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A Novel Modification of Infrahyoid Myocutaneous Flap for Reconstruction

of Oral Cavity Defects

Mehrdad Jafari, Reza Hekmati, Ebrahim Karimi, Farrokh Heidari,

Sepideh Alvandi, Kayvan Aghazadeh, Mohammadreza Firouzifar,
Reza Erfanian, Saeed Sohrabpour

PII: S0266-4356(21)00194-7
DOI: https://doi.org/10.1016/j.bjoms.2021.05.008
Reference: YBJOM 6484

To appear in: British Journal of Oral & Maxillofacial Surgery

Accepted Date: 9 May 2021

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© 2020 Published by Elsevier.

A Novel Modification of Infrahyoid Myocutaneous Flap for Reconstruction of Oral Cavity

Defects

Short running title: Modified IHF for tongue reconstruction

Mehrdad Jafari1, Reza Hekmati1, Ebrahim Karimi1, Farrokh Heidari1, Sepideh Alvandi1, Kayvan

Aghazadeh1, Mohammadreza Firouzifar1, Reza Erfanian1, Saeed Sohrabpour 1*

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Otorhinolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran

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MJ: MD, mehrdadj82@yahoo.com

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RH: MD, dr_rezahekmati@yahoo.com

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EK: MD, karimient@gmail.com, ORCID: 0000-0001-5356-1440

FH: MD-MPH, farrokh.heidari@yahoo.com, ORCID: 0000-0002-6904-5691

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SA: MD, Sepideh_alvandi@yahoo.com
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KA: MD, aghazadeh@sina.tums.ac.ir

MF: MD, mrfirouzifar@sina.tums.ac.ir

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RE: MD, r_erfanian@sina.tums.ac.ir ORCID: 0000-0001-8147-5320

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SS: MD, sohrabpour1364@gmail.com

*Correspondence: Saeed Sohrabpour, MD, Assistant Professor of Ear, Nose and Throat; Otorhinolaryngology
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Research Center, Amir Alam Hospital, North Sadi Ave, Tehran, Iran. Postal Code: 1145765111 Email:

r_erfanian@sina.tums.ac.ir Tel/fax: +98 21 5565 8500

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Abstract

Purpose: This study is intended to describe the technique used and the results obtained with the modification of the

infrahyoid flap (IHF) for the reconstruction of oral tongue defects following resection for advanced squamous cell

carcinoma (SCC).

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Methods: Patients with oral tongue defects following ablation surgery for T2 to T4a SCC were reconstructed using

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the modified infrahyoid flap. Demographic data, tumour characteristics, and the complications were evaluated for

each patient.

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Results: We observed no complications regarding the healing process of donor site and success of the flap in 49 (of

55 patients) patients. None of the flaps had massive oedema or venous congestion in the post-operative period. Six
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patients experienced flap-related complications of which 5 had partial skin paddle necrosis but eventually, their flaps

recovered and reepithelialised without any further intervention. However, total flap necrosis was seen in one patient
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in whom pectoralis major flap was used for the defect reconstruction following a revision surgery. History of

previous neck radiotherapy (p-value = 0.003), and tumours stage (p-value = 0.017), and metastasis to cervical lymph
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node (p-value = 0.004) were associated with higher prevalence of partial or total flap necrosis.

Conclusion: The modified infrahyoid flap is a reliable, quick, and simple procedure with reasonable cost that makes

it a valuable option for the reconstruction of the oropharynx and oral cavity with minimal donor site morbidity and
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good outcomes. It seems the modified IHF is a valid surgical procedure that may be considered in selected
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oncological patients undergoing reconstruction of oral tongue defects with less complication.

Keywords: Modified infrahyoid flap, Reconstruction flap, Oral cavity defects, Oropharyngeal defects, Tongue

cancer

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Introduction

Nowadays in the era of microvascular free, diverse surgical modalities for reconstruction of head and neck defects

are available and applicable1. Therefore, the prominent targets of the different types of defect reconstruction

techniques are minimal morbidity and acceptable functional and cosmetic outcomes 2,3.

