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Reconstructive Plastic
Surgery of the Head and Neck describes the current
state-of-the-art techniques used in head and neck
reconstruction. Residents, fellows and attendings can follow
the up-to-date, step-by-step instructions and images in this book to
perform reconstructive surgical techniques for head and neck cancer
patients. The cutting-edge descriptions of computer modeling,
robotic surgery, and composite tissue allotransplantation lay
the foundation for continued innovation.

Key Features:

  • Algorithms for each head and neck sub-region to guide
    clinical decision-making

  • Step-by-step technical descriptions of the most commonly
    used flaps in head and neck reconstruction

  • "Pearls and Pitfalls" sections outline key concepts and
    critical nuances in surgical technique or patient management

Edited by surgeons from the renowned MD Anderson Cancer Center in
Houston, Texas, with commentaries from master surgeons around the
world, this book is an essential resource for residents, fellows, and
attendings to find the best surgical solutions when they are faced with
challenging head and neck cancer cases.
1 Mac Win
347 / 366
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ISBN 13:
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Reconstructive Plastic Surgery of the Head and Neck
Current Techniques and Flap Atlas

Matthew M. Hanasono, MD
Professor and Fellowship Program Director
Department of Plastic Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas
Geoffrey L. Robb, MD
Department of Plastic Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas
Roman J. Skoracki, MD, FRCSC, FACS
Professor and Division Chief of Reconstructive Oncologic Plastic Surgery
Department of Plastic Surgery
The Ohio State University Wexner Medical Center
Columbus, Ohio
Peirong Yu, MD, FACS
Department of Plastic Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas

765 illustrations

New York • Stuttgart • Delhi • Rio de Janeiro

Executive Editor: Timothy Y. Hiscock
Managing Editor: Elizabeth Palumbo
Director, Editorial Services: Mary Jo Casey
Production Editor: Kenneth L. Chumbley
International Production Director: Andreas Schabert; 
Vice President, Editorial and E-Product Development:
â•…â•…Vera Spillner
International Marketing Director: Fiona Henderson
International Sales Director: Louisa Turrell
Director of Sales, North America: Mike Roseman
Senior Vice President and Chief Operating Officer:
â•…â•…Sarah Vanderbilt
President: Brian D. Scanlan
Library of Congress Cataloging-in-Publication Data
Names: Hanasono, Matthew M., author. | Robb, Geoffrey L., author. |
Skoracki, Roman J., author. | Yu, Peirong, author.
Title: Reconstructive plastic surgery of the head and neck : current
techniques and flap atlas / Matthew M. Hanasono, Geoffrey L. Robb,
Roman J. Skoracki, Peirong Yu.
Description: New York : Thieme, [2016] | Includes bibliographical
references and index.
Identifiers: LCCN 2015048818| ISBN 9781604068078 (hardcover) |
9781604068139 (eISBN)
Subjects: | MESH: Reconstructive Surgical Procedures--methods |
Head--surgery | Neck--surgery | Head and Neck Neoplasms--surgery
| Surgical Flaps
Classification: LCC RD119 | NLM WE 700 | DDC 617.9/52--dc23 LC
record available at

Important note: Medicine is an ever-changing science undergoing
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Nevertheless, this does not involve, imply, or express any guarantee
or responsibility on the part of the publishers in respect to any dosage
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user is requested to examine carefully the manufacturers’ lea﬇ets
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from the statements made in the present book. Such examination
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Some of the product names, patents, and registered designs referred
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even though specistc reference to this fact is not always made in the text.
Therefore, the appearance of a name without designation as proprietary
is not to be construed as a representation by the publisher that it is in
the public domain.

Copyright © 2016 Thieme Medical Publishers, Inc.
Thieme Publishers New York
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Cover design: Thieme Publishing Group
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Printed in China by Asia Pacific Offset â•…â•…â•… 5 4 3 2 1
ISBN 978-1-60406-807-8
Also available as an e-book:
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This book, including all parts thereof, is legally protected by copyright.
Any use, exploitation, or commercialization outside the narrow limits
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and liable to prosecution. This applies in particular to photostat
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and storage.

We dedicate this book to our mentors, colleagues, and patients for their inspiration, commitment,
and courage. We also dedicate this work to our families for their patience, support, and love.
We have written this book for our students, residents, and fellows. We hope that the information
contained herein will capture your imagination and that you will one day take head and neck
reconstruction far beyond anything we can imagine.
Matthew M. Hanasono
Geoffrey L. Robb
Roman J. Skoracki
Peirong Yu

Videos.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . ix
Preface. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . xi
Contributors .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . xiii
Section Iâ•… Topics in Head and Neck Reconstruction
1 Lip Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

		 Matthew M. Hanasono
Expert Commentary, Lawrence J. Gottlieb

2 Oral Cavity Reconstruction. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ 18

		 Peirong Yu
Expert Commentary, Ming-Huei Cheng
Speech Therapy Multidisciplinary Commentary, Katherine A. Hutcheson

3 Mandibular Reconstruction . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . 40

		 Matthew M. Hanasono
Expert Commentary, Evan Matros and Joseph J. Disa

4 Pharyngoesophageal Reconstruction. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . 60

		 Peirong Yu
Expert Commentary, Peter C. Neligan

5 Reconstruction of Tracheal Defects. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . 81

		 Peirong Yu

6 Laryngotracheal Reconstruction with Prefabricated Free Flaps and Tracheal Allotransplantation . . . . . . . . . . . . . . . . . .å°“ . . . . . . 92

Jan Jeroen Vranckx

7 Midfacial Reconstruction. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . 100

		 Matthew M. Hanasono and Roman J. Skoracki
Reconstructive Expert Commentary, James S. Brown

8 Skull Base Reconstruction. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ 117

		 Matthew M. Hanasono

9 Scalp and Calvarial Reconstruction. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . 128

		 Albert Chao and Matthew M. Hanasono
Reconstructive Expert Commentary, Michael R. Zenn

10 Facial Nerve Reconstruction. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . 148

		 Matthew M. Hanasono
Reconstructive Expert Commentary, Michael Klebuc

11 Principles of Multidisciplinary Care in Head and Neck Cancer Treatment . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . 168

		 Steven S. Chang and Randal S. Weber

12 Recipient Vessel Dissection. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . 173

		 Matthew M. Hanasono

13 Postoperative Care and Management of Surgical Complications. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . 181

		 Peirong Yu

14 Management of Osteoradionecrosis of the Mandible . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . 188

		 Peirong Yu

15 Dental and Facial Prosthetic Rehabilitation. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . 203

		 Theresa M. Hofstede, Patricia C. Montgomery, and Richard C. Cardoso

16 Robotic Reconstructive Surgery. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . 220

		 Amir Ibrahim, Karim A. Sarhane, F. Christopher Holsinger, and Jesse C. Selber

17 Composite Tissue Allotransplantation of the Face. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . 230

		 Ericka M. Bueno, Ryan Michael Gobble, and Bohdan Pomahac

18 Imaging and Computer Modeling in Head and Neck Reconstruction. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . 241

		 Matthew M. Hanasono and Roman J. Skoracki

Section IIâ•… Flap Atlas
19 Anterolateral and Anteromedial Thigh Flaps. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . 255
		 Peirong Yu

20 Radial Forearm Free Flap. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . 264

		 Edward I. Chang and Matthew M. Hanasono


viii Contents
21 Ulnar Artery Perforator Flap. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . 272

		 Peirong Yu

22 Rectus Abdominis Flap. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . 277
Geoffrey L. Robb

23 Fibular Flap . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . 285

		 Matthew M. Hanasono

24 Iliac Crest Flap. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . 292
Peirong Yu and Geoffrey L. Robb

25 Latissimus Dorsi Flap/Thoracodorsal Artery Perforator Flap . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . 298

		 Goo-Hyun Mun

26 Scapular and Parascapular Flaps. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . 306

		 Sydney Ch’ng and Roman J. Skoracki

27 Free Jejunal and Supercharged Jejunal Flaps. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . 314

		 Peirong Yu

28 Pectoralis Major Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319

		 Matthew M. Hanasono

29 Supraclavicular Artery Island Flap . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . 326

		 Michael W. Chu and Ernest S. Chiu

30 Internal Mammary Artery Perforator Flap. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . 331

		 Peirong Yu

31 Local Flaps in Head and Neck Reconstruction. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ 335

		 Edward I. Chang and Matthew M. Hanasono

		Index.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 343

Chapter 2
Video 2.1

Hemiglossectomy Reconstruction with Radial Forearm Free Flap (see also Chapter 20)

Chapter 3
Video 3.1

Mandibular Reconstruction with Fibula Osteocutaneous Free Flap (see also Chapter 23)

Chapter 4
Video 4.1

Pharyngoesophageal Reconstruction with the Anterolateral/Anteromedial Thigh Flap

Chapter 7
Video 7.1
Video 7.2

Posterior Maxillary Reconstruction with Anterolateral Thigh Free Flap (see also Chapter 19)
Hemimaxillectomy Reconstruction with Fibula Osteocutaneous Free Flap (see also Chapter 23)

Chapter 9
Video 9.1

Latissimus Dorsi Muscle Free Flap for Scalp Reconstruction (see also Chapter 25)

Chapter 16
Video 16.1
Video 16.2
Video 16.3

Robotic Microvascular Anastomosis
Facial Artery Myomucosal Flap
Trans-Oral Robotic Inset

