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重野, 健一郎

恩田, 健志

髙野, 正行

口腔顎顔面外科学

A Case of ２-year-old girl Underwent Closed Reduction and Fixation for the Fracture of Submedian Mandible and Bilateral Condyle

令和４年度東京歯科大学学会評議員会ならびに総会報告

中久喜, 藍

吉田, 香織

金子, 瑠実

権, 洗眞

塩谷, 麻衣

島津, 幸平

鈴木, 真理子

辻, 優人

森井, 雅子

江里口, 麻子

小鹿, 恭太郎

半田, 俊之

片倉, 朗

一戸, 達也

歯科麻酔学

口腔病態外科学

№１９：全身麻酔後に陰圧性肺水腫を発生したと思われる一例

第15回日本口腔検査学会総会・学術大会報告

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Aida, N

Ohno, T

Azuma, T

生化学

口腔科学研究センター

Progress and Current Status in Hajdu-Cheney Syndrome with Focus on Novel Genetic Research

Seki, H

Shiga, T

Mihara, T

Hoshijima, H

Hosokawa, Y

Hyuga, S

Fujita, T

Koshika, K

Okada, R

Kurose, H

Ideno, S

Ouchi, T

市病・麻酔科

Effects of intrathecal opioids on cesarean section: a systematic review and Bayesian network meta-analysis of randomized controlled trials

