Accepted Manuscript Submental artery island flap in intraoral reconstruction: a review Amin Rahpeyma, Saeedeh khajehahmadi
PII:
S1010-5182(14)00021-3
DOI:
10.1016/j.jcms.2014.01.020
Reference:
YJCMS 1704
To appear in:
Journal of Cranio-Maxillofacial Surgery
Received Date: 15 July 2013 Revised Date:
18 September 2013
Accepted Date: 3 January 2014
Please cite this article as: Rahpeyma A, khajehahmadi S, Submental artery island flap in intraoral reconstruction: a review, Journal of Cranio-Maxillofacial Surgery (2014), doi: 10.1016/ j.jcms.2014.01.020. 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.
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Titel: Submental artery island flap in intraoral reconstruction:
Running title: Submental artery island flap 1. Amin Rahpeyma
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a review
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Affiliation: Assistant Professor of Oral and Maxillofacial Surgery, Oral and Maxillofacial Diseases Research Center, School of Dentistry, Mashhad University of Medical Sciences. Postal Address: Oral and Maxillofacial Surgery, Oral and Maxillofacial Diseases Research Center of Mashhad University of Medical Sciences ,Vakilabad Blvd, Mashhad, Iran
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E-mail Address: [email protected]
Work Telephone Number: +98(511)8829501 Work Fax Number: + 98(511)8829500
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2. Saeedeh khajehahmadi*
Affiliation: Assistant Professor of Oral and Maxillofacial Pathology, Dental Research
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Center , School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran. *Correspondence:
Dr. Saeedeh khajehahmadi Postal Address: Dental Research Center of Medical Sciences, Mashhad, Iran. Vakilabad Blvd, Mashhad, Iran
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Work Telephone Number: +98(511)8829501 Work Fax Number: + 98(511)8829500
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Email: [email protected] and
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[email protected]
ACCEPTED MANUSCRIPT Title: Submental artery island flap in intraoral reconstruction: a review Abstract Background: The Submental flap was first introduced 20 years ago (1993). Advances in techniques and new findings from anatomic studies expanded the indications and improved the flap
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characteristics. Indications, limitation, and all possible variants of this flap are discussed comprehensively in this article.
Materials and Methods: A literature review was performed. We paid attention to the anatomy of submental region, and especially to submental artery and vein, muscles and lymphatics. Surgical
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techniques for each possible variant of this flap and examples of each situation are presented. Indications of submental flap for facial, oesophageal, pharyngeal, laryngeal, and oral cavity
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reconstruction were assessed.
Results: Ninety studies meeting the inclusion criteria were reviewed. Classification of the submental flap based on skin paddle composition and blood supply is presented. Major modifications such as pedicled, free, and perforator flaps are discussed comprehensively and minor variants of submental flap such as bipaddled, bipedicled, expanded, deepithelialized, and interposition submental flaps are
submental flap were done.
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discussed, briefly. A historical look at this topic is presented to show how and by whom advances in
Conclusion: The Submental flap has a wide arc of rotation; it is easy to rise and has low donor site
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morbidity. It is a safe, simple, and predictable method for reconstruction of oral cavity.
Key words: Submental flap/ Oral reconstruction/ Submental artery.
1. Introduction Reconstruction of the oral cavity after surgical resections is an interesting topic. Pedicled flaps have vital role in reconstruction of medium to large sized defects of oral cavity (Squaquara et al., 2010; Tosco et al., 2012). The Submentalflap was first introduced by Martin in 1993 and was widely
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ACCEPTED MANUSCRIPT accepted by reconstructive surgeons working in the field of maxillofacial or head & neck reconstruction (Martin et al., 1993). Classification of this flap is based on blood supply and composition of the flap paddle. It has a wide arc of rotation, so it can be used for reconstruction of skin and tissues in the neck inferior to the submental region such as larynx and oesophagus or tissue above the submental region in such as facial skin, oral cavity and oro-nasopharynx (Yang et al.,
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2010;You et al., 2010; Shi and Wang, 2012).
For skin reconstruction it is mainly used as a pedicled interpolated flap, but a transposition variant in which the edge of skin defect is in the line with the edge of the flap's skin paddle and free flap variant
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Ahmad and Shankhdhar, 2010; Markeeva et al., 2012).
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in which recipient site is far away from submental region is also available (Abouchadi et al., 2007;
It has constant axial vessels, appropriate pedicle length, large skin paddle, wide pivotal movement and well hidden scar in donor area (Tan et al., 2006). In this article, variants of this flap for intraoral reconstruction are discussed. 2. Materials and Methods
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This article pays attention to the anatomy of submental region, and especially to the submental artery and vein, muscles and lymphatics. Surgical techniques for possible variants of this flap and examples of each situation are presented. Indications of submental flap for facial, oesophageal, pharyngeal,
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laryngeal, and oral cavity reconstruction were assessed.
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2.1. Anatomical assessment 2.1.1: Submental artery
The Submental artery is a constant branch of the facial artery. It has also the largest diameter of the branches of the facial artery in the neck (Jiang et al., 2008). It's diameter at origin is reported between 1.2-2mm (Zhang et al., 1997; Li et al., 2007). It originates from the facial artery 27.5 mm distal to the division of facial artery from the external carotid artery. It has five main branches in the course toward the midline and anastomoses in 92% of cases with contralateral artery (Magden et al., 2004).This artery is located medial to the mandibular inferior border (Kimet al., 2012). Its branches are as follows: a, Glandular branches to the submandibular and sublingual salivary glands. b, Myelohyoid branch. c)
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ACCEPTED MANUSCRIPT Mandibular periosteal branch. d), Digastric branch. e), Skin perforator branches (Hwanget al., 2005; Ishihara et al., 2008).This artery communicates with the inferior alveolar artery through intramandibular anastomosis, sublingual artery in floor of mouth, myelohyoid and mental artery (Kawai et al., 2006; Molnar et al., 2012). It is the main blood supply of floor of mouth in 60% of cases (Bavitz et al., 1994). The anterior end of this artery passes bellow anterior belly of digastric muscle in
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56%-81% of cases (Fig .1) (Atamaz Pinar et al., 2005; Li et al., 2007; Patel et al., 2007). It has 2-4 skin perforator branches. Major (constant) perforator branches (one or two) pass medial or lateral to anterior belly of digastric muscle and minor perforators pass through the anterior belly of digastric
al., 2010).
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2.1.2. Veins in submental region (Matsui et al., 2009)
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muscle (Potter et al., 2012).These skin perforators participate in the rich subdermal plexus (Matsui et
There are three sources of venous drainage in the submental region:
a) Concomitant submental veins: these are one pair and are in close relation with submental artery. They pass superficial to the submandibular salivary gland and drain into the facial vein.
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b) Large superficial vein reaching the lateral border of anterior belly of digastric muscle. c) Anterior jugular veins: They are located near the midline and drain into external jugular vein. These
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veins will intentionally be ligated in the submental artery island flap elevation procedure. 2.1.3. Muscles and lymphatics (Hatef et al., 2009)
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In the submental region, there is a superficial compartment of submental fat and platysma muscle, under the skin. The anterior bellies of the digastric muscles are located deeper and the myelohyoid muscle is located deep to the digastric muscles. 3. Results
Ninety studies meeting the inclusion criteria were reviewed. Major modifications such as pedicled, free, and perforator flaps are discussed comprehensively and minor variants of submental flap such as bipaddled, bipedicled, expanded, deepithelialized, and interposition submental flaps are discussed, briefly.
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ACCEPTED MANUSCRIPT 3.1. Classification of submental artery island flap based on the flap composition 3.1.1. Myocutaneous flaps Pedicled flaps can have the same thickness in the distal half (thin flap) or may be more bulky with the inclusion of the anterior belly of digastric and myelohyoid muscles (thick flap). Inclusion of the the
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anterior belly of digastric and myelohyoid muscle increases the blood supply of the flap. 3.1.2. Osteomuscular flap
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This is a composite flap and the paddle can include some segment of the inferior mandibular border. It is possible to incorporate the full thickness of the inferior mandibular border or the surgeon can only
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use the lingual cortex (inner mandibular cortex). In the former, the donor mandible needs to be reconstructed while in the later there in no need for reconstruction of donor site. With full thickness inferior mandibular rim harvest, the surgeon has to consider the distance to the inferior dental canal before performing the vertical bony cuts. Using the full thickness of the inferior mandibular border in the flap has sufficient thickness for insertion of dental implants (simultaneously
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or delayed) while the lingual mandibular cortex is thin and needs further augmentation for dental implant insertion. The bone transferred by this flap can be used for maxillary or zygomatic reconstruction after resection of benign or malignant lesions.
