Submental Artery Research Articles

A Surgical Approach to the Harvest of the Vascularized Submandibular and Submental Lymph Node Flap: The "Through-the-Gland" Dissection Technique.

Extremity lymphedema is a pathological condition resulting from absence of lymph nodes and disease of lymphatic vessels, often due to oncologic clearance of lymph nodes. In recent years, vascularized lymph node transfer has become a rapidly emerging method of lymphatic reconstruction shown to lead to lymphatic regeneration. In particular, lymphatic flaps based on the submental artery have shown good results with its favorable donor site and available nodes. The lymph nodes here are in close relation to the submandibular gland and require careful dissection around and through the gland for safe harvest. We studied this region of the neck and describe the blood supply to the lymph nodes, their variable positions in relation to the gland, and our technique of dissecting through the submandibular gland while keeping the lymph nodes' hilar blood supply intact. We dissected 2 cadaver heads (4 sides of the neck) to study the submandibular and submental lymph nodes, where to locate them in relation to the submandibular gland and how best to dissect through the submandibular gland for access while keeping the hilar supply intact. We applied this knowledge in 6 clinical cases and provide a brief description of our "through-the-gland" dissection technique. The submandibular lymph nodes may lie (1) superficial and posterior to the gland, (2) between the superficial and deep parts of the submandibular gland, or (3) anteriorly and submental. They are classified as superficial, deep, and submental, respectively. The through-the-gland dissection technique gave the surgeon improved access and exposure to the lymph nodes. It also facilitated safer dissection because their hilar blood supply is well visualized. The through-the-gland technique of harvesting vascularized submandibular lymph node flaps is a safe technique that allows the surgeon to clearly identify and preserve blood supply of lymph nodes.

Research progress of pedicled flaps for defect repair and reconstruction after head and neck tumor resection

To summarize the current status of pedicled flaps for defect repair and reconstruction after head and neck tumor resection, and to present its application prospects. Related literature was reviewed, and the role evolution of pedicled flaps in the reconstruction of head and neck defects were discussed. The advance, anatomical basis, indications, advantages, disadvantages, and modification of several frequently used pedicled flaps were summarized. The evolution of pedicled flaps application showed a resurgence trend in recent years. Some new pedicled flaps, e.g., submental artery island flap, supraclavicular artery island flap, submandibular gland flap, and facial artery musculomucosal flap, can acquire equivalent or even superior outcome to free flaps in certain cases. Technological modification of some traditional pedicled flaps, e.g., nasolabial flap, pectoralis major myocutaneous flap, latissimus dorsi musculocutaneous flap, temporalis myofascial flap, and temporoparietal fascial flap, can further broaden their indications. These traditional flaps still occupy an irreplaceable role, especially in patients with poor condition and institution with immature microsurgical techniques. The pedicled flaps still plays an important role in head and neck reconstruction after tumor resection. In certain cases, they demonstrate some advantages over free flaps, e.g., more convenient harvest, more rapid recovery, less expenditure, and better functional and aesthetic effect.

Submental artery island flap versus free flap reconstruction of lateral facial soft tissue and parotidectomy defects: Comparison of outcomes and patient factors

ObjectivesThe submental artery island flap (SIF) has recently been described in temporal bone defects. At our institution we have broadened the application of the SIF and modified the harvest technique for complex lateral facial and skull base defects. Our primary aim is to evaluate the outcomes of patients undergoing complex lateral facial soft tissue, parotidectomy, and temporal bone defects who are reconstructed with the SIF to a similar cohort undergoing free tissue transfer reconstruction. Materials and methodsNineteen patients undergoing SIF and 54 patients undergoing free tissue flaps for oncologic lateral facial, parotidectomy and temporal bone defects were retrospectively identified. Comparative statistics were used to analyze variables between the two cohorts, specifically operative time, flap size, length of stay, regional recurrence, disease free survival, and overall survival. ResultsNo significant difference in demographic and disease related variables was observed. Operative time was significantly lower in SIF group with mean of 412.9 (SD 93.4) minutes compared to 544.1 (SD 139.9) minutes in free flap group. Flap size was significantly larger in free tissue transfer, 32.4 (SD 17.5) cm2 (SIF) compared to mean area of 105.2 (SD 53.2) cm2 (Free tissue transfer). A significant difference in length of stay was also noted between groups. There was no regional recurrence of disease in level I–III in SIF group. There was no significant difference in DFS or OS between the two groups. ConclusionSIF is an oncologically sound option for reconstruction of lateral facial soft tissue, parotidectomy, and temporal bone defects.

