Abstract
Background
The goals of successful reconstructive surgery are to restore function and cosmesis; however, limitation of resources can become an important consideration in low-middle income countries.
Methods
We describe our experience using the submental island flap in two cases during a short-term surgical camp in East Africa.
Results
The submental island flap was utilized as an excellent alternative to a free flap to reconstruct a subtotal maxillectomy and a parotidectomy defect in two patients.
Conclusions
We demonstrate the successful use of this flap and describe some necessary modifications to achieve optimal results in a resource limited setting.
1
Introduction
Head and neck cancer affects people worldwide, with over 550,000 new cases annually . Unfortunately, in developing countries, the burden of surgical disease far surpasses provider capacity. One striking example is seen in Uganda: a country of 37 million people, with only thirty otolaryngologists and two otolaryngology residency programs . We formed a team of surgeons and nurses that travel twice a year to conduct head and neck surgical camps in conjunction with the Uganda Cancer Institute in Kampala, Uganda. Our primary goal is to perform surgeries on patients who otherwise would not have access to appropriate medical care. Secondarily, we aim to equip Ugandan staff with the surgical knowledge and skills to perform these procedures with their own resources.
Traveling surgical missions have become increasingly popular: 550 organizations sponsor up to 6000 mission trips every year, spending more than 250 million dollars annually . Surgeons operating in low income countries must go beyond patient factors and also weigh anesthetic, nursing, and infrastructure considerations, forcing them to use resources wisely. In a surgical camp setting, incorporating state of the art techniques, such as microvascular free tissue transfer, is not always the best option especially if they require resources that will not be available after the surgical team departs. Alternative procedures should be utilized if they offer similar outcomes while utilizing fewer resources. Here, we demonstrate our use of a submental island flap (SIF) as an alternative to a free tissue transfer flap.
The SIF has proven value in head and neck reconstruction, including the oncologic setting when patients are appropriately selected . It is thin, pliable, and possesses a long, reliable pedicle. Additionally, a large surface area can be harvested. It has similar applications as the radial forearm flap without the need for advanced microvascular technique. However, as free flaps have become the gold standard, there has been a paucity of literature using the SIF for palate reconstruction within the last ten years, and there are no reports of its potential benefits compared to a free flap in resource-limited settings.
Here we present our case series illustrating the successful use and challenges of the SIF in reconstructing hemi-palate and parotid defects.
1.1
Case 1: Palate defect
A 45 year old female presented to the ENT surgical camp with a 17 year history of right maxillary swelling and nasal obstruction that recurred despite multiple prior surgeries. Pathology was consistent with pleomorphic adenoma, and imaging showed a lytic, multicystic lesion involving the right maxillary sinus, maxilla, and palate with erosion of the lateral nasal wall.
A subtotal maxillectomy was performed, leaving a hemipalatal defect ( Fig. 1 ). Focus then shifted to reconstruction, where the SIF was raised as described by Patel . Unfortunately, in this patient, the venous drainage was observed to arise low in the external system, limiting the length of flap extension. Therefore, to increase arc of rotation, the facial vein was ligated and anastomosed to the ipsilateral external jugular vein using a 3.0 mm coupler, creating a “hybrid” pedicle SIF . This was all done with surgical loupes at 3.5× magnification. The flap was then tunneled intraorally around the buccal space and laid into the palatal defect. The venous anastomosis allowed adequate pedicle length to reach the free margin of the defect with minimal tension. In total, the anastomosis only added 10 min to the procedure due to availability of the coupler.
1.2
Case 2: Parotid defect
The second use of the SIF was in a 10 year old female with an 8-month history of enlarging left postauricular mass. On exam, she had a large exophytic tumor arising from the left parotid with overlying skin changes, but facial nerve function was intact. CT scan showed a large parotid tumor involving the deep lobe extending into the parapharyngeal space and the undersurface of the mandible. Biopsy of the mass reported pleomorphic adenoma with dysplasia and metaplastic oncocytic cells. Intraoperatively, it was apparent that the tumor involved the facial nerve and tracked through the stylomastoid foramen into the mastoid tip, and it was clearly a malignant process. A total parotidectomy was performed, followed by a limited mastoidectomy to identify uninvolved nerve proximally. The affected segment was resected and nerve grafting was performed using a lower cervical plexus sensory nerve. The SIF was an ideal option for the reconstruction of the parotid/mastoid defect, providing the necessary contour and bulk for good cosmesis. The flap was harvested and rotated to cover our defect ( Fig. 2 ). The final pathology revealed mucoepidermoid carcinoma.
