|Year : 2022 | Volume
| Issue : 1 | Page : 43-47
Infrahyoid flap: Myocutaneous pedicled flap for reconstrcution of tongue carcinomas
Harish Saluja1, Seemit Shah1, Shivani Sachdeva2, Anuj Dadhich1
1 Department of Oral and Maxillofacial Surgery, Pravara Institute of Medical Sciences, Rural Dental College, Loni, Maharashtra, India
2 Department of Periodontology, Pravara Institute of Medical Sciences, Rural Dental College, Loni, Maharashtra, India
|Date of Submission||13-Jan-2022|
|Date of Decision||11-Mar-2022|
|Date of Acceptance||01-Jun-2022|
|Date of Web Publication||23-Jun-2022|
Department of Oral and Maxillofacial Surgery, Pravara Institute of Medical Sciences, Rural Dental College, Loni, Maharashtra
Source of Support: None, Conflict of Interest: None
The infrahyoid flap (IHF) is a myocutaneous pedicled flap which is mostly supplied by the superior thyroid vessels through the infrahyoid muscles perforators. The flap is thin and it could be transferred as a pedicle of superior thyroid artery along with the vein for the reconstruction of medium-sized defects of head and neck surgeries. The added advantage of this flap is that it is pliable and provides a skin island which is approximately seven by four centimeters from the central part of the anterior neck. The best substitute for reconstruction of oral defects is IHF. It can be carried out for the moderate defects of mouth along with that of pharynx carcinomas. The flap can be either unilateral or bilateral superior thyroid pedicle flaps but the main limitations are restricted arc of rotation and small flap volume. The IHF is contraindicated in cases with prior irradiation as well as cases of neck metastasis. The flap is most trusted and can be easily yielded during dissections of the head and neck; oncologically, it is safe and it carries least morbidity of the donor site.
Keywords: Infrahyoid flap, myocutaneous flap, tongue reconstruction
|How to cite this article:|
Saluja H, Shah S, Sachdeva S, Dadhich A. Infrahyoid flap: Myocutaneous pedicled flap for reconstrcution of tongue carcinomas. J Head Neck Physicians Surg 2022;10:43-7
|How to cite this URL:|
Saluja H, Shah S, Sachdeva S, Dadhich A. Infrahyoid flap: Myocutaneous pedicled flap for reconstrcution of tongue carcinomas. J Head Neck Physicians Surg [serial online] 2022 [cited 2022 Oct 4];10:43-7. Available from: https://www.jhnps.org/text.asp?2022/10/1/43/347986
| Background|| |
Wang and Shen in 1980 first introduced the infrahyoid flap (IHF) or the neurovascular myocutaneous IHF for reconstruction after excision of tongue ablation as it has innervations from ansa cervicalis. IHF is described as a convenient, reliable, and simple technique for the reconstruction of moderate defects which involve less than half of the tongue, and those involving oral cavity, oropharynx, hypopharynx, parotid gland, and one-third of lower face.,, Surgical modifications have been acquainted due to issues of esthetics and venous return., IHF has a composite structure that is vascularized by the superior thyroid artery and vein pedicle, is innervated by the deep branches of ansa cervicalis, and includes the upper parts of sternohyoid, sternothyroid, and omohyoid muscles., While, the size of the skin island on the flap can be adjusted according to the dimensions of the defect, a maximum of nine centimeters in length and five centimeters width is reported in published studies.
