|LETTER TO THE EDITOR
|Ahead of print
Modified submental flap reconstruction for verrucous–papillary lesions of the oral cavity
Arvind Krishnamurthy, Ramakrishna R Yarram
Department of Surgical Oncology, Cancer Institute (WIA), 38, Sardar Patel Rd, Adyar, Chennai, Tamil Nadu, India
|Date of Submission||02-Jun-2019|
|Date of Decision||24-Jun-2019|
|Date of Acceptance||08-Jan-2020|
|Date of Web Publication||22-Jul-2020|
Department of Surgical Oncology, Cancer Institute (WIA), 38, Sardar Patel Rd, Adyar, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The submental flap (SMF) has over the years become a versatile flap in head and neck reconstruction, ever since it was first described more than 25 years ago. The SMFs have been primarily used in defects reconstruction of the oral cavity and oropharynx. The vast majority of the publications in the literature pertain to the use of SMF as an islanded flap. The design of SMF is flexible and can be tailored according to the reconstructive defect.,,,,
We had earlier described our novel technique of modified submental flap (m-SMF) for the reconstruction of verrucous–papillary lesions (VPLs) harboring the malignant potential of the oral cavity. From then on, we have used the flap in 30 patients (predominantly buccal mucosa, n = 29) and additionally share our experience pertaining to the oncological outcomes. The mean total operating time for the entire procedure was 120 minutes, while the mean exclusive reconstruction time was 69 minutes. The mean defect size was 4 × 3 cm and the largest reconstructed defect size was 8 × 5 cm. While 27 patients had uneventful recoveries, 3 patients suffered partial flap loss. Although various factors like age, sex, site, comorbid illness, tobacco use, alcohol use, and body mass index were studied as possible predictors of flap morbidities, none of them were found to be significant.
The mean duration of followup in our cohort was 27.5 months (3.8–70 months). Three events were noted, which included 2 primary recurrences and one nodal recurrence. The local recurrences, both of which occurred in close proximity of the m-SMF, could be surgically managed. A split skin graft following a wide excision was performed in one patient, while the local recurrence in the other patient necessitated a left lower alveolus composite resection with a pectoralis major myocutaneous flap for reconstruction. The patient with the isolated level II nodal recurrence was planned for a neck dissection and adjuvant radiotherapy; however, the patient declined treatment despite extensive counselling and subsequently defaulted. The postoperative cosmetic, swallowing, and speech functions were found to be well preserved in all our patients [Figure 1]a and b].
|Figure 1: (a) Postoperative photograph showing the well-healed and concealed donor site scar under the antegonial notch of the mandible. (b) The modified submental flap insetted in the left buccal mucosa|
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One of the primary concerns regarding the submental flap is the oncological safety, because of the close proximity of the flap and its pedicle to the submental and submandibular nodes, which drains the oral cavity. We restricted the use of our m-SMF to reconstruct the defects of the oral cavity in patients in whom the preoperative biopsy was not suggestive of an invasive squamous cell carcinoma. Despite this, 46% of our patients harbored invasive squamous cell carcinoma in the final histopathogy. This highlights the various challenges in the diagnosis and management of the VPLs harboring malignant potential of the oral cavity. However, over the years, many authors have expressed no major oncological concerns even if the flap is performed for patients with invasive squamous carcinomas, claiming that a sound oncologic resection is achievable by carefully removing the lymph node bearing tissue and thinning the pedicle. Furthermore, many authors have described SMF to compare favorably to the free flaps for some specific indications achieving similar outcomes at a much lower cost.
Our study thus reiterates that the m-SMF as described by us adds to the reconstructive armamentarium for defects following the resection of VPLs harboring malignant potential of the oral cavity, considering the minimal flap morbidity and good functional and short-term oncological outcomes. Furthermore, the m-SMF is technically easier and quicker to harvest and, hence, can be an attractive viable option even in resource-constrained settings.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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