Submental artery island flap for reconstruction of the lower and mid face

Two submental island flaps for reconstructing oral and maxillofacial defects following cancer ablation

PURPOSE

The purpose of this study was to assess the reliability of 2 patterns of submental island flaps--the facial-submental artery island flap and the reverse facial-submental artery island flap--used for reconstruction of oral and maxillofacial defects following cancer ablation.

PATIENTS AND METHODS

Thirty-eight soft tissue defects were repaired with facial-submental artery island flaps and reverse facial-submental artery island flaps following cancer surgery. The ages of the patients ranged from 28 to 90 years; 24 were male and 14 were female. The primary lesions included squamous cell carcinoma of the tongue (8 cases), buccal mucosa (16), floor of the mouth (4), lower gingiva (3), oropharynx (2); recurrent squamous cell carcinoma of the palate (3); and basal cell carcinoma of the facial skin (2). The clinical stage of the tumors was stage I in 5 cases, stage II in 25, and stage III in 8. Facial-submental artery island flaps were used in 20 cases, reverse facial-submental artery island flaps in 18. The size of the skin paddle varied from a minimum of 4 cm x 8 cm to a maximum of 5 cm x 15 cm. Direct closure was achieved at all donor sites.

RESULTS

The postoperative outcome for 2 patterns of submental flaps was 36 cases surviving, 2 of complete necrosis, and one other of temporary palsy of the marginal mandibular branch of the facial nerve. The success rate was 95% and 94.4% for the facial-submental artery island flap and the reverse facial-submental artery island flap, respectively. The form and function of recipient sites were well recovered. The donor site leaves a well-hidden scar. The follow-up period was 3 to 24 months, 1 patient died of tumor local recurrences and 2 cases of cervical recurrence were observed.

CONCLUSION

Two patterns of submental island flaps are safe, rapid, and simple to elevate. The facial-submental artery island flap can reliably be used for reconstruction of the lower and middle thirds of the medium-sized oral and maxillofacial defects and the reverse pattern for reconstruction of the middle and upper thirds of the medium-sized oral and maxillofacial defects.

Reconstruction with Submental Flap for Aggressive Orofacial Cancer

BACKGROUND

The submental flap was described for head and neck reconstruction more than a decade ago. Its application is confined mainly to nonmalignant diseases or low-grade malignancies, as the submental flap resides in the level I lymphatic drainage region of the neck. The authors report the use of the submental flap for soft-tissue reconstruction in a selected group of patients with aggressive orofacial cancer.

METHODS

From March of 2003 to September of 2005, 10 patients (nine with intraoral squamous cell carcinoma and one with facial angiosarcoma) underwent submental flap reconstruction after surgical extirpation of aggressive orofacial malignancies. The indications were severe comorbidity, old age, the presence of another incurable cancer, and/or the patient's skepticism about undergoing a free flap operation.

RESULTS

Of the surviving patients, the median follow-up was 21 months (range, 2 to 37 months). There were no cases of total flap failure, but partial necrosis occurred in two cases. Three patients experienced tumor recurrence, but only one case might have been related to use of the submental flap. Postoperative oral function, in terms of swallowing and speech, was well preserved; conventional dentures were fabricated for four patients.

CONCLUSIONS

In selected patients with aggressive orofacial cancer, the submental flap is an expedient alternative to free tissue transfer for reconstruction. Nonetheless, indiscriminate use might compromise the oncological outcome, so it cannot be regarded as a standard method of treatment.

The submental island flap in head and neck reconstruction

The authors describe their experience with the submental island flap for the primary correction of head and neck deformities following oncologic surgery, over the past 5 years. The use of this flap is reported in 12 patients, with a mean age of 67 years, requiring facial or intraoral reconstruction. A brief review of the key points and some refinements in the operative technique are discussed. The reconstruction of defects with a submental island flap was successful in every patient. Complications encountered were one case of temporary palsy of the marginal mandibular branch of the facial nerve and one case of orocutaneous fistula. All the donor site defects were closed primarily. The submental island flap is an excellent choice for the reconstruction of head and neck defects because of its reliability, versatility, colour and texture match, and relative ease of application.

