S o f t T i s s u e Re c o n s t r u c t i o n

for Head and Neck A blative

Defects
Stavan Y. Patel, DDS, MD*, Andrew T. Meram, DDS, MD,
Dongsoo D. Kim, DMD, MD

KEYWORDS
 Head and neck  Soft tissue  Reconstruction  Goals  Algorithm  Flaps

KEY POINTS
 Maintenance of integrity, reconstruction of function and form, minimizing morbidity, and improving
quality of life are the main goals of head and neck reconstruction; they should be prioritized when
selecting a reconstructive option.
 The ideal reconstructive solution should be based on factors related to each individual patient, sur-
gical defect, local and regional anatomy, surgeon expertise, surgical facility, and reconstructive
goals.
 History of head and neck irradiation should be especially kept in mind when developing an
approach to flap selection.
 For a given defect, the reconstructive algorithm is a tool to aid in flap selection and should be indi-
vidualized based on patient, surgeon, and anatomic limitations.
 Radial forearm free flap, anterolateral thigh free flap, pectoralis major flap, and latissimus dorsi free
and pedicled flaps are the workhorse flaps used in the reconstruction of head and neck soft tissue
defects.

INTRODUCTION
The history of head and neck oncology dates back
to the premodern era, with modern ablative head
and neck surgery gaining popularity at the end of
nineteenth century. Early head and neck recon-
structive surgery for ablative oncologic defects
can be traced back to the beginning of the twen-
tieth century with Esser’s publication of axial
patterned island flaps1 and the use of split-
thickness skin grafts2 in 1917 as well as Blair3
describing the use of regional flaps for the recon-
struction of oral cavity defects in 1925.4 The latter
until the 1970s and 1980s that the bulk of the cur-
rent techniques used in reconstruction of head and
neck ablative defects were described, effectively
ushering in the modern era of head and neck
reconstructive surgery.
Reconstruction of head and neck ablative de-
fects is an extremely vast and complicated sub-
ject, with a plethora of literature published on
this topic. Currently in the literature, because of
the variability of ablative defects, there is no
consensus on which reconstructive option is best
for a given defect. An in-depth discussion of every
reconstructive option available for every possible
oralmaxsurgery.theclinics.com

half of the twentieth century saw the development head and neck defect is out of the scope of this
and popularization of local and regional flaps and publication.
the advent of microvascular surgery.5,6 It was not

Disclosure: The authors have nothing to disclose.

Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Sci-
ence Center, 1501 Kings Highway, Shreveport, LA 71103, USA
* Corresponding author.
E-mail address: spate9@lsuhsc.edu

Oral Maxillofacial Surg Clin N Am 31 (2019) 39–68

https://doi.org/10.1016/j.coms.2018.08.004
1042-3699/19/Ó 2018 Elsevier Inc. All rights reserved.
40 Patel et al
In this article, the authors attempt to outline and
simplify soft tissue reconstructive options based
on common ablative soft tissue defects, the goals
of reconstruction of each defect, and factors
considered during flap selection. A reconstructive
algorithm for the most common defects was devel-
oped based on current evidence and the authors’
experience to streamline decision-making. Also,
the authors discuss the indications, pearls, pitfalls,
and challenges in the use of common soft tissue
flaps for head and neck reconstructive surgery.
GOALS OF RECONSTRUCTION
Currently in head and neck reconstruction, the
reconstructive ladder is of historical value and
not commonly used. The reconstructive ladder de-
scribes progressively increasing complexity of
reconstructive options: starting with healing by
secondary intention and progressing to primary
closure, grafts, local flaps, regional flaps, and
finally distant flaps. The reconstructive ladder
has several limitations, as it does not take into
consideration the goals of reconstruction, which
are maintenance of integrity, function, and form7
while minimizing morbidity and improving quality
of life. The simplest surgical option may not be
the best surgical option for a complex reconstruc-
tion, ultimately failing to provide the most optimal
outcome. The concept of a reconstructive
elevator, which gives the surgeon freedom to
choose the appropriate level of reconstructive sur-
gery for a given defect, is more appropriate. The
goals of reconstruction should be individualized,
including consideration of patients’ body habitus,
comorbidities, health, and wishes. If all the goals
of reconstruction cannot be met, then they should
be prioritized. An ideal reconstructive option for
any given defect should be based on goals of
reconstruction, which are prioritized as follows:
1. Maintenance of the integrity of head and neck
tissues: Integrity of the respiratory tract,
alimentary tract, face, and neck and isolation
of the intracranial content are the most impor-
tant considerations when reconstructing head
and neck defects.
2. Functional reconstruction of the defect: Table 1
shows functional reconstructive goals based
on individual head and neck units (regional
groups).
3. Restoration of form: Recreate facial contour,
consistency (texture, color, bulkiness), and
dimension (width, height, projection).
4. Minimize the surgical anesthetic, complications,
and morbidity.
5. Improve quality of life.
SELECTION OF RECONSTRUCTIVE OPTION
For primary (single stage) reconstruction of an
ablative defect, the option to be used to recon-
struct a defect needs to be decided before the
ablation of cancer. Ideal selection of reconstruc-
tive options is based on several factors, which
are related to individual patients, surgical defect,
their anatomy, surgeon expertise, surgical facility,
and reconstructive goals. One or a combination of
these factors can change the reconstructive op-
tion for a given patient. Table 2 shows a list of
common reconstructive options (grafts and flaps)
used in soft tissue reconstruction of the head
and neck region.
Patient-related factors that are considered while
selecting a reconstructive option include health
comorbidities, body habitus, cancer prognosis,
history of head and neck radiation and surgery,
family support, and personal wishes. Patient
comorbidities and body habitus can affect anes-
thesia management, surgical time, intraoperative
positioning, and specific flap selection. For
example, because of extensive deposits of sub-
dermal fat, harvest of anterolateral thigh (ALT) or
rectus abdominis flaps are generally avoided in
obese patients. An acquired or inherited hyperco-
agulable disorder is an absolute contraindication
to performing microvascular free tissue transfer.8
Radiation treatment has important implications
on the choice of flap, as both recipient and donor
site can be affected by radiation.9–11 A history of
head and neck radiation would limit local flap se-
lection because of a lack of local vascularized tis-
sue availability and may introduce challenges in
free tissue transfer (FTT) in a vessel-depleted
neck. To prevent long-term complications in pa-
tients who have been previously irradiated or
plan to undergo adjuvant radiation, it is important
to consider regional flap or FTT for defects with
thin or compromised local tissue overlying bone
or reconstructive hardware. Patient prognosis,
family support, and goals for immediate recon-
struction should be discussed in depth with pa-
tients before narrowing down the reconstructive
choices.
For primary reconstruction of an ablative defect,
the optimal reconstructive option needs to be
decided before the ablation. It should be based
on an accurate preoperative prediction of the
size, depth, location, and extent of the tumor.
Additionally, it should be focused around facial
subunits and type of tissues involved. Oncologic
presentation and resection of head and neck tu-
mors is highly variable, as are the defects that
are created by extirpation of these tumors. These
ablative defects vary significantly from patient to
 Soft Tissue Reconstruction 41

