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The submental island flap for reconstruction of intraoral defects in oral cancer patients
Oral Oncology (2008) 44, 1014– 1018
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/oraloncology
The submental island flap for reconstruction of intraoral defects in oral cancer patients Paul Sebastian, Shaji Thomas, Bipin T. Varghese *, Elizabeth M. Iype, P.G. Balagopal, P.C. Mathew Head and Neck Service, Division of Surgical Oncology, Regional Cancer Centre, Trivandrum 695 011, India Received 13 December 2007; received in revised form 19 February 2008; accepted 19 February 2008 Available online 11 July 2008
KEYWORDS Submental flap; Head and neck reconstruction; Oral cancer
Summary 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 · 3 cm to 7 · 6 cm, with a mean size of 4.9 · 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.
ª 2008 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +91 471 2444744; fax: +91 471 2552217. E-mail address: [email protected] (B.T. Varghese). 1368-8375/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2008.02.013
The submental island flap for reconstruction of intraoral defects in oral cancer patients
Introduction The reconstruction of oral defects following ablative surgery has a significant impact on the quality of life for patients suffering from oral cancer. A variety of local flaps such as Nasolabial flap, Sternocleidomastoid flap and the Platysma flap, and free flaps like the radial forearm and anterolateral thigh (ALT) flap have been the main options available so far to the reconstructive surgeon. However all these options have their shortcomings. When reconstructing the face or oral cavity the flap should be reliable, functionally and cosmetically acceptable with minimum donor site morbidity and match the recipient site in terms of color, texture and thickness.1 The submental island flap, an axial pattern skin flap first described by Martin et al.2 in 1993, meets most of these requirements when used for reconstruction of selected defects in the head and neck. However the authors cautioned against the use of the flap in oral cancer due to the risk of nodal metastases and the difficulty in clearing the level I lymph nodes. The earliest reported use of the submental island flap for reconstruction in oral squamous cell carcinoma was by Sterne and Hall3 in 1996. Subsequently, others have also used this technique for reconstruction in oral cancer patients, though the issue of its oncological safety remains controversial.
Methods Thirty consecutive cases of submental island flap reconstruction for small to moderate sized defects of oral cavity done between October 2004 and December 2006 were studied prospectively. The flap was raised either in a retrograde or an anterograde fashion by skeletonising the submental artery and vein with the facial artery and vein. Lesions more than 5 cm in largest dimension and patients who had palpable or radiologically demonstrable neck node metastases at the time of surgery were not considered suitable for this form of reconstruction. The site and stage of the tumour, type of resection, management of the neck and the technique of flap transfer were recorded. The patients were followed up to assess flap viability, cosmesis, function (speech and swallowing) and locoregional recurrence.
Flap design and operative technique (Fig. 1) The patient is positioned supine with head extended and turned to the opposite side. The laxity of the submental skin island is assessed by pinching the proposed skin island to be harvested. Once the pinch test is positive and possibility of primary closure of the donor area is ensured, an elliptical island is marked in the submental area such that the ipsilateral anterior belly of digastric lies beneath it. Although it is desirable to keep the ellipse with in the midline, depending on the laxity of the skin, it can be extended up to the medial border of the contralateral digastric muscle. A subplatysmal skin island is then dissected out. The submental artery and vein are easily identified over the mylehyoid muscle as a branch or tributary of the facial artery and the anterior facial vein which in turn drains to
1015
the common facial vein or the external jugular vein. The level of arterial branching and the venous confluence is approximately 1.5–2 cm below the lower border of the mandible. The submental artery (and vein) then courses beneath the anterior belly of digastric and arborises to the submental skin along its medial border. The entire branching of the facial artery occurs with in the substance of the submandibular gland or deep to it where as the venous system is usually superficial to the gland. Using these land marks the facial vessels and submental vessels are skeletonised with the subplatysmal skin island, either in a anterograde fashion from the facial vessels or in a retrograde manner from the submental vessels. In either case the terminal vessels are protected by including the overlying segment of the anterior belly of digasric muscle. The underlying mylohyoid muscle is either cut or a strip of it included with the pedicle when the flap need to be tunneled to a defect medial to the mandible (tongue, floor of mouth, etc.). All other branches and tributaries of the facial vessels are ligated and severed. A pedicle length of approximately 5 cm is easily obtained when the entire facial artery is retained, which is usually sufficient. This can be further enhanced by ligating the distal portion of the facial artery after the submental artery is given off (along with the corresponding vein). By ligating the proximal portion of the artery with the corresponding vein, it is also possible to design a reverse flow flap which can reach even up to the infraorbital region. We recommend the use of loupe during the dissection of the terminal portion of the pedicle to enhance the level 1 clearance with out compromising the flap vasularity.
