Skin Grafts and Flaps
in Oral Cavity Reconstruction
Victor L. Schramm, Jr, MD; Jonas T. Johnson, MD; Eugene N. Myers, MD
\s=b\ Split-thickness skin grafts and
regional flaps have been used to recon-
struct deficits produced by oral cavity
and oropharyngeal cancer resection in
191 patients. The rate of complication,
delay in oral alimentation, and the postop-
erative length of hospitalization was
greater for pectoralis myocutaneous and
deltopectoral flap reconstructions than
for skin grafts, even when comparably
sized defects are considered. The
adverse effect of weight loss is greater on
flap reconstructions than skin grafts and
is influenced little by preoperative nutri-
tional therapy. Skin graft reconstruction
is recommended for moderate and large
defects. The pectoralis myocutaneous
flap may be reserved for massive defects
or when the anterior part of the mandible
has been resected.
(Arch Otolaryngol 1983;109:175-177)
Thenique
choice of reconstructive tech¬
to be used following resec¬
tion in the oral cavity or oropharynx
to treat squamous cell carcinoma
depends on the extent and location of
the defect produced and on the func¬
tional deficit that results from the
resection. The primary goal of such
reconstructive surgery should be
obtaining maximal oral cavity func¬
tion with a minimum of complica¬
tions. When defects are too large to
close primarily or when doing so
would result in severe functional dis¬
ability, epithelial augmentation may
Accepted for publication Aug 18, 1982.
From the Department of Otolaryngology, Uni-
versity of Pittsburgh School of Medicine, Eye
and Ear Hospital.
Read in part before the American Academy of
Facial Plastic and Reconstructive Surgery, Palm
Beach, Fla, May 7, 1982.
Reprint requests to Department of Otolaryn-
gology, University of Pittsburgh School of Medi-
cine, Eye and Ear Hospital, 230 Lothrop St,
Pittsburgh, PA 15213 (Dr Schramm).
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be accomplished by the application of
a skin graft or by interposition of a
flap. This report discusses when split-
thickness skin grafts and regional
flaps should be used for reconstruc¬
tion of the oral cavity and oropharyn¬
geal defects and the results of using
either of these techniques for recon¬
struction. The type and frequency of
complications to be expected with
these reconstructive techniques are
defined, and the effects that preopera¬
tive radiation therapy, weight loss,
age, and concurrent disease have on
the results of such surgery are
described.
STUDY DESIGN
From July 1973 through December 1981,
a total of 191 patients underwent resection
of the oral cavity or oropharynx at the Eye
and Ear Hospital or the Veterans Admin¬
istration Hospital, Pittsburgh, to remove
squamous cell carcinomas. The surgical
deficit created by resection was recon¬
structed with split-thickness grafts in 122
patients and with regional pedicle flaps in
69 patients. The patients ranged in age
from 35 to 82 years, with a mean age of 60
years. There were 146 men and 45 women
in the series.
RESULTS
Split-thickness Skin Graft
Superficial Anterior Floor of Mouth
Resurfacing.—A three-dimensional in¬
traoral resection was done for 48
patients who had superficial squa¬
mous cell carcinoma of the anterior
floor of the mouth. The procedure
included an upper marginal mandibu¬
lar resection in 19 patients, and a
tracheostomy was performed in 41
patients. The postoperative length of
stay ranged from seven to 16 days
(mean, nine days). These patients
were able to begin swallowing seven
or eight days following surgery.
Five of the 48 patients experienced
complications related to surgery: two
patients had partial loss of the split-
thickness skin graft, one patient sus¬
tained an anterior mandibular frac¬
ture during the marginal mandibulec-
tomy, and pulmonary infections
developed in two patients. There were
no long-term complications related to
marginal mandibulectomy or to the
skin-grafting procedure. Speech and
swallowing function postoperatively
varied from normal only when the
resection involved the anterior part of
the tongue. The skin graft contracture
was noted to be less when the margin¬
al mandibulectomy was done. The
skin grafts are cleansed by the normal
process of deglutition, do not collect
squamous debris on their surface, and
require no special care by the
patient.
