Intraoral Soft Tissue Reconstruction After Cancer Ablation: A Comparison of the Pectoralis Major Flap and the Free Radial Forearm Flap Mark A. Schusterman, MD, Stephen S. Kroll, MD, Randal S. Weber, MD, Robert M. Byers, Oscar Guillamondegui, MD, Helmuth Goepfert, MD, Houston.~~~~~
We compared, by retrospective chart review, the free radial forearm flap and the pectoralis major flap in repairing intraoral soft tissue defects resulting from tumor ablation. Statistical significance of differences was determined using Fisher’s exact test and chi-square analysis. Fifty-one free flap and 126 musculocutaneous flap transfers were analyzed. The former were used more often for defects in the anterior part of the oral cavity, whereas the latter were used more frequently in the posterior part. Significantly more patients with pectoralis major flap transfers had late-stage (T3 and T4) disease than did those in the free radial forearm flap group (p = 0.004). Also, the complication rate was significantly higher in the pectoralis major flap group (p = 0.01) ; this was due to differences in the rates of dehiscence, fistula formation, and flap loss. We thus conclude that, despite the need for microsurgery, the free radial forearm flap is at least as reliable as the pectoralis major flap and that the choice of flap should be based on defect considerations rather than on the perceived reliability of the reconstructive method.
From the Re-constructive Plastic Surgery Service (MAS, SSK) and the Department of Head and Neck Surgery.(RSW, RMB, OG, HG), The University of Texas M. D. Andersbn Cancer Center, Houston, Texas. Raquests for reprints should ba address&I to Mark A. Schusterman, MD, The University of Texas M. D. Anderson Cancer Canter Reconstructive Plastic Surgery Service, 1515 Holcombe Boulevard, Houston, Texas 77030. Presented at the 37th Annual Meeting of the Society of Head and Neck Surgeons, Maui, Hawaii, May 1-4, 1991.
MD,
he goals of soft tissue reconstruction of the oral cavT ity should be: (1) to achieve a healed wound and not delay adjuvant therapy; (2) to maximize tongue function and therefore deglutition and speech; and (3) to restore cosmesis. The technique chosen must therefore be highly reliable, enhance tongue mobility, and be cosmetically appealing, both at the recipient site as well as the donor site. Primary closure consisting of suturing the tongue to the buccal mucosa or lip is possible for patients with small tissue losses, but it can compromise function and cosmesis, especially if performed in the anterior part of the oral cavity. Tongue flaps have also been utilized, but, again, limitation of tongue mobility will occur [I]. Split-thickness skin grafts have heen used, but fibrosis, graft contraction, and poor take in an irradiated field limit their usefulness [ 21. The forehead flap described by McGregor [3] has been useful in the past, but the donor site is cosmetically unappealing, and the pedicle bulk and orientation can make flap insertion difficult. The deltopectoral flap described by Bakamjian [4] has also been used, but the often precarious axial blood flow and need for multiple surgeries limit its availability. Microsurgery for soft tissue transplantation was instituted on a widespread basis in the mid-1970s and the earliest reports of its use were associated with intraoral soft tissue reconstruction [5,q. These early successes using free flaps were rapidly overrun, however, by the implementation of musculocutaneous flap use [7l. Use of the pectoralis major flap was first described for repair of intraoral soft tissue defects in 1979 and has since become a standard because of its relative reliability, the ease of its dissection, and, most important, the fact that the surgeon does not need microsurgical expertise to transfer the flap 174. Preference for this method has recently been challenged by a resurgence in microsurgical transfer of the free radial forearm flap for intraoral reconstruction. First described in China in 1978, the free radial forearm flap is composed of the volar wrist skin, with the radial artery and veins and the cephalic vein available as donor vessels [9]. It is believed to be a reliable free flap because of the large caliber of the donor vessels, and it may be as reliable for soft tissue repair as the nonmicrovascular pectoralis major flap. This retrospective sequential study comparing the use of the two flaps attempts to answer that question. PATIENTS
AND METHODS
We retrospectively reviewed the charts of all patients who received a pectoralis major flap or free radial fore-
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 OCTOBER 1991
397
SCHUSTERMANET AL
arm flap transfer for repair of a soft tissue intraoral defect from January 1983 to August 1990. Patients were assigned to one procedure or the other based on the size of the defect and physician preference. Parameters measured included demographic data (patient age and sex), tumor data (histology and stage), flap data (including type and recipient vessels, when indicated), and complications. Complications were defined as flap dehiscence, fistula formation, infection, hematoma, and flap loss (i.e., more than 50% loss of flap skin). Statistical significance of any differences between the two groups was determined using the Fisher’s exact test and chi-square analysis.
