Flaps based on facial arteriovenous system for the reconstruction of head-and-neck cancer defects

Nageswara Rao Noothanapati; Krishnakumar Thankappan; Nisha Rajrattansingh Akali; Tejal Patel; Deepak Balasubramanian; Subramania Iyer

doi:10.4103/jhnps.jhnps_56_20

REVIEW ARTICLE

Year : 2020 | Volume : 8 | Issue : 2 | Page : 80-86

Flaps based on facial arteriovenous system for the reconstruction of head-and-neck cancer defects

Nageswara Rao Noothanapati¹, Krishnakumar Thankappan¹, Nisha Rajrattansingh Akali¹, Tejal Patel¹, Deepak Balasubramanian¹, Subramania Iyer²
¹ Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
² Department of Head and Neck Surgery and Oncology; Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Submission	09-Nov-2020
Date of Decision	10-Nov-2020
Date of Acceptance	10-Nov-2020
Date of Web Publication	8-Dec-2020

Correspondence Address:
Subramania Iyer
Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, AIMS Ponekkara PO, Kochi - 682 041, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jhnps.jhnps_56_20

Abstract

Facial artery is a branch of the external carotid system extending from the upper neck to the nasion. Various flaps are described in the literature based on the facial artery and vein in the neck and face to reconstruct the head-and-neck cancer defects, either superiorly based or inferiorly based. This article summarizes the flaps and their variations based on the facial arteriovenous system. The flap harvest techniques, the indications, advantages and the limitations of the nasolabial flap, facial artery myomucosal flap, and submental flap are described, with appropriate case demonstrations. Variations of the flaps are also discussed.

Keywords: Facial artery, head-and-neck reconstruction, nasolabial flap, oral cancer, pedicled flaps, submental flap

How to cite this article:
Noothanapati NR, Thankappan K, Akali NR, Patel T, Balasubramanian D, Iyer S. Flaps based on facial arteriovenous system for the reconstruction of head-and-neck cancer defects. J Head Neck Physicians Surg 2020;8:80-6

How to cite this URL:
Noothanapati NR, Thankappan K, Akali NR, Patel T, Balasubramanian D, Iyer S. Flaps based on facial arteriovenous system for the reconstruction of head-and-neck cancer defects. J Head Neck Physicians Surg [serial online] 2020 [cited 2023 May 29];8:80-6. Available from: https://www.jhnps.org/text.asp?2020/8/2/80/302638

Introduction

Facial artery is responsible for the rich vascularity of the lower two-thirds of the face. It is a branch of the external carotid system, starts from its origin in the upper neck, crosses over the mandible, and runs till the nasion. Various flaps are described in the literature based on the facial artery and vein in the neck and face to reconstruct the head-and-neck cancer defects, either superiorly based or inferiorly based. This article reviews the major flaps based on facial arteriovenous pedicle for head-and-neck defect reconstruction, the techniques of harvest, indications, and contraindications.

Anatomy Of the Facial Artery

Facial artery is an anterior branch of the external carotid system, but it may arise from the linguofacial trunk (20%) or thyrolinguofacial trunk (2.5%).^[1] It usually runs deep to the posterior belly of digastric and stylohyoid, passes between the submandibular gland and mandible, and then enters the face by crossing over the mandible. The facial artery runs between superficial facial muscles (zygomaticus major and minor, levator labii superioris, and levator labii superioris alaeque nasi) and deep facial muscles (buccinator and levator anguli oris).^[2],[3],[4] In the neck, the facial artery gives multiple branches; flaps based on these branches are submandibular gland flap,^[5] submandibular facial artery island flaps, and submental artery perforator flap.^[6] In the face, the facial artery gives multiple branches at the different levels as branches to the lower lip (inferior labial artery), labiomental region (horizontal or vertical labiomental artery), upper lip (superior labial artery), nose (inferior and lateral alar artery and nasal septal artery), and angular and ocular region (angular artery and detoured branch).^[7] [Figure 1] shows the anatomy of the facial artery.

Figure 1: Anatomy of the facial artery

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Facial Venous Drainage System

The facial vein originates at the inner cantus of the eye by merging supratrochlear and supraorbital veins. It runs downward to the angle of the mandible, forms a common facial vein joining with the anterior division of the retromandibular vein, and drains into the internal jugular (47%), or external jugular (37%), or anterior jugular vein (16%).^[8] The facial vein is situated in a fibrous canal formed by anterior and posterior laminae of the parotid-masseteric fascia, has a constant course, and runs posterior to the facial artery, anterior to the parotid duct, and deep to the zygomaticus major muscle and facial nerve motor branches.^[9] [Figure 2] shows the anatomy of the facial venous system.

