Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

728
Section 9
Plastic and Reconstructive Surgery
clinical margins are often indistinct, especially with
superfi cial basal cell carcinoma on the thin skin of the
eyelid and those infi ltrating into the lid margin and
tarsal plate, thus making it very diffi cult to achieve nega-
tive histologic margins with narrow surgical margins. In
the inner canthus region, basal cell carcinoma tends to
invade deeply, and when the tumor appears to be fi xed
to bone, it often involves the lacrimal drainage system
or extends into the orbit. The reason for deep exten-
sion of small tumors is not the often quoted “embryonic
fusion plane” theory. Instead, it is well documented that
basal cell carcinomas are stromal dependent for contin-
ued growth. That is, they will invade tissue only with the
appropriate stromal components. Basal cell carcinoma
grows slowly and poorly in fatty tissue, but it grows more
quickly in fascia and muscle. With little protective fat in
the periocular region, basal cell carcinoma quickly
invades through the dermis and into the deeper tissues
of the medial and lateral canthus and orbital septum.
These extensions are invisible and hard to predict, and
the small microscopic extensions do not appear on
current imaging systems such as MRI or CT. Mohs
surgery or careful complete margin examination is
important for successful management of skin cancer in
this location.
Ears
Basal cell carcinoma, squamous cell carcinoma, atypical
fi broxanthoma, and melanoma are most common on
the ears. Chondrodermatitis nodularis helicis or focal
pressure dermatitis of the ear can simulate skin cancer,
thus emphasizing the value of biopsy before initiating
surgical excision. On the ear, skin cancer margins
are diffi cult to outline with certainty, and recurrence
rates are high. Tumors tend to invade through the thin
skin quickly down to perichondrium and spread later-
ally with little visual surface change. This is particularly
true on the antihelix and conchal bowl, as well as exten-
sions down into the external canal. Tumors rarely
invade cartilage, but sacrifi cing cartilage may be neces-
sary to achieve negative surgical margins during exci-
sion. In the preauricular and postauricular sulcus, the
lack of fat allows tumor to invade quickly, and deep
negative surgical margins are often diffi cult to
achieve.
Lips
Basal cell carcinoma is the most common tumor on
the upper lip, whereas squamous cell carcinoma is
the most frequently seen tumor on the lower lip.
Squamous cell carcinoma on the lower lip is often
associated with a dense infl ammatory infi ltrate, which
makes the true depth of invasion diffi cult to assess.
The tumor frequently feels deeper than is seen micro-
scopically. However, the in situ component of squa-
mous cell carcinoma on the lip often extends laterally
much wider than appears clinically. One option in the
treatment of lip lesions is to excise the invasive portion
surgically and treat the in situ component with a more
conservative approach such as laser destruction of the
vermilion.
Nose
Basal cell carcinoma, squamous cell carcinoma, mela-
noma, and Merkel cell carcinoma are often seen on the
nose. In this location, depth of tumor invasion is most
diffi cult to estimate, especially on the lower third of the
nose. The lack of fat allows early invasive tumors easy
access to muscle and fi brous tissue. Underlying carti-
lage also makes it diffi cult to palpate tumors adequately
to determine tumor depth with confi dence. Squamous
cell carcinoma arising from the nasal septum frequently
invades deeply to the bone of the nasal spine. Recur-
rence rates for all skin cancers are high for these
reasons, and therefore very careful examination of
margins or Mohs surgery is helpful to ensure clear
pathology margins.
Cheeks
All forms of skin cancer are seen on the cheeks, includ-
ing DFSP and angiosarcoma. The fat is often a barrier
to invasion of deeper structures until the cancer
becomes very large. Involvement of the medial portion
of the cheek adjacent to the nose or the lateral preau-
ricular aspect of the cheeks is associated with the most
diffi culty during excision because of enhancement of
tumor invasiveness by the superfi cially located muscle
or aponeurotic layers.
Forehead, Temple, and Scalp
All forms of skin cancer are seen in these locations.
Squamous cell carcinoma tends to be aggressive in
these locations, with satellite metastases being a common
complication of large tumors. Management of multiple
satellite and in transit metastases includes surgical exci-
sion when possible and the use of adjuvant wide-fi eld
radiation for local and regional control when multiple
widespread metastasis has occurred. The bone of the
skull acts as a strong barrier to invasion, but when the
periosteum is removed during excision and the bone is
pitted, the surgeon can safely assume that early bone
invasion has occurred. In this case the outer cortex
should be removed with an osteotome or burr or by
excision, followed by split-thickness skin grafting. Early
bone invasion is not easily seen with imaging studies
and must be part of the intraoperative assessment of
these tumors.
Neck
Skin cancers of the neck are the least diffi cult. Estimat-
ing depth and lateral margins is rarely complex, and
the excess loose skin makes reconstruction straightfor-
ward. Care must be taken to avoid the greater auricular
nerve on the lateral infra-auricular aspect of the neck
and the spinal accessory nerve on the posterior lateral
portion of the neck.
Reconstruction
The surgical approach to skin cancer must also include
plans for surgical reconstruction. Before reconstructing
any wound after excision of skin cancer, it is important

Chapter 80
Management of Skin Cancer of the Head and Neck
729
to have reasonable certainty that the excision margins
are clear of tumor. Re-excision for positive margins is
very diffi cult, especially after local fl aps, complicated
repairs, or repair with extensive undermining of tissue
has occurred. Reasonable certainty of negative margins
includes evidence-based width of surgical margins
around well-defi ned primary lesions with convincing
clinical judgment that the margins are clear. However,
for large, deep, recurrent, or poorly defi ned tumors,
reasonable certainty should include negative histopath-
ologic margins by extensive examination of the margin
or by Mohs surgery. Otherwise, reasonable certainty
occurs only with delayed reconstruction after margins
have been determined to be negative by permanent
paraffi n sections.
In most locations, reconstructive choices are pre-
dictable and results are reproducible. The following
discussion of reconstruction choices covers the majority
of defects after excision of skin cancer; however, each
defect is unique and each has its own challenges. Selec-
tion of the method of repair depends mainly on (1) the
likelihood of negative margins, (2) the laxity and avail-
ability of adjacent skin for closure, and (3) the desire
of the patient for a good cosmetic outcome.
Periorbital Repair
One of the fi rst considerations of periorbital recon-
struction is protection of the eyes, especially the cornea.
Poorly planned repairs may result in ectropion with
exposure-induced desiccation of the conjunctiva or
keratitis from drying of the cornea. Suture must be
placed in a manner that prevents irritation of the globe
as well. Eyelid margin repair is often best done by an
oculoplastic surgeon. In the skin around the eye within
the orbital rim, primary closure is easily performed if
special care is taken to move tissue horizontally, even if
the orientation of the ellipse is somewhat oblique. It is
important to have the patient open the eye and for the
surgeon to check for lid apposition or displacement
after placing the fi rst key suture. Larger defects of the
lower lid can be repaired with rotation fl aps based infe-
riorly and laterally. Care should be taken to design the
fl ap by extending the lateral incision superiorly so that
during rotation when the superior portion of the fl ap
moves medially and inferiorly, the eyelid is not pulled
down. A full-thickness skin graft also provides a good
cosmetic result, especially in the medial and lateral
canthus areas. On the lower lid, the inevitable shrink-
age of the graft increases the risk of ectropion, and
therefore it is a secondary choice. For treatment of
defects of the brow, the surgeon must plan to move
hair-bearing skin and maintain brow continuity even if
brow length is shortened. Vertically oriented primary
closure for small defects and island pedicle fl aps
for larger defects work well. Rarely, hair-bearing full-
thickness composite grafts can be harvested from the
temples with special care to maintain proper orienta-
tion of the hair follicles, even to the point of a double
graft in which the top graft of hair faces inferior and
lateral and the bottom half of the graft faces superior
and lateral.
Ears
Helical wound defects are the most common challeng-
ing reconstruction of the ear. When the defect pre-
serves cartilage and provides a good vascular base, a
full-thickness skin graft from the postauricular donor
site provides a very good cosmetic result. For defects
that extend to cartilage or include cartilage but are less
than 1 to 1.5 cm, helical rim advancement fl aps work
well (Fig. 80-4). During design it is important to cut
anteriorly through the skin and cartilage but not
through the posterior skin. Instead, undermining with
separation of the posterior skin from the cartilage leaves
a large vascular base for the helical rim fl ap. If the cut
extends through anterior skin, cartilage, and posterior
skin, only a small base of the helix is left to provide
vascular supply to the fl ap, and the tip is often compro-
mised. For large defects on the helical rim, an advance-
ment fl ap from the postauricular surface through the
postauricular sulcus can be performed as either a one-
or two-stage procedure. This provides a reproducible
repair and may require cartilage replacement from the
ipsilateral conchal bowl if cartilage is missing in the
helical rim. For superfi cial defects on the scapha, split-
thickness skin grafts from the postauricular mastoid
work well. Defects inside the rim of the scapha heal
nicely by secondary intention without the need for
repair. Defects of the external canal should be grafted
if they involve more than half the circumference to
prevent stenosis of the canal. Very large defects consist-
ing of more than half the ear may do best with a pros-
thesis rather than surgical reconstruction. When
planning to use a prosthesis, salvage of the tragus is
important to help hide the prosthetic border. Wedge
resection of the ear often results in an inferior cosmetic
result when compared with other reconstruction choices
and should be avoided if possible.
Upper Lip
Most wounds up to 1 to 1.5 cm can be repaired as a
vertically oriented primary closure.8 There is no value
in attempting to avoid cutting through the vermilion
border and the inferior triangle and using laterally
based incisions above it such as an A-to-T closure. Verti-
cal incisions around the vermilion should extend
around the lip and superiorly onto the labial mucosa.
The caveat is to avoid ending Burow’s triangle on the
vermilion or lip margin because this often results in
inferior displacement of the lip.
Defects of the philtrum can be closed primarily
only if they are very small. Larger superfi cial defects
down to muscle can be grafted with donor skin from
the preauricular, postauricular, or conchal bowl skin or
from Burow’s triangle harvested from above the defect
and extending to the inferior columella. Large and
deep defects of the medial aspect of the lip into muscle
near the philtral crest that are too large for primary
closure can be closed with horizontally moving advance-
ment fl aps using a perialar crescent and, if necessary,
another Burow’s triangle lateral to the commissure of
the mouth. Defects of the lateral portion of the lip are

730
Section 9
Plastic and Reconstructive Surgery
A
B
C
D
Figure 80-4. Helical rim advancement fl ap. A, Defect after excision of basal cell carcinoma. B, Bilateral helical rim advancement fl aps elevated
with a broad posterior base. C, Immediate postoperative result. D, Cosmetic result after 6 months.
more easily repaired. Superior lateral defects respond
nicely to island pedicle fl ap repair (Fig. 80-5). Prefera-
bly, these fl aps are designed within the cosmetic unit of
the lip and nasolabial fold. If necessary, the fl ap may be
designed to include the medial cheek skin as well. It is
important for the apex of the triangular island pedicle
fl ap to be oriented vertically at the most inferior portion
to prevent distortion of the commissure or upward pull
of the lip. For large inferior lateral defects of the upper
lip, inferior or laterally based transposition fl aps may
be helpful. Rarely are Karapanzic or Abbé fl aps
necessary.
Lower Lip
Primary closure of defects of the lower lip is usually
possible even if the defects extend up to half of the
width of the lip. For the best cosmetic result, primary
closure is not a simple wedge resection. A fusiform or
elliptical excision of skin is performed so that the supe-
rior triangle, if it involves the vermilion, extends around
the lip and then inferiorly onto the labial mucosa. For
larger defects, some muscle may be excised to minimize
bulk on closure, but less muscle than skin should always
be excised. Next, both the skin and mucosa are under-
mined above the muscle and laterally to elevate fl aps of
skin and mucosa. The muscle is closed fi rst, and then
the skin and mucosa are advanced over the muscle and
closed in layered fashion. Squamous cell carcinoma
arising from the vermilion of the lower lip often pre-
sents a problem of dealing with extensive in situ disease
along large portions of the vermilion. To minimize the
deformity of excision, one option is to excise the inva-

Chapter 80
Management of Skin Cancer of the Head and Neck
731
sive portion of squamous cell carcinoma, make plans
for primary closure, and then treat the in situ portion
with carbon dioxide laser destruction or alternatively
with superfi cial vermilionectomy and mucosal advance-
ment. Very large defects on the lip are fortunately very
rare but may require full-thickness cheek advancement
with a turnover of labial or buccal mucosa to re-create
the mucosa and vermilion of the lip.
Nose
Reconstruction of the nose requires a mastery of local
fl aps and grafts.9 For purposes of discussion, the nose
can be divided into reconstruction of the upper two
thirds and reconstruction of the lower third of the nose.
For defects of the upper two thirds of the nose, the skin
is less sebaceous than the lower third. Very large defects
in the nasal sidewall and dorsum can be repaired with
full-thickness skin grafts and good cosmetic results
achieved if the wound depth is not signifi cantly greater
than the thickness of the grafted skin from postauricu-
lar or supraclavicular donor sites. For very deep defects,
especially in thick sebaceous skin on the nose, a fore-
head fl ap provides a good result. Small midline defects
up to 1 cm on the nose can be closed primarily with
long vertical incisions extending from the nasal root to
the inferior nasal tip and including extensive under-
mining at the level of perichondrium and nasal bone,
essentially skeletonizing the nasal tip and dorsum. This
technique may narrow the nose slightly but usually pro-
vides an excellent cosmetic result. Small defects on the
nasal sidewall can also be closed primarily or may be
closed with small inferior and laterally based transposi-
tion fl aps.
The lower third of the nose is more diffi cult to
repair because of the unique thick sebaceous skin,
limited opportunity to recruit nearby skin, and the
need to prevent distortion of the tip or alar rim. For
defects of the tip, long primary closure as noted earlier
usually works well with wounds less than 1 cm in diam-
eter. Defects on the lateral tip or sidewall up to 1.5 cm
can be repaired with a bilobed fl ap (Fig. 80-6).10 For
defects of the lower sidewall and ala, a single-stage naso-
labial fl ap using cheek skin can provide a very good
result if care is taken in the design to excise Burow’s
triangle superiorly and advance the cheek skin while
closing the donor site by tacking the suture line to the
immobile tissue above periosteum in the area of the
lateral ala and the triangular portion of the upper lip.
This preserves the alar crease, prevents tenting across
the nasolabial fold, and minimizes the risk of trapdoor-
ing. The fl ap should be trimmed of excess fat before
suturing into the defect (Fig. 80-7). Defects of the ala
alone may be repaired with a two-stage nasolabial inter-
polation fl ap, especially if cartilage is necessary to
support the alar rim.11 Large defects on the tip and ala
can be repaired nicely with a two-stage forehead fl ap
A
C
B
Figure 80-5. Island pedicle fl ap reconstruction of the lip. A, Defect
on the superior lateral aspect of the upper lip. B, Immediate postopera-
tive result. C, Cosmetic result after 6 months.

732
Section 9
Plastic and Reconstructive Surgery
A
B
C
Figure 80-6. Bilobed fl ap on the nose. A, Defect after excision of a
basal cell carcinoma. B, Immediate postoperative result. C, Cosmetic
result after 6 months.
(Fig. 80-8). Grafts on the lower third of the nose are
useful when the defect is small and no deeper than the
thickness of grafted skin. The conchal bowl of the ear
is a very good donor site for this area because the skin
of the ear matches the skin of the nose better than any
other donor skin. In addition, the donor site can heal
by secondary intention by simply removing a small plug
of cartilage in the center of the wound to allow granula-
tion tissue to cover the remainder of cartilage and
promote re-epithelialization of the wound.
Forehead, Temple, and Scalp
The majority of wounds on the forehead can be closed
primarily, often even wounds up to 2 cm in diameter.
However, contrary to popular practice, vertically ori-
ented closures provide better results than horizontal
closures do. Very small defects less than 1 cm may be
closed horizontally. Anything 1 cm or larger may lift the
brow and create asymmetry or an irregular pattern in
the horizontal wrinkle lines of the forehead, and hori-
zontal closures often result in a persistent numb area
above the wound that is disturbing to patients. Skin
grafts on the forehead are noticeable and are rarely a
good choice for repair. In fact, when no good options
for closure exist, allowing the wound to heal by second-
ary intention is usually better than a skin graft.
On the temple and lateral aspect of the forehead,
primary closures are most useful, but with orientation
along radial lines so that the closure is vertical on the
lateral part of the forehead but horizontal when located
lateral to the canthus. Transposition fl aps may also be
useful on the temple and lateral aspect of the forehead,
especially near the hairline. In this area, special care to
avoid the temporal branch of the facial nerve during
excision and undermining is important.
Scalp
Most scalp wounds less than 2 cm in diameter can be
closed primarily after wide undermining below the
galea. For larger defects in hair-bearing skin, a very
large rotation fl ap may cover the wound. Scalp skin
stretches very little, and large wounds require a very
large rotation fl ap. Healing by secondary intention is
often a good choice, even in hair-bearing areas, because
the defect contracts signifi cantly and may result in a
wound smaller than any secondary defect created
during rotation of large fl aps. Skin grafts on a balding
scalp are a good choice for repair if the wound cannot
be closed primarily. When periosteum is removed and
bone is exposed, large fl aps may be necessary to cover
exposed bone. Burring of the bone to cause bleeding,
followed by the application of a split-thickness skin
graft, is a possible option, but burring of the outer
cortex destroys its barrier function to invasion by tumor.
Tumor recurrence in this area can then easily invade
the bone, thus making treatment of recurrences a high-
risk operation. Burring of bone as management of
exposed bone should be a last resort.

Chapter 80
Management of Skin Cancer of the Head and Neck
733
Cheeks
The loose skin of the cheeks makes primary closure
possible even for very large defects. Closures are usually
oriented vertically in the lateral and preauricular parts
of the cheek, are crescent shaped in the midcheek area,
and are obliquely oriented parallel to the nasolabial
fold for medial cheek defects. For large superior medial
cheek defects unable to be closed primarily, full cheek
rotation fl aps provide good results (Fig. 80-9). Large
wounds on the midportion of the cheek may be repaired
with island pedicle fl aps. Large lateral and inferior
wounds can be repaired with transposition fl aps consist-
ing of loose skin from the neck area as well.
Neck
The neck, like the cheek, has the advantage of large
amounts of loose skin, and therefore almost all wounds
can be closed primarily or with transposition fl aps.
POSTOPERATIVE MANAGEMENT
The immediate concerns during the postoperative
period are pain and bleeding. Most patients claim that
the aching or pain after skin cancer surgery is handled
well by acetaminophen for minor procedures and
minor narcotic pain relievers for larger procedures,
especially for wounds under tension or those involving
muscle. Bleeding is a risk, particularly in the fi rst 6 to
8 hours postoperatively, and is minimized by careful
intraoperative hemostasis, a well-placed dressing that
applies pressure over the wound and undermined areas,
and instructions to the patient to minimize physical
activity. Patients should be instructed that if bleeding
occurs, steady pressure for 20 minutes should stop most
bleeding episodes.
After 4 weeks, when the wound has developed
tensile strength, patients may massage their wounds to
minimize swelling and fi rmness of the scar. Rarely is any
scar revision worthwhile before 3 months. At 3 months
dermabrasion of wounds on the nose may be helpful,
and at 6 months re-evaluation of wounds for any other
revision surgery can be considered.
Managing Open Wounds
Some wounds are best managed without reconstruc-
tion. Small biopsy wounds; wounds after excision of
A
B
C
D
Figure 80-7. Single-stage nasolabial fl ap reconstruction of the nose. A, Defect of the ala with loss of the alar rim. B, Immediate postoperative
result with the fl ap turned under the alar rim. C, Immediate result with preservation of all creases and sulci. D, Cosmetic result after 6
months.

