Submental Island Flap (axial patterned) for

Reconstruction of Head and Neck Defects

MADE BY: DR SHARIQUE NAZIR
FCPS OMFS
History of the Procedure
 Surgeons often must treat head and neck defects caused by ablative surgery or injury. Reconstruction of complex head and neck defects with
functional and morphologic restoration has long been a highly challenging and complex surgical undertaking. Many techniques have been
developed to treat these defects, including skin grafts, local or regional flaps, free vascularized tissue transfer, and tissue expansion for
reconstruction.
 Although skin grafting is technically simple and can provide good esthetic results with low morbidity, it cannot be used for complex defects.
Tissue expansion is another option for cutaneous coverage, but this technique requires multiple operative procedures and a significant
commitment by the patient.
 Random pattern flaps (advancement flap, rotation flap) and platysma myocutaneous flaps can provide a good color match for the face; however,
they are often unreliable, and mobility and the amount of tissue that can be used are limited. Also, in many cases the scars at the donor site are
unacceptable.
 A pedicled flap, such as a trapezius or pectoralis myocutaneous flap, can provide sufficient transplant tissue and is suitable for reconstructing
large head and neck defects. However, this flap is too bulky to be suitable for reconstructing small or medium sized defects in the head amd
neck region
 Advances in microsurgery have allowed many complex facial defects to be reconstructed with free flaps, such as radial forearm or other free
fasciocutaneous flaps; however, the color and texture of these flaps show a definite demarcation with the neighboring facial skin. In addition,
these flaps are more surgically complex and have the potential for flap failure associated with microsurgical techniques.
 For reconstruction of head and neck defects, the flap should be reliable, pliable, and functionally and cosmetically acceptable; it also should
have minimum donor site morbidity and should match the recipient site in color, texture, and thickness.
 In 1993, Martin et al. first described a new axial-patterned island flap based on the submental artery. This new flap, the submental island flap,
enhanced the reliability and mobility of the random cervical platysma myocutaneous flap and also was free of the limitations of the latter,
described previously.
 The submental island flap consists of thin, pliable tissues with a perfect color match and is similar to facial skin. It also has a robust blood
supply and a good arc of rotation. When applied in older patients, this procedure can also reduce the submental fullness and have positive
esthetic results. Significant research on its anatomy and applications has shown that the submental island flap is ideal for head and neck
reconstruction.
 This flap also has been described as a free flap. All these advantages make the submental island flap easy to work with, and it is widely used by
numerous other authors.
Anatomy
 The basis for the submental island flap is the submental artery, which is reported to be a well-defined, consistent branch of the
facial artery with a diameter of 1 to 2 mm.
 It arises from the facial artery (5-6.5 cm from the origin of the facial artery on the external carotid artery), deep or superficial to
the submandibular gland and may be deep (70%) or superficial (30%) to the digastric muscle, approximately 1.5 to 2 cm below
the inferior border of the mandible
 It courses just superficial to the mylohyoid muscle as it passes forward and medially in level Ia of the neck below the
mandibular border, ending behind the mandibular symphysis just lateral to the midline.
 Most commonly, it runs deep to the anterior belly of the digastric muscle and sends off some branches to the submental skin,
lower lip, and sublingual gland
 Along its course, one to four cutaneous perforators are found piercing the overlying platysma, forming a subdermal plexus that
anastomoses extensively with the contralateral branches, providing a possible large random extension on the other side.
 It is easily identified in a groove on the medial surface of the submandibular gland
 Venous drainage of this flap is through the submental vein into the facial vein. There are one to three anastomoses between these
vessels and the external jugular vein, which plays a major role in the surgical procedure and in some cases may be used for the
venous drainage of the flap.5,15
 Because of its reliable blood supply, this flap can be harvested from mandibular angle to mandibular angle, with the width
determined by the flaccidity of the neck skin; this allows direct closure with a well-hidden donor scar of up to 18 × 7 cm in size.
The pedicle may be up to 8 cm long, and the arc of the pedicle is such that the flap easily reaches defects of the face.
 A modified technique is to include the mylohyoid muscle in the flap, thereby protecting the vascular pedicle and limiting the
vascular dissection necessary
Indications for the Use of the Procedure
 For reconstruction of head and neck defects, the ideal is to achieve both functional and esthetic outcomes.
Additional donor site morbidity should be avoided, especially with benign diseases.
 The proximity of the donor site and its characteristics of reliability, excellent skin match, minimal donor site
morbidity, and a long pedicle make the submental island flap an ideal method for reconstruction of head and neck
defects caused by trauma, burns, or surgical defects.
 Furthermore, the relative simplicity of raising this flap gives the additional benefit of a shorter operative time,
especially in older patients and those with significant comorbidities.
 Since its introduction, the submental flap has achieved great success in the intraoral reconstruction of floor of the
mouth, gingival, palate, cheek, oropharynx, and esophageal defects, in addition to cutaneous reconstruction of the
lip, nose, preauricular region, and temporal region; some authors have even reported its use for forehead defects.