Clinical application of submental artery perforator flap in oral and maxillofacial defect restoration after tumor resection

Objective: To summarize the clinical anatomical features and surgical technique of the submental artery perforator flap (SMAPF), and to evaluate the outcome and value of the flap for oral cavity reconstruction after cancer ablation. Methods: A total of 56 patients with oral cancer were included in this study. The modified SMAPF excluded the anterior belly of the digastric muscle and submental fatty tissue. The primary sites of malignancy were buccal mucosa (n=24), tongue (n=21), mandibular gingiva (n=6), mouth floor (n=3), soft palate (n=2). Results: The flap size varied from 3 cm×5 cm to 5 cm×12 cm. Four flaps presented mild venous congestion, which was salvaged with conservative measures such as acupuncture and blood letting. Overall flap survival rate was 100%. The SMAPF with septocutaneous perforator was used in 49 cases and with musculocutaneous perforator in seven cases. External jugular vein and internal jugular vein provides venous drainage were applied in half cases respectively. All the patients showed a good recovery of tongue mobility and mouth opening with a follow-up of 3-41 months. Local recurrence was detected in one patient 4 months after operation. Conclusions: The SMAPF is a reliable flap for oral cavity reconstruction with outstanding functional and aesthetic outcomes.

Reconstruction of intraoral defects after resection of cancer with two types of submental artery perforator flaps

The submental island flap is a common choice for reconstruction of intraoral defects. To obtain a thinner, more pliable flap and get a better oncological result, the submental artery perforator flap has been proposed, and to assess its feasibility for closure of defects after resection of cancers of the oral cavity we studied 20 patients, each of whom was treated in this way. All the flaps were classified into those with septocutaneous perforators (n=16) and those with musculocutaneous perforators (n=4), and the main veins that drained the flaps were two submental veins (n=17). There were two patterns of venous drainage: in pattern 1 (n=9) the external jugular vein provided the primary venous drainage, and in pattern 2, the submental veins drained mainly into the facial vein, the common facial vein, and the internal jugular (n=10). In one patient the submental veins bypassed the facial vein to drain into the internal jugular. Eighteen of the 20 patients had no postoperative complications. The remaining two developed mild venous congestion of the flaps, which was resolved with conservative management and no skin loss. No local or regional recurrence was detected after a mean (range) follow-up of 21 (4-35) months. This is a simple, reliable flap that can be used for the reconstruction of intraoral defects after resections for cancer, but its oncological outcome still requires proof in long-term, large-scale, clinical trials.

Versatility of the submental island flap in head and reconstruction

<p class="abstract"><strong>Background:</strong> Head neck cancer is major cause of morbidity and mortality worldwide. India has one of the highest incidences of oral cancer and accounts for about 30% of all new cases annually. Ablative surgery is main stay of treatment which is followed by reconstructive surgery. Microvascular surgery revolutionized onco-reconstruction which requires great expertise even in tertiary cancer centre and it is not possible many times due to long waiting list for it or patient condition. Here there is role locoregional pedicled flap which mitigate this problem to great extent to achieve acceptable functional and aesthetic outcome. One such flap worth to keep in surgeon armamentarium is submental island flap. Submental artery island flap (SIF) is an axial fasciocutaneous flap that includes skin, subcutaneous tissue, platysma, and fat and is pedicled on the submental artery and veins.</p><p class="abstract"><strong>Methods:</strong> This study conducted in our institute a tertiary level cancer hospital. This is retrospective study. Data extracted from department database between periods February 2015 to May 2017. It includes 12 patients diagnosed with different sub site oral cancer, operated in department of head neck oncology for oral cancer and reconstruction fallowing ablative surgery done by submental island flap by ablative surgeon. </p><p class="abstract"><strong>Results:</strong> Submental island flaps are comparable in their outcome with radial forearm free flap. They carry a good color match with facial tissue. It is thin and has a reliable vascular morphology.</p><strong>Conclusions:</strong> When combined with the reported experience of other surgeons, our preliminary experience shows that the SIF is an excellent alternative in the reconstruction of head and neck defects because of its reliability, versatility, and relative ease of application. Neck dissection can plan as an adjunctive procedure to the SIF with certain limitation.

