The fate of intraoral free muscle flaps: is skin necessary?

Intraoral free musculocutaneous flaps can be bulky and inflexible for reconstruction of mucosal and soft-tissue defects to the head and neck. Free muscle flaps alone can be much less bulky and restore better contour than musculocutaneous flaps. When using free muscle flaps, however, it was felt that a skin graft was needed for proper epithelialization without significant contracture. Nine patients, average age 59 years (range 42 to 71 years), six males and three females, underwent extirpation of head and neck tumors and reconstruction with free muscle flaps only. Mucosal defects from 4 x 4 to 12 x 10 cm (four floor of mouth, five hard palate) were filled. Reconstruction was done with seven free rectus abdominis muscle flaps and two internal oblique/iliac bone flaps. All flaps survived with no significant complications. There was one minor abdominal wound separation. All patients who were able to swallow started oral feedings by 2 weeks postoperatively. Total epithelialization of even the large defects was completed by 8 weeks. Histologic assessment revealed an early fibrin layer over the muscle at 1 week with eventual epithelialization that was indistinguishable microscopically from normal surrounding mucosa. There was some contracture in all the flaps, but this was not clinically significant, even in the large defects. Intraoral free muscle flaps offer a safe and reliable reconstructive method that has led to a good functional result.