The musculocutaneous infrahyoid flap: surgical key points

HEAD AND NECK

The musculocutaneous infrahyoid flap: surgical key points

Haıtham Mirghani • Gustavo Meyer •

Stephane Hans • Gilles Dolivet • Sophie Perie •

Daniel Brasnu • Jean Lacau St Guily

Received: 23 May 2011 / Accepted: 19 July 2011 / Published online: 4 August 2011

� Springer-Verlag 2011

Abstract For the first time in 1979, it was described by

Wang that the infrahyoid musculocutaneous flap (IHMC

flap) appears to be extremely suitable for medium-sized

head and neck defect. Nevertheless, this flap remains

unpopular because of its pretended lack of reliability. The

aim of this study is to describe the surgical key points and

to expose its main advantages. An IHMC flap was achieved

on 32 patients to repair tissue loss due to surgical resection

of a squamous cell carcinoma of the upper aero-digestive

tract, from March 2006 to January 2010. Medical records

of each of these patients were retrospectively analysed by

the investigators including the detailed clinical, patholog-

ical and operative reports. No patient presented with total

flap necrosis. However, we experienced four skin paddles

necrosis. In two cases, the necrosis was total and in two

cases partial. All donor sites were closed primarily without

any tension. One patient showed a major dehiscence of the

neck skin incision that required a pectoralis major flap. The

IHMC flap is reliable and the harvesting technique is

simple when the surgical key points are respected. Its

advantages make it a convenient flap for medium-sized

head and neck defect.

Keywords Infrahyoid flap � Medium-sized defect �Reliable

Introduction

The infrahyoid musculocutaneous flap (IHMC flap) has

been described for the first time in 1986 by Wang et al. [1].

This flap is pedicled on the superior thyroid vessels.

Infrahyoid muscles blood supply and cutaneous vasculari-

sation of the neck have been well documented by Eliachar

et al. [2] and Rabson et al. [3]. IHMC flap appears to be

extremely suitable for medium-sized defect of oral cavity,

pharynx and lower third of the face. Being thin and supple,

it is able to fit to many anatomical configurations [4, 5]. In

spite of its numerous qualities, the mucocutaneous infra-

hyoid flap is not widely spread. Several surgeons think that

its venous drainage is fragile and prefer using more ‘‘reli-

able’’ flaps [4, 5]. Technical improvements have been

recently introduced by Dolivet et al. [6]. These innovations

attempt to enhance the venous drainage and aesthetic

results at the donor site. The aim of this publication is to

outline the surgical procedure key points based on our

experience. Advantages and inconvenience will be descri-

bed and compared with other flaps commonly used in head

and neck surgery.

H. Mirghani (&)

Department of Otolaryngology, Head and Neck Surgery,

Institut Gustave Roussy, 39 rue Camille Desmoulin,

94800 Villejuif, France

e-mail: [email protected]

G. Meyer � S. Hans � D. Brasnu


Faculty of Medicine, University Rene Descartes Paris V,

Hospital Georges Pompidou, Assistance Publique

Hopitaux de Paris, Paris, France

G. Dolivet

Head and Neck Surgery Unit, Oncologic Surgery Department,

Centre Alexis Vautrin, Vandoeuvre les Nancy,

France

S. Perie � J. L. S. Guily


Faculty of Medicine, University Pierre et Marie Curie Paris VI,

Hospital Tenon, Assistance Publique Hopitaux de Paris, Paris,

France

123

Eur Arch Otorhinolaryngol (2012) 269:1213–1217

DOI 10.1007/s00405-011-1724-6

Patients and methods

An infrahyoid flap was achieved on 28 men and four

women to repair tissue loss due to surgical resection of a

squamous cell carcinoma (SCC) of the upper aero-diges-

tive tract (Table 1), from March 2006 to January 2010.

Medical records (Table 1) of each patient were retro-

spectively analysed by the investigators including the

detailed clinical, pathological and operative reports.

Three patients had already been treated for a former

SCC of the upper aero-digestive tract: two of them had

surgery of the tumoral area associated with neck dissection

(patient no. 8 and 18) and the third had concomitant che-

moradiotherapy (patient no. 9).