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

The submental artery island pedicled flap (SMIF) is an underused alternative for reconstruction of head and neck defects after tumor ablation. The purpose of this study was to perform a comparative evaluation of reconstructive outcomes based on surgical site and ablative defect volume in patients who underwent reconstruction with the SMIF versus the forearm free flap (FFF). A retrospective cohort study of all patients with oral cavity and oropharyngeal defects reconstructed with the SMIF and a cohort of patients with similar volume defects reconstructed with the FFF were compared for oncologic safety and viability of equivalent reconstructive outcomes. All statistical comparisons were assessed by analysis of variance and Fisher exact test. Average age was 61.8years in the SMIF group versus 57.9years in the FFF group. The most common defect was located in the tongue, with squamous cell carcinoma being the most common pathology identified. Flap volumes were similar (SMIF, 38.79cm3; FFF, 39.77cm3). Significant comparative outcomes identified with SMIF versus FFF reconstruction included shorter anesthesia times (815 vs 1,209minutes; P<.001), shorter operative times (653 vs 1,031minutes; P<.001), and less blood loss (223 vs 398mL; P=.04). Postoperative Eastern Co-operative Oncology Group performance score increased more for the FFF than for the SMIF group (+0.33 vs+1.25; P=.0019). Recipient site complication rates were lower for the FFF group (0.17 vs 0.42 per patient) but were not statistically relevant. There were equal rates of recurrence at the local surgical site and no differences in speech and swallowing function. Mean follow-up was 15.5months. This is the first study to compare the SMIF with the FFF for reconstruction of oral cavity defects based on ablative volume deficit. The SMIF is a viable surgical option compared with the FFF that can be considered oncologically safe in the N0 neck, allowing for an excellent esthetic reconstruction, with decreased operative time, hospital stay, and donor site morbidity.

Maxillary Reconstruction Using Submental Artery Island Flap and Sagittal Mandibular Ramus/Coronoid Process Graft Pedicled With Temporalis Muscle

The purpose of this study is to describe maxillary reconstruction using the submental artery island flap and the sagittal mandibular ramus and coronoid process graft pedicled with the temporalis muscle through the modified lateral lip and submandibular approach. From May 2013 to September 2016, 11 patients with maxillary defects secondary to maxillary cancer ablation who underwent maxillary reconstruction using a submental artery island flap and a sagittal mandibular ramus and coronoid process graft pedicled with the temporalis muscle through the modified lateral lip and submandibular approach were enrolled in this prospective study. All submental artery island flaps and sagittal mandibular ramus and coronoid process grafts were successful, with satisfactory functional and esthetic outcomes. No functional impairment at the donor site occurred in any case. The submental artery island flap combined with the sagittal mandibular ramus and coronoid process graft is a feasible and acceptable technique for maxillary reconstruction in older patients because it is safe, quick, and straightforward to harvest and it offers a very acceptable esthetic and satisfactory outcome, with the advantage of low morbidity of the donor site. When combined with the 3-dimensional virtual operative method, the technique can improve postoperative outcomes.

Frequency and anatomical features of the mandibular lingual foramina: systematic review and meta-analysis.

Lingual mandibular foramina are peculiar anatomical variations often present on the bone surface of the inferior jaw. These structures host vascular and nervous anastomosis deriving from the branches of the submental artery, lingual artery, and the mylohyoid nerve. Reports pointed out intra-operative massive bleeding accidents during implant interventions occurred in this area. The aim of this systematic review and meta-analysis was to summarize quantitatively the features of the lingual foramina on the midline of the inferior jaw. We performed a systematic review and meta-analysis complying the PRISMA statement and registering it in PROSPERO database. The frequency rate of the foramina resulted to have a point estimate of 0.965. The means of the diameters showed to have a point estimate of 0.840 with a standard error of 0.06. The results showed a significant high frequency reported in the literature of this variation, with a quite important diameter, sign of significant caliber of the related vessels. Even if this variation is underreported in modern textbooks of oral anatomy, we suggest an accurate screening via CT scan pre-operatively. In addition, a proper risk management is necessary to minimize injure hazard and properly managing the vascular plexus of the anterior floor of oral cavity.

