Efficacy of Platysmal flap for Surgical Defects Reconstruction in Oral Submucous Fibrosis: A Literature Review

Platysmal myocutaneous flaps have been used historically since 1887, when Austrian surgeon Robert Gersuny reported reconstructing a cheek defect of full thickness using a cervical skin/plastysma flap that was inward rotated to make a new buccal mucosal lining. But it wasn’t popular until 1978 when Futrell et al. [1] presented the platysma myocutaneous flap as a desirable reconstructive approach with a number of benefits [2]. The platysmal myocutaneous flap is basically a pedicled flap based on axial pattern that can enhance the reconstructive options of head and neck surgeons and offer a compelling choice with a number of potential benefits [3]. The flap’s vascularity is quite dependable because it consists of both muscle and skin. It allows for complete reconstruction in a single surgical step, and the precise amount of tissue required may be planned without running the potential risk of introducing too little or too much tissue into the Oro-facial region [4]. Additionally, local intraoral flaps are avoided as they may impair speech, deglutition, and denture fitting. Furthermore, the donor site can be approximated primarily with little donor deformation, and the entire procedure can be completed quickly without the requirement for specialised microvascular expertise [5]. Thus, it can be hypothesised that the platysmal myocutaneous flap may be able to play a big role in head and neck reconstruction because of these important advantages and negligible drawbacks [1]. The present study is aimed to assess the efficacy of using platysmal flap in surgical management of oral submucous fibrosis.

Search strategy

The PICOT format was used to define the research question. Patients with oral submucous fibrosis who are having fibrous band resection and platysmal myocutaneous flap reconstruction are the target population for this study. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement criteria, a systematic review was conducted. The Cochrane Database of Systematic Reviews (CDSR), PubMed/ MEDLINE, Scopus, and the Cochrane central register of controlled trials (CENTRAL) were the electronic databases that were consulted. The articles included discussed the evaluation of the surgical results of platysmal myocutaneous flaps used for intraoral reconstruction after surgical excision of fibrous bands in cases of oral submucous fibrosis. All relevant abstracts were evaluated after the exclusion criteria were applied, and the full texts of the chosen publications were acquired. In order to identify any papers that could be included in the study, the references of the chosen articles were also examined. The flow diagram for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method is depicted in Figure 1.

Figure 1:Flow diagram of articles screening and selection process for studies. Arrows represent the step-wise process.

Search terminologies

Medical Subject Headings (MeSH) terms from the National Library of Medicine (NLM) were chosen and used alongside text words. The MeSH phrases “Platysmal myocutaneous flap,” and “oral submucous fibrosis” were utilized to give a systematic approach to access information when more than one author used different terms for the same idea.

Inclusion criteria

The Medical Subject Heading (MeSH) terms used for the search included Platysma, and oral submucous fibrosis. Only the articles published in English were included in the study. Patients who had undergone surgery for Stage III and IV oral submucous fibrosis and had undergone reconstruction with platysmal myocutaneous flap were included in the study.

Exclusion criteria

Articles that reported on the outcomes based on cadaver studies, and animal studies, as well as research that did not provide a specific statement of our primary outcome, studies in which other potentially malignant disorders, carcinomas were managed with platysmal flap were excluded. Articles written in languages other than English were not considered. Duplicate articles, interviews, commentaries, conference abstracts and case reports were not accepted.

Data extraction and management

All data extracted was input into a predefined Microsoft Excel sheet (Microsoft Inc., Redmond, WA, USA). A data extraction form was used to extract the following data: Name of the authors, year of publication, number of patients, mouth opening-postoperative, flap dehiscence, partial flap loss, skin loss, other complications and conclusion. All disputes were resolved by a third reviewer.

Nine articles from PubMed using the advance search method using a combination of regular keywords and MeSH terms, three from the Cochrane Library, and nine from Scopus using the regular keywords were among the 21 relevant articles that were located. Twelve article’s titles and abstracts were checked after duplicate articles were removed. Just 12 of the examined articles were pertinent to this line of inquiry. These twelve articles were ultimately chosen for evaluation. Six of them did not match the inclusion requirements, and one was inaccessible, thus only five were included in our study. Using standardised quality assessment techniques, we evaluated five papers for quality evaluation; following the quality appraisal, all publications were qualified. Figure 1 displays the literature’s PRISMA flowchart and the studies’ search methodology. According to most research, platysmal flap is a technique sensitive alternative that can be used for reconstruction after surgical excision of fibrous bands in Stage 3 and Stage 4 Oral submucous fibrosis (Table 1).

Table 1:Efficacy of platysmal flap for surgical defects reconstruction in oral submucous fibrosis.

Since 1978, intraoral reconstruction has been accomplished using the platysma myocutaneous flap. While some experts have questioned the widespread usage of this flap, others have documented excellent results. Virens observed a high prevalence of wound complications and evaluated functional results following repair using the platysma myocutaneuos flap [6]. PMF can be inferiorly, posteriorly, or superiorly based; superiorly based flaps are typically used to restore face and oral abnormalities [7]. The branch of facial artery, “submental artery”, provides the platysma myocutaneous flap with a substantial blood supply. Other sources of blood supply include the transverse cervical, occipital thyroid, and post-auricular veins [6] Additionally, the mental, sublingual and sublingual arteries have substantial nasolabial and cheek arterial anastomoses, and retrograde filling does take place following proximal ligation of the facial artery. Because of this, the platysma flap can be employed following radical or functional neck dissection [6].

