Functional lower lip reconstruction with a forearm flap combined with a free gracilis muscle transfer

Gracilis free flap in head and neck reconstruction beyond facial palsy reanimation

INTRODUCTION

The gracilis muscle free flap has gained popularity in head and neck reconstruction due to minimal donor-site morbidity, reliable vascular pedicle, strong muscular component, and possibility to perform nerve coaptation. However, almost all the existing evidence in the literature is related to its use for facial palsy reanimation. The aim of this study was therefore to review and provide a comprehensive summary of all the possible indications and outcomes of this versatile free flap in head neck reconstructive surgery.

MATERIALS AND METHODS

A systematic review of the literature was conducted including articles from 1970 to 2019. All articles were examined and described.

RESULTS

Twenty-seven papers published between 1994 and 2019 were identified for analysis. The evidence highlights the use of the gracilis muscle free flap for parotid, forehead and midface defects, oral tongue, oral sphincter, lower and upper lip, cheek, and oral commissure defects, among others, as the most common defects reconstructed.

CONCLUSION

This flap represents an easy to harvest and versatile free flap with low donor-site morbidity and multiple proven uses in head & neck reconstruction. We therefore encourage reconstructive surgeons to include this flap in their armoury, either as a first or as a second-line option.

Dynamic Reconstruction of the Lower Lip With Free Functioning Gracilis Muscle Transfer

ABSTRACT

The restoration of large full-thickness lip defects still remains a formidable challenge for the reconstructive surgeons. Traumatic injuries, infections and tumors (primarily squamous cell carcinoma) are the most common source of the lip defects. Lower lips are more important in providing oral competence, unfortunately throughout the life-time they are significantly more exposed to ultraviolet radiation and thus are the most common site for the lip cancers (89%). This type of defect requires a complex reconstruction of an adequate sphincter function, defined vermilion, proper oral lining and sufficient mouth opening. To maintain the oral competence, it is of paramount importance to restore the function of orbicularis oris, which principally composes the body of the lip. Currently, the dynamic reconstructions are gaining considerable interest. They enables not only improvement of appearance but also a restoration of function and preservation of health-related quality of life. The use of the free gracilis muscle transfer to reconstruct the lower lip and its dynamic character in contrast to other, static reconstructions can provide the sufficient movement of the lower lip, which does not depend on function of other mimic muscles as it becomes an independent motor unit with its own neurotization. In our opinion the free functioning gracilis muscle flap, due to its anatomic and functional features as well as low-rate donor-site morbidity is the worth considering option for a lower lip reconstruction.

Modified Stair-Step Flap With Turnover Flap for Drooling Correction After Lower Lip Composite Defect Reconstruction

BACKGROUND

Oral commissure and buccal complex defects are commonly seen after cancer ablation. Free flap reconstruction can offer adequate soft tissue volume and outer skin lining. However, oral incompetence often occurs when an oral commissure has defects, particularly when the patient receives postoperative radiotherapy. The purpose of this article was to describe our method of the modified stair-step technique and improve the oral competence.

METHODS

This study involves 22 patients who had partial lower lip and/or upper lip defects and underwent flap reconstruction and/or postoperative radiotherapy resulting in oral incontinence. Fourteen patients had been treated with an anterolateral thigh flap, 7 patients had been treated with a radial forearm flap, and 1 patient had been treated with a fibular osteocutaneous flap. Our modified stair-step commissuroplasty was done in all cases, and a debulking procedure was done in each second operation.

RESULTS

Acceptable oral continence and contour were achieved in 19 patients. Some patients still had drooling after their second operation, but it was considerably less than before.

CONCLUSIONS

This technique is an easy procedure for revision of lower lip deformities after oral commissure reconstruction.

