Submental island flap vs free tissue transfer in oral cavity reconstruction: Systematic review and meta‐analysis

Reconstruction of Defects After Oral Cancer Surgery With the Superior Thyroid Artery Perforator Flap

OBJECTIVE

The superior thyroid artery perforator flap (STAPF) was previously presented as a type of locoregional pedicled flap for lateral facial and temple defects. In this study, we aimed to present our clinical experience with this flap for the reconstruction of soft tissue defects after oral cancer surgery.

METHODS

From February 2019 to December 2022, 24 patients with oral cancers at the School and Hospital of Stomatology, Peking University were included. Among these patients, 10 had cancers located in the tongue, five in the cheek inside the oral cavity, three in the lower gingiva, two in the upper gingiva, two in the floor of the mouth, and two in the palate. All patients were treated with extended tumor resection, neck dissection, and STAPFs to reconstruct the soft tissue defects. The details of the flap, including the flap size, venous flow, vascular pedicle length, the attatched muscle, and operation time were evaluated.

RESULTS

The dimensions of the flap skin paddle ranged from 3 cm × 5 cm to 6 × 14 cm. Fourteen patients had a closely concomitant superior thyroid vein perforator. Ten patients had non-closely concomitant superior thyroid veins perforators which retrograde external jugular vein. The vascular pedicle length ranged from 5 to 9 cm. The infrahyoid muscle group or sternocleidomastoid muscle was included in the flaps in three patients. A total of 23/24 flaps were successful.

CONCLUSIONS

The STAPF is a viable reconstructive option for patients with oral cancers. It has the advantages of being robust, being thin, short operation time, and minor donor site complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Medial sural artery perforator free flap versus radial forearm free flap in oral cavity reconstruction and donor site morbidity

OBJECTIVE

Radial Forearm Free flap (RFFF) is widely used in head and neck reconstruction, yet its donor site defect remains a significant drawback. The Medial Sural Artery Perforator Free Flap (MSAPFF) is considered an alternative flap to RFFF. This study aims to comprehensively analyze their characteristics, outcomes, and their impact on patient quality of life.

METHODS

All patients who underwent oral cavity reconstruction using RFFF and MSAPFF between February 2017 and April 2023 were included in this study. Flap characteristics, outcomes and post-operative complications were recorded and compared. Subjective donor site morbidity, aesthetic and functional results, and quality of life were also analyzed.

RESULTS

The study included 76 patients: 37 underwent reconstruction with RFFF, and 39 with MSAPFF. There was no significance difference between the RFFF and MSAPFF regarding the success rate (97.2% vs 97.4%), flap size (4.8 × 8.8 cm2 vs 5 × 9.8 cm2), hospital of stay (15.5 days vs 13.5 days) and recipient site complications (P > 0.05). However, MSAPFF showed larger flap thickness (P = 0.001), smaller arterial caliber (P = 0.008), shorter pedicle length (P = 0.001), and longer harvesting time (P < 0.001). No significant difference was observed between the pre-and postoperative ranges of wrist and ankle movements or in recipient site complications. MSAPFF showed a significant difference in donor site morbidity (P < 0.05).

CONCLUSION

The MSAPFF is an excellent alternative to the RFFF for repairing oral cavity defects, with additional advantage of a well-hidden scar on the posterior calf, a larger flap thickness, accepted pedicle length and arterial caliber. However, one should consider the harvesting time and surgical skills required in comparison to the RFFF.

CLINICAL RELEVANCE

The study highlights the importance of the MSAPFF as an alternative option for RFFF with less donor site morbidity and high success rate in oral cavity reconstruction and improved patient Quality of life after ablative surgery.

A retrospective propensity score-matched analysis of oncological and functional outcomes of submental island flap versus radial forearm free flap for oral cavity cancer reconstruction

BACKGROUND

This retrospective study aims to compare the oncological and functional outcomes of the submental island flap versus the radial forearm free flap used for oral cavity cancer reconstruction after minimizing differences in baseline characteristics.