In recent decades the advancement of microsurgical techniques and equipment has led to the development of

microvascular free flaps surgeries and their results 4,5. Despite this evolution, a new reconstructive technique for the

small and medium-sized oral cavity defects based on an infrahyoid fasciomyocutaneous pedicled flap has been

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documented in the literature6,7. The infrahyoid flap (IHF) was first reported by Wang et al in 1986 for intraoral

defect reconstruction after the surgical treatment of tongue cancer 8. IHF is a reliable, expeditious, and simple

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procedure with reasonable cost that makes it a valuable option for reconstruction9.

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We observed several cases of post-operative erative flap congestion due to insufficient venous return which usually

led to partial or total failure of the flap with consequent salivary fistulas to the neck spaces and predisposing the
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patient to further complications. In this study we present our experience of performing a novel modification to the

traditional IHF technique for reconstruction after ablation surgery for tongue cancer to overcome the
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abovementioned congestion.

Materials and Methods

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In this study we performed modified IHF for the defect reconstruction after excision of primary oral tongue

squamous cell carcinoma (SCC). 29 cases were associated with ipsilateral and 13 cases associated with bilateral ND
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alongside resection. The study protocol was approved by the local ethics review committee of Tehran University of

Medical Sciences (IR.TUMS.MEDICINE.REC.1398.041) and written consent was obtained from all patients.
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Patients with oral tongue SCC with a defect size of minimum 3 x 5 to maximum 4 x 7 centimetres (medium size

defect) without major involvement of base of tongue were enrolled for reconstruction by IHF. Patients having prior

history of any surgery in the ipsilateral neck and/or pathologic lymph nodes with involvement of internal jugular

vein were excluded. There were no exclusion criteria based on age, gender, past medical history and previous

radiotherapy.

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From September 2016 to 2019 (3 years), 55 patients were enrolled in the study. All the flaps were harvested, using

the same surgical technique in a single stage procedure by two of the authors (SS & MJ). Demographic data, past

medical history, habit history, serum haemoglobin level, and history of neck radiotherapy and tumour characteristics

(according to the 7th edition of the TNM classification established in 2010 by the American Joint Committee on

Cancer)10 were collected for each patient. The statistical package IBM SPSS (version 24.0 Armonk, NY: IBM Corp)

was used for analysis. T-test and chi-square test or fisher exact test were used to compare flap conditioning in terms

of continuous and categorical variables, respectively. P values of <0.05 were considered to indicate statistical

significance.

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Technique and Modification

After excision of the tumour and confirmation of free margins by frozen section study, dimensions of the defect were

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measured. The IHF was designed at the same neck side as the tumour resection. The medial limit of the flap was

situated at the midline and the corresponding lateral extension extended 3 to 4 cm from the midline. Its upper margin

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fell on the hyoid bone and lower margin was at the level of the suprasternal notch (figure 1).

A skin incision was made and the sternohyoid and sternothyroid muscles just above the suprasternal notch and the
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omohyoid muscle at the intermediate tendon were transected. At this stage we modified the routine technique and
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instead of raising the flap along the avascular plane of the thyroid gland capsule we included the superior half of the

ipsilateral thyroid gland, its capsule and its superior pole above the level of the cricoid cartilage in the flap (figure 2

and 3). The distal branches of the superior thyroid pedicle were clipped and Ansa Cervicalis was included in the flap
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if possible. The infrahyoid muscles (including the thyrohyoid muscle) were completely divided from the thyroid

cartilage and the body of the hyoid bone. Meticulous dissection was done to preserve the superior laryngeal nerve. As the

flap became freely mobile with pedicle as its axis, the skin-muscle-thyroid complex was tunnelled through the floor of mouth
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after partially cutting mylohyoid and sutured to the outlines of the defect (figure 4).

