EXPERIENCES WITH FUNCTIONAL GRACILIS MUSCLE FLAP IN LOWER LIP RECONSTRUCTION OSMAN KORAY COSKUNFIRAT, M.D.,1* GAMZE BEKTAS, M.D.,1 ANI CINPOLAT, M.D.,1 KERIM UNAL, M.D.,1 and NESIL COSKUNFIRAT, M.D.2
Objective: Reconstruction of the lips is pivotal because the lips play an essential role in facial aesthetics and have unique functional properties. We presented our experience in reconstruction of total or subtotal lower lip defects with functional gracillis muscle flap covered split-thickness skin graft (STSG) in patients. Methods: Between 2009 and 2011, seven patients underwent resection of lower lip squamous cell carcinoma and lip reconstruction. Gracillis muscle flap was performed for reconstruction. Recipient vessels were the facial artery and vein. Motor nerve of the gracillis muscle was coapted to the marginal branch of the facial nerve. Gracillis muscle was covered with STSG. Patients were evaluated about mouth opening, oral competence, word articulation, the color match of the graft, the contraction of the muscle by physical examination. Electromyographic studies and sensation tests were performed. Results: Postoperative course was uneventful for all of the flaps. No microvascular revisions were needed. One patient was reoperated because of wound dehiscence under local anaesthesia. Mean follow up period was 15 months. After three months, movement of the reconstructed lip was observed. Color of the grafted skin was matched with the skin of the face. The patients had no problems with word articulation, oral continence, or mouth opening. The electromyographic study showed recovery of motor innervation. After 1 year, the patients demonstrated recovered sensitivity with the sensation test. Conclusion: Considering functional results, superior aesthetic appearance, and minimal donor-site morbidity of the functional gracillis transfer covered skin graft, we think that this method may be an alternative for reconstruction of large C 2015 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2015. full-thickness defects of the lower lip. V
Lip
reconstruction is pivotal because lips play an essential role in facial aesthetics and have unique functional properties. To reconstruct a large full-thickness defect of more than two thirds of the lip, while maintaining these functions; such as articulation, mastication, provision for oral competence, expression of emotion, could be challenging.1 Lower lip reconstruction is more significant because, oral competence depends greatly on a functional lower lip having good muscular function as well as adequate height and sensation.1,2 In the literature, several procedures have been reported for reconstruction of large defects of the lower lip. The lower lip can be reconstructed using local flaps such as cheek advancement flaps,3,4 rotation,5,6 nasolabial flaps,7,8 or combination of local flaps,9,10 regional pedicled flaps,10,11 and free flaps.12–17 However, local flap and regional flap procedures are unsuitable when the total lip resection is performed on a patient who lacks laxity of tissue and they can cause severe microstomia and abnormal appearance of the lip.18 For this reason, large full-thickness defects of the lower lip are better repaired with microvascu1 Department of Plastic, Reconstructive and Aesthetic Surgery, Akdeniz University School of Medicine, Antalya, Turkey 2 Department of Anesthesiology, Akdeniz University School of Medicine, Antalya, Turkey Conflict of Interest: None of the authors of this manuscript have any commercial association that might pose or create a conflict of interest with the information presented in the submitted manuscript. This includes: consultancies, stock ownership, or other equity interests, patent licensing arrangements, and payments for conducting or publicizing the study described in the manuscript. *Correspondence to: Dr. Osman Koray Coskunfirat, M.D., Akdeniz € i, Antalya, Tu €ktif ve Estetik Cerrahi Klinig €rkiye. Universitesi, Plastik Rekonstru E-mail: [email protected] Received 9 November 2014; Revision accepted 10 May 2015; Accepted 12 May 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22431
Ó 2015 Wiley Periodicals, Inc.
lar free tissue transfer.2,13–17 There is no widely accepted way of managing. It is generally agreed that the best option, or at least the most commonly used, currently available to reconstruct the lip with a free flap is the composite tenofascio-cutaneous radial forearm flap13–15 or composite anterolateral thigh-fascia-latae flap.17 However, these flaps do not have their own motility. In addition, color and texture match is not perfect. Recently, gracillis muscle flap which is often used in free tissue transfer, has been started to be used in lip reconstruction.19–23 In this report, we presented our experience in reconstruction of total or subtotal lower lip defects with the functional gracillis muscle flap covered split thickness skin graft (STSG) in a series of 7 cases. PATIENTS AND METHODS
Between 2009 and 2011, seven patients underwent resection of lower lip squamous cell carcinoma (SCC) and lip reconstruction. All patients were male, their ages were between 46 and 75 years old and they had 60– 100% lip defect with included commissure in two patients (Table 1). Tumor resection and reconstruction with innervated gracillis free flap and skin graft was performed. All patients had bilateral supraomohyoid neck dissection simultaneously. SURGICAL TECHNIQUE
In the surgical operations, two team approach was used. One team performed tumor resection on the lower lip, bilateral supraomohyoid neck dissection and prepared the facial artery, vein and marginal mandibular nerve as recipient vessels and nerve. During the resection, second team harvested a free gracillis muscle from the
2
Coskunfirat et al. Table 1. The Patient Characteristics
Case number
Age
Sex
Lesion
1
63
Male
SCC
% 90 Lip
7 3 4 cm
2
75
Male
SCC
6 3 5 cm
3
67
Male
SCC
60% Lip, including right commissure and lower cheek % 90 Lip
4
46
Male
SCC
% 80 Lip
6 3 4 cm
5
51
Male
SCC
8 3 5 cm
6
65
Male
SCC
% 90 Lip, including right commissure %100 Lip
7
56
Male
SCC
%90 Lip
8 3 4 cm
Defect
Flap size
6 3 4 cm
7 3 5 cm
Recipient vessels-nerve
Flap survival
Complication
Facial artery and vein- marjinal mandibular nerve Facial artery and vein- marjinal mandibular nerve
Survived Survived
Wound dehiscence None
Facial artery and veinmandibular nerve Facial artery and veinmandibular nerve Facial artery and veinmandibular nerve Facial artery and veinmandibular nerve Facial artery and veinmandibular nerve
marjinal
Survived
None
marjinal
Survived
None
marjinal
Survived
None
marjinal
Survived
None
marjinal
Survived
None
Figure 1. A 51-year-old man affected by SCC of the lower lip required a radical full-thickness lower lip resection (a). The resection involved 90% of the lower lip right commissure (b). Gracillis muscle flap was harvested 8 3 5 cm, with medial circumflex femoral artery, vein, and obturator nerve (c). The right facial artery and vein were prepared as recipient vessels and marginal mandibular nerve was dissected (d). Anastomoses were performed and the motor nerve of gracillis muscle was coapted to marginal mandibular nerve. The muscle was inset, taking care to suture the edge of the flap, to the buccinator muscle laterally. The whole inner and outer surface of muscle was covered with STSG harvested from thigh (e). Postoperative period was uneventful. Six-month postoperative view (f).