Radiological and Microsurgical Anatomy for Variation of the Mandible: Comparative Study of Human and Macaca fascicularis

Recent studies using cone-beam computer tomography (CBCT) have added to our understanding of anatomical variation in the mandible of humans. However, the distribution of nerves cannot be revealed by CBCT. There have been investigations of the distribution of nerves relating to the mandible, but some proposed causes of these variations remain controversial. In this study, we observed a total of 10 sides from five mandibles of Macaca fascicularis of unknown age and sex using CBCT and dissection under stereomicroscopy. Nine of the 10 sides had two mental foramina in each side. Innervation by the mental nerves depended on the locations of those foramina. The long branch to the mandibular angle ran with a branch of the facial artery, which joined the mental artery in all 10 sides. Five specimens had a median perforating canal in the mandibular bone. In addition, a branch of the sublingual artery, which joined with the small branches of the submental artery, entered the mandibular bone from the median lingual foramen. This foramen was located in the lower part of the mandibular symphysis and passed via the median perforating canal to exit from the median labial foramen, also located in the lower part of the mandibular symphysis. We speculate that the median perforating canal of the mandible, rarely found in humans, is the remnant of the feeding artery of the fetal mandible, and in M. fascicularis is seen in all specimens because they have no mental protuberance. Anat Rec, 300:1464-1471, 2017. © 2017 Wiley Periodicals, Inc.

Progress of anatomic research and clinical application of facial artery perforator flap

To summarize the present status and progress of the anatomy researches and clinical application of the facial artery perforator flap (FAPF). The relative researches focused on the anatomy researches and clinical application of FAPF were extensively reviewed, analyzed, and summarized. The facial artery perforator (FAP) has constant anatomy. There are more facial artery perforators in the perioral region, and each FAP has two accompanying veins. Distinguished by inferior mandibular border, the upper and the lower flaps both are used for reconstruction of defects on the face. The most widely-used upper flap was FAPF, which is excellent choice of defects in mid-face. Additionally, angular artery perforator flap and lateral nasal artery perforator flap are becoming more and more popular. While submental artery perforator flap, whose pedicle locates under inferior mandibular border, is most used for reconstruction of lower face. FAPF for face defect repair can achieve good outcomes of function and appearance in clinical application. Based on multiple advantages of good aesthetics and function outcomes, high survival rate, flexible design, and simple operation, FAPF is an optimal choice for defect repair of perioral region and nasal ala. However, Further study is needed to determine whether retaining tissue around the pedicle will affect vein reflux of the flap.

Topographical relationship between positions of lingual foramina and attachment of mylohyoid muscle in mental region.

Lingual foramina can be observed between the lingual aspects of the mandible in humans. A sublingual artery is thought to exist in sublingual space and a submental artery in submaxillary space, which pierce the mandible through lingual foramina. During surgery for oral implant placement between apices of the mental foramen, it is important to determine the existence and positioning of lingual foramina. The purpose of this study was to investigate the positions of lingual foramina in relation to the mylohyoid muscle and vertical position of the mylohyoid line using cone-beam computed tomography (CBCT) images. We examined 20 formalin-perfused cadavers. The mylohyoid muscle was dissected and marked with a silicone tube, then CBCT images were obtained to evaluate the relationship of that muscle with lingual foramina. We observed 37 lingual foramina in the 20 cadavers. As for vertical positioning, 16 lingual foramina were found in sublingual space, while in horizontal positioning, 6 were found in the anterior region of sublingual space. The ratio of vertical distance from the inferior margin to the mylohyoid line and mental spine was lower in the anterior region as compared to the posterior region. In this study, lingual foramina were found to commonly exist in sublingual space above the mylohyoid muscle and pierce the mesial side. For evaluation of the vertical position of the mylohyoid line, it is better to use the stable mental spine rather than the alveolar process.

Analysis of the blood supply to the post-fracture edentulous mandible: study by colour Doppler sonography

This study assessed the arterial blood supply to the mandible of edentulous patients treated for mandibular fractures using colour Doppler ultrasound. The blood supply of edentulous patients surgically treated for mandibular fractures (group A) and edentulous fracture-free individuals (group B) was assessed. Only the fractured sides were evaluated in the first group (N = 17), whereas each side was evaluated in the second group (N = 20). The arterial flow of six sites was assessed. The systolic-peak maximum velocity (SPV), final diastolic velocity (FDV), resistive index (RI), pulsatility index (PI), acceleration and flow direction of each artery were obtained. Additionally, the presence of local vascular obstructive factors was evaluated. The differences between groups were analysed using the Kruskal-Wallis test, which was complemented by the Mann-Whitney test, for correlations between the degree of alveolar atrophy and the study factors (p < 0.050). There was a significant decrease in the flow of certain arteries, especially the submental (SPV, p = 0.007, PI, p = 0.022, and acceleration, p = 0.015), in the fracture group. The facial artery in both groups showed lower values related to local obstructive factors (SPV, p = 0.001, FDV, p = 0.040, and PI, p = 0.030). The submental artery flow was higher (SPV, p = 0.006, and FDV, p = 0.009) in non-atrophic individuals. There was a decreased flow mainly in the submental artery, but there were no cases of major vascular injury in edentulous patients treated for mandibular fractures.

