Aesth Plast Surg DOI 10.1007/s00266-014-0438-8
I N N OV A T I V E T E C H N I QU E S
CRANIOFACIAL/MAXILLOFACIAL
A Novel Flap Technique for Repairing Large Lower Lip Defects Gurkan Kayabasoglu • Alpen Nacar Shan R. Baker
•
Received: 23 September 2014 / Accepted: 2 December 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract There are many well-established methods for the reconstruction of the lower lip. The selection of a particular method generally relies on the amount of lip resected and the amount of lip remaining. In cases of large defects ([50 % of the lip length) where direct closure and lip-switch techniques are inadequate, a perioral flap is used. All techniques for perioral flaps described until now result in an unwanted decrease in circumoral opening. The only available method that keeps the circumoral opening the same is a distant or regional free flap, and this technique is usually reserved for more extreme defects because it is more radical, technically demanding, and can pose a greater risk of complications. In this study, we describe a novel technique for reconstruction of the lower lip using a perioral flap in which the circumoral opening is kept the same. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
G. Kayabasoglu (&) Otolaryngology Head and Neck Surgery Department, Sakarya University Medical School, Adnan Menderes Cad No. 145, Adapazari, Sakarya, Turkey e-mail: [email protected]; [email protected] A. Nacar St. George’s University Hospital, St. George’s, Grenada e-mail: [email protected] S. R. Baker Otolaryngology, Head and Neck Surgery and Facial Plastic Surgery Department, University of Michigan, Ann Arbor, MI, USA e-mail: [email protected]
Keywords Lip Cancer Flap Reconstruction Graft Oral Surgical management
Introduction The importance of the lips as anatomical structures goes beyond their vital functions, including eating and drinking, phonation, speaking, and expressing emotions. Reconstruction of the lower lip, in cases of lip cancer, often requires a complex surgical approach to best achieve the goal of restoring oral competence and maintaining an adequate oral aperture to facilitate oral hygiene. Restoration of the lip should not be the only consideration in assessing a successful reconstruction. It is important to keep in mind factors such as the patient’s postoperative use of the lips in social situations, the cosmetic appearance of the reconstructed lip, and the preservation of the ability to accommodate dentures. Microstomia is to be avoided as it can pose functional, social and psychological difficulties for the patient [1]. There are many methods of lip reconstruction, and the selection of a particular method is influenced by the amount of lip remaining following resection. For small defects of the lip, the preferred method is direct approximation of the remaining tissues of the lip. For cases in which there is insufficient lip for primary repair, the opposing lip can provide tissue in a lip-switch technique such as the Abbe– Sabatini flap or Estlander flap [2]. For larger defects[50 % of the lip width, transfer of tissue adjacent to the perioral region using the Gilles fan flap or Bernard-von BurrowWebster flap can be considered. Due to the nature and design of these techniques, there may be an unavoidable decrease in the width of the lip and circumoral opening [3]. Another option for reconstruction usually reserved for extremely
123
Aesth Plast Surg Fig. 1 Left The outline of the large myocutaneous flap. Right An illustration showing the three flaps that are used in the reconstruction. Arrows show the vectors of the flaps
large lip defects is the use of regional or distant microsurgical flaps. These techniques are often more extensive and technically demanding, and can pose a greater risk of complications. Our goal in the case presented was to devise a technique that would provide an unchanged lip width and circumoral opening using a more regional approach by utilizing tissue from the perioral region [1].
