastases have been detected in the
cervical nodes.
The classifi cation of these tumors (T) is based on
the measured size of the primary lesion ( Table 35-1 ).
Regardless of the size of the primary tumor, any invasion
of the tumor into adjacent and deeper structures repre-
sents more aggressive behavior and therefore upstages
the tumor. The classifi cation of the nodal involvement has
been unchanged with the latest (6th edition) American
Joint Committee on Cancer system revision of 2002
( Table 35-2 ). The one major change with the 6th edition
is in the separation of the stage IV tumors ( Table 35-3 )
into those that are locally advanced, surgically resectable
(stage IVa), and may be salvaged, from those that are
not resectable (stage IVb) but potentially treatable by
chemotherapy, and those that have evidence of distant
metastases (stage IVc).
Treatment
Stage I Disease . Stage I disease is best treated by local
excision. Although radioactive seed implants have also
been used successfully for early lesions of the fl oor of the
mouth, 29 it has some distinct limitations because of the
expertise necessary to properly plan and execute this
treatment. Excision and primary closure of the wound
may be successful in very small lesions. However, in larger
resections, this type of closure will surely lead to a tethered
tongue and defi cient articulation.
Tongue Flap . A resection of the ipsilateral anterior tongue
can be covered by the lateral rotation of the remaining
tongue. The tongue fl ap can be used quite effectively from
the lateral aspects of the tongue to resurface lateral or
anterior fl oor of mouth defects ( Figure 35-9 ).
FIGURE 35-6. A vertical imaginary plane at the junction of the hard and soft palates
separates the oropharynx from the oral cavity.
Oral cavity
Nasopharynx
Oropharynx
Hypopharynx
Glottis

386 • CHAPTER 35
Stage II Disease . Stage II disease can be resected locally,
but these larger lesions often encroach upon the mandi-
ble and may require rim resections of the mandible 30 , 31 to
get adequate margins ( Figure 35-10 ), while still provid-
ing local control rates equal to segmental resection of the
mandible. 30 While marginal resections take a vertical seg-
ment of the inner table of the mandible, a rim mandibulec-
tomy, on the other hand, takes a horizontal segment of the
full thickness of the mandible and has been shown to not
weaken the structural integrity of the mandible. 32
The reconstruction of these surgical defects may be via
an apron fl ap, 33 , 34 the platysma fl ap, 35 the sternocleido-
mastoid musculocutaneous fl ap, 36 , 37 or a free fl ap (for
a reconstruction without tethering the tongue). Larger
defects may require reconstruction with the pectoralis
major myocutaneous fl ap, latissimus dorsi myocutaneous
fl ap, or free fl aps of muscle or bone, with or without over-
lying skin.
Platysma Flap . The apron fl ap is actually a musculocu-
taneous fl ap incorporating the platysma muscle. It was
originally used as a vertical fl ap overlying the anterior neck
( Figure 35-11 ). This muscle may be used to transport a
transversely outlined paddle of skin on the posterolateral
aspect of the neck, incorporating the posterior blood sup-
ply to the platysma muscle. 38 , 39
CLINICAL APPLICATION . The vertical platysma fl ap is suitable
for coverage of small defects in the fl oor of mouth, under-
surface of the tongue, and lower lip. The transverse plat-
ysma fl ap can be used to cover defects on the outer surface
of the lips, cheek, and preauricular skin.
TECHNIQUE . A paddle of skin is outlined in the middle por-
tion of the neck ( Figure 35-11 ). The fl ap is then elevated
with skin and underlying platysma muscle, incorporating
branches of the facial vessels for blood supply. The base
of the fl ap is de-epithelialized and turned under the man-
dible to reach the fl oor of mouth and resurface the defect.
The skin remains at the distal end of the fl ap. The de-
epithelialized base of the fl ap is covered with the raw
surface of the root of the tongue. The donor site on the
anterior neck is covered with a skin graft.
The transverse platysma fl ap can be outlined as paral-
lel incisions cutting through the skin, subcutaneous fat,
and the platysma muscle fi bers ( Figure 35-12 ). Once the
submuscular plane is reached, the fl ap is dissected up
to its base, taking care to not cut into the undersurface
of the muscle, and to avoid damage to its intramuscular
blood supply. The donor site can then be closed with neck
advancement fl aps.
ADVANTAGES . This fl ap provides thin, pliable tissue for the
small defects of the anterior portion of the oral cavity, and
the incorporation of the platysma muscle improves the
vascularity of the fl ap. The transverse platysma fl ap donor
site can be closed with a cervical advancement fl ap result-
ing in a very acceptable linear scar of the neck.
TECHNIQUE . A traction suture is placed through the tip of
the tongue to stabilize the extended tongue. The fl ap is
taken from the lateral aspect of the tongue, with equal
amounts from the dorsal and ventral surfaces. The incisions
are angled in to excise a wedge of tongue muscle in the
fl ap, to dissect a fl ap of adequate thickness (and vascular-
ity), and to permit easy closure of the donor site. As the dis-
section proceeds posteriorly, the fl ap should become wider
to ensure a more vascular and more reliable fl ap. Then the
fl ap is transferred to the wound, and the muscle of the
tongue fl ap is anchored securely to the wound margins.
ADVANTAGES . This is a very reliable vascular fl ap that does
not leave a scar on the face or neck. The donor site is closed
by direct suturing, and it does not leave a sensory or motor
defi cit.
DISADVANTAGES . Although we have had very good successes
with this fl ap, there is always the potential that the use of
this fl ap could have some adverse effects on the speech of
some patients.
3%
10%
16%
35%
36%
20%
FIGURE 35-7. Common sites of cancer of the oral
cavity by order of incidence: anterior tongue, fl oor of mouth,
posterior tongue, gingival, buccal mucosa, hard palate.
(From Chicarilli ZN, Ariyan S. Cancer of the Oral Cavity Basic
Principles. In: Ariyan S, ed. Cancer of the Head and Neck . St. Louis,
MO: CV Mosby; 1987.)

HEAD AND NECK CANCER • 387
DISADVANTAGES. The fl ap is unreliable in patients with
previous radiation therapy to the face and neck, as it has
probably caused fi brosis to the delicate blood supply. In
addition, patients with previous neck dissections most
likely have signifi cant scarring of the platysma muscle, pre-
cluding its use in the fl ap. The donor site of the full apron
fl ap requires coverage with a skin graft.
Sternocleidomastoid Flap . The sternocleidomastoid
(SCM) muscle has three blood supplies: (1) a branch of
the occipital artery superiorly, (2) the superior thyroid
artery in the midportion, or (3) the thyrocervical trunk
inferiorly ( Figure 35-13 ). This fl ap can be used for recon-
struction, incorporating a superiorly based fl ap with a skin
paddle inferiorly ( Figure 35-14 ), which can then be trans-
ported under the mandible to reconstruct a surgical defect
in the fl oor of the mouth. Alternatively, an inferiorly based
fl ap with the skin over the mastoid portion of the fl ap
( Figure 35-15 ) can be transported to reach the fl oor of the
mouth, or twisted 180 degrees on its vertical axis to reach
the lateral pharynx or tonsillar fossa.
TECHNIQUE . Once the skin incisions are made along the out-
line of the skin paddle, another skin incision is made along
the midaxis of the SCM muscle along its entire length
( Figure 35-16 ) to expose the anterior and posterior bor-
ders of the attachments of the cervical fascia. The skin
paddle should be sutured securely to the underlying SCM
muscle fascia to protect the delicate musculocutaneous
vessels from shearing while being transferred during the
reconstruction. This is even more important over the supr-
aclavicular area, where there is abundant loose areolar tis-
sue and very thin delicate blood vessels to the skin. Traction
sutures placed at the distal end of the muscle pedicle, can
help to elevate the fl ap from the deeper layer of the invest-
ing fascia once the fascia is cut along the anterior and pos-
terior borders of the muscle. The muscle pedicle should
be dissected out only as is needed to reach the recipient
wound; in this fashion, the middle blood supply may often
be preserved. The fl ap may then be transferred under the
mandible into the fl oor of mouth, to securely anchor the
muscle pedicle to durable structures along the periphery
of the wound (periosteum or adjacent muscular fascia).
26%
43%
20%
11%
FIGURE 35-8. Common sites of cancer of the oropharynx by order of incidence:
tosillar fossa, soft palate, base of tongue, posterior pharyngeal wall. (From Chicarilli ZN and
Ariyan S: In Ariyan S, ed., Cancer of the Head and Neck, CV Mosby, St. Louis, 1987.)

388 • CHAPTER 35
TABLE 35-1. Primary Tumor (T)
Classifi cation of the Oral Cavity and
Oropharynx
Tis: Carcinoma in situ
T1: Tumor #2 cm in greatest dimension
T2: Tumor .2 cm but ,4 cm in greatest dimension
T3: Tumor .4 cm in greatest dimension
T4: Tumor invading adjacent structures
(Lip) Tumor invades through cortical bone, inferior
alveolar nerve, fl oor of mouth, or skin of face
(ie, chin or nose)
4a: (Oral cavity) Tumor invades through cortical bone
into deep muscles of tongue maxillary sinus, or
skin of face
4b: Tumor invades masticatory space, pterygoid
plates, or skull base, and/or encases carotid artery
From Greene FL, Page DL, Fleming ID, et al. AJCC Cancer
Staging Manual . 6th ed. New York: Springer; 2002.
TABLE 35-2. Nodal (N) Classifi cation of
Cancers of the Oral Cavity and Oropharynx
N0: No regional nodal metastases
N1: Metastases in a single ipsilateral lymph node,
#3 cm in greatest dimension
N2: Metastases in a single ipsilateral lymph node,
.3 cm, but ,6 cm in greatest dimension; or
multiple ipsilateral lymph nodes, none .6 cm; or
contralateral or bilateral lymph nodes, none .6 cm
in greatest dimension
N3: Metastases in any lymph node .6 cm in greatest
dimension
From Greene FL, Page DL, Fleming ID, et al. AJCC Cancer
Staging Manual. 6th ed. New York: Springer; 2002.
TABLE 35-3. Stage Grouping of Cancers
of the Oral Cavity and Oropharynx
Stage
N0
N1
N2
N3
Any M
T1
I
III
IVa
IVb
IVc
T2
II
III
IVa
IVb
IVc
T3
III
III
IVa
IVb
IVc
T4a
IVa
IVa
IVa
IVb
IVc
T4b
IVb
IVb
IVb
IVb
IVc
This is essential in order to prevent shearing the small ves-
sels to the skin paddle by traction on the muscle pedicle
when the patient moves the neck in the early postopera-
tive period. Since the skin paddle of this fl ap is usually
small (often only 3 3 6 cm), the donor site can usually be
closed by advancement of local tissue.
CLINICAL APPLICATION . This fl ap is suitable for reconstruc-
tion of small defects in the oral cavity, lateral tongue,
retromolar trigone, and tonsillar fossa. I have often used
this fl ap successfully on either end of the muscle pedicle,
even in patients with previous radiation therapy to the
neck, 37 , 40 with the following proviso: that the skin and
muscle are still soft and pliable, and radiation is not sus-
pected until the patient’s history determines it to be so.
This is because a soft neck probably signifi es that there
is no signifi cant fi brosis from the previous radiation.
However, this fl ap should not be used in any patient who
has clinical evidence of radiation thickening of the skin,
as this represents fi brosis of the fi ne vessels to the skin, as
well as scarring of the muscle.
ADVANTAGES . This fl ap permits the transfer of local tissue
in one stage without delay. The donor site of the skin can
be closed with advancement fl aps, and skin grafts can be
avoided.
DISADVANTAGES . Even with careful selection of the
patients, a third of the fl aps exhibit epidermal loss. In such
cases, the remainder of the fl ap remains intact (including
the dermal portion of the skin) and will re-epithelialize
without additional surgical intervention. Another disad-
vantage is the cosmetic defi ciency in patients with a thin
neck as a result of the transfer of the muscle.
Pectoralis Major Flap . The pectoralis major muscle is a
fl at muscle on the chest that has a large and easily iden-
tifi able dominant blood supply from the thoracoacromial
artery, a branch of the sublavian artery. The reliability of
a large portion of skin elevated on only a narrow portion
of this muscle was fi rst reported by Ariyan and Krizek 41 in
1977. The vascular anatomy of this muscle was defi ned as
having its dominant blood supply from the thoracoacro-
mial artery, its minor blood supply from the lateral thoracic
artery, and additional segmental blood fl ow from perfora-
tor vessels from the internal mammary arteries. 41 , 42
The pectoralis major fl ap can be used for large defects
of the oral cavity, pharynx, orbital exenterations, tempo-
ral bone resections, and large craniofacial resections.43–45 In
thin patients, it has also been used successfully for phary-
noesophageal reconstructions. The safety, reliability, and
versatility of this fl ap for various reconstructions has been
validated by a number of other authors. 46 – 48
TECHNIQUE . The vascular pedicle is fi rst outlined on the
chest by an axis drawn from the shoulder tip to the
xyphoid—the thoracoacromial vessels exit the mid-
portion of the clavical at a perpendicular to this axis,
and then follow distally along this line ( Figure 35-17 ).
The skin paddle is drawn to the size necessary for the
planned reconstruction, centered on this vascular axis.

