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Editorial Manager(tm) for Plastic and Reconstructive Surgery Manuscript Draft Manuscript Number: Title: Submental flap in facial reconstructive surgery: long term casuistry revision Article Type: Follow-up Clinics Keywords: facial cancer; submental flap; long term outcomes. Corresponding Author: Mr Tommaso Fabrizio, MD Corresponding Author's Institution: Regional Cancer Centre, Ospedale Oncologico Regionale,Rionero in Vulture, Potenza, Italy First Author: Juri Tassinari, MD Order of Authors: Juri Tassinari, MD; Gianfranco Orlandino, MD; Luca Calabrese, MD; Tommaso Fabrizio, MD

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AUTHOR FORMS Please complete and sign all three forms. Form 1. Prior Publication Certification This manuscript contains original material. Neither the article nor any part of its essential substance, Tables or figures has been or will be published elsewhere before appearing in PRS. Signed:_____Tommaso Fabrizio_____________________________________ 2. Some of the material in this paper has been, or is being published elsewhere. Details are in the appended letter. Signed:__________________________________________ Form 2. Assignment of any and all copyright In consideration of the American Society of Plastic Surgeons, Inc. (ASPS) taking action in reviewing and editing my (our) submission, the author(s) undersigned hereby transfer, assign and otherwise convey all copyright ownership to ASPS in the event that such work is published by the ASPS. Must be signed by all Authors: Signed:___Juri Tassinari___________________________________________________ Date: 09/16/09 Signed:__Gianfranco Orlandino____________________________________________________ Date: 09/16/09 Signed:_Luca Calabrese_____________________________________________________ Date: 09/16/09 Signed:___Tommaso Fabrizio___________________________________________________ Date: 09/16/09 Signed:______________________________________________________ Date: Signed:______________________________________________________ Date:

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Form 3. Conflict of Interest Disclosure statement by an Author of a manuscript submitted to Plastic and Reconstructive Surgery® We have submitted for publication in Plastic and Reconstructive Surgery® a manuscript entitled: Submental flap in facial reconstructive surgery: long term casuistry revision We hereby certify, that: No financial support or benefits have been received by me or any co-author, by any member of my (our) immediate family or any individual or entity with whom or with which I (we) have a relationship from any commercial source which is related directly or indirectly to the scientific work which is reported on in the article except as described below. {I (we) understand an example of such a financial interest would be a consulting relationship or stock interest in any business entity which is included in the subject mater of the manuscript or which sells a product relating to the subject matter of the manuscript.} In addition to filling out and signing this declaration, I acknowledge that I (we) also made complete disclosure in the manuscript itself, stating all sources of funds that have supported this work and also a statement of financial interest, if any. Each author on the manuscript has disclosed any commercial association or financial disclosure that might pose a conflict of interest with information presented in this manuscript. If the authors have no financial interest or commercial association with any of the subject matter or products mentioned in our manuscript, that too will be indicated. I (we) hereby agree that such disclosures will be printed with the manuscript if it is accepted. Furthermore, I (we) understand that potential sanctions may be imposed by Plastic and Reconstructive Surgery for violation of this complete disclosure policy. I (we) understand that potential disciplinary actions may include warning letters, refusal to publish an article in question, retraction of a published paper, notification to our primary institution, and/or exclusion from publication in Plastic and Reconstructive Surgery for a specified time frame. The corresponding author has the obligation of having any and all co-authors sign this form and date his or her signature. __________Tom m aso Fabrizio____09/16/09____________________________________________ Signatu re and Date _____Juri Tassinari, 09/16/09_____________________________________________________ Signature and Date ___Gianfranco Orland ino 09/16/09_______________________________________________________ Signature and Date Luca Calabrese 09/16/09

________________________________ Copyright© 2009 American Society of Plastic Surgeons All rights reserved • Published for the ASPS by Lippincott Williams & Wilkins

*Cover Letter

I consider this paper useful, in order to show to the young surgeons like me how important could be the submental flap for the reconstruction of large defects of middle face. The long term revision casuistry, perhaps the largest one in Italy, that I had the possibility to review shows very well the great usefulness of the flap described by Dr. Martin in 1990, also in modern plastic surgery times. It could be considered, in my opinion, a first choice reconstructive technique for large defects of head and neck region.

Table

Table n° Cases Average age Histology

47 70 years 30 12 4

Cancer Area

Skin paddle

Post-operative days Complications

1 22 11 9 5 7 cm 4 cm 15 cm 6 cm 14 5 39 cases 6 cases 2 cases

Mix

S.C.C. B.C.C. Parotid Adenocarcino ma. Melanoma Cheek Temporal Parotid Lower lip Max width Min width Max length Min length Max Min None Hematoma Partial necrosis

Tab 1: principal features of the casuistry.