One patient (patient no. 22) had previously been treated

by radiotherapy for head and neck lymphoma. The SCC

was located in the oral cavity in 21 cases and in the oro-

pharynx in 11 cases.

Twelve patients were classified N0. The other 20 had at

least one cervical lymph node metastasis. A modified neck

dissection was performed in 29 patients. Three patients

previously treated for head and neck SCC did not undergo

neck dissection.

Surgical technique

A fusiform skin paddle centred over the infrahyoid muscle

and the cricothyroid region is outlined. The flap is raised

from the side of the defect when the loss is lateral or from

either side when the loss is median. The inferior insertions

of the sternohyoid and sternothyroid muscles are severed

Table 1 Patients description

LOW lateral oropharyngeal

wall, SPN skin paddle necrosis

Patient Age/sex Localisation Staging Former cancer Complication

1 55/M Floor of the mouth T2N0 – –

2 82/F Cheek T2N0 – –

3 61/M LOW T3N3 – –

4 71/M LOW T3N2c – –

5 69/F Mobile tongue T4N2b – –

6 47/M LOW T4N2b – –

7 65/M LOW T4N2c – –

8 51/M Mobile tongue T2N0 Oropharyngeal cancer –

9 73/M LOW T2N0 Hypopharyngeal cancer Neck dehiscence

10 66/M LOW T3N2c – –

11 51/M LOW T3N2c – –

12 42/M Floor of the mouth T3N2c – Total SPN

13 52/M Base of tongue T4N1 – –

14 47/M Mobile tongue T2N0 – Partial SPN

15 46/M Floor of the mouth T4aN2b – –

16 53/M Mobile tongue T2N0 – –

17 61/M Mobile tongue T2N0 – –

18 57/M Floor of the mouth T2N0 Floor mouth cancer –


20 49/M Floor of the mouth T2N1 – Total SPN

21 47/M Base of tongue T2N2a – –

22 64/F Cheek T3N0 Cheek lymphoma –

23 65/M Base of tongue T2N0 – –


25 71/M Floor of the mouth T2N0 – Partial SPN

26 28/M Mobile tongue T4aN2b – –

27 62/F Mobile Tongue T4aN0 – –

28 45/M Mobile tongue T4aN1 – –

29 51/M Mobile tongue T4aN1 – –


31 58/M Soft palate T2N2c – –


1214 Eur Arch Otorhinolaryngol (2012) 269:1213–1217

123

from the sternal notch. Laterally, the superior belly of the

omohyoid muscle is divided from the inferior segment. The

medial border of the flap is the linea alba. The IHMCF is

raised from lateral to medial and from caudal to cephalad.

Dissection is made above the level of the thyroid gland

capsule until reaching the upper thyroid pole where the

terminal branches of the superior thyroid artery are selec-

tively tied (Fig. 1).

Common and external carotid artery is dissected, until

the superior thyroid artery appears. All the veins draining

the flap in the direction of the internal jugular vein must be

preserved in addition to the superior thyroid vein. The flap

is secured by stitching the skin and muscles together.

Thereafter, the insertion of the sternothyroid and the thy-

rohyoid muscles is subperichondraly released from the

thyroid cartilage. The dissection is lead until the hyoid

bone and the infrahyoid muscles are severed from the

hyoid bone by their posterior side (Fig. 2). The flap is

finally transferred to cover the defect.

Results

An average time of 30 min was needed for flap elevation.

In patients with prior neck surgery or radiotherapy, surgical

time was extended to 50 min.

Post operative course was eventless in 27 patients. We

experienced four skin paddles necrosis. In two cases, the

necrosis was total and in two cases partial (\25%). In both

cases of total skin necrosis, an obvious reason was found.

In one case, the skin island had not been stitched to the

muscles inducing shearing of perforating arteries. In the

other case, the flap pedicle has been compressed by

haematoma (patient under lysine acetylsalicylate).

No muscle necrosis was seen. Necrotic skin parts, partial

or total, were resected to allow secondary epithelialization

of the underlying muscles.

