Systematic review of submental artery island flap versus free flap in head and neck reconstruction

Submental island flap reconstruction in oral cavity cancer patients with pathological level I lymph node metastasis: Flap site recurrence and survival analysis

OBJECTIVES

The study aimed to determine flap site recurrence rate in oral squamous cell carcinoma patients who had undergone reconstruction with submental island flap, to evaluate factors affecting flap site recurrence, particularly pathological level I lymph node status, and assess survival outcomes.

METHODS

Fifty-six patients with squamous cell carcinoma of the oral cavity who underwent surgical resection and submental island flap reconstruction between October 2012 and February 2024 were enrolled onto the study. Tumor recurrence and survival outcomes were analyzed. A Kaplan-Meier estimate of locoregional recurrence-free survival (LRRFS), disease-specific survival (DSS), and overall survival (OS) was calculated. Factors affecting flap site recurrence and survival outcomes were assessed.

RESULTS

Most patients (78.57 %) were in the advanced stage (stage III-IV), and 21.43 % had pathological level I lymph node metastasis. Flap site recurrence rate was observed in 5.36 % of cases, without any identifiable factors predicting the recurrence, including pathological level I lymph node metastasis. The 5-year LRRFS, DSS, and OS rates were 60.28 %, 84.55 %, and 67.38 %, respectively. Positive resection margin, perineural invasion, and extranodal extension adversely affected LRRFS.

CONCLUSIONS

Submental island flap reconstruction in selected oral squamous cell carcinoma patients is oncologically safe regarding low flap site recurrence rate, satisfactory survival outcomes, and pathological level I lymph node metastasis did not affect the flap site recurrence.

Topographic anatomy of the submental artery and its clinical implications for reconstructive surgery

Knowledge about the anatomy of the submental artery (SA) is of immense importance when performing plastic and reconstructive procedures. A retrospective study was performed to analyze the topographic anatomy of the SA. The measurements were performed on 80 consecutive patients who underwent head and neck computed tomography angiography (CTA). The SA was present in 131 out of 137 hemifaces (95.6%). The vessel originated from the facial artery in all cases (100.0%). Moreover, the SA was found to have 0-4 branches. However, most commonly, the said artery had no branches of considerable size (51.1%). Due to the high variability of the course of the said artery, the authors of the present study created a novel classification system presenting the most prevalent courses of the SA in the submental region. The current study utilized 131 hemifaces of 80 (CTA) to create a heat map of the SA, illustrating its precise origin and course in the submental region. The findings of this study could assist surgeons in developing a mental map of the arterial anatomy of the submental region, potentially improving the efficiency of localizing the SA and reducing the risk of complications during plastic and reconstructive procedures.

Narrative Review: Submental Artery Island Pedicled Flap, Indications, Tips, and Pitfalls

Study Design

Narrative review.

Objective

To describe the advantages, challenges, and potential indications of the submental artery island flap as a local pedicled flap for head and neck reconstruction.

Methods

We conducted a comprehensive review of the literature to describe the submental artery island flap's surgical technique, indications, and outcomes. Data sources included peer-reviewed articles, case reports, and clinical studies on using the submental flap in head and neck surgery reconstruction.

Results

The submental artery island flap, while offering advantages such as minimal donor site morbidity, and good cosmetic outcomes, presents challenges related to the pedicle dissection and patient selection. This flap is particularly suitable for defects in the oral cavity, oropharynx, parotid bed, and midface or neck skin. Simultaneous neck dissection is feasible but should be approached with caution in patients with a history of prior neck surgery.

Conclusions

The submental artery island flap is a valuable option for selected cases. When performed in the right patient with a correct technique, this flap can reconstruct defects in the oral cavity, oropharynx, parotid bed, and skin of the midface or neck with a minimally visible scar of the donor site.

