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

Sonographic Evaluation of the Submandibular Region and Perforators Mapping Before Harvesting a Submental Flap May Reduce Vascular-Related Complications

The submental flap (SF) may serve as an alternative to free flap microvascular reconstruction in the head and neck region for appropriately selected patients. However, despite its apparent simplicity, the SF can be associated with a significant incidence of vascular complications affecting the transferred tissues. The aim of this study was to evaluate the usefulness of preoperative color Doppler ultrasonography (CDU) in planning the submental flap. A total of 62 patients with oral cavity cancers who underwent reconstruction using the submental flap were included. In the first group, perforators and the vascular course were assessed preoperatively using CDU. The second group comprised retrospectively selected patients who did not undergo preoperative perforator mapping. Perforators were most commonly located lateral to the digastric muscle. We observed a lower overall incidence of flap perfusion disorders in patients who underwent CDU evaluation (6 versus 1; P=0.105). Moreover, these patients required fewer reoperations. In conclusion preoperative sonographic assessment of the submandibular region should be performed on all patients for whom SF reconstruction is planned. This approach enables precise identification of vessels and their trajectories, facilitating safer and more efficient flap elevation.

Preservation of the Nerve to the Mylohyoid Muscle During Submental Island Flaps: An Anatomic Feasibility Study for Facial Nerve Reanimation Procedures

The submental island flap is an axial pattern pedicle flap widely used in head and neck surgery because of its ease and success. Indications of the submental island flap range from reconstruction for the malignant tumor resection to loss of temporal bone and facial skin due to trauma. Whereas, intraoperative facial nerve injury is not uncommon. We verified whether it was possible to localize the nerve to the mylohyoid muscle and reanimate the facial nerve during submental island flap procedures by preserving the mylohyoid muscle using human fresh cadaveric specimens. Six cadaveric heads were dissected and the position of the nerve to the mylohyoid muscle identified to the mylohyoid triangle documented. We identified the nerve to the mylohyoid muscle on all sides within the mylohyoid triangle and were able to separate the nerve from the submental island flap completely. Our results suggest that facial nerve reanimation using the nerve to the mylohyoid muscle can be used while reconstructing with a submental island flap in cases of intraoperative facial nerve injury.

The contralateral-based submental artery island flap: feasibility and oncological safety in oral cancer-related defect reconstruction

OBJECTIVES

Oncologic risk is a serious concern of submental artery island flaps. Here, we introduce the contralateral-based submental artery island flap (C-SAIF) and demonstrate its feasibility and long-term oncological safety in reconstructing oral cancer-related defects.

METHODS

An anatomical study was performed concentrating on the pedicle length in seven cadavers. Then, a retrospective study was carried out on C-SAIF patients operated on by a single team. The standard surgical technique of C-SAIF was conducted. Outcomes including operative time, length of hospital stay, volume of intraoperative blood loss, and scores of the Multidisciplinary Salivary Gland Society (MSGS) questionnaire were compared with a similar cohort reconstructed with anterolateral thigh free flap (ALTF). In addition, oncological outcomes were evaluated by the 5-year cumulative survival rate between C-SAIF and ALTF patients.

RESULTS

The pedicle length of C-SAIF was sufficient for the flap to be extended to the contralateral oral cavity. Fifty-two patients were included in the retrospective study, and nineteen of them underwent reconstruction with C-SAIF. The operative time of C-SAIF was shorter (p = 0.003), and the intraoperative blood loss was less (p = 0.004) than that of ALTF. There was no difference in MSGS scores. The results of survival analysis revealed comparable survival curves for the two groups in terms of overall survival, disease-specific survival, and disease-free survival.

CONCLUSION

C-SAIF is a feasible and reliable flap for reconstructing oral cancer-related defects. Moreover, it is an effective island flap to preserve the perforator and pedicle without compromising oncological safety.

Extended Pedicled Perforator Plus Submental Flap for Large Cheek Defect Reconstruction

The submental flap is an alternative repair technique in the maxillo-facial region when microsurgical reconstruction is not required or is difficult to apply. The purpose of this study was to illustrate the benefits of restoring the cheeks with an extended pedicled submental flap.

Method

Eight patients aged 58 to 81 years with cheek cancer presented to the surgery department at the Benha University Hospital in Egypt, from May 2019 to October 2021 for the removal of their tumors and reconstruction of the resulting defects, using the extended submental perforator plus pedicled artery flap.

