Functional reconstruction using a depressor anguli oris musculocutaneous flap for large lower lip defects, especially for elderly patients

Lower lip reconstruction using McGregor fan technique with or without depressor anguli oris chimeric flap. Is there a difference in function and aesthetic outcomes?

BACKGROUND

Lower lip reconstruction aims to maintain facial subunit function and aesthetics. We present a minor modification of the McGregor flap technique, in which depressor anguli oris (DAO) muscle is separately elevated as a chimeric flap together to investigate the outcomes for reconstructing lower lip defects using various functional parameters.

METHODS

The study included patients who underwent surgical repair of lower lip defects using a McGregor fan flap with or without DAO muscle chimeric flap between January 2018 and May 2021. The patients were divided into our modified technique with DAO chimeric flap (study group) and conventional McGregor (control group). The primary outcomes were functional evaluation of oral competency, speech intelligibility, and tactile sensation of reconstructed lip outcomes. The functional satisfaction and Patient and Observer Scar Assessment Scale (POSAS) were analyzed.

RESULTS

A total of 20 patients were enrolled (10 patients for each group). Excellent oral competence was present in 12 patients, favorably significant in patients with DAO chimeric flap (n = 8/10, p = 0.018). All patients had intelligible speech with insignificant differences between the two groups. No patients demonstrated differences to light touch from baseline sensation at 1 year. Patients in the study group reported more lip function satisfaction (p = 0.049). The POSAS score indicates satisfaction with the appearance of all patients.

CONCLUSION

McGregor fan technique combined with DAO muscle chimeric flap offers a good choice by maintaining sensory and motor functions. Our minor modification can ensure the integrity of the oral sphincter, leading to improved lower lip function.

Functional and Aesthetic Lower Lip Reconstruction Using the Yotsuyanagy Flap

ABSTRACT

Lower lip defects are a major challenge from a reconstructive perspective. The lower lip is an anatomical region formed by different types of tissue, and it is essential to obtain adequate functional and aesthetic results. When local tissue is available to be a donor area, it becomes the best option to repair the defect. This article's purpose is to present our experience in reconstruction of partial or transfixing total defects of the lower lip with the musculocutaneous flap of the depressor anguli oris described by Yotsuyanagi.

A New Modification of Fan Flap for Large Lower Lip Defects

BACKGROUND AND AIMS

The reconstruction of the lower lip defects which may result from malignancy, trauma, and burn is necessary for mastication, oral competence, salivary retain, articulation, and aesthetic appearance of the face. While small (30% of the lower lip) and medium (30%-80% of the lower lip) size defects are reconstructed using primary repair and local flaps, reconstruction of the large defects including total and near-total of the lower lip is very challenging entity. We introduce a new modification of the fan flap named extended fan flap for reconstruction of the total and near-total lower lip defects.

MATERIAL AND METHODS

The extended fan flap was used for 12 patients with defects involving more than 80% of the lower lip due to squamous cell carcinoma excision. Most of the patients were males (80.9%) with an average age of 66.8 years (range, 47-82 years).

RESULTS

No major complication is observed in the postoperative period. The functional and aesthetic results were satisfactory. The sphincter function for normal mastication, eating, and salivary retain was reestablished. No microstomy was seen and insertion of artificial dentition was possible for patients.

CONCLUSION

We believe that the unilateral extended fan flap is a reliable and safe option with satisfactory functional and aesthetic results for total and near-total (more than 80%) lower lip defects.

Unit Advancement Flap for Lower Lip Reconstruction

BACKGROUND

Lower lip reconstruction requires consideration of esthetic and functional outcome in selecting a surgical procedure, and reconstruction with local tissue is useful. The authors reconstructed full-thickness defects with a unit advancement flap.

METHODS

Reconstruction was performed using this method in 4 patients with lower lip squamous cell carcinoma in whom tumor resection with preservation of the mouth angle was possible. The lower lip resection width was 30 to 45 mm, accounting for 50% to 68% of the entire width of the lower lip. The flap was prepared by lateral extension from above the mental unit and matched with the potential wrinkle line of the lower lip in order to design a unit morphology surrounded by the anterior margin of the depressor labii inferioris muscle. It was elevated as a full-thickness flap composed of the orbicularis oris muscle, skin, and mucosa of the residual lower lip from the bilateral sides, and advanced to the defect. Flap transfer was adjusted by small triangular resection of the skin on the lateral side of the mental unit.

RESULTS

The postoperative scar was inconspicuous in all patients and there was no impairment of the mouth opening-closing or articulation functions.

