Submental Artery Research Articles

Versatility and aesthetic performance of the submental flap for reconstruction of skin defects in head and neck

The submental flap (SMF) is a reliable option for head and neck reconstruction. It is a pedicle flap based on the submental artery and vein, divisions of the facial pedicle.The purpose of this Operative Technique is to describe the step-by-step setup of the submental flap for reconstruction of the preauricular region and to briefly examine its versatility and range of choices in skin and soft tissue defect reconstruction (see Supplemental video in the online version of the article).The harvesting of the SMF provides an aesthetically acceptable result for both the donor and reconstructed sites. The main advantages of the flap are its excellent color and texture match to the tissue in the cheek, and the possibility of restoring pilosity in male patients.In the opinion of the authors, the SMF is one of the best reconstructive alternatives for defects in the lower two-thirds of the face in elderly male patients.

Lymph Node Ratio in Head and Neck Cancer with Submental Flap Reconstruction.

This study aimed to investigate the relationship between the lymph node ratio (LNR) and survival results of patients with head and neck squamous cell carcinoma (HNSCC) reconstructed by a submental artery flap (SMAF) to limit tumor size. This study retrospectively recruited 49 patients with HNSCC who underwent both primary resection and neck dissection with SMAF reconstruction. The LNR was the ratio of the number of metastatic lymph nodes to the sum number of examined lymph nodes. A LNR of 0.04 was the best cut-off value for HNSCC-specific death on receiver operating curve analysis. Patients with LNRs > 0.04 were univariately related to cancer-specific, disease-free, distant metastasis-free, and locoregional recurrence-free survival than those with LNRs ≤ 0.04 by log-rank test. In a Cox's proportional hazards model with hazard ratio (HR) and 95% confidence interval (CI) adjusting for pathological stage, extranodal extension and or surgical margins, the LNR (>0.04/≤0.04) predicted multivariate shorter cancer-specific (HR = 9.24, 95% CI = 1.49-176), disease-free (HR = 3.44, 95% CI = 1.23-10.3), and distant metastasis-free (HR = 9.76, 95% CI = 1.57-187) survival. In conclusion, LNR for patients of HNSCC with SMAF reconstruction for limited tumor size was a prognostic factor for survival outcomes.

Advances in oral tongue reconstruction: a reconstructive paradigm and review of functional outcomes.

Glossectomy remains a common treatment of oral tongue malignancies, which has a range of functional impacts depending on the extent of resection. This review aims to categorize and provide context for the approach to reconstructing these defects using recent evidence. The reconstruction method of choice should be tailored to the size and location of the glossectomy defect with special consideration to replace tongue volume and preserve mobility. There has been an increasing focus on patient-reported outcomes in oral tongue reconstruction. For defects beyond one-third of the tongue, free tissue reconstruction, and more recently, the submental artery island flap yield excellent results. Advances in reconstruction of larger defects have included preoperative soft tissue planning and assessment of outcomes in total glossectomy patients with laryngeal preservation. Depending on the defect, the appropriate reconstruction may range from healing by secondary intention to large volume free tissue transfer. In general, functional outcomes diminish with increasing size and complexity of the defect regardless of the reconstructive technique.

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

ObjectivesThe 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 methodsThe 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). ResultsPatients 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). ConclusionsFor 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.

Oncological outcome of contralateral submental artery island flap versus primary closure in tongue squamous cell carcinoma: randomized non-inferiority clinical trial

The aim of this study was to test the non-inferiority of the contralateral submental island flap (CSIF) compared with primary closure (PC) regarding local recurrence after partial glossectomy in patients with oral tongue squamous cell carcinoma (OTSCC). This open-label, non-inferiority randomized controlled trial enrolled patients with cT1–2 lateralized OTSCC. The primary outcome was local recurrence by 12 months postoperative. Non-inferiority would be declared if the upper limit of the two-sided 95% confidence interval (CI) for the proportion difference in local recurrence between the two groups did not exceed a non-inferiority margin of 15.0%. The functional outcome was assessed for superiority through secondary outcomes. In the intention-to-treat analysis, the local recurrence rate was 3.1% (1/32) in the CSIF group versus 9.4% (3/32) in the PC group; the proportion difference was − 6.3% (95% CI −18.0% to 5.5%). In the per-protocol analysis, the local recurrence rate was 3.1% (1/32) versus 3.3% (1/30); the proportion difference was − 0.2% (95% CI −9% to 8.6%). Speech was significantly superior in the CSIF group (P = 0.001). In conclusion, the CSIF was found to be non-inferior to PC regarding local recurrence at 1 year. A limitation of this study is the relatively large non-inferiority margin and consequently relatively small sample size. Further studies with a smaller non-inferiority margin and therefore larger sample size are needed to validate these findings.

