1. Reconstruction of the
Oral Cavity
Michael Underbrink, M.D.
Anna Pou, M.D.

2. Introduction
! Difficult challenge
! Complex anatomy and function
! Goals
! Restore preoperative function
! Cosmesis
! Patient status is important consideration
! Variety of reconstruction options

3. Anatomy
! Vermilion to junction of
hard and soft palate
superiorly
! Inferiorly to circumvallate
papillae
! Structures: lips, alveolar
ridges, buccal mucosa,
retromolar trigone, hard
palate, floor of mouth,
mobile tongue
! Functions: speech,
mastication, bolus
preparation and initiation
of deglutition

4. Functional Considerations
! Oral sphincter
! Speech, mastication and deglutition
! Provides a watertight closure for bolus
preparation
! Prevents escape of saliva

5. Functional Considerations
! Alveolar Ridges
! Covered with thin, adherent mucosa
! Elevated above floor of mouth
! Lingual and buccal sulci direct the flow of food
and saliva during bolus processing

6. Functional Considerations
! Floor of the mouth
! Allows unrestricted mobility of the oral tongue
! Collects food and saliva (bolus preparation)

7. Functional Considerations
! Oral (mobile) tongue
! Speech and deglutition
! Mobility allows for:
! Articulation of speech
! Bolus manipulation in preparation for deglutition
! Sensory functions: proprioception, pain, taste
! Assists in mastication and bolus processing

8. Functional Considerations
! Hard palate
! Opposes tongue
! Important for speech and bolus preparation

9. Functional Considerations
! Buccal Mucosa
! Lines the cheek
! Functions in mastication and deglutition
! Allows expansion for mastication
! Thin to avoid restriction of dental closure

10. Functional Considerations
! Base of tongue
! Often involved with oral cavity defects
! Participates in taste, deglutition and speech
! Must occlude oropharynx during deglutition
! Some consonants require BOT to touch hard
palate

11. Patient Factors
! Individualize options
! Type of tissue
! Anticipated functional gain
! Anticipated donor morbidity
! Need for innervation
! Success rate
! Intraoperative positioning
! Operative time
! Dental restoration
! Overall medical status

12. Patient Factors
! Preoperative counseling
! Complete medical history
! Diabetes, atherosclerosis, previous radiation
! Cardiopulmonary status (operating time,
aspiration risk)
! Smoking history
! Patient expectations and motivation are
very important

13. Floor of Mouth Reconstruction
! Requires soft and mobile tissue
! Allow mobility of oral tongue
! Avoid scar contracture (i.e., secondary
intention)
! Avoid bulk (glossoptosis, obliteration of
lower lip sulcus)

14. Floor of Mouth Reconstruction
! Smaller defects
! Split thickness skin graft
! Harvest from lateral thigh at 0.017 in
! Provides water-tight closure, no hair
! Stabilize with bolster
! Survives over muscle and cancellous bone (via
imbibition and neovascularization)
! Also good for lateral FOM and retromolar trigone

15. Floor of Mouth Reconstruction

16. Floor of Mouth Reconstruction
! Moderate defects involving a larger
portion of mylohyoid
! Nasolabial flap
! Based on angular artery
! Better for older patients with lax skin
! Requires two stages and temporary fistula
! Bite block necessary

17. Floor of Mouth Reconstruction

18. Floor of Mouth Reconstruction
! Moderate defects (continued)
! Regional flaps
! Forehead flap (rarely used)
! Platysma flap
! Facial artery musculomucosal flap (FAMM)
! Deltopectoral flap (historical significance)

19. Floor of Mouth Reconstruction
! Forehead flap
! Superficial temporal artery
! Reliable 2/3 across the forehead
! Tunneled into cheek below zygoma
! Requires orocutaneous fistula
! Obvious donor site (skin graft)
! Second stage to inset flap

20. Floor of Mouth Reconstruction
! Submental artery island flap
! Thin, supple skin
! Submental branch of facial artery
! Primary closure of donor site
! Poor reliability if:
! Facial artery sacrificed
! Irradiated necks