NS
Tongue
FOM
BOT
q Pectoralis MaJorFlap
Pharynx Lsrnyx
RMT/ Tonsil
BUCCCI
H Free Radlel Forearm Flap
RESULTS Fifty-one patients had had defects repaired using free radial forearm flaps and 126 using pectoralis major flaps. The patients’ mean ages were similar (free flaps, 55.4 years old; pectoralis major flaps, 58.2 years old). The male-to-female ratio was 1:1.2 in the free flap group and 3:l in the pectoralis major flap group. Tobacco use was greater among those receiving musculocutaneous transfer than among those in the other group (109 of 126 [87%] and 34 of 51 [67%], respectively [p = 0.004]), but 100 alcohol consumption was similar (69 of 126 [ 55%] and 30 of 51 [59%]). The incidence of previous radiotherapy was SO 1 also similar (51 of 126 [40%] and 20 of 5 1 [39%]). The I I I frequency of previous chemotherapy was greater among those in whom the musculocutaneous flap was used (18 of 126 [ 14%] versus 4 of 51 [8%]), but this difference was not statistically significant. The flap chosen by defect site is shown in Figure 1. The free radial forearm flap was used more for floor of the mouth, tongue, and buccal mucosa defects; converseT3+T4 Tl +TZ ly, the pectoralis major flap was used principally for posn Free Redlel Forearm Flep I-J Pectorallshqor flap terior defects involving the pharynx, larynx, and base of tongue. The free flap tended to be used more for patients Flgure2. Choice of flap by tumorstage (early,Ti and T2; late, T3 and T4). Note that the free radial forearm flap waS used more with early stage disease (Tl and T2) and the pectoralis often for early staga disease and the pectoralis major flap, for major flap, for patients with late-stage disease (T3 and late-stage disease, wlth the latter difference being statistically T4) (Figure 2). A higher percentage of patients with latesignificant.NS = not significant. stage disease were in the pectoralis major flap group (88 of 126 [70%]) than in the free flap group (23 of 5 1 [45%]) (p = 0.004). The complication rates by surgical technique are given in Table I. The pectoralis major flap group had significantly higher rates for overall complications and for fistuTABLE I la formation. Flap dehiscence and flap loss were more Complications by Surgical Technique frequent in the pectoralis major flap group, although the Flap Used I p values indicate that these differences were marginal. PMF (%) Complication FRFF (%) p Value Rates of hematoma and infection were similar between the groups. 31 /I26 (25) 6/51 (12) 0.09 Dehiscence 301126 (24) 3151 (6) 0.003 Fistula formation Because the musculocutaneous flap tended to be used 15/126 (12) 7/51 (14) NS Infection for more advanced defects, we compared the complicaHematoma E/126 (6) NS 2/51 (4) tion rates according to stage of disease. There were more 16/126 (14) 3151 (6) 0.09 Flap loss complications in the pectoralis major group compared 72/126 (57) 16/51 (35) 0.01 Total patients with the free flap group for both early stage (Tl and T2: 7 with complications of 17 [41%] versus 3 of 11 [27%]) and late stage (T3 and PMF = pectoralismajor flap; FRFF = tree radial forearm flap; NS = not T4: 50 of 88 [57%] versus 4 of 9 [44%]) disease, although significant. the differences were not statistically significant. Flgure 1. Choice of flap by defect site. The free radii1 forearm flap Is used more for floor of mouth (FOM), tongue, and buccal mucosa defects, whereas the pectoralismajor flap is usedmore for base of tongue(SOT), pharynx,larynx,and_retromolar trigone (RMT)/tonsildefects. Values indicatelevelsof significance.NS = not significant.
