S413 ANTEROLATERAL THIGH OSTEOMYOFASCIOCUTANEOUS FREE FLAP - THE FEMUR BONE FLAP Robert M Brody, MD, Nirnimesh C Pandey, MD, Mihir R Patel, MD, Michael T Purkey, MD, Bert W O'Malley Jr., MD, Christopher H Rassekh, MD, Gregory S Weinstein, MD, Ara A Chalian, MD, Jason G Newman, MD, Stephen B Cannady, MD; University of Pennsylvania Background: The anterolateral thigh (ALT) free flap is one of the most versatile and commonly used donor sites in head and neck reconstruction of soft tissue defects. When faced with a defect requiring bony reconstruction, the ALT is consistently abandoned because it does not have an osseus component. In addition, the reconstructive team typically delays the start of flap harvest until it becomes apparent whether the defect requires either a soft tissue or osteocutaneous flap. To date, there is a single case report in the literature describing the use of an ALT free flap that incorporates corticocancellous femur bone to reconstruct a complex lower extremity wound. In this report, we detail the clinical outcomes of the first three patients reported who underwent reconstruction of the head and neck using an ALT osteomyocutaneous (ALT-O) free flap. Design: Case Series, Radiographic Study Methods: A series of ten patients with normal lower extremity vasculature who underwent angiography of the lower extremity were analyzed to assess the variability of vascular distribution to the femoral cortex. Seven years of experience with ALT soft tissue harvests by the lead author confirmed vascular supply was consistent for the ALT-O free flap. In three patients corticocancellous split-femur ranging from 3 to 10 cm was harvested from the middle third of the femoral shaft with vastus intermedius as periosteal blood supply to reconstruct bony defects of the head and neck. Results: Angiography of ten patients with normal blood supply confirmed a consistent blood supply to the femur. During routine harvest, the lead author assessed for blood supply to vastus intermedius and femoral cortex to confirm consistent blood supply. Case one involved a total maxillectomy defect. Case two involved a total maxillectomy in which the bony portion of the flap was used to reconstruct a hemi-palate defect. Case three involved the reconstruction of a left mandibulectomy defect. Patients have been followed post-operatively with physical therapy. No fractures or orthopedic injuries have been seen to date with range of follow up 2-24 months. Conclusions: The ALT free flap has become the workhorse flap in the reconstruction of soft tissue defects. The ALT-O free flap is ideally suited for the head and neck reconstructive surgeon who must make intra-operative decisions regarding whether bone will be needed to reconstruct an ablative surgical defect. The ALT-O flap has consistent vascular anatomy to the cortex of the femur and provides additional

corticocancellous bone and overlying vastus intermedius muscle for the reconstruction of complex craniofacial defects. Careful selection and use of thin bone segments appear to allow for good function immediately postoperatively. Risk of future fracture will be followed in a prospective fashion, though previous strength studies indicate up to 40 percent of bone circumference can safely be harvested. This flap allows for harvest of ALT in the usual fashion and later incorporation of bone if the ablation proceeds to involve bone.

