The submental flap for oral cavity reconstruction: Extended indications and technical refinements

Amin, Sakkary, Khalil, Rifaat, Zayed

Description

and purpose The submental flap is gaining popularity as a simple technique for reconstruction of small to moderate size defects of the oral cavity. However, its role in composite defects involving the jaw is not clearly defined. Indeed, controversy exists about the flap's interference with an oncologically sound neck dissection Patients and Methods A total of 21 patients with oral cavity cancers over a three year period were included. All patients underwent surgical resection and immediate reconstruction with submental flap except one patient who had delayed reconstruction with reversed flap. The flap was used for reconstruction of intra-oral soft tissue defect in 13 patients and composite defects in 8 patients. Results Of 21 patients 12 were males and 9 were females, age ranged from 32 to 83 years. The primary tumor sites included buccal mucosa (7), tongue (4), alveolar margin (3), floor of mouth (5) and lip (2). Eventually in this study, we adopted completing the neck dissection first before flap harvest. Complete flap loss occurred in 2 whereas 3 patients had partial flap loss. Follow up ranged from 3 to 44 months, one patient died from metastatic disease. Four patients developed neck recurrences. Conclusion The submental flap is a valid option for reconstruction of intra-oral soft tissue as well as composite oral defects particularly in elderly patients. However, oncologically sound neck dissection should be assured.

Sujets

• Submental
• Flap
• Oral

Informations

• Publié par: biomed
• Publié le: 01 janvier 2011
• Nombre de lectures: 126
• Langue: English
• Poids de l'ouvrage: 1 Mo

