283
Patient selection and decision-making
Fig. 11.6 A 46-year-old male patient suffered from buccal carcinoma, stage 1.
Right buccal mucosa defect with marginal mandibulectomy was presented post
tumor ablation surgery. (Courtesy of Dr. Chih Wei Wu.)
Fig. 11.7 A profunda artery perforator flap 7 × 21 cm was designed on his left
medial thigh with the assistance of hand-held Doppler to map the myocutaneous
perforators, along the posterior border of the gracilis muscle. (Courtesy of Dr. Chih
Wei Wu.)
Fig. 11.8 Several myocutaneous perforators were identified with blue arrows.
(Courtesy of Dr. Chih Wei Wu.)
Fig. 11.9 The profunda artery perforator flap was harvested and based on only one
myocutaneous perforator with intramuscular dissection. (Courtesy of Dr. Chih Wei Wu.)
to form the shape of the sulcus. It is also common that the
inner surface of the lower and/or upper lip is involved.
Although the wound between the edge of the lip and the
lower gum can usually be closed primarily, direct closure
results in an unnatural appearance and impacts postoperative
function.
If the defect extends from the buccal mucosa to the trigone
region, the mandible is often exposed. Such defects commonly
involve the posterior tongue. Although the tissues in this area
are relatively loose, making primary wound closure possible
in some cases, direct wound closure distorts the natural
anatomy of the tonsillar pillar and tethers the tongue. An
anatomical change can result in food regurgitation into the
nasal cavity. Tongue tethering also limits function with regard
to eating and speaking.
Flap selection for pure buccal mucosa reconstruction
depends on the thickness of the flap required. According to
the authors’ experience, a free radial forearm or ulnar forearm
flap is usually adequate (see Figs. 11.1–11.5). A anterolateral
thigh (ALT) perforator flap is required for a thicker defect. A
medial sural artery perforator (MSAP) flap or deep profunda
artery perforator flap (PAP) is a feasible alternative32,33 (Figs.
11.6–11.10). In severe trauma or in advanced cancer resection,
the defect can extend from the mucosa to the external skin
(through-and-through defect), often requiring a bulky myo
cutaneous flap or a thick fasciocutaneous flap with chimeric
flap design or de-epithelialization of the central flap to facili
tate reconstruction (Figs. 11.11–11.14). Each of the skin paddles
can be customized according to the defect, preventing distor
tion of the mouth angle.
If the resection is accompanied by marginal mandibulec
tomy, sufficient coverage of the exposed mandible bone with
a thick fasciocutaneous flap or myocutaneous flap prevents
tethering of tongue movement after reconstruction and
284
SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
rebuilds the symmetric bulk of the face. An ALT flap with or
without the vastus lateralis muscle is the preferred choice for
reconstruction.
Sometimes an inferior maxillectomy is part of an advanced
buccal mucosal tumor resection, which leaves a dead space in
the inferior maxillary area that requires soft-tissue obliteration
to avoid fluid accumulation and postoperative infection. It is
not uncommon that part of the soft or hard palate is involved
in the resection. Few of the palatal wounds can be closed
primarily; inadequate tissue resurfacing can result in develop
ment of an oronasal fistula and causes food regurgitation
and hypernasality. A myocutaneous flap provides sufficient
muscle to obliterate the dead space while providing buccal
and palatal resurfacing. An ALT flap with vastus lateralis
muscle is used most frequently in the authors’ experience.
A free transverse rectus abdominis myocutaneous (TRAM)
or vertical rectus abdominis myocutaneous (VRAM) flap can
alternatively be used.
Table 11.1 summarizes the characteristics of each available
flap and its clinical applications in buccal mucosa reconstruc
tion. Table 11.2 provides guidelines for flap selection for
variable buccal defects.
Fig. 11.10 At the 12- month follow-up, the patient was satisfied with the
functional result. (Courtesy of Dr. Chih Wei Wu.)
Fig. 11.11 A male patient aged 59 years presented with buccal carcinoma, stage
4. Tumor resection involved his right buccal mucosa, mandible with marginal
mandibulectomy, and cheek skin, resulting in a through-and-through defect.
Fig. 11.12 By mapping the perforators with pencil Doppler, a chimeric
anterolateral thigh flap 17 × 7 cm was designed on his left thigh based on separate
perforators.
Fig. 11.13 The chimeric flap included one fasciocutaneous skin paddle for cheek
skin reconstruction and one myocutaneous flap for buccal mucosa reconstruction
and covering the exposed mandible bone with volume replacement after marginal
mandibulectomy.
Fig. 11.14 Result of immediate reconstruction.
285
Patient selection and decision-making
flap, latissimus dorsi myocutaneous flap,39 pectoralis major
(PM) myocutaneous flap,56 and trapezius island flap.57 The
ALT flap has emerged in recent decades as a popular option
for head and neck reconstruction due to its reliability, long
pedicle, and acceptable donor morbidity. Due to its versatility,
this flap has been used both to provide bulk and to ensure
mobility.34,45,46,58–61 Most publications have reported only the
use of a single flap to reconstruct a limited range of tongue
defects while others compared two flaps but generally gave
little or no information for why one flap was selected over
another. Based on various clinical experiences, there is not one
preferred flap over another for tongue reconstruction. Only
defect evaluation and proper flap selection based on the defect
make a successful reconstruction. For Class I patients (defects
≤50%), a forearm flap, basing on the radial or ulnar artery,
which is thin and pliable with a long pedicle is recommended
(Figs. 11.15–11.17); an ALT perforator flap can be used alter
natively in thin patients. Class II describes defects where up
to 75% of the tongue is removed. In this classification system,
a distinction is made between defects of less than 66% (IIa)
and up to than 75% (IIb). The additional division between
Fig. 11.15 A 27-year-old male patient sustained a hemi-tongue defect after cancer
resection.
Fig. 11.16 An ulnar forearm flap, 6 × 10 cm, with well-preserved ulnar and all
partendons of the flexors, was raised from his left forearm.
Fig. 11.17 The patient was satisfied with the good functional result as well as
cosmesis.
Decision-making for tongue reconstruction
(see Table 11.3)
The tongue’s multifunctional role in articulation, deglutition,
and airway protection makes reconstruction difficult. Various
flap designs and inset techniques have been introduced for
tongue reconstruction, such as creation of omega-shaped
profile with radial forearm flap, mushroom flap design for total
tongue reconstruction, use of rectangular template to provide
simple design with dynamic reconstruction, and combination
of native tongue tip rotation and wedge de-epithelialization
optimized tongue tip sensation and reduce pooling on the
mouth floor.33–37 Chiu and Burd38 further expanded on this
technique by describing their semicircular design with wedge
de-epithelialization or resection to increase tongue elevation
and deepening of the tongue floor at the mouth sulcus. Very
little has been reported regarding the refinement of total
tongue reconstruction, probably due to the mistaken notion
that such reconstructions serve no purpose other than volume
restoration.39,40
Re-innervation of the skin flap to enhance the sensitivity of
the reconstructed tongue has been introduced. However, the
final result of re-innervation of the skin flap seems to fail
to provide better sensation function after reconstruction.41
The result of re-innervation is also not constant, since
many patients will require postoperative radiotherapy and
the nerve may possibly be damaged.
Most authors would classify tongue defects after tongue
resection as hemiglossectomy, subtotal, and total glossectomy
defects.33,34,42–46 A goal-directed classification for tongue defects
should not only provide descriptions but also facilitate precise
judgment with therapeutic consequences. Cheng’s modified
classification (I, IIa, IIb, III) separates tongue defects into three
major groups, which dictate the type of donor flap chosen and
is useful for preoperative planning (Table 11.3).47
Current strategies for tongue reconstruction should either
maintain mobility or provide bulk of the tongue depending
on the defect. Flaps that maintain mobility are usually thin,
such as the infrahyoid myofascial flap,48–50 MSAP flap,51,52
radial forearm flap,33,43–46,53 and ulnar forearm flap.54,55 Flaps
that provide bulk include the rectus abdominis myocutaneous
286
SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
a better neotongue profile for defects crossing the midline in
Class IIa and IIb. In total glossectomy defects (Class III), a
specially designed pentagonal-shaped ALT myocutaneous
flap facilitates better flap inset, provides adequate volume,
and gives an aesthetically pleasing neotongue tip (see Fig.
11.22). The “V” shape of the pentagon posteriorly allows a
greater sloping profile when viewed in cross-section as well
as an increasing posterior-to-anterior tongue projection. Such
a design yields a well-shaped tissue bulk that resembles a
normal tongue more closely in its lateral and frontal views.
The anterior “I” shape allows increased elevation and freeing
of the neotongue tip and also creates a gingival sulcus that
prevents saliva pooling and subsequent drooling. Most of
these patients provide ratings of “good” and above for diet or
Class IIa (greater than 50% to 66% resected) and IIb (greater
than 66% to 75% resected) permits further refinements in flap
selection. For Class IIa patients, an ALT flap is preferred over
the radial forearm flap due to the larger flap size available,
especially when encountering any accompanying mouth floor
or buccal defects. Flaps other than ALT flap can be used as an
alternative. Free MSAP with the inclusion of a piece of gas
trocnemius can be a good choice (Figs. 11.18–11.21). For Class
IIb defects, the small amount of remaining tongue (about 25%)
probably has no functional role, but it likely plays an impor
tant role in maintaining the anatomical integrity of the base
of the tongue, the retromolar trigone, or one side of the ptery
goid fossa, depending on its location. The thickness of the
subcutaneous tissue in the ALT myocutaneous flap provides
Fig. 11.18 The design of a medial sural artery perforator flap. A line is made from
the midpoint of popliteal crease to the Achilles tendon. The distal border of the
medial gastrocnemius muscle is also marked. The major myocutaneous perforator
is located on the line parallel to the first line and 6 cm from the popliteal crease.
(Courtesy of Dr. Hung-Kai Kao; Plast Reconstr Surg. 2010;125:1. Fig. 1.)
Fig. 11.19 A medial sural artery perforator flap with chimeric partial
gastrocnemius muscle was harvested for reconstruction. (Courtesy of Dr. Hung-Kai
Kao.)
Fig. 11.20 The reconstructed tongue showed good projection and adequate
volume by the chimeric medial sural artery perforator flap. (Courtesy of Dr.
Hung-Kai Kao.)
Fig. 11.21 The donor site scar was acceptable by the patient. (Courtesy of Dr.
Hung-Kai Kao.)
287
Patient selection and decision-making
Fig. 11.22 A pentagonal anterolateral thigh musculocutaneous flap sized 10 ×
15 cm with a segment of vastus lateralis is used to reconstruct a total tongue
defect. The distance from B to F is 10 cm and from A to D is 15 cm. The vastus
lateralis is 5 × 10 cm. B and F are sutured to form the floor of the mouth, and A
becomes the tip of the neotongue. The margins between B and C and E and F are
repaired to the gingival mucosa of the mandible. The distance between C, D, and E
forms the base of the tongue and trigone. The pedicle is placed anteriorly to reach
the recipient vessels in the neck. A, tongue tip; B and F, floor of mouth; C and E,
trigone; D, base of tongue; VL, vastus lateralis muscle; 1, teeth; 2, lateral circumflex
femoral vessel; 3, anterolateral thigh musculocutaneous flap.
A
A
B, F
D
F
,B
C, E
C
E
C, , E
D
1
3
2
VL
VL
Fig. 11.23 A 52-year-old male patient with tongue cancer cT4aN0M0 stage 4 who
has undergone total tongue resection which resulted in total tongue defect.
Fig. 11.24 A pentagonal-shape anterolateral thigh myocutaneous flap measured 10
× 15 cm was designed on left thigh.
A
B
C
D
E
F
Fig. 11.25 The anterolateral thigh myocutaneous flap was elevated with the vastus
lateralis muscle 8 × 6 cm to augment neotongue volume.
Fig. 11.26 This neotongue flap showed good projection and shape.
cosmetic appearance following reconstruction using this
method (Figs. 11.22–11.26).47
In both Class IIb and III, an ALT musculocutaneous flap
rather than a fasciocutaneous flap should be used for recon
struction to provide more bulk to augment the base of the
tongue. The bulk at the base of the tongue is important to close
off the oropharynx during swallowing with the assistance of
the movement of hyoid bone. The rectus abdominis myocu
taneous flap62 and the latissimus dorsi myocutaneous flap39,47
are alternative flap options for near-total or total tongue
reconstruction, but with more significant donor site morbidity.
288
SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
Clinical experiences
Table 11.3 addresses the clinical experience of tongue recon
struction by the authors. The review echoes our strategic
approaches of tongue reconstruction with the defect-oriented
flap selection and inset. More of the defects were reconstructed
with recommended flaps while other reconstructions were
performed using the alternative flaps for individual reasons.
Flap selection should be based on the defect as well as the
patient’s own character. For example, a defect post tumor
recurrence with the previously recommended flap being used
before or a positive Allen test in the forearm can drive the
surgeon to choose flaps other than recommended ones. With
our strategies, the overall complications are acceptable with
high success rates. More and more skin flaps are now being
explored in tongue reconstruction, all with satisfactory results.
There is a trend of using ulnar forearm flaps more often
instead of the radial forearm flap, which in our experience,
have achieved good results. Advantages of this flap include
minimal donor site morbidity creating a less conspicuous scar
and offering more sizable perforators. For bulkier flaps, the
ALT flap remains our first choice and the authors have also
used other flaps, such as anteromedial thigh (AMT) and PAP
flaps.
Decision-making for
mandibular reconstruction
Daniel categorized lower-jaw defects as isolated, compound,
composite, extensive composite, or en bloc.63,64 Isolated defects
include any single bone tissue resection; compound defects
refer to those involving two tissue layers, such as bone and
oral lining or bone and external skin. Composite defects
Table 11.5 Variable classifications of mandibular defects
Cheng’s
classification
Daniel’s
classification
Jewer’s and
Boyd’s
classification
Defects
Available
management
Examples
Ia
Isolated
Central (C)
Bone only
Plating, bone graft,
bone flap
Benign tumor, trauma
Ib
Isolated
Lateral (L)
Bone only
Plating, bone graft,
bone flap
Benign tumor, trauma
Ic
Isolated
Hemimandibulectomy
(H)
Bone only
Plating, bone graft,
bone flap
Benign tumor, trauma
IIa
Compound
HCL + mucosal (m)
Bone and intraoral
mucosa
Osteocutaneous flap
Stage 3–4 oromandibular
cancer
IIb
Compound
HCL + skin (s)
Bone and external
skin
Osteocutaneous flap
Osteoradionecrosis of
mandible
IIc
Compound
–
Bone, external skin,
and extended soft
tissue
Osteocutaneous flap,
OPAC flap
Osteoradionecrosis of
mandible
IIIa
Composite
HCL + mucosa and
skin (ms)
Composite 3 layers
Options in Table 11.7
Stage 4 oromandibular
cancer, gunshot wound
IIIb
Extensive
composite
–
Composite 3 layers
and partial tongue
Options in Table 11.7
Stage 4 oromandibular
cancer, gunshot wound
IIIc
Extensive
composite
–
Composite 3 layers
and partial maxilla
Options in Table 11.7
Stage 4 oromandibular
cancer, gunshot wound
indicate a three-layer-defect involving the mucosal lining,
bone, and external skin; finally, extended composite or en bloc
defects also include loss of soft tissue. Jewer et al. classified
mandibular defects of the bone as central, lateral, or hemi
mandibular.65 The classification system was further modified
by Urken et al. to consider associated soft-tissue defects66 and
by Boyd et al. to recognize subcategories such as mucosa, skin,
or a combination of both.67 Schultz and colleagues classified
the mandibular defect based on the bone defect and the avail
ability regarding ipsilateral recipient vessels.68 These classifi
cations were based on the availability of reconstructive
options. With the development of microsurgical techniques
and better understanding of the perforator flap concept, more
reconstructive alternatives became available. A modified
mandibular defect classification is given here by the authors
to define in advance the components involved in the man
dibular defect. The modification aims to include the missing
tissue in detail and helps with decision-making and choosing
the most optimal flaps for reconstruction. This is outlined in
Table 11.5 with the integration of different classifications from
the literature. The available flaps and their characters are
listed in Table 11.6. In Table 11.7, the reader can find the
subclassification of Cheng’s classification III and recom
mended reconstruction options.
Clinical experiences
Table 11.5 lists the variable classifications of mandible defects,
and Cheng’s modified classifications indicate the defects with
the orientation of missing bone, inner, and outer layers of soft
tissues. By using the classification as a clinical indicator for
flap selection, the authors completed 190 cases of mandible
reconstructions with fibula-based bone-carrying flaps and
289
Patient selection and decision-making
reached 100% success rate without any flap-related compli
cations or donor site morbidities. Class II defect, being the
most common, bears a re-exploration rate of 17.82% in IIa
and 12.5% in IIb in our experience. However, with careful
surgical planning and early intervention for re-exploration,
turned in an overall flap success rate of 98.95%. The classi
fication system classifies defects, provides recommendations
regarding flap selection, and reflects surgical complexity.
Class I defect refers to those with only bone missing and
is the most straightforward situation for reconstruction. It
Table 11.6 Comparisons of osteocutaneous flaps for mandibular reconstructions
Bone
Skin
Muscle
availability
Pedicle
length
Donor site
morbidity
Disadvantages
Height
Firmness
Length
Reliability
Pliability
Fibula
++
++++
++++
(25 cm)
++++
++++
++++, soleus
+++
++++
Flap inset
Iliac
++++
++++
+++
+
+
–
+
++
Donor site
morbidity,
partial skin
paddle loss
Scapula
+
+
++
(7 cm)
++++
+++
++++,
latissimus
dorsi
++
+++
Intraoperative
change of
position
Radius
+
++
+
(10–12 cm)
++++
++++
–
++++
+
Radius fracture
Rib
++
++
++
(8–10 cm)
++
++
++, pectoralis
major,
serratus
anterior
++
+++
Tenuous
periosteal
perfusion
Second
metatarsal
+
++++
+
(6 cm)
++++
++++
–
+++
++
Donor-site
morbidity
Table 11.7 Reconstructive options for mandibular defect Type III in Cheng’s classification.