Results

The average blood loss was 250 cm³ (range: 50-400 cm³). The average operation took 3 hours to complete, including excision and rebuilding (a range of 2.5 to 3.5 hours). The length of the postoperative hospital stay was 2 to 4 days. Fortunately, there was no complete flap loss; nonetheless, distal flap necrosis in one case left a raw area, which was allowed to heal naturally, and hemorrhages in two cases were conservatively handled.

Conclusions

For the reconstruction of cheek abnormalities, the submental flap is a viable alternative, particularly in older patients or patients whose overall health has declined and who need less severe therapies and quicker surgery. The submental flap, which conceals the donor site, provides a dependable supply of skin for facial resurfacing with excellent color, shape, and texture matching. The flap is quick, and easy to raise.

Regional pedicled flap salvage options for large head and neck defects: The old, the new, and the forgotten

Objectives

The objective of this article is to review options for regional pedicled reconstruction for large head and neck defects in a salvage setting.

Methods

Relevant regional pedicled flaps were identified and reviewed. Expert opinion and supporting literature were used to summarize and describe the available options.

Results

Specific regional pedicled flap options are presented including the pectoralis major flap, deltopectoral flap, supraclavicular flap, submental flap, latissimus flap, and trapezius flap.

Conclusions

Regional pedicled flaps are useful options in a salvage setting even for large defects and should be in the armamentarium of any reconstructive head and neck surgeon. Each flap option carries specific characteristics and considerations.

Reverse Facial-Submental Artery Osteomyocutaneous Flap, a Novel Choice for Previously Operated Huge Alveolar Clefts

Adult previously operated alveolar cleft palate presents a pronounced challenge for optimal surgical reconstruction. This optimal reconstruction dictates the restoration of soft tissues in addition to hard tissues to achieve prime functional results. Regional flaps usually used for the reconstruction of such defects were considered as either bulky or none bone bearing flaps. Furthermore, using free flaps for reconstruction can rise the concerns of increased intraoperative complications and greater suspected donor site morbidities. Here we present three unfavorably previously operated patients with current huge alveolar cleft palates, planned for the reconstruction with reverse facial-submental artery osteomyocutaneous flap. Besides, detailed flap harvesting technique, results, prosthetic restoration post to flap surgery, and follow up are presented in this article. We found the reverse facial- submental osteomyocutaneous flap as a novel and reliable choice for functional reconstruction of challenging huge alveolar cleft palates. The reverse facial-submental flap has not been yet mentioned in the medical literature for the reconstruction of alveolar clefts.

Colgajo submentoniano en la reconstrucción de cabeza y cuello

Introducción. Los colgajos del territorio de la arteria submentoniana pueden ser utilizados como un colgajo cutáneo, musculofacial y osteocutáneo, realizando cierres primarios del defecto del sitio donante, sin generar defectos funcionales ni estéticos mayores. Métodos. Describir la experiencia de nuestro equipo quirúrgico, las complicaciones relacionadas con el uso del colgajo y los resultados oncológicos, así como los desenlaces tardíos durante el seguimiento de los pacientes incluidos en el estudio. Resultados. Se incluyeron veintiún pacientes, con una edad media de 66 años (rango 52 - 86), con patología oncológica de lengua, labio inferior, paladar blando, nariz, órbita y orofaringe. Todos los pacientes fueron sometidos a disección selectiva ipsilateral del cuello, tras la extracción del colgajo y en todos los casos se preservó el nervio mandibular marginal. Se registraron complicaciones como la necrosis parcial. La estancia hospitalaria media fue de 8 días. Conclusiones. El colgajo de la arteria submentoniana ha mostrado resultados favorables debido a su uso versátil, amplio arco de rotación, color y baja morbilidad del sitio donante. Se recomienda realizar estudios más robustos, que incluyan la experiencia de diversos especialistas en países que compartan las mismas limitaciones técnicas y características sociodemográficas.

The submental island flap in head and neck reconstruction: A 10-year experience examining application, oncologic safety, and role of comorbidity

Background

We present our experience on reconstructive versatility and risk of nodal transfer with the submental island flap (SIF). We also examine the role of comorbidity as a predictor of complications.

Methods

Retrospective cohort study of patients undergoing SIF over 10-year period. Comorbidity determined using Adult Comorbidity Evaluation 27 index (ACE-27). Univariable/multivariable logistic regressions performed to determine association of these characteristics and rates of major complications.