21. Floor of Mouth Platysma Flap
Reconstruction

22. Floor of Mouth Reconstruction
! FAMM flap
! Branch of facial artery
! Contains mucosa, buccinator muscle, and fat
! 2 x 8 cm flap without injury to facial nerve

23. Floor of Mouth Reconstruction

24. Floor of Mouth Reconstruction
! Deltopectoral Flap
! Axial distant flap
! First four perforators
of internal mammary
! Deltoid portion is
random
! Preliminary delay
procedure
! Creates dependent
orocutaneous fistula

25. Floor of Mouth Reconstruction
! Fasciocutaneous free flaps
! Thin nature and pliability
! Radial forearm has low incidence of failure to
this site
! Provides tongue mobility and free movement
of food during deglutition

26. Floor of Mouth Reconstruction
! Radial forearm free flap
! Based on radial artery
! Outflow: two venae comitantes, basilic vein, cephalic
vein
! Long vascular pedicle with dependable supply
! Potential sensation (posterior cutaneous nerve
anastomosed to lingual)
! Disadvantage: donor site morbidity (STSG, potential
loss of thumb and index finger, potential decreased
forearm function)

27. Floor of Mouth Reconstruction

28. Anterior Tongue Reconstruction
! Very difficult to reconstruct
! Complex intrinsic musculature and
function
! Redundancy is advantageous
! Near hemiglossectomy does not significantly
alter function

29. Anterior Tongue Reconstruction
! Defects <50% can be closed primarily +/-
STSG
! Larger or composite defects require more
bulk (i.e, fasciocutaneous free flap)
! Lateral arm free flap is good for defects
including posterior aspect of tongue/FOM

30. Anterior Tongue Reconstruction

31. Anterior Tongue Reconstruction

32. Anterior Tongue Reconstruction
! Lateral Arm free flap
! Posterior radial collateral artery
! Paired venae comitantes
! 12 x 18 cm paddle possible (6 x 8 cm allows
for primary closure)
! Potential sensate flap (posterior cutaneous
nerve)
! Disadvantages: donor site appearance, hair
growth, elbow pain, lateral forearm
numbness

33. Anterior Tongue Reconstruction

34. Buccal Cavity Reconstruction
! Small defects – primary closure possible
! Larger superficial defects
! Quilted skin/mucosal grafts
! Temporoparietal fascial flap (STSG for lining)
! Large full-thickness defects
! Pectoralis major myocutaneous flap
! Latissimus dorsi myocutaneous flap
! Fasciocutaneous free flaps

35. Buccal Cavity Reconstruction

36. Mandibular Reconstruction
! Goals
! Reconstitute
mandibular continuity
! Allow for future dental
restoration
! Anterior defects
! Worst functional
defects
! “Andy Gump”
deformity
! Lateral defects
! Easier to reconstruct
! Less functional
problems

37. Mandibular Reconstruction
! Fibula osseocutaneous free flap ideal for
anterior defects (minimal soft tissue
defect)
! Based on peroneal vessels
! Multiple osteotomies allowable (for
contouring)
! 25 cm of bone available (entire defects)
! Sensate (lateral cutaneous nerve)
! Reliable for osseointegrated dental implants

38. Fibula Free Flap

39. Fibula Free Flap

40. Mandibular Reconstruction
! Scapular free flap for anterior defects with
massive soft tissue loss (i.e., total glossectomy)
! Circumflex scapular artery and vein
! 14 cm of bone available (lateral aspect)
! Allows osseointegrated implants
! Long pedicle to axillary artery
! Multiple fasciocutaneous/musculocutaneous flaps
available (scapular, parascapular, latissimus dorsi,
serratus anterior)
! Major drawback: patient positioning

41. Scapula Free Flap

42. Mandibular Reconstruction
! Lateral mandible defects
! Regional/Distant/Free flap with mandibular
swing
! Low profile reconstruction plate with soft
tissue coverage
! Patient factors which prevent dental restoration
! Plate exposure rate of about 5%
! Compared to anterior exposure rate near 20%
! Osseocutaneous free flaps (iliac, scapular,
fibula)