Results There were 19 men and 11 women, with ages ranging from 30 to 78 years (mean ± SD of 53 ± 11 years). Eighteen patients had T2 lesions, seven had T3 lesions, and two had T1 lesions. One patient had a Tx status and two patients had T4 lesions at initial presentation which were down staged to T2 status by Neo-adjuvant Chemotherapy (NACT). Twenty-one patients were clinically N0, seven had N1 status, and two patients were N3 downstaged to clinical N0 status by NACT. The site wise distribution of all the cases is shown in Table 1. Three patients had recurrence or residual disease following chemoradiation, three had previous surgery for oral cancer, one of whom had a neck dissection as well. Table 2 depicts distribution of the type of neck dissections done. With the exception of one patient who had a previous neck dissection, all patients underwent neck dissection or at least a level I clearance along with the wide excision of the primary lesion. The flap in this patient was based on the opposite submental artery. Contralateral neck dissection was carried out in two patients. Those patients with adverse tumour factors or positive neck nodes received postoperative radiation. The size of the primary lesion at the time of surgery ranged from 1 · 2 cm to 4 · 5 cm (mean size 3.1 · 2.7 cm). The mean size of the intraoral defects was 5.07 · 4 cm, the largest measuring 7 · 6 cm. The skin paddles of the flaps ranged in size from 3 · 3 cm to 7 · 6 cm, with a mean size of 4.9 · 4 cm. All flaps exhibited
1016
P. Sebastian et al.
Figure 1 Flap design and operative technique: (i) Line drawing describing the vascular anatomy of SMIF. (ii) Steps of flap harvest (a–d); (a) cancer of the right lateral border of the tongue ready for wide excision, (b) defect after the wide excision of the lesion, (c) submental skin island flap pedicled on the skeletonised submental artery and vein and (d) the flap being inset to the defect.
good mobility and reached the intraoral recipient site without tension to the pedicle. The donor site was closed primarily in all cases. All patients had microscopic tumour free margins, seven patients had positive nodes at levels 1, 2 or 3, one of whom also had extracapsular spread at level 3 and one had a positive contralateral level 2 node with extracapsular spread. Both of these patients had received NACT prior to surgery in order to downstage the disease.
The post-op hospital stay ranged from 1 to 17 days, with a mean period of 4.93 days. Total flap loss was seen in one patient and superficial flap loss in another. However these wounds settled well with conservative management with out adding significant morbidity for the patients. Six patients had immediate postoperative venous congestion, which resolved completely over a period of 10 days. The donor site healed uneventfully and the resulting scar was well concealed without any disfigurement in all cases
The submental island flap for reconstruction of intraoral defects in oral cancer patients Table 1 Site distribution (N = 30) Buccal mucosa (BM) Retromolar trigone (RMT) Floor of mouth (FOM) and adjacent lower alveolus (LA) Lower lip and adjacent lower alveolus Ventral tongue Lat/dorsal tongue
2 1 1 1 1 24
Table 2 Type of neck dissections and their distribution (N = 30) No neck dissection Level 1 clearance only Supraomohyoid neck dissection (SOND) Bilateral SOND Functional neck dissection (FND) Modified neck dissection (MND) type 2 Radical neck dissection (RND) Modified neck dissection (MND) type 2 with contralateral RND
1 3 16 1 6 1 1 1
(Fig. 2). Persistent hair growth was seen in one male patient even 3 months after surgery requiring repeated epilation. The long term cosmesis and function (speech and swallowing) were good in all the patients studied (Fig. 2). All patients were followed up for periods ranging from 4 to 25 months with a median of 13.5 months. One patient developed a recurrence at the primary site as well as distant metastasis, one patient had distant metastases alone, and two patients had second primaries. Two patients developed contra lateral nodal recurrence on follow up, but none of the patients had nodal recurrence on the ipsilateral side.