734
Section 9
Plastic and Reconstructive Surgery
A
C
B
Figure 80-8. Paramedian forehead fl ap for large nasal reconstruc-
tion. A, Full-thickness defect of the nasal tip, ala, sidewall, and vestibu-
lar dome. B, Reconstruction with mucosal advancement for nasal
lining, cartilage graft for support, and a paramedian forehead fl ap for
skin coverage. C, Cosmetic result after 6 months.
small cancers at the medial canthus, alar crease, ear,
forehead, and scalp; and even large graft donor sites
may heal better by secondary intention than by recon-
struction. Wounds in concave areas heal with better
cosmetic results than do wounds on convex surfaces.
Scars from wounds on pigmented skin or a red, ruddy
complexion will be more noticeable than the same scar
in pale, white skin. A scar is better camoufl aged in skin
with other lesions such as lentigines or keratoses than
in fl awless, smooth skin. All wounds contract and can
therefore create distortion of nearby structures during
healing, such as eclabion and ectropion. With these
predictable events in mind, one can make a better
informed decision about which wounds can heal and
which wounds should be repaired.
COMPLICATIONS
Aside from pain and bleeding, most postoperative com-
plications appear in the fi rst few weeks. Surgical site
infections are noted as early as 48 hours but most com-
monly 5 to 7 days after surgery. An infection is almost
always red and painful. Purulent discharge may not be
present. Redness may also be due to normal wound
healing or be exaggerated by a tight closure, excess
intraoperative electrocoagulation to control brisk bleed-
ing, or poor tissue handling or suturing technique. The
diagnosis of a surgical site infection is a clinical diagno-
sis by the surgeon alone. There is no absolute set of
criteria for infection. Even culture results do not defi ne
infection; they serve as only a guide for appropriate
antibiotic therapy once a diagnosis is made.
Hematoma at the surgical site should be drained if
possible and can usually be achieved through a 1- to
2-cm opening in the incision line. Local anesthesia may
be necessary if the blood is coagulated, and pressure is
necessary to evacuate the hematoma. Interstitial hema-
tomas occur when blood and fl uid infi ltrate the tissue
without a pooled collection. They cannot be drained.
Fortunately, interstitial hematomas resolve quickly and
completely.
Necrosis of fl aps and grafts may begin to occur at
1 week and develop over the subsequent few weeks.
Because it is diffi cult to estimate the true extent of

Chapter 80
Management of Skin Cancer of the Head and Neck
735
tissue loss in the fi rst week or two, it is better to delay
any decision to débride tissue until the full extent of
necrosis is evident by the appearance of a black eschar
or autolysis and separation of fully necrotic skin. Many
times dark or violaceous tissue will heal nicely with -
out the need for débridement. Early débridement is
discouraged.
One frustrating event in the postoperative course
is an open wound that fails to heal. Nonhealing wounds
are often caused by one of three conditions. The
most common is overgrowth of Candida albicans
caused by the topical application of antibiotics and
the use of occlusive dressings continuously for 3 weeks
or longer. There may be no clinical evidence of
infection by yeast. By simply adding or switching to a
topical antiyeast medication, healing can be promoted.
If the wound does not respond to antiyeast medications,
the failure to heal may be related to a skin condition
called erosive pustular dermatosis. This commonly
occurs on the scalp and forehead, although it can
be seen elsewhere as superfi cial erosions with thick
yellow and greasy crusts. This condition responds
quickly to the topical application of potent corticoste-
roid creams.
When exuberant granulation tissue appears ele-
vated over the wound edges, scraping it with a curette
or scalpel may promote wound healing. Local anesthe-
sia with epinephrine plus a pressure dressing is helpful
to control oozing and bleeding. If the granulation tissue
is only minimally elevated, it does not interfere with
healing and no manipulation is necessary. Topical treat-
ment of granulation tissue with silver nitrate or other
caustic agents delays wound healing and is not
recommended.
PATIENT EDUCATION
An important part of the postoperative management of
patients after skin cancer surgery is education of the
patient. Patients should be advised of their prognosis
and risk for recurrence locally, regionally, and systemi-
cally, all of which differ according to tumor type, size,
location, and treatment. Patients should be advised
about their family risk as well. Patients with a history of
B
A
D
C
Figure 80-9. Cheek rotation fl ap. A, Large defect on the superior medial aspect of the cheek. B, Rotation fl ap incised and undermined.
C, Immediate postoperative result. D, Cosmetic result at 6 months.

736
Section 9
Plastic and Reconstructive Surgery
melanoma and dysplastic nevus syndrome may have
family members at increased risk who should be evalu-
ated. Patients with sebaceous carcinoma are at increased
risk for gastrointestinal malignancies because of its asso-
ciation with familial polyposis, and their families should
also be screened.
Patients with a tumor at risk for regional
recurrence in lymph nodes should be instructed in
self-palpation of lymph nodes. Instruction should
emphasize the method of palpation and that most
regional disease is discovered fi rst by the patient.
Instruction may result in earlier detection by the patient
before regularly scheduled follow-up appointments.
One should emphasize the method of palpation and
advise that involved nodes are not usually painful. They
should also be instructed to palpate for satellite and in
transit disease.
Most skin cancers are associated with ultraviolet
light exposure. Patients should be instructed to mini-
mize exposure to ultraviolet light through the liberal
use of sunscreens and protective clothing. Sunscreens
should absorb ultraviolet light in both the UVA and
UVB range. Most people do not apply sunscreens liber-
ally enough to get the absorption indicated on the label
by the sun protective factor (SPF) value, so UVB protec-
tion ratings of SPF 30 or higher are better than a rating
of 15. Sources of artifi cial light in tanning booths are
just as harmful as sunlight and should be avoided as
well.
FOLLOW-UP
Patients with a history of skin cancer have at least a 40%
risk of a second skin cancer within the fi rst 5 years after
surgery and a higher risk if they have squamous cell
carcinoma or a history of multiple skin cancers. For this
reason they should be instructed in self-examination of
their skin at least monthly with a description of the
appearance of skin cancer. They should also be advised
to undergo full-body skin examination by a dermatolo-
gist at least yearly to detect new skin cancers early.
Follow-up schedules to observe for signs of local,
regional, or distant disease depend on the tumor type
and stage. For example, patients with high-risk tumors
such as Merkel cell carcinoma, thick melanomas, or
deep squamous cell carcinomas may be monitored
every 2 months, whereas those with uncomplicated low-
risk basal cell carcinoma should be scheduled for yearly
follow-up.
Follow-up for evaluation of the cosmetic result of
reconstruction varies with the procedure. Repairs at risk
of contraction and distortion may benefi t from the
injection of high-dose intralesional steroids (triamcino-
lone, 40 mg/mL) 1 month after surgery in areas such
as the lower eyelid or upper lip. Dermabrasion of suture
lines on the thick sebaceous skin of the nose occasion-
ally helps and is valuable at 3 months. Most other surgi-
cal revisions are best delayed until 6 months because of
spontaneous improvement in the early stages of wound
healing.
PEARLS
• Always have a pathology report from a biopsy of the
lesion and understand its signifi cance before
planning surgery.
• Know the literature about skin cancer. There are
standards for treatment that include surgical
margins, laboratory and imaging evaluations, and
the value of adjuvant therapy, including surgery,
radiation therapy, immunotherapy, and
chemotherapy.
• Learn how to visualize tumor margins with bright
lights and stretching the skin.
• Respect the need for clear surgical margins and
learn the meaning of the pathologist’s interpretation
of clear surgical margins.
• Practice quality assurance to improve the quality of
patient care and the results of surgery.
PITFALLS
• Failure to respect local recurrence of disease results
in a high risk for persistent disease when retreating
recurrent cancer.
• The use of surgical excision as the only option for
treating skin cancer overlooks important alternative
choices, including destruction, Mohs surgery,
radiation therapy, and topical therapy.
• Immediate reconstruction after excision of complex
cancer before clear margins are documented may
result in buried and fragmented persistent tumor
and more diffi cult re-excision and repair options.
• Failure to seek the help of other specialists for
diffi cult cancers may adversely affect patient care.
• Failure to arrange and ensure continued patient care
may result in missed or delayed treatment of
recurrent disease, as well as discovery of new
primary skin cancers.
References
1. Zitelli JA: Mohs surgery—concepts and misconceptions. Int J Der-
matol 24:541-548, 1985.
2. Cook J, Zitelli JA: Mohs micrographic surgery: A cost analysis.
J Am Acad Dermatol 39:698-703, 1998.
3. Wolf DJ, Zitelli JA: Surgical margins for basal cell carcinoma.
Arch Dermatol 123:213-215, 1987.
4. Brodland DG, Zitelli JA: Surgical margins for excision of primary
cutaneous squamous cell carcinoma. J Am Acad Dermatol 27:241-
248, 1992.
5. Bricca GM, Brodland DG, Ren D, et al: Cutaneous head and neck
melanoma treated with Mohs micrographic surgery. J Am Acad
Dermatol 52:92-100, 2005.
6. Morton DL, Cochran AJ, Thompson JF, et al: Sentinel node
biopsy for early-stage melanoma: Accuracy and morbidity in
MSLT-I, an international multicenter trial. Ann Surg 242:302-
313, 2005.

Chapter 80
Management of Skin Cancer of the Head and Neck
737
7. Abide JM, Nahai F, Bennett RG: The meaning of surgical margins.
Plast Reconstr Surg 73:492-497, 1984.
8. Zitelli JA, Brodland DG: A regional approach to reconstruction
of the upper lip. J Dermatol Surg Oncol 17:143-148, 1991.
9. Burget GC, Menick FJ: Aesthetic Reconstruction of the Nose.
Chicago, CV Mosby, 1994.
10. Zitelli JA: The bilobed fl ap in nasal reconstruction. Arch Derma-
tol 125:957-959, 1989.
11. Zitelli JA: The nasolabial fl ap as a single-stage procedure. Arch
Dermatol 126:1445-1448, 1990.

Chapter 81
Microvascular Reconstruction of the Head
and Neck
Frederic W.-B. Deleyiannis, Brian R. Gastman, and James M. Russavage
The goals of reconstruction are to restore premorbid
function and quality of life. Successful reconstruction
requires careful consideration of both the surgical
defect and patient-specifi c variables, such as general
health, radiation status, and dental rehabilitation.
Cardiac, vascular, and pulmonary disease, as well as
alcoholism, are common in patients with cancer of the
head and neck and may independently have an impact
on survival and limit reconstructive options. For
example, the fi bula would be a poor donor site in an
individual with severe lower extremity peripheral vascu-
lar disease. Radiation induces soft tissue fi brosis, in par-
ticular, perivascular fi brosis. Therefore, a history of
previous radiation therapy with its anticipated decreased
vascularity may guide reconstructive options toward
using a pedicled or free fl ap instead of a skin graft.
The anticipated defect should be classifi ed accord-
ing to the extent of rigid, soft tissue, and neurologic
components. When possible, resected tissue should be
reconstructed with tissue that duplicates both the
appearance and the function of the resected tissue.
Epithelium can be used to resurface mucosal or skin
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 transfer are
among the range of options that the reconstructive
surgeon must possess to customize the reconstruction
to an individual patient.
Free tissue transfer offers a well-accepted, superior
ability to restore form and function with certain major
head and neck defects. Microvascular surgery provides
distinct advantages for reconstruction of osseous defects
of the mandible, large glossectomy defects, total or
near-total pharyngeal defects, and complex defects of
the midface and skull base.
PATIENT SELECTION AND PREOPERATIVE
EVALUATION
Early experience with free fl aps was primarily concerned
with free skin fl aps (i.e., the free groin fl ap and free
dorsalis pedis artery fl ap). As experience with microsur-
gery grew and knowledge about vascular anatomy
expanded, transfer of musculocutaneous and osteocu-
taneous fl aps became as commonplace as transfer of
free cutaneous fl aps. Theoretically, any tissue with a
defi ned vascular circuit can be transferred as a free fl ap,
but for head and neck reconstruction, eight free fl aps
are particularly useful: the radial forearm, parascapular
and scapular, lateral arm, rectus abdominis, fi bula, iliac
crest, and anterolateral thigh fl aps.
Radial Forearm Free Flap
The radial forearm free fl ap (RFFF) is a fasciocutane-
ous free fl ap that derives it blood supply from branches
of the radial artery running in the intermuscular septum
between the brachioradialis and fl exor carpi radialis
muscles.1 The major advantage of the RFFF is the large
amount of thin forearm skin that can be harvested for
reconstruction of any associated intraoral or external
skin defect. A segment of radius vascularized by vessels
passing from the radial artery through the lateral inter-
muscular septum and perforating vessels through the
muscle belly of the fl exor pollicis longus may be trans-
ferred with the RFFF (Fig. 81-1). Approximately 10 cm
of bone can be harvested between the insertion of the
pronator teres and the insertion of the brachioradialis.
A “boat-shaped” osteotomy as opposed to right-angle
bone cuts may help avoid the complication of fracture.2
Only 30% of the cross-sectional area of the radius
should be removed to preserve the structural integrity
739

740
Section 9
Plastic and Reconstructive Surgery
A
C
E
B
D
F
Figure 81-1. Osteocutaneous radial
forearm free fl ap for a lateral man-
dibular defect. A, Lateral mandibular
and fl oor of the mouth defect after
resection of T4 carcinoma. B, Flap
design with the radius, skin paddle,
cephalic vein, and radial artery
marked. C, Perforators to the radius
from the radial artery traversing
through the fl exor pollicis longus
and pronator quadratus identifi ed.
D, Keel-shaped osteotomies from the
insertion point of the brachioradialis
to the origin of the pronator teres. E,
Inset of the radius with the skin
paddle used for reconstruction of the
fl oor of the mouth. F, Final closure.
of the radius. Provided that the periosteum is carefully
preserved on the volar and radial aspects of the segment
of the radius, one or two osteotomies may be performed
from the medullary aspect to allow reconstruction
of anterior symphyseal and parasymphyseal defects.
Whereas the anterior projection of the anterior man-
dible can be re-created with an osteotomized radial
forearm osteocutaneous fl ap, the vertical height of the
anterior mandible cannot be created. The bony segment
of the radius is usually too thin to allow placement of
osseointegrated implants. The antebrachial cutaneous
nerves of the forearm can be incorporated into the fl ap
to make the RFFF a sensate fl ap. However, spontaneous
return of fl ap sensation has been documented in
patients who underwent reconstruction of the oral
cavity with noninnervated fl aps.3
An Allen’s test should be performed before harvest-
ing or RFFF to assess the adequacy of ulnar collateral
circulation to the hand. If a positive Allen’s test is
detected, one should use a different fl ap for reconstruc-
tion or be prepared to replace the radial artery with a
vein graft.

Chapter 81
Microvascular Reconstruction of the Head and Neck
741
Scapular and Parascapular Fasciocutaneous
and Osteocutaneous Flaps
The branching pattern of the circumfl ex scapular artery
and vein permits the harvest of a number of fasciocuta-
neous and osteocutaneous fl aps for reconstruction of
the oral cavity. The scapular fl ap is based on the hori-
zontal cutaneous branch of the circumfl ex scapular
artery (Fig. 81-2). The parascapular fl ap is based on the
descending cutaneous branch of the circumfl ex scapu-
lar artery. Up to 14 cm of the lateral border of the
scapula vascularized by periosteal branches from the
circumfl ex scapular artery and vein can be isolated.
Unlike other osteocutaneous fl aps, the scapular bone
and the two skin paddles can be orientated indepen-
dently of one another for reconstruction of complex
three-dimensional defects.4 In addition, the latissimus
dorsi and serratus anterior muscles vascularized by the
thoracodorsal artery and vein can be harvested with the
scapular fl aps based on the common vascular pedicle
of the subscapular artery and vein.
The disadvantages of these fl aps are that they
require harvesting in the lateral position, the lateral
border of the scapula is quite thin and may preclude
secondary osseointegration, and the segmental perios-
teal blood supply may be compromised if multiple oste-
otomies are required to shape the scapula for anterior
defects. The skin on the back can also be the thickest
in the body, and with obesity these fl aps can be quite
thick.
Lateral Arm Flap
The lateral arm fl ap is a reliable fasciocutaneous fl ap
that has the distinct advantages that its vascular supply,
the profunda brachii artery, is a nonessential artery
whose harvest does not jeopardize the vascular supply
to the upper extremity and the donor site can be closed
A
B
C
D
E
Figure 81-2. Scapular fasciocuta-
neous fl ap. A, Composite resection of
the lateral mandible, fl oor of the
mouth, and cheek skin. B, Mandibu-
lar continuity restored with a recon-
struction plate. C, Flap design.
D, Scapular fl ap harvested. E, Flap
inset with a strip of skin de-epithelial-
ized to allow two skin paddles—one
for the cheek and neck skin and one
for reconstruction of the fl oor of the
mouth.

