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76
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L. Ganry and A. Quimby
a
c
Fig. 5.19 (a–d) Horizontal PAP free ap with dissection of its pedicle from below and deeper to the gracilis muscle.
The ap can be raised with the gracilis muscle or as a fasciocutaneous ap only
b
d
smaller pedicle length, ~7–8cm, with a
smaller pedicle diameter (close to
1mm). The radial nerve is also at risk
during the harvest, as it crosses the
humeral bone close to the pedicle
(Fig.5.19).
Its design is on a line drawn from the
lateral epicondyle to the midline of the
deltoid muscle. Pedicle can be articially lengthened by designing the ap
closer to the elbow lateral epicondyle,
and the skin can also be raised on the
lateral epicondyle and below.
It can be harvested with bone if needed,
but like for the RFFF, it should not be
the rst choice in vascularized bone free
ap.
However, it is a donor site which could
become a possible rst choice for a vascular periosteal free ap (from the distal
aspect of the humeral bone), typically
indicated for ORN treatment.
– Supercial circumex iliac perforator
(SCIP) free ap:
One of the most versatile free aps, but
less popular in head and neck as it provides a short pedicle and small-size vessels [64].
Chimeric presentation: can harvest very
thin skin paddle, with vascularized
nerve (lateral femoral cutaneous nerve),
muscle (sartorius muscle), bone (anterior and superior iliac spine), and lymph
nodes.
Donor site is inconspicuous with minimal donor-site morbidity.
Anatomy is versatile as it can present as
an axial ap (can be harvested above the
fascia supercialis) or as a direct perforator ap. It can present with a supercial venous drainage too.
Multiple skin paddle design is possible.
A common confusion exists regarding
the SCIP free ap: whether it is raised
5 Surgical Optimization
77
a
c
b
d
Fig. 5.20 (a–d) Lateral arm free ap, with exposure of the radial nerve at the lateral aspect of the humeral bone
from the supercial branch of the supercial circumex iliac pedicle or deep
branch. Another challenge is due to the
presence of the Scarpa fascia (or deep
fascia), an unusual layer of connective
tissue found deeper to the fascia supercialis in the pelvic region, and above the
fascia of the external oblique muscle
(Fig.5.20).
– Subscapular system:
One of the most versatile parts of the
human body, especially for soft tissue.
Can harvest large muscles with skin
paddle, such as the musculocutaneous
latissimus dorsi (LD) free ap or as a
perforator ap for skin paddle only (tho-
racodorsal artery perforator ap,
TDAP). Less commonly, a fasciocutane-
• Other soft tissue free aps and pedicle aps
ous skin paddle only from the circumex scapular artery can also be harvested
but with the need for a lateral decubitus
position, making this isolated choice
less popular in head and neck surgery
(Figs.5.21 and 5.22).
TDAP perforator is always found 8cm
below the axillary fossa and 2cm behind
the anterior border of the LD muscle.
Can be combined with other muscles
and bone from the subscapular system
(scapula tip, lateral border, or a combination of both).
Can provide a vascularized LD nerve
for complete vascularized facial nerve
reconstruction (Fig.5.23).
for head and neck reconstruction
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L. Ganry and A. Quimby
a
b
c
Fig. 5.21 (a–c) SCIP free ap raised as a thin ap above the fascia supercialis, on the supercial branch of the super-
cial circumex iliac pedicle
– Superior gluteal artery perforator (SGAP)
free ap is not popular in head and neck
reconstruction, as it implies a lateral decubitus position to be harvested. The benet
of this ap is that it has very thick dermis,
which is preferred for extremity reconstruction, typically the volar aspect of the
foot (Fig.5.24).
– Pedicled aps are also a major aspect of
head and neck reconstruction, but not the
topic here:
Trapezius ap for posterior scalp
reconstruction
Pedicle pectoralis major musculocutaneous (PMMC) ap for neck and lower
face reconstruction
Supraclavicular ap for neck and lower
face reconstruction
Internal mammary artery perforator
(IMAP) ap for neck reconstruction
Submental/infrahyoid ap for intraoral
and lower/midface reconstruction
LD ap for lateral skull base defect
Facial cutaneous perforator/propeller/
axial aps such as rotational ap, paramedian forehead ap, melolabial ap,
and nasolabial ap for oncodermato-
logic/trauma cases
• Specic considerations for bony aps
In the vast majority of cases, the pedicle position is one of the most important considerations in free ap design. The pedicle should
be positioned in such a way that it will avoid
any unnecessary loops to reach the ipsilateral
recipient vessels, while still maintaining an
adequate length to reach contralateral recipient vessels without tension.
