Reverse facial artery-submental artery deepithelialised submental island flap to reconstruct maxillary defects following cancer ablation

The Submental Artery Island Flap for Reconstruction of Acquired Maxillary and Palatal Defects After Tumor Ablation: Reversed Flow Versus the Extended Antegrade Design

BACKGROUND

The submental artery island flap (SIF) is a valid option for palatal reconstruction. However, the main limitation for its application for palatal defects is the arc of rotation. A novel modification for tunneling of the antegrade design of SIF that allows a compliant easy reach to the defect is described.

METHODS

Eighteen patients with Brown class II maxillectomy defects were included. Reconstruction started using reversed flow SIF in five patients then shifted to the modified antegrade technique in the remaining patients. Speech, swallowing, chewing, other parameters, and oncological outcomes were assessed.

RESULTS

The reversed flow group has high complications. In the antegrade SIF group, all flaps survived. One developed marginal flap necrosis that healed spontaneously. The follow-up period ranged from 1 to 4.2 years with favorable functional outcome and with no evidence of recurrence.

CONCLUSION

The modified SIF antegrade design is a reliable option for palate reconstruction that allows favorable functional and oncological outcome.

Submental Flap in the Reconstruction of Palatal Defects

Amongst oral cancers, malignancies of the palate and the upper gingivo-buccal complex are relatively uncommon. Following resection, defects in the palate lead to a nasal speech and nasal regurgitation on swallowing. This is best overcome with a prosthetic obturator which occludes the palatal defect and has dentures for the upper alveolus. It may not be possible to fit a prosthetic obturator in edentulous patients and in patients with trismus. Microvascular free flaps though commonly used for such defects, are time consuming, expensive and require a specialised setup. This study assesses the submental flap for its feasibility to repair palatal defects, the sturdiness of the flap, its functional outcome and the oncological safety in using the flap. This is a retrospective analysis of 46 patients, where palatal defects for oral cancers were reconstructed with the submental flap. Oncological safety was studied in 41 patients with a median follow-up of 34.5 months. 20 patients were studied for their functional outcomes using the parameters, adopted from the University of Washington-Quality of Life questionnaire. Complete flap loss was seen in 4 (8.7%) patients while 2 (4.35%) patients had minor dehiscence. No donor site morbidity was reported. Locoregional Recurrences and distant metastasis were noted in 13 of the 41 patients studied. The mean score was highest for speech at 95.5% while the lowest mean score was for mouth opening at 42.5%. The submental flap is an effective and reliable alternative for the reconstruction of palatal defects.

Reconstruction with submental flap for aggressive orofacial cancer- an updated series

PURPOSE

Submental flap is gaining popularity for head and neck reconstruction. We have reported in 2007 our early experience of using submental flap for aggressive orofacial malignancy. Novel flap design and application is described in this updated series.

MATERIALS AND METHODS

15 patients who had received submental flap reconstruction after extirpation of newly diagnosed aggressive orofacial lesions were retrieved. The details of the flap harvest was studied for flap size, inclusion of mylohyoid muscle, antegrade versus retrograde blood supply, and compared with our previous series.

RESULTS

The dimension of flap skin paddle was 30cm² (range 20-72). Retrograde pedicle flow was used in 2(13.3%) patients. Mylohyoid muscle was included in the flap in 6(40%) patients. There was no total flap necrosis while partial flap necrosis occurred in 1 patient(6.7%). There was a significant increase of inclusion of mylohyoid muscle to the flap in this series (p = 0.02). Novel techniques including double-paddled flap skin to resurface full-thickness defect and chimeric osteocutaneous mandible submental flap for maxillary defect were successfully performed.

CONCLUSIONS

Submental flap is a viable reconstructive option in selected patients with aggressive orofacial malignancy. The indications are expanding and its technical modification is evolving and resulting in more innovative applications.

Maxillary Reconstruction Using Submental Artery Island Flap and Sagittal Mandibular Ramus/Coronoid Process Graft Pedicled With Temporalis Muscle

PURPOSE

The purpose of this study is to describe maxillary reconstruction using the submental artery island flap and the sagittal mandibular ramus and coronoid process graft pedicled with the temporalis muscle through the modified lateral lip and submandibular approach.

MATERIALS AND METHODS

From May 2013 to September 2016, 11 patients with maxillary defects secondary to maxillary cancer ablation who underwent maxillary reconstruction using a submental artery island flap and a sagittal mandibular ramus and coronoid process graft pedicled with the temporalis muscle through the modified lateral lip and submandibular approach were enrolled in this prospective study.

RESULTS

All submental artery island flaps and sagittal mandibular ramus and coronoid process grafts were successful, with satisfactory functional and esthetic outcomes. No functional impairment at the donor site occurred in any case.

