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\begin{document}

\title{VEIN PRESERVATION STRATEGIES TO IMPROVE THE SURVIVAL RATE OF THE
INFRAHYOID MUSCULOCUTANEOUS FLAP}



\author[1]{Khoi Nguyen}%
\author[2]{Tham Ngo}%
\author[2]{Can Nguyen}%
\author[3]{Richard Wein}%
\affil[1]{Pham Ngoc Thach University of Medicine}%
\affil[2]{Oncology Hospital Ho Chi Minh City}%
\affil[3]{Tufts University School of Medicine}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
The infrahyoid musculocutaneous flap (IHMCF) is a good alternative in
the reconstruction of moderate-sized oral cavity surgical defects.
Insufficient venous drainage can significantly affect the survival rate
of this flap. Objectives Indentify the survival rates of the IHMCF and
evaluate the functional capacity of reonstructed patients. Design We
report a case series. Setting This study took place at the department of
Head and Neck surgery of Oncology Hospital Ho Chi Minh City, the largest
oncology center in South Vietnam. Participants We have 112 patients with
defects after oral cavity resection for cancer that underwent IHMCF
reconstruction from November 2013 to November 2018. In the raising of
the flap, our technical approach specifically attempts to preserve more
secondary veins for IHMCF. Main outcome measures Postoperative vitality
of the flap was checked by clinical observation. The last examination
was performed at 1 month after reconstructive operation. The functional
capacity of our patients was evaluated by three doctors (head and neck
surgeon, radiation oncologist, physiatrist) with understandability of
speech scale and the functional oral intake score items. Results Two
cases of partial skin necrosis (1.8\%) were experienced. The majority of
patients demonstrate favorable functional rehabilitation at long-term
follow up. Conclusions. The IHMCF is a reliable flap suitable for
medium-sized defects of the oral cavity. Altering the surgical approach
to specifically preserve more venous outflow can improve the survival
rate of the flap. Key words: infrahyoid musculocutaneous flap oral
cavity defect%
\end{abstract}%



\sloppy


\emph{The infrahyoid musculocutaneous flap (IHMCF) is a good alternative
in the reconstruction of moderate-sized oral cavity surgical defects.
Insufficient venous drainage can significantly affect the survival rate
of this flap.}

\emph{Objectives}

\emph{Indentify the survival rates of the IHMCF and evaluate the
functional capacity of reonstructed patients.}

\emph{Design}

\emph{We report a case series.}

\emph{Setting}

\emph{This study took place at the department of Head and Neck surgery
of Oncology Hospital Ho Chi Minh City, the largest oncology center in
South Vietnam.}

\emph{Participants We have 112 patients with defects after oral cavity
resection for cancer that underwent IHMCF reconstruction from November
2013 to November 2018. In the raising of the flap, our technical
approach specifically attempts to preserve more secondary veins for
IHMCF.}

\emph{Main outcome measures}

\emph{Postoperative vitality of the flap was checked by clinical
observation. The last examination was performed at 1 month after
reconstructive operation.}

\emph{The functional capacity of our patients was evaluated by three
doctors (head and neck surgeon, radiation oncologist, physiatrist) with
understandability of speech scale and the functional oral intake score
items} .

\emph{Results}

\emph{Two cases of partial skin necrosis (1.8\%) were experienced. The
majority of patients demonstrate favorable functional rehabilitation at
long-term follow up. Conclusions.}

\emph{The IHMCF is a reliable flap suitable for medium-sized defects of
the oral cavity. Altering the surgical approach to specifically preserve
more venous outflow can improve the survival rate of the flap.}

\emph{Key words:}

infrahyoid musculocutaneous flap

oral cavity defect

Key points

\begin{itemize}
\tightlist
\item
  \emph{The infrahyoid musculocutaneous flap (IHMCF) is a good
  alternative in the reconstruction of moderate-sized oral cavity
  surgical defects.}
\item
  \emph{The skin flap necrosis rate could reach 47\% because of venous
  drainage.}
\item
  \emph{Postoperative complications can result in an increase in the
  length of hospital stay.}
\item
  \emph{Modified surgical approach to specifically preserve more venous
  outflow can improve the survival rate of the flap.}
\item
  \emph{The majority of patients demonstrate favorable functional
  rehabilitation at 3 months after reconstructive operation.}
\end{itemize}

\textbf{Introduction}

In 1980, Wang and Shen first reported the infrahyoid musculocutaneous
flap (IHMCF). This flap has proven to be useful in the reconstruction of
moderate-sized (T2-T3) intraoral defects. The main blood supply of the
IHMCF is from the superior thyroid artery, the first branch of the
external carotid artery.

Within the surgical literature, the complication rate is very variable,
ranging from 3\% to 47\%\textsuperscript{1}. The insufficient venous
drainage is the major factor related to the survival of the skin
paddle\textsuperscript{2}. We report on our variation in the surgical
technique of raising the flap with the intent to improve the
postoperative survival rate.

\textbf{Materials and methods}

From November 2013 to November 2018, 112 patients with oral cavity
squamous cell carcinoma (SCC), 79 men and 33 women, underwent infrahyoid
flap reconstruction after tumor ablation procedures. The age of patients
ranged from 29 to 76 years, with median of 58 years. The primary sites
of patients in the series were oral tongue (68), floor of mouth (31),
and alveolar ridge (13) (table 1).