Surgical Technique The reconstructive technique consists of using three different transposition flaps: a large myocutaneous chin flap transferred from an inferolateral to a superomedial position to close the primary lip defect. A smaller myocutaneous chin flap is harvested from the chin adjacent to the donor site of the primary flap and is used to assist with closure of the chin donor site. A third mucosal transposition interpolated flap harvested from the upper lip is used to reconstruct the vermilion in the area of the defect (Fig. 1). The primary myocutaneous flap of the same width and height as the defect, with the neurovascular pedicle carefully protected, is created by making an incision starting at the intersection point of the melolabial crease and the modiolus, and curving inferomedially in a ‘‘C’’ shape configuration ending along the labiomental crease at a point below the inferior border of the defect. The flap is transposed superiorly and the distal end is approximated to the medial end of the remaining lip. To repair the donor site of the primary flap, a second incision is made starting from the most inferomedial point of the defect and continuing inferiorly downward toward the mandible. This incision is then continued as a second incision which is made superolaterally, angled 45° to the first incision, on the side opposite of the defect. These incisions create a superiorly pedicled myocutaneous transposition chin flap which is transposed to repair the donor site of the first flap (Fig. 2). To reconstruct the vermilion for the reconstructed lip segment, a laterally pedicled interpolated mucosal
123
transposition flap is created from the inner aspect of the upper lip. The mucosal flap should be the same height as the resected vermilion and should be sufficiently long so that it can extend from the oral commissure on the side of the defect to the most medial point of defect where the normal vermilion ends (Fig. 3). After approximately 2–3 weeks, the mucosal flap will have established sufficient vascular connections with the recipient site. At that point, the pedicle is transected and the flap is inset (Fig. 4).
Methods This technique has been performed on eight patients (six males and two females.) The average age of patients was 63 years (range 54–76 years). The average follow-up duration was 14 months (range 12–23 months) and no major complications were noted in any of the patients. In two patients (2/8), a minor commissuroplasty procedure under local anaesthesia was done 6 months postoperatively. Although there are no specific indications for the use of our technique other than the patient having a large fullthickness defect ([50 % of the lower lip), the patients in whom we have employed this technique all had Stage T3 or T4 lip cancer.
Discussion Although there are many techniques for lower lip reconstruction, none are completely ideal. Large full-thickness defects ([50 % of the lip) cannot be closed with approximation of the remaining lip tissue without causing considerable microstomia. In cases of total or near-total defects of the lower lip, the use of free flaps is a more promising option, and may be preferred.
Aesth Plast Surg
With the exception of free flap techniques, all techniques described above for lower lip reconstruction reduce the width of the lower lip and circumoral opening. To avoid microstomia, additional tissue other than the lips must be recruited to assist in the reconstruction. Perioral tissue transfer, using the Abbe–Sabatini flap, Estlander flap or Karapandzic flap, uses lip tissue and does not provide additional tissue for reconstruction. Thus, large lip defects reconstructed with these flaps will result in microstomia [2]. In addition, these flaps can compromise the appearance of the neighbouring structures, affect muscle functionality and decrease the width of the lip and circumoral opening. The technique we describe preserves the circumoral opening by utilizing tissue transferred from the area inferomedial to the defect, transposed in such a way as to maintain the original lip width. Compared to bilateral Gilles fan flaps, the technique described does not require incisions made laterally into the adjacent cheek, and therefore better preserves facial muscular function. The technique enables protection of the neurovascular pedicle of the remaining lip segments minimizing sensory loss. In addition, compared to melolabial transposition flaps and Bernard-von Burrow-Webster cheek flaps, the technique is simpler in design, and requires fewer
incisions in the surrounding areas, which may result in improved aesthetic results [4]. With the exception of the melolabial transposition flap, the Gilles fan flap and Bernard-von Burrow-Webster techniques require transfer of tissue from both sides of the defect. Our technique utilizes unilateral tissue only which enables the preservation of the oral commissure on the side opposite the defect providing better overall aesthetic results, and reducing the risk of hypoesthesia [5]. Importantly, flaps requiring tissue transfer from the cheek inevitably impact the aesthetic outcome of the procedure and risk impairing the functionality of facial muscles. The technique described here in has the advantage of maintaining reconstruction within the aesthetic region of the lip and chin and does not utilize tissue from other facial aesthetic regions [6]. This approach eliminates the risk of compromising the function of adjacent facial muscles. Another advantage of our technique is the relatively simple design and execution of the reconstruction of defects confined to the lower lip. A key feature of the technique is the preservation of the neurovascular structures encountered in the plane of dissection, leading to optimal oral competence and sensory preservation (Fig. 5).
