Case Report Rapport de cas Nasal-skin-fold transposition flap for upper lip reconstruction in a French bulldog Manuel Benlloch-Gonzalez, Stéphanie Lafarge, Bernard Bouvy, Cyrill Poncet Abstract — Upper-lip reconstruction after mast-cell tumor-resection in a French bulldog was achieved by using a transposition flap from the nasal-skin-fold and an oral mucosal flap. The new technique is an alternative for reconstruction of extensive upper-lip defects in brachycephalic dogs and achieves satisfactory functional and cosmetic results. Résumé — Lambeau de transposition provenant du repli cutané nasal pour une reconstruction de la lèvre supérieure chez un Bouledogue français. Une reconstruction de la lèvre supérieure après une résection d’une tumeur à mastocytes chez un Bouledogue français a été réalisée en utilisant un lambeau de transposition provenant du repli cutané nasal et un lambeau oral des muqueuses. La nouvelle technique représente une option pour la reconstruction de défauts importants de la lèvre supérieure chez les chiens brachycéphaliques et donne des résultats fonctionnels et esthétiques satisfaisants. (Traduit par Isabelle Vallières)
Can Vet J 2013;54:983–986
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efects of the lips in dogs may result from trauma, tumor resection, and congenital disorders (1). Most of these lesions can be repaired using the lower labial pedicle, buccal rotation, upper labial pull-down, local tissue advancement, or transposition flaps and geometric closure techniques (2–5). The management of more extensive defects affecting the rostral upper lip presents challenges for reconstruction due to the limited availability of skin for tension-free closure. Only the facial transposition skin flap based at the commissure of the lip and the full-thickness labial advancement flap have been reported to successfully achieve the reconstruction of extensive rostral defects of the upper lips (4–6). This report describes the use of a novel technique based on the transposition of the nasal-skinfold (NSF) for upper-lip reconstruction in a French bulldog.
Case description A 5-year-old, 10-kg female French bulldog was presented with a labial mass that had been noticed 2 months previously and which had grown rapidly. An erythematous, alopecic, slightly raised, firm, 2 cm 3 3 cm mass was present over the rostral half of the right upper-lip showing signs of local infiltration, irritaDepartment of Small Animal Surgery and Medicine, Centre Hospitalier Vétérinaire Frégis — 43, Avenue Aristide Briand, 94110 Arcueil, France. Address all correspondence to Dr. Benlloch-Gonzalez; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. CVJ / VOL 54 / OCTOBER 2013
tion, and inflammation (Figure 1). Physical examination was otherwise unremarkable. A fine-needle aspiration of the mass and regional lymph node was performed: large mononuclear cells with intracytoplasmic purple granules were observed, suggestive of a mast-cell-tumor (MCT). Cytology of the submandibular lymph node aspirate identified a small number of mast cells mixed with the lymphoid population, but could not determine whether they were neoplastic or part of the normal immunologic cellular community. Clinical staging tests performed consisted of complete blood cell count, serum biochemistry, urinalysis, thoracic radiographs, and abdominal ultrasound. A splenic fine-needle aspiration and cytologic examination revealed no evidence of metastatic disease. Incisional biopsy of the mass was then suggested to be the best approach for definitive diagnosis but this option was refused by the owner. After discussion with the owner, it was decided to perform a wide resection of the mass aiming for 2-cm clean lateral macroscopic margins and upper lip reconstruction. Submandibular lymph node resection was also planned. This approach would provide definitive tumor histologic grading, staging, and potential cure in case of a low grade MCT. The owner was advised that in case of a high grade MCT clean margins may not be achieved and a multimodal approach would be recommended. Pre-anes thes ia medications inclu ded ranitidin e (GlaxoSmithKline, Marly-le-Roy cedex, France), 2 mg/kg body weight (BW), IV, dexamethasone (Intervet, Beaucouze cedex, France), 0.2 mg/kg BW, IV, metoclopramide (Ceva santé animale, Libourne, France), 0.5 mg/kg BW, IV, morphine hydrochloride (C.D.M Lavoisier, Paris, France), 0.2 mg/kg, SC, acepromazine maleate (Vétoquinol, Lure cedex, France), 0.05 mg/kg BW, SC, and glycopyrrolate (Vétoquinol), 0.01 mg/kg BW, IV. Anesthesia was induced with proprofol 983
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Figure 1. Preoperative view of the mast cell tumor. The margins of the skin flap (dotted line) and lip excision (dashed line) are represented.