Oral Tongue and Buccal Resection.—
Nine patients underwent isolated oral
or buccal resections that were
tongue
resurfaced by split-thickness grafts.
None of these patients underwent
simultaneous neck dissection. Their
postoperative length of stay varied
from seven to 20 days (mean, 12 days),
and swallowing was started six to 18
days following surgery (mean, ten
days). Two of these patients had pul¬
monary complications; in one patient,
the graft healed incompletely. No oth¬
er complications occurred.
Composite Resection of the Anterior
and Lateral Oral Cavity.—Skin grafts
were applied to resurface major ante¬
rior and lateral resections in 21
patients. Six patients in this group
had T2 lesions, 12 had T3 lesions, and
three patients had T4 lesions. Initia¬
tion of swallowing in these patients
ranged from six to 30 days following
surgery (mean, ten days), and their
postoperative length of stay ranged
 Outcome of Oral Cavity and Oropharyngeal Reconstruction

Mean Marginal
Postoperative Incomplete Separation Total
Mean Mean Length Pulmonary Graft or Flap Total Wound
No. of Age, Swallow, of Stay, Complication, Healing, Necrosis, Necrosis, Fistula, Complication,
Reconstruction Patients yr Days Days No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
STSG" anterior floor
of mouth 60 8 9 2(4) 3(6) 0(0) 3(6)
STSG partial
glossectomy
buccal 2 (22) 1 (11) 0(0) 1 (11)
STSG oral cavity and
oropharynx 19 (43) 7(16)t 3(7)t 7(16)
STSG oral cavity 64 10 16 10 (47) 2(10) 1 (5) 3(14)
Pectoralis
myocutaneous flap 23 11 (48) 9(39) 1 (4) 3(13) 11 (48)
Deltopectoral flap 46 62 37 42 22 (46) 12 (26) 0(0) 12 (26)* 23 (50)
*STSG indicates split-thickness skin graft.
tTwo patients had temporary salivary leaks into a suction drain but no fistula.
¿ Secondary fistula around flap developing after return of carrier portion of flap.

from ten to 39 days, with a mean of 16
days.
Complications arose in three of
these patients: a partial graft loss
occurred in one patient, a wound
infection in one patient, and a fistula
in one patient. The fistula occurred
following planned high-dose preoper¬
ative radiation therapy and required
secondary flap reconstruction. One
patient died postoperatively as a
result of cardiac disease. Nearly one
half of these patients had pulmonary
complications, an incidence that was
correlated with the degree of preexist¬
ing pulmonary disease. Full-course
postoperative radiation therapy was
administered to five patients; there
were no complications related to high-
dose radiation therapy of the skin-
grafted area.
A preoperative weight loss of more
than 4.5 kg was noted in 11 of the 21
patients. Two of the six patients with
a T2 lesion had a weight loss, while
nine of 15 patients with T3 or T4
lesions had lost more than 4.5 kg.
Nutritional supplementation by tube
feeding or parenteral alimentation
was given preoperatively to six of 11
patients. Since the incidence of wound
complication was low, no comment
can be made regarding the benefit of
preoperative nutritional support.
Oral Cavity and Oropharyngeal Resec¬
tion.—Skin grafts were used to recon¬
struct posterior oral cavity and adja¬
cent pharyngeal defects in 44 patients.
Included were ten patients with T2
lesions, 19 with T3 lesions, and six
patients with T4 lesions. In this group,
the postoperative length of stay
ranged from nine to 49 days, with a
mean of 17 days. The patients were
able to swallow from six to 21 days
following surgery, with oral alimenta¬
tion being reestablished by a mean of
11 days following surgery.
The wound complication rate of
16% included two partial graft losses,
two exposed mandibles that required
local débridement, one fistula that
closed with local care, and two fistulas
that required secondary closure. A
temporary salivary leak into a suction
drainage system occurred on two
occasions because of faulty placement
of the drainage system adjacent to the
line of closure. Pulmonary complica¬
tions were noted in 15 of the 44
patients. Preexisting pulmonary and
cardiovascular disease increased the
rate of complication as well as the
postoperative length of stay, mainly
because of an increased incidence of
pulmonary infection. Age, stage,
nodal status, and prior radiation ther¬
apy had no effect on the outcome of
reconstructive surgery.
