Strategies in Lip Reconstruction

Primary repair with no flaps for lower lip defects (30-80 %) after cancer excision

Reconstruction of the lip is a necessary procedure when lip tumors are excised. Although many good techniques have been described, they often have disadvantages such as necrosis and extensive suture lines. In our approach, we aim to minimize the suture line and avoid tissue necrosis for medium-sized lip defects (30-80 %). This is a surgical technique report from a single center. After tumor resection, we made a bilateral 15 mm horizontal skin and mucosa incision from the angles of the lip to the lateral sides. The mucosa and skin were dissected from the underlying muscle, and the muscle was cut approximately 15 mm on each side. The lip defect was then closed and sutured in four layers. Finally, the released mucosa was sutured to the corner of the incised skin. We followed the patients for 36 months and found that their speech intelligibility, sensation, mobility, and aesthetic satisfaction were preserved. The scars were also less pronounced compared to flaps, and there were no signs of edema or drooling. In conclusion, our technique offers many advantages for moderate defects of lower lip tumors. By avoiding the use of flaps, we eliminate the complications associated with flap surgery while achieving aesthetically satisfactory results. However, further evaluation by other surgeons is necessary to fully examine the technique's benefits.

A Novel Technique to Convert Static Sling into a Dynamic Sling in Reconstruction of Total Lower Lip Defects Using Palmaris Longus Tendon with Free Radial Forearm Flap and Case Series

Lower lip reconstruction has been a major challenge for the reconstructive surgeons since time immemorial. Various types of reconstruction had been described for the reconstruction of lower lip ranging from local flaps to free tissue transfer to free functioning muscle transfer. For complete lower lip defects, the free radial forearm flap with palmaris longus tendon has been the standard of reconstruction for many years. Literatures suggests various techniques for utilizing palmaris longus tendon sling as a static as well as dynamic structure. The limitation with static reconstruction is the loss of sling support with time leading to eversion and drooping of the reconstructed lower lip and drooling of saliva. In this article we describe a simpler and novel technique which converts static reconstruction into a dynamic one with a series of 5 patients. Aim of this prospective study was to evaluate the post operative functional and aesthetic outcome of our technique of total lower lip reconstruction using free radial forearm flap with palmaris longus sling reconstruction. The medical records included were demographics, including age, gender, and reason for the acquired defect, lip reconstructed, reconstructive method, flap survival, and outcomes. At 6 months follow up, all patients had satisfactory outcome and were able to take oral diets and none of the patients complained of drooling, an inability to eat in a public setting, or microstomia. This technique which is a simpler modification can be helpful in converting the traditional static sling reconstruction of lower lip into a dynamic one resulting in good aesthetic and functional outcomes.

Oral Cavity Reconstruction

This summary provides a concise overview of oral cavity reconstruction to optimize functional outcomes in the modern era. Soft tissue and osseous reconstruction options for a wide range of oral cavity sites including lip, oral tongue, floor of mouth, buccal, hard palate, and composite oromandibular resections are reviewed. The appropriate applications of primary closure, secondary intention, skin grafts, and dermal substitute grafts are included. Anatomic considerations, indications, contraindications, and complications of local, regional, and free flaps in oral cavity reconstruction are discussed. Specific defects and the appropriate options for reconstruction of those defects are delineated.

Single-Stage Continent Reconstruction of Composite Pericommissural Defects Using a Combination of Pacman-Style Free Radial Forearm Flaps and Modified Elastic Musculomucosal Flaps

Introduction Based on the cross-innervation of buccal and marginal mandibular branches of the facial nerve, oblique elastic musculomucosal flaps (OEMMFs) can be harvested and used for continent neo-commissure and modiolus reconstructions. The composite pericommissural defects can then be reconstructed with double cutaneous paddles in Pacman-style free radial forearm flap (PFRFF). This novel single-stage continent reconstruction of composite post-excisional commissure and pericommissural (CPECPC) defects is evaluated in this study.

Patients and Methods This retrospective cohort study was conducted from April 2016 to March 2019. Forty-two patients underwent this type of reconstruction using a combination of PFRFF and OEMMF for the CPECPC defects. They were followed for an average period of 11.5 months. At the end of the follow-up period, they were assessed using the objective institutional scoring system by two independent observers and final score was computed for each patient.

Results The average score obtained at the end of the follow-up period was 11.5 (p = 0.035) using the institutional assessment scoring system, which evaluated both the overall aesthesis and function of the neo-commissure and modiolus.

Conclusions The combination of OEMMF and PFRRF for the single-stage reconstruction of CPECPC defects is a useful addendum for re-establishing the aesthesis and continence at the reconstructed site.