1
J
398
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 OCTOBER 1991
INTRAORAL SOFT TISSUE RECONSTRUCTION
COMMENTS
When choosing any type of reconstructive technique, the surgeon must first determine the goals of the reconstruction and then use the technique with the characteristics that allow these goals to be met in the best possible manner. As stated earlier, the main characteristics to be considered in choosing a technique for repairing head and neck cancer defects are, in descending order of importance, reliability, function, and cosmesis. Due to their high reliability, the pectoralis major musculocutaneous flap and the free radial forearm flap have both become the flaps of choice for intraoral soft tissue defects at our institution. Our results indicate that, despite the need for microvascular surgery for flap transfer, the free radial forearm flap is at least as reliable as the pectoralis major musculocutaneous flap. Although free flap procedures were first performed in 1975 [&a, 2 years before musculocutaneous flaps became popular, these latter flaps soon became the standard technique for head and neck reconstructions because of their ease of dissection and the perception of higher reliability of the nonmicrovascular transfer. Although the latissimus dorsi, trapezius, sternocleidomastoid, and platysma have all been described and advocated as donor sites [8,20-231, the widest acceptance by far has been for the pectoralis major. The advantages of using the pectoralis major flap are its simplicity in design, ease of dissection, and high reliability. In addition, the flap can be dissected with the patient supine. Another advantage is that the pectoralis major flap is large enough to cover the carotid artery in those patients requiring a radical neck dissection as well. This characteristic can, however, be a disadvantage in those patients undergoing a functional neck dissection, which spares the sternocleidomastoid muscle. Not only is coverage of the vessels in the neck unnecessary in this situation, but the added bulk in the neck is unsightly. The bulkiness of the pectoralis major flap can be either an advantage or a disadvantage, depending on the circumstances. Our surgeons have tended to use the pectoralis major flap when bulk is beneficial, such as after subtotal or total glossectomy in which an attempt is made to spare the larynx. The goal of such reconstructions is not tongue mobility but rather replacement of tongue bulk, so the flap acts as an obturator to prevent aspiration. When a partial glossectomy or a floor-of-mouth excision has been performed and a large segment of mobile tongue remains, the goal should be to preserve tongue mobility rather than replace bulk; therefore, the flap must be thin, supple, reliable, and have a low donor site morbidity. With these considerations in mind, attention has turned to the use of thin microvascular flaps such as the dorsalis pedis flap, the groin flap, the lateral arm flap, and the radial forearm flap [5,6,14-14. We believe that, because of reliability, functional characteristics, and low donor site morbidity, the free radial forearm flap should be the flap of choice under most circumstances. The free radial forearm flap is a reliable flap by virtue
of its large-caliber donor vessels. The use of functional neck dissections at our institution has made available large-caliber recipient vessels, in particular the internal jugular vein and external carotid artery, thus enhancing our ability to transfer the flap. Large donor vessels, large recipient vessels, and end-to-side anastomoses are all believed to be important factors that ensure flap reliability, which is of importance for immediate reconstruction after cancer ablation. In conclusion, despite the need for microsurgical expertise when using the free radial forearm flap, this technique does not appear to have a complication rate higher than that of the pectoralis major flap; in fact, the free flap may actually have a lower complication rate when used to repair similarly sized defects. The free radial forearm flap is especially useful for repairing smaller defects in the anterior part of the oral cavity, where tongue mobility is important. The pectoralis major flap may be best used to repair larger defects in the posterior part of the oral cavity, where bulk may be a requirement.
