Reconstruction of perioral defects following resection for oral squamous cell carcinoma

Reconstruction of Squamous Cell Carcinoma on Oral Commissure With Hatchet-Shaped Flap

The mouth is a unique and prominent element of the lower face. Given the complex anatomy, aesthetic appearance, and function of the oral commissure, its reconstruction due to various causes presents a significant challenge for surgeons. Squamous cell carcinoma (SCC) of the lip is the most common type of oral cancer, accounting for approximately 25% to 30% of all oral cancers. Wide excision is the treatment of choice, and the prognosis is generally favorable. We encountered a case of SCC of the right oral commissure in a 69-year-old man. We designed a hatchet-shaped flap to minimize anatomical disruption and, as a result, achieved satisfactory outcomes in terms of both functionality and aesthetics.

Reconstruction of Broad Lower Lip Defects Using Karapandzic-Type Flaps

BACKGROUND

Reconstruction of lower lip defects is challenging because of the functional and aesthetic demands of the lower face. We review the functional and aesthetic outcomes of the Karapandzic-type flaps for reconstructing lower lip defects.

METHODS

A retrospective review of patients who underwent repair using Karapandzic-type flaps.

RESULTS

Fifty patients with lower lip defects ranging from 20% to 95% (mean 59.2% ± 20%) were included. Eighteen patients (36%) were repaired using a bilateral flap, and 32 (64%) were reconstructed using a unilateral flap design. All patients had preservation of oral competency and a satisfactory aesthetic result. No patient complained of microstomia. A complication rate of 8% was noted ( n = 4) with postoperative wound infection and small areas of dehiscence. There was no statistically significant difference in complication rates in patients older than 75 years, in patients with a history of head/neck radiation, or in defects greater than 70% of lower lip breadth.

CONCLUSION

Karapandzic-type flaps are versatile and reliable for the reconstruction of a broad range of lower lip defects. This one-stage procedure can produce superior functional and aesthetic results as compared with other local and distant flaps with minimal risk of functional microstomia.

Lower Lip Reconstruction Using the Karapandzic Flap Technique

The perioral region, comprising the upper and lower lips, plays important functional, aesthetic, and anatomical roles. Postoperative defects in perioral structures present a considerable challenge for reconstruction. Currently, reconstruction of perioral structures is performed using local, distant, and free flaps. Herein, we present a case of reconstruction with a Karapandzic flap after the excision of basal cell carcinoma in the lower lip. The patient was a 76-year-old man with a skin tumor on his left lower lip. He consulted a dermatologist regarding the tumor growth and was diagnosed with basal cell carcinoma upon biopsy. Dermatological excision of the tumor at a 7-mm margin resulted in a defect in half of the lower lip, cheek skin, and corner of the mouth. The defects were reconstructed using a Karapandzic flap for functional considerations. The patient was satisfied with his aesthetic appearance, and no functional deficits were observed. In conclusion, the Karapandzic flap is suitable for reconstructing large defects of the lower lip and can be completed quickly and safely in a single procedure.

Commissuroplasty using the triangular cheek flap in patients with free flap reconstruction of through and through buccal defects

Extensive resections of advanced stage oral cavity cancers can sometimes lead to significant through and through buccal defects with compromise of the oral commissure/lips. Post free flap reconstruction, such patients often require a secondary delayed commissuroplasty to assist with improved oral function and quality of life. In current literature, limited methods exist for free flap commissuroplasty with some key limitations, particularly their negative impact on buccal sulcus or oral vestibule. Our technique of the triangular cheek flap commissuroplasty allows the surgeon to reconstruct a neo-commissure without compromising the oral vestibular depth or decreasing mouth opening. Through this pictorial essay we describe a detailed surgical technique for secondary reconstruction of the oral commissure.

Complex midfacial defects: Is the extended Abbé flap the ideal solution to a tough problem?

OBJECTIVES

The aim of this study was to investigate the role of the extended Abbé flap in the reconstruction of complex midfacial defects (upper lip, nasal base and medial cheek). We describe our personal experience with this method and present some interesting aspects from the relevant literature.