Bony free aps are contoured to match the
facial defect. Accounting for spatial position
of the pedicle is of paramount importance, as
it will be dictated by the reconstructive needs.
• Fibula Free Flap (FFF)
– Planning osteotomies without VSP for
mandibular reconstruction:
a
5 Surgical Optimization
79
b
c
e
g
d
f
h
Fig. 5.22 (a–h) Scapulo-dorsal chimeric free ap with
latissimus dorsi musculocutaneous ap and osseous lateral border of the scapula combined with a circumex
skin paddle—needs two positions in such setting to be
able to dissect the circumex skin paddle and close the
donor site
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Fig. 5.23 Scapulo-dorsal chimeric free ap with latissimus dorsi musculocutaneous ap and TDAP skin paddle— needs only one position of the patient
Fig. 5.24 Vascularized latissimus dorsi motor nerve and
TDAP adipose paddle for facial nerve reconstruction
Choose the leg side, the pedicle side,
and the rotation of the bone into the
defect using the “hand” trick by Al Deek
etal. [65]: the surgeon’s hand from the
same side of the chosen bula forms a
st with the thumb up. The thumb represents the peroneal vessels and the proximal end of the bone, and the dorsal
surface of the proximal phalanges represents the lateral surface of the bula
bone. This very simple and efcient
concept has been modied and is now
represented by the “rock-paper- scissors”
concept. The bula is the “rock” as previously described symbolized by the st
with the thumb up [66] (Fig.5.25).
L. Ganry and A. Quimby
For a freestyle approach, we are using
the mandibular defect classication by
Urken etal. [67] (condyle, ramus, body,
and symphysis) to anticipate before the
surgery the resected segment(s) length
and to adapt our reconstruction.
The resection length can be measured,
between symphysis (2.0–3cm on the
vestibular side), body (7.5–8.5 cm),
and ramus-condyle complex to reconstruct the same length of the bone. The
neo- condyle should be suspended and
seated in the fossa but never be in contact with the skull base to avoid any
interference. The angles ramus-body
or body- symphysis happen to be without signicant variations between
gender and morphology in European
population [68] or North American
population [69]. The ramus-body
angle is around 120–125°, and bodysymphysis angle is also around
115–120°:
○ For ramus-body angle construction:
use a 60° angle template (one angle
of an equilateral large triangle, for
example) to remove a cuneiform
bony segment of 60°, which will create an angle of 120 with the two fragments of bone (Figs. 5.26a and
5.27a).
○ For a body-symphysis angle con-
struction: same procedure in a different position for this angle. The
mandibular arch usually has a bigonial length between 8.5 and 9.5cm.
In case the surgeon needs to deproject the neo-mandible (e.g., irradiated eld), an angle of 135° can be
obtained with a 45° template (by cutting in half a 90° angle template)
(Figs.5.26b and 5.27b).
Minimum length of bula bone fragments is around 2.0cm on the pedicle
side (usually the lingual side) to allow
efcient vascularization to the bone.
However, evidence of fragments <2cm,
especially seen in maxillary reconstruc-
ab
5 Surgical Optimization
abc
81
Fig. 5.25 (a–c) The “rock” in “rock-paper-scissors” con-
cept for orientation of the bula free ap. (a) In a superior
view, with yellow surface = lateral aspect of the bula,
green surface=medial aspect of the bula, with the thumb
Fig. 5.26 (a, b) Ramus-body/body-symphysis angles in a 1.95m tall European male patient
tion, seems to present the same vascular
outcome.
Anterior projection should match the
mandibular teeth arcade to avoid unnecessary overprojection of the chin in nonirradiated case.
