*4.2.2.3 Alternative options*

For selected patients in whom free tissue transfer is not an option, the pectoralis major myocutaneous flap offers a reliable reconstructive procedure following both

**Figure 6.** *(a) Tongue defect after resection, (b) RFFF harvest and (c) RFFF insetting.*

**Figure 7.** *(a) ALT flap design and (b) ALT flap harvest.*

primary and salvage surgery (**Figure 8**). This flap based on the thoracoacromial artery can be raised as a myocutaneous or fasciocutaneous flap. It is reliable, robust, and easily harvested in terms to tongue reconstruction and can provide muscle and skin to fulfill the tongue and floor of the mouth and effectively separate the oral cavity from the neck. It must be suspended across the mandibular arch by either suturing

**151**

**4.3 Cheek**

**Figure 8.**

*Major pectoral flap harvest.*

*Modalities and State of Art in Oral Cancer Reconstruction*

time but are an excellent alternative when needed.

The cheek resection is done less frequently except in some countries like India, where cheek cancer is frequent and as a consequence of chewing tobacco; usually its oncological resections leave a complex defect that includes skin and mucosa in an area where a functional lip is required to avoid food spillage. The consequent

to the pterygoid musculature or securing to the mandible using drill holes to avoid and prevent the flap from falling [26]. This flap is considered a horse battle in rescue setting when a free flap fails. When the defect includes mandible, during the reconstruction it must have keep in mind that mandible contributes to airway stability, oral competence, speech, deglutition and mastication, so the goal of this reconstruction must include the preservation of the ability to open the mouth, occlusion, and the restoration of the inter arch continuity solutions to promote dental implants and restore chewing as mentioned in floor of mouth defects extended to mandibula. Not reconstructing the central defects will conclude in loss of the lip support with Andy Gump deformity, and not reconstructing the lateral defects will cause malocclusion and lateral shift in the position of mandible, so any intent must be done to reconstruct the mandible. Options in reconstruction include metal plates (**Figure 7**), non-vascularized bone grafts, osteomyocutaneous pedicled flaps, and osteocutaneous free flaps. Fixing soft tissues just with plates was widely used in the past and usually results in extrusion intraorally, external exposure or fracture of the plate up to 60% of the cases with a worst defect and a very poor functional outcome [27]. Autogenous bone grafts from iliac crest, scapula, or calvarium usually end in no vascularization of the new bone and its atrophy even more if radiation is added to the treatment, and finally similar results as the plating alone are obtained, so similarly they are no more used. Currently the gold standard in mandible reconstruction is the osteocutaneous free flaps (**Figure 9a**–**c**) and carries the same consideration as mentioned in floor of mouth reconstruction with a trend to perform a first time micro vascularized bone reconstruction with dental implants mainly in a previous dentulous young patient [28]. In an aged edentulous patient in the reconstruction setting, there is most likely no need to be aware for dental implants unlike dentulous young patient. Again, in selected patients with poor clinical condition and not suitable for a long procedure, a osteocutaneous pediculate flap such as a osteomyocutaneous trapezius flap [29] or a bicortical parietal osteofascial pedicled flap [30] can be perform providing a better functional result compared with just soft tissue coverage. Both flaps require experience, skills, and anatomic knowledge to harvest them in a short period of

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

*Modalities and State of Art in Oral Cancer Reconstruction DOI: http://dx.doi.org/10.5772/intechopen.91049*

**Figure 8.** *Major pectoral flap harvest.*

*Oral Diseases*

**150**

**Figure 7.**

*(a) ALT flap design and (b) ALT flap harvest.*

**Figure 6.**

primary and salvage surgery (**Figure 8**). This flap based on the thoracoacromial artery can be raised as a myocutaneous or fasciocutaneous flap. It is reliable, robust, and easily harvested in terms to tongue reconstruction and can provide muscle and skin to fulfill the tongue and floor of the mouth and effectively separate the oral cavity from the neck. It must be suspended across the mandibular arch by either suturing