The main advantages of flap are, that the neurovascular myocutaneous IHF can be prepared prior to neck dissection, it does not inhibit the dissection procedure, does not require any additional incision, and can be primarily closed. It can be used bilaterally when necessary. Complication rates after reconstruction are reported to range from 3% to 47% and to mostly be due to insufficient venous return., The small- and medium-sized oropharyngeal defects can be sufficiently and functionally reconstructed with successful outcomes comparable to free flaps, and can be preferred in elderly patients where micro-anastomoses are most likely to fail. In large-sized defects, however, IHFs are reported to be likely insufficient., While previous thyroid surgery, neck dissection, and presence of metastatic disease localized to level III or IV of the neck restrict the use of the IHF technique, it should not be used in patients diagnosed with N3 neck metastasis according to the TNM staging system. When used with regard of its restrictions and contraindications, IHF is a simple reconstruction technique that preserves swallowing and speech functions and brings high patient satisfaction in oropharyngeal defects especially when tongue reconstruction is done using IHF.,
| Review of Literature|| |
Clairmont and Conley in 1977 gave the first report for use of infrahyoid muscles as a free pedicled flap with intention of reconstruction. In this report, it was emphasized to transpose the infrahyoid muscles for reconstruction of the anterior floor of the mouth. The report further clarified that trans positioning of the infrahyoid muscles upwards helps to preserve the superior thyroid artery and also the innervations by the ansa hyoglossus which promotes the viability of IFH flap. Eliachar et al. further included the concept of transposing skin paddle with the infrahyoid muscles for reconstruction of laryngotracheal defects. Their approach was using a rotary-door flap as the myocutaneous flap with an added advantage of dual blood supply from the superior as well as inferior thyroid arteries., Having thus substantial limitation on the arch of rotation (coming from the need of maintaining both cranial and caudal pedicles), this rotary-door flap was therefore, recommended only for laryngotracheal defects. Rabson et al. pointed out that the inferior cervical skin approaching the midline receives blood supply from the perforator vessels of superior thyroid artery which piercing the infrahyoid muscles.
The most authoritative and critical step was reserved by Wang et al. in 1986, as they were the first to report in the English literature the surgical technique and results of 112 head and neck reconstructions in 108 patients, describing the IHF as it is known to us today. The flap was mainly transposed to replace intraoral defects, with blood supply mainly from the superior thyroid vessels. It was an important finding in the first report by Wang, as IFH flap was easy, simple and particularly convenient for the old-aged people. The case series by Wang starts from May 1979, but Clairmont and Conley started the IHF.
The IHF comes forth as a technique that can be performed in the same session to repair the defects that occur due to the surgical treatment of tongue and mouth cancers, without requiring additional incisions and donor site reconstruction. Myocutaneous flaps and microvascular free flaps are the techniques which are being used currently for reconstruction of the head and neck after resective surgeries in carcinoms. However, in certain circumstances, such as the resection of oropharyngeal and tongue carcinomas, a pectoralis major or a trapezius flap can be bulky and preclude appropriate functional and esthetic results. Wang et al. and Rojananin et al. also elaborated about the myocutaneous flap used for reconstruction in head and neck surgeries after major resection. They designed a flap which was substantiated on the use of unilateral or the bilateral superior thyroid pedicle which has been proved to be helpful in the reconstruction of various head and neck surgeries such as that of intraoral, pharyngeal, and parotid region defects because it was thin and easy to perform.,
| Methods|| |
The present paper is a narrative review of the available literature reporting with terminology or quotation “infrahyoid myocutaneous flap” which was searched. The search has been carried out using a web search in PubMed/Medline, Google Scholar, Web of Science, and Scopus. The mesh terminology used was infrahyoid myocutaneous flap which could be found anywhere in the text. The search was limited to review papers and those that were published only in language English. No limit has been set in time. There were 46 review papers in total which were published having infrahyoid myocutaneous flap terminology which could be found anywhere in the text.
This review is intended to highlight the advantages of IFH which can be given in the field of head and neck surgery.
In its original description by Wang et al. the IHF was harvested as the myocutaneous flap after ipsilateral modified radical or selective neck dissection was completed. The harvesting of the IHF does not interfere with the extent of the neck dissection, since this flap lies in the central compartment of the neck, medial to the carotid artery at neck level VI. When a therapeutic modified radical neck dissection was indicated, it was performed with standard method but by preservation of the superior thyroid vein as one the main requisite along with the caudal stump of the internal jugular vein.