Results

Fifty-eight patients underwent SIF reconstruction, 27 (45%) patients had moderate/severe comorbidity, and 24 (41%) experienced major complication. Multivariable analysis identified ACE-27 scores >2 predictive of major flap complications (OR: 17.38, 95% CI: 1.96-153.74, p = .01) and medical complications (OR: 5.8, 95% CI: 1.11-30.23, p = .037). There were no cases of pathologic nodal transfer.

Conclusion

The SIF is a versatile flap and oncologically safe in carefully selected patients. The ACE-27 index is strongly predictive of major postoperative complications.

Level of Evidence

4.

Submental Artery Island Flap in Oral Cavity Reconstruction. An Observational, Retrospective Two-centre Study

Introduction  The submental flap provides an alternative technique in orofacial reconstruction, especially in situations in which free flaps are not available, or the patients are unfit. Objective  To demonstrate the oncological safety and benefits of this flap in oral cavity reconstruction. Methods  A total of 14 patients with oral cavity cancers, who underwent submental flap reconstruction from January 2016 to January 2018, were included in the study. Results  There were 11 male and 3 female patients with a mean age of 66.7 ± 14 (Min: 52/Max: 91) years old. The most common primary tumor site was the mobile tongue in 12 (85.7%) patients. All of the patients underwent ipsilateral selective neck dissection after the flap was harvested. Flap partial necrosis was observed in one patient, and total necrosis in another one. The mean follow-up was of one year. Nonlocal or regional recurrences were observed. Conclusion  Submental island flap represents a good option in oral cavity reconstruction in a restricted setting or in patients considered not fit for free flap reconstruction. Preoperative selection of clinically neck node-negative patients is essential due to the potential risk of occult metastasis.

Composite submental flaps in facial reconstructive surgery involving the zygoma and orbit

BACKGROUND

The submental island flap (SIF) is a reliable option for reconstructing defects in the facial region and offers several advantages when compared to free-flap alternatives. While the reconstructive applications of the SIF have been demonstrated in the lower face, there are limited reports on its utility as a composite flap for reconstructing defects of the upper facial skeleton. To our knowledge, we report the first cases of composite (osteocutaneous) SIFs used for reconstruction of complex facial defects involving the zygoma and lateral orbit respectively.

CASE PRESENTATIONS

Three consecutive cases are presented. All were performed following resection of skin cancers with invasion of the upper facial skeleton. The first case was a 68-year-old male with a longstanding history of non-melanoma skin cancers who presented with a 7 cm recurrent basal cell carcinoma (BCC) with bicortical invasion of the left zygoma. The second case was an 88-year-old female with several squamous cell carcinomas (SCC), including a dominant 7.1 cm SCC on the right temple with orbital invasion. A third case was a 75-year-old immunosuppressed male with a 6.5 cm SCC of the right cheek with invasion of the orbit and zygoma following prior resection as well as high dose radiotherapy. The operative management of all cases involved harvesting the SIF on its vascular pedicle alongside the inferior portion of the mandible with rigid fixation to address the bony defects. The first case was robust throughout adjuvant radiotherapy with no flap complications after 2 year follow up. The second patient received adjuvant radiation therapy to an area that was previously radiated. Although the flap remained viable for a year, the patient experienced delayed soft tissue loss over the bony segment and eventual devitalization of the distal flap. The third case achieved a satisfactory result with no complications.

CONCLUSIONS

Our case series outlines a unique application of the composite (osteocutaneous) submental island flap (SIF) for reconstruction of complex facial defects involving the upper facial skeleton. The osteocutaneous SIF should be used with caution in patients receiving adjuvant radiotherapy who have a history of previous radiation to the same or overlapping field.

Clinical Implications of the Submental and Sublingual Arteries in Relation to the Mylohyoid Boutonnière

OBJECTIVE

Mylohyoid musculature may be included in the submental artery flap to protect perforators. However, blood vessels may pass through the mylohyoid muscle and therefore cause bleeding and risk to pedicle or perforator injury when a mylohyoid-containing flap is lifted. The objectives of this study were to identify the prevalence of the submental and sublingual arteries that traverse the mylohyoid and to assess relationships between vasculature transmitted through mylohyoid muscles and mylohyoid boutonnières.

STUDY DESIGN

Cross-sectional human cadaveric study.

SETTING

The West Virginia University School of Medicine human gross anatomic laboratories.

SUBJECTS AND METHODS

A total of 43 intact mylohyoid muscles from 22 cadavers were dissected. The prevalence of submental vasculature perforating the mylohyoid was recorded in addition to the prevalence and contents of mylohyoid boutonnières.