Table 1
Functional reconstructive goals based on head and neck units

Unit Subunits Functional Goals of Reconstruction

Head Cranium, scalp Provide bony continuity
Avoid exposure of cranial bone
Keep intracranial contents isolated
Midface Nose, eyes, ears, cheek, Nasal breathing
maxilla, skull base Patent auditory canal
Globe position
Unrestricted globe movement
Unobstructed vision
Eye lid competency
Avoid entropion or ectropion
Intelligible speech
Mastication
Separate sinuses
Isolate intracranial components
Lower face Mandible, lips Unrestricted temporomandibular joint mobility
Stable occlusion
Diet
Mastication
Intelligible speech
Lip competency
Avoid microstomia
Unrestricted mouth opening
Oral cavity Tongue, floor of mouth, Intelligible speech
palate, buccal mucosa, Swallowing
dentition Provide alimentary tract
Isolation of oral cavity from sinuses and nasal cavity
Unrestricted mouth opening
Avoid aspiration
Mastication
Diet
Stable occlusion
Neck Pharynx, larynx, esophagus Provide alimentary tract
Stable airway
Functional swallowing
Avoid aspiration
Intelligible speech
Protect great vessels

patient and between surgeons; their classification
is quite challenging, although several excellent
classifications based on specific locations
have been published.9,11–24 Because of such vari-
ability, an ablative defect-oriented reconstructive
approach is ideal. The reconstruction should be
tailored to the defect size, depth, location, and
type of tissue needed for reconstruction. To
compensate for shrinkage after harvest, most
soft tissue flaps are designed to be 10% to 20%
larger than the defect itself. Because of skin elas-
ticity, the amount of tissue shrinkage is greater in
younger patients when compared with their older
counterparts.
Patient-specific anatomic factors also play an
important role in the selection of reconstructive
choice. Specific anatomic variations may preclude
the use of certain regional pedicled or distant free
flaps. Examples include a lack of ulnar collateral
circulation to the thumb and forefinger precluding
patients form being considered for a radial forearm
(RF) free flap or a congenitally missing pectoralis
major (PM) muscle disqualifying patients from hav-
ing a PM myocutaneous (MC) or myofascial (MF)
flap.
Individual surgeon and facility-related factors
also play a role in the selection of reconstructive
options. Availability of a head and neck team not
only allows the surgeon to narrow down the recon-
structive choice but also greatly improves commu-
nication; cuts down on surgical time; improves
surgical outcomes; assists in postoperative
42 Patel et al

Table 2
Soft tissue reconstructive options for the head and neck region

Distant
 Radial forearm free flap
 Ulnar forearm free flap
 Lateral arm free flap
 Anterolateral thigh
free flap
 Anteromedial thigh
free flap
 Tensor fascial lata free
flap
 Gracilis free flap
 Peroneal artery free
flap
 Posterior tibial artery
free flap
 Rectus abdominis free
fap
 Parascapular free
flap
 Latissimus dorsi free
flap
 Serratus anterior free
flap
 Jejunal free flap
 Omental free flap
 Gastro-omental free
flap
Flaps
Regional Local Grafts
 Supraclavicular artery  Submental island flap  Split-thickness
island flap  Sternocleidomastoid skin graft
 Pedicled latissimus flap  Full-thickness
dorsi flap  Platysma flap skin graft
 Trapezius flap  Temporoparietal flap  Composite
 Pectoralis major flap  Temporalis flap grafts
 Deltopectoral flap  Scalp/pericranial  Fascial grafts
 Internal mammary ar- flap  Allografts
tery perforator flap  Paramedian forehead
 Pedicled internal mam- flap
mary artery rectus ab-  Cervicofacial flap
dominis flap  Cervicothoracic flap
 Nasolabial flap
 Nasoseptal flap
 Facial artery myo-
mucosal flap
 Palatal island flap
 Pharyngeal flap
 Tongue flap
 Buccal fat pad flap
 Lip, nose, ear, eyelid
flaps
 Rotational
 Advancement
 Transposition

recovery, adjuvant therapy, and patient rehabilita-
tion; and improves quality of life.9,20,25–29 Before
deciding on a reconstructive solution, surgeons
should consider the facility resources and equip-
ment available to them and their own experience,
comfort, skills, and knowledge of local, regional,
and distant anatomy.
The best technique and option for reconstruc-
tion will continue to remain a debate because of
variations in defects and their classification
schemes, surgeons’ preference, and geographic
distinctions. But if the patient-, surgeon-, and
facility-related factors are kept in mind while
prioritizing goals of reconstruction, an ideal
reconstructive option for any given defect can
be achieved.
THE RECONSTRUCTIVE ALGORITHM
Based on prioritization of the reconstructive goals
mentioned earlier and the factors considered in
selection of reconstructive options, the authors
developed an algorithm for the reconstruction of
head and neck defects (Figs. 1–13). The algorithm
provides defect-oriented reconstructive options.
The head and neck can be categorized into 7
broad regional groups and then further subdivided
into reconstructive subgroups (see Fig. 1). This
categorization allows the authors to characterize
and cluster the most common ablative defects
found in these regions and then provides ideal
reconstructive options for each commonly
encountered defect. The algorithm is based on
data from the current published literature7,9–101
and the authors’ institution’s experience with
reconstructing these defects.
To allow for selection of the best reconstructive
tool in the most ideal conditions, the authors did
not take into account patient-specific factors,
such as body habitus, cancer prognosis, family
support, and personal wishes; also, surgeon-
and facility-related factors were not taken into
consideration. Reconstructive goals are priori-
tized based on maintenance of integrity, restora-
tion of function and form, minimizing morbidity,
and improving short- and long-term quality of
life. The soft tissue reconstructive options are
divided into 4 broad categories: healing by
 Soft Tissue Reconstruction 43

Fig. 1. Outline of algorithm. Reconstructive strategy is based on ablative defects, which were first categorized
into 7 broad regional groups (head, midface, lower face, oral cavity, laryngopharynx, salivary glands, and chal-
lenging case) and further subdivided into subgroups. BOT, base of tongue; FOM, floor of mouth.

secondary intention, primary closure, grafts, and flaps are then described based on their proximity
flaps (see Table 2). to recipient sites as local, regional, and/or distant.
Grafts include skin, fascial, composite (chon- For simplicity, the flaps with the bulk of their tissue
dro-cutaneous) autografts, and allografts. The being limited to the head and neck region are

Fig. 2. General overview of reconstructive algorithm. FTT, free tissue transfer; Local, local flaps; Primary, primary
wound closure; Regional, regional flaps; XRT, head and neck radiation.
44 Patel et al

Fig. 3. Head reconstruction. FC, fasciocutaneous; FTT, free tissue transfer; Integra, xenograft-based bilayer wound
matrix; LDFF, latissimus dorsi free flap; Local, local flaps; MC, myocutaneous; MF, myofascial; PLDF, pedicled latis-
simus dorsi flap; Primary, primary wound closure; PTF, pedicled trapezius flap; Regional, regional flaps; RFFF, radial
forearm free flap; STSG, split-thickness skin graft; Wound VAC, negative pressure vacuum-assisted closure device.

