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Regional Flaps in Head and Neck Reconstruction: A Reappraisal

Article  in  Journal of Oral and Maxillofacial Surgery · March 2015

DOI: 10.1016/j.joms.2014.10.021

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 SURGICAL ONCOLOGY AND RECONSTRUCTION

Regional Flaps in Head and Neck

Reconstruction: A Reappraisal
Giacomo Colletti, MD,* Karim Tewfik, MD,y Alessandro Bardazzi, MD,z
Fabiana Allevi, MD,x Matteo Chiapasco, MD,k Marco Mandala, MD,{
and Dimitri Rabbiosi, MD#
Purpose: Starting from our experience with 45 consecutive cases of regional pedicled flaps, we have
underlined the effectiveness and reliability of a variety of flaps. The marketing laws as applied to surgical
innovations are reviewed to help in the understanding of why regional flaps are regaining wide popularity
in head and neck reconstruction.
Materials and Methods: From January 2009 to January 2014, 45 regional flaps were harvested at
San Paolo Hospital to reconstruct head and neck defects. These included 35 pectoralis major muscular
and myocutaneous flaps, 4 lower trapezius island or pedicled flaps, 3 supraclavicular flaps, 2 latissimus
dorsi pedicled flaps, and 1 fasciocutaneous temporal flap. The basic literature of marketing regarding
the diffusion of new products was also reviewed.
Results: Two myocutaneous pectoralis major flaps were complicated by necrosis of the cutaneous
paddle (one complete and one partial). No complete loss of any of the 45 flaps was observed. At 6 months
of follow-up, 2 patients had died of multiple organ failure after prolonged sepsis. The 43 remaining patients
had acceptable morphologic and functional results.
Conclusions: Regional and free flaps appear to compete in many cases for the same indications. From the
results of the present case series, regional flaps can be considered reliable reconstructive choices that are
less expensive than their free flap alternatives. The ‘‘resurrection’’ of regional flaps can be partially justified
by the changes in the global economy and the required adaptation of developed and developing countries.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 73:571.e1-571.e10, 2015

Free flaps have been considered the reference standard
for head and neck reconstruction,1 even after removal
of benign neoplasms.2 Local and regional flaps, howev-
er, are still a safe and useful option. After a period of
apparent oblivion, an increasing number of studies
have been published, with various investigators
inviting surgeons to reconsider the use of these
flaps.3-5 In some cases, local or regional pedicled flaps
represent the best reconstructive option. The
mucosal cheek flap, Bichat fat pad flap, buccinator
myomucosal flap, facial artery myomucosal flap, and
temporalis muscle flap should be the first choice for
limited maxillary and mandibular defects (cheek
mucosa and Bichat fat pad flap6); limited tongue,

*Assistant, Division of Maxillo-Facial Surgery, Department of
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Universita degli Studi di Milano, Milan, Italy.
yResident, Division of Maxillo-Facial Surgery, Department of
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Universita degli Studi di Milano, Milan, Italy.
zResident, Division of Maxillo-Facial Surgery, Department of
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Universita degli Studi di Milano, Milan, Italy.
xResident, Division of Maxillo-Facial Surgery, Department of
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Universita degli Studi di Milano, Milan, Italy.
kHead, Division of Oral Surgery, Department of Biomedical,
Surgical and Dental Sciences, San Paolo Hospital, Universita degli
Studi di Milano, Milan, Italy.
{Assistant, Department of Otolaryngology, University of Verona,
Verona, Italy.
#Assistant, Division of Maxillo-Facial Surgery, Department of
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Universita degli Studi di Milano, Milan, Italy.
Address correspondence and reprint requests to Dr Colletti:
Division of Maxillo-Facial Surgery, Department of Biomedical, Surgi-
cal and Dental Sciences, San Paolo Hospital, Universita degli Studi di
Milano, Piazza della Repubblica 1/a, Milan 20121 Italy; e-mail:
giacomo.colletti@gmail.com
Received August 25 2014
Accepted October 21 2014
Ó 2015 American Association of Oral and Maxillofacial Surgeons
0278-2391/14/01620-6
http://dx.doi.org/10.1016/j.joms.2014.10.021