RESULTS

Of 43 mylohyoid muscles, 21 (48.8%) transmitted the submental or sublingual arteries, and 30 (69.1%) possessed boutonnières. One muscle had 2 boutonnières. Of 31 mylohyoid boutonnières, 21 transmitted blood vessels (67.7%). Specifically, 9 transmitted an artery and a vein (29.0%), and 12 transmitted an artery (38.7%). Ten boutonnières (32.3%) were exclusively occupied by fascia.

CONCLUSION

This report identifies the importance of identifying and carefully ligating branches of the submental artery that pierce the mylohyoid during elevation of the submental island flap. This report also identifies that a boutonnière is often present where a submental or sublingual artery is traversing the mylohyoid to supply sublingual glands, tongue, and anterior mandible.

Vertical Submental Island Flap for Head and Neck Reconstruction

Regional flaps remain a cornerstone of head and neck reconstruction. Among their many functions, they serve a vital role in salvage surgery and for those in whom medical comorbidities preclude the use of microvascular free flaps. Recent research has also examined their potential benefit in value-based healthcare metrics such as operative time, cost, intensive care unit care, and length of stay as compared to free-flap reconstruction. The submental island flap is one such entity that is well described and validated to provide predictable, oncologically sound coverage for defects of the lower third of the face and oral cavity. Its application has also been documented for repair of defects of the midface, temporal region, oropharynx, and hypopharynx, albeit less frequently. Since its original description, there have been several modifications of this axial-based flap, though none of a vertically oriented long axis. We describe a case of a vertically based submental island flap for maxillary reconstruction that allowed for debulking and recontouring of prior pectoralis flap and correction of submental ptosis.

Effect of Prior Radiotherapy on the Outcome of Submental Island Flap in Head and Neck Reconstruction

The submental island flap is a new alternative to the reconstruction of various head and neck defects. But there has been a relative paucity of information about the use of this flap in irradiated patients. The authors present their preliminary experience in the use of this flap in irradiated and nonirradiated patients. Eighty-one patients (53 nonirradiated and 28 irradiated patients) underwent reconstruction with the submental island flap between March 2011 and August 2017. The authors have 13 patients of venous congestion (7 in nonirradiated and 6 in irradiated group), 7 patients of partial necrosis of the flap (4 in nonirradiated and 3 in irradiated group). The authors also have 3 patients of transient paralysis of marginal mandibular nerve (2 in the nonirradiated and 1 in irradiated group), and 2 patients of pharyngo-cutaneous fistula in nonirradiated group. The authors have no cases of total flap loss, permanent paralysis of marginal mandibular nerve but have dehiscence of the submental area after harvesting the flap in an irradiated patient. When combined with the reported experience of other surgeons, the authors' preliminary experience showed that the submental island flap was an excellent alternative in the reconstruction of head and neck defects in both irradiated and nonirradiated patients because of its reliability, versatility, and relatively acceptable complications.

The submental arrowhead variation of the mylohyoid and anterior belly of the digastric muscles

PURPOSE

Submental anatomical variation is of clinical importance with regard to head and neck surgeries. One such anatomical variation is that of additional musculature joining the intermediate tendon of the digastric muscle to the midline of the mylohyoid musculature-a variation which this report refers to, accordingly, as an arrowhead variation. Though the arrowhead variation has been described in several case reports, it has not been subject to cross-sectional study. The purpose of this study is to determine the prevalence of the arrowhead variation.

METHODS

Prevalence of the arrowhead variation was assessed in 19 cadavers via gross dissection.

RESULTS

Two of the 19 cadavers (10.5%) were found to have arrowhead variations. The arrowhead variation was found in one male (1:11; 9.1%) and one female (1:8; 12.5%), respectively.

CONCLUSIONS

This report demonstrates that the submental arrowhead variation of the anterior digastric and mylohyoid musculature has been reported in isolated case reports since the nineteenth century. This report is the first cross-sectional study of the arrowhead variant, identifying it in approximately one in ten individuals and in both sexes. Therefore, the presence of an arrowhead variation should be regularly considered with regard to diagnosis of submental masses. Likewise, the arrowhead variation should be considered in the preoperative planning of the myriad operations performed in the submental region.