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3.2. Classification of submental artery island flap based on blood supply 3.2.1. Pedicled flap: The Submental artery island flap can be pedicled inferiorly or superiorly.
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Inferiorly pedicled or orthograde variant depends on intact facial artery for blood perfusion. Superiorly pedicled, retrograde or reverse flow variant depends on retrograde flow of blood stream through anastomosis of angular artery with facial artery (Fig .2). The infraorbital artery and transverse facial artery also have important roles. 3.2.2. Free flap: This flap is a good choice for microvascular anastomosis, based on the external diameter of submental artery/ vein and pedicle length.
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ACCEPTED MANUSCRIPT 3.2.3. Perforator flap: If the surgeon preserves the submental perforator vessels, it is not necessary to include the platysma muscle in a submental flap, so it is possible to raise a thin flap based on the vascular pedicle of the submental artery. 3.3. Minor modifications of the submental artery island flap
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3.3.1. Bipaddled: This modification is useful for reconstruction of through and through cheek defects. This flap contains two skin paddles with raw intervening tissue (deepthelialized tissue). One skin paddle covers the skin defect and the other is used for intraoral reconstruction (Fig.3).
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3.3.2. Bipedicled: This variant receives its blood supply from the facial arteries bilaterally, so it has more blood perfusion.
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It can be used for reconstruction of soft tissue defects of upper lip. A disadvantage of this flap is limited mobility and its advantage is increased blood supply (Fig.4).
3.3.3. Expanded submental flap: A soft tissue expander can be used in submental region bellow the platysma and then added soft tissue and the increased skin paddle can be transferred by the flap.
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3.3.4. Deepithelialized submental flap: Removing hair containing skin during the first operation will solve the problem of hair for intra oral reconstruction in male patients. Other options are laser ablation or removing hairs in a second procedure 6 weeks after the first operation, .
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3.3.5. Interposition submental flap: In most cases, the submental flap is used as a lining or forcoverage. In some situations this flap can be used for soft tissue augmentation as interposition flap;
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such as reconstruction of facial deformities in hemifacial microsomia. 4. Discussion
It is now twenty years since reconstructive surgeons started to use the submental flap. Martin in 1993 described it as a modification of cervical flaps and also made some suggestions like;" distally based flap, osteocutaneous flap and using tissue expanders", that were followed by others and lead to the introduction of new modifications(Table1) (Martin et al.,1993; Faltaous and Yetman 1996; Sterne et al., 1996; Curran et al., 1997; Yilmaz et al., 1997; Janssen et al., 1998; Kitazawa et al., 1999; Kim et
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ACCEPTED MANUSCRIPT al., 2002; Tan et al., 2007). In this table a historical look at this topic is presented to show how and by who advances in submental flap were made. The Submental artery island flap is used for reconstruction of facial skin, oropharynx, esophagus and nasopharynx after surgical resections or traumatic events(Li et al., 2009; Parmar and Goldstein 2009;
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Chen F et al., 2009; Kau et al., 2010; Ramkumar et al., 2012; Wang et al., 2012). It is an ideal flap for facial skin reconstruction, because it replaces the tissue removed with a tissue of the same colour and consistency. The Submental flap has a thin and pliable tissue which is a perfect match for facial skin, and in males the flap hairs resembles that of beard and moustache considering
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their density, colour, and quality(Fig. 5) (Hatef et al., 2009; Sun et al., 2013).
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The submental artery has a vital role in blood perfusion of this flap. This artery is the main source of blood supply in the superiorly based platysmal myocutaneous flap, digastric muscle flap and myelohyoid flap (Aszmann et al., 1998; Chen et al., 1999; Savoldelli et al., 2008). In dentoalveolar and implant surgery, knowing the anatomy of this artery is important for prevention and management of life threatening haemorrhage in floor of mouth (Del Castillo-Pardo de Vera et al., 2008; Fujita et al.,
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2012; Katsumi et al., 2013). The donor site is located in the submental region and is often closed primarily with a good inconspicuous scar (Varghese, 2011; Lee et al., 2013). The skin paddle of the flap is elliptical with the first incision in the submental crease, 1.5cm behind the inferior mandibular border. Skin pinch test determines the width of the flap (Chen et al., 2009 a). Skin paddles as large as
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16 × 8cm have been reported (Uppin et al., 2009).
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For increasing skin paddle size, the use of expanders in the submental region is recommended (Tan et al., 2007).
For patients in who a pinch test shows little available skin, subcutaneous dissection in the subdermal plane and use of deepithelialized variant is the solution. A V-Y advancement flap for repairing submental defect to obtain larger skin paddle should also be considered (Chen et al., 2009 b). There are two ways to increase pedicle length in the orthograde variant; dissection of the facial artery through the submandibular salivary gland and ligation and cutting it after submental artery branch division. A reverse flow submental flap with ligation/cuting of the facial artery proximal to the division of submental artery gives the flap more mobility (Fig.6).
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ACCEPTED MANUSCRIPT A Penrose drain was recommended for prevention of hematoma in submental region, but it is not necessary and leads to unaesthetic scar (Genden et al., 2004). In old patients, this flap can reduce the submental fullness, so it has positive aesthetic results (Pelissier et al., 1997). Possible complications in the donor site include hypertrophic scar, wound dehiscence and orocutaneous fistula
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formation (Multinu et al., 2007; Carpentier et al., 2008). A pedicled submental flap with orthograde blood supply is used for reconstruction in the oral cavity particularly in retromolar pad, tongue, floor of mouth, mandibular alveolar ridge, and buccal mucosa.
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Reconstruction of the palate and maxillary alveolar ridge using a retrograde variant is possible, this procedure needs facial artery/vein ligation and cutting, proximal to the submental artery division from
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facial artery. Orthograde variant with dissection of the facial artery to the origin (external carotid artery) can also be used for palatomaxillary reconstruction (Curran et al., 1997; Genden et al., 2004). Another complication of submental flap harvest is the possibility of damage to the marginal mandibular nerve (Yamauchi et al., 2010). For preventing this possible complication supraplatysmal dissection was introduced as a less dangerous dissection (Kannan, 2013). Permanent injury to this
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nerve in experienced hands is relatively uncommon.
The retrograde variant relies on anastomosis between the external and internal carotid arteries via the angular artery (Chen et al., 2011). The presence of facial vein valves can lead to flap necrosis,
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although the majority of authors have reported good results in this flap and the reverse flow facial artery flap is supported by scientific experiment (Rojananin et al., 1996).