classified as local flaps. They include axial
patterned flaps, such as a submental island flap
or paramedian forehead flap, and rotational,
advancement and/or transpositional flaps, which
are used to reconstruct defects immediately adja-
cent to them. In a nonirradiated field, local flaps
are excellent at matching skin characteristics,
subcutaneous tissue and sometimes muscle
depending on the flap and site of harvest. Local
freestyle perforator or rotational flaps can be also
considered for use as they match color, bulkiness
and texture to the recipient area of small to
medium-sized defects in the cosmetically expen-
sive and demanding head and neck region.11 A
list of all known nonaxial patterned flaps is too
great and not included in this algorithm. Also, there
are several excellent choices of local flaps that
could be used for the reconstruction of each given
defect; because of this, a choice of an individual
local flap for each defect is not further elaborated
in the algorithm. Regional flaps are classified
here as pedicled axial patterned rotational flaps
with the bulk of their tissue coming from regions
other than the head and neck. They include flaps,
such as the pedicled pectoralis major, latissimus
dorsi, trapezius, and supraclavicular artery island
flap (Fig. 14). Distant flaps could either be pedicled
or free flaps that would require microvascular
anastomosis. Because the utilization of pedicled
distant flaps is limited, all the distant flaps that
the authors consider for soft tissue reconstruction
are free flaps. Candidacy for FTT is based on pa-
tients being able to tolerate an extended period
of general anesthetic, having the appropriate
anatomic variants for safe harvest of tissue, and
not having comorbidities that would compromise
microvascular surgery and free flap transfer. This
article focuses on soft tissue reconstruction of de-
fects; but within the head and neck, a lot of these
complex soft tissue defects often have an osseous
component. To appropriately address these soft
tissue defects with osseous components, the
osteo-cutaneous (OC) fibula, scapula, and deep
circumflex iliac artery free flaps are included in
the algorithm for completion.
The regional and distant flaps are then further
subclassified based on type of tissue involved:
cutaneous, fascial, fasciocutaneous (FC), MC,
MF, adipofascial (AF), OC, and chimeric (CHI).
CHI flaps (Fig. 15) are defined as multiple indepen-
dent flaps with individual arterial and venous sup-
plies based on a common terminal vascular
pedicle.52,53,102
Unless size is specifically mentioned in the
algorithm, the ablative defects are organized
into small/superficial (<2–3 cm), moderate depth/
marginal defect (3–6 cm), and large/composite
(>6–7 cm) categories. Extremely large and
3-dimensionally (3D) complex postablative defects
that cross multiple reconstructive units are termed
mega defects; because of their large size/
complexity, a separate reconstructive algorithm
was created with reconstructive options described
in order of preference.
For a more comprehensive algorithm, special
consideration was given to defects in a previously
Fig. 4. Midface reconstruction. ALTFF, anterolateral thigh free flap; CHI, chimeric; Dental Rehab, rehabilitation of dentition using removable or fixed prosthesis; FC, fas-

Soft Tissue Reconstruction

ciocutaneous; FFF, fibula free flap; FTT, free tissue transfer; Local, local flaps; MC, myocutaneous; OC, osteo-cutaneous; Prosthesis, maxillofacial osteo-integrated implants
and supported prosthesis; RAFF, rectus abdominis free flap; Regional, regional flaps; RFFF, radial forearm free flap; SCAIF, supraclavicular artery island flap; SFF, scapula
free flap; STSG, split-thickness skin graft; XRT, head and neck radiation.

45
 46
Patel et al
Fig. 5. Nose reconstruction. Composite, composite chondro-cutaneous autografts; FTSG, full-thickness skin graft; FTT, free tissue transfer; Local, local flaps; OC, osteo-
cutaneous; RFFF, radial forearm free flap; STSG, split-thickness skin graft; XRT, head and neck radiation.
 Soft Tissue Reconstruction
Fig. 6. Ear reconstruction. Composite, composite chondro-cutaneous autografts; FTSG, full-thickness skin graft; FTT, free tissue transfer; Local, local flaps; Primary, pri-
mary wound closure; Regional, regional flaps; RFFF, radial forearm free flap; SCAIF, supraclavicular artery island flap.

47
48 Patel et al
Fig. 7. Eyelid reconstruction. Local, local flaps; Primary, primary wound closure.
irradiated field due to the presence of compro-
mised local tissue for reconstruction. A hostile
neck is a term denoted to patients with a history
of head and neck radiation and a previously oper-
ated vessel-depleted neck. In these cases, if pa-
tients are not a candidate for FTT, then the
authors preferentially reconstruct these defects
with regional pedicled MC PM or latissimus dorsi
(LD) flaps. In patients with exposed great vessels
and the need for adjuvant radiation therapy, a pref-
erence to FTT is given as a primary means of
reconstruction.16 If patients with a vessel-
depleted neck are candidates for FTT, then appro-
priate investigation for distant neck arterial anasto-
mosis sites (ie, contralateral neck, ipsilateral
transverse cervical artery, internal mammary ar-
tery, and thoracoacromial artery) is performed. If
the internal and external jugular veins are both
compromised, then the venous anastomosis op-
tions are limited to an interpositional vein graft or
a cephalic vein transposition.55,94,96,103,104 Alter-
natively a Corlett loop can be used to create new
arterial and venous anastomosis sites in the
neck.105
Finally, reconstruction of soft tissue
defects with dentition-supported obturators or
osteo-integrated implant-supported maxillofacial
prostheses is also considered in this algorithm.
Another consideration includes transected cranial
nerves; if the proximal and distal nerve segments
are identifiable, then they can be reconstructed
with primary neurorrhaphy, nerve autograft, or al-
lografts. Because this article focuses on primary
reconstruction, secondary reconstructive options,
such as tissue expanders or delayed reconstruc-
tion, are not considered. Although the authors’
algorithm may not be applicable for every conceiv-
able defect, it provides a reliable reconstruction
strategy with low morbidity and allows for expe-
dient restoration of integrity, function, and form.
WORKHORSE SOFT TISSUE FLAPS
As discussed previously, there are several flap op-
tions available for the reconstruction of head and
neck soft tissue defects. The most commonly
described free flaps in reconstructive literature for
head and neck defects include the radial forearm,
anterolateral thigh, latissimus dorsi, rectus abdom-
inis, jejunum, fibula, scapula, and iliac crest.66,99–101
Lutz and Wei66 in 2005 proposed 3 workhorse free
flaps that can be used for the reconstruction of
most head and neck defects. These flaps included
the radial forearm, anterolateral thigh, and the fibula
free flaps. The LD and PM pedicled flaps, although
not initially considered for the reconstruction of
ablative defects, are excellent choices in patients
who are not candidates for FTT. For the most
commonly used soft tissue flaps (radial forearm,
anterolateral thigh, latissimus dorsi, and PM flaps),
the authors discuss indications, surgical consider-
ations, pitfalls, and challenges for each.
Radial Forearm Free Flap
The RF FC free flap was initially described in the
Chinese literature by Yang and colleagues106 in
 Soft Tissue Reconstruction
Fig. 8. Mandible reconstruction. ALTFF, anterolateral thigh free flap; CHI, chimeric; FC, fasciocutaneous; FFF, fibula free flap; FTT, free tissue transfer; ICBG, iliac crest bone
graft; Local flaps; MC, myocutaneous; OC, osteo-cutaneous; PLDF, pedicled latissimus dorsi flap; PMF, pectoralis major flap; Primary, primary wound closure; Regional,
regional flaps; RFFF, radial forearm free flap; RMT, retromolar trigone; SCAIF, supraclavicular artery island flap.