HEAD AND NECK CANCER • 389
FIGURE 35-9. Resection of a tumor of the fl oor of mouth (A) can be reconstructed
with one or two local fl aps from the lateral portions of the tongue. The lateral fl ap (B) is
raised with a wedge of the underlying tongue musculature, based on its posterior blood
supply (C). The fl aps can then be sutured together and to the wound margins (D). When
the fl aps mature, they are soft, pliable, and allow for good protrusion of the tongue tip,
without loss of length (E, F).
A
B
C
D
F
E

390 • CHAPTER 35
FIGURE 35-10. A cancer of the fl oor of mouth can be
resected with a full thickness of the body of the mandible,
while preserving the cortical base and the integrity of the
mandibular arch. (See also Figure 35-16).
A
B
C
D
FIGURE 35-11. A small paddle of skin (A) can be transferred on a vertically oriented
pedicle of platysma muscle (B), to reconstruct a resection of the fl oor of mouth (C), and
can be seen at 4 years following the surgery (D).
To be sure that the fl ap is elevated without injury to the
blood supply, it is best to visualize the vessels directly.
This is most readily done by making an incision along
the lateral aspect of the skin paddle, down to the under-
lying pectoralis major muscle, and splitting the muscle
along its fi bers until the subpectoral fascia is penetrated.
A large retractor is then placed in this subpectoral plane
and the muscle is separated and elevated from the chest
wall by fi nger dissection in this loose areolar plane—this
is a bloodless fi nger dissection. The vascular pedicle is
then easily visualized directly in this subpectoral plane,
and protected during the remainder of the dissection of
the fl ap.

HEAD AND NECK CANCER • 391
B
FIGURE 35-12. A radical resection of a tumor overlying the parotid gland
(A), is reconstructed with a segment of skin across the neck incorporating the underlying
transverse portion of platysma muscle (B). The fl ap is tunneled under the facial skin
(C), the skin of the buried portion of the fl ap is removed leaving only platysma muscle, the
complete the repair in one stage (D). The fl ap donor site in the neck is closed primarily.
D
C
A
As the dissection is carried along the periphery of the
fl ap, sutures are placed to anchor the skin paddle to the
underlying muscle fascia to prevent inadvertent shear-
ing of the small vertical musculocutaneous blood vessels.
The muscle pedicale that is dissected along with the skin
paddle needs only to be as wide as is necessary to incor-
porate the thoracoacromial vessels, generally about 4 to 6
cm ( Figure 35-18 ). Once the muscle pedicle is dissected
up to the clavicular border, the muscle is then dissected
off the clavicle, freeing its attachment to this bone, and
separating it by a few centimeters. However, the vessels
should not be skeletonized during this dissection, but
should be left attached to the subpectoral fascia under
the clavicle, to allow the tethering which would protect
the vessels from shearing injury. This fascial attachment
allows the detached muscle pedicle to turn above and
over the clavicle, with only the vessels and accompanying
fascia to lie over the bone. In this fashion, the clavicular
bulge from the muscle pedicle may be avoided.
The entire skin paddle is drawn to lie over the pectoralis
major. If a larger skin paddle is required, a portion of it may
be extended beyond the inferior margin of the pectoralis
major. However, it should incorporate the underlying fas-
cia of the external oblique muscle, and half or more of the
skin paddle should still remain over the pectoralis major.
Finally, unless an extraordinarily large skin paddle is
required, the donor site can be readily closed by dissec-
tion along the chest wall laterally, and advancement of this
large chest fl ap.
CLINICAL APPLICATION . The pectoralis major is very use-
ful for the reconstruction of large defects at a number of

392 • CHAPTER 35
surgical resection sites. Within the oral cavity it provides
suffi cient bulk following total glossectomy. Since it has
been demonstrated that this muscle fl ap can provide nutri-
ent fl ow to the rib through the periosteal blood supply, 49
this musculocutaneous fl ap can be harvested with a seg-
ment of underlying rib for replacement of bone and soft
tissue of the mandible and malar region.
Most patients who have cancers of the oropharyngeal
area are underweight because of diffi culty with swallowing.
As a result, the fl ap can be used to facilitate reconstruction
of the pharyngoesophagus in thin patients ( Figure 35-19 ).
Two musculocutaneous pedicles can be harvested, either
in tandem (with the intervening skin removed) or side-by-
side (one on the thoracodorsal blood supply and one on
the lateral thoracic blood supply) for through-and-through
resections of the cheek. 50
Furthermore, this fl ap has had signifi cant applications in
the reconstructions of very large defects of the skull base
in temporal bone resections ( Figure 35-20 ), radical orbital
resections ( Figure 35-21 ), and fronto-orbitomaxillary
resections 45 ( Figure 35-22 ).
ADVANTAGES . The pectoralis major fl ap is very reliable, and
surgeons do not need additional instruments or surgical
skills, as would be necessary for microsurgical free fl aps.
These reconstructions can be performed virtually in any
operating room around the world. The muscle in the fl ap
provides additional blood supply if the site of reconstruc-
tion has been previously treated with high dose radia-
tion, and the fl ap can tolerate additional postoperative
radiation. In older female patients, the skin paddle can
be harvested from the medial and parasternal aspect of
the chest so as not to distort the breast form. In younger
women, the skin can be designed in the inframammary
area to maintain the shape of the breast mound. 51
DISADVANTAGES . While hair-bearing tissue may be trans-
ferred to the intraoral area in hairy males, this is not quite
as problematic in the oropharyngeal reconstructions as it
may seem. The hair on the chest is very short, and the
individual hair follicles are very fragile, break off, and fall
out before they get long.
Reconstructions of the frontal, orbital, or maxillary
areas may require the muscle pedicle to be left exposed on
the surface of the face, requiring a secondary procedure to
divide and inset the fl ap, at which point the pedicle may
be discarded.
Trapezius Flap . The trapezius is a fl at triangular muscle
overlying the neck, shoulder and upper back. The muscle
is supplied with three blood vessels: the upper cervi-
cal portion of the muscle is supplied by a branch of the
occipital artery; the distal portion of the shoulder seg-
ment overlying the acromion is supplied by a branch of
the suprascapular artery; and the remainder of the muscle
over the back is nourished by the dominant blood supply
from transverse cervical artery. This blood supply trav-
els along the undersurface of the muscle, descending the
back along the paraspinous region.
The trapezius myocutaneous fl ap, described by Deme-
gasso and Piazza, 52 , 53 was designed entirely on the trans-
verse cervical blood supply, to transport a skin paddle
to various sites of the oropharyngeal area. McGraw and
associates 54 , 55 reported the use of this fl ap designed trans-
versely along the shoulder, as in epaulettes of a uniform
( Figure 35-23A ), on its occipital blood supply. Ariyan 56
reported the application of this design entirely on the
transverse portion of the muscle to the shoulder tip, pre-
serving the transverse cervical artery, but transecting the
suprascapular artery at the tip of the shoulder. Since the
transverse cervical artery descends along the undersur-
face of the muscle along the back, Mathes and Nahai 57
described the design of the fl ap along the paraspinous
back ( Figure 35-23B ), providing a long fl ap nourished by
SCM
Occ
SCM
TC
ST
FIGURE 35-13. The three blood supplies to the
sternocleidomastoid (SCM) muscle include the branches of
the occipital artery (Occ) above, the branch of the superior
thyroid artery (ST) in the midportion, and the branch from
the thyrocervical trunk (TC) in the lower portion. (From Ariyan
S. One-stage reconstruction for defects of the mouth using a
sternomastoid myocutaneous fl ap. Plast Reconstr Surg . 1979;66:618.)

HEAD AND NECK CANCER • 393
this axial blood supply. Proposing that the blood to the
fl ap would fl ow retrograde from the back if the transverse
cervical artery has been transected in the neck during a
radical neck dissection, Gardiener et al. 58 subsequently
reported the successful use of a trapezius myocutaneous
fl ap designed transversely on the shoulder, after dissecting
and freeing and preserving the descending portion of the
blood vessels as a “mesentery.” Finally, as with many myo-
cutaneous fl aps, the trapezius was demonstrated by Panje
and Cutting 59 to be capable of incorporating the attached
acromion to reconstruct a segment of resected mandible.
Technique . The outline of the anterior border of the
muscle is marked on the skin of the neck and shoulder.
The anterior border of the skin paddle is along this bor-
der of the muscle, and the posterior border of the skin is
marked according to the width of the fl ap that is desired
( Figure 35-24 ). The distal end of the fl ap is marked accord-
ing to the length to which the fl ap must reach to the recip-
ient defect.
The incisions along the skin markings are deepened to
include the muscle as the pedicle. If the distal end of the
fl ap is beyond the crest of the acromion, then the fascia of
the deltoid and part of the periostium covering the acro-
mion should be incorporated with the muscle. As the mus-
cle is dissected up to its base in the neck, the transverse
cervical artery and vein are identifi ed deep to the trapezius
and above the levator scapulae muscles, and preserved.
The dissection then continues medially up to the base of
the neck and the muscle may be left attached to include
the branch of the occipital artery, or the muscle may be
detached here to be transported as an island vascular fl ap.
If the acromion or the transverse spine of the scapula is
needed, then the muscle is not detached from the bone at
the distal end of the fl ap. A segment of the needed bone is
marked with a surgical pen and the segment of bone is cut
with a power tool and left attached to the muscle pedicle.
If a large segment of skin or a long pedicle is required,
then the skin paddle is marked on the back of the chest,
descending in a vertical direction along the paraspinous
portion of the muscle. To do so, the operation begins
with prepping the head and neck area, the entire arm,
as well as the axilla, anterior chest, and posterior chest
within the fi eld of surgery. The sterile drapes are stapled
FIGURE 35-14. A segment of skin outlined on the inferior portion of the neck
overlying the SCM can be elevated with the muscle as its pedicle based superiorly with
the branch of the occipital artery.

