New way to raise the V-Y advancement flap for reconstruction of the lower lip: bipedicled orbicularis oris musculocutaneous flap technique

Myomucosal composite graft: A simple technique for full-thickness vermilion defects of the lower lip

Reconstruction of vermillion defects of the lower lip requires careful consideration of functional and aesthetic aspects. Traditionally, various local flap methods involving tissue advancement from the corner of the mouth, lateral chin, and medial cheek have been commonly employed to fill lower lip defects. However, these approaches have inherent limitations, which include technical complexity, disruption of the orbicularis oris muscle, lip tightening, microstomia, and visible scarring. To overcome these limitations, we employed a free myomucosal composite graft from the lower lip to reconstruct small to medium vermilion defects. Our technique is based on a simple and reproducible surgical approach that facilitates natural volume rearrangement of tissues. Moreover, this method enables precise inset and tension-free repair, prevents lip tightening, and offers excellent aesthetic outcomes with no vertical scarring and appropriate color matching with surrounding tissues.

Surgical Lip Cancer Reconstruction in the COVID-19 Era: Are Free Flaps or Loco-Regional Flaps Better?

Lip carcinoma is one of the most frequent conditions affecting the general population. It is among the ten most common neoplasms, but despite advances in research and therapy, its prognosis has not improved in a significant way in the past few years, making it a challenge in the medical research field and in surgical treatment. This study was conducted with the aim of evaluating the available reconstructive surgical options for the treatment of lip carcinomas in order to define which could be the most appropriate technique to achieve satisfying aesthetic and functional outcomes considering hospital resources in the COVID-19 era. Seventeen patients were included in this retrospective study, which took place between January 2019 and April 2021. There were two groups: seven patients who underwent a radial forearm free flap and ten who underwent locoregional flaps. The statistical analysis was performed to evaluate four different endpoints. Surgical length, ICU stay, and hospitalization time were minor for locoregional flaps. There was no statistically significant difference between the two groups when considering post-operative complications. Locoregional flaps have a more aesthetically pleasing result, but from a functional point of view, the results can be superimposable. Both techniques are associated with adequate speech, mouth opening, sealing, and symmetry. Given the impact of the COVID-19 pandemic on the healthcare system, locoregional flaps have been proven to be a good surgical option in the reconstruction of lip defects both in terms of aesthetics and functional outcome.

Medial Upper Lip Vermillion Reconstruction with a Labial Artery-based Cross-lip Vermillion Flap

A defect of the central upper lip vermillion generally requires “like for like” reconstruction because this part of the upper lip can attract attention and has a unique structure and color. In this article, we report use of a labial artery-based horizontal long cross-lip flap for central upper lip vermillion reconstruction. In the first stage of surgery, a horizontal long vermillion flap from the lower lip starting at the left commissure with a vascular pedicle containing an inferior labial artery was raised and transposed to the upper vermillion defect. In the second stage, 12 days later, the pedicle was divided to complete the reconstruction. There were no postoperative complications in articulation or eating, and the patient was satisfied with the esthetic outcome. This surgical technique reduces microstomia and inconvenience in eating and speaking compared with a common horizontal cross-lip flap and provides better color- and texture-matched tissue compared to reconstruction using a tongue flap or mucosal flap. The technique is simple, requires a relatively short surgical time, has minimum donor-site morbidity and permits good esthetic and functional reconstruction of the central upper lip vermillion for a relatively small defect.

Combined Tongue Flap and Deepithelialized Advancement Flap for Thick Lower Lip Reconstruction

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We repaired a long horizontal defect in the lower lip caused by the resection of squamous cell carcinoma by reconstructing the white lip with a V-Y advancement flap and vermilion with a tongue flap. During this procedure, we deepithelialized the V-Y flap, lifted the upper margin of the flap and sutured it to the remaining upper margin of the lip, and then covered it with the tongue flap, resulting in the successful reconstruction of a thick lip. There were no postoperative complications in articulation or swallowing. This novel procedure is a simple method to aesthetically and functionally reconstruct a thick lower lip.

Functional Sharing of the Upper Orbicularis Oris Muscle for the Reconstruction of the Lower Lip

The lip reconstruction is a very controversial topic in plastic surgery and many flaps have been described for this purpose. Despite all of the interventions, some patients still have problems such as drooling and gingival show that decrease their quality of life. In this study, the authors report a patient whose lower lip was resected totally for squamous cell carcinoma. His lip was reconstructed with radial forearm flap and the patient was referred to our clinic with the aforementioned complaints. A portion of the orbicularis oris muscle of the upper lip was designed as a bipedicled flap, and it was transposed to the lower lip to make the initial flap functional. After the operation, the sphincteric function of the lip was better, and the problems as drooling and gingival show were absent. In conclusion, this flap can be a good option to make the initial nonfunctional flaps (such as radial forearm flap), functional in the aspect of lower lip reconstruction. It has a function, and it is concordant with the principle of "reconstructing like with like." The native muscle tissue of the upper lip can be transferred partially to maintain physiologic oral competency.

Facial Artery Perforator and Depressor Anguli Oris Muscle Chimeric Flap: A New Design of an Old Flap

BACKGROUND

The aim of this study was to investigate the reliability and outcomes of the facial artery perforator and separately elevated depressor anguli oris (DAO) muscle chimeric flap for the reconstruction of partial or total lower lip defects.

