SURGICAL ONCOLOGY AND RECONSTRUCTION
Total Lower Lip Reconstruction With a Double Mental Neurovascular V-Y Island Advancement Flap Qi-Gen Fang, MS,* Shuang Shi, MS,y Xu Zhang, MS,z Zhen-Ning Li, MS,x Fa-Yu Liu, MD,k and Chang-Fu Sun, MD{ Purpose:
To assess the effectiveness of double mental V-Y island advancement flaps for total lower lip reconstructions.
Materials and Methods:
During a 6-year period, from 2006 to 2012, total lower lip reconstruction was performed in 12 patients using double mental V-Y island advanced flaps. The resulting lip function and superiority of each flap were analyzed. To assess any cosmetic implications, patients were asked to answer the Appearance Domain section from the University of Washington Quality of Life Questionnaire at least 12 months after discharge from the hospital.
Results:
All flaps survived completely and no short-term postoperative complications occurred. The mean follow-up time was 34.5 months (range, 15 to 69 months) and there was no recurrence of disease. All patients were capable of consuming a regular oral diet and no patients complained of an inability to eat in a public setting, drooling, or microstomia. The mean preoperative and postoperative open-mouth widths were 4.1 and 3.7 cm, respectively, and the mean reduced open-mouth width was 10%. The intercommissural width varied from 4.6 to 6.8 cm (mean, 5.5 cm). The mean postoperative 2-point discrimination was 11.2 mm (range, 9 to 13 mm). The mean score for the Appearance Domain section was 93.8 (range, 75 to 100).
Conclusion:
The mental V-Y island advancement flap reconstruction is a reliable procedure for total lower lip reconstruction. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:834.e1-834.e6, 2014
Lip cancer is a common form of malignant tumor in the oral cavity, specifically the lower lip. Fortunately, there are various reconstructive procedures that have been developed to treat defects after cancer ablation. For defects that affect an area smaller than one third of the lower lip, primary closure is recommended; for defects affecting a larger area, Abbe,1 Bernard,2 Karapandzic,3 and Webster4 flaps are available. For total
lower lip defects, free tissue transfers are most frequently recommended, although this may be complicated for patients of advanced age or for those with systemic disorders that require a high level of technical support. The mental V-Y island advancement flap was first introduced by Bayramicli et al,5 but there are few reports of its use in functional total lower lip
Received from the School of Stomatology, China Medical University, Shenyang, Liaoning, China.
Address correspondence and reprint requests to Dr Sun: Department of Oral and Maxillofacial Surgery, School of Stomatology, China
*Resident,
Department
of
Oral
Maxillofacial
Surgery,
Oromaxillofacial-Head and Neck Surgery.
Shenyang, Liaoning 110002, People’s Republic of China; e-mail:
yResident, Pediatric Density. zResident,
Department
Medical University, No 117, Nanjing North Street, Heping District, [email protected]
of
Oral
Maxillofacial
Surgery,
Received October 1 2013
Oral
Maxillofacial
Surgery,
Ó 2014 American Association of Oral and Maxillofacial Surgeons
Oromaxillofacial-Head and Neck Surgery. kProfessor, Department of Oral
Maxillofacial
Surgery,
Oromaxillofacial-Head and Neck Surgery. xResident,
Department
of
Accepted December 9 2013 0278-2391/13/01541-3$36.00/0 http://dx.doi.org/10.1016/j.joms.2013.12.010
Oromaxillofacial-Head and Neck Surgery. {Professor, Department Head, Department of Oral Maxillofacial Surgery, Oromaxillofacial-Head and Neck Surgery.