MATERIALS AND METHODS

Between 2003 and 2017 we retrospectively evaluated the records of all patients with defects of the upper lip and nasal base after the resection of malignant tumors or traumata and reconstruction by means of the extended Abbé flap. We looked for information on the origin of the defect, the functional result, the aesthetic outcome and postoperative complications. The functional result of the reconstruction of the oral commissure was assessed with regard to postoperative subjective speech integrity, preservation of competence of the oral sphincter and lip sensation. The aesthetic outcome was evaluated with regard to limitations in facial expression and scar formation.

RESULTS

The study included 8 patients. Follow-up in the oncological cases was 85 months (range: 20-150 months). No tumor recurrences were detected. All patients achieved normal oral competence and mouth opening. No cases of blunting or microstomia were detected.

CONCLUSION

Reconstruction of the upper lip and nasal base with the extended Abbé flap is associated with an outstanding functional outcome that is cosmetically very acceptable.

Modified Bilateral Perialar Crescent Flap for Reconstruction of Combined Upper Lip and Premaxillary Defect

Many reconstruction methods are performed for combined defects of upper lip and premaxilla in oral cancer patients, which are complicated and multiple staged procedures, compromising the functional or structural unit. In this case report, we present a modification of the bilateral perialar crescent flap for reconstructing the combined defect of upper lip and premaxilla in a single stage. A patient diagnosed with well-differentiated squamous cell carcinoma of premaxilla and upper lip, involving a surgical defect of more than one-third but less than two-thirds of the lip underwent two cycles of neoadjuvant chemotherapy. Later wide local excision of the lesion and simultaneous reconstruction with a modified perialar crescent flap was performed in a single stage. Patient recovered uneventfully and tolerated the procedure well, without any complications. The patient was found to be satisfied with the functional and esthetic result. The reduced upper lip support which was a result of the bony defect of the premaxilla, was corrected with a dental prosthesis. This modification is a useful reconstruction tool for oral cancer patients with combined defects of upper lip and premaxilla.

Effective method for reconstruction of remaining lower lip vermilion defect after a mental V-Y advancement flap

Background

The mental V-Y advancement flap method is useful for reconstruction of lower lip defect because of its many advantages. However, it is not easy to select the optimal reconstructive method for the vermilion defect that remains after application of the mental V-Y advancement flap. In choosing the representative surgical method for vermilion mucosal reconstruction including mucosal V-Y advancement flap, buccal mucosal flap, and buccal mucosal graft. We describe an efficient technique to large lower lip defects combining mental V-Y advancement flap and buccal mucosal graft

Methods

This study included 16 patients who underwent reconstructive surgery for full-thickness and large defect (> half the entire width) of the lower lip from October 2006 to September 2017. The operation was conducted using mental V-Y advancement flap with various vermilion mucosal reconstruction methods considering the location of the defect and the amount of residual tissue of the lip coloboma after excision.

Results

All patients underwent mental V-Y advancement flap. In vermilion mucosal reconstruction, five patients underwent mucosal V-Y advancement flap, three underwent buccal mucosal flap, and eight underwent buccal mucosal graft. There were good aesthetic and functional results in all patients who underwent buccal mucosal graft. However, two patients who underwent mucosal V-Y advancement flap complained of oral incompetence, and all patients who underwent buccal mucosal flap had oral commissure deformity.

Conclusion

Buccal mucosal graft combined with mental V-Y advancement flap can produce suitable functional and aesthetic outcomes in near total lower lip reconstruction in patient with large mucosal defect including vermilion portion.