REFERENCES 1. Komisar A, Lawson W. A compendium of intraoral flaps. Head Neck Surg 1985; 8: 91-9. 2. Schramm VL, Myers EN. Skin grafts in oral cavity reconstruction. Arch Otolaryngol 1980; 106: 528-32. 3. McGregor IA. The temporal flap in intraoral cancer: its use in repairing the post-excisional defect. Br J Plast Surg 1963; 16: 318-25. 4. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Piast Reconstr Surg 1965; 36: 173-84. 5. Harashina T, Fujino T, Aoyagi F. Reconstruction of the oral cavity with a free flap. Plast Reconstr Surg 1976; 58: 412-4. 6. Panje W, Bardach J, Krause C. Reconstruction of the oral cavity with a free flap. Plast Reconstr Surg 1976; 58: 415-8. 7. McGraw JB, Dibbell DG. Experimental definition of independent myocutaneous vascular territories. Plast Reconstr Surg 1977; 60: 212-20. 8. Ariyan S. Further experiences with the pectoralis major myocutaneous flap for the immediate repair of defects from excisions of head and neck cancers. Plast Reconstr Surg 1979; 64: 605-12. 9. Manktelow RT. Microvascular reconstruction. Berlin: SpringerVerlag, 1986: 25-30. 10. Barton FE, Spicer TE, Byrd HS. Head and neck reconstruction with the latissimus dorsi myocutaneous flap: anatomic observations of 60 cases. Plast Reconstr Surg 1983; 71: 199-204. 11. Ariyan S. The stemocleidomastoid myocutaneous flap. Laryngoscope 1980; 90: 676-9. 12. Demergasso F, Piazza MV. Trapezius myocutaneous flap in reconstructive surgery for head and neck cancer: an original technique. Am J Surg 1979; 138: 533-6. 13. Futrell JW, Johns ME, Edgerton MT, Cantrell RW, FitzHugh GS. Platysma myocutaneous flap for intraoral reconstruction. Am J Surg 1978; 136: 504-11. 14. McGraw JB, Furlow LT. The dorsalis pedis arterialized flap. Plast Reconstr Surg 1975; 55: 177-85. 15. Katsaros J, Schusterman MA, Beppu M, Banis JC, Acland RD. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 1984; 12: 489-500. 16. Song R, Gao Y, Song Y, Yu Y. The forearm flap. Clin Plast Surg 1982; 91: 21-6.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 OCTOBER 1991
399
We compared, by retrospective chart review, the free radial forearm flap and the pectoralis major flap in repairing intraoral soft tissue defects resulting from tumor ablation. Statistical significance of differences was determined using Fisher’s exact test and chi-square analysis. Fifty-one free flap and 126 musculocutaneous flap transfers were analyzed. The former were used more often for defects in the anterior part of the oral cavity, whereas the latter were used more frequently in the posterior part. Significantly more patients with pectoralis major flap transfers had late-stage (T3 and T4) disease than did those in the free radial forearm flap group (p = 0.004). Also, the complication rate was significantly higher in the pectoralis major flap group (p = 0.01) ; this was due to differences in the rates of dehiscence, fistula formation, and flap loss. We thus conclude that, despite the need for microsurgery, the free radial forearm flap is at least as reliable as the pectoralis major flap and that the choice of flap should be based on defect considerations rather than on the perceived reliability of the reconstructive method.
From the Re-constructive Plastic Surgery Service (MAS, SSK) and the Department of Head and Neck Surgery.(RSW, RMB, OG, HG), The University of Texas M. D. Andersbn Cancer Center, Houston, Texas. Raquests for reprints should ba address&I to Mark A. Schusterman, MD, The University of Texas M. D. Anderson Cancer Canter Reconstructive Plastic Surgery Service, 1515 Holcombe Boulevard, Houston, Texas 77030. Presented at the 37th Annual Meeting of the Society of Head and Neck Surgeons, Maui, Hawaii, May 1-4, 1991.