Single-stage reconstruction of large defect of oral commissure and lips by submental artery island flap

Large defect of the lip and buccal mucosa created due to wide resection of the cancer is difficult to reconstruct and always a challenge. Such defects are complex as there is loss of outer skin, muscle, soft tissue, and inner mucosal lining. We report the use of submental artery island flap (SAIF) in the reconstruction of a large defect of oral commissure and buccal mucosa in a 70-year-old female with the diagnosis of verrucous carcinoma. The final outcome was optimal in terms of cosmetic and functional results. We obtained good lip seal without any problem in speech and swallowing. SAIF is an excellent alternative option for reconstruction of large complex defects of lips and oral commissure. It has a reliable vascular supply and provides a thin and pliable tissue for reconstruction in such critical area of face.

Reconstruction of intraoral defects after resection of cancer with two types of submental artery perforator flaps

The submental island flap is a common choice for reconstruction of intraoral defects. To obtain a thinner, more pliable flap and get a better oncological result, the submental artery perforator flap has been proposed, and to assess its feasibility for closure of defects after resection of cancers of the oral cavity we studied 20 patients, each of whom was treated in this way. All the flaps were classified into those with septocutaneous perforators (n=16) and those with musculocutaneous perforators (n=4), and the main veins that drained the flaps were two submental veins (n=17). There were two patterns of venous drainage: in pattern 1 (n=9) the external jugular vein provided the primary venous drainage, and in pattern 2, the submental veins drained mainly into the facial vein, the common facial vein, and the internal jugular (n=10). In one patient the submental veins bypassed the facial vein to drain into the internal jugular. Eighteen of the 20 patients had no postoperative complications. The remaining two developed mild venous congestion of the flaps, which was resolved with conservative management and no skin loss. No local or regional recurrence was detected after a mean (range) follow-up of 21 (4-35) months. This is a simple, reliable flap that can be used for the reconstruction of intraoral defects after resections for cancer, but its oncological outcome still requires proof in long-term, large-scale, clinical trials.

The Submental Island Flap in Head and Neck Cancer

Objectives

The submental flap provides an alternative technique in orofacial reconstruction, especially in situations where free flap services are not available. The objective of this study is to demonstrate the oncological safety and benefits of this flap in oral cavity reconstruction in a tertiary care cancer hospital.

Materials and Methods

A total of 27 patients with oral cavity cancers, which underwent submental flap reconstruction from 2015 to 2017 at Shaukat Khanum Cancer Memorial Hospital, were included in the study. We have retrospectively reviewed records of these patients.

Results

There were 25 male and 2 female patients with age ranging from 21 to 73 years. Most common primary tumor sites were buccal mucosa (13), tongue (7), and lower alveolus (7). All patients underwent ipsilateral selective neck dissection after flap was harvested. Complete flap loss was observed in three, whereas one patient had flap dehiscence that subsequently healed. Mean follow-up was 11 months. There were four regional recurrences but no local recurrence. On the last follow-up (minimum 6 months), 15 patients were alive without any disease, 4 were alive with disease, and 3 had died.

Conclusion

Submental flap is a satisfactory option for oral cavity reconstruction. However, preoperative selection of clinically neck node-negative patient is extremely important as it has potential risk of occult metastasis.

The Retaining Ligament of the Anterior Digastric Muscle

The anterior belly of the digastric muscle (ABDM) is important in numerous esthetic surgeries including rhytidectomy, alteration of the cervicomental angle via partial resection of the ABDM muscle belly, and suprahyoid muscular medialization and suspension. Recently, the connection between the ABDM and the mylohyoid muscle (MH) has been proposed as important for the mechanism of the digastric corset procedure. This report refers to the connection between the ABDM and the MH as a type of retaining ligament of the anterior digastric muscle (RLAD). This report is the first to directly demonstrate the existence of the RLAD, via photograph and video, and document variation in its attachment sites, its composition, and its behavior when traction forces are applied. In addition to the importance of the RLAD in plastic surgery, the RLAD may affect neurovascular structures between the ABDM and MH and serve as a physical barrier separating the submental fascial space from the submandibular fascial space and, therefore, influence the spread of infection.

Utilization of a submental island flap and 3D printed model for skull base reconstruction: Infantile giant cranio-cervicofacial teratoma

Transcranial masses in the infant population can leave considerable skull base defects following resection. Traditional reconstructive techniques can result in significant morbidity or poor cosmetic results. We present a case of a large skull base defect in a six week-old infant, after removal of a giant cranio-cervicofacial teratoma, which was reconstructed using a versatile submental island flap. Additionally, preoperative planning and intraoperative navigation was advanced with the use of a 3D constructed model of the patient's mass.