S414 SCAPULAR/PARASCAPULAR FREE TISSUE TRANSFER: A RELIABLE RECONSTRUCTIVE ANSWER FOR NEARLY EVERY COMPLEX HEAD AND NECK DEFECT Robert G Keller, MD, Caroline A Banks, MD, Terry A Day, MD, Eric J Lentsch, MD, Judith M Skoner, MD; Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA IMPORTANCE: Scapular/parascapular free tissue transfer has been identified as one of the most versatile and reliable flaps for head and neck reconstruction, yet, still is thought of by a many surgeons as a second-choice flap. In the current study, we present our data on the largest American series of scapular/parascapular microvascular reconstructions, to justify this flap as the true workhorse for nearly any complex head & neck defect reconstruction. METHODS: After IRB approval, a retrospective chart review was conducted of all patients undergoing head and neck defect reconstruction with scapular/parascapular free tissue transfer, by a single primary surgeon over a 7-year period (2006-2013) at a tertiary academic referral center. Data assessed included demographics, preoperative health/smoking status, prior treatments, surgical indications, final defect description, intraoperative details, donor/recipient site complications, flap survival, postoperative inpatient events and functional follow-up status. A systematic literature review of scapular/parascapular free flap head and neck reconstruction was also performed. RESULTS: A total of 106 patients underwent scapular/parascapular free tissue transfer by the senior author as above. Mean patient age was 60 years (range 18-94), 78% of these were male, 86% Caucasian and 14% African American. The majority of patients (78%) reported a tobacco history with 45% being active tobacco users at the time of surgery; 47% of patients reported a heavy alcohol use history with 39% still drinking at time of surgery. Prevalence of moderate-severe perioperative malnutrition in this population was 80%. Most common indications for surgery included squamous cell carcinoma (79%), mandibular osteoradionecrosis (8%) and parotid neoplasm (4%). Defects ranged in character and included: oral cavity, oropharynx, hypopharynx, larynx, mandible, maxilla, nasal vault, midface/orbit, scalp, face, neck, and anterior and lateral skull base. Sixty-one percent of patients underwent fasciocutaneous free tissue transfer, and 39% required bony reconstruction with an osteocutaneous scapular free flap. Mean flap skin paddle size was 133cm2 (SD 64cm2) with a maximum harvested skin paddle size of 315cm2. Mean harvested bone length was 9cm with a maximum length of 14cm harvested. All donor sites were closed primarily, with or without prophylactic postoperative negative-pressure wound therapy. Average hospital stay was 14 days (SD 8.3). Mean length of postoperative follow-up was 10 months. Donor site complication rate was <5% and did not affect ambulation. There were 2 partial free flap losses, and only 1 complete flap loss (<1%) out of the 106 total flaps performed. CONCLUSIONS: Our study represents the largest reported American series of scapular/parascapular free flap reconstructions of the head and neck, and the second largest series of such in the international

literature. With the primary limitation being only lateral decubitus positioning for harvest, our series demonstrates that the scapular/parascapular free tissue transfer can potentially eliminate the need for a second flap in extensive composite defects, offer high flap survival rates, utility in patients with peripheral vascular disease and ambulatory difficulties, and very low donor site morbidity, yet still provides unparalleled flexibility for reconstructing a wide variety of complex bony and massive soft tissue defects of the head & neck.

S415 RECONSTRUCTION OF UPPER DIGESTIVE TRACT BY BIOENGINEERED FLAPS I V Reshetov, Prof, E V Batukhtina, A P Polyakov, M M Phyliushin, I V Rebrikova; PA Hertzen Moscow Cancer Research Institute Objective: surgical rehabilitation of patients with defects of upper digestive tract according to morpho-functional principles using bioengineered autologic and allogenic flaps. Protocol of clinical implementation of the method was approved by the Academic Council and the Ethics Committee of PA Hertzen Moscow Cancer Research Institute. Materials and Methods. 38 patients with locally advanced tumors of oropharynx who underwent radical surgery with forming of orostoma or pharyngostoma for local control were included in the protocol. Patients were divided in two randomized groups according to the method of pharynx reconstruction. First group included patients (n=18) with implanted micrografts of autologic epithelium on the fibers of pectoralis mayor muscle. In the patients of second group (n=20) tissue equivalent containing allogenic fibroblasts and keratinocytes was implanted on the fibers of pectoralis mayor muscle. Implanted fragments of the mucous membrane were placed in the artificial pocket on the anterior pectoral wall for 30-45 days. Pharynx reconstruction was performed on the second stage; fragments of prefabricated mucous membrane were taken for the morphological investigation. Results: epithelization of the mucous membrane of the flap after reconstruction and full flap survival were registered in all patients in 1st and 2nd groups. Full organ function recovery was noticed in 94,4% (n=17) cases in 1st group, in 100% (n=20) cases in 2nd group. In 2 patients in 1st group and 8 patients in 2nd group postoperative period was complicated by ligature fistulas that were closed during the period from 12 to 24 days after conservative therapy without a negative impact on bioengineered flap. Discussion: morphological investigation demonstrated the appearing of epithelium in 55,6% (n=10) of cases in 1st group on 45 day and in 95% (n=19) cases in 2nd group on 30 day. In case of using allogenic tissue equivalent epidermal keratinocytes were replaced with histotypic epithelium, otherwise in case of autologic micrografts implantation epithelialization occurred by cell migration and proliferation through the mechanism of contraction. Conclusion: the use of bioengineered flaps can improve the results of complex combined defects elimination by imparting the flap properties corresponding to the problem of reconstruction and providing a complete anatomical and functional rehabilitation. Application of autologic mucous micrografts is a cheaper method available for widespread use.