METHODS

Propensity scores for each oral cavity cancer patient who underwent surgical resection and immediate reconstruction with a submental island flap or a radial forearm free flap with a flap size ≤ 60 cm2 between October 2008 and December 2021 were generated based on the likelihood of being selected given their baseline characteristics. Patients were matched using a 1:1 nearest-neighbor approach.

RESULTS

The final matched-pair analysis included 51 patients in each group. The 5-year overall survival, disease-specific survival, and locoregional control rates were 70.1% and 64.8% (p = 0.612), 77.3% and 83.7% (p = 0.857), and 76.1% and 73.3% (p = 0.664), respectively, for the submental island flap group and the radial forearm free flap group. Speech and swallowing functions were comparable between groups. However, there were significantly lower rates of complication associated with both donor and recipient sites in the submental island flap group, and also the duration of hospital stays and hospital costs were significantly lower in these patients. A subgroup analysis of patients in which the reconstruction was carried out using the submental island flap procedure revealed that in selected cases, the presence of clinically and pathologically positive level I lymph nodes did not affect survival or locoregional control rates.

CONCLUSIONS

Although this study was not randomized, the matched-pair analysis of surgically treated oral cavity cancer patients showed that submental island flap reconstruction is as effective as radial forearm free flap reconstruction with regard to oncological and functional outcomes with lower complication rates, hospital stay, and hospital costs. This flap can be safely and effectively performed in selected cases with a clinical level I lymph node smaller than 1.5 cm and no signs of extranodal extension.

Submental island flap versus supraclavicular island flap in oral tongue cancer reconstruction: Perioperative and functional outcomes

BACKGROUND

The primary treatment for oral tongue cancer in both early and advanced stages involves surgical resection, which often affects tongue function. When microvascular free flaps are unsuitable for tongue reconstruction following cancer ablation, locoregional pedicled flaps become viable alternatives, for example, submental and supraclavicular island flaps. This study compares perioperative and functional outcomes between submental and supraclavicular flaps in tongue cancer reconstruction.

METHODS

This retrospective cohort study analyzed the outcomes of 46 patients who underwent tongue resection and reconstruction with a submental or supraclavicular island flap between January 2015 and December 2022. We evaluated patient demographics, flap outcomes, postoperative complications, and speech and swallowing outcomes.

RESULTS

The study included 24 submental and 22 supraclavicular island flap reconstructions. While demographic data were similar between the two groups, the submental island flap group had significantly shorter operative times than the supraclavicular group (291 and 347 min, respectively, p = 0.018), reduced hospital stays (14.8 and 18.6 days, respectively, p = 0.016), fewer major recipient site complications necessitating interventions under general anesthesia (1 and 6 patients, respectively, p = 0.043), and less recipient wound dehiscence (1 and 8 patients, respectively, p = 0.009). Speech and swallowing outcomes were comparable in the two groups.

CONCLUSION

The submental island flap appears to be a more favorable option for tongue reconstruction than the supraclavicular island flap, offering advantages in operative time, length of hospital stays, and lower rates of major complications and wound dehiscence.

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.

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.

Clinical comparison of superior thyroid artery perforator flap and sternocleidomastoid myocutaneous flap for intraoral reconstruction

