EJSO (2005) 31, 294–298

www.ejso.com

Modification of the infra hyoid musculo-cutaneous

flap
G. Doliveta,*, P. Gangloffa, J. Sarinib, J. Ton Vanc, X. Garrona,
F. Guilleminc, J.L. Lefebvred
a
Head and Neck Surgery Unit, Unité de chirurgie cervico-faciale, Centre Alexis Vautrin, Avenue de
Bourgogne, Brabois, 54511 Vandoeuvre les Nancy Cedex, France
b
Oncologic Surgery Department, Institut Claudius Regaud, 20-24 rue du pont Saint Pierre, 31052 Toulouse
Cedex, France
c
Oncologic Surgery Department, Centre Alexis Vautrin, Avenue de Bourgogne, Brabois, 54511 Vandoeuvre
les Nancy Cedex, France
d
Head and Neck Surgery Department, Centre Oscar Lambret, 3 rue F. Combemale BP 307, 59020 Lille
Cedex, France

Accepted for publication 21 October 2004

Available online 15 December 2004

KEYWORDS Abstract Background. In 1986, Wang described the infra hyoid musculo-cutaneous
Infrahyoid flap. Here, we report technical adaptations and improvements to this flap.
myocutaneous flap; Methods. From 1994 to 1996, we performed 61 infrahyoid flaps using the classical
Head and neck; procedure. After 5 years of technical evolution, we studied a new series of 91 flaps
Cancer; from January 2000 to June 2002. We reviewed our experience with the infra hyoid
Rehabilitation flap and described the surgical procedure, its evolution and the impact on the
fiability of the flap.
Results. In the two series, the main arterial pedicle was usually the superior
thyroid artery. Venous drainage was more variable; consequently we always
performed a modified neck dissection with preservation of the internal jugular
vein. In the first series, the surgical results were good with only seven local
complications essentially skin necrosis. The functional and aesthetic results seemed
acceptable.
In the second series, the results, after technical evolution with better venous
drainage and cervical closure, were improved (only one necrosis) and the indications
were extended.
Conclusion. With experience, the infra hyoid myocutaneous flaps is reliable and
appears as a particularly useful flap for oral cavity, oral pharynx and pharyngeo-
laryngeal reconstruction.
q 2004 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: C33 3 83 59 84 46.

E-mail address: g.dolivet@nancy.fnclcc.fr (G. Dolivet).