394 • CHAPTER 35
FIGURE 35-15. A segment of skin outlined on the
mastoid attachment of the muscle (A) can be elevated with the
blood supply provided by the thyrocervical trunk inferiorly to
reach the fl oor of mouth (B) or the lateral pharynx (C).
A
B
C

HEAD AND NECK CANCER • 395
to the back, and the patient is returned to the supine
position in order to continue with the surgical draping.
After the resection is completed, the patient is turned
onto the opposite side and the fl ap margins are outlined
on the back with a marking pen. The incisions are made
through the skin, deepened through the muscle, the sub-
muscular plane is entered, and the fl ap is dissected up to
the neck, identifying and protecting the vascular pedicle
along the undersurface of the muscle.
CLINICAL APPLICATION . This fl ap can be harvested as a trans-
verse fl ap along the shoulder for reconstructions of the
cheek and neck. The posterior vertical variant of the fl ap
can be used for reconstructions of the base of skull, or
occipital portion of the cranium. The fl ap can incorporate
the transverse spine for repair of the body of the mandible,
or the acromion for reconstruction of the symphyseal por-
tion of the jaw.
FIGURE 35-16. A cancer of the fl oor of mouth was resected (A) together with a full
thickness of the alveolar portion of the mandible while preserving the cortical base and
the integrity of the mandibular arch (as in Figure 35-10). A skin paddle overlying the lower
portion of the sternocleidomastoid muscle was elevated on its superior blood supply (B),
transferred under the mandible to reconstruct the fl oor of mouth and undersurface of
tongue seen at 10 months (C). The dental occlusion can be restored with a dental bridge
(D) to the posterior molar that was preserved.
A
B
C
D

396 • CHAPTER 35
ADVATAGES . The fl ap can be used for one-stage recon-
structions without necessitating delaying incisions. The
donor site of the descending vertical fl ap can be closed
primarily without diffi culty. Unless a large portion of
skin is necessary, the donor site of the transverse variant
of the fl ap on the shoulder can also be closed primarily.
DISADVANTAGES . The transposition of the fl ap to reach the
area of reconstruction often results in bulk at the base of
the neck, which may limit the extent of reach of the fl ap.
If the muscle at the base of the fl ap is cut to convert it
into a vascular island fl ap, it results in a more mobile and
versatile fl ap, but it requires a more tedious dissection. If
the descending vertical fl ap is required, the patient must
be turned midway during the operation to the lateral decu-
bitus position to harvest the fl ap.
Latissimus Dorsi Flap . The latissimus dorsi is a large
fl at muscle along the lateral and posterior chest wall
( Figure 35-23B ). The primary blood supply is from
the thoracodorsal vessels which attach to the muscle
approximately 10 cm from the insertion of the muscle to
the humerus. The vessels travel axially along the under-
surface of the muscle in the direction of the muscle fi bers.
The muscle also has a secondary segmental blood sup-
ply from perforating vessels along the paraspinous origins
of the muscle. Following the development and popular
use of this myocutaneous fl ap for breast reconstruction,
Quillen 60 , 61 reported the use of this fl ap for reconstruc-
tions in the head and neck area. In a fashion similar to
the pectoralis major muscle, the axial dominant blood
supply of the latissimus dorsi bifurcates at the muscle
attachment to permit the use of two separate segments
of the split muscle to transfer two skin paddles if such is
necessary. 62
TECHNIQUE . The preparation of the patient for the use of
this fl ap requires prepping the entire arm, axilla, and chest,
both anteriorly and posteriorly. The drapes are then sta-
pled to the back and the patient is returned to the supine
position. Once the resection is performed, the head and
neck wound is evaluated to determine the size of the skin
paddle and the volume of muscle bulk that is required.
The skin paddle is marked along the lateral border of the
FIGURE 35-17. The skin paddle of the pectoralis major fl ap is outlined on the
underlying blood supply, centered on an axis from the shoulder tip to the xyphoid. Only
that narrow portion of the muscle that is needed is taken as a vascular pedicle, and the
muscle is separated from the clavicular attachments, leaving the fl ap as a true vascular
island fl ap.

HEAD AND NECK CANCER • 397
muscle at the necessary distance from the axilla to provide
enough length to the muscle pedicle to reach the site of
the reconstruction.
The skin incision is begun along the lateral border of
the muscle, and the dissection is carried into the axilla. The
thoracodorsal vessels are readily identifi ed along the under-
surface of the muscle, and the dissection is continued up
toward the apex of the axilla to the level of the subscapular
artery. The vascular branches to the serratus anterior and
terres major muscles are identifi ed, and may be transected
FIGURE 35-18. A cancer of the right lateral fl oor of
mouth and tongue (A) was resected leaving a large defect.
This was reconstructed with a paddle of skin outlined on the
vascular axis of the pectoralis major muscle (B), a narrow
portion of which was elevated as the pedicle of the fl ap. The
clavicular portion of the muscle was removed, leaving only the
vessels and fascia attached (C) to cross over the clavicle, and
under the neck skin (D). The healed fl ap provides suffi cient
tissue (E) to replace the missing portion of the lateral tongue.
A
B
C
D
E

398 • CHAPTER 35
to provide further mobility of the muscle pedicle. If the tho-
racodorsal vessels had been divided by a previous surgical
procedure in the axilla, then the branch to the serratus ante-
rior is preserved, which should be suffi cient to provide ret-
rograde arterial fl ow into the latissimus dorsi. The vascular
pedicle to the fl ap must not be skeletonized, but dissected
free while preserving a portion of the surrounding fascial
tissue to prevent traction damage to the blood vessels.
Once the vascular blood supply is identifi ed and dis-
sected free, the remainder of the skin incision is completed
around the skin paddle to the latissimus dorsi muscle fas-
cia, a longitudinal segment of a portion of the muscle is
split along its fi bers, and the tendinous portion of the inser-
tion is transected to free up the fl ap. At this point, a tun-
nel is prepared from the axilla, along the plane under the
pectoralis muscle toward the midportion of the clavicle.
FIGURE 35-19. A patient with a pharyngeal fi xed tumor (A) had a
laryngopharyngectomy needed a reconstruction of the cervical esophagus (B) which
was performed with a pectoralis major fl ap with a thin skin paddle located over the
parasternal medial chest. This skin paddle was elevated with only a narrow portion of the
muscle (C) incorporating the thoracoacromial vessels, and the clavicular attachments of
the muscle were excised, brought over the clavicle and the cervical skin tube constructed
over the narrow posterior pharyngeal mucosa (D).
A
B
D
C

HEAD AND NECK CANCER • 399
This tunnel must separate the attachment of the pectoralis
major from the clavicle to allow passage of the fl ap into
the region of the neck for the reconstruction. The donor
site can often be closed readily by direct advancement of
the chest fl ap.
CLINICAL APPLICATIONS . The latissimus dorsi may be used for
most of the applications that have been described for the
pectoralis major fl ap. It can provide a large amount of skin
and soft tissue for large surgical defects ( Fig ure 35-25 ).
In fact, when the advantages and disadvantages are evalu-
ated, it is best applied to those cases in which the patient
chooses not to have an incision along the anterior chest, or
those cases in which the pectoralis major is not available
due to previous surgery or congenital absence.
ADVANTAGES . The latissimus dorsi can provide very large
amounts of tissue for reconstruction and has a large arc of
rotation. It is as reliable as the pectoralis major fl ap. Some
women patients may prefer to have a surgical scar along
the posterior chest.
DISADVANTAGES . The major disadvantage of this fl ap is
the positional change of the patient from the supine to
the lateral decubitus position required during the recon-
structive portion of the procedure in order to get access
to the skin and muscle along the back. The fl ap must also
be tunneled under the subpectoral space and over the
clavicle to gain access to the neck. This process mandates
a pedicle of muscle to lie over the clavicle, which then
leads to bulky tissue at this juncture after the transfer.
MICROVASCULAR FREE
FLAP RECONSTRUCTION
Microvascular surgery is a technique of transfer of tis-
sue from one part of the body to another part, when the
vascular pedicle of the fl ap cannot reach the distance.
In those cases, the vessels can be transected and reat-
tached at the more distant site. The advent of microsur-
gical techniques led to the development of various donor
sites for the harvesting of this tissue. While it is true that
myocutaneous fl aps can be transferred by microsurgery
to more distant sites, most of the reconstructions of the
head and neck with the myocutaneous fl aps employs the
regional donor sites described above. However, the need
for thinner, more pliable, and less bulky donor sites led
to the trials and acceptance of several other donor sites
which can provide suffi cient tissue for reliable recon-
structions in the oropharyngeal area.
While microsurgery has traditionally employed the use
of fi ne 8-0 to 10-0 sutures for the circumferential repair
of the vessels under the operative microscope, many sur-
geons have learned to modify this technology to facili-
tate this delicate and time-consuming procedure. One
of the things learned from digital replantation was that
the operative microscope often required repositioning
several times during the procedure, which usually takes
time. On the other hand, the use of operating loupes
allows for repositioning of the operator’s head to change
the fi eld of vision instantly. A comprehensive review of
the free fl aps performed at one institution demonstrated
equal success and survival of free fl aps within the head
and neck performed with either the microscope or the
FIGURE 35-19. (continued) The reconstructed fl ap healed without any bulk over the
clavicle or neck (E), and the barium swallow (F) demonstrated a very patent pharynx.
E
F

400 • CHAPTER 35
operating loupes. 63 Use of operating loupes made the
procedure far less tedious, and shortened the operating
time.
Another modifi cation that has simplifi ed the surgical
procedure has been the development of the microvascular
anastomotic coupling device (microcoupler). The micro-
coupler is a pair of rings composed of high-density poly-
ethylene with a central opening, and multiple interlocking
stainless steel pins along the perimeter of both rings. This
allows the surgeon to pass each of two ends of vessels
through the center of each ring, splay them open, impale
the end of each vessel on one of the two opposite rings,
and approximate and lock the two rings for the comple-
tion of the anastomosis in one maneuver. The success and
reliability of this coupler has been reported in a large series
of clinical cases, 64 as well as in some head and neck cases. 65
Although the coupler has been used mostly for the anasto-
mosis of veins, we have found the device to be equally as
successful for the arterial anastomosis, 66 and therefore use
it for the entire microvascular anastomisis on as many of
the free fl aps as we can ( Figure 35-26 ).
Jejunal Free Flap . Longmire 67 was the fi rst surgeon to
report in 1946 the reconstruction of the esophagus with
an antethoracic transposition of a pedicled loop of jejunum
for the repair of a strictured esophagus. Subsequentlty,
Seidenberg 68 and his colleagues reported the fi rst repair
of an esophagus with the microvascular transfer of an iso-
lated segment of jejunum in 1959, followed by a report of
Jurkiewicz 69 in 1965. There have been subsequent reports
of larger series demonstrating the reliability and success
rates of free tissue transfers of a loop of jejunum for phar-
yngoesophageal reconstruction, as well as a fl at patch of
jejunum developed by the longitudinal opening of a seg-
ment of jejunum along its antimesenteric side. 70
TECHNIQUE . Once the tumor has been resected, the appro-
priate vessels in the neck are prepared for the vascular
anastomosis of the free fl ap. While any artery and vein can
be used for these anastomoses, I believe it is more prudent
to use larger vessels, particularly in patients who have been
previously treated with radiation therapy, which can result
in thickening of the walls of these vessels. Therefore, my
FIGURE 35-20. A recurrent squamous cell carcinoma with invasion of the mastoid
bone required a radical temporal bone resection (A). This was covered with a large
pectoralis major myocutaneous fl ap tunneled under the neck (B) skin for a one-stage
reconstruction (C).
A
B
C