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The retrograde variant is also described for reconstruction of facial skin in midface, periorbital area, orbital socket, inferior temple area, auricle, and oropharynx (Karaça et al., 2006; Chen et al., 2010; Bakhos et al., 2011; Zhang et al., 2011). A free submental artery flap is also possible, because of the large diameter of submental artery/ vein and its appropriate size of pedicle (Higgins and Backstein, 2007). It is described for nasal reconstruction and in lower extremity lymphpoedema (elephantiasis) in which submental lymph node transplant establishes lymph drainage and bypasses lymphatic vessel occlusion (Pistre et al., 2001; Burić et al., 2010; Cheng et al., 2012). Because of the vicinity of the donor site to the oral cavity, a free submental flap is not used in oral cavity reconstruction. Submental flaps are successfully transferred in patients with a history of radiotherapy in head and neck region;
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ACCEPTED MANUSCRIPT however it is a possible cause of failure in limited cases (Wu et al., 2002; Taghinia et al., 2009).This flap needs an intact facial artery/vein for success, so it is contraindicated in patients with a history of neck dissection in which the facial artery and vein are sacrificed (Jianget al., 2006). A deepithelialized variant was introduced for solving the problem of hair in intraoral, oropharyngeal, and laryngeal reconstruction in the male patients (Vural and Suen, 2000; Lee et al., 2013). The interposition
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submental flap lies within a soft tissue pocket, so deepithelialization is necessary even in female patients. Deepithelialization depends on the migration of epithelial cells (basal cells) from the adjacent mucosa (secondary epithelialization) (Cheung et al., 1997). The submental flap is mainly used for
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reconstruction of oral cavity defects after cancer surgery, particularly after squamous cell carcinoma (SCC) ablation (Amin et al., 2011; ZHANG et al., 2012).There are some concerns about oncologic safety of this flap (Merten et al., 2002; Paydarfar and Patel, 2011). Possible limitations of this flap in
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the management of intraoral SCCs are posibility of metastatic tissue transfer with this flap and cancer recurrence in the flap base; therefore it is widely accepted that this flap should not be used in clinical/radiographic positive necks, although reverse flow submental flaps that do not rely on intact facial artery/vein are used concomitant with radical neck surgery (Chen et al., 2007; Wang et al., 2011). In the orthograde variant, if the results of cervical lymph node frozen sections become positive,
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this flap should not be used and the surgeon should consider a more aggressive procedure with facial artery and vein sacrifice. This flap is recommended for intraoral reconstruction after SCC ablation with supraomohyoid neck dissection and preservation of the facial artery and vein (Chen et al., 2008).
et al., 2008).
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Surveillance of the submental flap is good (Jiang et al., 2000; Li, 2005; Chow et al., 2007; Sebastian
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Theoretically the failure rate will increase when the patient has a positive history of radiotherapy, when retrograde blood flow flap is used or when supraplatysmal small dissection technique is applied, but in clinical practice, they all work well. Ultrasound colour Doppler with facial artery/vein and skin perforator localization will dramatically reduce the failure rate (Yamauchi et al., 2010). Submental intubation is not possible when a submental artery island flap is considered for reconstruction (Eipeet al., 2005). The term "submental flap" should not be used for all skin island pedicle flaps that use submental skin for reconstruction (Thornton and Reece, 2008). According to the definition, the submental artery island flap is a pedicled skin island flap that contains an axial vessel (submental artery) in its pedicle (Kimyai-Asadi and Goldberg, 2005). The combination of a submental flap and
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ACCEPTED MANUSCRIPT other flaps is described in the literature. Submental and nasolabial flaps for reconstruction of oral commissure, upper and lower lip; submental flap accompanying toe web for reconstruction of lower lip and oral commissure and submental flap with superficial temporal fascia for treatment of noma have been described (Koshima et al., 2000; Daya et al., 2001; Barthélémy et al., 2002).
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5. Conclusion Classification of this flap is based on blood supply and composition of the flap paddle. It has a wide arc of rotation. It is easy to raise and has low donor site morbidity. The Submental artery island flap is
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safe and is a simple and predictable technique for oral cavity reconstruction.
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periorbital soft tissue and socket reconstruction. Head Neck 28:40 45, 2006 Kau RL, Kim N, Hinni ML, Patel NP: Repair of esophageal perforation due to anterior cervical spine instrumentation. Laryngoscope 120:739 742, 2010
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island flap in facial soft tissue defect]. Zhonghua Zheng Xing Wai Ke Za Zhi 25:419 421, 2009 Li L, Gao XL, Song YZ, Xu H, Yu GY, Zhu ZH, Liu JM: Anatomy of arteries and veins of submandibular glands. Chin Med J (Engl) 120:1179 1182, 2007
Li Z: [Repairing defects of tongue and mouth floor with submental island flap after tumor surgery].
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Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 19:786 788, 2005
Magden O, Edizer M, Tayfur V, Atabey A: Anatomic study of the vasculature of the submental artery flap. Plast Reconstr Surg 114:1719 1723, 2004
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Markeeva E, Trémezaygues L, Vogt T, Rass K: Submental transposition flap for a large defect after
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excision of a recurrent basal cell carcinoma on the chin. J Dtsch Dermatol Ges 10:846 848, 2012 Martin D, Pascal JF, Baudet J, Mondie JM, Farhat JB, Athoum A, et.al: The submental island flap: a new donor site. Anatomy and clinical applications as a free or pedicled flap. Plast Reconstr Surg 92:867 873, 1993 Matsui A, Lee BT, Winer JH, Laurence RG, Frangioni JV: Predictive capability of near-infrared fluorescence angiography in submental perforator flap survival. Plast Reconstr Surg 126:1518 1527, 2010
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ACCEPTED MANUSCRIPT Matsui A, Lee BT, Winer JH, Laurence RG, Frangioni JV: Submental perforator flap design with a near-infrared fluorescence imaging system: the relationship among number of perforators, flap perfusion, and venous drainage. Plast Reconstr Surg 124:1098 1104, 2009 Merten SL, Jiang RP, Caminer D: The submental artery island flap for head and neck reconstruction.
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ANZ J Surg 72:121-4, 2002 Molnar G, Plachtovics M, Baksa G, Patonay L, Mommaerts MY: Intraosseous territory of the facial artery in the maxilla and anterior mandible: implications for allotransplantation. J Craniomaxillofac
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Surg 40:180 184, 2012
Multinu A, Ferrari S, Bianchi B, Balestreri A, Scozzafava E, Ferri A, et al: The submental island flap in
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head and neck reconstruction. Int J Oral Maxillofac Surg 36:716 720, 2007
Patel UA, Bayles SW, Hayden RE; The submental flap: A modified technique for resident training. Laryngoscope 117:186 189, 2007
Parmar PS, Goldstein DP: The submental island flap in head and neck reconstruction. Curr Opin
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Otolaryngol Head Neck Surg 17:263 266, 2009
Paydarfar JA, Patel UA: Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 137:82 87, 2011
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Pelissier P, Casoli V, Martin D, Demiri E, Baudet J: [Submentalisland flaps. Surgical technique and possible variations in facial reconstruction]. Rev Laryngol Otol Rhinol (Bord) 118:39 42, 1997
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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 28:303 309, 2001 Potter S, De Blacam C, Kosutic D: True submental artery perforator flap for total soft-tissue chin reconstruction. Microsurgery 32:502 504, 2012 Ramkumar A, Francis NJ, Senthil Kumar R, Dinesh Kumar S: Bipaddledsubmental artery flap. Int J Oral MaxillofacSurg41:458 460, 2012
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ACCEPTED MANUSCRIPT Rojananin S, Igarashi T, Ratanavichitrasin A, Lertakayamanee N, Ruksamanee A: Experimental study of the facial artery: relevance to its reverse flow competence and cutaneous blood supply of the neck for clinical use as a new flap. Head Neck 18:17 23, 1996 Savoldelli C, Castillo L, Guevara N, Santini J, Odin G: [The superior pedicledplatysma-myocutaneous
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flap]. Rev StomatolChirMaxillofac109:98 102, 2008 Sebastian P, Thomas S, Varghese BT, Iype EM, Balagopal PG, Mathew PC: The submental island flap for reconstruction of intraoral defects in oral cancer patients. Oral Oncol 44:1014 1018, 2008
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Shi CL, Wang XC: Reconstruction of lower face defect or deformity with submental artery perforator flaps. Ann Plast Surg 69:41 44, 2012
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Squaquara R, Kim Evans KF, Spanio di Spilimbergo S, Mardini S: Intraoral reconstruction using local and regional flaps. Semin Plast Surg 24:198 211, 2010
Sterne GD, Januszkiewicz JS, Hall PN, Bardsley AF: The submental island flap.Br J Plast Surg 49:85 89, 1996