Chapter 21
Video 21.1

The Ulnar Artery Perforator Flap

Chapter 27
Video 27.1

Total Esophageal Reconstruction with the Supercharged Jejunal Flap


Concurrent with advances in the treatment of head
and neck malignancies, head and neck reconstruction has flourished in recent years. Not only have we
made great strides in restoring form and function to
patients suffering from head and neck cancer, but
the ability to reliably reconstruct surgical defects
has also helped to improve cancer control by allowing more aggressive and complete oncologic ablation
and facilitating timely administration of adjuvant
therapies. As experience has enabled reconstructive surgeons to achieve consistently high flap success rates with predictably good functional and aesthetic results, the complexity of the surgical defects
that we feel comfortable addressing has increased.
Moreover, as survival from head and neck cancer has
improved, we have observed an increase in second
(or even third) primary cancers as well as long-term
complications of treatment (such as osteoradionecrosis) in cancer survivors that frequently present
even greater reconstructive challenges than the original cancer. To meet these challenges, reconstructive
surgeons have explored new flaps and combinations
of flaps, while seeking to minimize donor site morbidity with refined flap selection and muscle-sparing perforator dissection. Furthermore, we have
reached beyond the boundaries of traditional surgical methods by embracing new techniques, such as
composite tissue allotransplantation, and incorporating cutting-edge technologies, such as computer
modeling, advanced imaging, and robotics, into our
operative workflow.
The goal of this book is to provide an up-to-date
guide to every aspect of head and neck reconstruction. We felt the need to fill a void since few recent
texts are devoted solely to this broad and complicated
field that is rich enough to be its own surgical specialty. We made every effort to make this book practical and complete. We believe trainees and young
surgeons, as well as seasoned veterans, will benefit
from the material presented, as both basic concepts
and advanced techniques are discussed. Without a
doubt, the coming years will see even more advances
in head and neck reconstruction as surgeons continue
to strive toward perfect and total restoration. We welcome such advances and hope that you, our readers,
will be inspired by this book to contribute to them.
This book is divided into two parts. The first part is
dedicated to various topics pertinent to modern head
and neck reconstruction. Our goal in these chapters is

to provide anatomic, functional, and oncologic information for a specific head and neck region and to present a reconstructive algorithm for that region based
on our experience with the many thousands of head
and neck reconstructions performed at MD Anderson
Cancer Center over the past three decades. However,
we set out to do much more than write a “how we do
it” book. To give a balanced view, we invited many of
the top reconstructive surgeons in the world to comment and expand upon our text. In many instances,
these commentaries demonstrate that there is often
more than one way to achieve excellent outcomes. In
others, it shows that, as far as we have come, there is
much yet to discover and learn.
Also in this section are a number of chapters
dealing with specific aspects of the comprehensive
care of the head and neck reconstruction patient,
including a broad overview of head and neck cancer treatment, management of complications, and
prosthetic rehabilitation, which may, in some cases,
be the best reconstructive option for a given patient.
Keeping with the spirit of discovery and innovation,
we have also included chapters on robotic surgery,
composite tissue allotransplantation, and imaging
and computer modeling, which we feel are important new directions within the field of head and neck
The second part describes how to perform what
we feel are the most important pedicled and free flaps
for the head and neck reconstructive surgeon to have
in his or her toolbox. Here, too, we acknowledge that
there is more than one “right” way to perform the
surgery, but hope that the reader will find the techniques we present, which have been refined by countless hours in the operating room, to be practical and
reliable. Throughout both parts of the book, we have
tried to illustrate the principles of reconstruction
with clinical examples, featuring high quality photographs and illustrations. Further personalizing this
text, we have added “Pearls and Pitfalls” sections that
outline key concepts and critical nuances in surgical
technique or patient management wherever they are
We sincerely thank all of our contributors for
their excellent work. In addition to the many expert
commentaries included in our book, we humbly
sought out the help of some extraordinary surgeons
for chapters that could only be written by the leading authority on certain topics, such as facial and


xii Preface
tracheal transplantation, as well as for the supraclavicular artery island flap and the thoracodorsal
artery perforator flap. We are even more appreciative of our patients who have given us permission
to share experience gained from their surgeries and
photos taken during the course of their care so that

others may benefit from their hardships. We welcome feedback and the chance to one day completely
rewrite this work based on further innovation and
evidenced-based research.
Matthew M. Hanasono

James S. Brown, MD, FRCS, FDSRCS
Department of Head and Neck Surgery
Aintree University Hospital
Liverpool University
Liverpool, England
Ericka M. Bueno, PhD
Scientific Director
Department of Plastic Surgery
Brigham and Women’s Surgery
Boston, Massachusetts
Richard C. Cardoso, DDS, MS, FACP
Assistant Professor
Department of Head and Neck Surgery
Section of Oral Oncology and Maxillofacial
The University of Texas MD Anderson Cancer Center
Houston, Texas
Edward I. Chang, MD, FACS
Assistant Professor
Department of Plastic Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas€
Steven S. Chang, MD, FACS
Director, Head and Neck Cancer Program
Josephine Ford Cancer Institute
Department of Otolarygnology–Head and Neck
Henry Ford Health System
Detroit, Michigan
Albert Chao, MD
Assistant Professor
Department of Plastic Surgery
The Ohio State University
Columbus, Ohio
Ming-Huei Cheng, MD, MBA, FACS
Department of Plastic and
Reconstructive Surgery€
Chief, Center for Tissue Engineering
Chang Gung Memorial Hospital
Linkou, Taiwan

Ernest S. Chiu, MD, FACS
Associate Professor of Plastic Surgery
Director, Helen L. and Martin S. Kimmel Hyperbaric
and Advanced Wound Healing Center
Hansjörg Wyss Department of Plastic Surgery
New York University Langone Medical Center
New York, New York
Sydney Ch’ng, MBBS, PhD, FRACS
Institute of Academic Surgery at RPA Hospital
University of Sydney
Sydney, Australia
Michael W. Chu, MD
Assistant Professor
Department of Plastic and Reconstruction Surgery
Indiana University School of Medicine
Indianapolis, Indiana
Joseph J. Disa, MD, FACS
Attending Surgeon
Memorial Sloan Kettering Cancer Center
Plastic and Reconstructive Surgery Service
Professor of Surgery
Weill Cornell Medical College
New York, New York
Ryan Michael Gobble, MD
Assistant Professor of Plastic Surgery
Department of Surgery
University of Cincinnati College of Medicine
Cincinnati, Ohio
Lawrence J. Gottlieb, MD, FACS
Director, Burn and Complex Wound Center
Department of Surgery
University of Chicago Medicine and
Biological Sciences
Chicago, Illinois
Matthew M. Hanasono, MD
Professor and Fellowship Program Director
Department of Plastic Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas


xiv Contributors
Theresa M. Hofstede, BSc, DDS, FACP
Associate Professor
Department of Head and Neck Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas

Peter C. Neligan, MB, FRCS(I), FRCSC, FACS
Department of Surgery
University of Washington Medical Center
Seattle, Washington

F. Christopher Holsinger, MD, FACS
Professor and Chief
Division of Head and Neck Surgery
Stanford University
Palo Alto, California

Bohdan Pomahac, MD
Director, Burn Center
Director, Plastic Surgery Transplantation
Division of Plastic Surgery
Brigham and Women’s Hospital
Boston, Massachusetts

Katherine A. Hutcheson, PhD
Associate Professor
Department of Head and Neck Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas
Amir Ibrahim, MD
Assistant Professor in Plastic Surgery
Department of Surgery
Division of Plastic Surgery
American University of Beirut Medical Center
Beirut, Lebanon
Michael Klebuc, MD
Associate Professor of Clinical Plastic
and Reconstructive Surgery
Weill Medical College, Cornell University
Institute for Reconstructive Surgery
Houston Methodist Hospital
Houston, Texas
Evan Matros, MD, MMSc, MPH
Assistant Professor
Plastic and Reconstructive Surgery Service
Memorial Sloan Kettering Cancer Center
New York, New York
Patricia C. Montgomery
Senior Anaplastologist
Department of Head and Neck Surgery
Section of Oral Oncology and Maxillofacial
The University of Texas MD Anderson Cancer Center
Houston, Texas
Goo-Hyun Mun, MD, PhD
Associate Professor
Department of Plastic Surgery
Samsung Medical Center
Sungkyunkwan University School of Medicine
Seoul, Republic of Korea

Geoffrey L. Robb, MD
Department of Plastic Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas
Karim A. Sarhane, MD, MSc
Department of Surgery
University of Toledo
Toledo, Ohio
Jesse C. Selber, MD, MPH
Associate Professor
Department of Plastic Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas
Roman J. Skoracki, MD, FRCSC, FACS
Professor and Division Chief of Reconstructive
Oncologic Plastic Surgery
Department of Plastic Surgery
The Ohio State University Wexner Medical Center
Columbus, Ohio
Jan Jeroen Vranckx, MD, PhD, FCCP, FAAPS
Chief, Department of Plastic and
Reconstructive Surgery
Professor of Surgery
KU-Leuven University
PI Lab of Plastic Surgery and Tissue Engineering
UZ-Gasthuisberg, KU-Leuven University Hospitals
Leuven, Belgium
Randal S. Weber, MD, FACS
Professor and Chair
John Brooks Williams and Elizabeth Williams
Distinguished University Chair in Cancer Medicine
Department of Head and Neck Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas

Peirong Yu, MD, FACS
Department of Plastic Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas

Michael R. Zenn, MD, MBA, FACS
Department of Plastic and Reconstructive Surgery
Duke University
Durham, North Carolina



Topics in Head and Neck Reconstruction


Lip Reconstruction
Matthew M. Hanasono

■⌀ Introduction
The challenge of lip reconstruction is to maintain oral
competence while still providing adequate mouth
opening, and to do so in an aesthetically pleasing
way. Oral competence is needed for speech articulation, for preventing loss of foods and liquids, and for
containing saliva, as well as for sucking, whistling,
and kissing. Too small of an oral aperture results in
problems with eating as well as oral hygiene and can
make use of dentures impossible. If the lips do not
oppose, the patient will drool, and speech and swallowing can be impaired. Aesthetically, even small
abnormalities of the vermilion line, Cupid’s bow, the
philtral columns, or the oral commissures can be
noticeable from a distance.
Numerous techniques have been described over
the years for lip reconstruction, each with specific
indications as well as advantages and disadvantages.
While free flap reconstructions for large defects continue to evolve, most recent local flap techniques
are modifications of tried and true methods. Several
reviews have proposed algorithms for flap selection
based on location and defect size. The exact method
chosen for a given patient depends not only on the
size and extent of the defect, but also on the quality of tissues, the patient’s needs and expectations,
and the surgeon’s experience. A practical and reliable approach that addresses both local and free flap
techniques is outlined below.

■⌀ Anatomy
The lips are each ~€5 to 6 cm long. The blood supply
comes from the paired superior and inferior labial
branches of the facial artery. These arteries run submucosally on the intraoral side of the lip. The motor
supply comes primarily from the buccal and marginal mandibular nerve branches. Sensory innervation comes from branches of the trigeminal nerve

(the superior labial branches of V2 for the upper lip
and the mental branches of V3 for the lower lip).
The sphincter function of the lips is provided by
the orbicularis oris muscle, which is arranged circularly around the mouth and has no bony attachments.
The orbicularis oris muscle has superficial fibers that
hold the lips away from the face and deep fibers that
approximate the lips to the alveolar arches. Ideally,
the sphincteric ring is restored during lip reconstruction, although many defects are too large for this
goal to be met. Several muscles dilate the mouth and
provide support to the central ring, including upper
lip dilators (zygomaticus major, zygomaticus minor,
levator labii superioris, and levator labii superioris
alaeque nasi), elevators of the oral commissure (levator anguli oris, buccinators, and risorius), and lower
lip depressors (depressor labii inferioris, depressor
anguli oris, mentalis, and platysma).
The vermilion is the exposed dry mucosal transition zone between the wet lip, which is supplied by
salivary glands, and the skin. Its red color is due to
the rich blood supply to the region. A thin, pale, junctional zone of skin, known as the white line, marks
the boundary of the vermilion where it meets the
cutaneous lip. Correct alignment of the white line is
necessary to achieve an optimal aesthetic result in
lip reconstruction.