The submental island pedicled flap and supraclavicular artery island flap in a free flap practice

Reconstruction of head and neck defects is a delicate endeavor that poses numerous intrinsic and extrinsic challenges, which are currently magnified by rising health care costs and limitations in system resources. Current trends in the United States heavily favor the use of free tissue transfer over locoregional pedicles flaps (LRPF); however, the latter group is often undervalued, offering high utility, practicality, and cost-efficiency whilst providing equivalent results. The submental island flap and supraclavicular artery island flap are two LRPF that should be in the arsenal of the modern reconstructive surgeon.

An anatomical study of the blood supply to the mylohyoid muscle: the so-called “mylohyoid branch” of the inferior alveolar artery is an arterial anastomosis

BackgroundThe aim of this study was to clarify the morphology of the mylohyoid branch of the inferior alveolar artery and the main blood supply to the mylohyoid muscle. Methods: The maxillary artery (MA) and inferior alveolar artery (IAA) within the infratemporal fossa, the facial and submental arteries within the submandibular triangle, and the nerve to the mylohyoid muscle and related artery were dissected in twelve sides from embalmed cadaveric heads. The main blood supply to the extraoral (inferior) surface of the mylohyoid muscle was recorded. Results: The mylohyoid branch of the inferior alveolar artery was an anastomosis of the descending branch of either the inferior alveolar or maxillary artery and the ascending branch of either the submental or facial artery. The anastomosis was classified into four types according to the origins of the arteries. The main blood supply to the extraoral surface of the mylohyoid muscle was the submental artery. Conclusions: The results of this study indicate that the mylohyoid branch of the IAA in human adults is an anastomosis of branches of the maxillary and facial arteries.

Increasing the Reach of the Submental Artery Island Flap Using the Y-V Pedicle Lengthening Technique: Video and Technical Considerations.

This article and instructional video detail a step-by-step approach to performing the Y-V venous pedicle lengthening technique, which can be used to increase the reach of the submental artery island flap by up to 5 cm, permitting reconstruction of soft-tissue defects of the middle and upper thirds of the face. This technique can also be used to maximize advancement of many common flaps around the body, including the medial plantar and lateral arm flaps.

Localizing the nerve to the mylohyoid using the mylohyoid triangle.

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

Reconstruction of Large Acquired Palatal Defects Using Facial-Submental Artery Island Flap.

To evaluate the feasibility and clinical effect of facial-submental artery island flap (FSAIF) in the repair of palatal defects, and to provide reference for the clinical application of submental artery island flap. Nine patients with palatal defects, the range of nasal palatal perforation defects were 3 cm × 4cm to 3 cm × 6 cm (median 3 cm × 5.4 cm), were repaired by FSAIF, and the sizes of FSAIF were 4 cm × 9cm to 4 cm × 12 cm (median 4 cm × 10.4 cm,). Postoperative clinical efficacy was evaluated, including infection and necrosis of mucosal flap and postoperative palatal fistula perforation. Patients were followed up to evaluate their chewing, swallowing, speech function, and satisfaction of appearance. All patients were successfully repaired with FSAIF. Followed up 13∼35 months, there was no palatal fistula perforation in all patients. The speech, agitation, and swallowing function were not affected and the patients were satisfied with the appearance. FSAIF is a safe and reliable method for palatal defect repair.

A rare anatomical variation of the submental artery.

The submental artery usually runs anteriorly on the inferior surface of the mylohyoid muscle, giving branches to that muscle and to the anterior belly of the digastric muscle, finally supplying the submental skin. Branches of it often perforate the mylohyoid muscle and enter the sublingual space. During a routine anatomy dissection, we encountered a case in which the main trunk of the submental artery perforated the mylohyoid muscle, where the sublingual artery usually runs. No branches coursed anteriorly to supply the submental skin. To our knowledge, this submental artery variation has not been reported in the English literature. Any surgical procedure in the submandibular area, such as the axial pattern submental local flap, requires knowledge of such arterial variations.

