Submental Flap for Soft Tissue Reconstruction Following

Radical Parotidectomy

Rodrigo Bayon, MDUniversity of Iowa Hospitals and ClinicsDepartment of Otolaryngology-Head & Neck SurgeryRodrigo-Bayon@uiowa.edu

Contact1. Martin D, Pascal JF, Baudet J et al. The submental island flap: a new donor site. Anatomy and clinical applications as a free or pedicled flap Plast Reconstr Surg. 1993 Oct;92(5):867-73.2. Howard BE, Nagel TH, Donald CB, Hinni ML, Hayden RE. Oncologic safety of the submental flap for reconstruction in oral cavity malignancies. Otolaryngol Head Neck Surg. 2014 Apr;150(4):558-62.3. Patel UA, Bayles SW, Hayden RE. The submental flap: A modified technique for resident training. Laryngoscope. 2007 Jan;117(1):186-9.4. Loyo M, Gourin CG. Free abdominal fat transfer (FAT) for partial and total parotidectomy defect reconstruction. Laryngoscope. 2016 May 30. 5. Bugis SP, Young JE, Archibald SD. Sternocleidomastoid flap following parotidectomy Head Neck. 1990 Sep-Oct;12(5):430-5. 6. Cannady SB, Seth R, Fritz MA et al. Total parotidectomy defect reconstruction using the buried free flapOtolaryngology–Head and Neck Surgery (2010) 143, 637-6437. Ch'ng S, Ashford BG, Gao K, McGuinness J, Clark JR. Reconstruction of post-radical parotidectomy defects. Plast Reconstr Surg. 2012 Feb;129(2):275e-287e8. Teknos TN, Nussenbaum B, Bradford CR et al. Reconstruction of complex parotidectomy defects using the lateral arm free tissue transfer. Otolaryngol Head Neck Surg. 2003 Sep;129(3):183-91.9. Tyla-Kotola T, Goldstein DP, Hofer SOP et al. Facial Nerve Reconstruction and Facial Disfigurement after Radical Parotidectomy. J Reconstr Microsurg 2015;31:313–318.10. Howard BE, Nagel TH, Barrs DM, Donald CB, Hayden RE. Reconstruction of Lateral Skull Base Defects: A Comparison of the Submental Flap to Free and Regional Flaps. Otolaryngol Head Neck Surg. 2016

Jun;154(6):1014-811. Paydarfar JA, Patel UA. ..Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg. 2011 Jan;137(1):82-7

References

Objectives: At this end of this presentation, participants will understand 1) the anatomy of the submental flap and technique of submental flap harvest 2) the utility of submental flap as “filler” for soft tissue defects of the preauricular region following radical parotidectomy.

Methods: This a case report of a 64 year old male presenting with a 6 month history of a parotid mass and 2 month history of facial paralysis found to have a parotid malignancy.

Results: A fine needle aspiration biopsy confirmed an epithelial malignancy and further work up revealed cervical adenopathy in levels II – IV, sparing the submandibular triangle. The patient underwent radical parotidectomy, neck dissection and facial nerve grafting. A submental flap was harvested in standard fashion and rotated into the defect. The flap was de-epithelialized and secured in place and buried under the patient’s native skin. The final pathology demonstrated a salivary duct carcinoma (Her2 positive) with multiple nodal metastases. He completed adjuvant chemoradiation and Trastuzumab. On follow up, he has maintained adequate bulk and good contour in the pre-auricular region.

Conclusion: Radical parotidectomy typically leaves patients with a significant cosmetic deformity of the pre-auricular region. The submental flap is a local flap that is in the surgical field and has characteristics that allow for excellent soft tissue reconstruction of this area.

Abstract

The patient underwent a radical parotidectomy with nerve grafting of the inferior division of the facial nerve. A modified radical neck dissection was performed. He had an uneventful post operative course and was discharged on post operative day #2. His pathology ultimately identified a salivary duct carcinoma with multiple nodal metastases. He received adjuvant chemoradiation therapy and Trastuzumab.