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Sun G, Lu M, Hu Q: Reconstruction of extensive lip and perioral defects after tumor excision. J Craniofac Surg 24:360 362, 2013
Taghinia AH, Movassaghi K, Wang AX, Pribaz JJ: Reconstruction of the upper aerodigestive tract
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with the submental artery flap. Plast Reconstr Surg 123:562 570, 2009 Tan O, Atik B, Parmaksizoglu D: Soft-tissue augmentation of the middle and lower face using the
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deepithelialized submental flap. Plast Reconstr Surg 119:873 879, 2007 Tan O, Kiroglu AF, Atik B, Yuca K: Reconstruction of the columella using the prefabricated reverse flow submental flap: A case report. Head Neck 28:653 657, 2006 Thornton JF, Reece EM: Submental pedicled perforator flap: V-Y advancement for chin reconstruction. J Oral Maxillofac Surg 66:2633 2637, 2008 Tosco P, Garzino-Demo P, Ramieri G, Tanteri G, Pecorari G, Caldarelli C, et al:The platysma myocutaneous flap (PMF) for head and neck reconstruction: a retrospective and multicentric analysis of 91 T1-T2 patients. J Craniomaxillofac Surg 40:e415 418, 2012
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ACCEPTED MANUSCRIPT Uppin SB, Ahmad QG, Yadav P, Shetty K: Use of the submental island flap in orofacial reconstruction--a review of 20 cases. J Plast Reconstr Aesthet Surg 62: 514 519, 2009 Varghese BT: Optimal design of a submental artery island flap. J Plast Reconstr Aesthet Surg 64:e183 184, 2011
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Vural E, Suen JY: The submental island flap in head and neck reconstruction. Head Neck 22:572 578, 2000
Wang JG, Chen WL, Ye HS, Yang ZH, Chai Q: Reverse facial artery-submental artery
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deepithelialised submental island flap to reconstruct maxillary defects following cancer ablation. J Craniomaxillofac Surg 39:499 502, 2011
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Wang WH, Hwang TZ, Chang CH, Lin YC: Reconstruction of pharyngeal defects with a submental island flap after hypopharyngeal carcinoma ablation. ORL J Otorhinolaryngol Relat Spec 74:304 309, 2012
Wu Y, Tang P, Qi Y, Xu Z, He Y: [Evaluation for submental island flap]. Zhonghua Kou Qiang Yi Xue
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Za Zhi 37:418 420, 2002
Yamauchi M, Yotsuyanagi T, Ezoe K, Saito T, Ikeda K, Arai K: Reverse facial artery flap from the submental region.J Plast Reconstr Aesthet Surg 63:583 588, 2010
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Yang X, Wen SX, Wang BQ: [Two cases of repair of pharyngocutaneous fistulas following supraglotticlaryngectomy with submental turnover skin flap]. Zhonghua Er Bi Yan HouTou Jing Wai
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Ke Za Zhi 45:1045 1046, 2010
Yilmaz M, Menderes A, Barutçu A: Submental artery island flap for reconstruction of the lower and mid face. Ann Plast Surg 39:30 35, 1997 You YH, Chen WL, Wang YP, Liang J: The feasibility of facial-submental artery island myocutaneous flaps for reconstructing defects of the oral floor following cancer ablation. OralSurg Oral Med Oral Pathol Oral Radiol Endod 109: e12 16, 2010
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ACCEPTED MANUSCRIPT Zhang B, Wang JG, Chen WL, Yang ZH, Huang ZQ: Reverse facial-submental artery island flap for reconstruction of oropharyngeal defects following middle and advanced-stage carcinoma ablation. Br J Oral Maxillofac Surg 49:194 197, 2011 Zhang CC, Wang JG, Yue ZL, Huang HZ, Chen WL, Pan CB, et al: [Clinical study of submental artery
Zhonghua Er Bi Yan HouTou Jing Wai Ke Za Zhi 47:285 288, 2012
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island myocutaneous flap for reconstruction of oral and maxillofacial defects following operation].
Zhang H, Yan Y, Sun G: [Applied anatomy of the submental vessels and submental flaps]. Zhonghua
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Zheng Xing Shao Shang Wai Ke Za Zhi 13:288 290, 1997
Figures
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Figure 1. a, Submental artery branches .b, Skin perforator branch of submental artery. Figure2. Submentalpedicle flap. a, Orthograde variant. b, Retrograde variant. Figure3. Bipaddled submental flap (schematic figure).
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Figure 4. Bipedicled submental flap (schematic picture).
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Figure 5. Submental flap for reconstruction of through and through cheek defect resulted from gunshot wound.
Figure 6. Four ways for increasing pedicle length. a, Dissection of submental artery through submandibular salivary gland or total removal of the gland. b, Dissection of facial vessels to the origin(external carotid artery) c, Ligation/cut of facial artery distal to division of submental artery. d, Ligation/cut of facial artery proximal to division of submental artery in reverse flow (retrograde) variant. The facial vein is not shown for simplicity.
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Table 1: The role of pioneer surgeons in introducing and improving submental flap characteristics. Year
Martin et al.
1993
Modification 1) Original description of the flap
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Pioneer surgeons
2) Free submental flap
Curran et al.
Retrograde variant
1996(cadaver) Inclusion
of anterior belly
of
1997(patient) digastric muscle in pedicle half
Yilmaz et al.
1997
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Faltaous and Yetman
1996
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Sterne et al.
Deepithelialized
osteomuscular
variant
1998
kitazawa et al.
1999
Kim et al.
2002
Tan et al.
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Janssen and Thimsen
2007
Patel et al.
Extended
Bipedicled
Perforator submental flap
Interposition Inclusion of mylohyoid muscle in
Li et al.
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2007
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Ramkumar et al.
pedicle half
2009
Expanded
2012
Bipaddled
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PII:
S1010-5182(14)00021-3
DOI:
10.1016/j.jcms.2014.01.020
Reference:
YJCMS 1704
To appear in:
Journal of Cranio-Maxillofacial Surgery
Received Date: 15 July 2013 Revised Date:
18 September 2013
Accepted Date: 3 January 2014
Please cite this article as: Rahpeyma A, khajehahmadi S, Submental artery island flap in intraoral reconstruction: a review, Journal of Cranio-Maxillofacial Surgery (2014), doi: 10.1016/ j.jcms.2014.01.020. 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.
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Titel: Submental artery island flap in intraoral reconstruction:
Running title: Submental artery island flap 1. Amin Rahpeyma
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a review
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Affiliation: Assistant Professor of Oral and Maxillofacial Surgery, Oral and Maxillofacial Diseases Research Center, School of Dentistry, Mashhad University of Medical Sciences. Postal Address: Oral and Maxillofacial Surgery, Oral and Maxillofacial Diseases Research Center of Mashhad University of Medical Sciences ,Vakilabad Blvd, Mashhad, Iran
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E-mail Address: [email protected]
Work Telephone Number: +98(511)8829501 Work Fax Number: + 98(511)8829500
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2. Saeedeh khajehahmadi*
Affiliation: Assistant Professor of Oral and Maxillofacial Pathology, Dental Research
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Center , School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran. *Correspondence:
Dr. Saeedeh khajehahmadi Postal Address: Dental Research Center of Medical Sciences, Mashhad, Iran. Vakilabad Blvd, Mashhad, Iran
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Work Telephone Number: +98(511)8829501 Work Fax Number: + 98(511)8829500
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Email: [email protected] and
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[email protected]
ACCEPTED MANUSCRIPT Title: Submental artery island flap in intraoral reconstruction: a review Abstract Background: The Submental flap was first introduced 20 years ago (1993). Advances in techniques and new findings from anatomic studies expanded the indications and improved the flap
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characteristics. Indications, limitation, and all possible variants of this flap are discussed comprehensively in this article.
Materials and Methods: A literature review was performed. We paid attention to the anatomy of submental region, and especially to submental artery and vein, muscles and lymphatics. Surgical
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techniques for each possible variant of this flap and examples of each situation are presented. Indications of submental flap for facial, oesophageal, pharyngeal, laryngeal, and oral cavity
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reconstruction were assessed.
Results: Ninety studies meeting the inclusion criteria were reviewed. Classification of the submental flap based on skin paddle composition and blood supply is presented. Major modifications such as pedicled, free, and perforator flaps are discussed comprehensively and minor variants of submental flap such as bipaddled, bipedicled, expanded, deepithelialized, and interposition submental flaps are
submental flap were done.
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discussed, briefly. A historical look at this topic is presented to show how and by whom advances in
Conclusion: The Submental flap has a wide arc of rotation; it is easy to rise and has low donor site
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morbidity. It is a safe, simple, and predictable method for reconstruction of oral cavity.
Key words: Submental flap/ Oral reconstruction/ Submental artery.