*Manuscript (Title Page, Abstract, Text, Acknowledgements, References, Legends)

Title page

Submental flap in facial reconstructive surgery: long term casuistry revision

J. Tassinari, G. Orlandino, *L. Calabrese T. Fabrizio, Unit of Plastic Reconstructive Surgery, Scientific Oncology Institute, Rionero in Vulture, Italy *Unit of Head and Neck, European Institute of Oncology, Milan, Italy Corresponding author: T. Fabrizio M.D. Director, Unit of Plastic Reconstructive Surgery Scientific Oncology Institute Via Padre Pio, 1 85028 Rionero in Vulture (Pz), Italy Phone 0039 0972 726735 e-mail: [email protected]

P.S.: presented as oral comunication at the 1ST European Meeting of Young Surgeons, Rome, June 18 – 20, 2009

Abstract Forty-seven (47) patients underwent ablative surgery and reconstruction using the submental artery island flap for oral and face cancer, between 1994 and 2008. They were 28 males and 19 females, aged from 48 to 84, with an average of 70. The follow up period ranged from 4 to 120 months with an average of 47.5 months. The size of the skin paddle ranged from 6 x 4 cm to 15 x 7 cm, with a mean size of 11.2 x 6 cm. The technical aspects of flap’s raising and the surgical results have been very carefully reviewed and the morpho-functional outcomes are presented.

Text Surgical anatomy The submental artery is a constant branch of the facial artery, arising about 5 - 6.5 cm from the origin of the facial artery after its exit from the sub-mandible gland. At its origin, it measures about 1-3 mm in calibre1, 2, and 3. It runs in a forward and medial direction over the mylohyoid muscle and below the mandible. In the anatomical studies by Faltous and Radall 4, the artery runs deeply to the anterior belly of the digastric muscle in 70% of cases and superficially to it in 30% of cases5. It may even run through the muscle, gives branches to the submandibular gland6, muscular branches to the mylohyoid digastric and the platysma and cutaneous perforators which pierce the platysma and anterior belly of the digastric muscle, in order to form a subdermal plexus which anastomoses extensively with the contralateral branches7, 8, and 9. The sub-mental artery gives anastomoses with its contralateral counterpart in 92% of cadavers 10. It ends over the anterior belly of the digastric muscle near the midline where it sends branches to the lower lip and in some cases to the sublingual gland. The skin territory can be as large as 10 x 16 cm in relation with the different anatomical studies4. The flap is drained by the submental vein, a branch of the common facial vein which drains into the internal jugular vein. There is at least one communicating vein between the facial vein and the external jugular vein 11, 12. Surgical technique Planning the flap The flap can be raised under general anesthesia. The patient is placed supine with the head and neck moderately extended. The surface marking of the origin of the submental artery is at point 5.5 (4-7) cm anterior to the angle of the mandible and 7 (3-15) mm from the mandible border. The surface marking of its termination is at a point 8 (2-12) mm behind the mandible border and 6 (4-8) mm laterals to the midline13, 14, and 15. Firstly, the upper limit of the flap is drawn within the mandible margin, taking care not to encroach too far anteriorly, which would produce a visible scar. This incision can be extended subsequently on the ipsilateral side to enable further dissection of the vascular pedicle if required16. The maximum paddle width permitting a direct closure can be determined using a simple pinch test and in this way the lower border of the flap is drawn. Patients and Methods From 1994 to 2008, we reconstructed with the sub mental flap forty-seven patients affected by skin cancer of the face. Thirty patients evidenced squamous cell carcinoma; twelve had basal cell carcinoma and four parotid adenocarcinoma and one showed malignant melanoma. All patients were operated under general anesthesia in ordinary hospitalization. All flaps were based on proximal pedicle. The technique to raise the flap is not very difficult. The first stage is to identify and preserve the marginal mandible branch of the facial nerve just to platysma depth and overlying the facial artery17. The upper limit of the flap is drawn within the mandibular margin, taking care not to encroach it too anteriorly, which would produce a visible scar. The margins of the flap are incised and the flap is raised commencing on the contra lateral side, dissecting all tissues off the mylohyoid and digastric muscles, and working towards the pedicle which can be completely skeletonised. The flap pedicle could be easily dissected, although in most flaps this step may be deemed unnecessary as a widely based pedicle may be sufficient to allow tension-free flap placement5. The facial artery is traced proximally and, as it disappears