Combined Use of an Innervated Radial Forearm Flap and Labia Minora Peripheral Skin Graft for Total Upper Lip Reconstruction

The repair of a total lip defect and reconstruction of the vermilion border of the lip is challenging. Here, the authors report the successful functional and esthetic reconstruction of an injured upper lip using a free radial forearm flap and labia minora peripheral skin graft. A 43-year-old woman accidentally fell, resulting in a full-thickness wound in her entire upper lip. One month after the injury, the upper lip was reconstructed with an innervated free radial forearm flap. Six months postoperatively, a Semmes-Weinstein monofilament pressure esthesiometer indicated good recovery of neurosensory function with a value of 2.83. Nine months after the injury, the vermilion border, white roll, and philtrum were reconstructed. The vermilion border was reconstructed using a labia minora peripheral skin graft. The philtrum was reproduced using pigmented skin harvested from the vicinity of the labia minora, and the white roll was reconstructed 3-dimensionally by turning the dermis beneath the skin. Satisfactory results were obtained. The combined use of an innervated free radial forearm flap and labia minora peripheral skin graft may be an option for repairing extensive upper lip defects.

Fusuma Sliding Flap for Lip Reconstruction of Lower Lip Cancer

Lower lip cancer is typically treated with surgical excision, and this frequently results in a large defect and severe aesthetic problems. Local flap reconstruction is suitable for restoring appearance and function, and it causes less surgical stress than a vascularized free flap. The Fusuma sliding flap is a local flap technique introduced by Kasai et al in 2008. Here, the authors report their use of this method for lip reconstruction in a 94-year-old Japanese female after the removal of a cancerous mass.

Reconstruction of a subtotal upper lip defect with a facial artery musculomucosal flap, kite flap, and radial forearm free flap: a case report

BACKGROUND

For reconstructive surgeons, massive midface defects, including large, full-thickness wounds on the upper lip, can be very challenging. Although there are many methods for reconstruction of upper lip defects, it is difficult to obtain satisfactory restoration of oral functions and good cosmetic results.

CASE PRESENTATION

This case report presents a man with massive midface defects, including upper lip, left nose, and cheek defects. Over the previous 2 years, the patient had three reconstructions with sequential free flaps for the resection of recurrent tumors, the first of which was in March of 2016; this resulted in the patient having massive midface defects, including an upper lip defect, a defect on the left side of the nose, and one on the left cheek. The defects were reconstructed using a radial forearm free flap (RFFF), a facial artery musculomucosal (FAMM) flap, and a kite flap. In June 2016, he underwent a second reconstruction, this time of the left nose defect, using a left anterolateral thigh (ALT) flap. In March of 2017, the patient underwent a third reconstruction with the use of a free ALT on the left intraoral cheek and the defects on the neck. All flaps survived. No complications were encountered postoperatively. The patient regained good oral sphincter function with no reports of drooling. Although the patient underwent three surgeries, the reconstruction results were acceptable.

CONCLUSIONS

For massive midface defects, including large, full-thickness wounds on the upper lip, the combination of a FAMM flap, kite flap, and RFFF promotes the reconstruction of the complex midface structure and improves the resulting functionality.

Reconstruction of Near-Total Loss of the Upper and Lower Lips due to Purpura Fulminans with Local Tissue and a Dual-Skin Paddled Anterolateral Thigh Flap

It is difficult to totally reconstruct the lip, achieving good functional and aesthetic results. There have been few reports of reconstructing complete lip defects. Moreover, upper and lower lip necrosis by purpura fulminans has not been reported. We present a case of a 60-year-old male purpura fulminans patient with upper and lower lip necrosis. Fortunately, our patient had retained his oral commissure function. We reconstructed this defect with an orbicularis oris muscle-skin-mucosal pedicled flap derived from the region between the nasolabial folds for upper lip; a similar bipedicled flap for the lower lip and the donor site was closed with a dual-skin paddled anterolateral thigh flap. Postoperative results were satisfactory, that is, no lip tightness or aperture restriction was seen, and symmetry had been achieved. The new lips exhibited complete sensory recovery. Drooling was minimal during rest and feeding. We could select a method that combined the advantages of local and free flaps. We consider our method for this defect is superior to those described in previous studies, in that the restoration of lip sensation and oral sphincter function can be achieved to some extent in 1 stage while preserving the oral commissure function.

