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Submental island flap has certain advantages in repairing postoperative defects of oral cancer, and it can often achieve similar or even better effects compared with those of the free tissue flap. In this study, according to the different characteristics of patients and postoperative defects of oral cancer, submental island flaps with different states of vascular pedicle were prepared, and its repair methods, safety, and clinical effects in treating postoperative defects of oral cancer were investigated. 83 patients with oral cancer who met the inclusion criteria were selected. According to the different characteristics of the patients and postoperative defects of oral cancer, the traditional submental island flap vascular pedicle was modified into three different states: submental artery perforator flap, vascular pedicled flap with the anterior belly of digastric muscle but without the submandibular gland (SIF with anterior belly of DM), and vascular pedicled flap with the anterior belly of the digastric muscle and the submandibular gland (SIF with anterior belly of DM and SG). The types of the submental artery and the drainage vein, flap survival, and complications, were observed. The flap was successfully harvested for all patients, and the submental artery could be found or separated for all of them, with the venous drainage to the internal jugular vein in 57 (57/83, 68.67%), to the external jugular vein in 18 (18/83, 21.69%), and to the anterior jugular vein in eight (8/83, 9.64%) cases. Submental artery perforator flap was used for 11 cases, complete necrosis occurred in two cases (2/11, 18.18%), partial necrosis occurred in one case (1/11, 9.09%); SIF with anterior belly of DM was used for 49 cases, complete necrosis occurred in one case (1/49, 2.04%), partial necrosis occurred in four cases (4/49, 8.16%); SIF with anterior belly of DM and SG was used for 23 cases, including chimeric flap combining the submental island flap and the submandibular gland used for 15 cases, there were no cases of complete or partial necrosis. Submental island flap was effective in repairing postoperative defects of oral cancer. Submental island flaps with three different states of vascular pedicle could repair oral cancer-affected tissues with different defect characteristics.
The incidence of head and neck tumors has been increasing year by year, especially the incidence of oral cancer has been high, and surgery is the main means to treat oral cancer1,2,3. Postoperative defects of oral cancer cause internal and external deformities of patients, which seriously affect their speech, swallowing and other functions4,5. Therefore, it is difficult for head and neck oncologists to completely remove oral tumors, immediately repair defects, restore the appearance and function of patients, reduce the physiological, psychological, and social impact on patients with oral cancer, and improve the quality of life6,7. Free flaps, such as anterior arm flap, lateral upper arm flap and anterolateral thigh flap, could achieve satisfactory appearance reconstruction effect, but microvascular anastomosis technology, as well as postoperative flap observation and nursing, have limited the wide applicability of free flaps8,9,10. In recent years, the submental island flap (SIF), supra clavicular flap, and other pedicled flaps have shown similar or even better repair effects than free flaps. SIFs were clinically safe and reliable, and had more advantages in terms of the operation time, the average length of hospital stay, cost, etc.11,12.
Among the 83 cases using SIFs, submental artery perforator flap was used for 11 cases; SIF with anterior belly of DM was used for 49 cases; SIF with anterior belly of DM and SG was used for 23 cases, including chimeric flap combining the SIF and submandibular gland used for 15 cases. The flap was successfully harvested for all patients, and the submental artery could be localized or separated for all of them, the submental artery starts from the facial artery on the deep surface of the submandibular gland and runs forward. The medial side is the mylohyoid muscle, the upper side is the lower margin of the mandible, and reaches the anterior belly of the digastric muscle, there are small branches to the submandibular gland, mylohyoid muscle, digastric muscle, mandibular periosteum and other places along the way. The terminal branch fuses with the contralateral submental artery in the submental region. There was a lot of variation in venous drainage, with a venous drainage to the internal jugular vein in 57 cases (57/83, 68.67%), to the external jugular vein in 18 (18/83, 21.69%), and the anterior jugular vein in eight (8/83, 9.64%) (Table 2).
