Original Research—Facial Plastic and Reconstructive Surgery
Otolaryngology–
Infrahyoid Myocutaneous Flap for
Medium-Sized Head and Neck Defects:
Surgical Outcome and Technique
Modification
Hanwei Peng, MD, PhD1*, Steven J. Wang, MD2*,
Xihong Yang, MD1, Haipeng Guo, MD1, and Muyuan Liu, MD1
Sponsorships or competing interests that may be relevant to content are dis-
closed at the end of this article.
Abstract
Objectives. To evaluate the surgical outcomes associated with
infrahyoid myocutaneous flaps used in the reconstruction of
medium-sized defects following head and neck cancer resec-
tion, as well as to discuss a novel technique modification.
Study Design. Case series with chart review.
Setting. University cancer hospital.
Subjects and Methods. A total of 20 patients with oral or hypo-
pharyngeal carcinoma who underwent infrahyoid myocutaneous
flap reconstruction between June 2005 and December 2011
were retrospectively studied. A novel technical modification of
flap harvest, preservation of the cranial portion of the anterior
jugular vein, was attempted in 15 flaps and was successful in 13
flaps. Functional evaluation was performed in all patients 3 to 6
months after the operation or postoperative radiation.
Results. Total flap necrosis, marginal skin paddle necrosis,
and total skin paddle loss were observed in 1, 2, and 1
patient(s), respectively. Pharyngocutaneous fistula without
flap problem occurred in 1 patient. No flap complications
occurred in 13 cases where the cranial portion of the ante-
rior jugular vein was successfully preserved. Functional
results were excellent in 16 patients, good in 3 patients, and
fair in 1 patient.
Conclusion. The infrahyoid myocutaneous flap is a reliable and
convenient technique that can serve as an alternative to free
flaps in the reconstruction of medium-sized defects of the
oral cavity or hypopharynx. Preservation of the cranial por-
tion of the anterior jugular vein is a novel technical modifica-
tion of harvesting this flap, which may result in better venous
return of the skin paddle and reduce skin paddle necrosis.
Keywords
infrahyoid myocutaneous flap, oral cavity, hypopharynx, ante-
rior jugular vein, functional outcome
Head and Neck Surgery
148(1) 47–53
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2013
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599812460211
http://otojournal.org
Received May 16, 2012; revised July 2, 2012; accepted August 14, 2012.
C
urrently, microvascular free flaps (eg, the free radial
forearm flap1 and the anterolateral thigh flap2) are
used worldwide in the reconstruction of defects fol-
lowing resection of head and neck cancers. However, the less
popular infrahyoid myocutaneous flap (IHMCF), after its
introduction by Wang et al3 in 1980, has also proven to be a
good alternative in select cases, particularly among aged
patients and those with severe general comorbidities.4-6
The IHMCF is a pedicled flap nourished by the superior
thyroid vessels through the perforators of the infrahyoid
muscles and innervated by the ansa cervicalis. This method
has been proposed as a reliable, versatile, and convenient
myocutaneous flap suitable for repairing medium-sized
defects in the oral cavity, oropharynx, hypopharynx, or
lower third of the face.7 However, despite its numerous
good qualities, IHMCF has not been widely popularized
because of its poor reliability due to its fragile venous drai-
nage. Technical modifications to improve its venous drai-
nage and improve aesthetic results at the donor site have
been described by Mirghani et al,5 Dolivet et al,8 and
Ricard et al.9 However, the complication rate of this flap
reportedly ranges from 0% to 47%.4,10 Apparently, further
technical improvement in harvesting an IHMCF is necessary
to increase the reliability of this flap. In the current study,
the IHMCF was used as an alternative to a free flap for the
reconstruction of defects in the oral cavity and pharynx fol-
lowing cancer ablative surgery. Surgical outcomes associ-
ated with this series are reported, as well as a novel surgical
1
Cancer Hospital of Shantou University Medical College, Shantou, China
2
University of California, San Francisco, California, USA
*
These authors contributed equally to this article.
Corresponding Author:
Hanwei Peng, MD, PhD, Department of Head and Neck Surgery, Cancer
Hospital of Shantou University Medical College, 7 Raoping Road, Shantou
City, Guangdong Province, Shantou, 515031, China
Email: penghanwei@126.com
48
modification that can potentially improve the venous drai-
nage of the IHMCF.
Materials and Methods
In the Department of Head and Neck Surgery, Cancer
Hospital of Shantou University Medical College, IHMCF is
used in select patients as an alternative to a radial forearm
flap or an anterolateral thigh flap in the reconstruction of
head and neck soft tissue defects resulting from cancer sur-
gery. The IHMCF reconstruction is considered in the fol-
lowing situations: the estimated defect is medium sized (eg,
less than 5.5 cm in width and less than 10 cm in length);
the defect is located in the hypopharynx or the lower part of
the oral cavity, including the tongue, floor of the mouth,
and alveolar ridge; and ipsilateral levels II and III are clini-
cally free from lymph node involvement based on palpation