571.e1
571.e2
palatal, and oral floor defects (buccinator myomucosal
flap,7 facial artery myomucosal flap8); medium size to
major maxillary defects in which bony reconstruction
is not needed or planned (temporalis muscle flap9).
The settings in which local or regional flaps will be
the preferred reconstructive technique have not been
discussed. The aim of the present report was to focus
on the indications and results for major regional flaps.
Several factors can result in surgeons choosing a
regional flap instead of a free flap. These include severe
patient comorbidities, adverse anatomic conditions
with a compromised blood supply, and previous radio-
therapy, among others. Furthermore, other circum-
stances, such as the lack of a microvascular surgical
team or financial issues, which can be observed in
developing countries, can make free flap reconstruc-
tion unfeasible. Finally, sensitivity to the economic
burden of healthcare could make regional flaps prefer-
able to free flaps in a variety of circumstances.
Materials and Methods
From January 2010 to January 2014 at San Paolo
Hospital (Milan, Italy), 45 regional flaps were used in
44 patients for head and neck reconstruction after
tumor resection (Table 1). Of the 45 regional flaps,
35 were pectoralis major flaps, 4 were lower trapezius
flaps, 3 were supraclavicular flaps, 2 were latissimus
dorsi pedicled flaps, and 1 was a temporalis fasciocuta-
neous flap. Most of the reconstructions were second-
ary to squamous cell carcinoma (n = 41), with the
remaining including 2 chordomas, 1 mixed cell carci-
noma, and 1 basal cell carcinoma. Reconstruction
with the buccinator myomucosal, facial artery myomu-
cosal, Bichat fat pad, and temporalis muscle flaps was
excluded from the present case series.
A total of 30 reconstructions were necessary to
restore intraoral defects, including 21 mandibular, 2
floor of the mouth, 5 partial tongue, and 2 hypophar-
yngeal defects. Of the 44 patients, 13 required skin
reconstruction, including 7 cheeks, 3 scalps (1 patient
with a scalp defect required reconstruction of 2
different regions), and 4 cervical-laryngeal fistulas. In
2 cases, pedicled flaps were used in association with
a fibula free flap. Both patients had large mandibular
defects that required through and through reconstruc-
tion. In almost all the mandibular defects (n = 20),
2.4-mm, load-bearing titanium plates were used as
fixation devices.
Regional flaps were chosen instead of free flaps for
the following reasons. In 3 cases (3 of 4 cases in which
a trapezius flap was used), the resection site was the
high occipital region. Thus, a lower trapezius flap
was harvested simultaneously with the reconstruc-
tion, eliminating the need to rotate the patient,
perform the reconstruction in a second session, or
REAPPRAISAL OF REGIONAL FLAPS
perform microvascular anastomoses in a difficult
position. The 2 latissimus dorsi pedicled flaps were
performed in patients with severe comorbidities to
shorten the operative time. The region of resection
(wide craniofacial resection) was close enough to
obtain safe closure with a pedicled latissimus flap.
All the supraclavicular flaps were performed in
patients with a vessel-depleted neck from previous
surgery and radiotherapy (n = 1) or as autonomized
salvage flaps (n = 2) after free flap failure. The remain-
ing patients in the present study underwent recon-
struction with pedicled flaps because of severe
comorbidities (eg, ischemic heart disease with diffuse
atherosclerosis) or a poor prognosis.
This was a retrospective study. As such, it was
granted exemption from the local institutional
review board. The present study adhered to the guide-
lines of the Declaration of Helsinki.
Results
No evidence of complete flap failure was observed.
In 1 patient, we observed complete skin loss with
survival of the muscular portion of the flap. In 1 case,
partial skin loss was detected. One patient required a
return to the operating room because of active
bleeding after closure of a pharyngocutaneous fistula
with a pectoralis major flap. After the thoracic wound
had been reopened and a bleeding perforator ligated,
he had a full recovery with no additional complica-
tions. No fistula was observed in any case. The donor
sites were closed primarily in all cases, except for the
latissimus dorsi pedicled flap, which required a
partial-thickness skin graft harvested from the thigh.
A total of 20 load-bearing plates were used to recon-
struct the bone mandibular defects. Of these plates, 7
presented with late extrusion (>12 months after the
first operation) and required removal. Two patients
died of multiple organ failure after prolonged sepsis
at 6 months postoperatively.
CASE 1
The first patient included in the present report was
a 55-year-old woman (patient 41, Figs 1 to 6) affected
by squamous cell carcinoma of the right border of the
tongue. She had severe comorbidities, including
ischemic heart disease and diffused arteriosclerotic arte-
riopathy. Thus, we chose a regional flap for reconstruc-
tion. With the patient under general anesthesia, she
underwent temporary tracheostomy, right selective
neck dissection (level I to III), right partial glossectomy,
and reconstruction with a pectoralis major flap. No com-
plications were observed during recovery. The follow-
up examination after 1 year showed the patient had
good functional and aesthetic outcomes with no evi-
dence of relapse.
COLLETTI ET AL 571.e3