Figure 2: Anatomy of the facial venous system

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Flaps Based on Facial Artery and Vein

Various flaps have been described in literature based on facial vessels; these are from simple rotation and islanded pedicled flaps to free flaps and facial transplant. Here, we are discussing each flap in detail about harvest technique, indications, and complications.

Nasolabial flap

Sushruta first described the nasolabial flap in 600 BC, and this was the start of plastic surgery in India. Esser was the first to describe the inferiorly based nasolabial flap, which he used to close an anterior palatal fistula.^[10] Since then, it has been widely used to reconstruct defects of the palate, tongue, floor of the mouth, lip, and nasal structure. Even though free flaps are the reconstructive technique of choice, they require skilled personnel, prolong the operative and anesthesia time, and increase surgery costs. Local flaps such as the nasolabial flap provide a good alternative in those patients where free flaps are precluded: Nasolabial flap is the most versatile local flap used for small-to-medium sized head-and-neck cancer defect reconstruction. It can be harvested either inferiorly based or superiorly based flap.

Harvest technique

The facial artery lies deep to the facial mimetic muscles and superficial to the buccinator at the medial edge of the flap. The extent of the flap is as follows; medially, 2–3 mm lateral to the nasolabial groove, superiorly, 1 cm short of the medial canthus, inferiorly, depending on the defect, it can be anywhere from the angle of mouth to the lower border of the mandible. The lateral extent of harvest depends on the skin thickness and laxity, and it should be possible to close the wound primarily tension free.

A delay is usually not done unless the flap harvested is a long thin subcutaneous flap of more than a 4:1 ratio. Flap harvesting is commenced from superior to inferior and from the medial to the lateral direction in a plane deep to the facial musculature, artery, and vein. The artery is carefully identified and preserved. At the lateral edge of the flap, the parotid duct and the buccal branches of the facial nerve should be identified and preserved. The tunnel is made through the nasolabial fold by blunt dissection through the deeper tissues to provide the most direct route of entry to the defect in the oral cavity. The tunnel should be sufficiently wide so as not to compress the pedicle. Part of the flap which lies below the cheek soft tissue is de-epithelized, and the rest is used to cover the defect. The donor defect is closed primarily. The direction of closure should be superiorly and medially to avoid any lower lid deformities.

Conventional nasolabial flap

The subdermal vascular plexus is formed by the facial, angular, transverse cervical, and infraorbital vessel, and it provides the blood supply to the nasolabial skin and muscles. The study by Agarwal et al.^[11] demonstrated that the flap has a random blood supply from the premaxilla. In their study, the facial artery was ligated in 83% of the cases during neck dissection, and yet the flap survived in most of them (90%). This is supported by the anatomical study by Hynes and Boyd in 1988. The nasolabial flap can thus be elevated in the subcutaneous plane. The advantage of this is that the flap harvested is thinner, and cheek biting can be avoided. [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d shows a nasolabial flap used to reconstruct a marginal mandibulectomy defect.

Figure 3: (a) Marginal mandibulectomy defect and the nasolabial flap marked. (b) Flap harvest. (c) Flap inset. (d) Donor site closure

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Islanded pedicled nasolabial flap

This is a fusiform-shaped flap completely islanded on the facial vessels. A thin cuff of soft tissue is left around the pedicle. It is brought into the neck through a subcutaneous tunnel lateral to the mandible. It is then introduced into the oral cavity either through the defect of the floor of the mouth during resection or by splitting the fibers of the mylohyoid medial to the mandible. The advantages over the conventional flap are that the islanded flap has a significantly larger arc of rotation, it can be used in a dentate mandible, it can be used for oropharyngeal and hypopharyngeal defects, it does not restrict the mobility of the tongue, equaling a significant advantage provided by free flaps, it does not require de-epithelialization, and it does not need to be a two-stage procedure.^[12] A prerequisite for its use is that facial vessels have to be preserved during neck dissection. [Figure 4]a,[Figure 4]b,[Figure 4]c shows the dissection and inset of islanded nasolabial flap for a tongue defect.

Figure 4: (a) Dissected islanded nasolabial flap. (b) Dissected flap pedicled into the neck.(c) Inset for a tongue defect

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Indications

Tongue and floor of mouth defect reconstruction
To cover buccal mucosa defects after excision of submucous fibrosis bands
To repair oropharyngeal and hypopharyngeal defects.

Limitations/complications

Unsightly facial scar but can be molded along the nasolabial groove
Injury to the marginal mandibular nerve
Hair growth is disturbing and needs frequent cleaning if present in an inaccessible area
Oral commissure pulled toward the donor site.