Option 1
Option 2
Option 3
Option 4
Option 5
Option 6
Cheng’s
classification
Defect
Soft-tissue flap
with reconstruction
plate
One free flap,
one pedicled
flap
Double free
flaps
Chimeric
flap – LCFA
Composite flap
– scapula
Composite
flap – OPAC
IIIa
Bone
Reconstruction
plate
Fibula
Fibula
Iliac
Scapula
Fibula
Mucosa
ALT flap or RA flap
Fibular skin
Fibular skin
ALT flap
Scapula/
parascapular
skin
Fibular skin
Soft tissue
Vastus lateralis,
rectus abdominis
Pectoralis
major,
deltopectoral
Vastus
lateralis,
rectus
abdominis
Vastus
lateralis
LD
Soleus
External
skin
ALT flap or RA flap
Pectoralis
major,
deltopectoral
Radial forearm
or ALT, RA
Groin skin
Scapula/
parascapular
skin
Fibular skin
IIIb
Tongue
ALT flap or RA flap
Fibular skin
Fibular skin
ALT flap
Scapula/
parascapular
skin
Fibular skin
IIIc
Maxilla
Vastus lateralis,
rectus abdominis
Pectoralis
major,
deltopectoral
Vastus
lateralis,
rectus
abdominis
Vastus
lateralis
LD
Soleus
ALT, anterolateral thigh perforator (fasciocutaneous) or musculocutaneous; LCFA, lateral circumflex femoral artery; LD, latissimus dorsi; OPAC, osteomyocutaneous
peroneal artery combined; RA, rectus abdominis musculocutaneous.
290
SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
Regional flaps
Deltopectoral flap
The deltopectoral flap was popularized around 1965 by Baka
mjian.73 Based on the internal mammary perforators emerging
from the second and third intercostal spaces, the flap extends
from the central chest wall to the deltoid region.
The flap can be designed around the perforators mapped
with a pencil Doppler. The flap base is situated in the ante
rior chest wall, and the flap extends superolaterally to the
deltoid region. The exact flap required should be measured
to ensure its ability to reach the defect. For an oral cavity
reconstruction, a lengthier flap is usually required. However,
the distal flap is a random flap with an uncertain blood
supply. To obtain a longer flap, a prefabrication or a delayed
procedure is usually required to reduce the risk of distal
flap necrosis.74
The disadvantages of the deltopectoral flap include the
unattractive donor site scar, the requirement of a second
surgery for flap division, and the possibility of a delayed
procedure to lengthen the available flap. Today, the deltopec
toral flap has been largely replaced by the PM myocutaneous
flap and surgeons are encouraged to reserve it as a salvage
procedure.
Pectoralis major myocutaneous flap
Since its introduction by Ariyan in 1979, the PM flap has
gained in popularity with a reliable blood supply and large
skin paddle with sufficient flap bulk.75 The PM flap can reach
the neck and lower third of the face, making it practical for
intraoral and external cheek reconstruction. Today, the PM
flap is useful for salvage procedures and in a vessel-depleted
neck where a free-flap transfer is not possible.
The PM flap is a myocutaneous flap comprising the PM
muscle and its overlying skin with blood supply coming from
the thoracoacromial artery and parasternal perforators. The
lateral thoracic artery runs along the lateral edge of the PM
muscle and sends off branches to augment the circulation of
the PM muscle. The thoracoacromial artery runs inferiorly at
the midpoint of the clavicle and this can be used as a pivot
point when designing the flap.
The cosmesis of the donor site is a major concern, with
scarring over the anterior chest wall, especially in women. An
alternative design is a nipple-sparing crescent-shaped skin
paddle from the parasternal area to the inframammary region.
However, care should be taken when designing the flap like
this because the inframammary region is less reliable in terms
of blood supply.
Flap elevation is started from a lateral incision to expose
the lateral border of the PM. Dissection is then carried out
under the PM muscle to include the thoracoacromial vessel.
Once the muscle has been identified and the location of the
vessel is confirmed, the medial border of skin edge can be
incised. The muscle is then detached medially and laterally,
and the flap is elevated toward the pedicle. The pedicle is
divided after 2–3 weeks. The PM flap can also be elevated as
an island flap with skeletonizing of the pedicle. The muscle
part of the flap can be buried under the neck skin, precluding
the need for a second operation to divide the pedicle. The PM
flap is a good alternative in head and neck reconstruction
when a free-flap transfer is not possible.
the overall success rate remains. Class III defines defects
involving three layers and requires larger soft-tissue volume
than usual. Because of the extended lesion, skin and soleus
muscles are both required for reconstruction, in need of resur
facing as well as volume re-establishment. It is understand
able that higher incidence of skin/muscle partial necrosis
can be developed. But a careful planning and early action of
re-exploration maintain our surgical success rate to be as high
as expected.
Treatment/surgical technique
Part I: Soft tissue flaps
Local flaps
Submental flap
The submental flap, as indicated by the name, is located in the
submental area. Because of its location, it is a soft-tissue flap
that can be transferred as a pedicled or free flap to the oral
cavity.
Its blood supply derives from the submental artery, which
is a continuous branch of the facial artery, located 5–6.5 cm
away from the origin of the facial artery. This branch penetrates
deep to the submandibular gland through the mylohyoid
muscle below the mandible angle, extending medially deep
to the anterior belly of the digastric muscle. As the vessel
travels along the mandible margin, it sends off cutaneous
perforators through the platysma muscle to the skin. The
anatomy is constant, and the flow it provides to the submental
skin is reliable.69–72
Flap design is initiated by marking the inferior mandible
border as the upper flap margin. The flap length extends from
the ipsilateral mandible angle to the contralateral mandible
angle. The flap width depends on the laxity of the skin: usually
a width of 5 cm can be obtained and can be even wider in
patients with loose skin. The flap can be elevated as an axial
flap or a perforator flap. An easier surgical technique involves
lifting the tissue as an axial flap without perforator dissection.
Incision can be started from either the inferior or superior
margin flap directly through the platysma muscle. Then, the
dissection is carried out with division of the anterior belly of
the digastric muscle, which is included in the flap to ensure
inclusion of the submental pedicle. When the pedicle is identi
fied, its branches to the submandibular gland should be
ligated carefully. Finally, when reaching the inferior border of
the mandible, care should be taken not to injure the marginal
mandibular nerve. The pedicle is then skeletonized and the
flap is ready to be transferred. If the flap is going to be trans
ferred as a free flap, dissection of the pedicle can be continued
to the facial vessels to obtain a better size and length for
anastomosis.
The arc of the submental flap is used for rotating it to the
lower third of the face and the entire oral cavity, making it a
suitable pedicle flap for oral cavity reconstruction.69–72 The
only drawback is that many oral cavity reconstructions are
performed during cancer ablation surgery, during which neck
lymph node dissection is often required. After a neck lymph
node dissection, the continuity of the submental skin and its
main pedicle are usually disrupted.
291
Treatment/surgical technique
neous perforators, is designed with the ulnar vessels centered.
The flap dissection is performed under tourniquet. An inci
sion is made in the radial border of the flap and a suprafascial
dissection is then carried out until the tendons of the flexor
digitorum superficialis are reached. Several septocutaneous
perforators can be seen entering the undersurface of the flap.
The fascia is then incised and the vascular pedicle is dissected
out under the FCU tendon. The entire skin flap can be nour
ished by these perforators, or split into two skin paddles
based on separate perforators in a chimeric fashion. The flap
design can therefore be more versatile and sophisticated.
After the ulnar vessels are divided and separated away from
the ulnar nerve, another skin incision is made on the ulnar
side of the flap edge, and dissection is continued until the
entire flap is elevated.
The ulnar forearm flap is an alternative to the radial forearm
flap when the Allen test demonstrates codominant or domi
nant perfusion to the hand by the radial artery. The donor scar
is also more favorable because of its location on the medial
surface of the forearm. Although dissection of the ulnar nerve
requires some technical training, flap dissection is straightfor
ward and easy once the surgeon is familiar with the technique.
It has been applied in oral cavity and tongue reconstruction
with favorable results (see Figs. 11.15–11.17). The authors
recommend clinical application of this flap for defects such as
thin oral mucosal defects and Class I tongue defects (hemi
glossectomy) (see Table 11.3).
Lateral arm flap
The lateral arm flap is perfused by the cutaneous branch of
the posterior radial collateral artery, which is within the lateral
intermuscular septum of the upper arm. The vascular pedicle
provides four to seven branches to the overlying skin.80
The flap is designed by drawing a line between the deltoid
tuberosity and the lateral epicondyle of the humerus. The
septocutaneous perforators are located along the lower part
of this line. After the flap is outlined, dissection from the
posterior to the anterior aspect is performed to explore the
intermuscular septum. Most of the perforators can thus be
identified, and the main pedicle can be traced proximally.
The lateral arm flap was once commonly used in head
and neck reconstruction. However, the vascular pedicle is
short and the pedicle vessels are usually small. With the
introduction of more soft-tissue flaps, the use of the lateral
arm flap in oral cavity reconstruction has been substantially
reduced.
Rectus abdominis musculocutaneous flap
The rectus abdominis musculocutaneous (RAM) flap can be
designed transversely or vertically depending on the skin
paddle required. By applying a perforator dissection tech
nique, a free deep inferior epigastric perforator (DIEP) flap
can be harvested from the same donor site without sacrificing
the rectus abdominis muscle.
The RAM flap has two vascular supplies: the deep inferior
epigastric vessel and the superior epigastric vessel. When
transferred as a free flap, the flap is based on the deep inferior
epigastric vessel to obtain a better blood supply. The RAM
flap has an adequate skin paddle with flap bulk for recon
struction of large head and neck defects. It had been used
commonly in buccal mucosa reconstruction (especially when
Free fasciocutaneous or musculocutaneous flaps
Radial forearm flap
Introduced by Yang in 1981, the free radial forearm flap is
currently one of the most commonly used flaps in head and
neck reconstruction.76 The radial forearm flap has become a
popular flap due to its large skin paddle, lengthy and sizeable
pedicle, and ease of flap harvest. Its thinness and pliability
also make it the first choice in most cases of thin buccal
mucosa reconstruction and small tongue defects (see Figs.
11.1–11.5).76
The radial forearm flap is a type C fasciocutaneous flap
derived from the radial artery. Before flap harvest, an Allen
test should be performed to confirm the dominance of the
ulnar artery. One or two of the concomitant veins are usually
adequate for venous drainage.77 Some authors harvest the
cephalic vein for another source of venous drainage. The
cephalic vein is larger in diameter than the radial vein; there
fore, venous anastomosis is easier. The flap is innervated by
the lateral antebrachial cutaneous nerves, which can be incor
porated if a sensate flap is desired.
Flap design is initiated by locating the radial artery by
palpation. The borders of the skin paddle are designed with
the radial artery axis centered, but not extending beyond the
anterior radial border of the forearm for cosmetic concern.
Under tourniquet, the flap dissection is carried out from the
radial edge of the flap in the suprafascial plane.78 A suprafas
cial dissection keeps the paratendons and lateral antebrachial
cutaneous nerve intact, thus reducing the donor site morbid
ity. After dividing the distal pedicle at the wrist, the dissection
is then continued from distal to proximal by carefully preserv
ing the deep fascia and conjoined tendon between the flexor
carpi radialis and brachioradialis muscles. After flap dissec
tion is finished, the tourniquet is released to perfuse the flap
for 15 minutes. Circulation of the hand should be re-evaluated.
Usually, sacrificing the radial artery does not cause any sig
nificant change in hand perfusion. However, an interposition
vein graft for vascular reconstruction can be indicated if the
distal fingers are not well perfused.79
The major drawbacks of the radial forearm flap are donor
site morbidities and poor donor site cosmesis. Although the
donor site morbidity can be reduced dramatically by a supra
fascia dissection, the grafted donor site remains unsightly.
Ulnar forearm flap
Located in the ulnar aspect of the forearm, the ulnar forearm
flap has similar advantages as the radial forearm flap with a
relatively less noticeable donor site scar. It is used much less
frequently than the radial forearm flap, probably because
dissection of the ulnar nerve is required during flap
elevation.
The ulnar forearm flap is based on the ulnar vessels under
the flexor carpi ulnaris (FCU) tendon. Similar to the radial
forearm flap, this approach requires an Allen test to confirm
well perfusion from the radial artery before surgery. The
ulnar artery and veins run underneath the FCU tendon and
give several sizeable septocutaneous perforators to the skin
paddle.55 The venae comitantes are adequate for venous
drainage although some prefer the basilic vein as a backup.
Flap design is started by marking the ulnar artery under
neath the FCU tendon. The skin paddle, based on septocuta
292
SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
Thoracodorsal artery perforator flap
The thoracodorsal artery perforator (TAP) flap is a modifica
tion of the traditional latissimus dorsi flap.89–91 The TAP flap
has the advantages of having similar skin color to the facial
skin and therefore can be used for facial resurfacing.
The musculocutaneous perforators of the TAP flap are
derived from the medial or inferior branches of the thora
codorsal vessels. The perforators can be detected by a pencil
Doppler either 4 cm below the scapular spine (medial branch),
or 10 cm below the axilla and 2 cm medial to the posterior
axillary line (inferior branch). Flap dissection is initiated from
the superior border of the flap with an incision directly above
the latissimus dorsi muscle. After the perforator is identi
fied, the intramuscular dissection is continued and the main
pedicle is dissected. The inferior border of the flap is incised
and the flap is elevated off the latissimus dorsi muscle. The
TAP flap has a reliable blood supply and leaves a hidden scar
on the back. However, the need to change the patient’s posi
tion during the operation can lengthen the operation time and
decrease its clinical application.
Medial sural artery perforator flap
The medial sural artery perforator (MSAP) flap was devel
oped in 2001 by Cavadas et al. and has now been used in head
and neck reconstruction with good results.92 It is a modifica
tion of the gastrocnemius muscle flap, which was originally
described for lower-extremity reconstruction.93
Most of the sizeable perforators of the MSAP flap are
located 8–12 cm inferior to the popliteal crease.32 Flap dissec
tion is started by making the anterior incision and continued
through a subfascial dissection to identify the perforators. The
MSAP flap is a good alternative for most small buccal defects
or moderate-sized buccal defects in obese patients where an
ALT flap is too bulky to be used (see Table 11.2). The donor
site can be closed primarily when the flap width is less than
5 cm. The major disadvantages include the visible location of
the donor site scar and poor intraoperative posture of the
surgeon for dissecting the flap (see Figs. 11.18–11.21).
Profunda artery perforator flap
The profunda artery perforator (PAP) flap is also known as
posterior thigh flap or adductor magnus perforator flaps.94–96
The PAP is used for breast reconstruction in recent years, and
the authors found it an alternative flap in head and neck
reconstruction (see Figs. 11.6–11.10). It comprises skin from
the posterior and medial thigh and can be designed trans
versely or vertically. Transverse flap design places the scar in
a well-hidden area while longitudinal flap design includes
more and reliable perforators and allows more versatile flap
design.97–99
The PAP flap is elevated basing on profunda femoris per
forators. These perforators are either septocutaneous perfora
tors running in the intermuscular septum between gracilis
and adductor magnus or intermuscular septum between the
adductor magnus and semimembranous muscles or myocu
taneous perforators running through the adductor magnus
muscle. A hand-held Doppler is used to map the perforators.
Flaps can be designed with elliptical skin paddle transversely
or vertically. The patient is placed in a supine frog-leg position
during preparation and flap harvest. An incision is first made
along the anterior margin of the flap to identify the perforator.
marginal mandibulectomy is present) and in total tongue
reconstruction. It is a reliable flap with a sizeable pedicle for
the anastomosis. The only drawback of this flap is the poten
tial abdominal wall weakness after surgery. Careful repair
of the fascia and use of mesh to repair large fascial defects
can decrease the incidence of abdominal bulge or hernia
postoperatively.
Anterolateral thigh fasciocutaneous or
musculocutaneous flap
The ALT flap was first introduced by Song et al. in 1984.81 It
gradually gained popularity when reconstructive surgeons
found it to be a reliable flap with a long and sizeable pedicle
that can be harvested with a large skin paddle and additional
muscle for the reconstruction of moderate to large oroman
dibular defects (see Figs. 11.11–11.14).82–88
The pedicle of the ALT flap is usually the descending
branch of the lateral circumflex femoral artery. Sometimes, its
perforators may come from the transverse or oblique branch
of the lateral circumflex femoral vessel. The pedicle of the ALT
flap runs in the muscle septum between the vastus lateralis
and rectus femoris muscles. A sizeable perforator can nourish
a skin paddle that is 15 cm in diameter. The vastus lateralis
muscle is nourished by the same pedicle and therefore can be
harvested together with the ALT fasciocutaneous flap if a
large flap volume is required. The transverse branch of the
lateral circumflex femoral artery also nourishes the tensor
fascia lata muscle and fascia. If fascia is required to serve as
a sling, the tensor fascia lata can be included in the flap
dissection.
The ALT flap usually contains more than one sizeable
perforator and can also be designed as a chimeric flap to cover
two or more separate defects.84,87,88 This is useful when there
are multiple buccal mucosal defects or when a through-and-
through defect is present (see Figs. 11.11–11.14). The ALT flap
can also be separated into two or more small independent
flaps to replace two or more defects simultaneously.87,88 The
ALT flap has frequently been applied in head and neck recon
struction, especially when the soft-tissue defect is extremely
large or when a forearm flap is not fit. The distance between
the lower extremity and the head and neck region also allows
a two-team approach during the surgery. The thickness of the
ALT flap can be thinned to improve its pliability.58,83 Flap
design is initiated by marking a straight line from the anterior
superior iliac spine to the lateral border of the patella. Most
of the perforators are located within a circle of 3 cm from the
midpoint of this axis. A hand-held Doppler can be used to
map the perforators.
Flap dissection can be suprafascial or subfascial. The
subfascial dissection is suggested for a beginner to minimize
the risk of perforator damage. The perforators can either
be septocutaneous (13%) or musculocutaneous (87%).82
The descending branch of the lateral circumflex femoral
vessels can be found in the intermuscular septum between
the vastus lateralis muscle and rectus femoris muscle.
Unroofing of the musculocutaneous perforators and deli
cate intramuscular dissection of the perforators are the key
points for this flap dissection. When the vastus lateralis
muscle is harvested along with the skin paddle, the motor
nerve can be preserved to avoid possible knee function
compromise.82,83
293
Treatment/surgical technique
Trapezius osteomusculocutaneous flap
The scapular spine can be harvested to a maximal length of
10 cm along with the pedicled trapezius muscle as an osteo
musculocutaneous flap.105–112 Although the harvesting is rela
tively straightforward, the restricted quality of the scapula
bone and possible shoulder morbidity, especially as related to
the acromion, may limit its clinical use.