834.e1
834.e2
FANG ET AL
Table 1. CLINICAL INFORMATION OF THESE PATIENTS
Case 1 2 3 4 5 6 7 8 9 10 11 12
Age (yr)
Gender
Diagnosis
Tumor Stage
Defect (%)
Follow-Up (mo)
Appearance Domain Score
Results
54 75 70 67 69 66 84 74 69 71 72 75
M M F F M F F M M M M M
SCC VC BCC SCC LC BCC BCC BCC BCC SCC SCC VC
T1 T2 T2 T2 Tis T2 T2 T2 T2 T2 T2 T2
90 98 95 100 95 100 95 100 100 96 98 100
24 15 43 28 19 46 26 52 69 34 28 30
100 100 100 75 100 75 100 100 75 100 100 100
alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease
Abbreviations: BCC, basal cell carcinoma; F, female; LC, leukoplakia cancer; M, male; SCC, squamous cell carcinoma; VC, verrucous carcinoma. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
reconstruction. This report describes the authors’ experience of using this local flap for total lower lip reconstruction and the clinical results obtained.
Materials and Methods The China Medical University institutional research committee (Shenyang, Liaoning, China) approved this study and all participants signed an informed consent agreement. From 2006 to 2012, double mental V-Y island advanced (DMA) flap reconstruction was performed
FIGURE 1. Line drawing depicts cancer involving the total lower lip. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
in 12 patients (8 male and 4 female) for total lower lip reconstruction. The patients had no history of surgery, radiotherapy, or chemotherapy. The mean age was 70.5 years (range, 54 to 84 yr). Four cases were squamous cell carcinoma, 5 cases were basal cell carcinoma, 2 cases were verrucous carcinoma, and 1 case was leukoplakia cancer. According to the 2002 Union for International Cancer Control classification, all lesions were categorized clinically as early stage (Table 1). To evaluate how the flap affected the patient cosmetically, each patient was asked to answer the Appearance Domain section from the University of Washington Quality of Life Questionnaire version 4 at least 12 months after discharge from the hospital. The lower lip posture is controlled by an intricate complex of muscles. Its fibers decussate at the commissures and in the middle, and it consists of a pars marginalis and a pars peripheralis anatomically. The sensation of the lower lip is controlled by the mental nerve, and the motor nerves of all these muscles come from the facial nerve. The mental nerve, with the mental branch of the inferior alveolar artery, emerges from the mental foramen. The musculocutaneous blood supply of this region reaches the dermis through hundreds of small perforators, and they terminate in a fine reticular pattern characterized by the labial artery territories. The mental branch of the inferior alveolar artery helps to supply the chin and anastomosis with the submental and inferior labial vessels. In general, the mental nerve, the branches of the inferior labial artery, and the lowest fibers of the pars peripheralis of the orbicularis oris muscle remain intact when the lower lip is resected as part of treatment for a T1 or T2 tumor.
834.e3
TOTAL LOWER LIP RECONSTRUCTION
FIGURE 2. Because the total lower lip shows cancer involvement, an adequate margin must be achieved after the tumor is completely resected. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
The surgical procedure was performed by the senior author (C.-F.S.) and was carried out in accordance with the procedure described by Bayramicli et al.5 An adequate intact margin, away from the tumor border (Figs 1, 2), was achieved after the tumor was resected completely. A DMA flap was designed in a triangular shape; the apex was laid inferiorly and incorporated the mental nerve (Figs 3, 4). After ablation of the tumor, the skin was incised down to the
subdermal tissues on the planned borders of the bilateral V-Y flap. After deepening the medial incision down to the periosteum, elevation of the flap from the bone was performed in a medial-to-lateral direction. The mandibular attachments of the depressor muscles were separated from the bone during elevation of the apex of the flap, and then the dissection was carried out superiorly at the lateral border, and special care was taken to preserve the orbicular oris and depressor anguli oris muscles intact. Thus, the V-Y flap, which was based on the intact neurovascular bundle and the orbicular oris and depressor anguli oris muscles, was created and advanced superiorly (Figs 5, 6). A new oral sphincter was created with these muscles. The orbicularis oris muscle remained intact, and on advancing the flap upward, bilateral muscle fibers opposed the marginal orbicularis oris fibers of the remaining lower lip. The muscle and skin were sutured separately as 2 layers in a double ‘‘Y’’ fashion after advancing the triangular flap, hence, the name ‘‘double mental V-Y island advancement flap’’ (Fig 7). The vermilion defect was reconstructed by a local mucosal flap. Data analysis was performed using SPSS 13.0 (SPSS, Inc, Chicago, IL).