The aim was to evaluate the techniques and outcomes of superior thyroid artery perforator flaps (STAPF) for intraoral reconstruction and to compare them with those of the sternocleidomastoid myocutaneous flap (SCMMF). The cases of 43 patients who underwent reconstruction with either a SCMMF or STAPF for the repair of a medium-sized intraoral defect, between January 2013 and December 2020, were reviewed retrospectively. Although both flaps are based on the superior thyroid artery, their specific harvesting techniques largely differ. All SCMMF (n = 23) were superiorly-based rotational flaps with myocutaneous designs. The STAPF cases (n = 20) included 18 septocutaneous flaps and two chimeric flaps. The flap size was larger in the STAPF group (P = 0.008), while incomplete level IIB dissection (oncological safety) was more frequent in the SCMMF group (P = 0.002). The flap necrosis rate was lower in the STAPF group (STAPF 15% vs SCMMF 34.8%, though this was not statistically significant). Cox multivariate analysis showed that the postoperative flap outcome (total flap necrosis vs flap survival; hazard ratio 27, 95% confidence interval 2.149-336.05; P = 0.001) and complications (excluding fistula) (hazard ratio 14, 95% confidence interval 1.314-142.767; P = 0.029) were associated with overall patient survival. Both speech (P < 0.001) and neck mobility (P < 0.001) functions were superior with STAPF reconstruction. Compared with the traditional SCMMF, the STAPF was found to have a lower necrosis rate with uncompromised oncological safety during harvesting. The STAPF is a good alternative for the repair of medium-sized head and neck defects.

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.

Reconstruction of nasopharyngeal defect with submental flap during surgery for nasopharyngeal malignant tumors

Objective

To investigate the feasibility and effect of a pedicled submental flap in postoperative defect repair of nasopharyngeal malignant tumors.

Methods

Eight cases (six women, two men; age, 29–63 years) of postoperative defects after resection of malignant nasopharyngeal tumors with a lesion stage of (r) T_1–3N_0–2M₀ were retrospectively analyzed. Preoperative enhanced thin-slice computed tomography of the neck was performed to predict the submental flap reflux vein. The submental flap was prefabricated during the operation, and the nasopharyngeal mass was removed through the parapharyngeal space approach combined with nasal endoscopy/mandibular external rotation/maxillary overturning. The submental flap was elevated to the nasopharyngeal defect area through the parapharyngeal space for repair.

Results

Intraoperative examination confirmed that among the eight submental flaps, three had venous drainage into the internal jugular vein and five had venous drainage into the external jugular vein; these findings were consistent with the preoperative computed tomography findings. The size of the submental flap was 8–10 cm × 5–6 cm. The repair range reached the eustachian orifice on the healthy side and extended to the posterior wall of the maxillary sinus on the affected side. The flap extended to the posterior upper part of the nasal septum at the top, to the oropharynx at the bottom, and to the bony surface of the skull base at the deep side. Primary healing after surgery was achieved, and no flap necrosis occurred. After 3–77 months of follow-up, one patient with recurrent nasopharyngeal carcinoma after radiotherapy developed cervical lymph node recurrence again, one patient with adenoid cystic carcinoma had lung metastasis, and the remaining six patients had no recurrence.

Conclusions

The pedicled submental flap is used to repair postoperative defects in the nasopharyngeal region through the cervical parapharyngeal space. It is a simple and fast procedure with adequate tissue volumes. The flap can effectively protect important structures such as the internal carotid artery and reduce the risk of infection and bleeding from postoperative wound exposure.

Tongue Reconstruction After Hemiglossectomy Due to Cancer by Submental Flap: A Case Series

We report three clinical cases using a submental flap to reconstruct the half-tongue defects after tongue cancer surgery at Hue Central Hospital (Hue city, Vietnam). The size of the flap ranged 30–60mm. The time to take flap ranged 50–60 minutes. All three patients did not have liquid accumulation, wound infection and bleeding after surgery; the flap survived well. All patients were taken the nasogastric tube out after ten days and discharged after two weeks. Postoperative functional (speech, swallowing) and tongue aesthetic assessments (symmetry) were good. These cases highlight that the submental flap is a choice for patients with flaws in the tongue. It ensures both functional and aesthetic for the regenerative tongue and donor site.

Quality of life in patients with cancer-related Brown IIb maxillary defect: A comparison between conventional obturation rehabilitation and submental flap reconstruction

OBJECTIVES

The purpose of this retrospective study was to compare the differences in quality of life (QOL) outcomes between the conventional obturator prostheses (COP) and the pedicled submental artery island flap (SAIF) in the reconstruction of Brown IIb maxillary defects.

