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 Table of Contents  
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 144-147

Oral reconstruction with submental flap

1 Assistant Professor, Oral and Maxillofacial Surgery, Oral and Maxillofacial Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
2 Assistant Professor, Oral and Maxillofacial Pathology, Dental Research Center, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran

Date of Web Publication3-Oct-2013

Correspondence Address:
Saeedeh Khajehahmadi
Dental Research Center, Mashhad University of Medical Sciences, Vakilabad Blvd, Mashhad, P. O. Box: 91735-984
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DOI: 10.4103/2231-0746.119224

PMID: 24205473

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Background: Submental flap is a useful technique for reconstruction of medium to large oral cavity defects. Hair bearing nature of this flap in men makes it less appropriate. Therefore, deepithelialized variant is introduced to overcome the problem of hair with this flap. Recently, application of this flap has been introduced in maxillofacial trauma patients. Materials and Methods: Deepithelialized orthograde submental flap is used for the reconstruction of oral cavity mucosal defects. Results: Four cases including two trauma patients and two squamous cell carcinomas (SCCs) of oral cavity were treated using deepithelialized orthograde submental flap. There were no complications in all four patients and secondary epithelialization occurred in raw surface of the flap which was exposed to oral cavity. Conclusion: Deepithelialized orthograde submental flap is very effective in reconstruction of oral cavity in men. The problem of hair is readily solved using this technique without jeopardizing flap blood supply.

Keywords: Avascular necrosis, papillary squamous cell carcinoma, submental flap

How to cite this article:
Rahpeyma A, Khajehahmadi S. Oral reconstruction with submental flap. Ann Maxillofac Surg 2013;3:144-7

How to cite this URL:
Rahpeyma A, Khajehahmadi S. Oral reconstruction with submental flap. Ann Maxillofac Surg [serial online] 2013 [cited 2021 Jul 31];3:144-7. Available from: https://www.amsjournal.com/text.asp?2013/3/2/144/119224

  Introduction Top

Reconstruction of oral mucosal defects in oral cavity after traumatic loss or pathologic resections has still remained a challenge. Depending on the size and location of mucosal defects; various methods such as direct suturing, secondary epithelialization, locoregional, and free flaps have been indicated. [1],[2] Submental flap has been introduced as a valuable technique for reconstruction of medium to large oral cavity defects. [3] However, as a result of hair bearing nature of this flap in men, it would be less appropriate for intraoral reconstructions. [4] To overcome this emerging problem deepithelialized variant has been introduced. [5] This survey is conducted to investigate the capability of this flap to cover soft tissue losses in traumatic events and pathologic resections of soft and hard tissues in oral cavity.

  Materials and Methods Top

Surgical technique

In four patients, orthograde submental flap (Pattel modification) is used. [6] Anterior belly of digastric muscle and mylohyoid muscle in pedicle half is included. In nonpedicle side, the paddle is composed of platysma, subcutaneous fat tissue, and skin. To apply deepithelialization, the skin is sharply dissected just below the hair follicles after flap elevation [Figure 1]. The raw surface of subcutaneous fat is exposed to oral cavity. After 3 weeks secondary epithelialization was completed.
Figure 1: (a) Orthograde submental flap (Pattle modification) is deepithelialized after flap elevation, (b) Deepithelialization began before flap elevation in patients with tight submental skin (not presented in our series)

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  Results Top

Demographic information of the patients is summarized in [Table 1]. Deepithelialized submental flap was used for the reconstruction of oral cavity for mucosal replacement [Figure 2], [Figure 3], [Figure 4] and [Figure 5]. Secondary epithelialization successfully occurred clinically 3 weeks after the operation [Figure 2]c. Etiology of mucosal defect was trauma (n = 2) and squamous cell carcinomas (SCC) (n = 2). In one patient, secondary operation was performed under local anesthesia to debulk the flap. Histological view 2 years after first operation is shown in [Figure 6]. In all patients deepithelialized submental flap successfully reconstructed the defect.
Figure 2: Avascular necrosis of the mandibular segment after trauma is managed with simultaneous bone grafting and deepithelialized submental flap (a) Before, (b) Immediately after, and (c) 3 weeks later, (d) Schematic picture of the flap

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Figure 3: Vestibuloplasty and bone graft coverage in a maxillofacial trauma patient was performed using deepithelialized submental flap (a) Before, (b) Immediately after, and (c) 3 weeks later