S416 VERSATILITY OF SUPERFICIAL CIRCUMFLEX ILIAC PERFORATOR (SCIP) FLAP IN HEAD AND NECK RECONSTRUCTION - APPLICATION OF SUPERMICROSURGICAL TECHNIQUE AND DEVICES- Takuya Iida, MD, Makoto Mihara, Hidehiko Yoshimatsu, Isao Koshima; University of Tokyo Introduction: Microvascular free tissue transfer has drastically altered the reconstruction of head and neck defects by providing better functional and clinical outcomes. The groin flap, however, has almost been neglected for the head and neck reconstruction, despite its many advantages including reduced donor site morbidity. The main reason for its lack of popularity is that the pedicle is short and relatively small. In 2004, Koshima et al. reported superficial circumflex iliac artery perforator (SCIP) flap that overcomes the disadvantages of the groin flap. We introduced SCIP flap to head and neck reconstruction as a new alternative to ALT flap. Patients and Methods: Twenty patients underwent free flap reconstruction using SCIP flap after excision of cancer in the head and neck region. The flap was elevated based on the perforators of superficial branch and/or deep branch of SCIA. The thickness of the flap was adjusted according to the defect. In 5 cases, sensate SCIP flap based on lateral cutaneous branches of intercostal nerves was transferred. Perfusion of the flaps was confirmed by Indocyanine green near-infrared camera after microvascular anastomosis. Results: The flaps survived completely except two cases which showed partial necrosis. The mean pedicle length was 7.1 cm, and the mean flap size was 12.2 x 6.1 cm. Sensate flaps showed good sensory recovery around 2 months after surgery. Conclusion: The SCIP flap has many advantages as follows; 1) low donor site morbidity 2) variable thickness from super-thin to bulky flap 3) sensate flap possible based on intercostal nerves. We believe that SCIP flap can be a versatile option in head and neck reconstruction.

S417 TWENTY YEARS OF FREE FLAP MANDIBLE RECONSTRUCTION: OUTCOMES AND DEVELOPMENT OF A COMPREHENSIVE ALGORITHM Evan Matros, Peter Cordeiro; Memorial Sloan-Kettering Cancer Center PURPOSE Traditional mandible reconstruction algorithms have stressed the importance of osseus flaps; however a more comprehensive approach should account for location and extent of soft tissue structures resected. A rationale for osseus and non-osseus mandibular reconstruction is presented with analysis of functional and aesthetic outcomes. METHODS Prospectively collected data of a single surgeon's experience with mandible reconstruction over the past 20 years was reviewed. Demographic data, surgical indications, type of flap reconstruction, and outcomes were collected. The extent of the soft tissue defect was characterized by number of anatomic areas/zones removed. A classification system was derived based on both location and quantity of bone and soft tissues excised. RESULTS 202 mandible defects were reconstructed using 211 free flaps from 1991-2010. Pathologic indications were squamous cell cancer 65%, sarcoma 13%, osteoradionecrosis 5%, ameloblastoma 4% and other 12%. 80% of cases underwent osseus reconstruction, 15% had soft tissue reconstruction only, and 4.5% required simultaneous soft tissue and osseus flaps. Osseus flaps included the fibula, radius, scapula, and iliac crest in 91%, 6.5%, 1.7% and .8% of cases respectively. The rectus abdominis flap was used in 87% of cases of a soft tissue flap alone. The radial forearm and fibula flaps were used together in 7/9 cases which required simultaneous osseus and soft tissue flaps. A reconstructive algorithm for flap selection based on bone defect location and quantity/location of soft tissue defect is presented (Table I). Osseus flaps had 1.66 osteotomies on average with autocondyle transplants in 31% of cases. 2% of flaps required re-explorations for flap salvage, with no complete flap losses. Partial/complete skin-island loss occurred in 5.9% of osteocutaneous fibula flaps requiring salvage with 3 radial forearm flaps and conservative management in 9 others. Compared to osteocutaneous flaps there was no complete or partial skin-island loss in any soft tissue flap (p<.05). A tight correlation was observed between use of soft tissue flaps and increased number of anatomic soft tissue zones resected (Figure 1). Rates of major and minor donor site complications were 3.5 and 7.5% respectively. Decreased results of speech, aesthetic and dietary outcomes were associated with anterior bony defects and an increased number of soft tissue zones excised. Median time to death for expired patients was 16.3 months. Median follow-up time for living patients is 6.7 years. CONCLUSIONS A novel algorithm for mandible reconstruction flap selection is proposed based on bone defect location and extent of soft tissue involvement. As a rule osseus reconstruction is preferred for all defects. For anterior defects rigidity provided by osseus flaps is mandatory. For posterior and lateral defects, increasing consideration should be given to soft tissue flaps, alone or in combination with osseus flaps, as the quantity of soft tissue excised increases.

