Submental Osteocutaneous Perforator Flap for Maxillary and Mandibular Reconstruction Following Tumor Resection

Accepted Manuscript Submental Osteocutaneous Perforator Flap for Maxillary and Mandibular Reconstruction Following Tumor Resection J.A. García-de Marcos, MD, PhD, S. Arroyo-Rodríguez, MD, DDS, FEBOMS, J. Rey Biel, MD, FEBOMS PII:

S0278-2391(15)01555-4

DOI:

10.1016/j.joms.2015.11.018

Reference:

YJOMS 57042

To appear in:

Journal of Oral and Maxillofacial Surgery

Received Date: 27 April 2015 Revised Date:

11 November 2015

Accepted Date: 14 November 2015

Please cite this article as: García-de Marcos JA, Arroyo-Rodríguez S, Rey Biel J, Submental Osteocutaneous Perforator Flap for Maxillary and Mandibular Reconstruction Following Tumor Resection, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/j.joms.2015.11.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT TITLE: SUBMENTAL OSTEOCUTANEOUS PERFORATOR FLAP FOR MAXILLARY AND MANDIBULAR RECONSTRUCTION FOLLOWING TUMOR RESECTION

AUTHOR NAMES AND AFFILIATIONS:

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J.A. García-de Marcos1, S. Arroyo-Rodríguez2, J. Rey Biel 3. (1) MD, PhD. Department of Oral and Maxillofacial Surgery. “Rey Juan Carlos”, University Hospital, Madrid. Spain.

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Albacete University Hospital. Albacete. Spain.

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(2) MD, DDS, FEBOMS. Department Head. Department of Oral and Maxillofacial Surgery.

(3) MD, FEBOMS. Department Head. Department of Oral and Maxillofacial Surgery. “Rey Juan Carlos”, University Hospital, Madrid. Spain.

CORRESPONDING AUTHOR:

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J.A. García-de Marcos. MD, Phd.

Address: C/ O´donnell 44, Madrid. Spain.

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Telephone number: 0034911885097

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E-mail: [email protected]

ACCEPTED MANUSCRIPT TITLE:

SUBMENTAL OSTEOCUTANEOUS PERFORATOR FLAP FOR MAXILLARY AND

MANDIBULAR RECONSTRUCTION FOLLOWING TUMOR RESECTION ABSTRACT

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Many different flaps have been used for reconstruction of the oral mucosa and the maxilla and mandible following tumor resection. These flaps may contain bone or not and may be free or locoregional. This study presents 2 cases of intraoral reconstruction using a submental

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osteocutaneous and fasciocutaneous perforator flap: one to reconstruct the maxilla and the other, the mandible. In the first, we describe a reverse-flow flap used for maxillary

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reconstruction, while the second analyzes reconstruction of a segmental mandibular defect. In both cases, functional, aesthetic, and oncologic outcomes were favorable at 9 months and 12 months of follow-up.

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Key Words: submental flap, perforator, mandible, maxilla

ACCEPTED MANUSCRIPT INTRODUCTION Based on the submental artery, the submental flap is a reliable option in facial reconstruction.[1-7] The technique was first described by Martin et al. in 1993, who detailed both the osteocutaneous and reverse-flow types of flap.[2] Reverse-flow flaps are designed by

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ligating the facial artery proximal to the root of the submental artery, which produces backward flow into the flap, thereby increasing the arc of rotation of the flap. In addition to skin and muscle tissue, the osteocutaneous flap uses part of the mandibular basal bone, which

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receives blood supply from the periosteal vessels.[1, 2] In 1996, Sterne et al. described the use of the submental flap for reconstruction of oral defects caused by cancer.[7, 8] Later, Chen et

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al. (2009) developed the reverse submental osteomuscular flap for reconstruction of the upper maxilla, using the anterior belly of the digastric and no skin.[3] Another reliable technique described in the literature is the perforator submental flap, which excludes the anterior belly of the digastric muscle and can be used in both standard and reverse-flow modalities.[1]

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This study presents 2 cases of oncological patients treated using the submental osteocutaneous perforator flap for bone and soft-tissue primary reconstruction (mandible or maxilla). In the first, we describe a variant of the flap reported by Chen (2009), the reverse-

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flow submental osteocutaneous and fasciocutaneous flap, which we used for reconstruction of

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a defect affecting the maxilla. The second case describes a segmental defect of the mandible reconstructed with the flap. ANATOMY AND SURGICAL TECHNIQUE The patient is placed in the supine position with the neck rotated to the contralateral side. Handheld Doppler ultrasonography is used to mark the facial artery where it courses past the mandibular basal bone and the perforator vessels. A skin paddle is traced so as to include all the perforator vessels of the submental artery as well as a segment of the mandibular basal bone (Fig.1).