Le lambeau sous-mental pédiculé

INTRODUCTION

Facial reconstruction technique can be simple or complicated. The choice of performing a flap is made according to several criteria. Since its first description the submental flap has been used in several indications. The aim of this article was to document maxillofacial surgeons on this flap technique.

ANATOMY

The submental artery is a major branch of the facial artery. This artery runs medial to the mandible and ends next to the mandibular symphysis. The submental artery supplies the submandibular lymph nodes, submandibular salivary gland, mylohyoid and digastric muscles, and the skin of the chin. The submental vein drains the tissues of the chin as well as the submandibular region.

TECHNIQUE

The integrity of the facial artery is a sine qua none condition before performing this flap. It is important that the submandibular gland and the submental vessels be well exposed. The anterior belly of the homolateral digastric muscle must be included in the flap. The donor side is closed after a large subcutaneous dissection of the neck and chin.

INDICATIONS

The pedicled submental flap is indicated in defects of the oral cavity and the lower two-thirds of the face.

ADVANTAGES

The submental flap is relatively easy to raise. This flap avoids dyschromia and provides soft-tissues presenting with the same quality as that of the tissue surrounding the defect. Sequels on the donor side are minor.

DISADVANTAGES

The submental flap is not indicated if a submental neck dissection is needed or in case of intraoral/frontal reconstruction with bearded skin. The submental flap is a simple and reliable procedure, with good aesthetics results and minor sequels.

The Submental Flap in Facial Reconstruction: Advantages and Limitations

PURPOSE

Complex defects resulting from surgical excision of facial cancer sometimes require reconstruction using microvascular free tissue transfer. Tissue transfer from areas distant from the face can resolve many problems, but often provides a poor cosmetic match with facial skin. The submental flap helps surmount this problem. Cervical skin has similarities with face skin, and because this is a regional flap, it helps eliminate microsurgical risks. In this article we present a series of 9 cases, review the anatomy and the surgical technique, and explain the advantages and limitations of the submental flap.

PATIENTS AND METHODS

A successive series of 9 patients in which this reconstruction was performed was reviewed retrospectively, and the results were analyzed.

RESULTS

Submental flap facial reconstruction was performed on 9 patients (8 men and 1 woman) between 1993 and 2004. Mean patient age was 53.6 years (range, 43 to 81 years). Eight of the 9 external skin coverage cases were associated with excision of cutaneous malignancies; 1 case involved treatment of burn sequelae. There were no cases of marginal mandibular nerve palsy. In 6 cases, venous drainage was disrupted after raising the flap, but without causing flap loss. This disruption was overcome in 4 to 5 days without the need for flap revision or any other interventions. Partial loss of the distal extent of the flap occurred in 2 cases. In all cases, moderately good skin color and texture match was achieved. Debulking of the flap was needed in 6 cases. The donor site recovered well with no hypertrophic scarring and no restriction to neck movement.

CONCLUSIONS

The submental artery island flap is a useful reconstructive procedure that offers options to the reconstructive surgeon and has definite advantages over distant flaps in terms of ease of dissection and donor site appearance.

Soft-Tissue Augmentation of the Middle and Lower Face Using the Deepithelialized Submental Flap

BACKGROUND

Facial contour augmentation is an entity often encountered by reconstructive surgeons. To date, very different autologous tissues such as fat, dermofat, dermal fascia, muscle, cartilage, and bone in the manner of grafts or flaps according to the requirements of the defect have been used for facial augmentation. Although many free flap procedures have become popular in facial contouring, these microsurgical methods have some limitations and risks, especially in patients who are not suitable for microsurgery. Moreover, the patient may wish to be treated by means of a more conservative procedure.

METHODS

The authors used the submental flap in deepithelialized fashion successfully for augmentation of the face in three patients who presented with hemifacial microsomia (n = 2) and longstanding facial paralysis (n = 1).