49
50 Patel et al
Fig. 9. Lip reconstruction. FC, fasciocutaneous; FTT, free tissue transfer; Local, local flaps; PLM, palmaris longus
muscle tendon; Primary, primary wound closure; Regional, regional flaps; RFFF, radial forearm free flap; SCAIF,
supraclavicular artery island flap.
1981, although they had developed the technique
a few years prior, in 1978. It was further popular-
ized by Soutar and colleagues107 for the recon-
struction of head and neck defects.
Indications and advantages
The RF is ideal for the reconstruction of small- to
moderate-sized soft tissue defects in the head
and neck, especially for intraoral defects whereby
thin, pliable, and hair-free skin is most suitable. It is
probably the most versatile flap for the reconstruc-
tion of postablative soft tissue defects because of
the characteristics of the tissue available as well as
its ease of harvest, excellent pedicle length, ability
to use a 2-team approach, and the availability of
including a small amount of bone and/or tendon
to the flap.
It has a relatively constant vascular anatomy,
with rare variation, and offers one of the longest
vascular pedicles, which allows this flap to reach
distant defects. It has good caliber vessels, with
dual venous outflows, one each from the superfi-
cial and deep venous systems. It can also be
used as a sensate flap based on the distribution
of the lateral antebrachial cutaneous nerve. It al-
lows for a 2-team approach and has minimal
donor site morbidity. The forearm skin has a fair
color match to the skin of the head and neck
region.
The RF flap can be harvested as a cutaneous
(suprafascial), fasciocutaneous, fascial, AF, or
OC flap (with inclusion of a partial-thickness
radius). Depending on the reconstructive need,
the palmaris longus muscle (PLM) tendon and
brachioradialis muscle (BRM) can also be incorpo-
rated into the flap design and construct. Common
head and neck defects reconstructed with the RF
flap include hypopharyngeal, pharyngeal wall,
glossectomy (Fig. 16), floor of mouth, buccal,
cheek, complex lip (Fig. 17), hard and soft palate,
marginal mandibulectomy, orbit, and scalp
defects.
Surgical and anatomic considerations
The arterial supply to the RF flap is from the radial
artery, while the venous drainage is from the
paired venae comitantes (VC) and often the ce-
phalic vein. The artery diameter ranges from 2.5
to 3.5 mm; the dominant VC diameter ranges
from 2 to 3 mm; the cephalic vein diameter ranges
from 2.5 to 4.0 mm. The cephalic vein runs in the
subcutaneous plane, and the lateral antebrachial
cutaneous nerve travels with it to the antecubital
fossa. The vascular pedicle ranges from 15 to
22 cm in length and travels in the lateral intermus-
cular septum created by the BRM laterally and the
flexor carpi radialis muscle (FCRM) medially.
Through this septum, the pedicle gives off the
most branches to the skin of the forearm. The
flap skin harvest zone can extend from antecubital
fossa proximally to the flexor crease of the wrist
distally. Mediolaterally, it extends between the
medial and lateral humeral epicondyles proximally,
from the extensor hallucis longus tendon laterally
to extensor carpi ulnaris medially, and to the wrist
flexor crease distally. Neurosensory innervation of
 Soft Tissue Reconstruction
Fig. 10. Oral cavity reconstruction. ALTFF, anterolateral thigh free flap; FC, fasciocutaneous; FFF, fibula free flap; FOM, floor of mouth; FTSG, full thickness skin graft; FTT,
free tissue transfer; local, local flaps; MC, myocutaneous; OC, osteo-cutaneous; PMF, pectoralis major flap; Primary, primary wound closure; Regional, regional flaps; RFFF,
radial forearm free flap; SCAIF, supraclavicular artery island flap; Secondary, wound healing via secondary intent; STSG, split-thickness skin graft.

51
 52
Patel et al
Fig. 11. Laryngopharyngeal reconstruction. ALTFF, anterolateral thigh free flap; FC, fasciocutaneous; FFF, fibula free flap; FTT, free tissue transfer; local, local flaps; MC,
myocutaneous; OC, osteocutaneous; PMF, pectoralis major flap; Primary, primary wound closure; RFFF, radial forearm free flap; Secondary, wound healing via secondary
intent; STSG, split-thickness skin graft.
 Soft Tissue Reconstruction
Fig. 12. Salivary gland defect reconstruction. Alloderm, allograft-based regenerative acellular dermal matrix; ALTFF, anterolateral thigh free flap; FOM, floor of mouth;
FTT, free tissue transfer; MC, myocutaneous; PLDF, pedicled latissimus dorsi flap; PMF, pectoralis major flap; Regional, regional flaps; TFL, tensor fascia lata.

53
54 Patel et al

and forefinger is mandatory. Patients are advised

Fig. 13. Mega defect reconstruction. ALTFF, anterolat-
eral thigh free flap; CHI, chimeric; FFF, fibula free flap;
FTT, free tissue transfer; MC, myocutaneous; PLDF,
pedicled latissimus dorsi flap; PMF, pectoralis major
flap; RAFF, rectus abdominis free flap; Regional,
regional flaps; SFF, scapula free flap.
the skin is from the medial and lateral antebrachial
cutaneous nerves. A maximum skin paddle of up
to 15  30 cm can be harvested based on the in-
dividual patient’s body habitus.
A preoperative Allen test to check for collateral
ulnar circulation via the palmar arch to the thumb
to avoid any venipunctures in the planned surgical
extremity at least 2 weeks before surgery. Flap
markings are made 1 to 2 cm proximal to the distal
wrist crease, centered over the radial artery, and
generally include the cephalic vein within the
lateral side of the markings. If the flap is small
and the markings do not reach the cephalic vein,
then the flap markings can be moved laterally to
include both the radial artery and cephalic vein
within the marked boundaries of the flap. Flap har-
vest is commonly performed under a tourniquet
that is inflated at 250 mm Hg, although it can be
harvested without tourniquet compression.
Dissection is started at the distal marking that is
parallel to the distal wrist crease and then on the
lateral followed by medial markings until the lateral
intermuscular septum is reached. It is generally
performed subfascial, but a suprafascial dissec-
tion can be executed for a cutaneous only flap.
The radial nerve is identified lateral to the FCRM
and preserved. Capillary refill on the thumb and
forefinger is checked after ligation of the radial ar-
tery to confirm collateral circulation. A thin film of
paratenon is preserved over the flexor tendons to
allow for optimal skin graft take and to prevent
scarring. When harvesting radius bone, it is impor-
tant to supinate the arm completely and remove no
more than one-quarter the circumference of the

Fig. 14. Parotid and neck defect reconstruction with supraclavicular artery island flap. (A) Cutaneous squamous
cell carcinoma involving the parotid gland was treated with wide local excision, superficial parotidectomy, and
modified radical neck dissection. (B) Postablative defect with inset of harvested supraclavicular artery island
flap. (C) After completion of flap inset into the defect. (D) One-year follow-up picture showing good coverage
of great vessels and excellent appearance of the flap as it follows the contour of the posterior mandible and
neck. Also has fair color match to the surrounding face and neck skin.
 Soft Tissue Reconstruction 55

Fig. 15. Base of tongue and neck defect reconstructed with ALT free flap. (A) Lip split mandibulotomy done to
access and resect recurrent base of tongue squamous cell carcinoma. (B) Harvest of CHI right ALT free flap for the
reconstruction of both base of tongue and neck defects. Separate fasciocutaneous skin paddles were fabricated
on the transverse (T) and descending (D) branches of the lateral circumflex femoral artery (asterisk). Vastus lat-
eralis muscle (VLM) was also included based on its individual perforator. (C) Inset of skin paddle based on trans-
verse branch into the base of tongue defect. (D) Inset of the descending branch skin paddle into the neck defect.

radius to prevent fractures. Flap harvest proceeds
distal to proximal, under loupe magnification, and
the PLM tendon, BRM, or radius bone are incorpo-
rated in the flap as needed. The proximal releasing
skin incision is made from the proximal edge of the
flap to the antecubital fossa, and the incision is
marked based on the reconstructive plan of the
donor defect. If an ulnar transposition flap is
planned for reconstruction, then this should be
taken into consideration before making the

Fig. 16. Partial glossectomy defect reconstruction with RF free flap. (A) Right lateral tongue squamous cell carcinoma,
which was treated with partial glossectomy. (B) Harvest of left fasciocutaneous RF free flap, note the dual venous out-
flows, one from each superficial (cephalic vein [V]) and deep (radial artery and vena comitantes [A]) venous systems.
The confluence of the vena comitantes to the cephalic vein is denoted by an asterisk. (C) Reconstructed tongue defect.
(D) One-year follow-up picture demonstrating good form and function of the defect site.
56 Patel et al

Fig. 17. Lip defect reconstruction with RF free flap. (A) Lower lip and left commissure defect. (B) Left RF free
flap markings, with dotted line denoting location of cephalic vein and the solid line above it marking the loca-
tion of the radial artery. Note the flap is marked 1 cm proximal to the flexor crease and centered over both the
cephalic vein and radial artery. (C) Lip defect reconstructed with local flap and left fasciocutaneous RF free flap
with palmaris longus tendon transfer. (D, E) Six-month follow-up pictures showing excellent mouth opening,
lip competency, and color match. Note the abrasion to the left lower chin area caused by a close shave of
facial hair.