contralateral thigh. The pedicle included the branch of the obturator nerve to the muscle. Muscle length was marked with vicryl sutures according to the resting tension and prepared for resection. The pedicle and muscle were divided after completing the resection of the tumor, bilateral supraomohyoid neck dissection, and dissection of the recipient vessels at the neck. A STSG was used to cover the whole inner and outer surface of the gracillis flap, which will form mucosal surface and skin surface (Fig. 1e). Skin graft was harvested from thigh and sutured to the remaining mucosa for reconstruction of the lining. The gracillis muscle flap was divided and trimmed to the required width and length, sparing innervations, and nourishment of the muscle subMicrosurgery DOI 10.1002/micr
units. Then, the muscle was inset, according to resting muscle tension, taking care to suture, at the edge of the flap to the buccinator muscle laterally. The flap pedicle was anastomosed to the facial artery and vein, and then the marginal branch of the facial nerve was coapted to the motor nerve of the gracillis muscle. Finally, STSG was covered over the gracillis muscle. The rehabilitation program was started within 3 weeks of the operation to recover voluntary active labial movement. Patients were examined at a baseline and followedup at 3 months, 6 months, and 1 year. Physical examination for mouth opening, oral competence, word articulation, color match of the graft, contraction of the muscle, electromyographic studies, and sensation tests included the
Gracilis Muscle Flap in Lower Lip Reconstruction
3
Table 2. Results of Physical Examination, Electromyographic Studies, and Sensation Tests
Case number
Mean follow up (months)
Functional outcomes and aesthetic results
1
33
Satisfactory
2
25
Satisfactory
3
15
Satisfactory
4
11
Satisfactory
5
9
Satisfactory
6
7
Satisfactory
7
5
Satisfactory
Electrodiagnositic test results (6 months after surgery, 5 months for case 7) Needle EMG
SMW (1 year after surgery)
TPD (1 year after surgery)
Motor response was determined in the flap with preauricular facial nerve stimulus Motor response was determined in the flap with preauricular facial nerve stimulus. Motor response was determined in the flap with preauricular facial nerve stimulus.
2.44
5 mm
2.36
3 mm
2.83
6mm
Motor response was determined in the flap with preauricular facial nerve stimulus. Motor response was determined in the flap with preauricular facial nerve stimulus. Motor response was determined in the flap with preauricular facial nerve stimulus. Motor response was determined in the flap with preauricular facial nerve stimulus.
Not available
Not available
Not available
Not available
Not available
Not available
Not available
Not available
Motor NCS
Normal pattern Motor unit potentials . No fibrillation or abnormal spontaneous activity . Normal pattern MUP. No fibrillation or abnormal spontaneous activity. Motor unit potentials with minimal polyphasicity. Abnormal spontaneous activity at the center of flap tissue. Low-amplitude MUP. No fibrillation or abnormal spontaneous activity. Low-amplitude, minimal polyphasic MUP. No fibrillation or abnormal spontaneous activity. Short-duration, low-amplitude MUP. No fibrillation or abnormal spontaneous activity. Normal pattern MUP. No fibrillation or abnormal spontaneous activity.
SMW: Semmes weinstein monofilament test; TPD: Two point discrimination test.
Semmes-Weinstein monofilament, a hot-and-cold discrimination test, and a static two-point discrimination test were performed. RESULTS
The size of flaps ranged from 8 3 6 cm to 5 3 4 cm. All of flaps were survival. In third week of the postoperative period, one patient was reoperated because of wound dehiscence under local anaesthesia and primary closure was performed (Table 1). No complications were seen in other cases. No microvascular revisions were needed. In the second stage, vermillion reconstruction with a facial artery musculomucosal flap was performed to three patients. No patients had to receive postoperative radiotherapy. Length of the follow-up period was between 5 and 33 months. Color of the grafted skin was matched with the skin of the face and contraction of the muscle was evident clinically three months after surgery. The patients had no drooling and there were no problems with normal word articulation, mouth opening, or eating. Oral continence was satisfactory without any air leakage during puffing; the mouth sphincter function was restored completely.
Needle electromyography (EMG) showed motor unit potentials in the muscle flap. Motor nerve conduction study (NCS) showed motor response in the flap with preauricular facial nerve stimulus. The results were interpreted as recovery of motor innervation from the facial nerve took place in the six months after surgery (Table 2). The results of sensory tests before postoperative first year illustrated loss of sensation on the reconstructed lip. However after 1 year, patients showed recovered sensitivity to temperature, normal results of the test with Semmes-Weinstein monofilaments for the cutaneous pressure threshold, and two-point discrimination results were between 3 and 6 mm (Table 2). Heat and cold sensation were preserved in the reconstructed vermillion and 2-point discrimination test results were between 5 mm and 8 mm. The patients were satisfied with the functional and aesthetic results. The representative cases are presented in Figures 1–3. DISCUSSION
Presently, there is no universally accepted technique for subtotal or total reconstruction of the lower lip.10 An Microsurgery DOI 10.1002/micr
4
Coskunfirat et al.