HEAD AND NECK CANCER • 401
FIGURE 35-21. A recurrent epidermoid carcinoma of the periorbital tissue
(A) demonstrated invasion of the intraorbital contents (B), requiring a radical orbital
exenteration (C). This was reconstructed with a narrow pectoralis major
myocutaneous fl ap (D),
A
B
C
D
preference is to use the internal jugular vein (or one of
its large branches, eg, facial vein) and the external carotid
artery (or one of its tributaries, eg, superior thyroid, ascend-
ing pharyngeal). Finally, the length of the esophageal seg-
ment that needs repair is measured.
The segment of bowel is then harvested from the
abdomen. A suitable segment of the jejunum is selected,
with a good vascular arcade, generally just distal to the
ligament of Treitz ( Figure 35-27 ). First, the vessels are
skeletonized meticulously, cutting and tying the branches
with fi ne ligatures. Once this has been completed, the two
ends of the segment of bowel are clamped and transected.
The unclamped segment of bowel is examined for proper
color, circulation, and bleeding from the mucosal edges.
This isolated segment is left attached by its main blood
supply to provide circulation, while the reanastomosis is
performed of the two ends of the main loop of bowel.
The isolated segment of the jejunum can then be moni-
tored for those few minutes to verify the proper circula-
tion. The proper artery and vein of this isolated segment
are then transected and tied, and the segment of bowel is
transferred to the recipient site in the head and neck area.
In this fashion, there will be minimal warm ischemia time
to the bowel.
The jejunal segment is then secured to the superior por-
tion of the wound with a suture to prevent motion during
the vascular repair. A nasogastric tube is passed into the
pharynx, through the segment of jejunum, then out the
distal esophagus into the stomach before the repair. If this
is a tube repair of an esophagus, it is easier to perform
the proximal suture line fi rst, as this is the more diffi cult
part of the procedure. The distal repair may be performed
next, before the vascular anastomosis. Alternatively, some
surgeons prefer to repair the vessels next in order to

402 • CHAPTER 35
visualize the mucosal bleeding of the revascularized seg-
ment of bowel, after which they repair the distal end of
the bowel.
The vessels are then repaired. The vein may be repaired
fi rst and examined for patency of the retrograde fl ow
through the suture line, followed by the arterial repair.
Alternatively, the artery may be repaired fi rst, fl ow
allowed through the segment of bowel, and the venous
outfl ow visualized to verify proper fl ow. In this case, the
arterial fl ow must be stopped with a vascular clamp while
the vein is subsequently repaired. Once the fl ow is estab-
lished, the segment of bowel is observed for color and
peristalsis to verify viability. If the distal end of the bowel
lumen has not been repaired completely, the mucosa can
be inspected for mucosal color and bleeding of the edges.
Another option is to have a second, but smaller, seg-
ment of bowel left attached to the vascular pedicle—this
segment serving only as a monitor of fl ow and mucosal
bleeding. At the end of the surgical reconstruction, this
segment can then be discarded, or the segment can be
left exiting the skin fl ap coverage, to serve as a moni-
tor of the bowel viability over the next 7 to 10 days. At
that time, the vascular pedicle at the exit site is clamped,
transected, tied, and this segment of bowel is discarded.
CLINICAL APPLICATION . The jejunum is best suited for recon-
struction of a circumferential resection of the cervical
esophagus. It is also applicable for the repair of a patch of
pharynx, resection of the buccal mucosa, and even fl oor
of mouth.
ADVANTAGES . This fl ap allows for the repair of a mucosa-
lined tube of the esophagus to be repaired with like-tissue.
There is no longitudinal suture line that can potentially
FIGURE 35-21. (continued) routed above the clavicle and fi lling the orbital contents
(E). At 12 days, the pedicle was transected at the infrorbital rim and inset over a penrose
drain (F), and the remainder of the pedicle was discarded. The reconstructed fl ap is
durable (G), and the chest donor site (H) is healed by direct closure.
E
F
H
G

HEAD AND NECK CANCER • 403
leak saliva and oral bacteria into the closed contents of the
neck. The segment of bowel can tolerate a full course of
postoperative radiation therapy.
DISADVANTAGES . The harvesting and repair of the
donor bowel is time-consuming, although this can be
circumvented by using two surgical teams—one to per-
form the resection of the recipient site and microvascular
repair in the head and neck, the second to harvest and
repair the donor bowel in the abdomen. There is always
the risk of subsequent intra-abdominal adhesions in the
postoperative period, with risk of bowel obstruction.
FIGURE 35-22. A recurrent epidermoid carcinoma (A) involved the ethmoid, frontal,
and maxillary sinuses, with invasion of the orbital contents. The tumor was removed with
a radical craniofascial resection (B). The resulting large facial defi cit was fi lled in with
and extended pectoralis major myocutaneous fl ap (C) in one stage. The fl ap pedical was
left attached outside the neck for 2 weeks, at which time it was divided and inset as a
second stage, and the pedicle was discarded (D).
A
B
D
C

404 • CHAPTER 35
Radial Forearm Free Flap . The fasciocutaneous fl ap
from the anterior surface of the radial forearm can be
particularly useful for head and neck reconstruction. The
fl ap has been shown to be easy to harvest, reliable for
repair, and possess robust durability for the reconstruc-
tion of various sites of the body. 71 , 72 It has been used for
the repair of the cervical esophagus with an excellent
outcome. 73
TECHNIQUE . The surgical defect of the resection site is mea-
sured and the necessary fl ap is outlined overlying the radial
artery on the distal volar forearm ( Figure 35-28 ). It is pref-
erable to outline the required fl ap with its central axis
directly over the radial artery as much as possible, even
though this is not essential, as the fl ap is harvested with the
fascia and accompanying vascular connections.
It is better to begin the dissection from the ulnar side of
the fl ap, and dissect toward the radial artery, as the fascia
is more readily identifi ed here. The muscle fascia does not
need to be harvested, because the risk of a hematoma is
otherwise greater, risking a greater loss of the skin graft
that is applied. The correct plane is just above the fl exor
retinaculum until the radial artery is approached, at which
time the dissection goes through this plane, down and
around the radial artery and its accompanying veins. The
artery at the distal limit of the fl ap is clamped, transected,
and ligated.
The dissection is then carried more radial to the artery,
and becomes more superfi cial again, coming up to the
fl exor retinaculum. As the dissection of the fl ap is com-
pleted in this direction, every attempt is made to not dam-
age the sensory branch of the radial nerve (small branches
are cut).
The fl ap dissection is carried more proximally where one
to two subcutaneous veins may be preserved with the fl ap.
This is not essential because the two radial artery venae
commitantes are suffi cient for the anastomoses in most
cases. However, it is recommended these subcutaneous
FIGURE 35-23. (A) The trapezius muscle with the occipital artery at the base
of the skull, the suprascapular artery at the shoulder tip, and the transverse cervical
artery in the middle, descending the back along the undersurface of the muscle.
(B) The distal trapezius outlined posteriorly over the descending portion of the transverse
cervical artery. The latissimus dorsi fl ap along the posterolateral chest is supplied by the
thoracodorsal vessels.
A
B

HEAD AND NECK CANCER • 405
veins be included with the fl ap as a precaution in the event
the other veins are damaged in the neck, or are deemed to
be insuffi cient.
The skin is incised proximal to the skin fl ap markings
to access the vessels deep to the fl exor muscles in order to
provide suffi cient length to the pedicle. Once the vessels
in the neck are judged to be properly prepared, the radial
artery and the veins of the fl ap are cut, and the proximal
ends ligated.
The fl ap is brought to the recipient site, and the perim-
eter of the fl ap is sutured securely to the margins of the
wound with 3-0 silk, or polyglycolic acid absorbable suture.
It is essential that the suture line is secure and somewhat
watertight so that salivary fl uid and oral bacteria do not
continue to contaminate the neck in the postoperative
period. Once the fl ap is secure, the vascular pedicle is
repaired. This can be performed either with microsutures
or with the microcoupler as discussed above.
Finally, the donor site on the forearm needs to be
repaired. If the harvested fl ap is small, the donor site can
be closed in some cases with transposition and advance-
ment fl aps of the forearm. Otherwise, the surgical
donor wound is covered with a split thickness skin graft
( Figure 35-29 ). If the fl exor retinaculum was preserved,
then the healed skin graft can glide over the fl exor ten-
dons without adherence.
CLINICAL APPLICATION . The radial forearm free fl ap is best
suited for the reconstruction of any defect that requires
thin, pliable tissue. This fl ap is ideal for the fl oor of mouth
( Figure 35-30 ), some repairs of partial resection of the
tongue, alveolus, retromolar trigone, and buccal surface.
This fl ap can also be used for the repair of fi stulae of the
pharynx, partial resections of the cervical esophagus, and
even for circumferential resections ( Figure 35-31 ).
FIGURE 35-24. The patient required a resection of recurrent carcinoma of the soft
tissues of the submandibular area (A). If the transverse cervical artery is known to have
been previously transected in the neck (B), then the vessel can be identifi ed along the
anterior margin of the undersurface of the muscle. Since this blood fl ow is now retrograde
from the back of the chest, the vessels are protected by direct vision, while the posterior
skin incision is made.
A
B

406 • CHAPTER 35
ADVANTAGES . Provides thin pliable skin and soft tissue of
varying sizes to reconstruct small- and moderate-sized
defects of the oral cavity. The donor site is easily managed
by direct closure or with a skin graft, in which case a small
splint will allow the patient to use the hand for meals.
I have also used a single large fl ap to resurface an extensive
resection of the entire forehead from one temporal hair-
line to the other.
DISADVANTAGES . The donor site on the forearm is visible,
and a failed skin graft can develop hypertrophic scars.
There can be symptomatic neuromas if there is damage to
the radial sensory nerve.
Scapular Free Flap . This fl ap of soft tissue is based over
the axial blood supply of the circumfl ex scapular artery,
a branch from the subscapular artery that penetrates
the triangular space formed by the teres major, the teres
minor, and the triceps muscles to reach the skin over
the posterior shoulder. 74 The circumfl ex scapular artery
then bifurcates into a transverse scapular branch and a
descending parascapular branch. This split of the main
axial vessel allows the surgeon to develop two separate
skin paddles. In fact, there is a third vascular branch that
enters the scapula along its descending lateral border to
provide endosteal blood supply, which allows the har-
vesting of a third fl ap incorporating a segment of bone. 75
This fl ap was very helpful for the reconstruction of major
soft tissue resections removed with a portion of the man-
dible in advanced oral cancers.
TECHNIQUE . The shoulder ipsilateral to the side of the
proposed mandibular rersection is prepped and draped
while the patient is turned to the opposite lateral decu-
bitus position. The patient is then placed supine for the
resection of the tumor and mandible. Subsequently, the
patient is returned to the lateral decubitus position for
harvest of the fl ap. To locate the triangular soft tissue
FIGURE 35-24. (continued) The incision is deepened through the muscle fi bers
until these vessels are approached (while still visualizing them directly), and the distal
portion of the vessels (C) are freed more posteriorly under the trapezius. This is continued
until enough of the vessel length is freed from the muscle to allow for transposition of
the fl ap (D, E).
C
E
D

HEAD AND NECK CANCER • 407
through which the vascular pedical traverses, the index
fi nger of the surgeon is placed in the posterior axillary
fold, and the thumb is placed on the posterior of the
shoulder until it falls in the depression between the teres
major and teres minor. This locates the site of penetra-
tion of the circumfl ex scapular artery, and is marked. The
two branches are then drawn horizontally and vertically
overlapping their ends over this point ( Figure 35-32 ), and
the lateral border of the scapula is marked, if a segment of
bone is needed. Either one or two skin paddles are then
drawn overlying the vessels, depending on the needs of
that particular reconstruction.
FIGURE 35-25. A recurrent epidermoid carcinoma
involving the skin and soft tissues of the mandibular and
cervical regions (A) in a patient in whom the pectoralis major
had been previously used. The defect was resurfaced with a
latissimus dorsi myocutaneous fl ap (B), with careful dissection
and preservation of the thoracodorsal vessels (C), for one-
stage repair (D). The fl ap is not bulky (E), and because it
has fresh muscular blood supply, can tolerate postoperative
radiation therapy.
A
B
D
C
E