Temporalis osteomuscular flap
The vascularized cranial bone based on the superficial tempo
ral artery has been used for mandibular reconstruction in the
form of either the outer cortex or full-thickness bone graft
with the temporalis muscle.113 The temporalis osteomuscular
flap that is harvested with the outer cortex usually has inad
equate bone stock for hardware fixation and can easily fracture
during shaping. Full-thickness calvarium is more durable, but
donor site cosmesis is a major concern.
Vascularized osteocutaneous flaps
Circumflex iliac osteocutaneous flap
The free circumflex iliac osteocutaneous flap was introduced
by Taylor et al. in 1979.114 The groin skin paddle can be elevated
together with the iliac crest for mandibular reconstruction
with a 94–95% success rate.114,115 The iliac osteocutaneous flap
has the advantages of having a reliable vascular supply to the
bone and providing good contour of the neomandible with its
natural curve without osteotomy. More recently, Dorafshar
et al. described the use of a split lateral iliac crest chimeric flap
based on the lateral femoral circumflex vessels to provide
vascularized bone and soft tissue for complex mandibular
reconstruction.115 In spite of the successful outcome reported
for mandibular reconstruction,116–120 the bulky skin paddle and
possible donor site morbidities, such as abdominal wall weak
ness, hernia, and contour deformity, remain a concern (see
Tables 11.6 and 11.7). Shenaq et al. successfully harvested the
inner cortex of the iliac as part of this flap to prevent complica
tions at the donor site.120
Scapular osteomusculocutaneous flap
The scapular osteomusculocutaneous flap includes the lateral
border of the scapula, scapular and/or parascapular skin,
and the latissimus dorsi muscle, based on the subscapular
artery. The scapular and parascapular skin flaps are valu
able options for coverage of large complex oromandibular
reconstruction.121–125 The lateral border of the scapula is nour
ished by the circumflex scapular artery and can be harvested
with maximal bone length of 14 cm.126–128 Some modifications
of the osteocutaneous scapular flap harvest have been made
in need of versatile flap design and variable reconstruction,
including the use of the medial border of the scapula or a
bipedicled structure.123,124 However, the bone quality of the
scapula is not as good as that of the ilium or the fibula. One
of the major drawbacks is the intraoperative change in posi
tion, which requires additional operation time (see Tables 11.6
and 11.7).
Radius with radial forearm flap
The inner volar cortex of the distal radius can be harvested
with the radial forearm flap as an osteocutaneous flap
Once the perforator is identified by subfascial dissection, the
perforator is dissected and skeletonized and the flap can be
elevated accordingly.
Summary and trends of soft-tissue flaps in head
and neck reconstruction
With a review of 1160 clinical cases done by the authors’ team
since 2000, the variety of soft-tissue flaps used in head and
neck reconstruction is expanding beyond free musculocutane
ous and fasciocutaneous flaps, ALT, and radial forearm flaps
with the inclusion of free ulnar forearm flap, medial sural
artery perforator flap, and profunda artery perforator flaps
(Figs. 11.6–11.10, 11.18–11.21).
The forearm flap remains the first choice when a thin soft-
tissue flap is required. However, the authors shift from using
exclusively radial forearm flaps to preferred ulnar forearm
flaps and then reach a patient-oriented selection between the
radial and ulnar forearm flap based on the vascular domi
nance over the hands.
Besides the forearm flap, the ALT flap remains one of our
favorites for obvious reasons: the flap is versatile with a per
forator flap design, and perforator dissection gives a long
vascular pedicle for reconstruction. With the inclusion of
vastus lateralis (VL) muscle, the flap volume can be expanded.
The location also allows a two-team approach to reduce surgi
cal time. There exists another flap with moderate flap thick
ness between the ALT and the forearm flap. The medial sural
artery perforator flap is not our flap of choice but can be used
as an alternative in patients whose ALT flaps are too thick and
where forearm flaps are not available or not adequate in flap
volume.
The PAP flap is a newly emerging flap that catches the
surgeon’s eyes for several advantages. Being located over the
medial thigh, the flap has a much better-hidden scar compared
to the ALT flap. Many of the perforators are septocutaneous
perforators, making the flap dissection easier and less time-
consuming. Its pedicle is long enough for most head and neck
reconstruction. The flap thickness also provides good flap
volume in reconstruction demand.
Part II: Bone-carrying flaps
Pedicled osteocutaneous flaps
Pectoralis major osteomusculocutaneous flap
The traditional PM flap can be modified to include the fifth
rib as a bony scaffold for mandibular reconstruction.100,101 With
more microsurgical bone-carrying flaps available, the PM flap
with rib is rarely used now. There are several drawbacks to
the flap that preclude its popularity. The fifth rib is supplied
by the periosteal–muscular plexus, which is small and not
always reliable. Flap inset can be difficult due to the pedicle
flap design. The strength of the fifth rib is not as conducive
either for hardware fixation or osseous integration as the
fibula or the ilium. Risks of pneumothorax and hemothorax
at the donor site are other possible complications. The sternum
may also be harvested with a PM flap for bony reconstruction
of the mandible, but long-term follow-up of this technique is
missing.100–104
294
SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
Recipient site preparation
There are four pairs of commonly applied arteries on either
side of the neck: the facial artery, superior thyroid artery,
superficial temporal artery, and the transverse cervical artery.
The external carotid artery is seldom used with end-to-side
technique due to the high risk of blow-out. The recipient
vessels could be damaged by the previous operative scar,
radiated fibrosis, or certain types of neck dissection. The
superficial temporal artery is usually spared by radiation
therapy and is reliable as a recipient site.135 The contralateral
vessels in the neck are also good alternatives for secondary
mandibular reconstruction.
Donor site selection
The fibula is a unique triangular bone, as seen in its cross-
section (Fig. 11.27). The peroneal vessels, comprising one
artery and two concomitant veins, are located on the postero
medial aspect of the fibula, posterior to the fascia of the pos
terior tibialis, inside the flexor hallucis longus (FHL), and
anterior to the posterior crucial septum. The skin paddle is
nourished and designed based on OSC perforators, which run
inside the posterior crucial septum (see Fig. 11.27). The septum
should ideally be located posterosuperiorly to the recon
structed fibula and the plate to avoid any tethering of the
perforators in the septum while insetting the skin paddle
intraorally. The lateral surface is the safest and preferred site
for reconstruction plate fixation (see Fig. 11.27). Plate fixation
on the anteromedial or posteromedial aspects of the fibula
could result in the inadvertent shearing, entanglement, or
outright disruption of either the vascular pedicle or the per
forators. The use of the skin flap for either intraoral mucosal
or cheek skin reconstruction will determine the final orienta
tion of the bone inset and the orientation of the vascular
pedicle. Therefore, the insetting of the bone to the plate has
only two alternatives for a specific lateral mandibular defect,
one as shown in Fig. 11.28 as the LLI group and the other
rotated 180°. If the fibula is turned upside down, the pedicle
or perforators are easily injured or compressed by the plate
and screws.
When the left fibula is harvested for left mandibular recon
struction and the skin paddle is used for the intraoral lining
(LLI group in Table 11.8), the pedicle is toward the right
(10–12 cm in length) for mandibular reconstruction.129,130
Postoperative full-length plaster cast for 3–4 weeks or the
use of a dynamic compression plate for rigid fixation (see
Table 11.6) is necessary to prevent postoperative radius
fracture. It is rarely used now for the concern of donor
site morbidity.
Fibular osteoseptocutaneous flap
Taylor et al. introduced the fibula osseous flap in 1975.131 The
free fibular osteoseptocutaneous (OSC) flap has undergone
subsequent development and is now widely recognized as the
standard for successful mandibular reconstruction.132 Wei et al.
demonstrated the reliability of harvesting the fibular bone flap
along with a skin paddle based on identifiable septocutaneous
perforators.133 The skin paddle of the fibular flap provides
pliable soft-tissue coverage for the underlying bone, mini or
reconstruction plates, and osseointegrated dental implants. To
accomplish the reconstruction in a more aesthetic manner or
fix several missing tissues in one microsurgical reconstruction,
Cheng further developed the osteomyocutaneous peroneal
artery combined (OPAC) flap based on its anatomy and per
forator flap concept.134 Fig. 11.26 demonstrates the evolution
of the fibular bone flap from a vascularized bone flap to a
vascularized osteoseptocutaneous flap and subsequently to an
OPAC flap.
Surgical technique: fibular osteoseptocutaneous
flap for mandibular reconstruction
(Tables 11.6–11.8)
Assessment of mandibular defects and
custom-made templates
Simple intermaxillary fixation is performed to obtain good
dental occlusion. A reconstruction plate is molded and affixed
to the two residual mandibular ends with at least two or three
screws on each end. A paper ruler template is tailored and
measured for the required fibula length, angle, and osteoto
mies. One or two sterile towels are used to map out the
requirements for intraoral lining and external coverage. The
proposed pedicle orientation is also marked on each sterile
drape template.
Table 11.8 Variable flap inset and available recipient vessels for mandibular reconstruction using fibular osteoseptocutaneous flap.
Group
Code
Donor site
– fibula
Recipient site
– mandible
Fibular skin site
transferred to
Recipient
vessels – right
Recipient
vessels – left
Notes
1
LLI
Left
Left
Intraoral mucosa
FA, STA
STA
2
LLC
Left
Left
External cheek skin
STA, STPA
3
LRI
Left
Right
Intraoral mucosa
STA, STPA
Higher complication rate
4
LRC
Left
Right
External cheek skin
STA
FA, STA
5
RLI
Right
Left
Intraoral mucosa
STA, STPA
Higher complication rate
6
RLC
Right
Left
External cheek skin
FA, STA
STA
7
RRI
Right
Right
Intraoral mucosa
STA
FA, STA
8
RRC
Right
Right
External cheek skin
STA, STPA
FA, facial artery; STA, superior thyroid artery; STPA, superficial temporal artery.
295
Treatment/surgical technique
temporal vein is flipped downward (see Fig. 11.36). Care must
be taken to release the superficial temporal vein proximally
from its attachments to the surrounding tissues in order to
avoid any sharp turn in the vessel.
On the other hand, if the right fibula OSC flap is used for
left mandibular reconstruction and the skin paddle is used for
intraoral mucosa resurfacing (RLI group in Table 11.8; Fig.
11.37), the vascular pedicle will be oriented inferiorly and
posterolaterally to the fibula, making the left superior thyroid
artery and superficial temporal artery the most reasonable
recipient vessels (see Table 11.8). If the right fibula OSC flap
is used for right mandibular reconstruction and the skin
paddle is used for intraoral lining, the anastomosis to the
ipsilateral facial artery, superior thyroid artery, or contralateral
superior thyroid artery gives the pedicle a gentle curvature
that is unlikely to kink and occlude (RRI group in Table 11.8;
Figs. 11.38–11.44). When the ipsilateral recipient vessels are
(Figs. 11.28–11.35). This pedicle can reach the ipsilateral supe
rior thyroid artery, contralateral facial artery, or superior
thyroid artery in the neck (see Table 11.8). When the left fibula
is used to reconstruct a right combined mandibular and buccal
cheek defect, the flap must be inset with the proximal fibula
pointing posteriorly towards the mandibular ramus so that
the skin paddle can be used to reconstruct the intraoral
mucosal lining (LRI group in Table 11.8; Fig. 11.36). In this
configuration, the vascular pedicle will run inferiorly and
posterolaterally to the fibula. To reach either the right superior
thyroid artery or the right superficial temporal artery, the
pedicle must make a sharp turn, which may make it suscep
tible to kinking (see Table 11.8 & Fig. 11.36). When the man
dibular defect is extended to the ramus, the only available
recipient vessel is the right superficial temporal artery, which
has size discrepancy with the donor vessels and can easily
kink, especially the venous anastomosis when the superficial
Fig. 11.27 The fibular flap evolves from a bone-only flap to an osteocutaneous flap with the inclusion of the septocutaneous perforator, and to the osteomyocutaneous flap
with an additional myocutaneous perforator nourishing a segment of soleus muscle. 1, fibula bone; 2, soleus muscle; 3, peroneal vessels; 4, skin paddle; 5, septocutaneous
perforator; 6, myocutaneous perforator.
1
3
5
2
4
6
Fig. 11.28 The left fibula osteocutaneous flap is transferred to left mandibular
defect type IIa (LLI group in Table 11.8). The lateral aspect of the fibula is used for
fixation of the reconstruction plate and screws. The skin paddle is reconstructed for
the intraoral lining. The pedicle of peroneal vessels is placed toward the right side
to reach the recipient vessels of the ipsilateral superior thyroid artery, right facial
artery or right superior thyroid artery. 1, residual mandible bone; 2, fibula bone; 3,
peroneal vessel; 4, skin paddle of fibula flap. Recipient vessels – ipsilateral
superior thyroid artery (STA), contralateral facial artery (FA) and STA.
STA
1
4
2
3
STA
FA
1
Fig. 11.29 A 70-year-old male patient with a lower gum squamous cell carcinoma
(T4N0M0) underwent left segmental mandibulectomy and modified radical neck
dissection. The mandibular defect type IIa included a bone defect of 9 cm in length,
a buccal mucosal and adjunct soft-tissue defect measured 9 × 4 cm. A
reconstruction plate was used to bridge the residual mandible ends after temporal
intermaxillary wiring for occlusion. The plate was placed 1 cm higher than the lower
margin of the native mandible for possible osseointegrating implantation. A paper
ruler was used as a tailored template for measurement of the length, angle, and
number of osteotomies.
296
SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
Fig. 11.30 An osteomyocutaneous peroneal artery combined flap was harvested
with a skin paddle of 12 × 8 cm based on two septocutaneous perforators; 6 cm
from both ends of the fibula were preserved. A soleus muscle cuff (10 × 5 cm) was
planned for harvest based on a myocutaneous perforator located on the proximal
third of the leg.
Fig. 11.31 The osteotomy was performed to obtain three bone segments (3.5, 4.5,
and 3 cm in length, respectively) to simulate the tailored paper ruler templates on
the back table. The pedicle located in the posteromedial aspect was skeletonized
with a length of 10 cm toward the right side in order to easily reach the recipient
vessels. The lateral aspect of the fibula is suitable for fixation of the reconstruction
plate and screws without injury of the pedicle and septocutaneous perforators. A
cuff of lateral soleus muscle nourished by an independent myocutaneous perforator,
10 × 5 cm, was elevated.
Fig. 11.32 Three fibula segments were fixed to the reconstruction plate with one
screw for each. The pedicle was placed forward to the right side and curved down
to reach the ipsilateral superior thyroid artery and facial vein (blue loop, facial vein).
Fig. 11.33 The soleus muscle could be flipped over on top of the fibula and
reconstruction plate to prevent exposure of the reconstruction plate and potential
osteoradionecrosis, as well as to provide better cheek contouring.
Fig. 11.34 At a follow-up at 24 months, the patient was satisfied with the
functional and cosmetic outcomes (A-P view).
297
Treatment/surgical technique
Fig. 11.35 The patient was satisfied with good functional recovery of open mouth,
stable mastication, and appropriate flap thickness.
Fig. 11.36 The left fibula osteocutaneous flap is transferred to a right mandibular
defect type IIa (LRI group in Table 11.8). The lateral aspect of the fibula is used for
fixation of the reconstruction plate and screws. The skin paddle is reconstructed for
the intraoral lining. The pedicle of peroneal vessels is placed laterally to reach the
recipient vessels of the ipsilateral superior thyroid artery or the superiorly ipsilateral
superficial temporal artery. 1, residual mandible bone; 2, fibula bone; 3, peroneal
vessel; 4, skin paddle of fibula flap. Recipient vessels – ipsilateral superior thyroid
artery (STA) and superficial temporal artery (STPA); FA, facial artery.
STA
FA
STPA
4
3
2
1
Fig. 11.37 The right fibular osteocutaneous flap is transferred to a left mandibular
defect type IIa (RLI group in Table 11.8). The lateral aspect of the fibula is used for
fixation of the reconstruction plate and screws. The skin paddle is reconstructed for
the intraoral lining. The pedicle of peroneal vessels is placed left-sided and laterally
to the ipsilateral superior thyroid artery or superiorly to the ipsilateral superficial
temporal artery. 1, residual mandible bone; 2, fibula bone; 3, peroneal vessel; 4,
skin paddle of fibula flap. Recipient vessels – ipsilateral superior thyroid artery
(STA) and superficial temporal artery (STPA).
STA
STPA
4
3
2
1
Fig. 11.38 The right fibula osteocutaneous flap is transferred to a right mandibular
defect type IIa (RRI group in Table 11.8). The lateral aspect of the fibula is used for
fixation of the reconstruction plate and screws. The skin paddle is reconstructed for
the intraoral lining. The pedicle of peroneal vessels is placed toward the left side to
reach the recipient vessels of the ipsilateral superior thyroid artery or contralateral
facial or superior thyroid arteries. 1, residual mandible bone; 2, fibula bone; 3,
peroneal vessel; 4, skin paddle of fibula flap. Recipient vessels – ipsilateral
superior thyroid artery (STA) and contralateral facial artery and superior thyroid
artery.
STA
4
2
3
STA
FA
1
not available, especially in patients who have undergone
radiation therapy, the contralateral neck vessels are alterna
tive recipient vessels (see Table 11.8). The skeletonized pedicle
is usually long and pliable enough to reach the contralateral
side of the neck without difficulty.
Osteomusculocutaneous peroneal artery combined flap
harvest (see Figs. 11.29–11.34 & 11.39–11.44)
The advantages of the fibular OSC flap are well established:
adequate length and bone volume for extensive reconstruc
tion and osseointegrated dental implant placement; a sturdy
periosteal and endosteal blood supply allowing one or
multiple osteotomies; a reliable skin paddle with adequate
skin to resurface both intraoral and external skin defects; a
distant donor site allowing for a two-team approach; and
low donor site morbidity. Despite these benefits, one of the
potential drawbacks of the OSC flap is the lack of available
soft tissue once extensive composite mandibular or maxil
lary defects present. Wide excision of intraoral tumors can
result in defects involving the bone, oral lining, external skin,
tongue, and masseter muscle. Despite an initial acceptable
reconstruction, radiotherapy often leads to thinning of the
skin paddle and subsequent contraction, producing a loss
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CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
of contour and hollowing of the cheek and neck area. In
advance, wound-healing problems can lead to plate exposure
and osteoradionecrosis.