We provide video of our modified technique of harvesting Infrahyoid Myocutaneous Flap. It’s available at the
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following link: https://youtu.be/qAiZObY4Kv0.

Results

In our study modified IHF was used for reconstruction of oral tongue after ablation surgery. Of the 55 patients, 34

were female. The mean age was 55.58 (34-73) years. Mean follow-up time was 19.8 months. Thirty four (61.8 %)

patients had history of smoking and 10 patients had history of prior head and neck radiotherapy. Eighteen patients

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had an underlying disease other than cancer (diabetes mellitus in 8, high blood pressure in 6, and ischemic heart

disease in 4 patients). Mean Haemoglobin level was 13.67 (10.9-15.3) grams per decilitre.

We observed no complication regarding the healing of the donor site and success of the flap in 49 patients. None of

the flaps had massive oedema or venous congestion in the post-operative period. Six patients experienced flap-

related complications of which 5 had partial skin paddle necrosis but eventually, all of these flaps recovered and

reepithelialised without any further intervention. However, total flap necrosis was seen in one patient in whom

pectoralis major flap was used for the defect reconstruction following a revision surgery. The patient was a 57-year-

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old male smoker with stage 3 oral tongue cancer with N1 metastatic cervical lymphadenopathy. The demographic

data in terms of flap condition is depicted in table 1.

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In this study, history of previous neck radiotherapy (p-value = 0.003), and tumours stage (p-value = 0.017), and

metastasis to cervical lymph node (p-value = 0.004) were associated with higher prevalence of partial or total flap

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necrosis. However, history smoking had no statically significant effect on such complications. The pathologic data

in terms of flap condition is depicted in table 2.

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No other complications such as donor site wound dehiscence, infection or hematoma were noticed. There were no
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changes in thyroid function or serum calcium levels in the post-operative period.

Discussion
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IHF is a pedicle myocutaneous flap vascularized by the superior thyroid artery and its branches through the

perforating vessels of the infrahyoid muscles. It is sensitively innervated by the deep branches of Ansa Cervicalis7.
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The flap venous return systems are divided into the superficial and deep veins. The skin paddle is drained by the

superficial venous system and infrahyoid muscles are drained by the superior thyroid vein11. The venous drainage
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could be variable and insufficient and may cause flap-related complications. Accordingly, preserving the venous

return systems as much as possible while harvesting the flap is needed12. In this study we tested a novel

modification regarding inclusion of superior half of ipsilateral thyroid gland and its superior pole in IHF. This

modification in harvesting technique leads to preservation of tiny blood vessels between the anterior thyroid capsule

and infrahyoid muscles and less manipulation of the vascular pedicle.

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In previous studies, various technical modifications have been introduced by Dolivet et al9, Ricard et al13 and

Mirghani et al14 in order to increase the flap venous drainage and to reduce the associated complications. In a

literature review study by Infante Cossio et al, in 2016 from 19 studies and 592 cases, 32 (5.4 %) IHFs had total

necrosis. In some studies of this review, history of neck radiotherapy had been considered as a contraindication for

reconstruction by IHF15. Our results show that only 1.8% (1 from 55) cases had the complete flap necrosis. In most

recent studies by Islek et al in Turkey16, Varma et al6 and Venkatasubramaniyan et al in India3, overall from 37

IHFs, 7 (19 %) cases experienced flap related complications (partial or total flap necrosis).

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Other studies did not discuss parameters that could interfere with IHF success rate. However, in our study patients

with flap-related complications had history of previous neck radiotherapy, higher tumour stage and more advanced

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metastasis to the cervical lymph nodes. We observed no evidence of recurrent disease occurring within the

transposed flap tissue after at least one year follow up. Also flap complications were not associated with any kind of

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neck dissection done in conjunction with the flap.