408 • CHAPTER 35
The dissection of the skin paddle begins from distal
to proximal at the level of the deep fascia. The vessels
are easily identifi ed in this fascial plane, as the vascular
pedicle needs to be dissected into the soft tissue triangle.
If a segment of the bone is required, care must be taken
to not damage the short arterial branch that enters the
bone. The segment of bone is cut with a power saw to
the size and shape required for the reconstruction. The
circumfl ex scapular artery is then dissected far enough in
the space between the teres major and minor muscles to
provide a pedicle of 4 to 8 cm, including the two accom-
panying veins.
CLINICAL APPLICATION . This is the ideal fl ap when an abun-
dant supply of tissue is required with a repair of the man-
dible. A composite resection of a segment of mandible,
together with the a through-and-through resection of
the cheek can be reconstructed with a segment of bone
and two skin paddles, one for external coverage and one
for buccal lining.
ADVANTAGES . The vascular pedicle is quite reliable, and a
signifi cant amount of skin can be harvested for large areas
of resection. The donor sites can be closed with local
advancement fl aps without the need for skin grafts.
DISADVANTAGES . The position of the patient needs to
be changed during the procedure, between the resec-
tion of the operative site and the harvesting of the fl ap.
Furthermore, the ablative and reconstructive teams are
not able to work simultaneously. If a segment of scapula
is incorporated, the bone in most patients is usually not
thick enough to permit osseointegrated dental implants.
Fibula Free Flap . The fi bula free fl ap has evolved into
the bone of choice for the reconstruction of the mandible
FIGURE 35-26. (A) Microcoupler applicator device holding two arterial ends on the
pins of the microcouplers prior to closing. (B, C) Pairs of artery and vein anastomosed
with microcouplers. (D) A free fl ap in the fl oor of mouth has been repaired using the
microcoupler to anastomose the radial artery ( center ) to the superior thyroid artery, and
the two venae comitantes to branches of the facial vein.
A
B
D
C

HEAD AND NECK CANCER • 409
FIGURE 35-27. (A) A donor segment of jejunum is identifi ed
based on a proper vascular arcade. (B) The proximal portion of
the segment is repaired to the base of tongue and oropharynx, the
distal end to the esophagus, and the mesenteric artery and vein are
anastomosed to the ascending pharyngeal artery and internal jugular
vein. (C) A secondary loop of bowel is left attached to the exterior
of the neck for monitoring of the viability of the primary segment of
bowel. (D) The fi nal healed wound after the secondary segment has
been removed. (E) A barium swallow showing the continuity of the
pharyngoesophagus.
A
B
C
D
E

410 • CHAPTER 35
since its introduction in 1989. 76 What makes this fl ap
ideal is the abundant length that can be harvested, up to
25 cm, and the thickness of the cross-section of the bone.
This choice of reconstruction of the mandible is ideal for
osseointegrated dental implants. In addition, skin overly-
ing the midportion of the fi bula has cutaneous perforating
vessels that can provide a small segment of thin skin for
intraoral lining.
TECHNIQUE . The leg is prepped circumferentially up to the
groin, and a sterile thigh touriquet is applied. The cuta-
neous perforating vessels are identifi ed with a doppler
probe and marked on the skin overlying the midportion of
the bone, and the skin paddle is outlined ( Figure 35-33 ).
The leg is elevated to exanguinate it by gravity, and the
tourniquet is infl ated. In this fashion, there is still some
blood in the vessels to help to visualize the structures
at the time of the dissections. First, the anterior skin
incision is made down to and including the underlying
muscle fascia. The skin paddle is dissected with the fas-
cia to protect the perforating vessels, until the septum is
reached. Here the dissection is carried into the muscles of
the lateral compartment with a needle-tip electrocautery
to harvest the bone with a thin 5-mm layer of muscle left
attached to the bone to protect the periosteal blood sup-
ply. The dissection is carried through the septum of the
lateral and anterior compartments, and the dissection is
continued with a muscular cuff. When the interosseous
septum is reached, this structure is incised carefully to
avoid damage to the vessels lying deeper to it.
Next, the posterior skin incision is made through the
fascia. The soleus is separated from the bone with electro-
cautery, and the fl exor hallucis longus muscle is incised.
The proximal osteotomy is performed at the level of
FIGURE 35-28. The radial artery is outlined on the
distal volar forearm, as well as any veins that can be seen
or palpated. The size and shape of the required fl ap is
outlined over this artery, and the proximal skin incision for
the dissection of the vascular pedicle is marked in a lazy-S
pattern.
FIGURE 35-29. If the skin paddle is small, the donor
site may be closed with advancement fl aps. If the fl exor
retinaculum is preserved, the skin graft will heal to this tissue
and allow the fl exor tendons to glide underneath it without
attachment to the overlying skin.
the neck of the fi bula, while the distal osteotomy is per-
formed at the length of bone necessary, leaving at least
4 to 6 cm of fi bula above the lateral malleolus to retain
ankle stability. The bone is then pulled laterally to expose
the tibialis posterior muscle, which is dissected with the
electrocautery. As this dissection is carried proximally,
the bone will be released further, exposing the vascular
pedicle. Proximally, the vessels are carefully visualized
during the dissection as it traverses toward the bone. If a
longer vascular pedicle is needed, and there is suffi cient
bone, the proximal periosteum is dissected with the vas-
cular pedicle off the bone, and this segment of stripped
bone can be transected with a sagittal saw. The segment
of bone can be shaped to the pattern of the resected man-
dible by performing osteotomies. The vascular pedicle is
dissected at the subperiosteal plane off the bone at the
site of each planned osteotomy. The segments of bone
can then be plated to complete the shape.
CLINICAL APPLICATION . This fl ap can be used for the recon-
struction of segmental, hemi-, or subtotal resections of the
mandible. It is particularly useful for one-stage reconstruc-
tions of mandible requiring a limited amount of intraoral
lining.
ADVANTAGES . The bone can be resected with minimal dis-
ability to the patient. It can provide large lengths of thick
bone that can be shaped with variable osteotomies. There
is suffi cient cross-sectional area to permit the placement
of osseointegrated dental implants. Thin pliable skin can
be harvested with the bone to provide intraoral lining. The
fl ap can be harvested by a second team of surgeons, while
the fi rst team is completing the resection of the tumor,
and preparing the neck vessels for the microvascular
anastomosis.

HEAD AND NECK CANCER • 411
A
B
D
C
FIGURE 35-30. The resection of an ulcerated carcinoma of the fl oor of mouth
(A) results in a moderate-sized defect requiring coverage of the mandible (B). The
fl ap is marked on the forearm and elevated, preserving the fl exor retinaculum (C), and
transferred to the fl oor of mouth (D). One week later, the fl ap and margins (E) show
appropriate healing.
E

412 • CHAPTER 35
DISADVANTAGES . While most patients are able to ambulate
within a week of the operation, some patients may need
an extended period of time to regain suffi cient ambula-
tion to become independent again. Ankle instability is
otherwise uncommon.
COMMENTS
While there has been a trend in publishing the successful
series of a number of microvascular free fl ap reconstruc-
tions, there is no single fl ap that is the “universal fl ap of
choice.” Surgeons who participate in reconstructions of
the head and neck area must be suffi ciently experienced
with all of the techniques mentioned in this chapter in
order to select the proper fl ap for each individual case,
based on the particular needs—whether that is based on
size of tissue, structures needed, previous fl aps that have
been already harvested, previous surgical scars, previ-
ous radiation to the donor or recipient sites, or patient
concerns about the location or extent of scars necessary
for the donor fl ap.
A previous review of this author’s fi rst 360 cases of
reconstruction reveals that the myocutaneous fl aps were
used in about half of the patients, and microvascular
free fl aps in the remainder, particularly when thin intro-
ral lining was required, or when bone was necessary for
mandibular resections ( Table 35-4 ). On a worldwide
basis, myocutaneous fl aps are utilized more readily by
surgeons, particularly because they do not require spe-
cial instruments or microscopes. However, the reliabil-
ity of performing the free fl aps with operating loupes
has extended the use of these fl aps for specialized needs.
Nevertheless, there are numerous reports attesting to
the far more extensive use of the pectoralis major fl ap
in South America, 77 Asia, 78 and Eastern Europe. 79 The
myocutaneous fl aps have robust blood supplies that allow
the use of intraoperative brachytherapy with radioactive
seeds, 29 and the addition of postoperative radiation far
FIGURE 35-31. A laryngopharyngectomy that required a circumferential resection
of the cervical esophagus (A) is repaired over a nasogastric tube, with the suture line
anteriorly (B). The cervical apron fl ap is then brought down to cover the repair (C).
A
B
C

HEAD AND NECK CANCER • 413
FIGURE 35-32. A patient with a recurrent epidermoid carcinoma of the fl oor of
mouth with invasion of the mandible and tumor involvement of the soft tissues of the face
required through and through resection (A). Two skin paddles incorporating the scapular
and parascapular vascular axes (B) were outlined, and these two separate fl aps were
harvested with a segment of scapular bone (C) on a third vascular pedicle. The segment
of bone was plated to the mandible (D). At 1 year, there is good contouring to the one
skin paddle on the neck (E), as well as the second skin paddle in the lateral fl oor of mouth
(F) covering the bone fl ap.
A
B
D
C
E
F

414 • CHAPTER 35
FIGURE 35-33. A paddle of skin from the leg (A) is harvested with a segment
of fi bula (B), to reconstruct a defect of the lateral fl oor of mouth (C) and body of the
mandible. At 1 month, there is good reconstitution of the mandible (D), and the fl oor of
mouth (E).
A
B
C
D
E
better than cutaneous fl aps. 80 We have also demonstrated
that a reconstruction with these myocutaneous fl aps per-
mits future resection of recurrent tumors, reelevation of
the residual myocutaneous fl ap, and reconstruction with
this same fl ap, thereby avoiding the dissection of a new
fl ap. 81
Patients with head and neck cancer should be seen and
evaluated by a multidsiciplinary team of physicians. All
treatment options should be considered and reviewed,
and the recommendations should take into account the
special needs of each individual patient. If an exten-
sive resection is performed, the head and neck surgeons
should remain facile with all the various techniques of
fl ap reconstructions, and should continue to select those
reconstructive methods that best fi t the surgical require-
ments of each case.

HEAD AND NECK CANCER • 415
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REFERENCES
TABLE 35-4. Distribution of Flaps Used for
364 Reconstructions of the Head and Neck
COMPLICATIONS
Skin Paddle
Flap
TH
Number
Percent
Pt
TH
PLATYSMA
9
11%
1
transverse
SCM
33
42%
superior
223
9
inferior
210
5
PECT. MAJOR
125
9%
oropharynx
253
6
1
neck
215
1
esophagus
28
orbitofacial
225
1
temp. bone
219
jaw/rib
25
1
1
TRAPEZIUS
18
LAT. DORSI
12
8%
1
FREE FLAP
133
7%
lat. Dorsi
212
3
jejunum
21
omentum
22
radial forearm
270
1
1
rib
23
scapula
215
2
cut.
27
osteocut
28
fi bula
232
osteo
216
1
osteocut
216
1
TOTAL
364
10%
29
2
5