behind the submandibular gland, downwards retraction on the gland will reveal the submental artery. The submental vein can be identified as it lies on the surface of the gland draining into the common facial vein18, 19. This produces a large skin paddle with a reliable, sturdy pedicle which can be tunneled to its recipient site. The donor site can be closed directly without additional dissection but if skin mobilization is required it should be done only on the cervical side to prevent eversion of the lower lip20, 21; the cervical skin should be sutured to the hyoid bone to maintain the cervicomental angle22, 23. The flap is then gently positioned on the recipient area. Avoiding every kind of pedicle traction with absorbable 3/0 simple stitches, the skin island is sutured. The soft texture and light thickness of the flap are really useful in order to sculpture in the best way the facial contour of the removed cancer area. In all patients, donor defects were closed by a direct suture. A draining device is generally located for two or three days after the operation.

Results Forty-seven (47) patients, affected by oral and face cancers, underwent ablative surgery and reconstruction using the submental artery island flap between 1994 and 2008. There were 28 males and 19 females, whose age ranged from 48 to 84 with an average age of 70. The follow up period ranged from 4 to 120 months with an average of 47.5 months. The size of the skin paddle ranged from 6 x 4 cm to 15 x 7 cm, with an average size of 11.2 x 6 cm. Thirty patients had a squamous cells cancer, eleven basal cells cancer, nine parotid adenocarcinoma and one malignant melanoma. Cancer was present in four different areas: check for 46,8%, temporal area for 23,4%, parotid region for 19,1% and lower lip for 10,6%. The longest post operative period was 14 days and the shortest five days. Fig 1 During this period, no major complications were noted and really satisfactory results were obtained. We never detected functional problems with the marginal mandible branch of the facial nerve. All flaps survived completely. Fig 2. Simple hematomas were discovered in only six patients and partial necrosis of flap in two. In these two cases we had the following clinical complications: A female patient 84 years old, 24 hours after the operation, and a male patient, 75 years old, 36 hours after the intervention had a very high blood pressure level, probably due to anesthesiology problems, which caused a very light hematoma but, although we promptly removed the coagulated blood, the compression of the very delicate venous vessels caused their definitive occlusion. That caused a partial necrosis of a small distal portion of the superficial layer of the flap. It was repaired by a skin graft. About the color of the flap tissue, it is very similar to the face’s one; however, in 3 cases the texture of the adipose tissue of the neck was far more flabby and bulky than the face, and the flap needed a debulking revision in local anesthesia to provide a good aesthetic result. The donor-site scar was well hidden below the mandible margin and healed well, with no restricted neck movements in any patient. Conclusion

This flap has been used successfully in forty-seven patients. Six immediate complications were observed for hematoma and two delayed complications for partial flap loss. The blood supply of the submental artery flap was always excellent, and dissection was not very hard. Another important aspect of the reconstructive possibilities of this flap is well represented in figure 3. When reconstruction with local flaps after skin tumor removal could failed or local recurrences of skin cancers or facial metastasis of other cancers occurred a very large demolition of the face is mandatory. In these cases the submental flap could be a very important alternative to other complicated flaps, microsurgical included, for the reconstruction of large defects of middle face. Considering the very large follow up period and the long term results that we have revaluated, considering that the pedicle is long enough to reach the contralateral side of the face and the frontal region, we believe that the submental flap, at the present time, could be numbered as the first choice flap for the reconstruction of middle size defect of the head as well as of the neck region.

