FIGURE  9.1  Design of the inferiorly based FAMM flap.

Reverse Facial–Submental Artery Island Flap

The traditional submental artery flap was first described by Martin in 1993, and the reverse flow facial–submental artery flap was studied anatomically and presented as a new flap by Rojananin et al. in 1996. Possibly because of reports of venous congestion, it did not gain popularity immediately, but multiple reports of large series using this flap to reconstruct oral and oropharyngeal defects have been published in this decade.

After the facial artery leaves the posterior submandibular gland, it gives off the submental branch before it courses over the mandibular notch to continue superiorly into the face. The submental branch runs on the superficial surface of the mylohyoid muscle either deep to the anterior belly of the digastric muscle (70%) or superficial to it (30%). Perforators from the artery come off proximal to the anterior belly of the digastric muscle, through it, and distal to it before piercing the platysma and supplying the overlying submental skin. The facial vein, which has no valves, runs posterior to the facial artery over the mandible, superficial to the submandibular gland, to join the retromandibular vein. The artery and vein have multiple anastomosing branches to arterial and venous vessels in the face. Because of this rich communicating system, there is no significant change in mean intra-arterial pressure in the submental artery after proximal occlusion of the facial artery. Basing the submental artery island flap on this retrograde flow allows a more beneficial axis of rotation and pedicle length to allow the flap to reach the soft palate.

Previous or concurrent neck dissection can interrupt the facial arterial blood supply to the submental island flap both proximally and distally and to the FAMM flap proximally. The anterograde FAMM flap may have adequate blood supply through collateral flow through the inferior labial artery even if the proximal facial artery is ligated. A Doppler should be used intraoperatively to ensure adequate blood supply during the elevation of the flap in this setting.

If the submental island flap is to be used, care must be taken during the neck dissection to preserve the blood supply of the submental artery and the venous outflow. Although this flap has been used in conjunction with a level I neck dissection, the dissection is more tedious. In the situation where there is a high expectation of metastatic cancer in the submental and submandibular triangle, the use of an alternative flap might be prudent. Previous neck dissection does not typically affect the ability to harvest the buccal adipose tissue and FAMM flaps successfully.

CONTRAINDICATIONS

The contraindications for the buccal adipose tissue pad flap, FAMM, and reverse submental island flap are limited to prior surgery that may have impacted the blood supply or tissue flap. In general, these are reliable flaps that have few contraindications.

PREOPERATIVE PLANNING

Careful preoperative history of previous treatment in the head and neck and careful preoperative examination of the oral cavity, oropharynx, and neck will prevent the surgeon from underestimating the extent of the defect or choosing an unfavorable reconstructive option. Even with this planning, the ultimate extent of the defect and the reconstructive challenge cannot always be anticipated preoperatively, and the reconstructive surgeon should discuss several options with the patient and have several reconstructive flaps in mind. As with any ablative and reconstructive surgery, careful communication should be maintained between the ablative and reconstructive team if they are not the same.

SURGICAL TECHNIQUE

Buccal Adipose Tissue Flap

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