Fig. 18. Preauricular and parotid defect reconstruction with ALT free flap. (A) A patient with full thickness defect
of left face after resection that involved the parotid and zygomatic arch. (B) ALT free flap markings showing
vascular anatomy and dominant skin perforators (asterisk) from the descending branch (D) of the lateral circumflex
femoral artery. (C) Defect reconstructed with a MC ALT free flap. (D) One-year follow-up picture showing long-
term maintenance of tissue bulk. Thigh skin is not an ideal match for the reconstruction of facial skin defects.
 Soft Tissue Reconstruction 57

Fig. 19. Glossolaryngectomy defect reconstruction with ALT free flap. (A) A total glossolaryngectomy and partial
pharyngectomy defect with MC ALT free flap being inset into the defect. (B) Right ALT free flap markings
showing vascular anatomy and dimensions of the skin paddle being harvested. Skin paddle shows marked re-
gions (tongue, pharynx, and esophagus,) that are to be reconstructed. (C) Glossectomy defect reconstructed
with distal end of MC ALT free flap to provide bulk to the tongue mound. (D) One-year follow-up intraoral
picture showing maintenance of the alimentary tract but loss of the muscle bulk after completion of adjuvant
radiation therapy.

releasing incision. The cephalic vein is dissected
first, and its dissection is taken further proximally
to its confluence with the VC. This technique al-
lows for both the superficial and deep venous sys-
tems to drain into one vein, which could then be
used for venous anastomosis. The BRM is then
retracted laterally, and the vascular pedicle is
dissected in the lateral intermuscular septum
proximally to its origin.

Fig. 20. Scalp defect reconstruction with LD free flap and split-thickness skin graft. (A) Large full-thickness left
scalp defect with exposed cranial bone. (B) Harvest of left MF LD free flap. (C) Flap inset into the defect and
coverage with meshed split-thickness skin graft from left thigh. (D, E) One-month follow-up picture demon-
strating excellent cranial contour and color match with surrounding scalp.
58 Patel et al

Fig. 21. Skull base, auriculectomy, and lateral facial defect reconstruction with pedicled LD flap. (A) Right middle
cranial fossa, auricle, temporomandibular joint, parotid, and facial skin defect. Temporal bone defect recon-
structed with titanium mesh. (B) Right MC LD flap markings showing vascular anatomy (thoracodorsal artery
[TD]), location of LD muscle, and its relation to the skin paddle. The dominant skin perforator is identified using
Doppler and marked (asterisk). (C) Exposure of LD muscle; note that the skin paddle has a broad base, is tacked
down to the underlying muscle, and is located completely within the muscle boundary to avoid random pattern
blood supply to the skin paddle. (D) Flap tunneled through the axilla and inset into the defect.

Closure of the flap donor defect generally re-
quires an ulnar transposition, local tissue advance-
ment, or split- or full-thickness skin graft. An
attempt is made to dissect the radial nerve away
from the defect and transpose it laterally under
native skin to prevent the thin skin graft from scar-
ring to the nerve. The forearm and wrist are immo-
bilized in a volar splint for 2 to 4 weeks to ensure
skin graft take and prevent tendon exposure. To
fit the complex 3D head and neck defects, the
RF flap can be harvested on separate skin paddles
based on the radial artery or the skin paddle can
be de-epithelialized in the middle and folded to
achieve an optimal reconstructive outcome. It
can also be harvested as one large skin paddle
and tubed to reconstruct circumferential hypo-
pharyngeal defects.
Pitfalls and challenges
A failed Allen test is an absolute contraindication
for harvest of an RF flap. Relative contraindica-
tions include a previous history of wrist fracture
if harvesting an OC flap or lacerations to the
forearm.
Given that the flap has a long vascular pedicle, it
is beneficial to include a cuff of fascia around the
vascular pedicle and subcutaneous tissue around
the cephalic vein to provide additional cushion
when the vessels sit in the tunnel that is created
at the reconstructive site. To prevent kinking of
the vessels at the proximal flap margin, a 2- to
3-cm cuff of subcutaneous tissue around the ves-
sels is incorporated into the flap.
Some disadvantages to using an RF flap include
differences in skin color, texture, and donor site
morbidity. Forearm skin texture is different than
the head and neck; if the flap is placed across
different esthetic zones, it gives a less-than-ideal
esthetic outcome. Donor site morbidity includes
a risk of radius fracture when an OC RF flap is har-
vested. Inability to close the donor site primarily
can result in variability of skin graft healing and
injury to the radial nerve, which causes formation
of a neuroma, hypoesthesia, or anesthesia of the
anatomic snuff box.
Fig. 16 shows a case in which a partial glossec-
tomy defect has been reconstructed with an FC
RF free flap. The RF flap in this case was nonsen-
sate but provided an ideal option to meet the
reconstructive goals of providing tissue bulk and
texture to permit for tongue mobility, diet, swal-
lowing, unrestricted mouth opening, and intelli-
gible speech.
Fig. 17 shows a lower lip defect that has been
reconstructed with an FC RF free flap with palma-
ris longus tendon transfer. The palmaris longus
tendon is suspended from the remaining right
lower lip to the left zygoma, and the left upper lip
 Soft Tissue Reconstruction 59

is advanced and suspended inferolaterally to
recreate a new modiolus. The reconstruction al-
lows for patients to maintain lip competency while
avoiding microstomia and maintain intelligible
speech and unrestricted mouth opening. The RF
flap is also a fair color match to the surrounding
facial skin.
Anterolateral Thigh Free Flap
The ALT septo-cutaneous perforator flap was
initially described by Song and colleagues108 in
1984 for the reconstruction of head and neck de-
fects. This flap has since been further popularized
by Wei and coworkers109 at the Chang Gung Me-
morial Hospital in Taiwan.
Indications and advantages
It is ideal for the reconstruction of moderate- to
large-sized soft tissue defects of the head and
neck region and in an area that requires vari-
ability in soft tissue bulk and skin paddle size.
It provides a long vascular pedicle with good
caliber vessels and a large skin paddle. The flap
can be used as a sensate flap based on the ALT
skin distribution of the lateral femoral cutaneous
nerve. It allows for a 2-team approach and has
minimal donor site morbidity.
The flap can be harvested with cutaneous, fas-
ciocutaneous, fascial, adipofascial, MF, or MC
components depending on the reconstructive
needs. Common head and neck areas recon-
structed using the ALT flap include through and
through cheek, non–tooth-bearing midface de-
fects, orbit, lateral face (Fig. 18), radical paroti-
dectomy, skull, scalp, neck, hypopharyngeal,
and large glossectomy (Fig. 19) defects. Exten-
sive and complex soft tissue defects can be
reconstructed using CHI variations and modifica-
tions of the flap. CHI flaps can be based on the
ascending, transverse, and descending branches
of the lateral circumflex femoral artery (LCFA) to
include the tensor fascia lata (TFL), vastus latera-
lis muscle (VLM), rectus femoris muscle (RFM),
and skin paddles from the lateral and medial
thigh.
Surgical and anatomic considerations
The arterial supply to the ALT flap is most
commonly from the septo-cutaneous or MC per-
forators of the descending branch of the LCFA,