The anatomical consideration was that the infrahyoid muscles include the sternohyoid muscle, the superior belly of the omohyoid muscle and the sternothyroid muscle for this IHF. Mostly, the unilateral flap serves the purpose and location of the defect governs the side of flap to be reflected for augmentation. Hence, the skin overlying the cervical incision for head and neck dissection is mostly marked on the same side of the neck as that of the resection site. The flap shape in a vertical position could be either rectangular or oval, and the overlying skin must include in the incision for uni- or bilateral head and neck dissection. The T-shaped incision was modified by S-shaped incision by Dolivet et al. for the neck incisions. The outline for IHF for medial edge lies at the midline, the upper edge at the level of hyoid bone and lower edge at the suprasternal notch, the lateral edge lies 3–5 cm away from the midline. When a tracheotomy is required, this is usually performed first and is important to prevent tracheotomy site contamination to the wound bed. It has been documented and recommended to secure the caudal edge of the overlying skin paddle to be at least at a distance of 1 cm above the incision for tracheotomy and to open the trachea under the thyroid isthmus. Thus, harvesting IHF will gradually create the communication with the tracheotomy at the side where the infrahyoid muscles were harvested. Sometimes, later on, to ensure the tight separation, thyroid isthmus, and edge of the sternum of the very sternocleidomastoid muscle can be sutured to the subcutaneous tissue above the tracheotomy opening. The skin and platysma all around the skin paddle are incised to allow prompt choke perforator vessels opening; the skin flaps are elevated and, before starting with the intended modified radical or selective neck dissection, the superficial cervical fascia along the anterior border of the sternocleidomastoid muscle, from the sternal insertion to the level of the hyoid bone, is incised and the dissection of the fascia proceeds until the omohyoid muscle is identified at its intersection with the internal jugular vein. The intermediate tendon is divided and the fascia, together with the anterior belly of the omohyoid muscle is elevated toward the lateral edge of the skin paddle and sutured to it. Neck dissection and primary tumor resection are now completed. The elevation of the flap starts by dividing the anterior jugular vein and sectioning the sternohyoid and sternothyroid muscles distally at the level of the suprasternal notch. The skin paddle is stitched to the underlying muscles and then the IHF is raised over the avascular plane of the proper capsule of the thyroid gland. When the dissection reaches the upper pole of the thyroid gland, the cricothyroid artery (at the midline of the neck) and the posterior branch of the superior thyroid artery (at its entrance in the upper pole of the gland) are cut, ligated, and kept with the flap. The sternothyroid muscle is detached from the thyroid cartilage. Fascial connections between the superficial and median cervical fascia are maintained in proximity of the neurovascular pedicle; these fascial connections are important to directly provide microvascular venous return toward the median cervical fascia and to protect the superior thyroid vein from twisting or kneeing., Special care must be taken in preserving the external branch of the superior laryngeal nerve, and therefore the thyrohyoid muscle is usually spared and left in place. Finally, the hyoid insertions of the sternohyoid and omohyoid muscles are severed, the entire flap remains attached only by the neurovascular pedicle formed by the superior thyroid artery and vein, and nerves from the ansa cervicalis, and is then ready to be transferred to reconstruct the defect, The arc of rotation of the IHF depends on the location of the carotid bifurcation and of the superior thyroid vessels, more cranial it is, the more convenient to reach upper sites. The zygomatic arch sets the superior limit for the IHF, usually for soft palate or lateral pharyngeal wall reconstructions the lower edge of the skin paddle is rotated to the most cranial portion of the defect. For oral cavity reconstructions the lower edge of the skin paddle is usually placed anteriorly and the upper edge posteriorly. After the flap is transposed to the donor site, the tacking sutures connecting the skin paddle with underlying fascia and muscles are removed, increasing the arc of rotation for the inset. If the width of the skin paddle is not >5 cm the donor site can be primarily closed with excellent aesthetic results and no scar-related impairment in neck movements, otherwise the transposition of a deltopectoral flap is usually necessary. [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g represents the tongue reconstruction done by IHF. [Figure 1]a represents the carcinoma of the tongue which was excised [Figure 1]b. The IHF was procured from the neck [Figure 1]d after markings done on the neck region [Figure 1]c. The IHF was rotated and lifted up with forceps [Figure 1]e. [Figure 1]f and [Figure 1]g depicts the flap being seated and sutured.
|Figure 1: Depicts the reconstruction of tongue using infrahyoid flap. (a-g) Represents the tongue reconstruction done by infrahyoid flap|
Click here to view
The venous drainage is through external and internal jugular systems, and the preservation of one's system is crucial: the superior thyroid vein provides drainage to the internal jugular vein; the cranial portion of the anterior jugular vein drains, with retrograde flow, into the external jugular vein. Few studies have suggested to preserve the cranial portion of anterior jugular vein and that makes it more feasible and reliable and preserving the external jugular vein makes ipsilateral neck dissection technically more demanding.