To counteract these problems when using the fibular osteo
cutanoeus flap, two potential solutions exist. The first is to
transfer a second flap (pedicled or free) to augment the soft
tissue or skin reconstruction, which requires another pair of
recipient vessels, and increase the operation time. The other
option is to increase the tissue that can potentially be har
vested with a fibular flap in a single operative procedure by
including a portion of the soleus muscle extending from a
separate myocutaneous perforator of the peroneal artery as
the OPAC flap.134,136 The OPAC flap has the advantages of
requiring single-flap harvest with all components, a single
Fig. 11.39 A 46-year-old male patient who was a victim of right mouth floor
cancer cT4N0M0 underwent wide excision and segmental mandibulectomy.
Cheng’s Class IIIa mandibular with buccal and cheek defects was presented.
Fig. 11.40 Temporary intermaxillary fixation obtained for occlusion. A
reconstruction plate was used for fixation of both residual mandibular ends. A paper
ruler template was used to tailor the osteotomy segment’s length and angle.
Fig. 11.41 An osteomusculocutaneous peroneal artery combined flap was
harvested with a skin paddle of 16 × 10 cm based on four septocutaneous
perforators; 6 cm from both ends of the fibula were preserved. The skin paddle was
planned to split into two parts.
Fig. 11.42 The osteomusculocutaneous peroneal artery combined flap was
elevated with a pedicle nourishing three tissue components, including two skin
paddles, two segments of fibula bone, and one piece of soleus. One skin flap was
used for the oral defect, the other one for external cheek coverage. The osteotomies
were done according to the paper ruler templates for mandibular reconstruction. A
piece of soleus muscle was elevated for bone coverage and cheek volume
reconstruction.
Fig. 11.43 The flap was inset with the fibula bone to the bone defect. The soleus
muscle, which was put in the neck in this photo, was then flipped over to cover the
bone and reconstruction plate. Red arrows mark two skin paddles.
299
Treatment/surgical technique
design and procedure using the traditional method for begin
ners. After division of the proximal peroneal pedicle, further
osteotomies are performed with an electric saw according to
the tailored paper ruler template displayed on the back table.
The skin paddle can be separated into two flaps based on each
perforator if two septocutaneous perforators are available (see
Figs. 11.31 & 11.42). The pedicle is skeletonized with removal
of unnecessary proximal periosteum and bone. Yagi et al.
highlighted the importance of respecting the geometry of the
fibula OSC flap to obtain good outcomes in mandibular
reconstruction.138 Some obstacles may appear during flap
shaping and insetting of a fibular OSC flap because of the
limited mobility of each integrated tissue component. It is
important to protect the vascular pedicle and septocutaneous
perforators to the skin paddle during the osteotomies to
prevent injury to these structures. Furthermore, the vascular
ity of the skin paddle can be compromised during flap inset
if the septum and its perforators are stretched over the fibula
bone and the plate to reach the defect. The minimal recom
mended bone segment length for osteotomy is 2.5 cm to
ensure the adequate inclusion of tiny perforators nourishing
the periosteum and subsequently the bone. The more osteoto
mies are made, the more the decrease of vascularity to the
distal segment can be encountered. This is because the proxi
mal bone segments are supplied by periosteal sources as well
as nutrient arteries while the distal segments are nourished
only by periosteal sources. In addition, when plating is applied
on top of the periosteum to fix the bone segments, there is a
concern of possible decrease in periosteal vascular flow to the
distal bone segments.
Flap inset
The insetting of the OPAC or fibular OSC flap starts with
fixing the osteotomized fibular segments that are contoured
to fit the reconstruction plate. The authors recommend only a
single screw fixation for each bone segment to minimize
vascular compromise to the fibula. One skin paddle based on
a septocutaneous perforator is then sutured to form the intra
oral lining, and a second skin paddle based on a separate
septocutaneous perforator from the same pedicle is used for
the external cheek if needed.
For certain indications, a piece of soleus muscle of OPAC
flap is harvested and placed on top of the fibula and recon
struction plate to improve cosmesis and prevent osteoradio
necrosis and plate exposure after postoperative radiation (see
Figs. 11.32, 11.33 & 11.43). It is recommended to keep the
ischemia time for fibular osteocutaneous flaps to less than 5
hours to reduce partial flap loss and other complication
rates.139
In an attempt to simplify surgical planning, some surgeons
prefer to use the contralateral leg as a donor site for mandibu
lar defects because two teams may work simultaneously
without any space conflict. Chang found that the left fibular
osteocutaneous flap had a higher vascular complication rate
when used for right mandibular reconstructions. This is likely
due to the more restricted spatial relationship between the
fibular flap inset and the available recipient vessels. An algo
rithm representing the different factors influencing the inset
geometry should include the side from which the flap was
harvested, the available recipient vessels, and the need for
intraoral or external skin reconstruction. It is recommended
donor site, and a single set of anastomoses, leading to reduced
operative time.
The harvest technique for the free fibular OSC flaps was
described by Wei and Cheng.134,136,137 Fibula bone is marked on
the skin. At both the proximal and distal ends, 6 cm in length
is preserved for knee and ankle stability (see Figs. 11.30 &
11.41). The septocutaneous perforators to the skin, which are
primarily located along the posterior margin of the fibula on
the middle and lower third of the leg, are marked preopera
tively by a hand-held Doppler. The skin island is centered
over the septocutaneous perforators. The skin incision is
made to the subcutaneous layer and kept above the fascia
through the anterior approach. The flap is partially elevated,
and the fascia is incised after passing through the anterior
cruciate ligament. The peroneus longus and brevis are elevated
off the fibula periosteum. The anterior cruciate ligament is
then divided. The periosteum of the fibula at both osteotomy
sites is removed, and the bone is osteotomized by an electric
saw. The fibula is then retracted posterolaterally to expose
the extensor digitorum longus, brevis, and posterior tibialis
muscles, which are all elevated off the periosteum. At this
time, the posterior skin incision is made with meticulous care
to keep the septocutaneous perforators intact inside the pos
terior cruciate septum. Distal ends of the peroneal vessels,
which may be separated from the fibula bone, are ligated and
divided. The pedicle is dissected out from the FHL. The FHL
is detached with an index finger inserted between the FHL
and posterior cruciate ligament, so as to protect the septocu
taneous perforators. The residual posterior cruciate septum
not containing the perforators is divided. The soleus muscle
can be included with the musculocutaneous perforators fre
quently identified at the proximal third of the peroneal vessels
(Figs. 11.31 & 11.42). The soleus muscle can be harvested 6 ×
14 cm, even up to half of soleus, without significant donor site
morbidity.
Osteotomies
Nowadays, a few surgeons have already shifted from manual-
planned osteotomy to computer-aided design (CAD) osteoto
mies. Here, the authors would like to describe the osteotomy
Fig. 11.44 Immediate postoperative result. Red arrows mark two skin paddles.
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CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
implants. If the height of the transplanted bone is insufficient,
the “double-barrel” fibular flap design provides adequate
bone height that allows stable fixation for osseointegrated
dental implants to be placed.140,141 Recently, new techniques
such as three-dimensional reconstruction images have been
introduced to assist the surgeon with complex mandibular
reconstruction with good results.142–147 Furthermore, rapid
prototyping technologies can construct physical models
from computer-aided designs via three-dimensional printers
(Figs. 11.45–11.50).
Computed-aided surgical design in mandible
reconstruction
Accurate preoperative three-dimensional planning is very
important in mandibular reconstruction. One of the major and
rapid evolutions in mandible reconstruction is the involve
ment of CAD. The earliest CAD can be dated back to 2004,
when Warnke et al. presented their work on using 3D CT scan
to produce scaffolds and incorporated the products with free
latissimus dorsi flap for reconstruction.148 Although it was
time-consuming (7 weeks before surgery), the concept and
computer-aided technique have inspired reconstructive sur
geons. Computer-aided design has fostered tremendous
advancement in mandibular reconstruction, and the applica
tions continue to evolve. While clinical application of tissue
engineering bone reconstruction remains uncertain, the idea
of CAD keeps progressing rapidly, especially in assisting
surgery. In general, computer-aided surgery can be applied to
preoperative surgical planning as well as patient-specific
customized reconstruction plans, guiding mandibulectomy,
and guiding osteotomies on bone graft.
The use of CAD helps to provide surgical accuracy, shorten
operation time, and minimize surgical morbidities. CAD helps
in virtual surgical planning, such as bone resection or osteoto
mies, and design and manufacturing of customized surgical
devices, such as reconstruction plate in mandible reconstruc
tion. With a patient’s CT scan data and the incorporation of 3D
printing, both the recipient site and donor site can be planned
to give more accurate surgical results. CAD with prototyp
ing, patient-specific precontoured reconstruction plate also
helps in enhancing surgical results. CAD-guided surgery
ends with accurately planned results and is considered more
accurate in comparison to manual reconstruction142–147 (see
Figs. 11.45–11.50).
to use an ipsilateral fibular osteocutaneous flap for mandibu
lar reconstruction to decrease the risk of vascular complica
tions. The ipsilateral superior thyroid artery, which is usually
preserved by the surgical oncologist, is the preferred recipient
artery. The contralateral superior thyroid artery constitutes an
equally viable alternative because up to 10–15 cm of the
length of the peroneal artery can usually be harvested.
Plating
Intermaxillary fixation with screws or wires can both
achieve good occlusion. A titanium reconstruction plate
is used to bridge both residual mandibular ends, with at
least two screws for each end (see Figs. 11.29 & 11.40). A
template using a paper ruler is made to match the contour
of the plate. Care must be taken not to injure the pedicle
or perforators during plating. Unicortical drilling and screw
fixation is recommended with the assistance of normal saline
irrigation to prevent overheating injury of the reconstructed
bone during platting. The plate can be positioned 1 cm higher
than the lower margin of the native mandible to achieve ad
equate height for occlusion and subsequent osseointegrated
Fig. 11.45 A 61-year-old female patient with left mandible osteoradionecrosis after
radiotherapy. The exposed left necrotic mandible bone was presented. (Courtesy of
Dr. Steve Henry.)
Fig. 11.46 Before surgery, the mandible resection
and the reconstruction using fibula osteocutaneous
flaps was planned with computer-aided design
(CAD). The CAD helped in the planning of fibula
osteotomy. (Courtesy of Dr. Steve Henry.)
301
Treatment/surgical technique
clusion and trismus. There are several alternatives to condyle
reconstruction, such as avascular bone graft, rounding off the
end of the fibula, costochondral graft attached to the fibula end,
or titanium condyle prosthesis.149 The condyle prosthesis has
been associated with a higher rate of hardware exposure and
even sensorineural hearing loss. The fibular osteocutaneous
flap had been reported for temporomandibular joint recon
struction with reasonable functional and cosmetic results.
Dental rehabilitation: osseointegrated dental implants
Dental rehabilitation may enhance functional and cosmetic
outcome after mandibular reconstruction. Either permanent
prosthesis with osseointegrated dental implants or removable
prosthesis can be used for the purpose of dental reconstruc
tion. These procedures are usually performed by the oral
surgeons and dentists. Briefly, the vestibuloplasty with split-
thickness skin graft or palatal mucosal graft is performed first
to obtain lingual and buccal sulci for a vestibule of 1.5 cm in
depth. The reconstructed bone stock (10 × 6 mm) is required
for the osseointegrated implant. The bone is exposed after
elevation of the periosteum and burred to yield a flat surface.
Drilling is applied for insertion of the implant at a depth of
5 mm. For a permanent prosthesis, consolidation of the
Ischemia time
The ischemia time starts at the time of pedicle division and
includes the osteotomy, the shaping and inset interval, and
ends with the completion of the arterial anastomosis. Several
factors determine ischemia time of the fibular flap transfer for
mandibular reconstruction: the surgeon’s experience; whether
the sequence of fibular osteotomies and fixation takes place
before or after pedicle division; whether the order of anasto
mosis is performed before or after flap insetting; and whether
the artery or vein is anastomosed first. Partial flap loss has
statistically been higher if the ischemia time is greater than 5
hours.139 Fibula bone survival did not differ significantly with
ischemia time. Partial flap loss seems to be primarily a problem
of the skin component of the fibular OSC flap, possibly due
to kinking, twisting, or too much tension at the septocutane
ous perforator during insetting and plating.
Temporomandibular joint reconstruction
Reconstruction of the temporomandibular joint usually yields
unfavorable results. If the condyle is not reconstructed, move
ment of the mandible, which relies only on the contralateral
temporomandibular joint, will eventually tilt, causing maloc
Fig. 11.47 Cutting guide for the fibular
osteotomies according to computer-aided design
for accurate length and angle of each osteotomy.
(Courtesy of Dr. Steve Henry.)
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CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
the anatomical relationship between the bone, vascular
pedicle, and skin paddle have made restrictions to flap inset.
An anatomy-based reconstruction plan is required for suc
cessful reconstruction with minimized complications. The
numbers addressed in Table 11.8 are the authors’ experiences
using fibula-based bone-carry flaps, either a free fibular OSC
flap or an OPAC flap for mandible reconstruction. In our
experience, the most important principle in determining skin
paddle inset is the pedicle course under minimal tension. This
helps to avoid the tension and tethering of the pedicle that
would otherwise compromise the perfusion to the skin paddle.
As expected, most of the recipient vessels fell into the red-
marked recommended ones, helping to place the flap in a
well-organized, natural-positioned setting and reduce vascu
lar compromise and its potential complications, such as partial
or total necrosis with patent arterial and venous anastomosis.
Based on our principles, the incidence of skin flap partial or
total necrosis is low and the overall success rate was as high
as 98.87%.
implant requires 3 months. Although the immediate osseoin
tegrated implant was introduced by Chang for benign
lesions,150,151 delayed osseointegration is recommended for
cancer patients who may eventually undergo radiotherapy.
Clinical experiences
Table 11.8 provides recommended guidelines for flap and
recipient vessel selection in mandibular reconstruction based
on the lesion side. Unlike true perforator flaps that allow very
versatile flap inset, the unique 3D structure of fibula bone and
Fig. 11.48 The reconstruction plate bending and plating can be performed
precisely. From this model a plate was pre-bent; note that the proximal and distal
holes in the mandible resection guide (“predictive holes”, indicated by the double
blue ovals) match the hole pattern in the plate, ensuring that the native mandible,
fibula segments, and plate will all fit together as in the computer model, and that
the relationship of the two condyles will be perfectly anatomic. (Courtesy of Dr.
Steve Henry.)
Fig. 11.49 With accurate planning, the osteotomy fit the plate precisely.
Photograph of the fibula segments and plate; note the perfect apposition of the
fibula segments and neomandibular angle. (Courtesy of Dr. Steve Henry.)
Fig. 11.50 Immediate postoperative appearance with the skin flap used to cover
the external defect. (Courtesy of Dr. Steve Henry.)
303
Outcome, prognosis, and complications
mised flap circulation that requires re-exploration, poor
wound healing, and wound infection.
The rate of re-exploration due to compromised flap circula
tion was reported at 5–25% of patients. However, the salvage
rate for a compromised flap is highly dependent on the time
of surgical intervention and the surgeon’s experience.152 Most
cases of compromised vascular flow will manifest on the first
postoperative day or within the first few days.152 More than
50% of the vascular compromise cases presented signs of
compromise as early as 4 hours postoperatively, and more
than 80% of the cases within the first 24 hours.152 With early
intervention, the salvage rate of total flap loss can be greater
than 80%. Vascular compromise can result from thrombosis
due to poor microsurgical techniques. More frequently,
however, it is related to improper flap inset, kinking, or twist
ing of the vascular pedicle.
Wound infection is a common complication for head and
neck reconstruction and accounts for up to 48% of all com
plications.153,154 Effective drainage of the neck and obliteration
of the dead space are important to decrease postoperative
hematoma and subsequent infection. Oral cavity cancer
patients are usually malnourished, and this has a negative
impact on wound healing. During surgery, a watertight
closure is important to prevent saliva leakage from the oral
cavity into the neck, which is one of the most common reasons
for neck wound infection and delayed wound healing.
Although the reported rate of orocutaneous fistula after
head and neck reconstruction is only 3%, its presence can
threaten the viability of the flap.155–157 Persistent exposure of
the vascular pedicle to oral secretions and oral flora increases
the incidence of infection and potential disruption of the
anastomosis. This is the most common reason for delayed
flap failure after wound infection. Enteral feeding as early as
possible can help to reduce malnutrition and other related
complications.
Chronic complications
Trismus is the most common long-term complication after
oral cavity reconstruction, usually due to scar contracture,
inadequate postoperative rehabilitation, and/or postopera
tive radiotherapy. The size of the free flap will usually shrink
to a certain extent after surgery. This condition is exacerbated
by radiotherapy. Progressive contraction of the flap can result
in a sunken appearance, a condition typically seen in patients
with through-and-through defects. Orocutaneous fistulae
with persistent saliva leakage from the oral cavity to the
neck may result from poor intraoral wound healing, teeth
necrosis, or osteoradionecrosis. Patients typically present
with nonhealing intraoral and neck wounds with persistent
discharge from the neck wound that does not improve
despite aggressive wound care and antibiotics. Treatments
should include enteral tube feeding and surgical debride
ment with flap coverage. Occasionally, the fistula is small
and cannot be visually identified. A methylene blue-water
test or a head and neck computed tomography scan can
be performed to help detect the fistulae. Once poor wound
healing presents, surgical debridement is frequently required
and should not be hesitated. Obtaining tissue around the
unhealed region for pathological review is important since
some tumor recurrence/residual tumors manifest as poor
wound healing.
Postoperative care
Patients are transferred to the intensive care unit for postop
erative flap monitoring for 3–7 days depending on the patients’
condition.
A tracheotomy or an endotracheal tube is required for
ventilator support overnight and the patient is usually sedated
on postoperative day 1. Restriction of neck motion is some
times required to prevent traction or avulsion of the vascular
anastomosis.
Prophylactic antibiotics for Gram-positive and Gram-
negative bacteria are given for 7 days. Due to the length of
the operation, a prophylactic proton pump inhibitor is admin
istered for 3 days to prevent stress ulcers. Relative overhydra
tion is preferred in patients without contraindication to
maintain adequate perfusion to the flap. Intake and output
are carefully monitored. Enteral feeding is started as early as
possible to ensure sufficient nutritional support. If enteral
feeding is not possible or if nutritional status is already poor
before surgery, short-term (3–5 days) partial parenteral nutri
tional support is recommended.