One third of this patient group lost
more than 4.5 kg prior to their hospi¬
talization. Three of the 15 patients
with weight loss had no nutritional
supplementation prior to surgery, and
12 had nasogastric or parenteral pre¬
operative feeding. The rate of wound
complication was slightly greater in
patients with weight loss, but because
of the infrequency of complications,
no importance could be given to the
value of preoperative nutritional sup¬
port.
Regional Pedicle Flaps
Pectoralis Myocutaneous Flap Recon¬
struction.—A pectoralis myocutaneous
flap was used to reconstruct the oral
cavity in a total of 23 patients, 16 who
had anterior or lateral oral cavity
defects and seven who had major
defects caused by resection of adja¬
cent oropharyngeal structures. Twen¬
ty-one of the patients had T4 lesions.
The mean postoperative length of stay
for these patients was 25 days, and
ranged from 15 to 50 days. Swallowing
was initiated ten to 27 days following
surgery (mean, 14 days).
Two thirds of the patients experi¬
enced a weight loss of greater than 4.5
kg. A wound complication arose in
nine of 13 patients who had had pre¬
operative nutritional support (naso¬
gastric feeding or total parenteral
nutrition). Four patients who had
experienced weight loss had no preop¬
erative nutritional support, and all
had wound complications.
Some marginal wound separation
or necrosis was documented in nine
(39%) of 23 patients, and one patient
had total flap necrosis related to
external mechanical compression. De¬
spite the intraoral wound separation,
an orocutaneous fistula developed in
only three patients (13% ), and in only
one of these was secondary recon¬
struction required. Pulmonary com¬
plications arose in 11 patients (48%).
The pulmonary complications were
twice as common in those patients
who had lost more than 4.5 kg, but the
incidence of pulmonary complication
was not altered by preoperative nutrì-

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tional support. The complication rate
was not affected by age, nodal status,
preexisting medical disease, or prior
radiation therapy.
Deltopectoral Flap Reconstruction.—
Before pectoralis myocutaneous flaps
were used for reconstruction, the
defects produced by resecting T2, T3,
and T4 lesions in 46 patients were
closed by deltopectoral flaps. One
patient in this group had a T2 lesion,
27 had T3 lesions, and 18 patients had
T4 lesions. The postoperative length
of stay in these patients ranged from
30 to 140 days, with a mean of 42 days.
Because creation of an orocutaneous
fistula was mandatory in these
patients, the mean time at which oral
alimentation was reinstituted was 42
days following surgery.
Complications arose in 23 (50%) of
the patients whose defects were
reconstructed with deltopectoral
flaps. Marginal separation or necrosis
occurred in 12 patients (26% ). Persist¬
ing orocutaneous fistulas around the
flap reconstruction or following divi¬
sion and return of the carrier portion
of the flap occurred in 12 patients
(26%). Pulmonary complications were
documented in 22 patients (46%).
Both pulmonary and wound complica¬
tions were relatively more common in
patients with T4 lesions, but occurred
with equal frequency in patients who
had lost more than 4.5 kg and those
who had lost less than 4.5 kg. Too few
patients in this group were treated
with preoperative nutritional support
to comment on its value. Prior radia¬
tion therapy, medical illness, age, and
nodal status had no influence on the
complication rate in these patients.
The Table compares the outcomes of
all types of reconstructive surgery.
COMMENT
Reconstruction of defects of moder¬
ate size in the anterior and lateral
oral cavity that result from wide
three-dimensional excision without
neck dissection is most effectively
completed with a split-thickness skin
graft rather than primary closure or
local rotation flap. Most importantly,
the skin graft allows maximal tongue
mobility. This technique also main¬
tains a lateral oral sulcus and does not
interfere with dental prosthetic reha-
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bilitation. When lesions approach but
do not invade the mandible, an upper
marginal mandibulectomy is recom¬
mended.1 This not only facilitates ade¬
quate resection, but actually improves
the final result by allowing a better fit
of dentures across the anterior part of
the mandible and by preventing skin
graft contracture.