0748-7983/$ - see front matter q 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejso.2004.10.006
Modification of the infra hyoid musculo-cutaneous flap
Introduction
Wang, in 1979, first performed a long series of
infrahyoid myocutaneous flaps (IHMCF) and in 1986
reported 112 flaps.1–4 From 1994 to 1998, we
performed a series of 61 infrahyoid flaps to
reconstruct mucous defects in the head and neck
region with this technique, which we subsequently
modified for head and neck surgery. We performed
a new series of 91 flaps in the year 2000/2001.
Here, we report our experience leading to
technical evolution with improvement of the results
and our current indications for using this flap.
Surgical anatomy of the flap
The infrahyoid muscles including stenohyoid (SH),
thyrohyoid (TH), strenothyroid (ST) and omohyoid
(OH) constitute the anatomical substratum of the
flap, completed by the plathysma and the overlying
skin.
Surgical technique
Our surgical procedure is as described in publi-
cations.1,4 The IHMCF is designed as an oval
vertically shape in a paramedian situation and can
measure up to 10 cm in its greatest length. The flap
is dissected in order to separate the flap from the
median cervical fascia. The inferior muscular part
of the flap is defined by sectioning the muscles
downwards (SH and ST) and outwards (intermediate
tendon of OH). The venous drainage has two
systems through the anterior jugular vein and the
superior thyroid vein. Then the strap muscles are
separated from the thyroid plane in order to
identify the superior thyroid artery and vein
pedicle. Collateral veins and superior laryngeal
artery (carefully separated from the superior
laryngeal nerve) can be ligated, allowing securing
the flap to the external carotid artery and the facial
vein, or perhaps the internal jugular vein. The SH is
usually upwardly sectioned at the insertion to the
hyoid bone. The flap is then placed to repair the
defect site.
At best, the flap extremity can reach a distance
of 15 cm (theoretical) around its rotation axis. The
effective region includes the cervical trachea up to
the velotonsil, including the inferior facial
cutaneous covering (under the labial-tragus com-
missura). Functionally, flap resection does not
induce phonatory, respiratory or swallowing
295
complications. Cutaneous closure was performed
without important difficulties (Fig. 1).
With experience, technical change in the pro-
cedure allowed definitive improvement of the flap
reliability and surgical edge stitching with better
final plastic result.
In series one, we experienced venous drainage
problems due to the frequent inadequacy of the
drainage system parallel to the arterial pedicle
which jeopardized the viability of the flap, particu-
larly its skin paddle.
In consequence, for the second series, we
modified the upper dissection procedure of the of
the infrahyoid muscles and stopped to cut them
directly (Fig. 2) in order to preserve tissular micro
venous drainage.
The dissection of the infrahyoid muscles from the
hyoid bone is now performed from back to front
preserving the periosteum of the hyoid bone. Thus,
an upper vascularisation with a venous drainage
towards digastric triangle network and mylohyoid
muscle is preserved. With these technical modifi-
cations, improving flap vascularisation, we rou-
tinely use infrahyoid flap in irradiated site (up to 50
grays) without skin paddle necrosis.
Since, January 2000, we have changed our
cervical incision in order to improve aspect of the
final scar. The design of the incision evolved from
an inverted t to an inverted z, skin being therefore,
less tensed at the stitching.
In rare case, in which size enhancement of the
flap is needed, we experimented flap site coverage
by classical delta pectoralis flap allowing dimension
increasement up to 15!5 cm2, as an antebrachial
free flap. This indication is also helpful in case of
dehiscence or in irradiated area.
Clinical study
Methodology
We compared two series of patients operated with
an IHMC flap before and after the technical change.
The first one is the continuum of a preliminary study
published3 as a first experience of the flap with the
classical described dissection with result compar-
able to the literature. The second one, with an
interval of 4 years, includes cases operated with the
new technique. We only compared the outcome of
the flap, the site, the tumour stage and the
functional results (Table 1) classified as good, fair
and bad. Other details given with the first series are
transposable to the second.
296
Figure 1 (1) Original incision and closure of the skin (first series). (2) Evolution of the incision with major
improvement of the quality of skin closure (second series).
Figure 2 Front view of the improved pedicule with
