*4.1.2.2 The supraclavicular pediculate flap*

The supraclavicular pediculate flap is an alternative to the submental flap particularly when a larger amount of skin is needed and in cases of huge nodal

**145**

**Figure 3.**

*Modalities and State of Art in Oral Cancer Reconstruction*

the defect you need to reconstruct (**Figure 3a**–**b**).

(VICF) or the scapula free flap (SFF) are the main options.

*(a) Yugal mucosa resection and (b) supraclavicular flap harvest.*

reconstruction must be considered.

*4.1.3.1 The radial forearm free flap*

*4.1.3 Large defects*

disease in level I. The flap can be raised if there are no bulky nodes in the neck in the level IV. The SCF is based on axial circulation from the supraclavicular artery which arises from the transverse cervical artery and in a small percentage of cases from the suprascapular artery. It can be used to reconstruct soft tissue defects measuring up to 20 cm in size after tumor excision, being an advantage over the SMF in FOM defects. As well as the submandibular flap, usually there is low donor site morbidity permitting its primary closure, and of course the main restriction is related to neck dissection in level IV due to the possibility to injure the cervical transverse pedicle impairing its vascularization [6]. Another advantage is that it can be raised at the end of the surgery after neck dissection or in cases when you do not plan to dissect level IV or there is no doubt about the probability to alter its vascularization; it can be harvested at the beginning of neck dissection once you have defined the size of

The main complication for both flaps is the loss of the flap due to arterial or venous ischemia. To prevent that fatal complication, a meticulous dissection is needed to preserve its vascularization during harvesting and trying to avoid tension during insetting. When only venous congestion is present, the flap may recover without additional intervention, but if ischemia is established, the lost flap must be retired to avoid infection and systemic complication, and if possible, a new way of

In a bigger or composite defect of FOM, the reconstruction can be a challenge, especially when the bone, tongue, and skin are involved. It is important to assess preoperatively the degree of bone invasion to suitably plan possible mandibulectomy requiring additional bone tissue for reconstruction. If only soft tissue is required, a radial forearm free flap (RFFF) or an anterolateral free flap (ALT) can be harvested, but if the bone required a fibula free flap (OCFF), the iliac crest flap

The radial forearm free flap based on the radial artery provides a pliable and thin skin that makes the RFFF an ideal choice for reconstruction of the floor of the mouth; in few cases if a small marginal segment of the bone is required, a composite radial free flap including a limited segment of radial bone can be obtained [7]; if furthermore the tongue is compromised, the RFFF can be insetted with a bilobed design allowing one lobe to restore the volume of the tongue and the second one to

*DOI: http://dx.doi.org/10.5772/intechopen.91049*

disease in level I. The flap can be raised if there are no bulky nodes in the neck in the level IV. The SCF is based on axial circulation from the supraclavicular artery which arises from the transverse cervical artery and in a small percentage of cases from the suprascapular artery. It can be used to reconstruct soft tissue defects measuring up to 20 cm in size after tumor excision, being an advantage over the SMF in FOM defects. As well as the submandibular flap, usually there is low donor site morbidity permitting its primary closure, and of course the main restriction is related to neck dissection in level IV due to the possibility to injure the cervical transverse pedicle impairing its vascularization [6]. Another advantage is that it can be raised at the end of the surgery after neck dissection or in cases when you do not plan to dissect level IV or there is no doubt about the probability to alter its vascularization; it can be harvested at the beginning of neck dissection once you have defined the size of the defect you need to reconstruct (**Figure 3a**–**b**).

The main complication for both flaps is the loss of the flap due to arterial or venous ischemia. To prevent that fatal complication, a meticulous dissection is needed to preserve its vascularization during harvesting and trying to avoid tension during insetting. When only venous congestion is present, the flap may recover without additional intervention, but if ischemia is established, the lost flap must be retired to avoid infection and systemic complication, and if possible, a new way of reconstruction must be considered.

### *4.1.3 Large defects*

*Oral Diseases*

must be planned if possible.

*4.1.2.1 The submental pediculate flap*

*4.1.2.2 The supraclavicular pediculate flap*

submental (SMF) and the supraclavicular flap (SCF). Additionally, in that kind of defects, especially when postoperative radiotherapy is projected, a pediculate flap

The submental pediculate flap is vascularized by the submental artery, a branch of facial artery. It must include a segment of the anterior belly of digastric to perfuse the overlying skin through perforants. The amount of tissue available to harvest depends on the pitching test that predicts the possibility of primary closure of the donor site. This flap entails to avoid sacrifice of its vascular pedicle so the clue is that it should be planned and harvested at the beginning of neck dissection [5] (**Figure 2a**–**c**). Sometimes nodal disease levels Ia and Ib limit the ability to harvest the submental flap without impairing the oncological resection. The main advantage of this flap is the proximity between the donor site and the floor of the mouth so it can be insetted easily; the main problem is that if it is harvested with a big amount of muscle, the result once insetted may be a bulky flap resulting on swallowing and speaking problems.