Reconstruction of the Oral Commissure With the Zisser Flap

The aim of this study was to investigate the role of the Zisser flap in the reconstruction of defects of the oral commissure. We describe our personal experience with this method and present some interesting aspects from the relevant literature. We retrospectively evaluated the records, from the period between 2003 and 2017, of all patients with defects of the oral commissure after resection of malignant tumors, traumas, or burns and reconstruction by means of the Zisser flap. We looked for information on the origin of the commissural defect, method of vermillion reconstruction using the lingual or buccal mucosa, functional result, esthetic outcome, and postoperative complications. The functional result of the reconstruction of the oral commissure was assessed regarding postoperative subjective speech integrity, preservation of competence of the oral sphincter, and lip sensation. The esthetic outcome was evaluated regarding limitations in facial expression and scar formation. The study included 13 patients. The follow-up period in the oncologic cases was 63.2 months (range, 10 to 140 months). No tumor recurrences were detected. Vermillion reconstruction was achieved by means of a buccal mucosal flap in 11 cases and a lingual mucosal flap in 2. All patients achieved normal oral competence and mouth opening except for 1 case, in which secondary commissuroplasty with restoration of sphincter function was needed. No cases of blunting or microstomia were detected. Reconstruction of the oral commissure with the Zisser flap is associated with an outstanding functional outcome that is cosmetically very acceptable.

Karapandzic Flap for Esthetic and Functional Reconstruction of Large Defect of Lower Lip

Squamous cell carcinoma is the most common cancer occurring in the oral cavity. The lips are one of the most common sites of occurrence with involvement, lower lip being more common than upper. Reconstruction of large defects of lower lip with good functional and esthetic outcome is the biggest challenge faced by the surgeon. Karapandzic flap is one the most commonly used technique for reconstruction of large defects of the lower lip.

Two-Piece Extraoral Prosthetic Rehabilitation to a Perineural Invasion Lip Cancer

Lip cancers can severely affect a person in terms of function, esthetics, and psychological trauma. After surgical resection, lip defects require special rehabilitation. This clinical report describes a neck prosthesis of a male patient diagnosed with lower lip squamous cell carcinoma with perineural involvement. The neck prosthesis was connected to the mandibular complete denture with cobalt samarium magnets. Both prostheses improved the patient's mastication, deglutition, and esthetics.

Karapandzic flap

For full-thickness lip defects, the choice of reconstructive option depends on the size of the defect. Defects of one-quarter to one-third of the upper lip can be closed primarily. Largerdefects measuring one-third to two-thirds of the lower lip width may be closed with the Karapandzic, Abbe or Estlander flaps. If the commissure is involved, both the Karapandzic and Estlander flaps may be used; however, the Karapandzic is probably the better choice because it is better at maintaining oral competence. In the case of larger lower lip defects (more than two-thirds of the lip), if there is sufficient adjacent cheek tissue, the surgeon may employ the Karapandzic (for defects up to three-fourths of the lower lip width) or the Bernard-Burow's techniques (to reconstruct the entire lower lip). A case of post-traumatic, lower lip defect, reconstructed with a bilateral karapandzic flap is presented here.

Reconstruction of perioral defects post-Mohs micrographic surgery: a dermatological surgeon's approach

BACKGROUND

The perioral location has great functional, aesthetic and social importance. Over 100 procedures have been described for lip reconstruction, emphasizing the challenges that reconstructive surgeons face when dealing with such defects.

OBJECTIVES

To outline the surgical reconstruction techniques of perioral defects post-Mohs micrographic surgery (MMS).

METHODS

The design and surgical techniques of reconstruction of perioral defects post-MMS are described.

RESULTS

The results of the surgical techniques described are illustrated.

CONCLUSIONS

Herein, we describe the nuances of reconstructive techniques that we have found useful for repairing perioral defects post-MMS.

An unexpected presentation of a traumatic wound on the lower lip: a case report

Introduction

Traumatic lip injuries present major challenges in terms of reconstructive options and the outcome of surgical management. The aetiology of lip injuries includes human bite as interpersonal violence. Bite wounds are always considered to be complex injuries contaminated with unique polymicrobial inoculum. A classification of facial bite injuries has been included and the surgical management of these lesions has also been discussed. We report a rare bite injury on the lower lip that resembled an ulcerative process.

