Reconstruction of the Upper Aerodigestive Tract with the Submental Artery Flap:

Submental Island Flaps for Lateral Reconstruction: Technical Refinements for Optimal Outcomes and Resource Efficiency

Objective

To describe our modifications to the submental island flap (SMIF) in a case series that demonstrates improved reproducibility, shortened length of stay (LOS), and reduced utilization of hospital resources.

Study Design

This retrospective case series with chart review included adult patients who underwent resection of malignant or benign tumors resulting in lateral facial, parotid, or temporal bone defects, which were reconstructed with SMIF.

Setting

A tertiary-care academic referral center.

Methods

Retrospective case series included all adult patients who underwent SMIF reconstruction between March 2020 and August 2021. Patient demographic and clinical data were collected. Primary outcomes were measures of hospital utilization including duration of surgery, LOS, and postoperative outcomes.

Results

Twenty-eight patients were included with a mean age of 71.7 years. Eighty percent were male. All patients underwent parotidectomy, and the mean operative time was 347 minutes. The median LOS was 2.5 days (range 0-16 days). Seventy-five percent of the flaps drained into the internal jugular vein, and 25% drained into the external jugular vein. No patients required reoperation or readmission. All flaps survived.

Conclusion

SMIFs are a safe and effective option for reconstruction of lateral facial, parotid, and temporal bone defects. Compared to free flap reconstruction, SMIFs offer reduced length of surgery, decreased use of health care resources, and lower rate of reoperation. As health care resource allocation is increasingly important, the SMIF offers an excellent alternative to free flap reconstruction of lateral defects.

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.

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.

The submental flap: Be wary

The submental island flap (SIF) is as an alternative to free flaps in head and neck reconstruction. 10 patients underwent submental flaps. All ten patients suffered failure of SIF as the definitive reconstructive procedure. Despite comparing favorably to free tissue transfer in published reports, our SIF had high failure rate.

Orocutaneous Fistula After Oral Cavity Resection and Reconstruction: Systematic Review and Meta-Analysis

OBJECTIVE

Orocutaneous fistula (OCF) after reconstruction for oral cavity resection can lead to prolonged hospitalization and adjuvant treatment delay. Few studies have examined factors leading to OCF after oral cavity resection. Primary objective: evaluate overall incidence and factors associated with OCF after oral cavity reconstruction.

DATA SOURCES

Scopus 1960-database was searched for terms: "orocutaneous fistula," "oro cutaneous fistula," "oral cutaneous fistula," "orocervical fistula," "oral cavity salivary fistula."

REVIEW METHODS

English language studies with >5 patients undergoing reconstruction after oral cavity cancer resection were included. About 1057 records initially screened; 214 full texts assessed; 78 full-texts included. PRISMA guidelines were followed, and MINORS criteria used to assess risk of bias. Data were pooled using random-effects model. Primary outcome was OCF incidence. Meta-analysis to determine the effect of preoperative radiation on OCF conducted on 12 eligible studies. Pre-collection hypothesis was that prior radiation therapy is associated with increased OCF incidence. Post-collection analyses: free versus pedicled flaps; mandible-sparing versus segmental mandibulectomy.

RESULTS

Seventy-eight studies were included in meta-analysis of overall OCF incidence. Pooled effect size showed overall incidence of OCF to be 7.71% (95% CI, 6.28%-9.13%) among 5400 patients. Meta-analysis of preoperative radiation therapy on OCF showed a pooled odds ratio of 1.68 (95% CI, 0.93-3.06). OCF incidence was similar between patients undergoing free versus pedicled reconstruction, or segmental mandibulectomy versus mandible-sparing resection.

CONCLUSION

Orocutaneous fistula after oral cavity resection has significant incidence and clinical impact. Risk of OCF persists despite advances in reconstructive options; there is a trend toward higher risk after prior radiation.

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.

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.

The submental flap for head and neck reconstruction: Comparison of outcomes to the radial forearm free flap

OBJECTIVES

To compare intraoperative, postoperative, functional, and oncologic outcomes of the submental island pedicled flap (SIPF) to the radial forearm free flap (RFFF).

STUDY DESIGN

Retrospective review; comparison with statistical analysis.

METHODS

A retrospective review was performed on patients at two tertiary care academic hospitals by a single surgeon. Consecutive patients who underwent cancer resection and reconstruction with SIPF or RFFF between 2004 and 2016 were included. Cancer staging, surgical procedure, hospital stay, complications, and functional and oncologic results were extracted.

