A Retrospective Volume Matched Analysis of the Submental Artery Island Pedicled Flap as Compared to the Forearm Free Flap: Is It a Good Alternative Choice for the Reconstruction of Defects of the Oral Cavity and Oropharynx?

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.

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.

Postoperative delirium in oral and maxillofacial surgery: a scoping review

BACKGROUND

Postoperative delirium (POD) in the oral and maxillofacial settings has gained more attention in recent decades. Due to advances in medical technology, treatment possibilities have expanded treatment for elderly and frail patients. This scoping review explores the correlation between POD and oral and maxillofacial surgery, summarizing screening and management protocols and identifying risk factors in this surgical field.

METHODS

This review follows the Scoping Review extension of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR). A comprehensive literature search was performed using multiple databases, focusing on articles published from 2002 to 2023 that discuss delirium in oral and maxillofacial surgery settings. The review was registered beforehand in the Open Science Framework ( https://osf.io/r2ebc ).

RESULTS

From the initial 644 articles, 68 met the inclusion criteria. These studies highlighted the significant heterogeneity in POD diagnosis methods. The review identifies multiple risk factors across the preoperative, intraoperative, and postoperative phases that influence the occurrence of POD. Significant and independent risk factors in multiple regression analysis were highlighted, creating a clinical prediction list for the occurrence of POD.

CONCLUSION

It is crucial to preoperatively identify patients at risk for POD and actively modify these risks throughout the patient's hospital stay. Implementing nonpharmacological preventive measures for at-risk patients is recommended to decrease the incidence of POD. Future research should focus on creating standardized specialty-specific protocols incorporating validated assessment tools and addressing the full spectrum of risk factors associated with POD.

Oral Reconstruction with Locoregional Flaps after Cancer Ablation: A Systematic Review of the Literature

Introduction: The planning of oral reconstruction after tumor resection is a pivotal point for head and neck surgeons. It is mandatory to consider two aspects: the size of the surgical defect and the complexity of the oral cavity as an anatomical region. We offer a review of the literature that focuses on four types of locoregional flaps that can be profitably used for such reconstruction: infrahyoid (IF), nasolabial (NF), platysma (PF), and submental (SF). Methods: The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This systematic review was carried out according to the PICOS acronym through a comprehensive electronic search on PubMed/MEDLINE, Cochrane Library, and Google Scholar databases. For each selected article, we extrapolated eight main parameters, of which all mean values were compared through an ANOVA test. The dimensions of the oral defects were referred to as "small" (<7 cm2), "medium" (7-50 cm2), or "large" (>50 cm2). Results: A total of 139 articles were selected with a total of 5898 patients. The mean ages for each type of flap were not statistically significant (p = 0.30, p > 0.05). Seven sublocations of oral defects were reported: The most common was the tongue (2003 [34.0%] patients), followed by the floor of the mouth (1786 [30.4%]), buccal mucosa (981 [16.6%]), cheek (422 [7.2%]), hard palate (302 [5.1%]), alveolar ridge (217 [3.7%]), and retromolar trigone (187 [3.2%]). The defects were mainly medium-sized (4507 [76.4%] patients), and fewer were small-sized (1056 [17.9%]) or large-sized (335 [5.7%]). Complications were noted, the most frequent of which was flap necrosis, seen in 0.57% of cases. The functional and esthetical results were mainly positive. Conclusions: Locoregional flaps represent a good alternative in medium-sized defects as well as a fairly good alternative in small- and large-sized defects when other options are ruled out.

Comparison of Flaps From Different Sites for Repairing Postoperative Soft Tissue Defects Regarding the Quality of Life in Patients With Oral Cancer: A Systematic Review

This study aims to compare flaps at different sites in treating soft tissue defects after oral cancer surgery and improving patients' quality of life (QoL). Databases were searched until September 2023. The extracted data included the scores of chewing, swallowing, speech, mood, and appearance based on the University of Washington QoL questionnaire, version 4. Two types of free flaps and 2 types of pedicled tissue flaps were included. The free flaps were the forearm free flap (FFF) and anterolateral thigh flap, and the pedicled tissue flaps were the submental artery island flap and pectoralis major myocutaneous flap (PMMF). Compared with FFF, there was no significant difference in the scores of chewing, swallowing, speech, and mood among anterolateral thigh, submental artery island flap, and PMMF, and PMMF generally had a higher score than FFF only in terms of appearance, with statistical significance. There is no significant difference in chewing, swallowing, speech, and mood between flaps from different sites in repairing postoperative soft tissue defects of oral cancer. Therefore, the widely used FFF may be the preferred choice considering the QoL of patients after oral cancer 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.

