Oropharyngeal Reconstruction Using A Pedicled Submandibular Gland Flap

Background: Locoregional flaps have been widely used for reconstruction of small and medium-sized oropharyngeal defects. As far as the authors know, the Submandibular gland(SMG) has been preserved in the patients underwent neck dissection for head and neck squamous cell carcinoma, to play a role as modality of preventive care for xerostomia in the patients undergoing postoperative radiotherapy. The SMG flap is a pedicled flap, which derives its blood supply from the facial artery based on the SMG. This study aims to describe the spectrum of the SMG flap applications in oral and pharyngeal reconstruction following tumor resection. Anatomy, harvesting procedure, indication, advantages, and limitation of this flap are also described.Methods: From July 2012 to October 2014, 20 patients admitted to Oral and Maxillofacial-Head & Neck Oncology department underwent surgical reconstruction using a pedicled SMG flap following ablative surgery in oral and pharyngeal regions were included. Patients with squamous cell carcinoma(SCC) were completely excluded from this cohort. Only small and medium-sized defects, resulting from resection of oral and pharyngeal masses were included in the study. Angiographic study was also conducted to investigate the anatomical distribution and potential arterial flow patterns of the facial artery in submandibular region by using a digital subtraction angiography(DSA) of 5 patients and by intra-arterial injecting of CT scan contrast media into the facial artery of 3 specimens collected following neck dissection.Results: All flaps were pedicled in the facial vessels(pedicled inferiorly in 17(85%) patients and pedicled superiorly in 3(15%)). The indications were: reconstruction of intraoral mucosal defects in 13(65%) patients(retromolar region, maxillary tubrosity, lateral pharyngeal wall, tongue), filling parapharyngeal dead space in 6(30%) patients and mastoid obliteration in 1(5%) patient. Atrophy of the flaps were seen in all patients but still of no clinical significance. Partial flap loss was observed in 1 patient and early leakage in 1 patients. No xerostomia observed in all patients. No recurrence had been encountered during the postoperative follow-up period of 3 to 26 months. Angiographic study demonstrated that the facial and submental arteries arborized inside the deep fascia and there is a possibility to raise the SMG with surrounding structure when unusually medium-sized and/or odd-shaped flaps are need; those structures include deep cervical fascia, digastric and mylohyoid muscles.Conclusion: The SMG flap is a useful tool in the armamentarium of the reconstructive surgeon; it is a simple and reliable alternative option for reconstruction of small- to medium-sized oropharyngeal defects in carefully selected cases, with better cosmetic and functional results. Decision regarding using of SMG flap for reconstruction of the oropharyngeal defects should be done during the operation with the help of visual examination and lymph node biopsy for frozen sections instead of preoperative planned based on clinical and radiographical examinations.