Wei-Liang Chen, DDS, MD, MBA, Jian-Tao Ye, DDS, MD, Zhao-Hui Yang, DDS, MD, Zhi-Quan Huang, DDS, MD, Da-Ming Zhang, DDS, MS, Ke Wang, DDS, MS

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1 ORIGINAL ARTICLE REVERSE FACIAL ARTERY SUBMENTAL ARTERY MANDIBULAR OSTEOMUSCULAR FLAP FOR THE RECONSTRUCTION OF MAXILLARY DEFECTS FOLLOWING THE REMOVAL OF BENIGN TUMORS Wei-Liang Chen, DDS, MD, MBA, Jian-Tao Ye, DDS, MD, Zhao-Hui Yang, DDS, MD, Zhi-Quan Huang, DDS, MD, Da-Ming Zhang, DDS, MS, Ke Wang, DDS, MS Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital, Sun Yat-sen University, Guangzhou , China. Accepted 8 September 2008 Published online 3 March 2009 in Wiley InterScience ( DOI: /hed Abstract: Background. Functional and aesthetic restoration in maxillary reconstruction remains a challenge. Although many free flap procedures have become popular in maxillary reconstruction, these microsurgical methods have certain limitations and risks. This study assessed the reliability of the reverse facial artery submental artery mandibular osteomuscular flap for reconstructing maxillary defects. Methods. Eight maxillary defects following benign tumor ablation were repaired with reverse facial artery submental artery mandibular osteomuscular flaps. The patients ranged in age from 16 to 33 years; 5 were male and 3 were female. Maxillary odontogenic myxoma was present in 3 cases, maxillary fibrous dysplasia and ameloblastoma in 2 cases each, and chondromyxoid fibroma in 1 case. The defects were classified as class 2a. Results. Primary reconstruction of the maxilla was carried out using a pedicled mandibular osteomuscular flap. No flap failures occurred. Dental reconstruction was successful in all patients. Proper aesthetics and complete functionality were obtained, and there were no donor-site problems. The patients were followed for 12 to 24 months, with an average of 18.6 months, and no recurrence was encountered. Correspondence to: W.-L. Chen VC 2009 Wiley Periodicals, Inc. Conclusion. The reverse facial artery submental artery mandibular osteomuscular flap is safe, quick, and simple to elevate. The flap can be used reliably for reconstructing maxillary defects. VC 2009 Wiley Periodicals, Inc. Head Neck 31: , 2009 Keywords: osteomuscular flap; facial artery; submental artery; maxillary defect; reconstructive surgery Maxillary defects are caused by ablative tumor surgery or trauma to the stomatognathic complex, including the palate, teeth, nasal cavity, and maxillary sinus. Functional and aesthetic restoration remains a challenge. For better aesthetic and functional results, the final goal should be successful oral rehabilitation and the restoration of dental occlusion using prostheses. Many pedicled and free tissue transfer techniques, with and without bone graft tissue flaps, have been used for maxillary reconstruction, including the temporalis muscle flap, 1 fibular osteocutaneous flap, 2 radial forearm osteocutaneous flap, 3 rectus abdominis flap with Reverse Facial Artery Submental Artery Mandibular Osteomuscular Flap HEAD & NECK DOI /hed June

costal cartilage, 4 rectus abdominis flap with nonvascularized bone, 5 and deep circumflex iliac artery flap with internal oblique muscular flap.