The Submental Flap for Reconstruction of Tongue Defects- Surgical Outcome and Quality of Life Assessment

Tongue defects following resection of cancers, have a major effect on speech and swallowing, impairing the quality of life. Free flaps such as the free radial artery forearm flap and anterolateral thigh flap have been ideal for the reconstruction of such defects depending upon the volume of tissue loss. Local flaps such as the submental flap and pectoralis major myocutaneous flap serve as an alternative in decreasing morbidity and improving functional outcomes. Surgical outcomes associated with submental flaps used in the reconstruction of tongue defects were evaluated in our study. This is a retrospective analysis of 545 patients, where the submental flap was used for the repair of tongue defects for cancer resections. Oncological safety was studied in 375 patients with a median follow-up of 48 months. 140 patients were studied for their functional outcomes using the parameters, adapted from the University of Washington- Quality of Life questionnaire. Complete flap loss was seen in 15(2.75%) patients while 22(4.03%) patients had partial loss of flap. Locoregional Recurrences, second primary, and distant metastases were noted in 91 of the 375 patients studied. The mean score for swallowing, speech, and taste were 72,71, and 69 respectively. The submental flap is an effective and reliable alternative for the reconstruction of tongue defects.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03858-3.

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.

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.

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.

[Functional evaluation of anterolateral thigh flap and forearm flap for repairing defects after oropharyngeal cancer]

Objective:To investigate the oropharyngeal function recovery of oropharyngeal squamous cell carcinoma repaired by anterolateral thigh flap and forearm flap. Methods:Retrospective study between September 2016 and September 2020 complete line 37 cases of oropharyngeal cancer postoperative soft tissue defect of femoral anterolateral flap or forearm flap to repair the patient data, in which 22 cases, using the forearm skin flap to repair 15 cases with femoral anterolateral flap, flap survival rate of preparation, compare the two groups, the incidence of vascular crisis, The functions of swallowing, speech, and velopharyngeal closure were evaluated. Results:21 cases of forearm flaps survived, and 1 case had vascular crisis. After surgical exploration, the contralateral forearm flaps survived transplantation. Fourteen anterolateral femoral flaps survived, 2 flaps had vascular crisis, and 1 flap survived after thrombus removal. The other one was repaired with pectoralis major myocutaneous flap for necrosis. Swallowing, speech, palatopharyngeal closure and other functions of the patients after the two kinds of flap repair had higher satisfaction. Conclusion:Forearm flap and anterolateral thigh flap are good choices for soft tissue defect after oropharyngeal cancer, Must act according to the special details choice appropriate therapeutic schedule.

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

PURPOSE

The aim of this systematic review is to compare the perioperative characteristics and outcomes of submental artery island flap (SAIF) to free tissue transfer (FTT) in head and neck reconstruction.

MATERIALS AND METHODS

Screening and data extraction were done with Pubmed, Embase, and Web of Science databases by two independent authors to identify randomized and observational studies that compared patient outcomes for SAIF vs. FTT for reconstruction head and neck cancer ablative surgery. Data were pooled with random-effects meta-analysis to determine pooled difference in means (DM), absolute risk differences, and 95% confidence intervals (CI). Heterogeneity was assessed with the I-squared statistic.

RESULTS

Initial query yielded 997 results, of which 7 studies met inclusion criteria. The pooled sample sizes for the SAIF and FTT cohorts were 155 and 198, respectively. SAIF reduced mean operative time by 193 min (95% CI -160 to -227), reduced hospital stay by 2.1 days (95% CI -0.9 to -3.4), and had a smaller flap area of 22.5cm² (95% CI 6.5 to 38.4). SAIF had a 5% higher incidence of partial flap necrosis than FTT (95% CI, 1 to 10), but all other perioperative complications, including recurrence rate in malignant cases, were statistically comparable.