Results FIGURE 3. Designation of the mental V-Y flap. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
All flaps survived completely and no short-term postoperative complications occurred. The mean follow-up time was 34.5 months (range, 15 to 69 months) and there was no disease recurrence. All
834.e4
FANG ET AL
FIGURE 4. The mental V-Y island advancement flap was designed in a triangular pattern after the tumor was resected. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
patients were capable of maintaining a regular oral diet and no patients complained of an inability to eat in a public setting, drooling, or microstomia (Fig 8). The mean preoperative and postoperative open-mouth widths were 4.1 cm and 3.7 cm respectively, and the mean reduced open-mouth width was 10% (range, 8.4% to 13.3%). The intercommissural width (ICW) varied from 4.6 to 6.8 cm (mean, 5.5 cm). The mean
FIGURE 5. Surgical dissection of the mental V-Y island advancement flap. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
postoperative 2-point discrimination was 11.2 mm (range, 9 to 13 mm). Most patients (75%) reported no change in their appearance, and the mean score for the Appearance Domain section was 93.8 (standard deviation [SD], 11.3; range, 75 to 100; Table 1).
Discussion An ideal lip reconstruction should result in the semblance of a vermillion, an adequate oral lining, complete external skin cover, and approximately normal function.6 Previous reports have described the application of Karapandzic, Webster, and Bernard flaps in lip reconstruction.2-4 These local flaps preserve an intact motor and sensory nerve supply and avoid the additional transaction of the orbicularis oris muscle fibers. Therefore, they can enhance movement and sensation by minimizing denervation and atrophy of the sphincter. Salgarelli et al7 reported on a wave technique for the treatment of lower lip defects: the procedure could be performed under local anesthesia without transaction of the orbicular oris, depressor labii inferioris, or depressor anguli oris. However, none of these flaps are recommended for lower lip defects that cover more than 75% of the lip because microstomia might occur. Currently, the free tissue transfer is an excellent choice for head and neck reconstruction. Yamauchi et al8 reported on a 1-stage operation to reconstruct a large lower lip defect using a radial forearm free flap and temporal muscle transfer, but they did not
834.e5
TOTAL LOWER LIP RECONSTRUCTION
FIGURE 6. The V-Y flap was created and advanced superiorly for total lower lip reconstruction. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
report on the functional results, such as open-mouth width and oral competence. Recently, Fernandes and Clemow9 reported on 13 successful total lower lip repairs using free flaps: all patients were capable of maintaining an oral diet and no patients complained of drooling. However, free tissue transfers require a high level of technical support, a long operation time, and suitable health status; therefore, this procedure is not suitable for every patient.10
FIGURE 7. Appearance immediately after reconstruction. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
Alternative methods to those stated earlier include using the neck flap,11 but this simply covers the defects without taking function into consideration (all sphincter function was absent). As mentioned earlier, the DMA flap was introduced by Bayramicli et al.5 Chen et al12 reported on the feasibility of the flap in total lower lip reconstruction, but they did not use objective measurements to assess the outcome of the procedure. In the present study, reconstruction using 12 DMA flaps was performed successfully in patients with total lower lip defects; all flaps survived completely and there were no complications. This satisfactory outcome may be due in part to the reliable blood supply for the flap, which came from the mental artery. The mean score for the Appearance Domain section was 93.8 (SD, 11.3; range, 75 to 100), suggesting that the cosmetic change was minor and that all patients were satisfied with their appearance. This is consistent with findings from previous studies.12 Similarly, Bayramicli et al5 reported that only 1 of their patients complained about the pincushion appearance of the flap. Furthermore, the authors of the present study analyzed the openmouth width and found that the mean postoperative open-mouth width was 3.7 cm and that the mean reduced open-mouth width was 10%. This indicates that the flap not only can guarantee the postoperative open-mouth width, but also can preserve the original open-mouth width. Moreover, the mean ICW in the present study was 5.5 cm, which is within the normal range for the ICW in normal adults.13 The flap caused few negative effects on the ICW.
