Alternatives to free flap surgery for maxillofacial reconstruction: focus on the submental island flap and the pectoralis major myocutaneous flap

Abstract

Background Microvascular tissue transfer (MTT) has been established as the gold standard in oral- and maxillofacial reconstruction. However, free flap surgery may be critical in multimorbid elderly patients and after surgery or radiotherapy, which aggravate microsurgery. This study evaluates indications and outcome of the submental island flap (SMIF) and the pectoralis major myocutaneous flap (PMMF) as alternatives to the free radial forearm flap (RFF). Methods This retrospective study included 134 patients who had undergone resection and reconstruction with SMIF, PMMF, or RFF at our department between 2005 and 2020. The level of comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI). Primary outcome variables were flap success, complications, wound dehiscence, surgery duration, as well as time at the ICU and the ward (hospitalization). Chi-square tests, t-tests, and ANOVA were performed for statistics. Results 24 SMIFs, 52 RFFs, and 58 PMMFs were included in this study. The flap types did not significantly differ in terms of flap success, complications, and healing disorders. The SMIF presented a success rate of 95.8% and was significantly more often used in elderly patients (mean age = 70.2 years; p < 0.001) with increased comorbidities than the PMMF (p < 0.01) and RFF (p < 0.001). SMIF reconstruction reduced surgery duration (p < 0.001) and time at the ICU (p = 0.009) and the ward (p < 0.001) more than PMMF and RFF reconstructions. PMMF reconstruction was successful in 91.4% of patients and was more frequently used after head and neck surgery (p < 0.001) and radiotherapy (p < 0.001) than SMIF and RFF reconstructions. Patients undergoing PMMF reconstruction more frequently required segmental jaw resection and had presented with advanced tumor stages (both p < 0.001). Nicotine and alcohol abuse was more frequent in the RFF and PMMF groups (both p < 0.001) than in the SMIF group. Conclusions The pedicled SMIF represents a valuable reconstructive option for elderly patients with increased comorbidity because of the shorter duration of surgery and hospitalization. On the other hand, the PMMF serves as a solid backup solution after head and neck surgery or radiotherapy. The rates of flap success, complications, and healing disorders of both pedicled flaps are comparable to those of free flap reconstruction.

Pedicled Flaps versus Free Flaps for Oral Cavity Cancer Reconstruction: A Comparison of Complications, Hospital Costs, and Functional Outcomes

“…3,5,[7][8][9]13,19,[21][22][23][24][25] However, some studies reported that patients in the pedicled flap group were significantly older than those in the free flap group. 4,16,26 In addition, the proportion of patients with ASA class I-II to those with ASA class III-IV was variably reported as lower, 4 similar, 5 or higher, 6,27 in the pedicled flap group compared with in the free flap group. Concerning disease characteristics, there were no differences in primary tumor location, T staging, and overall N staging, which are similar to those recorded in previous studies.…”

“…[8][9][10][11][12] There has been a recent resurgence of interest in the use of pedicled flaps in addition to the "workhorse" pectoralis major myocutaneous flap, including a submental island flap, temporalis myofascial flap, and supraclavicular island flap, which increases versatility in most of the head and neck defects. 4,6,10,11,[13][14][15][16] In addition, with the global strain on hospital resources during the COVID-19 pandemic, pedicled flaps can be a useful reconstruction in the current situation. 17,18 The purpose of the present study is to compare postoperative outcomes, including surgical complications, duration of hospital stay, hospital costs, and functional results in oral cavity cancer patients who underwent surgical resection followed by soft tissue reconstruction with a pedicled flap including pectoralis major myocutaneous, submental island, temporalis myofascial, and supraclavicular island flaps or a free flap including radial forearm and anterolateral thigh free flaps.…”

“… 8 9 10 11 12 There has been a recent resurgence of interest in the use of pedicled flaps in addition to the “workhorse” pectoralis major myocutaneous flap, including a submental island flap, temporalis myofascial flap, and supraclavicular island flap, which increases versatility in most of the head and neck defects. 4 6 10 11 13 14 15 16 In addition, with the global strain on hospital resources during the COVID-19 pandemic, pedicled flaps can be a useful reconstruction in the current situation. 17 18 …”

Comparison of Flaps From Different Sites for Repairing Postoperative Soft Tissue Defects Regarding the Quality of Life in Patients With Oral Cancer: A Systematic Review

“…Therefore, PMMF has a high success rate in clinical applications. Under the cases of patients receiving radiotherapy who encounter tissue contracture, large demand for flap tissue, patients undergoing secondary surgery who are unable to access available vessels, and challenging microsurgery, the PMMF is still an important candidate flap 25,26 . The significant difference in appearance scores between PMMF and FFF may be due to the fact that PMMF has less negative impact on the appearance of patients than FFF because the donor site is hidden, and the scar is not likely to be exposed.…”

Repair of postoperative defects of oral cancer with submental island flaps based on vascular pedicles of different states: a multicenter retrospective study

“…Postoperative defects of oral cancer cause internal and external deformities of patients, which seriously affect their speech, swallowing and other functions 4,5 . Therefore, it is difficult for head and neck oncologists to completely remove oral tumors, immediately repair defects, restore the appearance and function of patients, reduce the physiological, psychological, and social impact on patients with oral cancer, and improve the quality of life 6,7 . Free flaps, such as anterior arm flap,…”