FIGURE 1. Preoperative image of squamous cell carcinoma of the
right border of the tongue in a 55-year-old woman (patient 41, case
1 in the present report).
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
FIGURE 3. Intraoperative image showing the tongue defect after
resection.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.

pedicled flap. Good wound healing was observed

CASE 2 during the weeks after surgery, and the follow-up
The second patient was 65-year-old woman (patient examination after 1 year showed good functional and
30, Figs 7 to 11) affected by an extensive squamous aesthetic outcomes without relapse.
cell carcinoma of the scalp that had previously been
treated with a nonradical excision by another unit.
The resection required positioning the patient
prone; therefore, we decided to simultaneously raise
a pedicled flap without the need to change the
patient’s position. She underwent wide scalp
resection and reconstruction with a lower trapezius

FIGURE 2. Preoperative magnetic resonance imaging scan FIGURE 4. Myocutaneous pectoralis major flap harvested to
showing extension of the squamous cell carcinoma of the tongue. reconstruct the tongue defect.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015. 2015.
571.e4
FIGURE 5. Intraoperative image showing complete reconstruction
of the tongue.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
CASE 3
The third patient was a 71-year-old man (patient 40,
Figs 12 to 16) affected by a large relapsing basal cell
carcinoma of the right middle third of the face with in-
traorbital invasion. The patient also had chronic heart
failure; therefore, the shortest procedure was chosen.
Under general anesthesia, he underwent a large exci-
sion with orbital exenteration. In the same operative
session, a latissimus dorsi pedicled flap was harvested.
Immediately after the resection, it was rotated to
reconstruct the defect. The donor site was repaired us-
ing a skin graft harvested from the patient’s thigh. At
the follow-up examination after 1 year, the patient
had acceptable aesthetic outcomes with no evidence
of relapse.
Discussion
Just as with most innovations in medical science,
the introduction of a new successful surgical tech-
FIGURE 6. Image at the 1-year follow-up visit showing satisfactory
morphologic and functional outcomes.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
REAPPRAISAL OF REGIONAL FLAPS
FIGURE 7. Patient 30 (case 2 in the present report), a 65-year-old
woman, with extensive squamous cell carcinoma of the scalp previ-
ously treated with nonradical excision.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
nique usually sees 3 different moments in its history.
The first phase is when the technique is introduced
and adopted only marginally. In the second period,
an ‘‘explosion’’ of its use and multicenter discussions
occur. Finally, in the third phase, a decrease occurs
in its popularity, although the technique is used
steadily, but with lower frequency than during its
‘‘hype’’ phase.
This type of diffusion was first described by Bass10
in 1969 and is typical of many innovations in the indus-
trial technology, agricultural, educational, pharmaceu-
tical, and consumer durable goods markets. Mahajan
et al11 in 1990 reviewed the Bass model and made addi-
tional refinements and extensions.
The Bass model can be drawn visually with a curve
that reflects a modification of a shifted, modified Gom-
pertz distribution (Fig 17). At times in this distribution,
a fourth phase of complete oblivion (Fig 17B) or of
