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84
border
S. Kohlert
Excise
Preserve
vermilion
Fig. 5.18 Extended Abbe ap
skin
Abbe flap extends
to inferior chin
advancement
Extended
Abbe flap
Cheek
and functional results for patients with large-scale defects of the lip and chin [51,
52], although there have been reports of long-term loss of oral competence in cer-
tain patients [16].
Modications to the RFFF technique aimed at providing dynamic reconstructions of major lip defects. Grinsell and Herle recently described a composite procedure including an innervated pronator quadratus muscle ap coapted to the buccal
branch for motor innervation and to the mental nerve (in lower lip reconstruction)
or infraorbital nerve (upper lip reconstruction) for sensory input [53].
Alternative Donor Sites forFree Tissue Transfer
While the RFFF is the workhorse for total lip and chin defects, other donor sites are
occasionally used for free tissue transfer as well. Functional gracilis muscle aps
(covered by split thickness skin grafts) can be employed for total lip defects. Studies
have demonstrated satisfactory cosmetic and functional outcomes (with clinical
recovery of sensation to the ap as well as normal pattern motor unit potentials in
the muscle on postoperative needle electromyography studies with this technique)
[54]. Composite defects of the lip and mandible can be reconstructed with osteocutaneous aps from a wide array of donor sites including the radial forearm, bula
[55], scapula [56], and latissimus dorsi with rib [57, 58]. While anterolateral thigh
aps have traditionally been felt to be too bulky for lip reconstruction, “super-thin”
ALT aps have been successfully employed for large lower lip and skin defects with
good success [59]. Details regarding the harvest of many of these aps can be found
in the later chapters of this text.
5 Reconstruction oftheLip
85
Complications ofLip Reconstruction
Complications of lip reconstruction can be divided into short-term and long-term
complications. Short-term complications include pain, infection, wound dehiscence, difculty tolerating a normal diet, ap failure, numbness of the surrounding
area (temporary or permanent), and need for additional surgery. Long-term complications include poor cosmetic result, microstomia (which may impair the patient’s
ability to wear dentures or eat certain foods), abnormal mobility of the lips/facial
muscles, dysarthria, and permanent loss of oral competence (and associated drooling). The risk of many of these complications is mitigated by a proper choice of
reconstructive method and meticulous operative technique, although not all can be
avoided completely (especially in patients presenting with very large and complicated defects).
Managing Microstomia
While the risk can be mitigated, microstomia is a somewhat common complication
of major lip reconstruction, especially in patients with large defects. In our practice,
signicant improvement is often seen when following therapy with a combination
of manual massage techniques, orofacial exercises, as well as the use of formal oral
stretching devices. A wide array of oral appliances have been developed throughout
the years [60]. We employ the Therabite® rehabilitation system (Atos Medical; New
Berlin, WI) for our patients with microstomia and trismus. Unfortunately, the
Therabite® can be prohibitively expensive for many patients, and we often employ
a modication of the thermoplastic mouth stretcher described by Dougherty [60,
61] for home-based exercises in this population.
Commissuroplasty
Blunting of the oral commissure is a potential complication of lip reconstruction,
especially when the defect involves the oral commissure. Given the nature of the
Estlander and Karapandzic aps, blunting is frequently observed after these procedures. Oral commissuroplasty can be performed secondarily to improve the cosmetic result.
There are two primary techniques for commmissuroplasty: buccal mucosal
advancement and myomucosal advancement (of the labial mucosa and the underlying orbicularis oris). Both approaches begin with a triangular-shaped resection of
the skin lateral to the blunted oral commissure, with the apex of the triangle in the
location of the expected position of a normal commissure.
The simpler of the two techniques (and our preferred approach) is the buccal
mucosal advancement ap technique. After wedge resection of the skin lateral to the
blunted commissure, the vermillion over the commissure is excised, and the underlying orbicularis oris is divided horizontally through the commissure. The upper
86
dcba
Mucous memb.
incisions
Fig. 5.19 Oral commissuroplasty
S. Kohlert
and lower muscle edges are then advanced and attached to the skin at the apex of the
previously excised triangular wedge (Fig.5.19). Buccal mucosa is then advanced
over the top of the muscle and secured to the skin with resorbable suture.
A full description of both approaches has been well described in an excellent
review article by Parsel and Winters [62].
Summary
Lip defects are commonly encountered by the head and neck reconstructive surgeons. Neoplasia, trauma, and congenital abnormalities are the most common causes.
There are a wide array of reconstructive options available for upper and lower lip
reconstructions that span the length of the reconstructive ladder. The surgeon should
carefully assess the defect (including which subsites are involved) and select the
least complex reconstructive option available that will result in a satisfactory cosmetic and functional result. Complications of reconstruction include poor cosmetic
result, temporary and/or permanent loss of sensation, impaired motor function and
loss of oral competence, dysarthria, and microstomia. A careful ap selection and
meticulous surgical technique can mitigate the risk of these complications.
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89
Part II
Muscular and Musculocutaneous Flaps
Pectoralis Major Flap
NimaVahidi, KevinQuinn, CherylYu, SeungLee,
andThomasS.Lee
Introduction
Reconstructive surgery with the pectoralis major myocutaneous ap was rst
described in 1968; however, it wasn’t until Ariyan in 1979 that its application in
head and neck reconstruction was well described [1–3]. It is now commonly used in
the reconstruction of soft tissue defects of the oral cavity, oropharynx, hypopharynx, as well as external skin defects of the face and neck. The pectoralis ap offers
both myocutaneous and myofascial ap options to support reconstruction needs.