Morphometrics of the Anterior Belly and Intermediate Tendon of the Digastric Muscle: Sexual Dimorphism and Implications for Surgery

The anterior belly of the digastric muscle (ABDM) is important in a variety of surgeries including submental lipectomy, rhytidectomy, alteration of the cervicomental angle via muscle resection, the "digastric corset" procedure for submental rejuvenation, the submental artery flap, and reanimation of the mouth after facial nerve palsy. Despite its clinical significance, little information exists regarding the morphometrics of the ABDM or its associated intermediate tendon. This study analyzed a total of 35 intact ABDMs and 43 intact intermediate tendons from 23 cadavers. Measurements were taken of the following parameters: muscle belly area, muscle belly length, intermediate tendon length, and intermediate tendon width at mid-tendon. Normative descriptive statistics are included within the report. Males were found to have significantly longer left-sided muscle bellies than right-sided bellies from males (U = 23.0; P = 0.044), left-sided bellies from females (U = 19.0; P = 0.020), and right-sided bellies from females (U = 12.0; P = 0.035). The morphometry, including sexual dimorphism, presented in this report can aid in the surgical planning and execution of numerous operations performed in head and neck, especially digastric muscle transfer surgery.

[Anatomic study of the submental artery relationships for submental flap raising]

INTRODUCTION

Submental flap is useful for intra-oral reconstructions and reconstructions of the lower two thirds of the face. Dissection is delicate because of a difficult exposure under the lower rim of the mandible, numerous collateral arterial branches and the proximity of the marginal branch of the facial nerve. The aim of our work was to propose anatomical landmarks in order to facilitate the submental flap raising.

MATERIAL AND METHOD

Ten bodies preserved in Biomet liquid were dissected bilaterally. The anatomic relationships between the marginal branch of the facial nerve and the mandible, the relationships of the submental artery, the amount and the location of its collateral branches were measured by means of a caliper.

RESULTS

The highest marginal branch observed was located 0.5 cm above the mandibular lower rim, while the lower one was located 0.6cm below this rim. The mean length measured between the facial artery at its crossing over the mandibular rim at the level of the pre-angular notch and the origin of the submental artery was 1.5cm. The average number of collateral branches was 3.6.

DISCUSSION

A skin incision made directly under the mandibular lower rim, as mentioned by some authors, may endanger the mandibular marginal branch of the facial nerve. Three positions of the submental artery in relation to the sub-maxillary gland are reported. The collateral branches are intended for gland, muscle, skin and bone. It is necessary to pay particular attention to the sub-lingual artery, an artery of big diameter that arises at 2.8cm on average from its origin and plunges towards the mouth's floor. It must not be followed at risk of clamping the thin pedicle destined to the digastric muscle. It is important to preserve the fat tissue around the submental pedicle in order to avoid venous congestion of the flap.

[Submental artery island flaps for reconstruction in the head and neck region]

BACKGROUND

Reconstruction of defects after extirpation of head and neck neoplasms is a highly challenging and complex surgical undertaking. Commonly used techniques, such as the radial forearm flap or anterior lateral thigh flap, have numerous disadvantages, e.g., donor-site morbidity, poor color match for cutaneous reconstruction, and excessive tissue bulk for intraoral reconstruction. Use of a submental artery island flap is a relatively new and increasingly performed option for reconstruction in the head and neck region.

MATERIALS AND METHODS

From March 2013 to August 2015, 12 patients were treated with a submental island flap after surgical resection of intraoral carcinomas or cutaneous neoplasms of the lower half of the face.

CASE DESCRIPTION

This paper reports on two cases. The first case describes reconstruction of the floor of the mouth using a pull-through technique after resection of a squamous cell carcinoma. The submental flap was pedicled on the contralateral side, since neck dissection of regions I-V had been performed on the ipsilateral side. The second case is a reconstruction of the lower midface with parts of the upper lip, after removal of a cutaneous spinalioma. In a N0 neck, no neck dissection was performed. The flap healed without problems in both patients, leading to a very good functional and cosmetic outcome.

CONCLUSION

The submental island flap demonstrates reliability and versatility for head and neck reconstructions. Its minimal donor site morbidity, excellent cosmetic match, pliability, and relative ease of dissection and application confer a definite advantage over distant flaps.

Reconstruction of an inferior orbital rim and cheek defect with a pedicled osteomyocutaneous submental flap

BACKGROUND

The purpose of this study was to present the feasibility of reconstructing an inferior orbital rim and cheek defect with a pedicled osteomyocutaneous submental flap.