Case presentation

A 30-year-old African man presented with a severe tissue defect on his lower lip to a Dental and Oral Department in Tanzania. He explained that 12 days ago he had been involved in a fight and someone had bitten his lower lip. An orofacial examination confirmed a serious loss of lip tissue that resembled a chronic ulcerative process. Accurate assessment of the lesion was made by a thorough evaluation of some parameters such as size, depth, presence of granulation tissue, fibrin coverage, wound edges, exudates and/or necrosis. A surgical debridement under local anaesthesia was carried out. Afterwards a layered suture was performed. Eventually the healing was complete and satisfactory.

Conclusions

A severe bite avulsive wound on the lower lip, despite the elapsed time before treatment, may have an excellent prognosis after a simple surgical procedure.

Application of modified Karapandzic flaps in large lower lip defect reconstruction

PURPOSE

Reconstruction of a lower lip defect with a Karapandzic flap often leads to greater rounding of the commissure. The aim of this study was to provide a new design of bilateral Karapandzic flap for large lower lip defect reconstruction.

MATERIALS AND METHODS

In this case-series retrospective study, a modification of the Karapandzic lip reconstruction technique was used with an additional incision to obtain more tissue. The esthetic outcome of the reconstruction was assessed using a 4-point scale with regard to the shape of the commissure, lip symmetry, appearance of the scar, and lip projection. Functional outcome was assessed by speech, preservation of oral competence, lip sensation, facial expression, diet, and denture usage.

RESULTS

Seventeen patients (13 male, 4 female; age range, 52 to 82 yr) with squamous cell carcinoma in the lower lip underwent single-stage lip reconstruction. Lip defects after tumor resection ranged from 50 to 90% of the lower lips. All patients achieved oral competence, without leading to greater rounding of the commissure. The esthetic outcome was considered good to excellent in 88% of cases and reconstruction did not lead to functional impairments in speech, oral competence, lip sensation, facial expression, diet, or denture usage.

CONCLUSIONS

The modified bilateral Karapandzic flap is a reliable technique to reconstruct large lip defects without leading to rounding of the commissure. With this technique, good esthetic and functional outcomes can be achieved.

[Post-traumatic reconstruction of the lower lip after total or subtotal amputation using the Webster's modification of the Bernard cheiloplasty -- advantages, disadvantages and limitations: three cases]

Webster's modification of the Bernard cheiloplasty is a well-known technique, usually applied to the reconstruction of total or subtotal amputations of the lower lip following oncological resection. We present three cases of post-traumatic reconstructions with interesting results.

A simple method for lower lip reconstruction after trauma using an advancement mucosal flap from the remaining lip

The traumatic injury of lower lip is a frequent clinical condition, and quite often, the soft tissue loss makes the reconstruction of lower lip's defect a challenging procedure. Many methods have been described to reconstruct these defects; however, most of them lack simplicity and require advance experience in flap surgery. In this report, a simple technique is presented for lower lip reconstruction following traumatic injury using an advancement mucosal flap from the remaining lower lip. With this method pleasant cosmetic result can be achieved.

Combined rotation and advancement flap reconstruction for a defect of the upper lip: 2 cases

Many types of upper lip reconstruction have been introduced to treat defects after a tumor excision or trauma. The authors treated two cases of upper lip defects. A 35-year-old woman presented with a squamous cell carcinoma of the left upper lip that had invaded the corner of the mouth. After resecting the tumor, the defect was 3.7×3.5 cm in size. A 52-year-old woman presented with a dog bite of the right upper lip. The defect measured 4.0×2.2 cm in size. The two cases were reconstructed by combined rotation and advancement of a cheek flap. This technique produced a good functional outcome that allowed for oral competence and created an opening of adequate size. A combination of rotation and an advancement flap can be used to treat upper lip defects in a single-stage procedure. This approach produces a good functional and cosmetic outcome.

Karapandzic flap and Bernard-Burrow-Webster flap for reconstruction of the lower lip

Squamous cell carcinoma is the most common malignant neoplasm of the lips, and in about 90% of cases it is located on the lower lip due to higher cumulative exposure to ultraviolet radiation. The authors present two surgical techniques for reconstruction of large lower lip defects, resulting from surgical excision of tumors, exemplifying and comparing them with two clinical cases.