Advantages

Same surgical field
Primary closure of donor site
Short operating time
Ease of harvest
Oncologically safe as it is far away from the nodal stations
Minimal morbidity – no loss of function.

Superiorly based nasolabial flap

Flap harvest technique is the same as inferiorly based except that pedicle is based superiorly. Complications are the same as the inferiorly based flap.

Indications

To reconstruct the nose defects
To reconstruct the orbit and lower eyelid defects.

Facial artery musculomucosal flap

The facial artery musculomucosal (FAMM) flap was first described in 1992 by Pribaz et al.^[13] Since then, a few modifications have been described. The flap can be based inferiorly on the facial artery or superiorly on the retrograde flow of the angular artery. Venous drainage of the FAMM flap is not necessarily by the facial vein but by the submucosal plexus.

Harvest technique

Facial artery territory can be marked using a sterile Doppler or using an incision deepened to the subcutaneous plane, the facial artery can be identified, and the flap is marked accordingly. Anteriorly an extension 1 cm short of the oral commissure, angle of the mouth is recommended. Posteriorly, the Stensen’s duct papilla against the first molar is identified and preserved. The superior and inferior extent should be considered at least 5–10 mm away from the gingivobuccal sulcus. The buccal flap consists of the mucosa, buccinator muscle, and subcutaneous tissue with the facial artery and facial vein and the skin laterally. The plane of dissection is just at the level of identifying the artery.

Superiorly based FAMM flap is based on the angular artery. When pedicled superiorly, it provides an adaptable vascularized tissue for medium defects of the nose, hard palate, superior lip, superior alveolar crest, and anterior skull base, leavening no external scar.^[14]

Islanded FAMM flap

It is a technical variant in which the flap is islanded on the facial vessels and is tunneled on the lingual side of the mandible.^[15] It allows a larger range of movement of the flap for inset. Ideally, to retain the cheek function without fibrosis of the secondary defect, the flap size should be limited 2 cm breadth. If larger than that, buccal fat pad can be used to cover the defect. However, this may not give optimal mucosal pliability at the donor site. Marginal mandibular paresis is one major complication which should be averted by careful dissection while transferring the flap to the neck.

Advantages

It avoids any external scar after harvest
It provides a great axis of rotation and range of reach, allowing the reconstruction of multiple sites
It is thin and pliable
It provides a fully functional mucosal tissue
It is a suitable reconstructive option, even in previously radiated patients
It offers a strong vasculature that withstands postoperative radiotherapy.^[16]

Indications

Pedicled FAMM flaps have been described for reconstruction of defects of the tongue and the palate. In small defects of mucosa overlying a marginal mandibulectomy where the remnant bone needs a cover, a FAMM flap can be used. FAMM flap provides an alternative in the management of postsurgical severe nasopharyngeal stenosis.^[17] The islanded FAMM flap could serve as good local flap for the reconstruction of small-to-medium-sized tongue defects,^[15] as it can be used in a single-stage procedure, provides an excellent color match, has a very predictable vasculature, is easy to master, results in minimal donor site morbidity, provides an instant mucosal surface on the tongue, is economically feasible, and is less technique sensitive when compared to microvascular free flap reconstruction.^[4] A case report of tracheal advancement with myomucosal island flap for laryngopharyngeal defect postpartial laryngectomy has been described with good functional outcomes.^[18] Another case report, using the islanded FAMM flap for a small partial pharyngeal defect, posttotal laryngectomy, to avoid tight closure and postoperative dysphagia is also reported. It provided a robust and predictable blood supply and adequate reach. There was no significant donor site morbidity. The musculomucosal flap replaced “like-with-like” tissue.^[19] [Figure 5]a,[Figure 5]b,[Figure 5]c,[Figure 5]d,[Figure 5]e,[Figure 5]f shows an islanded FAMM flap used to reconstruct a glossectomy defect.

Figure 5: (a) Facial artery myomucosal flap marked on cheek. (b) Flap harvest. (c) Tongue defect. (d) Pedicled flap brought down into the neck. (e) Flap inset. (f) Outcome after 6 months

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Submental flap

This flap was first described by a French team (Martin, 1993), based on the submental artery, which is a consistent branch of facial artery,^[20] runs superficial to the mylohyoid and deep to the anterior belly of digastric in 70% of cases, and enters into the level Ia to give perforators to the platysma and skin.^[21] This flap can be used as a cutaneous, musculofacial (cervicofacial and platysma), or osteocutaneous flap.^[20] The length of the flap from the mandible angle to angle is approximately 18 cm. The breadth of the flap is about 7 cm. A pinch test is done to see the feasibility of the primary closure. The diameter of the artery is 1–1.5 mm.