Fig. 22. Retromolar trigone and posterior maxillary defect reconstruction with a PM flap. (A) Right retromolar
trigone squamous cell carcinoma, which was treated with wide local excision (marginal mandibulectomy, infra-
structure maxillectomy, and partial pharyngectomy). (B) Right MC PM flap markings showing vascular anatomy
(thoracoacromial artery [TA]) and location of the skin paddle (asterisk) in relation to the chest anatomy. Also
marked is the planned lip split mandibulectomy incision. (C) Ablative defect, neck dissection, and flap harvest
sites. Note that the skin paddle has a broad base, is tacked down to the underlying muscle, and is located
completely within the muscle boundary to avoid random pattern blood supply to the skin paddle. Sufficiently
wide tunnel is created under the skin bridge on the right side for passive passage of the flap to the head and
neck region. (D) Flap inset into the oral cavity defect.
60 Patel et al

Fig. 23. Mandibular defect reconstruction with PM flap. (A) Left mandibular squamous cell carcinoma that was
treated with segmental mandibulectomy. (B) Patient reconstructed with a titanium reconstruction plate and left
MC PM flap. Skin paddle (asterisk) of the flap is planned at the inferior extent of the pectoralis muscle to provide
the longest arc of rotation. (C) After the flap is lifted and the sternal and humeral attachments of the PM muscle
are detached, the vascular pedicle (asterisk) can be visualized easily. Note that the pectoralis minor muscle is left
undisturbed on the chest wall. The skin paddle is then passively passed through the skin tunnel into the neck and
then inset into the mandibular oral cavity mucosal defect. (D) One-month follow-up picture demonstrating good
mouth opening and maintenance of integrity of the oral cavity defect.

and the venous drainage is via the paired VC. Ar-
tery diameter ranges from 1.5 to 2.5 mm, and
vein diameter ranges from 2 to 3 mm. Perfora-
tors to the thigh skin, less commonly, have
been reported to arise from the transverse
branch of the LCFA, profunda femoris artery, or
the femoral artery. Complete absence of perfo-
rators has been reported in 1% to 5% of pa-
tients. Neurosensory innervation to the skin
paddle is from the lateral femoral cutaneous
nerve, and the motor innervation to the VLM is
from the posterior division of the femoral nerve.
The vascular pedicle consists of the descending
branch of the LCFA, paired VC, and the motor
branches of the femoral nerve to the VLM and
RFM. Vascular pedicle length ranges from 8 to
16 cm. It lies within the intermuscular septum
between the VLM and RFM; it gives off perfora-
tors to the skin, which could be MC (w85% of
cases) or septo-cutaneous. The flap skin harvest
zone extends superiorly to the greater
trochanter, inferiorly to 3 cm above the patella,
medially to the medial edge of the RFM, and
laterally to the lateral edge of the VLM. A skin
paddle size of up to 25  35 cm can be
harvested.
In patients with abdominal obesity who are un-
dergoing ALT free flap harvest, the anterior
abdominal wall panniculus should be carefully
retracted and suspended superiorly to prevent
injury to the panniculus soft tissue and to allow
for easier access to the vascular pedicle origin
from the profunda femoris system. A straight line
from the anterior superior iliac spine to the superior
lateral patella is drawn to represent the intermus-
cular septum between the VLM and RFM. A 3-
cm radius circle is drawn at the midpoint of this
line, and a dominant perforator to the ALT skin
paddle is found using Doppler sonography gener-
ally in the inferior lateral quadrant of this circle. The
flap is centered over the most dominant skin
perforator.
Incision and dissection is initially started on the
medial aspect of the flap margin over the RFM.
Dissection is performed from medial to lateral in
a subfascial plane to harvest a fasciocutaneous
flap and in a suprafascial plane to harvest a thinner
flap. Dissection is continued laterally under loupe
magnification until skin perforators are identified
to be either MC or septo-cutaneous. The septo-
cutaneous perforator can be followed back to the
vascular pedicle in the intermuscular groove. MC
perforators need to be mapped through the VLM
by carefully unroofing the muscle fibers from top
of the perforator. An MC perforator can be either
dissected from the VLM by ligating the muscular