Figure 2. The defect after full-thickness upper-lip resection and the harvested nasal-skin-fold and oral-mucosal flaps.
(Fresenius Kabi, Schelle, Belgium), 4 mg/kg BW, IV and maintained on 1.5 L/min of oxygen with 2% isoflurane (Baxter S.A.S., Maurepas, France). The right side of the face and neck was clipped and aseptically prepared. The oral cavity was lavaged with a 0.05% chlorhexidine solution. The right submandibular lymph node was first excised. Afterwards a resection of the entire lip was performed in order to get the widest margins possible. Upper lip reconstruction was accomplished using a transposition skin flap combined with an oral mucosal flap. To create the nasal transposition skin flap, a cutaneous incision was made over the caudal and rostral ridges of the NSF from its base laterally, to the top of the nose. The incisions were then connected with a third perpendicular incision at the mid-dorsal surface of the nose (Figure 1). The skin flap was carefully undermined respecting the nasolabialis muscle and facial vessels until it could be transposed ventrally for complete covering of the defect left by the resection of the upper lip. A 6 cm 3 2.5 cm flap was obtained. The buccal-mucosal defect was repaired using a flap created with 2 incisions converging cranially from the buccal mucosa of the labial commissure of the mouth to the buccal vestibule (Figure 2). The skin flap was first transposed 45° and sutured to the philtrum. Afterwards, the mucosal flap was advanced and apposed to the gingival mucosa rostrally, lining the NSF flap by contact of both flaps’ internal surfaces. Finally, the mucosal and cutaneous flaps were sutured to reconstruct the mucocutaneous border of the lip (Figure 3). No-tension closure of the defect was obtained. The excised lip and lymph node were submitted for histopathologic analysis. The dog recovered uneventfully from anesthesia, and there were no postoperative complications. Pain was managed with morphine hydrochloride (C.D.M Lavoisier) 0.2 mg/kg BW, SC, q4h, for 1 d and the dog was placed on cephalexin monohydrate (Sogeval, Laval cedex, France),
15 mg/kg BW, PO, q12h for 1 wk. The dog was hospitalized for 1 day, during which she seemed comfortable, eating and drinking normally. Histopathologic analysis of the mass showed a poorly demarcated infiltration of the skin by a dense population of tumor cells that were morphologically consistent with poorly differentiated mast cells. They were characterized by round-to-oval nuclei, light, eosinophilic cytoplasm and variable amounts of basophilic granulation, and they showed marked anisocytosis, anisokaryosis, multinucleation, large and irregular nuclei, and atypical mitotic figures. Mass excision was complete but with narrow margins (no tumor cells within 1 mm of the surgical margins). The tandem duplication mutation (ITD) in exon 11 of the c-kit gene was detected in tumor-derived DNA. The lymph node was hyperplastic and showed infiltration by a small number of mast cells with rare metachromatic granules in the cytoplasm and marked atypia visible after toluidine blue staining. A stage-2, grade-III MCT was therefore diagnosed (7–9). Histologic results and prognosis related to this tumor were discussed with the owner, who was interested in continuing palliative treatment with chemotherapy. Adjunctive-targeted therapy was instituted using toceranib phosphate (Palladia, Pfizer Italia s.r.l., Ascoli Piceno, Italy) 3.25 mg/kg BW, PO, q48h. During routine follow-up examinations, the dog showed good tolerance to the drug and the owners reported normal quality of life with satisfactory functionality of the lip and acceptable cosmetic appearance (Figure 4). Ten weeks after surgery, the dog was less active and a mass was noted in the right submandibular region. The cytologic examination of the submandibular mass was consistent with a suspected lymph node metastasis. Toceranib phosphate seemed to have lost effectiveness and the treatment was discontinued. A rescue therapy with vinblastine (vinblastine sulfate; EG Labo Boulogne-Billancourt cedex,
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Figure 3. Reconstruction of the oral vestibule and the mucocutaneous suture.
Figure 4. View at 6 weeks after surgery.
