neck reconstruction.2 It presents the advanta-
geous features of thinness, pliability, and ver-
satility in design shared by the radial forearm
free flap for head and neck reconstruction.
Moreover, it presents the advantage of provid-
ing an excellent color match for the head and
neck region, it can be raised easily, it has an aes-
thetically pleasing donor site, and it avoids the
potential complications linked to microsurgical
The flap can be used to cover numerous peri-
oral, intraoral, and facial defects, and can be used
as a cutaneous, myocutaneous, fasciocutaneous,
or osteocutaneous flap.3 It may also be superiorly
based to reconstruct superior oral and maxillofa-
cial defects, in which case it is termed the reverse
submental artery flap.4
Moreover, the use of this flap does not pre-
clude a prophylactic neck dissection, although
it must be used with caution in the presence of
metastatic disease in the neck.5 Other contra-
indications include previous radiotherapy, liga-
tion of the facial artery, or prior ipsilateral neck
he submental island flap was first described
in 1992 by Martin et al.1 as a submental
artery regional flap for soft-tissue head and
We present the case of a 98-year-old man who
underwent multiple resections and reconstruc-
tions of a cutaneous squamous cell carcinoma of
the skin. The patient was in good general health
otherwise. Before presentation to our service,
the patient noted a right parotid swelling associ-
ated with cutaneous ulceration, and right facial
paralysis. After appropriate investigations, includ-
ing fine-needle aspiration biopsy and computed
tomographic imaging, the mass was noted to be an
intraparotid recurrence of the squamous cell car-
cinoma in the superficial and deep lobes. Results
of the metastatic workup were negative. After
informed consent, the patient was brought to the
operating room for radical parotidectomy, includ-
ing cutaneous resection and ipsilateral functional
neck dissection. After ipsilateral neck dissection
and total parotidectomy including facial nerve
sacrifice resulting from involvement by the tumor,
the area to reconstruct consisted of a deep lateral,
preauricular, soft-tissue defect.
Disclosure: The authors have no financial interests
Copyright © 2014 by the American Society of Plastic Surgeons
Sami P. Moubayed, M.D.
Akram Rahal, M.D.
Tareck Ayad, M.D.
Montreal, Quebec, Canada
Summary: A clinical case of a man undergoing radical parotidectomy with skin
resection for an intraparotid recurrence of squamous cell carcinoma is pre-
sented. A step-by-step video description of the regional submental island flap,
based on the right submental vessels, is presented and discussed. Long-term
results at 1 year in terms of color match at the recipient and donor sites are
excellent, along with no functional consequence. (Plast. Reconstr. Surg. 133:
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
From the Otolaryngology–Head and Neck Surgery Ser-
vice, Université de Montréal Hospital Center; and
the Otolaryngology–Head and Neck Surgery Service,
Received for publication August 6, 2013; accepted September
The Submental Island Flap for Soft-Tissue Head
and Neck Reconstruction: Step-by-Step Video
Description and Long-Term Results
Video Plus content is available for this article.
Direct URL citations appear in the text; simply
type the URL address into any Web browser to
access this content. Clickable links to the ma-
terial are provided in the HTML text of this
article on the Journal’s Web site (www.PRSJour-
Volume 133, Number 3 • Submental Island Flap
STEP-BY-STEP SURGICAL TECHNIQUE
Here are the key anatomical points to remem-
ber (Fig. 1):
• The marginal mandibular branch of the
facial nerve must be avoided by incising two
fingerbreadths below the mandible at the
level of the submandibular gland.
• Medial to both glands, in the submental
area, the incision is brought back up to the
level of the inferior border of the mandible.
• The flap includes the platysma and is raised in
a plane superficial to the mylohyoid muscle.
• The facial artery and vein, branches of the
external carotid and internal jugular, are
used to identify the submental vessels, on
which the flap is based.
• The facial artery and vein run close to the
submandibular salivary gland, which must
be identified and removed on the ipsilat-
• The anterior belly of the ipsilateral digas-
tric muscle must be included in the flap
because perforators to the skin island can
run either medial, lateral, or through the
anterior belly of the digastric muscle.