Prior to wide-scale adoption of microvascular free tissue transfer in the 1980s,
the pectoralis myocutaneous ap was used extensively for head and neck reconstruction. It still remains a popular reconstructive option in developing nations with
a limited access to microvascular surgery and is now used selectively in developed
nations, particularly in the setting of salvage surgery or in patients without adequate
donor vessels for free ap reconstruction [4].
6
N. Vahidi · C. Yu · S. Lee · T. S. Lee (*)
Department of Otolaryngology, Virginia Commonwealth University Medical Center,
Richmond, VA, USA
e-mail: Nima.vahidi@vcuhealth.org; Cheryl.yu@vcuhealth.org; Seong.lee@vcu.edu;
Thomas.Lee@vcuhealth.org
K. Quinn
Department of Otolaryngology, Ohio State University Medical Center, Columbus, OH, USA
e-mail: Kevin.quinn@osumc.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_6
93
94
N. Vahidi et al.
Anatomy
The pectoralis major muscle is situated in the upper chest and functions to rotate
and adduct the arm. It has four sites of origin which include the anterior surface of
the medial half of the clavicle, the anterior surface of the lateral half of the manubrium and sternum, the costal cartilage from the second to sixth ribs, and the aponeurosis of the external oblique muscle. From these points, the muscle bers
converge laterally toward their insertion on the humerus. The pectoralis minor muscle, which lies deep to the pectoralis major, originates from the anterior surface of
the third and fth ribs and inserts on the coracoid process of the scapula. It functions
to draw the scapula downward and forward. Typically, there is an avascular, fatty
tissue plane present between the pectoralis major and pectoralis minor within which
the motor nerve to the pectoralis major muscle is found. Deep to the pectoralis
muscles are the serratus anterior and intercostal muscles. Superolaterally, the pectoralis major muscle is bordered by the deltoid muscle.
Neurovascular Supply
The pectoralis major ap is an axial ap based on the pectoral branch of the thoracoacromial artery and vein (Fig.6.1). The thoracoacromial artery is a branch of the
axillary artery which is itself a continuation of the subclavian artery and can be
traced back to the aorta.
The thoracoacromial trunk arises from the second segment of the axillary artery
associated with the pectoralis minor muscle and has four distal branches including
the acromial, humeral, clavicular, and pectoral branches. The pectoral branch travels along the deep surface of the pectoralis major muscle (supercial to the pectoralis minor muscle) and provides the majority of its blood supply. The lateral thoracic
artery, which also arises from the second segment of the axillary artery, provides a
secondary blood supply but is often sacriced to maximize ap reach which can be
restricted by its lateral attachment. The pectoralis perforator vessels may also provide supplemental blood supply to the overlying skin.
The venous drainage of the pectoralis major mirrors the arterial supply, with
pectoral veins draining directly to the axillary vein. The cephalic vein which provides venous drainage for the upper extremities also supports the drainage of portions of the skin overlying the pectoralis muscle.
The pectoralis major muscle is innervated by the medial and lateral pectoral
nerves which arise from the brachial plexus. Additionally, the pectoralis major and
minor receive innervation from the seventh and eight cervical and rst thoracic
nerves. Of note, the motor nerve that innervates the pectoralis major muscle is often
sacriced during the harvesting process. It will appear as a nerve structure that
pierces the pectoralis minor muscle and enters the pectoralis major muscle from its
deep aspect. The denervated pectoralis major muscle will often lose signicant soft
tissue volume as a result of muscle atrophy, which can be advantageous in certain
scenarios where such loss of tissue bulk is desired. However, if this volume loss is
undesirable, such as if the ap is being used for near total glossectomy
oral branch of
6 Pectoralis Major Flap
Clavicle
Pect
thoracoacromial
artery/vein
Pectoralis minor
muscle
Lateral thoracic
artery
Pectoralis major
muscle
Xyphoid
Fig. 6.1 Anatomical depiction of the left chest, highlighting surgical landmarks for the pectoralis
ap harvest. Halfway point along the clavicle marks the approximate location where the pectoral
branch of thoracoacromial artery and vein is located immediately deep to the pectoralis major
muscle. The pectoral branch of the thoracoacromial artery provides the primary blood supply for
the pectoralis major, while the lateral thoracic is a secondary blood vessel and is often sacriced
during ap harvest
95
reconstruction, the surgeon should consider providing additional muscle and soft
tissue bulk as in anticipation of these post-operative changes.
Advantages
– The pectoralis ap offers a single-stage reconstructive option.
– It is a relatively easy ap to harvest and offers an abundance of soft tissue volume
as well as a large skin ap for reconstruction.
– The vascular supply of the pectoralis ap is reliably identiable within a well-
established tissue plane located deep to the pectoralis major muscle.
– The tissue bulk and well-vascularized nature of the pectoralis major ap afford it
a superior ability to withstand contamination with saliva, tissue infection, or
radiation damage. It also typically lies outside the primary radiation elds for
head and neck cancer and can provide healthy, non-radiated tissues in the previ-
ously irradiated patient. Thus, it is ideal for intraoral, pharyngeal mucosal defects
in patients who are poor free ap candidates. Furthermore, it is the ap of choice
in situations where there is a potential for carotid artery injury or exposure in the
setting of a radical neck dissection with resection of sternocleidomastoid muscle.