The patient was last seen 6 months post-operatively and is extremely satisfied with his cosmetic appearance (figure 6) . There is no evidence of locoregional recurrence.

Introduction

We present a case of a 64 year old male presenting with a parotid mass and sudden onset facial paralysis of the marginal mandibular branch. An Epithelial malignancy was diagnosed using fine needle aspiration biopsy. A Radical parotidectomy and neck dissection were recommended. The patient was concerned about the cosmetic deformity of a radical parotidectomy and chose flap reconstruction with a submental island flap after risks, benefits and alternatives were discussed.

Technique: A submental flap was harvested in fashion described my previous authors.1,3 A 5 x 9 cm skin island was designed based on measurements taken from the parotid specimen and defect (figure 2 and 3a and b, respectively). The submental artery and vein were identified posterolateral to the submandibular gland and traced proximal to distal with careful skeletonization of the pedicle vessels. The flap was then raised in a distal to proximal fashion in a sub-platysmal plane. Both the ipsilateral anterior belly of digastric and mylohyoid were included in the flap to achieve maximal bulk. The flap was rotated into the radical parotidectomy defect and the geometry of the vessels carefully assessed to avoid kinking or compression. The skin paddle was evaluated for any evidence of venous congestion or arterial insufficiency (figure 4). The flap was then de-epithelialized and sutured into position (figure 5).

Methods and Materials

Radical parotidectomy for advanced malignancies of the parotid gland often leave patients not only with functional deficits related to facial nerve sacrifice, but also with significant cosmetic deformity of the pre-auricular region. A variety of strategies have been described in the literature. Free fat grafts have been shown to be a good option in many of these defects.4 However graft viability and long term outcomes in the setting of radiation therapy are not predictable. Multiple authors have used local and free tissue transfers to address these soft tissue deficits with good success.5-9

However, free tissue transfer requires microvascular expertise and is associated with extended hospital stays for flap monitoring.

The submental flap has many characteristics which make it an ideal reconstructive option for the preauricular region. It is a donor site which is local and typically in the operative field. The additional scar required hides well on the underside of the mandible. It has a consistent, reliable blood supply that allows for transfer of a large skin paddle. The shape and size of the flap closely resembles that of the parotid gland itself, with a thinner distal portion and thicker proximal portion. The volume of the flap can be tailored by harvesting the mylohyoid in addition to the anterior belly of the digastric. Lastly, no microvascular expertise is required, allowing for a shorter operative time and hospital stay.10,11

Limitations in the use of this flap include use in patients who have known level I nodal disease as well as use in patients with inadequate submental soft tissues to harvest a sufficient volume to obliterate the defect. Prior neck dissection or radiation therapy may also impact on a surgeon’s ability to safely harvest this flap. Lastly, the volume of this flap may not be adequate in patients with massive defects and free tissue transfer should be considered.

Discussion

The submental island flap is a versatile flap that allows for soft tissue reconstruction of radical parotidectomy defects with little impact on hospital length of stay, excellent cosmetic outcomes and minimal donor site morbidity.

Conclusions

The submental flap was first introduced by Marten et al in 1993 for reconstruction of facial defects1. Its use has since been expanded to include reconstruction of a variety of defects including oral cavity, orbital defects and lateral skull base. It’s use in patients at risk for level I nodal metastasis has been established.2 At our institution as well as others, it has become a workhorse for reconstruction of pre-auricular defects that involve skin due to its proximity to the wound, excellent color match, and ability to transfer hair baring skin. We have recently expanded its use to reconstruct soft tissue only defects including radical parotidectomy defects which leave patients with significant deformity (figure 1).

Results

Figure 1 Radical parotidectomy defect

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LOGO

Figure 6: 6 month post-operative photos

Figure 3a parotid defect w/ nerve graft Figure 3b Submental island design

Figure 4 Flap rotated into defect Figure 5 De-epithelialized flap

Figure 2 Surgical specimen

Submental Flap for Soft Tissue Reconstruction Following Radical Parotidectomy

Rodrigo Bayon, MD1

1University of Iowa Hospitals & Clinics Department of Otolaryngology – Head & Neck Surgery