■⌀ Small Lip Defects
Full-thickness defects approaching one-third the
width of the lower lip can be closed directly as a
wedge (Fig.€1.1). Smaller defects can be closed as a
V-shaped wedge. As the size of the defect increases,
the wedge can be modified to a W-shape, to avoid
crossing the mental crease onto the chin. For larger
defects, closer to one-third of the lip width (or even
slightly larger in patients with sufficient tissue laxity), releasing incisions can be made along the mental crease to permit advancement of the lateral lip
tissues for closure, which will usually produce a


4 Iâ•… Topics in Head and Neck Reconstruction
Fig.€1.1╅ (a) Defect encompassing approximately one-third of the width of the lower
lip. A vermilionectomy has also been performed. (b) Bilateral lip advancement flaps
were performed and the labial mucosa was
advanced to replace the missing vermilion
lip epithelium. (c) The postoperative result,
(d) with excellent mouth opening.




superior result (Fig.€1.2). All lip closures should be
performed in three layers, including the mucosa, the
orbicularis oris muscle, and the skin, with care taken
to precisely realign the white line. Notching of the
lip due to contracture of the incision line can occur,
especially in an irradiated field. Primary or secondary z-plasty may help to lengthen the scar. Use of a

pentagonal excision rather than a V-shaped wedge
may also be of benefit for small defects.
The upper lip is less accommodating, and wedge
closures should be reserved for defects involving
less than about one-fourth of the width of the lip.
Wedge closure of larger defects will result in excessive tightness, causing the upper lip to sit posterior

Fig.€1.2╅ Diagram demonstrating
(a–c) Abbe and (d,e) Estlander cross
lip flaps for intermediate-size lip
defects. The Abbe flap pedicle is
divided ~ 14 to 21 days after the initial surgery.






1â•… Lip Reconstruction
to the lower lip. An advancement flap, with an incision made along the junction of the upper lip and the
floor of the nose, as well as a perialar crescentic excision that permits further movement, can decrease
the tightness of closure.1 Defects that involve the
philtrum can be closed with direct closure or bilateral advancement flaps, although the result will not
restore the philtral columns and Cupid’s bow shape
of the vermilion border. A more aesthetic reconstruction of the philtrum usually requires utilization
of the Abbe cross lip flap, discussed below.

■⌀ Intermediate Lip Defects
Most defects of the upper and lower lip, up to about
two-thirds of the lip width (often even slightly more
in the lower lip), are best managed with either lip





switch flaps (Abbe or Estlander flaps) or circumoral
advancement-rotation flaps (Karapandzic flaps). The
lip switch flap, known as an Abbe flap2 when used
to reconstruct the central lip, and an Estlander flap3
for commissural reconstruction, involves transferring full-thickness lip tissue from the opposing lip
based on a labial artery pedicle (Fig.€1.3). The width
of the flap should be about one-half of the width of
the excised tissue, which will reduce the size of the
upper and lower lip by the same amount. For practical purposes, the maximum width of a lip switch
flap is ~€2 cm. The height of the flap should be the
same as the height of the defect.
The Abbe flap should be designed so that its pedicle is centered on the defect, although it is best not
to include either of the philtral columns when the
flap originates from the upper lip, if possible.4 The
Estlander flap should utilize the melolabial crease as
one border.


Fig.€1.3╅ (a) A defect encompassing about one-half of the width of the lower lip in an older patient with substantial tissue laxity. (b)
A rectangular Abbe flap, based on the right superior labial artery, is elevated and rotated into the defect. (c) Approximately 3 weeks
after the initial surgery, the pedicle is divided. A vessel loop acting as a tourniquet around the pedicle demonstrates viability of the
flap based on vascular ingrowth from the wound edges. (d) The postoperative result, (e) with good mouth opening.


6 Iâ•… Topics in Head and Neck Reconstruction
Although traditionally the Abbe flap is thought
of as triangular in shape, it may be designed to fit
in W-shaped or rectangular defects. It is particularly
useful for restoring the philtral subunit of the upper
lip. The Abbe flap requires maintaining a bridge of
tissue containing the arterial pedicle between the
donor lip and the recipient lip for a period of 14 to
21 days. During that time, oral intake is compromised. The flap can be injured if the mouth is opened
widely, so patients are usually limited to taking in
liquids with a straw, or a nasogastric feeding tube
can be placed.
The Estlander flap does not require pedicle division, although the patient can often benefit from revision to eliminate blunting and medialization of the
commissure. Commissuroplasty can be performed to
improve cosmesis and mouth opening after spontaneous remodeling is allowed for a period of at least
4 to 6 months following initial lip reconstruction

with an Estlander flap. A simple method is to incise
or remove a wedge of skin lateral to the commissure, then evert the buccal mucosa to simulate the
vermilion lip (Fig.€1.4). Only a very modest amount
of commissural movement should be performed by
this method to avoid oral incontinence, although the
procedure can be repeated to widen the commissure
a little bit at a time. Alternatively, commissuroplasty
can be performed by rotation and advancement of a
superiorly based vermilion-mucosa flap following an
incision of the cheek just lateral to the commissure
(Fig.€1.5).5 The resulting vermilion defect is reconstructed by advancing labial mucosa toward the
white line.
An alternative to Abbe and Estlander flaps is the
Karapandzic technique, which involves circumoral
rotation-advancement flaps.6 The Karapandzic technique is similar to the circumoral advancementrotation flaps originally described by von Bruns7

Fig.€1.4╅ Commissuroplasty to
improve mouth opening and to
lateralize the oral commissure following initial lip reconstruction.
(a)€Planned incisions. (b)€Removal
of a triangle of skin and markings for muscle and mucosal incisions. (c)€Eversion of the mucosa.
(d)€Completed commissuroplasty.





1â•… Lip Reconstruction








Fig.€1.5╅ (a,b) Alternative technique for commissuroplasty in a patient who had undergone lip reconstruction that resulted in a
small oral aperture with a medialized oral commissure. (c,d) A skin incision is made lateral to the commissure and a vermilion flap
is rotated into the new commissure location. Orbicularis oris muscle is also lateralized using a deep buried suture. (e) The labial
mucosa is everted to cover the vermilion defect. (f,g) The postoperative result shows the left oral commissure in a more favorable,
although not perfectly symmetrical, position, with improved mouth opening.

in 1857, but preserves the neurovascular supply to
the lip flaps, making them more reliable as well as
functional and sensate. In this technique, skin incisions are planned so that the height of the flaps is
equivalent to the height of the lip defect, not necessarily staying within the melolabial crease laterally (Fig.€1.6). Deep to the skin, perioral muscles
are selectively lysed while preserving nerves and
blood vessels to the remaining lip until adequate flap
mobility is achieved. Finally, the mucosal incisions
are made in a “cut as you go” fashion; typically, the
incision is shorter than the skin length required due
to the more distensible nature of the mucosal tissues. Leaving adequate mucosa along the gingiva is
important not only for having enough tissue to sew

to, but also for preserving a gingivolabial sulcus in
denture users.
A unilateral Karapandzic flap can reconstruct
smaller defects, up to nearly 50% of the lip width,
while bilateral Karapandzic flaps can be used for
defects spanning two-thirds the width of the lip or
even slightly more. The larger the defect, the greater
the risk for microstomia, since no lip tissue is added,
just as with other local lip flaps mentioned thus far.
Blunting or rounding of the commissures can also
occur but usually improves with time. The various lip
flaps, including advancement, Abbe, Estlander, and
Karapandzic flaps, can also be combined, depending on the defect and the location of donor lip tissue


8 Iâ•… Topics in Head and Neck Reconstruction
Fig.€1.6╅ Diagram demonstrating the Karapandzic technique of circumoral neurovascular flap reconstruction for
intermediate to large lip defects. This technique can be
applied to both lower and upper lip defects, although it
does not restore the philtral columns or the Cupid’s bow
shape of the upper lip vermilion border.






Fig.€1.7╅ (a) A defect involving nearly two-thirds of the lower lip width, including the left oral commissure. (b) A right Karapandzic
flap is combined with a left Estlander flap, which is used to restore the commissure. (c) Note that the nerves and blood vessels supplying the Karapandzic flap are preserved. (d,e) Postoperative result.

■⌀ Near-Total and Total Lip Defects
Reconstruction of near-total and total defects is especially challenging. Local tissue techniques for lower
lip reconstruction include use of nasolabial flaps
(e.g., “gate flaps” described by Fujimori8) or cheek
advancement techniques (e.g., Webster modification
of the Bernard-Burrow repair9,10) (Fig.€1.8). Similarly,
inferiorly based nasolabial flaps or cheek advance-

ment flaps with perialar crescentic excisions can
be performed for upper lip reconstruction. None of
these procedures provides a functional lip segment
because the motor innervation is divided and/or the
muscle fibers transferred are perpendicular to the
orbicularis oris fibers. An Abbe flap from the lower lip
to the central portion of the reconstructed upper lip
to restore the appearance of the philtrum and to supply additional tissue can augment upper lip repairs.
When using an Abbe flap to reconstruct the philtrum,

1â•… Lip Reconstruction





the width of the flap should be the same as the width
of the original philtrum. Local tissue reconstruction
may be satisfactory in patients with significant cheek
tissue redundancy but often results in substantial
microstomia and an adynamic, insensate lip.
An alternative to local tissue repair for near-total
and total lip reconstruction is free tissue transfer.
Most frequently, the radial forearm fasciocutaneous free flap is chosen because of its thinness and
pliability.4,11 When used for lower lip reconstruction,
the flap is suspended over a palmaris longus tendon
sling to help prevent oral incompetence. The tendon is either suspended to the zygomatic bones via
screw-anchored sutures or woven into the remaining perioral muscles at the modioli. The width of the
flap is also restricted to about half of the width of the
defect to provide resting tension in an effort to minimize ptosis and eversion of the flap. On the other
hand, the height of the flap should be as great as, or