2 costal cartilage, 4 rectus abdominis flap with nonvascularized bone, 5 and deep circumflex iliac artery flap with internal oblique muscular flap. 6 However, these microsurgical methods have certain limitations and risks in the functional and aesthetic restoration of younger patients, in elderly patients or patients with systemic diseases who are not suitable candidates for long operations, and in patients operated on previously who have inadequate recipient vessels. Moreover, the patient may wish to be treated by more conservative means. This study evaluated the reverse facial artery submental artery mandibular osteomuscular flap for reconstructing maxillary defects following the removal of benign tumors. PATIENTS AND METHODS Materials. This retrospective study included 8 patients with benign tumors involving the maxilla who underwent surgical resection and sequential maxillary reconstruction using a reverse facial artery submental artery mandibular osteomuscular flap between September 2005 and March 2007 at the Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital, Sun Yat-sen University, China. There were 5 males and 3 females. They ranged in age from 16 to 33 years, with a mean of 25.3 years. Maxillary odontogenic myxoma was present in 3 cases, fibrous dysplasia and ameloblastoma in 2 cases each, and chondromyxoid fibroma in 1 case. In all patients, the lower 5 walls of the maxilla were resected, including the palate, while leaving the oral mucosa and sparing the orbital floor (subtotal maxillectomy) (see Figure 1). The remaining defects were classified as class 2a according to the classification of Brown et al. 7 Patient records and all available documents and radiographs were reviewed. The data on flap survival and complication rates, such as wound infection, dehiscence, and partial or total loss of the bone transplant, were collected. The success of the maxillary dental rehabilitation was also evaluated. The mean follow-up was 18.6 months (range, months). Surgical Anatomy. Doppler mapping was used to identify the facial and submental arteries preoperatively in all the patients. The facial artery is FIGURE 1. A 13-year-old boy with an odontogenic myxoma of the maxilla. (A) Preoperative appearance. (B) The 6 7cm 2 mass in the right maxilla. (C) The tumor specimen. [Color figure can be viewed in the online issue, which is available at the principal superficial artery to the face. After leaving the submandibular gland, it gives off the submental artery as a consistent branch. It runs on top of the mylohyoid muscle below the mandible. In 70% of dissections, it is deep to the 726 Reverse Facial Artery Submental Artery Mandibular Osteomuscular Flap HEAD & NECK DOI /hed June 2009

anterior belly of the digastric muscle, whereas in the other 30% it runs superficial to it. Several perforators from the artery supply the platysma muscle and overlying skin.

3 anterior belly of the digastric muscle, whereas in the other 30% it runs superficial to it. Several perforators from the artery supply the platysma muscle and overlying skin. There are usually 2 major perforators, with 1 coming off proximal to the digastric muscle and the other distal. Minor perforators come directly through the anterior belly of the digastric muscle. 8 It terminates close to the mandibular symphysis in a subdermal plexus, anastomosed extensively with the contralateral terminal branches and giving off several branches to the mandible, and several perforators from the submental artery supply the mandibular margin bone. On the face, it gives off many important branches, such as the inferior labial, superior labial, and lateral nasal arteries. The superior and inferior labial arteries anastomose with their counterparts from the opposite side, along the lips. Distal to its superior branch, it is called the angular artery. The internal maxillary artery contributes many branches that anastomose with the facial artery, such as the anterior ethmoidal infraorbital, buccal, descending palatine, and mental arteries. 9 The facial vein has no valves. It passes downward and backward behind the facial artery after crossing the body of the mandible; it runs obliquely back under the platysma, but superficial to the submandibular gland, to join the retromolar vein. The facial vein communicates much more extensively in the face to both the ipsilateral internal and external jugular veins via the pterygoid venous and the transverse facial temporal, maxillary, and retromolar veins or to the opposite side via the superior and inferior labial veins. 10 Rojananin et al 11 found that there was no significant change in the mean intraarterial pressure in the facial artery after proximal ligation and occlusion of the contralateral relevant artery. This implies that the reverse facial artery submental artery mandibular osteomuscular flap is reliable for reconstructing maxillary defects. Surgical Technique. The reverse facial artery submental artery mandibular osteomuscular flap is raised under general anesthesia. For surgery, the patient is placed in the supine position with the head and neck extended moderately. The reverse facial artery submental artery mandibular osteomuscular flap is outlined and it measures 5 cm 10 cm, including the platysma, anterior belly of the digastric muscle, and a 1.5 cm 7 cm mandibular flap (Figure 2). FIGURE 2. Outline of the facial arterial terminal branching determined using the Doppler probe and outline of the reverse facial artery submental artery mandibular osteomuscular flap. [Color figure can be viewed in the online issue, which is available at Because the marginal mandibular branch of the facial nerve lies underneath the flap, the skin incision in the upper margin of the flap is made 1.5 cm below the body of the mandible, starting from the operating site to the middle line of the mandible, and the lateral margin is set below the mandibular angle. The skin is raised, exposing the platysma. The first procedure in raising the flap is to identify and preserve the marginal mandibular branch of the facial nerve to the depth of the platysma and the overlying facial artery, and both tips of the flap over the mandibular angle rising above the platysma and subplatysmal plane are entered anterior to the facial artery (Figure 3). Temporary palsy of the marginal mandibular branch of the facial nerve can be avoided. The inferior borders of the mandible with the platysma are sectioned with an oscillating saw. The periosteum is preserved. The flap is raised medially, dissecting all the tissues off the mylohyoid muscle and keeping the mandibular bone and platysma with the flap. The anterior belly of the digastric muscle is included in the flap to prevent venous congestion. The facial artery is traced proximally and, as it disappears behind the submandibular gland, downward retraction on the gland reveals the submental artery. The submental vein can be identified as it lies on the surface of the gland draining into the facial vein and common facial vein (Figure 4). For a reverse facial submental artery mandibular osteomuscular flap, the proximal facial artery and common facial vein to the branching point of the submental pedicle Reverse Facial Artery Submental Artery Mandibular Osteomuscular Flap HEAD & NECK DOI /hed June