S418 THE PEDICLED THORACODORSAL ARTERY PERFORATOR FLAP FOR HEAD AND NECK RECONSTRUCTION: "THE A-Z FLAP" Ayman A Amin, MD, Mohamed H Zedan, MD, Mohamed A Ellabban, MD, Ashraf H Shawky, MD, Mohamed A Rifaat, MD; Department of Surgical Oncology, National Cancer Institute, Cairo University, Egypt Introduction: Reconstruction of defects following tumor resection is one of the challenges in head and neck surgery. Free flap reconstruction of soft tissue and skin defects is considered the best option in most cases; however this requires microvascular expertise and may not be an option in some patients and or hospitals. Objective: We wanted to assess and introduce the pedicled Thoracodorsal Artery Perforator (TDAP) flap as an alternative to the more commonly used flaps in the head and neck region. Our study focused on the harvest technique, anatomical variations, functional and aesthetic outcomes at various sites in the head and neck and the limitations of the flap. Methods: A prospective study of 21 patients with head and neck tumors who required defect reconstruction following tumor resection at the National Cancer Institute, Cairo University, Egypt, between July 2012 and July 2013 was undertaken. Our study included 10 males and 11 females. Mean age was 45 (18-68 years). Study cohorts included tumor site, previous therapy, extent of surgery and defect characteristics. Flap parameters included dimensions, number of perforators, pedicle length. Functional and aesthetic outcomes were evaluated. Patients underwent preoperative perforator localization, using a hand held doppler. All flaps were delivered into the neck through a trans-axillary tunnel. The flap was harvested without changing the patients' position. Results: A total of 22 flaps were raised for reconstruction in 21 patients. Surgical defects included pharyngeo-esophageal (9), oral cavity (5), mid face (3) and skin (4) defects.A contralateral flap was harvested after failure of the initial side used in one case. Two perforators were identified in 19 flaps (86%) and only one was detected in 3 flaps. The average pedicle length was 18 cm. Sixteen flaps were used for immediate reconstruction and 6 flaps were used as delayed/salvage reconstruction. All but 5 flaps were successful. Regarding the flaps used in the neck there was only one flap loss (1/13), however, the reliability of the pedicled flap decreases for mid face defects (3 patients) with a success rate of 33%. Partial flap loss was encountered in 2 cases.

A pharyngeocutanous fistula complicated two patients needing hypopharyngeal reconstruction. All donor sites were closed primarily. Latissmus function was preserved in 21/22 (95%); one patient developed postoperative weakness. Wound infection was noted in 5 patients. Conclusion: Although the free TDAP has been previously reported, the pedicled TDAP has not been described in the literature. It is a promising new technique in head and neck reconstruction. The flap can be used for almost any defect lying below the hard palate and can provide a very large pliable fasciocutanous island making it a highly versatile option. The flap can be raised without changing the patient's position. Harvesting the flap as a muscle sparing latissmus flap with a small cuff of muscle surrounding the perforators is a practical, safe and fast method with negligible effects on muscle function. It has come to be known as the A-Z flap at our institute due to our increasing use of it and its versatility.