MATERIALS AND METHODS

The QOL of 116 eligible patients who had a lapse ≥ 12 months after the cancer-related maxilla ablation was evaluated by the University of Washington quality of life scale (UW-QOL), Performance Status Scale for Head and Neck (PSS-HN), and Obturator Functioning Scale (OFS).

RESULTS

Patients in the SAIF group reported statistically and clinically significant higher overall QOL scores but lower chewing scores in the UW-QOL scale when compared with those in the COP group (P < 0.05). Clinically significantly higher scores were also observed in the recreation and anxiety domains in the UW-QOL scale for the SAIF group, but there was no statistical significances. The COP group reported more complaints about the nasal leakage when swallowing and the shape of the upper lip, and had a stronger willingness to avoid family or social events in the OFS (P < 0.05).

CONCLUSIONS

For patients with Brown IIb defects, SAIF reconstruction can achieve reduced nasal leakage when swallowing, improved upper-lip contour, increased social activity, and superior overall QOL than COP. The inferior chewing function in the SAIF group indicated the need for dental rehabilitation with a conventional denture or osseointegrated implants.

Radical resection and reconstruction in patients with adenoid cystic carcinoma in the minor salivary glands of the palate

Background

This study evaluated the clinical outcomes of the patients with adenoid cystic carcinoma (ACC) of the minor salivary glands of the palate.

Methods

Forty-four patients with stage I–II disease and 14 patients with stage III–IV disease underwent radical excision and reconstruction with a facial-submental artery island flap (FSAIF) and titanium mesh plus a free anterolateral thigh flap (ALTF) and radiotherapy respectively. Patients with stage III–IV disease subsequently received cobalt Co 60 adjuvant radiotherapy. Ki-67 expression was determined semiquantitatively in 52 patients with ACC by based on the cytoplasm staining intensity and percentage of positively stained tumor cells.

Results

The median (range) follow-up was 32.9 (14–58) months. Forty-one (71.7%) patients survived without disease recurrence. Nine patients (15.5%) survived with recurrent tumors (four with local recurrence, three with regional recurrence requiring salvage surgery, and two with distant metastasis); among these patients, five had overlapping recurrence. Eight patients (13.8%) died of regional, distant, or multiorgan metastasis (range: 22–42 months). The overall median (95% CI) survival time was 32.5 (25.0–39.5) months, and the median (95% CI) progression-free survival time was 32.9 (28.5–36.9) months. Rates of survival and recurrence differed significantly between patients with low- and high-grade tumors, patients with clinical stage I–II disease and those with stage III–IV disease, patients with and without lymph node metastasis, patients who underwent radical excision with versus without radiotherapy, and patients with low and high Ki-67 expression.

Conclusion

Radical resection and reconstruction with FSAIF is suitable methods for the the treatment of stage I–II ACC of the minor salivary glands of the palate. Stage III–IV tumors require radical resection, reconstruction with titanium mesh and free ALTF, and radiotherapy.

Health-Related Quality of Life in Oral Cancer Patients: Scoping Review and Critical Appraisal of Investigated Determinants

Simple Summary

Oral cancer may strongly impair patients’ quality of life. Huge efforts have been made during recent decades in trying to improve the treatment outcomes in terms of patients’ survival, self-perception, and satisfaction. Consequently, the investigation into health-related quality of life (HRQOL) became an established and worldwide practice. Hundreds of studies tried to clarify which could be the most important variables that impact HRQOL in head and neck cancer patients. However, such a complex topic may be influenced by a multitude of interconnected aspects and several controversies were reported. In this study the current literature was reviewed to identify all those possible sources of bias that may be encountered in trying to correlate HRQOL to patient-specific or disease/treatment-specific aspects. As a result, a list of recommendations was reported to enhance the evidence of future studies.