and computed tomography or magnetic resonance images.
For aged or debilitated patients, IHMCF is the first choice if
the volume and skin area are adequate to cover the esti-
mated defect. Patients who previously underwent a thyroi-
dectomy in the ipsilateral side or radiation to the neck are
considered unsuitable for IHMCF reconstruction. When
both an IHMCF and a free flap are considered for defect
reconstruction, selection of donor site is made by the patient
after being informed of the advantages and disadvantages of
each procedure.
From June 2005 to December 2011, a total of 20 patients
in accordance to the aforementioned criteria underwent
IHMCF reconstruction after cancer ablation and neck dis-
section in a single-stage procedure. The ages of the patients
ranged from 26 to 79 years, with a median age of 57 years.
Overall, 5 were female, and 15 were male. All patients had
squamous cell carcinomas. The primary sites included oral
tongue (n = 11), base of the tongue (n = 2), floor of the
mouth (n = 5), and hypopharynx (n = 2). Disease was
staged according to the sixth edition of the TNM classifica-
tion established by the International Union Against Cancer
(UICC)/American Joint Committee on Cancer (AJCC).11
Seven patients had T3 primaries, and the remaining 13 had
T2. Seven patients in this series had pathologic N1 disease,
2 patients were clinically N0 but had occult nodal metas-
tases (Nos. 1 and 16), and the other N1 patients had clini-
cally evident nodes located in levels other than ipsilateral
level I, II, or III (Nos. 14, 17, 19, and 20) for IHMCF har-
vest with preservation of the cranial portion of anterior
jugular vein or had level I adenopathy (No. 3) and under-
went IHMCF harvest with the traditional method.
All patients underwent a single IHMCF reconstruction
taken from the ipsilateral neck without any other flaps. The
dimensions of the skin paddle ranged from a minimum of 7
cm in length and 4 cm in width to a maximum of 9 cm in
length and 5.5 cm in width; the average size was 7.55 cm
long and 4.80 cm wide.
Neoadjuvant chemotherapy was offered to patients with
T3 primary tumors. Six of 7 patients with T3 tumors
(patient No. 12 declined) received neoadjuvant chemother-
apy consisting of 2 cycles of cisplatin, pingyangmycin, and
Otolaryngology–Head and Neck Surgery 148(1)
fluorouracil. One patient (No. 1) had recurrent carcinoma of
the tongue after a previous surgery, whereas another patient
(No. 15) had undergone an esophagectomy due to esopha-
geal carcinoma 5 years earlier. The other 18 patients had
primary carcinomas. Clinical data for these patients are
shown in Table 1.
Surgical Procedure
All operations were performed under general anesthesia.
Tracheotomy was required in 5 patients. The skin paddle
corresponding to the estimated size of the defect was
designed as an oval shape in a vertical position centered
over the infrahyoid muscle and the cricothyroid region
(Figure 1). The medial limit of the IHMCF was at the mid-
line, the upper limit at the level of the hyoid bone, and the
lower limit at the suprasternal notch; the lateral limit was 4
to 5.5 cm from the midline.
Harvesting of the IHMCF was performed before the neck
dissection. The myocutaneous flap was raised starting from
the midline. Distally, the anterior jugular vein (AJV) and
sternohyoid and sternothyroid muscles were then divided
near their origins. The lateral border of the skin paddle was
then incised and the superior belly of the omohyoid was
divided from the inferior segment. The inferior root of the
ansa cervicalis was identified and preserved during this pro-
cedure. The flap was then raised over an avascular plane of
fascia covering the thyroid gland until the superior pole of
the thyroid gland was reached. At the upper pole of the
thyroid gland, the distal branches of the superior thyroid
artery and veins that supply the thyroid gland were individu-
ally divided and ligated. The common and external carotid
arteries were dissected until the superior thyroid artery
appeared. All of the veins draining the flap in the direction
of the internal jugular vein were preserved in addition to the
superior thyroid vein. Thereafter, the insertion of the ster-
nothyroid and thyrohyoid muscles was subperichondrially
released from the thyroid cartilage following Dolivet et al’s
technique.8 The dissection was continued until the hyoid
bone and the infrahyoid muscles were severed from the
hyoid bone on their posterior aspect. After the pedicle was
released thoroughly (Figure 2), the flap was freely trans-
ferred to cover the defects, either through an intraoral channel
for oral defects (Figure 3) or directly for hypopharyngeal
defects. The secondary defect was closed primarily without
any tension (Figure 4).
After experiencing venous drainage problems due to the
inadequacy of the drainage system parallel to the arterial
pedicle that jeopardized the viability of the skin paddle, we
performed a novel technique modification in harvesting the
IHMCF. We took efforts to dissect and preserve the cranial
portion of the AJV until it joined the facial vein or the
external jugular vein before dividing the musculature from
the hyoid bone (Figure 2).
Data Analysis
Clinical data, including the status of the flap and complica-
tions, were collected by reviewing the medical records. All
Peng et al 49