Sakuma, H

Takemaru, M

市病・形成外科

Posted at the Institutional Resources for Unique Collection and Academic Archives at Tokyo Dental College,
Available from http://ir.tdc.ac.jp/
Title
Reverse Facial-submental Artery Island Flap with
Reinnervation of the Anterior Belly of the
Digastric Muscle
Author(s)
Alternative
Sakuma, H; Takemaru, M
Journal Archives of plastic surgery, 49(3): 423-426
URL http://hdl.handle.net/10130/6168
Right
© 2022. The Korean Society of Plastic and
Reconstructive Surgeons. This is an open access
article published by Thieme under the terms of the
Creative Commons Attribution-NonDerivative-
NonCommercial License, permitting copying and
reproduction so long as the original work is given
appropriate credit. Contents may not be used for
commercial purposes, or adapted, remixed,
transformed or built upon.
(https://creativecommons.org/licenses/by-nc-
nd/4.0/)
Description
Reverse Facial-submental Artery Island Flap with
Reinnervation of the Anterior Belly of the
Digastric Muscle
Hisashi Sakuma, MD1,2 Masashi Takemaru, MD2
1Department of Plastic and Reconstructive Surgery, Ichikawa General
Hospital, Tokyo Dental College, Ichikawa, Chiba, Japan
2Department of Plastic and Reconstructive Surgery, Yokohama
Municipal Citizen’s Hospital, Yokohama, Kanagawa, Japan
Arch Plast Surg 2022;49:423–426.
Address for correspondence Hisashi Sakuma, MD, Department of
Plastic and Reconstructive Surgery, Ichikawa General Hospital, Tokyo
Dental College, 5-11-13, Sugano, Ichikawa, Chiba 272-8513, Japan
(e-mail: prssakuma@gmail.com).
The lateral lip subunit not only functions as an oral sphincter
but also serves as an attachment or transition part of the lip
elevators, anatomically. Therefore, when performing recon-
struction including the mimetic muscles, lost muscular
function should be regained without sacrificing the function
of adjacent mimetic muscles including the modiolus. Con-
ventional flaps, such as the Abbe flap and Estlander flap,1,2
restore sphincter function within 1 year via reinnervation of
denervated muscle from the same facial nerve.3 However, it
has drawbacks, such as displacing the modiolus, leaving
scars on the lower lip, and making the lip tight when the
defect is large. Local flaps, including the levator labii supe-
rioris, can help regain sphincter function by its reinnervation
from the buccal branch of the facial nerve, but pose concerns,
such as mass movement ,and decreased lip elevation func-
tion.4 A nasolabial orbicularis oris myocutaneous flap, nour-
ished by the facial artery, is created to restore oral sphincter
function by advancing the orbicularis oris muscle and
achieve good esthetics.5 However, it has disadvantages,
such as visible scarring, around the oral commissure and
slightly small mouth. Freeflaps conjoining the neurovascular
muscle are useful for a dynamic reconstruction of moderate
Keywords
► plastic surgery
► carcinoma
► basal cell
► surgical flaps
Abstract Reconstruction of the upper lateral lip subunit is challenging, and use of several
classical local flaps have been previously reported. However, these methods have
drawbacks such as visible scarring, anatomic distortion, and functional disability. To
obtain satisfactory results, preservation of perioral function is important. We report a
case of functional upper lip reconstruction after tumor resection using a reverse facial-
submental artery island flap with a reinnervated anterior belly of the digastric muscle
(ABDM) without sacrificing the perioral structure. A 73-year-old man presented with
basal cell carcinoma on the left upper lip which was widely excised, including the
orbicularis oris muscle. The remaining 4 cm3.5 cm defect was reconstructed using a
reverse facial-submental artery island flap with ipsilateral ABDM. The motor nerve of
the ABDM was sutured with the stump of the buccal branch of the ipsilateral facial
nerve. The postoperative course was uneventful, and good functional and esthetic
recovery were observed at 12-month follow-up. This procedure may be an alternative
option for reconstruction of lateral upper lip defects.
DOI https://doi.org/
10.1055/s-0042-1748653.
ISSN 2234-6163.
© 2022. The Korean Society of Plastic and Reconstructive Surgeons.
All rights reserved.
This is an open access article published by Thieme under the terms of the
Creative Commons Attribution-NonDerivative-NonCommercial-License,
permitting copying and reproduction so long as the original work is given
appropriate credit. Contents may not be used for commercial purposes, or
adapted, remixed, transformed or built upon. (https://creativecommons.org/
licenses/by-nc-nd/4.0/)
Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor,
New York, NY 10001, USA
THIEME
Pediatric/Craniomaxillofacial/Head & Neck: Idea and Innovation 423
Article published online: 2022-05-27
or subtotal defect of the full-thickness lipwithout sacrificing
perioral musculature; however, these procedures are more
invasive and complicated.6
Herein, we report a case of functional upper lip re-
construction after tumor resection using a reverse facial-
submental artery island flap with reinnervated anterior
belly of the digastric muscle (ABDM) without sacrificing
the perioral structure.
Case Report
A 73-year-oldman had a 3 cm2.5 cm basal cell carcinoma of
the left upper lip. After full-thickness excision of the skin and
orbicularis oris muscle with a 5-mm surgical margin, almost
the entire lateral lip subunit was resected, leaving the vermil-
ion and oral mucosa. An 8 cm4 cm skin paddle with a
3 cm7cm long ipsilateral ABDM, located between the digas-
tric fossa of the mandibular internal surface and intermediate
tendon, was elevated, including its feeding vessels such as the
submental artery and vein (►Figs. 1A, 2A). The mylohyoid
nerve, which is the motor nerve of the ABDM, was secured to
obtain a nerve length of 3 cm. The submental artery and vein
were dissected to the bifurcation of the trunk of the facial
artery and vein, and the distal part of the facial artery and vein
were severed to create a reverse-flow flap which was trans-
ferred to theupper lip througha subcutaneous tunnel. Theskin
paddle was rotated approximately 90degrees to match the
direction of the orbicularis oris muscle fibers to that of the
ABDM (►Figs. 1B, 2B). After the stumpof themylohyoidnerve
was sutured to thebuccal branch of the facial nerve (►Fig. 2C),
the ABDM and skin paddle were trimmed and sutured to the
tissue defect (►Fig. 2D).
The flap showed very mild congestion but survived with-
out necrosis. However, because of its bulkiness, defatting of
the flap was performed 3 months postoperatively. Four
months postoperatively, there was contraction of the trans-
ferred muscle, and 12 months postoperatively, satisfactory
voluntary contraction of the transferred muscle and color
and texture match of the flap were observed (►Fig. 3A, 3B).
This study was performed with respect to the ethical
standards of the Declaration of Helsinki. The patient provid-
ed written informed consent for the publication and the use
of his images.
Discussion
The reverse facial-submentall artery flap has been used for
reconstruction of moderate defects in the oral cavity, oro-