RESULTS

Adequate augmentation was achieved in all cases, without any complications. All donor sites were closed primarily and healed well. Patient satisfaction was perfect in all cases. A second debulking procedure was performed in case 3 only. The average follow-up was 1 year.

CONCLUSIONS

The authors believe that the deepithelialized submental flap can be used safely for all facial contour restorations of the lower and midface necessitated by various causes, including hemifacial microsomia and facial paralysis as a main or adjunct procedure. In these cases, this flap may be a good alternative, especially for patients who are not suitable for microsurgery.

Reconstruction of the columella using the prefabricated reverse flow submental flap: A case report

BACKGROUND

The reconstruction of columellar defects is still a challenging procedure because of limited local and regional flap options and the characteristics of the anatomy of this site. Although a number of methods are available to repair nasal columella defects, no treatment of choice ensuring an excellent texture- and color-matched tissue in one stage has been determined to date.

METHOD

In this case, we used a reverse-flow submental island flap prefabricated with the costal cartilage for the reconstruction of a complex columellar defect.

RESULT

The flap survived completely with reversible venous congestion. The cosmetic result and nasal respiratory function were acceptable during the follow-up time of 6 months.

CONCLUSION

We propose that the prefabricated reverse submental flap may be an alternative among the surgical options for columellar defects. This flap may also be considered in the reconstructive repertoire of other composite defects of the head and neck region.

Reverse-flow submental artery flap for periorbital soft tissue and socket reconstruction

BACKGROUND

The submental artery island flap is a recently described local flap that may be used for reconstruction of the lower and middle thirds of the face and oral cavity. The reverse-flow manner of the flap has been used in limited cases because of possible drawbacks such as venous congestion. We present our experience with the use of reverse-flow submental artery flap and describe the surgical technique.

METHODS

This versatile flap was successfully used for large periorbital soft-tissue defects and socket reconstruction in six patients in the past 2 years. The diagnosis of three patients was basal cell carcinoma of the eyelids, which required orbital exenteration, and the other patient had traumatic periorbital defects. The flap size varied from a minimum of 4 x 6 cm to a maximum of 6 x 8 cm.

RESULTS

No major complications were noted other than one case of temporary palsy of the marginal mandibular branch of the facial nerve and one other of venous congestion, which subsided spontaneously. In all patients, the results were satisfactory, with acceptable cosmesis.

CONCLUSIONS

The reverse-flow submental artery island flap is safe, rapid, and simple to raise and leaves a well-hidden scar. We believe that this flap surpasses the other flaps in reconstruction of large periorbital soft-tissue defects and socket.

The anatomical features and surgical usage of the submental artery

The skin characteristics make the submental region an available flap site for facial and intraoral reconstructions. For this reason, the anatomy of the submental region and the submental artery (SA) has gained in importance recently. The SA branches out from the facial artery at the level of superior edge of the submandibular gland. The SA runs anteromedially below the mandible and superficial to the mylohyoid muscle. It gives off some perforating branches to the overlying platysma and underlying mylohyoid muscle during its course. The terminal branches continue toward the midline, crossing the anterior belly of digastric muscle either superficially or deep, and end at the mental region in general. Some perforating arteries from the terminal branches supply the anterior belly of digastric muscle. This study aimed to describe the anatomical features of the SA and its branches to help in the preparation of submental arterial flaps.

Island pedicle flap

The island pedicle flap uses an island of skin that is detached from its epidermal and dermal attachments while retaining its vascular supply from an underlying pedicle to repair a cutaneous defect. Proper design of this flap requires familiarity with the anatomic and vascular basis of the flap and with technical aspects of flap mobility. Transposition, tunneling, interpolation, myocutaneous, and transcartilage variants of the island pedicle flap are discussed. This flap is most useful for defects on the upper cutaneous lip and eyebrow, but its use on the nose, ears, and periorbital area are indispensable for the repair of select defects.

