Abstract
Background: The submental island flap (SIF) is a pedicled flap based upon the submental artery and vein. Its utility in reconstruction following ablative head and neck procedures has been applied to various subsites including skin, lip, buccal mucosa, retromolar trigone, parotidectomy defects, and tongue. We review our experience using the SIF for reconstruction following tumor ablation.
Methods: This prospective case series with medical record review includes consecutive patients undergoing SIF reconstruction following ablative surgery for malignancy at a single tertiary care facility between November 2014 and November 2016. We examined preoperative variables, surgical procedures, and postoperative outcomes.
Results: Thirty-seven patients met inclusion criteria. Twenty-nine were male; the average age was 64.3 (±12.4) years. Seventeen cancers involved the oral cavity, 11 involved the skin, 8 were in the oropharynx, and 1 was in the paranasal sinus. The average size of the SIF was 38.8 cm2 (±17.6 cm2). Four partial flap losses occurred; none required revision surgery. The average length of stay for these patients was 7.2 (±6.1) days.
Conclusion: The SIF is a robust flap that can be reliably used for a variety of head and neck defects following tumor ablation with an acceptable rate of donor- and flap-related complications.
INTRODUCTION
In 1993, Martin et al first described the submental island flap (SIF) as a reliable alternative to more conventional means of reconstruction after oncologic ablative procedures of the head and neck.1 The authors demonstrated that the SIF was an excellent option for reconstruction of facial defects following resection of low-grade cutaneous malignancies.1 As the increasing familiarity with the SIF resulted in shorter operations and decreased hospitalizations, some surgeons now prefer this technique to free tissue transfer for intraoral and skin defects.2,3 Furthermore, in addition to having superior color matching to facial skin, the SIF allows for an aesthetically pleasing donor site.4
The SIF is based off the submental artery, which is a reliable branch of the facial artery and is the main contributor to the SIF.1 The submental artery arises deep to the submandibular gland. It courses forward behind the body of the mandible and across the mylohyoid muscle.5 At this point, the artery either continues superficial (30%) or deep (70%) to the anterior belly of the digastric muscle, terminating at the mandibular symphysis.5,6 Up to 4 cutaneous perforators have been described; however, cadaveric studies have only been able to consistently find 1 reliable perforator to supply the skin paddle.7 Venous drainage of the SIF is via the submental vein that drains into the facial vein.8
Limitations of the SIF have been previously described. These limitations include a restricted arc of rotation of the pedicle and the concern of oncologic safety.9,10 With meticulous dissection of the fascia overlying the pedicle, dividing the facial artery and vein distal to the origin of the submental artery, and creating an anastomosis to a vein in proximity to the recipient site, the restricted arc of rotation can be overcome.8,11,12 Obtaining a sound oncologic resection is achievable by carefully removing the lymph node–bearing tissue and thinning the pedicle as safely as possible.6
Previous studies have demonstrated the applicability of the SIF to oral cavity or skin reconstruction.3,13-16 However, a paucity of literature examines the utility of this flap for reconstruction across multiple head and neck subsites. We hypothesized that the SIF is a reliable and valuable reconstructive option for various subsites of the head and neck, including oropharyngeal, parotid, and oral cavity defects.
METHODS
This prospective case series with chart review includes 37 consecutive patients undergoing SIF reconstruction following ablative surgery at a single tertiary care facility between November 2014 and November 2016. Inclusion criteria were adults >18 years with a diagnosis of malignancy of the head and neck undergoing ablative surgery with reconstruction using the SIF. Exclusion criteria were patients undergoing other methods of reconstruction including free tissue transfer, patients without a diagnosis of head and neck malignancy, and patients in whom SIF harvest was aborted intraoperatively because of ablative defects requiring larger reconstructive techniques. Demographics, preoperative risk factors, tumor characteristics, and operative variables were collected. Clinical and pathologic tumor staging was in accordance with the American Joint Committee on Cancer 2010 criteria.17 Operative notes and pathology reports were reviewed. Surface area (SA) was calculated from the dimensions reported in the operative note by using the equation for the SA of an ellipse (SA=a × b × π). Data were gathered regarding the type of ablative procedure performed, closure of the donor site, and human papilloma virus (HPV) status. Postoperative variables such as length of stay (LOS), partial or total flap loss, salivary fistula formation, and wound dehiscence were recorded. Institutional review board approval was obtained.
RESULTS
Thirty-seven patients met inclusion criteria (Table); their average age was 64.3 (±12.4) years. Twenty-nine (78%) patients were male. Four patients had radiation therapy prior to surgery; 3 patients had chemoradiation. Twelve patients had T1 lesions, 18 had T2 lesions, 2 had T3 lesions, and 5 had Tx lesions (presumed cutaneous primaries with delayed nodal metastases). Six patients had stage I, 10 had stage II, 8 had stage III, and 13 had stage IV disease.
Patients With Submental Island Flaps Performed Between November 2014 and November 2016
Seventeen patients had an oral cavity malignancy, 11 patients had a skin primary lesion, 8 had an oropharyngeal cancer, and 1 had a paranasal sinus cancer. Oral cavity subsites included tongue (7), floor of mouth (3), combined floor of mouth and tongue (4), buccal mucosa (1), retromolar trigone (1), and mandibular gingiva (1). Eight patients were HPV-positive; 6 of these patients underwent transoral robotic surgery (TORS) resection. A seventh patient had an HPV-negative squamous cell carcinoma of the oropharynx and also underwent TORS resection.