742
Section 9
Plastic and Reconstructive Surgery
with a linear scar.5 The axis of the fl ap is centered on
the lateral intermuscular septum, which is located
between the triceps posteriorly and the brachialis and
the brachioradialis anteriorly (Fig. 81-3). After the pro-
funda brachii branches from the brachial artery, it
travels in the spiral groove with the radial nerve. As the
profunda brachii enters the septum, it divides into ante-
rior and posterior radial collateral arteries. The poste-
rior radial collateral artery supplies the lateral arm fl ap.
The vascular pedicle is usually ligated in the spiral
groove, but additional length can be obtained by dis-
secting deep to the lateral and long head of the triceps.
The posterior cutaneous nerve of the arm, which is
closely associated with the posterior radial collateral
artery, can be incorporated into the fl ap to make the
lateral arm fl ap a sensate fl ap. Donor site complica-
tions, including radial nerve palsy and hyperesthesia of
the proximal lateral forearm skin caused by damage to
the posterior cutaneous nerve of the forearm, have
been reported but are seldom seen.
Rectus Abdominis Free Musculocutaneous
Flap
The rectus abdominis free musculocutaneous fl ap is
based on periumbilical perforators from the deep infe-
rior epigastric arteries.6 Incorporation of the perium-
bilical perforators permits the skin paddle to be oriented
in virtually any direction from the midline (Fig. 81-4).
After the perforators are identifi ed, the anterior rectus
sheath is incised medial to the linea semilunaris and
lateral to the linea alba. To preserve the strength of the
abdominal wall, the anterior rectus sheath should not
be harvested below the arcuate line. Inferiorly, the ante-
rior rectus sheath is incised vertically to completely
expose the rectus muscle. The deep inferior epigastric
pedicle is identifi ed after the rectus muscle is bluntly
dissected free from the posterior rectus sheath. The
vascular pedicle, up to 15 cm in length, is exposed all
the way to the origin of the vessels from the external
iliac artery and vein. The intercostal nerves that supply
the rectus muscle and overlying skin are mixed sensory
and motor nerves, but microanastomosis to a sensory
nerve in the head and neck has not yet resulted in a
report of restoration of sensation. Closure of the
abdominal wall can be accomplished by direct approxi-
mation of the residual anterior fascial margins. Few
reports have quantifi ed the functional effect of harvest-
ing a single rectus muscle on lifestyle. Most surgeons
would agree that unless patients are engaged in vigor-
ous physical activity, harvest of a unilateral rectus muscle
has little impact.
Fibular Free Flap
The fi bula is our fi rst line choice for mandibular recon-
struction (Fig. 81-5). It can be transferred as a free
osseous, free osteocutaneous, or free osteomuscular
fl ap.7 The skin of the lateral aspect of the calf is sup-
plied by septocutaneous perforators that traverse the
posterior crural septum between the posterior compart-
ment muscles (the gastrocnemius and soleus) and the
B
A
C
Figure 81-3. Lateral arm fl ap. A, Flap design with the position of the posterior radial
collateral artery marked in red. B, Radial nerve identifi ed. C, Flap harvested.

Chapter 81
Microvascular Reconstruction of the Head and Neck
743
lateral anterior compartment muscles (the peroneus
longus and brevis). Musculocutaneous perforators that
run through the fl exor hallucis and soleus may also
supply the skin. Consequently, when harvesting an
osteocutaneous fi bular fl ap, one should include a cuff
of fl exor hallucis and soleus muscle to protect these
perforators. Even with care taken to protect the septo-
cutaneous and musculocutaneous perforators, loss of
the skin paddle has been reported in 5% to 10% of
cases. The fi bula may be harvested with a lateral cuff
of soleus muscle without a skin paddle and be used to
replace oral lining by allowing the exposed muscle to
mucosalize. The fi bula will provide up to 26 cm of bone
vascularized by the peroneal artery and its two venae
comitantes. The peroneal artery provides both endos-
teal and periosteal blood supply to the fi bula, and con-
sequently blood supply to multiple bony segments of
the fi bula can be maintained through these segmental
periosteal perforators after multiple osteotomies of the
fi bula. The cross-sectional area of the fi bula approxi-
mates the cross-sectional area of the midbody of the
mandible and is ideally suited for placement of osseo-
integrated implants for dental rehabilitation.
The need for preoperative vascular assessment
before fi bular transfer is controversial. Large series per-
formed without preoperative imaging have reported no
adverse sequelae, yet given the prevalence of risk factors
for peripheral vascular disease in the head and neck
cancer population, others have stressed the need for
vascular evaluation. According to Futran and colleagues,
ankle-arm index screening and color fl ow Doppler
imaging may be more economical and effi cient ways to
A
B
C
D
Figure 81-4. Rectus myocutaneous
free fl ap. A, Total orbitomaxillectomy
defect. B, Flap design with two skin
paddles—one for orbit and cheek
skin reconstruction and the other for
palate reconstruction. C, Postopera-
tive frontal view. D, Postoperative
view of the palatal reconstruction.

744
Section 9
Plastic and Reconstructive Surgery
B
A
D
C
E
F
G
H
I
Figure 81-5. Fibular osteocutaneous
free fl ap and pectoralis major myocu-
taneous fl ap for near-total mandibu-
lectomy and total glossectomy. A,
Near-total mandibulectomy and total
glossectomy defect. B, Osteocutaneous
fi bular free fl ap design with the skin
perforators (P) marked. The skin
paddle is to be used for fl oor of the
mouth and anterior tongue reconstruc-
tion. C, Pectoralis fl ap for posterior
tongue reconstruction. D, Inset of the
pectoralis fl ap. E, Closing wedge oste-
otomies of the fi bula. F, Inset of the
fi bular free fl ap with the skin paddle to
be rotated over the plate and sewn to
the pectoralis fl ap. G, Inset of the
greater saphenous vein graft into the
proximal internal jugular vein stump.
Both internal jugular veins had been
ligated during the resection. H, Final
inset—oral cavity. I, Final inset—lateral
view.
evaluate the vasculature of the lower extremity than
angiography or magnetic resonance angiography.8
Two criticisms of use of the fi bular free fl ap have
been the height discrepancy between the fi bular bone
and the native mandible and the inability to reconstruct
associated large soft tissue defects (e.g., large glossec-
tomy defects or through-and-through defects). Re -
cent innovations have addressed these criticisms. Jones
and associates described a “double-barrel” technique in
which the fi bula is folded on itself to effectively double
the height of the neomandible.9 In conjunction with a
fi bula free fl ap, large soft tissue defects can be repaired
with a second fl ap, either an RFFF or a pectoralis myo-
cutaneous fl ap. After free fi bula harvest, most patients
will have some decrease in their range of motion of
ankle plantar fl exion and dorsifl exion and loss of knee
and ankle strength. However, as demonstrated by
Anthony and coworkers, these decreases are not severe
enough to have an impact on patients’ daily
activities.10
Iliac Crest
As the popularity of the fi bula fl ap has grown, the indica-
tions for use of an iliac crest free fl ap have decreased.
The iliac crest will provide a large segment of corticocan-
cellous bone, up to 14 cm in length, vascularized by the
deep circumfl ex iliac artery and its two venae comitan-
tes.11 The deep circumfl ex iliac vessels can be dissected
to their origin from the external iliac vessels to provide
a pedicle length between 8 and 10 cm. The height of the
native mandible can be matched by harvesting an appro-
priate amount of bone from the iliac crest (Fig. 81-6).
Depending on the location of the mandibular defect,
preoperative planning with models of the mandible and
iliac crest will help the surgeon pattern the segment of

Chapter 81
Microvascular Reconstruction of the Head and Neck
745
the iliac crest bone on the ipsilateral or contralateral iliac
crest to use the normal curve of the superior iliac crest.
Cutaneous perforators along the medial aspect of the
iliac crest supply an area of overlying skin that can be
harvested with the bone as an osteocutaneous fl ap. To
preserve these cutaneous perforators, a cuff of external
oblique muscle, internal oblique muscle, and transver-
sus abdominis muscle through which the perforators
traverse should be harvested. The thickness of the overly-
ing subcutaneous tissue can make an osteocutaneous
iliac crest fl ap too bulky for intraoral use. To decrease
the bulkiness, one can harvest the iliac crest bone with a
paddle of internal oblique muscle (supplied by the
ascending branch of the deep circumfl ex artery), which
is then skin-grafted.
Femoral nerve injury, hernia, gait disturbance, and
pain are potential donor site morbidities. Harvest of the
internal oblique muscle can also cause denervation of
the rectus abdominis through interruption of its motor
nerve supply, which runs between the internal oblique
and transversus abdominis. Forrest and coauthors
reported on donor site complications in 82 patients who
underwent transfer of a free iliac crest fl ap.12 Sensory
disturbances (27%), contour irregularity (20%), poor
scar (12%), hernia (10%), gait disturbance (11%), and
pain lasting longer than 1 year (8%) were documented.
Jejunal Free Flap
The jejunal free fl ap was the fi rst free tissue transfer
reported in the literature in 1959. Its continued use for
circumferential pharyngeal defects is a testimony to its
time-tested importance in head and neck reconstruc-
tion. This fl ap can be used as a mucosal tube or as a
patch. Its advantages for pharyngeal reconstruction
include a diameter that matches that of the cervical
esophagus, the potential for peristalsis, and innate
secretory ability. Large series report success rates higher
than 90% with fi stula rates between 15% and 20%.13
The jejunum can now be harvested laparoscopi -
cally, thereby reducing much of the postoperative
convalescence.14
Some of the relative disadvantages of this fl ap
include abdominal complication rates as high as 5.8%.15
Tracheoesophageal puncture (TEP) speech may be less
discernible than that with other fl aps because of the
intrinsic moistness of the jejunum. The serosa of the
fl ap may also impede neovascularization, which may
place the fl ap in jeopardy if the pedicle is divided during
subsequent head and neck surgery. In addition, the
plicae circularis of the jejunum may trap food and cause
signifi cant halitosis.
Flap harvest is usually performed by qualifi ed
general surgeons and may be done simultaneously with
the extirpative procedure. Preoperative bowel prepara-
tion is not essential. The jejunal arteries arise from the
superior mesenteric artery and form a series of vascular
arcades that run in the mesentery. Large segments of
jejunum can be harvested by proximally dividing a
single jejunal vessel that feeds multiple arcades.
To limit ischemia to the jejunum, one should divide
the pedicle only after the pharyngeal defect and recipi-
ent vessels have been prepared. During inset, if there is
a size mismatch at the level of the base of tongue, the
antimesenteric border may be divided to “open” up the
proximal end. Any redundancy in the jejunum after
inset may cause the jejunum to fold on itself and become
a barrier to food transport. To prevent such redun-
dancy, we perform the base of the tongue inset fi rst and
then the vascular microanastomosis. With perfusion re-
established the jejunum expands, and after this expan-
sion we resect any redundant jejunum before completing
the mucosal anastomosis to the cervical esophagus. A
jejunal feeding tube is usually placed because long-term
supplementation may be required even after oral intake
of food has begun.
Anterolateral Thigh Flap
The anterolateral thigh free fl ap has recently gained
popularity in soft tissue reconstruction of the head and
neck.16 It is a perforator fl ap derived from the descend-
ing branch of the lateral circumfl ex femoral artery. Its
A
B
Figure 81-6. Iliac crest—internal oblique free fl ap. A, Flap design
with the expected internal oblique muscle harvest indicated in purple.
B, Iliac crest inset for restoration of an anterior mandibular defect.

746
Section 9
Plastic and Reconstructive Surgery
advantages include a long pedicle with a suitable vessel
diameter and the possibility of harvesting the fl ap with
thigh musculature (the vastus lateralis, rectus femoris,
tensor fasciae lata, or any combination of these muscles)
or as a sensate fl ap (by incorporating the anterior branch
of the lateral cutaneous nerve of the thigh). Because of
its distance from the head and neck, harvest can be per-
formed simultaneously with tumor extirpation.
Flap elevation begins by mapping the cutaneous
perforators with a pencil Doppler probe. These perfora-
tors are located by fi rst marking the midpoint between
the anterior superior iliac spine and the superolateral
corner of the patella (Fig. 81-7A and B). A circle cen-
tered at this midpoint is then drawn with a radius of
3 cm. The majority of the cutaneous perforators are
located in the inferolateral quadrant of this circle. The
fl ap is then harvested with its center over these perfora-
tors and its long axis parallel to that of the thigh. The
fl ap can be elevated with or without the fascia lata
(suprafascial dissection). The skin and subcutaneous
tissue of the fl ap are raised until the perforator or per-
forators to the skin are defi ned. Once the skin vessel or
vessels are seen, they are dissected until the main pedicle
is reached (Fig. 81-7C). If the skin vessel is a musculo-
cutaneous perforator (the majority of patients), harvest
includes intramuscular dissection through the vastus
lateralis muscle. If the skin vessel is a septocutaneous
perforator, the dissection is simpler and proceeds
between the vastus lateralis and rectus femoris muscles.16
The length of the pedicle is 8 to 16 cm, with a vessel
diameter larger than 2 mm.
A skin defect of less than 9 cm in width can be closed
primarily without any reported evidence of compart-
ment syndrome. Larger defects require skin grafting. A
distinct disadvantage is the thickness of the fl ap in over-
weight individuals. However, the fl ap can be trimmed to
the subdermal fat level for use as a thinner fl ap (4 mm).
In subfascial dissections, loss of the fascia lata may leave
a bulge in the lateral aspect of the thigh. The vastus late-
ralis muscle is a major constituent of the quadriceps
femoris. However, in cases in which the vastus lateralis
has been taken for reconstructive purposes, nearly
normal quadriceps function has been reported.17
SURGICAL APPROACHES
Mandibular Defects
The indications for mandibular reconstruction remain
a subject of legitimate controversy. The fact that major
mandibular resection carries with it signifi cant func-
tional and cosmetic sequelae is undisputed, but the
effect of mandibular resection on function is highly
variable. The level of postoperative disability depends
on (1) the preoperative condition of the oral cavity
(including the presence or absence of viable teeth), (2)
the extent of mandible to be included in the resection,
(3) the site of the tumor (anterior versus lateral), and
(4) the soft tissues to be resected. When the mandible
is resected with an accompanying large soft tissue defect,
the mandibular defect is sometimes “incidental” to the
rest of the wound. Closure of the soft tissue defect with
restoration of function and coverage of the planned
mandibular reconstruction becomes the primary goal.
The extent of mandibular resection is critical in
predicting the disability secondary to surgery. Some
patients function well after segmental lateral mandibu-
lectomy without restoration of mandibular continuity.
However, a contour deformity of the lower third of the
face will develop in patients whose defects have not
been reconstructed, and the pull of the contralateral
muscles of mastication displaces the remaining mandi-
ble toward the side of the defect. In patients with denti-
A
B
C
D
Figure 81-7. Anterior lateral thigh fl ap (ALTF). A, Circle marking
the location of the cutaneous perforator. B, Flap design based on the
location of the perforator. C, A single musculocutaneous perforator
supplies the entire fl ap. D, Total pharyngeal reconstruction using the
ALTF. The fascia lata has been wrapped around the reconstruction
for an additional layer of closure.

Chapter 81
Microvascular Reconstruction of the Head and Neck
747
tion this results in malocclusion. For these reasons,
most surgeons offer patients primary reconstruction of
lateral mandibular defects.
Numerous reports have supported the use of a
reconstruction plate with soft tissue coverage to recon-
struct pure lateral mandibular defects (see Fig. 81-2).
Soft tissue coverage has generally been provided by a
pectoralis myocutaneous fl ap or an RFFF. Delayed recon-
structive failure secondary to external plate exposure or
plate fracture has generally been reported to occur in
5% to 7% of cases. For lateral mandibular defects,
Shpitzer and colleagues advocate the use of an osteocu-
taneous free fl ap.18 In their report comparing three dif-
ferent reconstruction techniques for lateral mandibular
defects (plate and pectoralis major myocutaneous fl ap
[PMMF], plate and RFFF, and osteocutaneous fl ap),
plates had to be removed in 7 of the 27 patients in the
PMMF group and 2 of the 16 patients in the RFFF group.
None of the 14 osteocutaneous free fl aps failed. Speech
was also best in the osteocutaneous free fl ap group.
Anterior mandibular resection can leave a patient
an oral cripple. When reconstruction is not attempted,
the retained segments of the mandible tend to collapse
toward the midline. This lack of support results in an
Andy Gump deformity with associated oral inconti-
nence and cosmetic deformity. Schusterman and associ-
ates, in a study of the use of AO plates for immediate
mandibular reconstruction, noted an unacceptably
high rate of plate failure in patients with anterior
defects.19 Plate extrusion developed in four of the six
patients (66%) who underwent reconstruction of ante-
rior defects with a plate and soft tissue fl ap. Free tissue
transfer of a composite osteocutaneous fl ap was thus
advocated as the reconstructive method of choice.
However, all centers do not report such a high rate of
anterior plate failure. In an evaluation of 51 cases of
primary mandibular reconstruction with the titanium
hollow-screw reconstruction plate, Irish and coauthors
reported a 19% incidence of plate failure in patients
with anterior defects and a 13% incidence of failure
with lateral defects.20 In their experience with 102 stain-
less steel and titanium bridging plates, the success rate
was 83% for lateral defects and 65% for anterior defects
at 2-year follow-up.21
Given the long-term problems of plate fracture and
exposure, we prefer to perform free vascularized bony
reconstruction for both lateral defects and anterior
defects (see Figs. 81-1 and 81-5). In patients who are
unwilling or unable to undergo free vascularized bone
transfer becomes of signifi cant comorbidity, poor prog-
nosis, or lack of recipient vessels, we perform a plate
and soft tissue fl ap reconstruction. If the goal of recon-
struction with a pectoralis fl ap is simply to close the
wound and allow a patient to avoid complications, one
should consider using a pectoralis fl ap only for soft
tissue reconstruction without restoration of mandibular
continuity with a reconstruction plate.22
Glossectomy Defects
Restoration of tongue function after ablative surgery
remains a major challenge for the reconstructive
surgeon. The ultimate goal is to restore form and func-
tion, but the complex set of intrinsic and extrinsic
muscles that provide coordinated motor activity cannot
be duplicated by reinnervated muscle fl aps. It is unre-
alistic to expect a unidirectional, reinnervated muscle,
such as the rectus abdominis, to mimic the complex
pattern of muscle contraction in the native tongue. The
attainable goals of tongue reconstruction are preserva-
tion of the mobility of the remaining tongue, restora-
tion of bulk so that the neotongue can contact the
palate to assist in articulation and swallowing, and res-
toration of sensation.
The extent of the glossectomy and the presence or
absence of an associated mandibulectomy defect deter-
mine one’s approach to reconstruction.23 Because of
the different functions of the two regions, the tongue
is divided into the mobile anterior part and the tongue
base. The mobility of the anterior tongue is critical
for articulation, mastication, and the oral phase of swal-
lowing. The tongue base is critical in completing
the pharyngeal phase of swallowing. The approach to
reconstructing the mobile tongue should involve the
use of thin, sensate, pliable tissues that maintain
maximum mobility and potentially restore sensation.
Defects of the tongue base present a separate problem.
The volume of the tongue base must be restored so that
it can contact the pharyngeal walls and generate force
to drive the food bolus through the pharynx.
The combination of a segmental mandibulectomy
defect and a partial glossectomy defect involving the
mobile tongue or both the mobile tongue and base of
tongue is a more challenging reconstruction. The
reconstructive options begin with fi rst choosing the
optimal fl ap for tongue reconstruction and then con-
sidering the options for the mandible. Two free fl aps,
in particular, a forearm fl ap with a fi bular fl ap, may be
necessary for complex composite defects. For segmen-
tal defects less than 8 cm and with signifi cant tongue
defects, an osteocutaneous RFFF is often our fi rst
choice. Lateral composite mandibular defects may be
reconstructed with a fasciocutaneous free fl ap or a ped-
icled fl ap and a mandibular reconstruction plate. Soft
tissue reconstruction without restoration of lateral man-
dibular continuity can also yield satisfactory outcomes.
Total tongue reconstruction involves creating bulk
for the neotongue and positioning the neotongue so
that its vertical height is suffi cient to achieve contact
with the palate. Free musculocutaneous fl aps, in par-
ticular, the rectus abdominis free fl ap, have the advan-
tage that the muscle of the fl ap can be used as a platform
for positioning the overlying fat and skin components.
Drill holes placed in the mandible can be used to secure
the muscle. The tendinous inscriptions in the rectus
abdominis fl ap offer better purchase for sutures than
do those directly placed in muscle. Fasciocutaneous
free fl aps, such as forearm, scapular, parascapular, or
anterolateral thigh, can also be de-epithelialized and
folded on themselves to create additional bulk and help
maintain the position of the neotongue. Total tongue
defects can also be reconstructed with a pectoralis
major myocutaneous fl ap (see Fig. 81-5C and D).

