The expert’s comment

In this paper, the Authors describe the removal of a large Merkel carcinoma in the submental area and the little used infrahyoid flap. The massive use of free flaps in head and neck has led to any pedicle flap being considered as second choice reconstruction. From a technical point of view, this may be true, but, in the reconstruction decison making, not only the defect has to be considered but also the patient’s co-morbidity – general and local conditions –, the oncologic perspective, the patient’s needs and ward organization problems. Thus we need to encourage, in selected cases, the use of regional pedicle flaps, as first choice reconstruction. The most used pedicle flaps for head and neck reconstruction are the myocutaneous pectoralis and temporalis flaps. The infrahyoid myocutaneous flap is an alternative option that should be considered for regional reconstruction. The infrahyoid area is nourished mainly by the superior thyroid vessels, which are usually preserved during neck dissection; the flap is easy to harvest and can be used for soft tissue defects created after surgical ablation of cancer of the mid-face, parotid region, oral cavity, oro-pharynx, or hypo-pharynx. In spite of its qualities, use of this flap is still reserved for sporadic cases. The infrahyoid musculocutaneous flap (IHMF), after the early experience of Conley in 1977, became popular when Wang in 1986 published his experience on 112 cases of reconstruction using infrahyoid myocutaneous flaps (IHMCFs) and on 260 cases in 1991 (Chinese literature). In the literature (Medline search), there are 18 articles reporting on the use of the infrahyoid flap, mainly from Chinese, English, French and German Authors. From an analysis of the data of the 319 cases described, the complications rate reported is extremely variable, ranging from 3 to 47%. The main problems are related to the reliability of the skin paddle and the venous drainage. For this reason, Wang, in the abstract of the Chinese article on 260 cases, where the complication rate is only 3%, first recommends to include in the harvest the sternal edge of the sternocleidomastoid (SCM) muscle to protect the platysma and the SCM branches of the superior thyroid artery. In 1994, Remmert, in a German article, first described a neurovascular infrahyoid flap for tongue reconstruction including in the flap the ansa cervicalis ipoglossii, introducing the concept of functional tongue reconstruction. In conclusion, this teaching case stresses that in oncologic surgery, during neck dissection, we have to bear in mind the possibility of using the infrahyoid flap as a reconstructive option. Obviously, neck dissection must be conservative sparing the internal jugular vein and the thyroid branches, often connected to the facial vascular system and extra-capsular lymph-node metastases at level III must be excluded, pre-operatively.