The flaps are monitored every hour for the first 24 hours
and every 2 hours for the next 24 hours, and then every
4 hours starting from postoperative day 3 to the time of
discharge. Physical examination of the flap (including color,
temperature, capillary refill, and puncture test) is usually
adequate. If there is a skin paddle on the outside of the
oral cavity, a hand-held Doppler can be used to monitor
vascular flow to the flap. Other devices, such as implantable
Doppler, laser Doppler, or an O2C machine, can be used as
alternatives.
Antithrombotic agents or vasodilation agents such as
heparin, low-molecular-weight Fraxiparine, promostan, or
dextran are not routinely prescribed. Such medications are
given only if the pedicle has a high risk of developing throm
bosis inside the vessels or when the surgeons find it necessary.
Patients are given gentle and gradual rehabilitation with
regard to mouth opening to prevent postoperative trismus by
postoperative day 7.
Outcome, prognosis, and complications
Complications after a flap transfer to the oral cavity are not
uncommon. Acute complications often relate to the surgery
itself, while chronic complications may result from improper
flap design and inset, poor patient self-care, scarring, or
complications related to cancer treatment, such as postopera
tive radiation therapy.
Complications post buccal and
tongue reconstructions
Acute complications
The keys for a high success rate of microsurgical free-flap
transfers include careful preoperative planning, delicate
flap dissection, accurate microsurgical anastomosis, proper
flap inset, and careful monitoring of the flap postoperatively.
Early re-exploration and management of the complications
are also very important. Acute complications include compro
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CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
An important concept of preventing osteoradionecrosis is
having enough soft-tissue and bone coverage in the irradiated
field. The risks of osteoradionecrosis, trismus, and plate
exposure were significantly lower in the OPAC flap with
soleus (29%) than the traditional fibular OSC flap (53.1%)161
(option 6 in Table 11.7). Additional soft-tissue coverage of the
hardware and bone can also be provided to decrease these
complications by means of a double free flap using one fibular
osteocutaneous flap and one ALT myocutaneous flap (option
3 in Table 11.7).
Secondary procedures
Common reasons for secondary revisions following oral
cavity reconstruction include functional correction and cos
metic improvement. When the tumor resection involves the
angle of the mouth, oral incompetence is an issue. The revi
sion improves the drooling, which is an inconvenience in
daily life, as well as improving overall aesthetic appearance.
If the upper and lower lips are largely preserved, a vermilion
advancement flap can usually reach a satisfactory cosmetic
result. However, if the lips are inadequate for advancement,
a tendon graft (usually the palmaris longus tendon) is required
to serve as a sling to reconstruct and restore oral competency,
and mucosal flaps such as facial artery musculomucosal
(FAMM) flap can be used to restore the appearance of lips.
Scar release with Z-plasty is an easy and effective procedure
to reduce scar contracture and to smooth out the flap edges.
Another commonly encountered problem is an oversized flap
or an inadequate flap volume, which results in an asymmetric
lower third of the face. Flap reduction can be achieved by
direct excision or liposuction. If inadequate flap volume is
present, fat injection can be performed. In selected patients
who present with severe soft-tissue insufficiency and bony
structure exposure, a second free-flap transfer is another
option.162
Complications post mandibular reconstruction
Acute complications
Acute complications appear within 1 week postoperatively,
including re-exploration, wound dehiscence, and partial skin
paddle loss. Subacute complications occur between 1 week
and 1 month postoperatively, consisting of infection, skin flap
loss, wound dehiscence, donor site morbidity, and fibula bone
loss. Chang reported a success rate of 98.2%, partial skin loss
of 29%, and partial bone loss of 3% in a series of 116 mandibu
lar reconstructions using fibular OSC flaps with a mean
ischemia time of 3.6 hours.139
Chronic complications
Chronic complications beyond the 1-month period include
infection, malocclusion, donor site morbidity, skin flap loss,
or radiotherapy-related orocutaneous fistula or osteoradione
crosis on the remaining bone or the reconstructed bone.
Osteoradionecrosis has been described as hypovascularity,
hypocellularity, and local tissue hypoxia.158 Radiation-related
osteoradionecrosis, neck contractures, and wound-healing
problems with subsequent plate exposure are frequent in
patients undergoing a fibular osteocutaneous flap for man
dibular reconstruction.159,160 Osteoradionecrosis due to oblit
eration of the inferior alveolar artery and radiated fibrosis of
the periosteum was reported to occur in 0.8–37% of cases.158
Osteoradionecrosis often involves the native residual man
dible; this typically occurs in the buccal cortex or the recon
structed bone flap.159
Once osteoradionecrosis develops, management should
include wide excision of the radionecrotic bone, coverage
with a muscle flap, or replacement with another osteocutane
ous flap. Hyperbaric oxygen has been used in the treatment
of osteoradionecrosis, without significant improvement. Its
use should be very careful for cancer patients due to potential
local recurrence.
15. Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: a
10-year follow-up study. Plast Reconstr Surg. 2002;110:438–449;
discussion 450–431. One of the earliest references with a single
surgeon’s experience using bone-carrying free flaps in mandible
reconstruction and follow-up of more than 10 years. Excellent
results were confirmed with minimal bony resorption, good aesthetic
outcome, and well-restored function. Most of the reconstructions
were done with free fibula flaps with one exception (Scapula flap).
It is one of the signature papers to confirm the applicability of
the free fibula flap in mandible reconstruction with long-term
follow-up.
30. Kao HK, Chang KP, Ching WC, et al. Postoperative morbidity and
mortality of head and neck cancers in patients with liver cirrhosis
undergoing surgical resection followed by microsurgical free tissue
transfer. Ann Surg Oncol. 2010;17:536–543.
41. Loewen IJ, Boliek CA, Harris J, et al. Oral sensation and function:
a comparison of patients with innervated radial forearm free flap
reconstruction to healthy matched controls. Head Neck.
2010;32:85–95.
47. Engel H, Huang JJ, Lin CY, et al. A strategic approach for tongue
reconstruction to achieve predictable and improved functional and
aesthetic outcomes. Plast Reconstr Surg. 2010;126:1967–1977. A
strategic approach of tongue reconstruction based on the extension of the
defects is proposed. Unlike most of the literature that addresses a single
flap in all kinds or a specific category of tongue reconstruction, this paper
provides comprehensive review of the defects and flap selection based on
the defects. There is not a single flap that can fit all the defects.
Reconstruction planning and flap selection should be based on the defect
and the availability of donor tissue. The information provided is
extremely useful and also very helpful for the beginner.
60. Wei FC, Celik N, Chen HC, et al. Combined anterolateral thigh
flap and vascularized fibula osteoseptocutaneous flap in
reconstruction of extensive composite mandibular defects. Plast
Reconstr Surg. 2002;109:45–52. It is not uncommon that the defect left
after tumor resection involves multiple important structures. This paper
demonstrates how the reconstructive surgeon can be challenged
sometimes by a huge defect and that the reconstruction can be achieved
successfully using two different free flaps at the same time to restore both
missing soft tissue and bone. It also highlights the importance that
reconstruction can actually help to extend the resectability of cancer with
the back-up of microsurgical reconstruction.
68. Schultz BD, Sosin M, Nam A, et al. Classification of mandible
defects and algorithm for microvascular reconstruction. Plast
Reconstr Surg. 2015;135:743e–754e.
Access the complete reference list online at
305
Secondary procedures
134. Cheng MH, Saint-Cyr M, Ali RS, et al. Osteomyocutaneous
peroneal artery-based combined flap for reconstruction of
composite and en bloc mandibular defects. Head Neck. 2009;31:361–
370. One of the major shortcomings of the fibular osteoseptocutaneous
flap is the insufficiency of soft tissue to replace soft-tissue deficiency or
cover the reconstructed mandible and reconstruction plate, which are
both vulnerable to being exposed after radiotherapy. In this paper, Cheng
and colleagues modified the free fibula flap with the inclusion of a piece of
soleus muscle basing on a pair of separate vessels from the peroneal
artery and vein. With the inclusion of the muscle, plate exposure rate
was successfully reduced. The soleus muscle designed based on the
“chimeric” concept also provides versatility of flap inset. The
modification of the fibular flap to the so-called “osteomyocutaneous
peroneal artery-based combined flap” expanded the application of the flap
to more extensive bone and soft-tissue defect reconstruction following
cancer resection. It also minimized long-term complications that may
potentially require another free tissue transfer to solve.
138. Yagi S, Kamei Y, Torii S. Donor side selection in mandibular
reconstruction using a free fibular osteocutaneous flap. Ann Plast
Surg. 2006;56:622–627.
147. Metzler P, Geiger EJ, Alcon A, et al. Three-dimensional virtual
surgery accuracy for free fibula mandibular reconstruction:
planned versus actual results. J Oral Maxillofac Surg. 2014;72:2601–
2612. One of the greatest challenges in performing mandible
reconstruction is to reproduce similar contour of the reconstructed
mandible and match the symmetry to the contralateral normal mandible.
It is experience-dependent. The use of computer-guided preoperative
planning provides the possibility to match the defect in maximal strength
and improve the reconstruction. It was shown in this paper that
preoperative CT planning successfully reproduces the preoperative
contour of the mandible and the use of CT-guided surgeries or
preoperative planning should be considered the next milestone in
mandible reconstruction.
160. Deutsch M, Kroll SS, Ainsle N, Wang B. Influence of radiation on
late complications in patients with free fibular flaps for
mandibular reconstruction. Ann Plast Surg. 1999;42:662–664.
305.e1
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28. Genden EM, Rinaldo A, Suarez C, et al. Complications of free flap
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32. Kao HK, Chang KP, Chen YA, et al. Anatomical basis and versatile
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33. Hsiao HT, Leu YS, Lin CC. Tongue reconstruction with free radial
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305.e2
SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
closure and free radial forearm flap reconstruction with
videofluoroscopy. Ann Plast Surg. 2003;50:450–455.
45. de Vicente JC, de Villalain L, Torre A, Pena I. Microvascular free
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47. Engel H, Huang JJ, Lin CY, et al. A strategic approach for tongue
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aesthetic outcomes. Plast Reconstr Surg. 2010;126:1967–1977. A
strategic approach of tongue reconstruction based on the extension of the
defects is proposed. Unlike most of the literature that addresses a single
flap in all kinds or a specific category of tongue reconstruction, this paper
provides comprehensive review of the defects and flap selection based on
the defects. There is not a single flap that can fit all the defects.
Reconstruction planning and flap selection should be based on the defect
and the availability of donor tissue. The information provided is
extremely useful and also very helpful for the beginner.
48. Tincani AJ, Del Negro A, Araujo PP, et al. Head and neck
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49. Windfuhr JP, Remmert S. Infrahyoid myofascial flap for tongue
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50. Deganello A, Manciocco V, Dolivet G, et al. Infrahyoid fascio-
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51. Chen SL, Yu CC, Chang MC, et al. Medial sural artery perforator
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52. Kao HK, Chang KP, Wei FC, Cheng MH. Comparison of the
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head and neck reconstructions. Plast Reconstr Surg.
2009;124:1125–1132.
53. Uwiera T, Seikaly H, Rieger J, et al. Functional outcomes after
hemiglossectomy and reconstruction with a bilobed radial forearm
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54. Salibian AH, Allison GR, Armstrong WB, et al. Functional
hemitongue reconstruction with the microvascular ulnar forearm
flap. Plast Reconstr Surg. 1999;104:654–660.
55. Huang JJ, Wu CW, Lam WL, et al. Anatomical basis and clinical
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56. Koh KS, Eom JS, Kirk I, et al. Pectoralis major musculocutaneous
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57. Chen WL, Yang ZH, Li JS, Huang ZQ. Reconstruction of the
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58. Huang CH, Chen HC, Huang YL, et al. Comparison of the radial
forearm flap and the thinned anterolateral thigh cutaneous flap for
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59. Celik N, Wei FC, Lin CH, et al. Technique and strategy in
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60. Wei FC, Celik N, Chen HC, et al. Combined anterolateral thigh
flap and vascularized fibula osteoseptocutaneous flap in
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Reconstr Surg. 2002;109:45–52. It is not uncommon that the defect left
after tumor resection involves multiple important structures. This paper
demonstrates how the reconstructive surgeon can be challenged
sometimes by a huge defect and that the reconstruction can be achieved
successfully using two different free flaps at the same time to restore both
missing soft tissue and bone. It also highlights the importance that
reconstruction can actually help to extend the resectability of cancer with
the back-up of microsurgical reconstruction.
61. Agostini V, Dini M, Mori A, et al. Adipofascial anterolateral thigh
free flap for tongue repair. Br J Plast Surg. 2003;56:614–618.
62. Liao G, Su Y, Zhang J, et al. Reconstruction of the tongue with
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63. Daniel RK. Mandibular reconstruction with free tissue transfers.
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64. Daniel RK. Reconstruction of mandibular defects with
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65. Jewer DD, Boyd JB, Manktelow RT, et al. Orofacial and
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66. Urken ML, Weinberg H, Vickery C, et al. Oromandibular
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67. Boyd JB, Gullane PJ, Rotstein LE, et al. Classification of
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68. Schultz BD, Sosin M, Nam A, et al. Classification of mandible
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69. Pistre V, Pelissier P, Martin D, Baudet J. The submental flap: its
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70. Magden O, Edizer M, Tayfur V, Atabey A. Anatomic study of the
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71. Chow TL, Chan TT, Chow TK, et al. Reconstruction with
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72. Multinu A, Ferrari S, Bianchi B, et al. The submental island flap in
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73. Bakamjian VY. A two-stage method for pharyngoesophageal
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74. Feng GM, Cigna E, Lai HK, et al. Deltopectoral flap revisited: role
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75. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap
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76. Yang GF, Chen BJ, Gao YZ. The free forearm flap. Chin Med J.
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77. Demirkan F, Wei FC, Lutz BS, et al. Reliability of the venae
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78. Chang SC, Miller G, Halbert CF, et al. Limiting donor site
morbidity by suprafascial dissection of the radial forearm flap.
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79. Heller F, Wei W, Wei FC. Chronic arterial insufficiency of the hand
with fingertip necrosis 1 year after harvesting a radial forearm free
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80. Ninkovic M, Harpf C, Schwabegger AH, Rumer-Moser A. The
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81. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap
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82. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variations and
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cases. Plast Reconstr Surg. 1998;102:1517–1523.
83. Kimura N, Satoh K, Hasumi T. Ostuka T. Clinical application of
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84. Huang WC, Chen HC, Jain V, et al. Reconstruction of through-
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305.e4
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CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
134. Cheng MH, Saint-Cyr M, Ali RS, et al. Osteomyocutaneous
peroneal artery-based combined flap for reconstruction of
composite and en bloc mandibular defects. Head Neck. 2009;31:361–
370. One of the major shortcomings of the fibular osteoseptocutaneous
flap is the insufficiency of soft tissue to replace soft-tissue deficiency or
cover the reconstructed mandible and reconstruction plate, which are
both vulnerable to being exposed after radiotherapy. In this paper, Cheng
and colleagues modified the free fibula flap with the inclusion of a piece of
soleus muscle basing on a pair of separate vessels from the peroneal
artery and vein. With the inclusion of the muscle, plate exposure rate
was successfully reduced. The soleus muscle designed based on the
“chimeric” concept also provides versatility of flap inset. The
modification of the fibular flap to the so-called “osteomyocutaneous
peroneal artery-based combined flap” expanded the application of the flap
to more extensive bone and soft-tissue defect reconstruction following
cancer resection. It also minimized long-term complications that may
potentially require another free tissue transfer to solve.
135. Shimizu F, Lin MP, Ellabban M, et al. Superficial temporal vessels
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136. Yazar S, Cheng MH, Wei FC, et al. Osteomyocutaneous peroneal
artery perforator flap for reconstruction of composite maxillary
defects. Head Neck. 2006;28:297–304.
137. Wei FC, Seah CS, Tsai YC, et al. Fibula osteoseptocutaneous flap
for reconstruction of composite mandibular defects. Plast Reconstr
Surg. 1994;93:294–304; discussion 305–306.
138. Yagi S, Kamei Y, Torii S. Donor side selection in mandibular
reconstruction using a free fibular osteocutaneous flap. Ann Plast
Surg. 2006;56:622–627.
139. Chang SY, Huang JJ, Tsao CK, et al. Does ischemia time affect the
outcome of free fibula flaps for head and neck reconstruction? A
review of 116 cases. Plast Reconstr Surg. 2010;126:1988–1995.
140. Gonzalez-Garcia R, Naval-Gias L, Rodriguez-Campo FJ, et al. Gap
ossification in the double-barrel technique for the reconstruction of
mandibular defects by means of the vascularized free fibular flap.
Plast Reconstr Surg. 2006;117:2519–2520.
141. Chang YM, Tsai CY, Wei FC. One-stage, double-barrel fibula
osteoseptocutaneous flap and immediate dental implants for
functional and aesthetic reconstruction of segmental mandibular
defects. Plast Reconstr Surg. 2008;122:143–145.
142. Fowell C, Edmondson S, Martin T, Praveen P. Rapid prototyping
and patient-specific pre-contoured reconstruction plate for
comminuted fractures of the mandible. Br J Oral Maxillofac Surg.
2015;53:1035–1037.
143. Wilde F, Cornelius CP, Schramm A. Computer-assisted mandibular
reconstruction using a patient-specific reconstruction plate
fabricated with computer-aided design and manufacturing
techniques. Craniomaxillofac Trauma Reconstr. 2014;7:158–166.
144. Toto JM, Chang EI, Agag R, et al. Improved operative efficiency of
free fibula flap mandible reconstruction with patient-specific,
computer-guided preoperative planning. Head Neck.
2015;37:1660–1664.
145. Wilde F, Winter K, Kletsch K, et al. Mandible reconstruction using
patient-specific pre-bent reconstruction plates: comparison of
standard and transfer key methods. Int J Comput Assist Radiol Surg.
2015;10:129–140.
146. Logan H, Wolfaardt J, Boulanger P, et al. Exploratory benchtop
study evaluating the use of surgical design and simulation in
fibula free flap mandibular reconstruction. J Otolaryngol Head Neck
Surg. 2013;42:42.