Functional and aesthetic outcome of different methods of reconstruction of full thickness lip defects

Background: The lip has functional and aesthetic importance. Lip defects occur due to the variety of etiology and the choice of their reconstruction has profound effect on functions and cosmesis. There are multiple options available for reconstruction according to defect size, but superiority of one method over another is still debated and hence the methods and their outcome were analyzed prospectively. Material and method: Twenty-one patients with all sizes and locations of defects in upper and lower lip with acquired etiology were included in the evaluation. Reconstruction was performed according to defect size, availability of local/regional and distant donor tissue, defect location, patients' comorbid conditions and patients' preference. Patients were assessed at 1 month and 6 months postoperatively. Observers' and patients' input were also taken into account for outcome. Results: Out of 21 patients, 5 free radial artery forearm flap reconstructions, 4 nasolabial flap reconstructions, 5 primary closures of defect, 4 Estlander flap reconstructions, 2 lip advancements, and one Karapandzic flap reconstruction were done. Free flap and nasolabial flap had hypoesthesia and incompetence if commissure is reconstructed and problem of bulk, restricted mobility and vermilion mismatch. Local and lip flaps were associated with decreased stoma size and some form of local scarring and asymmetry. However, all patients were satisfied with the functional and aesthetic outcome. Conclusion: Local flaps are better in terms of functional and aesthetic outcome but with some degree of microstomia which was well tolerated by most patients. Regional and distant flaps provide reconstruction where no other option is available and provide good functional support and acceptable cosmesis.

Mucomuscular Elastic Flap for Lower Lip Vermilion Reconstruction: Experience in a Series of Cases in Pediatric Patients

ABSTRACT

The mucocutaneous line and the lip vermilion are important structures from an esthetic standpoint but also in relation to the functionality of the mouth. In the literature, several types of flaps have been described for reparation of labial defects in adults. In this study, the authors analyze results of surgical reconstruction of the lower lip in the pediatric population using unilateral or bilateral mucomuscular elastic flaps for labial reconstruction. A retrospective analysis of 10 patients operated between 2003 and 2018 at our institution was made. The following demographic and clinical data were collected: age, sex, diagnosis, type of flap, follow-up, results, and complications. The Strasser scale was chosen for assessment of postoperative photographic results. Average age was 8.1 years (range 3-18). The most frequent etiology was arteriovenous malformation seen in 60% of cases. All cases corresponded to a defect of the lower lip. The average percentage of lip compromised was 44% and the largest length of compromise observed was 60% of the lip. Follow-up was on average 2.4 years. Esthetic results according to the Strasser method were as follows: 1 patient presented an excellent esthetic result, 5 good, 4 regular, and 0 poor.Considering the esthetic outcomes and low incidence of complications of the mucomuscular elastic flap, it is an acceptable and recommended technique of choice for lip vermilion reconstruction.

Elegance in Upper Lip Reconstruction

Restoration of the upper lip provides a reconstructive challenge because of its anatomical and aesthetic requirements. This article provides a "where is it on the lip" approach to reconstruct small to subtotal defects of the upper lip that are feasible to perform in the office setting. Emphasis is placed on adherence to core principles, attention to macroaesthetic and microaesthetic landmarks, and technical refinements of well-established reconstructive techniques. These tenets include algorithms for central and lateral defects, precise use of the Abbe flap, use of local tissue rearrangement and skin grafts, and appropriate management of scars. A strong understanding of the anatomical and aesthetic nuances of the upper lip will allow for enhancement of conventional reconstructive procedures to optimize functional and aesthetic outcomes.

Lip Repair after Mohs Surgery for Squamous Cell Carcinoma by Bilateral Tissue Expanding Vermillion Myocutaneous Flap (Goldstein Technique Modified by Sawada)

Squamous cell carcinoma is the most common malignancy of the lower lip. Environmental factors such as ultraviolet light exposure, arsenic and smoking are contributing factors to the increasing incidence. Mohs surgery is the treatment of choice ensuring the lowest recurrence rates. The closure of the surgical defects, however, can be a challenge. Multiple and versatile methods of reconstructing vermilion defects have been described. Among these options, Goldstein developed the adjacent ipsilateral vermilion flap based on an arterialized myocutaneous flap. The original technique was modified by Sawada based on bilateral adjacent vermilion advancement flap for closure of central vermilion defects. We report the use of bilateral flaps - Sawada’s technique (instead of unilateral as suggested by Goldstein) in medium (2 cm of extension) to large defects (> 2 cm) to achieve an effective and functional reconstruction of vermillion defects after Mohs surgery for lip cancer.