Lip reconstruction using a functioning serratus anterior free flap: preliminary study

Reconstructive surgery to the lips requires the replacement of defective tissues with similarly functioning tissues. While non-dynamic free tissue transfers provide adequate lower lip reconstruction, improved benefits may be obtained with innervated free muscle flaps. This study reports the use of innervated serratus anterior muscle free flaps for lip reconstruction in five patients. All patients had squamous cell carcinoma of either the upper or lower lip. After resection of the tumours, the resultant defects comprised two-thirds of the lips. The innervated serratus anterior muscle free flap was transferred to the lip and an end-to-end vascular anastomosis on the facial artery was performed. The marginal mandibular branch of the facial nerve was preferred for nerve coaptation. The inner and outer surfaces of the flaps were grafted with a split-thickness skin graft. Concentric needle electromyography of the orbicularis oris and frontal muscles was performed for all patients in the preoperative, postoperative, and follow-up periods. All patients survived the surgical operation. Three patients achieved perfect oral sphincter function without drooling. Electromyography at 1 year postoperative demonstrated the successful reinnervation of the serratus anterior muscle. This study demonstrates that lip reconstruction using an innervated serratus anterior muscle free flap is a reliable method, providing a functional lower lip.

One Stage Aesthetic and Functional Reconstruction of Major Lower Lip Defects

INTRODUCTION

Multiple techniques have been used for reconstruction of large defects of the lower lip. However, some complications, such as microstomia, distortion of oral commissure, lip functional problems, and sensory loss might occur with these techniques. The aim of this work is to evaluate a new method of reconstruction of large lower lip defects after excision of squamous cell carcinoma.

PATIENTS AND METHODS

Eighteen patients with lower lip squamous cell carcinomas were managed with this new technique of reconstruction using dermal fat flap, mucobuccal flap, and muscle transfer after excision of the tumor with 1-cm safety margin on both sides. The functional and aesthetic assessments were performed at least 6 months after surgery, and the results were compared statistically with a control group.

RESULTS

Of the 18 patients, sensibility was normal in 16 (89%) and complete competence was determined in all cases (100%). In 17 patients (94%), complete and symmetric pouting and mouth-opening movements were ensured. Interlabial measurements would be better in all patients. Nasolabial asymmetry was detected in 1 patient (6%) and apparent mentolabial scar tissue was detected in 2 patients (11%). The new vermilion was of equal width to the upper lip vermilion in 15 patients (83%).

CONCLUSIONS

Based on our results, this technique could be considered a good choice for repair of major lip defects. In addition, using this technique will give good aesthetic and functional results.

Correction of the Lower Lip With a Cartilage Graft and Lip Resection in Patients With Facioscapulohumeral Muscular Dystrophy

Facioscapulohumeral muscular dystrophy is an autosomal-dominant, slowly progressive myopathy that involves facial, shoulder, and upper arm muscles. Facial muscle atrophy and weakness leads to drooping of the lower lip, which has unfavorable functional and aesthetic outcomes. While there are several methods to correct drooping of the lower lip, including lip resection, free vascularized muscle transfer, and fascia suspension, there are no reports describing the use of an auricular cartilage graft to elevate the lip. The use of an auricular cartilage graft has several advantages, including a less invasive procedure and a longer-lasting effect. In this study, 3 patients with facioscapulohumeral muscular dystrophy underwent surgery involving an auricular cartilage graft with lip resection to sustain the lower lip, and satisfactory results were obtained. This procedure is simple and minimally invasive; thus, the authors believe that this is an appropriate technique to correct similar patients of lip deformity.

Treatment and long-term follow-up of oral cancer postoperative sialorrhea with dermal sling operation

INTRODUCTION

Reconstruction of a full-thickness defect that includes oral commissure presents a considerable challenge to maxillofacial and plastic surgeons. The goals of reconstruction are both functional and cosmetic. Sialorrhea, or drooling, is a major problem after flap reconstruction and influences the quality of life of the patient. In this article, we report on our experience performing a dermal sling operation to treat postoperative sialorrhea in patients with oral cancer.