147. Metzler P, Geiger EJ, Alcon A, et al. Three-dimensional virtual
surgery accuracy for free fibula mandibular reconstruction:
planned versus actual results. J Oral Maxillofac Surg. 2014;72:2601–
2612. One of the greatest challenges in performing mandible
reconstruction is to reproduce similar contour of the reconstructed
mandible and match the symmetry to the contralateral normal mandible.
It is experience-dependent. The use of computer-guided preoperative
planning provides the possibility to match the defect in maximal strength
and improve the reconstruction. It was shown in this paper that
preoperative CT planning successfully reproduces the preoperative
contour of the mandible and the use of CT-guided surgeries or
preoperative planning should be considered the next milestone in
mandible reconstruction.
148. Warnke PH, Springer IN, Wiltfang J, et al. Growth and
transplantation of a custom vascularised bone graft in a man.
Lancet. 2004;364:766–770.
149. Patel A, Maisel R. Condylar prostheses in head and neck cancer
reconstruction. Arch Otolaryngol Head Neck Surg. 2001;127:842–846.
150. Chang YM, Santamaria E, Wei FC, et al. Primary insertion of
osseointegrated dental implants into fibula osteoseptocutaneous
free flap for mandible reconstruction. Plast Reconstr Surg.
1998;102:680–688.
151. Chang YM, Shen YF, Lin HN, et al. Total reconstruction and
rehabilitation with vascularized fibula graft and osseointegrated
teeth implantation after segmental mandibulectomy for fibrous
dysplasia. Plast Reconstr Surg. 2004;113:1205–1208.
152. Chen KT, Mardini S, Chuang DC, et al. Timing of presentation of
the first signs of vascular compromise dictates the salvage
outcome of free flap transfers. Plast Reconstr Surg.
2007;120:187–195.
153. Penel N, Lefebvre D, Fournier C, et al. Risk factors for wound
infection in head and neck cancer surgery: a prospective study.
Head Neck. 2001;23:447–455.
154. Liu SA, Wong YK, Poon CK, et al. Risk factors for wound infection
after surgery in primary oral cavity cancer patients. Laryngoscope.
2007;117:166–171.
155. Singh B, Cordeiro PG, Santamaria E, et al. Factors associated with
complications in microvascular reconstruction of head and neck
defects. Plast Reconstr Surg. 1999;103:403–411.
156. Suh JD, Sercarz JA, Abemayor E, et al. Analysis of outcome and
complications in 400 cases of microvascular head and neck
reconstruction. Arch Otolaryngol Head Neck Surg. 2004;130:962–966.
157. Huang RY, Sercarz JA, Smith J, Blackwell KE. Effect of salivary
fistulas on free flap failure: a laboratory and clinical investigation.
Laryngoscope. 2005;115:517–521.
158. Marx RE. Osteoradionecrosis: a new concept of its
pathophysiology. J Oral Maxillofac Surg. 1983;41:283–288.
159. Shaha AR, Cordeiro PG, Hidalgo DA, et al. Resection and
immediate microvascular reconstruction in the management of
osteoradionecrosis of the mandible. Head Neck. 1997;19:406–411.
160. Deutsch M, Kroll SS, Ainsle N, Wang B. Influence of radiation on
late complications in patients with free fibular flaps for
mandibular reconstruction. Ann Plast Surg. 1999;42:662–664.
161. Gazyakan E, Wu CW, Huang JJ, et al. Minimizing
osteoradionecrosis after mandibular reconstruction and radiation
in advanced head and neck cancer patients. J Surg Oncol.
2016;114:399–404.
162. Wei FC, Demirkan F, Chen HC, et al. Management of secondary
soft-tissue deficits following microsurgical head and neck
reconstruction by means of another free flap. Plast Reconstr Surg.
1999;103:1158–1166.
SECTION II • Head and Neck Reconstruction
12
Lip reconstruction
Peter C. Neligan and Lawrence J. Gottlieb
SYNOPSIS
■ Accurate three-layered closure of lip defects is imperative to preserve
function.
■ Local tissue should be used whenever possible.
■ Small defects can be closed by direct repair:
• defects up to 25% of the width of the upper lip can be closed; and
• defects up to 30% of the width of the lower lip can be closed.
■ Intermediate defects are best reconstructed with local flaps.
■ Total or sub-total lip defects are best reconstructed with free tissue.
Introduction
As the most prominent feature of the lower third of the face,
the lips have significant functional, aesthetic, and social
importance. Even subtle changes in the appearance of the
vermilion border, labial commissures, or Cupid’s bow are
readily visible to the casual observer, and deformity can have
a profound and lasting effect on the patient’s self-image and
quality of life.
Restoration of the lips is complicated by the fact that they
are mobile structures and need to function (aesthetically and
mechanically) differently when in repose and when animated
since function and aesthetics are inextricably linked in these
functional units. In addition, as mobile structures, they are
subjected to distortion by gravity, scar, and possibly radiation
and denervation. Neuromuscular injury or dysfunction can
cause asymmetry at rest and particularly during facial expres
sion. This can lead to distressing functional disability. Loss of
labial competence may be characterized by impairment in the
ability to articulate, whistle, suck, kiss, and, probably most
importantly, to control salivary secretions with consequent
drooling. Surgeons have long appreciated the significance of
lip function and aesthetics and many creative surgical tech
niques have been devised to reconstruct various lip defects.
These techniques have evolved, and newer procedures have
been developed that effectively address small to moderate
defects. However, while many of the current techniques work
well for small to moderate lip defects, the ultimate reconstruc
tive approach for larger defects of the lip has remained elusive,
and currently available methods provide results that are less
than optimal.1
Access the Historical Perspective section online at
Anatomic and functional considerations
in lip reconstruction
The laminar structure of the lips consists of three layers:
mucosa, muscle, and skin. Externally, the cutaneous portion
of the lip surrounds and transitions into the mucosal lip. This
transition between these two regions is characterized by the
mucocutaneous ridge, or vermilion border. At the midline of
the upper lip, there is a V-shaped indentation of the mucocu
taneous ridge that is known as Cupid’s bow. Above Cupid’s
bow, a vertical groove-shaped depression called the philtrum
is bordered on either side by elevations known as philtral
ridges or columns (Fig. 12.1). The vermilion forms the major
aesthetic feature of the upper and lower lips. The vermilion
is composed of modified mucosa that lacks minor salivary
glands. The characteristic color of the vermilion stems from a
rich blood supply that underlies a very thin epithelial struc
ture. The maxillary and mandibular divisions of the trigeminal
nerve provide sensation to both upper and lower lips. The
boundaries of the upper lip are defined by the base of the nose
centrally and by the nasolabial folds laterally. The inferior
margin of the lower lip is defined by the mental crease (labio
mental crease) that separates the lip from the chin.9 The upper
and lower lips differ in that the lower lip is composed of a
single aesthetic unit while the upper lip has multiple subunits.
According to Burget and Menick’s description,10 each side of
Access video lecture content for this chapter online at expertconsult.com
306.e1
Historical perspective
Historical perspective
In 600BC, Sushruta, an Indian surgeon, published the first
written description of lip reconstruction.2 Not much has been
recorded for the next 2000 years until 1597, when Gaspare
Tagliacozzi reported the use of pedicle flaps from the arm for
reconstruction of upper lip defects. Most of the reconstructive
techniques in present use are modifications or refinements of
techniques that were described in the medical literature over
the past two centuries. In 1857, Victor von Bruns described
the use of bilateral superiorly based nasolabial flaps for
reconstruction of the lower lip.3 These full-thickness flaps,
however, led to denervation, not only of the remaining lower
lip, but of the upper lip as well. Von Bruns actually refined
his technique and ultimately described a technique almost
exactly similar to that described by Karapandzic.4 This tech
nique eliminated full-thickness extension of the flap through
the labial mucosa, emphasizing preservation of sensory and
motor nerve fibers. The Gillies fan flap is a refinement of
another approach advocated by von Bruns that employed two
quadrilateral, inferiorly-based nasolabial flaps.3,5 The first
hair-bearing flap based on the superficial temporal artery to
reconstruct the upper lip was reported by JFS Esser in 1934.6
Microsurgical reconstruction of the upper lip was introduced
by Walton and Bunkis in 1983,7 and microsurgical reconstruc
tion of the lower lip was introduced by Sakai in 1989.8 Under
standing the rationale of these techniques is important because
refinements of these various techniques continue to appear in
the literature.
307
Anatomic and functional considerations in lip reconstruction
superioris also contribute to this function. The depressor
muscles include the depressor anguli oris and the platysma,
with minor contributions from the depressor labii inferioris.
Variations in the contraction of all of these muscles result in
the versatility of movement of this region and the myriad of
shapes and expressions that contribute not only to facial
aesthetics and animation but also to function. The modiolus
is just lateral to the oral commissure. It is a 1 cm-thick fibro
vascular region of muscle fiber intersection of the levator
muscles and the depressor muscles that attach firmly to the
dermis approximately 1.5 cm lateral to the oral commissure.
The modiolus can be located by compressing the skin and
mucosa of the commissure using bidigital palpation with the
thumb and index finger.13 The appearance of the labial com
missures is significantly affected by movement of the modiolus
on each side, which results from the summation of opposing
contractile forces of the levator muscles (zygomaticus major
and levator anguli oris) and the depressor muscles (depressor
anguli oris and platysma).14,15 Sometimes there is a dimple
here. When present, the dimple results from a dermal inser
tion arising from the inferior muscle bundle of a bifid zygo
maticus major muscle.16,17 The elevators and depressors of the
lips are innervated by the buccal and mandibular branches of
the facial nerve, respectively. Disruption of the musculature
that attaches to the modiolar region (or their neural supply)
can alter the appearance of the labial commissure at rest and
during function secondary to imbalanced muscular contrac
tion. This gives a very abnormal appearance to the mouth and
is one of the greatest complaints of patients with facial paraly
sis. Modiolar motion can be analyzed to measure the success
of facial reanimation in these.18
The blood supply to the lips comes from the facial arteries,
which give rise to the inferior and superior labial arteries. The
variability of these vessels, both in terms of course as well as
of presence, has been shown by anatomic studies and dissec
tions. The superior labial arteries from each side generally
anastomose in the midportion of the upper lip, coursing
between the mucosa and orbicularis muscle in some patients
and through the muscle in the others.19 The inferior labial
artery, on the other hand, routinely courses between the
mucosa of the inner aspect of the lip and the muscle.19 Two
separate cadaveric studies found that the inferior labial artery
was absent on one side in 10% and 64%, respectively, of the
cadavers evaluated.19,20 The bilateral presence of inferior labial
arteries was not always predictive of an end-to-end anasto
mosis between these vessels, and other arterial branches from
the facial arteries were frequently identified (e.g., labiomental,
sublabial arteries).19,20 Even though the variable arterial distri
bution of this region could, at least in theory, affect the survival
of reconstructive procedures involving the lip, local flap
reconstruction has been performed for centuries with predict
ably excellent survival rates. Although the lips are an impor
tant aesthetic feature of the lower face, they also play an
important role in facial expression. Oral competence is neces
sary for eating and drinking, and intact neuromuscular func
tion is essential for speech articulation and other functions
such as whistling and sucking. The lower lip functions as a
dam that retains saliva and prevents drooling. The upper lip
contributes to oral competence by providing opposition to the
lower lip to effect closure.21 Sensation allows the lips to
monitor the texture and temperature of substances prior to
oral intake.
the upper lip has two aesthetic subunits: the medial topo
graphic subunit is one-half the philtrum, whereas the lateral
subunit is bordered by the philtrum medially, the nostril sill
and alar base superiorly, and the nasolabial fold laterally.
Another way to think about the upper lip is that it is composed
of three subunits: the philtrum centrally and the lateral lip
elements on either side of the philtrum (Fig. 12.1).11 As we age,
multiple rhytids develop on the lips which theoretically and
practically divide the lips into many more subunits.
The thickness of the lip largely results from the underlying
orbicularis oris muscle, which forms a functional sphincteric
ring and is essentially sandwiched between the skin on the
outside, and the mucosa on the inside. The orbicularis oris has
two functions that, at first, might seem diametrically opposed
but that, on reflection, make sense. The superficial fibers of
this muscle function to protrude the lips away from the facial
plane, whereas the deep and oblique fibers approximate the
lips to the alveolar arch.12 The middle portion of the buccina
tor muscle extends anteriorly to the corner of the mouth and
decussates so that the upper fibers of the mid-buccinator
merge with the orbicularis fibers of the lower lip, and the
lower fibers merge with the orbicularis fibers of the upper
lip.12 Several muscles elevate the lip. The two most important
elevator muscles are the zygomaticus major and the levator
anguli oris; the zygomaticus minor and the levator labii
Fig. 12.1 The aesthetic landmarks of the lips are seen. The curve of the upper lip
resembles a bow, known as Cupid’s bow. The central concavity of the upper lip is
the philtrum, bounded on either side by the convex philtral columns. The lateral
elements of the upper lip are bounded by the philtral ridge medially, the nasal
vestibule and alar base superiorly, and the nasolabial fold laterally. The mental
crease separates the lower lip from the aesthetic unit of the chin.
308
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CHAPTER 12 • Lip reconstruction
repairing or reconstructing the lips that have significant tissue
loss is resulting microstomia. While patients can function
reasonably well with a small degree of microstomia, it is very
important to minimize it, as it may not only interfere with
function but can also hamper oral hygiene and patients should
be counseled prior to surgery that denture insertion and
removal may be difficult or, quite simply, not possible.
Decreases in the shape or depth of the labial vestibule can
exacerbate oral incompetence and drooling and may preclude
patients from wearing a removable prosthesis. Preservation
of labial sensation is vitally important to maximize oral com
petence and to fulfill its other sensory roles.
Because of the anatomic configuration of the upper lip and,
specifically, because of its aesthetic subunit structure, recon
struction of the upper lip presents certain aesthetic challenges
that are not of concern during lower lip reconstruction. Loss
of the philtral ridges and Cupid’s bow creates a noticeable
cosmetic deformity that presents a significant reconstructive
challenge especially in woman and children. In profile, the
upper lip should protrude in front of the lower lip, so a
reconstruction that results in excisional tightness with reduc
tion or elimination of this relationship is not only undesirable,
but also will certainly result in an inferior aesthetic outcome.
In contrast, the lower lip is better able to withstand tissue loss
without significant changes in its profile appearance and can
sustain a loss of one-third of its breadth before tightness or
asymmetry begins to show.
Early lip reconstruction techniques focused primarily on
primary closure of the surgical defect, whereas more contem
porary techniques attempt to address the importance of an
aesthetic, functional result. Reconstruction of the aesthetic
subunits as described by Burget and Menick10 is helpful, and
aesthetic features such as Cupid’s bow and the philtral
columns must be carefully restored. Failure to restore these
landmarks results in an abnormal appearance that is instantly
detectable. One of the features that is readily picked up by the
human eye is asymmetry. Surgery that results in asymmetry
is typically more noticeable than symmetric alterations. As an
example, rounding of both commissures is less obvious than
rounding of one side. Whenever possible, the height, projec
tion, and relationship between upper and lower lips should
also be preserved or replicated. This is most easily achieved
by using tissue from the adjacent or opposing lip.24,25
Patient selection is, arguably, less important than recon
structive choice. In the case of trauma, the damage is already
done and the surgeon’s task is to repair and reconstruct the
lip so that it is as functional and aesthetically pleasing as
possible. For patients facing lip resection for disease, the task
is no different, i.e., the surgeon must reconstruct the lip to be
as functional and aesthetically pleasing as possible. However,
in the latter case, the surgeon has the luxury of planning what
reconstruction will best suit the patient. The choice depends
on multiple factors, such as prognosis, general medical condi
tion, availability of local tissue, history of prior radiation
as well as co-morbidities. The lips are somewhat unique,
however, in that the need to reconstruct the lips is very dif
ferent from, as an example, the need to reconstruct a breast.
Oral competence is vital for normal eating, articulation, and
communication, so the option not to reconstruct the lip is
really nonexistent. The algorithm presented later in this
chapter (see Fig. 12.17, below) can be used as a guide in
selecting the most appropriate procedure for a given defect.
Lip function
As the principal aesthetic feature of the lower face, an impor
tant function of the lips is to facilitate human interaction. This
requires the lips to appear normal in repose and animation.
In addition to the function of “looking normal”, lips facilitate
articulating certain sounds; maintenance of oral competence
during eating, drinking, sucking, and speaking; as well as the
expression of emotions with the ability to smile and kiss. In
concert with motion of the mandible, they allow access to the
mouth not only for food but also for oral and dental hygiene
as well as insertion and removal of dentures. Its mucosal
lining keeps its inner surface moist and serves incredibly
complex immune functions as a “barrier organ” with the
ability to distinguish between commensal and pathogenic
microorganisms. Sensation allows the lips to monitor the
texture and temperature of substances prior to oral intake.
Patient selection and presentation
Goals of lip reconstruction
The goals of lip reconstruction (Box 12.1) are several. The most
important of these is function. No matter how good a recon
structed lip looks, if it cannot maintain oral competence, the
reconstruction is a failure. Maintenance of oral competence is
vital. Similarly important is maintenance of an adequate oral
aperture to facilitate oral hygiene and/or to accommodate
removable dentures. The labial vestibule is an important
feature of labial anatomy, and its preservation or re-creation
is important for oral hygiene, dental care, and denture fitting.
In order to achieve these functions, preservation of labial
sensation is important, and because of the vital role of the lips
in facial aesthetics, maximization of cosmesis is one of the key
goals of reconstruction.22
In situations where the orbicularis oris muscle has been
disrupted, it is vitally important to restore continuity of that
muscle if at all possible. Careful re-approximation of muscle
edges with intact motor innervation usually results in com
plete restoration of dynamic orbicularis function. Although
some authors contend that the upper lip functions primarily
as a curtain that could be replaced with a static flap recon
struction, there is no doubt that a completely intact sphincter
with active function and sensation yields the best functional
result.10,23 In cases where reconstruction of a complete circum
oral muscular sphincter is not feasible, bridging the gap
between the ends of the muscle with an adynamic segment of
tendon or fascia, that provides some degree of oral compe
tence, should be pursued. One of the main dangers in
BOX 12.1 Goals of lip reconstruction
• Preservation of function.
• Reconstitution of orbicularis oris.
• Three-layered closure.
• Accurate alignment of vermilion.