Major defects of the oral cavity and
oropharynx that are in continuity
with a neck dissection may be recon¬
structed by a split-thickness skin
graft or regional flap. Split-thickness
skin graft reconstruction of oral cavi¬
ty and oropharyngeal defects has sev¬
eral advantages over primary closure
or regional flap reconstruction. The
postoperative complication rate for
split-thickness skin graft reconstruc¬
tion is no greater than for patients
treated by primary closure and is con¬
siderably less than when regional
flaps are used for reconstruction. The
technique adds very little operative
time, and its success is not adversely
affected by the prior radiation thera¬
py. Postoperative length of hospital¬
ization and the time required for oral
alimentation is less for similar
patients undergoing skin graft rather
than flap reconstruction.
The functional result following
split-thickness graft reconstruction
both for speech and swallowing is
superior to that for patients treated
by primary closure.2 This technique
also allows maximal mobility of the
remaining tongue, and provides a pli¬
able self-cleansing epithelial surface
that tolerates postoperative radiation
therapy without the development of
edema or necrosis. When skin graft
reconstruction is utilized, however,
there might not be enough tissue
should secondary mandibular recon¬
struction become necessary. Never¬
theless, few patients are candidates
for mandibular reconstruction, and
even when these reconstructions are
successful, they provide little im¬
provement in function or dental reha¬
bilitation.3 A skin graft adequately
covers an anterior marginal mandibu¬
lar resection, but care must be excer-
cised to provide soft-tissue coverage
over the resected end of the mandible
when a composite resection is per¬
formed. The skin graft does not inter-
fere with tongue mobility, as does a
pedicle flap when placed in the anteri¬
or floor of the mouth.
Although the single-stage pectora¬
lis major myocutaneous flap is prefer¬
able to a deltopectoral flap for recon¬
struction of the oral cavity, the com¬
plication of the former procedure is
still substantial.4 In this series, com¬
plications occurred twice as frequent¬
ly when a pectoralis myocutaneous
flap rather than a split-thickness skin
graft was used for reconstruction of
defects of similar size. Weight loss
and prior radiation therapy have
greater adverse effects on flap recon¬
struction than on skin grafts, and
when complications arise following
flap reconstruction, they are more
major and generally require more
prolonged hospitalization than those
occurring in patients whose defects
are reconstructed with skin grafts.
What then is the optimal recon¬
structive technique for oral cavity-
oropharyngeal defects? It is our rec¬
ommendation that a regional myocu¬
taneous flap reconstruction be consid¬
ered in situations when a segment of
the anterior part of the mandible is
resected, when reconstruction of any
mandibular defect is contemplated, or
when total or near-total glossectomy
has been included in the resection. If
cosmetic appearance is a major con¬
cern following composite resection,
the bulk provided by a pectoralis myo¬
cutaneous flap reconstruction is an
advantage. However, the adynamic
bulk of a flap is not always advanta¬
geous, especially when interposed
between tongue and mandible or when
it obliterates the lateral oral sulcus.
Except for reconstruction of massive
defects and the situations just men¬
tioned, split-thickness skin graft
reconstruction is the most advanta¬
geous.
References
1. Schramm VL, Myers EN, Sigler BA: Surgi-
cal management of early epidermoid cancer of
the anterior floor of the mouth. Laryngoscope
1980;90:207-215.
2. Schramm VL, Myers EN: Skin grafts in oral
cavity reconstruction. Arch Otolaryngol
1980;106:528-532.
3. Lawson W, Loscalzo LJ, Baek S, et al: Expe-
rience with immediate and delayed mandibular
reconstruction. Laryngoscope 1982;92:5-10.
4. Baek S, Lawson W, Biller HF: An analysis of
135 pectoralis major myocutaneous flaps. Plast
Reconstr Surg 1982;69:460-467.