Advanced squamous cell carcinoma involving both upper and lower lips and oral commissure with simultaneous reconstruction by local flap: a case report

Introduction

Squamous cell carcinoma is one of the most common malignant tumors of the skin and oral mucosa. However, squamous cell carcinoma involving near total upper and lower lip and oral commissure is rarely seen in the English literature. Simultaneous reconstruction of the upper and lower lips has been inconclusive and presents a challenge to the surgeon. We report such a case and outline our simultaneous reconstruction with local flaps. To the best of our knowledge this has never been reported.

Case presentation

A 73-year-old Thai woman presented with a large rapidly growing squamous cell carcinoma involving the upper lip, lower lip, left oral commissure and left cheek. En bloc resection of upper lip, lower lip, left oral commissure and buccal region was performed. Left radical neck dissection and right modified neck dissection were performed. Reconstruction of the upper lip with a left nasolabial-cheek cervicofacial rotational-advancement flap and right cheek advancement with perialar crescent flap was performed. The lower lip was reconstructed with bilateral labiomental advancement flaps.

Conclusions

Squamous cell carcinoma can grow rapidly and spread along the orbicularis oris muscle and across the oral commissure to the opposite lip. In advanced cancer, multimodal treatment is necessary. No gold standard in the reconstruction of both upper and lower lips has been established. We report the case of an advanced squamous cell carcinoma involving both the upper lip, lower lip, left oral commissure and buccal area and simultaneous reconstruction with local flap coverage that, to the best of our knowledge, has never been reported.

A simple "fishtail flap" for surgical correction of microstomia

Treatment of microstomia, whether congenital or acquired, has long challenged the ingenuity of surgeons. In all instances, the challenge remains the ability to preserve function and provide and maintain reasonable aesthetics. The following case report presents 2 different cases of surgical correction of microstomia, resulting from flap reconstructions after perioral tumor surgery. We developed a technique that uses pericommissural mucomuscular advancement flap, "a simple fishtail flap," and used this to correct deformed oral commissures in an attempt to elongate the oral aperture in a functional and aesthetically acceptable manner without recurrence. Results have shown that, with the use of our fishtail design, we can restore the unique architecture of the oral commissure with the postoperative intercommissural distance improved by more than 10 mm and the interincisal width enlarged by approximately 5 mm. Our solution was functional and aesthetically acceptable, as well as simpler and cheaper, in comparison with the traditional surgical methods that are usually expensive, complex, and less practical. We believe that, in cases in which either the contracture is mild or a commissurotomy can be expected to increase the width and the general size of the oral aperture, this relatively conservative technique, if judiciously used, can be performed with ease and safety with good results.

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

We describe a new way to raise the V-Y advancement flap, which is useful for reconstruction of the lower lip. Various other methods have been reported in the past, but it has been necessary to choose the most suitable method for each particular case. A V-Y advancement flap from the submandibular region is one of the useful techniques to reconstruct the lower lip, and it is suitable for a wide horizontal defect. However, the conventional V-Y flap is insufficiently mobile and the reconstructed vermilion is thin because of the limitation of the pedicle. In such a case, the reconstructed lip may sag or cause an embarrassing defect. We developed a new way to raise the flap to obviate these problems. We use the V-Y advancement flap from the inferior margin of the defect in a conventional way after excision of the tumour, and use a mucosal flap to reconstruct the vermilion border. The skin side of the V-Y flap is undermined, and the orbicularis oris muscles are preserved on both sides as pedicles. The flap is then raised as a bipedicled musculocutaneous flap, which has adequate movement. After the flap has been sutured, the superior margin of the flap is de-epithelialised, and used to create the volume of the vermilion border. Functionally and cosmetically good results were achieved.

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.