834.e6
FANG ET AL
FIGURE 8. Postoperative image after V-Y flap reconstruction. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
The static 2-point discrimination test proved to be a reliable, reproducible method for assessing sensation of the face and neck.14 The results showed that the mean postoperative 2-point discrimination was 11.2 mm, which was concurrent with that reported by previous investigators.5,14 This confirmed that the sensation function could be adequately restored by the mental neurovascular bundle. Therefore, the authors propose that this technique should be regarded as one of the procedures available for functional reconstruction of total or subtotal lower lip defects, However, it should be noted that the V-Y flap is not suitable for defects that extend to the mental region or those that involve the mandible. In these cases, free flaps are preferred.9 In summary, reconstruction with mental V-Y island advancement flaps can result in a satisfactory appearance, preserve the original open-mouth width, and restore sensation; therefore, it is a reliable procedure for total lower lip reconstruction.
References 1. Ebrahimi A, Maghsoudnia GR, Arshadi AA: Prospective comparative study of lower lip defects reconstruction with different local flaps. J Craniofac Surg 22:2255, 2011 2. Unsal Tuna EE, Oksuzler O, Ozbek C, et al: Functional and aesthetic results obtained by modified Bernard reconstruction technique after tumor excision in lower lip cancers. J Plast Reconstr Aesthet Surg 63:981, 2010
3. Etbunandan M, Macpherson DW, Santbanam V: Karapandzix flap for reconstruction of lip defects. J Oral Maxillofac Surg 65:2512, 2007 4. Minagawa T, Maeda T, Sbioya R: Esthetic and safe lower lip reconstruction of an asymmetric defect due to cancer resection: A modified Webster method combined with a nasolabial flap. J Oral Maxillofac Surg 69:e256, 2011 5. Bayramicli M, Numanoglu A, Tezel E: The mental V-Y island advancement flap in functional lower lip reconstruction. Plast Reconstr Surg 100:1682, 1997 6. Keskin M, Sutcu M, Tosun Z, et al: Reconstruction of total lower lip defects using radial forearm free flap with subsequent tongue flap. J Craniofac Surg 21:349, 2010 7. Salgarelli AC, Magnoni C, Bellini P: Wave technique for treatment of lower lip cancer. J Craniomaxillofac Surg 40:e386, 2012 8. Yamauchi M, Yotsuyanagi T, Yokoi K, et al: One-stage reconstruction of a large defect of the lower lip and oral commissure. Br J Plast Surg 58:614, 2005 9. Fernandes R, Clemow J: Outcomes of total or near-total lip reconstruction with microvascular tissue transfer. J Oral Maxillofac Surg 70:2899, 2012 10. Fang QG, Safdar J, Shi S, et al: Comparison studies of different flaps for reconstruction of buccal defects. J Craniofac Surg 24: e450, 2013 11. Yildirim S, Karaca M, Bilgic IM, et al: Lower lip reconstruction with neck flaps as a salvage procedure. J Craniofac Surg 21: 840, 2010 12. Chen WL, Wang YY, Zhou M, et al: Double mental neurovascular V-Y island advancement flaps combined with tongue flaps for functionally reconstructing total lower-lip defects. J Craniofac Surg 23:181, 2012 13. Farkas LG, Katic MJ, Forrest CR: International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg 16:615, 2005 14. Costas PD, Heatley G, Seckel BR: Normal sensation of the human face and neck. Plast Reconstr Surg 93:1141, 1994
Total Lower Lip Reconstruction With a Double Mental Neurovascular V-Y Island Advancement Flap Qi-Gen Fang, MS,* Shuang Shi, MS,y Xu Zhang, MS,z Zhen-Ning Li, MS,x Fa-Yu Liu, MD,k and Chang-Fu Sun, MD{ Purpose:
To assess the effectiveness of double mental V-Y island advancement flaps for total lower lip reconstructions.