Figure 2. A 63-year-old man who had SCC on the lower lip underwent resection and reconstruction with functional gracillis muscle flap (a,b). He was reoperated in the third week of postoperative period, under local anaesthesia, because of wound dehiscence at the lateral side of flap and primary closure was performed. The color match of the grafted skin with the skin of the face was satisfactory and contraction of the muscle was evident clinically 24th months after the operation (c,d). Oral continence was satisfactory without any air leakage during puffing (e).
ideal lip reconstruction should have good muscular function, adequate height, and sensation, allow sufficient opening for food and dentures and have an acceptable
aesthetic appearance.9 In the literature, several procedures have been reported for reconstruction of large defects of the lips. In principle, the lower lip can be reconstructed
Figure 3. A 46-year-old male patient had lower lip SCC (a). He underwent the resection of tumor involving 80% of the lower lip (b). Reconstruction was made with functional gracillis muscle flap covered with STSG. The flap was seen oedematous at postoperative one month (c). At sixth month after surgery, functional and aesthetic results were satisfactory (d,e). In second stage, vermillion reconstruction with facial artery musculomucosal flap was performed (f). The patient was satisfied with functional and aesthetic results.
Microsurgery DOI 10.1002/micr
Gracilis Muscle Flap in Lower Lip Reconstruction
using local flaps such as cheek advancement flaps3,4 karapandzic,5,6 nasolabial flaps,7,8 or combinations9,10 as well as regional pedicled flaps,10,11 and free flaps.12–17 Cheek advancement flaps that use tissue from the adjacent cheek may provide a superior colour match but they are adynamic and require significant laxity of the cheeks to prevent severe microstomia.3,4 The reconstructed lower lip is usually tight with a bulky upper lip, and a large amount of healthy tissue in the nasolabial and chin–labial area is disregarded.9 An innervated orbicularis oris flap was described by Karapandzic5 in 1974. It is probably the most popular and the most effective method amongst local flaps that the oral sphincter is recreated by incorporating the remaining lip tissue, which remains vascularized and sensate. However, this technique results in severe microstomia and abnormal appearance if the defect is large.18 Total lower lip reconstruction is also possible with an extended Karapandzic flap to avoid microstomia. The central segment of the lower lip after reconstruction with extended Karapandzic flaps has an adynamic region where the muscular sphincter is discontinuous, and the central vermillion is not replaced by lip tissue.24 The innervated depressor anguli oris flap consisted of the depressor anguli oris muscle with overlying skin and underlying lower mucosa was used for lower lip reconstruction.25 A buccal musculomucosal flap26 and an innervated buccal musculomucosal flap27 have been reported for wide defects. The actions of these muscles, the depressor and the buccinator muscle, oppose that of the orbicularis oris muscle, since those three muscles radiate away from the orbicularis oris muscle and act to open the mouth. Because of their function, they cannot be used as substitutes for the orbicularis oris muscle.22 Considering regional flaps, sternocleidomastoid or deltopectoral, these flaps appear very voluminous and require two-stage procedures.11 They cause bulkiness on the neck and an unpleasant appearance of the donor sites. Finally, free flaps may provide desired results in head and neck reconstruction for large defects. These can be used due to paucity of available soft tissue, previous radiation therapy, or previous surgery. The main advantages of a free flap are that the residual tissues are well preserved and the surgeon is not concerned about the final amount of the tissue resection.28 While free-tissue transfer can provide an abundance of soft tissue, care must be taken in selecting a donor site with an appropriate match in colour, texture, and pliability.28 The flap most often performed for total lip reconstruction is the radial forearm flap.12–15 Good aesthetic and functional results have been reported here. However, the radial forearm flap does not have its own motility; and, the colour and texture match is not perfect. In addition, donor-site morbidity is evident. To improve the oral
5
competence and provide some motility, fixation of the palmaris longus tendon or looping it around the modiolus28 has become an integral part of the method. With the advancement of perforator flaps, they have become options for lip reconstruction available to the reconstructive microsurgeon. Perforator flaps allow tissue to be thinned based on a preferential cutaneous blood supply and have minimal donor-site morbidity.29 Composite anterolateral thigh-fascia latae flap have been reported as a good alternative to radial forearm-palmaris longus flap for total lower lip reconstruction.17 However, all lower lip static reconstructions are essentially tension bands that relax with time and lose aspects of their barrier function.28 The combination of perioral muscle flaps and radial forearm flap was used to achieve dynamic reconstruction and techniques that use both free flaps for lip resurfacing and temporalis muscle turn-down flaps for lip elevation have been described for dynamic slings.30 Although these techniques may prevent ptosis of the lateral lip, they are unable to provide spontaneous symmetrical lower lip movement and with time, the degree of function achieved does not compare with the native lip’s mobility.30 Udea et al. has reported an innervated gracillis muscle flap placed between the folded skin islands of a radial forearm flap for dynamic lower lip reconstruction21,22 and achieved reasonable orbicularis functional outcome with ability to voluntarily animate the flap. The authors report that using the forearm flap to cover the muscle provides a large enough area with a thin flap to enable the muscle to move.22 According to our opinion, with this combination, the reconstructed lip looked thick and bulky even if functionally valid and the colour match was not suitable. Ninkovic et al.23 used a free gracillis muscular flap as well as a facial artery musculo-mucosal flap31 for the vermillion and a skin graft to the external surface, in reported series of two cases; and, achieved good functional and aesthetic results. Cordova et al presented their experience in lower lip reconstruction with a reinnervated free muscular gracillis flap for the muscular layer, an innervated musculo-mucosal flap for the vermillion and a full-thickness skin graft for the cutaneous layer in 2 cases of subtotal full-thickness defects of the lower lip after cancer excision.32 We preferred to overlay the entire surface of functional gracillis muscle flap with a single STSG graft harvested from thigh in our series of seven cases. Because we observed a loss of volume and contraction of flap in the first 3 month period, in order to create an aligned white roll, we performed vermillion reconstruction 3–6 months later, in the second stage. Covering the muscle surface with skin graft presented a natural appearance forming a thin subcutaneous tissue in contrast to the previous combination with radial forearm flap. Such an Microsurgery DOI 10.1002/micr
6
Coskunfirat et al.