Harvest technique

Flap design is to be marked according to the defect size, submandibular gland to be dissected off to the facial artery and vein without injuring the marginal mandibular nerve. Identify the submental pedicle; dissect till the lateral border of the mylohyoid only. Elevate the contralateral side skin flap, including the platysma, until the midline; after that, the dissection is carried deeper to the mylohyoid level. Then, the anterior belly is dissected off the mandible and hyoid bone. In the conventional method, the pedicle is dissected off the mylohyoid muscle, but the mylohyoid is included in the flap in the modified method.^[22] Now, the flap is islanded on the submental artery and can be tunneled to the final defect reconstruction. The donor site can be closed primarily with a drain in situ. [Figure 6]a,[Figure 6]b,[Figure 6]c,[Figure 6]d,[Figure 6]e,[Figure 6]f shows the steps of a submental flap used for a buccal mucosal defect.

Figure 6: (a) Preoperative lesion. (b) Postexcision defect, carcinoma buccal mucosa. (c) Submental flap marking. (d) The flap dissected. (e) Outcome after 1 year. (f) Donor site after 1 year

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Indications

Submental artery islanded flap can be used to reconstruct the following:

Oral cavity defects, i.e., tongue, the floor of the mouth, buccal mucosa, lip, and alveolar defects
Oropharyngeal defects
Hypopharyngeal and laryngectomy defects
Esophageal defects
Parotidectomy defects involving the skin.

This submental flap can be used as a free flap for platysma sparing vascularized lymph node flap transfer to treat extremity lymphedema.^[23]

Contraindications

Regional metastasis at the level I nodes
History of previous trauma to facial pedicle/submental arteries
Primary tongue or floor of mouth disease involving the mylohyoid muscle.

Complications

Injury to the marginal mandibular nerve
Recurrence in nodes of the flap^[24]
Hematoma, infection, and wound dehiscence
Flap loss
In males, hair growth can be a problem.

Reverse submental artery flap

The flap design and harvest technique are the same as the submental artery flap, except that the facial artery and vein ligated at the neck side (toward the external carotid and jugular vein). This increases the pedicle length.

Indications

This flap can be used to reconstruct the defects involving the following:

Orbit and periorbit area^[25]
Temporal/zygomatic area^[25],[26]
Palate/maxilla^[26]
Oropharyngeal^[26]
Nose/perinasal area.^[26]

Complications and contraindications are the same as submental artery flap.

Submental artery osteocutaneous flap can be harvested, including 1–1.5 cm inferior border of the mandible to reconstruct the zygomatic/maxillary bone defects.^[27]

Submandibular gland flap

This flap is supplied by the facial artery with multiple small branches, based on this submandibular gland flap described for parotidectomy and oropharyngeal defects. It is very useful to fill the dead space with durable volume that will not atrophy with good cosmetic and functional outcome.^[5],[28]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer-reviewed publication.

Ethical approval

Permission was taken from the institutional ethics committee prior to starting the project. All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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2.	Dupoirieux L, Plane L, Gard C, Penneau M. Anatomical basis and results of the facial artery musculomucosal flap for oral reconstruction. Br J Oral Maxillofac Surg 1999;37:25-8.
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17.	Nangole FW, Khainga SO. FAMM flap in reconstructing postsurgical nasopharyngeal airway stenosis. Plast Surg Int 2014;2014:276058.
18.	Joseph ST, Naveen BS, Mohan TM, Tharayil TJ. Tracheal advancement with myomucosal island flap for partial laryngopharyngectomy defect reconstruction. Head Neck 2018;40:E40-4.
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20.	Martin D, Pascal JF, Baudet J, Mondie JM, Farhat JB, Athoum A, et al. The submental island flap: A new donor site. Anatomy and clinical applications as a free or pedicled flap. Plast Reconstr Surg 1993;92:867-73.
21.	Faltaous AA, Yetman RJ. The submental artery flap: An anatomic study. Plast Reconstr Surg 1996;97:56-60.
22.	Patel UA, Bayles SW, Hayden RE. The submental flap: A modified technique for resident training. Laryngoscope 2007;117:186-9.
23.	Poccia I, Lin CY, Cheng MH. Platysma-sparing vascularized submental lymph node flap transfer for extremity lymphedema. J Surg Oncol 2017;115:48-53.
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28.	Liang KY, Breen MS, Tracy JC, Vaezi AE. Submandibular gland flap for reconstruction after parotidectomy. Laryngoscope 2020;130:E155-62.