Materials and Methods:
During a 6-year period, from 2006 to 2012, total lower lip reconstruction was performed in 12 patients using double mental V-Y island advanced flaps. The resulting lip function and superiority of each flap were analyzed. To assess any cosmetic implications, patients were asked to answer the Appearance Domain section from the University of Washington Quality of Life Questionnaire at least 12 months after discharge from the hospital.
Results:
All flaps survived completely and no short-term postoperative complications occurred. The mean follow-up time was 34.5 months (range, 15 to 69 months) and there was no recurrence of disease. All patients were capable of consuming a regular oral diet and no patients complained of an inability to eat in a public setting, drooling, or microstomia. The mean preoperative and postoperative open-mouth widths were 4.1 and 3.7 cm, respectively, and the mean reduced open-mouth width was 10%. The intercommissural width varied from 4.6 to 6.8 cm (mean, 5.5 cm). The mean postoperative 2-point discrimination was 11.2 mm (range, 9 to 13 mm). The mean score for the Appearance Domain section was 93.8 (range, 75 to 100).
Conclusion:
The mental V-Y island advancement flap reconstruction is a reliable procedure for total lower lip reconstruction. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:834.e1-834.e6, 2014
Lip cancer is a common form of malignant tumor in the oral cavity, specifically the lower lip. Fortunately, there are various reconstructive procedures that have been developed to treat defects after cancer ablation. For defects that affect an area smaller than one third of the lower lip, primary closure is recommended; for defects affecting a larger area, Abbe,1 Bernard,2 Karapandzic,3 and Webster4 flaps are available. For total
lower lip defects, free tissue transfers are most frequently recommended, although this may be complicated for patients of advanced age or for those with systemic disorders that require a high level of technical support. The mental V-Y island advancement flap was first introduced by Bayramicli et al,5 but there are few reports of its use in functional total lower lip
Received from the School of Stomatology, China Medical University, Shenyang, Liaoning, China.
Address correspondence and reprint requests to Dr Sun: Department of Oral and Maxillofacial Surgery, School of Stomatology, China
*Resident,
Department
of
Oral
Maxillofacial
Surgery,
Oromaxillofacial-Head and Neck Surgery.
Shenyang, Liaoning 110002, People’s Republic of China; e-mail:
yResident, Pediatric Density. zResident,
Department
Medical University, No 117, Nanjing North Street, Heping District, [email protected]
of
Oral
Maxillofacial
Surgery,
Received October 1 2013
Oral
Maxillofacial
Surgery,
Ó 2014 American Association of Oral and Maxillofacial Surgeons
Oromaxillofacial-Head and Neck Surgery. kProfessor, Department of Oral
Maxillofacial
Surgery,
Oromaxillofacial-Head and Neck Surgery. xResident,
Department
of
Accepted December 9 2013 0278-2391/13/01541-3$36.00/0 http://dx.doi.org/10.1016/j.joms.2013.12.010
Oromaxillofacial-Head and Neck Surgery. {Professor, Department Head, Department of Oral Maxillofacial Surgery, Oromaxillofacial-Head and Neck Surgery.