extent that; owing to this thinness, wrinkles, and folds on the skin could be observed during the contraction as a natural lip. We provided the speed and convenience to the surgeon using a single large skin graft harvested from thigh and achieved a color match that was better than our expectations. This method shortened the operative time considerably, especially when compared with cases, which combined with other free flaps. Operation time varied between 2 and 3 hours when two teams operated simultaneously. This also reduced the morbidity. In our case series as different from the others in the literature; a wide, one-piece STSG from thigh was used to overlay the entire inner and outer surface of gracilis muscle and vermillion reconstruction was performed in a second stage. This refinement made the technique faster and simpler. We performed vermillion reconstruction using FAMM flap which is an axial flap consisting of the mucosa, submucosa, a small amount of buccinator muscle, and a more deeply lying facial artery and venous plexus.31 The FAMM flap is ideal for reconstructing lip mucosa because it consists of similar tissue, with the same color, texture, and moisture as a normal lip.31 Also, the bulk of the flap helps to restore lip fullness. These axial flaps are robust, a long flap measuring 7–8 cm can be raised safely.31 The sensitivity of the reconstructed lip was regained after one year. The regaining of sensation in the case of a flap transposed in the oral cavity has already been studied on various noninnervated free flaps and the sensory recovery was showed with sensation test.33,34 However, the physiological mechanism for the return of sensation in noninnervated free flaps is still not clear. It is assumed that the regeneration of nerve fibres along pre-existing nerve tissue or migration of sensitive receptors in the mouth mucosa. Another factor regarding sensory recovery is re-education of sensation and cortical “reprogramming.” Recovery of sensation should improve over the time as a result of this mechanism. Providing sensation to the lip is essential so that the patient can retain the ability to assess fluid and food temperature during drinking and eating.2 Although our patients regained sensitivity of the reconstructed lip after one year, patients had no drooling except for the first month, there were no problems with normal word articulation, mouth opening or eating. CONCLUSION
There is no definitive, widely accepted way of managing large full-thickness defects of the lower lip. Considering functional results, superior aesthetic appearance, and minimal donor-site morbidity of the functional gracillis transfer covered skin graft, we think that this method may be an alternative for large full-thickness defects of the lower lip. Microsurgery DOI 10.1002/micr
ACKNOWLEDGMENTS
The authors thank the Akdeniz University Faculty of Medicine for their support for this project.
REFERENCES 1. Jackson JT. Lip reconstruction. In: Jackson JT, editor. Local Flaps in Head and Neck Reconstruction. St. Louis: Mosby; 1985. pp 327–411. 2. Coppit GL, Lin DT, Burkey BB. Current concepts in lip reconstruction. Curr Opin Otolaryngol Head Neck Surg 2004;12:281–287. 3. Bernard C. Cancer de la levre inferieure opere par un procede nouveau. Bull Mem Soc Chir Paris 1853;3:357 4. Webster RC, Coffey RJ, Kelleher RE. Total and partial reconstruction of the lower lip with innervated muscle-bearing flaps. Plast Reconstr Surg 1960;25:360–371. 5. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93–97. 6. McGregor IA. Reconstruction of the lower lip. Br J Plast Surg 1983; 36:40–47. 7. Nakajima T, Yoshimura Y, Kami T. Reconstruction of the lower lip with a fan shaped flap based on the facial artery. Br J Plast Surg 1984;37:52–54. 8. Fujimori R. Gate flap for the total reconstruction of the lower lip. Br J Plast Surg. 1980;33:340 9. Luce EA. Reconstruction of the lower lip. Clin Plast Surg 1995;22: 109–121. 10. Galyon SW, Frodel JL. Lip and perioral defects. Otolaryngol Clin 2001;34:647–666. 11. Bakamjian VY, Long M, Rigg B. Experience with the medially based deltopectoral flap in reconstructive surgery of the head and neck. Br J Plast Surg 1971;24:174–183. 12. Wei FC, Tan BK, Chen IH, Hau SP, Liau CT. Mimicking lip features in free-flap reconstruction of lip defects. Br J Plast Surg 2001;54:8–11. 13. Sadove RC, Luce EA, McGrath PC. Reconstruction of the lower lip and chin with the composite radial forearm palmaris longus free flap. Plast Reconstr Surg 1991;88:209–214. 14. Furuta S, Sakaguchi Y, Iwasawa M, Kurita H, Minemura T. Reconstruction of the lips, oral commissure and full-thickness cheek with a composite radial forearm palmaris longus free flap. Ann Plast Surg 1994;33:544–547. 15. Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Total lower lip reconstruction with a composite radial forearm-palmaris longus tendon flap: A clinical series. Plast Reconstr Surg 2004;113:19–23. 16. Koshima I, Inagawa K, Urushibara K, Moriguchi T. Combined submental flap with toe web for reconstruction of the lip with oral commissure. Br J Plast Surg 2000;53:616–619. 17. Yildirim S, Gideroglu K, Aydogdu E, Avci G, Akan M, Akoz T. Composite anterolateral thigh-fascia lata flap: A good alternative to radial forearm-palmaris longus flap for total lower lip reconstruction. Plast Reconstr Surg 2006;117:2033–2041. 18. Kroll SS. Staged sequential flap reconstruction for large lower lip defects. Plast Rec Surg 1991;88:620–625. 19. Nicoli F, Chilgar RM, Sapountzis S, Yeo MS, Lazzeri D, Ciudad P, Kiranantawat K, S€ onmez TT, Maruccia M, Lim SY, Constantinides J, Chen HC. Reconstruction after orbital exenteration using gracillis muscle free flap. Microsurgery 2015;35:169–176. 20. Trignano E, Fallico N, Dessy LA, Armenti AF, Scuderi N, Rubino C, Ramakrishnan V. Transverse upper gracillis flap with implant in postmastectomy breast reconstruction: A case report. Microsurgery 2014;34:149–152. 21. Wechselberger G, Hladik M, Reichl H, Ensat F, Edelbauer M, Haug D, Schoeller T. The transverse musculocutaneous gracillis flap for chest wall reconstruction in male patients with Poland’s syndrome. Microsurgery 2013;33:282–286. 22. Ueda K, Oba S, Nakai K, Okada M, Kurokawa N, Nuri T. Functional reconstruction of the upper and lower lips and commissure with a forearm flap combined with a free gracillis muscle transfer. J Plast Reconstr Aesthet Surg 2009;62:337–340.