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Figure 4: Alveolar ridge and floor of the mouth squamous cell carcinoma with bone invasion (T4) was reconstructed by deepithelialized submental flap (a) Before, (b) Immediately after, and (c) 3 weeks later

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Figure 5: Huge papillary squamous cell carcinoma (SCC) of oral cavity and oropharynx reconstructed after resection with deepithelialized submental flap (a) Before, (b) Immediately after, and (c) 3 weeks later

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Figure 6: Histologic section of secondary epithelialization in deepithelialized submental flap. Fibrous changes in fat tissue that is covered by thin keratinized squamous epithelium (2 years after operation, H&E staining, original magnification ×40)

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Table 1: Information of the four male patients managed with deepithelialized orthograde submental flap for intraoral reconstruction

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  Discussion Top

Submental flap was introduced by Martin in 1993. It can be used both as free or pedicle flap. [7] Structural variants of this flap are fasciocutaneous, myocutaneous, and osteomuscular. [8] Based on blood perfusion, this flap is classified into orthograde and reverse flow. [9] This flap has several advantages including ease of flap elevation, inconspicuous donor site scar, simplicity, large paddle size, wide arc of rotation, axial blood supply, proximity to the oral cavity, and providing different thicknesses. [10],[11] This flap has been successfully used to reconstruct oral cavity, facial skin, oropharynges, and pharyngocutaneous fistula. [12],[13],[14] Application of this flap in maxillofacial trauma patients has also been recently introduced. Hair bearing nature of this flap in some races with heavy beards makes it unpleasant for intraoral reconstructions. Despite the limitations of hair in oral cavity, this flap is widely used for reconstruction in males [Table 2]. [15],[16],[17],[18],[9] In some east Asian races, this flap is used readily without the problem of hair in men. [19] The problem of hair have been managed using different methods including laser ablation, second operations, mechanical depilation, and electrolysis. [20],[21] Postoperative radiotherapy in malignant oral cavity lesions has inhibitory effect on hair growth of this flap. [22] These procedures are time consuming and costly, specially in patients with malignant oral cavity lesions who require postoperative radiotherapy. Moreover, the interval during which the hair is growing on the flap in oral cavity is not pleasing for the patients. Eating is difficult and entrapment of the food and debris produce bad odor and sense. [23] Secondary operations or laser ablation in pharynx and larynx is difficult specially if multiple sessions are required. [24] Although deepithelialization of the submental flap was introduced in 1997, [25] it was not widely applied for hair bearing submental flaps which may be due to the fear of surgeons to compromise blood supply of the paddle, specially the most distal parts.
Table 2: A summary of published data reporting the use of submental flaps for oral cavity/hypopharynx region after cancer ablation

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Deepithelialization procedure could be performed through two different methods. First, deepithelialization is performed after flap elevation and hair bearing skin of the flap is discarded. This procedure is recommended for patients whose pinch test shows loose tissue and skin in submental area. The majority of the patients are at old ages therefore the elimination of this skin has good esthetic results. [26] In patients who do not have excessive skin in submental area and the pinch test shows little skin laxity, this procedure can lead to wound breakdown and dehiscence in submental area. In such situations deepithelialization is performed before flap elevation. In this procedure no skin is discarded, so wound dehiscence is not a matter of concern.

  Conclusion Top

We concluded that deepithelialization is a safe procedure for submental flap in men and it does not jeopardize the blood supply of the flap.

  Acknowledgement Top

This study was supported by a grant from the Vice Chancellor of Research of Mashhad's University of Medical Sciences, Iran.