Fig. 2 Left The primary flap transposed superiorly and the distal end approximated to the medial end of the remaining lip. Right An illustration showing the movement of the small myocutaneous chin flap, which is used to assist with closure of the chin donor site
Fig. 3 The laterally pedicled interpolated mucosal transposition flap from the inner aspect of the upper lip, which is used to reconstruct the vermilion for the reconstructed lip segment
123
Aesth Plast Surg Fig. 4 The completed procedure showing the new positions of all three flaps
Fig. 5 a 42 mm length of lower lip defect of a 71-year-old male patient. b Postoperative view of patient A after 13 months. c 56 mm of length lower lip defect of a 63-year-old male patient. d Postoperative view of patient C after 7 months
A limitation of our technique is that the chin must consist of healthy tissue and be of normal size. If the defect extends into the area of the chin, the technique cannot be utilized. In those cases, a suitable alternative method of lip repair must be selected. Disadvantages of this technique include the possibility of performing commissuroplasty post-operatively to correct minor irregularities of the commissure, and the fact that a two-step process is involved with the mucosal flap being inset 2–3 weeks following the original procedure. Conclusion The method described allows for reconstruction of large lower lip defects, while maintaining the width of the lower lip. Reconstruction is confined to the aesthetic region of the lower lip/chin aesthetic units. Acknowledgments All financial and material support for this research and work were provided by authors. There are no financial disclosures.
123
Conflict of interest The authors declare that there are no conflicts of interest or ethical adherence in this scientific study.
References 1. Gilles HD, Millard DR (1957) The principles and art of plastic surgery. Little, Brown & Co., Boston, pp 497–519 2. Mazzola RF, Lupo G (1994) Evolving concepts in lip reconstruction. Clin Plast Surg 11:583–617 3. McGregor IA (1983) Reconstruction of the lower lip. Br J Plast Surg 36:40–47 4. McHugh M (1977) Reconstruction of the lower lip using a neurovascular island flap. Br J Plast Surg 30:316–318 5. Vatanasapt V, Chadbunchachai W, Taksophan P, Komthong R (1987) Bilateral neurovascular cheek flaps for one stage lower lip reconstruction. Br J Plast Surg 40:173–175 6. Martin T, Sury F, Goga D, Parmentier J, Rozen A, Laure B (2012) Reconstruction of large defects of the lips and commissure using a composite radial forearm palmaris longus free flap associated with a lengthening temporalis myoplasty. Ann Plast Surg 69:169–172
I N N OV A T I V E T E C H N I QU E S
CRANIOFACIAL/MAXILLOFACIAL
A Novel Flap Technique for Repairing Large Lower Lip Defects Gurkan Kayabasoglu • Alpen Nacar Shan R. Baker
•
Received: 23 September 2014 / Accepted: 2 December 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract There are many well-established methods for the reconstruction of the lower lip. The selection of a particular method generally relies on the amount of lip resected and the amount of lip remaining. In cases of large defects ([50 % of the lip length) where direct closure and lip-switch techniques are inadequate, a perioral flap is used. All techniques for perioral flaps described until now result in an unwanted decrease in circumoral opening. The only available method that keeps the circumoral opening the same is a distant or regional free flap, and this technique is usually reserved for more extreme defects because it is more radical, technically demanding, and can pose a greater risk of complications. In this study, we describe a novel technique for reconstruction of the lower lip using a perioral flap in which the circumoral opening is kept the same. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
G. Kayabasoglu (&) Otolaryngology Head and Neck Surgery Department, Sakarya University Medical School, Adnan Menderes Cad No. 145, Adapazari, Sakarya, Turkey e-mail: [email protected]; [email protected] A. Nacar St. George’s University Hospital, St. George’s, Grenada e-mail: [email protected] S. R. Baker Otolaryngology, Head and Neck Surgery and Facial Plastic Surgery Department, University of Michigan, Ann Arbor, MI, USA e-mail: [email protected]
Keywords Lip Cancer Flap Reconstruction Graft Oral Surgical management