416 • CHAPTER 35
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INTRODUCTION
The oral cavity is the most prevalent site for primary
cancers within the head and neck and represents the
sixth most common malignancy in the United States.
The American Cancer Society and the National Cancer
Institute’s Surveillance, Epidemiology, and End Results
(SEER) report indicates that approximately 5% of all
newly diagnosed cancers in the United States are can-
cers of the oral cavity and adjacent structures. The most
common primary malignancy of the oral cavity is oral
squamous cell carcinoma (OSCC), accounting for 90%
of lesions, with the majority of patients presenting with
advanced stage disease. Due to the advanced stage at the
time of presentation, only half of all patients with newly
diagnosed oral cancer remain alive 5 years from the time
of their diagnosis.
There is no single etiologic agent that is solely respon-
sible for cancer of the oral cavity. Carcinogenesis is likely
due to a combination of intrinsic and extrinsic factors
which function synergistically over a long period of time.
The strongest correlation for development of oral cancer
is exposure to extrinsic carcinogens, such as tobacco and
alcohol. While the use of tobacco exposure remains the
leading risk factor for the development of oral cancer, with
alcohol second, the two in combination have a synergistic
effect. Recently, it has been discovered that Epstein-Barr
virus, HIV, and human papilloma virus infections are also
associated with oral cancers.
Oral cancer is predominantly a disease of middle to
later age, with a median age at presentation of 68 years in
the United States. Oral cancer demonstrates a male pre-
dominance, but the incidence in women has progressively
increased in recent years. In 1934, 15% of newly diagnosed
cases were women. This has increased to 47% in 1998. This
change may be due to inherent genetic susceptibilities in
women, but its exact etiology remains the topic of active
investigation. Changes in social behaviors such as smoking
and alcohol use may also be the cause of these changes in
demographics.
PATIENT EVALUATION AND SELECTION
The oral cavity is bordered by the mucosal surface of the
lip anteriorly, the hard palate superiorly, and the fl oor of
the mouth inferiorly. The posterior extent of the oral cav-
ity is the junction of the hard and soft palates superiorly,
and the circumvallate papillae inferiorly. The anterior
tonsillar pillar created by the mucosal refl ection of the
palatoglossus muscle is the most posterior aspect of the
oral cavity. Tumors arising from the tonsillar fossa and
posteriorly are managed differently than OSCC.
The oral cavity is divided into various subsites
( Figure 36-1 ), which are useful in identifi cation and
classifi cation of OSCC. They vary in their incidence of
development of OSCC and in approaches of surgical
management. They include the mucosal lip anteriorly,
the buccal mucosa laterally, the lower gingiva inferolat-
erally, the retromolar trigone posterolaterally, the upper
gingival laterally, the hard palate superiorly, the fl oor of
the mouth inferiorly, and the oral anterior two thirds of
the tongue.
The lymphatic drainage of the oral cavity progresses
initially to the ipsilateral facial, submental, submandibu-
lar, and jugulodigastric nodes (ie, levels I, II, and III of the
neck), and progresses to levels IV and V (infraomohyoid
and posterior triangle nodes) ( Figure 36-2 ). The midline
is drained by bilateral lymphatics.
Most patients with oral cancer present with advanced
stage disease, with regional, or less commonly distant,
metastases at the time of diagnosis. These patients typi-
cally present with signs or symptoms of their metastatic
Oral Cancer
Suhail K. Mithani, MD / Anthony P. Tufaro, DDS, MD, FACS
36
c h a p t e r

420 • CHAPTER 36
disease (palpable lymph nodes, pulmonary nodule).
Occasionally these patients present with symptoms that
are associated with local invasion of the primary tumor
(bleeding, mass effect, dysphagia, and odynophagia).
Key to reduction of morbidity and mortality in oral
cancer is early diagnosis and appropriate management
( Figure 36-3 ). Physical examination of the oral cavity in
high-risk patients is the most important aspect of early
recognition of oral cancer and precancerous lesions. Most
early stage oral cancers are less than 2 cm in diameter.
The most common locations of OSCC are the fl oor of
the mouth, the ventrolateral tongue, the lingual aspect of
the retromolar trigone, the hard palate, and the anterior
tonsillar pillar.
The anterior oral cavity and ventral aspect of the
tongue can be evaluated by asking a patient to open the
oral vestibule and direct the tip of the tongue dorsally
until it contacts the hard palate. By grasping the ante-
rior third of the tongue and directing it anteriorly, the
posterior fl oor of mouth, the retromolar trigone, and
the posterior ventrolateral tongue can be visualized. As
an adjunct, a mirror can be used to visualize the lingual
aspect of the retromolar trigone. Complete examination
includes manual palpation of all mucosal surfaces for
Buccal
Hard palate
Retro trig.
Soft palate
Floor of mouth
Circ. v. pap.
A
Cheek
Gum
Lip
Retromolar
trigone
Floor of mouth
Tongue
Hard palate
B
FIGURE 36-1. Oral cavity subsites.
Ia
Ib
IIa
IIb
III
IV
Va
Vb
FIGURE 36-2. Lymph node drainage of the head
and neck. Node levels. I: Submental and submandibular
nodes. Level II: Upper internal jugular nodes, posterior
to the back of the submandibular salivary gland, anterior
to the back of the sternocleidomastoid muscle and
above the level of the bottom of the body of the hyoid
bone. Level III: Middle jugular nodes, between the level
of the bottom of the body of the hyoid bone and the level of
the bottom of the cricoid arch, anterior to the back of the
sternocleidomastoid muscle. Level IV: Low jugular nodes,
between the level of the bottom of the cricoid arch and the
level of the clavicle, anterior to a line connecting the back
of the sternocleidomastoid muscle and the posterolateral
margin of the anterior scalene muscles; they are lateral
to the carotid arteries. Level V: Posterior triangle nodes,
posterior to the back of the sternocleidomastoid muscle,
and posterior to the line described in level IV. Level VI:
Posterior triangle nodes, posterior to the back of the
sternocleidomastoid muscle, and posterior to the line
described in level IV.

ORAL CANCER • 421
0
Stage I
Stage II
Stage III
Stage IV
20
Percentage
40
60
80
100
FIGURE 36-3. Oral squamous cell cancer survival
by stage.
irregularity, fi rm areas that may represent submucosal
disease, and the cervical region for adenopathy.
PREOPERATIVE EVALUATION
For small lesions felt to have a high risk of malignant
potential by patient history or clinical appearance, surgi-
cal excision with 1-cm margins is the preferred method
to achieve defi nitive diagnosis. For larger lesions, transoral
biopsy using local anesthetic is warranted and can provide
suffi cient pathologic evidence to make a diagnosis. Fine-
needle aspiration of suspicious nodal disease can provide
adequate tissue for pathological analysis. Pan endoscopy is
advocated for patients with larger tumors. This technique
allows the accurate evaluation of the extent of the primary
lesion and thus more accurate staging and at the same time
identifi cation of possible synchronous lesions
In addition to tissue diagnosis, radiographic imaging
can help delineate the extent of the disease, identify
metastases, and identify synchronous lesions (up to 15%
occurrence). CT scan of the head and neck for tumor
extent and metastatic disease is indicated for all but the
most limited tumors and is absolutely warranted in the
setting of advanced stage disease (ie, palpable nodes).
MRI with gadolinium contrast is benefi cial when bony or
perineural invasion is clinically evident or suspected. MRI
may provide better soft tissue imaging than CT, making
it more desirable for head and neck imaging of malignan-
cies of the tongue. Chest x-ray is the imaging modality
of choice for initial evaluation for metastatic pulmonary
disease. Suspicious lesions may be further evaluated by
CT scan of the chest. PET-CT may also be of benefi t if a
suspicious lesion is identifi ed by chest x-ray, but its cost
coupled with the equivocality of its benefi t over CT scan
for oral malignancy limits its value.
Staging and Survival
Oral cavity cancer is staged using the TNM (tumor, node,
metastasis) system following guidelines of the American
Joint Committee on Cancer ( Figure 36-4 ). Initial staging
of malignancy is based on clinical evaluation and radio-
graphic imaging. Final staging is based on pathological
evaluation and histology if surgical excision is performed.
The single-most important factor impacting long-term
outcome is the stage of disease at the time of diagnosis.
Additionally, the presence of lymph node metastasis is an
important prognostic sign. The presence of cervical node
metastasis decreases survival by 50% when compared
with patients without cervical nodal metastasis and iden-
tical tumor characteristics. Prognosis varies also by site
of tumor within the oral cavity. Stages I and II cancers
account for nearly 75% of newly diagnosed OSCC of the
lip. This group of tumors tend to present at an earlier stage,
and therefore are amenable to successful treatment with
cure rates of 90% to 100%. Early cancers of the retromolar
trigone, hard palate, and upper gingiva are also amenable
to successful treatment at rates approaching that of can-
cer of the lip; however, these lesions are often identifi ed
at a later stage. Survival is diminished in early cancers of
the anterior tongue, the fl oor of the mouth, and buccal
mucosa; however, local control rates of up to 90% can be
achieved with appropriate multimodality therapy.
Stage III disease accounts for approximately 20% of
newly diagnosed OSCC. Invasive lesions of the retromo-
lar trigone without spread to cervical lymph nodes are
curable, and demonstrate local control rates of up to 90%.
Locally advanced lesions of the hard palate, upper gingiva,
and buccal mucosa have a local control rate of up to 80%.
In the absence of clinical evidence of spread to cervical
lymph nodes, moderately advanced lesions of the fl oor
of the mouth, and anterior tongue are generally curable,
with survival rates of up to 70% and 65%, respectively.
TREATMENT MODALITY SELECTION
Stages I and II tumors of the oral cavity are can be cured
by surgery or radiotherapy alone. Tumor depth of inva-
sion greater than or equal to 3 mm in T1 and T2 disease
signifi cantly increases the risk of regional lymph node
metastasis. Advanced cancers (stages III and IV) of the lip
and oral cavity require multiple modality therapy with
limited exceptions. Furthermore, because locoregional
recurrence and development or progression of meta-
static disease is likely, advanced stage patients with oral
cancer should be considered for clinical trials of radia-
tion modifi ers or combination chemotherapy in addition
to surgery and/or radiation therapy.
SURGICAL MANAGEMENT
Surgical management of cancers of the oral cavity is dic-
tated by the site of tumor, its location and relationship to
adjacent structures. Extent of surgical resection is dictated
by the goal of the operative procedure (ie, curative or pal-
liative). There are several surgical approaches to the oral
cavity: peroral, mandibulotomy, lower cheek fl ap, visor
fl aps, and upper cheek fl ap.
Peroral Resection
Most small and moderate-sized tumors, T1 and T2, of
the oral cavity can be resected using a peroral technique

422 • CHAPTER 36
( Figure 36-5 ). Lesions of the anterior two thirds of the
tongue can be safely resected through the open mouth.
The surgery is best done under general anesthesia. A
nasal endotracheal tube facilitates complete visualiza-
tion. For tumors of the lateral border of the tongue, a
wedge resection of the tongue is achieved with a trans-
versely oriented incision. This will shorten the tongue
somewhat but will give the patient a better overall func-
tional outcome. A longitudinally oriented excision will
result in an elongated, “serpentine” tongue that can inter-
fere with function.
One-centimeter margins are marked out and the
resection carried out with cautery. Care should be taken
to avoid injury to the lingual and hypoglossal nerves.
Functional defi cits in either or both of these nerves lead
to signifi cant disability. Frozen sections are sent from
the deep muscular and mucosal margins. The defect is
closed in layers after careful hemostasis is established.
FIGURE 36-4. AJCC staging of oral cavity and lip lesions.

ORAL CANCER • 423
Absorbable sutures are used in the muscular layer and
the mucosa. Burying the knots on the mucosal closure
will decrease abrasion of adjacent tissues. Clear liquids
and oral rinses can begin in 24 hours.
Most thin T1 and T2 lesions of the anterior fl oor of
mouth and the buccal mucosa are amendable to resec-
tion and either direct primary closure or healing via sec-
ondary intention. Resections that extend into the deeper
structures, musculature, if left to heal by secondary inten-
tion will cause signifi cant scarring and possible limitation
of function. These resections may be reconstructed with
a full-thickness skin graft from the supraclavicular fossa,
or other sites in the head and neck. It should be sutured
in place and reinforced with a bolster dressing. This tech-
nique should help avoid signifi cant scar contracture.
Resections of the hard and soft palate present with
unique problems for reconstruction. Often, the size of the
resection will preclude the use of local tissue fl aps for clo-
sure. The options are healing by secondary intention, skin
graft, or primary closure. The process of secondary inten-
tion healing is quite effi cient and made much less painful
for the patient when a stent is used. The patient is referred
to their dentist prior to resection for the stent fabrication.
At the time of surgery, the stent is placed. This technique
is also very effective when a skin graft is placed. The stent
can protect the skin graft and decrease patient discomfort.
Primary closures in the area of the hard palate will often
leave an area of denuded periosteum at the donor site.
Here, again, the use of a preoperatively fabricated stent will
facilitate wound healing and decrease patient discomfort.
Malignant lesions of the alveolus and fl oor of mouth are
often adherent to the adjacent bone. There must be a com-
plete evaluation of the bone preoperatively. When tumor
develops adjacent to dentition, often the malignant lesion
A
B
C
D
FIGURE 36-5. Peroral resection of tongue lesion. (A) The extent of resection is
outlined with marking pen; 1-cm margins are desired. (B) Initial incision. (C) Defect after
removal of lesion. (D) Result after primary closure. Note transverse closure to optimize
postoperative function.