748
Section 9
Plastic and Reconstructive Surgery
Because of its bulk, an iliac crest osteocutaneous fl ap
should be considered for reconstruction of total glos-
sectomy defects with anterior mandibular defects.
Pharyngectomy Defect
The major goal of pharyngeal reconstruction is restora-
tion of swallowing. Laryngeal preservation in the setting
of a major pharyngeal defect is especially challenging
because aspiration is inevitable. In addition to the
patient’s preoperative function, designing a reconstruc-
tion that can minimize aspiration may be the critical
issue that determines whether patients will be able to
keep their larynx. It is important to choose a fl ap that
can be inset at the level of the hypopharynx both to
prevent stenosis and to not be too bulky and cause
obstruction. Although the pectoralis major fl ap has
been used with success, the radial forearm fl ap offers
many advantages.24 Its pliability allows exact replace-
ment of the hypopharyngeal mucosa. In addition, with
a radial forearm fl ap a nonvascularized rib graft can be
used to reconstruct the infrastructure of the larynx.25
Anastomosis of an antebrachial cutaneous nerve of the
forearm fl ap with the superior laryngeal nerve may
assist the neopharynx in regaining sensation.
In most cases of advanced laryngopharyngeal or
pharyngeal carcinoma the larynx is resected. When a
strip of hypopharyngeal mucosa remains after total
laryngopharyngectomy, controversy exists concerning
the relative benefi ts of resecting the remaining mucosa
and converting the defect to a circumferential defect.
Preservation of the remaining mucosa and incorpora-
tion of this mucosa into the reconstruction may reduce
the risk of stenosis. However, the additional suture lines
may place the reconstruction at greater risk for a fi stula
than is the case with a tubed free fl ap.
For circumferential defects the jejunal free fl ap has
been the “gold standard.”26 It requires no tubing and
thus one less suture line. Most studies report that the
jejunal free fl ap has stenosis and fi stula rates that are
lower than or equal to those of tubed fasciocutaneous
fl aps.27 The major alternative to the jejunum is a tubed
RFFF (Fig. 81-8). Its advantages over the jejunum
include the lack of abdominal harvest, better TEP
speech, and the ability to create separate skin paddles
for cervical skin reconstruction.27 The use of a Mont-
gomery stent may lower fi stula and stenosis rates.28 The
anterolateral thigh free fl ap may also be used for pha-
ryngeal reconstruction and has the additional advan-
tage that the fascia lata may be included to provide an
extra layer of closure for the neopharynx (see Fig.
81-7D). Studies are ongoing to determine the effective-
ness of this reconstruction.29
If the cervical esophageal resection extends below
the thoracic inlet, most reconstructive surgeons would
not place a reconstructive suture line within the chest
because of the increased morbidity of a salivary leak.
Gastric pull-up continues to be the gold standard for
defects that extend below the thoracic inlet.
A
B
C
D
Figure 81-8. Total pharyngeal reconstruction with a radial forearm fasciocutaneous
free fl ap (RFFF) harvested with a monitor paddle. A, Flap design with a monitor paddle.
B, The RFFF tubed for circumferential pharyngeal reconstruction. The monitor paddle
is connected to the tubed skin paddle with subcutaneous tissue. C, Anastomosis to the
right transverse cervical artery and vein. D, Monitor paddle inset within the cervical
incision.

Chapter 81
Microvascular Reconstruction of the Head and Neck
749
Midface and Maxillectomy Defects
Defects in the midface occur after resection of tumors
that arise from the paranasal sinuses, palate, overlying
skin, nasal cavity, skull base, orbital contents, or oral
mucosa. As a result, extensive midface reconstructions
may require independently reconstructing the palate,
orbit, cheek, and bony midface (maxilla and zygoma).
Recently, Cordeiro and Santamaria proposed a clas-
sifi cation system and algorithm for reconstruction of
maxillectomy and midfacial structures.30 The tempora-
lis muscle, soft tissue free fl aps (rectus abdominis and
radial forearm), nonvascularized bone (rib or calvaria),
and vascularized bone fl aps (osteocutaneous RFFF)
were used to construct a variety of maxillectomy defects.
Palatal defects were closed only with soft tissue (see Fig.
81-4). The nonvascularized and vascularized bone was
used for osseous reconstruction of the zygoma, maxilla,
and orbital fl oor.
Other algorithms containing many other free fl aps
and designs have been adopted.31 Many have focused
on various osteocutaneous fl aps such as the fi bula and
the iliac crest. These latter fl aps allow osteointegration
of implants for dental rehabilitation.32 In cases of com-
bined midface and lip resection, oral competency can
be restored by using local fl aps, such as the Abbé lip
switch fl ap, in combination with free tissue transfer.
Skull Base Defects
Although small defects can and should be reconstructed
with local fl aps, such as pericranial or temporoparietal
fascial fl aps, many defects in the expanding spectrum
of extirpative endeavors will require free tissue trans-
fer.33 The main reconstructive needs of skull base
defects include separating the intracranial and extra-
cranial spaces to avoid intracranial infections, obliterat-
ing the dead space with coverage of vital structures,
preventing brain herniation, diminishing the risk of
cerebrospinal fl uid leakage, and restoring cosmesis.
The rectus and latissimus myocutaneous (or myofas-
cial) free fl aps (Fig. 81-9) are two of the fl aps commonly
chosen.34 The rich vascular supply of the fl aps’ muscle
component can allow neovascularization of dural recon-
structions and free bone grafts, and their large subcu-
taneous fat and skin islands can obliterate dead space
and be used to reconstruct any skin defi cit. In some
instances of massive resection, multiple fl aps may be
needed. In such cases the subscapular artery system
allows a combination of fl aps based on one pedicle. For
example, a latissimus dorsi myocutaneous fl ap may be
harvested with a scapular osteocutaneous or fasciocuta-
neous fl ap.35
POSTOPERATIVE MANAGEMENT:
FREE FLAP MONITORING
The gold standard for assessing the viability of a free
tissue transfer remains clinical examination. We prefer
nursing assessment of all fl aps (with Doppler examina-
tion of the pedicle) every hour for the fi rst 72 hours
and physician assessment every 6 hours. Color, turgor,
temperature, evidence of edema, quantity and quality
of blood extravasation after pinprick, and quality of the
Doppler sound are all basic methods of assessment. The
arterial signal should increase in strength during sub-
sequent postoperative days. The venous signal should
be augmentable.
Signs of venous congestion include bluish discolor-
ation, increased warmth and swelling, and quick and
bluish blood return after pinprick (Fig. 81-10). The
arterial Doppler sound may be “hammer-like,” indica-
tive of outfl ow obstruction, and there may be loss of
the venous signal. With arterial compromise the fl ap
appears pale, feels cool, and has a loss or delay of bright
red blood with pinprick of the fl ap. The Doppler sound
may be present but can be faint, and areas thought to
represent skin perforators may be lost totally, an indica-
tion of early loss of vascular infl ow. If there is any
A
B
Figure 81-9. Latissimus dorsi free
fl ap. A, Muscle harvested. B, Recon-
struction of the lateral temporal bone
resection.

750
Section 9
Plastic and Reconstructive Surgery
A
D
B
E
C
Figure 81-10. Venous outfl ow ob -
struction and restoration (postopera-
tive day 1, same patient as in Fig. 81-5).
A, Venous congestion of a fi bular free
fl ap: bluish blood with pinprick of a
fl ap skin paddle. B, Saphenous vein
graft and internal jugular vein clotted.
C, Clots in the venae comitantes of the
fi bular fl ap cleared with a no. 3 Fogarty
catheter. D, Cephalic vein rotated from
the right upper extremity to the neck.
E, Restoration of venous outfl ow with
anastomosis of the cephalic vein to the
peroneal vena comitans.
be separately incorporated into the cervical skin closure.
This permits clinical assessment and pinprick examina-
tion. Later, as an outpatient under local anesthesia, this
skin island can be removed, and the cervical skin suture
line can be reapproximated. Because of its vasculature
arcade, a small portion of the jejunum can be separated
from the rest of the fl ap and externalized for monitor-
ing (Fig. 81-11). Afterward (approximately 3 to 5 days
after surgery), this segment can be removed by ligating
the base with a suture. When assessing buried fl aps
without an externalized portion, one can rely on a
Doppler signal that is transmitted through the cervical
apron fl ap. However, such assessment can be inaccurate
if one mistakes the carotid artery and internal jugular
vein as the vascular supply to the fl ap. Although we do
not routinely use them, implantable Doppler systems
are also available for monitoring fl aps.36
Figure 81-11. Monitor loop of a jejunal free fl ap used for pharyn-
geal reconstruction.
concern about vascular infl ow or outfl ow obstruction,
the patient should be returned to the operating room
immediately for surgical exploration.
Most fasciocutaneous fl aps that are buried, such as
for pharyngeal defects, can allow a small skin paddle to
PEARLS
• Any redundancy in the jejunum after inset may cause
the jejunum to fold on itself and become a barrier to
food transport. To prevent such redundancy, the
base of the tongue inset should be performed fi rst
and then the vascular microanastomosis. With
perfusion re-established, the jejunum expands. After
this expansion, any redundant jejunum should be
resected before completing the mucosal anastomosis
to the cervical esophagus.

Chapter 81
Microvascular Reconstruction of the Head and Neck
751
• For fl aps that are buried, such as the radial forearm
fasciocutaneous free fl ap for pharyngeal defects, a
small skin paddle can be separately incorporated in
the cervical skin closure to allow clinical assessment
and pinprick examination.
• For maxillectomy and midface defects, volume and
surface area requirements will dictate whether a
rectus free fl ap or a radial forearm free fl ap should
be selected. Relatively large-volume defects (e.g.,
total maxillectomy) are commonly reconstructed
with a rectus free fl ap with separate skin paddles
designed for reconstruction of the palate and skin.
• Through-and-through composite segmental defects
of the mandible can often be reconstructed with a
single osteocutaneous radial forearm free fl ap or
fi bular free fl ap. A large skin paddle should be
harvested with the fl ap so that an area of skin can
be de-epithelialized to create two skin paddles—one
for oral cavity reconstruction and the other for
cutaneous reconstruction.
• If there are no recipient veins in the neck for
microanastomosis, the cephalic vein can be
transected distally in the arm and rotated to the
head and neck for microanastomosis.
PITFALLS
• The pedicle length of a rectus abdominis fl ap may
be insuffi cient to reach the neck, especially when the
mandible is intact. Careful planning of the skin
paddle and intramuscular dissection of the pedicle
from the rectus muscle may be necessary to ensure
adequate length.
• Aggressive harvest (>40%) of the radial bone may
lead to pathologic fracture of the radius.
Prophylactic plating of the radius should be
considered to prevent fracture.
• Irreversible ischemic changes in the jejunum can
occur within 2 hours. The jejunal vessels should be
divided and transferred from the abdomen only after
the recipient vessels have been isolated for
microanastomosis.
• Failure to recognize venous congestion will lead to
total loss of the fl ap. Leeches should be used only as
treatment of venous congestion after problems with
the microanastomosis and pedicle have been
excluded by surgical exploration.
• Harvest of a fi bular free fl ap in patients with
peripheral vascular disease (an ankle-arm index
<1.0) but with three-vessel runoff may still lead to
delayed wound healing at the harvest site and failure
of complete take of a skin graft on the lower
extremity cutaneous defect.
References
1. Jacobson MC, Franssen E, Fliss DM, et al: Free forearm fl ap in
oral reconstruction. Functional outcome. Arch Otolaryngol Head
Neck Surg 121:959-964, 1995.
2. Bardsley AF, Soutar DS, Elliot D, Batchelor AG: Reducing mor-
bidity in the radial forearm fl ap donor site. Plast Reconstr Surg
86:287-292, discussion 293-294, 1990.
3. Close LG, Truelson JM, Milledge RA, Schweitzer C: Sensory
recovery in noninnervated fl aps used for oral cavity and oropha-
ryngeal reconstruction. Arch Otolaryngol Head Neck Surg
121:967-972, 1995.
4. Swartz WM, Banis JC, Newton ED, et al: The osteocutaneous
scapular fl ap for mandibular and maxillary reconstruction. Plast
Reconstr Surg 77:530-545, 1986.
5. Ninkovic M, Harpf C, Schwabegger AH, Rumer-Moser A: The
lateral arm fl ap. Clin Plast Surg 28:367-374, 2001.
6. Urken ML, Turk JB, Weinberg H, et al: The rectus abdominis
free fl ap in head and neck reconstruction. Arch Otolaryngol
Head Neck Surg 117:857-866, 1991.
7. Hidalgo DA, Rekow A: A review of 60 consecutive fi bula free fl ap
mandible reconstructions. Plast Reconstr Surg 96:585-596, discus-
sion 597-602, 1995.
8. Futran ND, Stack BC Jr, Zaccardi MJ: Preoperative color fl ow
Doppler imaging for fi bula free tissue transfers. Ann Vasc Surg
12:445-450, 1998.
9. Jones NF, Swartz WM, Mears DC, et al: The “double barrel” free
vascularized fi bular bone graft. Plast Reconstr Surg 81:378-385,
1988.
10. Anthony JP, Rawnsley JD, Benhaim P, et al: Donor leg morbidity
and function after fi bula free fl ap mandible reconstruction. Plast
Reconstr Surg 96:146-152, 1995.
11. Urken ML, Vickery C, Weinberg H, et al: The internal oblique–
iliac crest osseomyocutaneous free fl ap in oromandibular recon-
struction. Report of 20 cases. Arch Otolaryngol Head Neck Surg
115:339-349, 1989.
12. Forrest C, Boyd B, Manktelow R, et al: The free vascularized iliac
crest tissue transfer: Donor site complications associated with
eighty-two cases. Br J Plast Surg 45:89-93, 1992.
13. Theile DR, Robinson DW, Theile DE, Coman WB: Free jejunal
interposition reconstruction after pharyngolaryngectomy: 201
consecutive cases. Head Neck 17:83-88, 1995.
14. Wadsworth JT, Futran N, Eubanks TR: Laparoscopic harvest of
the jejunal free fl ap for reconstruction of hypopharyngeal and
cervical esophageal defects. Arch Otolaryngol Head Neck Surg
128:1384-1387, 2002.
15. Shangold LM, Urken ML, Lawson W: Jejunal transplantation for
pharyngoesophageal reconstruction. Otolaryngol Clin North Am
24:1321-1342, 1991.
16. Wei FC, Jain V, Celik N, et al: Have we found an ideal soft-tissue
fl ap? An experience with 672 anterolateral thigh fl aps. Plast
Reconstr Surg 109:2219-2226, discussion 2227-2230, 2002.
17. Huang LY, Lin H, Liu YT, et al: Anterolateral thigh vastus lateralis
myocutaneous fl ap for vulvar reconstruction after radical vulvec-
tomy: A preliminary experience. Gynecol Oncol 78:391-393,
2000.
18. Shpitzer T, Neligan PC, Gullane PJ, et al: The free iliac crest and
fi bula fl aps in vascularized oromandibular reconstruction: Com-
parison and long-term evaluation. Head Neck 21:639-647, 1999.
19. Schusterman MA, Reece GP, Kroll SS, Weldon ME: Use of the
AO plate for immediate mandibular reconstruction in cancer
patients. Plast Reconstr Surg 88:588-593, 1991.
20. Irish JC, Gullane PJ, Gilbert RW, et al: Primary mandibular
reconstruction with the titanium hollow screw reconstruction
plate: Evaluation of 51 cases. Plast Reconstr Surg 96:93-99,
1995.
21. Gullane P, Boyd B, Brown D: Primary mandibular reconstruction:
Using plate and fl ap. Proceedings of the Third International
Conference on Head and Neck Cancer. Head Neck Cancer 3:807-
823, 1993.
22. Deleyiannis FWB, Carolyn C, Lee E, et al: Reconstruction of the
lateral mandibulectony defect: Management based on prognosis
and the location and volume of the soft tissue resection. Laryn-
goscope 116:2071-2080, 2006.

752
Section 9
Plastic and Reconstructive Surgery
23. Urken ML, Moscoso JF, Lawson W, Biller HF: A systematic
approach to functional reconstruction of the oral cavity following
partial and total glossectomy. Arch Otolaryngol Head Neck Surg
120:589-601, 1994.
24. Schuller DE, Mountain RE, Nicholson RE, et al: One-stage recon-
struction of partial laryngopharyngeal defects. Laryngoscope
107:247-253, 1997.
25. Urken ML, Blackwell K, Biller HF: Reconstruction of the laryn-
gopharynx after hemicricoid/hemithyroid cartilage resection.
Preliminary functional results. Arch Otolaryngol Head Neck Surg
123:1213-1222, 1997.
26. Disa JJ, Pusic AL, Hidalgo DA, Cordeiro PG: Microvascular recon-
struction of the hypopharynx: Defect classifi cation, treatment
algorithm, and functional outcome based on 165 consecutive
cases. Plast Reconstr Surg 111:652-660, discussion 661-663,
2003.
27. Azizzadeh B, Yafai S, Rawnsley JD, et al: Radial forearm free fl ap
pharyngoesophageal reconstruction. Laryngoscope 111:807-810,
2001.
28. Varvares MA, Cheney ML, Gliklich RE, et al: Use of the radial
forearm fasciocutaneous free fl ap and Montgomery salivary
bypass tube for pharyngoesophageal reconstruction. Head Neck
22:463-468, 2000.
29. Chana JS, Wei FC: A review of the advantages of the anterolateral
thigh fl ap in head and neck reconstruction. Br J Plast Surg
57:603-609, 2004.
30. Cordeiro PG, Santamaria E: A classifi cation system and algorithm
for reconstruction of maxillectomy and midfacial defects. Plast
Reconstr Surg 105:2331-2346, discussion 2347-2348, 2000.
31. Kelley P, Klebuc M, Hollier L: Complex midface reconstruction:
Maximizing contour and bone graft survival utilizing periosteal
free fl aps. J Craniofac Surg 14:413-416, 2003.
32. Anthony JP, Foster RD, Sharma AB, et al: Reconstruction of a
complex midfacial defect with the folded fi bular free fl ap and
osseointegrated implants. Ann Plast Surg 37:204-210, 1996.
33. Chang DW, Robb GL: Microvascular reconstruction of the skull
base. Semin Surg Oncol 19:211-217, 2000.
34. Besteiro JM, Aki FE, Ferreira MC, et al: Free fl ap reconstruction
of tumors involving the cranial base. Microsurgery 15:9-13,
1994.
35. Evans GR, Luethke RW: A latissimus/scapula combined myo-
osseous free fl ap based on the subscapular artery used for elbow
reconstruction. Ann Plast Surg 30:175-179, 1993.
36. Swartz WM, Jones NF, Cherup L, Klein A: Direct monitoring of
microvascular anastomoses with the 20-MHz ultrasonic Doppler
probe: An experimental and clinical study. Plast Reconstr Surg
81:149-161, 1988.