Anatomic Study of the Vasculature of the Submental Artery Flap

The submental artery island flap is a versatile option in head and neck reconstruction. This flap may be used for the coverage of perioral, intraoral, and other facial defects, leaving a relatively acceptable donor-site scar. In this study, the submental region of 13 formalin-fixed cadavers was dissected bilaterally. Comprehensive anatomical information regarding the pedicle of the flap and its relationship with the important adjacent structures is provided. The mean values of the measurements of the facial and submental arteries were as follows: the facial artery was 2.7 mm in diameter at the origin, and it crossed the mandibular border 26.6 mm from the mandibular angle. The origin of the submental artery was 27.5 mm from the origin of the facial artery, 5.0 mm from the mandibular border, and 23.8 mm from the mandibular angle. The diameter of the submental artery was 1.7 mm at the origin. The artery was found mostly to course superficial to the submandibular gland. In one case, the artery passed through the gland. The total length of the submental artery was 58.9 mm. The artery anastomosed with the contralateral artery in 92 percent of the cadavers. The submental artery was deep to the anterior belly of the digastric muscle in 81 percent of the cases. This study presents detailed anatomical data about the location, dimension, and relationship of the facial artery, the submental artery, and the submental vein that may be useful during dissection of the submental artery island flap.

Hair-bearing submental artery island flap for reconstruction of mustache and beard

Loss of mustache and beard in the adult male caused by severe burn, trauma, or tumor resection may cause cosmetic and psychological problems for these patients. Reconstruction of the elements of the face presents difficult and often daunting problems for plastic surgeons. The tissue that will be used for this purpose should have the same characteristics as the facial area, consisting of thin, pliable, hair-bearing tissue with a good color match. There is a very limited amount of donor area that has these characteristics. A hair-bearing submental island flap was used successfully for mustache and beard reconstruction in 11 male patients during the last 5 years. The scar was on the mentum in four cases, right cheek in two cases, right half of the upper lip in two cases, left cheek in one case, left half of the upper lip in one case, and both sides of the upper lip in one case. The submental island flap is supplied by the submental artery, a branch of the facial artery. The maximum flap size was 13 x 6 cm and the minimum size was 6 x 3 cm (average, 10 x 4 cm) in this series. Direct closure was achieved at all donor sites. Patients were followed up for 6 months to 5 years. No major complication was noted other than one case of temporary palsy of the marginal mandibular branch of the facial nerve. The mean postoperative stay was 7 days. Color and texture match were good. Hair growth on the flap was normal, and characteristics of the hair were the same as the intact side of the face in all patients. The submental island flap is safe, rapid, and simple to raise and leaves a well-hidden donor-site scar. The authors believe that the submental artery island flap surpasses the other flaps in reconstruction of the mustache and beard in male patients. Application of the technique and results are discussed in this article.

[Full thickness defects of the lips. Reconstructive techniques and indications]

The full-thickness tissue loss of the lip leads to the loss of lip continuity. The classic principle is to repair a lip with a lip, giving the best results. Although the size of tissue lost can force to use local flaps, these could be naso-labio-jugal, labio-mental or submental. Even though the microsurgical labial replantation is the technique of choice, unfortunately, most of the time it cannot be done as a result of the situation and the conservation of the avulsed fragment.

An anatomic study and clinical applications of the reversed submental perforator-based island flap

The authors present their experience with the reversed submental perforator-based island flap for nose reconstruction and their anatomic and clinical studies. There have been several descriptions on the reversed pattern of the submental flap, but its anatomic background and clinical availability are still questionable. The submental area was analyzed by anatomic dissection on four fresh cadavers that were injected with a barium mixture. The anatomic data were accumulated with the authors' clinical experience with eight patients treated with a submental island flap. On the basis of these studies, the location of reliable perforators was constant at the lateral and/or medial border of the anterior belly of the digastric muscle, but their locations were not always symmetric on both sides in the submental territory. Unlike the comitant submental vein, another larger superficial vein has a different course before reaching the lateral border of the anterior digastric belly, and therefore, it must be included in the reversed flap. The premised anatomic results and the clinical experience prove the reliability of the reversed submental perforator-based island flap as a versatile option in midface reconstruction, including the nose, once the dissection has been carefully done, respecting the anatomic points that can be found in this study.