The functional capacity of reconstructed patients was subsequently
evaluated by three doctors (head and neck surgeon, radiation oncologist,
physiatrist) with the scores averaged (table
2\textsuperscript{3},3\textsuperscript{4}). This assessment was
conducted at 3 months after reconstructive operation (28 patients not
require adjuvant radiotherapy) or after radiotherapy (84 patients).

\textbf{Modified surgical techniques}

In this series, the techniques suggested by Dolivet et
al\textsuperscript{5} and Deganello et al\textsuperscript{1} were used
in all patients. Dolivet et al\textsuperscript{3} tried to preserve
venous drainage towards digastric triangle network and mylohyoid muscle.
Deganello et al\textsuperscript{1} left fascial connections between the
superficial and median cervical fascia intact because of microvascular
venous return. In addition to these techniques, we also preserve a minor
venous tributary to internal jugular vein, below the superior thyroid
vein, and the communicating vein to external jugular vein when possible.
While performing the incision for the lateral border of the skin flap,
we dissect through the platysma meticulously preserving the
communicating vein to external jugular vein that is immediately below
this muscle. The IHMCF is usually raised from the bottom-up. During the
dissection along the internal jugular vein a minor venous tributary at
the level of upper thyroid pole is also identified and preserved.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1. The IHMCF has both the minor venous tributary to internal
jugular vein (arrow head) and the communicating vein to external jugular
(arrow).

\textbf{Results}

There were only two cases of partial skin necrosis (1.8\%) and no cases
of complete flap loss. The average dimension of the flaps in or series
is 8 x 3.5 cm. The average length of~hospital stay is 7.6 \selectlanguage{ngerman}± 1.2 days.
Postoperatively, the majority of our patients can communicate on the
phone (understandability of speech score 3 -- 4), with only two cases of
oral tongue cancer receiving a score of 2. All of patients have the
capacity for oral diet (swallowing function score 6 -- 7). One case oral
tongue T4 carcinoma had a score 5 (table 1).

We detected and preserved the minor vein below the superior thyroid in
87 cases (78\%). The communicating vein to external jugular vein was
recorded in 28 cases (25\%). We were able to preserve both veins in 12
cases. In 9 of our cases (8\%) had neither of these veins capable of
preservation.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 2. Patient with right oral tongue reconstruction with IHMCF at 3
months postop.

\textbf{Discussion}

In comparison with the other flaps for oral reconstruction, there are
only a limited number of original articles concerning the IHMCF. This
flap is fairly robust, predominantly hairless, and is adequate option
for modest-sized oral cavity defects. Raising IHMCF does not carry the
same risk of violating the principles of an oncologic dissection as may
can occur with the dissection required for a pedicled submental island
flap\textsuperscript{6}.

Flap failure with the IHMCF is typically a result of venous
insufficiency. Many authors have modified surgical techniques to improve
the survival of the skin paddle\textsuperscript{1,2,5}. The importance
of avoiding partial skin flap necrosis cannot be under estimated.
Postoperative salivary fistulas as a result wound dehiscence can result
in an increase in the length of hospital stay.

With our modified surgical techniques, the survival rate of IHMCF is
100\%. None of patients in our series developed a salivary fistula. The
main disadvantage of our technique is the resultant shortening of the
flap arc rotation for the flap because of a wider vasculature pedicle.
With our technique, our flaps were able to easily reach the floor of
mouth and alveolar ridge defects, however reconstruction of the anterior
tongue at the tip can be challenging.

\textbf{Conclusion}

The IHMCF can be a very reliable alternative for the reconstruction of
specific moderate-sized oral cavity defects. Modifications to the
technique of raising the flap, with attention to more aggressively
preserving venous drainage pathways (potentially at the expense of
limiting the arc of rotation for inset) can improve the viability rate
of the flap.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  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 Mar;29(3):285-291.
\item
  Peng H, Wang SJ, Yang X, Guo H, Liu M. Infrahyoid myocutaneous flap
  for medium-suzed head and neck defects: surgical outome and technique
  modification. Otolaryngology -- Head and Neck Surgery 2013;148:47--53.
\item
  List MA, Ritter-Sterr C, Lansky SB. A Performance Status Scale for
  Head and Neck Cancer Patients\emph{.} Cancer, 1990 Aug 1; 66(3):
  564-569.
\item
  Song XM, Ye JH, Yuan Y, ~Zhang SY,~Jiang HB,~Wu YN. Radial Forearm
  Free Flap for Reconstruction of a Large Defect after Radical Ablation
  of Carcinoma of the Tongue and Floor of the Mouth: Some New
  Modifications. ORL J Otorhinolaryngol Relat Spec. 2010;~Jun;72(2):
  106-112.
\item
  Dolivet G, Gangloff P, Sarini J, Ton Van J, Garron X, Guillemin F,
  Lefebvre JL. Modification of the infra hyoid musculo-cutaneous flap.
  Eur J Surg Oncol 2005;31:294--298
\item
  Archibald S, Gupta M, Thoma A (2015). Oral tongue reconstruction. In:
  Ross D. Farhadieh, Neil W. Bulstrode and Sabrina Cugno editors.
  Plastic and Reconstructive Surgery: Approaches and Techniques. John
  Wiley \& Sons; 2015: 318 -- 329.
\end{enumerate}

\textbf{Hosted file}

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