Outcomes of internal mammary artery perforator flap in head and neck reconstruction: A systematic review

This study aims to evaluate the functional and prognostic outcomes associated with the internal mammary artery perforator (IMAP) flap in various head and neck defect repairs, given the current lack of clarity on its effectiveness. We performed a systematic review of various databases: PubMed, Embase, Scopus, Web of Science, and ScienceDirect using keywords such as "Internal mammary artery perforator flap" and "IMAP." Screening and data extractions were performed by two individual reviewers. Articles were considered eligible if they included sufficient information on IMAP flap features, their applications in the head and neck, and outcomes. From 264 articles analyzed, 24 studies were included for qualitative analysis. Out of which, 125 patients who received internal mammary artery perforator flaps were included. Most of the patients, 103 (88%), received pedicled IMAP flaps, and 22 (12%) received IMAP free flaps. The second internal mammary artery (IMA) was favored as the single perforator (81.5%), with the combination of the first and second IMA being the primary choice for dual perforators (92.5%). IMAP flaps were predominantly single perforator flaps (65%), with 35% being dual perforator flaps. Among various applications, IMAP flaps are commonly employed in the reconstruction of neck defects (25.5%), pharyngocutaneous fistula repair (20.8%), and burn scar contracture restoration (8%). Only seven (5.6%) patients had flap complications, including venous congestion (1.6%), partial necrosis (1.6%), complete necrosis (1.6%), and incision dehiscence (0.8%). Donor sites were predominantly closed by the primary closure (92%). 3.2% of donor sites had minor complications. The average follow-up was 12.6 (IQR: 6-18) months. This systematic review highlights the effectiveness and safety of IMAP flaps in head and neck reconstruction, with positive outcomes and minimal complications.

Submental Island Flaps for Lateral Reconstruction: Technical Refinements for Optimal Outcomes and Resource Efficiency

Objective

To describe our modifications to the submental island flap (SMIF) in a case series that demonstrates improved reproducibility, shortened length of stay (LOS), and reduced utilization of hospital resources.

Study Design

This retrospective case series with chart review included adult patients who underwent resection of malignant or benign tumors resulting in lateral facial, parotid, or temporal bone defects, which were reconstructed with SMIF.

Setting

A tertiary-care academic referral center.

Methods

Retrospective case series included all adult patients who underwent SMIF reconstruction between March 2020 and August 2021. Patient demographic and clinical data were collected. Primary outcomes were measures of hospital utilization including duration of surgery, LOS, and postoperative outcomes.

Results

Twenty-eight patients were included with a mean age of 71.7 years. Eighty percent were male. All patients underwent parotidectomy, and the mean operative time was 347 minutes. The median LOS was 2.5 days (range 0-16 days). Seventy-five percent of the flaps drained into the internal jugular vein, and 25% drained into the external jugular vein. No patients required reoperation or readmission. All flaps survived.

Conclusion

SMIFs are a safe and effective option for reconstruction of lateral facial, parotid, and temporal bone defects. Compared to free flap reconstruction, SMIFs offer reduced length of surgery, decreased use of health care resources, and lower rate of reoperation. As health care resource allocation is increasingly important, the SMIF offers an excellent alternative to free flap reconstruction of lateral defects.

Algorithm for the reconstruction of the parotid region: a single institution experience

OBJECTIVE

This study aims to discuss the characteristics and treatment methods of malignant tumors in the parotid region, as well as the therapeutic effects of immediate free flap reconstruction of soft tissue for postoperative defects.

MATERIALS AND METHODS

A retrospective review was conducted on 11 cases of soft tissue flap reconstruction for postoperative defects following the resection of malignant tumors in the parotid region. Statistical analysis was performed based on clinical data.

RESULTS

Among the 11 cases of malignant tumors in the parotid region, there were 2 cases of secretory carcinoma (SC) of the salivary gland, 2 cases of squamous cell carcinoma (SCC), 2 cases of carcinosarcoma, 1 case of mucoepidermoid carcinoma (MEC), 1 case of epithelial-myoepithelial carcinoma (EMC), 1 case of salivary duct carcinoma (SDC), 1 case of basal cell carcinoma (BCC), and 1 case of osteosarcoma. Among these cases, 4 were initial diagnoses and 7 were recurrent tumors. The defect repairs involved: 8 cases with anterolateral thigh free flap (ALTF), 2 cases with pectoralis major muscle flaps, and 1 case with forearm flap. The size of the flaps ranged from approximately 1 cm × 3 cm to 7 cm × 15 cm. The recipient vessels included: 4 cases with the facial artery, 4 cases with the superior thyroid artery, and 1 case with the external carotid artery. The ratio of recipient vein anastomosis was: 57% for branches of the internal jugular vein, 29% for the facial vein, and 14% for the external jugular vein. Among the 8 cases that underwent neck lymph node dissection, one case showed lymph node metastasis on pathological examination. In the initial diagnosis cases, 2 cases received postoperative radiotherapy, and 1 case received 125I seed implantation therapeutic treatment after experiencing two recurrences. Postoperative follow-up revealed that 2 cases underwent reoperation due to local tumor recurrence, and there were 2 cases lost to follow-up. The survival outcomes after treatment included: one case of distant metastasis and one case of death from non-cancerous diseases.