 With a rich vascular network between the ipsilateral and contralateral facial arteries and veins, the submental flap
can be used for contralateral defects, in which case a Y-V technique or other procedure is required to increase the
length of the pedicle. This flap can also be designed as a free flap, if required, or as an axial-pattern
osteocutaneous flap in the reconstruction of facial bony defects through the use of a segment of the mandibular
rim.
 As an island flap, it can also be used safely for patients who received prior radiation treatment in a therapeutic
dose. However, in those cases, direct closure of the donor site may be incomplete and may require skin grafts.
This flap is particularly suited for reconstruction of hair-bearing areas in men. It also should be given serious
consideration for the treatment of intraoral defects.
Limitations and Contraindications
 For example, metastatic disease in either the submental (level Ia) or submandibular
(level Ib) lymph node basins is a contraindication.
 Another contraindication is injury or ligation of the submental or facial vascular
system during previous neck surgery. Although the pedicle of the flap is reliable and
 constant as reported, anatomic anomalies of the vessels are a
 contraindication; the author recommends preoperative examination
 of these vessels to exclude anatomic anomalies. Preoperative
 identification of the facial and submental arteries
 with three-dimensional computed tomography angiography
 have been previously reported to be helpful in evaluating the
 vessels and avoiding injury.30 Relative limitations and contraindications
 include an obese neck17 and reconstruction of
 hairless facial regions in men.
TECHNIQUE: Reconstruction with a Submental
Island Flap
A submental island flap can be harvested by two
methods: in an anterograde fashion from the facial
vessels and in a retrograde manner from the submental
vessels. The techniques applied are the same, but the
sequence of flap dissection is different. However, no
significant differences are seen in the outcomes. The
author prefers the retrograde manner, which is introduced
below.
 STEP 1: Anesthesia, Positioning, and Armamentarium
 The submental flap procedure is performed under general anesthesia.
 The method of intubation is based on the site of the defect
 and must take into account surgical convenience. The patient is
 placed in the supine position, with the neck moderately extended
 before harvesting of the flap begins. If tolerated by the patient, a
 shoulder roll may be placed to aid in extension of the neck. The
 armamentarium consists of a standard soft tissue tray, nerve
 stimulator, and vascular clips or ties. Doppler ultrasound may be
 useful for locating the vessels.
 STEP 2: Flap Design
 Depending on the defect created by excision of the lesions, the flap is
horizontally designed in the area served by the submental artery.
 It should be a little bigger in size than the defect, although the maximum
dimension that can be reliably harvested is 15 × 7 cm.
 The flap should be spindle-shaped or elliptical to facilitate primary closure.
 Its superior limit should be at least 1 cm below the inferior border of the
mandible to prevent inferior lip eversion and to hide the donor site scar as
much as possible. The lower limit, defined above the cervicomental angle,
depends on the laxity of the skin and could be determined by a simple pinch
test.
 To perform this test, the surgeon pinches the skin of the submental area
between two fingers before outlining the flap; this helps evaluate skin laxity
and the likelihood of performing direct closure.
 The length of the skin paddle can be determined by the distance from the pivot
point below the ipsilateral antegonial notch to the most distal point of the
defect. This length should equal the distance from the ipsilateral antegonial
notch to the most distal extent of the designed flap along the course of the
ipsilateral submental artery. It is important to note that the flap design may
cross the midline and will be based on the excellent collateral flow of the
vessels in this region. The borders of the flap can be marked, and relevant
vessels are identified preoperatively
 STEP 3: Incisions and Dissection of the Flap
 After the elliptical portions of the flap have been marked, an incision is made through skin, subcutaneous tissue, and
platysma.
 The dissection starts on the contralateral side.
 After incision of the upper border of the flap, the marginal mandibular branch of the facial nerve is identified near the lateral
edge of the flap within the superficial layer of the deep cervical fascia, just deep to the platysmal plane. Dissection continues
to the submandibular gland.
 The facial and submental vessels of the contralateral side are dissected. After ligation of the vessels and their perforators to
the submandibular gland and deep tissues, the flap is detached from the underlying muscles in the subplatysmal plane above
the digastric muscle. Dissection is carried out continuously toward the origin of the pedicle.
 When the midline is reached, dissection is performed carefully to identify the ipsilateral submental vessels.
 Some authors advise raising the anterior belly of the ipsilateral digastric muscle with the flap to protect the submental artery
during harvest. Although this is probably not necessary, it provides an additional margin of safety in preserving the vascular
supply and makes the dissection easier. In some cases the anterior belly of the digastric muscle helps reconstruction. If the
ipsilateral anterior belly of the digastric muscle is included in the flap, it should be released from its attachments; the
submental artery and vein then are dissected from the deep fascia connections. Also, the ipsilateral marginal mandibular
branch of the facial nerve must be carefully identified and protected during the dissection. When the dissection reaches the
origin of the submental vessels, all branches to the submandibular gland are ligated and the submental artery island is created
with a wide arc of rotation. If this flap is designed as a free flap, it may be harvested according to the required pedicle length.
