Submental Artery Flap Research Articles

Reconstruction of Intra-Oral Defects with Submental Artery Flap: A Comparison of pN+ and pN0 Oral Squamous Cell Carcinoma Patients

Aim: To compare the reconstruction of intra-oral defects with submental artery flap among pN+ and pN0 oral squamous cell carcinoma patients. Methodology: A comparative analytical prospective study was conducted in the Department of Oral and Maxillofacial Surgery, University of Lahore, from January 1, 2022, to November 1, 2022. Fifty-five confirmed cases of oral squamous cell carcinoma were included. The inclusion criteria were based on oral cavity carcinoma patients presenting for tumour resection and reconstruction of the resultant defects with the submental artery flap. A pinch test was applied to estimate the flap width, wherein the flap length and skin paddle were designed in accordance with the defect size. Results: The mean age of the patients was 58.81±1.2 years, with a significant variance in the pN+ and pN0 patients below 60 years of age. There were 27 males and 18 females with primary treatment of T1–4 OSCC. The primary site of the tumour was observed to be highest in the tongue region in pN+ (52.17%) and pN0 (43.75%) cases, followed by the buccal mucosa, which presented with 30.43% of pN+ cases and 37.5% in pN0 patients. The majority of the patients had moderately differentiated tumours in pN+ (82.6%) and pN0 (56.25%) patients. Within the 55 cases for reconstruction with SAFs, there were 58.1% who had pN0, while 41.8% had pN+ presentation. In the pN0 patients, 96.8% did not have any recurrence, while only 1 patient had local or regional recurrence in the neck region. Conclusion: Vigilant neck dissection, in addition to suitable adjuvant treatments, does not increase the loco-regional recurrence risk in patients suffering from pN+ oral squamous cell carcinoma. Keywords: Lymph nodes, submental artery flap (SAF), reconstruction, oral squamous cell carcinoma (OSCC)

The Utility of Sub-Mental Artery Island Flap for Reconstruction of Oral Cavity Defect After Oncological Resection: An Institutional Experience.

The submental artery island flap has been used for reconstruction of mild to moderate size oral defects after resection despite its controversy of oncological safety.Our study aims to assess the efficiency and oncological safety of submental artery flap in oral reconstruction.Twenty-three oral cancer patients who underwent resection and reconstruction using the submental artery island flap at State Cancer Institute, Guwahati, India, between February 2021 and February 2022 were retrospectively studied for the flap viability, complications, and function and locoregional recurrence.There were 9 men and 14 women with mean age of 58.56 years. The follow up period ranged from 7months to 18 months with a median of 12 months. There was no loss of flap, i.e., 100% success rate of flap survival. One patient presented with locoregional recurrence at 11 months of follow up. Three male patients had hair growth on the flap inside oral cavity. There was one case of marginal nerve palsy and one case of donor site wound dehiscence which healed conservatively. The functions and donor site cosmesis were good in all the patients.Submental artery island flap is a good option for reconstruction in select cases of oral cancer.

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.

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.

Are contralateral submental artery perforator flaps feasible for the reconstruction of postoperative defects of oral cancer?

We evaluated the clinical applications of the reconstruction of postoperative defects of the oral cavity using contralateral submental artery flaps. A retrospective study of 18 patients with postoperative intraoral cancer defects reconstructed with contralateral submental artery perforator flaps between October 2018 and October 2019 in our department was conducted. The defect area, flap size, and complications were evaluated. All patients were diagnosed based on pathological examinations: 2 with adenoid cystic carcinoma and 16 with squamous cell carcinoma. The submental artery perforator flap used for simultaneous repair was 8 to 15 cm in length and 4 to 6.5 cm in width. The survival rate of flap reconstruction was 100% with no donor site complications. Contralateral submental artery flap reconstruction is a suitable alternative for moderate to large intraoral defects, postoperative mouth floor defects, and oral cavity composite defects of oral malignant tumors without contralateral lymph node metastases.