424 • CHAPTER 36
will extend down the periodontal ligament and into the
soft cancellous bone rather than direct invasion through
the cortical bone.
In patients where there is signifi cant tumor burden adja-
cent to bone, a marginal resection may be done. The bone
will represent the “deep margin.” A marginal mandibular
resection will leave the inferior border intact and reduce
the functional defi cit.
Marginal resections are very diffi cult in the edentulous
mandible where residual bone stock is often atrophic.
Patterns of bone resorption with time may leave the patient
with a pencil thin mandible that is prone to fracture, par-
ticularly if any bone is attempted to be resected.
It is important to round all bony surfaces after the
marginal resection. This will reduce the possibility of
erosion and exposure. The rounded bone edges will
decrease stress and potential for fracture. This small step
will improve the patient’s ability to wear prosthesis in
the postoperative period. The defect created by the mar-
ginal resection can often be closed with the local tissue.
The resection decreases the height of bone and mobili-
zation of buccal soft tissue and the fl oor of mouth will
often allow for primary closure. A radial forearm free tis-
sue transfer is an excellent option for more complicated
reconstruction. A marginal resection is contraindicated
in cases of gross tumor invasion into bone as identifi ed
on radiographs or clinical examination, tumor metastasis
(ie, renal cell, prostate) to bone, or evidence of invasion
of the inferior alveolar canal and its contents, which may
present as paresthesia.
Mandibulotomy
Tumors arising in the middle and extending into the pos-
terior third of the tongue and fl oor of mouth, or lesions
arising or extending into the oropharynx will need wider
access for oncologic resection. The use of mandibulo-
tomy will allow wide and safe access to the posterior
oral cavity back to the prevertebral space ( Figure 36-6 ).
A panoramic radiograph of the mandible is obtained
preoperatively to plan proper placement of the osteot-
omy to avoid tooth roots and other anatomic and den-
tal obstacles (eg, bridgework, infected teeth, impacted
teeth).
The osteotomy is planned just anterior to the mental
nerve. This will allow for an easier osteotomy between
the premolar roots and the canine, which have a natu-
ral divergence. This approach will preserve the inferior
alveolar nerve and sensation to the lip and gingiva. If
the mandibulotomy is placed in a more posterior posi-
tion, the osteotomy will be in the direct portal of any
radiation that may be needed in the postoperative period
and, as stated earlier, the inferior alveolar nerve will be
transected. Placement of the mandibulotomy in a more
anterior position will usually require extraction of a tooth
to facilitate the bone cut. If the tooth is not extracted,
the roots of the anterior teeth are at high risk of injury
and it opens the possibility of infection.
The mandibulotomy is carried out by dividing the
lower lip and elevating a cheek fl ap. The mental nerve is
identifi ed and a site selected for the osteotomy. The site
is marked on the bone. A bone plate is fi xed to the infe-
rior border of the mandible with 2-mm screws placed in
a bicortical fashion. The planned osteotomy should fall
directly under the central hole of a 7-hole plate. This will
allow for three screws on either side of the osteotomy.
The holes are drilled and the screws placed. A smaller
plate is now place in the tension band position again
with the central hole of a 5-hole plate over the osteot-
omy. These screws are placed in a monocortical fashion
to avoid injury to the dental roots. The holes are drilled
and the screws placed.
The plates are now removed and held on the back
table. The osteotomy is carried out with a sagittal saw. As
the alveolar ridge is approached, the bone is scored and
the fi nal osteotomy is carried out with fi ne osteotomes.
The mandible is now able to be opened and excellent
access is given to the fl oor of mouth, posterior tongue,
and pharynx. Using cautery, the mucosa is carefully
opened. As the mylohyoid muscle is divided, close atten-
tion must be paid to the hypoglossal and lingual nerves.
They are found very superfi cially crossing from lateral to
medial across the fl oor of the mouth. At the termination
of the resection the soft tissue is re-approximated with
absorbable sutures. The muscles can be re-approximated
with interrupted sutures in an effort to reconstruct the
diaphragm of the fl oor of the mouth and ensure return
to normal function. The bone plates are reapplied to
the mandible in the predrilled holes. There should be a
small bone gap to account for the thickness of the saw
blade. Using this technique, the patient’s occlusion will
be unchanged from presurgical occlusion.
Resection of the Maxilla
for Oral Cavity Tumors
Resection of the maxilla is indicated for the management
of tumors arising on the gingiva, hard or soft palate, or
buccal sulcus ( Figure 36-7 ). The maxillary ostectomy is
indicated for tumors adherent to or invasive to the bony
maxilla. Depending on the extent of invasion, the max-
illary resection may be as simple as an alveolectomy for
small lesions progressing up through palatal fenestration,
partial or medial maxillectomy to complete maxillectomy.
For this discussion, we will limit the extent of resection to
more localized tumors.
The surgical plan begins with axial and coronal CT as
well as a panoramic dental radiograph. Dental impres-
sions preoperatively for the fabrication of stents are often
important.
Small lesions are addressed with mucosal incisions
down to bone with adequate margins. The bone is scored
or sectioned with a cutting burr or saw. The fi nal cuts are
fi nished with fi ne osteotomies. The small defect can be
dressed with petrolatum gauze and allowed to granulate
in. The dressing is removed at 1 week and the area will

ORAL CANCER • 425
A
B
C
D
FIGURE 36-6. Mandibulotomy for access to lesion in the posterior oral cavity.
(A) Mandible preplated with osteotomy site marked. Adaptation of plate prior to
osteotomy is critical in successful reconstruction. (B) Access to posterior oral cavity after
Mandibulotomy. (C) Fixation of Osteotomy. (D) End of Surgery.
re-mucosalize. A dental stent or obturator will reduce dis-
comfort and speed healing.
Large tumors will need to be addressed with an
upper cheek fl ap, Weber-Ferguson incision, for access.
Attention to detail for placement of the skin incision is
of great importance. The incision will be in the central
gaze of all people the patient comes in contact with, and
the incision should be placed along the lines of esthetic
units. The cheek fl ap is elevated with adequate soft tis-
sue margins. The infraorbital nerve is preserved if pos-
sible. The denuded portions of the cheek fl ap can be skin
grafted. The maxillary sinus can be covered with a skin
graft if the mucosa is removed. The skin graft is held in
place with petrolatum gauze and a prefabricated stent is
used to cover the defect and stabilize the packing. The
stent and packing are removed at 1 week. The patient is
instructed in daily irrigation and can obtain a fi nal pros-
thesis in 2 to 4 months, depending on healing.
Neck Dissection
The presence of nodal metastasis has a profound nega-
tive effect on patient survival, decreasing 5-year, disease-
specifi c survival by 50%. The American Cancer Society
states that more than 40% of patients with oral cavity
and pharyngeal squamous cell carcinomas present with
regional metastasis at their initial examination. The risk of
occult metastasis is relatively high for most primary oral
cavity cancers. The risk of oral cavity occult metastasis
is directly related to the thickness of the primary tumor.
Tumors of 3 to 5 mm in thickness have an occult meta-
static rate of about 30%.

426 • CHAPTER 36
A
B
D
C
FIGURE 36-7. Partial alveolectomy for oral cavity lesion. (A) Lesion arising from
left hard palate abutting maxillary alveolus. (B) Access to the maxilla utilizing a modifi ed
Weber-Ferguson incision and gingivabuccal sulcus incision. (C) Defect after removal of
portion of maxillary alveolus and palate. (D) Pathologic specimen.
Levels I, II, and III are at the highest risk for occult
metastasis from oral cavity primary tumors. The suprao-
mohyoid neck dissection has been shown to be effective
for the management of the clinically N0 neck in patients
at risk for occult metastasis. Approximately 30% of these
patients will have positive nodal disease at pathologic
evaluation. In patients with clinical evidence of cervical
nodal metastasis, a therapeutic neck dissection, includ-
ing levels I to V, is indicated ( Figure 36-8 ). Most often
a therapeutic neck dissection for an oral cavity primary
is a modifi ed neck dissection sparing the sternocleido-
mastoid muscle, the internal jugular vein, and the spinal
accessory nerve.
Technique: Supraomohyoid Neck Dissection
The incision is placed in a natural skin crease and extends
from the mastoid area to the midline approaching the
hyoid bone. The incision is two fi nger breaths below the
angle of the mandible. The incision is carried through the
platysma muscle, and superior and inferior subplatysmal
fl aps are raised. The greater auricular nerve and the mar-
ginal mandibular branch are identifi ed and preserved.
The marginal mandibular branch is found directly on the
capsule of the submandibular gland and is elevated with
either bipolar cautery or scissors. The nerve is retracted in
a cephalad direction. Next, the fascia overlying the ante-
rior border of the sternocleidomastoid muscle is incised
and the muscle freed of the investing fascia. The spinal
accessory nerve is identifi ed as it passes deep to the pos-
terior belly of the digastric muscle. The nerve is traced to
the point it enters the SCM. The nerve is freed using scis-
sors. The fi brofatty node–bearing tissue from level IIB is
passed deep to the nerve and the dissection proceeds down
the internal jugular vein to the omohyoid muscle. The
omohyoid is followed to the hyoid bone. The fi brofatty