References 1. Tan O, Atik B, Parmaksizoglu D. Soft-tissue augmentation of the middle and lower face using the deepithelialized submental. Plast Reconstr Surg. 2007 Mar; 119(3):873-9. 2. Uysal AC, Alagöz MS, Unlü RE, Sensöz O. An anatomic study and clinical applications of the reversed submental perforator-based island flap. Plast Reconstr Surg.2003 Aug; 112(2):690-1. 3. Sterne GD, Januszkiewicz JS, Hall PN, Bardsley AF. The submental island flap. Br J Plast Surg. 1996 Mar; 49(2):85-9. 4. Faltous A, Yetman Randall J. The submental artery flap: an anatomic study. Plast Reconstr Surg. 1996; 97:56-62. 5. Demir Z, Velidedeoluğlu H, Celebioğlu S. Repair of Pharyngocutaneous fistulas with the submental artery island flap. Plastic Reconstrction Surgery. 2005 Jan; 115(1):38-44. 6. Martin D, Baudet J, Mondie JM, Peri G. The submental island skin flap. A surgical protocol. Prospects of use. Ann Chir Plast Esthet. 1990; 35(6): 480-4 7. Kim JT, Kim SK, Koshima I, Moriguchi T. An anatomic study and clinical applications of the reversed submental perforator-based island flap. Plast Reconstr Surg. 2002 Jun; 109(7):2204-10. 8. Multinu A, Ferrari S, Bianchi B, Balestreri A, Scozzafava E, Ferri A, Sesenna E. The submental island flap in head and neck reconstruction. Int J Oral Maxillofac Surg. 2007 Aug; 36(8): 716-20. 9. Naficy S, Baker SR. The extended Abbe flap in the reconstruction of complex midfacial defects. Arch Facial Plast Surg. 2000 Apr-Jun; 2(2):141-4. 10. Magden O, Edizer M, Tayfur V, Atabey A. Anatomic study of the vasculature of the submental artery flap. Plast Reconstr Surg. 2004 Dec; 114(7):1719-23. 11. Karaçal N, Ambarcioglu O, Topal U, Sapan LA, Kutlu N. Riverse-flow submental artery flap for periorbital soft tissue and socket reconstruction. Head Neck. 2006 Jan; 28(1):40-5. 12. Ramirez OM. Cervicoplasty: nonexcisional anterior approach. Plast Reconstr Surg. 1997 May; 99(6):1576-85. 13. Barthèlèmy I, Martin D, Sannajust JP, Marck K, pistre V, Mondlè JM. Prefabricated superficial temporal fascia flap combined with a submental flap in noma surgery. Plast Reconstr Surg. 2002 Mar; 109(3):936-40. 14. Pistre V, Pelissier P, Martin D, Lim A, Baudet J. Ten years of experience with the submental flap. Plast Reconstr Surg. 2001 Nov; 108(6):1576-81.

15. Daya M, Mahomva O, Madaree A. Multistaged reconstruction of the oral commissures and upper and lower lip with an island submental flap and a nasolabiali flap. Plast Reconstr Surg. 2001 Sep 15; 108(4):968-71. 16. Jansses DA, Thimsen DA. The extended submental island lip flap: an alternative for esophageal repair. Plast Reconstr Surg. 1998 Sep;102(3):835-8. 17. Demir Z, Kurtay A, Sahin U, Velidedeoğlu H, Celebioğlu S. Hair-bearing submental artery island flap for reconstruction of mustache and beard. Plast Reconstr Surg. 2003 Aug; 112(2): 423-9. 18. Yuksel F, Celikoz B, Ergun O, Peker F, Açikel C, Ebrinc S. Management of maxillofacial problems in self-inflicted rifle wounds. Ann Plast Surg.2004 Aug; 53(2):111-7. 19. Chow TL, Chan TT, Chow TK, Fung SC, Lam SH. Reconstruction with submental flap for aggressive orofacial cancer. Plast Reconstr. Surg. 2007 Aug; 120(2): 431-6. 20. Koshima I, Inagawa K, Urushibara K, Moriguchi T. Combined submental flap with toe web for reconstruction of the lip with oral commissure. Br J Plast Surg. 2000 Oct; 53(7):616-9. 21. Vural E, Suen JY. The submental island flap in head and neck reconstruction. Head Neck. 2000 Sep; 22(6):572-8. 22. Tan O, Kiroglu AF, Atik B, Yuca K. Reconstruction of the columella using the prefabricated reverse flow submental flap: a case report. Head Neck. 2006 Jul; 28(7):653-7 23. Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of the vascular territories and perforating cutaneous vessels. Plast Reconstr Surg. 1992; 89: 591-605.

Legend

Fig 1. A) Local recurrence of a S.C.C.; B) MRI aspect of the tumor; C) Post-operative cosmetic result of the reconstructed region at the F.U. visit after 1 year Fig 2. A. Pre-operative view of S.C.C. in left temporal-parietal region. B. Post-operative aspect of reconstructed region after one month Fig 3. A. S.C.C. of inferior left eyelid and zygomatic region. B. Local recurrence and multinodular cutaneous metastases. C. MRI view of the recurrence. D. Cosmetic result of reconstructed region with a very large submental flap after one year.

Table n° Cases Average age Histology

47 70 years 30 12 4

Cancer Area

Skin paddle

Post-operative days Complications

1 22 11 9 5 7 cm 4 cm 15 cm 6 cm 14 5 39 cases 6 cases 2 cases

Mix

S.C.C. B.C.C. Parotid Adenocarcino ma. Melanoma Cheek Temporal Parotid Lower lip Max width Min width Max length Min length Max Min None Hematoma Partial necrosis

Tab 1: principal features of the casuistry.

Figure

A

C

Figure 1

B

A

Figure:2

B

A

C

Figure 3.

B

D