Reconstruction of hypopharyngeal defects with submental flap after laryngopharyngectomy

Design and application of submental island flap to reconstruct non-circumferential defect after hypopharyngeal carcinoma resection: a prospective study of 27 cases

BACKGROUND

This study investigated the effects of reconstruction of hypopharyngeal non-circumferential defects with a submental island flap after ablation of hypopharyngeal carcinoma.

OBJECTIVES

The purpose of our study was to identify advantages and limitations of the submental flap for reconstruction of non-circumferential hypopharyngeal defects.

METHODS

A total of 27 patients who had stage II-IV hypopharyngeal cancer and underwent pharyngeal reconstruction with a submental flap by the senior author in both Department of Otolaryngology Head Neck Surgery, Chinese PLA General Hospital and Department of Otolaryngology Head Neck Surgery, Beijing Friendship Hospital, Capital Medical University.

RESULTS

96.3% (26/27) cases of submental island flap survived. There were two pharyngocutaneous fistulas, one recovered spontaneously, and the other was associated with flap necrosis, underwent neck debridement and flap removal. All except for one patient had decannulation of their nasogastric tube 2 weeks postoperatively. There was no evidence of a stricture or stenosis of the laryngopharynx, nor any sign of aspiration, except for one with esophageal inlet stricture caused by radiotherapy. There were two cases of obvious paraesthesia pharynges due to beard growth at the submental flap after reconstruction. 63.0% (17/27) patients are alive and 37% (10/27) have died of disease. The 3-year survival rate is 56.3% and the 5-year survival rate is 50.0%.

CONCLUSION

The submental flap reconstruction for moderately sized non-circumferential hypopharyngeal defects is a recommended treatment option.

Reconstructive considerations in low and middle-income countries

PURPOSE OF REVIEW

Surgical mission trips in head and neck surgery are common. There are an increasing number of surgical groups performing complex reconstructions in low and middle-income countries (LMIC). Consideration of reconstructive options that are location and patient specific are critical for optimum patient care and local physician education.

RECENT FINDINGS

The pectoralis muscle regional flap is a versatile and reliable option and has been shown to reconstruct defects in nearly every head and neck subsite. Additional regional flap options described are the supraclavicular island flap and submental island flap. There are 15 published case series describing experience with performing microvascular reconstructions in LMIC. The average success rate was 87.1%. Both loupe and microscope magnification are used.

SUMMARY

Complex reconstructions are successfully being performed in LMIC. Although microvascular reconstruction is being utilized by some groups, local and patient-specific factors should be carefully considered, as many regional and local flap options available provide the same reconstruction benefit while minimizing operating room time, resources, and postoperative care needs.

Vascular anatomy is a determining factor of successful submental flap raising: a retrospective study of 70 clinical cases

The vascular anatomy of submental flaps (SFs) represents a determining factor in successful SF raising. However, little attention has been focused on the venous return of SFs. Thus, the present study aimed to investigate SF venous return. This study enrolled patients who underwent SF reconstructive surgery in a tertiary referral center between November 2009 and October 2016. The drainage pathway of the SF venous return was routinely identified during the course of our operations to prevent damage during head and neck surgery. The venous return data of 70 patients were reviewed. The size of the flaps ranged from 15 to 84 cm², and total flap loss was not observed in the case series. All of the submental arteries originated from the facial artery; however, the submental veins of 70 patients returned to either the internal jugular vein (IJV, 72.9%) or the external jugular vein (EJV, 27.1%). Our data suggest that drainage of the submental vein into the EJV, which has been previously overlooked, should receive greater attention during SF surgeries. The results support mandatory preservation of the EJV and IJV and indicate that vascular anatomy is a determining factor for successful SF raising.

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.

The free inverted omega-shaped flap for circumferential hypopharyngeal reconstruction with simultaneous neck skin defect

BACKGROUND

Circumferential hypopharyngeal defect with simultaneous skin defect can pose complicated reconstructive challenge for reconstructive microsurgeons. Our experience with the versatile inverted-omega flap tubing design is proposed to accommodate such problem.

METHODS

From 2012 to 2015, 13 anterolateral thigh (ALT) flaps and one anteromedial thigh (AMT) flap were harvested for reconstruction of circumferential hypopharyngeal defects with skin defects in 14 patients. All patients were males except one. Patient age ranged from 42 to 67 years (average, 53.1 years). Fifty-seven percent were recurrent cases. All but one patient received preoperative chemoradiotherapy.

RESULTS

The average flap size was 29 × 8 cm (range: 25-31 × 6-10 cm² ). An average of 2.6 perforators was included in each flap (2-4 perforators/flap). All flaps survived. One venous thrombosis was noted and salvaged after thrombolectomy and vein graft. The mean follow-up period was 25 months. The fistula rate was 21.4% (three patients). One fistula never healed because of early recurrence; one fistula healed after surgical intervention; and one fistula need a loco-regional flap for secondary reconstruction. Three postoperative strictures were noted (21.4%).