The submental artery serves as a feeder for the platysma myocutaneous flap’s superiorly based design [8]. The flap should be raised following facial artery identification, preserving its continuity through meticulous dissection of the blood vessel’s intraglandular trajectory [9]. The medial and superior aspects of the platysma muscle contain the anterior aspect of the facial artery. Maintaining the submental artery’s patency is essential for maximising the viability of the superiorly based platysma flap [10]. The platysma muscle is reached by the superior thyroid artery near the sternocleidomastoid muscle’s anterior border in the middle part of the neck [11]. These results show that maintaining a healthy occipital artery while maintaining the sternocleidomastoid muscle is the basis for the posteriorly base design of the platysma myocutaneous flap [8].

Additionally, adequate venous drainage is essential for flap survival [12]. The external jugular and submental veins serve as the primary venous drainage channels for platysma muscle. Therefore, it is important to protect these vessels as much as possible, and this is simple to do [6]. Due to the vertical venous drainage pattern, which is mostly composed of superficial veins, especially the facial, anterior, and external jugular veins, the platysmal flap is more vulnerable to congestion than arterial insufficiency and should not be torqued on an axis, tensed, or knicked [6]. While raising a platysmal flap, it is advisable to maintain the integrity of facial artery. However, even when the ipsilateral facial artery is ligated, the flap could usually survive well [3].

The flap can be used either superiorly or posteriorly based. So, they can provide sufficient amount of pliable soft tissue that can be used for reconstruction of small to medium sized skin or mucosal defects of oral cavity [6]. Superior colour matching, easy donor site access from the operating field, low morbidity of donor site, ease of closing the donor site primarily, and an appropriate thickness of flap for oral deformities are some of the benefits of the PMF [3]. Total or partial necrosis of the skin island, hematoma, fistula, dehiscence, and cellulitis are among the problems that might arise while using this flap; their rates range from 18% to 45% [6].

Venous congestion is one of the main complication of using a superiorly based Platysma Myocutaneous Flap (PMF). The major venous drainage of platysmal muscle is through the external jugular and submental veins. Maximum attention should be taken to conserve these vessels [6]. The Relative contraindications of using platysma flap in reconstruction include prior neck irradiation or neck dissection, ligation of facial artery. These parameters are mostly associated with impaired perfusion post operatively and is thought to be an important factor that is responsible for an increased flap failure rate [2].

Platysmal flap can be an efficient reconstructive option with minimal complications particularly in young age group where scarring is unacceptable. Although, the procedure is technique sensitive, the result yielded is superior and can be successfully used even in medically compromised patients. To further assess the efficacy of platysmal myocutaneous flap in the surgical treatment of oral submucous fibrosis, multicenter research including bigger patient groups are required.

1. Futrell JW, Johns ME, Edgerton MT, Cantrell RW, Hugh FGS (1978) Platysma myocutaneous flap for intraoral reconstruction. Am J Surg 136(4): 504-507.
2. Eckardt AM (2013) Platysma myocutaneous flap-its current role in reconstructive surgery of oral soft tissue defects. J Korean Assoc Oral Maxillofac Surg 39(1): 3-8.
3. Bande C, Joshi A, Gawande M, Tiwari M, Rode V (2018) Utility of superiorly based platysma myocutaneous flap for reconstruction of intraoral surgical defects: Our experience. Oral and Maxillofacial Surgery 22(1): 45-51.
4. Lathi P, Tiwari R, Singh VK, Giri R, Thanvi G, et al. (2022) Comparison of platysma myocutaneous flap, nasolabial flap and buccal fatpad in the treatment of oral submucous fibrosis: 30 patient case series. International Journal of Medical Science in Clinical Research and Review 5(4): 256-262.
5. Kocer U, Ozdemir R, Ulusoy MG, Uysal A, Sungur N, et al. (2005) Anatomy of the platysma muscle and the evaluation of it for the reconstruction of facial defects. Journal of Craniofacial Surgery 16(3): 463-470.
6. Ramanujam S, Venkatachalam S, Subramaniyan M, Subramaniyan D (2015) Platysma myocutaneous flap for reconstruction of intraoral defects following excision of oral sub mucous fibrosis: A report of 10 cases. Journal of Pharmacy and Bioallied Sciences 7(Suppl 2): S708-S711.
7. Gangwar S, Kumari P, Chaudhary UC (2023) Efficacy of platysma flap in oral submucous fibrosis: Preliminary study. International Dental Journal of Student's Research 11(1): 24-27.
8. Uehara M, Helman JI, Lillie JH, Brooks SL (2001) Blood supply to the platysma muscle flap: An anatomic study with clinical correlation. J Oral Maxillofac Surg 59(6): 642-646.
9. Sikkerimath BC, Dandagi S, Anshu A, Jose A (2021) Comparative evaluation of reconstructive methods in oral submucous fibrosis. Journal of Maxillofacial and Oral Surgery 20(4): 597-606.
10. Bande CR, Datarkar A, Khare N (2013) Extended nasolabial flap compared with the platysma myocutaneous muscle flap for reconstruction of intraoral defects after release of oral submucous fibrosis: A comparative study. British Journal of Oral and Maxillofacial Surgery 51(1): 37-40.
11. Singh WT, Bhola N, Singh DN, Agarwal A, Devi PA, et al. (2024) A retrospective study comparing the surgical results of platysma myocutaneous flap, buccal pad of fat, and nasolabial flap for reconstruction after fibrotomy in cases of oral submucous fibrosis. Cureus 16(5): e60297.
12. Baur DA, Williams J, Alakaily X (2014) The platysma myocutaneous flap. Oral and Maxillofacial Surgery Clinics 26(3): 381-387.