The supraclavicular pediculate flap is an alternative to the submental flap particularly when a larger amount of skin is needed and in cases of huge nodal

*(a) Submandibular flap harvest, (b) submandibular flap insetting, and (c) final result.*

**144**

**Figure 2.**

In a bigger or composite defect of FOM, the reconstruction can be a challenge, especially when the bone, tongue, and skin are involved. It is important to assess preoperatively the degree of bone invasion to suitably plan possible mandibulectomy requiring additional bone tissue for reconstruction. If only soft tissue is required, a radial forearm free flap (RFFF) or an anterolateral free flap (ALT) can be harvested, but if the bone required a fibula free flap (OCFF), the iliac crest flap (VICF) or the scapula free flap (SFF) are the main options.

## *4.1.3.1 The radial forearm free flap*

The radial forearm free flap based on the radial artery provides a pliable and thin skin that makes the RFFF an ideal choice for reconstruction of the floor of the mouth; in few cases if a small marginal segment of the bone is required, a composite radial free flap including a limited segment of radial bone can be obtained [7]; if furthermore the tongue is compromised, the RFFF can be insetted with a bilobed design allowing one lobe to restore the volume of the tongue and the second one to

**Figure 3.** *(a) Yugal mucosa resection and (b) supraclavicular flap harvest.*

resurfaces the FOM [8]. The RFFF is considered the battle horse in microvascular reconstruction due to the skin quality, the length of the pedicle, the size of the vessels, and the easy preoperative assessing since it does not require vascular images just the Allen test to evaluate distal perfusion of the hand provided by palmar arch, and additionally, it is easily harvested. Its limit is usually referred to the size in cm that can be harvested (up to 20 × 12 cm), but it almost never applies as an exception in oral cavity reconstruction. The principal risk and disadvantage of the osteocutaneous radial free flap is the risk of fracture when a segment of the bone is included in the RFFF, so prophylactic fixation of the radius with the appropriately sized 2.4-mm locking reconstruction plate is performed to avoid fracture of the donor site [9]. The disadvantages of this flap are the hairy non-mucosalizing skin paddle, the cosmetic deformity of the donor site due to skin grafting that sometimes let an ugly scar and, in some cases, a bulky dysfunctional flap. The hairy skin can atrophy after radiation, or it can be treated with laser peeling, so in most of the cases, the final reconstruction result is excellent. To improve the cosmetic result of the donor site, any effort must be done to preserve the paratenon over the flexor tendons; setting a 4 mm better than a 2 mm skin graft over the donor site with an appropriate plaster bandage for temporal immobilization is also suggested. This usually ends in a better cosmetic result. Finally, to avoid a bulky dysfunctional flap, planning an adequate design of the size and form of the flap before harvesting is advisable.

#### *4.1.3.2 The ALT flap*

The ALT flap is also proposed as an excellent recourse when only the skin and soft tissue are required, especially in thin patients; it is advocated by many as a first choice to avoid the donor site morbidity. This flap pending on a septocutaneous branch coming from the lateral circumflex femoral artery involves a more difficult dissection due to the smaller diameter of the vessels [10]. It can be harvested thinner (supra fascial) or thicker (subfascial) depending on specific needs of skin and soft tissue. One important advantage is that can be raised even bigger allowing primary closure. The disadvantage of a hairy non-mucosalizing skin paddle is like the RFFF, and in an obese patient the flap is unacceptably bulky. Another disadvantage occurs when the nerve branch to the vastus lateralis muscle is cut unnoticed causing knee instability. In rare occasions the donor site needs to be skin grafted.

#### *4.1.3.3 The osteocutaneous fibula free flap*

The osteocutaneous fibula free flap is considered by many, the gold standard when oncological resection includes a large segmental mandibular defect that may or no include skin and is generally the first choice [8, 11] and the iliac crest and scapula [12] are alternatives chiefly in segmental small defects. The osteocutaneous fibula free flap (OCFF) based on peroneal artery is a reliable, and versatile flap for mandibular reconstruction and is considered the gold standard in mandibular reconstruction. It usually offers enough length of bone and skin to reconstruct a partial or complete mandibular resection and allows to place bone-integrated implants. It is essential to plan its harvesting and design from the beginning at the outpatient clinic, since it is mandatory to perform limb vascular imaging studies to assess the normal vascular anatomy and avoid fatal vascular morbidity or ischemia of the donor limb after bone resection. It does not need to plate the remaining fibula that remains attached to the tibia, and if harvesting in the right way, it does not cause limb instability. As a norm, it is easy to harvest and one-stage reconstruction can be performed. There are some downsides to it; first the size of the skin