1. Introduction Reconstruction of the oral cavity after surgical resections is an interesting topic. Pedicled flaps have vital role in reconstruction of medium to large sized defects of oral cavity (Squaquara et al., 2010; Tosco et al., 2012). The Submentalflap was first introduced by Martin in 1993 and was widely
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ACCEPTED MANUSCRIPT accepted by reconstructive surgeons working in the field of maxillofacial or head & neck reconstruction (Martin et al., 1993). Classification of this flap is based on blood supply and composition of the flap paddle. It has a wide arc of rotation, so it can be used for reconstruction of skin and tissues in the neck inferior to the submental region such as larynx and oesophagus or tissue above the submental region in such as facial skin, oral cavity and oro-nasopharynx (Yang et al.,
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2010;You et al., 2010; Shi and Wang, 2012).
For skin reconstruction it is mainly used as a pedicled interpolated flap, but a transposition variant in which the edge of skin defect is in the line with the edge of the flap's skin paddle and free flap variant
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Ahmad and Shankhdhar, 2010; Markeeva et al., 2012).
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in which recipient site is far away from submental region is also available (Abouchadi et al., 2007;
It has constant axial vessels, appropriate pedicle length, large skin paddle, wide pivotal movement and well hidden scar in donor area (Tan et al., 2006). In this article, variants of this flap for intraoral reconstruction are discussed. 2. Materials and Methods
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This article pays attention to the anatomy of submental region, and especially to the submental artery and vein, muscles and lymphatics. Surgical techniques for possible variants of this flap and examples of each situation are presented. Indications of submental flap for facial, oesophageal, pharyngeal,
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laryngeal, and oral cavity reconstruction were assessed.
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2.1. Anatomical assessment 2.1.1: Submental artery
The Submental artery is a constant branch of the facial artery. It has also the largest diameter of the branches of the facial artery in the neck (Jiang et al., 2008). It's diameter at origin is reported between 1.2-2mm (Zhang et al., 1997; Li et al., 2007). It originates from the facial artery 27.5 mm distal to the division of facial artery from the external carotid artery. It has five main branches in the course toward the midline and anastomoses in 92% of cases with contralateral artery (Magden et al., 2004).This artery is located medial to the mandibular inferior border (Kimet al., 2012). Its branches are as follows: a, Glandular branches to the submandibular and sublingual salivary glands. b, Myelohyoid branch. c)
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ACCEPTED MANUSCRIPT Mandibular periosteal branch. d), Digastric branch. e), Skin perforator branches (Hwanget al., 2005; Ishihara et al., 2008).This artery communicates with the inferior alveolar artery through intramandibular anastomosis, sublingual artery in floor of mouth, myelohyoid and mental artery (Kawai et al., 2006; Molnar et al., 2012). It is the main blood supply of floor of mouth in 60% of cases (Bavitz et al., 1994). The anterior end of this artery passes bellow anterior belly of digastric muscle in
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56%-81% of cases (Fig .1) (Atamaz Pinar et al., 2005; Li et al., 2007; Patel et al., 2007). It has 2-4 skin perforator branches. Major (constant) perforator branches (one or two) pass medial or lateral to anterior belly of digastric muscle and minor perforators pass through the anterior belly of digastric
al., 2010).
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2.1.2. Veins in submental region (Matsui et al., 2009)
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muscle (Potter et al., 2012).These skin perforators participate in the rich subdermal plexus (Matsui et
There are three sources of venous drainage in the submental region:
a) Concomitant submental veins: these are one pair and are in close relation with submental artery. They pass superficial to the submandibular salivary gland and drain into the facial vein.
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b) Large superficial vein reaching the lateral border of anterior belly of digastric muscle. c) Anterior jugular veins: They are located near the midline and drain into external jugular vein. These
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veins will intentionally be ligated in the submental artery island flap elevation procedure. 2.1.3. Muscles and lymphatics (Hatef et al., 2009)
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In the submental region, there is a superficial compartment of submental fat and platysma muscle, under the skin. The anterior bellies of the digastric muscles are located deeper and the myelohyoid muscle is located deep to the digastric muscles. 3. Results
Ninety studies meeting the inclusion criteria were reviewed. Major modifications such as pedicled, free, and perforator flaps are discussed comprehensively and minor variants of submental flap such as bipaddled, bipedicled, expanded, deepithelialized, and interposition submental flaps are discussed, briefly.
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anterior belly of digastric and myelohyoid muscle increases the blood supply of the flap. 3.1.2. Osteomuscular flap
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This is a composite flap and the paddle can include some segment of the inferior mandibular border. It is possible to incorporate the full thickness of the inferior mandibular border or the surgeon can only
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use the lingual cortex (inner mandibular cortex). In the former, the donor mandible needs to be reconstructed while in the later there in no need for reconstruction of donor site. With full thickness inferior mandibular rim harvest, the surgeon has to consider the distance to the inferior dental canal before performing the vertical bony cuts. Using the full thickness of the inferior mandibular border in the flap has sufficient thickness for insertion of dental implants (simultaneously
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or delayed) while the lingual mandibular cortex is thin and needs further augmentation for dental implant insertion. The bone transferred by this flap can be used for maxillary or zygomatic reconstruction after resection of benign or malignant lesions.
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3.2. Classification of submental artery island flap based on blood supply 3.2.1. Pedicled flap: The Submental artery island flap can be pedicled inferiorly or superiorly.
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Inferiorly pedicled or orthograde variant depends on intact facial artery for blood perfusion. Superiorly pedicled, retrograde or reverse flow variant depends on retrograde flow of blood stream through anastomosis of angular artery with facial artery (Fig .2). The infraorbital artery and transverse facial artery also have important roles. 3.2.2. Free flap: This flap is a good choice for microvascular anastomosis, based on the external diameter of submental artery/ vein and pedicle length.
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3.3.1. Bipaddled: This modification is useful for reconstruction of through and through cheek defects. This flap contains two skin paddles with raw intervening tissue (deepthelialized tissue). One skin paddle covers the skin defect and the other is used for intraoral reconstruction (Fig.3).
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3.3.2. Bipedicled: This variant receives its blood supply from the facial arteries bilaterally, so it has more blood perfusion.
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It can be used for reconstruction of soft tissue defects of upper lip. A disadvantage of this flap is limited mobility and its advantage is increased blood supply (Fig.4).
3.3.3. Expanded submental flap: A soft tissue expander can be used in submental region bellow the platysma and then added soft tissue and the increased skin paddle can be transferred by the flap.
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3.3.4. Deepithelialized submental flap: Removing hair containing skin during the first operation will solve the problem of hair for intra oral reconstruction in male patients. Other options are laser ablation or removing hairs in a second procedure 6 weeks after the first operation, .
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3.3.5. Interposition submental flap: In most cases, the submental flap is used as a lining or forcoverage. In some situations this flap can be used for soft tissue augmentation as interposition flap;
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such as reconstruction of facial deformities in hemifacial microsomia. 4. Discussion
It is now twenty years since reconstructive surgeons started to use the submental flap. Martin in 1993 described it as a modification of cervical flaps and also made some suggestions like;" distally based flap, osteocutaneous flap and using tissue expanders", that were followed by others and lead to the introduction of new modifications(Table1) (Martin et al.,1993; Faltaous and Yetman 1996; Sterne et al., 1996; Curran et al., 1997; Yilmaz et al., 1997; Janssen et al., 1998; Kitazawa et al., 1999; Kim et
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ACCEPTED MANUSCRIPT al., 2002; Tan et al., 2007). In this table a historical look at this topic is presented to show how and by who advances in submental flap were made. The Submental artery island flap is used for reconstruction of facial skin, oropharynx, esophagus and nasopharynx after surgical resections or traumatic events(Li et al., 2009; Parmar and Goldstein 2009;
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Chen F et al., 2009; Kau et al., 2010; Ramkumar et al., 2012; Wang et al., 2012). It is an ideal flap for facial skin reconstruction, because it replaces the tissue removed with a tissue of the same colour and consistency. The Submental flap has a thin and pliable tissue which is a perfect match for facial skin, and in males the flap hairs resembles that of beard and moustache considering
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their density, colour, and quality(Fig. 5) (Hatef et al., 2009; Sun et al., 2013).
