title: The Hybrid Submental Flap for Tongue Reconstruction.
abstract: OBJECTIVE
  To describe a hybrid submental flap using pedicled and microvascular techniques to circumvent a restricting vascular anatomy and increase the rotational arc of the skin paddle.
  
  
  METHODS
  This case report and literature review describes a hybrid submental flap. A standard submental island flap was planned and elevated for reconstruction of an acquired lateral tongue defect secondary to oncologic ablation. Aberrant venous anatomy was encountered in which the submental vein drained directly into the internal jugular vein, thus limiting the arc of rotation. The facial vein was ligated at its branch point from the internal jugular vein and anastomosed to the external jugular vein. Medical records were reviewed, including clinical and operative notes. A standard free flap postoperative protocol was adhered to, including aspirin, enoxaparin sodium, flap checks, and internal monitoring using a venous Flow Coupler (Synovis Micro Companies Alliance, Inc, Birmingham, AL).
  
  
  RESULTS
  The hybrid submental flap was used effectively for lateral tongue reconstruction. Hybridization of the flap allowed for increased pedicle length and mobilization of the skin paddle. The flap remained well perfused postoperatively, with excellent speech and swallow function after adjuvant chemoradiotherapy.
  
  
  CONCLUSIONS
  The hybrid submental flap is technically feasible and can be a valuable bailout procedure when aberrant vascular anatomy limits the arc of rotation. Ligation and anastomosis of the vein, versus the artery, is more likely to be required because of the more variable drainage patterns and potential valves that would prevent retrograde flow in a Y-V procedure. Retrograde arterial perfusion through the angular branch of the facial artery, by ligation of the submental artery at its proximal takeoff from the facial artery, is a well-documented method to gain cephalad arc of rotation in cases of restrictive arterial anatomy.
authors.affiliation: Fellow, Oral-Head and Neck Oncology and Microvascular Surgery, Department of Oral and Maxillofacial Surgery, University of Maryland, Baltimore, MD. Electronic address: thann001@umaryland.edu.
authors.forename: Todd C
authors.initials: TC
authors.lastname: Hanna
authors.affiliation: Assistant Professor and Fellowship Director, Oral-Head and Neck Oncology and Microvascular Surgery, Department of Oral and Maxillofacial Surgery, University of Maryland, Baltimore, MD.
authors.forename: Joshua E
authors.initials: JE
authors.lastname: Lubek
mesh_terms: D000328:Adult; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D019651:Plastic Surgery Procedures; D013524:Surgical Flaps; D014062:Tongue Neoplasms / Q000601:surgery*