| Discussion|| |
In India and South Asia, oral cancer is reported to be one of the most common carcinomas. The treatment of oral cancer is not only limited to cure, but also requires good reconstruction of the surgical defects for the better quality of the life. The quality of life is the aim which a surgeon looks while treating head and neck cancers. However, it becomes a big challenge when it is carcinoma of the tongue because the speech and movements of tongue are impaired. There are many well-proved options for reconstruction purposes for the defects of oral cavity including locoregional flaps to microvascular free flaps. Static flaps like Permanent Magnet Moving Coil, radial forearm can provide bulk, but they cannot restore functions of the tongue. Wang et al. familiarized all the head and neck surgeons with the IHF for the reconstruction of various intraoral as well as extraoral resection sites. However, this flap was most useful for tongue because of its motor innervation (Ansa cervicalis). The IHF enables bolus propulsion because during the deglutition the hyoid bone elevates and this pushes the IHF backward and hence the propulsion. This has been possible because the IHF is transposed without detaching it from the hyoid bone. Hence, the muscular activity is still preserved.
For defects limited to the tongue base, IHF is perfectly suited to the resected area having the desired thickness. As originally suggested by Wang et al., it is wise to preserve the motor innervations of the infrahyoid muscles (provided by the Ansa cervicalis) in all cases of tongue reconstruction, to prevent subsequent atrophy. Majoufre-Lefebvre et al. introduced the horizontal IHF claiming fewer cosmetic sequelae at the donor site; this technique was then implemented in a large series of 276 cases from the same group, and the authors also stated that no additional scars in the neck were required. This is certainly true when a selective neck dissection I-III is planned (as it happened for the 275 squamous cell carcinoma patients in this series), nevertheless only the neck incision for a vertically oriented flap allows a comprehensive neck dissection without further incisions. Furthermore, a vertically oriented flap has a superior arc of rotation as compared to a horizontal flap, allowing for upper reconstructions that reach the soft palate.
Its main advantages of the IHF for tongue reconstructions are:
- The flap is thin and more easily pliable
- The voluntary neural innervations of ansa cervicalis make this flap as a better option for reconstructions of movable tongue
- Reconstruction with IHF increases the volume of the mobile parts of the tongue, and thereby, favorably affects speech and swallowing functions
- Atrophy is prevented with the restoration of esthetics and functions in the donor area
- The IHF technique allowed primary closure by concealing the donor site within the incision of the neck dissection, thus enabled esthetically successful outcomes
- No additional scars and skin defects are there by this approach as the flap is procured by the neck dissection
- Not just it is a versatile flap, it can be used in other areas around the tongue and that too without the need of a plastic surgeon
- It is hairless in most cases
The challenges faced by the infrahyoid myocutaneous flap are that it should be planned preoperatively while it is mandatory to preserve the internal jugular vein. Furthermore, it should not be recommended in cases with metastatic lymph nodes at level III or IV.
In their 1986 series including 112 patients Wang et al. reported no total flap losses; only partial skin necrosis in 11 patients, in whose cases defects had healed by secondary intention within one to 2 months. While a flap success rate of 90% was reported in these series, failure rate was reported to be higher in cases with internal as well as external jugular veins which were resected together compared to those in which internal along with external jugular veins which were preserved. Another study published in 2001 reported to have found partial skin necrosis in two, total skin necrosis in two, and flap necrosis in one patient of the total 53 patients who underwent oral cavity defect reconstruction. Second surgery was not required in any of the cases. In a study conducted by İşlek et al., it was reported that IHF, is an appropriate substitute for reconstruction of tongue and floor of mouth, but in the study, there was partial skin necrosis which developed in two patients; where healing occurred by secondary intention, and other was treated with revision surgery using partial-thickness skin graft (PTSG) on the 34th day after the primary surgery. In the latter patient's decision for defect revision with PTSG was taken to avoid the risk of delaying radiotherapy.