Single-stage reconstruction for buccal mucosa tumor resection including the labial commissure using a facial artery musculomucosal flap and a vermilion advancement flap

Resection of buccal mucosa tumors may occasionally involve the labial angle and peripheral skin. Reconstruction is required when the resection involves more than one-third of the lip. We describe a single-stage reconstruction using a facial artery musculomucosal (FAMM) flap and a vermilion advancement flap after buccal mucosa resection including the labial angle. A 62-year-old woman with carcinoma in situ of the buccal mucosa underwent tumor resection. The resection included the right labial angle and peripheral skin. The resection did not lead to a massive lip defect, but a wide defect resulted on the mucosal side. The defect on the mucosal side was reconstructed using a FAMM flap, while the vermilion defect was covered using a vermilion advancement flap. Reconstruction performed using the FAMM flap and vermilion advancement flap produced aesthetically and functionally satisfactory outcomes.

A Modified Single-Step Method to Repair a Central Defect of the Upper Lip

INTRODUCTION

Defects in the central region of the upper lip are difficult to repair.

DISCUSSION

Several techniques have been described, many of them requiring a second surgical procedure to obtain acceptable aesthetic results.

CASE REPORT

A patient with a soft defect in the central region of the upper lip following aggression by human bite is presented. To repair the defect, the principles described by Goldstein for lateral lip defects were used (Goldstein in Plast Reconstr Surg 85(3):446-452, 1990; Robotti et al. in J Plast Reconstr Aesthet Surg 63:431-439, 2010).

CONCLUSION

In this particular case, two full-thickness advancing miomucosal flaps from the vermilion of the upper lip were used with predictable aesthetic results.

Modified Bilateral Neurovascular Cheek Flap: Functional Reconstruction of Extensive Lower Lip Defects

BACKGROUND

Reconstruction of extensive lower lip defects is challenging, and functional outcomes are difficult to achieve.

METHODS

A modified bilateral neurovascular cheek (MBNC) flap has been described. The data of patients with cancer of the lower lip treated with wide excision and reconstructed with the MBNC flap in the Plastic Surgery Unit, Srinagarind Hospital, Khon Kaen University, from 1966 to 2012 were reviewed.

RESULTS

Of the total of 143 patients included, 90.91% were women, and their age ranged from 32 to 100 years. All defects involved 70% or greater of the lower lip, which included oral commissure, buccal mucosa, or cheek skin and upper lip. All 20 patients who were followed up demonstrated good outcomes of intercommissural distance, interlabial distance, sulcus depth, and 2-point discrimination compared with normal lip parameters according to age group and satisfaction with treatment.

CONCLUSIONS

Reconstruction of extensive lower lip defects with the MBNC flap provided good oral competence and functional outcomes. The flap provided adequate lip height and width, with proper position of oral commissure and vermilion reconstruction. The awareness about neurovascular anatomy of the lip and cheek and gentle dissection preserve the lip function. The flap overcomes the drawbacks of Karapandzic technique, which is microstomia, and of Bernard technique, which is a tight adynamic lower lip. It can be used in defects of more than two-thirds of the lip, extending to the cheek, commissural reconstruction, and secondary reconstruction.

The use of a modified abbé island flap to reconstruct primary lip defects of over 80

BACKGROUND

Lip reconstruction for defects greater than 80 % present a challenge in maintaining acceptable oral function and good aesthetic results. Abbé flaps offer an excellent reconstructive option but are limited to defects under 65 %.

METHODS

We describe a two-stage "modified Abbé island flap" technique whereby a full-thickness myocutaneous flap is combined with a modified Karapandzic flap, allowing for reconstruction of total and near total lip defects.

RESULTS

Six patients underwent successful two-stage lower and upper lip reconstruction with this technique. Oral competence and satisfactory aesthetic outcomes were achieved in all six cases. There were no complications. Although microstomia was noted to a certain extent, we argue this impact to be less than the morbidity of a free flap that lacks sphincteric function.

CONCLUSION

The "Modified Abbé Island Flap" can be used to reconstruct near-total lip defects using locally innervated, well-vascularized tissues that recreate the oral sphincter and restore oral competence. The combination of the conventional Abbé flap with a modified Karapandzic flap provides reliable results and significantly reduces operating time.

Combined Submental-tongue Flap for Reconstruction of Subtotal Traumatic Avulsion of Lower Lip: A Technical Note

Delayed reconstruction of large lower lip defects after traumatic avulsion is a challenge in medically compromised patients with concomitant cheek skin burn. Combination of orthograde submental transposition flap and anteriorly based ventral rectangular myomucosal tongue flap is useful. The former reconstructs the body of the defect, and the latter masks the red lip, resembling vermilion. In this article, the detailed surgical technique is explained. Literature review of tongue flap and submental flap in the lower lip reconstruction is presented.