834.e1
834.e2
FANG ET AL
Table 1. CLINICAL INFORMATION OF THESE PATIENTS
Case 1 2 3 4 5 6 7 8 9 10 11 12
Age (yr)
Gender
Diagnosis
Tumor Stage
Defect (%)
Follow-Up (mo)
Appearance Domain Score
Results
54 75 70 67 69 66 84 74 69 71 72 75
M M F F M F F M M M M M
SCC VC BCC SCC LC BCC BCC BCC BCC SCC SCC VC
T1 T2 T2 T2 Tis T2 T2 T2 T2 T2 T2 T2
90 98 95 100 95 100 95 100 100 96 98 100
24 15 43 28 19 46 26 52 69 34 28 30
100 100 100 75 100 75 100 100 75 100 100 100
alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease alive without disease
Abbreviations: BCC, basal cell carcinoma; F, female; LC, leukoplakia cancer; M, male; SCC, squamous cell carcinoma; VC, verrucous carcinoma. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
reconstruction. This report describes the authors’ experience of using this local flap for total lower lip reconstruction and the clinical results obtained.
Materials and Methods The China Medical University institutional research committee (Shenyang, Liaoning, China) approved this study and all participants signed an informed consent agreement. From 2006 to 2012, double mental V-Y island advanced (DMA) flap reconstruction was performed
FIGURE 1. Line drawing depicts cancer involving the total lower lip. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
in 12 patients (8 male and 4 female) for total lower lip reconstruction. The patients had no history of surgery, radiotherapy, or chemotherapy. The mean age was 70.5 years (range, 54 to 84 yr). Four cases were squamous cell carcinoma, 5 cases were basal cell carcinoma, 2 cases were verrucous carcinoma, and 1 case was leukoplakia cancer. According to the 2002 Union for International Cancer Control classification, all lesions were categorized clinically as early stage (Table 1). To evaluate how the flap affected the patient cosmetically, each patient was asked to answer the Appearance Domain section from the University of Washington Quality of Life Questionnaire version 4 at least 12 months after discharge from the hospital. The lower lip posture is controlled by an intricate complex of muscles. Its fibers decussate at the commissures and in the middle, and it consists of a pars marginalis and a pars peripheralis anatomically. The sensation of the lower lip is controlled by the mental nerve, and the motor nerves of all these muscles come from the facial nerve. The mental nerve, with the mental branch of the inferior alveolar artery, emerges from the mental foramen. The musculocutaneous blood supply of this region reaches the dermis through hundreds of small perforators, and they terminate in a fine reticular pattern characterized by the labial artery territories. The mental branch of the inferior alveolar artery helps to supply the chin and anastomosis with the submental and inferior labial vessels. In general, the mental nerve, the branches of the inferior labial artery, and the lowest fibers of the pars peripheralis of the orbicularis oris muscle remain intact when the lower lip is resected as part of treatment for a T1 or T2 tumor.
834.e3
TOTAL LOWER LIP RECONSTRUCTION
FIGURE 2. Because the total lower lip shows cancer involvement, an adequate margin must be achieved after the tumor is completely resected. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
The surgical procedure was performed by the senior author (C.-F.S.) and was carried out in accordance with the procedure described by Bayramicli et al.5 An adequate intact margin, away from the tumor border (Figs 1, 2), was achieved after the tumor was resected completely. A DMA flap was designed in a triangular shape; the apex was laid inferiorly and incorporated the mental nerve (Figs 3, 4). After ablation of the tumor, the skin was incised down to the
subdermal tissues on the planned borders of the bilateral V-Y flap. After deepening the medial incision down to the periosteum, elevation of the flap from the bone was performed in a medial-to-lateral direction. The mandibular attachments of the depressor muscles were separated from the bone during elevation of the apex of the flap, and then the dissection was carried out superiorly at the lateral border, and special care was taken to preserve the orbicular oris and depressor anguli oris muscles intact. Thus, the V-Y flap, which was based on the intact neurovascular bundle and the orbicular oris and depressor anguli oris muscles, was created and advanced superiorly (Figs 5, 6). A new oral sphincter was created with these muscles. The orbicularis oris muscle remained intact, and on advancing the flap upward, bilateral muscle fibers opposed the marginal orbicularis oris fibers of the remaining lower lip. The muscle and skin were sutured separately as 2 layers in a double ‘‘Y’’ fashion after advancing the triangular flap, hence, the name ‘‘double mental V-Y island advancement flap’’ (Fig 7). The vermilion defect was reconstructed by a local mucosal flap. Data analysis was performed using SPSS 13.0 (SPSS, Inc, Chicago, IL).