*(a) Tongue defect after resection, (b) RFFF harvest and (c) RFFF insetting.*

to the pterygoid musculature or securing to the mandible using drill holes to avoid and prevent the flap from falling [26]. This flap is considered a horse battle in rescue setting when a free flap fails. When the defect includes mandible, during the reconstruction it must have keep in mind that mandible contributes to airway stability, oral competence, speech, deglutition and mastication, so the goal of this reconstruction must include the preservation of the ability to open the mouth, occlusion, and the restoration of the inter arch continuity solutions to promote dental implants and restore chewing as mentioned in floor of mouth defects extended to mandibula. Not reconstructing the central defects will conclude in loss of the lip support with Andy Gump deformity, and not reconstructing the lateral defects will cause malocclusion and lateral shift in the position of mandible, so any intent must be done to reconstruct the mandible. Options in reconstruction include metal plates (**Figure 7**), non-vascularized bone grafts, osteomyocutaneous pedicled flaps, and osteocutaneous free flaps. Fixing soft tissues just with plates was widely used in the past and usually results in extrusion intraorally, external exposure or fracture of the plate up to 60% of the cases with a worst defect and a very poor functional outcome [27]. Autogenous bone grafts from iliac crest, scapula, or calvarium usually end in no vascularization of the new bone and its atrophy even more if radiation is added to the treatment, and finally similar results as the plating alone are obtained, so similarly they are no more used.

Currently the gold standard in mandible reconstruction is the osteocutaneous free flaps (**Figure 9a**–**c**) and carries the same consideration as mentioned in floor of mouth reconstruction with a trend to perform a first time micro vascularized bone reconstruction with dental implants mainly in a previous dentulous young patient [28]. In an aged edentulous patient in the reconstruction setting, there is most likely no need to be aware for dental implants unlike dentulous young patient. Again, in selected patients with poor clinical condition and not suitable for a long procedure, a osteocutaneous pediculate flap such as a osteomyocutaneous trapezius flap [29] or a bicortical parietal osteofascial pedicled flap [30] can be perform providing a better functional result compared with just soft tissue coverage. Both flaps require experience, skills, and anatomic knowledge to harvest them in a short period of time but are an excellent alternative when needed.

#### **4.3 Cheek**

The cheek resection is done less frequently except in some countries like India, where cheek cancer is frequent and as a consequence of chewing tobacco; usually its oncological resections leave a complex defect that includes skin and mucosa in an area where a functional lip is required to avoid food spillage. The consequent

defect may be small or big and simple or composite associated to another oral cavity subsite resection. Small lesions of the cheek could be let alone to epithelize, but a bigger one will end in a scar and retraction, so a reconstruction must be done. In most of the cases a facial artery mucomucosal flap (FAMM) could be used. This flap based on a branch of the facial artery is elevated in the layer underneath the facial artery including the overlying buccinators muscle and a small portion of orbicularis oris muscle close to the oral commissure; it is rotated to cover the defect commonly restoring it, and the donor site could be primary closed or let it to heal secondarily without impairing its final functional result. A huge defect might need a pediculate flap such as submandibular or supraclavicular flap or even a microvascular free flap. Some encourage for the supraclavicular pediculate flap as the first option in this scenery, which usually provides a good amount of a non-bulky tissue without affecting oncological resection of node neck dissection in level Ia and Ib, and adducing that submandibular flap is too bulky to placed it in this specific region.

#### **4.4 Hard palate**

The extent of resection of hard palate is crucial to define the type and modality of reconstruction. The defect may be small and involve any portion of the hard palate, the premaxilla, or any portion of the maxillary alveolus with or without tooth-bearing or may be as huge as more than 50% of the hard palate. Many of the times, it is associated with partial or total maxillectomy so ending in a complex defect. Small defects can be let just to re-epithelize with excellent results. For a bigger one, a skin graft can be used; the problem is to support it long enough to achieve its integration to the hard palate; sometimes, the flap is detached and lost in which case healing by second intention is required. Small to medium defects may demand to harvest a palatal mucoperiosteal flap (PMPF). This flap is based on the greater palatine artery; preserving this vascular pedicle allows to rotate