CONCLUSION

Immediate soft tissue flap reconstruction is an important and valuable option to address postoperative defects in patients afflicted with malignant tumors in the parotid region.

Harms Reporting in Systematic Reviews of the Microvascular Free Flap in Head and Neck Reconstruction

OBJECTIVE

To evaluate harms reporting in systematic reviews (SRs) of microvascular free flap (MFF) in head and neck reconstruction.

DATA SOURCES

This cross-sectional analysis included searches from the following major databases from 2012 to June 1, 2022: MEDLINE (Pubmed and Ovid), Embase, Epistemonikos, and the Cochrane Database of Systematic Reviews.

REVIEW METHODS

In a masked duplicate manner, screening was performed using Rayyan, and data were extracted using a pilot-tested Google form. A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) was used to appraise the methodological quality of reviews and the corrected covered area was calculated to detect primary study overlap across all reviews. Reviews were then grouped in pairs of 2, called dyads, and the corrected covered area was calculated again for each individual dyad. Dyads with high overlap (≥50%) were further investigated for the accuracy of harms reporting.

RESULTS

Our initial search yielded 268 records, with 50 SRs meeting the inclusion criteria. A total of 46 (92%) of the included reviews demonstrated 50% or more adherence to the items assessed in our harms checklist. Our corrected covered area tool revealed 0.6% primary study overlap across all reviews, and 1 dyad with high overlap (≥50%). No statistically significant relationship was observed between the completeness of harms reporting and reviews listing harms as a primary outcome, reviews reporting adherence to Preferred Reporting Items of Systematic Reviews and Meta-Analyses, or a review's AMSTAR rating.

CONCLUSION

This study identifies how harms reporting in SRs of MFF reconstruction of the head and neck can be improved and provides suggestions with the potential to mitigate the paucity in current literature.

Oral Cavity Reconstruction

This summary provides a concise overview of oral cavity reconstruction to optimize functional outcomes in the modern era. Soft tissue and osseous reconstruction options for a wide range of oral cavity sites including lip, oral tongue, floor of mouth, buccal, hard palate, and composite oromandibular resections are reviewed. The appropriate applications of primary closure, secondary intention, skin grafts, and dermal substitute grafts are included. Anatomic considerations, indications, contraindications, and complications of local, regional, and free flaps in oral cavity reconstruction are discussed. Specific defects and the appropriate options for reconstruction of those defects are delineated.

Oncologic safety of the pedicled submental island flap for reconstruction in oral tongue squamous cell carcinoma: An analysis of 101 cases

OBJECTIVE

To evaluate whether the pedicle submental island flap (SIF) can be safely used in the oral tongue squamous cell carcinoma (OTSCC) patients with pathologically node-positive (pN+) neck, especially pN+ at level I.

METHODS

Retrospectively, 101 OTSCC patients with SIF reconstruction were enrolled. Oncological outcomes included the total locoregional recurrence, the SIF related locoregional recurrence (SRLR) which referred to the local recurrence at flap and ipsilateral neck recurrence at level I, recurrence free survival (RFS), overall survival (OS), and disease specific survival (DSS).

RESULTS

Sixty-one patients were pathologically node-negative (pN0) and 40 were pN+. Thirteen patients experienced locoregional recurrence, of which 5 had a SRLR. The pN+ group had a significantly higher locoregional recurrence rate, lower 5-year RFS, OS and DSS than pN0 group (P < 0.05). Patients with pN0 had a significantly higher neck RFS when compared to those with pN+ either at level I (P = 0.005) or at other levels (P < 0.001). However, the neck RFS was similar between the two subgroups of pN+ (P = 0.550). Especially, patients with pN+ at level I had a significantly higher SRLR rate (P = 0.006) compared to those with pN0 at level I. Multivariate analysis showed that pN+ was an unfavorable factor for tumor recurrence and OS.