Abstract

Background: health-related quality of life (HRQOL) represents a secondary endpoint of medical interventions in oncological patients. Our aim was to highlight potential sources of bias that could be encountered when evaluating HRQOL in oral cancer patients. Methods: this review followed PRISMA-ScR recommendations. Participants: patients treated for oral cancer. Concept: HRQOL assessed by EORTC QLQ-C30 and QLQ-H&N35/QLQ-H&N43. A critical appraisal of included studies was performed to evaluate the accuracy of data stratification with respect to HRQOL determinants. Results: overall, 30 studies met the inclusion criteria, totaling 1833 patients. In total, 8 sociodemographic (SDG) and 15 disease/treatment-specific (DT) HRQOL determinants (independent variables) were identified. The mean number of the independent variables was 6.1 (SD, 4.3)—5.0 (SD, 4.0) DT-related and 1.1 (SD, 1.8) SDG-related variables per article. None of the included papers considered all the identified determinants simultaneously. Conclusions: a substantial lack of evidence regarding HRQOL determinants was demonstrated. This strongly weakens the reliability of the reported findings due to the challenging presence of baseline confounding, selection, and omitted variable biases. The proposed approach recommends the use of further evaluation tools that gather more variables in a single score together with a selection of more homogeneous, reproducible, and comparable cohorts based on the identified baseline confounding.

The Effect of Medial Sural Artery Perforator Flap on Reconstruction of Soft Tissue Defects: A Meta-Analysis With Multiple Free Soft Flaps

BACKGROUND

With the gradual popularity of relatively novel medial sural artery perforator flap (MSAPF), robust studies are needed to compare the surgical outcomes of MSAPF versus multiple free soft flaps (MFSFs) to verify the advantages and disadvantages of MSAPF.

METHODS

The authors searched PubMed, Web of Science, EMBASE, Cochrane Library, Chinese BioMedical Literature Database (CBM), and China National Knowledge Infrastructure (CNKI) until September, 2020, to identify studies that compared surgical outcomes of MSAPF and MFSFs. Two authors followed the PRISMA guidelines, individually extracted the data and performed the quality assessments. Survival rate of flaps, satisfaction degree of patients in recipient and donor site, skin grafting, and morbidity of recipient and donor site were evaluated.

RESULTS

A total of 441 cases from 7 studies were included in our analysis. No significant differences were found regarding survival rate of flaps, recipient morbidity, and recipient satisfaction degree between the 2 groups. However, MSAPF group was significantly superior to MFSFs group in terms of skin grafting, morbidity, and satisfaction degree of donor site.

CONCLUSION

Our meta-analysis showed that the MSPAF and MFSFs groups were similar in terms of survival rate of flaps, recipient morbidity, and recipient satisfaction degree. Medial sural artery perforator flap group was superior to MFSFs group in terms of morbidity and satisfaction degree of donor site. The results may prove that MSAPF is gaining popularity for a reason and is a good choice for repairing soft tissue defects.

A comparative study on using superior thyroid artery perforator flaps versus traditional sternocleidomastoid myocutaneous flaps for reconstructions after oral cancer ablation: "New tricks for old dogs"?

OBJECTIVES

To introduce new superior thyroid artery perforator flaps (STAPF), and to compare the clinical outcomes with sternocleidomastoid myocutaneous flaps (SCMMF) for their intraoral applications.

MATERIALS AND METHODS

Between January 2013 and December 2020, forty-three oral cancer patients who received post-oncologic reconstructions with one of these two regional flaps were retrospectively collected. Their techniques and outcomes were compared. All the STAPFs were preprepared with radiologic evaluations.

RESULTS

Despite the common arterial origins, the compositions and harvesting procedures of STAPF and SCMMF were different. Though SCMMFs (n = 23) were designed in rotational styles, most STAPFs (n = 20) were septocutaneous perforator flaps, with 2 chimeric ones. In addition, the sizes of STAPFs were generally larger than those of SCMMFs (p = 0.006). Success rate for STAPFs was much higher, with only three partial cutaneous necroses. Radiotherapy delay was more frequently found in those reconstructed with SCMMFs (P = 0.046), mostly due to fistula formations. Besides, incomplete level IIB dissections were also reported in 9 (20.9%) patients in SCMMF group. In our study, the overall survival was affected by both flap conditions (p = 0.014, 1.333-12.881) and postoperative surgical complications (except fistula) (P = 0.005, 2.240-84.134). Functionally speaking, post-reconstructive speech and neck mobility (p < 0.001) were better in the STAPF group.