Paris), 2 mg/m2, IV, every week and prednisolone (Megasolone; Mérial, Lyon, France), 1 mg/kg BW, PO, q24h was then conducted. At the 4th week of the induction sessions, the dog’s activity was low, its body weight had decreased to 8.4 kg, and the lymph node was still markedly enlarged. Given the resistance to this chemotherapeutic agent a second rescue therapy, using lomustine (Belustine; ProStrakan Pharma, Saint-Cloud, France) 70 mg/m2, IV, and prednisolone (Megasolone), 1 mg/ kg BW, PO, q48h, was instituted. Two weeks later, the dog’s condition had deteriorated further, and 5 mo after surgery the dog was euthanized. Neither evidence of local recurrence nor complications were noted over the reconstructed lip at the time of euthanasia. No postmortem examination was performed.
tension-free closure of the donor and recipient sites (12). The lip reconstruction using this technique permitted a normal functionality of the lip without limiting full mouth-opening capacity as observed with the lower labial pedicle technique (5). Once the NSF flap was transposed, the short hair was directed in a caudo-ventral direction laterally which contributed to a satisfactory cosmetic result. Interestingly, with the use of the facial transposition skin flap based at the commissure of the lip, the dorsal orientation of the long hair originally located at the area of the neck, has been reported to promote nasal irritation and occasional sneezing (6). During mass resection, hemostasia of the terminal branches of the superior labial artery and lateral nasal artery was needed, but otherwise meticulous atraumatic technique was used to preserve the blood supply of the dorsal nasal artery arising from the infraorbital neurovascular pedicle at the base of the flap (13). However, vascularization of the nasal fold seemed to be robust as previous reports involving ligation of the infraorbital artery have not documented any adverse effect on regional perfusion (14–16) which is maintained by the collateral circulation of the lip and muzzle from the facial and the contralateral infraorbital arteries (13,14). Other potential indications for the use of the NSF subdermal plexus flap, include caudo-dorsal transposition for reconstruction of defects in adjacent structures as lower eyelids or to close defects secondary to orbital exenteration. One limitation of lip reconstruction using the NSF technique is related to the depth of the nasal fold, the size of which varies among dogs; the technique employed here is therefore useful only for candidates with well-developed NSF, such as English and French bulldogs or pugs, as nasal skin folds are naturally present in these breeds (17). We recommend careful evaluation of the NSF for presence of intertrigo, especially in ulcerated, erythematous,
Discussion Reconstruction of extensive upper-lip defects has been previously achieved with a lower labial pedicle, a facial transposition skin flap based at the commissure of the lip, and a full-thickness labial advancement flap techniques; nevertheless, only the 2 latter techniques are reported to provide sufficient skin for reconstruction of the rostral third of the upper lip (2–6). The transposition of the NSF in this French bulldog enabled reconstruction of the upper lip after its radical resection and was considered as an alternative for reconstruction of extensive defects of the upper-lip including its rostral region. Skin folds have been successfully used for reconstruction of skin defects. The axillary and the inguinal folds have been reported to cover large skin defects in the trunk, caudal abdomen, proximal limbs, and inguinal regions (10,11). To our knowledge, the use of a nasal fold has not been previously described for use in facial reconstruction. The NSF in this case represented an ideal donor site as it provided sufficient elastic local skin available to elevate a subdermal plexus flap and allow CVJ / VOL 54 / OCTOBER 2013
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fibrotic, or hyperplastic skin folds. Although these pathologies may be subjected to extended antibiotic and anti-inflammatory therapy to control the lesions before surgery, the need for this is questionable as after surgery the skin fold gets better ventilation and a short course of treatment is often sufficient to resolve the dermatitis (18). Another concern related to nasal-fold surgery could be iatrogenic ectropion (17); to prevent this possibility, attention is needed to not exceed the limits of the nasal fold’s ridges during the elevation of the flap in order to allow tensionfree closure of the donor site. Healing of oral mucous membranes occurs via a combination of contraction and epithelialization (5). Although oral mucous membranes regenerate rapidly, in large mucosal defects excessive wound contraction can result in deformity and loss of functionality of the lip (5,19). Among the techniques employed to reconstruct large upper lip defects only the full-thickness labial advancement flap and the lower labial pedicle rotation flap include an oral mucous lining in the same surgical maneuver (3,4). Nevertheless, in previous clinical application of the lower labial pedicle rotation flap for upper lip reconstruction the absence of oral mucosa repair did not cause any complication and a continuous mucous membrane lined the buccal surface of the original defects within 2 wk (5). In order to avoid previously mentioned potential complications, a mucosal-advancement flap was employed in this dog. Its use is recommended to enhance normal healing of the lip and to decrease discomfort. Taking into account the encouraging functional and cosmetic result in this dog, the nasal-skin-fold transposition flap has the advantage of providing a flap with a robust blood supply, which, lined with buccal mucosa, represents a satisfactory method of managing large upper lip defects in brachycephalic dogs. Transposition of the NSF using other angles and directions warrants further investigation. CVJ
References 1. Anderson GM. Soft tissues of the oral cavity. In: Tobias KM, Johnston SA, eds. Veterinary Surgery: Small Animals. 1st ed. Vol 2. St. Louis, Missouri: Elsevier Saunders, 2012:1425–1438. 2. Pavletic MM. Pedicle grafts. In: Slatter DH, ed. Textbook of Small Animal Surgery. 3rd ed. Philadelphia, Pennsylvania: WB Saunders, 2003:292–321.