[Structures of lip reconstruction]

Although the incidence of tumors of the lips is low, they are the most common oral tumors and their therapy is often challenging for the surgeon. Depending on the extent of resected lip tissue, various surgical procedures are performed for reconstruction. They all follow the goal to combine complete tumor resection with maximal functional and aesthetic restoration. Surgical procedures are classified regarding the direction of tissue mobilization into one-, two- and three-dimensional techniques. Even though more than two hundred different techniques have been described, only a small number are used on a regular basis. To select the appropriate procedure for the individual patient the exact anatomic location and size of the defect have to be taken into consideration. Treatment algorithms may guide the surgeon to a suitable reconstructive procedure for each case. Complications may occur more often due to the size and the site of the procedure. Final functional and aesthetic results are usually satisfying.

Injectable biomaterials for regenerating complex craniofacial tissues

Engineering complex tissues requires a precisely formulated combination of cells, spatiotemporally released bioactive factors, and a specialized scaffold support system. Injectable materials, particularly those delivered in aqueous solution, are considered ideal delivery vehicles for cells and bioactive factors and can also be delivered through minimally invasive methods and fill complex 3D shapes. In this review, we examine injectable materials that form scaffolds or networks capable of both replacing tissue function early after delivery and supporting tissue regeneration over a time period of weeks to months. The use of these materials for tissue engineering within the craniofacial complex is challenging but ideal as many highly specialized and functional tissues reside within a small volume in the craniofacial structures and the need for minimally invasive interventions is desirable due to aesthetic considerations. Current biomaterials and strategies used to treat craniofacial defects are examined, followed by a review of craniofacial tissue engineering, and finally an examination of current technologies used for injectable scaffold development and drug and cell delivery using these materials.

Adding versatility to the reconstruction of intraoral lining: opened pocket method

Reconstruction of a full-thickness cheek defect, especially one associated with a large lip and oral commissure defect, remains a challenge. After tumor excision, replacement of the oral mucosa is often necessary. The oral mucosa is a thin, pliable lining. Because the skin of the forearm is ideally suited for replacement of oral lining, being thin, pliable, and predominantly hairless, the radial forearm flap is the most frequently used soft-tissue flap for this purpose. In addition, the vascularity of the area allows substantial variation in the design of the flap, both in relation to its site and size. On the other hand, the radial forearm flap might be unusable in some occasions, such as in the case presented here. Thus, a search for an alternative free flap is required. We used a prefabricated scapular free flap to reconstruct a large concomitant lip and full-thickness cheek defect resulting from perioral cancer ablation. We introduce a new "opened pocket" method for reconstruction of the intra-oral lining without folding the flap. Resection of the tumor resulted in a defect including 45% of the upper lip, 50% of the lower lip, and a large, full-thickness defect of the cheek. The resultant defect was temporarily closed with a split-thickness skin graft. Meanwhile, the left scapular fasciocutaneous flap was prefabricated for permanent closure of the defect. The left scapular flap was outlined horizontally, and the flap orientation for the defect was estimated. Then, the distal portion of the flap was harvested and incised to create lips and oral commissure. Afterward, the raw surface under the neo-lip regions and the base where the flap was raised was grafted with one piece from a thick, split-thickness skin graft. Fourteen days later, the patient was taken back to the operating room for reconstruction of the defect with free transfer of a prefabricated scapular fascia-cutaneous flap. The grafted distal region of the flap was raised with the deep fascia located under the graft. Thus, a pocket was obtained. The flap was placed in the defect for final tailoring. Mucosal defect was evaluated to decide where the pocket was to be opened. Then, the grafted fascial portion of the flap was incised from the free edge to the neocommissure. Consequently, lower and upper lip mucosa were achieved by opening the pocket. The prefabricated flap was adapted to the defect with the appropriate sutures. The superior thyroid artery and internal jugular vein were used as recipient vessels. The postoperative period was uneventful. There were no healing problems of the suture lines of the opened pocket, and both labial sulci were quite adequate. The patient was able to resume a soft diet 10 days after the operation. She also had a satisfactory oral competence and an acceptable appearance, without microstomia. Despite its disadvantages, prefabrication can make the scapular fascia-cutaneous flap suitable for reconstruction of a large, concomitant lip and full-thickness cheek defect when other more appropriate flaps are not available. The opened pocket method appears not only to add flexibility to the restoration of the intra-oral lining but also reduces the stress resulting from free flap adaptation.