  References Top

1.Kau RL, Kim N, Hinni ML, Patel NP. Repair of esophageal perforation due to anterior cervical spine instrumentation. Laryngoscope 2010;120:739-42.  Back to cited text no. 1
2.Bulut OC, Federspil PA, Plinkert PK, Simon C. Reconstruction of maxillary defects using a free scapular angle flap. HNO 2013;61:321-6.  Back to cited text no. 2
3.Parmar PS, Goldstein DP. The submental island flap in head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2009;17:263-6.  Back to cited text no. 3
4.Lee RG, Baskin JZ. Improving outcomes of locoregional flaps: An emphasis on anatomy and basic science. Curr Opin Otolaryngol Head Neck Surg 2006;14:260-4.  Back to cited text no. 4
5.Tan O, Atik B, Parmaksizoglu D. Soft-tissue augmentation of the middle and lower face using the deepithelialized submental flap. Plast Reconstr Surg 2007;119:873-9.  Back to cited text no. 5
6.Patel UA, Bayles SW, Hayden RE. The submental flap: A modified technique for resident training. Laryngoscope 2007;117:186-9.  Back to cited text no. 6
7.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 2001;28:303-9.  Back to cited text no. 7
8.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 2009;31:725-31.  Back to cited text no. 8
9.Chen WL, Li JS, Yang ZH, Huang ZQ, Wang JU, Zhang B. Two submental island flaps for reconstructing oral and maxillofacial defects following cancer ablation. J Oral Maxillofac Surg 2008;66:1145-56.  Back to cited text no. 9
10.Pappas-Politis E, Driscoll DC, Pierpont YN, Albear PR, Carter WL, Gould LJ. Treatment of eccrine carcinoma of the chin via submental island flap. Eplasty 2010;10:e27.  Back to cited text no. 10
11.Tassinari J, Orlandino G, Fabrizio T, Calabrese L. Submental flap in facial reconstructive surgery: Long-term casuistry revision. Plast Reconstr Surg 2010;126:139-40e.  Back to cited text no. 11
12.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. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e12-6.  Back to cited text no. 12
13.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 2011;49:194-7.  Back to cited text no. 13
14.Demir Z, Velidedeoðlu H, Celebioðlu S. Repair of pharyngocutaneous fistulas with the submental artery island flap. Plast Reconstr Surg 2005;115:38-44.  Back to cited text no. 14
15.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 2008;44:1014-8.  Back to cited text no. 15
16.Amin AA, Sakkary MA, Khalil AA, Rifaat MA, Zayed SB. The submental flap for oral cavity reconstruction: Extended indications and technical refinements. Head Neck Oncol 2011;3:51.  Back to cited text no. 16
17.Jiang B, Gu Y, Chen W. Submental island flaps for reconstruction of hypopharyngeal non-circumferential defects after hypopharyngeal carcinoma removal. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2006;20:1183-5.  Back to cited text no. 17
18.Chen WL, Yang ZH, Li JS, Huang ZQ, Wang JG, Zhang B. Submental flap for reconstructing tongue defect with V-Y advancement flap for repairing submental defect. Otolaryngol Head Neck Surg 2009;141:202-6.  Back to cited text no. 18
19.Lee JC, Chu YH, Lin YS, Kao CH. Reconstruction of hypopharyngeal defects with submental flap after laryngopharyngectomy. Eur Arch Otorhinolaryngol 2013;270:319-23.  Back to cited text no. 19
20.Conroy FJ, Mahaffey PJ. Intraoral flap depilation using the long-pulsed alexandrite laser. J Plast Reconstr Aesthet Surg 2009;62:e421-3.  Back to cited text no. 20
21.Hall RR, Pearce DJ, Brown T, McMichael AJ. Unwanted palatal hair: A consequence of complex oropharyngeal reconstruction. J Dermatolog Treat 2009;20:149-51.  Back to cited text no. 21
22.Di Franco R, Sammarco E, Calvanese MG, De Natale F, Falivene S, Di Lecce A, et al. Preventing the acute skin side effects in patients treated with radiotherapy for breast cancer: The use of corneometry in order to evaluate the protective effect of moisturizing creams. Radiat Oncol 2013;8:57.  Back to cited text no. 22
23.Shim TN, Abdullah A, Lanigan S, Avery C. Hairy intraoral flap: An unusual indication for laser epilation: A series of 5 cases and review of the literature. Br J Oral Maxillofac Surg 2011;49:e50-2.  Back to cited text no. 23
24.Toft K, Keller GS, Blackwell KE. Ectopic hair growth after flap reconstruction of the head and neck. Arch Facial Plast Surg 2000;2:148-50.  Back to cited text no. 24
25.Yilmaz M, Menderes A, Barutçu A. Submental artery island flap for reconstruction of the lower and mid face. Ann Plast Surg 1997;39: 30-5.  Back to cited text no. 25
26.Genden EM, Buchbinder D, Urken ML. The submental island flap for palatal reconstruction: A novel technique. J Oral Maxillofac Surg 2004;62:387-90.  Back to cited text no. 26


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]

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