**147**

*Modalities and State of Art in Oral Cancer Reconstruction*

paddle is limited just to permit primary closure of skin donor site; but if needed it also can be skin grafted. Second the hairy and non-mucosalizing skin paddle that is placed intraorally could end in an disturbing sensation, usually temporally if radiation is added to the treatment, and third in cases of arterial or venous disease in the lower extremities or previous surgery, there is a formal contraindication for

The scapula free flap (SFF) based on the circumflex artery arising from the subscapular artery, which is a branch of the axillary artery in the upper thorax, similarly provides acceptable bone length while supplying significantly larger skin and soft tissue paddles (up to double in overall area). It is an excellent alternative to small and wide to medium defects when wide bone is necessary. The main disadvantage of this flap is the need of repositioning during the surgical procedure

The vascularized iliac crest bone flap (VICF) has also been proposed as a new approach to reconstruct a mandibular deformity, especially in lateral mandibular defects [15]. This flap is based on the deep circumflex iliac vessels and usually harbors consistent anatomy; the length of the vessel averages 8–10 cm, and its diameter averages 2–3 mm. Pending on specific reconstruction needs may be harvested as a full thickness bicortical or as a partial thickness unicortical bone, and its main advantage is the natural curved contour of the bone that is ideal for lateral mandibular reconstruction. It can be raised with skin or muscle when needed. The donor site morbidity is related to the local appearance deformity and the probability

Nowadays three of the osteocutaneous free flaps previously mentioned could be combined with the use of a three-dimensional virtual technology to preoperatively plan the resection, the design of the plates for bone fixation, and the cutting guides to enhance the functional and cosmetic results. This new technology is proposed to optimize surgical outcome and as a safer way of modeling. It can also be implemented in mandibular or midface reconstruction using fibula free flap or iliac crest flap. It requires a preoperative CT scan planning design and preparation of the customized mandibular reconstruction plate and cutting guides providing a most precise reconstruction [16, 17]. Current communication between the resective surgeon, reconstructive surgeon, and team that supports the technology is necessary to assess all the information previous to surgery. The principal limits are the cost and access to the technology but usually are over headed by the benefit of a precise reconstruction. With this tendency to a more precise reconstruction and rehabilitation, one important aim of bone reconstruction is to restore the chewing function so dental implants are required to best accomplish that. The moment to inset them in the postoperative scenery usually takes up to 3 or 4 years waiting to finish healing and therapies including radiation and preventing osteoradionecrosis of the new mandible. With that in mind, there is a new trend to inset dental implants during the first reconstruction procedure and before radiation so that the chewing can be restored earlier [18]. To accomplish that goal, a preoperative consult with the maxillofacial surgeon is mandatory so can be involved in planning implants setting.

The additional fatal complications of the micro vascularized flaps are the arterial or venous ischemia. A strict postoperative care must be done for an early detection

*DOI: http://dx.doi.org/10.5772/intechopen.91049*

flap harvesting [13].

*4.1.3.4 The scapula free flap (SFF)*

restraining a double team approach [14].

to develop a future hernia.

*4.1.3.5 The vascularized iliac crest bone flap (VICF)*

paddle is limited just to permit primary closure of skin donor site; but if needed it also can be skin grafted. Second the hairy and non-mucosalizing skin paddle that is placed intraorally could end in an disturbing sensation, usually temporally if radiation is added to the treatment, and third in cases of arterial or venous disease in the lower extremities or previous surgery, there is a formal contraindication for flap harvesting [13].

#### *4.1.3.4 The scapula free flap (SFF)*

*Oral Diseases*

*4.1.3.2 The ALT flap*

*4.1.3.3 The osteocutaneous fibula free flap*

resurfaces the FOM [8]. The RFFF is considered the battle horse in microvascular reconstruction due to the skin quality, the length of the pedicle, the size of the vessels, and the easy preoperative assessing since it does not require vascular images just the Allen test to evaluate distal perfusion of the hand provided by palmar arch, and additionally, it is easily harvested. Its limit is usually referred to the size in cm that can be harvested (up to 20 × 12 cm), but it almost never applies as an exception in oral cavity reconstruction. The principal risk and disadvantage of the osteocutaneous radial free flap is the risk of fracture when a segment of the bone is included in the RFFF, so prophylactic fixation of the radius with the appropriately sized 2.4-mm locking reconstruction plate is performed to avoid fracture of the donor site [9]. The disadvantages of this flap are the hairy non-mucosalizing skin paddle, the cosmetic deformity of the donor site due to skin grafting that sometimes let an ugly scar and, in some cases, a bulky dysfunctional flap. The hairy skin can atrophy after radiation, or it can be treated with laser peeling, so in most of the cases, the final reconstruction result is excellent. To improve the cosmetic result of the donor site, any effort must be done to preserve the paratenon over the flexor tendons; setting a 4 mm better than a 2 mm skin graft over the donor site with an appropriate plaster bandage for temporal immobilization is also suggested. This usually ends in a better cosmetic result. Finally, to avoid a bulky dysfunctional flap, planning an adequate

design of the size and form of the flap before harvesting is advisable.