Turned in fasciocutaneous island flap from face and neck based on subdermal microcirculation for reconstruction of the oral cavity following cancer surgery.

Background:The skin and soft tissues of the face and neck have a rich plexus of dermal-subdermal vessels, which creates the possibility of raising a fasciocutaneous flap based on this vascular supply. A turned in fasciocutaneous island flap (TIFCIF) from an adjacent area of the defect can provide a simple substitute to many complex reconstructive procedures.Materials and Methods:Fifteen patients underwent wide excision for oral cancer and upper neck dissection, maintaining bone framework, between August 2010 and June 2014. The reconstruction was done with a ’turned in fasciocutaneous island flap’ (TIFCIF) from the upper neck-lower face based on subdermal superficial adipofascial microvascular network instead of a specific known feeder vessel. The upper cervical flap, the donor site, when raised during the initial incision and the upper neck dissection, was cut off from the facial artery, the submental artery, the superior thyroid and the transverse cervical arteries. The microcirculation depended largely on the rich vascular plexus formed of the branches of the superficial temporal and the maxillary arteries. The donor site was primarily closed in Fourteen of the Fifteen patients. Eight patients received post-surgery irradiation.Results:All the flaps survived and healed and withstood radiation well. Two patients had flap dehiscence from suture line, of which one needed reattachment while other a minor one healed by itself and one patient had occasional drooling. There was no difficulty in eating or swallowing.Conclusions:A random patterned TIFCIF based on superficial subdermal adipofascial microcirculation, formed of a rich vascular plexus in the face and neck region can provide a simple alternative for intraoral reconstruction.

Contrast CT-scan for preoperative planning of VSLN (vascularized submental lymph-node) transfer.

Vascularized submental lymph-node (VSLN) transfer is gaining popularity as a reliable donor-site in microsurgical treatment of lymphedema. However, variations in number, location, and blood supply to submental lymph-nodes as well as associate skin-paddle make a predictable flap harvest a challenging task. We analyzed this region on preoperative imaging, to improve accuracy of VSLN transfers. Contrast CT-scan analysis of VSLN-flap areas was performed in 58 patients. Number and location of visibly vascularized lymph nodes as well as submental artery perforators were identified, documented, and compared. About 409 lymph-nodes were found in 50 patients. No significant difference was found in the number of nodes between the right and left side. Significantly more lymph-nodes were found in zones 1B than zones 1A. In eight patients nodes were not identified. In the remaining 50 patients position of the visibly vascularized submental lymph-node was predictable. Significantly less lymph-nodes can be found in zone 1a then zone 1b. Location of visibly vascularized lymph nodes can be identified predictably in relation to bony landmarks. Blood supply to 1a nodes and particularly location of dominant skin perforator is unpredictable due to potential crossover. Contrast CT scan can help identify location and blood supply to submental lymph-nodes in most patients. J. Surg. Oncol. 2017;115:23-26. © 2016 Wiley Periodicals, Inc.

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.

Surgical anatomy of the vascularized submental lymph node flap: Anatomic study of correlation of submental artery perforators and quantity of submental lymph node.