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3. Pavletic MM. Facial reconstruction. In: Atlas of Small Animal Wound Management and Reconstructive Surgery. 3rd ed. Ames, Iowa: WileyBlackwell, 2010:433–480. 4. Degner DA. Facial reconstructive surgery. Clin Tech Small Anim Pract 2007;22:82–88. 5. Smeak DD. Lower labial pedicle rotation flap for reconstruction of large upper lip defects in two dogs. J Am Anim Hosp Assoc 1992; 28:565–569. 6. Yates G, Landon B, Edwards G. Investigation and clinical application of a novel axial pattern flap for nasal and facial reconstruction in the dog. Aust Vet J 2007;85:113–118. 7. Patnaik AK, Ehler WJ, MacEwen EG. Canine cutaneous mast cell tumor: Morphologic grading and survival time in 83 dogs. Vet Pathol 1984;21:469–474. 8. Kiupel M, Webster JD, Bailey KL, et al. Proposal of a 2-tier histologic grading system for canine cutaneous mast cell tumors to more accurately predict biological behaviour. Vet Pathol 2011;48:147–155. 9. Turrel JM, Kitchell BE, Miller LM, et al. Prognostic factors for radiation treatment for mast cell tumors in 85 dogs. J Am Vet Med Assoc 1988;193:936–940. 10. Hunt GB. Skin fold advancement flaps for closing large sternal and inguinal wounds in cats and dogs. Vet Surg 1995;24:172–175. 11. Hunt GB, Tisdall PL, Liptak JM, Beck JA, Swinney GR, Malik R. Skin-fold advancement flaps for closing large proximal limb and trunk defects in dogs and cats. Vet Surg 2001;30:440–448. 12. Pavletic MM. Skin flaps in reconstructive surgery. Vet Clin North Am 1990;20:81–103. 13. Evans HE. The head and arteries. In: Miller’s Anatomy of the Dog. 3rd ed. Philadelphia, Pennsylvania: WB Saunders, 1993:586–681. 14. Salisbury SK, Richardson DC, Lantz GC. Partial maxillectomy and premaxillectomy in the treatment of oral neoplasia in the dog and cat. Vet Surg 1986;15:16–26. 15. Wallace J, Matthiesen DT, Patnaik AK. Hemimaxillectomy for the treatment of oral tumors in 69 dogs. Vet Surg 1992;21:337–341. 16. Lascelles BDX, Thomson MJ, Dernell WS, Straw RC, Lafferty M, Withrow SJ. Combined dorsolateral and intraoral approach for the resection of tumors of the maxilla in the dog. J Am Anim Hosp Assoc 2003;39:294–305. 17. White RAS. Surgical treatment of specific skin disorders. In: Slatter DH, ed. Textbook of Small Animal Surgery. 3rd ed. Philadelphia, Pennsylvania: WB Saunders, 2003:339–355. 18. Muller GH, Kirk RW, Scott DW, Griffin CE. Environmental skin diseases. In: Muller & Kirk’s Small Animal Dermatology. 6th ed. Philadelphia, Pennsylvania: WB Saunders, 2001:1073–1111. 19. Pavletic MM. Oral reconstructive surgical techniques. In: Atlas of Small Animal Wound Management and Reconstructive Surgery. 3rd ed. Ames, Iowa: Wiley-Blackwell, 2010:511–534.
