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implications for a reconstructive practice.

SUBMENTAL ISLAND PEDICLED FLAP
History
The submental island pedicled flap was first described in 1993 by Martin et al. in their search to identify
[11]
an alternative LRPF for the reconstruction of the face. At the time, the various cervical flaps used for facial
reconstruction were based on random supply and posed several drawbacks including equivocal reliability,
[11]
reach limited to the lower third of the face, and donor site morbidity . The submental island flap (SIPF)
solved many of these issues owing to its ease of harvest, excellent reliability, and long pedicle. Furthermore,
given its location posterior to the mandibular arch and pliability of skin in the area, closure of the donor site
[12]
was noted to be relatively tension free with a well-hidden, favorable scar. Sterne et al. first described the
use of this flap for intraoral defects in 1996, and for the past two decades, it has remained a popular
technique owing to its pliability, wide arc of rotation, and single operative field. Patel et al. further refined
[13]
the technique in 2007, with early dissection of facial vessels and inclusion of the mylohyoid muscle
providing additional protection to the distal submental pedicle and cutaneous perforators, which improved
reliability, ease of harvest, and led to enhancement of trainee education. Furthermore, this important
modification has been independently observed to significantly reduce the rate of flap-related
[14]
complications .
Surgical technique and pearls
Depending on the nature of the expected surgical defect and the presence of a one vs. two surgeon team, we
generally opt to harvest and mobilize the flap prior to performing any extirpative surgery. Generally, a
unilateral hemiapron incision is designed laterally, merging into the lateral apex of the planned submental
skin flap. Generally, a “D” or crescent-shaped paddle is designed. The choice of paddle size is variable;
however, efforts should be taken to prioritize primary closure of the donor site, which can be predicted with
a pinch test. Following marking of the planned incisions, the neck is sharply opened and subplatysmal flaps
are elevated. Although incisions are also made around the periphery of the flap, we initially do not violate
the subcutaneous tissue and fascia underlying the skin paddle. The marginal mandibular nerve and its
associated branches are then located and carefully dissected, and retracted superiorly. At this point,
meticulous dissection of the submandibular gland is performed, with particular care given to preventing
undue sheering on the facial artery and submental pedicle. Arterial branches into the submandibular gland
are carefully clipped and ligated. Once the gland has been removed from the field, the submental vessels are
dissected a short distance to the lateral border of the mylohyoid, and further dissection is terminated. The
flap is then raised from the contralateral side in a subplatysmal plane and the midline of the mylohyoid
muscle is approached. At this point, the sacrifice of the ipsilateral anterior belly from its origin at the
digastric fossa facilitates inferior displacement of the submental artery pedicle and provides clear
visualization of the mylohyoid muscle. The mylohyoid is then transected at the midline and detached from
the mandible and the hyoid, without violating the underlying geniohyoid muscle. This maneuver then
allows complete mobilization of the flap. At this point, dissection of the vascular pedicle can proceed
proximally towards the great vessels to increase total pedicle length and arc of rotation. The flap may then
be tunneled subcutaneously or intraorally as needed. The donor site can then be readily closed primarily.

Pitfalls
Although the SIPF is widely regarded as a robust locoregional option for head and neck reconstruction,
several important points have been made regarding its utility. Of note, the most common criticism is its role
in patients with advanced oral cavity cancer with locoregional disease. The entirety of the oral cavity,
including the tongue, lips, and floor of the mouth, has a robust lymphatic system with a drainage pathway
that incorporates the level I lymph node basin. Given that dissection of the SIPF involves including the