Fig.€1.8╅ Techniques for total lower lip
repair. (a) Planned incisions for total lower
lip repair with cheek advancement flaps
(Webster modification of the Bernard-Burrow repair). The four triangles indicated
by the dashed lines are excised and the
cheeks are advanced medially toward each
other. (b) Completed repair in which the
buccal mucosa has been everted to replace
the missing vermillion lip. (c) Planned incisions for total lower lip repair with nasolabial or “gate” flaps. The two gate flaps are
rotated medially and the buccal mucosa
is everted to replace the missing vermillion lip. (d) Completed repair in which
the nasolabial flap donor sites have been
closed primarily.

slightly greater than, the original lip height, since
postoperative tissue contracture usually reduces the
height of the reconstructed lip. The aesthetic result
of free flap reconstruction is usually best when the
entire facial subunit of the lip is replaced, which may
require converting a near-total defect into a total
defect. The lateral antebrachial cutaneous nerve and
the cut end of the mental nerve can be anastomosed
to provide sensation. A ventral tongue flap or a facial
artery myomucosal (FAMM) flap can be performed
secondarily to restore the vermilion color of the lip
to a de-epithelialized portion of the free flap.12 Medical tattooing can also be used.
The advantage of free flap reconstruction over
cheek advancement and nasolabial flap reconstruction is that wound tension is greatly decreased by
supplying a large quantity of tissue that is also well
vascularized, which can be particularly important in
a previously irradiated patient. Like the local tissue


10 Iâ•… Topics in Head and Neck Reconstruction
flap options for near-total and total lower lip reconstruction, the free flap is adynamic. When used for
lower lip reconstruction, a folded free flap works as a
dam to prevent drooling, but it can still be associated
with major problems with eating. When used for
upper lip reconstruction, a folded free flap is usually
functionally more successful, since it mainly serves
as a drape to cover the maxillary teeth, while the
native lower lip provides oral competence. In both
cases, the color match with the rest of the face may
be poor, and the free flap usually results in the facial
appearance of a ventriloquist’s dummy.
Recently, we described a modification of the
Karapandzic technique that can be used for neartotal and total lower lip defects.13,14 In this technique,
lower cheek flaps are cantilevered on traditional
Karapandzic neurovascular rotation-advancement
flaps (Fig.€1.9). The buccal mucosa is everted onto
the lower cheek flaps to restore the appearance of the
vermilion lip. In contrast to the traditional Karapandzic technique, this technique uses additional tissue
from the cheeks and recruits opposing lip tissue to
restore the missing lip, reducing the risk for postoperative microstomia. In fact, the amount of lip that is
typically restored by the extended Karapandzic flaps
usually permits a generous amount of mouth opening postoperatively.
Although a small portion of the reconstructed
lip will be adynamic, it does not seem to have a significant effect on oral competence, just as it does
not with Abbe and Estlander flaps, which involve a
similar amount of adynamic tissue. Compared with
cheek advancement flaps, nasolabial flaps, and free
flaps, the extended Karapandzic flap lip reconstruction yields superior sphincteric function of the lip.
Sensation is preserved, and the cosmetic outcome is
usually superior to free flap reconstruction. For less

than total defects that are eccentrically located to one
side or another, a combination of a traditional Karapandzic flap that takes advantage of remaining adjacent lip tissue and an extended Karapandzic flap on
the side of the greater defect can be used (Fig.€1.10).
Because of these advantages, the extended Karapandzic technique is our preferred method of addressing
near-total and total lip defects, with free flaps being
the secondary choice when the extended Karapandzic flaps are precluded by lack of adjacent tissue or
prior surgery that might compromise flap reliability.
Our algorithm for selecting lip reconstruction
techniques is summarized in Fig.€1.11.

■⌀ Composite and Extended Lip

For some head and neck cancers, the lip is involved
secondarily by direct spread, such as from tumors
of the floor of mouth or gingiva. On the other hand,
some lip cancers spread to adjacent structures. In
these cases, although it is sometimes tempting to
use a single flap, it is usually best to reconstruct each
structure separately.15
Cancers of the lower lip, for example, may involve
the mandible by direct spread or via invasion of the
mental nerve (Fig.€1.12). In such cases, the mandible
is reconstructed with an osseous or osteocutaneous
free flap and the lip is reconstructed with local flaps
if possible. If the facial artery remains intact following the resection, it is probably prudent not to
utilize it as a recipient blood vessel for a free flap,
although blood flow to the lips usually remains sufficient to perform local flap reconstruction even
after loss of one or both facial arteries due to col-

Fig.€1.9╅Total lower lip reconstruction with
extended Karapandzic flaps. Traditional Karapandzic
flaps are extended by lower cheek tissue, which is
rotated medially an additional 90 degrees to reconstruct the central lower lip. (a) Planned incisions.
Note that the triangles of skin indicated by the
dashed lines are discarded. (b) Completed reconstruction in which point A is sutured to point A1 and
point B is sutured to point B1 after rotation of the
lower cheek tissue as well as circumoral advancement of the Karapandzic flaps.

1â•… Lip Reconstruction








Fig.€1.10╅ (a) A near-total lower lip defect sparing the right oral commissure. (b) A right Karapandzic flap and a left extended
Karapandzic flap are designed. (c,d) Circumoral incisions are made, and the neurovascular supply to the flaps is carefully preserved.
The left buccal mucosa is everted to replace the vermilion portion of the lip. (e) Appearance at the completion of surgery and (f,g)
at 1 year postoperatively.

Fig.€1.11╅ Algorithm for upper and lower lip reconstruction.


12 Iâ•… Topics in Head and Neck Reconstruction
Fig.€1.12╅ (a) A right lower lip cancer invading the mental nerve, requiring a hemimandibulectomy and two-third lower lip resection. (b) A fibular osteocutaneous free
flap was used to reconstruct the mandibular defect. (c,d) The lip defect was reconstructed with bilateral Karapandzic flaps. (e,f) Postoperative result.







lateral circulation coming from the angular artery,
which is a terminal branch of the internal carotid
artery. When a very large defect leaves insufficient
local tissues for reconstruction of the lower lip, the
skin paddle from an osteocutaneous free flap may
also serve to reconstruct the floor of the mouth and
the lip, but the functional and aesthetic results are
usually disappointing.
Upper lip cancers may spread to the maxilla as
well as to the nose by direct extension. In these cases,
staged nasal reconstruction should be performed
separate from lip reconstruction. When postoperative radiation therapy is planned, it is usually best to

perform delayed nasal reconstruction, because delicate reconstructions of the nose that involve multiple
layers, including bone or cartilage grafts for support,
do not tolerate radiation well. Small defects of the
premaxilla can be obturated or reconstructed with
an osteocutaneous free flap; however, this should
be done immediately at the time of resection. Otherwise, the upper lip reconstruction, whether performed with local tissues or a folded fasciocutaneous
free flap, will contract and make later attempts to
restore midfacial projection very difficult. Large
defects of the anterior maxilla require osteocutaneous free flap reconstruction.

1â•… Lip Reconstruction

■⌀ Postoperative Care
Patients are restricted to a liquid diet or kept NPO
and fed via a nasogastric feeding tube for several days
after lip reconstruction. Incisions should be cleansed
gently with soap and water or dilute hydrogen peroxide beginning the first postoperative day and antibiotic ointment should be applied twice daily for
~€1 week. Wide mouth opening should be avoided
until the incisions are well healed, which may take
many weeks in previously irradiated patients. After
the wounds are completely healed, mouth stretching and scar massage are encouraged. For defects
that involve the commissure, patients should be
instructed to perform finger retraction laterally to
widen the oral aperture. For cases with functionally significant microstomia, a prosthedontist may
be able to help create oral appliances that passively
stretch the reconstructed lips.

■⌀ Complications
Local flaps need to be designed so that their pedicle
blood supply is not compromised. In cases where
bilateral neck dissections have been performed,
the facial arteries will likely have been ligated and
flaps need to be checked for adequate vascularity,
as evidenced by brisk bright red bleeding from the
cut edge of the distal flap and pulsations from the
ligated labial artery. Aggressive trimming of the pedicled portion of the Abbe and Estlander cross lip flaps
in particular may need to be avoided. In such cases,
refinement can be postponed until a second stage.
Previously irradiated patients are at increased risk
for fistula formation, and small fistulas can be managed by keeping the patient on NPO status and by
placing a nasogastric feeding tube, facilitating spontaneous healing.
To some extent, all patients undergoing lip
reconstruction with local flaps are at risk for
microstomia. In some cases, commissuroplasty can
help increase the size of the oral aperture following reconstruction of a lateral defect. A central lip
defect may be improved by secondary reconstruction with an Abbe flap. Reconstructions with free
flaps or larger denervated local flaps often result
in loss of oral competence, causing drooling as well
as difficulties with feeding and speech. Notching
of the lip at incision lines can also occur. In many
cases, the defects can be improved by excision of
the scar and by closure that incorporates z-plasty
flaps on the mucosal side.

Pearls and Pitfalls
• V-shaped or W-shaped defects involving a
third of the lower lip and a quarter of the
upper lip can usually be closed primarily,
while slightly larger defects can be closed with
unilateral or bilateral lip advancement flaps.
• Central defects involving two-thirds of the
lip width can be closed with an Abbe cross
lip flap; lateral defects involving the oral
commissure and two-thirds of the lip width
can be closed with an Estlander cross lip flap.
• Blunting and medialization of the oral
commissure is not uncommon with the
Estlander cross lip flap but can be improved
with secondary commissuroplasty.
• The Karapandzic technique of creating
circumoral neurovascular flaps is often
the best method of maintaining the oral
sphincteric function in defects of up to twothirds of the lip or even slightly more.
• Extended Karapandzic flaps can be used to
reconstruct near-total or total lip defects,
recreating the oral sphincter with sensate,
well-vascularized tissue.
• Free flaps may be the best or only option for
near-total or total lip reconstruction but are
often suboptimal due to oral incompetence
and skin color and texture mismatch.
• Composite or extensive defects should be
reconstructed in a way that respects facial
subunits, if possible.
• Free flaps for mandibular and maxillary
reconstruction can be combined with local
flaps for lip reconstruction to give optimal