**153**

**Figure 10.**

*palate outcome after 2 years of reconstruction.*

*Modalities and State of Art in Oral Cancer Reconstruction*

it to resurface the mucosal defect [31]. Its limit is related to the amount of tissue needed, and up to 3 cm can be covered with this flap. In a bigger 3–5 cm hole, also a submandibular pediculate flap could be used to cover it. In as much as in this location, there are no specific needs for muscle or for a thicker soft tissue; any attempt should be done to assemble it with just enough muscle behind that guarantees skin perfusion by perforants preventing necrosis and providing a flat new tissue. A composite defect that includes the maxillary alveolus with tooth-bearing or partial to total maxillectomy will end in oroantral communication (**Figure 10a** and **b**). This type of reconstruction needs special considerations that are not the subject of this chapter and are best described in midface reconstruction; in general terms the main goal of the reconstruction is to restore chewing and solve the oroantral communication, so options for small include lesions and the use of an obturator that covers the opening avoiding leaks through the paranasal sinus and improving chew. As the aperture gets bigger, soft tissue flaps like a radial forearm free flap or an anterolateral thigh free flap are needed [32], and if dental implants are planned, microvascular osteocutaneous flaps obtained from fibula free flap or

*(a) Hard palate defect after resection, (b) hard palate outcome after 1 month reconstruction and (c) hard* 

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

iliac crest free flap must be designed.

#### *Modalities and State of Art in Oral Cancer Reconstruction DOI: http://dx.doi.org/10.5772/intechopen.91049*

*Oral Diseases*

defect may be small or big and simple or composite associated to another oral cavity subsite resection. Small lesions of the cheek could be let alone to epithelize, but a bigger one will end in a scar and retraction, so a reconstruction must be done. In most of the cases a facial artery mucomucosal flap (FAMM) could be used. This flap based on a branch of the facial artery is elevated in the layer underneath the facial artery including the overlying buccinators muscle and a small portion of orbicularis oris muscle close to the oral commissure; it is rotated to cover the defect commonly restoring it, and the donor site could be primary closed or let it to heal secondarily without impairing its final functional result. A huge defect might need a pediculate flap such as submandibular or supraclavicular flap or even a microvascular free flap. Some encourage for the supraclavicular pediculate flap as the first option in this scenery, which usually provides a good amount of a non-bulky tissue without affecting oncological resection of node neck dissection in level Ia and Ib, and adducing that submandibular flap is too bulky to placed it in this specific region.

*(a) FFF harvest, (b) FFF insetting and (c) FFF early postoperative outcome.*

The extent of resection of hard palate is crucial to define the type and modality of reconstruction. The defect may be small and involve any portion of the hard palate, the premaxilla, or any portion of the maxillary alveolus with or without tooth-bearing or may be as huge as more than 50% of the hard palate. Many of the times, it is associated with partial or total maxillectomy so ending in a complex defect. Small defects can be let just to re-epithelize with excellent results. For a bigger one, a skin graft can be used; the problem is to support it long enough to achieve its integration to the hard palate; sometimes, the flap is detached and lost in which case healing by second intention is required. Small to medium defects may demand to harvest a palatal mucoperiosteal flap (PMPF). This flap is based on the greater palatine artery; preserving this vascular pedicle allows to rotate

**152**

**4.4 Hard palate**

**Figure 9.**

it to resurface the mucosal defect [31]. Its limit is related to the amount of tissue needed, and up to 3 cm can be covered with this flap. In a bigger 3–5 cm hole, also a submandibular pediculate flap could be used to cover it. In as much as in this location, there are no specific needs for muscle or for a thicker soft tissue; any attempt should be done to assemble it with just enough muscle behind that guarantees skin perfusion by perforants preventing necrosis and providing a flat new tissue. A composite defect that includes the maxillary alveolus with tooth-bearing or partial to total maxillectomy will end in oroantral communication (**Figure 10a** and **b**). This type of reconstruction needs special considerations that are not the subject of this chapter and are best described in midface reconstruction; in general terms the main goal of the reconstruction is to restore chewing and solve the oroantral communication, so options for small include lesions and the use of an obturator that covers the opening avoiding leaks through the paranasal sinus and improving chew. As the aperture gets bigger, soft tissue flaps like a radial forearm free flap or an anterolateral thigh free flap are needed [32], and if dental implants are planned, microvascular osteocutaneous flaps obtained from fibula free flap or iliac crest free flap must be designed.

#### **Figure 10.**

*(a) Hard palate defect after resection, (b) hard palate outcome after 1 month reconstruction and (c) hard palate outcome after 2 years of reconstruction.*