CONCLUSION

Our data did not support the use of SIF in OTSCC patients with pN+ neck at level I due to an significantly increased SRLR rate compared to those with pN0 neck at level I.

Reconstruction surgery in head and neck cancer patients amidst the COVID-19 pandemic: Current practice and lessons for the future

The coronavirus disease 2019 (COVID-19) pandemic has imposed a radical change in daily life and work routine. In this context, health systems have suffered important and serious repercussions in all fields. Among the changes brought about by the state of global health emergency, adjustments to guidelines, priorities, structures, professional teams, and epidemiological data stand out. In light of this, the oncological field has witnessed several changes in the approach to cancer, whether due to delay in diagnosis, screening deficit, personnel shortage or the psychological impact that the pandemic has had on cancer patients. This article focuses on the management of oral carcinoma and the surgical approaches that oral and maxillofacial specialists have had at their disposal during the health emergency. In this period, the oral and maxillofacial surgeons have faced many obstacles. The proximity of maxillofacial structures to the airways, the need of elective and punctual procedures in cancerous lesions, the aggressiveness of head and neck tumors, and the need for important healthcare costs to support such delicate surgeries are examples of some of the challenges imposed for this field. One of the possible surgical 'solutions' to the difficulties in managing surgical cases of oral carcinoma during the pandemic is locoregional flaps, which in the pre-COVID-19 era were less used than free flaps. However, during the health emergency, its use has been widely reassessed. This setback may represent a precedent for opening up new reflections. In the course of a long-term pandemic, a reassessment of the validity of different medical and surgical therapeutic approaches should be considered. Finally, given that the pandemic has high-lighted vulnerabilities and shortcomings in a number of ways, including the issues of essential resource shortages, underinvestment in public health services, lack of coordination and versatility among politicians, policymakers and health leaders, resulting in overloaded health systems, rapid case development, and high mortality, a more careful analysis of the changes needed in different health systems to satisfactorily face future emergencies is essential to be carried out. This should be directed especially towards improving the management of health systems, their coordination as well as reviewing related practices, even in the surgical field.

Facial-submental island flap for reconstruction of hemitongue defects in young, middle-aged and elderly patients with early and middle stage oral tongue squamous cell carcinoma

BACKGROUND

This study evaluated the outcomes of facial-submental artery island flap (FSAIF) for reconstruction of the hemitongue following cancer ablation in patients with early and middle-stage oral tongue squamous cell carcinoma (OTSCC).

METHODS

In total, 122 patients with early and middle-stage OTSCC were divided into young, middle-aged, and elderly groups. The Adult Comorbidity Evaluation-27 (ACE-27) index was used to determine the presence of comorbidities. The patients underwent surgical treatment with hemiglossectomy, neck dissection, and hemitongue reconstruction using FSAIF. In addition, stage I (n = 15) and II (n = 69) patients underwent ipsilateral selective neck dissection, whereas those with stage III (n = 38) underwent radical neck dissection. Six patients with T3N1 disease also underwent cobalt-60 adjuvant radiotherapy.

RESULTS

Young and elderly patients exhibited significant differences in comorbidities, as assessed by the ACE-27 (p < .05). The skin paddles in the young, middle-aged, and elderly patients were 3 × 9 to 4 × 12 cm, 3 × 11 to 4 × 12, and 3 ×  10 to 5 × 13 cm in size, respectively. FSAIF failure occurred in four patients (success rate: 96.7%). No significant differences were observed in the skin paddle of the flap or rate of flap failure among the age groups (p > .05). Clavien-Dindo grades I, II, IIIa, IIIb, Iva, and IVb were assigned to 7.1, 36.1, 38.5, 9.8, 4.1, and 4.1% of the patients, respectively, with significant differences seen between the young and elderly patients (p < .05). In total, 52.5% of patients could eat normally, whereas 32.8% required a soft diet. Furthermore, 53.3 and 33.6% of patients achieved normal and intelligible speech, respectively. The aesthetic results were rated as excellent and good in 32.8 and 58.2% of patients, respectively. In total, 68.0% of the patients were alive and exhibited no evidence of disease, while 19.7% were alive with active disease. In addition, 12.3% of patients with stage III OTSCC died due to local recurrence or distant metastases. No differences in swallowing, speech, aesthetic, or survival outcomes were observed among the groups.