CVJ / VOL 54 / OCTOBER 2013
Can Vet J 2013;54:983–986
D
efects of the lips in dogs may result from trauma, tumor resection, and congenital disorders (1). Most of these lesions can be repaired using the lower labial pedicle, buccal rotation, upper labial pull-down, local tissue advancement, or transposition flaps and geometric closure techniques (2–5). The management of more extensive defects affecting the rostral upper lip presents challenges for reconstruction due to the limited availability of skin for tension-free closure. Only the facial transposition skin flap based at the commissure of the lip and the full-thickness labial advancement flap have been reported to successfully achieve the reconstruction of extensive rostral defects of the upper lips (4–6). This report describes the use of a novel technique based on the transposition of the nasal-skinfold (NSF) for upper-lip reconstruction in a French bulldog.
Case description A 5-year-old, 10-kg female French bulldog was presented with a labial mass that had been noticed 2 months previously and which had grown rapidly. An erythematous, alopecic, slightly raised, firm, 2 cm 3 3 cm mass was present over the rostral half of the right upper-lip showing signs of local infiltration, irritaDepartment of Small Animal Surgery and Medicine, Centre Hospitalier Vétérinaire Frégis — 43, Avenue Aristide Briand, 94110 Arcueil, France. Address all correspondence to Dr. Benlloch-Gonzalez; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. CVJ / VOL 54 / OCTOBER 2013
tion, and inflammation (Figure 1). Physical examination was otherwise unremarkable. A fine-needle aspiration of the mass and regional lymph node was performed: large mononuclear cells with intracytoplasmic purple granules were observed, suggestive of a mast-cell-tumor (MCT). Cytology of the submandibular lymph node aspirate identified a small number of mast cells mixed with the lymphoid population, but could not determine whether they were neoplastic or part of the normal immunologic cellular community. Clinical staging tests performed consisted of complete blood cell count, serum biochemistry, urinalysis, thoracic radiographs, and abdominal ultrasound. A splenic fine-needle aspiration and cytologic examination revealed no evidence of metastatic disease. Incisional biopsy of the mass was then suggested to be the best approach for definitive diagnosis but this option was refused by the owner. After discussion with the owner, it was decided to perform a wide resection of the mass aiming for 2-cm clean lateral macroscopic margins and upper lip reconstruction. Submandibular lymph node resection was also planned. This approach would provide definitive tumor histologic grading, staging, and potential cure in case of a low grade MCT. The owner was advised that in case of a high grade MCT clean margins may not be achieved and a multimodal approach would be recommended. Pre-anes thes ia medications inclu ded ranitidin e (GlaxoSmithKline, Marly-le-Roy cedex, France), 2 mg/kg body weight (BW), IV, dexamethasone (Intervet, Beaucouze cedex, France), 0.2 mg/kg BW, IV, metoclopramide (Ceva santé animale, Libourne, France), 0.5 mg/kg BW, IV, morphine hydrochloride (C.D.M Lavoisier, Paris, France), 0.2 mg/kg, SC, acepromazine maleate (Vétoquinol, Lure cedex, France), 0.05 mg/kg BW, SC, and glycopyrrolate (Vétoquinol), 0.01 mg/kg BW, IV. Anesthesia was induced with proprofol 983
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Figure 1. Preoperative view of the mast cell tumor. The margins of the skin flap (dotted line) and lip excision (dashed line) are represented.
Figure 2. The defect after full-thickness upper-lip resection and the harvested nasal-skin-fold and oral-mucosal flaps.
