The anatomical features and surgical usage of the submental artery

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Surg Radiol Anat (2005) 27: 201–205
DOI 10.1007/s00276-005-0317-8
O R I GI N A L A R T IC L E
Yelda Atamaz Pinar Æ Figen Govsa Æ Okan Bilge
The anatomical features and surgical usage of the submental artery
Received: 8 March 2004 / Accepted: 7 September 2004 / Published online: 8 July 2005
Springer-Verlag 2005
Abstract The skin characteristics make the submental
region an available flap site for facial and intraoral
reconstructions. For this reason, the anatomy of the
submental region and the submental artery (SA) has
gained in importance recently. The SA branches out
from the facial artery at the level of superior edge of the
submandibular gland. The SA runs anteromedially below the mandible and superficial to the mylohyoid
muscle. It gives off some perforating branches to the
overlying platysma and underlying mylohyoid muscle
during its course. The terminal branches continue toward the midline, crossing the anterior belly of digastric
muscle either superficially or deep, and end at the mental
region in general. Some perforating arteries from the
terminal branches supply the anterior belly of digastric
muscle. This study aimed to describe the anatomical
features of the SA and its branches to help in the
preparation of submental arterial flaps.
Keywords Submental artery Æ Flap Æ Submental
region Æ Anatomy
Introduction
Reconstruction of complex facial defects is frequently
challenging. The flap should be thin and pliable with
good facial color match. The skin of the submental area
has these important characteristics. Recently and independently, the submental island flap was developed and
applied clinically in France [2, 13]. Martin et al.
described the submental island flap supplied by the
submental vessels and presented clinical applications.
The flap has been used for the reconstruction of facial
defects by many surgeons [10, 13, 19].
The submental artery (SA) is the largest branch of the
facial artery (FA) in the neck. The FA climbs superiorly
leaning against the posterior face of the submandibular
gland and gives off the SA behind or at the superior edge
of the gland [19]. The SA runs anteromedially below the
mandible and then runs superficial to the mylohyoid
muscle to reach the chin. It gives off some branches to
the submandibular gland and also perforating branches
to the platysma and mylohyoid muscles [23]. One of the
perforating branches of the mylohyoid muscle is larger
than the others and it runs deep. This artery connects
with the arterial circulation of the tongue and the floor
of the mouth [15]. The terminal branches of the SA
continue toward the midline and give off some perforating branches while crossing the anterior belly of the
digastric muscle either superficially or deep [6]. The
terminal branches curve to the chin and some of them
join the arterial circulation of the lips via labiomental
arteries or the inferior labial artery [20]. The submental
region, including the digastric and submental triangles,
is an ideal donor site for reconstruction of facial and
intraoral defects. The skin of this region is thin and has a
good facial color match. On the other hand, submentalbased flaps can have a long vascular pedicle to use in
nasal and forehead reconstructions if the FA is included
[5, 6, 7, 10, 11, 13, 14, 15].
Materials and methods
Y. Atamaz Pinar Æ F. Govsa Æ O. Bilge
Department of Anatomy, Faculty of Medicine,
Ege University, Izmır, Turkey
F. Govsa (&)
Ege Üniversitesi Tıp Fakültesi Anatomi Anabilim Dalı,
TR-35100 Izmir, Turkey
E-mail: [email protected]
Tel.: +90-232-3881098
Fax: +90-232-3393546
The main aim of this study was to determine the anatomical features of the SA and blood supply to the
submental region. For these purposes, we have discussed
our anatomical findings in the surgical usage of the SA.
We have therefore conducted a complementary anatomical study on the vascular pattern to improve the
reliability of the study.
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Twenty-five male human cadavers (between 40 and
60 years of age) were dissected bilaterally in the laboratory of the Anatomy Department of the Medical
Faculty of Ege University. The cadavers were fixed in
10% formalin solution.
After the skin dissection of the carotid triangle, the
platysma muscle was released from the edge of the
mandible with careful preservation of the FA and vein.