FIGURE 3. The marginal mandibular branch of the facial nerve, proximal facial artery, and distal facial artery are identified carefully.

] are then ligated, and the flap is returned to a reverse-flow pattern supplied by the distal facial pedicle (Figure 5).

In this way, further pedicle advancement and a greater arc of rotation can be achieved for the defects. The tunnel should be broad enough not to compress the flap.

The proximal facial artery and common facial vein are ligated, and a reverse facial submental artery mandibular osteomuscular flap supplied by the distal facial artery is harvested. ] (see Figure 6).

4 FIGURE 3. The marginal mandibular branch of the facial nerve, proximal facial artery, and distal facial artery are identified carefully. [Color figure can be viewed in the online issue, which is available at are then ligated, and the flap is returned to a reverse-flow pattern supplied by the distal facial pedicle (Figure 5). The mandibular bone needs to be cut and bent into the shape of the maxilla, and the flap is rotated into the postablative defect. The elevated flap is passed under the marginal mandibular nerve. In this way, further pedicle advancement and a greater arc of rotation can be achieved for the defects. The tunnel should be broad enough not to compress the flap. Excessive stretching of the flap and excessive suture tension should be avoided. The flap is rotated into the postablative defect and fixed rigidly with microplates and screws FIGURE 5. The proximal facial artery and common facial vein are ligated, and a reverse facial submental artery mandibular osteomuscular flap supplied by the distal facial artery is harvested. [Color figure can be viewed in the online issue, which is available at (see Figure 6). The defects of the mandible are repaired with a MEDPOR Surgical Implant (MEDPOR; Porex Surgical, College Park, GA) fixed with microplates and screws. The donor area is closed primarily. RESULTS All of the lesions were widely excised extending to the maxilla. Primary reconstruction of the class 2a defects of the maxilla was carried out using a reverse facial submental artery mandibular osteomuscular flap. No flaps failed. No FIGURE 4. The facial artery, facial vein, and common facial vein are identified. A cm 2 piece of the inferior border of the mandible with the platysma is harvested. [Color figure can be viewed in the online issue, which is available at FIGURE 6. The flap is rotated into the postablative defect and fixed using a titanium miniplate. [Color figure can be viewed in the online issue, which is available at com.] 728 Reverse Facial Artery Submental Artery Mandibular Osteomuscular Flap HEAD & NECK DOI /hed June 2009

of the mandibular bone repaired with a MEDPOR surgical implant, which was fixed with microplates and screws. [Color figure can be viewed in the online issue, which is available at www.interscience.