(Fresenius Kabi, Schelle, Belgium), 4 mg/kg BW, IV and maintained on 1.5 L/min of oxygen with 2% isoflurane (Baxter S.A.S., Maurepas, France). The right side of the face and neck was clipped and aseptically prepared. The oral cavity was lavaged with a 0.05% chlorhexidine solution. The right submandibular lymph node was first excised. Afterwards a resection of the entire lip was performed in order to get the widest margins possible. Upper lip reconstruction was accomplished using a transposition skin flap combined with an oral mucosal flap. To create the nasal transposition skin flap, a cutaneous incision was made over the caudal and rostral ridges of the NSF from its base laterally, to the top of the nose. The incisions were then connected with a third perpendicular incision at the mid-dorsal surface of the nose (Figure 1). The skin flap was carefully undermined respecting the nasolabialis muscle and facial vessels until it could be transposed ventrally for complete covering of the defect left by the resection of the upper lip. A 6 cm 3 2.5 cm flap was obtained. The buccal-mucosal defect was repaired using a flap created with 2 incisions converging cranially from the buccal mucosa of the labial commissure of the mouth to the buccal vestibule (Figure 2). The skin flap was first transposed 45° and sutured to the philtrum. Afterwards, the mucosal flap was advanced and apposed to the gingival mucosa rostrally, lining the NSF flap by contact of both flaps’ internal surfaces. Finally, the mucosal and cutaneous flaps were sutured to reconstruct the mucocutaneous border of the lip (Figure 3). No-tension closure of the defect was obtained. The excised lip and lymph node were submitted for histopathologic analysis. The dog recovered uneventfully from anesthesia, and there were no postoperative complications. Pain was managed with morphine hydrochloride (C.D.M Lavoisier) 0.2 mg/kg BW, SC, q4h, for 1 d and the dog was placed on cephalexin monohydrate (Sogeval, Laval cedex, France),
15 mg/kg BW, PO, q12h for 1 wk. The dog was hospitalized for 1 day, during which she seemed comfortable, eating and drinking normally. Histopathologic analysis of the mass showed a poorly demarcated infiltration of the skin by a dense population of tumor cells that were morphologically consistent with poorly differentiated mast cells. They were characterized by round-to-oval nuclei, light, eosinophilic cytoplasm and variable amounts of basophilic granulation, and they showed marked anisocytosis, anisokaryosis, multinucleation, large and irregular nuclei, and atypical mitotic figures. Mass excision was complete but with narrow margins (no tumor cells within 1 mm of the surgical margins). The tandem duplication mutation (ITD) in exon 11 of the c-kit gene was detected in tumor-derived DNA. The lymph node was hyperplastic and showed infiltration by a small number of mast cells with rare metachromatic granules in the cytoplasm and marked atypia visible after toluidine blue staining. A stage-2, grade-III MCT was therefore diagnosed (7–9). Histologic results and prognosis related to this tumor were discussed with the owner, who was interested in continuing palliative treatment with chemotherapy. Adjunctive-targeted therapy was instituted using toceranib phosphate (Palladia, Pfizer Italia s.r.l., Ascoli Piceno, Italy) 3.25 mg/kg BW, PO, q48h. During routine follow-up examinations, the dog showed good tolerance to the drug and the owners reported normal quality of life with satisfactory functionality of the lip and acceptable cosmetic appearance (Figure 4). Ten weeks after surgery, the dog was less active and a mass was noted in the right submandibular region. The cytologic examination of the submandibular mass was consistent with a suspected lymph node metastasis. Toceranib phosphate seemed to have lost effectiveness and the treatment was discontinued. A rescue therapy with vinblastine (vinblastine sulfate; EG Labo Boulogne-Billancourt cedex,
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Figure 3. Reconstruction of the oral vestibule and the mucocutaneous suture.
Figure 4. View at 6 weeks after surgery.
Paris), 2 mg/m2, IV, every week and prednisolone (Megasolone; Mérial, Lyon, France), 1 mg/kg BW, PO, q24h was then conducted. At the 4th week of the induction sessions, the dog’s activity was low, its body weight had decreased to 8.4 kg, and the lymph node was still markedly enlarged. Given the resistance to this chemotherapeutic agent a second rescue therapy, using lomustine (Belustine; ProStrakan Pharma, Saint-Cloud, France) 70 mg/m2, IV, and prednisolone (Megasolone), 1 mg/ kg BW, PO, q48h, was instituted. Two weeks later, the dog’s condition had deteriorated further, and 5 mo after surgery the dog was euthanized. Neither evidence of local recurrence nor complications were noted over the reconstructed lip at the time of euthanasia. No postmortem examination was performed.