Comprehensive Review of the Submental Flap in Head and Neck and Facial Reconstruction: What Plastic Surgeons Need to Know.

Since its first introduction by Martin and colleagues (1993) and with further revisions by Sterne et al (1996), the submental artery flap (SMAF) has proven to be an effective, reliable, safe, and valuable option in head, neck, and facial reconstructive surgeries. The SMAF utilizes a long pedicle based on the submental artery, a branch of the facial artery, which provides good reach to the lower two-thirds of the face with excellent cosmetic outcomes. It also maintains a good skin color match for facial and cervical defects with a mostly hidden donor site scar (in the majority of cases the donor site can be primarily closed after raising the flap). Although the use of the SMAF is associated with high patient and surgeon satisfaction along with low rates of complications, disadvantages including flap thickness and the hair-bearing nature of the submental skin, which may be problematic for coverage of orofacial defects, especially in male patients. Although it has been almost 30 years since its introduction, and the SMAF has been successfully used in over 500 reported cases of pediatric and adult patients, a comprehensive review of the different aspects of the SMAF is lacking in the medical literature.

The potential for facial artery injury during mandibular third molar extraction. An anatomical study using contrast-enhanced computed tomography.

The purpose of this study was to evaluate the risk of injury to the facial (FA) and related arteries during mandibular third molar (MTM) extraction using contrast-enhanced computed tomography (CE-CT). CE-CT images of the MTM region were retrospectively reviewed. The area of the MTM was equally divided into three zones in the coronal images from mesial to distal, that is, zone 1, zone 2, and zone 3. The FA, submental artery (SMA), and sublingual artery (SLA) were identified. The distance from the mandible to FA, SMA, and SLA and the diameter of the FA, SMA, and SLA was measured in three zones, respectively. The thickness of the facial soft tissues and width of the mandible were measured at their maximum. The mean distance from the FA to the buccal cortical bone in zone 1, zone 2 and zone 3 was 2.24 mm, 2.39 mm and 1.67 mm, respectively. The SMA and SLA were found to be distal to the mandible. The mean diameter of the FA was 1.26 mm in males and 1.04 mm in females, respectively (p < 0.0001). The distance between the FA and buccal cortical bone of the mandible, and the patients' weight showed moderate correlation in zones 1 and 2. Based on our findings, the FA can be damaged if the surgical invasion reaches the facial soft tissues during MTM surgery. The patients' weight might be a good predictor for FA injury when CE-CT is not available.

Resurgence of regional flaps for head and neck reconstruction.

The strain on healthcare resources in light of the COVID-19 pandemic has forced many head and neck surgeons to explore reconstructive options that may decrease length of stay. Here, we review three common and versatile regional flaps used in head and neck reconstruction that are comparable alternatives to free tissue transfer. Initial anatomic descriptions of the facial artery musculocutaneous (FAMM) flap, the supraclavicular artery island flap and the submental artery island flap were published decades ago. Since then, many have proposed modifications to these descriptions to improve technical ease and patient outcomes. Benefits of regional flaps include ease of harvest, comparable outcomes to free tissue microvascular flaps, shorter operative time and hospital length of stay. Drawbacks to regional flaps include limitations to size and reach, partial necrosis, wound dehiscence and surgeon experience. The integrity of the vascular pedicle is also contingent upon vessel preservation during the cancer ablation. Although a resurgence of regional flaps began well before the COVID-19 pandemic, many institutions began looking for alternatives to free flap reconstruction to conserve healthcare resources and minimize patient hospitalization time in the past year. There has been a revival of regional flaps such as the FAMM, supraclavicular and submental flaps that are valuable reconstructive options for many defects of the head and neck.

Variations in the venous supply of the floor of the oral cavity: Assessment of relative hemorrhage risk during surgery.