Table 1. Demographic Data of Patients Who Underwent IHMCF Reconstruction

Tumor Pathologic AJV Primary Nodal Paddle Functional
Case No. Age, y Sex Site Stage Preservation Surgery Surgery Size, cm Complication Result

1 41 F OT T3N2b NA T 1 FOM 1 MM MND 835 — Good

2 56 F OT T2N0 NA T SND 8 3 4.5 — Excellent
3 73 M FOM T2N2b NA FOM 1 MM bilSND 735 TFN 1 fistula Fair
4 54 F OT T2N0 NA T SND 735 Skin paddle Excellent
5 41 M OT T2N0 NA T SND 734 Marginal Excellent
6 60 M FOM T2N0 Yes T bilSND 735 — Excellent
7 59 M OT T2N0 Yes T SND 8 3 4.5 — Excellent
8 67 M FOM T2N0 Yes FOM 1 MM bilSND 8 3 5.5 — Excellent
9 52 M OT T2N0 Yes T SND 735 — Excellent
10 26 M OT T2N0 No T SND 1 MND 734 Marginal Excellent
11 57 M OT T2N0 Yes T SND 735 — Excellent
12 58 F BT T3N0 Yes T 1 BT SND 735 — Excellent
13 79 M BT T3N0 Yes T 1 BT SND 1 MND 835 — Excellent
14 49 M FOM T3N2b Yes FOM 1 MM bilSND 935 — Good
15 56 M FOM T2N0 Yes T MND 735 — Good
16 61 M OT T2N1 Yes T bilSND 835 — Excellent
17 46 M HP T3N2c Yes LP bilMND 935 — Excellent
18 66 M OT T2N0 Yes T SND 735 — Excellent
19 67 M HP T3N2b No LP bilMND 7 3 4.5 Fistula Excellent
20 57 F OT T3N2b Yes T MND 834 — Excellent

Abbreviations: —, none; AJV, anterior jugular vein; bilMND, bilateral modified neck dissection; bilSND, bilateral selective neck dissection (levels I-III); BT, base
of the tongue; F, female; FOM, floor of the mouth; FOM 1 MM, resection of the floor of the mouth plus marginal mandibulectomy; HP, hypopharynx; LP, par-
tial laryngopharyngectomy; M, male; Marginal, marginal skin paddle necrosis; MND, modified neck dissection; OT, oral tongue; NA, not attempted; Skin
Paddle, skin paddle necrosis; SND, selective neck dissection (levels I-III); T, hemiglossectomy; T 1 BT, hemiglossectomy 1 resection of the base of the
tongue; TFN, total flap necrosis.

This study conformed to the World Medical Association

Declaration of Helsinki and the subsequent amendments and
was approved by the Ethical Committee of the Cancer
Hospital of Shantou University Medical College.