Discussion Over the past 13 years, the Submental island flap has proved to be a reliable reconstructive option in head and neck sur-
1017
gery, being simple and rapid to harvest,4,5 and providing a large surface area (approx. 15 · 6 cm)2 with minimal donor site morbidity. It has a reliable and predictable pedicle, and the large caliber of the vessels (approx 2 mm)2 makes possible its use as a free flap if required, adding to its versatility. One of the outstanding features of the submental island flap is its excellent reach and mobility. This has proved especially advantageous for reconstruction of mobile structures such as the tongue. The relatively thin skin over the submental area makes it suitable for reconstruction of intraoral defects. In male patients hair growth on the skin paddle may be a problem, at least initially which in our series had resolved in all but one patient by the third postoperative month. The other major reported complication associated with the submental flap is marginal mandibular nerve paresis.6,7 There were no incidence of marginal mandibular nerve paresis in the present series, which we believe can be easily avoided by identifying and preserving the nerve early on in the dissection. Donor site complications are extremely rare with the submental flap.8,9 The donor site cosmesis with the submental flap is excellent, with the scar being well hidden under the horizontal ramus of the mandible, practically invisible in bearded male patients. Primary closure of the donor site defect is possible in virtually all patients.1 Doubts have been voiced time and again regarding the oncological safety of the submental island flap, and some authors have cautioned against its use in patients with oral squamous cell carcinoma.2,3 The prime concern in this regard is the close proximity of the flap and its pedicle to the submental and submandibular nodes which drain most of the lower third of the face and the oral cavity. This raises the possibility of inadvertent inclusion of lymphatic tissue overrun by malignant cells into the flap or its pedicle.4 However many authors have expressed an opinion (which we share) that the SIF is not contraindicated in oral cancer patients provided they do not have established nodal disease. It is essential that careful removal of all lymphatic tissue be carried out and the pedicle is thinned as much as possible.1 The surgeon should also be prepared
Figure 2 Final appearance of a well settled submental flap and its donor site: (i) Defect after wide excision and marginal mandibulectomy, done for cancer of the retromolar trigone and adjacent buccal mucosa,which has been reconstructed with ipsilateral SMIF. (ii) Donor site scar of the same patient.
1018 to consider abandoning the plan for a SIF and opting for another option intraoperatively if suspicious nodes in level I are encountered. Frozen section of the suspicious nodes would be useful in this situation. A contralateral neck dissection may also be considered if the lesion is close to or crosses the midline. These recommendations however need further validation by more studies with long term follow up of the patients, preferably for periods over 3–4 years and we too hope to publish our updated data by then.
Conclusion The submental artery island flap is a simple reliable and versatile flap for reconstruction of intraoral defects after excision for oral cancer. It provides good functional and cosmetic results without much morbidity. It appears to be oncologically safe but should be avoided in patients with palpable or radiologically demonstrable neck node metastases. Careful patient selection is however mandatory and alternative options should be considered in high risk individuals. Further study with long term follow up of patients is needed before the issue can be put to rest.
Conflict of Interest Statement None declared.
P. Sebastian et al.
References 1. Vural E, Suen JY. The submental island flap in head and neck reconstruction. Head Neck 2000;22:572–8. 2. Martin D, Pascal JF, Baudet J, et al. The submental island flap: a new donor site. Anatomy and clinical applications as a free or pedicled flap. Plast Reconstr Surg 1993;92:867–73. 3. Sterne GD, Januszkiewicz JS, Hall PN, Bardsley AF. The submental island flap. Brit J Plast Surg 1996;49:85–9. 4. Pistre V, Pelissier P, Martin D, Lim A, Baudet J. Ten years of experience with the submental flap. Plast Reconstr Surg 2001;108:1576–81. 5. Merten SL, Jiang RP, Caminer D. The submental artery island flap for head and neck reconstruction. Aust NZ J Surg 2002;72: 121–4. 6. Abouchadi A, Capon-Degardin N, Patenotre P, Martinot-Duquennoy V, Pellerin P. The submental flap in facial reconstruction: advantages and limitations. J Oral Maxil Surg 2007;65:863–9. 7. Curran AJ, Neligan P, Gullane PJ. Submental artery island flap. Laryngoscope 1997;107:1545–9. 8. Multinu A, Ferrari S, Bianchi B, et al. The submental island flap in head and neck reconstruction. Int J Oral Maxil Surg. 9. Pistre V, Pelissier P, Martin D, Baudet J. The submental flap: its uses as a pedicled or free flap for facial reconstruction. Clin Plast Surg 2001;28:303–9.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/oraloncology
The submental island flap for reconstruction of intraoral defects in oral cancer patients Paul Sebastian, Shaji Thomas, Bipin T. Varghese *, Elizabeth M. Iype, P.G. Balagopal, P.C. Mathew Head and Neck Service, Division of Surgical Oncology, Regional Cancer Centre, Trivandrum 695 011, India Received 13 December 2007; received in revised form 19 February 2008; accepted 19 February 2008 Available online 11 July 2008
KEYWORDS Submental flap; Head and neck reconstruction; Oral cancer
Summary 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 · 3 cm to 7 · 6 cm, with a mean size of 4.9 · 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.