43. Mandibular Reconstruction

44. Mandibular Reconstruction
! Iliac crest free flap for lateral defects
! Internal oblique musculature included
! Contour similar to native mandible
! Reliable for osseointegrated implants
! Deep circumflex iliac artery
! Disadvantages (difficult harvest, donor site
deformity, abdominal weakness,
postoperative hematoma, lateral thigh
pain/anesthesia)
! Split inner cortex modification reduces
morbidity

45. Mandibular Reconstruction

46. Mandibular Reconstruction

47. Special Considerations
! Total Glossectomy Defects
! Often accompany oral cavity defects with
extensive disease
! Require bulk for reconstruction
! Goals
! Direct secretions laterally
! Provide contact of neo-tongue with palate
! Use flaps which will not atrophy over time
! Palatal drop prosthesis

48. Special Considerations
! Total Glossectomy Defects
! Rectus abdominis free flap
! Inferior and superior epigastric arteries
! Motor nerve (intercostal) anastomosis retains bulk
! Latissimus dorsi myocutaneous free flap
! Thoracodorsal artery
! Motor nerve (thoracodorsal)
! Pedicled flaps (PMMF, latissimus dorsi)

49. Special Considerations
! Total glossectomy with laryngeal
preservation
! Select patients
! Good health without cardiopulmonary disease
! Can tolerate aspiration
! Disease does not involve valleculae or
preepiglottic space
! Must maintain intact superior laryngeal nerve
! Laryngeal suspension lessens aspiration

50. Decision Making in Oral Cavity Reconstruction
Defect Type
Soft Tissue Bone
Floor of Mouth Buccal Mucosa Tongue
Superficial
Anterior Defect Lateral Defect
Primary Closure
Skin/Mucosal Grafts
Full Thickness
Regional Flaps Osseocutaneous free flaps
Fasciocutaneous Free Flaps
Large Full Thickness
Fasciocutaneous Free Flaps
Pedicled musculocutaneous flaps Regional/Distant Flap
Small <50% Loss and Mandibular Swing
STSG Primary Closure Reconstruction Plate and
Moderate Skin Graft Regional/Distant Flaps
Regional Flaps Combined Defects Osseocutaneous Free Flaps
Fasciocutaneous Free Flaps Fasciocutaneous free flaps
Large Total Glossectomy
Pedicled Fasciocutaneous flap Myocutaneous free flaps
Fasciocutaneous free flaps Pedicled musculocutaneous flaps

51. Conclusion
! Multitude of reconstructive options
! Remember functional characteristics of
tissue involved
! Various patient factors to consider
! Preoperative counseling essential
! High success rates possible with proper
patient selection

52. References
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of indications and results in 244 consecutive cases at the Toronto General Hospital. J Otolaryngol. 2001 Feb; 30(1): 34-40
Toronto Otolaryngol. 34-
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! Abemayor E, Blackwell KE. Reconstruction of soft tissue defects in the oral cavity and oropharynx. Arch Otolaryngol Head Neck Surg.
oropharynx. Surg.
2000 Jul; 126(7): 909-12
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! Berenholz L, Kessler A, Segal S. Platysma myocutaneous flap for intraoral reconstruction: an option in the compromised patient. Int J
Oral Maxillofac Surg. 1999 Aug; 28(4): 285-7
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! Burkey BB, Coleman JR Jr. Current concepts in oromandibular reconstruction. Otolaryngol Clin North Am. 1997 Aug; 30(4): 607-30
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! Hausamen JE, Neukam FW. Resection of tumors in tongue, floor of the mouth, and mandible: possibilities of primary reconstruction.
Recent Results Cancer Res. 1994; 134:25-35
134:25-
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! Boyd JB. Use of reconstruction plates in conjunction with soft-tissue free flaps for oromandibular reconstruction. Clin Plast Surg. 1994
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Jan; 21(1): 69-77
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! Yousif NJ, Matloub HS, Sanger JR, Campbell B. Soft-tissue reconstruction of the oral cavity. Clin Plast Surg. 1994 Jan; 21(1): 15-23
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