• Maintenance of relationship between upper and lower lips.
• Optimization of aesthetics in repose and with animation.
309
Operative technique
Fig. 12.2 Breaking up the linear scar by introducing a vertical element to an excision will allow for more precise closure as the vermilion borders can be accurately
approximated (marked with dots). Furthermore, the resulting scar will not be linear and will therefore be less likely to contract.
Operative technique
Defect-specific reconstruction of the lip
Following injury to the lips or following surgical resection for
disease, there are several options for reconstruction of the
lips:12,26 The first choice, of course, is to use the remaining lip
segment, and if the defect size allows, this is by far the best
option. This choice assumes that there is enough lip to effect
the repair while not creating distortion or microstomia.
Another consideration is whether or not the defect is full
thickness and whether all three elements, skin, muscle, and
mucosa, need to be replaced. Regardless of what the defect is,
local tissue is the best option because it replaces what has been
lost and is the perfect match in terms of color, thickness and
composition. Although defects of the upper lip of less than
25% can be closed by direct approximation, it should be noted
that direct closure of defects greater than 10% of the upper lip
will generally lead to distortion of the philtral column espe
cially in younger patients. For the lower lip, a slightly larger
defect, up to 30%, can be closed directly. Once again, care
must be taken to ensure accurate closure of all layers. Repair
of the orbicularis oris and reconstitution of the circumoral
sphincter is the most important aspect of a functional repair.
For through-and-through defects, if there is insufficient lip
to effect a direct closure, the next choice becomes flaps from
adjacent lip components or the opposite lip. Several lip-switch
options are discussed below and fulfill the requirement of
providing tissue of like composition and appearance. Some
times, however, there simply is not enough lip tissue to
achieve this, in which case it may become necessary to use
tissue from the adjacent cheek, nasolabial region, or neck. A
very useful source of tissue that can be used to reconstruct the
lip, particularly when a through-and-through reconstruction
is not required, is to use tissue from the submental region. For
extreme defects, however, there is no other option but to use
regional, distant or free flaps.
Defects of the vermilion
There are a few important points of which to be cognizant
when repairing a lip. One is the appreciation of the fact that
the human eye can detect asymmetry remarkably accurately.
The lips are very symmetrical, and the different elements of
the lip blend with each other in a very pleasing and aesthetic
way. The junction between vermilion and white lip, for
example, is smooth and seamless. When the line of the ver
milion is broken or when a segment of vermilion impinges on
the white lip, the abnormality is immediately obvious. When
dealing with lacerations, there is not a lot, in terms of repair
options, that the surgeon can do. However, being precise in
repair of the vermilion border and white lip roll will produce
a scar that is imperceptible. When resecting a lesion that
crossed the vermilion, however, there are some options. As
surgeons, we know that scars contract and a straight-line scar
that crosses the vermilion will not only contract but may
possibly produce a visible deformity. In order to avoid this,
breaking up the scar by incorporating a step in the excision
may prevent this contraction, make the repair easier and
minimize the risk of a visible scar (Fig. 12.2).
Loss or lack of vermilion may be due to injury, denervation,
scar, or resection. Vermilionectomy is a procedure that is done
to remove very superficial lesions in the vermilion, such as
superficial squamous cell carcinoma, or to remove dysplastic
tissue with malignant potential such as actinic cheilitis. Fol
lowing vermilionectomy, a procedure that is also known as a
lip-shave, reconstruction is achieved by advancing the buccal
mucosa to cover the defect and to re-establish the mucocuta
neous junction (Fig. 12.3).1 If there is any degree of tightness,
back-cuts are made to facilitate further advancement of the
mucosa. This type of vermilion reconstruction can sometimes
result in excessive thinning of the lip from mucosal retraction
or scar contraction, and decreased mucosal sensation.9,27
However, in general, the results of lip-shave are excellent.
Other approaches to reconstruction of the vermilion include
the mucosal V–Y advancement flap, the cross-lip mucosal
flap, and transposition flaps harvested from the buccal mucosa
or the ventral surface of the tongue.9,28 Buccal mucosal flaps
tend to be more erythematous than natural vermilion, result
ing in a color mismatch with the remaining vermilion.27
Mucosal tongue flaps require a second procedure 14–21 days
later to release and inset the flap. A musculomucosal flap that
includes buccal mucosa and buccinator muscle anteriorly
pedicled on buccal branches of the facial artery and innervated
sensory branches of the infraorbital nerve has been advocated
as one option to remedy the loss of sensation in defects that
also include loss of orbicularis muscle.29 A modified Estlander
310
SECTION II
CHAPTER 12 • Lip reconstruction
above the mental crease (in situations where the mental crease
is violated) helps minimize subsequent contracture and pre
serves the natural curve of the lip and chin. If actinic cheilitis
of the adjacent lip is present, vermilionectomy can also be
performed in combination with the wedge excision, using a
labial mucosal advancement flap to recreate the vermilion
border (Fig. 12.7). This technique provides an elegant recon
struction of the vermilion, and the cosmetic outcome of this
procedure is usually excellent. The aesthetic result following
repair of a V-type excision is often less satisfactory in the
myomucosal flap transferring vermilion and underlying
innervated orbicularis muscle to a denervated atrophic lower
lip can be helpful to regain oral competence (Fig. 12.4).
Small defects
Primary closure of defects that involve as much as one-quarter
of the upper lip or one-third of the lower lip can be achieved
(Box 12.2).21 A V-shaped wedge design usually permits closure
of smaller defects, whereas a W-plasty placed at the base of
the V facilitates the closure of larger defects of the lower lip.
Furthermore, this modification will generally allow for the
scar to be kept above the mental crease. This is particularly
important in non-midline excisions. It improves the cosmetic
appearance of the repair, as it preserves the integrity of the
chin aesthetic subunit (Fig. 12.5). Wedge-shaped defects of the
lateral lip should be more obliquely oriented so that the line
of closure parallels the relaxed skin tension lines. If a W-plasty
is incorporated into a lateral lip defect, the angle formed by
the lateral V-shaped subunit of the W should be larger and
more obliquely oriented than the medial subunit to properly
align the closure.9,22 Alternatively, rather than using a V or W,
resection shape can be dictated by the direction of skin rhytids
and relaxed skin tension lines (Fig. 12.6). Careful attention to
meticulous approximation of the vermilion border and closure
of all three layers will ensure optimal cosmesis and function.
Placing a micro-Z-plasty just below the white roll and just
Fig. 12.3 (A) An area of vermilion is marked for excision. (B) The vermilion has been excised and a mucosal flap raised from the buccal mucosa. (C) The mucosal flap
has been advanced and sutured to the white lip to recreate the mucocutaneous junction. (D) Postoperative appearance showing good restoration of vermilion.
A
B
C
D
BOX 12.2 Wedge resection of the lip: technical tips
• Up to 25% of the upper lip can be resected and repaired
directly.
• Up to 10% in younger patients without distortion
• Up to 30% of the lower lip can be resected and repaired
directly.
• Careful approximation of the muscle layer ensures a functional
repair.
• Micro Z-plasties at concavities preserves the gentle curves of
lips.
• Consider a W resection for larger wedges in order to keep the
scar above the mental crease.
311
Operative technique
Fig. 12.4 (A,B) 74-year-old female with oral incompetence from denervated orbicularis oris muscle on right side of lower lip. She has a history of buccal mucosal
cancer, osteoradionecrosis, and multiple reconstructive procedures including radial forearm free flap to right buccal mucosa and fibular osteocutaneous free flap for
osteoradionecrosis. Note excess skin of right side of upper lip from previous tightening procedure of lower lip. (C) A modified Estlander myomucosal flap elevated
with suture attached and defect created in lower lip. (D) Flap being transferred. (E) Correction of drooling and deformity in repose, although commissure is blunted.
(F) Although drooling corrected, mild microstomia created.
A
B
C
D
E
F
312
SECTION II
CHAPTER 12 • Lip reconstruction
Fig. 12.5 Patient with a squamous cell carcinoma of the lower lip. A wedge
excision has been planned and the patient is marked for a “W” excision in order to
keep the scar above the mental crease and out of the aesthetic subunit of the chin.
Fig. 12.6 (A) Markings for excision of basal cell carcinoma of lower lip in a 71-year-old male. Vermilion border, skin lines and rhytids marked on skin. (B) Defect after
excision with negative margins on frozen section. (C) Free-style closure dictated by skin lines and rhytids, note precise alignment of vermilion and micro Z-plasty just below
vermilion border. (D) Result 14 years postoperatively.
A
B
C
D
upper lip, because the upper lip is able to withstand much
less tissue loss before distortion of the philtral column or
tightness becomes clinically apparent. The normal overhang
of upper and lower lip is lost as a consequence of closure-
induced tension. In addition, the anchorage of soft tissues
around the pyriform aperture to the underlying bony skeleton
limits compensatory movement of the remaining lip. This
problem can be minimized by using a T excision, which facili
tates advancement of the lateral lip elements towards the
midline. The symmetry of Cupid’s bow is easily lost with
even minor excision in the region of the philtrum. Webster’s30
technique of crescentic perialar cheek excision is an extension
of the T-excision technique that increases upper lip movement
without disturbing the lateral muscle function (Fig. 12.8).
Webster frequently supplements the perialar excisions with
the addition of an Abbé flap lest there be too much tension30
(Fig. 12.9). If the defect is created lateral to the philtral columns,
313
Operative technique
Fig. 12.7 (A) Patient with a small squamous cell carcinoma of the lip requiring
wedge resection. The patient also has significant actinic cheilitis requiring a
lip-shave. (B) Resection has begun and includes a central wedge of the lower lip in
continuity with the vermilion. (C) Mucosal flaps have been elevated. (D) The surgical
defect is seen. (E) The left mucosal flap is advanced. (F) Both mucosal flaps have
been advanced, the wedge closed and the mucocutaneous junction re-established.
(G) Postoperative appearance.
A
B
C
D
E
F
G
primary closure will frequently produce a deformity of the
philtral column and lip tightness. This can be minimized by
reconstructing the lateral lip subunit with a crescent-shaped
lateral lip VY flap, removing the tension from the medial lip
and planning all scars at the border of the aesthetic subunit
or parallel to natural rhytids (Fig. 12.10). Alternatively, it is
occasionally preferable to use a lip-switch flap from the lower
lip, even when the defect makes up less than 25% of the lip’s
width. This is particularly the case with central (philtral)
defects or in younger patients whose tissues are less lax and
where cosmesis is often of even greater importance.
Intermediate defects
For all the reasons already described, local flaps are the best
option for reconstructing larger defects involving up to
314
SECTION II
CHAPTER 12 • Lip reconstruction
Fig. 12.8 (A) Resection of a central segment of the upper lip is shown. A “T” excision is performed with a Webster crescentic perialar excision allowing for advancement
of the lip elements. (B) A schematic of the closure is shown.
A
B
Fig. 12.9 Schematic of Webster’s crescentic perialar excisions supplemented with an Abbé flap.
A
B
two-thirds the width of either upper or lower lip. These flaps
involve either a lip-switching maneuver, rotation of tissue
from one lip to another, or recruitment and advancement of
adjacent tissue, such as cheek tissue, to achieve the reconstruc
tion. Lip-switch (cross-lip) flaps are axial flaps based on the
labial arteries (Box 12.3). They replace tissue like with like,
having the capability of replacing the trilaminar defect in one
lip with trilaminar tissue from the other. The classic Abbé flap
can reconstruct medial or lateral lip defects with a full-
thickness composite flap that reconstructs all three layers
and restores continuity of the vermilion.31 The Abbé cross-lip
flap can also be used to replace any one of the trilaminar
315
Operative technique
Fig. 12.10 (A) 72-year-old female with basal cell carcinoma of upper lip. (B) Margins and landmarks marked. (C) Defect. (D) Crescent VY flap closure with incisions
along or parallel to aesthetic unit borders. (E,F) 5 month follow-up with no distortion of philtral column.
A
B
C
D
E
F
316
SECTION II
CHAPTER 12 • Lip reconstruction
and cosmetic result. However, in this case, since the flap is
rotated, no pedicle division is necessary. One disadvantage is
the blunting of the commissure that is seen. However, this
rarely requires any correction (Fig. 12.14). Several modifica
tions of cross-lip flaps have also been described.
There are, however, several limitations to the cross-lip
flaps. Even though the orbicularis muscle is reconstructed and
continuity of the circumoral sphincter is re-established, dis
ruption of the motor supply leads to varying degrees of
abnormal lip motility. Where small flaps have been utilized,
this may be barely if at all appreciable. However, where larger
reconstructions have been performed, the change in motility
may be more obvious. A trap-door deformity or pin-cushioning
occasionally develops at the recipient site, and the cross-lip
flap tends to appear thicker than the adjacent lip.9,10,27,31,32 It
also should be noted that cross-lip flaps in men will have the
hair growing in the wrong direction, generally precluding one
from sporting a mustache. The fan flap, initially described by
Gillies and Millard5 in 1957, is a modification of a technique
described by von Bruns that utilizes quadrilateral inferiorly
based nasolabial flaps.3 This flap rotates tissue around the
commissure in the same fashion as an Estlander flap, but more
tissue from the nasolabial region is included.12 A vertical
releasing incision is made in the donor lip.9 A unilateral flap
can be performed to reconstruct a lip defect, but bilateral fan
flaps are more frequently employed to reconstruct total or
sub-total defects (Fig. 12.15).12 Although defects involving up
to 80% of the lip can be reconstructed with the Gillies fan flap,
the biggest and least desirable sequel is significant microsto
mia as well as deficiency of the vermilion. Furthermore,
denervation of the orbicularis oris can lead to oral incompe
tence. However, at least partial re-innervation seems to
occur over a period of 12–18 months.9,12,33 The circumoral
advancement-rotation flap initially described by von Bruns in
1857 utilized full-thickness flaps that resulted in extensive
denervation of the orbicularis muscle.3 Although this tech
nique effectively closed large composite defects of the lower
lip, reconstruction was accomplished at the expense of sensa
tion, motor function, and oral competence. These full-thickness
flaps fell into disrepute until 1974, when Karapandzic4 pub
lished a modification of von Bruns’ technique. The incisional
design of the Karapandzic flap, as it is now known, was
identical to those advocated by von Bruns, but full-thickness
flaps were not created, and the neurovascular supply to the
lip was preserved via meticulous dissection (Fig. 12.16).
Although most authors report its use for the closure of lip
defects that involve up to two-thirds of the lip, others state
that the Karapandzic flap can successfully replace 80% of the
total lip length.1,9,12,25 However, reconstructing such a large
defect with this technique can result in significant microsto
mia. This flap may be used to reconstruct defects of the upper
or lower lip in the following manner: curvilinear circumoral
incisions are extended bilaterally from the base of the defect,
placing the incisions within the mental crease and the nasola
bial creases. The incisions are designed to maintain a uniform
thickness of the flap bilaterally. Because the nasolabial crease
closely approximates the commissure, the incision should be
placed slightly lateral to the nasolabial crease in this region,
to maintain uniform thickness of the flap. If the defect is
eccentrically located, the flap should be designed so that the
contralateral lower lip is the longer limb of the flap. Careful
dissection of the peripheral muscle fibers and concentric
components of the lip and does not necessarily need to contain
all layers throughout the flap. Ideally, the exact size of the
defect should be reconstructed with an exact template of the
missing aesthetic subunit. Adhering to the aesthetic subunit
principle, Burget and Menick10 suggested that defects consti
tuting more than half of a topographic subunit of the upper
lip necessitate removal of the remaining portions of the
subunit so that reconstruction of the entire subunit can be
performed by using an exact foil template of the defect to
design the Abbé flap in the lower lip. For central defects, the
lateral segments should be advanced medially so the defect
remaining is the normal size of the philtrum. Reconstructing
this aesthetic subunit with an exact template generally pro
vides a more favorable aesthetic result (Fig. 12.11).
Although it is ideal to replace an exact template of what is
missing, frequently the donor lip cannot “give up” all that is
needed. Surgical technique is important, and there are a few
technical principles that are important to follow to achieve
optimal results. The first is that the width of the flap does not
always need to be as big as the width of the defect. This
technical trick allows for repair of the defect by taking advan
tage of the inherent elasticity of the lip tissues while, at the
same time, reducing the amount of tissue that has to be sac
rificed from the donor lip, thereby making closure of the
secondary defect easier. So both lips end up a little smaller,
but by taking some tissue from both lips, a better balance
between the two lips is maintained. The second principle is
that the height of the flap needs to match that of the defect.
While one can get away with less width, less height will result
in some element of notching and will produce a significantly
inferior result. Finally, the position of the flap relative to the
opposite lip is an important technical point to appreciate. This
refers particularly to the Abbé flap and is important because
the position of the flap determines the position of the pedicle.
This is very important to appreciate. When the entire subunit
is not being reconstructed, the pedicle should be placed
roughly at the mid-position of the defect. The reason for this
is that the flap will be half the width of the defect so that when
the secondary defect is closed, the pedicle ends up being in
precise alignment with one end of the defect. This is best
explained in Fig. 12.12. Pedicle division is performed 14–21
days later as shown in Fig. 12.13.
The Estlander flap is, in reality, an Abbé flap that is brought
around the commissure.32 Once again, the width of the flap is
usually one-half the width of the defect and is the same height
as the defect. Using this technique, defects that involve the
commissure and as much as 50% of the lower or upper lip can
be adequately reconstructed with an acceptable functional
BOX 12.3 Lip-switch flaps: technical tips
• Subunit reconstruction demands that flap size should exactly
replicate subunit size and shape.
• In non-subunit reconstruction, width of the flap should be half
the width of the defect.
• Height of the flap should be the same as height of the defect.
• Pedicle of Abbé flap should be placed at the edge of defect for
subunit reconstruction and at the midpoint of the defect for
non-subunit reconstruction.
• Pedicle division at 14–21 days.
317
Operative technique
Fig. 12.11 (A) 35-year-old female with recurrent basal cell carcinoma of upper lip. Note skin graft from previous reconstruction. (B) Skin markings of tumor, scars, and
landmarks with methylene blue tattoo of vermilion border. (C) Full-thickness excision of tumor. (D) Residual skin graft removed and crescentic perialar excisions performed
to narrow the defect to approximate a normal philtrum. Note exact size of Abbé flap planned to fill residual defect. (E) Abbé flap transferred. Note micro Z-plasties of lower
lip below white role and above labial mental angle. (F) Final result.