MD,
he goals of soft tissue reconstruction of the oral cavT ity should be: (1) to achieve a healed wound and not delay adjuvant therapy; (2) to maximize tongue function and therefore deglutition and speech; and (3) to restore cosmesis. The technique chosen must therefore be highly reliable, enhance tongue mobility, and be cosmetically appealing, both at the recipient site as well as the donor site. Primary closure consisting of suturing the tongue to the buccal mucosa or lip is possible for patients with small tissue losses, but it can compromise function and cosmesis, especially if performed in the anterior part of the oral cavity. Tongue flaps have also been utilized, but, again, limitation of tongue mobility will occur [I]. Split-thickness skin grafts have heen used, but fibrosis, graft contraction, and poor take in an irradiated field limit their usefulness [ 21. The forehead flap described by McGregor [3] has been useful in the past, but the donor site is cosmetically unappealing, and the pedicle bulk and orientation can make flap insertion difficult. The deltopectoral flap described by Bakamjian [4] has also been used, but the often precarious axial blood flow and need for multiple surgeries limit its availability. Microsurgery for soft tissue transplantation was instituted on a widespread basis in the mid-1970s and the earliest reports of its use were associated with intraoral soft tissue reconstruction [5,q. These early successes using free flaps were rapidly overrun, however, by the implementation of musculocutaneous flap use [7l. Use of the pectoralis major flap was first described for repair of intraoral soft tissue defects in 1979 and has since become a standard because of its relative reliability, the ease of its dissection, and, most important, the fact that the surgeon does not need microsurgical expertise to transfer the flap 174. Preference for this method has recently been challenged by a resurgence in microsurgical transfer of the free radial forearm flap for intraoral reconstruction. First described in China in 1978, the free radial forearm flap is composed of the volar wrist skin, with the radial artery and veins and the cephalic vein available as donor vessels [9]. It is believed to be a reliable free flap because of the large caliber of the donor vessels, and it may be as reliable for soft tissue repair as the nonmicrovascular pectoralis major flap. This retrospective sequential study comparing the use of the two flaps attempts to answer that question. PATIENTS
AND METHODS
We retrospectively reviewed the charts of all patients who received a pectoralis major flap or free radial fore-
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 OCTOBER 1991
397
SCHUSTERMANET AL
arm flap transfer for repair of a soft tissue intraoral defect from January 1983 to August 1990. Patients were assigned to one procedure or the other based on the size of the defect and physician preference. Parameters measured included demographic data (patient age and sex), tumor data (histology and stage), flap data (including type and recipient vessels, when indicated), and complications. Complications were defined as flap dehiscence, fistula formation, infection, hematoma, and flap loss (i.e., more than 50% loss of flap skin). Statistical significance of any differences between the two groups was determined using the Fisher’s exact test and chi-square analysis.
NS
Tongue
FOM
BOT
q Pectoralis MaJorFlap
Pharynx Lsrnyx
RMT/ Tonsil
BUCCCI
H Free Radlel Forearm Flap
RESULTS Fifty-one patients had had defects repaired using free radial forearm flaps and 126 using pectoralis major flaps. The patients’ mean ages were similar (free flaps, 55.4 years old; pectoralis major flaps, 58.2 years old). The male-to-female ratio was 1:1.2 in the free flap group and 3:l in the pectoralis major flap group. Tobacco use was greater among those receiving musculocutaneous transfer than among those in the other group (109 of 126 [87%] and 34 of 51 [67%], respectively [p = 0.004]), but 100 alcohol consumption was similar (69 of 126 [ 55%] and 30 of 51 [59%]). The incidence of previous radiotherapy was SO 1 also similar (51 of 126 [40%] and 20 of 5 1 [39%]). The I I I frequency of previous chemotherapy was greater among those in whom the musculocutaneous flap was used (18 of 126 [ 14%] versus 4 of 51 [8%]), but this difference was not statistically significant. The flap chosen by defect site is shown in Figure 1. The free radial