Results FIGURE 3. Designation of the mental V-Y flap. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
All flaps survived completely and no short-term postoperative complications occurred. The mean follow-up time was 34.5 months (range, 15 to 69 months) and there was no disease recurrence. All
834.e4
FANG ET AL
FIGURE 4. The mental V-Y island advancement flap was designed in a triangular pattern after the tumor was resected. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
patients were capable of maintaining a regular oral diet and no patients complained of an inability to eat in a public setting, drooling, or microstomia (Fig 8). The mean preoperative and postoperative open-mouth widths were 4.1 cm and 3.7 cm respectively, and the mean reduced open-mouth width was 10% (range, 8.4% to 13.3%). The intercommissural width (ICW) varied from 4.6 to 6.8 cm (mean, 5.5 cm). The mean
FIGURE 5. Surgical dissection of the mental V-Y island advancement flap. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
postoperative 2-point discrimination was 11.2 mm (range, 9 to 13 mm). Most patients (75%) reported no change in their appearance, and the mean score for the Appearance Domain section was 93.8 (standard deviation [SD], 11.3; range, 75 to 100; Table 1).
Discussion An ideal lip reconstruction should result in the semblance of a vermillion, an adequate oral lining, complete external skin cover, and approximately normal function.6 Previous reports have described the application of Karapandzic, Webster, and Bernard flaps in lip reconstruction.2-4 These local flaps preserve an intact motor and sensory nerve supply and avoid the additional transaction of the orbicularis oris muscle fibers. Therefore, they can enhance movement and sensation by minimizing denervation and atrophy of the sphincter. Salgarelli et al7 reported on a wave technique for the treatment of lower lip defects: the procedure could be performed under local anesthesia without transaction of the orbicular oris, depressor labii inferioris, or depressor anguli oris. However, none of these flaps are recommended for lower lip defects that cover more than 75% of the lip because microstomia might occur. Currently, the free tissue transfer is an excellent choice for head and neck reconstruction. Yamauchi et al8 reported on a 1-stage operation to reconstruct a large lower lip defect using a radial forearm free flap and temporal muscle transfer, but they did not
834.e5
TOTAL LOWER LIP RECONSTRUCTION
FIGURE 6. The V-Y flap was created and advanced superiorly for total lower lip reconstruction. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
report on the functional results, such as open-mouth width and oral competence. Recently, Fernandes and Clemow9 reported on 13 successful total lower lip repairs using free flaps: all patients were capable of maintaining an oral diet and no patients complained of drooling. However, free tissue transfers require a high level of technical support, a long operation time, and suitable health status; therefore, this procedure is not suitable for every patient.10
FIGURE 7. Appearance immediately after reconstruction. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
Alternative methods to those stated earlier include using the neck flap,11 but this simply covers the defects without taking function into consideration (all sphincter function was absent). As mentioned earlier, the DMA flap was introduced by Bayramicli et al.5 Chen et al12 reported on the feasibility of the flap in total lower lip reconstruction, but they did not use objective measurements to assess the outcome of the procedure. In the present study, reconstruction using 12 DMA flaps was performed successfully in patients with total lower lip defects; all flaps survived completely and there were no complications. This satisfactory outcome may be due in part to the reliable blood supply for the flap, which came from the mental artery. The mean score for the Appearance Domain section was 93.8 (SD, 11.3; range, 75 to 100), suggesting that the cosmetic change was minor and that all patients were satisfied with their appearance. This is consistent with findings from previous studies.12 Similarly, Bayramicli et al5 reported that only 1 of their patients complained about the pincushion appearance of the flap. Furthermore, the authors of the present study analyzed the openmouth width and found that the mean postoperative open-mouth width was 3.7 cm and that the mean reduced open-mouth width was 10%. This indicates that the flap not only can guarantee the postoperative open-mouth width, but also can preserve the original open-mouth width. Moreover, the mean ICW in the present study was 5.5 cm, which is within the normal range for the ICW in normal adults.13 The flap caused few negative effects on the ICW.