14 Iâ•… Topics in Head and Neck Reconstruction

Expert Commentary by Lawrence J. Gottlieb
The lips are the most prominent feature of the
lower third of the face and have significant functional, aesthetic, and social importance. They
facilitate the articulation of certain sounds, the
maintenance of oral competence during eating,
drinking, sucking, and speaking, and the expression of emotions via smiling and kissing. In concert
with motion of the mandible, they allow access
to the mouth, not only for food intake but also for
oral and dental hygiene, as well as for insertion and
removal of dentures. The oral 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.
When we think of a functional lip, we should
think not only of the skin covering but also of all
the components beneath the skin that give human
lips their three-dimensional characteristics that
allow for communication, expression of emotions,
and all the functions mentioned above. Therefore,
the functional unit of the lips is the three-dimensional aesthetic unit. Ideally, reconstruction of the
functional unit of the lip restores all missing components and results in a skin surface similar to the
surface that was lost, with its borders hidden by
natural skin folds, shadows, or hair, while maintaining an adequate stomal aperture and at the
same time ensuring lip competence.
Restoration of the lips is complicated by the fact
that the lips are mobile structures that function
(aesthetically and mechanically) differently when
in repose than when animated, since function and
aesthetics are inextricably linked in the lips’ functional units. In addition, as mobile structures, the
lips are subjected to distortion by gravity, scar, and
possibly radiation and denervation. Functional and
aesthetic reconstruction of the mobile lip is further
complicated when an adjacent facial unit’s function is compromised by scars, trauma, radiation,
and muscular dysfunction.
Lip reconstruction may be indicated for loss or
abnormality of mucosa, vermilion, skin, subcutaneous tissue, muscle (denervation), or a combination
of some or all of these components. The description
of repair for each of these components is beyond
the scope of this commentary. By and large, the
most frequent circumstances requiring lip reconstruction are partial-thickness defects (loss of skin
and subcutaneous tissue) or full-thickness defects
from trauma or tumor extirpation.
Partial-thickness defects can generally be
closed primarily (if small enough), or with a skin
graft or flap (if too large to close primarily). In most
situations, skin grafts provide a less than optimal

aesthetic result, with discrepancies of color, texture, composition, and elasticity. When dealing
with a partial or complete loss of a portion of the
lip, adjacent “like” tissue will usually provide the
best replacement, particularly when considering
the qualities of skin cover. Although small skin cancers of the lips can be excised as a simple wedge,
V-shaped wedge, or W-shaped wedge, as nicely
described in the chapter, I rarely excise in such a
fashion. Rather, for lower lip excisions, I excise
the skin below the white line with an angulated V
dictated by the direction of skin rhytids. Closure
requires meticulous approximation of each layer,
with particular attention to lining up the vermilion border and white roll. Breaking up the closure
below the white roll by adding a small z-plasty
or other interdigitations helps restore the gentle
curve of the lip and avoids notching of the incision
line (Fig.€1.13 and Fig.€1.14).
For all but the smallest lateral upper lip defects,
primary closure frequently causes distortion of the
philtrum. Therefore, for larger lateral defects, I usually close with a crescent-shaped V-Y flap, reconstructing the aesthetic unit and paying particular
attention to the small triangular portion of the lip
just lateral to the nasal ala (Fig.€1.15). When lip
defects are too large to close with “like” adjacent
tissue, then a lip switch type procedure (Abbe or
Estlander) or circumoral rotation-advancement
(Karapandzic) flap should be considered. These
procedures are paradigmatic of the restoration of
the functional unit, in that they restore all the components (skin, muscle, and mucosa) of the missing portion of the lip. Although denervated when
transferred, the transferred muscle within these lip
segments generally regains some function through
direct neurotization. The advantages, disadvantages, and limitations of these procedures as well
as the various cheek-based flaps are well covered
in the chapter, and they are not reiterated here
other than to say that, as we push these concepts
to larger and larger defects, one must balance the
advantages of having like tissue and competent lips
with the disadvantages of the addition of a significant amount of facial scars, the distortion seen with
animation, and the relative microstomia produced.
When the defect is too large to close with “like”
tissue, then regional or distant tissue is required.
Invariably, if distant skin is used for reconstruction,
the result is less than ideal, as skin from different
parts of the body and even from different parts of
the face, head, and neck has different qualities of
color, texture, composition, pliability, and elasticity, as well as different attachments to deeper tissue, whether they be subcutaneous fat or muscle

1â•… Lip Reconstruction
Fig.€1.13╅ (a) An 85-year-old female
with basal cell carcinoma, with excision planned as an angulated “V.”
(b) Defect after excision. Note that
the vermilion border was previously
tattooed to facilitate precise approximation. (c) Closure in layers. Arrow
points to small z-plasty to break up
the scar. (d) Postoperative result.







Fig.€1.14╅ (a) A 61-year-old female undergoing re-excision of previously biopsied lesion. (b) Postoperative appearance at 2
weeks. Note angulation and interdigitation of incision below precisely approximated white roll. (c) Postoperative appearance
with a barely perceptible scar.

fibers, and the different attachments lead to discrepancies in how well reconstructed lips look in
animation versus repose.
Distant tissue, frequently in the form of a free
tissue transfer, is generally required to successfully
reconstruct greater than 80% of the lip. For a successful functional reconstruction of the lower lip,
the orbicularis sphincter needs to be reconstructed
or spanned. This is most frequently accomplished
with the palmaris longus tendon of a radial forearm
free flap (or fascia from other flaps) spanning from
modiolus to modiolus, or to mobilized lateral muscle components (i.e., internal Karapandzic technique).16 Suspending the palmaris longus tendon

to fixed points merely allows the flap to drape over
the tendon as if it were a clothes line and produces
an adynamic lip. The best functional reconstruction using free flaps suspends the reconstructed lip
skin independently of orbicularis sphincter restoration. Others have bridged the orbicularis muscle
loss with innervated muscle flaps, including a free
gracilis muscle covered by a skin graft17 or an innervated platysmal myocutaneous flap from the submental area of the neck.18 Although many advocate
neurorrhaphy with sensory nerves of cutaneous
free flaps, this is not absolutely necessary, because
the flaps generally regain sensation with time from
spontaneous neurotization.


16 Iâ•… Topics in Head and Neck Reconstruction






Fig.€1.15╅ (a) A 64-year-old female with basal cell carcinoma of upper lip. Lesion and critical landmarks are marked. (b) Lesion
excised and crescent V-Y flap marked. Note incorporation of a point to recreate triangular space lateral to the nasal ala. (c) Deepithelialized skin from above the lesion will be anchored to the nasal spine to limit any lateral pull or secondary distortion of
scar. (d) Postoperative appearance, with a barely perceptible scar and without distortion of philtrum. (e) Minimal asymmetry
noted with smiling.

Aesthetically pleasing reconstruction of large
defects of the upper lip, with its gentle curves
and delicate lines, is difficult, especially in women
and children. Burget and Menick have successfully reconstructed large unilateral lateral defects
with a large aesthetic subunit Abbe cross lip flap.19
Overall, the best techniques for total or subtotal
central upper lip reconstruction utilize bilateral lip
or cheek advancement flaps complemented with
an Abbe cross lip flap to create a semblance of a
The advantage of free flap reconstruction of
partial-thickness defects of the upper lip is the
avoidance of any additional facial scars other than
within the aesthetic unit or subunit; the disadvantage is the resultant abnormal color, texture, and
composition of the transferred tissue (Fig.€1.16).
Full-thickness reconstruction of the upper lip
tends to fare better in men if they are willing to
wear a mustache. Hair-bearing fasciocutaneous
flaps based on the superficial temporal vessels to
resurface skin defects have been described, as have
composite osteocutaneous flaps for more complex
reconstructive needs (Fig.€1.17).16 Although using
hair-bearing flaps to reconstruct the entire upper
lip aesthetic unit successfully camouflages any
irregularities of the reconstruction, if it is shaved,
the lip looks like a “blob” and needs multistage
revisions to look reasonable.

Whatever tissue is used to reconstruct the lip,
one should try to hide scars along the borders of
the aesthetic units or subunits of the lip or within
(or parallel to) natural skin lines. In addition,
although the lips may not be perfectly symmetrical, obtaining relative symmetry and avoiding distortion in repose, while minimizing distortion with
animation, are essential to a successful reconstruction. The goal of lip reconstruction is for a casual
observer not to be able to notice the scars (or the
reconstruction) in normal social interactions.

Fig.€1.16╅ Abnormal color, texture, and thickness of radial
forearm free flap aesthetic subunit reconstruction of left
side of upper lip.

1â•… Lip Reconstruction




Fig.€1.17╅ (a) A 72-year-old male with an indolent basal cell carcinoma of his
upper lip. (b) Wide excision included the entire upper lip, extending into the medial
aspects of the cheeks, a portion of the left lower lip, left commissure, a thin layer of
the anterior portion of the maxilla, columella, nasal floor, and small portions of each
nasal ala. (c) After negative pathological margins were obtained, the cheeks were
advanced medially to each nasolabial fold and the upper lip was reconstructed with
a hair-bearing osteofasciocutaneous temporoparietal free flap. (d) Postoperative
result demonstrating the camouflage effect of the hair-bearing flap.










Webster JP. Crescentic peri-alar cheek excision for upper lip flap advancement with a short history of upper lip repair. Plast Reconstr Surg (1946) 1955;16(6):
Abbe R. A new plastic operation for the relief of deformity due to double harelip. Plast Reconstr Surg
Estlander JA. A method of reconstruction loss of
substance in one lip from the other lip. Arch Klin
Chir 1872;14:622, reprinted in Plast Reconstr Surg
Neligan PC. Strategies in lip reconstruction. Clin Plast
Surg 2009;36(3):477–485
Kroll SS. Staged sequential flap reconstruction for
large lower lip defects. Plast Reconstr Surg 1991;88(4):
620–625, discussion 626–627
Hauben DJ. Victor von Bruns (1812–1883) and his contributions to plastic and reconstructive surgery. Plast
Reconstr Surg 1985;75(1):120–127
Karapandzic M. Reconstruction of lip defects by local
arterial flaps. Br J Plast Surg 1974;27(1):93–97
Bernard C. Cancer de la levre inferieure; restauration
a l’aide de lambeaux quadratiares-latereaux. Scalpel
(Brux) 1852;5:162–165
Webster RC, Coffey RJ, Kelleher RE. Total and partial
reconstruction of the lower lip with innervated muscle-bearing flaps. Plast Reconstr Surg Transplant Bull
Fujimori R. “Gate flap” for the total reconstruction of
the lower lip. Br J Plast Surg 1980;33(3):340–345