Figure 1. The skin was designed into an oval shape in a vertical
position centered over the infrahyoid muscle and the cricothyroid
region.
patients were followed up for at least 3 months, with a
medium follow-up time of 2.5 years. Postoperative func-
tional results regarding diet and speech were assessed at the
outpatient follow-up visit using a score system following
Hell et al.12 A score of 7 points was rated as excellent, 6
and 5 points as good, 4 points as fair, and fewer than 4
points as poor.
Results
The average harvest time for an IHMCF was 30 minutes.
All flaps were transferred to the surgical defects without
tension. The postoperative course was event free in 15
patients. Total flap necrosis occurred in 1 patient (No. 3)
who had carcinoma in the floor of the mouth. The subse-
quent orocutaneous fistula healed without any surgical inter-
vention. Skin paddle problems were encountered in 3
patients. In 2 cases (No. 5 and 10), necrosis was marginal
without any disturbance in wound healing; in the other case
(No. 4), the skin paddle was totally lost, and secondary
epithelialization of the underlying muscles was observed
after removal of the necrotic skin paddle. The skin paddle
loss did not affect the final functional result, however. All
flap necroses were observed at 3 to 5 days after the opera-
tion due to chronic venous congestion.
Preservation of the cranial portion of the AJV was suc-
cessful in 13 of 15 attempted cases (Nos. 6-20). The causes
of failure involved unexpected vessel injury in 1 case (No.
10) and an absence of identifiable communication of the
50
Figure 2. Cranial portion of the anterior jugular vein was pre-
served as part of the pedicle to improve venous drainage of the
skin paddle. The flap was easily made into an innervated flap by the
inclusion of the ansa cervicalis.
Figure 3. The flap was transferred to the oral cavity through an
intraoral channel without twisting or creating tension on the pedi-
cle. Blood supply of the flap was excellent.
Figure 4. The donor site was closed primarily.
cranial portion of the AJV to the facial vein or external
jugular vein in the other case (No. 19). Two of the 7 flaps
with IHMCF harvested in the traditional method suffered
Otolaryngology–Head and Neck Surgery 148(1)
complete loss of the skin paddle. In 13 flaps whose cranial
portion of the AJV was preserved, no skin paddle necrosis
was observed. Flap survival was significantly higher in
these 13 patients than in the other 7 patients (P = .007, x2
test).
Orocutaneous fistula due to flap necrosis occurred in
patient No. 3 as was mentioned before. One patient (No. 19)
developed a pharyngocutaneous fistula without any flap
problems as verified by laryngoscopy, and the fistula healed
in 14 days without surgical intervention.
All patients were discharged with complete restoration
of oral intake (mean time, 10 days; range, 6-15 days),
except patient No. 3, who needed a nasogastric feeding
tube for 2 months until wound granulation was achieved.
Tracheotomy closure was possible in all 5 patients at 5 to
8 days postoperatively.
No flap complications occurred in the 6 patients who
underwent neoadjuvant chemotherapy. Postoperative radia-
tion was performed in 8 patients with T3 and/or N2 dis-
eases. For patient No. 3, postoperative radiation could not
be given because of total flap necrosis and subsequent pro-
longed orocutaneous fistula. Three patients had tumor recur-
rence during follow-up. One patient (No. 1) died from both
local and regional recurrence 15 months after the operation.
One patient (No. 15) developed recurrence of his former
cancer 24 months postoperatively and died after palliative
chemotherapy. One patient (No. 3) developed a secondary
hypopharyngeal squamous cell carcinoma and survived after
a total laryngectomy. The remaining 17 patients survived
without tumor recurrence as of last follow-up.
Functional evaluation was performed in all patients at 3
to 6 months after the operation or postoperative radiation
therapy, if treated. Three patients (Nos. 1, 14, and 15)
showed good functional results. Patient No. 3 had a fair
functional result. The other 16 patients showed excellent
diet and speech function at evaluation.
Discussion
Anatomically, the venous return of the infrahyoid region is
primarily achieved by the AJV, whose variable and rudi-
mentary valves are located at the caudal extremity and, sec-
ondarily, by the superior thyroid veins.13,14 However, both
the distal and proximal segments of the AJV and its attri-
butes are severed in harvesting a traditional IHMCF,7
whereas the superior thyroid vein is maintained as the main
venous drainage. In our experience, the cranial portion of
the AJV sometimes communicated with the internal jugular
vein (via the facial vein) or the external jugular vein
through one or more attributes beneath the platysma; as
such, it can be preserved as a portion of the pedicle to pro-
vide sufficient venous drainage of the flap, particularly its
skin paddle. After encountering venous drainage problems
in 3 of the first 5 flaps in our series, we modified our har-
vest technique and attempted to dissect and preserve the cra-
nial portion of the AJV. Preservation of the cranial portion
of the AJV was successful in all but 2 of the remaining 15
cases. Flap survival was significantly higher in cases where
Peng et al
Figure 5. One month after the operation, the reconstructed
tongue was well shaped without scarring and atrophy due to inclu-
sion of the ansa cervicalis in the pedicle.
the cranial portion of the AJV was preserved compared with