Chapter 82
Regional Pedicle Flaps
Ernest K. Manders
The use of pedicle fl aps has signifi cantly improved the
safety and functional outcomes of head and neck
surgery. The reliability and ready availability of pedicle
fl aps make them the most commonly used means of
reconstructing defects created in the course of extirpa-
tive surgery. Because of the aggressiveness of today’s
chemotherapy and radiation therapy protocols, the
ability to bring oxygenated tissue with a nourishing
blood supply to the surgical defect has been critical.
Moreover, many of these fl aps can be created and trans-
ferred without needing to reposition the patient intra-
operatively. They do not require microvascular expertise,
along with the painstaking time spent under the micro-
scope, nor do they tend to signifi cantly increase the
duration of the operative procedure. This chapter pre-
sents an overview of the relevant anatomy, steps for
technical execution, and common complications of
pedicled fl aps for the head and neck.
Several excellent general references and atlases
have been prepared to assist surgeons contemplating
head and neck reconstruction with regional fl aps. Three
excellent sources are listed at the beginning of the ref-
erence section.1-3
PECTORALIS MAJOR FLAP
The pectoralis major fl ap is the most commonly used
muscle or myocutaneous fl ap worldwide in head and
neck surgery and certainly one of the most reliable of
all the pedicle fl aps.4-7 It has a long tradition of use in
reconstruction of the oral cavity and oropharynx and
can be used with a cutaneous island or as a myofascial
fl ap alone (Fig. 82-1). Its ability to protect the great
vessels of the neck is literally a lifesaving attribute.
The pectoralis major muscle provides the bulk of
the fl ap and is nourished by the pectoral branches of
the thoracoacromial artery. The thoracoacromial artery
branches from the subclavian artery deep to the clavicle
and enters the underside of the pectoralis major muscle
at about the midpoint of the clavicle. One can draw the
course of the thoracoacromial artery on the skin of the
chest by marking the clavicle at its midpoint. If one
draws a line from the xyphoid to the acromion and
constructs a perpendicular to this line that meets the
midpoint of the clavicle, the artery’s course corresponds
to the vertical perpendicular and the medial portion of
the line from xyphoid to acromion. When elevating the
pectoralis major, the artery can be seen running in fat
on the underside of the muscle.
Additionally, the lateral thoracic artery enters the
lateral portion of the sternal head of the pectoralis
major muscle but is routinely sacrifi ced during harvest
to maximize the arc of rotation of the fl ap. Usually, this
will not compromise fl ap viability, but a wary surgeon
is advised to inspect the course of the thoracoacromial
fi rst. Some authors have reported that perhaps one in
seven patients has a sternal portion of the muscle served
predominantly by a branch of the lateral thoracic
artery.
The skin overlying the medial aspect of the pecto-
ralis major muscle is nourished by perforators from the
internal mammary artery, especially those arising from
rib interspaces 2, 3, and 4, with perforators from inter-
spaces 3 and 4 playing particularly prominent roles.
These perforators are the arterial input for the classic
deltopectoral fl ap.
The origin of the pectoralis major is divided into
three segments: clavicular, sternocostal, and the apo-
neurosis of the external oblique. The clavicular origin
arises from the medial third of the clavicle. The sterno-
costal origin arises from the sternum and the fi rst six
ribs. The third origin arises from the attachment of the
inferior edge of the pectoralis muscle to the aponeuro-
sis and the fascia of the external oblique muscle. The
insertion of the pectoralis major runs deep to the
deltoid and inserts on the greater tubercle of
the humerus. The medial edge of the deltoid and the
tendinous insertion of the pectoralis major are almost
753

A
B
C
D
E
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F

Chapter 82
Regional Pedicle Flaps
755
indistinguishable from one another. The cephalic vein
can be used as a guide to differentiate between them.
The thoracoacromial artery will run the length of the
muscle on its deep surface as described earlier.
The pectoralis muscle mass stretches across the
superior anterior aspect of the chest, where it acts to
abduct and medially rotate the humerus. Use of the
muscle in construction of a fl ap does not cause signifi -
cant functional disability. Because of the length avail-
able in this fl ap, the pectoralis major muscle can be
used for defects ranging from the lower part of the neck
such as a stoma after laryngectomy, the upper part of
the neck, the tongue and fl oor of the mouth, and the
lateral head/auricular area.
A skin island is often used to replace mucosa when
a pectoralis major myocutaneous fl ap is positioned in
the site of the defect. The skin island is fed by perfora-
tors of the thoracoacromial system emerging from the
anterior surface of the muscle. If the skin island is
extended off the boundaries of the muscle in any direc-
tion, the portion of skin extending beyond the muscle
will have a random blood supply and can be less reli-
able. However, the skin island can be placed anywhere
on the anterior surface of the muscle that would be
usable in fi lling the defect. This is often approximated
during surgery by positioning a towel at the origin of
the thoracoacromial artery below the clavicle and
extending inferiorly to the inferior edge of the skin
island. In this way the arc of rotation and the length of
the muscle on its pedicle can be evaluated to ensure
adequate advancement.
The incision for liberating the pectoralis major
muscle from the overlying skin and the underlying
chest wall can be varied, depending on the concerns
of the patient and the needs of the reconstructive pro-
cedure. Typically, the skin island is positioned near
the end of the fl ap, close to the caudal portion of the
muscle origin. It is often possible to dissect out the
muscle through an incision in the inframammary fold.
If a skin fl ap is needed, the skin and subcutaneous
tissue can be incised to expose the pectoralis muscle,
which can then be raised through these incisions around
the skin island. The skin island is fed by perforators
from the thoracoacromial artery running through the
muscle, and thus care must be taken to not undercut
or shear the skin island from the muscle. Several stay
sutures tacking the skin island to the muscle are helpful
toward this end, and the inferior sutures may be left
long to help bring the fl ap up into its fi nal position.
The use of long stay sutures wrapped around the sur-
geon’s fi nger provides traction and fl exibility as the
surgeon pulls the fl ap below the neck skin overlying the
clavicle. The crucial technical detail to be observed in
fl ap advancement is making the tunnel under the cla-
vicular skin large enough to easily accommodate the
bulk of the muscle. Sometimes it will be necessary to
incise this skin and place a skin graft over the muscle.
Any area of the skin island directly over the muscle
should have a good blood supply. Portions of the skin
that extend beyond the pectoralis will be random, and
their survivability is less reliable. Flaps may be harvested
with one skin island, two as in the case of a bilobed fl ap,
or no skin island at all. Inclusion of rib has been used
when osseous reconstruction is needed, although this
is much less commonly done today now that experience
with osteocutaneous free fl aps is so extensive. If the fi fth
rib is harvested along with the fl ap, care must be taken
to not separate the muscle from the fi fth rib because
the rib derives its blood supply from perforators running
through the muscle to the periosteum over the surface
of the rib.
In a female patient, a curvilinear incision inferior
to the breast, in the breast crease, can avoid the more
obvious scarring that can still be seen with low neck
lines when the incision runs on the anterior chest wall.
In addition, the fi brofatty breast tissue can easily be
elevated away off the muscle as a complete unit when
making an incision in the inframammary fold.
As the pectoralis muscle is lifted off the chest wall,
it must be divided at its medial origin and lateral inser-
tion. The connection of the muscle to the proximal end
of the humerus will ultimately need to be released to
allow enough mobility for the fl ap to fi ll a defect in the
head and neck region. These muscle divisions are best
accomplished with electrocautery. Care must be taken
to avoid disruption of the feeder vessels on the under-
surface of the pectoralis major. The nerve supply to the
pectoralis major muscle arises from the lateral (C5 to
C7) and medial (C8, T1) pectoral nerves. These nerves
are often cut when raising this fl ap to provide an ade-
quate arc of rotation. This causes some long-term
atrophy of the muscle, which is often advantageous in
head and neck reconstruction.
The muscle may be released medially from the
sternum and laterally at the anterior axillary line near
its insertion. It may then be brought over the clavicle,
under the supraclavicular skin, and into the defect.
Alternatively, the muscle may be divided on either side
of the thoracoacromial vascular bundle down to the
distal end of the fl ap, which may be larger and even
include a cutaneous portion. This fl ap is like a lollipop
and creates less of a deformity in the neck. However, it
does not have the expanse of tissue to cover deep neck
structures, including the great vessels, that the wider
pectoralis major fl ap does.
When positioning this fl ap the operator must be
careful to not overly twist, kink, or crimp the vascular
pedicle. If the operator’s hand can be comfortably
placed below the skin of the inferior portion of the neck
and supraclavicular area from the neck incision into the
chest incision, there is little danger the vascular pedicle
will be compromised. Similarly, experimenting with the
most natural pattern for the fl ap to fi ll the defect can
Figure 82-1. Pectoralis myocutaneous fl ap. A, Defect for a pecto-
ralis myocutaneous fl ap. B, Incision for fl ap elevation. C, Pectoralis
fl ap ready for coverage of the defect. D, Pectoralis myocutaneous fl ap
in place. E, Pectoralis fl ap for closure of the oral cavity. F, Flap in
place. G, Pectoralis myocutaneous fl ap lining the oral cavity in
another patient.

756
Section 9
Plastic and Reconstructive Surgery
avoid excessive rotation and reduction of the blood
supply.
Complications are fortunately relatively infrequent
with this fl ap, and hence it is used frequently in head
and neck reconstruction. Full necrosis of the fl ap is
uncommon. Partial necrosis is not uncommon, however,
although local wound care is typically suffi cient to
resolve problems encountered with healing. On occa-
sion, a split-thickness skin graft will need to be used for
coverage of a donor site defect. This is preferable to
having the chest wound break down later because of a
closure that is too tight. The operator must be wary of
tension on the donor site closure when a large skin
island has been harvested. A skin graft whose appear-
ance bothers the patient can probably be removed later
with the technique of serial excision.
Using at least two suction drains helps avoid but
cannot absolutely prevent a postoperative hematoma.
Particularly if the patient’s blood pressure is elevated or
if an episode of excessive coughing occurs, a sudden
bulge in the donor area may herald a subcutaneous
hematoma. Of course, careful hemostasis must be
obtained as the fl ap is harvested to help avoid this
complication.
When advanced, the fl ap can be wrapped around
bone or reconstruction plates (or both). A cutaneous
paddle can be intraoral, extraoral, or both if a bridge
of skin between the paddles is de-epithelialized and
buried. The surgeon soon learns that myocutaneous
fl aps to the head and neck must be suspended ade-
quately to obtain the best results. External cutaneous
paddles in particular will invariably settle and appear to
hang with time, and patients should be advised of this
possibility. Later corrective surgery is frequently possi-
ble to achieve a signifi cant measure of improvement.
LATISSIMUS DORSI FLAP
The latissimus dorsi fl ap remains the most generally
dependable and versatile fl ap in the reconstructive
surgery armamentarium.8-10 It is a broad fl at muscle of
considerable length. It originates from an aponeurosis
that joins the posterior layer of the thoracolumbar
fascia from about the sixth thoracic vertebra to the
posterior iliac crest. The muscle inserts into the inter-
tubercular groove of the humerus. Its considerable
length allows it to easily reach the head and neck area
as a pedicled fl ap (Fig. 82-2). For this purpose it may
be tunneled subcutaneously over the pectoralis major,
under the pectoralis major insertion fi bers and over the
lateral aspect of the clavicle, or under the clavicle itself.
In the head and neck area the latissimus dorsi fl ap may
be used for surface reconstruction, and it may also be
advanced into the oral cavity and even used for esopha-
geal reconstructions. If a skin paddle is required, it is
best to base it on the middle of the muscle because the
most distal portion at the origin is not reliably well
perfused.
The muscle is approached with the patient bumped
up to expose the back or in a decubitus position. A
transverse incision high in the axilla is extended along
the posterior axillary fold to expose the lateral border
of the muscle. The dissection separates the overlying
back skin and subcutaneous tissue from the posterior
aspect of the muscle, except where a cutaneous portion
may be required. Electrocautery is used to release the
muscle from its origin. The anterior dissection should
respect the long thoracic artery to the serratus muscle,
where it lies just a centimeter or so behind and under
the anterior border of the latissimus muscle. The tho-
racodorsal artery serves the latissimus muscle. The tho-
racodorsal neurovascular bundle is relatively large and
may easily be traced to its origin from the subscapular
artery. For transposition to the region of the head and
neck, painstaking vascular dissection is required so that
the muscle can be mobilized on its vascular leash and
advanced to above the ear, the maxilla, or across the
base of the neck as needed.
As for reconstructions with the pectoralis major
muscle, it is essential that the latissimus be supported
with multiple sutures so that it does not descend and
thereby dehisce the wound or create a sagging fl ap that
B
A
Figure 82-2. Latissimus dorsi fl ap. A, Latissimus dorsi donor site incision. B, Latissimus fl ap in place with a skin graft.

Chapter 82
Regional Pedicle Flaps
757
is less functional and attractive than when inset in the
operating room. Some sagging late is almost always a
problem, but early dehiscence must be avoided.
STERNOCLEIDOMASTOID MUSCLE FLAP
The sternocleidomastoid (SCM) fl ap can be based
either from its inferior origin on the sternum and clav-
icle or from its superior insertion on the mastoid
process11,12 because of the multiple arterial blood supply
to the muscle along its course. The principal blood
supply to the SCM is via the occipital artery at the supe-
rior aspect of the muscle. Further inferiorly along its
course the muscle receives blood from the postauricu-
lar artery, branches from the superior thyroid artery,
and branches from the thyrocervical trunk. A skin island
can be incorporated with this fl ap and derives its blood
supply from perforators running through the SCM.
Motor neural input to the SCM comes from branches
of the spinal accessory nerve. In addition, C2 and C3
supply innervation, with disagreement whether this
innervation is motor or sensory in nature.
There is some controversy about using the SCM
fl ap when cervical metastases from an upper aerodiges-
tive tract malignancy are present. Spread down the
internal jugular chain lymph nodes can bring the cervi-
cal metastases into contact with the SCM, and in this
situation a different reconstructive option should
be considered. If the SCM must be excised to complete
the neck dissection, another fl ap must obviously be
considered.
Evaluation of the arc of rotation that will best allow
the fl ap to fi ll the defect will determine how the fl ap
will be pedicled. Basing the fl ap superiorly or inferiorly
will allow suffi cient length to place the skin island in
the oral cavity. Occasionally, periosteum from the clav-
icle or full- or split-thickness clavicle can be incor -
porated as part of an SCM fl ap. This necessitates a
superiorly based fl ap, which carries with it the advan-
tage of preserving the most robust arterial feeders,
namely, the occipital and the superior thyroid. Its dis-
advantage is that the platysma muscle overlies the SCM
in the caudal neck. This extra layer of tissue between
the SCM and the skin island reduces the perforators
that supply the skin in this region, and authors have
noted a substantial rate of partial or complete skin
island necrosis. This is even more common in an irradi-
ated neck. The inferiorly based SCM fl ap carries with it
the advantage of a more robust supply of skin perfora-
tors because the platysma does not cross between the
SCM and the skin in this region of the neck. The dis-
advantage of a inferiorly based fl ap is that it relies on
caudal arterial supply to the SCM muscle, branches off
the thyrocervical trunk, which places the blood supply
to the muscle as a whole in more jeopardy.
To incorporate periosteum for repair of the ante-
rior tracheal wall or part of the larynx, care must be
taken to elevate the periosteum in continuity with the
SCM muscle to preserve the blood supply. This also
holds true for partial-thickness or full-thickness clavicle.
Clavicular bone can then be used to repair anterior
tracheal/laryngeal defects. Meyer has popularized this
technique, which has been ascribed to Lindholm.13 It is
recommended that if periosteum is being used as a
patch to repair the anterior tracheal wall, a tracheos-
tomy tube be placed inferior to the defect and either
a T tube (with the tracheostomy tube inserted into it)
or a Montgomery laryngeal stent (with through-and-
through stay sutures brought out through the skin and
traversing from one side of the neck to the other while
passing through the stent) be placed within the airway.
In this manner, the fl accid periosteum will be stented
to prevent collapse into the airway lumen. The Mont-
gomery stent or T tube would need to be removed later
in the operating room.
Raising the SCM fl ap generally does not present
unique challenges to the head and neck surgeon. All
the vital structures of the carotid sheath, as well as the
hypoglossal nerve, lie deep to the SCM muscle. In addi-
tion, the carotid sheath lies deep to the omohyoid
muscle in the inferior aspect of the neck. The hypoglos-
sal nerve lies deep to the digastric muscle more superi-
orly. Therefore, the SCM muscle may be raised relatively
quickly if the omohyoid and digastric muscles are iden-
tifi ed deep to it. Superiorly, one must be cognizant of
cranial nerve XI as it courses superiorly. It will split the
SCM muscle as it descends in the neck.
The arc of rotation must be carefully considered
when planning this fl ap. In the case of a superiorly
based fl ap, preservation of the superior thyroid artery
will improve the blood supply but often restricts the arc
of rotation. Generally, two of the three arterial supplies
to the SCM muscle are sacrifi ced for the sake of attain-
ing adequate rotation.
When the periosteum or clavicle is incorporated as
part of the fl ap, the sternal head of the muscle can
often be sacrifi ced for ease of placement of the clavicu-
lar head and periosteum or bone into the defect. Occa-
sionally, looping the clavicular head deep to the sternal
head will accomplish the same task without sacrifi ce of
the sternal head.
TRAPEZIUS MUSCLE FLAP
Use of a cutaneous trapezius muscle fl ap extends back
to 1842, when Mutter used it for the release of burn
contractures in the neck. The three varieties of trape-
zius fl ap (superior, lateral island, and lower island) have
been well described by many surgeons. These concepts
are defi ned in the following text as they relate to spe-
cifi c fl aps.14-17
The trapezius is a triangular muscle that extends
along the midline of the spine from the skull base to
the about the 10th thoracic vertebra. It inserts on the
lateral third of the clavicle, the scapular spine, and the
acromion. It defi nes the posterior border of the pos-
terior triangle of the neck. The trapezius functions
to elevate and retract the shoulder and rotate the
scapula.
Motor innervation of the trapezius is supplied by
the spinal accessory nerve, cranial nerve XI. Contribu-
tions from C2 to C4 are also present, but it is unclear