Serletti JM, Tavin E, Moran SL, Coniglio JU. Total lower
lip reconstruction with a sensate composite radial forearm-palmaris longus free flap and a tongue flap. Plast
Reconstr Surg 1997;99(2):559–561
Pribaz JJ, Meara JG, Wright S, Smith JD, Stephens W,
Breuing KH. Lip and vermilion reconstruction with the
facial artery musculomucosal flap. Plast Reconstr Surg
Langstein HN, Robb GL. Lip and perioral reconstruction.
Clin Plast Surg 2005;32(3):431–445, viii
Hanasono MM, Langstein HR. The extended Karapandzic flap for total and near-total lip reconstruction.
Plast Reconstr Surg 2011;127:1199–1205
Cordeiro PG, Santamaria E. Primary reconstruction of
complex midfacial defects with combined lip-switch
procedures and free flaps. Plast Reconstr Surg 1999;
Gottlieb L, Agarwal S. Autologous alternatives to facial transplantation. J Reconstr Microsurg 2012;28(1):
Ninkovic M, Spanio di Spilimbergo S, Ninkovic M. Lower lip reconstruction: introduction of a new procedure
using a functioning gracilis muscle free flap. Plast Reconstr Surg 2007;119(5):1472–1480
Bauer T, Schoeller T, Rhomberg M, Piza-Katzer H,
Wechselberger G. Myocutaneous platysma flap for
full-thickness reconstruction of the upper and lower
lip and commissura. Plast Reconstr Surg 2001;108(6):
Burget GC, Menick FJ. Aesthetic restoration of onehalf the upper lip. Plast Reconstr Surg 1986;78(5):




Oral Cavity Reconstruction
Peirong Yu

■⌀ Introduction

■⌀ Regional Anatomy

The oral cavity is the most common site for squamous cell carcinoma of the head and neck. In the
United States, the tongue and floor of the mouth are
the most common sites for primary cancers, whereas
in some regions of Asia, buccal cancer is most common. The organs in the oral cavity, particularly the
tongue, play important roles in speech and swallowing, as well as in airway protection. The base of
the tongue is more important for swallowing function, whereas the oral tongue is more important for
speech and food manipulation. Proper reconstruction of these vital organs in the oral cavity may prevent life-threatening complications, restore function,
and improve quality of life and patient self-image.
Providing basic tissue coverage without taking into
account these considerations is no longer acceptable
in modern-day practice.
This chapter focuses on reconstruction of defects
of the floor of the mouth, buccal surfaces and cheek,
and tongue. The goal of reconstruction of the floor
of the mouth is to provide thin and pliable lining so
as not to obstruct lingual mobility. Similarly, buccal
reconstruction also requires thin flaps to avoid bulk.
Reconstructions after total or subtotal glossectomy
require a large volume of tissue to provide enough
bulk for better speech, swallowing, and airway protection. Conversely, the goal of reconstructing partial
glossectomy defects is to preserve the mobility of
the remaining tongue by providing a thin and supple
flap. Sensory reinnervation is also an important part
of oral cavity reconstruction. The patient and family
should be made fully aware of potential functional
sequelae of a total or subtotal glossectomy, including
the possibility of long-term tube feeding and tracheostomy dependency.

The oral cavity consists of the the lips, buccal mucosa,
mandibular and maxillary alveolar ridge, retromolar
trigone, hard palate, floor of the mouth, and anterior (oral or mobile) tongue (Fig.€2.1). Sensation in
the oral cavity is provided by V2 and V3, branches of
the fifth cranial nerve (CN). General sensation to the
anterior two-thirds of the tongue is via the lingual
nerve (CN V3) and taste is via the chorda tympani
(CN VII), accompanying the lingual nerve. Sensation

Fig.€2.1╅ The oral cavity consists of the lips, buccal mucosa,
mandibular and maxillary alveolar ridge, retromolar trigone
(RMT), hard palate, floor of the mouth, and oral tongue. The
main structures in the oral pharynx are the base of the tongue,
tonsillar pillars, lateral and posterior pharyngeal walls, and soft

2â•… Oral Cavity Reconstruction
in the oral cavity also contributes to the swallowing
mechanism. Motor innervation of intrinsic oropharyngeal musculature is via the hypoglossal nerve (CN
XII). Vascular supply to the tongue is via the lingual
artery, a branch of the external carotid artery.

■⌀ Reconstruction of Defects of
the Floor of the Mouth

Defects of the floor of the mouth (FOM) are usually
associated with a glossectomy or mandibulectomy.
Isolated FOM defects that do not include the suprahyoid musculature may be repaired by skin graft or
reconstructed with a local flap, such as a submental flap or facial artery myomucosal (FAMM) flap,1,2
whereas combined defects resulting from glossectomy, mandibulectomy, or neck dissection require
more substantial reconstruction.

Isolated Floor of Mouth Defects
If no bone is exposed and the suprahyoid musculature
is intact, FOM defects can be repaired by skin graft or
they may be allowed to mucosalize spontaneously.
When skin grafts are used, they are usually secured
with a bolster dressing, which is removed 5 or 6 days
after surgery. Partial skin graft loss is common for oral
cavity reconstruction. No further management is necessary. Remucosalization can be expected.
FOM defects can also be reconstructed with local
flaps, especially when a small area of bone is exposed
or postoperative radiotherapy is planned. The submental flap or FAMM flap can reach the FOM easily
with minimal donor-site morbidity. The FAMM flap
is usually limited to a 2 cm width to allow primary
closure of the donor site.1 Therefore, its use is limited. The blood supply to the FAMM flap is provided
by the facial artery. When a FAMM flap is elevated,
a small amount of buccinator muscle is included in
the flap, along with the buccal mucosa and the facial
artery. Venous drainage depends mainly on the buccal venous plexus rather than the facial vein itself,
which may not be included in the flap.2 Although
the FAMM flap can be superiorly based on the angular artery to repair palatal defects, the flap needs to
be inferiorly based on the main facial artery to be
rotated to the floor of the mouth with the pivot point
near the retromolar trigone.
The submental flap can be harvested with a
width of 4 to 6 cm, depending on the redundancy of
the submental skin, while allowing primary closure
of the donor site. This flap is vascularized by a branch

of the facial artery. The anterior belly of the digastric muscle is usually included to ensure adequate
Since the facial artery supplies both the FAMM
flap and the submental flap, facial artery availability
can be an issue when a neck dissection is required.
The facial artery is commonly ligated and divided
during a neck dissection. For immediate reconstruction, the submental flap can be raised first before
neck dissection, if oncologically feasible, to ensure
its blood supply. Therefore, good communication
between the oncologic surgeon and reconstructive
surgeon is essential.

Extended Floor of Mouth Defects
When the FOM defect extends to the upper neck,
with resection of part of the suprahyoid musculature
along with a neck dissection, there is essentially a
large connection between the oral cavity and neck,
with exposure of the mandible, and a submandibular
dead space. The goals of reconstruction are to seal
the oral cavity from the neck and to eliminate the
submandibular dead space while providing reliable
lining for the FOM. Therefore, more extensive flap
reconstruction is indicated. Local or regional flaps are
usually not adequate or may not be the best choice
to achieve functional and aesthetic reconstruction.
Choices for flaps are discussed below.

The Radial Forearm Fasciocutaneous Free Flap
The radial forearm fasciocutaneous flap is a flap of
choice because it provides a thin and supple lining that recreates the lingual sulcus once healed
(Fig.€2.2). The flap is reliable and has a robust blood
supply. Flap elevation is straightforward and can
usually be completed well within 1 hour. To obliterate the submandibular dead space, some adipofascial
tissue in the upper arm is included during flap elevation (Fig.€2.2c). This adipofascial tissue is proximal to
the skin flap and is nicely positioned under the mandible during flap insetting.
A disadvantage of the radial forearm flap (RFF)
is that, in thin patients, the flap is too thin to fill the
upper neck dead space, thus increasing the risk of
infection. The donor site requires skin grafting, with
potential risks of tendon exposure, tendon adhesions,
and unfavorable aesthetic results. Anesthesia in the
proximal thenar area from sacrifice of the lateral antebrachial cutaneous nerve is common, and occasionally radial sensory nerve injury can occur, resulting in
numbness in the radial aspect of the fingers.


20 Iâ•… Topics in Head and Neck Reconstruction




Fig.€2.2â•… (a) A 35-year-old female underwent resection of a left floor of mouth tumor with a 2.5 × 4.5 cm mucosal defect in the left
lingual sulcus. (b) A radial forearm flap was harvested with some adipofascial tissue to fill the upper neck dead space. (c) Six-month
follow-up showing full range of mobility of the tongue with preservation of the lingual sulcus and (d) a well-healed donor site.

The Ulnar Artery Perforator Flap or
Ulnar Forearm Free Flap
The ulnar forearm flap is more distally based, similar to the RFF, whereas the ulnar artery perforator
(UAP) flap is more proximally located to avoid tendon exposure above the wrist. The donor site is more
hidden, and small defects can be closed primarily.
The UAP flap is usually hairless and is as thin as the
RFF. The author now prefers the UAP flap to the RFF.
A small segment of the flexor carpi ulnaris muscle
can be included to obliterate the dead space (Fig.€2.3)
without compromising hand function.
The disadvantage of the UAP flap is that the pedicle is shorter, usually 4 to 5 cm long. Also, dissection
along the ulnar nerve can be tedious. Furthermore,
the UAP flap is a true perforator flap, with small
perforating vessels, making it less robust than the
RFF, and dissection is more technically demanding.
However, in most head and neck reconstructions,
the recipient vessels are within short reach. Therefore, a long vascular pedicle is not needed. In fact, a
long pedicle will usually require careful looping and
is less desirable.

Fig.€2.3╅ A small segment of the flexor carpi ulnaris muscle
can be included in the ulnar artery perforator flap for small
dead space filling.

2â•… Oral Cavity Reconstruction

The Anterolateral Thigh Free Flap
The anterolateral thigh (ALT) free flap is a good choice
for FOM reconstruction in patients with thin subcutaneous tissue in the thigh. In most Western patients,
however, the ALT flap may be thicker than desired for
FOM reconstruction (Fig.€2.4). This is particularly true
when the flap needs to cover the exposed mandible
intraorally to replace gingival loss, although immediate flap thinning can be safely performed to reduce
the bulk. Debulking can also be performed at a second
stage several months later, even after radiotherapy
(Fig.€2.5). The advantage of the anterolateral thigh flap
is the minimal donor-site morbidity, and flap elevation can be simultaneously performed with tumor
resection by the primary surgical team, whereas the
forearm flap is usually elevated after tumor resection.
In addition, various amounts of the vastus lateralis
muscle can be harvested to cover the mandible and
to eliminate the submandibular and upper neck dead
space. Replacing FOM defects with a bulky flap should
be avoided because it may restrict tongue mobility

Fig.€2.4╅ Following resection of the ventral tongue, closure of
the remaining mobile tongue to itself may result in a “snake
tongue,” with loss of volume in the mobile tongue. A thick flap
for floor of mouth reconstruction may obliterate the labial sulcus, causing drooling and obstruction of tongue mobility.

and obliterate the lingual sulcus, causing drooling. In
obese patients, even the RFF may be too bulky, and
flap thinning is necessary.