The submental artery island flap for head and neck reconstruction

BACKGROUND

Following excisional surgery for head and neck cancer, most complex defects are reconstructed using microvascular free tissue transfer. These methods offer many advantages; however, they are of increasing complexity with attendant risks of flap loss and donor site problems. The submental artery island flap is a recently described local flap that may be used for reconstruction of the lower and middle thirds of the face and oral cavity, and offers the advantages of simplicity, reliability and excellent cosmesis. We have been using this flap as an alternative to free tissue transfer, and in this paper we present our series of 11 cases, after a review of the recent literature, anatomy and surgical technique. The advantages and limitations of the use of this flap are presented.

METHODS

A consecutive series of 11 patients in which this reconstruction was performed was reviewed retrospectively, and the results studied. Advantages and disadvantages of this reconstructive method were determined to define appropriate indications and contra-indications for its use.

RESULTS

We have used this flap in 11 patients for post-excisional soft tissue reconstruction of the head and neck, both as skin and as a mucosal replacement. In all but two patients the results were satisfactory, with excellent cosmesis when used as skin replacement. One patient required secondary debulking and one had complete flap loss. In all, the donor site was satisfactory.

CONCLUSIONS

The Submenal Artery Island Flap is a useful addition to the reconstructive surgeon's options and has definite advantages over distant flaps in terms of ease of dissection, final cosmetic appearance and donor site appearance.

Ten years of experience with the submental flap

This article describes the authors' experience with the submental flap over the past 10 years. A brief review of the key points and some refinements in the operative technique are discussed. The results concern 31 patients with a mean age of 57 years. All flaps were pedicled except two. One case of composite flap with bone was used. The mean size of the flap was 11.8 x 5.5 cm, and the mean postoperative stay was 11.1 days. Complications encountered were one case of temporary palsy of the marginal mandibular branch of the facial nerve, one hematoma at the recipient site, and two cases of partial flap loss. Color and texture match were good. The authors believe this flap to have great clinical potential and to be a worthwhile addition to the existing surgical armamentarium.

Combined submental flap with toe web for reconstruction of the lip with oral commissure

We present a new method employing a combined submental island flap and dorsalis pedis flap with the first toe web for reconstruction of a large lip defect including the oral commissure. The advantages of this method are: there is an excellent colour match; an anatomical structure similar to that of the oral commissure produces excellent results; there is superb function of the oral commissure; a donor-scar deformity can be avoided, since both flaps come from concealed areas; and good lining by the thin dorsal skin of the foot and submental skin results in a single-stage operation. The disadvantages are that complicated microvascular anastomoses may be required and there is a possibility of venous congestion of the submental flap in cases with a hypoplastic venous system. The use of the anterior jugular vein within the flap may be a key to overcoming this problem.

The submental island flap in head and neck reconstruction

BACKGROUND

The submental island flap (SIF) is a new alternative in the reconstruction of various head and neck defects. We present our preliminary experience in the use of this flap and describe the surgical technique.

METHODS

Nine patients underwent reconstruction with the SIF between January 1998 and July 1999. The SIF has been used for the reconstruction of the cervical esophageal stenosis in 2 patients, floor of mouth and tongue defects in 6 patients, and a hemilaryngectomy defect in 1 patient.

RESULTS

With the exception of one partial flap loss caused by arterial insufficiency, no flap failures were observed. All the donor site defects but one were closed primarily. One patient who underwent reconstruction of a hemilaryngectomy defect underwent revision surgery because of intractable hair growth on the transferred skin paddle. Marginal mandibular nerve function was intact in all the cases.

CONCLUSIONS

When combined with the reported experience of other surgeons, our preliminary experience showed that the SIF was an excellent alternative in the reconstruction of head and neck defects because of its reliability, versatility, and relative ease of application.