CONCLUSIONS

FSAIF is a simple, safe, and reliable method for reconstructing hemitongue defects following cancer ablation in young, middle-aged, and elderly patients with early and middle-stage OTSCC.

Clinical Application of Submental Island Flaps in Repair and Reconstruction of Head and Neck Tumors: Retrospective Review of a Single-Center Experience

BACKGROUND

Based on our cadaveric study findings and the clinical practice, the improved submental island flaps (SIF) used on a case series to reconstruct postoperative defects were reviewed and analyzed, to summarize the technical operation of flap cutting and propose the anterograde anatomical technique of point-line-plane alignment.

METHODS

The cadaveric study was carried out first and a case series of about 23 head and neck tumor cases that underwent one-stage SIF repair were reviewed and followed up. The intraoperative anatomy, the technical essentials for vascular pedicle protection and submandibular lymph nodes treatment, and the rational design of flap incisions were analyzed and described.

RESULTS

Most patients (21/23, 91.3%), comprising 19 males and 4 females with a mean age of 59 years, recovered completely from the application of SIFs in the repair and reconstruction of head and neck tumors; Only 2 patients experienced partial flap necrosis, which resolved following a local dressing change. The predominant donor site complication was transitory paralysis of the mandibular marginal branch of the facial nerve (MMBFN) (3/23, 13.0%), and the donor site was closed in one stage without skin grafting. The hair growth on skin flaps was not an issue for male patients requiring postoperative radiotherapy.

CONCLUSIONS

SIF is a viable choice for correcting abnormalities of the head and neck tumor with the convenience of flap cutting and the effectiveness of the repair. In addition, it permits simultaneous treatment of the lymph nodes in the region I.

Advances in oral tongue reconstruction: a reconstructive paradigm and review of functional outcomes

PURPOSE OF REVIEW

Glossectomy remains a common treatment of oral tongue malignancies, which has a range of functional impacts depending on the extent of resection. This review aims to categorize and provide context for the approach to reconstructing these defects using recent evidence.

RECENT FINDINGS

The reconstruction method of choice should be tailored to the size and location of the glossectomy defect with special consideration to replace tongue volume and preserve mobility. There has been an increasing focus on patient-reported outcomes in oral tongue reconstruction. For defects beyond one-third of the tongue, free tissue reconstruction, and more recently, the submental artery island flap yield excellent results. Advances in reconstruction of larger defects have included preoperative soft tissue planning and assessment of outcomes in total glossectomy patients with laryngeal preservation.

SUMMARY

Depending on the defect, the appropriate reconstruction may range from healing by secondary intention to large volume free tissue transfer. In general, functional outcomes diminish with increasing size and complexity of the defect regardless of the reconstructive technique.

[The application of submental flap in the nasopharyngectomy for nasopharyngeal carcinoma]

Objective:To explore the anatomy and clinical application of submental flap in the nasopharyngectomy for nasopharyngeal carcinoma. Methods:The anatomical study of the submental flap was carried out on 5 cadavers, focusing on exploring the channel of the submental flap transposition to the nasopharyngeal skull base area, and analyzing the nasopharyngeal skull base area covered by the submental flap. A retrospective analysis of 4 patients with submental flap repairment after nasopharyngectomy was performed, and the surgical methods and techniques of submental flap to repair nasopharyngeal nasal skull base defect were introduced in detail. Rusults: It showed that the submental flap could be transposed into the nasopharyngeal skull base through the posteromedial of the mandible-posterior pterygoid muscle-parapharyngeal space channel, and could cover the paraclival internal carotid artery. Clinical practice showed that the submental flap was successfully used to repair the nasopharyngeal skull base defect in 4 patients, and the submental flap grew well in the follow-up. Conclusion:The submental flap is suitable for the repair of the nasopharyngeal skull base defect after nasopharyngeal carcinoma surgery, and it is worthy of clinical promotion.