There is little anatomical evidence about the venous plexus in the floor of the oral cavity, although venous injury can elicit late postoperative bleeding after oral surgery and it is difficult to identify the exact location of such an injury. The aim of this study was to assess the relative risk for venous injury during surgery. We investigated the course patterns of the venous plexus in the floor of the oral cavity and analyzed their relationships to those of the arteries using 23 human cadavers (41 halves) in the anatomy course at Niigata University during 2016-2018. The venous plexus in the floor of the oral cavity comprised the perforating submental vein, the vena comitans of the hypoglossal nerve, the vena comitans of the submandibular duct, the vena comitans of the lingual nerve, the sublingual vein, and the deep lingual vein. Individual variations of this plexus include duplications or absences of some veins. There is a high incidence of a submental branch running above the mylohyoid or perforating submental artery in the sublingual fossa among individuals with the perforating submental vein piercing the mylohyoid muscle, whereas the sublingual artery has a high incidence there when there is no perforating submental vein. The course patterns of arteries in the floor of the oral cavity can be predicted by estimating the course patterns of the submental veins. The course patterns of the submental veins or veins associated with the nerves and submandibular duct need to be carefully considered during surgery.

The Journey of the Lingual Artery from the Neck to the Oral Cavity: A Cadaveric Study.

Descriptive cross-sectional. The origin of the lingual artery (LA) has been well studied due to its implication in neck dissection, but the course thereafter to the oral cavity is less described. This cadaveric study traced the journey of the LA from the external carotid artery to its terminal branches in the tongue. Following bilateral neck dissections in 35 black Kenyan cadavers, the incidence of Beclard's, Lesser's and Pirogoff's triangles, the types of LA origin with its length, relationship to the hyoglossus muscle and anastomosis with other vessels were documented. Beclard's triangle was found in 64 dissections (91.42%), Lesser's in 46 dissections (65.71%) and Pirogoff's in 39 dissections (55.71%). The LA presented either as a solitary branch (67.15%) or as a branch of either the linguofacial (LFT-24.29%), thyrolingual (TLT-2.72%) or thyrolinguofacial (TLFT-2.86%) trunk. The solitary LA was the longest at 6.93 mm, followed by the TLT branch (6.58 mm), LFT branch (6.12 mm) and TLFT branch (5.65 mm). The majority of solitary LA and LA branches of LFT and TLFT passed through the hyoglossus, while all LA branches of the TLT coursed medial to the muscle. All variants of LA have been found to anastomose with the submental artery (SMA) at frequencies that ranged from 11.10% to 100%. The LA was found in all cadavers and all Beclards' triangles. There is a significant incidence of LFT and TLFT variants in the Kenyan population. The LA passed either through or medial to the hyoglossus with no lateral relationship being observed.

Thin submental artery perforator flap for upper lip reconstruction: A case report

Reconstruction of upper lip defects can be challenging even for experienced surgeons. In order to restore both function and morphology, the use of quality soft tissue is essential. To this effect, the most common solution is the use of local flaps, or, in extreme situations, a free flap. However, a thin cutaneous upper lip defect may require a different approach. Perforator flaps are versatile and may allow an efficient reconstruction of soft tissue defects using adjacent similar tissues, providing the benefit of "like with like" coverage. We present the case of a 41-year-old female with a 1 × 1.5 cm basal cell carcinoma of the right-side upper lip, initially treated with a full thickness skin graft. Due to poor aesthetic and functional result, a thin submental artery perforator (SMAP) flap reconstruction was performed. Flaps' dimensions were 6 cm long and 4 cm wide and it was based on a perforator arising from the submental artery. Dissection was conducted above the platysma muscle, and the SMAP flap was transferred into the defect through a subcutaneous tunnel created below the mandible and posterior to the anterior belly of digastric muscle. The pedicle length of 6.5 cm was adequate for a tension free inset of the flap. Postoperative course was uneventful and the patient was discharged after 2 days. The 4-month follow-up showed a satisfying functional and aesthetic outcome with a concealed donor site scar. This report points out the coverage potential of the thin SMAP flap, which can be successfully used for a harmonious reconstruction in both color and texture of the upper lip.