ª 2008 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +91 471 2444744; fax: +91 471 2552217. E-mail address: [email protected] (B.T. Varghese). 1368-8375/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2008.02.013
The submental island flap for reconstruction of intraoral defects in oral cancer patients
Introduction The reconstruction of oral defects following ablative surgery has a significant impact on the quality of life for patients suffering from oral cancer. A variety of local flaps such as Nasolabial flap, Sternocleidomastoid flap and the Platysma flap, and free flaps like the radial forearm and anterolateral thigh (ALT) flap have been the main options available so far to the reconstructive surgeon. However all these options have their shortcomings. When reconstructing the face or oral cavity the flap should be reliable, functionally and cosmetically acceptable with minimum donor site morbidity and match the recipient site in terms of color, texture and thickness.1 The submental island flap, an axial pattern skin flap first described by Martin et al.2 in 1993, meets most of these requirements when used for reconstruction of selected defects in the head and neck. However the authors cautioned against the use of the flap in oral cancer due to the risk of nodal metastases and the difficulty in clearing the level I lymph nodes. The earliest reported use of the submental island flap for reconstruction in oral squamous cell carcinoma was by Sterne and Hall3 in 1996. Subsequently, others have also used this technique for reconstruction in oral cancer patients, though the issue of its oncological safety remains controversial.
Methods Thirty consecutive cases of submental island flap reconstruction for small to moderate sized defects of oral cavity done between October 2004 and December 2006 were studied prospectively. The flap was raised either in a retrograde or an anterograde fashion by skeletonising the submental artery and vein with the facial artery and vein. Lesions more than 5 cm in largest dimension and patients who had palpable or radiologically demonstrable neck node metastases at the time of surgery were not considered suitable for this form of reconstruction. The site and stage of the tumour, type of resection, management of the neck and the technique of flap transfer were recorded. The patients were followed up to assess flap viability, cosmesis, function (speech and swallowing) and locoregional recurrence.
Flap design and operative technique (Fig. 1) The patient is positioned supine with head extended and turned to the opposite side. The laxity of the submental skin island is assessed by pinching the proposed skin island to be harvested. Once the pinch test is positive and possibility of primary closure of the donor area is ensured, an elliptical island is marked in the submental area such that the ipsilateral anterior belly of digastric lies beneath it. Although it is desirable to keep the ellipse with in the midline, depending on the laxity of the skin, it can be extended up to the medial border of the contralateral digastric muscle. A subplatysmal skin island is then dissected out. The submental artery and vein are easily identified over the mylehyoid muscle as a branch or tributary of the facial artery and the anterior facial vein which in turn drains to
1015
the common facial vein or the external jugular vein. The level of arterial branching and the venous confluence is approximately 1.5–2 cm below the lower border of the mandible. The submental artery (and vein) then courses beneath the anterior belly of digastric and arborises to the submental skin along its medial border. The entire branching of the facial artery occurs with in the substance of the submandibular gland or deep to it where as the venous system is usually superficial to the gland. Using these land marks the facial vessels and submental vessels are skeletonised with the subplatysmal skin island, either in a anterograde fashion from the facial vessels or in a retrograde manner from the submental vessels. In either case the terminal vessels are protected by including the overlying segment of the anterior belly of digasric muscle. The underlying mylohyoid muscle is either cut or a strip of it included with the pedicle when the flap need to be tunneled to a defect medial to the mandible (tongue, floor of mouth, etc.). All other branches and tributaries of the facial vessels are ligated and severed. A pedicle length of approximately 5 cm is easily obtained when the entire facial artery is retained, which is usually sufficient. This can be further enhanced by ligating the distal portion of the facial artery after the submental artery is given off (along with the corresponding vein). By ligating the proximal portion of the artery with the corresponding vein, it is also possible to design a reverse flow flap which can reach even up to the infraorbital region. We recommend the use of loupe during the dissection of the terminal portion of the pedicle to enhance the level 1 clearance with out compromising the flap vasularity.