CONCLUSIONS

The SAIF requires less operative time, hospital stay, and has comparable perioperative outcomes to FTT, but the area of flap harvest is significantly smaller. The findings of this study add to the growing body of evidence demonstrating the safety and reliability of SAIF in head and neck reconstruction.

Fasciocutaneous Type Axial Pattern Local and Regional Flaps: Alternative to Free Flaps?

Emerging usage of carefully harvested, pedicled, local and regional, skin, mucosal, and myomucosal island has a potential to save operating time and resources. Presented here are two such flaps which serves as work horses for moderate defects of the oral cavity, i.e. the islanded nasolabial and facial artery myomucosal flaps, and the technical considerations advocated by the author.

Higher incidences of neuropathic pain and altered sensation following radial forearm free flap: A systematic review

BACKGROUND

The radial forearm free flap (RFFF) has been used extensively for complex tissue defect reconstructions; however, the potential for significant donor-site morbidity remains a major drawback. Despite an abundance of literature on donor-site morbidities, no consensus has been reached on exact incidences of sensory morbidities that vary largely between 0% and 46%. Incidences of neuropathic pain in the donor site following RFFF still lack, even though clinical experience shows it often occurs. Therefore, the purpose of this systematic review was to identify the incidence of neuropathic pain and altered sensation in the hand following harvesting of a RFFF.

METHODS

A systematic search was performed in multiple databases (Embase, Medline, Cochrane, Web of Science, and Google Scholar). Studies from 1990 onwards that reported donor-site morbidities following harvest of the RFFF were included. Analyzed parameters included hand pain, hypoesthesia, cold intolerance, hyperesthesia, neuroma formation, paresthesia, sharp sensation loss, light sensation loss, and defect closure.

RESULTS

Of the 987 selected studies, 51 eligible articles were selected. The mean level of evidence was 3 (SD 0.6). Twenty articles reported pain as a donor-site morbidity, and the mean incidence of pain reported was 23% (SD 7.8). Hypoesthesia was reported by 37 articles and had a mean incidence of 34% (SD 25). Locations of pain and hypoesthesia included, amongst others, the area of the radial sensory nerve and the skin graft area. The mean incidences of cold intolerance and hyperesthesia were 13% (SD 13) and 16% (SD 15), respectively.

CONCLUSION

The results of this systematic review suggest that 23% of all patients are dealing with neuropathic pain in the donor-site following harvest of an RFFF. Future studies should therefore focus on the prognostic factors and preventive measures of neuropathic pain to further improve clinical outcomes of this widely used flap.

Outcomes of patients with minor salivary gland mucoepidermoid carcinoma of the palate undergoing submental flap reconstruction following radical resection

OBJECTIVE

To investigate the outcomes of patients with mucoepidermoid carcinoma of the palate undergoing pedicled facial-submental artery island flap (FSIF) reconstruction following resection.

PATIENTS AND METHODS

41 patients with early stage disease and 9 patients with advanced-stage disease underwent radical excision and neck dissection. 37 IIb, 4 class IIa and 9 IIIb maxillary defects were reconstructed with FSIF, folded FSIF or folded FSIF with titanium mesh respectively. The skin paddles were 3 × 8 to 5 × 15 cm and 3 × 8 to 5 × 14 cm, respectively. 5 patients with high grade disease were treated with cobalt 60 adjuvant radiotherapy after operation.

RESULTS

One flap failure occurred, yielding a success rate of 98.0% in the reconstruction of palate II and III defects with FSIF or titanium mesh. The patients were seen for follow-up for 16-60 months postoperative. 76.0% patients alive with no disease (AND); 14.0% patients alive with disease (AD) and 10.0% died of disease (DD). Rates of AND, AD and DD differed significantly according to histopathologic grade and TNM stage (P < 0.001); rates of AND, AD and DD differed obviously according to necrosis of the tumors lymph node metastasis, and tumour cell anaplasia and treatment (P < 0.05).

CONCLUSIONS

Radical resection with wide safety margins of normal tissues including neck dissection is the mainstay of treatment modality. The patients with high grade disease should be treated with postoperative radiotherapy. The FSIF is a reliable and safe method for repairing Brown class II maxillary defects.