post-dissection of the hyoı̈d bone.
G. Dolivet et al.
First series (1994–1998)
Material and method. From November 1994 to May
1998 (41 months), 61 patients were operated on for
cancer of the upper aerodigestive tract using the
IHMCF to repair mucous defects. This series
included 54 men and 7 women, with a mean age
of 53 years and ranged from 32 to 80 years. Sixty
patients presented with a more or less differen-
tiated epidermoid carcinoma. The shape of the skin
paddle varied according to the surgeon’s prefer-
ence and/or the sites to be repaired. The staging of
disease is presented according to the Union Inter-
nationale Contre le Cancer (UICC) tumour-nodes-
metastasis (TNM).5 Two patients could not be
classified because of previous head and neck radio-
therapy. Post-operative radiotherapy was per-
formed in 53 patients, four patients received
post-operative brachytherapy.
Clinical outcomes. The flap was most often vascu-
larized by the upper thyroid pedicle or one of its
branches (60/61). The venous drainage was variable
from patient to patient. For two patients, the right
and left pedicles were preserved. In one case, a
microsurgical venous reimplantation was necessary
to enable a good positioning of the flap.
The flap was mainly used for floor of mouth or
oral cavity reconstruction procedure (47/61). In
Modification of the infra hyoid musculo-cutaneous flap
Table 1 Series description
First series
N Function Post-operat-
ive compli-
cation
Oral cavity 47 35 Good, 11 6 Skin paddle
fair, 1 bad necrosis,
2 cervical
dehiscence,
1 fistula
Oropharynx 11 5 Good, 5
fair, 1 bad
Larynx
Hypopharynx 3 2 Good, 1 fair 1 Flap
necrosis
this series, the mean flap dimensions were 7!4 cm2
with a range of 3!2 to 10!5 cm3. The cervical
closure was always performed without any second
flap necessity. A neck dissection, homolateral to
the sampling site was systematically performed,
with preservation of the internal jugular vein in all
cases. The flap was performed after neck radio-
therapy in four cases.
Forty-one patients had cicatrisation without
complications for the flap or the donor site. Local
complications occurred in 10 patients. The majority
of patients (42/61) were able to eat normally. The
remaining 19 patients had to adapt their eating
habits by mincing (17/19) or by mixing (2/19) their
food (Table 1).
Second series (2000–2001)
Between January 2000 and June 2001, we pro-
ceeded 91 infrahyoid flaps with the new surgical
procedure, 15 after neck radiotherapy. Results
were analysed for global survival of flap and
functional result (global and in accordance to the
tumoral site or the tumoral stage).
The flap survived without any complication in 88
cases. There was only one total necrosis in
irradiated area and two partial necrosis in non-
irradiated area. The global functional result was:
good in 62 cases, fair in 23, poor in 6.
According to the site, the results were, respect-
ively: for oral cavity: 23, 5 and 3 cases; for
oropharynx: 20, 14 and 2 cases; for larynx: 10, 2
and 1 case, and for hypopharynx: 9, 2 and 0 case.
According to the tumoral stage, they were: for
T1 (14 cases): 12, 2 and 0 case; for T2 (32 cases): 24,
7 and 1 case; for T3 (23 cases): 20, 2 and 1 case; for
T4 (22 cases): 9, 8 and 5 cases.
297
Second series
N Function Post-operat-
ive compli-
cation
31 23 Good, 5 1 Necrosis,
fair, 3 bad 1 skin paddle
necrosis
36 20 Good, 14 1 Skin paddle
fair, 2 bad necrosis
13 10 Good, 2
fair, 1 bad
11 9 Good, 2 fair
Discussion
In our first series, the results in terms of flap
reliability were comparable with those published in
the literature.1–3 The usual respect of contraindica-
tions helped to avoid the complications encoun-
tered by other authors.4 The main surgical contra
indications are a previous thyroid surgery, radical
neck dissection or indication of resection on the
side of the flap, muscular involvement on the
resection site and/or history of head and neck
radiotherapy. The use of this flap in irradiated sites
was rare in our experience (7%). As reported by
Magrin,4 and although not confirmed in our experi-
ence, the success rate for this type of flap decreases
from 90 to 53% in case of prior irradiation. A relative
contraindication to the flap is the existence of a
palpable lymph node in the region of the flap
pedicle. In our experience, in only one case a
dissected flap had to be resected because the
pedicle was in close proximity to a metastatic node.
Conversely to Wang,1 the size of the cutaneous
flap sampled was always compatible with a direct
suture of the sampling site. Skin paddle necrosis
was considered as minor complication because the
underlying strap muscle was viable. Among the
cases of skin paddle necrosis with good muscular