Yu's flap for lower lip and reverse Yu's flap for upper lip reconstruction: 20 years experience

Reconstruction of defects of the lip caused by cancer with its requirements of a complicated anatomical structure, important physiological function, and acceptable cosmetic result, is a challenge for oral and maxillofacial and plastic surgeons. A method that combines rotation and advancement flaps was described by Yu in 1989 for the reconstruction of defects of the lower lip. In our department between January 1992 and December 2012, 8 patients had reverse Yu flaps for the reconstruction of upper lip defects and 56 patients had classic Yu flaps for lower lip defects. Patients with defects located laterally to the upper lips, ranging from ⅓ to ½, had unilateral reverse Yu flaps, and bilateral procedures were done for defects of less than ⅔ of the lips. However, if the defects were located in the centre of the upper lips, between ⅓ and ½, they were treated with bilateral reverse Yu flaps. Patients with defects between ⅓ and ⅔ of lower lips had unilateral Yu flaps, and if the defects were wider than ⅔ of the lower lips, the procedure was bilateral. No flap failed and desirable functional and aesthetic outcomes were recorded in all cases. Here we report our experience with the Yu flap for the benefit of other surgeons.

A new technique for reconstruction of lower-lip and labial commissure defects: a proposal for the association of Abbe-Estlander and vermilion myomucosal flap techniques

OBJECTIVE

Reconstruction of large lower-lip defects is a complex surgical procedure, especially when associated with defects that compromise the oral commissure. Various wide resections have been proposed with the aim to preserve orolabial function and achieve a pleasant esthetic result. However, no consensus exists on the optimum procedure. We propose a new technique that combines an Abbe-Estlander flap with a vermilion myocutaneous lower-lip flap.

STUDY DESIGN

Five consecutive patients presenting with lower-lip and oral commissure defects underwent surgical procedure. Surgical outcomes were analyzed based on oral competence, symmetry, sensibility, ability to wear denture prostheses, and postoperative complications.

RESULTS

All patients achieved satisfactory functional and esthetic results during the 12-month follow-up period.

CONCLUSIONS

The association of the Abbe-Estlander flap and the vermilion myomucosal lower-lip flap provides reliable results for the reconstruction of small and large defects involving the lower lip and the oral commissure.

The nasolabial flap as a one-stage procedure for reconstruction of intermediate-to-large lip defects with functional and aesthetic assessments

OBJECTIVES

The primary function of the lip is oral competence. The lips are also fundamental in facial aesthetics. Thus in lip reconstruction, it is paramount to achieve both good functional and aesthetic outcomes. Local flaps are able to provide the best tissue match in intermediate and large lip defects. Nevertheless, there has been limited literature on using the musculocutaneous nasolabial flap as a one-stage procedure for lip reconstruction.

METHODS

The authors recruited 21 patients who underwent a one-stage nasolabial musculocutaneous flap reconstruction for lip defects for the study. The modiolus at the mouth angle was preserved and the nasolabial flap was de-epithelised and tunnelled subcutaneously in all patients for reconstructing the lips. Electromyography was performed for 14 flaps to detect muscle activity. Oral competency was assessed using the Drooling Rating Scale and aesthetic outcomes were also analysed postoperatively with the Patient and Observer Scar Assessment Scale.

RESULTS

All patients successfully underwent lip reconstruction with the musculocutaneous nasolabial flap. There were no flap failures. Electromyographic activity was detected in 10 out of the 14 flaps tested. Oral competencies were well preserved and there were no cases of microstomia. Aesthetic results were also good.

CONCLUSION

The nasolabial flap for one-stage reconstruction of lip defects following lip resection is feasible. Good functional and aesthetic outcome can be achieved.

Reconstruction for defects of the lower lip after tumor ablation

BACKGROUND

The lip carcinoma, which frequently affects the lower lip, is one of the most common cancers of the head and neck region composing 25% to 30% of all oral cancers. The accepted method of therapy for lip cancer is surgical excision and reconstruction. The repair should satisfy 2 fundamental requirements: to achieve appropriate aesthetic quality and to conserve labial function. Currently, a wide range of reconstructive procedures have been developed.

OBJECTIVE

The objective of the study was to summarize the clinical experience of reconstruction for lower lip defects to facilitate the selection of a proper reconstructive strategy for different conditions in clinical practice.

METHODS

We performed a retrospective analysis of 43 patients who had undergone a standardized reconstructive approach based on the literature published and our own experience over the past 4 years.

RESULTS

Over an average period of 7.5 months' follow-up, recurrences or major complications did not happen, and most patients were satisfied with their functional and aesthetical outcome. Focusing on the location and the width of the defects of lower lip, a table has been exhibited to orient the surgeons to select a suitable reconstructive procedure for each patient.

CONCLUSIONS

Successful reconstruction of all defects can be attained, if as many surgical procedures as possible have been mastered, and a more proper means used.