Clinical Implications of the Submental and Sublingual Arteries in Relation to the Mylohyoid Boutonnière.

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. Cross-sectional human cadaveric study. The West Virginia University School of Medicine human gross anatomic laboratories. 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. 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. 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.

Morphometrics of the Anterior Belly and Intermediate Tendon of the Digastric Muscle: Sexual Dimorphism and Implications for Surgery.

The anterior belly of the digastric muscle (ABDM) is important in a variety of surgeries including submental lipectomy, rhytidectomy, alteration of the cervicomental angle via muscle resection, the "digastric corset" procedure for submental rejuvenation, the submental artery flap, and reanimation of the mouth after facial nerve palsy. Despite its clinical significance, little information exists regarding the morphometrics of the ABDM or its associated intermediate tendon. This study analyzed a total of 35 intact ABDMs and 43 intact intermediate tendons from 23 cadavers. Measurements were taken of the following parameters: muscle belly area, muscle belly length, intermediate tendon length, and intermediate tendon width at mid-tendon. Normative descriptive statistics are included within the report. Males were found to have significantly longer left-sided muscle bellies than right-sided bellies from males (U = 23.0; P = 0.044), left-sided bellies from females (U = 19.0; P = 0.020), and right-sided bellies from females (U = 12.0; P = 0.035). The morphometry, including sexual dimorphism, presented in this report can aid in the surgical planning and execution of numerous operations performed in head and neck, especially digastric muscle transfer surgery.

Submental Artery Flap with Sentinel Lymph Node Biopsy in the Reconstruction of Oral Cancer

Microvascular free flaps form the gold standard for reconstruction of defects after intraoral cancer surgery, but not all patients are suitable candidates for microsurgery. The submental artery flap is an alternative to free tissue transfer especially in patients who do not tolerate extensive operations due to major comorbidities. However, in metastatic neck disease, this option has not been recommended due to theoretical intraoral transfer of cancer cells. The aim of this study was to consider the indications and benefits of the submental artery perforator flap in patients with intraoral cancer. Ten patients with early (N = 2) or locally advanced (N = 8) intraoral cancer, who were not candidates for free tissue transfer because of major comorbidities, were managed with tumor resection and coverage of the defect with the submental artery flap. The minimum follow-up time for all patients was 6 years. The average defect size was 5 × 9 cm. Two patients developed major complications and one of them had a flap loss. Sentinel lymph node biopsy was used in three cases to rule out positive neck disease close to the flap pedicle. During the follow-up time 6 out of 10 patients had a local recurrence and there were no appearances of metastatic neck disease. The submental artery flap is an alternative option to intraoral microvascular reconstruction in patients with major comorbidities. Sentinel lymph node biopsy can be used as an adjunct to enhance oncological safety.

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.

The Importance of Variant Anterior Digastric Musculature in Head and Neck Surgery

Anterior belly of the digastric muscle (ABDM) variations have been reported to occur in as few as 2.7% to as many as 69.6% of individuals. ABDM variants may cause confusion during surgeries including submental lipectomy, rhytidectomy, surgical alteration of the cervicomental angle via partial resection of the ABDM, muscle transfer for reanimation of the mouth, and submental artery flap procedures. Therefore, knowledge of ABMD variants may aid in surgical planning and prevent confusion and disorientation during operations in the submental region. This report presents examples of ABMD variants and promotes novel ideas for the utilization of variant ABDM transfer to reanimate the mouth after marginal mandibular branch of facial nerve (MMBFN) palsy. Also presented is a unique perspective with regard to exclusion of normal and variant ABDM from the submental artery flap as a surgical contingency plan in the event of MMBFN palsy occurring as a result of flap surgery. Research was supported by funding from the WV Research Challenge Fund [HEPC.dsr.14.13].

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.