CONCLUSION

For the circumferential hypopharyngeal defect with simultaneous neck skin defect, this inverted-omega ALT tubing design offers an alternative choice for such complicated reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:51-59, 2018.

Applied anatomy of the submental island flap and its clinical application in the repair of defects following hypopharyngeal carcinoma resection

Objective

To explore the feasibility of the submental island flap in the repair of hypopharyngeal defects.

Methods

We collected wet specimens of fresh cadaveric heads from the Han Chinese adult population for applied anatomy of the submental island flap, and followed five patients with pyriform sinus carcinoma after reconstruction surgery using submental island flaps.

Results

We found that the average length and width of the submental island flaps were (65.20 ± 11.69) mm and (46.70 ± 6.59) mm, respectively. The skin flap in all five patients survived after surgery, and tracheal tubes and gastric tubes were removed 7–36 days after surgery. Patients were followed up for 24–42 months, pharyngeal flaps grew well, and speech and swallowing functions were satisfactory.

Conclusion

The submental island flap is a preferred material for the repair of hypopharyngeal defects after hypopharyngeal carcinoma resection, because of good blood supply, easy harvesting, and high survival rate.

A new option with the pedicle thoracoacromial artery perforator flap for hypopharyngeal reconstructions

OBJECTIVES/HYPOTHESIS

The reconstruction of hypopharyngeal defects should focus on minimizing morbidity in a high-risk population while achieving adequate functional results with regard to the restoration of speech, swallowing, and airway control. We introduce the clinical application of the thoracoacromial artery perforator (TAAP) flap as a new reconstructive option for hypopharyngeal defects.

METHODS

This method was used to restore oncologic hypopharyngeal defects in nine patients: three who had previous irradiation and surgery, one who had previous surgery only, and another who had previous radiotherapy only.

RESULTS

All of the TAAP flaps of our series were transferred successfully and survived entirely. The donor sites were closed primarily in all cases. No fistulas, stenosis/strictures, dehiscence, or swelling occurred. Pectoralis major muscle function was completely preserved in all patients.

CONCLUSIONS

The use of TAAP flap to reconstruct hypopharyngeal defect is a simple and effective method that does not require microsurgical skills. The flap is thin and pliable, with a reliable blood supply.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1315-1320, 2016.

Management of different kinds of head and neck defects with the submental flap for reconstruction

Head and neck surgeries often accompany with moderate-sized defects that require time-consuming reconstructions by free flaps. The submental flap is a versatile and time-effective option for reconstruction of orofacial defects providing acceptable cosmetic and functional results without requiring microsurgical techniques. A retrospective case series study of patients who underwent reconstruction with the submental flap between 2009 and 2013 was conducted. There were 36 patients (33 men and 3 women), with a mean age of 56.4 years, enrolled in this study. The primary lesion sites included oral cavity (24 patients), pharynx (8 patients), larynx (2 patients), neck (1 patient) as well as maxillary sinus (1 patient). All flaps were harvested as the myocutaneous flaps. All donor sites were closed primarily without the need of additional surgery. No complete loss of the flap was encountered and two cases developed marginal necrosis of the flap. The submental flap had a reliable pedicle and had minimal donor-site morbidity. It is an excellent flap option for patients with small- to medium-sized defects in head and neck 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.

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.

Modified incision design for submental flap: an excellent design method for the reconstruction of a defect after head and neck tumor resection

Background

The usage of submental flap is a good method for head and neck reconstruction, but it has some risk also, such as anatomical variations and surgical errors. In this article, we present a modified incision design for the submental flap.

Methods

We designed a modified submental flap incision method based on the overlap of the incision outline of the submental flap, platysma myocutaneous flap and infrahyoid myocutaneous flap. If we found that the submental flap was unreliable during the neck dissection at the level III, II and Ib areas, the infrahyoid myocutaneous flap or platysma myocutaneous flap was used to replace it. Between 2004 and 2012, we performed 30 cases using this method. As control, 33 radial forearm free flaps were counted. Significant differences were evaluated using the χ² test and Mann-Whitney U. Survival and recurrence were analyzed using the Kaplan-Meier method.

Results

Of the 30 patients, 27 finally received a submental flap, 1 patient received an infrahyoid myocutaneous flap, and 2 patients received a platysma myocutaneous flap. In patients who received the submental flap, the average operation time was 5.9 hours, 2.4 hours shorter than the radial forearm free flap group; the average age was 61.8, 6.1 years older than the radial forearm free flap group; the survival time and recurrence time did not significantly differ with those of the forearm free flap group; and the success rate was higher than traditional methods.

Conclusions

The wider indications, less required time, the similar low risk of recurrence and death as radial forearm free flap, higher success rate than traditional submental flap harvest methods, and ability to safely harvest a submental flap make the modified incision design a reliable method.