Extrait

Amin et al. Head & Neck Oncology 2011, 3:51
http://www.headandneckoncology.org/content/3/1/51
RESEARCH Open Access
The submental flap for oral cavity reconstruction:
Extended indications and technical refinements
1 1* 2 1 1Ayman A Amin , Mostafa A Sakkary , Ashraf A Khalil , Mohammmed A Rifaat and Sherif B Zayed
Abstract
Background and purpose: The submental flap is gaining popularity as a simple technique for reconstruction of
small to moderate size defects of the oral cavity. However, its role in composite defects involving the jaw is not
clearly defined. Indeed, controversy exists about the flap’s interference with an oncologically sound neck dissection
Patients and Methods: A total of 21 patients with oral cavity cancers over a three year period were included. All
patients underwent surgical resection and immediate reconstruction with submental flap except one patient who
had delayed reconstruction with reversed flap. The flap was used for reconstruction of intra-oral soft tissue defect
in 13 patients and composite defects in 8 patients.
Results: Of 21 patients 12 were males and 9 were females, age ranged from 32 to 83 years. The primary tumor
sites included buccal mucosa (7), tongue (4), alveolar margin (3), floor of mouth (5) and lip (2). Eventually in this
study, we adopted completing the neck dissection first before flap harvest. Complete flap loss occurred in 2
whereas 3 patients had partial flap loss. Follow up ranged from 3 to 44 months, one patient died from metastatic
disease. Four patients developed neck recurrences.
Conclusion: The submental flap is a valid option for reconstruction of intra-oral soft tissue as well as composite
oral defects particularly in elderly patients. However, oncologically sound neck dissection should be assured.
Keywords: submental, flap, oral, composite resection, mandibulectomy
Background simultaneously done for either clinically evident nodal
Oral cavity cancer is the sixth most common cancer disease or for large primary tumors or tumors with a
worldwide, and comprises 30% of all head and neck can- depth of invasion greater than 4 mm. The prognosis for
cers. Oral cancer occurs most commonly in middle-aged early lesions (T1 and T2) of the oral cavity is good, with
and elderly individuals [1]. a 5-year survival of 80% to 90%. Survival for advanced
Most tumors of the oral cavity are squamous cell car- lesions (T3 and T4) can only range from 30%to 60% [3].
cinomas (SCC), but other histological types such as Surgical excision of larger lesions usually creates a two
minor salivary gland carcinomas, lymphomas and mela- dimensional or three dimensional defects. The recon-
nomas may rarely occur. The presence of nodal metas- struction of such defects has a significant impact on the
tasesisthe most significantpredictor of adverse quality of life for oral cancer patients [4]. Split thickness
outcome in head and neck SCC [2]. skin grafts, loco- regional flaps, and free flaps have been
Surgery has been the mainstay for primary manage- used to reconstruct oral cavity defects. Skin grafts may
be useful for superficial defects, but they have their lim-ment of oral cavity cancer, while radiotherapy is offered
postoperatively to patients at high risk for loco regional itations [5]. Pectoralis major myocutaneous flap and del-
recurrence. The excision entails removal of the tumor topectoral flap have the disadvantages of being too
with a margin of at least 1-1.5 cm. Neck dissection is bulky, have a limited reach and may require a second
session for refashioning and division of the pedicle. A
variety of local flaps such as Nasolabial flap, Sternoclei-
* Correspondence: [e-mail] domastoid flap and the Platysma flap, have been used,1Surgery department, National Cancer Institute (NCI), Kasr El-Aini St.,Fom El-
but they are either unreliable or of limited versatility inKhalig, Cairo 11796, Egypt
Full list of author information is available at the end of the article
© 2011 Amin et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.Amin et al. Head & Neck Oncology 2011, 3:51 Page 2 of 7
http://www.headandneckoncology.org/content/3/1/51
terms of coverage of intraoral defects. Free flaps such as Table 1 Types of pathology
the radial forearm or the anterolateral thigh (ALT) flaps Pathology Number of patients (%)
have became the first choice in the last two decades and - Squamous cell carcinoma 17 80.96
are still currently used with great success in reconstruct- - Microinvasive SCC 2 9.52
ing extensive intra-oral defects. However they need - Adenoid cystic carcinoma 1 4.76
trained personnel, microsurgical setup, and are usually - peripheral ameloblastoma 1 4.76
associated with an increased operative time and a longer Total 21 100%
hospital stay (Poster presentation) [6].
The submental artery flap was first described by Mar-
Consent was obtained from patients after full explana-tin et al [7] in 1993. The earliest reported use of this
tion of the surgical procedure, the likely outcome andflap for reconstruction in oral carcinoma was by Sterne
the potential complications that may occur. Writtenand Hall [8] in 1996. Since it was described, the flap has
informed consent was obtained from the patient forbeen extensively used for reconstruction of small to
publication of this case report and accompanyingmoderate size oral cavity soft tissue defects [9-13]. How-
images. A copy of the written consent is available forever, its role in composite oral cavity defects has not
review by the Editor-in-Chief of this journal. The studybeen clearly described. In addition, controversy exists
proposal has been approved by our research and ethicalabout its interference with neck dissection.
committee.In this article we have evaluated the reliability of this
flap in reconstruction of small to medium sized soft tis-
Surgical Techniquesuedefectsoftheoralcavityaswellascomposite
The patient lies supine with the head extended anddefects.
turned to the opposite side.
Loup magnification is usedMethods
Flap designFrom May 2007 to October 2010 at the National Cancer
An ellipse of skin is outlined in the submental areaInstitute and Cairo Teaching Hospital, Egypt, a total of 21
across the midline. The upper incision is made 1.5 cmpatients with oral cavity carcinoma presented to the sur-
below the mandible in the midline and 3.5 cm belowgery department for the resection of their tumors and have
the angles of the mandible on both sides. The maximalbeen offered reconstruction of the resultant defects with
width of the flap is determined by a pinch test in orderthe submental artery flap. Elderly patients, patients prefer-
to close the donor site primarily. The length of the flapring neck donor site, and those with medical co-morbid-
is designed according to the size of the defect and mayities precluding the option of free tissue transfer to be done
span from one mandibular angle to the other if neces-safely, were included in this study. Patients with nodal
sary. The skin paddle may also be designed to accom-stagemorethanN1wereexcludedfromthestudy.Flap
modate unilateral or bilateral neck dissection.viability, complications, functional and cosmetic results as
Neck dissectionwell as loco-regional control rate were all evaluated.
this starts first, taking extreme caution to preserve theAll of our patients were Egyptian Semitic Whites. The
facial vessels. Then following completion of the neckage of patients at presentation ranged from 32 to 83
dissection, flap harvesting starts. This approach shouldyears (mean is 59 years). Out Of the twenty one
assure an oncologically safe procedure. On approachingpatients, there were 12 males and 9 females. Six male
the submandibular triangle, the facial artery and veinpatients are smoker, and none of the patients was alco-
are carefully dissected away from the submandibularholic. Co morbid diseases were present in four patients
gland by ligating the branches going to the gland andand the ASA Physical Status scoring ranged from 1 to 3.
preserving the submental vessels. In case bilateral neckThe main presenting symptom in 17 patients was an
dissection is needed, the flap should be harvested on theintraoral ulcer that failed to respond to medical treat-
ment by the referring physician. The remaining four
patients presented with local recurrence after previous Table 2 Primary tumor sites:
surgery and radiotherapy for oral cancer. All patients
Site Number of patients (%)
have preoperative histological diagnosis (table 1). The
- Buccal mucosa 7 33.4
buccal mucosa was the most common primary site
- Floor of mouth 5 23.8
involved (33.3%), followed by the floor of mouth (table
- Tongue 4 19.0
2). The lesions were staged clinically as stage T2 (n =
- Alveolar margin 3 14.3
9), T3 (n = 9), and T4 (n = 3). All of our patients were
- Lip 2 9.5
clinically N0, and all patients were non metastatic (M0)
Total 21 100%at presentation.Amin et al. Head & Neck Oncology 2011, 3:51 Page 3 of 7
http://www.headandneckoncology.org/content/3/1/51
less involved side of the neck which should be com- nasogastric tube was inserted in all cases and used for
pleted first. immediate post-operative feeding, for t