METHOD

A 77-year-old women with a right nasosinusal adenoid cystic carcinoma invading soft tissues and skin of the cheek, the inferior rim of the orbit, the hard palate, and the middle turbinate is presented. A right radical maxillectomy with preservation of the eye was performed. A pedicled osteomyocutaneous submental island flap was used to reconstruct the defect. An inferior marginal mandibular section was incorporated with the flap and used to reconstruct the inferior orbital rim.

RESULTS

Satisfactory cosmetic and functional results were reached by reconstructing the inferior rim of the orbit and the cheek skin using this flap.

CONCLUSION

This is the first case report of an osteomyocutaneous submental flap for reconstruction of an inferior orbital rim defect.

Exclusion of musculature from the submental flap: a contingency plan for facial nerve palsy

Summary:

Submental flap surgery is a useful and versatile reconstructive procedure. Currently, disagreement exists regarding the need to include the anterior belly of the digastric muscle or mylohyoid in the submental flap. The report outlines the value of excluding normal and variant anterior digastric and mylohyoid musculature from the submental flap as a contingency plan for marginal mandibular branch of facial nerve palsy. Also, the article addresses variant anterior digastric musculature, a common anatomical finding, as it relates to the submental flap. The question of whether or not to include the anterior digastric musculature does not necessitate an all-or-none decision. In the case of multiple anterior digastric bellies, some bellies may be included in the flap, whereas others are not. The location of the submental vessels and the desired bulk or contour of the flap should guide the decision of which anterior digastric bellies, if any, are included in the flap.

[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.

Reverse facial artery flap to reconstruct the medium-sized defects in the middle facial region following cancer ablation

This retrospective clinical study assessed the reliability of the reverse facial artery flap to reconstruct the medium-sized defects in the middle facial region following cancer ablation.Fifteen medium-sized defects were repaired with reversed facial artery flap following cancer surgery. The ages of the patients ranged from 2 to 69 years; 9 were male and 6 were female. The primary lesions included palate (5 cases), maxillary gingival (6 cases), cheek or buccal mucosa (3 case), and upper lip (1 case). The size of the skin paddle varied from 4.0 cm × 6.0 cm to 5.0 cm × 10.0 cm. Direct closure was achieved at all donor sites. Fourteen of the 15 flaps survived. No donor-site problems occurred. Two patients appeared to have temporary injury of facial nerve after operation. The follow-up period ranged from 8 to 36 months; 1 patient died as a result of local recurrence and 1 patient developed cervical recurrence.Consequently, it has been demonstrated that the reversed facial artery flap had reliable blood supply and can reliably and conveniently be used for reconstruction of the medium-sized defects, especially in the middle third of oral and maxillofacial region.

Oral reconstruction with submental flap

BACKGROUND

Submental flap is a useful technique for reconstruction of medium to large oral cavity defects. Hair bearing nature of this flap in men makes it less appropriate. Therefore, deepithelialized variant is introduced to overcome the problem of hair with this flap. Recently, application of this flap has been introduced in maxillofacial trauma patients.

MATERIALS AND METHODS

Deepithelialized orthograde submental flap is used for the reconstruction of oral cavity mucosal defects.

RESULTS

Four cases including two trauma patients and two squamous cell carcinomas (SCCs) of oral cavity were treated using deepithelialized orthograde submental flap. There were no complications in all four patients and secondary epithelialization occurred in raw surface of the flap which was exposed to oral cavity.

CONCLUSION

Deepithelialized orthograde submental flap is very effective in reconstruction of oral cavity in men. The problem of hair is readily solved using this technique without jeopardizing flap blood supply.

Versatile use of submental tissue for reconstruction of perioral soft tissue defects

To obtain optimum aesthetic result, perioral soft tissue defects require reconstruction using similar tissue. The submental area has very similar characteristics to perioral soft tissue and consists of thin, pliable tissue with a perfect color match. Therefore, we have used submental tissues for reconstruction of perioral soft tissue defects and application of the techniques, and results are discussed in this article. Between February 2001 and April 2008, 14 perioral soft tissue reconstruction procedures using the submental tissues were performed. The defect was on the upper lip including nasal columella in 5 cases, mentum in 3 cases, and oral commissure including buccal cheek in 6 cases. The techniques that were used included composite graft in 3 cases, local advancement flap in 3 cases, pedicled flap in 5 cases, and free flap in 3 cases. Patients were followed up for 9 months to 5 years. During this period, no major complications were noted, and satisfactory aesthetic results were obtained. All transferred submental tissues survived. In all patients, donor defects were closed primarily except in cases of local advancement flap. The donor-site scar was inconspicuous and well hidden below the mandibular margin and did not restrict neck motion in all patients. In particular, hair restoration on the flap was excellent in male patients. We believe that the submental area can provide useful soft tissue for perioral soft tissue defects because it provides a good color and texture match with perioral skin and can be harvested with minimal donor-site morbidity.