The skin paddle loss did not affect the final result,

except in one patient who developed a scar between the

tongue and the rebuilt floor of the mouth. A second oper-

ation was needed to release the tongue.

All donor sites were closed primarily without any ten-

sion. One patient showed a major dehiscence of the neck

skin incision. This patient (patient no. 9) had undergone

radiochemotherapy for a prior cancer. A pectoralis major

flap was needed to cover the neck (Table 1).

Discussion

The benefits of the IHMC flap in head and neck recon-

struction have been described by many authors [4, 7–9]. It

appears to be extremely suitable for medium-sized defects

of oral cavity, pharynx and lower third of the face because

it is thin, supple and usually hairless. The flap harvesting is

fast and the donor site is close to the original operating

field. The resulting donor site scar is acceptable and allows

the performance of neck dissection. Nevertheless, this flap

remains unpopular [5, 6]. The two main reasons of this

unpopularity are the supposed demanding surgical tech-

nique and its lack of reliability, due to the variability of its

venous return [4, 5]. The main complication observed both

in our population and in previous reports is the partial or

complete loss of the skin paddle [6, 7]. Total flap necrosis

is rare [4, 6]. The primary reason of the skin paddle loss is

venous return insufficiency, but other factors may be

incriminated such as pedicle twisting or excessive traction

on the flap [4, 10].

In our experience, the presence of a skin paddle is

important because it prevents from shrinkage that can lead

to fixation of mobile structure such as the tongue in cases

of oral cavity cancers.

To reduce the risk of necrosis some surgical key points

must be respected:

Fig. 1 Selective ligature of superior thyroid artery terminal branches

Fig. 2 Flap complete elevation

Eur Arch Otorhinolaryngol (2012) 269:1213–1217 1215

123

– Dissection of the vascular pedicle must be led from the

upper thyroid pole to its origin on the external carotid.

The goal of retrograde dissection is the preservation of

the small branches of the superior thyroid artery

providing the infrahyoid muscles blood supply.

– All the veins (facial, lingual,…) draining the flap area

must be preserved if possible to enhance the venous

drainage.

– Dissection of the infrahyoid muscles from the hyoid

bone must be done from back to front to preserve the

periosteum of the hyoid bone which also assists to the

microvascular tissue drainage [6].

– The skin island must include the cricothyroid region,

where most of the perforating arteries lie.

– The skin paddle must be sutured to the muscle to avoid

injury to the small musculocutaneous perforators.

– The flap must reach the recipient site without tension

on the skin paddle; traction should be placed on the

muscle and not on the skin paddle.

In case of skin paddle necroses, there is no need to

perform a second flap to cover the defect caused by the

tumoral excision. The infrahyoid muscles are still alive and

allow secondary epithelialisation.

Many flaps are available for head and neck reconstruc-

tion. These include cheek flaps (naso-genian and facial

artery musculo-mucosal flap), neck flaps (submental and

the sternocleidomastoid muscle flap), trunk flaps (pecto-

ralis major and latissimus dorsi flap) and free flaps.

The infrahyoid flap is larger than cheek flaps. For oral

cavity reconstruction, it is introduced into the mouth

through the neck and does not cover the jaw. It does not

require teeth removal and it is compatible with dental

prothesis without any weaning procedure.

The infrahyoid flap is more reliable than the submental

flap or the sternocleidomastoid flap when a neck dissection

is performed. Because the superior thyroid pedicle is less

exposed than the submental or the occipital pedicle espe-

cially during level I and II dissection.

The IHMC flap is less bulky than a pectoralis major or a

latissimus dorsi flap. It provides better functional results

[4].

The IHMC flap obviates the need for a free flap in many

cases. Its skin paddle can reach up to 40 cm2 (10 9 4 cm)

without any neck closure problem. The flap elevation does

not require microvascular expertise and vigilant monitoring

of the free flap during the first postoperative days [5, 11].

The infrahyoid flap has two main disadvantages. Its

limited volume can be a restraining factor in some cases.

The flap dissection requires more precision in opposition

with the blunt dissection of many flaps.

Classical contraindication of the IHMC flap is previous

thyroidectomy, neck dissection or radiotherapy [8, 11]. In

our experience, this contraindication can sometimes be

relativised.