• The contralateral digastric muscle is left
See Video, Supplemental Digital Content 1,
for a step-by-step illustration of the technique,
available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid
users, at http://links.lww.com/PRS/A951. The sub-
mental island is drawn to fill in the defect, and a
pinch test is performed to delineate the maximal
width of the skin paddle that will allow primary
closure to be possible.
The inferior incision is performed first and
the ipsilateral submandibular salivary gland is dis-
sected after having gone through skin, subcutane-
ous tissue, and platysma. Care is taken to preserve
both the facial artery and vein on that side. The
vascular tributaries to the submandibular gland
are carefully identified and ligated as close as pos-
sible to the gland.
After the submandibular gland is excised, the
submental vessels that branch off the facial artery
Fig. 1. submental artery island flap. AD, anterior belly of the
digastric muscle; FV, facial vessels including artery and vein;
MH, mylohyoid muscle; MM, marginal mandibular branch of
the facial nerve; P, platysma muscle; SG, submandibular salivary
gland; SV, submental vessels including artery and vein.
Video. supplemental digital Content 1, a step-by-step illustration
of the technique, is available in the “Related Videos” section of the
full-text article on PRsJournal.com or, for ovid users, at http://links.
686 Download full-text
Plastic and Reconstructive Surgery • March 2014
and vein are easily identified. The skin paddle is
then dissected in the subplatysmal plane starting
at the contralateral side. The dissection plane is
superficial to the anterior belly of the digastric
muscle on the contralateral side.
On the opposite side, the anterior belly of the
ipsilateral digastric muscle is then identified, and
its common tendon is sectioned. The muscle is
then elevated with the skin paddle.
While elevating the digastric muscle, the nerve
to the mylohyoid muscle is encountered and sec-
tioned without functional consequence to the
patient. The attachment of the anterior belly of the
digastric muscle to the mandible is then sectioned.
The superior incision is then completed, and
the facial vessels are identified distally. These ves-
sels are isolated and cut distal to the origins of the
submental vessels. This allows the flap to be freely
mobile to reach the soft-tissue defect. As we can
see, the anterior belly of the ipsilateral digastric
muscle is included and preserved in the flap. The
flap is then inset and sutured into place, and neck
drains are left in place,
With this flap, especially in an elderly patient
with redundant submental skin, the long-term
results at 1 year at the recipient and donor
sites are very good in terms of color match and
contour. The patient had no functional conse-
quence in terms of speech, swallowing, and neck
motion. Postoperative facial paralysis was noted
that resulted from facial nerve involvement by
the tumor, and will be addressed using ancillary
We have presented a step-by-step description
of the submental artery island flap for soft-tissue
myocutaneous reconstruction, with excellent
long-term results. The main advantages of this
flap are excellent color match to facial skin, sup-
pleness, and an easily concealable donor-site inci-
sion that can be closed primarily.
Tareck Ayad, M.D.
Otolaryngology–Head and Neck Surgery
Université de Montréal Hospital Center
1560 Sherbrooke Street East
Montreal, Quebec H2L 4M1, Canada
The authors thank Roula Drossis, medical illus-
trator, for the graphic representation of the submental
1. Martin D, Pascal JF, Baudet J, et al. The submental island
flap: A new donor site. Anatomy and clinical applications as
a free or pedicled flap. Plast Reconstr Surg. 1993;92:867–873.
2. Tang M, Ding M, Almutairi K, Morris SF. Three-dimensional
angiography of the submental artery perforator flap. J Plast
Reconstr Aesthet Surg. 2011;64:608–613.
3. Parmar PS, Goldstein DP. The submental island flap in head
and neck reconstruction. Curr Opin Otolaryngol Head Neck
4. You YH, Chen WL, Wang YP, Liang J, Zhang DM. Reverse
facial-submental artery island flap for the reconstruction
of maxillary defects after cancer ablation. J Craniofac Surg.
5. Merten SL, Jiang RP, Caminer D. The submental artery
island flap for head and neck reconstruction. ANZ J Surg.