The platysma was moved medially preserving its perforating arteries. The submandibular gland was pulled
forward and the FA was exposed. Red-colored liquid
latex was injected into the SA at the branching point.
After the injection, the perforating branches and the
termination of the SA were defined. While determining
these findings, we took the studies of Martin et al. [13,
14], Faltaous and Yetman [6], Piehslinger et al. [18],
Bavitz et al. [1] and Curran et al. [3] into consideration.
The caliber of the SA at the bifurcation and the largest
perforating branch to the mylohyoid muscle were measured with a digital caliper (0.02 mm Shock&Proof).
Results
The submandibular and submental triangles were dissected bilaterally in the 25 cadavers and in total there
were 50 SAs. The external diameter of the SA varied
between 0.82 and 2.80 mm (min—max) with a mean of
1.80±0.46 mm on the left side, and between 1.02 and
2.72 mm (min—max) with a mean of 1.88±0.48 mm on
the right side.
It was observed that the SA supplied the overlying
platysma, the skin and the underlying mylohyoid muscle
with its thin perforating branches. The SA gave off one
to four anterior perforators that pierced the platysma.
The platysma was moved, so that the SA was totally
exposed. It was seen that it gave off four to six thin
branches to the submandibular gland and two or three
thin branches to the submandibular lymph nodes. All
these structures were moved inferolaterally and the trace
of SA over the mylohyoid muscle was observed. Although some terminal branches near the midline entered
the anterior belly of the digastric muscle, some branches
crossed the midline and anastomosed with the terminal
branches of the opposite SA. In 10 samples (20%), one
large terminal branch passed to the skin and anastomosed with the labiomental arteries or inferior labial
arteries to join the labial arterial circulation. Only in one
sample (2%), on the right side, did the SA curve posterior and inferior to the hyoid bone beneath the anterior belly of the digastric muscle and anastomose with a
branch of the superior thyroid artery.
The terminal branches of SA ran superficial to the
anterior belly of the digastric muscle in 44% of cases (11
left, 11 right), while in the remaining 56% (14 left, 14
right) they ran deep (Figs. 1, 2, 3).
A large branch of the SA perforating the mylohyoid
muscle was found in 30 of the 50 dissections (60%). In
the submandibular triangle, the SA gave off a large
Fig. 1 The terminal branch of the submental artery (SA, arrow)
curves to the chin and anastomoses with the labiomental or inferior
labial arteries to join the labial arterial circulation. md, digastric
muscle; vl, vertical labiomental artery; af, facial artery
perforating branch which coursed deep to the floor of
the mouth and anastomosed with the sublingual vessels.
In all the cases, this large perforating artery originated
from the proximal part of the SA, near the posterior
belly of the digastric muscle or its tendon. The diameter
of this large perforating artery varied between 0.50 and
Fig. 2 A large branch of the SA (arrow) perforating the mylohyoid
muscle. The terminal branches of the SA run superficial to the
anterior belly of the digastric muscle. mm, mylohyoid muscle; md,
digastric muscle; as, submental artery
203
Fig. 3 The terminal branches of the SA (arrow) run superficial to
the anterior belly of the digastric muscle. md, digastric muscle; bm,
basis mandibulae; af, facial artery
2.32 mm (min—max) with a mean of 1.25±0.58 mm on
the left, and between 0.42 and 2.42 mm (min—max)
with a mean of 1.48±0.65 mm on the right side. The SA
became thinner after the branching of the large perforating artery. In the other 30 samples, a few thin perforating branches (looking like a dry tree) were
observed, not just one main perforating branch (Fig. 4).
Discussion
The ideal flaps for resurfacing should be thin and reliable and have a good color match [13]. The flap should
also be able to be dissected easily and have a large arc of
rotation with minimal donor site morbidity [2, 8, 15].