‘‘resurrection’’ (Fig 17C) of the product can occur. A
recent example of resurrection of a consumer product
is that of Bausch and Lomb’s Ray Ban Wayfarer eye-
glasses.12 These eyeglasses saw a period of high popu-
larity from their introduction in the market in 1956 to
the beginning of the 1990s. Then they became almost
COLLETTI ET AL
FIGURE 8. Wide scalp and cranial bone resection with exposure
of the dura.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
forgotten. In 2007, the original Wayfarer were brought
back to the market in their original form and saw a
new era of widespread diffusion in the market. The
diffusion of a scientific innovation (and, as such, any
surgical technique) follows the same rules of marketing
science.
Since their introduction in the 1960s13 (although
some regional pedicled flaps were described much
earlier14), pedicled regional flaps went through wide-
spread diffusion that made them the standard tech-
nique in head and neck reconstruction. However, at
the end of the 1980s and the beginning of the 1990s,
free flaps became popular, and pedicled regional flaps
were used with decreasing frequency.
It appears that in the recent history of head and
neck reconstruction, pedicled and free flaps have
concurred for the same indications and that their
use, in some cases, can be mutually exclusive. There-
fore, during the boom period of free flaps, pedicled
regional flaps have been almost abandoned. In
contrast, currently, when we are probably facing the
steady state of free flap diffusion, the use of regional
flaps is, in fact, being resurrected.
Still, free flaps are considered the reference standard
for many cases of head and neck reconstruction; how-
571.e5
FIGURE 9. Lower trapezius island flap harvested to reconstruct the
scalp defect.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
ever, a significant body of data has been increasing
slowly but steadily in which pedicled flaps have
been used in comparable settings. In many instances,
pedicled or microvascular soft tissue flaps compete
for the same indication, each technique with its advan-
tages and disadvantages.
The key question seems to be in which circum-
stances would free flaps have the advantage over
regional flaps and in which circumstances regional flaps
would be preferable or superior. It has been reported
that free flaps have superior success rates compared
with pedicled flaps. Free flaps appear to be extremely
reliable, with a reported success rate of $95% in
some reports.1 Two very large case series, however,
have declared success rates ranging from 97.6 to 98%
for the pectoralis major pedicled flap.15,16 Only a
multicenter, prospective, randomized study could
definitively prove the superior reliability of free flaps
compared with pedicled flaps; however, no such
study has been published. Comparing different case
series with each other can only provide an idea of flap
reliability. Also, if we compare these case series, it
appears that pedicled and free flaps are equally reliable.
Another key aspect is donor site morbidity. The pro-
ponents of different techniques have tended to declare
571.e6 REAPPRAISAL OF REGIONAL FLAPS

FIGURE 12. View of a 71-year-old man (patient 40, case 3 in the

present report) affected by a large relapsing basal cell carcinoma of
the right middle third of the face with intraorbital invasion.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
FIGURE 10. Intraoperative image showing completed scalp
reconstruction.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.