The submental flap for oral cavity reconstruction: extended indications and technical refinements

Background and purpose

The submental flap is gaining popularity as a simple technique for reconstruction of small to moderate size defects of the oral cavity. However, its role in composite defects involving the jaw is not clearly defined. Indeed, controversy exists about the flap's interference with an oncologically sound neck dissection

Patients and Methods

A total of 21 patients with oral cavity cancers over a three year period were included. All patients underwent surgical resection and immediate reconstruction with submental flap except one patient who had delayed reconstruction with reversed flap. The flap was used for reconstruction of intra-oral soft tissue defect in 13 patients and composite defects in 8 patients.

Results

Of 21 patients 12 were males and 9 were females, age ranged from 32 to 83 years. The primary tumor sites included buccal mucosa (7), tongue (4), alveolar margin (3), floor of mouth (5) and lip (2). Eventually in this study, we adopted completing the neck dissection first before flap harvest. Complete flap loss occurred in 2 whereas 3 patients had partial flap loss. Follow up ranged from 3 to 44 months, one patient died from metastatic disease. Four patients developed neck recurrences.

Conclusion

The submental flap is a valid option for reconstruction of intra-oral soft tissue as well as composite oral defects particularly in elderly patients. However, oncologically sound neck dissection should be assured.

Submental Flap for Reconstructing Tongue Defect with V-Y Advancement Flap for Repairing Submental Defect

OBJECTIVE: To assess the reliability of the facial-submental artery island flap for reconstructing tongue defects and the aesthetic benefits of using two V-Y islanded flaps for repairing the resulting submental defect.

STUDY DESIGN: Case series with chart review.

SETTING: Patient with tongue cancer, younger patient, cosmetic outcome.

SUBJECTS AND METHODS: Thirty-three tongue defects were repaired with facial-submental artery island flaps, and the submental defects were repaired with two V-Y advancement flaps. The ages of the patients ranged from 28 to 57 years; 19 were men and 14 were women. All of the lesions were tongue squamous cell carcinoma. The size of the facial-submental artery island flap ranged from 3.5 × 7.0 to 5.0 × 8.0 cm. The size of the V-Y advancement flaps ranged from 3.0 × 3.0 to 4.0 × 4.0 cm. Direct closure was achieved at all donor sites.

RESULTS: The facial-submental artery island flaps and V-Y advancement flaps survived in 93.9 percent and 97.0 percent, respectively. The patients were followed for 12 to 26 months. The functional results in terms of speech and swallowing were good, and the aesthetic outcomes using two V-Y advancement flaps to repair the submental defects were satisfactory. Two patients with extracapsular lymph node spread developed local recurrence: One is alive with disease and the other is dead.

CONCLUSIONS: The facial-submental artery island flap is a simple, reliable flap that is preferred for reconstructing tongue defects. Using two V-Y advancement flaps for repairing the donor site defect improves the cosmetic outcome in the submental region.

Reverse facial artery flap from the submental region

BACKGROUND

Of all the local flaps that allow elevation of a sufficiently large-sized flap while also leaving an inconspicuous donor-site scar, the submental island flap is frequently used for the reconstruction of a defect in the lower two-thirds of the face. However, this flap has certain disadvantages such as the technique being slightly difficult to perform and, more importantly, that it carries a significant risk of injury to the facial nerve.

METHODS

Here, we propose the reverse facial artery flap, elevated from the submandibular region. Our method creates a flap that includes only the platysma under the skin island, without either the submental or facial artery. However, above the superior border of the skin island, the flap includes the facial artery along with subcutaneous soft tissue. The blood circulation of the skin island is in a random pattern and that of the subcutaneous pedicle is in an axial pattern.

RESULTS

Four cases were treated using our method. There were no complications in all four cases, and the results were also cosmetically very good.

CONCLUSIONS

As compared to the submental island flap, our method is easier to perform and carries a much lower risk of damage to the marginal mandibular branch of the facial nerve, as the facial artery crosses over the facial nerve at only one point. In addition, the method produces a thin flap. Therefore, when considering correction of a small-sized defect in the lower two-thirds of the face, our method has a number of advantages over the submental island flap.