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The submental artery has a vital role in blood perfusion of this flap. This artery is the main source of blood supply in the superiorly based platysmal myocutaneous flap, digastric muscle flap and myelohyoid flap (Aszmann et al., 1998; Chen et al., 1999; Savoldelli et al., 2008). In dentoalveolar and implant surgery, knowing the anatomy of this artery is important for prevention and management of life threatening haemorrhage in floor of mouth (Del Castillo-Pardo de Vera et al., 2008; Fujita et al.,
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2012; Katsumi et al., 2013). The donor site is located in the submental region and is often closed primarily with a good inconspicuous scar (Varghese, 2011; Lee et al., 2013). The skin paddle of the flap is elliptical with the first incision in the submental crease, 1.5cm behind the inferior mandibular border. Skin pinch test determines the width of the flap (Chen et al., 2009 a). Skin paddles as large as
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16 × 8cm have been reported (Uppin et al., 2009).
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For increasing skin paddle size, the use of expanders in the submental region is recommended (Tan et al., 2007).
For patients in who a pinch test shows little available skin, subcutaneous dissection in the subdermal plane and use of deepithelialized variant is the solution. A V-Y advancement flap for repairing submental defect to obtain larger skin paddle should also be considered (Chen et al., 2009 b). There are two ways to increase pedicle length in the orthograde variant; dissection of the facial artery through the submandibular salivary gland and ligation and cutting it after submental artery branch division. A reverse flow submental flap with ligation/cuting of the facial artery proximal to the division of submental artery gives the flap more mobility (Fig.6).
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formation (Multinu et al., 2007; Carpentier et al., 2008). A pedicled submental flap with orthograde blood supply is used for reconstruction in the oral cavity particularly in retromolar pad, tongue, floor of mouth, mandibular alveolar ridge, and buccal mucosa.
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Reconstruction of the palate and maxillary alveolar ridge using a retrograde variant is possible, this procedure needs facial artery/vein ligation and cutting, proximal to the submental artery division from
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facial artery. Orthograde variant with dissection of the facial artery to the origin (external carotid artery) can also be used for palatomaxillary reconstruction (Curran et al., 1997; Genden et al., 2004). Another complication of submental flap harvest is the possibility of damage to the marginal mandibular nerve (Yamauchi et al., 2010). For preventing this possible complication supraplatysmal dissection was introduced as a less dangerous dissection (Kannan, 2013). Permanent injury to this
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nerve in experienced hands is relatively uncommon.
The retrograde variant relies on anastomosis between the external and internal carotid arteries via the angular artery (Chen et al., 2011). The presence of facial vein valves can lead to flap necrosis,
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although the majority of authors have reported good results in this flap and the reverse flow facial artery flap is supported by scientific experiment (Rojananin et al., 1996).
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The retrograde variant is also described for reconstruction of facial skin in midface, periorbital area, orbital socket, inferior temple area, auricle, and oropharynx (Karaça et al., 2006; Chen et al., 2010; Bakhos et al., 2011; Zhang et al., 2011). A free submental artery flap is also possible, because of the large diameter of submental artery/ vein and its appropriate size of pedicle (Higgins and Backstein, 2007). It is described for nasal reconstruction and in lower extremity lymphpoedema (elephantiasis) in which submental lymph node transplant establishes lymph drainage and bypasses lymphatic vessel occlusion (Pistre et al., 2001; Burić et al., 2010; Cheng et al., 2012). Because of the vicinity of the donor site to the oral cavity, a free submental flap is not used in oral cavity reconstruction. Submental flaps are successfully transferred in patients with a history of radiotherapy in head and neck region;
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submental flap lies within a soft tissue pocket, so deepithelialization is necessary even in female patients. Deepithelialization depends on the migration of epithelial cells (basal cells) from the adjacent mucosa (secondary epithelialization) (Cheung et al., 1997). The submental flap is mainly used for
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reconstruction of oral cavity defects after cancer surgery, particularly after squamous cell carcinoma (SCC) ablation (Amin et al., 2011; ZHANG et al., 2012).There are some concerns about oncologic safety of this flap (Merten et al., 2002; Paydarfar and Patel, 2011). Possible limitations of this flap in
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the management of intraoral SCCs are posibility of metastatic tissue transfer with this flap and cancer recurrence in the flap base; therefore it is widely accepted that this flap should not be used in clinical/radiographic positive necks, although reverse flow submental flaps that do not rely on intact facial artery/vein are used concomitant with radical neck surgery (Chen et al., 2007; Wang et al., 2011). In the orthograde variant, if the results of cervical lymph node frozen sections become positive,
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this flap should not be used and the surgeon should consider a more aggressive procedure with facial artery and vein sacrifice. This flap is recommended for intraoral reconstruction after SCC ablation with supraomohyoid neck dissection and preservation of the facial artery and vein (Chen et al., 2008).
et al., 2008).
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Surveillance of the submental flap is good (Jiang et al., 2000; Li, 2005; Chow et al., 2007; Sebastian
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Theoretically the failure rate will increase when the patient has a positive history of radiotherapy, when retrograde blood flow flap is used or when supraplatysmal small dissection technique is applied, but in clinical practice, they all work well. Ultrasound colour Doppler with facial artery/vein and skin perforator localization will dramatically reduce the failure rate (Yamauchi et al., 2010). Submental intubation is not possible when a submental artery island flap is considered for reconstruction (Eipeet al., 2005). The term "submental flap" should not be used for all skin island pedicle flaps that use submental skin for reconstruction (Thornton and Reece, 2008). According to the definition, the submental artery island flap is a pedicled skin island flap that contains an axial vessel (submental artery) in its pedicle (Kimyai-Asadi and Goldberg, 2005). The combination of a submental flap and
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ACCEPTED MANUSCRIPT other flaps is described in the literature. Submental and nasolabial flaps for reconstruction of oral commissure, upper and lower lip; submental flap accompanying toe web for reconstruction of lower lip and oral commissure and submental flap with superficial temporal fascia for treatment of noma have been described (Koshima et al., 2000; Daya et al., 2001; Barthélémy et al., 2002).
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5. Conclusion Classification of this flap is based on blood supply and composition of the flap paddle. It has a wide arc of rotation. It is easy to raise and has low donor site morbidity. The Submental artery island flap is
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safe and is a simple and predictable technique for oral cavity reconstruction.