MATERIALS AND METHODS

Preoperative and postoperative levels of sialorrhea were evaluated based on the Drooling Severity and Frequency Scale. Dermal sling operations were performed on 27 patients from January 2000 to December 2013. In these patients, 12 cases were reviewed and followed up over 1 year.

RESULTS

Of the 12 patients, 11 were men and one was a woman, with the mean age of 58 years (range, 40-79 years). There were no operative complications. The mean preoperative score was 4.75 (range, 3-7), and the mean postoperative score was 3.83 (range, 2-5). This change was significant (P=0.005), with valuation with the Wilcoxon signed rank test. The mean time of follow-up was 3.5 years (range, 1.1-7.7 years).

CONCLUSIONS

The dermal sling operation is an acceptable treatment for postoperative sialorrhea in patients with commissure-involved oral cancer.

The innervated gracilis muscle for microsurgical functional lip reconstruction: review of the literature

Reconstruction of the lower and upper lip should meet both aesthetic and functional requirements, whenever possible. Achievement of these goals presents a major challenge particularly in extensive lip defects requiring microsurgical reconstruction. Successful reconstructive outcomes have been reported using free fasciocutaneous flaps such as composite radial forearm flap or anterolateral thigh flap in conjunction with static tendon slings. In recent years, neurovascular gracilis muscle transfer has been introduced in hopes to overcome noncontractile properties of these flaps and to restore oral competence by muscle contractility. This article reviews the available data on the innervated gracilis muscle transfer for functional lip reconstruction. Tips and techniques gleaned from all of the current literature are discussed.

Technical details concerning myomucosal advancement method in the repair of large lower lip defects

The most important decision that a surgeon has to make in large lower lip defect reconstruction is whether to use a free flap or local flap. Despite efficient transplantation, serious cosmetic problems can occur in total or in near-total lower lip reconstruction with a free flap. On the other hand, better cosmetic results can be brought about in reconstructions with local flaps when a repair is made in tissues with similar properties in terms of color, thickness, or pilosity. However, functional problems such as microstomy can be encountered when inefficient transplantation is carried out during local flap repairs. If a repair technique with local flap that enables efficient transplantation can be applied, satisfactory cosmetic as well as functional results can be provided. In this text, the technical details of the myomucosal advancement flap method, which is a successful functional local flap application with good cosmetic results, were reported and explained with the help of schematic drawings.

Lip reconstruction

Lip reconstruction poses a particular challenge to the plastic surgeon in that the lips are the dynamic center of the lower third of the face. Their role in aesthetic balance, facial expression, speech, and deglutination is not replicated by any other tissue substitute. The goals of lip reconstruction are both functional and aesthetic, and the surgical techniques employed are often overlapping. This discussion will focus on lip defects with significant tissue loss that require flap reconstruction. Flaps described include Webster-Bernard cheek advancement flaps, Abbe cross-lip flaps, Karapandzic rotation advancement flaps, and single and dual free-flap lip reconstructions. The principles and techniques described are broadly applicable to other flap designs that are required to meet both the aesthetic and functional goals of lip reconstruction.

Microvascular reconstruction of major lip defects

Reconstruction of extensive lip defects is a challenging task for reconstructive microsurgeons. This article reviews the goals of lip reconstruction after major ablative or traumatic lip losses and outlines the free flap options available to achieve these goals.

Functional reconstruction of the upper and lower lips and commissure with a forearm flap combined with a free gracilis muscle transfer

After resection of an arterio-venous malformation of the upper and lower lips and commissure we performed reconstruction with a forearm flap combined with a free gracilis muscle transfer. First the motor nerve of the gracilis muscle was anastomsed to a buccal nerve branch in the cheek. In a second operation, the red lip was reconstructed with an oral mucosal graft, and the upper lip skin was reconstructed with a local flap. The patient obtained good oral sphincter function for eating, speaking and air inflation.