Twenty-Five Years of Experience with the Submental Flap in Facial Reconstruction: Evolution and Technical Refinements following 311 Cases in Europe and Africa

Abstract

Background: The submental flap is a pedicled island flap with excellent colour match for facial reconstruction. The flap can be raised with muscle, submandibular gland or bone and can be transposed to reach defects up to two thirds of the face. We report the primary author's experience of 25 years using the submental flap from its original description to most recent technical evolutions in both Europe and Africa. Methods: This is a retrospective study including all patients with facial defects reconstructed using a submental flap between 1991 and 2016. This study included the use of all four variations of the submental flap: "platysmal', "digastric", "extended" and "super extended". We report technical adaptations and complications encountered. Results: We performed 311 facial reconstructions using submental flaps: 32 "platysmal", 133 "digastric", 91 "extended" and 45 "super extended" variations. In conjunction with these reconstructions, we performed 10 osteocutanous submental flaps and 2 free flaps. We report 2 cases of total flap necrosis (0.6%) and 28 minor complications including: 23 cases of distal skin necrosis (7%), 1 reversible mandibular facial nerve palsy (0.3%) and 3 hematomas (1%). Conclusions: The submental flap has proven to be a reliable flap for head and neck reconstruction. The four technical modifications described employ varying amounts of soft tissue to replace tissue lost and can include vascularized bone from the mandibular margin. This flap exemplifies Gillies' principle of "replacing like with like" and should be discussed as an alternative to free tissue transfer in facial reconstruction, especially in settings where resources are limited.

Comprehensive Review of the Submental Flap in Head and Neck and Facial Reconstruction: What Plastic Surgeons Need to Know

“…If nearby musculature is not utilized to bulk the paddle, surgeons must be meticulous in dissection in order to preserve the perforator vessels. 2 A second incision is made at the mandibular margin and the flap is raised with traction allowing for dissection of the facial artery to its origin. At this point, the ADG is divided (unless a muscleincluding approach is taken) and, along with the mylohyoid, is released from the hyoid bone.…”

“…Harvest of the SMAF results in a mostly hidden donor site scar. High patient satisfaction rates and low complication rates have been reported in previous case series 2 . The main disadvantages of the SMAF include flap thickness and the hair-bearing nature of the submental skin which may be problematic in oro-facial defects, especially in male patients.…”

“…High patient satisfaction rates and low complication rates have been reported in previous case series. 2 The main disadvantages of the SMAF include flap thickness and the hair-bearing nature of the submental skin which may be problematic in oro-facial defects, especially in male patients. While it has been almost 30 years since the introduction of this reconstructive technique, and there have been over 500 successful reported cases of SMAF use, a comprehensive review of different aspects of the SMAF in the medical literature is lacking.…”

Protocol for a Systematic Review of Outcomes From Microsurgical Free Tissue Transfer Performed on Short-term Surgical Missions in Low-income and Middle-income Countries

“…However, a select few centres in LMICs are undertaking these procedures as part of standard practice (15)(16)(17). Local and regional alternatives do exist, however many of these are also technically demanding, and even with extensive training, microsurgical equipment and techniques, they are vulnerable to complications requiring further surgery (18)(19)(20)(21). However, there is also some data in support of successful local reconstructive alternatives being used effectively in low-resource contexts (21).…”

Protocol for a systematic review of outcomes from microsurgical free-tissue transfer performed on short-term collaborative surgical trips in low-income and middle-income countries

“…Local and regional reconstructive alternatives do exist (e.g. transposition or pedicled flaps); however, many of these are also technically demanding, and even with extensive training, microsurgical equipment and techniques, they are vulnerable to complications requiring further surgery [19][20][21][22]. However, there is also some data in support of successful local reconstructive alternatives being used effectively in low-resource contexts [22].…”