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References Abouchadi A, Capon-Degardin N, Patenôtre P, Martinot-Duquennoy V, Pellerin P: The submental flap
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Bavitz JB, Harn SD, HomzeEJ: Arterialsupply to the floor of the mouth and lingualgingiva . Oral Surg Oral Med Oral Pathol 77:232 235, 1994 Burić N, Krasić D, Pesić Z, Jovanović G: [Microvascular submental island flap prelaminated with oral mucosa in reconstruction of the lateral defect of nose]. Med Pregl 63:723 727, 2010 Carpentier S, Lebeau P, Vandurne B, Gheerardyn R, Vanwijck R, et al: The versatility of the submental flap: a case report. J Plast Reconstr Aesthet Surg 61:207 209, 2008 Chen F, Wang L, Liang C, Liu S, Zou J, Zhao H: [Clinical study on submental island flaps in repairing pharyngeal fistula]. ZhongguoXiu Fu Chong Jian Wai Ke Za Zhi 23:322 324, 2009
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ACCEPTED MANUSCRIPT Chen H, Zhong S, Xu D: [The applied anatomy of the periosteal flap composed of submental artery and dgastric muscle]. Zhonghua Er Bi Yan Hou Ke Za Zhi 34:16 17, 1999 Chen WL, Li JS, Yang ZH, Huang ZQ, Wang JU, Zhang B: Twosubmental island flaps for reconstructing oral and maxillofacial defects following cancer ablation. J Oral Maxillofac Surg 66:1145
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Chen WL, Ye JT, Yang ZH, Huang ZQ, Zhang DM, Wang K: Reverse facial artery-submental artery mandibular osteomuscular flap for the reconstruction of maxillary defects following the removal of benign tumors. Head Neck 31:725 731, 2009 a
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Chen XM, Mao CL, Chen H, Zhen ZN, Zhao M, Li JZ, et al.: [Application of reversed
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pedicledsubmental island flap]. ZhonghuaEr Bi Yan Hou Tou Jing Wai Ke Za Zhi 42:849 851, 2007 Cheng MH, Huang JJ, Nguyen DH, Saint-Cyr M, Zenn MR, Tan BK, et al: A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. GynecolOncol 126:93 98, 2012 Cheung LK, Samman N, TidemanH: Temporalis myofascial flap in maxillofacial reconstruction: clinical and histological studies of the oral healing process. Br J Oral Maxillofac Surg 35:406 412, 1997 Chow TL, Chan TT, Chow TK, Fung SC, Lam SH: Reconstruction with submental flap for aggressive orofacialcancer. Plast Reconstr Surg 120:431 436, 2007
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ACCEPTED MANUSCRIPT Curran AJ, Neligan P, Gullane PJ: Submental artery island flap. Laryngoscope 107:1545 1549, 1997 Del Castillo-Pardo de Vera JL, López-ArcasCalleja JM, Burgueño-García M: Hematoma of the floor of the mouth and airway obstruction during mandibular dental implant placement: a case report. Oral Maxillofac Surg 12:223 226, 2008
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Daya M, Mahomva O, MadareeA: Multistaged reconstruction of the oral commissures and upper and lower lip with an island submental flap and a nasolabial flap. Plast Reconstr Surg 108:968 971, 2001 Genden EM, Buchbinder D, Urken ML: The submental island flap for palatal reconstruction: a novel
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technique. J Oral Maxillofac Surg 62:387 390, 2004
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cancrumoris: a case report. Paediatr Anaesth 15:1009 1012, 2005
Faltaous AA, Yetman RJ: The submental artery flap: an anatomic study. Plast Reconstr Surg 97:56 60, 1996
Fujita S, Ide Y, Abe S: Variations of vascular distribution in the mandibular anterior lingual region: a
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high risk of vascular injury during implant surgery. Implant Dent21:259 264, 2012 Hatef DA, Koshy JC, Sandoval SE, Echo AP, Izaddoost SA, HollierLH: The submental fat
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compartment of the neck. Semin Plast Surg 23:288 291, 2009 Higgins KM, Backstein R: Thesubmental island flap: a regional and free flap with a myriad of
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reconstructive applications. J Otolaryngo l36:88 92, 2007 Hwang K, Han JY, Chung RS, Chung IH: Submental perforating artery: a culprit of bleeding during facelift. J Craniofac Surg 16:3 5, 2005 Ishihara T, Igata T, Masuguchi S, Matsushita S, Sakai K, Ihn H: Submental perforator flap: location and number of submental perforating vessels. Scand J Plast Reconstr Surg Hand Surg 42:127 131, 2008 Janssen DA, Thimsen DA: The extended submental island lip flap: an alternative for esophageal repair. Last Reconstr Surg 102: 835 838, 1998
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ACCEPTED MANUSCRIPT Jiang B, Gu Y, Chen W: [Submentalisland flaps for reconstruction of hypopharyngeal noncircumferential defects after hypopharyngeal carcinoma removal]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 20:1183 1185, 2006 Jiang B, Fang M, Jiang SQ, Xu YL, Han L: The application of submental island flap in head and neck
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surgery]. Shanghai Kou Qiang Yi Xue 9:194 196, 2000 Jiang GH, Yan JH, Lin CL, Huang Y, Wen H, Li WM: [Anatomic study of the facial artery using multislice spiral CT angiography]. Nan Fang Yi Ke Da Xue Xue Bao 28:457 459, 2008
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Kannan RY: Supraplatysmal Submental Artery Perforator Flap: Minimizing Risk to the Marginal Mandibular Nerve. Ann Plast Surg 2013 Mar 21
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Katsumi Y, Tanaka R, Hayashi T, Koga T, Takagi R, Ohshima H:Variation in arterial supply to the floor of the mouth and assessment of relative hemorrhage risk in implant surgery. Clin Oral Implants Res 24:434 440, 2013
Karaçal N, Ambarcioglu O, Topal U, Sapan LA, Kutlu N: Reverse-flow submental artery flap for
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periorbital soft tissue and socket reconstruction. Head Neck 28:40 45, 2006 Kau RL, Kim N, Hinni ML, Patel NP: Repair of esophageal perforation due to anterior cervical spine instrumentation. Laryngoscope 120:739 742, 2010
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Kawai T, Sato I, Yosue T, Takamori H, Sunohara M: Anastomosis between the inferior alveolar artery branches and submental artery in human mandible. Surg Radiol Anat28:308 310, 2006
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Kim DH, Won SY, Choi DY, Kim HS, Jung UW, Kim HJ, et al: Topography of the submental artery that should be considered in bleeding during dentoalveolar surgery. J Craniofac Surg 23: 1453 1456, 2012 Kim JT, Kim SK, Koshima I, Moriguchi T: An anatomic study and clinical applications of the reversed submental perforator-based island flap. PlastReconstrSurg109:2204 2210, 2002 Kimyai-Asadi A, Goldberg LH: Island pedicle flap. Dermatol Clin 23:113 127, 2005 Kitazawa T, Harashina T, Taira H, Takamatsu A: Bipedicled submental island flap for upper lip reconstruction. Ann Plast Surg 42:83 86, 1999
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ACCEPTED MANUSCRIPT Koshima I, Inagawa K, Urushibara K, Moriguchi T: Combinedsubmental flap with toe web for reconstruction of the lip with oral commissure. Br J Plast Surg 53:616 619, 2000 Lee JC, Chu YH, Lin YS, Kao CH: Reconstruction of hypopharyngeal defects with submental flap after laryngopharyngectomy. Eur Arch Otorhinolaryngol 270:319 23, 2013
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Lee JC, Lai WS, Kao CH, Hsu CH, Chu YH, Lin YS: Multiple-Parameter Evaluation Demonstrates Low Donor-Site Morbidity After Submental Flap Harvesting. J Oral Maxillofac Surg, 2013 May 3. Li GP, Li XJ, Sui J, Chen SC, Liu ZL: [Applied anatomy study on the reversed submental island flap].
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Zhonghua Er Bi Yan HouTou Jing Wai Ke Za Zhi 42: 268 272, 2007
Li FY, Li YQ, Chen W, Li Q, Zhou CD, Tang Y, et al: [Clinical application of expanded submental
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island flap in facial soft tissue defect]. Zhonghua Zheng Xing Wai Ke Za Zhi 25:419 421, 2009 Li L, Gao XL, Song YZ, Xu H, Yu GY, Zhu ZH, Liu JM: Anatomy of arteries and veins of submandibular glands. Chin Med J (Engl) 120:1179 1182, 2007
Li Z: [Repairing defects of tongue and mouth floor with submental island flap after tumor surgery].
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Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 19:786 788, 2005
Magden O, Edizer M, Tayfur V, Atabey A: Anatomic study of the vasculature of the submental artery flap. Plast Reconstr Surg 114:1719 1723, 2004
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Markeeva E, Trémezaygues L, Vogt T, Rass K: Submental transposition flap for a large defect after
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excision of a recurrent basal cell carcinoma on the chin. J Dtsch Dermatol Ges 10:846 848, 2012 Martin D, Pascal JF, Baudet J, Mondie JM, Farhat JB, Athoum A, et.al: The submental island flap: a new donor site. Anatomy and clinical applications as a free or pedicled flap. Plast Reconstr Surg 92:867 873, 1993 Matsui A, Lee BT, Winer JH, Laurence RG, Frangioni JV: Predictive capability of near-infrared fluorescence angiography in submental perforator flap survival. Plast Reconstr Surg 126:1518 1527, 2010
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ACCEPTED MANUSCRIPT Matsui A, Lee BT, Winer JH, Laurence RG, Frangioni JV: Submental perforator flap design with a near-infrared fluorescence imaging system: the relationship among number of perforators, flap perfusion, and venous drainage. Plast Reconstr Surg 124:1098 1104, 2009 Merten SL, Jiang RP, Caminer D: The submental artery island flap for head and neck reconstruction.