Harvesting the submental flap for vascularized lymph node transfer (VLNT) presents a challenging procedure because of, the topographic variation of the submental artery (SA) and the marginal mandible nerve (MMN) and the limited pedicle length for a free tissue transfer. The aim of this study was to evaluate surgical anatomical landmarks and variations of the submental lymph node flap (SLNF). The authors examined the characteristics and landmarks of 18 SLNF in nine fresh cadavers. The diameter, length, and caliber of the SA and its relation to bony anatomic landmarks were measured. In addition, the number of lymph nodes (LNN) was evaluated through dissection and ultrasound. Within the designated SLNF (10 × 5 cm2 ), the number of LNN was on average 3 ± 0.6, with an average size of 4.5 ± 1.8 mm × 2.9 ± 1.2 mm. Projection of the LNN on the mandible, measured from the gnathion (GT, median-sagittal-plane) toward the gonion (GN, mandibular angle), was at 63.4 ± 5.8 mm (e.g., 65%) of the mandible for the first lymph node (LN), and for the following LNN was at 50.4 ± 7.7 mm (e.g., 52%), 44.0 ± 8.6 mm (e.g., 45%), and 40.50 ± 2.1 mm (e.g., 42%). The MMN consistently crossed the mandible body and the facial artery (FA) from dorso-caudal to ventro-cranial at 72 ± 5.2 mm, e.g., 75% of the mandible's length. Here, the nerve always lay superficial to the FA and was on average 0.96 ± 0.14 mm in diameter. Submental artery was located on average at 64 mm (e.g., 66%) of the mandible, with an average diameter of 1.34 ± 0.2 mm. The submental lymph node flap has a constant vascular supply by the submental artery. Lymph node count is on average three. Lymph nodes are close to the submental artery and its perforators. Marginal mandibular nerve lies superficial to the facial artery and crosses the artery at 75% of the mandible body length (gnathion to gonion = 100%). J. Surg. Oncol. 2017;115:54-59. © 2016 Wiley Periodicals, Inc.

Oncological Safety of Submental Artery Island Flap in Oral Reconstruction - Analysis of 229 Cases.

Submental artery island flap (SMIF) is gaining popularity as a viable alternative to free flaps in carefully selected oral cavity defects after surgical extirpation of cancers.The current paper looks into the overall efficacy and oncological safety of the flap based on a prospective audit of 229 cases done at a high volume cancer center from october 2004 to september 2012 and concludes that SMIF is a oncologically safe,reliable reconstructive option in carefully selected oral cancers undergoing surgical resections.

The Use of Submental Artery Perforator Island Flap Without Including Digastric Muscle in the Reconstruction of Lower Face and Intraoral Defects.

For reconstruction of intraoral and lower face defects, it is important to use flaps that prevent reliable and pliable soft tissue and it is possible to use aesthetically most compatible with recipient site. In this study, the authors aimed to present their clinical experiences and results of lower face and intraoral defects reconstructions with submental artery island perforator flap without including the digastric muscle to have a thinner and useful flap. Six patients with lower face and intraoral defects that were reconstructed using the submental artery island flap between November 2013 and February 2015 were retrospectively analyzed. Patient demographics, age, sex, defect etiologies, and complications were assessed. Hand Doppler examination was performed and submental artery marked preoperatively. The superior border of the flap was designed at least 1 cm away from the mandibular border to avoid injury to the marginal mandibular nerve and prevent lip eversion. After the identification of the submental artery via the retrograde dissection, the anterior belly of the digastric muscle was not included the flap to prevent a thinner flap. After the dissection, the island flap was transferred to the defect site through a subcutaneous tunnel. The donor sites were closed primarily. A partially flap necrosis was occurred in 1 patient due to hematome in the tunnel around the pedicle. The wound healed uneventfully with conservative management. In the remaining patients there were no complications. The submental artery perforator island flap without including the digastric muscle is a reliable and suitable option for the medium-sized defects in the lower face and intraoral defects.

Gross anatomical classification of the courses of the human lingual artery

There are many reports on the variation of origin site of the lingual artery branching from the external carotid artery. However, there are few reports systematically investigating the course of the lingual artery in detail from branching site to the body of tongue. The purpose of this study is to classify systematically the courses of the lingual artery including variations. Using 111 body sides of 63 Japanese cadavers for dissection practices, the lingual artery and the surrounding structures were investigated gross anatomically. The courses of the lingual artery were classified into five types based on the positional relationships with the hyoglossus and the mylohyoid as follows; type M: coursing medial to the hyoglossus (normal course, 104 sides), type L: coursing lateral to the hyoglossus (2 sides), type T: transferring its course from lateral to medial to the hyoglossus (2 sides), type P: penetrating the mylohyoid (2 sides), and type C: the coinciding of types M and P (1 side). Types L, T, P, and C were considered to be variant lingual arteries. Types M and T, type L, and type P arose from the external carotid, facial, and submental arteries, respectively. In types L and P, adding to the variant lingual artery, the remnant of the normal lingual artery was also observed. The present study provides detailed information on the courses of lingual artery which will be of clinical importance especially in the super-selective arterial angiography.