Gracilis Muscle Flap in Lower Lip Reconstruction 23. Ninkovic M, Spilimbergo SS, Ninkovic M. Lower lip reconstruction: Introduction of a new procedure using a functioning gracillis muscle free flap. Plast Reconstr Surg 2007;119:1472–1480. 24. Hanasono MM, Langstein HN. Extended Karapandzic flaps for near-total and total lower lip defects. Plast Reconstr Surg 2011;127:1199–1205. 25. Yotsuyanagi T, Nihei Y, Yokoi K, Sawada Y. Functional reconstruction using a depressor anguli oris musculocutaneous flap for large lower lip defects, especially for elderly patients. Plast Reconstr Surg 1999;103:850–856. 26. Ono I, Gunji G, Tateshita T, Sanbe N. Reconstruction of defects of the entire vermilion with a buccal musculomucosal flap following resection of malignant tumors of the lower lip. Plast Reconstr Surg 1997;100:422–430. 27. Zhao Z, Li Y, Xiao S, Fan X, Liu P, Zhang Z, Li S, Deng C, He M. Innervated buccal musculomucosal flap for wider vermilion and orbicularis oris muscle reconstruction. Plast Reconstr Surg 2005;116: 846–852. 28. Baumann D, Robb G. Lip reconstruction. Semin Plast Surg 2008;22: 269–280.
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29. Giessler GA, Cornelius CP, Suominen S, Borsche A, Fieger AJ, Schmidt AB, Fischer H. Primary and secondary procedures in functional and aesthetic reconstruction of noma-associated complex central facial defects. Plast Reconstr Surg 2007;120:134–143. 30. Yamauchi M, Yotsuyanagi T, Yokoi K, Urushidate S, Yamashita K, Higuma Y. One-stage reconstruction of a large defect of the lower lip and oral commissure. Br J Plast Surg 2005;58:614–618. 31. Pribaz JJ, Meara JG, Wright S, Smith JD, Stephens W, Breuing KH. Lip and vermilion reconstruction with the facial artery musculomucosal flap. Plast Reconstr Surg 2000;105:864–872. 32. Cordova A, D’Arpa S, Moschella F. Gracillis free muscle transfer for morphofunctional reconstruction of the lower lip. Head Neck 2008;30:684–689. 33. Vriens JP, Acosta R, Soutar DS, Webster MH. Recovery of sensation in the radial forearm free flap in oral reconstruction. Plast Reconstr Surg 1996;98:649–656. 34. Sabesan T, Ramchandani PL, Ilankovan V. Sensory recovery of noninnervated free flap in oral and oropharyngeal reconstruction. Int J Oral Maxillofac Surg 2008;37:819–823.
Microsurgery DOI 10.1002/micr
Objective: Reconstruction of the lips is pivotal because the lips play an essential role in facial aesthetics and have unique functional properties. We presented our experience in reconstruction of total or subtotal lower lip defects with functional gracillis muscle flap covered split-thickness skin graft (STSG) in patients. Methods: Between 2009 and 2011, seven patients underwent resection of lower lip squamous cell carcinoma and lip reconstruction. Gracillis muscle flap was performed for reconstruction. Recipient vessels were the facial artery and vein. Motor nerve of the gracillis muscle was coapted to the marginal branch of the facial nerve. Gracillis muscle was covered with STSG. Patients were evaluated about mouth opening, oral competence, word articulation, the color match of the graft, the contraction of the muscle by physical examination. Electromyographic studies and sensation tests were performed. Results: Postoperative course was uneventful for all of the flaps. No microvascular revisions were needed. One patient was reoperated because of wound dehiscence under local anaesthesia. Mean follow up period was 15 months. After three months, movement of the reconstructed lip was observed. Color of the grafted skin was matched with the skin of the face. The patients had no problems with word articulation, oral continence, or mouth opening. The electromyographic study showed recovery of motor innervation. After 1 year, the patients demonstrated recovered sensitivity with the sensation test. Conclusion: Considering functional results, superior aesthetic appearance, and minimal donor-site morbidity of the functional gracillis transfer covered skin graft, we think that this method may be an alternative for reconstruction of large C 2015 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2015. full-thickness defects of the lower lip. V
Lip
reconstruction is pivotal because lips play an essential role in facial aesthetics and have unique functional properties. To reconstruct a large full-thickness defect of more than two thirds of the lip, while maintaining these functions; such as articulation, mastication, provision for oral competence, expression of emotion, could be challenging.1 Lower lip reconstruction is more significant because, oral competence depends greatly on a functional lower lip having good muscular function as well as adequate height and sensation.1,2 In the literature, several procedures have been reported for reconstruction of large defects of the lower lip. The lower lip can be reconstructed using local flaps such as cheek advancement flaps,3,4 rotation,5,6 nasolabial flaps,7,8 or combination of local flaps,9,10 regional pedicled flaps,10,11 and free flaps.12–17 However, local flap and regional flap procedures are unsuitable when the total lip resection is performed on a patient who lacks laxity of tissue and they can cause severe microstomia and abnormal appearance of the lip.18 For this reason, large full-thickness defects of the lower lip are better repaired with microvascu1 Department of Plastic, Reconstructive and Aesthetic Surgery, Akdeniz University School of Medicine, Antalya, Turkey 2 Department of Anesthesiology, Akdeniz University School of Medicine, Antalya, Turkey Conflict of Interest: None of the authors of this manuscript have any commercial association that might pose or create a conflict of interest with the information presented in the submitted manuscript. This includes: consultancies, stock ownership, or other equity interests, patent licensing arrangements, and payments for conducting or publicizing the study described in the manuscript. *Correspondence to: Dr. Osman Koray Coskunfirat, M.D., Akdeniz € i, Antalya, Tu €ktif ve Estetik Cerrahi Klinig €rkiye. Universitesi, Plastik Rekonstru E-mail: [email protected] Received 9 November 2014; Revision accepted 10 May 2015; Accepted 12 May 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22431
Ó 2015 Wiley Periodicals, Inc.