Results There were 19 men and 11 women, with ages ranging from 30 to 78 years (mean ± SD of 53 ± 11 years). Eighteen patients had T2 lesions, seven had T3 lesions, and two had T1 lesions. One patient had a Tx status and two patients had T4 lesions at initial presentation which were down staged to T2 status by Neo-adjuvant Chemotherapy (NACT). Twenty-one patients were clinically N0, seven had N1 status, and two patients were N3 downstaged to clinical N0 status by NACT. The site wise distribution of all the cases is shown in Table 1. Three patients had recurrence or residual disease following chemoradiation, three had previous surgery for oral cancer, one of whom had a neck dissection as well. Table 2 depicts distribution of the type of neck dissections done. With the exception of one patient who had a previous neck dissection, all patients underwent neck dissection or at least a level I clearance along with the wide excision of the primary lesion. The flap in this patient was based on the opposite submental artery. Contralateral neck dissection was carried out in two patients. Those patients with adverse tumour factors or positive neck nodes received postoperative radiation. The size of the primary lesion at the time of surgery ranged from 1 · 2 cm to 4 · 5 cm (mean size 3.1 · 2.7 cm). The mean size of the intraoral defects was 5.07 · 4 cm, the largest measuring 7 · 6 cm. The skin paddles of the flaps ranged in size from 3 · 3 cm to 7 · 6 cm, with a mean size of 4.9 · 4 cm. All flaps exhibited
1016
P. Sebastian et al.
Figure 1 Flap design and operative technique: (i) Line drawing describing the vascular anatomy of SMIF. (ii) Steps of flap harvest (a–d); (a) cancer of the right lateral border of the tongue ready for wide excision, (b) defect after the wide excision of the lesion, (c) submental skin island flap pedicled on the skeletonised submental artery and vein and (d) the flap being inset to the defect.
good mobility and reached the intraoral recipient site without tension to the pedicle. The donor site was closed primarily in all cases. All patients had microscopic tumour free margins, seven patients had positive nodes at levels 1, 2 or 3, one of whom also had extracapsular spread at level 3 and one had a positive contralateral level 2 node with extracapsular spread. Both of these patients had received NACT prior to surgery in order to downstage the disease.
The post-op hospital stay ranged from 1 to 17 days, with a mean period of 4.93 days. Total flap loss was seen in one patient and superficial flap loss in another. However these wounds settled well with conservative management with out adding significant morbidity for the patients. Six patients had immediate postoperative venous congestion, which resolved completely over a period of 10 days. The donor site healed uneventfully and the resulting scar was well concealed without any disfigurement in all cases
The submental island flap for reconstruction of intraoral defects in oral cancer patients Table 1 Site distribution (N = 30) Buccal mucosa (BM) Retromolar trigone (RMT) Floor of mouth (FOM) and adjacent lower alveolus (LA) Lower lip and adjacent lower alveolus Ventral tongue Lat/dorsal tongue
2 1 1 1 1 24
Table 2 Type of neck dissections and their distribution (N = 30) No neck dissection Level 1 clearance only Supraomohyoid neck dissection (SOND) Bilateral SOND Functional neck dissection (FND) Modified neck dissection (MND) type 2 Radical neck dissection (RND) Modified neck dissection (MND) type 2 with contralateral RND
1 3 16 1 6 1 1 1
(Fig. 2). Persistent hair growth was seen in one male patient even 3 months after surgery requiring repeated epilation. The long term cosmesis and function (speech and swallowing) were good in all the patients studied (Fig. 2). All patients were followed up for periods ranging from 4 to 25 months with a median of 13.5 months. One patient developed a recurrence at the primary site as well as distant metastasis, one patient had distant metastases alone, and two patients had second primaries. Two patients developed contra lateral nodal recurrence on follow up, but none of the patients had nodal recurrence on the ipsilateral side.