ORAL CANCER • 427
SCM
SAN
SAN
IJ
HYPO N
DIG P
DIG A
OMO A
OMO P
FIGURE 36-8. Neck dissection. Structures identifi ed:
SAN, spinal accessory nerve; SCM, Sternocleidomastoid
muscle; DIG P, digastric muscle posterior belly; DIG A,
digastric muscle anterior belly; HYPO N, hypoglossal nerve;
IJ, internal jugular vein; OMO A, omohyoid muscle anterior
belly; OMO P, omohyoid muscle posterior belly.
tissue from the submental area is elevated using electro-
cautery. Care is taken to maintain good hemostasis in this
area to avoid injury to the lingual and hypoglossal nerves.
Cautery is used to dissect from anterior to posterior along
the anterior belly of the digastric muscle. The dissection
proceeds until the posterior edge of the mylohyoid muscle
is identifi ed. The mylohyoid is retracted to expose the sub-
mandibular gland. The gland is retracted posteriorly and
the lingual nerve is identifi ed in the cephalic portion of the
submandibular triangle. Care is taken to identify the secre-
tomotor fi bers going into the gland. They are clamped,
divided, and ligated. The hypoglossal nerve is identifi ed as
it crosses deep to the digastric tendon. The facial vein and
artery are identifi ed and divided. Wharton duct will pass
between the two nerves. The specimen is elevated poste-
riorly and the contents of levels I, II, and III are delivered
in continuity.
Technique: Modifi ed Radical Neck Dissection
The upper transverse incision is the same as for the suprao-
mohyoid dissection. A vertical incision is carried down to
the midpoint of the clavicle in a lazy-S. This should be
planned to lie over the sternocleidomastoid muscle. This
will protect the deeper vascular structures if there is a
dehiscence of the incision line, particularly if radiation
may be used in the postoperative period. The operation
begins in level V. The posterior fl ap is elevated and care is
taken to avoid injury to the spinal accessory nerve. It can
be found by identifying the trapezius muscle and fi nd-
ing the nerve on the deep surface of the muscle, where
the nerve enters at the junction of the middle and distal
thirds of the muscle. Once the nerve is found and freed
from investing tissue, the dissection starts in the apex of
the posterior triangle taking the fi brofatty node–bearing
tissue off of the deep muscles, the splenius capitis, and
levator scapulae. The dissection proceeds inferiorly and
is passed under the spinal accessory nerve down to clavi-
cle. The specimen is elevated anteriorly and the posterior
belly of the omohyoid is identifi ed. This muscle will be
freed and elevated so that the entire aspect of level IV
can be removed. The dissection should slow in this area
to avoid injury to the brachial plexus, phrenic nerves,
and internal jugular vein. As the internal jugular vein is
approached, in the left neck, all tissue must be divided
between clamps and ligated in an effort to avoid lym-
phatic leak from injury to the thoracic duct. The entire
specimen is passed deep to the SCM and combined with
the tissue from levels I, II, and III. The dissection then
proceeds as the supraomohyoid dissection. The fl aps are
closed over closed suction drains. The platysma muscle is
closed with interrupted sutures.
Adjuvant Therapy
Complete discussion of this topic is beyond the scope of
this chapter. However, in general, terms external beam
radiation is indicated for patients with multiple posi-
tive nodes, nodes completely replaced by tumor, extra
nodal extension of disease, and perineural and perivas-
cular tumor invasion. Recent reports have indicated that
patients at high risk for local regional failure may ben-
efi t from chemotherapeutic agents in conjunction with
surgery and radiation. The use of chemotherapy may
improve local regional control but shows little or no
improvement in survival.
COMPLICATIONS
There is a broad range of complications of surgery of the
oral cavity. They range from failure to affect an onco-
logic cure, to local wound breakdown and subsequent
infection, and sequelae of radiation therapy resulting in
injury to bone in the irradiated fi eld. Due to the often
times diffi cult nature of achieving ideal and appropri-
ate resection in the face of advanced or invasive disease,
these complications are at times unavoidable; however,
they may be minimized by careful planning, attention
to detail, and adherence to the oncologic principles set
forth in the previous sections.
Wound Infection
Wound dehiscence can result in infections which are
diffi cult to be treated with only antibiotics and may be
complicated by development of a salivary fi stula. The
most critical aspect in prevention of wound breakdown
is meticulous attention to the suture line, which must be
approximated completely, with apposition of tissue in a
watertight fashion along the entire length of the incision.

428 • CHAPTER 36
Oral incision lines are constantly bathed in the salivary
microbiologic milieu which is conducive to infection of
the underlying soft tissue and bone if the suture line is
compromised in any way. Meticulous attention to the
suture line is especially critical in patients after onco-
logic resection due to the impaired wound healing asso-
ciated with subsequent radiation therapy after surgery.
Additionally, appropriate preoperative antibiotics have
been shown to diminish the likelihood of infection,
but are not a substitute for appropriate closure. Broad-
spectrum antibiotics and debridement of infected tissue
with packing and healing with secondary intention is
the initial management of wound infection. Bony hard-
ware in the region of wound infection must be removed
with attempts at reconstruction deferred until infection
is managed. In the setting of intractable wounds, fl ap
reconstruction is often required to facilitate infection
resolution.
Osteoradionecrosis
Radiation therapy is an important adjuvant to surgical
resection for management of oral cancer, especially for
local control of advanced disease, but it is not without
its sequelae. Tissues surrounding the irradiated fi eld are
subject to devitalization, hypovascularity, and hypoxia.
In the oral cavity this can retard wound healing of the
soft tissue and lead to devitalization and necrosis of the
bone, also known as osteoradionecrosis (ORN). ORN
and inevitable wound breakdown is highly associated
with development of infection. The incidence of ORN
increases with increased radiation exposure (.6000
cGy) and occurrence can either be spontaneous or asso-
ciated with local trauma such as tooth extraction, biopsy,
or surgery that stresses the regenerative capacity of the
bone. The mandible is the most commonly affected
bone by ORN after oral cancer resection. The incidence
of ORN can be greatly diminished by thorough dental
evaluation and extraction of infected or nonrestorable
dentition in all patients with oral cancer who may con-
ceivably receive radiation therapy. Extraction of diseased
teeth should be carried out at least 3 weeks prior to radi-
ation. All patients who receive radiation therapy should
undergo prophylactic fl uoride therapy daily for life to
prevent radiation caries.
The management of ORN involves hyperbaric oxygen
and limited sequestrectomy for early stage disease and
radical debridement of nonviable or infected tissues for
more advanced disease, which may involve bone, subcu-
taneous tissue, and/or skin. Reconstruction can employ
bone graft, but the hypoxic nature of the wound bed
especially in the setting of further irradiation, makes
this an inadequate option for reconstruction. Free vas-
cularized bone fl aps are the optimal choice for recon-
struction of ORN of the mandible requiring extensive
debridement.
OUTCOMES ASSESSMENT
Aside from the development of immediate or delayed
complications described above, the assessment of sur-
gical outcomes is directly related to the recurrence of
tumor. This may be local recurrence in the vicinity of
the oral cavity, regional recurrence in the draining lymph
node basins, or metastatic recurrence in sites distant to
the original tumor.
Local Recurrence
Return of tumor to the site of original resection is termed
local recurrence . Diagnosis is made by clinical evaluation
of the site of primary disease or patient complaints similar
to the initial presentation of disease. Its incidence is high-
est in the fi rst 2 years after initial resection and is highly
unlikely to occur after 5 disease-free years. Local recur-
rence is likely due to incomplete initial resection with
residual micro- or macroscopic disease present at the time
of initial extirpation. Adherence to the principle of achiev-
ing 1-cm margins in all planes is the most likely method to
prevent local recurrence. Often, oral cancer is associated
with a desmoplastic reaction in the surrounding tissues,
making the margin of tumor spread indistinct and diffi cult
to defi ne clinically. When it is unclear whether appropri-
ate margins have been achieved with wide excision, intra-
operative frozen section with pathologic analysis should
be undertaken in the plane which is in question. A 1-cm
additional margin should be taken beyond the extent of
pathologically positive frozen section. Management of
local recurrence follows the same principles as primary
resection with a goal of achievement of at least 1-cm
margins. Oftentimes, resection of local recurrence is
complicated by intervening radiation therapy which cre-
ates concerns about wound healing and underscores the
importance of adequate resection at the time of initial
procedure. The management of local recurrence is a signif-
icant problem and should be addressed as soon as possible.
The surveillance schedule for the fi rst 2 years after initial
management is directed at early diagnosis, with clinical
examinations every 3 months, and imaging studies (CT,
MRI, ultrasound) on a 6- or 12-month basis.
Regional Recurrence
Regional recurrence is defi ned as development of malig-
nant spread of disease to the lymph nodes of the regional
nodal basin after resection of the initial disease. This can
be associated with local recurrence, but oftentimes it is
not. A diagnosis of regional recurrence is made by clini-
cal examination and imaging studies which are routinely
performed in the postoperative period after resection.
Avoidance of regional recurrence is best made by appro-
priate selection of patients for neck dissection at the time
of initial operation. Patients with cervical lymph nodes
larger than 1 cm in size or that are fi xed often have nodal

ORAL CANCER • 429
metastases. Suspicious lymph nodes should be biopsied
preoperatively by fi ne-needle aspiration. Patients with
biopsy-proven nodal disease should undergo uni- or
bilateral neck dissection at the time of initial opera-
tion, depending on the distribution of nodal disease.
Additionally, patients with primary tumors that invade
more than 3 mm into the basement membrane should
undergo a staging supraomohyoid neck dissection, due to
their propensity to have occult metastases.
SUGGESTED READING
Bessell A, Glenny AM, Furness S, et al. Interventions for the treat-
ment of oral and oropharyngeal cancers: surgical treatment.
Cochrane Database Syst Rev. 2011;9:CD006205.
Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL,
Trotti A, eds. AJCC Cancer Staging Manual. 7th ed. New
York: Springer-Verlag; 2009.
Noonan VL, Kabani S. Diagnosis and management of suspi-
cious lesions of the oral cavity. Otolaryngol Clin North Am.
2005;38(1):21–35, vii.
Ow TJ, Myers JN. Current management of advanced resectable
oral cavity squamous cell carcinoma. Clin Exp Otorhinolar-
yngol. 2011;4(1):1–10.
Pentenero M, Gandolfo S, Carrozzo M. Importance of tumor
thickness and depth of invasion in nodal involvement and
prognosis of oral squamous cell carcinoma: a review of the
literature. Head Neck. 2005;27(12):1080–1091.

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37
Intraoral Reconstruction
Frederic W.-B. Deleyiannis, MD, MPhil, MPH, FACS
INTRODUCTION
Oral cavity cancer and its treatment affect some of the
most fundamental functions of life, including eating,
communicating, and interacting socially. The treatment,
which may consist of surgery, radiation, or chemotherapy,
often is functionally and cosmetically devastating. Facial
disfi gurement, decreased understandability or absence of
speech, and diffi culty with swallowing and chewing are
common side effects of treatment. These disabilities can
alter patients’ self-esteem, limit their activity and employ-
ment, and decrease social interactions with family and
friends. 1
PATIENT SELECTION
The goals of reconstruction are to restore an individual
to his premorbid function and quality of life. Successful
reconstruction requires careful consideration of both the
surgical defect and patient-specifi c variables, such as gen-
eral medical health, radiation status, and dental rehabilita-
tion needs. Cardiac, vascular, and pulmonary disease, as
well as alcoholism, are common in head and neck can-
cer patients, and may independently impact survival and
limit reconstructive options. 2 For example, an individual
with severe, lower extremity, peripheral vascular disease
would likely not be a good candidate for a fi bular free
fl ap. Radiation induces soft tissue fi brosis, in particular,
perivascular fi brosis. Therefore, a history of prior radia-
tion and the anticipated decreased vascularity may guide
reconstructive options toward using a pedicled or free fl ap
instead of a skin graft. 3
The anticipated defect should be classifi ed on the extent
of the bony, soft tissue, and neurologic component. When
possible, respected tissue should be reconstructed with tis-
sue that duplicates both the appearance and the function
of the resected tissue. Epithelium can be used to resurface
muscle or mucosal defects. Muscle can be used to restore
bulk and motion, and palatal and mandibular skeletal
defects can be reconstructed with bone. Skin grafts, local
or regional fl aps, prosthetic devices, and free tissue trans-
fer are among the range of options that the reconstructive
surgeon must possess to customize the reconstruction to
an individual patient.
PATIENT PREPARATION
Oral cavity reconstruction should occur at the same time
as tumor resection. Patients undergoing a glossectomy,
mandibulectomy, and/or resection of their palate often
will require a tracheotomy to manage the airway. Another
important factor to consider is the status of the neck and
whether a lymph node dissection is needed or has been
previously done. Neck dissection can infl uence the recon-
structive decision in many ways, including the need to cover
the vessels of the neck (ie, if neck skin has been resected)
and the choice and side of infl ow and outfl ow vessels for a
free fl ap. If the reconstructive team is not performing the
tumor resection, the preoperative surgical plan should be
discussed with the head and neck surgical team to clarify
the expected extent of the defect, to plan the surgical inci-
sions, and to position the patient so that two teams can
work simultaneously. Positioning the patient 180 degrees
from the anesthesia team will allow suffi cient room for the
extirpative team to work in the head and neck and the
reconstructive team to simultaneously harvest a free fl ap
from the upper extremity, abdomen, or lower extremity.
TECHNIQUE
Primary Repair
Small defects of the oral cavity following extirpation of
smaller lesions may require little or no reconstruction,
c h a p t e r