The ALT flap is also proposed as an excellent recourse when only the skin and soft tissue are required, especially in thin patients; it is advocated by many as a first choice to avoid the donor site morbidity. This flap pending on a septocutaneous branch coming from the lateral circumflex femoral artery involves a more difficult dissection due to the smaller diameter of the vessels [10]. It can be harvested thinner (supra fascial) or thicker (subfascial) depending on specific needs of skin and soft tissue. One important advantage is that can be raised even bigger allowing primary closure. The disadvantage of a hairy non-mucosalizing skin paddle is like the RFFF, and in an obese patient the flap is unacceptably bulky. Another disadvantage occurs when the nerve branch to the vastus lateralis muscle is cut unnoticed causing knee instability. In rare occasions the donor site needs to be skin grafted.

The osteocutaneous fibula free flap is considered by many, the gold standard when oncological resection includes a large segmental mandibular defect that may or no include skin and is generally the first choice [8, 11] and the iliac crest and scapula [12] are alternatives chiefly in segmental small defects. The osteocutaneous fibula free flap (OCFF) based on peroneal artery is a reliable, and versatile flap for mandibular reconstruction and is considered the gold standard in mandibular reconstruction. It usually offers enough length of bone and skin to reconstruct a partial or complete mandibular resection and allows to place bone-integrated implants. It is essential to plan its harvesting and design from the beginning at the outpatient clinic, since it is mandatory to perform limb vascular imaging studies to assess the normal vascular anatomy and avoid fatal vascular morbidity or ischemia of the donor limb after bone resection. It does not need to plate the remaining fibula that remains attached to the tibia, and if harvesting in the right way, it does not cause limb instability. As a norm, it is easy to harvest and one-stage reconstruction can be performed. There are some downsides to it; first the size of the skin

**146**

The scapula free flap (SFF) based on the circumflex artery arising from the subscapular artery, which is a branch of the axillary artery in the upper thorax, similarly provides acceptable bone length while supplying significantly larger skin and soft tissue paddles (up to double in overall area). It is an excellent alternative to small and wide to medium defects when wide bone is necessary. The main disadvantage of this flap is the need of repositioning during the surgical procedure restraining a double team approach [14].

#### *4.1.3.5 The vascularized iliac crest bone flap (VICF)*

The vascularized iliac crest bone flap (VICF) has also been proposed as a new approach to reconstruct a mandibular deformity, especially in lateral mandibular defects [15]. This flap is based on the deep circumflex iliac vessels and usually harbors consistent anatomy; the length of the vessel averages 8–10 cm, and its diameter averages 2–3 mm. Pending on specific reconstruction needs may be harvested as a full thickness bicortical or as a partial thickness unicortical bone, and its main advantage is the natural curved contour of the bone that is ideal for lateral mandibular reconstruction. It can be raised with skin or muscle when needed. The donor site morbidity is related to the local appearance deformity and the probability to develop a future hernia.

Nowadays three of the osteocutaneous free flaps previously mentioned could be combined with the use of a three-dimensional virtual technology to preoperatively plan the resection, the design of the plates for bone fixation, and the cutting guides to enhance the functional and cosmetic results. This new technology is proposed to optimize surgical outcome and as a safer way of modeling. It can also be implemented in mandibular or midface reconstruction using fibula free flap or iliac crest flap. It requires a preoperative CT scan planning design and preparation of the customized mandibular reconstruction plate and cutting guides providing a most precise reconstruction [16, 17]. Current communication between the resective surgeon, reconstructive surgeon, and team that supports the technology is necessary to assess all the information previous to surgery. The principal limits are the cost and access to the technology but usually are over headed by the benefit of a precise reconstruction. With this tendency to a more precise reconstruction and rehabilitation, one important aim of bone reconstruction is to restore the chewing function so dental implants are required to best accomplish that. The moment to inset them in the postoperative scenery usually takes up to 3 or 4 years waiting to finish healing and therapies including radiation and preventing osteoradionecrosis of the new mandible. With that in mind, there is a new trend to inset dental implants during the first reconstruction procedure and before radiation so that the chewing can be restored earlier [18]. To accomplish that goal, a preoperative consult with the maxillofacial surgeon is mandatory so can be involved in planning implants setting.

The additional fatal complications of the micro vascularized flaps are the arterial or venous ischemia. A strict postoperative care must be done for an early detection

of venous or arterial suffering which may allow an appropriate reoperation in an intent of saving the flap. In the fatal case of flap loss, again it is crucial to retire the dead tissue and if possible cover the defect with a new pediculate or micro vascularized flap.