758
Section 9
Plastic and Reconstructive Surgery
to what degree they play a role in functioning of the
muscle. The blood supply to the trapezius is from the
occipital artery, paraspinous perforators, the transverse
cervical artery, and the dorsal scapular artery.
There are three distinct ways that the trapezius
muscle can be used as a fl ap for head and neck recon-
struction, as described in the following sections.
Superior Trapezius Flap
This fl ap is based on the occipital artery and the para-
spinous perforators. It extends from the occiput, along
the anterior border of the trapezius toward the shoul-
der, and then back again medially up to the midline of
the spine. It creates a long tongue of tissue, both muscle
and skin, for use in the head and neck. Elevation of this
fl ap relies on elevation of the trapezius muscle with the
skin overlying it remaining attached. This fl ap has been
described as being divided into three angiosomes. The
fi rst is the most medial; it extends from the midline of
the spine toward the shoulder and receives its blood
supply from the occipital artery and the paraspinous
perforators. The second angiosome extends laterally
from this one and receives its blood supply from the
transverse cervical artery as it courses over the clavicle.
The last angiosome extends laterally from the second
and ends over the deltoid muscle. This last angiosome
receives its blood supply from a branch of the thora-
coacromial artery. Choke arteries that run through the
skin allow the paraspinous perforators to supply the
third angiosome if the transverse cervical artery is inter-
rupted, such as during the course of neck dissection.
This fl ap can then be swung medially onto the neck to
repair loss of cutaneous tissue on the neck. A skin graft
is required for closure of the donor site defect. Either
intervening skin from the neck that is covered by the
fl ap is removed so that the entire length of the fl ap can
be inset, or the underlying neck skin can be left in place
and the base of the fl ap taken down and replaced in its
original location as a delayed secondary procedure.
Lateral Island Flap
In this fl ap the transverse cervical artery (TCA) and vein
(TCV) must be meticulously dissected in the inferior
portion of the posterior triangle of the neck and traced
to their entry into the trapezius muscle. The skin island
is situated along the anterior edge of the trapezius and
extends inferiorly along the back of the patient. Care
must be taken to preserve the pedicle artery and vein,
especially if neck dissection has previously been per-
formed. Additionally, the TCA and TCV may pass
through portions of the brachial plexus and not allow
harvest of the fl ap because of an inability to rotate the
fl ap into position. Once the TCA and TCV have been
dissected in the root of the neck and followed to their
insertion in the trapezius muscle, the skin island can be
adjusted so that the vascular pedicle is centered in the
skin island. After the pedicle has been secured, a skin
incision is made around the skin island and through
the trapezius muscle. The skin and muscle island is then
elevated off the underlying muscles while paying atten-
tion to not disrupt the vascular pedicle. The pedicle
and attached skin/muscle island are then swung into
position in the neck. Greater arc of rotation can be
obtained when medial dissection along the pedicle
frees the pedicle from surrounding tissue. Closure of
the donor site defect can then be accomplished, fre-
quently without a skin graft, as long as wide undermin-
ing is done.
Lower Trapezius Island Flap
This fl ap has the longest arc of rotation of any of the
three; however, it does require exposure of the patient’s
back and therefore positioning the patient in the decu-
bitus position is required (Fig. 82-3). The arm is ad -
ducted and medially rotated. The lower trapezius fl ap
is based on the TCA and possibly the dorsal scapular
artery (DSA). The skin island is positioned between the
spine and the medial edge of the scapula. Dissection
starts by incising the skin from the distal tip of the skin
island superiorly toward the clavicle. Wide undermin-
ing of the medial and lateral skin is then accomplished.
The inferior lateral edge of the trapezius muscle is iden-
tifi ed and then dissected from the underlying muscles
by proceeding in a superior direction. The skin island
remains attached to the trapezius muscle as it is ele-
vated. The DSA and dorsal scapular vein (DSV) will be
encountered as they penetrate from the underlying
rhomboids into the inferior portion of the trapezius
muscle. With digital pressure the artery can be com-
pressed lightly and bleeding from the edge of the skin
island assessed. If deemed adequate, the DSA and DSV
can be ligated and the dissection continued superiorly.
The trapezius muscle must be freed from its attach-
ments along the spine. In doing this the paraspinous
perforators must be cauterized or ligated. Additionally,
the attachments to the scapular spine must be incised.
The TCA and TCV will be identifi ed as the superior
edge of the levator scapulae and the rhomboid minor
are encountered. The DSA enters the trapezius from
the deep musculature, between the rhomboid major
and minor, inferior to the entry of the TCA. This fl ap
will often yield a lengthy pedicle suffi cient to reach to
the auricle or side of the face.
TEMPOROPARIETAL FASCIAL FLAP
The temporoparietal fascial fl ap is useful for recon-
struction of the ear, the orbit, the anterior cranial base,
the superior and middle thirds of the face, and even
the oral cavity (Fig. 82-4).18-20 The anatomy is quite
straightforward in that the fl ap is based on the parietal
branch or the superfi cial temporal artery and vein.
These vessels ascend just anterior to the auricle and
branch approximately 2 to 4 cm above the zygomatic
arch. They must be preserved when raising the fl ap,
especially as one approaches the base of the fl ap.
A Doppler monitor may be helpful in guiding
dissection.
The fl ap is approached with a scalp incision from
the root of the helix of the ear to the top of the tem-
poral fossa. The scalp is raised off the deeper soft tissues

Chapter 82
Regional Pedicle Flaps
759
A
B
C
D
Figure 82-3. Trapezius fl ap. A, Defect of the face and scalp. B, Planning of the trapezius fl ap. C, Elevation of the trapezius fl ap. D, Recon-
struction with the trapezius fl ap. (Courtesy of Dr. B. Chandrasekhar.)
in an adipose plane below the hair follicles. Care must
be exerted here so that no areas of alopecia are created
by dissection that is too superfi cial. The soft tissues are
incised in an arc paralleling the line of origin of the
temporalis muscle, and the fl ap is raised off the deep
temporalis fascia itself. Anteriorly, care must be taken
to avoid injury to the temporal branch of the facial
nerve. The fl ap includes the galea and may be extended
somewhat by including periosteum above the line of
origin of the temporalis. The fl ap is narrowed as the
base of the pedicle is approached at the point where
the parietal branch of the superfi cial temporal artery
enters the fl ap.
Closure of the donor defect is direct, and there
should be no observable donor defect. The fl ap can be
buried or covered with a split-thickness skin graft with
great success. It will reach the orbit and the oral cavity
with ease. This fl ap is without peer in covering the car-
tilage framework of the external ear.
TEMPORALIS MUSCLE FLAP
The temporalis muscle fl ap is particularly useful for
reconstruction of defects in the region of the auricle,
the orbit and infratemporal fossa, and the hard palate
and even intraoral defects (Fig. 82-5).21-23 It is not used
with a cutaneous component because a scalp defect and
an area of alopecia would be created.
The temporalis muscle is fan shaped and passes
under the zygomatic arch to insert on the coronoid
process of the mandible. There are two major vascular
inputs, the anterior and the posterior deep temporal

C
A
D
B
Figure 82-4. Temporoparietal fascia (TPF) fl ap. A, Planning the TPF fl ap incision. B, Elevation of the TPF fl ap. C, Delivery of the TPF fl ap
into the oral cavity. D, TPF fl ap in place to close an intraoral defect. (Courtesy of Dr. Michael Carstens.)
A
B
Figure 82-5. Temporalis fl ap. A, Defect in the auricular area covered with a temporalis fl ap. B, Late follow-up of the temporalis fl ap.

Chapter 82
Regional Pedicle Flaps
761
arteries. After freeing its origin, the muscle can be
turned posteriorly over a defect in the auricular area or
moved anteriorly to fi ll the orbit. If a portion of the
zygomatic arch is removed, the muscle may be advanced
caudally to the lower border of the mandible.
Flap elevation is quite easy, and the challenge to
the surgeon is usually moving the muscle where it is
needed once the origin is released. Most commonly it
is directed toward the orbit, the infratemporal fossa, or
the hard palate.
DELTOPECTORAL FLAP
The deltopectoral fl ap was once the most commonly
used fl ap in head and neck surgery, but it has largely
been superseded by the pectoralis major fl ap, which is
more robust and can be raised and inset with confi -
dence without a delay procedure.24-26 The deltopectoral
fl ap can be used with great success for reconstruc -
tion of defects of the middle and lower thirds of the
face, the oral cavity, the neck, and the esophagus
(Fig. 82-6).
It is raised over the upper part of the chest, based
in the peristernal area, and extended laterally and
cephalad to the deltoid region. It may even be extended
to the posterior aspect of the shoulder if delayed. It is
perfused by the fi rst through third peristernal perfora-
tors of the internal mammary artery. A fl ap 10 cm in
width and 20 cm in length can be reliably raised and
used with a high likelihood of success. Longer fl aps
should be delayed. The fascia of the pectoralis major
muscle may be raised with the fl ap.
When the end of the fl ap is inset for its intended
purpose, the proximal portion of the fl ap that is not
inset as part of the reconstruction may be tubed. Later,
2 or 3 weeks after elevation, the fl ap may be divided
with inset of the base of the fl ap into the donor area,
or the redundant fl ap may simply be excised. Skin graft-
ing is usually required to close the donor site wound,
and the resulting defect is noticeable.
B
A
D
C
Figure 82-6. Deltopectoral (DP) fl ap. A, Hypopharyngeal defect. B, Delay of the DP fl ap with a split-thickness skin graft on the underside.
C, Elevation of the DP fl ap with a skin graft for lining at the site of the defect. D, DP fl ap in place with a skin graft placed over the donor
defect. (Courtesy of Dr. Frederic W.-B. Deleyiannis.)

762
Section 9
Plastic and Reconstructive Surgery
CERVICOPECTORAL FLAP
The cervicopectoral fl ap is a skin fl ap of large propor-
tions that affords coverage of lateral neck and cheek
defects.27 The blood supply is essentially that of the
deltopectoral fl ap. The skin fl ap is raised from the infe-
rior border of the neck or cheek defect across the tra-
pezius muscle 2 cm behind its anterior border and
down across the acromioclavicular point of the shoul-
der and the top of the anterior axillary fold (Fig. 82-7).
A backcut may be needed to facilitate full rotation, and
dog-ears at the anterior jaw line and in the axilla should
be excised at the time of closure. The fl ap is raised in
a plane just deep to the platysma muscle and the ante-
rior pectoral fascia, and care must be exercised to avoid
disruption of the internal thoracic perforators medially
at the very base of the fl ap.
The cervicopectoral fl ap has skin color and texture
like that of the resected skin, although depending on
the cephalad border it may not carry bearded skin. It
can be assessed via fl uorescein perfusion before full
inset to ensure reconstruction with fully viable tissue.
Extensive mobilization will allow closure of defects mea-
suring 10 cm in diameter with a very satisfactory appear-
ance at the site of reconstruction and a minimal donor
site defect. The scar is quite acceptable and the fl ap is
robust. To achieve the advancement possible with this
fl ap, the surgeon must undermine extensively. The
plane is easily entered and traversed, and there is very
low morbidity. In view of the ready availability of this
fl ap and the excellent tissue match, this fl ap is probably
underused for head and neck reconstruction.
CONCLUSION
This listing will provide the head and neck surgeon with
a number of options for restoring cover and continence
at places where defects are created. As pointed out,
these fl aps do not require much time and can bring a
long extirpative operation to a fairly rapid conclusion.
Familiarity with these techniques will prove lifesaving
for some patients. Local pedicled fl aps have been one
of the factors that have transformed head and neck
surgery to the safer and predictable endeavor that it is
today. These fl aps are a welcome alternative at crucial
moments in the treatment of patients stricken with neo-
plasms of the head and neck.
A
B
C
Figure 82-7. Cervicopectoral fl ap. A, Defect requiring closure. B, Elevation and advancement of the cervicopectoral fl ap with elimination of
the defect. C, The fl ap has healed completely and the patient has undergone postoperative radiation therapy. (Courtesy of Dr. James
Russavage.)
PEARLS
• A good working knowledge of the anatomy of the
muscles of the head and neck and upper thorax is
essential for the successful use of pedicle fl aps.
• The pectoralis major fl ap is almost always a good
alternative for reconstruction of head and neck
defects.
• The latissimus dorsi and the cervicopectoral fl aps
are often excellent choices for head and neck
reconstruction.
• Planning can afford both lining at the mucosal level
and skin cover when both are needed.
• When fl aps are passed subcutaneously, the
passageway must be large to avoid constriction of
the pedicle.

Chapter 82
Regional Pedicle Flaps
763
tions and report of 60 cases. Plast Reconstr Surg 71:199-204,
1983.
9. Watson JS, Robertson GA, Lendrum J, et al: Pharyngeal recon-
struction using the latissimus dorsi myocutaneous fl ap. Br J Plast
Surg 35:401-407, 1982.
10. Yamamoto K, Takagi N, Miyashita Y, et al: Facial reconstruction
with latissimus dorsi myocutaneous island fl ap following total
maxillectomy. J Craniomaxillofac Surg 15:288-294, 1987.
11. Zhao YF, Zhang WF, Zhao JH: Reconstruction of intraoral defects
after cancer surgery using cervical pedicle fl aps. J Oral Maxillo-
facial Surg 59:1142-1146, 2001.
12. Charles GA, Hamaker RC, Singer MI: Sternocleidomastoid myo-
cutaneous fl ap. Laryngoscope 97:970-974, 1987.
13. Meyer R: Current treatment of stenoses. In Reconstructive
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14. Mathes SJ, Vasconez LO: The cervicohumeral fl ap. Plast Reconstr
Surg 61:7-12, 1978.
15. Baek SM, Biller HF, Krespi YP, Lawson W: The lower trapezius
island myocutaneous fl ap. Ann Plast Surg 5:108-114, 1980.
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17. Panje W: Myocutaneous trapezius fl ap. Head Neck Surg 2:206-
212, 1980.
18. Abul-Hassan HS, Asher GVD, Acland RD: Surgical anatomy and
blood supply of the fascial layers of the temporal region. Plast
Reconstr Surg 77:17-24, 1986.
19. Antonyshyn O, Gruss JS, Bart BD: Versatility of temporal muscle
and fascial fl aps. Br J Plast Surg 41:118-131, 1988.
20. Carstens MH, Greco RJ, Hurwitz DJ, Tolhurst DE: Clinical appli-
cations of the subgaleal fascia. Plast Reconstr Surg 87:615-626,
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21. Bakamjian VY, Souther SG: Use of temporal muscle fl ap for
reconstruction after orbitomaxillary resections for cancer. Plast
Reconstr Surg 56:171-177, 1975.
22. Koranda FC, McMahon MF, Jernstorm VR: The temporalis
muscle fl ap for intraoral reconstruction. Arch Otorhinolaryngol
113:740-743, 1987.
23. Reese AB, Jones IS: Exenteration of the orbit and repair by trans-
plantation of the temporalis muscle. Am J Ophthalmol 51:217-
222, 1961.
24. Bakamjian VY: A two-stage method of pharyngoesophageal recon-
struction with a primary pectoral skin fl ap. Plast Reconstr Surg
36:173-184, 1965.
25. Mendelson BC, Woods JE, Masson JK: Experience with the delto-
pectoral fl ap. Plast Reconstr Surg 59:360-365, 1977.
26. Krizek TJ, Robson MC: Potential pitfalls in the use of the delto-
pectoral fl ap. Plast Reconstr Surg 50:326-332, 1972.
27. Becker DW: A cervicopectoral rotation fl ap for cheek coverage.
Plast Reconstr Surg 61:868-870, 1978.
PITFALLS
• A lack of respect for the vascular anatomy of a
pedicle fl ap will often result in compromise of the
fl ap and even its loss.
• Be on the lookout for a lateral thoracic contribution
that is the dominant artery serving the sternal
portion of the pectoralis major muscle.
• Do not forget that fl uorescein testing of fl aps can
help one ensure a successful reconstruction. Failure
to test when in doubt may result in a necrotic fl ap.
• Support for the fl aps with multiple suture
suspensions and no tension along the line of the
fl ap is essential for aesthetically pleasing
reconstructions.
• Do not forget that fl aps can be revised with benefi t
when the primary mission of closure and recovery is
accomplished, and do not forget to assure the
patient of this.
References
1. Baker SR, Swanson NA: Local Flaps in Facial Reconstruction.
St Louis, CV Mosby, 1995.
2. Strauch B, Vasconez LO, Hall-Findlay EJ: Grabb’s Encyclopedia
of Flaps. Boston, Little, Brown, 1990.
3. Mathes SJ, Nahai F: Reconstructive Surgery: Principles, Anatomy,
and Techniques. New York, Churchill Livingstone, 1997.
4. Ariyan S: The pectoralis major myocutaneous fl ap: A versatile fl ap
for reconstruction in the head and neck. Plast Reconstr Surg
63:73-81, 1979.
5. Freeman JL, Walker EP, Wilson JSP, Shaw HJ: The vascular
anatomy of the pectoralis major fl ap. Br J Plast Surg 34:3-10,
1981.
6. Tobin GR: Pectoralis major segmental anatomy and segmentally
split pectoralis major fl aps. Plast Reconstr Surg 75:814-824,
1985.
7. Baek SM, Lawson W, Biller HF: An analysis of 133 pectoralis
major myocutaneous fl aps. Plast Reconstr Surg 69:460-467,
1982.
8. Barton FE, Spicer TE, Byrd HS: Head and neck reconstruction
with the latissimus dorsi myocutaneous fl ap: Anatomic observa-