We have operated two patients with prior neck dissec-

tion and two patients with prior radiotherapy. We experi-

enced no major difficulties during flap dissection except

fibrosis. All the flaps were successful, but one patient

showed a major dehiscence of the neck skin incision. This

patient has been treated for a previous oropharyngeal SCC

by radiochemotherapy (66 Gy). It appears that prior

radiotherapy is more a problem for the donor site healing

than for the flap itself. Nevertheless, as reported by Magrin

[12], the success rate for this flap decreases from 90 to 53%

in case of prior irradiation. These two reasons lead us to

prefer the use of another flap if the patient was previously

treated by radiotherapy.

Prior neck dissection is not a contraindication for us, if

the internal jugular vein has been preserved.

Conclusion

The IHMC flap is reliable and its harvesting is simple when

the surgical key points are respected. Complications are

easy to manage. The IHMC flap has proven to be helpful in

the reconstruction of a wide range of moderate-sized head

and neck defects in this series of 32 patients. Its use should

be more spread.

An ethical committee has approved this manuscript. The

specific name of this ethic committee is The French Society

of ENT and Head and Neck Surgery.

Conflict of interest The authors declare that they have no conflict

of interest.

References

1. Wang HS, Shen JW, Ma DB, Wang JD, Tian AL (1986) The

infrahyoid myocutaneous flap for reconstruction after resection of

head and neck cancer. Cancer 57:663–668

2. Eliachar I, Marcovich A, Har Shai Y, Lindenbaum E (1984)

Arterial blood supply of the infrahyoid muscles: an anatomical

study. Head Neck Surg 7:8–14

3. Rabson JA, Hurwitz DJ, Futrell JW (1985) The cutaneous blood

supply of neck: relevance to incision planning and surgical

reconstruction. Br J Plast Surg 38:208–219

4. Verhulst J, Souza Leao R (2004) The infrahyoid musculocuta-

neous flap: experience of 153 cases in the reconstruction of the

oropharynx and oral cavity after tumoral excision. Rev Laryngol

Otol Rhinol (Bord) 125:49–53

5. Deganello A, Manciocco V, Dolivet G, Leemans CR, Spriano G

(2007) Infrahyoid fascio-myocutaneous flap as an alternative to

free radial forearm flap in head and neck reconstruction. Head

Neck 29:285–291

6. Dolivet G, Gangloff P, Sarini J, Ton Van J, Garron X, Guillemin

F, Lefebvre JL (2005) Modification of the infrahyoid musculo-

cutaneous flap. Eur J Surg Oncol 31:294–298

1216 Eur Arch Otorhinolaryngol (2012) 269:1213–1217

123

7. Lockhart R, Menard P, Chout P, Favre-Dauvergne E, Berard P,

Bertrand JC (1998) Infrahyoid myocutaneous flap in reconstruc-

tive maxillofacial cancer and trauma surgery. Int J Oral Max-

illofac Surg 27:40–44

8. Zhao YF, Zhang WF, Zhao JH (2001) Reconstruction of intraoral

defects after cancer surgery using cervical pedicle flaps. J Oral

Maxillofac Surg 59:1142–1146

9. Windfuhr JP, Remmert S (2006) Infrahyoid myofascial flap for

tongue reconstruction. Eur Arch Otorhinolaryngol 263:1013–

1022

10. Rojananin S, Suphaphongs N, Ballantyne AJ (1991) The infra-

hyoid musculocutaneous flap in head and neck reconstruction.

Am J Surg 162:400–403

11. Minni A, Mascelli A, Suriano M (2010) The infrahyoid myocu-

taneous flap in intra-oral reconstruction as an alternative to free

flaps. Acta Otolaryngol 130:733–738

12. Magrin J, Kowalski LP, Santo GE, Waksmann G, DiPaula RA

(1993) Infrahyoid myocutaneous flap in head and neck recon-

struction. Head Neck 15:522–525

Eur Arch Otorhinolaryngol (2012) 269:1213–1217 1217

123

Documents

The musculocutaneous infrahyoid flap: surgical key points