forearm flap was used more for floor of the mouth, tongue, and buccal mucosa defects; converseT3+T4 Tl +TZ ly, the pectoralis major flap was used principally for posn Free Redlel Forearm Flep I-J Pectorallshqor flap terior defects involving the pharynx, larynx, and base of tongue. The free flap tended to be used more for patients Flgure2. Choice of flap by tumorstage (early,Ti and T2; late, T3 and T4). Note that the free radial forearm flap waS used more with early stage disease (Tl and T2) and the pectoralis often for early staga disease and the pectoralis major flap, for major flap, for patients with late-stage disease (T3 and late-stage disease, wlth the latter difference being statistically T4) (Figure 2). A higher percentage of patients with latesignificant.NS = not significant. stage disease were in the pectoralis major flap group (88 of 126 [70%]) than in the free flap group (23 of 5 1 [45%]) (p = 0.004). The complication rates by surgical technique are given in Table I. The pectoralis major flap group had significantly higher rates for overall complications and for fistuTABLE I la formation. Flap dehiscence and flap loss were more Complications by Surgical Technique frequent in the pectoralis major flap group, although the Flap Used I p values indicate that these differences were marginal. PMF (%) Complication FRFF (%) p Value Rates of hematoma and infection were similar between the groups. 31 /I26 (25) 6/51 (12) 0.09 Dehiscence 301126 (24) 3151 (6) 0.003 Fistula formation Because the musculocutaneous flap tended to be used 15/126 (12) 7/51 (14) NS Infection for more advanced defects, we compared the complicaHematoma E/126 (6) NS 2/51 (4) tion rates according to stage of disease. There were more 16/126 (14) 3151 (6) 0.09 Flap loss complications in the pectoralis major group compared 72/126 (57) 16/51 (35) 0.01 Total patients with the free flap group for both early stage (Tl and T2: 7 with complications of 17 [41%] versus 3 of 11 [27%]) and late stage (T3 and PMF = pectoralismajor flap; FRFF = tree radial forearm flap; NS = not T4: 50 of 88 [57%] versus 4 of 9 [44%]) disease, although significant. the differences were not statistically significant. Flgure 1. Choice of flap by defect site. The free radii1 forearm flap Is used more for floor of mouth (FOM), tongue, and buccal mucosa defects, whereas the pectoralismajor flap is usedmore for base of tongue(SOT), pharynx,larynx,and_retromolar trigone (RMT)/tonsildefects. Values indicatelevelsof significance.NS = not significant.
1
J
398
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 OCTOBER 1991
INTRAORAL SOFT TISSUE RECONSTRUCTION
COMMENTS
When choosing any type of reconstructive technique, the surgeon must first determine the goals of the reconstruction and then use the technique with the characteristics that allow these goals to be met in the best possible manner. As stated earlier, the main characteristics to be considered in choosing a technique for repairing head and neck cancer defects are, in descending order of importance, reliability, function, and cosmesis. Due to their high reliability, the pectoralis major musculocutaneous flap and the free radial forearm flap have both become the flaps of choice for intraoral soft tissue defects at our institution. Our results indicate that, despite the need for microvascular surgery for flap transfer, the free radial forearm flap is at least as reliable as the pectoralis major musculocutaneous flap. Although free flap procedures were first performed in 1975 [&a, 2 years before musculocutaneous flaps became popular, these latter flaps soon became the standard technique for head and neck reconstructions because of their ease of dissection and the perception of higher reliability of the nonmicrovascular transfer. Although the latissimus dorsi, trapezius, sternocleidomastoid, and platysma have all been described and advocated as donor sites [8,20-231, the widest acceptance by far has been for the pectoralis major. The advantages of using the pectoralis major flap are its simplicity in design, ease of dissection, and high reliability. In addition, the flap can be dissected with the patient supine. Another advantage is that the pectoralis major flap is large enough to cover the carotid artery in those patients requiring a radical neck dissection as well. This characteristic can, however, be a disadvantage in those patients undergoing a functional neck dissection, which spares the sternocleidomastoid