METHODS

Eleven patients with malignant skin tumors located at the lower lip were operated between 2013 and 2015. After the excision of the tumor with adequate clear margins using margin controlled excision technique, an appropriate flap fitting to the resultant defect based on the perforators of the facial artery and DAO muscle was prepared and placed into the defect. The DAO muscle activity was tested with electromyography in the postoperative first year examination.

RESULTS

Besides 1 patient with transient venous insufficiency, all the flaps healed well without a partial or total flap loss. The mean follow-up period was 10 months. No new primary tumor or recurrence was observed. Although in 1 patient, transient asymmetric smiling and mild drooling was observed, the overall oral competence results were found to be quite satisfactory. The electromyography evaluation of DAO muscle of 5 patients who reached the postoperative first year examination showed action potential results in normal limits with a slight decrease. All patients were satisfied with the final esthetic and functional result.

CONCLUSIONS

The facial artery perforator and depressor angel oris muscle chimeric flap is a valuable option for reconstruction of lower lip defects providing esthetically and functionally good results.

Parallel pocket incision: Less invasive surgical intervention for the treatment of intractable pressure ulcer with wound edge undermining

BACKGROUND

The treatment of deep pressure ulcer with a wide wound edge undermining (pocket) is challenging, especially when conservative treatments are ineffective. As most patients with a pressure ulcer suffer from systemic comorbidities, invasive surgery cannot be performed on all patients, and less invasive treatment is required.

METHODS

Less invasive surgical intervention to a deep pressure ulcer, parallel pocket incision (PPI), was performed on 10 patients with intractable pressure ulcers with a pocket formation. In PPI procedures, two parallel skin incisions were made to open up the deepest fold of the pocket and to preserve the skin overlying the pocket lesion; through the created incisions, the necrotic tissues around the deepest fold of the undermining could be easily removed, which facilitated spontaneous wound healing. Postoperative results and complications were evaluated.

RESULTS

All PPI procedures were safely performed under local infiltration anesthesia without major postoperative complication; minor bleeding was seen intraoperatively in three patients, which could be easily controlled with electric cautery coagulation. Nine of 10 ulcers were cured after PPI, and one could not be followed up due to the patient's death non-related to the pressure ulcer. For the nine cured patients, the average time for cure was 14.9 weeks, and no recurrence was observed at postoperative 6 months.

CONCLUSIONS

PPI is a simple, technically easy, and less invasive surgical intervention to an intractable pressure ulcer with a pocket, which can be safely performed under local infiltration anesthesia even on a patient with severe systemic comorbidities.

A new technique for one-stage total lower lip reconstruction: Achieving the perfect balance

BACKGROUND

Reconstruction of extensive lower lip defects is difficult. The authors describe a new technique of one-stage total lower lip reconstruction, with the ultimate goal being achievement of the delicate balance between adequate mouth opening and competent mouth closure, with satisfactory aesthetic outcome.

METHODS

The authors applied their new reconstructive technique in a patient with extensive lower lip defect following excision of squamous cell carcinoma. Bilateral inferiorly based nasolabial flaps were used for reconstruction of lower lip. For vermillion reconstruction, a bucket-handle mucomuscular flap from upper lip was designed primarily using the pars marginalis portion of orbicularis oris. Compared with previously described techniques, this procedure is unique with respect to the alignment of the nasolabial flaps in relation to one another. Furthermore, this technique of vermillion reconstruction is a one-stage procedure with minimal morbidity, enables preservation of the vascular pedicle and innervation and maintains the orientation of orbicularis oris, thus providing a competent oral sphincter. To the authors' knowledge, this mucomuscular upper lip flap has not been described earlier and has definite advantages over the commonly used methods of vermillion reconstruction.

RESULTS

The functional and aesthetic outcomes are satisfactory on follow-up, with normal lip movements and sensation, adequate mouth opening and oral competence, good colour and texture match with adjacent tissues, and excellent volume and quality of the vermillion. No subsequent corrective surgery is required.

CONCLUSIONS

This technique is simple and achieves the main goals of total lower lip reconstruction in a single stage with minimal morbidity.

Reconstruction of the thoracic tracheal defects with portions of deepithelialized myocutaneous flaps after resection of a large tumor

OBJECTIVE

To study the possibility of using portions of deepithelialized myocutaneous flaps to the reconstruction of thoracic tracheal defects after resection of a large tumor.

METHODS

From June 2007 to June 2012, five cases of defects of the thoracic trachea were reconstructed by applying portions of deepithelialized myocutaneous flaps. The patients were 27-61 years old with 4 male cases and 1 female. The cervical trachea ranged in diameter from 4-8.5 cm with circumferences of approximately 1/3-2/5 of the bronchial circumference.

RESULTS

All five patients with thoracic tracheal defects after resection of a large tumor were cured of portions of deepithelialized myocutaneous flaps, with no tracheal stricture remaining and vomica successfully eliminated. During the first 1 to 3 months after the operation, bronchoscopy showed that the tracheal lumens were smooth, and the visible skin of the musculocutaneous flaps became gray and exhibited a small amount of white discharge.

CONCLUSIONS

Despite this being a small series and short follow-up, this thoracic tracheal reconstruction with portions of deepithelialized myocutaneous flaps shows encouraging preliminary results and could be an alternative to other methods for the treatment of carefully selected patients with thoracic tracheal defects.