A
B
C
D
E
F
318
SECTION II
CHAPTER 12 • Lip reconstruction
undermining allows advancement without any dissection of
the mucosa. Preservation of the neurovascular bundles is
imperative. A unilateral flap is adequate for smaller defects,
whereas defects that constitute more than 50% of the lip
require bilateral flaps. Function is restored because only the
peripheral rim of orbicularis oris muscle is incised and the
buccinator muscle is preserved. The Karapandzic flap results
in blunting or rounding of both commissures, which is usually
less noticeable than alteration of only one commissure. Some
degree of microstomia is also inevitable, which may preclude
the use of dentures. Because the combined width of the upper
and lower lips is approximately 15 cm, reconstruction of a
5 cm defect results in a rounded oral aperture with a circum
ference that is two-thirds of the original.9,12,21,22 However,
because of the superior and predictable functional results that
can be achieved with acceptable aesthetics, the Karapandzic
flap is possibly the flap of choice for most larger intermediate
full-thickness defects.
Frequently, a defect is too wide to close directly but is not
wide enough to require a flap such as the Estlander or Abbé
flap. Johanson et al.34,35 proposed the stair-step advancement
flap for such a defect. Though ideally suited for smaller
defects, this technique is capable of reconstructing defects
extending to as much as two-thirds of the lower lip (Fig.
12.17).35 This technique involves the excision of 2–4 small
rectangles arranged in a stair-step fashion that descend from
medial to lateral at a 45° angle from either side of the base of
Fig. 12.12 Schematic of an Abbé flap from the lower lip to the upper. Note that
the width of the Abbé flap is half the width of the defect, while the height of the flap
is the same as the height of the defect. The pedicle will be planned at a point
opposite the midportion of the defect and will end up at the medial end of the
defect following rotation of the flap.
Fig. 12.13 (A) Patient with a squamous cell carcinoma of the left side of the upper lip. (B) The resection and the
Abbé flap are marked. (C) The resection has been completed and the Abbé flap is being rotated from the lower lip.
(D) Inset is complete and the pedicle remains attached, effectively securing the lower to the upper lip. (E) Patient
was seen 3 weeks later at the time of pedicle division. The flap appears viable. (F) Postoperative appearance.
A
B
C
D
E
F
319
Operative technique
Fig. 12.14 (A) Schematic of Estlander flap designed to reconstruct a defect of the
lower lip. (B) Patient with squamous cell carcinoma of the lower lip. (C) The lesion
has been excised and the flap designed. Note the dimensions of the flap. The width
is half that of the defect but the height is the same as the height of the defect. (D)
The flap is being rotated into the defect. (E) Final inset of the flap and closure of the
donor defect. (F) Final appearance. Note the slight blunting of the commissure.
A
B
C
D
E
F
320
SECTION II
CHAPTER 12 • Lip reconstruction
Fig. 12.15 A schematic of the Gillies fan flap is shown. Note the releasing incisions on the upper lip that allow the flap to rotate and advance.
A
B
Fig. 12.16 (A) Patient with a squamous cell carcinoma of the lower lip. Note the scar from a previous wedge resection. (B) The resection has been completed and the
markings made for a Karapandzic flap. (C) The flaps are rotated and advanced. Note that this is not a through-and-through dissection so that the motor and sensory nerves
can be preserved. (D) Postoperative appearance showing good cosmesis and function.
A
B
C
D
321
Operative technique
chin can be preserved (Fig. 12.17). For this reason, the step
technique is better than a wedge resection of similar size that
would encroach on the chin subunit. The stair-step design
allows for closure of the defect and minimizes contracture.
Large defects
Defects that involve up to 80% of the total lip length may be
reconstructed with bilateral Gillies fan flaps or the Karapan
dzic flap, as described above.12 Reconstruction of total or
near-total defects constituting more than 80% of the lip typi
cally leads to a poor aesthetic outcome and compromised
oral competence. Because of denervation, the lip is largely
adynamic. Dieffenbach (1845),37 Bernard (1853), von Burow
(1855) and von Bruns (1857)3,12 all described techniques of
the defect. When the defect is located laterally, the step inci
sion is outlined exclusively on the remaining long side of the
lip.36 If the defect is located near the midline or its horizontal
length exceeds 20 mm, the staircase pattern is marked on both
sides of the lower lip. The first horizontal incision is made
parallel to the vermilion border and is approximately half of
the width of the resected region. Usually 2–4 additional steps
are necessary in the vertical direction; the width of each step
is approximately one-half of its height. Finally, a triangle is
excised with its apex located inferiorly. Each of the rectangles
and the triangle are excised through the full thickness of the
lower lip. This allows advancement of the flap in the direction
of the defect with each succeeding higher step in the staircase,
and the wound is closed in layers. By placing the step inci
sions outside of the mental crease, the aesthetic unit of the
Fig. 12.17 (A) Schematic of a step flap reconstruction. Note that the steps are excised to allow the flaps to advance. Note also that the scar remains above the mental
crease. (B) Patient following resection of a squamous cell carcinoma of the lower lip. Markings have been made for a unilateral step resection. (C) Postoperative
appearance.
A
Step removed
Width is half
the height
B
C
322
SECTION II
CHAPTER 12 • Lip reconstruction
the lower lip, modifications of the gate flap have also been
proposed for total upper lip reconstruction.40 Reconstruction
with any of these nasolabial flap designs is associated with
suboptimal oral competence and aesthetics, and denervation
of the flaps is inevitable. In an effort to address the limita
tions of local flaps for large lip defects, some surgeons have
employed the use of multiple local flaps. Kroll41 advocated
reconstructing large lower lip defects by re-establishing the
oral sphincter with an extended Karapandzic flap, followed
by two sequential Abbé flaps 3 weeks apart to augment the
central lower lip and a commissure plasty to widen the oral
aperture. The Abbé flaps were harvested from a philtral
ridge so that the scar was relatively inconspicuous and any
notching of the upper vermilion from scar contraction could
be disguised as a peak in the Cupid’s bow. Using this tech
nique, Kroll noted that the transfer of redundant upper lip
tissue improved the appearance and volume of the lower lip,
particularly near the midline. In contrast, Williams and col
leagues24,25 reconstructed these defects by simultaneously
performing a modified Bernard–Burow cheek advancement
flap in combination with a medially based (Abbé) cross-lip
flap. In contrast to Kroll’s technique, they purport that less
microstomia develops, and the orientation of the modiolus is
not disturbed. Kroll’s technique was described for lower lip
defects, whereas Williams et al.’s approach can be used for
upper and lower defects.
cheek advancement from which the current reconstructive
methods that employ horizontal cheek advancement flaps
have evolved. Bernard and von Burow described the trans
position of full-thickness flaps to reconstruct the upper or
lower lip, reconstructing the vermilion with a mucosal
advancement flap.12 Transposition of these cutaneous flaps
required the excision of four triangular regions of redundant
cheek skin to reconstruct the upper lip and the excision of
three cutaneous triangles to reconstruct the lower lip. The
reconstructive technique has become known as the “Bernard
cheiloplasty” or the Bernard–Burow cheek advancement, and
the triangular soft tissue excisions are referred to as “Burow’s
triangles”.9,30,38 Webster27 suggested modifications of this
technique that align the scars with the relaxed skin tension
lines of the face. Although microstomia can be avoided with
this approach, there is no functional orbicularis. Conse
quently, oral competence relies on the development of a tight
adynamic lower lip. Prior to free tissue transfer, nasolabial
flaps played a prominent role in total lip reconstruction. Dief
fenbach37 initially described the use of nasolabial flaps for
upper lip reconstruction. The rectangular-shaped nasolabial
flaps that von Bruns described in 1857 for lower lip defects
were inferiorly-based.3 The “gate flap” design, originally
published by Fujimori39 in 1980, rotates two nasolabial island
flaps through 90°. These flaps are based on the angular artery
(Fig. 12.18). Although Fujimori’s technique was fashioned for
Fig. 12.18 (A) Patient with a large
squamous cell carcinoma of the lower lip
requiring total resection. (B) The resection
is complete and bilateral Fujimori gate flaps
have been designed. (C) The flaps are
rotated into the defect and the secondary
defects closed. (D) Postoperative
appearance showing significant deformity of
the lower face.
A
B
C
D
323
Operative technique
As we push these concepts to larger and larger defects, one
must balance the advantages of having like tissue and com
petent lips with the disadvantages of adding a significant
amount of additional scarring to the face, distortion seen with
animation and the relative microstomia produced. These
concerns have moved most surgeons to consider distant or
free tissue transfers for defects approaching and greater than
80% of the lip.
The radial forearm flap is the free tissue transfer technique
that is most frequently employed for the reconstruction of
total lower lip defects. Sakai et al.8 in 1989 reported the recon
struction of a lower lip defect with a composite radial
forearm–palmaris longus tendon free flap. The forearm flap
is folded over the tendon sling to resurface the internal and
external surfaces of the lip and cheek. A microneural anasto
mosis between the lateral antebrachial cutaneous nerve and
the cut end of the mental nerve can be performed to achieve
sensory reinnervation.42,43 A ventral tongue flap may be used
to recreate the vermilion border, although a second procedure
is necessary. Following flap reconstruction, medical tattooing
can also be used to create the vermilion with acceptable cos
metic results.44,45
Oral competence and aesthetics are optimized for lower lip
reconstruction by placing the palmaris longus tendon under
the appropriate degree of tension. Lip entropion can develop
if the palmaris longus tendon is inset too tightly (bow-strung),
and ectropion may develop if inadequate tension is placed on
the tendon. Sakai et al.8 sutured the palmaris tendon to the
orbicularis oris muscle and dermis in the nasolabial region to
suspend the reconstruction. Other surgeons have reported
good outcomes by suturing the tendon to the periosteum of
the malar eminence or to the orbicularis muscle of the upper
lip near the philtral columns.42,46 Our personal preference is to
weave the palmaris sling through the remaining orbicularis
muscle and then through itself47 or to mobilized lateral muscle
components (i.e. internal Karapandzic technique).48 Tension
can be adjusted at the time of inset to optimize lip position.
If adequate tension is placed on the tendon by the facial
musculature at the modioli, the muscle action from the
remaining facial muscles is transferred to the neolip, resulting
in a more dynamic suspension. Using this technique, the
tendon assumes some degree of dynamism because the orbi
cularis through which it is woven retains some function (Fig.
12.19).49 Other surgeons have similarly chosen the modiolus
as the preferred site of anchorage for the tendon.47 The design
of the radial forearm free flap directly impacts the ultimate
functional and aesthetic result. In our experience, optimal
suspensory support for the tendon is achieved by slightly
overcorrecting the tension. It is important to ensure that the
pedicle is not compressed when the flap is folded over the
tendon. The best functional reconstruction using free flaps
suspends the reconstructed lip skin independently of orbicu
laris sphincter restoration. Adequate suspension of the pal
maris tendon alone will not eliminate lip ptosis and ectropion.
Independent suspension of the skin segment may be accom
plished by de-epithelializing skin tab extensions to be tacked
to the malar areas47 or by making the width of the flap nar
rower than the width of the defect (approx. 75%). Because the
height of the skin excision and the mucosal resection usually
differ, the skin and mucosal elements of the flap must be
planned accordingly. Furthermore, fibrosis following surgery
and radiation therapy tends to diminish the vertical height of
the lip 6–12 months after reconstruction, so the vertical height
of the reconstruction should be slightly greater than the height
of the defect. It is also important to note that the height of the
mucosal element of the lip will usually be shorter than the
A
Tendon
Flap
Tendon
Flap
Fig. 12.19 (A) Schematic of palmaris/radial forearm flap reconstruction of the lower lip showing the Palmaris tendon woven through the remaining orbicularis muscle.
Continued
324
SECTION II
CHAPTER 12 • Lip reconstruction
B
C
D
E
F
Fig. 12.19, cont’d (B) Patient shown with a large squamous cell carcinoma of the
lower lip. (C) Resection of the lower lip planned. (D) The planned radial forearm
flap. Note the different dimensions of the skin and mucosal segments of the flap.
(E) Postoperative appearance. (F) Note that the patient can purse his lips and has
good oral competence.
325
Postoperative care
bilateral commissure plasty. This involves enlargement of the
stomal opening by extending the commissure. The landmarks
are the mid-pupillary lines. A vertical line dropped from the
mid-pupil defines the normal position of the commissure. To
correct microstomia, a through-and-through incision of the
scar contracture is made from the commissure, horizontally
to this line. The resulting raw areas are covered with mucosal
rhomboid flaps (Fig. 12.21). Correction of microstomia caused
by resection and reconstruction with, for example, Karapan
dzic flaps, is more challenging and surgical release as described
above risks denervation and thereby limits the extent of
microstomia correction possible. Initial attempts at stretching
and splinting should be tried first. If surgical release is
required, the continuity of the sphincteric orbicularis oris
muscle should be maintained if at all possible. The boundaries
of this muscle are hard to determine in these situations and it
becomes a matter of judgment. In patients such as those
depicted in Fig. 12.20, the microstomia is caused by scar
contracture, so that when the microstomia is corrected it must
be maintained by splinting.
Complications
Most of the complications encountered in lip reconstruction
have already been alluded to earlier in this chapter. The
standard complications that apply to any operation obviously
apply in these repairs, and the patient must be counseled
about the possibility of postoperative wound infection, wound
dehiscence, bleeding, etc. With lip-switch procedures, and
with the Abbé flap in particular, there is a risk of pedicle
avulsion, and it is important to ensure that the pedicle is not
too radically skeletonized. Not only can an exposed pedicle
be avulsed but it can thrombose or bleed. Fortunately, this
complication is rare. With free flap lip reconstruction, the
standard risks of microsurgical procedures apply and include
partial and total flap loss, as well as the complications associ
ated with flap harvest. However, the complications that are
most predictable are those of microstomia, denervation, oral
incontinence and aesthetic deformity. All of these have been
discussed earlier in this chapter.
Postoperative care
The protocol for postoperative care depends on the procedure
performed. Oral hygiene is important whatever the proce
dure, particularly if there are sutures intra-orally. For extensive
reconstructions, the patient may need to be on a liquid or soft
diet for several days after the procedure. Patients often find it
more comfortable to suck a liquid diet through a straw ini
tially. This is particularly the case for patients who have had
an Abbé flap. Regardless of the complexity of the reconstruc
tion, patients are generally instructed to rinse with a mouth
wash such as 0.12% chlorhexidine gluconate oral rinse after
eating, for 4 or 5 days after the procedure. Patients need to be
instructed about dental hygiene. Using a toothbrush in the
early postoperative period may not only be uncomfortable
but may disrupt suture lines. So the postoperative regimen
for each patient will depend on the procedure performed and
may need to be individualized. Fig. 12.22 presents an algo
rithmic approach to lip reconstruction.
skin element. So these two elements of the defect need to be
carefully measured so that the flap can be properly designed.
The ultimate free flap reconstructive technique of the lip,
which would also incorporate muscle between the inner and
outer layers and restore the vermilion component, has not
been described. Nevertheless, the composite radial forearm–
palmaris longus tendon free flap has several advantages over
pedicled flaps. This reconstruction allows for a single-stage
procedure that results in complete skin coverage and intraoral
lining. The large amount of skin that can be used with the
radial forearm flap usually results in an adequate stomal size,
minimizing the risk of microstomia. Although the color match
between the radial forearm flap and surrounding facial tissue
is frequently suboptimal, acceptable cosmetic results are
attainable by respecting the borders of the aesthetic subunits
during surgical resection and reconstructive planning. In
Japan, temporalis, masseter, and depressor anguli oris muscle
transfers have been used in place of the palmaris longus
tendon to achieve a more dynamic functional result when the
lower lip is reconstructed with a radial forearm flap.50–52
Others have bridged the orbicularis muscle loss with inner
vated muscle flaps including a free gracilis muscle covered by
a skin graft53 or an innervated platysmal myocutaneous flap
from the submental area of the neck54. The functional out
comes with these reconstructive approaches have not been
rigorously evaluated, and a prospective assessment of oral
competence and dynamic function should be conducted to
compare the outcomes following the use of palmaris longus
tendon and muscle transfer techniques.
Though most commonly used for the lower lip, the radial
forearm flap has also been used for total upper lip reconstruc
tion.46 The abnormal color, texture and composition as well as
the inability to recreate the fine, delicate curves and contours
of the upper lip generally results in a less than acceptable
aesthetic result, especially in woman and children. Recon
struction of >80% of the upper lip in men has been more
successful by camouflaging the defect with hair-bearing scalp
flaps.7,48,55,56 The best results incorporate fascial spanning of
orbicularis defects, a skin design that respects aesthetic units
and hair growth in the correct direction.48 These flaps tend to
be thick and relatively stiff. If the patient chooses to shave the
hair, multiple revisions are required to produce an acceptable
aesthetic outcome.
Secondary procedures
Secondary procedures may sometimes be necessary. Simple
scar revision may be necessary in situations where scarring is
very prominent or where scar contracture causes a visible or
functional deformity. The standard principles of scar revision
apply; Z-plasty or W-plasty for tight scars, skin grafts or
further local flaps to release contractures. A skin graft may be
necessary, for example, to correct an entropion or ectropion of
the lip that is due to scar contracture. Occasionally, a dener
vated lower lip will become ptotic and some sort of lip
shortening procedure may be necessary. These operations,
however, are not routine and which procedure to do on which
patient will depend very much on the specific problem. One
operation that is somewhat standardized, however, in second
ary reconstruction, is the correction of microstomia. Fig. 12.20
shows a patient with post-burn microstomia corrected with
326
SECTION II
CHAPTER 12 • Lip reconstruction
Fig. 12.20 (A) Patient with severe post-burn microstomia. (B) Patient appearance
at the end of the commissure plasty. The rhomboid flaps are sutured at the
mucocutaneous junction in upper and lower lips (see Fig. 12.16). (C) Patient seen
wearing his splint postoperatively. This patient wore his splint, except to eat, for 6
months. (D,E) At 10 year follow-up, showing maintenance of commissure position
and excellent function.
A
B
C
D
E
327
Postoperative care
Fig. 12.21 (A) Schematic of split of commissure with rhomboid flaps marked above and below. (B) Flaps are raised. (C) Flaps are being rotated into the defect. (D) Flaps
rotated into the defect; secondary defect closed by direct approximation.
A
B
C
D
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