those where it was not, suggesting that the preservation of
the cranial portion of the AJV may improve venous drai-
nage of the IHMCF possibly by retrograde venous flow of
the AJV through attributes to the facial vein and external
jugular vein. However, further anatomic studies are neces-
sary to identify whether there are any rudimentary valves
located at the cranial portion of the AJV and how they
affect venous drainage of the IHMCF.
In selecting an appropriate reconstructive procedure, several
factors should be taken into account: volume and size of the
defect, tissue compatibility, procedure convenience, reliability
of the flap, donor site morbidities, and general status of the
patient. The most widespread method currently employed for
the reconstruction of extensive defects after resection of head
and neck cancers is microvascular free flap transfer because of
its versatility and reliability.15 However, microvascular free
flap reconstruction is time-consuming and technique sensitive.
Not all patients, particularly those who are aged and with poor
general status, are suitable for a free flap reconstruction.6 The
pectoralis major flap is the most widely used pedicled flap in
head and neck reconstruction.15 However, the pectoralis flap
may be too bulky for many small to moderately sized defects
and can be associated with significant donor site morbidity. In
select cases, the less popular IHMCF deserves consideration.
The pectoralis flap remains the preferred technique, rather than
the IHMCF, for patients not suitable for free flap reconstruc-
tion because of vessel-depleted necks or with a history of prior
radiation to the neck.
The IHMCF has several advantages: (1) This flap can be
harvested during neck dissection by one surgical team, and
the donor site can undergo primary closure without addi-
tional incision. (2) This flap can easily be made into an
innervated flap by means of the ansa cervicalis for preven-
tion of scarring and atrophy of the reconstructed tongue
(Figure 5). All IHMCFs in this series had successful pre-
servation of the ansa cervicalis nerve. The functional result
51
was excellent in 10 of 11 patients who underwent hemiglos-
sectomy and innervated IHMCF reconstruction in this
series. (3) The donor site is close to the defect, allowing the
flap to be easily transferred without twisting or tension of
the pedicle. (4) There is no need for postural fixation after
the operation, which was better tolerated by aged and debili-
tated patients. (5) The flap is thin and pliable, making it
suitable for anterior floor of the mouth reconstruction.
However, limited bulk and skin islands restrict the use of
the IHMCF in large defects. Similar to other reports, IHMCFs
in our series were used in the reconstruction of small or mod-
erate defects. Furthermore, venous drainage of the flap can be
insufficient, resulting in necrosis of the flap or its skin paddle.
For this reason, many surgeons would choose a more complex
but reliable free flap rather than a simple but less reliable
IHMCF for small or moderate defects. Table 2 summarizes
representative reports of IHMCF flaps in the English litera-
ture.4-8,10,12,16-22 The reported complication rate of the flap
ranged from 0% to 47%.4,10 Most authors acknowledged that
the main problems were related to poor reliability of the skin
paddle due to insufficient venous drainage. To improve venous
drainage of the IHMCF, Dolivet and colleagues8 performed a
modification of the traditional surgical technique by detaching
the infrahyoid muscles from the hyoid bone in a subperiosteal
plane to preserve microvenous drainage toward the digastric
triangle network. These authors also changed the cervical inci-
sion from an inverted T to an inverted Z, which led to a
higher success rate of the flap and better aesthetic results. This
modification was followed by a subsequent series, which
showed increased flap survival.5,6 We followed Dolivet et al’s
procedure and also modified our harvest technique in 13
patients to preserve the cranial portion of the AJV in an
attempt to further improve venous drainage of the flap.
A potential disadvantage of the IHMCF is that its vascu-
lar pedicle is in the vicinity of lymph nodes that may con-
tain metastatic cancer, such as those associated with
primary tumors of the oral cavity and pharynx. Preservation
of the cranial portion of the AJV could further increase the
risk of undertreating the neck by extending the vascular
pedicle into level 1 of the neck. However, our technique,
which we describe in Materials and Methods and illustrate
in Figure 2, meticulously skeletonizes the vascular pedicle
of the flap, permitting thorough dissection of the lymph
nodes in ipsilateral level I, II, and III. Thus, we believe the
risk of undertreating the neck in these regions when there
are no clinically involved nodes is minimized. Nonetheless,
to avoid risk of compromising oncologic control in the
neck, we did not perform the IHMCF using our novel tech-
nique in any patients with clinically involved lymph nodes
in ipsilateral levels I, II, or III. Only 1 patient in our series
developed a neck failure, which was in contralateral level
IV. Thus, in this limited series, our results support the
notion that this technique modification does not increase
risk of neck recurrence. However, further study with larger
samples and longer follow-up are necessary to verify the
oncologic safety of IHMCF reconstruction for oral cavity
and hypopharynx cancers.
52 Otolaryngology–Head and Neck Surgery 148(1)