A rare case of bilateral buccal lesions reconstructed with bipaddle submental artery island flap and buccal fat pad flap along with review of literature

&lt;p class="abstract"&gt;Reconstruction of full-thickness buccal defect involving oral commissure which demanding, it requires restoring competency of commissure besides providing lining for two surfaces simultaneously. Such defects prerequisites a pedicled flap each for mucosal and cutaneous surfaces else a free flap with double-paddle skin is needed. We present a case of a 45-year-old gentleman with bilateral buccal mucosa lesions; left side proliferative squamous cell carcinoma (T4N0M0) infiltrating into the cheek and right-sided large verrucous lesion. Reconstruction of verrucous lesion defect was done with buccal fat pad flap following wide local excision, while the SCC lesion resulting defect was reconstructed with de-epithelized bipaddle submental artery island flap (SAIF). Postoperatively patient had an uneventful recovery. The bipaddled SAIF has emerged as innovative modification of the conventional submental flap for reconstruction of composite oro-facial wounds provides lining for both surfaces, requires a shorter operative time than a free flap and avoids donor site deformity associated with double paddled Pectoralis cutaneous flap. The complexity of bilateral buccal defects and utilization of bipaddled design for reconstruction warrants submission of this case with just two cases reported in the literature. &lt;/p&gt;

Application of submental artery perforator flap in reconstruction surgery in pharyngeal carcinoma

Objective: To evaluate clinical applications and efficacy of submental artery perforator flap in reconstruction surgery after removal of pharyngeal carcinoma. Methods: A total of 27 patients in the Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University were included, 23 males and 4 females with age from 40 to 70 years old, and 17 patients were hypopharyngeal carcinoma (HPC) and 10 patients were oropharyngeal carcinoma (OPC). All patients underwent tumor resection followed by simultaneously reconstruction surgery using submental artery perforator flap between January 2015 and December 2019. Of 5 patients with palatine tonsil cancer, 4 underwent the combined approach of neck and oral resection and 1 with madibulotomy. All 5 patients with tongue base cancer received transhyoid partial glossotomy with or without partial laryngectomy. Sixteen patients with pyriform sinus carcinoma received partial laryngo-pharyngectomy with preservation of laryngeal functions. One patient with posterior hypopharyngeal wall carcinoma had partial pharyngectomy. Prognosis and laryngeal functions were analyzed after reconstruction surgery with submental artery perforator flap in patients with pharyngeal carcinoma. Results: The 27 patients were followed up for 6-66 months, with a median of 13 months, of them 24 patients were alive without recurrence or metastasis, 1 patient died of recurrence, 1 patient died of esophageal carcinoma and 1 patient was alive with the recurrence of tongue base carcinoma. Postoperative complications included flap failure for 1 case, pharyngeal fistula for 1 case, subcutaneous hydrops for 2 cases and lymphatic fistula for 1 case. Total 2 and 3 year survival rates were 92.9% and 88.9%, respectively. Total decanulation rate was 92.6%; decanulation rate and intubation time were 16/17 and 3.5 months in HPC patients; and decanulation rate and intubation time were 9/10 and 2 months in OPC patients. Total oral feeding rate was 92.6% and nasogastric feeding time was 3.5 weeks in HPC patients and 3 weeks in OPC patients. Conclusion: The submental artery perforator flap is an excellent choice for reconstruction surgery after removal of oropharyngeal and hypopharyngeal carcinoma, with good outcomes of laryngeal functions.

Surgical anatomy of the submental artery perforator flap and assessment for application in postoperative reconstruction following oral cancer surgery: a prospective clinical study

The submental artery perforator flap (SMAPF) has an elongated pedicle, allowing good cosmetic outcomes to be achieved following oral reconstruction surgery. The improper dissection of perforators often leads to a vascular flap crisis. To avoid this, some surgeons choose to carry amounts of connective tissue around the pedicle. However the inclusion of connective tissue on the pedicle raises concerns about oncological safety. A surgical anatomical study of the submental vessel patterns and subdivisions of the cervical level I lymph nodes was conducted on 33 patients with primary oral cancer who underwent reconstruction with a SMAPF after tumour resection. The variations in vessels and cervical level I lymph nodes observed during SMAPF harvesting were recorded and analyzed. Two patterns of submental artery perforators and three patterns of submental veins were identified. The different characteristics of the lymph node distribution were elucidated for five subdivisions. All SMAPFs survived (n=33, 100%); however, two SMAPFs exhibited partial losses. The 3-year survival rate of patients was 84.5±6.4%, and there were no suspected flap-related recurrences. With detailed anatomical information on the vascular system and lymph node subdivision, SMAPFs are a reliable choice for postoperative reconstruction following oral cancer surgery, meeting the standards for oncological safety.