Abstract
Objective
The submental flap is a fasciocutaneous flap used in head and neck reconstruction. The aim of this study was to share the indications and outcomes of submental flap reconstruction based on our experience.
Methods
A retrospective descriptive study was conducted on a group of 14 patients who underwent reconstructive surgery of the orofacial region with the submental flap. All reconstructions were performed following oncologic resections.
Results
The submental flap was employed for the reconstruction of mobile tongue in 5 cases, maxilla and hard palate in 4 cases, cheek in 2 cases, floor of the mouth in 1 case, retromolar trigone in 1 case and oropharyngeal defects in 1 case. Satisfactory oral cavity opening was achieved in all cases. No transfer of metastatic lymph nodes to the recipient area was detected in this study.
Conclusions
The submental flap significantly shortens the surgical time compared to microvascular flaps. In our experience, the necessity for neck lymph node surgery does not preclude the use of the submental flap. Meticulous dissection of the flap greatly reduces the risk of potential transfer of tumours through the flap to the recipient area.
Keywords: Submental flap, Reconstructive surgery, Head and neck surgery
Introduction
Surgery plays a fundamental role in the treatment of orofacial region tumours. In the reconstruction of defects resulting from oncologic resections, the pursuit of optimal aesthetic and functional outcomes has in recent years led to the use of microvascular flaps as the preferred technique for repairing complex defects.1 However, the use of free flaps is not always feasible and, in certain cases, may not be the most suitable technique. A good alternative, especially for oral cavity defects, is the submental flap.2, 3, 4
The submental flap is a fasciocutaneous flap that was first described in 1993 by Martin et al.5 Its use is less widespread in the reconstruction of defects in the head and neck area compared to other fasciocutaneous flaps such as the deltopectoral or supraclavicular flaps. This may be because the surgical technique requires preservation of the submental pedicle during submandibular lymph node dissection, which complicates but does not preclude the procedure. However, its advantages are remarkable, particularly in tongue reconstruction and cervicofacial skin defects because of the quality of the tissue it provides, minimal donor site morbidity and its size, allowing for skin islands ranging from 7 to 18 cm.4,6 It is generally used as a pedicled flap, although it could be employed as a free flap.
In head and neck surgery, the choice of reconstructive technique depends on multiple factors such as the tissues involved in the defect, patient's baseline health, surgeon's preferences and skills and characteristics of the hospital centre. The aim of this article was to share the indications and outcomes of submental flap reconstruction based on our experience.
Materials and methods
A retrospective descriptive study was conducted on a group of 14 patients who underwent orofacial region reconstructive surgery using the submental flap between 2015 and 2022. All procedures were performed in the Department of Otorhinolaryngology and Head and Neck Surgery at the Valencian Institute of Oncology Foundation.
The study included 7 men (50 %) and 7 women (50 %), with a mean age of 64.43 years (SD: 13.59, Range: 45–85 years). All reconstructions were performed following oncologic resections, and in all the cases, the reconstruction was carried out during the same surgical procedure as tumour resection. In 10 cases (71.4 %), surgery was performed as the primary treatment, whereas in 4 cases (28.6 %), it was a salvage procedure after previous oncologic treatments (surgery or radiotherapy).
Patient were followed-up for at least 10 years whenever possible, according to our centre's protocol, with monthly physical examinations during the first year, bimonthly during the second year and semi-annually from the third year onwards, along with local radiological assessments using MRI semi-annually during the first year and annually from the second year onwards (Table 1).
Table 1.
Demographic and clinicopathological data of patients in this study.
| Sex | Age (years) | Comorbidity | Tumour | Primary surgery or rescue surgery | Previous radiotherapy | |
|---|---|---|---|---|---|---|
| Case 1 | Female | 58 | Floor of the mouth SCC T2N0 | Salvage | Yes | |
| Case 2 | Male | 54 | Oral tongue SCC T2N0 | Primary | No | |
| Case 3 | Male | 85 | HT, DL | Cheek Mucosa with jaw affection SCC T4N0 | Primary | No |
| Case 4 | Female | 82 | DL | Oral tongue SCC T2N0 | Primary | No |
| Case 5 | Male | 67 | Cheek skin SCC T2N2b | Salvage | No | |
| Case 6 | Female | 78 | HT | Oral tongue SCC T2N0 | Primary | No |
| Case 7 | Male | 60 | HT | Oropharynx SCC T2N0 | Primary | Yes |
| Case 8 | Male | 52 | Maxillary Sinus Esthesioneuroblastoma T4N1 | Salvage | Yes | |
| Case 9 | Male | 70 | HT | Bone palate SCC T4aN0 | Primary | No |
| Case 10 | Female | 84 | DM, HT, DL | Oral tongue SCC T3N0 | Primary | No |
| Case 11 | Male | 50 | Upper gum SCC with affection of maxillary sinus T4N1 | Primary | No | |
| Case 12 | Female | 52 | HT | Maxillary Sinus Esthesioneuroblastoma T4N0 | Salvage | Yes |
| Case 13 | Female | 45 | Retromolar trigone SCC T3N0 | Primary | No | |
| Case 14 | Female | 65 | Oral tongue SCC T3N0 | Primary | No |
HT, hypertension; DL, dyslipemia; DM, diabetes mellitus; SCC, squamous cell carcinoma.