Chapter 83
Cleft Lip and Palate: Comprehensive
Treatment and Technique
Anil Gungor, Ramon Ruiz, and Bernard J. Costello
Comprehensive treatment of cleft lip and palate defor-
mities requires thoughtful consideration of the ana-
tomic complexities of the deformity and the delicate
balance between intervention and growth. Comprehen-
sive and coordinated care from infancy through adoles-
cence is essential to achieve an ideal outcome. Surgeons
with formal training and experience in all phases of
care must be actively involved in planning and treat-
ment.1,2 Specifi c goals of surgical care for children born
with a cleft lip and palate include:
• Normalized aesthetic appearance of the lip and
nose
• Intact primary and secondary palates
• Normalized speech, language, and hearing
• Nasal airway patency
• Class I occlusion with normal masticatory function
• Good dental and periodontal health
• Normal psychosocial development
What makes these goals challenging in some chil-
dren is the wide spectrum of cleft lip, palate, and nasal
deformities. The range of manifestations from one
affected child to another is highly variable. An asymp-
tomatic bifi d uvula is an example of a clinically incon-
sequential cleft. A relatively simple deformity may
include a submucous cleft palate that causes speech
abnormality after an uneventful adenoidectomy. An
occult cleft lip with an intact philtral ridge and sym-
metrical Cupid’s bow and an otherwise normal-looking
child with a small notch in the alveolar ridge are other
such examples of minimal deformities. Unfortunately,
the other end of the spectrum includes wide bilateral
clefts of the lip and palate or facial dysplasia with several
associated anomalies (Fig. 83-1).
A cleft surgeon has the tasks of addressing
anatomic and functional defi ciencies at the initial
evaluation and planning for future functional and
aesthetic needs. Success in these endeavors is depen-
dent on many factors, including the severity of disrup-
tion of bone, cartilage, and soft tissue. Surgical skill
and technique matched to the nature and severity
of the deformity are the fundamental factors in
obtaining superior results. Attention to all aspects
of care, such as anatomic variants, the biology of
scar formation, parent education, and cooperation,
is very important in determining success. A healthy
and collaborative team environment is essential in
achieving these goals.
This chapter presents a technical overview of the
reconstruction of cleft lip and palate deformities. Sur-
gical reconstruction of clefts requires that surgeons
undertaking this important work maintain a cognitive
understanding of the complex malformation itself, the
varied operative techniques used, facial growth consid-
erations, and the psychosocial health of the patient and
family. The objectives of this chapter are to present the
overall staged reconstructive approach for repair of
cleft lip and palate from infancy through the time of
skeletal maturity, as well as a focused discussion of the
specifi c surgical procedures involved in primary repair
of clefts of the lip and palate.
CLASSIFICATION OF CLEFTS
Classifi cation of clefts is necessary to describe the defor-
mities, to study causative factors, and to compare results
of treatment undertaken. Several classifi cation systems
have been described.2-5 Simple classifi cation systems
are valuable for everyday use and are easy to under-
stand; they provide broad groups with large numbers of
patients in each group for research and analysis.
However, simple classifi cation systems fail to detail
the variations in severity of cleft manifestations. As a
consequence, there has been a tendency to use more
765

766
Section 9
Plastic and Reconstructive Surgery
complex classifi cation systems, which are more diffi cult
to use clinically but provide better information for
research and outcomes analysis.
There is infi nite variation in the confi guration of
clefts, and a compromise between simple and complex
classifi cation systems has to be reached. Regardless of
complexity, all classifi cation systems use basic nasal (ala,
dome, columella, nostril sill, septum, vomer), labial
(vermilion, philtrum, Cupid’s bow, Lister’s tubercle,
red and white lines, prolabium), and palatal (incisive
foramen, primary and secondary palate, hard and soft
palate, alveolar process, attachment to septum) land-
marks for reporting.
The LAHSHAL system is a basic and useful classifi -
cation that allows easy compilation of data. Starting
from the patient’s right side, the cleft status is recorded
as C(omplete), I(ncomplete), or X (absent) for the
L(ip), A(lveolus), H(ard palate), S(oft palate), H(ard
palate), A(lveolus), and L(ip) (Table 83-1). Craniofa-
A
B
C
D
Figure 83-1. Because cleft lips come in a variety of confi gurations, each repair must be individually customized to establish the most normal
morphology. A, Microform left unilateral cleft lip only, not requiring repair. B, Minor left incomplete unilateral cleft lip only. C, Right incom-
plete unilateral cleft lip and palate with a Simonart band. D, Wide right complete unilateral cleft lip and palate.
Table 83-1
CLASSIFICATION OF CLEFTS
Right
Left
L
A
H
S
H
A
L
I
C
C
C
X
X
X
This example is for a unilateral right incomplete cleft lip (l)
with a complete cleft alveolus (A) and hard (H) and soft (S)
palates. The vomer is attached to the left side of the hard palate.
The alveolus and lip on the left side are intact.
C, complete; I, incomplete; X, no cleft.
cial clefting may be described with Tessier’s orbitocen-
tric system of numbering (Fig. 83-2).
INTERDISCIPLINARY CARE
Successful management of the child born with a cleft
lip and palate requires coordinated care provided by

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
767
individuals from a number of different specialties,
including otolaryngology, oral and maxillofacial surgery,
plastic surgery, genetics/dysmorphology, speech/
language pathology, orthodontics, prosthodontics,
and others.1,2,6 Because care is provided over the entire
course of the child’s development, long-term follow-up
is critical to ensure complete and comprehensive
care.
Rehabilitation of a patient with a cleft is best per-
formed as an interdisciplinary effort. Most children
with clefts have multiple interrelated issues, and several
team models are available to address these issues in an
interdisciplinary fashion. Key members of the team are
the cleft surgeon or surgeons, orthodontist, and speech-
language pathologist. Cleft surgeons may be trained
plastic surgeons, oral and maxillofacial surgeons, or
otolaryngologists. Other key persons may include the
pediatric dentist, geneticist/dysmorphologist, pediatri-
cian, psychologist, and social worker. The team director
may or may not be a cleft surgeon but should be a
nonbiased participant in care. The formation of inter-
disciplinary cleft teams serves two key objectives of
successful cleft care: (1) coordinated care provided by
all the necessary disciplines and (2) continuity of care
with close interval follow-up of the patient through -
out periods of active growth and ongoing stages of
reconstruction.
In a carousel team, patients are seen on the same
day by all specialists. Comprehensive evaluation is not
performed, at the time of decision making information
may be incomplete, and one practitioner’s treatment
decision may not refl ect the complete status of the
patient until all the information can be reviewed by
everyone involved. In a triage team, one gatekeeper
organizes outpatient referrals to specialists through
multiple visits. This approach is often costly and requires
a team meeting of all the practitioners to provide com-
prehensive care.
Multidisciplinary teams have many specialists, but
they may not necessarily be cooperative or interactive.
The best organization of care occurs when multidisci-
plinary teams are also interdisciplinary. Interdisciplin-
ary teams work together to come up with the best
treatment plan for a given patient. In this treatment
model, decisions are based on a collaborative process,
and each member is cognizant of other members’ treat-
ment priorities.
PRENATAL DIAGNOSIS
Team involvement ideally starts in the prenatal
period.1,2,7,8 Prenatal diagnosis by ultrasound presents
an opportunity to introduce team members and their
roles early in the process and provides reassurance,
familiarity, and a structured approach for the various
issues, including counseling, treatment, and feeding
approaches. Prenatal sonographic detection of clefts is
often dependent on cleft type and severity. When a cleft
is present, the overall detection rate is approximately
65% (isolated cleft palate, 22%; isolated cleft lip, 67%;
cleft lip and palate, 93%).1
Figure 83-2. A and B, Complex facial clefts can be classifi ed accord-
ing to Tessier’s orbitocentric system of numbering. Clefts may involve
all tissue planes, including the skin, mucosa, bone, teeth, muscle,
brain, peripheral nerve, and other specialized structures.
A
14
13
1211
10
9
8
6
7
5
4
3
2
1
0
B
0 12 3
4
5
6
8
7
9
10
11
12
13
14

768
Section 9
Plastic and Reconstructive Surgery
Additional testing may be warranted to evaluate the
possibility of associated deformities, syndromes, and
sequences that could affect the birthing process. Excep-
tionally skilled ultrasonographers can visualize airway
development and other abnormalities that may require
early intervention with fetal surgery, ex utero intrapar-
tum procedures, extracorporeal membrane oxygen-
ation, or surgical airway management (tracheotomy) at
the time of delivery. Evaluations of any associated mal-
formations are completed via three-dimensional ultra-
sound, magnetic resonance imaging, and other genetic
evaluations. These detailed evaluations can be very
helpful in understanding the nature of various deformi-
ties, the likelihood of an uneventful birth, and the need
for additional evaluation and treatment.
SEQUENCING OF PROCEDURES
Because of many different treatment philosophies, the
timing of treatment interventions varies from one cleft
center to another. Therefore, it is diffi cult to produce
a timing regimen that everyone agrees on.1,2,9-11 A sample
timeline of staged reconstruction of cleft lip and palate
deformities is presented in Table 83-2. This is a general
timeline and requires an individualized approach based
on aesthetic and functional priorities.
The timing of cleft lip and palate repair is contro-
versial. Despite a number of meaningful advancements
in the care of patients with cleft lip and palate, there is
a lack of consensus regarding the timing and specifi c
techniques used during each stage of cleft reconstruc-
tion. Surgeons must continue to carefully balance the
functional needs, aesthetic concerns, and the issue
of ongoing growth when deciding how and when to
intervene. In no other type of deformity is the effect of
early surgery on growth more apparent than in the
treatment of cleft lip and palate deformities. The deci-
sion to surgically manipulate the tissues of a growing
child should not be made lightly and should take into
account the possible growth restriction that can occur
with early surgery. Nevertheless, many patients with
congenital deformities will benefi t from early surgical
intervention for functional or psychosocial reasons.
Understanding the growth and development of the cra-
niofacial skeleton is essential to the treatment planning
process.1,2
MANAGEMENT OF AIRWAY
OBSTRUCTION IN PATIENTS WITH CLEFTS
Features of the airway depend on the type of cleft and
its severity. An intact palate provides tongue support
and prevents glossoptosis. Lacking this support, a child
with a wide cleft palate will have obstruction of the
upper airway of varying severity. This obstruction is pro-
nounced in children with associated syndromes and the
Robin sequence in which mandibular growth is com-
promised. Prone positioning, feeding adaptation, and
time may resolve the mild obstruction. In some cases a
nasal airway can provide relief for a few weeks to months.
Airway evaluation via fl exible and rigid endoscopy is
warranted to determine the extent of airway obstruc-
tion, as well as additional airway compromise (i.e.,
choanal atresia, laryngotracheomalacia, subglottic ste-
nosis). In severe cases of obstruction, surgical options
include glossopexy, mandibular distraction osteogene-
sis, and tracheotomy. Diffi cult intubation should be
anticipated, and additional equipment such as a Bullard
laryngoscope, laryngeal mask airway, or fl exible endo-
scopic intubation devices should be available.
PRESURGICAL ORTHOPEDICS
Presurgical orthopedic (PSO) devices are used to
mechanically manipulate the position of the alveolar
segments before defi nitive lip and nasal repair. A custom
acrylic prosthesis is used to mold the lip and maxillary
dental arch. As the greater segment is pushed into posi-
tion, space is cut away within the palatal plate to allow
the lesser segment to drift into the proper arch form.
When the lip has an incomplete cleft, the alveolar
segments are usually molded into a reasonable arch
form, and maxillary arch orthopedic devices are not
necessary.
Nasoalveolar molding is a technique that combines
maxillary arch orthopedics with a PSO device and lip
and nasal contour shaping via nasal-vestibular projec-
Table 83-2
TIMELINE FOR STAGED
RECONSTRUCTION OF CLEFT LIP AND
PALATE DEFORMITIES
Procedure
Timing
Airway evaluation and
intervention
After initial assessment
when necessary
Presurgical orthopedics,
nasoalveolar molding, lip
adhesion
Before lip repair in select
cases
Cleft lip/nasal repair
After 10 wk
Cleft palate repair
9-18 mo
Myringotomy and tubes
At the time of lip or palate
repair, depending on the
presence of middle ear
effusion and hearing status
Pharyngeal fl ap or
pharyngoplasty
3-5 yr or later, depending
on speech development
Maxillary/alveolar
reconstruction with bone
grafting
6-9 yr, depending on dental
development
Cleft orthognathic
surgery
14-16 yr in girls, 16-18 yr in
boys
Cleft septorhinoplasty
After 5 yr of age but
preferably at skeletal
maturity after orthognathic
surgery when possible
Cleft lip revision
Anytime after initial
remodeling and scar
maturation, but best after
5 yr of age

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
769
tion (Fig. 83-3).12-17 The importance of this technique is
emphasized by surgeons who advocate primary nasal
repair at the time of lip repair for children with wide
clefts and severe nasal deformities, especially those with
a very short columella. Successful use of PSO devices
requires a dedicated pediatric dentist or orthodontist,
a good laboratory, and diligent parents. Noncompli-
ance can be a problem, so for this and other reasons,
some centers rely on pin-retained prostheses. However,
these appliances have been associated with signifi cant
midface growth restriction.17
Some surgeons perform a surgical lip adhesion pro-
cedure at about 3 months to mold the alveolar seg-
ments into better position before defi nitive repair.
Effective PSO devices may obviate the need for a lip
adhesion procedure and the additional anesthetic
required for it.18 Although initial results are reportedly
good, use of these devices and their effi cacy are still
controversial because long-term outcome studies
showing improved aesthetics, higher retention of
dentition, and better dental arch form are still not
available.1,2,14-16,19
LIP ADHESION
In exceptionally wide unilateral or bilateral clefts or in
extremely asymmetrical bilateral clefts, it may be helpful
to approximate the segments of the cleft lip before
defi nitive lip repair to achieve a better relationship of
both the lip structures and the dental arches. In this
technique, which is used by some surgeons, small fl aps
of tissue are advanced across the cleft site (Fig. 83-4).
Care is taken to not disturb natural landmarks, and a
through-and-through horizontal tension suture is
placed. When used, lip adhesion is usually completed
at 3 months of age. The defi nitive lip repair is then
completed 3 to 6 months later by excising the scar and
reapproximating the remaining lip structures.
Figure 83-3. A, Frontal and lateral views of the Grayson nasoalveolar molding (NAM) appliance showing the nasal projections that help mold
the nasal cartilage and maxillary segments into a more appropriate confi guration before repair. B, Segments before the use of NAM. C, Seg-
ments after NAM but before closure.
B
C
A

770
Section 9
Plastic and Reconstructive Surgery
PRIMARY UNILATERAL CLEFT LIP REPAIR
Unilateral clefts of the lip and nose have a high degree
of variability, and thus each repair design is unique (see
Fig. 83-1). One repair technique preferred by the
authors for cleft lip and nasal deformities is shown in
Figures 83-5 and 83-6 and is usually performed after 10
weeks of age. The goal of the repair is to create a three-
layered closure of skin, muscle, and mucosa in which
hypoplastic tissue at the cleft margins is excised and
normal tissues are approximated. Critical in the process
is reconstruction of the orbicularis oris musculature
into a continuous, functional sphincter. The Millard
rotation-advancement technique has the advantage of
allowing each of the incision lines to fall within the
natural contours of the lip and nose.1,2,20,21 This is an
advantage because it is diffi cult to achieve “mirror
image” symmetry in a unilateral cleft lip and nose with
the normal side immediately adjacent to the surgical
site. A Z-plasty technique such as the Randall-Tennison
repair may not achieve this level of symmetry because
the Z-shaped scar is directly adjacent to the linear non-
clefted philtrum. Achieving symmetry is more diffi cult
when the rotation portion of the cleft is quite short in
comparison with the advancement segment. There is a
great degree of variability in repair techniques from
surgeon to surgeon. Several techniques are discussed as
examples of unilateral and bilateral lip repair.
All landmarks are carefully marked with the use of
operating loupes and surgical calipers (Fig. 83-5A).
Marking starts with identifi cation of the low point
(midline) (1) and the peak (2) of Cupid’s bow on the
noncleft side (NCS). The distance between these two
points is used to determine the position of the peak of
Cupid’s bow on the cleft side (CS) (3). The alar base
on the NCS (4), the columellar base (5), and the com-
missures (6 and 7) are marked. The lateral peak of
Cupid’s bow (8) is marked by taking the distance from
the CS commissure and the width of the vermilion into
account. The combined vertical height of the wet and
dry vermilion at point 8 should match the vertical
height of the vermilion at point 3. Therefore, 8 can be
placed within 1 to 2 mm of the measured distance
(matching the distance between 2 and 6) from the com-
missure to match the vermilion in height.
The tip of the advancement fl ap (9) is marked
so that the distance between points 8 and 9 matches the
distance between 2 and 5 (see Fig. 83-5A). The surgeon
must avoid discolored, hypoplastic skin with increased
vascular patterns when designing the fl ap. The slightest
difference in color here will be highly visible against the
contrast provided by the NCS lip and columella skin.
The rotation incision is followed by a very small
(<1 mm) releasing cut (y) made high in the lip in a
near-perpendicular angle to the rotation incision (see
Fig. 83-5B). This should allow the NCS to drop down
without tension and create a symmetrical prolabium
with minimal transgression of the upper philtral
column.
The orbicularis oris is dissected from the skin along
the rotation and advancement fl aps (see Fig. 83-5C).
The dissection is performed to facilitate layered closure.
If feasible, the muscle may be interdigitated. The
mucosal closure is started in the sulcus and extended
Figure 83-4. Example of the lip adhesion technique used by some surgeons
as a fi rst stage in closing wide clefts. A, Flaps are designed to bridge the defect.
B, Undermining allows approximation. C, A retention suture may be used
before closure for additional support. (From Senders CW: Presurgical orthopedics.
Facial Plast Surg Clinics North Am 4:333-342, 1996.)
A
B
C

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
771
Figure 83-5. A, Key landmarks of a
unilateral cleft lip repair are marked
with a fi ne marking instrument. B,
Hypoplastic tissue is excised by fol-
lowing the key landmarks, and a
variety of backcuts can be made to
address symmetry.
toward the wet vermilion with 4-0 chromic or polygly-
colic acid suture. The skin is closed with 5-0 or 6-0 nylon
or with absorbable suture (see Fig. 83-5D).
Primary nasal reconstruction may be considered at
the time of lip repair to reposition the displaced lower
lateral cartilage and alar tissue. Several techniques have
been advocated, and considerable variation exists with
respect to the exact nasal reconstruction performed
by each surgeon.1,2,12,22 Primary nasal repair may be
achieved by releasing and reshaping the lower lateral
cartilage and alar base and augmenting the area with
allogeneic subdermal grafts or even formal open rhino-
plasty. Because lip repair is done at such an early point
in growth and development, the authors prefer minimal
surgical dissection because of the effects of scarring on
subsequent growth of these tissues. McComb described
a technique that has become popular in which the
lower lateral cartilage is dissected free from the alar
base and the surrounding attachments through the
incision at the alar crease.22
The lower lateral cartilage is dissected free of skin
(including that between the medial crura and dome)
Cupid’s peak CS
Alar base CS
Lateral peak
Cupid’s bow CS
Commissure
Wet Vermillion
3-r
8-r (to align red line)
CS
Cleft side
NCS
non-cleft side
A
Red line
Midline
White line
Cupid’s peak NCS
Alar base NCS
Base of columella
5
9
8
r
r
7
3
1
2
4
6
B
Tip of
advancement
flap (x)
9
r
r
y
3
r
y