Table 2. Representative Reports on Infrahyoid Myocutaneous Flap Reconstruction

Complications, No. (%)

Total Total Skin Partial Skin

Year Lead Author Defects Case No. Flap Necrosis Paddle Necrosis Paddle Necrosis Others

1986 Wang7 Oral cavity, parotid 112 0 0 11 (9.8) 0

1991 Rojananin16 Oral cavity, lower lip, parotid, skin 22 0 2 (9.1) 3 (13.6) 2 (9.1)
1993 Magrin10 Oral cavity, oropharynx, hypopharynx 15 3 (20.0) 4 (26.7)
1997 Remmert17 Tongue 11 0 0 1 (9.1) 0
1997 Hell12 Oral cavity, pharyngeal wall 23 1 (4.3) 0 0 0
1998 Lockhart18 Oral cavity 21 0 4 (19.0) 4 (19.0) 0
2001 Zhao19 Oral cavity 53 1 (1.9) 1 (1.9) 2 (3.8) 0
2005 Dolivet8 Oral cavity, pharynx, larynx 61 1 (1.6) 6 (9.8) 0 3
91 1 (1.1) 2 (2.2) 0 0
2006 Gangloff20 Soft palate 23 0 0 2 (8.7) 2
2006 Tincani21 Oral cavity 14 0 0 4 (28.6) 1 (7.1)
2007 Seidl22 Pharyngeal fistula 6 0 0 0 0
2009 Minni4 Tongue 32 0 0 0 0
2011 Mirghani5 Oral cavity, oropharynx 32 0 2 (6.3) 2 (6.3) 1 (3.1)
2012 Deganello6 Oral cavity, oropharynx 18 0 0 1 (5.6) 0
Total 534 7 (1.3) 21 (3.9) 30 (5.6) 9 (1.7)

Conclusion 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002;109:

The IHMCF is a reliable and convenient flap that can serve
as a good alternative to free flaps in the reconstruction of
small- to medium-sized defects of the oral cavity or hypo-
pharynx following cancer ablation. Preservation of the cra-
nial portion of the AJV in harvesting this flap may result in
better venous return of the skin paddle and reduce skin
paddle necrosis. However, this is a small retrospective study
from a single institution. Further prospective research with
larger samples and anatomic studies on the AJV are needed
to verify these conclusions.
Author Contributions
Hanwei Peng, concept, design, data collector, writer, final
approval; Steven J. Wang, concept, design, data analysis, reviser
for important content, final approval; Xihong Yang, data analysis,
drafting, final approval; Haipeng Guo, data analysis, final
approval; Muyuan Liu, data collector, final approval.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: The Science and Technology Planning Project of
Guangdong Province, China (Grant No. 2008B030301244)
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