The Extended Sub-Mental Artery Flap for Complex Orofacial Reconstruction

The Extended Sub-Mental Artery Flap for Complex Orofacial Reconstruction

Bipaddled submental artery flap

Oral cancer is a major public health problem in India. Most patients present with locally advanced disease requiring complex resection and reconstruction strategies. Costs, operating time and availability of expertise are major issues that influence efficient health delivery, especially in developing countries such as India. Technically simple and widely reproducible techniques may be used successfully where applicable, to overcome these issues. The submental artery flap is a well described and acceptable alternative to the radial artery forearm free flap in oral cavity reconstruction. Researchers have demonstrated its technical ease of performance and reproducibility amongst trainees. Here the authors describe the bipaddled submental artery flap, a modification of the standard flap, which can be used to provide lining as well as skin cover for a full thickness cheek defect. Two skin paddles are fashioned taking advantage of the vascular anatomy of the submental vessels.

Reconstruction of the Upper Aerodigestive Tract with the Submental Artery Flap

: The submental artery flap has rekindled interest in using cervical flaps for reconstruction of head and neck defects. In this article, the authors present their experience with this flap for defects of the upper aerodigestive tract. : This is a retrospective study of 21 patients who underwent upper aerodigestive tract reconstruction with submental artery flaps from 1997 to 2005. The flap was used primarily to reconstruct defects after tumor extirpation, severe infections, and burns. In one case, the flap was used to close an esophagocutaneous fistula. Nine patients had irradiation. Three patients had flap prelamination before transfer. : The flaps in all 12 patients who had not undergone irradiation survived. With the exception of a small fistula in one patient and transient marginal mandibular nerve palsy in another, none of these patients experienced any major complications. In contrast, six of the nine patients who had been irradiated experienced major complications. These included total flap loss in one, partial flap losses in two, and scar contractures in another three. The difference in major complication rates between these two groups was statistically significant (0 percent versus 67 percent, p < 0.01). : In nonirradiated tissues, the submental artery flap is an excellent choice for reconstruction of moderate-sized defects of the upper aerodigestive tract because of its reliability and versatility and the ease with which it can be applied.

The submental island flap for reconstruction of intraoral defects in oral cancer patients

The submental artery island flap (SIF) is gaining acceptance as a simple and reliable option in selected oral oncologic reconstructions. The present study aims to assess the usefulness of submental artery flap in oral reconstruction with respect to flap reliability, cosmesis, function, donor site morbidity and oncological safety. Thirty (30) patients who underwent ablative surgery and reconstruction using the submental artery island flap for oral cancer at Regional Cancer Centre, Trivandrum, India, between October 2004 and December 2006 were prospectively studied for the flap viability, cosmesis, function (speech and swallowing) and locoregional recurrence. The site and stage of the tumour, type of resection, management of the neck and the technique of flap transfer were recorded and the patients were followed up to assess the status of the flap and its donor site and the oncologic outcomes. There were 19 men and 11 women, ages of whom ranged from 30 years to 78 years with a mean+/-SD of 53+/-11 years. With the exception of one patient who had undergone neck dissection as part of a previous surgery, all patients underwent neck dissection or at least a level I clearance along with the wide excision of the primary lesion. The follow up period ranged from 4 to 25 months with a median of 13.5 months. Six patients either recurred locoregionally or had metachronous second primary constituting an over all recurrence rate of 20%. The size of the skin paddle ranged from 3 x 3 cm to 7 x 6 cm, with a mean size of 4.9 x 4 cm. One total and one partial flap loss were observed. One patient had intractable hair growth on the flap even 3 months after surgery. Donor site healing was excellent in all cases and the donor site scar was well hidden. The long term cosmesis and functions were good in all the patients. The submental artery island flap is a simple and reliable option for oral cancer reconstruction in carefully selected cases, with acceptable cosmetic and functional results and reasonable oncological safety.