ACCEPTED MANUSCRIPT A transverse cervical incision is made in the same way as for cervical dissection, continuing to the posterior edge of the skin paddle. The marginal branch of the facial nerve is located and preserved. The facial artery is dissected and the origin of the submental artery is located. The submental artery has 2 small venae comitantes that drain into the facial vein. The venae

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comitantes have valves that work in the opposite direction of the reversed venous flow, making additional venous drainage based on the facial vein (submental vein) necessary when performing the reverse-flow technique. The submental vein normally drains into the facial

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vein, which in turn joins the posterior facial vein to form the common facial vein, which drains into the internal jugular vein. Both the submental artery and vein are previously dissected. The

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submental artery runs above the mylohyoid muscle under the mandible.[1] In 70% of cases, this artery runs deep to the anterior belly of the digastric muscle, while in the other 30% of cases it runs superficial to the digastric. Several perforator vessels arising from the artery supply the platysma and the overlying skin with blood.[1, 3, 4] At the mandibular symphysis,

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the terminal branch of the submental artery connects to the contralateral terminal branch and curves upward around the mandibular border, dividing into superficial and deep branches in the lower lip. [1, 3] Separated from the submental artery and its venae comitantes, the

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submental vein runs a relatively straight course superior and superficial to the submandibular gland. The submental artery and vein meet at the lateral border of the anterior belly of the

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digastric muscle and run together from this point until they supply a perforator to the overlying skin.[1] Medial to the lateral border of the anterior belly of the digastric muscle, the submental vessels give rise to minor branches to the mandibular periostum.[1] Therefore, in the 2 cases described, we preserved a cuff of the anterior belly of the digastric muscle found adjacent to the pedicle, inserting it in the bone to protect these vessels (Fig. 2). The bone segment is raised, preserving as much of the periostum as possible and taking care to ensure that the dental nerve remains intact. Also, the platysma and the overlying skin are included in the flap to cover the soft tissues (Fig.3).

ACCEPTED MANUSCRIPT If the pedicle is not long enough or if the reverse technique is not performed, the facial vessels may be ligated distally to the source of the submental artery, providing 1 to 2 cm of pedicle length. If the reverse-flow technique is used, the artery and vein must be ligated proximally to the origin of the submental branches, vascularizing the flap through reverse distal facial

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flow.[3] In order to increase the arc of rotation and move the flap, the flap must be carried underneath the marginal mandibular nerve (Fig.4).[1, 4] The tunnel used for the vessels should be wide enough so as not to compromise blood supply.[9]

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Donor sites may be closed without complications when the defect measures up to 8 cm in

periostum of the hyoid bone[1, 2] CLINICAL CASES Case 1

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width. An appropriate cervicomental angle is achieved by suturing the inferior neck flap to the

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An 81-year-old man presented to our hospital with squamous cell carcinoma (SCC) located in the upper gingiva. Clinical and radiologic staging revealed a cT4aN0M0 lesion. The lesion was 4 × 3 cm in size and extended from the upper right lateral incisor to the upper left first premolar

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(Fig. 5.A). Past medical history included hypertension, type 2 diabetes, chronic renal failure, and a solitary kidney. The authors decided to perform a partial maxillectomy for this class IIc

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defect (according to the Brown and Shaw classification), including the upper right canine to the upper left second premolar (pT4aN0M0) (Fig. 5B). Reconstruction was performed using a reverse-flow submental osteocutaneous flap with a bone length of 6 cm and a skin island measuring 7 × 4 cm (Fig. 1-4). The bone was attached to the remaining maxilla using two 2.0 miniplates (Fig.6). The skin island was used to reconstruct the gum and vestibular mucosa, while the palatal mucosa was allowed to bleed so as to heal by secondary intention (Fig. 7). Coadjuvant radiotherapy followed treatment. No signs of local or regional recurrence were

ACCEPTED MANUSCRIPT observed at 9 months of post-surgical follow-up, and the functional and aesthetic outcomes were satisfactory (Fig. 8). Case 2

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A 70-year-old man presented to our hospital with SCC located on the floor of the mouth with invasion of the mandible (cT4aN0M0). Arteriography of the legs showed substantial atheromatosis with bilateral attenuation of the posterior tibial artery. Resection was

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performed leaving safety margins for the lesion on the floor of the mouth; a segmental osteotomy of 4.5 cm was performed in the area of symphysis; and bilateral supraomohyoid