The average size of the SIFs was 38.8 cm2 (±17.6 cm2), with a range of 14.1-94.2 cm2. All donor sites were closed primarily. Five donor site complications occurred. Four patients developed a donor site dehiscence, and 1 patient developed an orocutaneous fistula. Four partial flap failures occurred, all of which were associated with either oral cavity or oropharynx reconstruction. Two flaps developed epidermolysis, 1 had ecchymosis, and 1 experienced partial loss of the anterior third of the flap, which healed by secondary intention. None required revision surgery. No issues occurred with 33 of the flaps (89%), and 100% of the SIFs were at least partially viable upon discharge and at postoperative follow-up examination in clinic. The average LOS of these patients was 7.2 (±6.1) days, with a range of 2-20 days. No deaths occurred within 30 days of surgery.
DISCUSSION
The SIF has been used successfully since its conception in 1993 to reconstruct defects of the head and neck. The majority of its uses involve reconstruction of lower facial defects after excision of malignant cutaneous tumors with low metastatic potential. The SIF has also been shown to be a reliable and oncologically safe flap in specific patients with aggressive tumors of the oral cavity and oropharynx.11 The SIF has been used for reconstruction of the nose, palatal defects, reconstruction of the neopharynx after laryngectomy, and coverage of spinal hardware.14
The utility of the SIF at our institution has been demonstrated by the large number performed since 2014 and its adaptation across a wide array of defects. The SIF currently accounts for 57% of all pedicled flaps at our institution, and it gained rapid acceptance among our head and neck surgeons. Its expansive utility is demonstrated with the successful reconstruction of both parotidectomy and auriculectomy defects, as well as lateral temporal bone resection with large cutaneous defects (Figure 1). Further versatility of the SIF has been demonstrated in patients undergoing superficial or total parotidectomy without large epithelial skin defects resulting in a noticeable concave deformity. We have found utility in deepithelizing the skin paddle with inset into the parotid defect for restoration of the normal facial contours. Deepithelizing the flap allows for good postoperative cosmesis of both the parotid defect and donor site (Figure 2).
A. Patient with a preoperative defect after undergoing partial Mohs resection of a basal cell carcinoma with positive margins in the parotid and external auditory canal. B. Submental flap inset after superficial parotidectomy and lateral temporal resection. The included muscle and soft tissue provided sufficient fill for the temporal bone and parotidectomy defects. (To see this image in color, click to https://education.ochsner.org/publishing-services/toc/barton-17-0039-fig1.)
Postoperative view of the donor site of a patient after partial glossectomy and floor-of-mouth resection with submental harvest demonstrates the incision used for submental flap harvest. (To see this image in color, click to https://education.ochsner.org/publishing-services/toc/barton-17-0039-fig2.)
Furthermore, with the development and implementation of TORS for oropharyngeal malignancies, the SIF provides an alternative to free flap or secondary intention for reconstruction. We have also found utility in placing the flap into the parapharyngeal space after deepithelizing the skin paddle (Figure 3). Placement into the parapharygneal space ensures coverage of the great vessels, replaces dissected tissue bulk, and assists with the prevention of a pharyngocutaneous fistula in cases with small through-and-through defects that can be repaired primarily by bolstering. Further studies are required to determine the effect of the SIF on swallowing outcomes. Although the submental flap was initially harvested in continuity with the neck dissection incision, the senior author (B.A.M.) has increasingly harvested the submental flap as an island pedicle flap in conjunction with a distinct incision for parotidectomy and/or neck dissection, resulting in acceptable cosmetic outcomes.
A. Mapped incision for the submental pedicled flap in conjunction with left parotidectomy and neck dissection. Flap width is determined by the pinch test and optimized based on the patient's individual redundancy. B. The submental flap was deepithelized, rotated, and tunneled under the skin to reconstruct the parotidectomy defect. (To see this image in color, click to https://education.ochsner.org/publishing-services/toc/barton-17-0039-fig3.)
Our success rate with the SIF was 100%, with only 3 flaps having superficial epidermolysis and ecchymosis and 1 flap having loss on the anterior third. Other minor complications resulted in minimal morbidity such as donor site dehiscence (4 patients) and development of orocutaneous fistula (1 patient), all of which resolved with medicated packing and, more important, did not result in reoperation.
The SIF differs from other pedicled flaps in the meticulous dissection of its pedicle. Dissection is required to achieve adequate mobility and to remove oncologically compromised tissue. Meticulous dissection of the pedicle could potentially cause more postoperative flap complications as a result of pedicle manipulation compared to the pectoralis major or the latissimus dorsi flap. However, as demonstrated by the minimal complication rate, we believe the SIF to be robust and reliable. Additionally, the SIF has been shown to be oncologically safe for the reconstruction of aggressive intraoral squamous cell carcinoma without any clinical lymphadenopathy in level I of the neck.9,16
The limitations of this study include a sample size that reflects the experience at a single institution. Furthermore, 2 head and neck surgeons performed all the SIFs. Differences between these surgeons may confound our results and their generalizability. Future directions should include the relationship between size and viability of the SIF, as well as oncologic outcomes. Moreover, additional research is necessary to examine the applicability and swallow outcomes of the SIF with HPV-positive oropharyngeal squamous cell carcinoma in patients undergoing TORS.
CONCLUSION
The SIF is a robust flap that can be used for a variety of head and neck defects following tumor ablation. In this prospective case series, we documented 5 donor site complications and 4 partial flap losses. No patients required revision surgery. The SIF is a versatile tool in the armamentarium of the reconstructive head and neck surgeon.
This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care, Medical Knowledge, Systems-Based Practice, and Practice-Based Learning and Improvement.
ACKNOWLEDGMENTS
The authors have no financial or proprietary interest in the subject matter of this article. This paper was presented as an oral presentation at the Triological Society Combined Sections Meeting, New Orleans, LA, on January 20, 2017.
- © Academic Division of Ochsner Clinic Foundation 2018
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