lar free tissue transfer.2,13–17 There is no widely accepted way of managing. It is generally agreed that the best option, or at least the most commonly used, currently available to reconstruct the lip with a free flap is the composite tenofascio-cutaneous radial forearm flap13–15 or composite anterolateral thigh-fascia-latae flap.17 However, these flaps do not have their own motility. In addition, color and texture match is not perfect. Recently, gracillis muscle flap which is often used in free tissue transfer, has been started to be used in lip reconstruction.19–23 In this report, we presented our experience in reconstruction of total or subtotal lower lip defects with the functional gracillis muscle flap covered split thickness skin graft (STSG) in a series of 7 cases. PATIENTS AND METHODS
Between 2009 and 2011, seven patients underwent resection of lower lip squamous cell carcinoma (SCC) and lip reconstruction. All patients were male, their ages were between 46 and 75 years old and they had 60– 100% lip defect with included commissure in two patients (Table 1). Tumor resection and reconstruction with innervated gracillis free flap and skin graft was performed. All patients had bilateral supraomohyoid neck dissection simultaneously. SURGICAL TECHNIQUE
In the surgical operations, two team approach was used. One team performed tumor resection on the lower lip, bilateral supraomohyoid neck dissection and prepared the facial artery, vein and marginal mandibular nerve as recipient vessels and nerve. During the resection, second team harvested a free gracillis muscle from the
2
Coskunfirat et al. Table 1. The Patient Characteristics
Case number
Age
Sex
Lesion
1
63
Male
SCC
% 90 Lip
7 3 4 cm
2
75
Male
SCC
6 3 5 cm
3
67
Male
SCC
60% Lip, including right commissure and lower cheek % 90 Lip
4
46
Male
SCC
% 80 Lip
6 3 4 cm
5
51
Male
SCC
8 3 5 cm
6
65
Male
SCC
% 90 Lip, including right commissure %100 Lip
7
56
Male
SCC
%90 Lip
8 3 4 cm
Defect
Flap size
6 3 4 cm
7 3 5 cm
Recipient vessels-nerve
Flap survival
Complication
Facial artery and vein- marjinal mandibular nerve Facial artery and vein- marjinal mandibular nerve
Survived Survived
Wound dehiscence None
Facial artery and veinmandibular nerve Facial artery and veinmandibular nerve Facial artery and veinmandibular nerve Facial artery and veinmandibular nerve Facial artery and veinmandibular nerve
marjinal
Survived
None
marjinal
Survived
None
marjinal
Survived
None
marjinal
Survived
None
marjinal
Survived
None
Figure 1. A 51-year-old man affected by SCC of the lower lip required a radical full-thickness lower lip resection (a). The resection involved 90% of the lower lip right commissure (b). Gracillis muscle flap was harvested 8 3 5 cm, with medial circumflex femoral artery, vein, and obturator nerve (c). The right facial artery and vein were prepared as recipient vessels and marginal mandibular nerve was dissected (d). Anastomoses were performed and the motor nerve of gracillis muscle was coapted to marginal mandibular nerve. The muscle was inset, taking care to suture the edge of the flap, to the buccinator muscle laterally. The whole inner and outer surface of muscle was covered with STSG harvested from thigh (e). Postoperative period was uneventful. Six-month postoperative view (f).
contralateral thigh. The pedicle included the branch of the obturator nerve to the muscle. Muscle length was marked with vicryl sutures according to the resting tension and prepared for resection. The pedicle and muscle were divided after completing the resection of the tumor, bilateral supraomohyoid neck dissection, and dissection of the recipient vessels at the neck. A STSG was used to cover the whole inner and outer surface of the gracillis flap, which will form mucosal surface and skin surface (Fig. 1e). Skin graft was harvested from thigh and sutured to the remaining mucosa for reconstruction of the lining. The gracillis muscle flap was divided and trimmed to the required width and length, sparing innervations, and nourishment of the muscle subMicrosurgery DOI 10.1002/micr
units. Then, the muscle was inset, according to resting muscle tension, taking care to suture, at the edge of the flap to the buccinator muscle laterally. The flap pedicle was anastomosed to the facial artery and vein, and then the marginal branch of the facial nerve was coapted to the motor nerve of the gracillis muscle. Finally, STSG was covered over the gracillis muscle. The rehabilitation program was started within 3 weeks of the operation to recover voluntary active labial movement. Patients were examined at a baseline and followedup at 3 months, 6 months, and 1 year. Physical examination for mouth opening, oral competence, word articulation, color match of the graft, contraction of the muscle, electromyographic studies, and sensation tests included the
Gracilis Muscle Flap in Lower Lip Reconstruction
3
Table 2. Results of Physical Examination, Electromyographic Studies, and Sensation Tests
Case number
Mean follow up (months)
Functional outcomes and aesthetic results
1
33
Satisfactory
2
25
Satisfactory
3
15
Satisfactory
4
11
Satisfactory
5
9
Satisfactory
6
7
Satisfactory
7
5
Satisfactory
Electrodiagnositic test results (6 months after surgery, 5 months for case 7) Needle EMG
SMW (1 year after surgery)
TPD (1 year after surgery)
Motor response was determined in the flap with preauricular facial nerve stimulus Motor response was determined in the flap with preauricular facial nerve stimulus. Motor response was determined in the flap with preauricular facial nerve stimulus.
2.44
5 mm
2.36
3 mm
2.83
6mm
Motor response was determined in the flap with preauricular facial nerve stimulus. Motor response was determined in the flap with preauricular facial nerve stimulus. Motor response was determined in the flap with preauricular facial nerve stimulus. Motor response was determined in the flap with preauricular facial nerve stimulus.
