Maxillofacial defects have a significant effect on the patients’ health and quality of life. Defects of this region result primarily from injuries of different etiology, tissue resection following surgical procedures on resection of masses of different origin, blast injuries, congenital anomalies, and iatrogenic injuries.

High aesthetic value of facial zone, structural features of maxillofacial region represented by the compactly located vital structures, and functional value of this zone determine the difficulty of conducting surgical procedures involving selection of individual plan in each particular case.

Today, selection of surgical treatment for patients with facial defects implies an integrated multidisciplinary approach involving maxillofacial and plastic surgeons, thereby ensuring optimal morphofunctional and aesthetic rehabilitation of patients.

Here we provide a clinical case of complex multistage surgical treatment of the female patient with soft tissue defect in the lower third of the face (jaw and lower lip) involving the use of submental flap and subsequent local tissue correction.

Submental flap proposed by D. Martin in 1993 was selected due to its popularity among oncologists and maxillofacial surgeons commonly operating head and neck for elimination of defects of the neck, esophagus, tongue, floor of the mouth, upper and lower lips [1–3].

The flap is supplied by the submental artery, after which it was named. The submental artery being a branch of the facial artery is a reliable and consistent blood supply source. The average artery diameter is 1.7 mm. On its way the artery produces 1–4 perforator branches to the skin area of the flap, thereby enabling harvesting the flap with a skin paddle sized 18 cm (length) and 7 cm (width). Venous drainage is provided by the eponymous vein that runs into the factial vein. The average vein diameter is 2.2 mm. The vascular pedicle can be 8 cm long, which enables flap rotation up to the zygomatic arch, thereby covering most possible zones in the middle and lower face [4–5].

The advantages of the flap include reliable blood supply, invisible scar hidden in the neck area, large skin paddle and long vascular pedicle, enabling a wide arc of flap rotation [6].

Meta-analysis involving comparison of using submental flaps and free tissue transfer for elimination of oral defects showed that the use of rotation submental flap was associated with less operative time, shorter hospitalization, fewer perioperative complications [7].

There are multiple case studies, in which the rotation submental flap was used to eliminate various maxillofacial defects. In particular, such flap was used to eliminate the upper lip defect with a very good aesthetic outcome [8]. The flap was applied to eliminate the lower lip defect preserving the oral cavity airtightness [9]. A case study was provided, in which two submental flaps were used for total reconstruction of the lower lip defect resulting from the malignant neoplasm resection [10].

Thus, submental flap is an ideal flap for elimination of facial defects due to texture that is similar to that of facial skin and color match. This can be an excellent alternative to free flaps when used in the head and neck reconstructive surgery [11, 12].

Clinical case

Female patient S., 38 years old, contacted the Department of Maxillofacial Surgery at the National Medical Research Center for Otorlaryngology of FMBA of Russia due to lower lip defect resulting from trauma, non-healing wounds in the chin region (fig. 1). Histological examination of wound tissues performed in the Center confirmed tissue necrosis and chronic inflammation.

The first stage of surgical treatment involved dissection of necrotic tissue in the mental region and lower lip. To close the resulting defect sized 7 × 3 cm, a submental fasciocutaneous flap sized 8.5 × 2 cm was harvested on the right submental artery and vein (fig. 2) with subsequent flap rotation through the skin tunnel and fixation in the mental region. The Minidop 8 portable Doppler (Bioss; Russia) was used to identify perforators supplying skin (fig. 3). The donor region was closed by placing a layer-by-layer suture to form a linear scar that was hardly visible in the submental region.

Venous stasis in the flap formed was observed during the first day. Hirudotherapy was performed for five days in order to improve circulation and reduce venous stasis (fig. 4). Beneficial effect was reported, the patient was discharged on day 7 in satisfactory condition (fig. 5).

Seven months after the defect closure a residual deformity in the form of cicatricial lower lip shortening and vermillion defect on the left was observed. The second stage of reconstruction involved restoration of the lower lip length/height on the left and elimination of vermillion defect using local tissues. To eliminate the lower lip mucosal defect, we cut a rotation flap via a “rabble” incision along the transitory fold, which was moved into the resulting defect after dissection of mucosal scars. After scar tissue dissection we cut multiple transposable triangular flaps (Z-plasty) from the skin of the lip and chin on the left, which enabled increasing the lower lip length on the left. The vermillion defect was eliminated using the method by Mirault involving cutting a triangular (tongue-shaped) flap from the vermillion border of the lateral lip fragment and a bed for the flap in the medial lower lip fragment. To restore the lower lip function, the remaining orbicularis oris muscle fragments were identified that were sutured by plication (superimposition of fragments). After that sutures were placed layer-by-layer. Stitches were removed on day 10. Wound healing by primary intention took place; no signs of inflammation were observed (fig. 6, fig. 7).

The patient was followed up for a year after surgery, good aesthetic and functional results were yielded with minimal donor region deformity. The patient could close her lips completely, she had no difficulty consuming fluids and foods of any texture (fig. 8–fig. 10).

Clinical case discussion

Various methods for reconstruction of surgical defects of the lower third of the face have been reported. Reconstructive options vary between primary closure and the use of free flaps, depending on the defect size and type [9].

However, for optimal outcome to be achieved, the donor and recipient sites should have similar characterstics in terms of skin quality, thickness, color and texture match. Thus, selection of local regional flap near the facial soft tissue defect is a perfect option [8, 13].

Closure of mental and buccal defects using free flaps and microsurgical technique does not allow one to obtain identical skin color and texture in Caucasian patients when using flaps harvested from the thoracortical, radial, femoral or shoulder areas.

To eliminate residual deformity after the defect closure, supplementary surgical reconstruction with local tissues is required for the patient’s appearance improvement.

Advances in microsurgery led to a better understanding of the fasciocutaneous perforator flaps anatomical features, thereby allowing reconstructive surgeons to gain new capabilities of eliminating complex maxillofacial defects [14].

CONCLUSION

Regional flaps are a good alternative to free flaps with vascular pedicles due to less operative time, lower requirements for the patient’s somatic status, surgeon’s skills, and operating room equipment [7]. This allows one to use flaps of this type in field surgery for immediate elimination of blast and gunshot defects in the lower third of the face.

Long vascular pedicle ensures wide flap rotation arc and the possibility of using the flap for elimination of almost any soft tissue defect of the lower third of the face, while skin characteristics identical to those in the buccal and mental areas make it possible to achieve good aesthetic outcome.

The clinical case reported represents an example of complex approach to surgical treatment of patients with maxillofacial defects involving the use of rotation submental flaps.