viability, two flap retractions occurred after radio-
therapy, only in the first series. May be, given the
small diameter of the feeding vessels,6,7 a post-
therapeutic sclerosis could induce the retractile
cicatrisation.
The versatility of the flap allowed in most of
cases to reconstruct approximately the pre-oper-
ative anatomy. When the treatment of the tumour
required a complete resection of the floor of
298
mouth, the thin flap only allowed for a partial
reconstruction of the defect. We, therefore, con-
cluded that the thickness of the flap could some-
times be a limiting factor, especially, after a ‘pull
through’ procedure. In all the other cases, the
thickness of the flap was considered as an advan-
tage. The reconstruction of a mucous defect with a
relatively thin material was in our experience one
of the main advantages of this flap. Where ever the
site to reconstruct (hypopharynx, oropharynx, oral
cavity), normal feeding was achieved in most cases
43/61 in the first series, 86/91 in the second.
In all cases, failure of pre-ablation equipment
was related to morphological modification of the
mandible levelled down to the floor of mouth.
Although, the system of speech evaluation was
subjective in our series, the results obtained
seemed equivalent to those obtained by Wang.1
An important issue to take into consideration was
the potential length of the arterial pedicle of the
flap which can be used in all areas of the upper
aerodigestive tract below the line between the
tragus and the lip commissural.3 Sometimes, the
anatomical characteristics of the patients did not
allow the flap to be well positioned due to a short
pedicle or the low implantation of the main
drainage vein (one case in the first series). In
order to avoid sacrificing the flap and/or necrosis, it
was possible to reimplant the venous pedicle in a
more favorable location by microsurgical tech-
nique. However, this flap, because of the vessel
diameter,6 did not seem to apply ideally to the
techniques of microsurgical reconstruction, but,
however, this possibility should be kept in mind.
The technical modification of dissection allows
certainly overcoming this problem with its
improved venous drainage through an upper venous
system.
The good results of the second series confirm the
improvement of the reliability of the new surgical
procedure, in diversified tumoral site and the
possibility of large use of this technique even for
large tumoral stage and in irradiated area. Func-
tional problems are solved in most of the cases by
highly specialized speech therapist.
G. Dolivet et al.
Conclusion
The infrahyoid myocutaneous flap is reliable, with
interesting plastic qualities. This is an additional
tool in the therapeutic possibilities for cervicofacial
reconstruction. Contraindications have to be
respected. The thickness of the flap may be
sometimes insufficient for the reconstruction of
the whole floor of mouth, and in those rare cases,
we use other flap or complementary techniques.
Likewise, the volume of the flap seems insuffi-
cient to envisage a satisfactory tongue reconstruc-
tion in case of large resection, but its indications
remain numerous for the upper aerodigestive tract
allowing the repair of large mucous or cutaneous
defects with acceptable functional or aesthetic
sequelae.
Our surgical technical research has led us to the
laryngeal and pharyngolaryngeal reconstruction
(i.e. after near total resection) with the IHMCF
and in some specific case, partial reconstruction of
cervical oesophagus. Our primary results seem to
confirm the elective choice of this flap for these
indications.
References
1. Wang HS, Shen JW, Ma DB, Wang J, Tian A. The infrahyoid
myocutaneous flap for reconstruction after resection of head
and neck cancer. Cancer 1986;57:663–8.
2. Rojananin S, Suphaphongs N, Ballantyne AJ. The infrahyoid
musculocutaneous flap in head and neck reconstruction. Am
J Surg 1991;162:400–3.
3. Dolivet G, Faucher A, Majoufre C, Micheik J, Renaud-Salis JL.
The infra-hyoid musculo-cutaneous flap in head and neck
reconstructive surgery: technique and first results. Rev
Laryngol 1994;115:225–9.
4. Magrin J, Kowalski LP, Santo GE, Walksmann G, DiPaula RA.
Infrahyoid myocutaneous flap in head and neck reconstruc-
tion. Head Neck 1993;15:522–5.
5. UICC Union Internationale Contre le Cancer. In: Hermanek P,
Sobin LH, editors. TNM classification of malignant tumours.
4th ed. 1987. p. 13–32 [Geneva].
6. Calloc’h F, Prades JM, Chelikh L, Dalmonego V, Martin Ch.
Infrahyoid paramedian musculocutaneous flap. Anatomical
bases. Review of the literature. JF ORL 1996;45:203–9.
7. Eliachar I, Marcovich A, Har Shai Y, Lindenbaum E. Arterial
blood supply to the infrahyoid muscles: an anatomical study.
Head Neck Surg 1984;7:8–14.