5 FIGURE 8. Three-dimensional CT 12 months postoperatively did not show any recurrence and confirmed volume maintenance and anatomical continuity of the mandibular bone graft and defects of the interior border of the mandibular bone repaired with a MEDPOR surgical implant, which was fixed with microplates and screws. [Color figure can be viewed in the online issue, which is available at quantitative assessment of the improvements in the functionality, aesthetic result, mouth opening, and success of dental rehabilitation. Proper aesthetics and complete functionality were obtained. Mouth opening was normal in all patients. Dental reconstruction was successful in all patients, and there were no donor-site problems (Figure 7). The patients were followed for 12 to 24 months, with an average of 18.6 months, and no recurrences were encountered. The clinical and postoperative 3-dimensional CT reconstruction did not show any recurrence and confirmed the maintenance of the result (Figure 8). FIGURE 7. Twelve months postoperatively. (A) The cosmetic result was maintained. (B) The donor site leaves a well-hidden scar. (C) There was no limitation of mouth opening. (D) After dental prosthetic rehabilitation. [Color figure can be viewed in the online issue, which is available at com.] palsy of the marginal mandibular branch of the facial nerve occurred. The outcome was assessed by a panel of 3 surgeons knowledgeable about and experienced in reconstructive and oncologic surgery. The primary efficacy measure was the DISCUSSION In 1993, Martin et al 12 described the use of a new island flap based on the submental artery for the reconstruction of orofacial defects. Stern et al 13 described by dividing the facial vessels proximal to the origin of the submental artery, basing the blood supply on retrograde flow from the distal facial vessels. This so-called reverseflow submental artery flap achieved additional pedicle length, allowing the flap to reach the upper midface. Karacal et al 14 successfully used the reverse-flow submental artery island flap for large periorbital soft-tissue defects and socket reconstruction. We believe that the proper name of the flap is facial submental artery island Reverse Facial Artery Submental Artery Mandibular Osteomuscular Flap HEAD & NECK DOI /hed June

6 flap, and that there are 2 patterns: the facial submental artery island flap and the reverse flap. Chen et al 15 repaired oral and maxillofacial defects with reverse facial artery submental artery island myocutaneous flaps following earlystage carcinoma ablation, and considered the reverse facial artery submental artery island myocutaneous flap reliable for reconstructing medium-sized oral and maxillofacial defects. We used reverse facial submental artery island flaps to repair lower oral defects of the tongue, buccal mucosa, and lower gingiva, and mediumsized facial defects of the middle and upper thirds of the oropharyngeal region, palate, and zygomatic region. The flap is considered safe, quick, and simple to elevate, and it results in minimal donor-site morbidity. 16 In our study, reverse facial submental artery mandibular osteomuscular flaps were used to reconstruct the maxillas in 8 patients with benign tumors involving the maxilla. There were no complications involving the flap or donor site. The outcomes were excellent. This procedure has the following advantages: it allows excellent aesthetics and a well-hidden donor scar; it is safe, quick, and simple to elevate; it is not necessary to form the contour of the maxilla; it has less potential for absorption; there is no donor morbidity; it provides a base to enable full dental and prosthetic rehabilitation with either implant-retained or conventional prostheses; and it may be a better choice for repairing defects of the maxilla following the dissection of benign tumors in younger patients. Flap necrosis is a critical complication. Venous congestion of the flap can occur within 12 hours, and the flap eventually dies. Yilmaz et al 17 successfully used a flap including the anterior belly of the digastric muscle for various defects in 14 patients. In anatomical studies, the submental artery originated from the facial artery in all of their samples; the submental artery ran superficial to the anterior belly of the digastric muscle in 44% to 70% of cases, whereas it ran deep in the remaining 30% to 56%. 8,18 We believe that the digastric muscle should be included in the flap to prevent failure. It is believed that an island flap based on the submental artery can form the interior margin of the mandible. 12 There have been no reports of reverse facial submental artery mandibular osteomuscular flaps. We included 1.5 cm 7.0 cm of the mandible and 5 cm 10 cm of platysma with the flap to repair class 2a defects of the maxilla. Karacal et al 14 reported using flaps of size between 4 cm 6cmand6cm 8cm for the reverse pattern of the flap and found that these surpassed other flaps for reconstructing large periorbital soft tissue defects and the socket. Daya et al 19 believed that a skin paddle as large as 7 cm 14 cm could be harvested. A skin paddle up to a size of 7 cm 18 cm may be possible, depending on the laxity of the submental skin. 12 Our study suggested that the reverse facial submental artery mandibular osteomuscular flap or reverse facial submental artery mandibular osteomyocutaneous flap can be used to reconstruct major maxillary defects following tumor ablation. CONCLUSION This article describes a new method for reconstructing maxillary defects using a reverse facial submental artery mandibular osteomuscular flap. Proper aesthetics and complete functionality were obtained, and the postoperative complications after harvesting the mandibular bone were minimal. This flap is a safe alternative donor site for repairing maxilla defects. REFERENCES 1. Clauser L, Curioni C, Spanio S. The use of the temporalis muscle flap in facial and craniofacial reconstructive surgery. A review of 182 cases. J Craniomaxillofac Surg 1995;23: Yim KK, Wei FC. Fibula osteoseptocutaneous free flap in maxillary reconstruction. Microsurgery 1994;15: Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm osteocutaneous sandwich free flap for reconstruction of the bilateral subtotal maxillectomy defect. Ann Plast Surg 1998;40: Yamamoto Y, Minakawa H, Kokubu I, et al. The rectus abdominis myocutaneous flap combined with vascularized costal cartilages in reconstructive craniofacial surgery. Plast Reconstr Surg 1997;100: Cordeiro PG, Santamaria E, Kraus DH, Strong EW, Shah JP. Reconstruction of total maxillectomy defects with preservation of the orbital contents. Plast Reconstr Surg 1998;102: Brown JS. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect. Head Neck 1996;18: Brown JS, Jones DC, Summerwill A, et al. Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg 2002;40: Faltaous AA, Yetman RJ. The submental artery flap: an anatomic study. Plast Reconstr Surg 1996;97: Williams PL, Warwick R. Gray s anatomy, 36th ed. Edinburgh: Churchill Livingstone; pp Williams PL, Warwick R. Gray s anatomy, 36th ed. Edinburgh: Churchill Livingstone; pp Reverse Facial Artery Submental Artery Mandibular Osteomuscular Flap HEAD & NECK DOI /hed June 2009