RESULTS

The study included 146 patients (57 SIPF; 89 RFFF). The most prevalent primary site was oral cavity, with a minority in the oropharynx, paranasal sinuses, or external face. Mean area of the SIPF was smaller at 28 cm² compared to 48 cm² for the RFFF. Operative time for SIPF was shorter at 6.5 hours compared to 9 hours for RFFF. Hospital stay was 8.0 days for SIPF patients and 10.0 days for RFFF patients. Multivariate analysis confirmed these differences were significant. Functional outcomes of speech quality and gastrostomy feeding tube dependence were similar between the SIPF and RFFF groups. There was no difference in local recurrence rate for SIPF (16%) and RFFF (19%), and there was no difference in overall recurrence. Kaplan-Meier curves showed no difference in recurrence between both groups, and multivariate logistic regression demonstrated no association between SIPF and local recurrence.

CONCLUSION

Operative time and hospital stay are both significantly reduced with the SIPF. Functional and oncologic results are similar with no contraindication to the SIPF. The SIPF is a good first-line choice for head and neck reconstruction.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:S1-S10, 2020.

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 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.

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.

Submental Artery Island Flap in Patients who Have Received Prior Neck Irradiation

Submental Artery Flap (SMAF) was first described in 1990 and has gained popularity ever since. However there has been relative paucity on information about the use of this flap in irradiated patients. Our aim was to explore the success of SMAF for reconstructing defects following oral cancer resection in this group of patients After prior approval from scientific and ethical committee, we performed a retrospective review of records of eleven patients who underwent SMAF reconstruction between March 2009 and September 2012. Seven patients (63 %) had undergone prior irradiation . The flap was viable in all the patients excepting for superficial epidermal loss in one patient who had undergone prior irradiation. There was major donor site complication in one, and recurrences in four patients, all in the irradiated group. SMAF may be used in patients with irradiated neck taking special precautions to avoid donor site morbidity. Previous neck irradiation may not affect flap viability.

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.

[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.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Multi-disciplinary approach for management of refractory benign occlusive esophageal strictures

BACKGROUND

Benign occlusive esophageal strictures create substantial morbidity and have poor surgical outcomes. Various endoscopic techniques have been described to manage these strictures. The challenge remains to maintain adequate long-term esophageal patency and to limit the need for serial endoscopic dilations. Little has been reported regarding the management of these benign occlusive strictures.

METHODS

We report a case series describing the management of technically challenging benign occlusive esophageal strictures. Three patients with occlusive esophageal strictures of differing etiologies were treated using a variety of endoscopic methodologies.

RESULTS

The first patient sustained a caustic oropharyngeal injury resulting in a proximal esophageal stricture which was treated by using a combined antegrade retrograde dilation (CARD) with argon plasma coagulation (APC) and needle knife dissection resulting in the successful recanalization and patency of his stricture. A second patient developed an esophageal stricture following radiotherapy, and was treated with a CARD procedure and serial balloon dilations in combination with APC to successfully achieve esophageal luminal patency. The final patient acquired an occlusive esophageal stricture after treatment for thyroid cancer which was treated with endoscopic needle knife dissection followed by serial balloon dilations to successfully manage this stricture.

CONCLUSIONS

Occlusive esophageal strictures pose a difficult challenge to gastroenterologists and little has been reported with regards to their endoscopic management. Using the CARD technique, needle knife dissection and APC, individually or in combination, luminal patency of occlusive esophageal strictures can be accomplished safely with good results.

The use of bipaddled submental flap for reconstructing composite buccal defect

Reconstruction of full-thickness buccal defect is challenging as two linings need to be addressed. Either two different flaps or double-paddle for one free flaps are necessary for this defect. The prolonged operation might not be tolerated by patients because of advanced age or medical comorbidity. A 77-year-old gentleman, with significant medical comorbidity, presented with a 4.0 × 4.5 cm ulcerative mass due to squamous cell carcinoma arising from the left buccal mucosa. The tumor extended to the left cheek skin. There was no palpable neck node. CT scan did not show any bony erosion or suspicious neck node. Full-thickness resection of the tumour was undertaken. For the full-thickness buccal defect, a bi-paddled pedicled submental flap after de-epithelialization of the flap skin was used for both the cutaneous and mucosal resurfacing. The flap survived completely and patient recovered smoothly. The surgery is simple and operation time is much shorter than free flap reconstruction. This modified utilization of submental flap simplifies the closure of complicated oro-facial wound.

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.

Where do perforator flaps fit in our armamentarium?

This article reviews historical aspects of flap development, leading up to the exciting recognition of perforator flaps. The role and use of perforator-type flaps in the reconstructive armamentarium is reviewed as it pertains to different regions of the body.