Submental island flap was effective in repairing postoperative defects of oral cancer. Submental island flaps with three different states of vascular pedicle could repair oral cancer-affected tissues with different defect characteristics. Perforator flap without the anterior belly of the digastric muscle and the submandibular gland had a thinner and longer vascular pedicle; it could repair medium and small superficial defects farther away and had a low local recurrence rate. However, the disadvantage of this flap was that venous drainage disorder could easily occur. For patients with deep invasion by the primary lesion or large defects, vascular pedicled flap with the anterior belly of digastric muscle but without the submandibular gland or vascular pedicled flap with the anterior belly of the digastric muscle and the submandibular gland can be chosen for repair. The anterior belly of the digastric muscle and the submandibular gland can be used to repair the floor of the mouth or other closed defects. If necessary, the submandibular gland and the submental island flap can be formed into a chimeric flap to repair larger oral defects, with a high survival rate of the flap, but there is a risk of local recurrence.
The usage of submental flap is a good method for head and neck reconstruction, but it has some risk also, such as anatomical variations and surgical errors. In this article, we present a modified incision design for the submental flap.
We designed a modified submental flap incision method based on the overlap of the incision outline of the submental flap, platysma myocutaneous flap and infrahyoid myocutaneous flap. If we found that the submental flap was unreliable during the neck dissection at the level III, II and Ib areas, the infrahyoid myocutaneous flap or platysma myocutaneous flap was used to replace it. Between 2004 and 2012, we performed 30 cases using this method. As control, 33 radial forearm free flaps were counted. Significant differences were evaluated using the χ2 test and Mann-Whitney U. Survival and recurrence were analyzed using the Kaplan-Meier method.
Of the 30 patients, 27 finally received a submental flap, 1 patient received an infrahyoid myocutaneous flap, and 2 patients received a platysma myocutaneous flap. In patients who received the submental flap, the average operation time was 5.9 hours, 2.4 hours shorter than the radial forearm free flap group; the average age was 61.8, 6.1 years older than the radial forearm free flap group; the survival time and recurrence time did not significantly differ with those of the forearm free flap group; and the success rate was higher than traditional methods.
The wider indications, less required time, the similar low risk of recurrence and death as radial forearm free flap, higher success rate than traditional submental flap harvest methods, and ability to safely harvest a submental flap make the modified incision design a reliable method.
The submental flap is one type of axial flap and was first reported by Martin et al in 1993 [2]. It is a time-honored method in head and neck reconstruction that can provide an excellent skin color, thickness and texture match, with cosmetically acceptable scars. However, there are some risk to give up of this flap due to difficult anatomical variations and surgical errors. In this article, we present our experience of using submental flap with a modified incision design. We believe that submental flap raised by this method will be more effective, and also hope this article, including a retrospective analysis of this flap, will be helpful for expanding the awareness and application of this useful flap system.
The submental artery, a constant branch 1 to 1.5 mm in diameter at its origin, arises after the facial artery exits from the submandibular gland. It runs medially on the mylohyoid muscle along the undersurface of the mandible and runs deep (70 percent) or above (30 percent) the anterior belly of the digastric muscle [3]. The flap is drained by the submental vein, which drains into the common facial vein over the submandibular gland [4].
The incision outlines of the submental flap, platysma myocutaneous flap and the infrahyoid myocutaneous flap are shown in Figure 1. Some overlap in the middle and upper neck can be observed (red line). Thus, we design the incision line as shown in Figure 2. Firstly, the neck and inferior border of the flap was incised (red line in Figure 2). Through this incision, the neck skin was undermined in a subplatysmal fashion, and the neck dissection at the level II and Ib areas was completed by traction of the sternomastoid muscle, resecting the submandibular gland, and carefully dissecting the pedicle of the submental flap. If we found that the pedicle was too thin, too short, had anatomical variations, was damaged, or was too close to the metastatic lymph node, the flap was abandoned. The superior thyroid artery and vein were then dissected, and the infrahyoid myocutaneous flap was raised or the incision was made posterior and superior to raise the platysma myocutaneous flap (Figure 3). After the pedicle vessels were identified, the level III lymphadenectomy was easily completed. Then, the superior border of the flap was incised,(black line in Figure 2), the flap was raised, and the level Ia lymphadenectomy was completed (Figure 4). The flap was then transferred to the defect site (Figure 5). 2b1af7f3a8