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neck dissection was carried out (pT4aN2aM0). Reconstruction involved a reverse-flow submental osteocutaneous flap with a bone length of 4.5 cm and a skin island measuring 7 × 3 cm (Fig. 9). The bone used to reconstruct the mandibular symphysis was attached with a 2.0 reconstruction plate reinforced with another 2.5 reconstruction plate located inferiorly (Fig. 10). The skin island was used to reconstruct the mucosa of the gum and the floor of the mouth

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(Fig. 11). Following the operation, 70 Gy adjuvant radiotherapy was administered. Neither local nor regional recurrence was found at 12 months of follow-up, and functional and

DISCUSSION

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aesthetic outcomes were satisfactory (Fig. 12).

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Many different flaps have been used for reconstruction of the oral mucosa and the maxilla and mandible following tumor resection. These flaps may contain bone or not, and may be free or locoregional. Microsurgical techniques have limitations and risks for elderly patients, patients with systemic disease (who are not candidates for prolonged surgical intervention), and patients who have undergone previous operations with inappropriate receiver vessels. Also, some patients may prefer a more conservative approach to reconstruction.[3, 4, 7]

ACCEPTED MANUSCRIPT The submental osteocutaneous and fasciocutaneous flap allows us to obtain a bone fragment of up to 10 × 2 cm.[1] Skin paddles may measure up to 7 × 18 cm.[2] In 2010, Chen et al. described use of the reverse-flow osteomuscular flap in 8 patients with benign tumors for reconstruction of type-2a defects according to the classification system

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designed by Brown, achieving positive aesthetic and functional results in all patients. [3] In 2011, the same author used the flap in 5 patients with the same characteristics as those in the prior study, placing the implants and elevating the flap in a single operation, achieving

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favorable aesthetic and functional results in all the patients. Of the 20 implants evaluated, only

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1 was lost.[9]

In order to prevent venous congestion, Chen et al. prefer to include the anterior belly of the digastric muscle when raising the osteomuscular flap.[3, 9] In our 2 cases, we performed a perforator flap without including the entire anterior belly; rather, we only included a 1-cm muscle cuff adjacent to the bone so as to improve blood flow. None of the cases exhibited

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failure of venous return in the flap.

Controversy surrounds the use of submental flaps in cancer patients.[7] In patients with N0

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head and neck cancer, submental pathologic lymph nodes may be affected; therefore, if included in the flap, they may create a risk of tumor spread to the reconstructed site.

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Nevertheless, patients with N0 disease may undergo pedicle dissection up to the platysma, which can be performed by locating the adenopathy sites and isolating them from the flap. These lymph nodes may be included in profilactic neck dissection after the elevation of the flap.[5, 7] In our series, case 2 (cT4aN0M0) underwent bilateral supraomohyoid neck dissection after the flap was raised. The tumor stage was pT4aN2aM0. Neither local nor regional recurrence was found at 12 months of follow-up. This result may support the view that, when skeletonized, the submental perforator flap may avoid the risk of tumor spread to the receptor site and allow for neck dissection during the same surgical procedure.

ACCEPTED MANUSCRIPT Damage to the marginal branch of the facial nerve is one of the possible consequences of raising this flap, and this complication occurs in up to 16% of cases. This undesired outcome may be avoided by locating the nerve during the procedure. [1] Indeed, in cases in which the bone is included in the flap, the dental nerve may be located using computed tomography.

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Once this is done, its localization is marked, allowing it to be avoided while designing the bone fragment. Also, use of a piezoelectric surgical cutting tool may prevent nerve damage in cases in which the nerve is near the osteotomy line. In male patients, another difficulty of this flap

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concerns translocation of hair-bearing skin. [1, 6]

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CONCLUSIONS

The submental osteocutaneous and fasciocutaneous perforator flap and the reverse-flow submental osteocutaneous flap allow for reconstruction of oncologic defects of the oral mucosa and the mandible or maxilla, yielding favorable aesthetic and functional outcomes. Both flaps are straightforward to perform and produce reliable results if the surgeon has

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adequate knowledge of the anatomy of the neck. We believe this flap should be taken into consideration when reconstructing defects of the maxilla and mandible in cN0 cancer patients.

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ACKNOWLEDGMENTS

We wish to thank Oliver Shaw (IIS-FJD) for editing the manuscript for aspects related to the

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English language.

ACCEPTED MANUSCRIPT REFERENCES 1.