There is a limitation to this study. A question may come to mind why the authors did not compare their results with
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the previous routine techniques of flap harvest in a head-to-head study. Since there was a significant improvement in

flap condition and survival after the application of the new technique the institution ethics committee did not
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approve a randomized controlled trial which would divide some of the patients to the previous less successful

procedure. Therefore, we hope that the results of this study would be used in future meta-analyses. We suggest that
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future researches be designed to compare the use of this new IHF for other subsites in head and neck.

Our study shows that the patients with medium size defects without major involvement of the base of tongue and
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having no prior history of any surgery in the ipsilateral neck, cervical radiotherapy and lymph nodes involvement,

the option of reconstruction with an IHF is a viable one.

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Conclusion

The infrahyoid flap is a reliable, quick, and simple procedure with a relatively reasonable cost that makes it a

valuable option for the reconstruction of the oropharynx and oral cavity with minimal donor site morbidity and good

outcomes. It seems the modified IHF is a valid surgical procedure that may be considered in selected oncological

patients undergoing reconstruction of oral tongue defects with a lower complication rate.

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Author contributions

MJ, SS, and EK: Conceptualization, Methodology, Surgery. RH, FH, and SA: Data gathering, Writing- Original

draft preparation. KA, MF: Visualization, Investigation. SS, MJ, RE: Writing- Reviewing and Editing,

Ethics statement/confirmation of patient permission

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The study protocol was approved by the local ethics review committee of Tehran University of Medical Sciences

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(IR.TUMS.MEDICINE.REC.1398.041). Written consent was obtained from all patients.

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Conflict of Interest
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The authors declare no conflict of interest.

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References

1. Cohan DM, Popat S, Kaplan SE, Rigual N, Loree T, Hicks Jr WL. Oropharyngeal cancer: current

understanding and management. Current opinion in otolaryngology & head and neck surgery. 2009;17(2):88-94.

2. 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(3):285-91.

3. Venkatasubramaniyan M, Rajappa SK, Agarwal M, Chopra A, Singh A, Paul R. Infrahyoid flap revisited–

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A head and neck surgical perspective in the Indian setting. Indian Journal of Cancer. 2020;57(1):62.

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4. Sabri A. Oropharyngeal reconstruction: current state of the art. Current opinion in otolaryngology & head

and neck surgery. 2003;11(4):251-4.

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5. Moncrieff M, Sandilla J, Clark J, Clifford A, Shannon K, Gao K, et al. Outcomes of primary surgical

treatment of T1 and T2 carcinomas of the oropharynx. The Laryngoscope. 2009;119(2):307-11.

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6. Varma H, Yeshwanth R, Prakash B, Mohammed Z. Infrahyoid Myofasciocutaneous Flap for

Reconstruction of Tongue Defects: Our Experience and Perspective. Indian journal of surgical oncology.
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2019;10(3):472-5.

7. Yan D, Zhang J, Min X. Modified Infrahyoid Myocutaneous Flap for Laryngopharyngeal Reconstruction.

Ear, Nose & Throat Journal. 2020;99(1):15-21.

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8. Wang H, Shen J, Ma D, Wang J, Tian A. The infrahyoid myocutaneous flap for reconstruction after

resection of head and neck cancer. Cancer. 1986;57(3):663-8.

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9. Dolivet G, Gangloff P, Sarini J, Van JT, Garron X, Guillemin F, et al. Modification of the infra hyoid

musculo-cutaneous flap. European Journal of Surgical Oncology (EJSO). 2005;31(3):294-8.

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10. Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer

staging manual and the future of TNM. Annals of surgical oncology. 2010;17(6):1471-4.

11. Verbruggen C, Majoufre C, Derosamel L, Dubreuil P-A, Vallade G, Mage C, et al. The horizontal

myocutaneous infrahyoid island flap for soft-tissue head and oral reconstruction: Step-by-step video description.