834.e6
FANG ET AL
FIGURE 8. Postoperative image after V-Y flap reconstruction. Fang et al. Total Lower Lip Reconstruction. J Oral Maxillofac Surg 2014.
The static 2-point discrimination test proved to be a reliable, reproducible method for assessing sensation of the face and neck.14 The results showed that the mean postoperative 2-point discrimination was 11.2 mm, which was concurrent with that reported by previous investigators.5,14 This confirmed that the sensation function could be adequately restored by the mental neurovascular bundle. Therefore, the authors propose that this technique should be regarded as one of the procedures available for functional reconstruction of total or subtotal lower lip defects, However, it should be noted that the V-Y flap is not suitable for defects that extend to the mental region or those that involve the mandible. In these cases, free flaps are preferred.9 In summary, reconstruction with mental V-Y island advancement flaps can result in a satisfactory appearance, preserve the original open-mouth width, and restore sensation; therefore, it is a reliable procedure for total lower lip reconstruction.
References 1. Ebrahimi A, Maghsoudnia GR, Arshadi AA: Prospective comparative study of lower lip defects reconstruction with different local flaps. J Craniofac Surg 22:2255, 2011 2. Unsal Tuna EE, Oksuzler O, Ozbek C, et al: Functional and aesthetic results obtained by modified Bernard reconstruction technique after tumor excision in lower lip cancers. J Plast Reconstr Aesthet Surg 63:981, 2010
3. Etbunandan M, Macpherson DW, Santbanam V: Karapandzix flap for reconstruction of lip defects. J Oral Maxillofac Surg 65:2512, 2007 4. Minagawa T, Maeda T, Sbioya R: Esthetic and safe lower lip reconstruction of an asymmetric defect due to cancer resection: A modified Webster method combined with a nasolabial flap. J Oral Maxillofac Surg 69:e256, 2011 5. Bayramicli M, Numanoglu A, Tezel E: The mental V-Y island advancement flap in functional lower lip reconstruction. Plast Reconstr Surg 100:1682, 1997 6. Keskin M, Sutcu M, Tosun Z, et al: Reconstruction of total lower lip defects using radial forearm free flap with subsequent tongue flap. J Craniofac Surg 21:349, 2010 7. Salgarelli AC, Magnoni C, Bellini P: Wave technique for treatment of lower lip cancer. J Craniomaxillofac Surg 40:e386, 2012 8. Yamauchi M, Yotsuyanagi T, Yokoi K, et al: One-stage reconstruction of a large defect of the lower lip and oral commissure. Br J Plast Surg 58:614, 2005 9. Fernandes R, Clemow J: Outcomes of total or near-total lip reconstruction with microvascular tissue transfer. J Oral Maxillofac Surg 70:2899, 2012 10. Fang QG, Safdar J, Shi S, et al: Comparison studies of different flaps for reconstruction of buccal defects. J Craniofac Surg 24: e450, 2013 11. Yildirim S, Karaca M, Bilgic IM, et al: Lower lip reconstruction with neck flaps as a salvage procedure. J Craniofac Surg 21: 840, 2010 12. Chen WL, Wang YY, Zhou M, et al: Double mental neurovascular V-Y island advancement flaps combined with tongue flaps for functionally reconstructing total lower-lip defects. J Craniofac Surg 23:181, 2012 13. Farkas LG, Katic MJ, Forrest CR: International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg 16:615, 2005 14. Costas PD, Heatley G, Seckel BR: Normal sensation of the human face and neck. Plast Reconstr Surg 93:1141, 1994