Kim JT: Submental artery perforator flap. In Blondeel P.N. MSF, Hallock G.G., Neligan

P.C. (ed) Perforator flaps. Anatomy, Technique, clinical applications, (ed. ST.LOUIS, Missouri, Quality Medical Publishing, Inc., 2006, p 161 Martin D. PJF, Baudet J., Mondie J.M., Bokhari Farhat J.,Athoum A., Le Gaillard P., Peri

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2.

G.: The submenta island flap: a new donor site. Anatomy and clinical applications as a free or pedicled flap. Plastic and reconstructive surgery 92:867, 1993

Chen WL, Ye JT, Yang ZH, Huang ZQ, Zhang DM, Wang K: Reverse facial artery-

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3.

submental artery mandibular osteomuscular flap for the reconstruction of maxillary defects

4.

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following the removal of benign tumors. Head Neck 31:725, 2009

You YH, Chen WL, Wang YP, Liang J, Zhang DM: Reverse facial-submental artery island

flap for the reconstruction of maxillary defects after cancer ablation. J Craniofac Surg 20:2217, 2009

You YH, Chen WL, Wang YP, Liang J: The feasibility of facial-submental artery island

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5.

myocutaneous flaps for reconstructing defects of the oral floor following cancer ablation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 109:e12, 2010 Jeong SH, Lee BI: Versatile use of submental tissue for reconstruction of perioral soft

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tissue defects. J Craniofac Surg 23:934, 2012 Amin AA, Sakkary MA, Khalil AA, Rifaat MA, Zayed SB: The submental flap for oral

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cavity reconstruction: extended indications and technical refinements. Head Neck Oncol 3:51, 2011 8.

Sterne GD JJ, Hall PN, Bardsley AF: The submental island flap. Brit J Plast Surg 49:85,

1996 9.

Chen WL, Zhou M, Ye JT, Yang ZH, Zhang DM: Maxillary functional reconstruction using

a reverse facial artery-submental artery mandibular osteomuscular flap with dental implants. J Oral Maxillofac Surg 69:2909, 2011

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FIGURES

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Figure 1. Flap design. The facial artery is marked on the right. The perforator vessels of the submental artery are marked with the letter X. The spindle-shaped line shows the skin paddle; the mandibular segment is marked with a rectangular shape.

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Figure 2. Flap-raising prior to inclusion of the basal bone of the mandible. Superior blue vessel loop (VL): marginal branch of the facial nerve; 2 blue and posterior VLs marking the facial vein

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and artery; blue and yellow VLs marking the confluence of the submental vein and artery. The osteotomy of the basal bone is outlined in pencil.

Figure 3. Submental osteocutaneous perforator flap including the basal bone of the mandible

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in which most of the periostum is preserved.

Figure 4. Reverse-flow variant of the submental osteocutaneous perforator flap. A: The flap is passed under the marginal branch of the facial nerve; B: Image depicting the length of the

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pedicle and the radius of action of the reverse-flow submental osteocutaneous and fasciocutaneous perforator flap after the flap is passed under the marginal branch of the facial

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nerve.

Figure 5. A: Image of the carcinoma in the upper gingiva with invasion of the maxilla; B: Image of the surgical resection

Figure 6. Osteosynthesis of the bone used for the flap to the remaining maxilla using 2 mini plates.

ACCEPTED MANUSCRIPT Figure 7. A: The flap and skin island used to reconstruct the gum and vestibular mucosa, while the gingiva and palatal mucosa were allowed to bleed so as to heal by secondary intention; B: Postoperative computed axial tomography.

B: Anterior image with the mouth open; C: Panoramic radiograph.

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Figure 8. Images obtained 9 months after the intervention. A: Appearance of the oral mucosa;

Figure 9. Raising of the flap. A: Flap-raising prior to inclusion of the bone fragment. A VL

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marking the submental artery and another submental vein. The most posterior VL marks the marginal branch of the facial nerve; B: Appearance of the flap following the osteotomy of the

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bone included in the flap; C: Submental osteocutaneous and fasciocutaneous perforator flap. The VL marks the submental pedicle, artery, and vein. An anterior vein was included and was also inserted in the flap in order to improve venous return.

Figure 10. The bone fragment of the flap was attached with a 2.0-mm reconstruction plate

view; B: Caudal view. Figure 11.

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reinforced with another reconstruction plate measuring 2.5 mm located inferiorly. A: Anterior

A: Appearance of the intraoral cavity after suturing of the skin island. B:

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Postoperative computed axial tomography; C: Computed tomography 3D reconstruction.

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Figure 12. Result 1 year after surgery. A: Intraoral; B: Anterior view; C: Panoramic radiograph.

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