E
Figure 83-5, cont’d C, A three-layered closure is
achieved by fi rst reconstructing the oral mucosa and
nasal fl oor and then the orbicularis oris musculature.
The skin fl aps should be passively closed without
tension. D, The rotation and advancement fl aps are
inset for optimized symmetry in all three dimensions.
E, Limited nasal dissection can be used to reposition
the lower lateral cartilage, as well as the lateral alar
tissue. These tissues must be released from their abnor-
mal insertions and repositioned for better symmetry. A
nasal bolster or silicone nasal formers may be placed
at the end of the procedure.
C
r
r
D

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
773
(see Fig. 83-5E) and suspended to the ipsilateral upper
lateral cartilage with a looping suture (see Fig. 83-1D).
If necessary, interdomal and suspension sutures (see
Fig. 83-1E) may be used to reposition and reorient the
nasal tip. This modifi cation requires extended dissec-
tion. The dislocated nasal septum is released, trans-
posed, and secured through the membranous septal
incision. The nasal ala is then repositioned to address
symmetry in all three dimensions. In most complete
unilateral clefts, the alar base has to be dissociated from
the lateral aspect of the lip and piriform aperture by
extending the circumalar incision to allow these ele-
ments to move independently. The advancement fl ap
will be advanced more than the ala. The tip of the
advancement fl ap may then be anchored to the mem-
branous septum. The nostril may be stented for several
weeks or longer with silicone nostril retainers or bol-
sters to prevent distortion in nostril shape.
Parents may feed their child immediately by the
same methods that were used preoperatively. Arm
restraints are routinely used to protect the lip from
trauma for approximately 2 weeks. Antibiotic ointment
may be applied in the fi rst few days, followed by gentle
massage several times per day starting 2 weeks after
repair to encourage remodeling of the scar.
PRIMARY BILATERAL LIP REPAIR
Bilateral cleft lip repair can be one of the most chal-
lenging technical procedures performed. The lack of
quality tissue and the widely displaced segments are
major challenges to achieving exceptional results, but
superior technique and adequate mobilization of the
tissue fl aps generally yield excellent aesthetic results
(Figs. 83-7 to 83-9). Additionally, the columella may be
quite short in length, and the premaxillary segment
may be signifi cantly rotated. Adequate mobilization of
the segments and attention to the details of using only
appropriately developed tissue will yield excellent
results, even in individuals with signifi cant asymmetry.
Although often more challenging than most unilat-
eral repairs, the technique for bilateral cleft lip and
nose reconstruction is similar in concept to that for
unilateral repair. Markings are made with a fi ne marking
instrument at key landmarks while being sure to not
include any hypoplastic tissue from within the cleft (Fig.
83-7). Points 12 and 13 should be made at the begin-
ning of the good white roll and vermilion, with a small
backcut extending laterally to allow advancement under
the prolabial tissue. Points 8 to 12 and 7 to 13 should
be equal in length, and the measurement at 2 to 4
should be no longer than 3 mm. This tissue will stretch
signifi cantly later as remodeling of the lip occurs. Inci-
sions within the nares should be made carefully so that
one does not excise too much tissue and make the nares
quite small. Backcuts around the alar base should be
long enough to allow nasal dissection, release of alar
tissue from the piriform rim, and advancement medi-
ally to reconstruct the nares.
Some surgeons have used operative techniques
involving banked fork fl aps to surgically lengthen the
columella and preserve hypoplastic tissue. Early and
aggressive tissue fl aps in the nostril and columella areas
do not look natural after signifi cant growth has occurred
and result in abnormal tissue contours. Although surgi-
cal attempts at lengthening the columella may look
A
B
C
Figure 83-6. A, Three-month-old child with a right-sided incom-
plete unilateral cleft lip. Note the short philtrum near the midline,
which must be rotated downward to avoid notching and to improve
symmetry. B, Nine-month-old boy after rotation-advancement repair
of his cleft lip and nasal deformities. C, The same child in B 21/2 years
after his cleft lip and nasal repairs.

Figure 83-7. A, The bilateral cleft of the lip and maxilla shown here is complete and highlights the nature of hypoplastic tissue along the
cleft edges. The importance of the nasal deformity is evident in the shorter columella and disrupted nasal complexes. B, Markings of the
authors’ preferred repair are shown with an emphasis on excision of hypoplastic tissue and approximating more normal tissue with the advance-
ment fl aps. Measurements should be roughly equal in the following fashion: 1 to 2 = 6 to 10; 5 to 4 = 7 to 11; 1 to 2 = 5 to 4; and 6 to 10
= 7 to 11. C, A new philtrum is created by excising the lateral hypoplastic tissue and elevating the philtrum superiorly. Additionally, the lateral
advancement fl aps are dissected into three distinct layers (skin, muscle, and mucosa). Nasal fl oor reconstruction also occurs in conjunction
with these advancement fl aps. D, The orbicularis oris musculature is approximated in the midline with multiple interrupted or mattress sutures,
or both. This is a critical step in total reconstruction of a functional lip. There is no musculature present in the premaxillary segment, and it
must be brought to the midline from each lateral advancement fl ap. The nasal fl oor fl aps are sutured at this time as well. The new vermilion
border is reconstructed in the midline with good white roll tissue advanced from the lateral fl aps. E, Final approximation of the skin and
mucosal tissues is performed in a manner that leaves the healing incision lines in the natural contours of the lip and nose.
B
6
8
12
10
1
5
7
9
13
11
2 3 4
A
C
D
E
774

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
775
A
B
Figure 83-8. A, Presurgical appearance of a bilateral cleft lip and palate with impressive asymmetry and rotation of the premaxillary segment.
Note the signifi cant nasal asymmetry and bunching of the orbicularis oris laterally. B, The same child at 14 months of age. No presurgical
orthopedic appliances were used.
B
C
A
Figure 83-9. A, Presurgical frontal view of a wide bilateral cleft lip and palate with signifi cant asymmetry and lack of columella length.
B, Presurgical left lateral view of a wide bilateral cleft lip and palate with a protrusive premaxillary segment. Note the short length of the colu-
mella. C, The same child after repair of her bilateral cleft lip and palate. No presurgical taping or orthopedic appliances were used.

776
Section 9
Plastic and Reconstructive Surgery
good initially, they frequently appear abnormally long
and excessively angular later in life. Revision of these
iatrogenic deformities is diffi cult, and some of the
contour irregularities will not be able to be revised ade-
quately. Usually, if the hypoplastic tissue is excised and
incisions within the medial nasal base and columella are
avoided, the long-term aesthetic results are excellent.
The authors prefer a primary nasal reconstruction
that can be performed in a fashion similar to the uni-
lateral technique described by McComb.1,2,22 Other
open rhinoplasty techniques involving either a direct
incision on the nasal tip or prolabial unwind -ing tech-
niques have been suggested.12 As with most early maneu-
vers, aggressive rhinoplasty at this time may result in
early scarring that affects the growth potential of the
surrounding tissues and makes revision more diffi cult
and long-term aesthetics less than ideal.
CLEFT LIP REVISION
Despite even the most superb techniques, many patients
who undergo cleft lip repair will benefi t from at least a
minor revision at some point in life. Although revision
procedures are often viewed as optional phases of cleft
lip reconstruction, surgeons must advise families of this
likelihood. The hard and soft tissues of the maxillofa-
cial complex grow and change as a child grows, and the
repaired lip is affected. Bilateral clefts will benefi t from
lip revision more often than unilateral clefts will. The
majority of lip growth is complete after the age of 5
years, and this may be the best time to consider revision
of the lip because the psychosocial benefi ts before
entering school may be considerable. Alternatively, revi-
sion of the lip can be delayed until the teenage years,
when most maxillofacial growth is complete. It is prefer-
able to wait until orthognathic surgery is completed (if
this becomes necessary) because these procedures will
considerably change the contour and shape of the nose
and lips.
The surgical objectives of cleft lip revision include
excision of residual scar, reapproximation of key ana-
tomic landmarks such as the vermilion-cutaneous junc-
tion and vermilion-mucosal junction, and leveling of
vertical lip lengths (philtral columns). Repair of the
orbicularis oris muscle as a distinct layer is critical to an
acceptable outcome. Although small scar revisions may
be considered in some patients, many patients will
benefi t from a revision that completely reconstructs the
area by excision of the scar, dissection of the tissues into
three layers (skin, muscle, and mucosa), and a recon-
struction that achieves improved symmetry and form.
As with the primary repair, 6-0 or smaller sutures may
be used to minimize stitch marks. Postoperative care
includes careful early wound care and avoidance of
extended sun exposure, similar to the instructions for
primary repairs.
PALATOPLASTY
There are two main goals of cleft palate repair during
infancy: (1) closure of the oral-nasal communication
involving the embryologic secondary palate and (2)
anatomic repair of the musculature within the soft
palate, which is important for normal production of
speech. The soft palate, or velum, is part of the complex
coupling and decoupling of the oral and nasal cavities
involved in the production of speech. When a cleft of
the soft palate is present, abnormal muscle insertions
are located at the posterior edge of the hard palate.
Surgery must not simply be aimed at closing the palatal
defect, but rather at release of abnormal muscle inser-
tions to create muscle continuity with improved orienta-
tion so that the velum may serve as a dynamic structure.
Despite successful repair of the palate, a signifi cant
number of children who undergo cleft palate repair will
still require speech therapy and have diffi culty closing
the velum for a variety of reasons.
Several techniques of palatoplasty with a substantial
number of modifi cations may be found in the literature.
Three popular techniques are discussed, including:
• Two-fl ap palatoplasty with intravelar veloplasty
• V-Y pushback with intravelar veloplasty
• Furlow palatoplasty
Before each procedure, the type and severity of the
cleft, position of the segments, degree of septum devia-
tion, width of the cleft, length and symmetry of the soft
palate, and mobility of the soft palate and pharyngeal
walls have to be considered. It is helpful to measure and
record palatal width, length, and other cleft dimensions
with calipers.
The patient is placed supine with the neck slightly
extended, and a shoulder roll is used. A cleft mouth
retractor is used to maximally open the mouth and at
the same time secure the endotracheal tube in a midline
position against the tongue. A small throat pack may be
fi tted in the hypopharynx around the tube. Incisions
are marked with a marking pen, gentian violet, or meth-
ylene blue. Lidocaine with epinephrine solution is
injected into the submucosal tissue and subperiosteal
plane and around the palatine foramen. Subperiosteal
injections can facilitate undermining of the mucoperi-
osteal fl aps and improve hemostasis. The surgeon
should avoid injecting into the neurovascular bundle.
If vomer fl aps are planned, the vomer is injected.
A variety of blades, including nos. 11, 15, and Beaver
6300 blades, are used to dissect the fl aps. A small half-
circle cutter is helpful when the cleft space is narrow.
The PS 5 is a fi ne all-purpose 3/8-inch cutter. The PS 4
cutter takes larger bites when required. In careful
hands, a cutting needle may be less traumatic than a
taper needle. However, if there is any tension on the
wound, tapered needles may be used to avoid mucosal
damage.
Two-Flap Palatoplasty with
Intravelar Veloplasty
In the authors’ practice this repair is the most appropri-
ate technique for a complete unilateral cleft palate
repair (Fig. 83-10).1,2,23,24 The nasal fl aps may be designed
so that a strip of mucoperiosteum is left on the medial

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
777
edge of the hard palate. The wider the cleft, the wider
the strip of mucoperiosteum left on the medial edge of
fl ap. The width and angle of the palatal shelves are also
considered when designing the incisions. When these
fl aps are elevated and mobilized to reconstruct the
nasal mucosal layer, they should meet each other
without tension. On the soft palate, the incisions should
follow the subtle transition line between the nasal and
oral mucosa into the tip of the uvula. In a wide cleft
(gaps larger than 15 mm), vomer fl aps may be designed
to aid in closure centrally.
Laterally, the fl aps are designed to include oral
mucoperiosteum only (see Fig. 83-10B). Gingiva should
be avoided. The incision line moves laterally at the junc-
tion of the alveolus, and the palatal shelf recovers its
posterior direction quickly once the lateral aspect of the
alveolus is reached and may continue 0.5 to 1 cm into
the soft palate.
Figure 83-10. A, A unilateral cleft of the primary and secondary palates is shown with typical involvement from the anterior vestibule to the
uvula. B, The Bardach palatoplasty technique requires two large full-thickness mucoperiosteal fl aps to be elevated from each palatal shelf. The
anterior portion (anterior to the incisive foramen) of the cleft is not reconstructed until the mixed-dentition stage. C, A layered closure is per-
formed in the Bardach palatoplasty by reapproximating the nasal mucosa. The muscle bellies of the levator palatini are elevated off their
abnormal insertions on the posterior palate. They are then reapproximated in the midline to create a dynamic functional sling for speech
purposes. D, Once the nasal mucosa and musculature of the soft palate are approximated, the oral mucosa is closed in the midline. The lateral
releasing incisions are quite easily closed primarily because of the length gained from the depth of the palate. In rare cases, with very wide
clefts, a portion of the lateral incisions may remain open and granulate by secondary intention.
A
B
C
D

778
Section 9
Plastic and Reconstructive Surgery
The oral mucosa is separated from the nasal mucosa
toward the tip of the uvula with a superfi cial incision.
Mucoperiosteal incisions on the hard palate have
to be fi rm, perpendicular to the palatal plane, and
should reach the palatal shelf with a continuous clean
cut. Hemostasis with a fi ne needle tip electrocautery
or bipolar electrocautery at low setting may be
performed.
Elevation of mucoperiosteum is started anterolater-
ally with a Woodson or other small elevator. Gentle
subperiosteal elevation of the tip of the fl ap is per-
formed. After elevation of the tip, a Freer elevator is
used to continue subperiosteal elevation posteriorly to
visualize and elevate tissue around the neurovascular
bundle. All muscular and tendinous attachments to the
hard palate shelf are detached with a combination of
sharp and blunt dissection while leaving the fl ap
attached to the hard palate by the neurovascular bundle
and lateral pedicle.
The soft palate is transposed medially by entering
the space of Ernst with a blunt instrument (Metzen-
baum scissors). To obtain more medial mobilization,
infracture of the hamulus may be performed but is
rarely necessary. Veau’s muscle inserts into the perios-
teum on the posterior edge of the hard palate in concert
with the tensor aponeurosis after it rounds the hamulus.
(Veau’s muscle is a clefted muscle consisting of the
levator and the palatopharyngeus.) Some surgeons
divide the tendon to mobilize muscles toward the
medial aspect.
Gentle traction is used to pull the neurovascular
bundle out of the greater palatine foramen (see Fig.
83-10C); the palatine foramen is surrounded by a peri-
osteal cone that can be incised superfi cially on either
side and posteriorly to allow maximal mobilization of
the fl ap. Additional dissection is necessary to provide
maximal mobility of the fl ap.
Complete dissection of Veau’s muscle from the
hard palate and nasal mucoperiosteum follows. Attach-
ments are stripped from the nasal mucoperiosteum
with sharp scissors and scalpel. Precise dissection allows
lengthening of the palate and posterior/medial trans-
fer of muscles to create a functional muscle sling. This
reconstruction is termed an intravelar velarplasty. Dis-
section of muscle from the nasal and oral mucosa is
more extensive than described in traditional two-fl ap
palatoplasty techniques. Complete dissection with repo-
sitioning and tightening of the palatopharyngeus and
levator in a posterior position is, for some, theoretically
more physiologic.
Once the fl aps are mobilized, closure of the nasal
layer begins anteriorly and should be tension free (see
Fig. 83-10C). Sutures are tied in knots on the nasal
surface. The difference in length between the two fl aps
is considered and spacing of the sutures adjusted at this
stage. There should be no tension at the hard palate–
soft palate junction. The soft palate muscles are retro-
positioned (overlapped if necessary) and sutured
together with two or three mattress sutures (3-0 to 4-0
resorbable suture). The oral layer is then closed with
single resorbable 4-0 or 5-0 interrupted or mattress
sutures and knots tied in the oral surface (see Fig.
83-10D).
The combined fl aps are anchored (tagged) to the
nasal mucoperiosteal closure with a 4-0 resorbable
suture at about the midpoint, and the tip is secured to
the alveolus with two to four sutures. These steps prevent
dead space between the oral and nasal layers and stabi-
lize the fl aps. The same objective can be achieved by
using three to four vertical mattress sutures through
both the oral and nasal layers. Exposed bone laterally
may be fi lled with microfi brillar collagen. A tongue
suture (3-0 silk/nylon) is applied to aid in tongue
advancement acutely in the rare instance of postopera-
tive obstruction. Surgeons should minimize the time
that the mouth gag retractor is activated during the
procedure to avoid more severe swelling.
V-Y Pushback with Intravelar Veloplasty
For many surgeons, the V-Y pushback operation is the
most appropriate technique for repair of a posterior
(soft palate) cleft with limited extension into the hard
palate (e.g., Robin-type cleft with unilateral or bilateral
incomplete hard palate involvement). Design principles
are similar to those for two-fl ap palatoplasty but include
a V to Y incision design on the hard palate for theoreti-
cal retropositioning of the soft palate. Mucoperiosteum
over the primary palate in front of the incisive foramen
is left intact, and fl aps are designed to leave this area in
a V form. For closure, the fl aps slide posteriorly to close
the gap, and transposition of this junction into a Y form
occurs. (This posterior displacement is limited to the
tip of the mucoperiosteal fl aps, is minimal, and should
not be confused with what is frequently called a push-
back palatoplasty in which posterior displacement aims
to reposition the velar muscles.) Intravelar veloplasty
and the remaining repair are identical to those used for
the two-fl ap technique. Generally, a vomer fl ap is not
necessary. The fl aps are secured to the anterior muco-
periosteum with several sutures. This technique is not
a good choice for a wide bilateral cleft that involves the
incisive foramen area because a residual fi stula will
remain that is often diffi cult to close and may affect
speech.
Furlow Palatoplasty
The Furlow technique closes the palate by mirror image
Z-plasties of the oral and nasal sides of the soft palate
(Fig. 83-11A to D).1,2,25 Palatal muscles are carried in the
posteriorly based fl aps of each Z-plasty to construct an
overlapping retropositioned palatal muscle sling. In
some studies, this technique is associated with a lower
frequency of velopharyngeal insuffi ciency (VPI) than
noted with other palatoplasty techniques and at times
is recommended for the treatment of VPI after another
type of repair as a secondary procedure.1,2,25,26
The landmarks that determine the fl ap angles and
fl ap design include the hamuli, the posterior edge of
the hard palate, the base of the uvular halves, and the
eustachian tube orifi ce (torus tubarius) (see Fig.
83-11E). The hamulus is palpable as a small bony eleva-