Arc of rotation allows for reconstruction of anterior and
lateral floor of mouth, buccal mucosa, retromolar trigon, glabellar region, and skin of the lower third of the
cheek and parotid region [3, 10, 11, 13, 16, 17]. The
submental area has many of these characteristics and
has been used by several authors for facial and intraoral
reconstructions. It is suitable for various reconstructive
problems of head and neck because the flap has a long
vascular pedicle once it is fully mobilized (Fig. 5) [4, 10,
19, 20, 22]. It would make an excellent flap for both
Fig. 4 The terminal branches of the SA (arrow) run deep to the
anterior belly of the digastric muscle, looking like a dry tree. md,
digastric muscle; bm, basis mandibulae; gl, submandibular gland
upper and lower lip reconstructions. It can also be very
useful in nasal reconstruction and it may be a good
alternative for the forehead flap. The donor site scar is
concealed by the mandibular margin [7]. The type of flap
can be selected (cutaneous, musculofacial or composite)
depending on the clinical situation [3, 6, 14, 21]. The skin
territories of the single-pedicled submental island flap
are as large as 7 cm · 15 cm [11].
The FA and SA provide the blood supply to the
upper medial aspect of the neck. The anatomy of the
platysma has been well described by Hurwitz et al. [8]. In
their study, the SA provided direct cutaneous branching
in 22 of 24 samples [8]. In the remaining two samples,
the SA was not present and the lingual artery gave the
cutaneous blood supply to this region. After giving off
the submental branch, the FA wound around the inferior border of the mandible and at the anterior edge of
the masseter entered the face. At this point, the FA sent
relatively small and short vessels to the undersurface of
the platysma [8]. The myocutaneous platysma flap derived its arterial blood supply predominantly from the
submental branch of the FA [19]. Later, the myocutaneous platysma flap was advanced and used in intraoral
204
Fig. 5 The flap includes the anterior belly of the digastric muscle.
(The terminal branches of the SA run deep to the anterior belly of
the digastric muscle.) md, digastric muscle; sa, submental artery
and facial reconstructions. The advantages of this flap
are: the proximity to the surgical area, and the fact that
the skin island pedicled by platysma muscle is easily
harvested and transplanted to the defect. To observe the
blood flow at the flaps, angiographic studies were advised [1, 5, 12, 18].
In 1997, Curran et al. [3] described the use of a new
island flap based on the SA, which is ideal for the
reconstruction of lower facial defects. The SA may pass
deep to, through or above the anterior belly of the
digastric muscle and it ends subcutaneously near the
midline. The flap can be safely raised to include skin
across the midline. In the surgical technique of the SA
island flap, the length of the skin paddle can be designed
between the two facial arteries. Dissection on the nonpedicled side is above the level of this muscle. On the
pedicled side, the flap includes the anterior belly of the
digastric muscle. First, the ipsilateral digastric muscle is
raised, and then the dissection proceeds laterally on the
surface of the submandibular gland until the FA is found
[3, 22]. Demir et al. [5] used the submental island flap for
beard and mustache reconstruction in male patients in
addition to their applications of the flap. Hair-bearing
scalp flaps have been used most often; however, the
quality of the flap differs from that of the normal face.
The mask-face appearance is an unacceptable result of
these methods. On the basis of their clinical experiences
and literature, Demir et al. suggested that the submental
island flap surpasses other flaps in the reconstruction of
the mustache or beard in male patients [5].
Merten et al. [15] described the submental region and
the arteries and mentioned the diameter of the SA as
1.0–1.5 mm. They used the SA island flap as an intraoral
flap, external auditory canal flap and commissural flap.
The chief benefit of this flap is undoubtedly the excellent
cosmetic match with the facial skin and the well-hidden
donor scar. Sterne et al. [19] also used the submental
island flap in the intraoral and preauricular regions.
Daya et al. used the submental island flap and the
nasolabial flap for patients with defects of the lip and
perioral region [4].
Large upper lip defects are traditionally treated with
bilateral lip advancement flaps or Karapandzic flaps that
borrow lateral cheek tissue. When lip defects include the
columella, cheek, and/or perialar tissues, these flaps and
traditional Abbe flaps may be inadequate. Kriet et al.