7 11. Rojananin S, Igarashi T, Ratanavichitrasin A, Lertakayamanee N, Ruksamanee A. Experimental study of the facial artery: relevance to its reverse flow competence and cutaneous blood supply of the neck for clinical use as a new flap. Head Neck 1996;18: 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;92: Stern GD, Januszkiewicz JS, Hall PN, Bardsley AF. The submental island flap. Br J Plast Surg 1996;49: Karacal N, Ambarcioglu O, Topal U, Sapan LA, Kutlu N. Reverse-flow submental artery flap for periorbital soft tissue and socket reconstruction. Head Neck 2006; 28: Chen WL, Yang ZH, Huang ZQ, Wang YY, Wang YJ, Li JS. Reverse facial artery-submental artery island myocutaneous flap for reconstruction of oral and maxillofacial defects following cancer ablation. Zhonghua Kou Qiang Yi Xue Za Zhi 2007;42: Chen WL, Li JS, Yang ZH, Huang ZQ, Wang JU, Zhang B. Two patterns of submental island flaps for reconstruction of oral and maxillofacial defects following cancer ablation. J Oral Maxillofac Surg 2008;66: Yilmaz M, Menderes A, Barutcu A. Submental artery island flap for reconstruction of the lower and mid face. Ann Plast Surg 1997;39: Atamaz Pinar Y, Govsa F, Bilge O. The anatomical features and surgical usage of the submental artery. Surg Radiol Anat 2005;27: Daya M, Mahomva O, Madaree A. Multistaged reconstruction of the oral commissures and upper and lower lip with an island submental flap and a nasolabial flap. Plast Reconstr Surg 2001;108: Reverse Facial Artery Submental Artery Mandibular Osteomuscular Flap HEAD & NECK DOI /hed June

THE SUBMENTAL ISLAND FLAP IN HEAD AND NECK RECONSTRUCTION

THE SUBMENTAL ISLAND FLAP IN HEAD AND NECK RECONSTRUCTION Emre Vural, MD, James Y. Suen, MD Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 West Markham,