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ANZ J Surg 72:121-4, 2002 Molnar G, Plachtovics M, Baksa G, Patonay L, Mommaerts MY: Intraosseous territory of the facial artery in the maxilla and anterior mandible: implications for allotransplantation. J Craniomaxillofac
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Multinu A, Ferrari S, Bianchi B, Balestreri A, Scozzafava E, Ferri A, et al: The submental island flap in
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head and neck reconstruction. Int J Oral Maxillofac Surg 36:716 720, 2007
Patel UA, Bayles SW, Hayden RE; The submental flap: A modified technique for resident training. Laryngoscope 117:186 189, 2007
Parmar PS, Goldstein DP: The submental island flap in head and neck reconstruction. Curr Opin
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Otolaryngol Head Neck Surg 17:263 266, 2009
Paydarfar JA, Patel UA: Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 137:82 87, 2011
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Pelissier P, Casoli V, Martin D, Demiri E, Baudet J: [Submentalisland flaps. Surgical technique and possible variations in facial reconstruction]. Rev Laryngol Otol Rhinol (Bord) 118:39 42, 1997
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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 28:303 309, 2001 Potter S, De Blacam C, Kosutic D: True submental artery perforator flap for total soft-tissue chin reconstruction. Microsurgery 32:502 504, 2012 Ramkumar A, Francis NJ, Senthil Kumar R, Dinesh Kumar S: Bipaddledsubmental artery flap. Int J Oral MaxillofacSurg41:458 460, 2012
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ACCEPTED MANUSCRIPT Rojananin S, Igarashi T, Ratanavichitrasin A, Lertakayamanee N, Ruksamanee A: Experimental study of the facial artery: relevance to its reverse flow competence and cutaneous blood supply of the neck for clinical use as a new flap. Head Neck 18:17 23, 1996 Savoldelli C, Castillo L, Guevara N, Santini J, Odin G: [The superior pedicledplatysma-myocutaneous
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flap]. Rev StomatolChirMaxillofac109:98 102, 2008 Sebastian P, Thomas S, Varghese BT, Iype EM, Balagopal PG, Mathew PC: The submental island flap for reconstruction of intraoral defects in oral cancer patients. Oral Oncol 44:1014 1018, 2008
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Shi CL, Wang XC: Reconstruction of lower face defect or deformity with submental artery perforator flaps. Ann Plast Surg 69:41 44, 2012
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Squaquara R, Kim Evans KF, Spanio di Spilimbergo S, Mardini S: Intraoral reconstruction using local and regional flaps. Semin Plast Surg 24:198 211, 2010
Sterne GD, Januszkiewicz JS, Hall PN, Bardsley AF: The submental island flap.Br J Plast Surg 49:85 89, 1996
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Sun G, Lu M, Hu Q: Reconstruction of extensive lip and perioral defects after tumor excision. J Craniofac Surg 24:360 362, 2013
Taghinia AH, Movassaghi K, Wang AX, Pribaz JJ: Reconstruction of the upper aerodigestive tract
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with the submental artery flap. Plast Reconstr Surg 123:562 570, 2009 Tan O, Atik B, Parmaksizoglu D: Soft-tissue augmentation of the middle and lower face using the
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deepithelialized submental flap. Plast Reconstr Surg 119:873 879, 2007 Tan O, Kiroglu AF, Atik B, Yuca K: Reconstruction of the columella using the prefabricated reverse flow submental flap: A case report. Head Neck 28:653 657, 2006 Thornton JF, Reece EM: Submental pedicled perforator flap: V-Y advancement for chin reconstruction. J Oral Maxillofac Surg 66:2633 2637, 2008 Tosco P, Garzino-Demo P, Ramieri G, Tanteri G, Pecorari G, Caldarelli C, et al:The platysma myocutaneous flap (PMF) for head and neck reconstruction: a retrospective and multicentric analysis of 91 T1-T2 patients. J Craniomaxillofac Surg 40:e415 418, 2012
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ACCEPTED MANUSCRIPT Uppin SB, Ahmad QG, Yadav P, Shetty K: Use of the submental island flap in orofacial reconstruction--a review of 20 cases. J Plast Reconstr Aesthet Surg 62: 514 519, 2009 Varghese BT: Optimal design of a submental artery island flap. J Plast Reconstr Aesthet Surg 64:e183 184, 2011
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Vural E, Suen JY: The submental island flap in head and neck reconstruction. Head Neck 22:572 578, 2000
Wang JG, Chen WL, Ye HS, Yang ZH, Chai Q: Reverse facial artery-submental artery
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deepithelialised submental island flap to reconstruct maxillary defects following cancer ablation. J Craniomaxillofac Surg 39:499 502, 2011
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Wang WH, Hwang TZ, Chang CH, Lin YC: Reconstruction of pharyngeal defects with a submental island flap after hypopharyngeal carcinoma ablation. ORL J Otorhinolaryngol Relat Spec 74:304 309, 2012
Wu Y, Tang P, Qi Y, Xu Z, He Y: [Evaluation for submental island flap]. Zhonghua Kou Qiang Yi Xue
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Za Zhi 37:418 420, 2002
Yamauchi M, Yotsuyanagi T, Ezoe K, Saito T, Ikeda K, Arai K: Reverse facial artery flap from the submental region.J Plast Reconstr Aesthet Surg 63:583 588, 2010
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Yang X, Wen SX, Wang BQ: [Two cases of repair of pharyngocutaneous fistulas following supraglotticlaryngectomy with submental turnover skin flap]. Zhonghua Er Bi Yan HouTou Jing Wai
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Ke Za Zhi 45:1045 1046, 2010
Yilmaz M, Menderes A, Barutçu A: Submental artery island flap for reconstruction of the lower and mid face. Ann Plast Surg 39:30 35, 1997 You YH, Chen WL, Wang YP, Liang J: The feasibility of facial-submental artery island myocutaneous flaps for reconstructing defects of the oral floor following cancer ablation. OralSurg Oral Med Oral Pathol Oral Radiol Endod 109: e12 16, 2010
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ACCEPTED MANUSCRIPT Zhang B, Wang JG, Chen WL, Yang ZH, Huang ZQ: Reverse facial-submental artery island flap for reconstruction of oropharyngeal defects following middle and advanced-stage carcinoma ablation. Br J Oral Maxillofac Surg 49:194 197, 2011 Zhang CC, Wang JG, Yue ZL, Huang HZ, Chen WL, Pan CB, et al: [Clinical study of submental artery
Zhonghua Er Bi Yan HouTou Jing Wai Ke Za Zhi 47:285 288, 2012
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island myocutaneous flap for reconstruction of oral and maxillofacial defects following operation].
Zhang H, Yan Y, Sun G: [Applied anatomy of the submental vessels and submental flaps]. Zhonghua
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Zheng Xing Shao Shang Wai Ke Za Zhi 13:288 290, 1997
Figures
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Figure 1. a, Submental artery branches .b, Skin perforator branch of submental artery. Figure2. Submentalpedicle flap. a, Orthograde variant. b, Retrograde variant. Figure3. Bipaddled submental flap (schematic figure).
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Figure 4. Bipedicled submental flap (schematic picture).
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Figure 5. Submental flap for reconstruction of through and through cheek defect resulted from gunshot wound.
Figure 6. Four ways for increasing pedicle length. a, Dissection of submental artery through submandibular salivary gland or total removal of the gland. b, Dissection of facial vessels to the origin(external carotid artery) c, Ligation/cut of facial artery distal to division of submental artery. d, Ligation/cut of facial artery proximal to division of submental artery in reverse flow (retrograde) variant. The facial vein is not shown for simplicity.
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Table 1: The role of pioneer surgeons in introducing and improving submental flap characteristics. Year
Martin et al.
1993
Modification 1) Original description of the flap
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Pioneer surgeons
2) Free submental flap
Curran et al.
Retrograde variant
1996(cadaver) Inclusion
of anterior belly
of
1997(patient) digastric muscle in pedicle half
Yilmaz et al.
1997
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Faltaous and Yetman
1996
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Sterne et al.
Deepithelialized
osteomuscular
variant
1998
kitazawa et al.
1999
Kim et al.
2002
Tan et al.
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Janssen and Thimsen
2007
Patel et al.
Extended
Bipedicled
Perforator submental flap
Interposition Inclusion of mylohyoid muscle in
Li et al.
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2007
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Ramkumar et al.
pedicle half
2009
Expanded
2012
Bipaddled
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