A Scarless Healing Tale: Comparing Homeostasis and Wound Healing of Oral Mucosa With Skin and Oesophagus

Epithelial tissues are the most rapidly dividing tissues in the body, holding a natural ability for renewal and regeneration. This ability is crucial for survival as epithelia are essential to provide the ultimate barrier against the external environment, protecting the underlying tissues. Tissue stem and progenitor cells are responsible for self-renewal and repair during homeostasis and following injury. Upon wounding, epithelial tissues undergo different phases of haemostasis, inflammation, proliferation and remodelling, often resulting in fibrosis and scarring. In this review, we explore the phenotypic differences between the skin, the oesophagus and the oral mucosa. We discuss the plasticity of these epithelial stem cells and contribution of different fibroblast subpopulations for tissue regeneration and wound healing. While these epithelial tissues share global mechanisms of stem cell behaviour for tissue renewal and regeneration, the oral mucosa is known for its outstanding healing potential with minimal scarring. We aim to provide an updated review of recent studies that combined cell therapy with bioengineering exporting the unique scarless properties of the oral mucosa to improve skin and oesophageal wound healing and to reduce fibrotic tissue formation. These advances open new avenues toward the ultimate goal of achieving scarless wound healing.

Consideration in Microvascular Reconstruction during Times of Social Crises: Perspectives on Resource Utilization

Reconstruction of head and neck surgical defects can be a complicated, costly process. While the era of cost-effective medicine has begun to broadly question the necessity of high-cost care, times of extraordinary sociomedical demand bring increased scrutiny to even routine costs and resource utilization. Within this context, we reviewed the advantages, drawbacks, and financial costs of both regional and free flap reconstructions, namely the decreased costs and hospital resource utilization that may be associated with reconstruction using regional flaps. Although beset by reports of partial necrosis in certain regional flaps-particularly the submental island, cervicofacial advancement, and supraclavicular artery island flaps-many reports have demonstrated complication and flap failure rates equivalent to those of free flaps. Additionally, regional flaps have been associated with decreased costs for hospital stay, most notably in cases of postoperative complications. In cases necessitating free flap reconstruction, cost-savings strategies such as bypassing postoperative intensive care unit admissions have been shown to provide satisfactory, safe outcomes. As the head and neck surgeon continues to adapt to the medical pressures of a global pandemic, resource-sparing approaches to oncologic care will persist in their newfound importance.

Maxillo-facial reconstruction following cancer ablation during COVID-19 pandemic in southern Italy

In COVID-19 pandemic era, one major concern is related to ensure optimal management to oncologic patients, even though a context of radical uncertainty. The aim of our effort is to guarantee high-quality and timely care, minimizing COVID-19 infection risk, according to our head and neck (HN) reconstructive mission, still more challenging because of the criticality of the period. Thus, our reconstructive decision algorithm is changed. Microvascular free flaps, reported to be the gold standard for surgical reconstruction, represent extremely specialized procedures necessitating an extended resource allocation not affordable in the adversities of the period. Therefore, we are obliged to define a paradigm shift in our approach, based on free-style reconstructive surgery principles of propeller flap concept. According to our experience, we believe that this viable and feasible surgical technique could represent a reconstructive landmark in this pandemic era, since any guideline is missing, besides HN reconstructive surgery is most likely heading towards a new reconstructive approach.

Assessment of surgical outcomes and oncological safety for submental artery perforator flap reconstruction after ablation of oral cancer

The submental artery perforator flap (SAPF) has been a new option for the intraoral reconstruction of oral squamous cell carcinoma (OSCC) patients in recent years, but its surgical outcomes have not been well assessed. We compared the surgical outcomes and oncological safety of SAPF reconstruction for medium-sized soft-tissue defects after the ablation of primary oral cancer with traditional submental island flaps (SIF) and anterolateral thigh perforator flaps (ALTPF). Fifty-one SAPFs, 30 SIF, and 74 ALTPF were reviewed for the intraoral medium-sized reconstructions after the ablation of oral cancer from our institutional clinical oncological databases. We performed comparative assessments on the variables of surgical outcome and oncological safety among the 3 cohorts. A Kaplan-Meier estimate of survival for each flap was calculated. Operating time was significantly reduced in the SIF and SAPF groups than ALTPF (p = 0.021 and 0.014, respectively). Flap thickness of SAPF was the significantly thinnest (mean 0.5 cm) among three groups. The common complications of donor site for both SAPF and SIF group were incision dehiscence and orocutaneous fistula. There was no significant difference in disease-free survival (DFS) among the 3 groups. However, several OSCC patients with the SIF reconstruction were found to have recurrences with a metastatic lymph node under the flap after the first operation. SAPF could be a versatile choice of the intraoral reconstruction for the medium-sized soft-tissue defects after the ablation of oral cancer.

