Is submental flap oncologically safe in oral cancer with nodal metastases? A study of 2020 cases

Introduction: Oral cancer is one of the leading malignancies, and its surgical treatment frequently results in complex defects that warrant reconstruction. Although the submental flap (SMF) is a versatile locoregional option, its oncological safety remains debated because of its close proximity to level I lymph nodes. Materials and methods: This retrospective cohort study based on a prospectively maintained database assessed oral cancer patients who had SMF reconstruction between January 2016 and March 2024 and followed untill September 2025. Locoregional recurrence rates were evaluated in this group. Surgical cost was compared between 188 SMFs and 141 free flap reconstructions (FFRs) performed consecutively. Results: A cohort of 2020 cases was included in the study after 139 cases were excluded from the initial pool of 2159 due to inadequate follow-up. The median follow-up was 69 months. 34.6% of cases had pathological nodal involvement (pN+). The likelihood of a locoregional recurrence was 21.7% overall. Compared to node-negative (pN0) patients (19.68%), pN+ patients had significantly higher recurrence rates (25.46%) (p-value = 0.002). Importantly, there was no discernible difference in recurrence between patients with level I metastases and those with metastases at other levels, from a subgroup analysis of pN+ patients (p-value = 0.919). SMF costs considerably less than FFR. Conclusions: The SMF provides acceptable oncological results with recurrence rates comparable to current literature. When used in conjunction with careful lymph node clearance, it does not jeopardize oncological safety, even in patients with level I nodal metastases.