CONCLUSION

The submental artery island flap combined with the sagittal mandibular ramus and coronoid process graft is a feasible and acceptable technique for maxillary reconstruction in older patients because it is safe, quick, and straightforward to harvest and it offers a very acceptable esthetic and satisfactory outcome, with the advantage of low morbidity of the donor site. When combined with the 3-dimensional virtual operative method, the technique can improve postoperative outcomes.

[Submental island flap: a review of the literature]

The submental island flap is a precious tool in reconstructive surgery. It was described by Martin in 1993, inspired by platysma flaps. In our days, we can find many reliable techniques for this procedure. We reviewed the main studies of the literature that described a total of 528 patients. The rate of partial necrosis was 5.1%, complete necrosis 1.7%, and reversible lesions of the marginal mandibular branch of the facial nerve 1.1%. His versatility makes this flap appropriate for the reconstruction of every part of the face: cheeks, nose, forehead, moustache, beard, and hairs. It can also be used de-epidermised with very good results, for the reconstruction of the buccal cavity, the tongue, the roof of the mouth, the larynx, and the proximal part of the esophagus. The SMAP (Submentalis Artery Perforator flap) is an alternative flap that provides even better cosmetic results. The development of indocyanine green and infrared cameras will allow in a close future to decrease the postoperative complications.

Maxillary reconstruction: Current concepts and controversies

Maxillary reconstruction is still an evolving art when compared to the reconstruction of the mandible. The defects of maxilla apart from affecting the functions of the speech, swallowing and mastication also cause cosmetic disfigurement. Rehabilitation of the form and function in patients with maxillary defects is either by using an obturator prosthesis or by a surgical reconstruction. Literature is abundant with a variety of reconstructive methods. The classification systems are also varied, with no universal acceptance of any one of them. The oncologic safety of these procedures is still debated, and conclusive evidence in this regard has not emerged yet. Management of the orbit is also not yet addressed properly. Tissue engineering, that has been hyped to be one of the possible solutions for this vexing reconstructive problem, has not come out with reliable and reproducible results so far. This review article discusses the rationale and oncological safety of the reconstructing the maxillary defects, critically analyzes the classification systems, offers the different reconstructive methods and touches upon the controversies in this subject. The management of the retained and exenterated orbit associated with maxillectomy is reviewed. The surgical morbidity, complications and the recent advances in this field are also looked into. An algorithm, based on our experience, is presented.

Submental flap in intraoral reconstruction after pathologic resections: indications and limitations

INTRODUCTION

Submental flap is used to reconstruct intraoral and facial soft tissue defects. Submental flap is used for intraoral reconstruction in eighteen patients. Complications of this flap that includes local recurrence, remaining metastatic lymph node in the field of neck dissection, wound dehiscence at donor site and probability of transferring metastatic tissue are evaluated.

MATERIALS AND METHODS

This flap is used as an alternative to free tissue transfer, and this article presents 18 cases after pathologic lesion resections, such as verrocous carcinoma (2 patients), odontogenic myxoma (1 patient), oral squamous cell carcinoma (SCC) (10 patients), adenoid cystic carcinoma (2 patients), leukoplakia (2 patients) as well as osteosarcoma in one patient.

RESULTS

There was no case of local recurrence and remaining metastatic lymph node in the field of neck dissection. A case of metastatic lymph node involvement in posterior triangle of the neck, 2 years after surgery was occurred. One case of metastatic tissue transfer and a case of wound dehiscence in submental region are reported.

CONCLUSION

Submental flap is an useful aid for reconstruction of oral cavity mucosal defects. Its use in oral SCC reconstruction should be done in carefully selected cases.

Reconstruction of complex oro-facial defects using the myocutaneous sub-mental artery flap

Oro-facial defects require reconstruction that provides suitable colour match and texture. Moreover inner and outer cheek lining and bulk are key considerations. In cases of severe oro-facial infections concomitant mandibular abnormality, for example trismus, can mandate the need for tissue to obturate mandibular defects. We assessed the use of the myocutaneous sub-mental artery flap (MSA) in non-oncological patients with such defects. Twenty two consecutive patients were included in this case series. All patients were survivors of Cancrum Oris (NOMA). Demographic details, nutritional status and co-morbidities were recorded. Defects were classified according to the tissues destroyed; cheek, mandible, oral cavity, lip(s), nose and eye(s). Simultaneous procedures carried out were recorded. The surgical anatomy of the MSA is described. All patients had composite defects of the cheek and oral cavity plus another local anatomical structure. Adjunct procedures such as trismus release were carried out in 18/22 patients. Four patients required a return to theatre. There was no trismus recurrence observed. No flap losses were incurred. The MSA is a robust flap with minimal incidence of major complications. The MSA negates the need for microsurgical tissue transfer. Furthermore the MSA provides adequate bulk to obturate these defects. Future applications of the MSA may include complex oro-facial oncological defects.