Plastic and Reconstructive Surgery. 2017;140(4):598e-600e.

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12. Deganello A, Leemans CR. The infrahyoid flap: A comprehensive review of an often overlooked

reconstructive method. Oral oncology. 2014;50(8):704-10.

13. Ricard A, Laurentjoye M, Siberchicot F, Majoufre-Lefebvre C. The horizontal infrahyoid

musculocutaneous flap in head and neck reconstruction. British Journal of Oral and Maxillofacial Surgery.

2009;47(1):76-7.

14. Mirghani H, Meyer G, Hans S, Dolivet G, Périé S, Brasnu D, et al. The musculocutaneous infrahyoid flap:

surgical key points. European Archives of Oto-Rhino-Laryngology. 2012;269(4):1213-7.

15. Infante‑ Cossio P, Gonzalez‑ Cardero E, Lopez‑ Martos R, Nuñez‑ Vera V, Olmos‑ Juarez E,

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Ruiz‑ Moya A, et al. Infrahyoid flap in oropharyngeal reconstruction following carcinoma resection: A study of 6

patients and literature review. Oncology letters. 2016;11(5):3493-500.

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16. 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. Turkish archives of otorhinolaryngology.

2018;56(2):85.

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Figure Legends

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Figure 1: Flap design markings according to defect size for modified infrahyoid myocutaneous flap.
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Figure 2: Elevation of superior half of ipsilateral thyroid lobe along with the flap.
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Figure 3: Final geometry of the flap pedicle before inset.

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Figure 4: Transfer of the flap into the oral cavity.

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Table 1: The demographic data regarding the flap outcome

Partial Total
Healthy flap p-value totally
necrosis necrosis

54.59
Age (year) (SD) 61.60 (6.65) 57.00 (0) 0.388 55.58 (10.26)
(10.51)

Male n (%) 19 (34.5 %) 1 (1.8 %) 1 (1.8 %) 21 (38.2 %)

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gender 0.312
Female n (%) 30 (54.5 %) 4 (7.3 %) 0 (0.0 %) 34 (61.8 %)

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Positive n (%) 15 (27.2 %) 3 (5.5 %) 1 (1.8 %) 19 (34.5 %)
Past medical
Negative n 0.321
history 34 (61.8 %) 2 (3.7 %) 0 (0.0 %) 36 (65.5 %)
(%)

Positive n (%) 28 (50.9 %) 5 (9.1 %)

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smoking Negative n 0.125
21 (38.2 %) 0 (0.0 %) 0 (0.0 %) 21 (38.2 %)
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(%)

Hemoglobin (gr/DLit) (SD) 13.52 (1.03) 13.94 (0.98) 12.7 (0) 0.498 13.67 (1.26)

History of neck Positive 7 (12.7 %) 3 (5.5 %) 0 (0.0 %) 10 (18.2 %)

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0.003
radiotherapy negative 42 (76.3 %) 2 (3.7 %) 1 (1.8 %) 45 (81.8 %)

Healthy Partial Total

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p-value totally
flap necrosis necrosis
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2 n (%) 6 (10.9) 0 (0.0 %) 0 (0.0 %) 6 (10.9 %)

Tumor
3 n (%) 34 (61.8 %) 1 (1.8 %) 0 (0.0 %) 0.017 35 (63.6 %)
staging
4a n (%) 9 (16.4 %) 4 (7.3 %) 1 (1.8 %) 14 (25.5 %)

N0 n (%) 24 (43.6 %) 0 (0.0 %) 0 (0.0 %) 0.004 24 (43.6 %)

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 metastasis N1 n (%) 24 (43.6 %) 3 (5.5 %) 1 (1.8 %) 28 (50.9 %)

neck lymph
N2 n (%) 1 (1.8 %) 2 (3.7 %) 0 (0.0 %) 3 (5.5 %)
nodes

Table 2: Primary tumor pathologic data regarding flap outcome

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