FIGURE 11. Image at the 1-year follow-up visit showing a satisfac- FIGURE 13. Intraoperative image showing extensive resection of
tory morphologic outcome. the right cranium and face.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015. 2015.
COLLETTI ET AL
FIGURE 14. Latissimus dorsi pedicled flap harvested to reconstruct
the defect. The donor site closure required a split-thickness skin graft
harvested from the thigh.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
that their technique is more anatomically respectful
and results in lower donor site morbidity. Again, this
does not appear to be related to whether the flap is a
regional pedicled or distant microvascular flap. Just
to cite a couple of examples, the donor site morbidity
of a pectoralis major muscle flap17,18 is not superior to
a latissimus dorsi microvascular flap19 and an inferior
trapezius myocutaneous flap20 does not have greater
donor site morbidity than a parascapular free flap.21
Considering the published data, it appears that the
most fragile donor site in terms of local donor site
complications is the forearm.22 The radial forearm
has usually been transferred as a free flap.
The amount and quality of soft tissues to be trans-
ferred might represent an argument in favor of free
flaps. Again, this is debatable. Reports have been pub-
lished of vast soft tissue reconstruction obtained with
either free or pedicled flaps.23,24 Horn et al,25 in their
recent study, compared free anterolateral thigh flaps
and latissimus dorsi flaps in the reconstruction of
extensive defects. The mean latissimus dorsi flap
571.e7
FIGURE 15. Intraoperative image showing the completed recon-
struction.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
surface was 115.8 cm2 (range 20.0 to 600.0). The
mean anterolateral thigh flap surface was 67.0 cm2
(range 20.0 to 330.0). In 1978, Maxwell et al26 re-
ported a latissimus dorsi pedicled flap dimension of
12  35 cm. In a recent study of trapezius island myo-
cutaneous flap, Chen et al27 described a mean size of
9.8  6.3 cm. In the present case series, ample recon-
structions were obtained with pedicled regional flaps.
Some situations exist in which free flaps and
regional flaps are simply not comparable. In major
bone reconstruction, free flaps are necessary, and
pedicled local or regional flaps (eg, pedicled calvarial
flaps) cannot offer the same amount and quality of
bone. Moreover, if soft tissues are lacking or unreli-
able (eg, after radiotherapy), bone from a microvas-
cular flap is mandatory. Free flaps are the only
choice for reconstruction in cases in which pedicled
flaps cannot reach a too-distant defect, such as major
full-thickness defects of the apex of the head. In such
cases, small defects can easily be reconstructed using
local scalp flaps; however, vast reconstruction will
require a large amount of soft tissue not provided
571.e8
FIGURE 16. Image at the 1-year follow-up visit showing a satisfac-
tory morphologic outcome.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
by any regional flap. Wide skull base defects for which
temporalis or pericranial flaps are insufficient or not
available need to be lined with reliable, well-
vascularized free flaps.28
Free flaps are needed for reconstruction that re-
quires unusual, thin, plicated shapes, such as the soft
palate and upper pharynx.29 Finally, free flaps have
the advantage that their very small pedicle (compared
with regional and random local flaps) can be easily and
safely passed through anatomic strictures.30,31
Regional flaps will be the only choice for very select
cases. The lack of donor vessels is one of these circum-
stances. Although it has been declared that bridge
vessels can be used to reach distant donor vessels in
the thorax, in the presence of a vessel-depleted
neck, a regional flap will be a better option.
Free flaps are more expensive procedures and
require specific instruments and training, making
regional flaps the preferred procedure in developing
countries. Also, with the economic crisis, we are
facing very high pressures for cost containment of
the health expense.32 According to some recent
REAPPRAISAL OF REGIONAL FLAPS
FIGURE 17. Bass model diagram. Line A shows the theoretical
progression of adoptions in time; line B represents complete
oblivion; and line C, a phase of resurrection.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg
2015.
investigations,33 regional flaps are less expensive
than their free flap counterparts. Thus, paradoxically,
it could be that regional flaps will regain the role of
the ‘‘workhorse’’ for head and neck reconstruction,17
leaving free flaps as the resource of choice only for
select cases, even in developed countries.
Two additional circumstances exist in which
deciding between free and pedicled flaps is arduous.
First is the case of patients with a poor oncologic
prognosis and/or with severe comorbidities. Clear
guidelines for major surgery in these cases are lacking
in published studies. Even if some investigators might
disagree,34 it would seem logical to choose the simplest
and shortest procedure for these patients.35 Thus,
regional flaps might seem preferable in such settings.
An interesting topic is the decision of reconstruc-
tion once a previous free flap has failed. This is a
debated issue, and although some investigators might
consider a regional flap as the ideal ‘‘salvage’’ recon-
structive procedure, other researchers could disagree
and consider a second free flap the most reliable pro-
cedure after failed microvascular reconstruction.36,37
Colletti et al3 recently published their experience
with autonomized regional flaps in these selected
cases. Autonomizing a regional flap maximizes the
chances of success, allowing the receiving site to
heal from the infection that almost invariably develops
after failure of a free flap and is one of the very few
absolute contraindications to performing microvas-
cular reconstruction. Finally, locoregional flaps still
remain a valid option in association with free flaps to
reconstruct extensive head and neck defects, such as
described by Bianchi et al.4
In conclusion, despite the increasing use of free
flaps, regional flaps are still a valid and safe option for
head and neck reconstruction that allow good
aesthetics and functional outcomes. Some issues not
commonly assessed, including economic costs and
COLLETTI ET AL 571.e9