Surgical technique
The pedicle of this flap is based on the submental artery, a constant branch of the facial artery, which courses medially to the submandibular gland.7,8 The flap is designed with its upper boundary parallel to the lower edge of the mandible, and the lower boundary should not be extended beyond the amount of skin marked by a pinch of the submental area to enable a direct closure of the donor site. The width of the flap can extend from angle to angle of the mandible and the dimension of the widest flap used in our series was 7 cm x 13 cm.
Elevation of the flap begins with an incision in the distal area of the skin island, including the layers corresponding to the skin, subcutaneous tissue and platysma. Next, the anterior belly of the digastric muscle is identified. The fibres of this muscle are sectioned at the mandibular and hyoid insertions to include it in the flap. Dissection then proceeds over the mylohyoid muscle to expose the submandibular space's fascia. After opening the space, the submandibular gland is dissected and removed if oncologic control requires it, while preserving the facial artery and vein as they traverse the gland. The submental branches originating from the facial artery are protected by performing dissection extremely close to the surface of the submandibular gland and only sectioning the blood vessels that enter the gland. Obtaining the flap continues in the proximal part, where the cutaneous, subcutaneous and platysmal layers are sectioned. The subplatysmal plane must be carefully exposed to avoid damaging the marginal branch of the facial nerve. Once the flap is pediculated, if it is to be used for intraoral reconstructions, it can be introduced into the oral cavity through a tunnel between the mylohyoid muscle and floor of the mouth.
A modified technique for obtaining this flap described by Patet et al. involves partial or complete inclusion of the mylohyoid muscle, providing greater protection to the vascular pedicle.9,10 Notably, this approach adds a larger volume to the flap1 (Fig. 1).
Figure 1.
Surgical technique. (A) Design of the submental flap; (B) surgical dissection of the flap and visualisation of the submandibular artery; (C, D) skin island including in the flap.
Results
The submental flap was used for the reconstruction of defects as follows: mobile tongue defects in 5 cases, maxilla and hard palate defects in 4 cases, cheek defects in 2 cases (1 with cutaneous extension and 1 with mandibular extension), floor of the mouth defect in 1 case, retromolar trigone defect in 1 case and oropharyngeal defect in 1 case (Figure 2, Figure 3).
Figure 2.
Localisation of the lesions.
Figure 3.
Reconstruction with submental flap in different sublocations. (A) Left retromolar trigone; (B) left maxilla and hard palate; (C) left hemi-tongue; (D) left cheek.
In 12 cases (85.71 %), cervical lymph node surgery was performed alongside the reconstruction. The classic submental flap technique was employed in 9 cases (64.29 %), whereas the modified technique was used in 5 cases (35.71 %), depending on the volume required for reconstruction.
The commencement of oral intake was at an average of 8 days after surgery (SD: 2.76, Range: 6–17 days).
Complications were recorded in 2 cases: 1 cervical hematoma requiring surgical revision and 1 partial flap dehiscence that was resolved with local wound care. The average length of hospital stay post-surgery was 11.36 days (SD: 3.34, Range: 8–19 days).
A good oral cavity opening was achieved in all cases. An oral cavity opening is considered good when the patient can insert a dental prosthesis if necessary. Regarding feeding, 1 patient required gastrostomy placement, whereas the other patients maintained the ability to eat orally. Among the 14 patients, 9 retained normal speech after surgery and 5 had modified but understandable speech.
In the oncologic follow-up, no cases in our series reported metastatic lymph node transfer to the recipient area with the flap (Table 2, Table 3).
Table 2.
Surgical details.
| Case | Resection | Cervical lymphatic node dissection | Reconstruction | Modified technique | RT |
|---|---|---|---|---|---|
| Case 1 | Glossopelvectomy | BFD | Submental flap | No | Adjuvant |
| Case 2 | Transmandibular partial glossectomy | UFD | Submental flap | Yes | Adjuvant |
| Case 3 | Resection of cheek tumour with partial maxillectomy | UFD | Submental flap | No | No |
| Case 4 | Partial glossectomy | UFD | Submental flap | No | No |
| Case 5 | Resection of buccal tumour with skin affection | UFD | Submental flap | No | Adjuvant |
| Case 6 | Partial glossectomy | UFD | Submental flap | No | Brachytherapy |
| Case 7 | Left oropharyngectomy with transmandibular approach | UFD | Submental flap | Yes | No |
| Case 8 | Right maxillectomy | UFD | Submental flap | Yes | Adjuvant |
| Case 9 | Left maxillectomy | BFD | Submental flap | Yes | Adjuvant |
| Case 10 | Partial glossectomy | UFD | Submental flap | No | No |
| Case 11 | Left maxillectomy | UFD | Submental flap + bone implants for obturated prothesis of palate bone | Yes | Adjuvant |
| Case 12 | Maxillectomy with degloving approach and resection of pterygomaxillary space | No | Submental flap + bone implants for obturated prothesis of palate bone | No | Proton therapy |
| Case 13 | Segmental mandibulectomy | UFD | Submental flap + osteosynthesis plate | No | Adjuvant |
| Case 14 | Partial glossectomy | BFD | Submental flap | No | Adjuvant |
BFD, bilateral functional dissection; UFD, unilateral functional dissection; RT, radiotherapy.