Introduction The importance of the lips as anatomical structures goes beyond their vital functions, including eating and drinking, phonation, speaking, and expressing emotions. Reconstruction of the lower lip, in cases of lip cancer, often requires a complex surgical approach to best achieve the goal of restoring oral competence and maintaining an adequate oral aperture to facilitate oral hygiene. Restoration of the lip should not be the only consideration in assessing a successful reconstruction. It is important to keep in mind factors such as the patient’s postoperative use of the lips in social situations, the cosmetic appearance of the reconstructed lip, and the preservation of the ability to accommodate dentures. Microstomia is to be avoided as it can pose functional, social and psychological difficulties for the patient [1]. There are many methods of lip reconstruction, and the selection of a particular method is influenced by the amount of lip remaining following resection. For small defects of the lip, the preferred method is direct approximation of the remaining tissues of the lip. For cases in which there is insufficient lip for primary repair, the opposing lip can provide tissue in a lip-switch technique such as the Abbe– Sabatini flap or Estlander flap [2]. For larger defects[50 % of the lip width, transfer of tissue adjacent to the perioral region using the Gilles fan flap or Bernard-von BurrowWebster flap can be considered. Due to the nature and design of these techniques, there may be an unavoidable decrease in the width of the lip and circumoral opening [3]. Another option for reconstruction usually reserved for extremely
123
Aesth Plast Surg Fig. 1 Left The outline of the large myocutaneous flap. Right An illustration showing the three flaps that are used in the reconstruction. Arrows show the vectors of the flaps
large lip defects is the use of regional or distant microsurgical flaps. These techniques are often more extensive and technically demanding, and can pose a greater risk of complications. Our goal in the case presented was to devise a technique that would provide an unchanged lip width and circumoral opening using a more regional approach by utilizing tissue from the perioral region [1].
Surgical Technique The reconstructive technique consists of using three different transposition flaps: a large myocutaneous chin flap transferred from an inferolateral to a superomedial position to close the primary lip defect. A smaller myocutaneous chin flap is harvested from the chin adjacent to the donor site of the primary flap and is used to assist with closure of the chin donor site. A third mucosal transposition interpolated flap harvested from the upper lip is used to reconstruct the vermilion in the area of the defect (Fig. 1). The primary myocutaneous flap of the same width and height as the defect, with the neurovascular pedicle carefully protected, is created by making an incision starting at the intersection point of the melolabial crease and the modiolus, and curving inferomedially in a ‘‘C’’ shape configuration ending along the labiomental crease at a point below the inferior border of the defect. The flap is transposed superiorly and the distal end is approximated to the medial end of the remaining lip. To repair the donor site of the primary flap, a second incision is made starting from the most inferomedial point of the defect and continuing inferiorly downward toward the mandible. This incision is then continued as a second incision which is made superolaterally, angled 45° to the first incision, on the side opposite of the defect. These incisions create a superiorly pedicled myocutaneous transposition chin flap which is transposed to repair the donor site of the first flap (Fig. 2). To reconstruct the vermilion for the reconstructed lip segment, a laterally pedicled interpolated mucosal
123
transposition flap is created from the inner aspect of the upper lip. The mucosal flap should be the same height as the resected vermilion and should be sufficiently long so that it can extend from the oral commissure on the side of the defect to the most medial point of defect where the normal vermilion ends (Fig. 3). After approximately 2–3 weeks, the mucosal flap will have established sufficient vascular connections with the recipient site. At that point, the pedicle is transected and the flap is inset (Fig. 4).
Methods This technique has been performed on eight patients (six males and two females.) The average age of patients was 63 years (range 54–76 years). The average follow-up duration was 14 months (range 12–23 months) and no major complications were noted in any of the patients. In two patients (2/8), a minor commissuroplasty procedure under local anaesthesia was done 6 months postoperatively. Although there are no specific indications for the use of our technique other than the patient having a large fullthickness defect ([50 % of the lower lip), the patients in whom we have employed this technique all had Stage T3 or T4 lip cancer.
Discussion Although there are many techniques for lower lip reconstruction, none are completely ideal. Large full-thickness defects ([50 % of the lip) cannot be closed with approximation of the remaining lip tissue without causing considerable microstomia. In cases of total or near-total defects of the lower lip, the use of free flaps is a more promising option, and may be preferred.
