What Is the Oncologic Safety of Using the Submental Flap to Reconstruct Oral Cavity Cancer Defects?

by Brent A. Chang, MD, Ameya A. Asarkar, MD, and Cherie-Ann O. Nathan, MD •

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

The submental flap has gained significant popularity for head and neck reconstruction in the past few decades. This flap is generally used as a pedicled flap and provides thin, pliable tissue of substantial size, making it ideal for reconstructing oral cavity cancer defects. Using a pedicled flap instead of a free flap has the benefit of decreasing operative time, length of hospital stay, need for intensive monitoring, and overall costs. However, the oncologic safety of using the submental flap for oral cavity cancer reconstruction has been controversial. The blood supply to the submental flap arises from the facial vessels in level I of the neck, which is a first-echelon lymphatic drainage basin for oral cavity malignancies. Some surgeons would argue that the submental vessels can be safely skeletonized while still achieving adequate oncologic clearance of lymphatic tissue. Other surgeons have advocated against submental flap reconstruction for oral cancer given the concern for increased risk of locoregional recurrence due to inadequate lymph node dissection or transplantation of malignant cells into the site of reconstruction.

Best Practice

It is oncologically safe to use the submental flap for reconstruction of oral cavity cancer defects. The surgeon must feel comfortable dissecting and preserving the submental vasculature while still achieving an oncologic resection of the level I lymphatic tissue. An adequate lymph node dissection of level I, at the minimum, should be performed even in the N0 neck. In the setting of the N+ neck, limited quality data support that the submental flap can be done with reasonable oncologic safety in very carefully selected patients; however, these data are at risk of selection bias, as N+ patients who could not undergo submental flap reconstruction were likely excluded. Thus, the surgeon should still proceed with caution and should strongly consider having a backup reconstructive option available (Laryngoscope. 2019;129:2443–2444).