Discussion Over the past 13 years, the Submental island flap has proved to be a reliable reconstructive option in head and neck sur-
1017
gery, being simple and rapid to harvest,4,5 and providing a large surface area (approx. 15 · 6 cm)2 with minimal donor site morbidity. It has a reliable and predictable pedicle, and the large caliber of the vessels (approx 2 mm)2 makes possible its use as a free flap if required, adding to its versatility. One of the outstanding features of the submental island flap is its excellent reach and mobility. This has proved especially advantageous for reconstruction of mobile structures such as the tongue. The relatively thin skin over the submental area makes it suitable for reconstruction of intraoral defects. In male patients hair growth on the skin paddle may be a problem, at least initially which in our series had resolved in all but one patient by the third postoperative month. The other major reported complication associated with the submental flap is marginal mandibular nerve paresis.6,7 There were no incidence of marginal mandibular nerve paresis in the present series, which we believe can be easily avoided by identifying and preserving the nerve early on in the dissection. Donor site complications are extremely rare with the submental flap.8,9 The donor site cosmesis with the submental flap is excellent, with the scar being well hidden under the horizontal ramus of the mandible, practically invisible in bearded male patients. Primary closure of the donor site defect is possible in virtually all patients.1 Doubts have been voiced time and again regarding the oncological safety of the submental island flap, and some authors have cautioned against its use in patients with oral squamous cell carcinoma.2,3 The prime concern in this regard is the close proximity of the flap and its pedicle to the submental and submandibular nodes which drain most of the lower third of the face and the oral cavity. This raises the possibility of inadvertent inclusion of lymphatic tissue overrun by malignant cells into the flap or its pedicle.4 However many authors have expressed an opinion (which we share) that the SIF is not contraindicated in oral cancer patients provided they do not have established nodal disease. It is essential that careful removal of all lymphatic tissue be carried out and the pedicle is thinned as much as possible.1 The surgeon should also be prepared
Figure 2 Final appearance of a well settled submental flap and its donor site: (i) Defect after wide excision and marginal mandibulectomy, done for cancer of the retromolar trigone and adjacent buccal mucosa,which has been reconstructed with ipsilateral SMIF. (ii) Donor site scar of the same patient.
1018 to consider abandoning the plan for a SIF and opting for another option intraoperatively if suspicious nodes in level I are encountered. Frozen section of the suspicious nodes would be useful in this situation. A contralateral neck dissection may also be considered if the lesion is close to or crosses the midline. These recommendations however need further validation by more studies with long term follow up of the patients, preferably for periods over 3–4 years and we too hope to publish our updated data by then.
Conclusion The submental artery island flap is a simple reliable and versatile flap for reconstruction of intraoral defects after excision for oral cancer. It provides good functional and cosmetic results without much morbidity. It appears to be oncologically safe but should be avoided in patients with palpable or radiologically demonstrable neck node metastases. Careful patient selection is however mandatory and alternative options should be considered in high risk individuals. Further study with long term follow up of patients is needed before the issue can be put to rest.
Conflict of Interest Statement None declared.
P. Sebastian et al.
References 1. Vural E, Suen JY. The submental island flap in head and neck reconstruction. Head Neck 2000;22:572–8. 2. Martin D, Pascal JF, Baudet J, et al. The submental island flap: a new donor site. Anatomy and clinical applications as a free or pedicled flap. Plast Reconstr Surg 1993;92:867–73. 3. Sterne GD, Januszkiewicz JS, Hall PN, Bardsley AF. The submental island flap. Brit J Plast Surg 1996;49:85–9. 4. Pistre V, Pelissier P, Martin D, Lim A, Baudet J. Ten years of experience with the submental flap. Plast Reconstr Surg 2001;108:1576–81. 5. Merten SL, Jiang RP, Caminer D. The submental artery island flap for head and neck reconstruction. Aust NZ J Surg 2002;72: 121–4. 6. Abouchadi A, Capon-Degardin N, Patenotre P, Martinot-Duquennoy V, Pellerin P. The submental flap in facial reconstruction: advantages and limitations. J Oral Maxil Surg 2007;65:863–9. 7. Curran AJ, Neligan P, Gullane PJ. Submental artery island flap. Laryngoscope 1997;107:1545–9. 8. Multinu A, Ferrari S, Bianchi B, et al. The submental island flap in head and neck reconstruction. Int J Oral Maxil Surg. 9. Pistre V, Pelissier P, Martin D, Baudet J. The submental flap: its uses as a pedicled or free flap for facial reconstruction. Clin Plast Surg 2001;28:303–9.