The Pectoralis Major Pedicled Flap
The pectoralis major muscle flap can be harvested
with ease and turned over the clavicle to reach the
upper neck and floor of mouth. Whether to include
a skin paddle is optional. The muscle placed in the
FOM can remucosalize within 5 to 7 days, or it can be
covered with skin grafts, although partial skin graft
loss is common. Nevertheless, a skin graft can serve
as a biological dressing for several days. In female
patients, it is usually best not to include a skin paddle, due to its thickness as well as the distortion of
the breast after harvest. The key to reconstruction
of such defects is to obliterate the dead space in the
FOM and upper neck to prevent infection. Therefore,
a pectoralis major muscle alone may work well. To
ensure easy reach to the FOM without tension and
better aesthetic results, it is advisable to elevate the
flap as an island flap. All the muscles around the vascular pedicle near the clavicle are divided to reduce
the bulk and increase the arc of rotation. The transversely oriented clavicular portion of the pectoralis
muscle is also divided to increase pedicle length. If
necessary, a segment of the clavicle can be resected
to allow the vascular pedicle to pass through and
then can be replaced with mini titanium plates.
The disadvantages of using the pectoralis major
flap include unfavorable aesthetic results in the neck
and possible neck contracture from fibrosis of the
muscle after radiotherapy. The flap also adds additional incisions in the chest. Therefore, it is not a good
choice in young patients, especially in young women.
In patients with a long neck and underdeveloped pectoralis major muscle, the muscle may not reach the
FOM easily, and its pull-down force may compromise
the reconstruction. In our practice, the pectoralis
major flap is usually reserved for high-risk patients,
such as those of advanced age and those with severe
medical comorbidity. In young and more functional
Fig.€2.5╅ (a) Debulking of the thick flap
used for floor of mouth reconstruction in
Fig.€2.4. (b) A 6-week follow-up photograph shows a completely healed flap after




22 Iâ•… Topics in Head and Neck Reconstruction
patients, a free flap is preferred to minimize neck
deformity and to maximize functional and aesthetic
outcomes. In the hands of experienced and efficient
microsurgeons, a free flap reconstruction may not add
much operating time, because elevation of a free flap
can usually be done simultaneously with tumor ablation, while elevation of the pectoralis flap cannot start
until tumor resection is completed.

the remaining labial mucosa defect is left to remucosalize spontaneously or is skin grafted. The remucosalization process takes approximately 1 week and
heals well. The same principle applies to mandibular
reconstruction with a fibular osteocutaneous flap in
patients in whom the labial mucosa defects extend
to the vermilion (Fig.€2.7).

Reconstruction of Floor of Mouth
Defects Involving the Ventral Tongue

■⌀ Reconstruction of

When resection of the FOM involves the ventral
tongue, it is common practice to close the tongue to
itself by folding the lateral edges of the tongue ventrally and to reconstruct the FOM with a flap. With
this technique, however, the bulk of the tongue is
reduced significantly, producing a “snake tongue”
deformity (Fig.€2.4) that results in impairment of
speech and swallowing functions. An alternative
approach, preferred by the author, is to resurface the
ventral tongue and the FOM simultaneously with a
thin radial forearm fasciocutaneous free flap or UAP
flap (Fig.€2.6). This technique preserves the volume
and mobility of the tongue. Great care is taken to
preserve the blood supply to the remaining tongue.
When the resection involves the mandibular gingiva and labial mucosa up to the vermilion border,
it is important not to sew the flap all the way to the
vermilion because this will obliterate the labial sulcus and push the lip downward, causing drooling
and deformity. Instead, the flap edge should be sewn
to the labial tissue at the base of the labial sulcus;

The most common defects in the oral cavity requiring reconstruction are glossectomy defects. Glossectomy defects can be partial, subtotal, or total. Small
defects of up to one-quarter or even one-third of the
tongue with minimal resection of the FOM may be
closed primarily or with a skin graft with maximum
preservation of tongue mobility and function. However, resection of the FOM combined with neck dissection creates a connection between the oral cavity
and the neck along the lingual cortex of the mandible. These defects, even if they involve less than onethird of the tongue, are best reconstructed with a
flap to minimize the risk of infection and fistula formation, which can potentially delay crucial adjuvant
therapy. The most common defects in our practice
are hemiglossectomy defects, which account for 65%
of all glossectomy defects that require reconstruction. Because the tongue is a highly functional organ
responsible for speech and deglutition, every effort
should be made to maximize its functional preservation while providing reliable coverage.



Glossectomy Defects


Fig.€2.6╅ An alternative approach to reconstructing the ventral tongue defect is to use a thin forearm flap, which is also needed to
reconstruct the floor of the mouth. Pictured are (a) the ventral tongue defect, (b) the RFF used to resurface the ventral tongue and
to reconstruct the floor of the mouth, and (c) the healed flap at 3 months after surgery, showing good mobility of the remaining
tongue with preservation of bulk.

2â•… Oral Cavity Reconstruction





Fig.€2.7╅ (a) When resection of labial mucosa approaches the vermilion border, (b,c) sewing the flap to the mucosal margin may
obliterate the labial sulcus and push the lower lip down, causing drooling. (d) A better approach is to inset the flap to the bottom
of the labial sulcus and to leave the raw surface on the lower lip to remucosalize spontaneously to preserve the labial sulcus and
prevent drooling.

Reconstruction of Partial
(Hemi-) Glossectomy Defects
Goals of Reconstruction
The tongue is a highly functional organ with complex mobility. After resection, the remaining tongue
has the ability to produce intelligible speech and
adequate food bolus manipulation as long as it is
not tethered. Therefore, the goal of reconstruction
is to preserve the mobility of the remaining tongue
in addition to providing basic soft tissue coverage. Excess bulk in the oral cavity may impede the
mobility of the remaining tongue, resulting in poor
function. Thus, a bulky flap should be avoided in
hemiglossectomy reconstruction. Consideration
should also be given to sensory reinnervation.

Choice of Flaps
A thin flap, such as the radial forearm fasciocutaneous
free flap, UAP flap, or a thin ALT free flap, is usually the
flap of choice. The radial and ulnar forearm free flaps
are the author’s preferred flaps for hemiglossectomy
reconstruction because they provide thin and pliable
tissue and allow for the possibility for sensory reinnervation. The ALT flap, which also has the potential
for sensory reinnervation, is another excellent choice,
and it may be the best option in thin patients due to
its minimal donor-site morbidity. The lateral arm flap
is also a good choice in thin patients, with the potential for sensory reinnervation and primary closure of
the donor site. However, the more difficult dissection
and smaller caliber (usually 1.5 mm) of the pedicle
artery make this flap less popular.


24 Iâ•… Topics in Head and Neck Reconstruction



Fig.€2.8╅ A hemiglossectomy defect (a) may extend only to the base of tongue or (b) involve the oropharyngeal wall, base of the
tongue, and lateral pharyngeal wall down to the epiglottis.

The pectoralis major muscle or myocutaneous
flap may provide basic coverage; however, its bulk
and potential to result in tongue tethering and neck
contracture are disadvantages for hemiglossectomy
reconstruction, as discussed above. The functional
outcomes following pectoralis major pedicle flap
reconstruction are usually compromised. Therefore,
this flap is usually reserved for salvage after a failed
free flap reconstruction or for use in high-risk cases
deemed unsuitable for free flap reconstruction.

nervation. The lingual nerve is a better recipient
nerve for sensory reinnervation of the neotongue
in comparison to other nerves, such as the inferior
alveolar nerve and the greater auricular nerve. The
lingual nerve can be found along the lingual cortex
and anterior to the angle of the mandible (Fig.€2.9).
It is usually 2 mm in diameter. After evaluation of
the defect, a Dobhoff feeding tube is inserted into
the stomach, if it has not been placed already by the
ablative surgeons.

Surgical Techniques
Evaluation of the Defect
The length of the surgical defect is measured from
the tip of the remaining tongue to the posterior limit,
which can be in the base of the tongue or immediately above the epiglottis. In the latter case, there
will also be a defect in the lateral pharyngeal wall
(Fig.€2.8). The width of the defect is difficult to measure accurately because of the loss of three-dimensional structure. A flap width of 6 to 8 cm is usually
required to adequately recreate the lateral sulcus
(gutter) and provide enough surface area coverage.
Neck dissection is commonly performed along with
a glossectomy; therefore, extra soft tissue is included
in the flap design to eliminate any submandibular/
upper neck dead space. The cut end of the lingual
nerve should be explored for potential sensory rein-

Fig.€2.9╅ The cut end of the lingual nerve can be found along
the lingual cortex of the mandible, just anterior to the mandibular angle.

2â•… Oral Cavity Reconstruction

Exploring Recipient Vessels
After assessment of the defect, the recipient vessels
are examined. The lingual artery is often exposed
and divided during glossectomy. It has a diameter
between 2 and 2.5 mm in most cases, making it an
ideal recipient artery. The artery is dissected back
to its origin from the external carotid artery and is
brought under the posterior belly of the digastric
muscle, which can be divided if necessary (Fig.€2.10).
To maximize the inflow of blood to the flap, the
curved portion of the artery is removed, leaving
only a 1 cm stump on the external carotid artery.

The author’s preferred recipient vein is the common
facial vein stump, which drains into the internal jugular vein. It has a diameter of 3 to 5 mm. The second
choice is to perform an end-to-side anastomosis on
the internal jugular vein itself. If the internal jugular
vein is also unavailable, the external jugular vein is
the next choice if it is in good condition. Care must
be exercised postoperatively if the external jugular
vein is used to prevent tight tracheostomy ties from
compressing this fairly superficial vein.

Flap Harvesting: The Radial Forearm Flap
The flap design is based on the dimensions of the
defect. Flap elevation is well described in the literature, with the following modifications. The author
prefers to use the venae comitantes as vein outflow
to the cephalic vein. In many patients, the cephalic
vein is far away from the radial artery. Including the
cephalic vein may unnecessarily increase the flap
width. In most cases, the venae comitantes of the RFF
are adequate for venous drainage. However, the venae
comitantes can be extremely small and inadequate
in some patients. Therefore, the author’s approach is
to tentatively outline the flap, centered on the radial
vessels, and make a small transverse incision at the
wrist crease to explore the venae comitantes first
(Fig.€2.11). If one of these veins is at least 1 mm in
diameter, there is no need to include the cephalic
vein. Otherwise, the flap design is shifted laterally
to capture the cephalic vein. Suprafascial dissection is preferred,3 and flap elevation is performed


Fig.€2.10╅ (a,b) The lingual artery can be found underneath
the posterior belly of the digastric muscle. It is trimmed back
to remove the curvature. The common facial vein stump off
the internal jugular vein (IJ) can be used for end-to-end anastomosis, commonly with a vein coupler.