vessel branches originating from the perforator or
by taking a 1-cm cuff of VLM around the perfo-
rator, which may make the MC perforator dissec-
tion simpler. For a thin suprafascial flap, a 1- to
2-cm cuff of fascia is maintained around the perfo-
rator as it pierces through the fascia to prevent
kinking of the cutaneous perforator. The suprafas-
cial flap should not be thinned, less than 5 mm, so
as to prevent injury to the subdermal vascular
plexus and marginal flap necrosis. Once the perfo-
rator is traced back to the pedicle, the lateral skin
incision is then made and the flap is dissected in
the lateral to medial direction in a subfascial or
suprafascial plane. The vascular pedicle is
dissected from a distal to proximal direction until
vessels are traced back to their origin from the
LCFA and vein. Injury to the motor branches of
the femoral nerve is avoided by dissecting the
nerve free from the vascular pedicle. The rectus
femoris branch (RFB) of the descending LCFA
should always be identified and preserved until
the ALT flap is completely ready to be harvested.
In the event the ALT perforator is injured or
compromised, the flap can be converted to an
anteromedial thigh (AMT) flap based on the RFB
of the descending LCFA. If no cutaneous perfora-
tors are identified from the medial incision, then
the flap dissection can be converted to a TFL-,
AMT-, or VLM-only flap. A 20-cm piece of VLM
can be incorporated into the flap if further bulk is
necessary for reconstruction.
A donor site defect that is less that 8 to 9 cm
wide can be closed primarily. Larger defects can
be skin grafted or a V-Y perforator-based rotational
flap or keystone flap can be used for closure of the
donor site defect. Meticulous hemostasis and
placement of drains before closure is important to
prevent the most common donor site complica-
tions of hematoma and/or seroma. The ALT flap
can be harvested on separate skin paddles based
on individual perforators or can be harvested as a
CHI flap based on one vascular pedicle. If only
one skin perforator is available, then the skin pad-
dle can be de-epithelialized in the middle and
folded to achieve an optimal reconstructive
outcome. The flap can also be tubed to reconstruct
circumferential hypopharyngeal defects.
Pitfalls and challenges
Absolute contraindications to performing an ALT
free flap include severe obesity, traumatic injury
to the upper thigh, and vascular surgery or bypass
of the femoral artery. Relative contraindication in-
cludes claudication and lack of a palpable popli-
teal pulse.
Appropriate orientation of a single perforator
flap is critical to avoid twisting or kinking of the
Soft Tissue Reconstruction 61
perforator. A suitable match of defect to flap size
and bulk is important, as a large flap in a small
defect can cause compression of the perforator
and compromise the flap skin paddle vascular
supply.
Thigh skin is generally lighter in color and thicker
when compared with skin of the head and neck re-
gion and not the most ideal match for esthetic
reconstruction of facial subunits. Variability in the
amount of subcutaneous fat makes them less
desirable for the reconstruction of small, shallow,
or 3D complex defects. Extensive hair growth in
men make them less suited for the reconstruction
of intraoral and other facial non–hair-bearing re-
gions. Variable vascular anatomy and MC course
of the perforators to the skin paddle require in-
depth knowledge of the local anatomy and a steep
learning curve for intramuscular dissection of the
perforators. The vascular anatomy is not as
consistent as the RF flap, and several anatomic
variants have been described in detail in other
publications.
Fig. 18 shows a case of a patient with a posta-
blative deep left malar and parotid defect, which
has been reconstructed with an MC ALT free
flap. In this case the bulk available from the ALT
flap provided an ideal reconstructive option to
add tissue volume and form to the lateral face.
Also, it allowed for unrestricted motion of the
mandible at the temporomandibular joint. The
ALT skin color is not an ideal match to the facial
skin.
Fig. 19 shows a case of a patient with a total
glosso-laryngectomy defect that has been recon-
structed with an MC ALT free flap. The ALT flap
in this case was inset to reconstruct the tongue
mound, maintain integrity of an alimentary tract,
isolate the airway, protect the great vessels, and
provide form to the neck. The femoral nerve
branch to the VLM was anastomosed to the left
hypoglossal nerve to allow the flap to maintain
bulk over time and assist with swallowing of oral
secretions.
Latissimus Dorsi Flap
The pedicled LD flap was initially described by
Tansini in 1896, and then again in 1906110,111 for
the reconstruction of chest defects and was rede-
scribed in 1976 by Olivari.112 It was subsequently
described for use in head and neck reconstruction
by Quillen in 1978 as a pedicled flap110,113 and
then as a free flap in the head and neck region
by Watson and colleagues114 in 1979.
Indications and advantages
The LD flap is best suited for the reconstruction of
large-sized soft tissue defects of the head and
62 Patel et al
neck region and in areas that require significant
bulk. It is most commonly used as a free flap for
the reconstruction of large scalp defects and as
a pedicled flap for salvage reconstruction of other
head and neck defects.
It has a relatively consistent vascular anatomy. It
provides for good caliber vessels, a long vascular
pedicle, and a very large skin paddle, which is
easy to harvest. In large complex defects, the
flap can be folded on itself for reconstruction. It
has minimal donor site morbidity and scarring
while providing a fair color match of the flap skin
to the head and neck region. It can be used both
as a free flap or an axial patterned regional rota-
tional flap; it can be harvested as an MC or MF
flap.
Common head and neck defects whereby the
LD free flap is preferentially used over other flaps
is in the reconstruction of extensive scalp defects
(Fig. 20) and in extensive defects of the neck, lar-
yngopharynx, lower face, tongue, midface, and
skull base. These extensive and complex defects
requiring both bone and soft tissue can be recon-
structed using CHI variations and modifications of
the flap based on the subscapular artery. A
pedicled rotational LD flap is used in salvage
reconstruction of the vessel depleted, previously
operated/irradiated neck, or when patient
anatomy does not provide a good option for free
tissue transfer. Common defects reconstructed
using a pedicled LD flap include a large neck, hy-
popharynx, lateral face, radical parotidectomy,
lateral skull base (Fig. 21), and lateral scalp de-
fects. Because of its long arc of rotation, the pedi-
cled LD flap can potentially reach the vertex of the
head.49
Surgical and anatomic considerations
The LD flap is supplied by the thoracodorsal ar-
tery, which is a branch of the subscapular artery;
the venous drainage is from the thoracodorsal
vein. The artery diameter ranges from 2 to 4 mm,
and the vein diameter ranges from 2 to 5 mm. Mo-
tor innervation to the LD muscle is from the thora-
codorsal nerve, and the sensory innervation is
from the cutaneous branches of the intercostal
nerves. Its vascular pedicle comprises the thora-
codorsal artery, vein, and nerve. The pedicle
length ranges from 6 to 12 cm and can be
extended by an average of 2 cm if the subscapular
artery and vein are included. The flap skin harvest
zone includes the area overlying the LD muscle. A
skin paddle of up to 20  35 cm can be harvested,
and the whole LD muscle can be harvested for the
reconstruction of large defects.
Flap markings are made preoperatively with
patients in a standing or sitting position but can
also be done after patients are positioned in
the operating room. Patients are positioned in
lateral decubitus with the arm abducted to 90
and the elbow flexed at 90 . The flap is marked
by drawing a straight line from the posterior axil-
lary fold to the mid iliac crest. The vascular
pedicle enters the muscle approximately 10 cm
below the axilla on this line. The anterior border
of the muscle is palpated and marked. Adduction
of the arm can help in palpation and marking of
the anterior border of LD muscle. The axis of
the flap is marked 1 to 2 cm posterior and paral-
lel to the anterior border of the LD muscle. If a
skin island is to be harvested, it should be
centered on the anterolateral border of the mus-
cle, as the highest number of perforators exist in
this area. A Doppler should be used to verify per-
forators to the skin in cases whereby a small skin
paddle is to be incorporated in the flap. Flap har-
vest is initiated by making an incision on the
anterior edge of the skin island and then extend-
ing superiorly to the axilla. The anterior border of
the LD muscle and vascular pedicle on its under-
surface are identified and dissected proximally to
its origin while staying on top of the serratus
muscle. The skin island can then be incised cir-
cumferentially, and the LD muscle is released
from its inferior and medial insertions. Stay su-
tures between the skin paddle and muscle are
placed to prevent shearing forces between
them from injuring the skin perforators. The
dissection then proceeds from distal to proximal
into the axilla. When performing axillary dissec-
tion of the pedicle, care should to taken not to
hyperabduct the arm to prevent brachial plexus
injury.
For a pedicled LD flap, a cuff of fascia and fat
should be preserved around the pedicle to cushion
and prevent compression and kinking of the
vascular pedicle in the axillary tunnel. If most of
the muscle is to be used for reconstruction, the
thoracodorsal nerve should be sacrificed to pre-
vent nerve compression and avoid muscle
contraction, which could cause traction at the
reconstruction site. The circumflex scapular ves-
sels should be sacrificed to allow for a longer arc
of rotation if the reconstruction defect is in the mid-
face or higher. Generally, keeping the circumflex
scapular intact will prevent torsion or kinking of
the vascular pedicle. Sufficient blunt dissection
should be performed between the PM and minor
muscles to create a tunnel from the axilla to the
neck. The tunnel should be sufficiently wide to
allow for free mobility of the surgeon’s hand
through the tunnel and allow for passive passage
of the flap. If the tunnel is too narrow, the clavicular
attachment of the PM muscle and the coronoid