CONCLUSIONS

With accumulated experiences on the use of locoregional flaps in the neck, STAPF, when well-prepared, can provide superior reconstructive outcomes for various intraoral defects. As a comparison with SCMMF in the same middle region, STAPF is a viable option with higher success rates and oncological safety for oral cancer patients.

Oncologic safety of submental island flap reconstruction in clinically node-negative oral cancer patients: a prospective comparative study

The purpose of this study was to evaluate the oncologic safety of submental island flap (SIF) reconstruction in clinically node-negative oral cancer patients. Forty-four clinically node-negative oral cancer patients with tumour size T1-T3 were divided into two groups. The Submental group consisted of 21 patients, who underwent submental island flap reconstruction whereas the control group consisted of 23 patients who underwent reconstruction with other locoregional or free flaps. The locoregional recurrence rate (LRR) and recurrence-free survival (RFS) in these two groups were assessed and compared. The follow-up period in the two groups ranged from six to 28 months, with a median follow-up period of 15 months and 21 months, respectively. Results showed that the LRR in the control and the submental group was 21.7% and 19%, respectively (p = 0.825). Kaplan-Meier curve showed that the difference in recurrence-free survival in the two groups was not statistically significant (p = 0.749). Multivariate and bivariate analyses did not establish any relationship between the predictive parameters and locoregional recurrence. Thus, the Submental island flap is a reliable and versatile locoregional flap for the reconstruction of post-resection defects in oral cancer. It has no predictive influence on locoregional recurrence in clinically node-negative oral cancer patients.

Localizing the nerve to the mylohyoid using the mylohyoid triangle

The nerve to the mylohyoid muscle has been well studied but there are no specific anatomical landmarks for identifying it. Therefore, we aimed to identify anatomical landmarks for localizing the nerve to the mylohyoid muscle in the submandibular region. Sixteen sides from eight embalmed Caucasian cadaveric heads were used in this study. The mean age at the time of death of the specimens was 80.3 years. The anterior and posterior bellies of the digastric muscle, submental artery, and mylohyoid muscle were dissected to verify their relationships with the nerve to the mylohyoid muscle. The nerve to the mylohyoid muscle was found medial to the submental artery, lateral to the anterior belly of the digastric muscle, and anterior to the posterior border of the mylohyoid muscle on all sides. Herein, we identified what we term the mylohyoid triangle. This anatomical region can help localize the nerve to the mylohyoid muscle.

Alternatives to free flap surgery for maxillofacial reconstruction: focus on the submental island flap and the pectoralis major myocutaneous flap

Background

Microvascular tissue transfer (MTT) has been established as the gold standard in oral- and maxillofacial reconstruction. However, free flap surgery may be critical in multimorbid elderly patients and after surgery or radiotherapy, which aggravate microsurgery. This study evaluates indications and outcome of the submental island flap (SMIF) and the pectoralis major myocutaneous flap (PMMF) as alternatives to the free radial forearm flap (RFF).

Methods

This retrospective study included 134 patients who had undergone resection and reconstruction with SMIF, PMMF, or RFF at our department between 2005 and 2020. The level of comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI). Primary outcome variables were flap success, complications, wound dehiscence, surgery duration, as well as time at the ICU and the ward (hospitalization). Chi-square tests, t-tests, and ANOVA were performed for statistics.