Table 1. PATIENTS RECRUITED FOR THE PRESENT STUDY

Pt. No. Diagnosis Tumor Site Flap Plate Complications

1 SCC Mandible PMF 2.4-mm LB Late plate extrusion

2 SCC Mandible PMF 2.4-mm LB Late plate extrusion
3 SCC Mandible PMF 2.4-mm LB Late plate extrusion
4 SCC Mandible PMF 2.4-mm LB —
5 SCC Tongue LTF — —
6 SCC Cheek PMF — Partial skin loss
7 SCC Mouth floor PMF — —
8 SCC Cheek PMF — —
9A Chordoma Scalp PMF — —
9B Chordoma Scalp LTF — —
10 SCC Mandible PMF 2.4-mm LB —
11 SCC Mouth floor PMF — —
12 SCC Mandible PMF 2.4-mm LB —
13 SCC Mandible PMF 2.4-mm LB —
14 SCC Mandible PMF 2.4-mm LB —
15 MCT Cheek PMF — —
16 SCC Mandible SF — —
17 SCC Tongue PMF — —
18 SCC Mandible PMF 2.4-mm LB Late plate extrusion, partial skin
loss, death
19 SCC Cheek TFF — —
20 SCC Mandible PMF 2.4-mm LB Death
21 SCC Mandible PMF 2.4-mm LB —
22 SCC Mandible PMF 2.4-mm LB —
23 SCC CLF PMF — —
24 SCC Mandible PMF 2.4-mm LB —
25 SCC Tongue PMF — —
26 SCC CLF PMF — Postoperative hemorrhage
27 SCC Tongue PMF — —
28 SCC Mandible PMF 2.4-mm LB —
29 SCC Mandible PMF 2.4-mm LB Late plate extrusion
30 SCC Scalp LTF — —
31 SCC Cheek LDF — —
32 SCC CLF SF — —
33 SCC Mandible PMF and FFF 2.4-mm LB —
34 SCC Cheek PMF — —
35 SCC Mandible PMF 2.4-mm LB Late plate extrusion
36 SCC CLF PMF — —
37 SCC Mandible SF and FFF 2.4-mm LB Late plate extrusion
38 SCC Hypopharynx PMF — —
39 SCC Hypopharynx PMF — —
40 BCC Cheek LDF — —
41 SCC Tongue PMF — —
42 SCC Mandible PMF 2.4-mm LB —
43 SCC Scalp LTF — —
44 SCC Mandible PMF 2.4-mm LB Total skin loss

Abbreviations: BSC, basal cell carcinoma; CLF, cervical-laryngeal fistula; FFF, free fibula flap; LB, load bearing; LDF, latissimus dorsi
flap; LTF, lower trapezius flap; MCT, mixed cell tumor; PFM, pectoralis major flap; Pt. No., patient number; SCC, squamous cell
carcinoma; SF, supraclavicular flap; TFF, temporalis fasciocutaneous flap.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
 571.e10
oncologic prognosis, should be carefully considered in
the evaluation of the best flap to use.
Acknowledgments
The authors acknowledge Dr Leonard Kaban for his help with the
discussion section. This was influenced very much by the concept of
‘ Leonard’s Law’’ regarding the acceptance of new surgical
techniques.
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