Fig.€2.11╅ A small exploratory incision was made first at the
wrist crease to confirm the size of the venae comitantes of the
radial forearm flap vascular pedicle. If both venae comitantes
are less than 1 mm in diameter, the flap design is shifted more
laterally to include the cephalic vein.


26 Iâ•… Topics in Head and Neck Reconstruction
ing the subcutaneous tissue attached to the flap and
the vascular pedicle (Fig.€2.12). The venae comitantes are usually no larger than 1.5 mm in diameter
before they converge; therefore, the vein is usually
taken above the convergence of the venae comitantes, where the diameter is greater than 2.5 mm in
most cases. Once the flap and the vascular pedicle
are completely dissected, the tourniquet is released
to perfuse the flap and the hand for several minutes
before dividing the pedicle.

Flap Harvesting: The Ulnar Artery
Perforator Flap
Fig.€2.12╅ When bulk is needed to fill the dead space in the
upper neck, the adipofascial tissue in the upper forearm can be
included in the RFF.

under tourniquet control. The thenar branches of
the superficial radial sensory nerve can be preserved
with suprafascial dissection. At the midforearm
level, the lateral antebrachial cutaneous nerve can
be found near the midline. This nerve is included in
the flap for sensory reinnervation. In most hemiglossectomy cases, there is a small dead space left under
the mandible. Therefore, some adipofascial tissue
from the proximal forearm is included in the flap to
fill the dead space, which is an important measure
to decrease the risks of infection and fistula formation. This is accomplished by elevating the proximal
forearm skin flaps below the subdermal plexus, leav-

The ulnar artery perforator flap is now preferred by
the author for reconstruction of hemiglossectomy
defects. (Key points for flap design and elevation are
discussed below under surgical techniques.) The distal border of the flap is usually 5 cm above the wrist
crease to avoid tendon exposure (Fig.€2.13). Dissection is performed under tourniquet control and
begins on the radial side and proceeds toward the
ulnar side. Suprafascial dissection is performed until
the perforators are seen where the fascia is incised
and subfascial dissection is performed. The perforators are small, thus meticulous dissection is required
(Fig.€2.14). The ulnar nerve is carefully separated
from the ulnar artery and vein, and retraction of the
nerve should be avoided. The medial antebrachial
cutaneous nerve is included in the flap for sensory
reinnervation (Fig.€2.14). A small segment of the
Fig.€2.13╅ The ulnar artery perforator flap is
designed over the ulnar artery, with the distal end
of the flap ~€5 cm above the wrist crease to minimize tendon exposure.

Fig.€2.14╅ The medial antebrachial cutaneous
nerve can be included in the ulnar artery perforator flap for sensory reinnervation. The perforators
are usually small; therefore, meticulous dissection
is required.

2â•… Oral Cavity Reconstruction
flexor carpi ulnaris muscle can be included for dead
space filling (Fig.€2.3).

ting is completed through the neck exposure, before
vascular anastomoses are performed. When flap insetting reaches the mandible, one can either proceed with
vascular anastomosis or continue the insetting intraorally depending on the surgeon’s preference and the
ischemia time. Intraorally, one lateral edge of the flap
is sutured to the gingiva and the other to the cutting
edge of the remaining tongue. A key step in flap insetting is to create the ventral sulcus of the neotongue to
avoid tethering. The distal medial corner of the flap is
sutured to the tip of the remaining tongue. The distal
edge of the flap is then sutured to the ventral surface of
the remaining tongue (Fig.€2.15), thus creating a ventral sulcus and lateral gutter (Fig.€2.16). A single layer
of interrupted 3–0 absorbable sutures is preferred by
the author, although some surgeons prefer horizontal
mattress sutures. It is important, however, not to tie the
horizontal mattress sutures too tightly so as to avoid
flap edge necrosis and fistula formation. When there is
no gingiva left to attach the flap to, it can be sewn to the
teeth by tying the suture knots around the teeth.

Flap Harvesting: The Anterolateral Thigh Flap
In thin patients, the ALT flap can also be used for
hemiglossectomy reconstruction. (Key points for
flap design and elevation are discussed below under
surgical techniques.) To fill the submandibular dead
space, a small segment of the vastus lateralis muscle
is included in the flap. The periphery of the flap can
be thinned to reduce the bulk, if necessary. The lateral femoral cutaneous nerve can be included in the
ALT flap for sensory reinnervation.

Flap Insetting
The distal end of the flap is oriented toward the tip of
the remaining tongue. Flap insetting starts from the
posterior end of the defect, either at the base of the
tongue or above the epiglottis. This part of flap inset-



Fig.€2.15╅ One important aspect of hemiglossectomy reconstruction is to preserve the mobility and avoid tethering of the remaining tongue. (a) The ventral sulcus from the tip of the tongue to the mandibular gingiva measures 6 to 8 cm. Therefore, a flap width
of 6 to 8 cm is required to recreate the ventral sulcus of the mobile tongue. (b) One corner of the distal flap is sewn to the tip of the
tongue, and the other, to the mandibular gingiva at the anterior midline.



Fig.€2.16╅ (a) Adequate width of the flap is needed to recreate the lateral gutter of the tongue. (b) Photograph taken 9 months
after surgery showing good mobility of the reconstructed tongue.


28 Iâ•… Topics in Head and Neck Reconstruction
Revascularization and Reinnervation
Once the flap is partially or completely inset, the flap
pedicle is brought under the mandible to the neck.
Great care should be taken not to twist the pedicle.
When the lingual artery and common facial vein
are used, the vascular pedicle is usually longer than
needed. The pedicle is then carefully positioned with
a gentle curve to avoid kinking. Next, the cut end of
the lingual nerve is freshened and the sensory nerve
from the flap is anastomosed to the lingual nerve
with several epineural 8–0 nylon sutures. This is
usually done with loupe magnification, as the lingual
nerve is inaccessible to the operating microscope.
Sensory recovery of the flap with this technique has
been well documented and, therefore, sensory reinnervation is strongly recommended. After the vascular and neural anastomoses are completed, the
extra adipofascial tissue or muscle from the flap is
carefully positioned to fill the submandibular space
while avoiding pedicle compression.
Next, the oral cavity is irrigated with normal
saline until clean. The neck wound is then irrigated
with an ample amount of warm normal saline (2 or
3 L), taking care not to squirt the saline directly on
the vascular pedicle to avoid vessel spasm. Meticulous hemostasis is essential to avoiding a postoperative hematoma, which can compress the vascular
pedicle. All areas should be carefully examined, even
if they have already been examined by the ablative
surgeons. A 15 Fr Blake drain is placed on each side
of the neck, lateral to the internal jugular vein. At this
point, the neck is slightly flexed (take out the shoulder roll and flex the neck to a neutral position), and
the vascular pedicle is examined again. Because the
neck is usually hyperextended during surgery, flexing the neck to a normal position can significantly
change the position of the vascular pedicle, causing
kinking or compression. The pedicle is repositioned if
necessary to avoid such problems. The neck incision
is then closed. Finally, the reinforced endotracheal
tube is replaced with a #6 Shiley tracheostomy tube,
if this has not been done by the ablative surgeons.

Reconstruction of Total or
Subtotal Glossectomy Defects
Goals of Reconstruction
Although functional outcomes after reconstruction for partial glossectomy defects are generally
good, speech and swallowing functions after reconstruction for total and subtotal glossectomy defects
remain disappointing. The extent of surgical resection may be the most important factor affecting
function. The more tongue musculature that is left

intact, the better the functional outcome will be.
Unlike with hemiglossectomy, once most or all of the
tongue is removed, mobility of the remaining tongue
is no longer a concern. Therefore, the main goal of
reconstruction is to provide enough tissue bulk. Tissue bulk is important for reconstructing large defects
of the tongue for two reasons. First, it is needed to
help the neotongue touch the palate to produce better speech and push food toward the hypopharyx.
Second, the tissue bulk diverts saliva and food to
the lateral pharyngeal gutters during swallowing to
minimize aspiration.4

Choice of Flaps
The Anterolateral Thigh Flap
To achieve adequate tissue bulk, large tongue defects
are typically reconstructed with a myocutaneous
flap. In Western patients, the ALT flap usually has the
right amount of bulk for total or near-total tongue
reconstruction5,6 and has become the author’s flap of
choice. It also has the advantages of providing sensory and motor reinnervation and minimal donorsite morbidity. This is particularly important in
high-risk patients. Also, a simultaneous two-team
approach is easily accomplished with the ALT flap.

The Vertical Rectus Abdominis Myocutaneous
(VRAM) Flap
The VRAM flap is a time-honored flap that is reliable
and easy to harvest.7 The subcutaneous fat in the
VRAM flap is softer than that in the ALT flap, making it easier to inset. The included rectus abdominis
muscle fills the upper neck defect nicely. However,
the VRAM has several disadvantages. In elderly
patients and those with significant chronic obstructive pulmonary disease with minimal pulmonary
reserve, harvesting the VRAM may further compromise their pulmonary function due to incisional
pain and abdominal weakness. Using muscle alone
with skin grafting is not recommended because significant atrophy can occur quickly, especially after
radiotherapy, resulting in a funnel shape that allows
food to pour into the hypopharynx and larynx, causing aspiration. Furthermore, sensory and motor reinnervation with the VRAM flap is not satisfactory.

Other Free Flaps
For obese patients in whom ALT or VRAM flaps are
too thick, the RFF, UAP flap, or the lateral arm flap
may be thick enough to provide adequate bulk. The
gracilis myocutaneous flap and the latissimus dorsi
myocutaneous flap also have been used, with motor

2â•… Oral Cavity Reconstruction

The Pedicled Pectoralis Major Flap
Free flap reconstruction is usually a much better
option than pedicled flaps for total or subtotal glossectomy defects. The pedicled pectoralis flap, however, may be used in high-risk patients who are poor
candidates for free flap reconstruction or in patients
in whom a free flap has failed.

Surgical Techniques
Flap Design and Elevation: The ALT Flap
Most subtotal glossectomy defects involve the entire
mobile tongue and 50% or more of the base of the
tongue. The FOM musculature is usually removed
during resection, with the hyoid bone as the distal
extent of the defect (Fig.€2.17