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.

Donor Site Morbidity in Submental Flap: Emphasizing on Facial Hairs Direction

Introduction

Donor site morbidity is an important factor for selecting a flap for reconstruction. Submental flap using submentum skin for reconstruction has low donor site morbidity. Up to now, donor site morbidity of submental flap in Caucasians has not been evaluated.

Materials and Methods

In a retrospective study, donor site morbidity of the submental flap including changes in hair direction, hypertrophic scars, and suture marks was evaluated.

Results

Forty patients with at least 2 years of follow-up were evaluated. Female patients indicated better esthetic results. Abrupt beard hair direction change occurred in five male patients. Two hypertrophic scars and one suture mark were recorded.

Conclusion

The direction of beard hairs in submentum may be changed after submental flap harvest. Accordingly, this is important in some ethnic and religious groups.

Submental flap practice patterns and perceived outcomes: A survey of 212 AHNS surgeons

OBJECTIVES

To describe American Head and Neck Society (AHNS) surgeon submental flap (SMF) practice patterns and to evaluate variables associated with SMF complications.

METHODS

The design is a cross-sectional study. An online survey was distributed to 782 AHNS surgeons between 11/11/16 and 12/31/16. Surgeon demographics, training, practice patterns and techniques were characterized and evaluated for associations with frequency of SMF complications.

RESULTS

Among 212 AHNS surgeons, 108 (50.9%) reported performing SMFs, of whom 86 provided complete responses. Most surgeons who performed the SMF routinely reconstructed oral cavity defects with the flap (86.1%, n = 74). Thirty-seven surgeons (43.0%) experienced "very few" complications with the SMF. Surgeons who practiced in the United States versus internationally (p = 0.003), performed more total career SMFs (p = 0.02), and routinely reconstructed parotid and oropharyngeal defects (p = 0.04 and p < 0.001) with SMFs were more frequently perceived to have "very few" complications. SMF surgeons reported more perceived complications with the SMF compared to pectoralis major (p = 0.001) and radial forearm free flaps (p = 0.01). However, similar perceived complications were reported between all three flaps when surgeons performed >30 SMF. Among 94 surgeons not performing SMFs, 71.3% had interest in a SMF training course.

CONCLUSIONS

Practice patterns of surgeons performing SMFs are diverse, although most use the flap for oral cavity reconstruction. While 43% of surgeons performing the SMF reported "very few" complications, overall complication rates with the SMF were higher compared to other flaps, potentially due to limited experience with the SMF. Increased training opportunities in SMF harvest and inset are indicated.

Submental Island Flap versus Free Flap Reconstruction for Complex Head and Neck Defects

Objective

Complex soft tissue reconstruction of the head and neck requires a viable, versatile, and dependable flap. Free flaps, such as the radial forearm and anterolateral thigh flap, have been the mainstay of complex head and neck reconstruction. However, a local pedicled flap, such as the submental island flap (SIF), could be a more effective and less demanding alternative. This systematic review and meta-analysis aim to compare free tissue transfer (FTT) with the SIF for head and neck reconstruction.

Data Sources

We performed a systematic search in PubMed and EMBASE databases. Meta-analysis was performed on outcomes reported in ≥3 studies.

Review Methods

Candidate articles were assessed for eligibility by 2 authors. Three authors performed data extraction and methodological quality of the included studies using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies.

Results

The search strategy resulted in 450 studies, of which 7 were included in the analysis, yielding 155 SIF and 198 FTT cases. Operating time and length of stay were significantly lower for the SIF than for FTT ( P = .05 and P = .0008). There was no significant difference between the groups for complete flap loss, debulking revisions, and oncologic recurrence.

Conclusion

These results suggest that the SIF reduces length of stay and operating time as compared with FTT in head and neck reconstruction. These findings suggest that the SIF can be considered an alternative reconstructive option to FTT when evaluating intraoral, lateral facial, skull base, and parotidectomy defects, given comparable defect size and tumor biology.