[12] developed extended Abbe flaps for this reason. They
designed Abbe flaps as extended to the submental region
in some patients. Since the cutaneous vascular territory
of the inferior labial artery and the anastomoses with the
SA were important in the Abbe flap design, they demonstrated these structures by dissections in three fresh
cadavers [12]. There is a similar condition in the study of
Janssen and Thimsen [9]. They extended the SA island
flap to the lower lip, and with a rotation they used this
flap for esophagocutaneous fistula. The importance of
the anastomoses between the SA and the inferior labial
artery can be seen with the help of these studies [9].
Kitazawa et al. also showed that the bipedicled submental island flap was ideal for the reconstruction of the
upper lip [11].
According to many textbooks of anatomy, the primary blood supply to the mandibular lingual gingiva
and the floor of the mouth is derived from the sublingual
branch of the lingual artery. However, today it is
thought that these regions are also supplied by both the
SA and the sublingual arteries. Bavitz et al. showed that
in 60% of cases the SA had a large perforating branch
which pierced the mylohyoid muscle [1]. In 93.2% of
these cases, the diameter of the perforating branch was
greater than the diameter of the SA. The perforating
branch was 37 mm posterior to the menton. Ligation by
compression of the SA at a point here may be considered. In the study by Bavitz et al., the sublingual artery
was small in cases where a large perforating artery was
observed [1]. In the study by Piehslinger et al., in three of
the 15 heads it was observed that the sublingual artery
originated from the SA bilaterally [18]. According to
these studies, as the SA is a major arterial source to the
floor of the mouth, standard hemorrhage control procedures require alteration. In particular, during implant
surgery hemorrhage in the submandibular area can be
stopped by applying broad pressure to the lower medial
border of the mandible or by bimanual digital compression on the side where the FA crosses and the SA
originates. However, anastomoses may indicate the need
for ligation of both the facial and lingual arteries. The
amount of blood from these arteries may accumulate in
the submandibular space to compromise the airway. A
205
sign of impending distress is a protruding tongue. The
tongue and epiglottis may be forced into the pharynx
and larynx, closing off the trachea [1, 2, 7, 18].
In our study, the SA ran superficial to the anterior
belly of the digastric muscle in 44% of cases (11 left, 11
right) while in the remaining 56% (14 left, 14 right) it ran
deep. Faltaous and Yetman reported that in 70% of
cases the submental vessels ran deep to the anterior belly
of the digastric muscle, which should be included in the
flap to prevent failure. In the remaining 30%, it ran
superficial to the SA [3, 6].
In our study, the external diameter of the SA varied
between 0.82 and 2.80 mm (min—max) with a mean of
1.80±0.46 mm on the left side, and between 1.02 and
2.72 mm (min—max) with a mean of 1.88±0.48 mm on
the right side. Martin et al. [14] and Sterne et al. [19]
gave this value as 2 mm (average), it was 2—3 mm
(average) according to Brüe et al. [2] and was between
1.0 and 1.5 mm according to Faltaous and Yetman [6]
and Merten et al. [15].
In all the samples in our study, the SA originated
from the FA. Martin et al. [14] observed that in one of
his 56 dissections the SA originated from the external
carotid artery. Hurwitz et al. [8] did not observe the SA
in two of their 24 samples. The SA predominantly provided the arterial blood supply to the superiorly based
design of the myocutaneous platysma flap. In the study
by Hurwitz, this region was supplied by the sublingual
artery in two cases [8].
The submental island flap has potentially a very
useful role in facial reconstruction. Its ease of access and
shorter operative time needed for elevation are obvious
advantages over free tissue transfer. Potential disadvantages of the flap include damage to the marginal
mandibular nerve. There are a few limitations which
preclude its use in certain situations, for example the
thickness of the flap and the hairy skin in males. If the
regions provided by the SA are determined in detail
(such as the length, width and extension) the characteristics of the flap originating from the submandibular
region can be better planned and also postoperative loss
of the flap will be reduced.
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