The position of the neo-mandible is usually matched to the inferior border of the
mandible, as the majority of patients
will not benet from dental rehabilitation, especially in oncological cases.
mimicking the pedicle. (b) In a medial view, (c) position
of the ipsilateral hand to match the bula in a standing
position
However, the goal of every mandibular
reconstruction should aim for dental
rehabilitation, and therefore, the bula
free ap can be raised 5–10mm above
the inferior border of the native mandible to improve dental rehabilitation
without losing lower facial contour.
This strategy avoids the need for a
double- barrel bula. However, it should
not be attempted in lean patients with
thin soft tissue envelope, regardless of
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L. Ganry and A. Quimby
ab
Fig. 5.27 (a, b) Ramus-body/body-symphysis angles in a 1.51m tall European female patient
postoperative radiotherapy requirement,
due to the visible loss of lower facial
contour.
The distal bula osteotomy should preserve 6–7cm of bone in adults to maintain ankle stability, and 6–7 cm at the
proximal osteotomy to avoid injury to
the common bular nerve.
– Maximum length of bone for mandibular
reconstruction (see Fig.5.5):
Usually can reconstruct from a condyle
to contralateral parasymphysis with a
symphysis in a U-shape. Alternatively, a
condyle to a contralateral angle with a
V-shape
An angle to angle or more, especially
with deprojection of the chin (typically
in ORN cases)
Can be combined with unilateral or
bilateral TMJ prosthesis for a total mandibular reconstruction
– Can be raised as a chimeric free ap with:
Fasciocutaneous skin paddle from the
bula pedicle
Fasciocutaneous skin paddle from the
soleus system
Fasciocutaneous skin paddle from the
supramalleolar system
Muscle cuffs from the soleus system or
the exor hallux longus (taking the FHL
muscle will avoid hallux claw deformation due to scars and brosis in the
remaining muscle, but the patient will
lose some degree of exion) (Fig.5.28)
Vascularized sural nerve included with
the skin paddle
– Choice between miniplate osteosynthesis
in load sharing (risk of plate fracture) and
large reconstructive bar in load bearing
(risk of plate exposition) depends on the
patient presentation, need for radiotherapy,
and team preference
– Can support dental implant during the
same procedure (bicortical implantation),
with or without immediate prosthesis
(“jaw-in-a-day” procedure), allowing an
immediate lip or cheek support
• Subscapular system—Scapula Free Flap
(SFF)
– Planning osteotomies without VSP for
maxillary reconstruction:
Choose the scapula side and the pedicle
side using the same hand concept. The
convexity of the scapula tip and the side
chosen depend on the pedicle position
and use for oral cavity reconstruction.
The open “hand” trick, also used as the
“paper” in the “rock-paper-scissors”
concept [70], helps to guide the inset of
the scapula, which could be the convex
ab
5 Surgical Optimization
Fig. 5.28 (a, b) Chimeric osseo-muscular bula free ap, including FHL and soleus muscles, for reconstruction of a
lateral mandibular defect associated with an infratemporal fossa resection
83
a
b
c
Fig. 5.29 (a–c) The “paper” in “rock-paper-scissors”
concept for orientation of the scapula free ap. (a) In an
anterior view, with the thumb mimicking the pedicle (b)
tip or the straight lateral border. The
thumb orients the pedicle laterally and
posteriorly, and the hand mimics the
curvature of the scapula bone (Fig.5.29).
A scapula tip is usually well suited for a
palatal reconstruction of the horizontal
aspect:
in a superior view, showing the concavity of the hand
mimicking the scapula, (c) position of the ipsilateral hand
to match the scapula in a standing position
○ For a total palatal reconstruction, the
posterior aspect of the tip should
benet from a rigid stabilization if
possible, using a groove designed
into the pterygoid plates, or a robust
anterior xation typically with
patient-specic plates extended to
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L. Ganry and A. Quimby
robust remaining pillars of the midface like zygomatic bones.
○ The tip of the scapula is classically
left without any skin paddle in the
oral or nasal cavity, allowing sponta-
neous mucoepithelialization.
A scapula lateral border is usually well
suited for a mandibular reconstruction.
○ The proximal osteotomy should pre-
serve 2cm of bone from the glenoid
fossa to avoid any intra-articular
fracture.