process insertion of the pectoralis minor muscle
can be separated. The humeral attachment of
the LD muscle should be detached once the tunnel
is prepared and the flap is ready to be inset, which
prevents any iatrogenic traction injury to the flap.
There is a higher chance of venous congestion if
the LD flap is used as a pedicled flap if the tunnel
is not of sufficient width or the pedicle is twisted or
kinked in the tunnel. Closure of the donor site is
performed in layers after placement of closed suc-
tion drains. Skin defects less than 10 cm wide are
generally able to be closed primarily.
Pitfalls and challenges
Absolute contraindications for harvest of the LD
flap include a history of previous surgery to the ax-
illa, an anterolateral thoracotomy, or history of ra-
diation to the posterolateral and upper chest wall.
The location of this flap and patient positioning
does not allow for a 2-team approach. Its requires
patients to be at least in a modified lateral decubi-
tus (45 ) position for the harvest of the flap and
may also require repositioning of patients based
on the location of the ablative defect. Variability
in the amount of subcutaneous fat and thick,
less pliable back skin makes the flap bulky and
less ideal for the reconstruction of small and
moderate-sized defects. There is a higher chance
of venous congestion if it is used as a pedicled
flap.
Fig. 20 shows a case of a full-thickness scalp
defect that was reconstructed with an MF LD
free flap and split-thickness skin graft. The combi-
nation of an MF LD free flap and split-thickness
skin graft provides ideal coverage of exposed cra-
nium, appropriate tissue bulk, and excellent color
match to the surrounding scalp.
Fig. 21 shows a case of a right cranial skull base,
parotid, and facial defect in a patient with a previ-
ously operated, vessel-depleted irradiated neck.
The defect was reconstructed with a pedicled
MC LD flap. The pedicled LD flap, in a compro-
mised surgical site, provides new vascularized tis-
sue with sufficient bulk to obliterate dead space at
the skull base. In this case, the bulk available from
the LD flap provided an ideal reconstructive option
to provide tissue volume at the skull base and form
to the lateral face.
Pectoralis Major Flap
The PM MF flap was initially described by Pickerel
and colleagues115 in 1947 for the reconstruction of
chest defects. In 1968 Hueston and McConchte116
described the use of the MC PM flap in the recon-
struction of sternal defects,116 and in 1979
Ariyan117 described its use in the head and neck.
Soft Tissue Reconstruction 63
Indications and advantages
The PM MC flap is most ideal for the reconstruc-
tion of moderate- to large-sized soft tissue defects
of the head and neck region and in areas requiring
significant bulk. It is generally used as an axial
patterned regional rotational flap, but free flaps
based on the thoracoacromial artery have also
been described.
The vascular anatomy of the flap is robust and
fairly consistent. It provides for a moderate length
vascular pedicle and a large skin paddle, which is
easy to harvest. In large complex defects, the flap
can be folded on itself for reconstruction. It is
generally associated with minimal donor site
morbidity and scarring, and it has a fair color
match of the flap skin to the head and neck region.
It can be harvested as either an MC or MF flap
based on reconstructive needs. A pedicled PM
rotational flap is generally used in salvage recon-
struction of the vessel-depleted previously oper-
ated/irradiated neck, or when patient anatomy or
comorbidities fail to provide a good option for
FTT. Common defects reconstructed using a pedi-
cled PM flap include neck, hypopharynx, lateral
face, radical parotidectomy, tongue, oral cavity
(Fig. 22), and mandible (Fig. 23) defects. Because
of its moderate arc of rotation, the pedicled PM
flap has limited reach for the reconstruction of
midface and cranial defects. The superior limit of
coverage by the PM flap medially is the superior
aspect of the tonsillar pillar (posterior maxillary tu-
berosity) and laterally the zygomatic arch. It has a
long history of reliability, versatility in its design,
and ease of harvest, which make it ideal for the
reconstruction of salvage defects and in compro-
mised patients where anesthetic and operating
time is of concern.
Surgical and anatomic considerations
Arterial supply to the PM flap is from the pectoral
branch of the thoracoacromial artery, and venous
drainage is via the paired VC. Artery diameter
ranges from 1.5 to 2.5 mm, and vein diameter
ranges from 0.5 to 4.0 mm. Motor innervation to
the PM muscle is from the lateral and medial pec-
toral nerves. The vascular pedicle consists of the
pectoral branch of the thoracoacromial artery
and paired VC. The flap skin harvest zone includes
the area overlying the PM muscle. Skin paddles of
up to 20  30 cm can be harvested based on
patients’ body habitus, and the entire PM muscle
can be harvested for the reconstruction of large
defects.
Patients are positioned supine intraoperatively,
and standard skin markings are made. A line
from the acromion to the xiphoid process is
made to denote the vertical path of the dominant
64 Patel et al
vascular pedicle. The skin paddle is generally
placed on the pectoralis muscle and medial to
the nipple areolar complex and is designed to
the appropriate size and shape. A curvilinear line
is drawn from the axillary fold to the cranial extent
of the skin paddle. This line denotes the inferior
extent of the deltopectoral flap, which is preserved
in most cases. In women, a skin paddle should be
designed in the inframammary fold for a more
esthetic outcome and to avoid cutting through
the bulk of breast tissue. This design will also pre-
vent medial displacement of the nipple and breast
tissue. To ensure skin paddle survival, all attempts
are made to place the skin paddle within the
boundaries and close to the lateral border of the
PM muscle. The nipple is generally not included
in the flap design. The lateral incision is made first
to define the lateral border of the PM muscle and
confirm that the skin paddle lies completely on
the PM muscle without any distal random
patterned vascular contribution. The skin paddle
is circumferentially incised and tacked down to
the PM muscle with sutures to prevent any
shearing forces on the skin perforators. The mus-
cle is elevated off of the chest wall lateral to medial
and caudal to cranial, staying on top of the pector-
alis minor muscle. The internal mammary perfora-
tors, in the second and third intercostal space, are
preserved by maintaining a cuff of PM muscle in
this area and staying lateral when transecting the
PM from the sternum in this region. These perfora-
tors would provide blood supply to the deltopec-
toral flap if it were needed in the future.
The vascular pedicle is directly visualized as
dissection proceeds proximally. While visualizing
the vascular pedicle, the humeral attachment of
the PM is transected. A cuff of fascia and fat
should be preserved around the pedicle to cushion
and prevent compression and kinking of the
vascular pedicle in the neck tunnel. The pectoral
nerves should be sacrificed to allow for greater
mobility of the flap at the pedicle, increase the
arc of rotation, and prevent postoperative muscle
contraction. Sufficient blunt dissection (at least 5
finger breadths) should be performed to create a
neck tunnel and to allow for passive passage of
the flap skin paddle. Closure of the donor site is
performed in layers after placement of closed suc-
tion drains. Donor sites after harvest of large skin
paddles may need to be reconstructed with a
skin graft.
Pitfalls and challenges
Absolute contraindications to performing a PM
flap include a congenital absence of PM muscle,
such as in patients with Poland syndrome, a his-
tory of radiation to the anterior chest wall, or
trauma compromising the muscle or its vascula-
ture. Caution is used in patients with a history of
a sternotomy, mastectomy, pacemaker, implant-
able venous access device, and/or breast implant
placement.
Because of its proximity to the neck, it generally
does not allow for a 2-team approach. Variability in
the amount of subcutaneous fat, breast tissue, and
thick, less pliable chest skin makes the flap bulky
and less ideal for the reconstruction of small-
sized defects. Also, because of the bulk of the
muscle, after skin flap inset into the defect, it
may be difficult to close the neck incision thereby
necessitating skin grafting of the exposed PM
muscle in the neck. Chest skin is not the ideal color
match to head and neck tissue. Harvest of the flap
does not have significant morbidity, but it may
cause asymmetry in breast tissue in women.
Fig. 22 shows a case of a patient with an intrao-
ral retromolar trigone and posterior maxillary post-
ablative defect that was reconstructed with a right
pedicled MC PM flap. The PM flap provides reli-
able robust vascularized tissue with sufficient
bulk for the reconstruction of this defect in patients
who are not candidates for FTT.
Fig. 23 shows a case of a patient who underwent
a left segmental mandibulectomy and reconstruc-
tion with a titanium reconstruction plate and
left pedicled MC PM flap. The flap provides consis-
tent vascular anatomy and a moderate to large
skin paddle that can be folded to reliably recon-
struct the mandibular defect in patients who are
not candidates for an OC free flap. The bulk
available with this flap allowed for maintenance of
oral integrity and coverage of neck vessels.
SUMMARY
Primary soft tissue reconstruction of ablative head
and neck defects is a complex topic that the au-
thors attempt to simplify for a broader application.
To achieve optimal outcomes, goals of recon-
struction should be prioritized and a defect-
oriented approach to flap selection should be
undertaken. The algorithm provided here is fluid
in nature. As the wealth of literature grows and
the authors continue to refine their techniques, it
is open to changes, additions, deletions, and chal-
lenges. Further work is ongoing at the authors’
institution to apply this defect-oriented approach
to stratify and reconstruct small defects with local
flaps in the head and neck.
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