It is crucial that, in malignant cases, the submandibular nodes are always checked during flap elevation, followed by selective
dissection.6,9 Also, the pedicle should be skeletonized to minimize the possibility of metastasis
 STEP 4: Elongation of the Pedicle
 A pedicle length of approximately 5 cm is easily obtained when the dissection is completed with the entire facial artery
retained; this is usually sufficient. A longer pedicle may be achieved by
 dividing the facial vessels distal to the origin of the submental
 artery or by dividing and anastomosing the taut submental or common facial vein to a suitable vein close to the recipient
site15;
 this provides an additional 1 to 2 cm of pedicle length. Another
 procedure that increases the length of the pedicle is the Y-V
 procedure. By ligating the facial vessels proximal to the origin of
 the submental artery with the corresponding vein, the surgeon can
 design the flap as a reverse-flow flap, which is supplied by the
 distal facial artery pedicle; in this way, extra length can be
 obtained, and the flap will reach up to the infraorbital region. A
 Y-V procedure can also be accomplished using the external jugular
 vein. This is done by locating a communicating branch between
 the facial and external jugular veins. The trunk of the facial vein
 is divided proximal to this communicating branch. Consequently,
 the Y-vascular pattern turns into a V-vascular pattern that allows
 up to 5 cm of additional distal mobilization of the flap.31
 STEP 5: Tunnel Preparation and Flap Transfer
 After the flap has been created, a tunnel may be made from the
 origin of the pedicle to the defect, if needed. This tunnel can be
 submucosal, subcutaneous, or a combination of these. The tunnel
 should be broad enough so as not to compress the flap. The skin
 paddle is carefully passed through the tunnel or primarily existing
 incision to the defect. Excessive stretching of the flap should be
 avoided. For further pedicle advancement and a greater arc of
 rotation, the marginal mandibular branch of the facial nerve can
 be dissected off the facial pedicle and the elevated submental
 artery island flap passed under the marginal mandibular nerve
 (Figure 112-2, F)
 STEP 6: Closure and Drainage
 When the flap is transferred to the site of the defect, it is trimmed
 to a shape suitable for the defect. After complete hemostasis and
 copious irrigation, the flap is sutured layer by layer to the margins
 of the defect without excessive tension. Usually the donor site
 can be closed directly without additional dissection, especially in
 elderly patients. The cervical skin can be sutured to the hyoid bone
 to maintain the cervicomental angle. In cases that pose difficulty
 with direct closure, skin on the cervical side, rather than the
 mandible side, should be mobilized, to prevent eversion of the
 lower lip. Flexion of the neck to facilitate closure should be
 avoided because it causes subsequent hypertrophic scars. Passive
 drains should be placed in the donor site and the subcutaneous
 tunnel to prevent a compressive hematoma (Figure 112-2, G).
 Avoidance and Management of Intraoperative
 Complications
 A sufficient blood supply to the submental island flap is
 crucial for successful reconstruction. When the flap is
 designed, the surgeon must make sure that its size and the
 length of the pedicle are adequate for reconstruction. Submental
 vessels must be carefully protected during flap harvesting.
 A flap that includes the ipsilateral anterior belly of
 the digastric muscle provides better venous drainage and
 prevents failure. The author recommends the use of loupes
 for dissecting submental vessels. Care should be taken, in the
 creation of the tunnel, to ensure that it is broad enough to
 allow transfer of the flap to the recipient site without excessive
 tension on or trauma to the skin paddle. Also, the surgeon
 should avoid distorting or overmanipulating the pedicle. Vascular
 anomalies should be excluded before surgery by ultrasound
 or computed tomography angiography (CTA),
 although only a few cases of such anomalies have been
 reported.5,12 Care should be taken to avoid injury to the
 marginal mandibular nerve when the flap is raised. The
 surgeon can prevent this type of injury by identifying and
 preserving the marginal mandibular nerve either before
 raising the flap or when dissection reaches this site.
 A visible scar or eversion of the lower lip can be avoided
 if the flap is created and sutured according to the techniques
 described in this chapter.
Postoperative Considerations
 Airway management is paramount for any case involving the head and neck region. Although airway swelling with
submental flaps is minimal in the author’s experience, it warrants consideration.
 Also, the patient should avoid wearing neckties during the initial postoperative period to avoid compromising
 the vascular pedicle. Although the success rate of the submental island flap is very high, partial or total loss of the
 flap cannot be entirely avoided. After surgery, moderate
 immobilization of the head is suggested, along with a perioperative course of steroids and antibiotics.
 Intensive observation of the flap after surgery is important,
 including its color, texture, temperature, and capillary refill.32 Almost all failures of submental flaps are caused by
 venous congestion. In most cases, this development resolves
 gradually; however, the surgeon should evaluate the cause to
 determine whether surgical intervention, decompression, or
 puncture of the flap is needed.
 For cases involving oral reconstruction, the patient should be fed through a nasogastric tube or should have liquid food
without chewing for 7 to 14 days. Oral care should be carefully performed three or four times every day. Drains may be
removed when the drainage has decreased to less than 30 mL
 in a 24-hour period. If the flap needs to be debulked for
 cosmetic purposes, this should be done 6 months after
 surgery.