09:10 AM: The Submental Artery Flap in Head and Neck Reconstruction

09:10 AM: The Submental Artery Flap in Head and Neck Reconstruction

Improving outcomes of locoregional flaps: an emphasis on anatomy and basic science

There has been renewed interest by surgeons in locoregional flaps for facial renconstructive problems previously thought to be optimally managed by microvascular tissue transfer. Complication rates of locoregional flaps are similar to those of free flaps. Successful reconstruction using local flaps is largely based on an understanding of regional vascular anatomy. Sternocleidomastoid and trapezius muscle flap studies have elucidated patterns of arterial and venous anatomy to allow for improved flap design. Perioral vascular studies in cadavers demonstrate consistent and reliable patterns of blood supply. The terminal vascular anatomy of the submental island flap has been recently studied. The reverse-flow submental artery flap has been used to reconstruct periorbital soft tissue defects. Preliminary studies show that a full-thickness forehead flap can be utilized to simultaneously reconstruct both the external and internal surfaces of the nose. Basic fibroblast growth factor has been found to have a protective effect on random skin flap viability. Locoregional flaps remain a useful tool for head and neck reconstruction, and often provide unique characteristics not available with free flap reconstruction. A sound understanding of vascular anatomy and recent basic science discoveries will significantly improve success of locoregional reconstruction.

Reverse-flow submental artery flap for periorbital soft tissue and socket reconstruction

The submental artery island flap is a recently described local flap that may be used for reconstruction of the lower and middle thirds of the face and oral cavity. The reverse-flow manner of the flap has been used in limited cases because of possible drawbacks such as venous congestion. We present our experience with the use of reverse-flow submental artery flap and describe the surgical technique. This versatile flap was successfully used for large periorbital soft-tissue defects and socket reconstruction in six patients in the past 2 years. The diagnosis of three patients was basal cell carcinoma of the eyelids, which required orbital exenteration, and the other patient had traumatic periorbital defects. The flap size varied from a minimum of 4 x 6 cm to a maximum of 6 x 8 cm. No major complications were noted other than one case of temporary palsy of the marginal mandibular branch of the facial nerve and one other of venous congestion, which subsided spontaneously. In all patients, the results were satisfactory, with acceptable cosmesis. The reverse-flow submental artery island flap is safe, rapid, and simple to raise and leaves a well-hidden scar. We believe that this flap surpasses the other flaps in reconstruction of large periorbital soft-tissue defects and socket.

Anatomic Study of the Vasculature of the Submental Artery Flap

The submental artery island flap is a versatile option in head and neck reconstruction. This flap may be used for the coverage of perioral, intraoral, and other facial defects, leaving a relatively acceptable donor-site scar. In this study, the submental region of 13 formalin-fixed cadavers was dissected bilaterally. Comprehensive anatomical information regarding the pedicle of the flap and its relationship with the important adjacent structures is provided. The mean values of the measurements of the facial and submental arteries were as follows: the facial artery was 2.7 mm in diameter at the origin, and it crossed the mandibular border 26.6 mm from the mandibular angle. The origin of the submental artery was 27.5 mm from the origin of the facial artery, 5.0 mm from the mandibular border, and 23.8 mm from the mandibular angle. The diameter of the submental artery was 1.7 mm at the origin. The artery was found mostly to course superficial to the submandibular gland. In one case, the artery passed through the gland. The total length of the submental artery was 58.9 mm. The artery anastomosed with the contralateral artery in 92 percent of the cadavers. The submental artery was deep to the anterior belly of the digastric muscle in 81 percent of the cases. This study presents detailed anatomical data about the location, dimension, and relationship of the facial artery, the submental artery, and the submental vein that may be useful during dissection of the submental artery island flap.

The submental artery flap

The submental artery flap is a reliable source of skin of excellent color, contour, and texture match for facial resurfacing. This versatile flap was successfully used for various defects in 19 patients and all flaps have survived with a few minor complications: marginal necrosis, venous congestion, dog ear formation, and infection. Low morbidity and complication rates and constant pedicle diameter provide a wide range of applicability locally throughout the lower face and midface and also as a free flap all over the body.