Not available
Not available
Not available
Not available
Not available
Not available
Not available
Not available
Motor NCS
Normal pattern Motor unit potentials . No fibrillation or abnormal spontaneous activity . Normal pattern MUP. No fibrillation or abnormal spontaneous activity. Motor unit potentials with minimal polyphasicity. Abnormal spontaneous activity at the center of flap tissue. Low-amplitude MUP. No fibrillation or abnormal spontaneous activity. Low-amplitude, minimal polyphasic MUP. No fibrillation or abnormal spontaneous activity. Short-duration, low-amplitude MUP. No fibrillation or abnormal spontaneous activity. Normal pattern MUP. No fibrillation or abnormal spontaneous activity.
SMW: Semmes weinstein monofilament test; TPD: Two point discrimination test.
Semmes-Weinstein monofilament, a hot-and-cold discrimination test, and a static two-point discrimination test were performed. RESULTS
The size of flaps ranged from 8 3 6 cm to 5 3 4 cm. All of flaps were survival. In third week of the postoperative period, one patient was reoperated because of wound dehiscence under local anaesthesia and primary closure was performed (Table 1). No complications were seen in other cases. No microvascular revisions were needed. In the second stage, vermillion reconstruction with a facial artery musculomucosal flap was performed to three patients. No patients had to receive postoperative radiotherapy. Length of the follow-up period was between 5 and 33 months. Color of the grafted skin was matched with the skin of the face and contraction of the muscle was evident clinically three months after surgery. The patients had no drooling and there were no problems with normal word articulation, mouth opening, or eating. Oral continence was satisfactory without any air leakage during puffing; the mouth sphincter function was restored completely.
Needle electromyography (EMG) showed motor unit potentials in the muscle flap. Motor nerve conduction study (NCS) showed motor response in the flap with preauricular facial nerve stimulus. The results were interpreted as recovery of motor innervation from the facial nerve took place in the six months after surgery (Table 2). The results of sensory tests before postoperative first year illustrated loss of sensation on the reconstructed lip. However after 1 year, patients showed recovered sensitivity to temperature, normal results of the test with Semmes-Weinstein monofilaments for the cutaneous pressure threshold, and two-point discrimination results were between 3 and 6 mm (Table 2). Heat and cold sensation were preserved in the reconstructed vermillion and 2-point discrimination test results were between 5 mm and 8 mm. The patients were satisfied with the functional and aesthetic results. The representative cases are presented in Figures 1–3. DISCUSSION
Presently, there is no universally accepted technique for subtotal or total reconstruction of the lower lip.10 An Microsurgery DOI 10.1002/micr
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Coskunfirat et al.
Figure 2. A 63-year-old man who had SCC on the lower lip underwent resection and reconstruction with functional gracillis muscle flap (a,b). He was reoperated in the third week of postoperative period, under local anaesthesia, because of wound dehiscence at the lateral side of flap and primary closure was performed. The color match of the grafted skin with the skin of the face was satisfactory and contraction of the muscle was evident clinically 24th months after the operation (c,d). Oral continence was satisfactory without any air leakage during puffing (e).
ideal lip reconstruction should have good muscular function, adequate height, and sensation, allow sufficient opening for food and dentures and have an acceptable
aesthetic appearance.9 In the literature, several procedures have been reported for reconstruction of large defects of the lips. In principle, the lower lip can be reconstructed
Figure 3. A 46-year-old male patient had lower lip SCC (a). He underwent the resection of tumor involving 80% of the lower lip (b). Reconstruction was made with functional gracillis muscle flap covered with STSG. The flap was seen oedematous at postoperative one month (c). At sixth month after surgery, functional and aesthetic results were satisfactory (d,e). In second stage, vermillion reconstruction with facial artery musculomucosal flap was performed (f). The patient was satisfied with functional and aesthetic results.
Microsurgery DOI 10.1002/micr
Gracilis Muscle Flap in Lower Lip Reconstruction
using local flaps such as cheek advancement flaps3,4 karapandzic,5,6 nasolabial flaps,7,8 or combinations9,10 as well as regional pedicled flaps,10,11 and free flaps.12–17 Cheek advancement flaps that use tissue from the adjacent cheek may provide a superior colour match but they are adynamic and require significant laxity of the cheeks to prevent severe microstomia.3,4 The reconstructed lower lip is usually tight with a bulky upper lip, and a large amount of healthy tissue in the nasolabial and chin–labial area is disregarded.9 An innervated orbicularis oris flap was described by Karapandzic5 in 1974. It is probably the most popular and the most effective method amongst local flaps that the oral sphincter is recreated by incorporating the remaining lip tissue, which remains vascularized and sensate. However, this technique results in severe microstomia and abnormal appearance if the defect is large.18 Total lower lip reconstruction is also possible with an extended Karapandzic flap to avoid microstomia. The central segment of the lower lip after reconstruction with extended Karapandzic flaps has an adynamic region where the muscular sphincter is discontinuous, and the central vermillion is not replaced by lip tissue.24 The innervated depressor anguli oris flap consisted of the depressor anguli oris muscle with overlying skin and underlying lower mucosa was used for lower lip reconstruction.25 A buccal musculomucosal flap26 and an innervated buccal musculomucosal flap27 have been reported for wide defects. The actions of these muscles, the depressor and the buccinator muscle, oppose that of the orbicularis oris muscle, since those three muscles radiate away from the orbicularis oris muscle and act to open the mouth. Because of their function, they cannot be used as substitutes for the orbicularis oris muscle.22 Considering regional flaps, sternocleidomastoid or deltopectoral, these flaps appear very voluminous and require two-stage procedures.11 They cause bulkiness on the neck and an unpleasant appearance of the donor sites. Finally, free flaps may provide desired results in head and neck reconstruction for large defects. These can be used due to paucity of available soft tissue, previous radiation therapy, or previous surgery. The main advantages of a free flap are that the residual tissues are well preserved and the surgeon is not concerned about the final amount of the tissue resection.28 While free-tissue transfer can provide an abundance of soft tissue, care must be taken in selecting a donor site with an appropriate match in colour, texture, and pliability.28 The flap most often performed for total lip reconstruction is the radial forearm flap.12–15 Good aesthetic and functional results have been reported here. However, the radial forearm flap does not have its own motility; and, the colour and texture match is not perfect. In addition, donor-site morbidity is evident. To improve the oral