While in the literature contraindications for using the IHF technique are defined as N3 stage and presence of level III–IV lymph node metastasis, the main concern in the presence of a level III–IV metastasis is indicated to be the risk of compromising the principles of oncologic surgery in favor of the flap.
| Conclusion|| |
IHF is a technique that can be quickly performed in the same session to repair the defects that occur due to the surgical treatment of tongue and mouth cancers, without requiring additional incisions and donor site reconstruction. It should be well-thought-out as an appropriate substitute to free flaps in selective cases where it can be applied easily for the success of the flap. One of the main preoperative considerations is previous history of chemoradiotherapy, though it is not an absolute contraindication for IHF., The skin paddle should be evaluated for radiation-induced fibrosis or telangiectasia or if the flap loses pliability. If any of these findings is found then the flap should not be considered as a treatment option because all these features lead to reduction in blood supply. However, if there is the absence of these features and flap appears as a normal paddle of skin, then it could be the best alternative which could be well-thought-out.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This material has never been published and is not currently under evaluation in any other peer reviewed publication.
| References|| |
Wang HS, Shen JW. Preliminary report on a new approach to the reconstruction of the tongue. Acta Acad Med Prim Shanghai 1980;7:256-9.
Wang HS, Shen JW, Ma DB, Wang JD, Tian AL. The infrahyoid myocutaneous flap for reconstruction after resection of head and neck cancer. Cancer 1986;57:663-8.
Deganello A, Leemans CR. The infrahyoid flap: A comprehensive review of an often overlooked reconstructive method. Oral Oncol 2014;50:704-10.
Magrin J, Kowalski LP, Santo GE, Waksmann G, Di Paula RA. Infrahyoid myocutaneous flap in head and neck reconstruction. Head Neck 1993;15:522-5.
Mirghani H, Meyer G, Hans S, Dolivet G, Périé S, Brasnu D, et al.
The musculocutaneous infrahyoid flap: Surgical key points. Eur Arch Otorhinolaryngol 2012;269:1213-7.
Dolivet G, Gangloff P, Sarini J, Ton Van J, Garron X, Guillemin F, et al.
Modification of the infra hyoid musculo-cutaneous flap. Eur J Surg Oncol 2005;31:294-8.
Peng H, Wang SJ, Yang X, Guo H, Liu M. Infrahyoid myocutaneous flap for medium-sized head and neck defects: Surgical outcome and technique modification. Otolaryngol Head Neck Surg 2013;148:47-53.
Deganello A, Manciocco V, Dolivet G, Leemans CR, Spriano G. Infrahyoid fascio-myocutaneous flap as an alternative to free radial forearm flap in head and neck reconstruction. Head Neck 2007;29:285-91.
Zhao YF, Zhang WF, Zhao JH. Reconstruction of intraoral defects after cancer surgery using cervical pedicle flaps. J Oral Maxillofac Surg 2001;59:1142-6.
McConnel FM, Pauloski BR, Logemann JA, Rademaker AW, Colangelo L, Shedd D, et al.
Functional results of primary closure vs. flaps in oropharyngeal reconstruction: A prospective study of speech and swallowing. Arch Otolaryngol Head Neck Surg 1998;124:625-30.
Clairmont AA, Conley JJ. Surgical technique – The strap muscle flap. J Otolaryngol 1977;6:200-2.
Eliachar I, Marcovich A, Shai YH. Rotary-door flap in laryngotracheal reconstruction. Arch Otolaryngol 1984;110:585-90.
Eliachar I, Marcovich A, Har Shai Y, Lindenbaum E. Arterial blood supply to the infrahyoid muscles: An anatomical study. Head Neck Surg 1984;7:8-14.
Rabson JA, Hurwitz DJ, Futrell JW. The cutaneous blood supply of the neck: Relevance to incision planning and surgical reconstruction. Br J Plast Surg 1985;38:208-19.
Rojananin S, Suphaphongs N, Ballantyne AJ. The infrahyoid musculocutaneous flap in head and neck reconstruction. Am J Surg 1991;162:400-3.
Majoufre-Lefebvre C, Laurentjoye M, Faucher A, Zwetyenga N, Siberchicot F, Ricard AS. The horizontal infrahyoid myocutaneous flap: Surgical technique. Rev Stomatol Chir Maxillofac 2008;109:106-9.
Gangloff P, Deganello A, Lacave ML, Verhaeghe JL, Lapeyre M, Maire F, et al.
Use of the infra hyoid musculo-cutaneous flap in soft palate reconstruction. Eur J Surg Oncol 2006;32:1165-9.
İşlek A, Balcı MK, Yüksel Ö, Önal K, Arslanoğlu S, Eren E. Infrahyoid flap, a convenient alternative for reconstruction of tongue and floor of mouth defects: Case series. Turk Arch Otorhinolaryngol 2018;56:85-8.