It is typically a free ap used for midface reconstruction, when the need of
soft tissue is an important component of
the reconstruction, or as a second or
third choice in mandibular reconstruction, when the bula free ap is not
available.
Combination of the scapula tip and lateral side is possible for extensive
defects, or to reconstruct a midface pillar and a palate.
Both osseous fragments are usually vascularized by two independent systems
(the angular branch for the tip, and the
deep periosteal branches of the circumex branch for the lateral border).
– With regard to the need for bone vascular-
ized free ap in maxillary reconstruction,
many options are possible. This means that
no option is optimal for a particular defect.
With the emergence of zygomatic implants,
bone reconstruction needs in palatal defect
(infrastructure) are becoming more obvious for defects greater than 50% (class D in
the new J.S. Brown classication [71]).
Vascularized bone support may be needed
in class II or III, but also in case of class C
with anterior palatal defect (including
advanced cleft defect), which may benet
from a robust bony support to stabilize the
projection of the tip of the nose and the
upper lip and allows for dental rehabilitation. Soft tissue-only free aps would be
sufcient otherwise in maxillectomy without the need for an orbital support (class I
and II). Soft tissue palatal reconstruction
can be combined with zygomatic implants
if dental rehabilitation is desired. It can
also be combined with an autograft or
patient-specic implant for the lower
orbital rim reconstruction (e.g., free rib
graft, free bone graft, PEEK implant). Nonvascularized autograft to the lower orbital
rim can bring numerous complications in
case of postoperative radiotherapy (wound
dehiscence, skin necrosis, resorption, lack
of orbital content support). Maxillary
reconstruction can also be staged with a
soft tissue-only free ap rst (e.g., ALT),
followed by a revision with a bony free ap
for better facial support, contours, and dental rehabilitation. This can be considered
6 months after the radiotherapy, ensuring
that the patient remains disease free. One
should remember that dental and facial
prostheses could be very successful in
selected cases, and also that reconstruction
of a midface is always far more complex in
staged procedures rather than primary
reconstruction.
– Maximum length of bone for a mandibular
reconstruction:
It can usually reconstruct from a contralateral parasymphysis to a contralateral
angle (Fig.5.30).
A wedge bony resection can be performed in a lateral border. However,
simple multiple monocortical fractures
should be performed to bend the bone
into multiple fragments without losing
any length (Fig.5.31).
A design using a reverse ow through
the thoracodorsal pedicle is possible to
maximize the length of pedicle (consider otherwise short for the lateral border of the scapula, and long for the
scapula tip).
– Can be raised as a chimeric free ap with
(see Fig.5.21):
Vascularized innervated serratus (and
ribs)
Vascularized LD/TDAP
Vascularized circumex skin paddles
(can be bifold)
ab
ab
5 Surgical Optimization
Fig. 5.30 (a, b) Inaccurate plan resulting in insufcient neo-mandible length with a scapular free ap
85
Fig. 5.31 (a, b) Monocortical osteotomies in scapula osseous lateral border, obtaining a curvature for mandibular
reconstruction without bone loss
Can always be raised in a double-team
approach, in dorsal decubitus, with the
exception of the fasciocutaneous skin
paddle from the circumex pedicle,
which will need a lateral decubitus to be
harvested and to close the donor site
– Can support dental implants during the
same procedure, but usually performed in a
second surgery with zygomatic implants or
regular dental implants for maxillary
reconstruction
• DCIA free ap
– Planning osteotomies without VSP for
maxillary or mandibular reconstruction:
Choose the iliac crest side and the pedicle side using the same hand concept.
The convexity of the iliac crest and the
side chosen depend on the pedicle position and use for oral cavity reconstruction. The open “hand” trick, also used as
the “scissors” in the “rock-paperscissors” concept [66], helps to guide
the inset of the DCIA.The thumb orients the pedicle in an anterior direction,
the curvature of the hand mimics the
curvature of the iliac crest, and the tip of
the second and third digits represents
the anterosuperior and inferior iliac
crest spines (Fig.5.32).
The superior part of the cortex of the
iliac crest is usually used for the alveolar bone in maxillary reconstruction and
for the basilar aspect in mandibular
reconstruction.
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