tension-free closure of the donor and recipient sites (12). The lip reconstruction using this technique permitted a normal functionality of the lip without limiting full mouth-opening capacity as observed with the lower labial pedicle technique (5). Once the NSF flap was transposed, the short hair was directed in a caudo-ventral direction laterally which contributed to a satisfactory cosmetic result. Interestingly, with the use of the facial transposition skin flap based at the commissure of the lip, the dorsal orientation of the long hair originally located at the area of the neck, has been reported to promote nasal irritation and occasional sneezing (6). During mass resection, hemostasia of the terminal branches of the superior labial artery and lateral nasal artery was needed, but otherwise meticulous atraumatic technique was used to preserve the blood supply of the dorsal nasal artery arising from the infraorbital neurovascular pedicle at the base of the flap (13). However, vascularization of the nasal fold seemed to be robust as previous reports involving ligation of the infraorbital artery have not documented any adverse effect on regional perfusion (14–16) which is maintained by the collateral circulation of the lip and muzzle from the facial and the contralateral infraorbital arteries (13,14). Other potential indications for the use of the NSF subdermal plexus flap, include caudo-dorsal transposition for reconstruction of defects in adjacent structures as lower eyelids or to close defects secondary to orbital exenteration. One limitation of lip reconstruction using the NSF technique is related to the depth of the nasal fold, the size of which varies among dogs; the technique employed here is therefore useful only for candidates with well-developed NSF, such as English and French bulldogs or pugs, as nasal skin folds are naturally present in these breeds (17). We recommend careful evaluation of the NSF for presence of intertrigo, especially in ulcerated, erythematous,
Discussion Reconstruction of extensive upper-lip defects has been previously achieved with a lower labial pedicle, a facial transposition skin flap based at the commissure of the lip, and a full-thickness labial advancement flap techniques; nevertheless, only the 2 latter techniques are reported to provide sufficient skin for reconstruction of the rostral third of the upper lip (2–6). The transposition of the NSF in this French bulldog enabled reconstruction of the upper lip after its radical resection and was considered as an alternative for reconstruction of extensive defects of the upper-lip including its rostral region. Skin folds have been successfully used for reconstruction of skin defects. The axillary and the inguinal folds have been reported to cover large skin defects in the trunk, caudal abdomen, proximal limbs, and inguinal regions (10,11). To our knowledge, the use of a nasal fold has not been previously described for use in facial reconstruction. The NSF in this case represented an ideal donor site as it provided sufficient elastic local skin available to elevate a subdermal plexus flap and allow CVJ / VOL 54 / OCTOBER 2013
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fibrotic, or hyperplastic skin folds. Although these pathologies may be subjected to extended antibiotic and anti-inflammatory therapy to control the lesions before surgery, the need for this is questionable as after surgery the skin fold gets better ventilation and a short course of treatment is often sufficient to resolve the dermatitis (18). Another concern related to nasal-fold surgery could be iatrogenic ectropion (17); to prevent this possibility, attention is needed to not exceed the limits of the nasal fold’s ridges during the elevation of the flap in order to allow tensionfree closure of the donor site. Healing of oral mucous membranes occurs via a combination of contraction and epithelialization (5). Although oral mucous membranes regenerate rapidly, in large mucosal defects excessive wound contraction can result in deformity and loss of functionality of the lip (5,19). Among the techniques employed to reconstruct large upper lip defects only the full-thickness labial advancement flap and the lower labial pedicle rotation flap include an oral mucous lining in the same surgical maneuver (3,4). Nevertheless, in previous clinical application of the lower labial pedicle rotation flap for upper lip reconstruction the absence of oral mucosa repair did not cause any complication and a continuous mucous membrane lined the buccal surface of the original defects within 2 wk (5). In order to avoid previously mentioned potential complications, a mucosal-advancement flap was employed in this dog. Its use is recommended to enhance normal healing of the lip and to decrease discomfort. Taking into account the encouraging functional and cosmetic result in this dog, the nasal-skin-fold transposition flap has the advantage of providing a flap with a robust blood supply, which, lined with buccal mucosa, represents a satisfactory method of managing large upper lip defects in brachycephalic dogs. Transposition of the NSF using other angles and directions warrants further investigation. CVJ
References 1. Anderson GM. Soft tissues of the oral cavity. In: Tobias KM, Johnston SA, eds. Veterinary Surgery: Small Animals. 1st ed. Vol 2. St. Louis, Missouri: Elsevier Saunders, 2012:1425–1438. 2. Pavletic MM. Pedicle grafts. In: Slatter DH, ed. Textbook of Small Animal Surgery. 3rd ed. Philadelphia, Pennsylvania: WB Saunders, 2003:292–321.
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