Aesth Plast Surg
With the exception of free flap techniques, all techniques described above for lower lip reconstruction reduce the width of the lower lip and circumoral opening. To avoid microstomia, additional tissue other than the lips must be recruited to assist in the reconstruction. Perioral tissue transfer, using the Abbe–Sabatini flap, Estlander flap or Karapandzic flap, uses lip tissue and does not provide additional tissue for reconstruction. Thus, large lip defects reconstructed with these flaps will result in microstomia [2]. In addition, these flaps can compromise the appearance of the neighbouring structures, affect muscle functionality and decrease the width of the lip and circumoral opening. The technique we describe preserves the circumoral opening by utilizing tissue transferred from the area inferomedial to the defect, transposed in such a way as to maintain the original lip width. Compared to bilateral Gilles fan flaps, the technique described does not require incisions made laterally into the adjacent cheek, and therefore better preserves facial muscular function. The technique enables protection of the neurovascular pedicle of the remaining lip segments minimizing sensory loss. In addition, compared to melolabial transposition flaps and Bernard-von Burrow-Webster cheek flaps, the technique is simpler in design, and requires fewer
incisions in the surrounding areas, which may result in improved aesthetic results [4]. With the exception of the melolabial transposition flap, the Gilles fan flap and Bernard-von Burrow-Webster techniques require transfer of tissue from both sides of the defect. Our technique utilizes unilateral tissue only which enables the preservation of the oral commissure on the side opposite the defect providing better overall aesthetic results, and reducing the risk of hypoesthesia [5]. Importantly, flaps requiring tissue transfer from the cheek inevitably impact the aesthetic outcome of the procedure and risk impairing the functionality of facial muscles. The technique described here in has the advantage of maintaining reconstruction within the aesthetic region of the lip and chin and does not utilize tissue from other facial aesthetic regions [6]. This approach eliminates the risk of compromising the function of adjacent facial muscles. Another advantage of our technique is the relatively simple design and execution of the reconstruction of defects confined to the lower lip. A key feature of the technique is the preservation of the neurovascular structures encountered in the plane of dissection, leading to optimal oral competence and sensory preservation (Fig. 5).
Fig. 2 Left The primary flap transposed superiorly and the distal end approximated to the medial end of the remaining lip. Right An illustration showing the movement of the small myocutaneous chin flap, which is used to assist with closure of the chin donor site
Fig. 3 The laterally pedicled interpolated mucosal transposition flap from the inner aspect of the upper lip, which is used to reconstruct the vermilion for the reconstructed lip segment
123
Aesth Plast Surg Fig. 4 The completed procedure showing the new positions of all three flaps
Fig. 5 a 42 mm length of lower lip defect of a 71-year-old male patient. b Postoperative view of patient A after 13 months. c 56 mm of length lower lip defect of a 63-year-old male patient. d Postoperative view of patient C after 7 months
A limitation of our technique is that the chin must consist of healthy tissue and be of normal size. If the defect extends into the area of the chin, the technique cannot be utilized. In those cases, a suitable alternative method of lip repair must be selected. Disadvantages of this technique include the possibility of performing commissuroplasty post-operatively to correct minor irregularities of the commissure, and the fact that a two-step process is involved with the mucosal flap being inset 2–3 weeks following the original procedure. Conclusion The method described allows for reconstruction of large lower lip defects, while maintaining the width of the lower lip. Reconstruction is confined to the aesthetic region of the lower lip/chin aesthetic units. Acknowledgments All financial and material support for this research and work were provided by authors. There are no financial disclosures.
123
Conflict of interest The authors declare that there are no conflicts of interest or ethical adherence in this scientific study.
References 1. Gilles HD, Millard DR (1957) The principles and art of plastic surgery. Little, Brown & Co., Boston, pp 497–519 2. Mazzola RF, Lupo G (1994) Evolving concepts in lip reconstruction. Clin Plast Surg 11:583–617 3. McGregor IA (1983) Reconstruction of the lower lip. Br J Plast Surg 36:40–47 4. McHugh M (1977) Reconstruction of the lower lip using a neurovascular island flap. Br J Plast Surg 30:316–318 5. Vatanasapt V, Chadbunchachai W, Taksophan P, Komthong R (1987) Bilateral neurovascular cheek flaps for one stage lower lip reconstruction. Br J Plast Surg 40:173–175 6. Martin T, Sury F, Goga D, Parmentier J, Rozen A, Laure B (2012) Reconstruction of large defects of the lips and commissure using a composite radial forearm palmaris longus free flap associated with a lengthening temporalis myoplasty. Ann Plast Surg 69:169–172