Table 3.
Results.
| Case | Hospitalisation (days) | Complications | Oral feeding (days) | Feeding | Speech | Oral opening |
|---|---|---|---|---|---|---|
| Case 1 | 15 | Hematoma (required surgery revision) | 10 | Normal | Normal | Good |
| Case 2 | 10 | No | 7 | Normal | Understandable | Good |
| Case 3 | 13 | No | 7 | Normal | Normal | Good |
| Case 4 | 15 | No | 7 | Normal | Normal | Good |
| Case 5 | 9 | No | 7 | Normal | Normal | Good |
| Case 6 | 10 | No | 7 | Normal | Normal | Good |
| Case 7 | 11 | No | 7 | Normal | Normal | Good |
| Case 8 | 14 | No | 7 | Nasogastric tube | Understandable | Good |
| Case 9 | 19 | Distal partial necrosis | 17 | Normal | Understandable | Good |
| Case 10 | 8 | No | 6 | Normal | Normal | Good |
| Case 11 | 10 | No | 8 | Normal | Understandable | Good |
| Case 12 | 9 | No | 7 | Normal | Normal | Good |
| Case 13 | 8 | No | 7 | Normal | Normal | Good |
| Case 14 | 8 | No | 7 | Normal | Understandable | Good |
Discussion
The submental flap is a fasciocutaneous or fasciomusculocutaneous flap, considering the inclusion of the anterior belly of the digastric muscle and mylohyoid muscle. It is primarily used for the reconstruction of oral cavity defects and also for other locations within the lower two-thirds of the face.
The flap is relatively easy to obtain, with good vascularisation, variable width and thickness and it does not require microsurgical sutures. Furthermore, donor site complications are minimal. It provides an adequate surgical field for performing cervical dissection alongside tumour resection, and the vitality and functionality results of the flap do not significantly differ from those obtained with microvascular free flaps.11
Given these characteristics, the submental flap is a reconstructive option to consider when patients have unfavourable characteristics, such as peripheral vascular disease or a high anaesthetic risk as the submental flaps shorten surgical time compared to microvascular free flaps.3
Regarding the surgical technique, including the anterior belly of the digastric muscle in the flap protects the perforators of the submental artery that pass through it on their way to the skin. Additionally, the inclusion of the mylohyoid muscle reduces the risk of injuring the submental vessels, although its inclusion increases the thickness of the flap, which must be considered in surgical planning.9,10 In our series, the mylohyoid muscle was included in the flap in 35.71 % of cases to obtain greater volume, and no additional morbidity was observed in these patients, consistent with the results of other authors such as Chow et al.1
The association of cervical lymph node dissection, in cases where oncologically indicated, poses an added technical challenge. In our experience, the need for neck lymph node surgery is not a criterion to rule out reconstruction with this flap, except if oncologic control requires the sacrifice of the facial artery or its submental branch. In fact, 85.71 % of cases in our series were associated with cervical lymph node dissections.
Contrastingly, there is some concern about the possibility of transferring tumour cells with the flap to the recipient site. In this regard, we agree with the inferences of Sittitrai et al.12 and Zenga et al.9 that meticulous dissection of the flap greatly reduces this possibility. In our experience, this complication was not detected in any case during patient follow-up.
Regarding perioperative complications described in the literature, total or partial necrosis of the submental flap (especially if the flaps have a large skin surface or are obtained from previously irradiated necks) is the most common; however, in our series, there were no cases of necrosis. Moreover, the complications, including partial flap dehiscence and cervical hematoma, observed in our patients are commonly described in the literature.3,13
Finally, and in line with the consulted literature,14 we consider that the outcomes in terms of oral cavity opening, feeding and speech obtained in our series to be good. Future studies comparing the functional outcomes in oral cavity reconstruction with different techniques employed by our group would be of great interest to provide a more precise assessment.
Conclusions
Based on the results obtained from our series, with low complication rate and good restoration of functionality, we advocate that the submental flap is a safe and valid option for the reconstruction of defects in the lower two-thirds of the face, oral cavity and oropharynx.
Funding
None.
Ethical approval
This study was approved by the Institutional Ethics Committee of Instituto Valenciano de Oncología (IVO) with the approval number/protocol number: 2020–13.
The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association's Declaration of Helsinki.
Written informed consent was obtained from each participant/patient for study participation and data publication.
Conflicts of interest
The authors declare no conflict of interest.
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