S419 UTILITY OF THE BUCCINATOR MYOMUCOSAL FLAP IN FLOOR OF MOUTH RECONSTRUCTION. Nathan Jowett, MD, MSc, Sela Eyal, MD, Rainald Knecht, MD, PhD, Balazs B Lörincz, MD; Universitätsklinikum Hamburg-Eppendorf (UKE) Introduction Large floor of mouth (FOM) ablative defects often necessitate the use of free flap reconstruction to achieve water tight closure and adequate post-operative tongue mobility. The buccinator myomucosal flap (BMMF), also known as the facial artery musculomucosal (FAMM) flap, has consistent and reliable vascular anatomy, large arc-of-rotation, relative ease of elevation, and minimal donor site morbidity. Despite these qualities, it is rarely used by head and neck surgeons for reconstruction of FOM defects. This study describes use of this flap and outcomes in patients presenting with T2 or small T3 FOM tumours who were not adequate candidates for microvascular reconstruction over a 12 month period at our institution. Methods Five patients met criteria and underwent the procedure. Two had received prior radiation therapy to the neck. All patients underwent concurrent neck dissection including ipsilateral level 1B with removal of the submandibular gland and preservation of the facial vessels. Results Defects ranged up to 9x4 cm in size. BMFF flaps with dimensions up to 9x3 cm were elevated. There were no instances of partial or total flap necrosis, fistula, hematoma, seroma, or sialocele. Cosmetic results were excellent in 3/5 patients. Two patients presented with mild post-operative contracture of the ipsilateral oral commissure. Long-term post-operative oral tongue mobility and articulation was excellent in all patients. Conclusions The BMFF flap is a viable and reliable option for reconstruction of T2 and small T3 defects of the FOM, and should be considered a workhorse flap for oral cavity defects. With careful dissection, a complete level 1B dissection may be concurrently performed with preservation of the facial vessels.

S420 THE PEDICLED INFRACLAVICULAR FLAP - A NOVEL FLAP FOR TISSUE COVERAGE AND NECK CONTOURING IN MODIFIED AND RADICAL NECK DISSECTION Samantha Tam, MD, Douglas Angel, MD, Kevin Fung, MD, S. Danielle MacNeil, MD, Anthony Nichols, MD, FRCSC, FACS, John Yoo, MD, FRCSC, FACS; Western University, London, ON, Canada Background: Radical neck dissections (RND) and modified radical neck dissections (MRND) result in significant tissue fibrosis and contour deformity. Especially in the salvage setting following chemoradiation, patients are at higher risk of wound breakdown and exposure of vital underlying structures. Augmenting soft-tissue coverage of the surgical bed with vascularized tissue may improve wound healing and reduce fibrosis, provide better protection of the great vessels, while potentially improving neck contour. Although regional muscle flaps, such as the pectoralis major, may be available these are not used following routine RND because of the added morbidity of the reconstruction. The pedicled infraclavicular flap is a novel flap that may enable soft-tissue augmentation with minimal donor-site morbidity. Based on the anterior perforator of the transverse cervical artery (TCA), this flap may be harvested as a fasciocutaneous or adipofascial flap. The purpose of this study was to describe the routine use of this novel flap for neck recontouring and soft tissue coverage following RND and MRND. Methods: Retrospective, observational case series and surgical description. Results: Ten consecutive patients undergoing RND or MRND and reconstructed with an adipofascial pedicled infraclavicular flap were included. Only patients who underwent sternocleidomastoid resection as part of the neck dissection were reconstructed. All patients received pre-operative or post-operative radiotherapy or chemoradiotherapy. Flap survival was 100%. Complications included seroma formation and hypertrophic scar at the donor site. In all patients, the infraclavicular flap provided complete coverage of the great vessels and lateral tissue bed, and improved neck contour. Conclusions: The preliminary results would suggest that routine use of the pedicled ICF following RND and MRND may offer an easy and reliable method of providing soft-tissue coverage, improved wound healing, and neck contour restoration. Long-term effects on wound healing, tissue fibrosis, and cosmesis will determine the overall value of this approach.