Results

24 SMIFs, 52 RFFs, and 58 PMMFs were included in this study. The flap types did not significantly differ in terms of flap success, complications, and healing disorders. The SMIF presented a success rate of 95.8% and was significantly more often used in elderly patients (mean age = 70.2 years; p < 0.001) with increased comorbidities than the PMMF (p < 0.01) and RFF (p < 0.001). SMIF reconstruction reduced surgery duration (p < 0.001) and time at the ICU (p = 0.009) and the ward (p < 0.001) more than PMMF and RFF reconstructions. PMMF reconstruction was successful in 91.4% of patients and was more frequently used after head and neck surgery (p < 0.001) and radiotherapy (p < 0.001) than SMIF and RFF reconstructions. Patients undergoing PMMF reconstruction more frequently required segmental jaw resection and had presented with advanced tumor stages (both p < 0.001). Nicotine and alcohol abuse was more frequent in the RFF and PMMF groups (both p < 0.001) than in the SMIF group.

Conclusions

The pedicled SMIF represents a valuable reconstructive option for elderly patients with increased comorbidity because of the shorter duration of surgery and hospitalization. On the other hand, the PMMF serves as a solid backup solution after head and neck surgery or radiotherapy. The rates of flap success, complications, and healing disorders of both pedicled flaps are comparable to those of free flap reconstruction.

Mucosal Melanoma of the Hard Palate: Surgical Treatment and Reconstruction

Mucosal melanomas of the head and neck region are uncommon pathologies that can affect the oral cavity, and are characterized by a high rate of mortality. Considering the lack of knowledge regarding risk and prognostic factors, current best clinical practice is represented by a large surgical excision with disease-free margins, eventually associated with a reconstructive flap. Indeed, given the frequent necessity of postoperative radiotherapy and fast healing process, a reconstruction of the surgical gap is advisable. Even if several flaps have been most commonly used, the submental island flap represents a valid alternative thanks to local advantages and similar oncologic outcomes compared to free flaps.

Modified submental platysmal adipomyofascial flap: is it a reliable alternate reconstructive option for small- to mid-sized defects especially in male patients with oral/oropharyngeal cancer?

Purpose

To introduce modified submental platysmal adipomyofascial flap as a new and viable hairless locoregional option for reconstruction of small- to mid-sized defects after ablative surgery in oral/oropharyngeal cancer patients keeping in mind the present pandemic situation.

Methods

An observational retrospective study was conducted using modified submental platysmal adipomyofascial flap as a locoregional reconstructive option for both intraoral and oropharyngeal defects in early-stage oral/oropharyngeal cancer patients, from Jan 2016 to May 2020 in a tertiary care hospital. All patients in this study were male and the overall flap outcome was evaluated with post-operative follow-up.

Results

Out of 18 patients, in 4 patients modified submental platysmal adipomyofascial flap was used as a combination of flaps for reconstruction. Six patients (33.33%) underwent adjuvant radiation therapy/radiation chemotherapy. The long-term functions (speech and swallowing) and cosmetic outcomes were good in the majority of the patients. One patient (5.55%) had pinhole oroantral fistula. No patient had any major flap failure.

Conclusion

Modified submental platysmal adipomyofascial flap can be considered as a good alternative in male patients for reconstruction of small- to mid-sized oral cavity/oropharyngeal defects post-resection, especially during the prevailing pandemic crisis. It is an oncologically safe procedure with the major advantage of providing a hairless flap for oral cavity, tonsillar and BOT resection defects with lesser donor site morbidity.

Penn Medicine Head and Neck Cancer Service Line COVID-19 management guidelines

INTRODUCTION

The COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus has altered the health care environment for the management of head and neck cancers. The purpose of these guidelines is to provide direction during the pandemic for rational Head and Neck Cancer management in order to achieve a medically and ethically appropriate balance of risks and benefits.

METHODS

Creation of consensus document.

RESULTS

The process yielded a consensus statement among a wide range of practitioners involved in the management of patients with head and neck cancer in a multihospital tertiary care health system.

CONCLUSIONS

These guidelines support an ethical approach for the management of head and neck cancers during the COVID-19 epidemic consistent with both the local standard of care as well as the head and neck oncological literature.