pharynx, maxilla, and periorbital region where the conven-
tional submental artery flap cannot be reconstructed by
severing the distal facial vessels to increase the mobility of
the vascular pedicle.7–9 The hemodynamics of the reversed
submental artery flap should be divided into reverse arterial
inflow and venous outflow. A previous study on reverse flow
demonstrated no significant change in the mean intra-arte-
rial pressure in the facial artery after proximal ligation, and a
stable reverse arterial flow was obtained by anastomosis
with the contralateral upper and lower labial arteries and the
lateral nasal artery.10 Further, it is necessary to consider the
presence of venous valves for venous outflow of the retro-
grade flap. While Nishihara et al reported in a study using
cadavers that facial veins lack valves,11 venous valves were
observed at minimum of one site in the facial vein, and at
three sites on an average, especially under the mandible.
Using a rabbit model, Jing et al12 showed that venous return
is through “bypass route” in its initial course, while in the
later course, the venous retrograde return is through “bypass
route” and “incompetent valves route.” In our case, since the
Fig. 1 Operative schema of a reversed facial-submental artery flap with ipsilateral ABDM. (A) The skin paddle with the ABDM is elevated and its
motor nerve, mylohyoid nerve is severed. The vascular pedicle is severed at the distal trunk of the facial artery and vein. (B) After the fap is
transferred to the upper lip defect, the skin paddle (red dotted flap) is rotated90°to match the direction of the orbicularis oris muscle fibers to
that of the ABDM (slanted line). The ABDM is trimmed and sutured to the defect of the orbicularis oris muscle, and themylohyoid nerve is sutured
to the stump of the left buccal branch of the facial nerve in end-to-end fashion (light blue dotted circle). ABDM, anterior belly of the digastric
muscle.
Archives of Plastic Surgery Vol. 49 No. 3/2022 © 2022. The Korean Society of Plastic and Reconstructive Surgeons. All rights reserved.
Submental Flap with Digastric Muscle Sakuma, Takemaru424
congestionwas verymild and transient, it is possible that the
venous valve in the lower margin of the mandible was
drained by regurgitation.
The ABDM originates from the digastric fossa on the inner
surface of themandible and passes downward and backward
and inserts or turns into the intermediate tendon which
attaches to the hyoid bone.13 The ABDM could be classified as
a type-II muscle with a major pedicle and two minor
pedicles, according to the system of Mathes and Nahai.14,15
The artery courses over the posterior surface of the anterior
belly of the digastric muscle, giving off the major dominant
pedicle of the muscle, approximately 1 cm after exiting
behind the submandibular gland, before the middle region
of the muscle. Faltaous and Yetman15 studied 24 cadavers
and reported that the submental artery runs deep into the
ABDM in 70% of cases and runs superficial to the ABDM in
30% of cases. The mylohyoid nerve is a branch of the
mandibular nerve that arises from the inferior alveolar
nerve, just before it enters the mandibular canal. The nerve
consistently contributes to the ABDMwithout branches until
it appears at the posterior border of the mylohyoid muscle.
Since the ABDM is 2-cm longer than the zygomaticus major,
it has sufficient length to replace this muscle.13 It can also
separate nerves and vascular pedicles independently, and it
has the potential for dynamic reconstruction of the mimetic
muscles lost after tumor ablation, trauma, and facial nerve
paralysis.16 Terzis and Kalantarian demonstrated the recon-
struction of lower lip depressors with ABDM.17 Both the
mandibular origin and the tendinous insertion were severed
Fig. 2 Intraoperative views. (A) The reversed facial-submental flap with ABDM was elevated. (B) The flap was transferred to the upper lip defect.
(C) The mylohyoid nerve was sutured to the stump of the left buccal branch of the facial nerve in end-to-end fashion, and the ABDM was sutured
to the muscular defect. (D) The redundant skin was trimmed and sutured. ABDM, anterior belly of the digastric muscle.
Fig. 3 Postoperative views. (A) Postoperative views 12 months after
the surgery, at rest. (b) Upon pursing the lips.
Archives of Plastic Surgery Vol. 49 No. 3/2022 © 2022. The Korean Society of Plastic and Reconstructive Surgeons. All rights reserved.
Submental Flap with Digastric Muscle Sakuma, Takemaru 425
and split into four slips while preserving the neurovascular
pedicles. They also reported a method of reinnervating
ABDM by suturing its motor nerve with a cross-facial nerve
graft in an end-to-end fashion near its entry point into the
muscle but limiting it to the reconstruction of the lower lip
depressors. The submental flap is widely used for the upper
lip reconstruction, but to the best of our knowledge, this is
the first to report the combination of the submental flap and
reinnervated ABDM.
The procedure followed in our case has certain drawbacks
such as the skin flap becoming bulkier and sometimes
requiring secondary correction and nonsuitability for cases
of regional metastatic disease involving the ipsilateral level-I
lymphatic tissuebed. However, there are advantages that it is
safe, quick, and simple to elevate; it allows a well-hidden
donor site scar with minimal morbidity; the elongation of
the vascular pedicle by its proximal ligation increases the
flexibility of muscle placement, so it can be used for dynamic
reconstruction of not only the lower lip depressormuscle but
also the orbicularis oris and the lip elevators or orbicularis
oculimuscle; even if themimeticmuscle defect is large, it can
obtain reliable reinnervation of the transferred muscle by
motor nerve coaptation; both the upper lip skin and orbi-
cularis oris muscle complex can be reconstructed without
sacrificing the perioral structure and the flap including the
mustache.
Conclusion
The reverse facial-submental artery island flap with ipsilat-
eral ABDM may be a versatile and reliable option for func-
tional and esthetic reconstruction of lateral upper lip defects.
Author Contributions
Conceptualization: S.H. Methodology: S.H. and T.M. Pre-
paring original draft: S.H. Approval of final manuscript: S.
H. and T.M.
Ethical Approval
This study was approved by the relevant institutional
review board and performed in accordance with the
principles of the Declaration of Helsinki.
Patient Consent
Informed consent was obtained from all individual par-
ticipants included in the study.
Conflict of Interest
None declared.
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Archives of Plastic Surgery Vol. 49 No. 3/2022 © 2022. The Korean Society of Plastic and Reconstructive Surgeons. All rights reserved.
Submental Flap with Digastric Muscle Sakuma, Takemaru426


Reverse Facial-submental Artery Island Flap with Reinnervation of the Anterior Belly of the Digastric Muscle

小谷地, 雅秀

菅原, 圭亮

立澤, 孝太郎

小高, 研人

松永, 智

西山, 明宏

笠原, 清弘

歯科放射線学

解剖学

№２６：ホログラム手術ガイドを応用した顎矯正手術における新たな顔貌プレディクションの開発

Tokyo Dental College

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