5
competence and provide some motility, fixation of the palmaris longus tendon or looping it around the modiolus28 has become an integral part of the method. With the advancement of perforator flaps, they have become options for lip reconstruction available to the reconstructive microsurgeon. Perforator flaps allow tissue to be thinned based on a preferential cutaneous blood supply and have minimal donor-site morbidity.29 Composite anterolateral thigh-fascia latae flap have been reported as a good alternative to radial forearm-palmaris longus flap for total lower lip reconstruction.17 However, all lower lip static reconstructions are essentially tension bands that relax with time and lose aspects of their barrier function.28 The combination of perioral muscle flaps and radial forearm flap was used to achieve dynamic reconstruction and techniques that use both free flaps for lip resurfacing and temporalis muscle turn-down flaps for lip elevation have been described for dynamic slings.30 Although these techniques may prevent ptosis of the lateral lip, they are unable to provide spontaneous symmetrical lower lip movement and with time, the degree of function achieved does not compare with the native lip’s mobility.30 Udea et al. has reported an innervated gracillis muscle flap placed between the folded skin islands of a radial forearm flap for dynamic lower lip reconstruction21,22 and achieved reasonable orbicularis functional outcome with ability to voluntarily animate the flap. The authors report that using the forearm flap to cover the muscle provides a large enough area with a thin flap to enable the muscle to move.22 According to our opinion, with this combination, the reconstructed lip looked thick and bulky even if functionally valid and the colour match was not suitable. Ninkovic et al.23 used a free gracillis muscular flap as well as a facial artery musculo-mucosal flap31 for the vermillion and a skin graft to the external surface, in reported series of two cases; and, achieved good functional and aesthetic results. Cordova et al presented their experience in lower lip reconstruction with a reinnervated free muscular gracillis flap for the muscular layer, an innervated musculo-mucosal flap for the vermillion and a full-thickness skin graft for the cutaneous layer in 2 cases of subtotal full-thickness defects of the lower lip after cancer excision.32 We preferred to overlay the entire surface of functional gracillis muscle flap with a single STSG graft harvested from thigh in our series of seven cases. Because we observed a loss of volume and contraction of flap in the first 3 month period, in order to create an aligned white roll, we performed vermillion reconstruction 3–6 months later, in the second stage. Covering the muscle surface with skin graft presented a natural appearance forming a thin subcutaneous tissue in contrast to the previous combination with radial forearm flap. Such an Microsurgery DOI 10.1002/micr
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Coskunfirat et al.
extent that; owing to this thinness, wrinkles, and folds on the skin could be observed during the contraction as a natural lip. We provided the speed and convenience to the surgeon using a single large skin graft harvested from thigh and achieved a color match that was better than our expectations. This method shortened the operative time considerably, especially when compared with cases, which combined with other free flaps. Operation time varied between 2 and 3 hours when two teams operated simultaneously. This also reduced the morbidity. In our case series as different from the others in the literature; a wide, one-piece STSG from thigh was used to overlay the entire inner and outer surface of gracilis muscle and vermillion reconstruction was performed in a second stage. This refinement made the technique faster and simpler. We performed vermillion reconstruction using FAMM flap which is an axial flap consisting of the mucosa, submucosa, a small amount of buccinator muscle, and a more deeply lying facial artery and venous plexus.31 The FAMM flap is ideal for reconstructing lip mucosa because it consists of similar tissue, with the same color, texture, and moisture as a normal lip.31 Also, the bulk of the flap helps to restore lip fullness. These axial flaps are robust, a long flap measuring 7–8 cm can be raised safely.31 The sensitivity of the reconstructed lip was regained after one year. The regaining of sensation in the case of a flap transposed in the oral cavity has already been studied on various noninnervated free flaps and the sensory recovery was showed with sensation test.33,34 However, the physiological mechanism for the return of sensation in noninnervated free flaps is still not clear. It is assumed that the regeneration of nerve fibres along pre-existing nerve tissue or migration of sensitive receptors in the mouth mucosa. Another factor regarding sensory recovery is re-education of sensation and cortical “reprogramming.” Recovery of sensation should improve over the time as a result of this mechanism. Providing sensation to the lip is essential so that the patient can retain the ability to assess fluid and food temperature during drinking and eating.2 Although our patients regained sensitivity of the reconstructed lip after one year, patients had no drooling except for the first month, there were no problems with normal word articulation, mouth opening or eating. CONCLUSION
There is no definitive, widely accepted way of managing large full-thickness defects of the lower lip. Considering functional results, superior aesthetic appearance, and minimal donor-site morbidity of the functional gracillis transfer covered skin graft, we think that this method may be an alternative for large full-thickness defects of the lower lip. Microsurgery DOI 10.1002/micr
ACKNOWLEDGMENTS
The authors thank the Akdeniz University Faculty of Medicine for their support for this project.
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29. Giessler GA, Cornelius CP, Suominen S, Borsche A, Fieger AJ, Schmidt AB, Fischer H. Primary and secondary procedures in functional and aesthetic reconstruction of noma-associated complex central facial defects. Plast Reconstr Surg 2007;120:134–143. 30. Yamauchi M, Yotsuyanagi T, Yokoi K, Urushidate S, Yamashita K, Higuma Y. One-stage reconstruction of a large defect of the lower lip and oral commissure. Br J Plast Surg 2005;58:614–618. 31. Pribaz JJ, Meara JG, Wright S, Smith JD, Stephens W, Breuing KH. Lip and vermilion reconstruction with the facial artery musculomucosal flap. Plast Reconstr Surg 2000;105:864–872. 32. Cordova A, D’Arpa S, Moschella F. Gracillis free muscle transfer for morphofunctional reconstruction of the lower lip. Head Neck 2008;30:684–689. 33. Vriens JP, Acosta R, Soutar DS, Webster MH. Recovery of sensation in the radial forearm free flap in oral reconstruction. Plast Reconstr Surg 1996;98:649–656. 34. Sabesan T, Ramchandani PL, Ilankovan V. Sensory recovery of noninnervated free flap in oral and oropharyngeal reconstruction. Int J Oral Maxillofac Surg 2008;37:819–823.
Microsurgery DOI 10.1002/micr