muscle. Not only is coverage of the vessels in the neck unnecessary in this situation, but the added bulk in the neck is unsightly. The bulkiness of the pectoralis major flap can be either an advantage or a disadvantage, depending on the circumstances. Our surgeons have tended to use the pectoralis major flap when bulk is beneficial, such as after subtotal or total glossectomy in which an attempt is made to spare the larynx. The goal of such reconstructions is not tongue mobility but rather replacement of tongue bulk, so the flap acts as an obturator to prevent aspiration. When a partial glossectomy or a floor-of-mouth excision has been performed and a large segment of mobile tongue remains, the goal should be to preserve tongue mobility rather than replace bulk; therefore, the flap must be thin, supple, reliable, and have a low donor site morbidity. With these considerations in mind, attention has turned to the use of thin microvascular flaps such as the dorsalis pedis flap, the groin flap, the lateral arm flap, and the radial forearm flap [5,6,14-14. We believe that, because of reliability, functional characteristics, and low donor site morbidity, the free radial forearm flap should be the flap of choice under most circumstances. The free radial forearm flap is a reliable flap by virtue
of its large-caliber donor vessels. The use of functional neck dissections at our institution has made available large-caliber recipient vessels, in particular the internal jugular vein and external carotid artery, thus enhancing our ability to transfer the flap. Large donor vessels, large recipient vessels, and end-to-side anastomoses are all believed to be important factors that ensure flap reliability, which is of importance for immediate reconstruction after cancer ablation. In conclusion, despite the need for microsurgical expertise when using the free radial forearm flap, this technique does not appear to have a complication rate higher than that of the pectoralis major flap; in fact, the free flap may actually have a lower complication rate when used to repair similarly sized defects. The free radial forearm flap is especially useful for repairing smaller defects in the anterior part of the oral cavity, where tongue mobility is important. The pectoralis major flap may be best used to repair larger defects in the posterior part of the oral cavity, where bulk may be a requirement.
REFERENCES 1. Komisar A, Lawson W. A compendium of intraoral flaps. Head Neck Surg 1985; 8: 91-9. 2. Schramm VL, Myers EN. Skin grafts in oral cavity reconstruction. Arch Otolaryngol 1980; 106: 528-32. 3. McGregor IA. The temporal flap in intraoral cancer: its use in repairing the post-excisional defect. Br J Plast Surg 1963; 16: 318-25. 4. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Piast Reconstr Surg 1965; 36: 173-84. 5. Harashina T, Fujino T, Aoyagi F. Reconstruction of the oral cavity with a free flap. Plast Reconstr Surg 1976; 58: 412-4. 6. Panje W, Bardach J, Krause C. Reconstruction of the oral cavity with a free flap. Plast Reconstr Surg 1976; 58: 415-8. 7. McGraw JB, Dibbell DG. Experimental definition of independent myocutaneous vascular territories. Plast Reconstr Surg 1977; 60: 212-20. 8. Ariyan S. Further experiences with the pectoralis major myocutaneous flap for the immediate repair of defects from excisions of head and neck cancers. Plast Reconstr Surg 1979; 64: 605-12. 9. Manktelow RT. Microvascular reconstruction. Berlin: SpringerVerlag, 1986: 25-30. 10. Barton FE, Spicer TE, Byrd HS. Head and neck reconstruction with the latissimus dorsi myocutaneous flap: anatomic observations of 60 cases. Plast Reconstr Surg 1983; 71: 199-204. 11. Ariyan S. The stemocleidomastoid myocutaneous flap. Laryngoscope 1980; 90: 676-9. 12. Demergasso F, Piazza MV. Trapezius myocutaneous flap in reconstructive surgery for head and neck cancer: an original technique. Am J Surg 1979; 138: 533-6. 13. Futrell JW, Johns ME, Edgerton MT, Cantrell RW, FitzHugh GS. Platysma myocutaneous flap for intraoral reconstruction. Am J Surg 1978; 136: 504-11. 14. McGraw JB, Furlow LT. The dorsalis pedis arterialized flap. Plast Reconstr Surg 1975; 55: 177-85. 15. Katsaros J, Schusterman MA, Beppu M, Banis JC, Acland RD. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 1984; 12: 489-500. 16. Song R, Gao Y, Song Y, Yu Y. The forearm flap. Clin Plast Surg 1982; 91: 21-6.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 OCTOBER 1991
399