CONCLUSIONS

This was a relatively simple surgical procedure. A blood supply of the flap was stable, and continuity of the orbicularis oris muscle was reconstructed by transferred the residual lower lip advancement flap from the bilateral sides. The postoperative mouth opening-closing function was sufficient, and dentures could be placed from an early phase in elderly patients. The postoperative scar was consistent with the lip unit morphology, being esthetically superior. This procedure may be applicable for reconstruction of defects approximately 1/3 to 2/3 the width of the lower lip where the mouth angle is preserved.

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.

Sling suspension using the anterior third of the temporalis muscle extended with tendon graft to correct oral incontinence after free flap reconstruction in cases of a major defect of the lower lip muscle

BACKGROUND

Oral incontinence is a common complication after free flap reconstruction after ablation of oral cancers. The postoperative incontinence was corrected with strong suspension to the temporalis muscle in cases of major or total defect of lower lip muscles.

METHODS

Eight patients with oral cancer with previous skin flaps for reconstruction of the lower lip had incontinence because of major or total loss of the lower lip muscle. A tendon graft was used as a suspension sling sutured to the anterior third of the bilateral temporalis muscle.

RESULTS

Oral continence without drooling was achieved by suspension of the temporalis muscle with free movement of the lower lip.

CONCLUSION

This is a good option for correcting the incontinence after major or total loss of lower lip muscles in patients with oral cancer.

Hemi-Bernard method: straightforward reconstruction of lower lip after malignant tumor resection

The Bernard method is a straightforward method for reconstructing lower lip defects after tumor resection. However, this method is difficult to apply when the defect is located on the unilateral side of the lower lip. This report describes the reconstruction of unilateral lower lip defects using a modified Bernard method, which is referred to as the hemi-Bernard method. Three patients (2 male and 1 female; mean defect, 55%) underwent reconstruction using the hemi-Bernard method after lower lip malignant tumor resection. No infection or flap necrosis occurred, and none of the 3 patients had difficulty with oral ingestion. Movement of the orbicularis oris muscle was retained in all patients. The hemi-Bernard method is straightforward and has several advantages, including extension of lower lip length. This method could be useful for reconstructing full-thickness defects located on the unilateral side of the lower lip.

Submandibular artery: bilobed platysma myocutaneous flap for total lower lip reconstruction

BACKGROUND

Lower lip reconstruction following cancer resection includes a variety of clinical and microsurgical options.

OBJECTIVE

We have developed a myocutaneous flap for full thickness reconstruction with a functioning muscle.

TECHNIQUE

In all patients, the submandibular artery was outlined using computerized tomographic angiography and Doppler. The flap was designed after resection. The first lobe was designed to fill the defect and was outlined 90° from the defect margin, with the submandibular artery in the center of the flap. A second lobe was then outlined 90° from the first lobe. The flap was raised along with the platysma muscle and artery, with the first lobe rotated to the lip and the second lobe inset into the first lobe site, permitting neck closure without skin redundancy.

RESULTS

From January to May 2012, 17 patients were treated with this flap, and all flaps survived. All of the patients had oral continence at sixteen months, and electromyography documented platysma function.

CONCLUSION

The flap provides single-stage lower lip reconstruction with functional muscle.

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.

Reconstruction of lateral lower lip defects with transverse lip advancement flap

BACKGROUND

Lower lip defects between one and two thirds of the lower lip are usually reconstructed with neighboring tissues from the upper lip, cheeks, or the mentum or a combination of these tissues. In this article, we offer a simple and effective reconstruction option that can be used for lateral defects between one third and two thirds of lower lip tissue. Utilizing the tremendous flexibility and expandability of the lip tissue, we tried to minimize the incisions and scar, and maximize the sensation and function with transverse advancement flap.

PATIENTS AND METHODS

Ten patients with lateral lower lip defects, after tumor ablation, were treated by this technique. After excision of tumor, the existing incision is extended to medial by following the natural labiomental crease. Full-thickness incision is ended at the level of commissure not to disturb the buccal and marginal mandibular branches of the facial nerve. Intraoral incision is made 1 cm above the gingivobuccal sulcus .The mental nerve was dissected and preserved to keep the sensorial innervation of the lower lip. Thus, transverse advancement labial flap that includes the orbicularis oris with intact neurovascular supply is freed to provide the desired advancement.

RESULTS

Satisfactory functional, aesthetical, and sensational results were obtained.

CONCLUSION

A dynamic reconstruction can be provided with superior results in terms of lip appearance and function with transverse lip advancement flap. In planning a lip reconstruction, we think that transverse lip advancement flap should be considered as a second ladder after primary closure.

Lower lip reconstruction after wide excision of a malignancy with barrel-shaped excision or the webster modification of the bernard operation

Background

Because there are numerous methods for reconstruction of the lower lip, it is not easy to choose the optimal method. In choosing the surgical method for lower lip reconstruction, we obtained acceptable outcomes based on our treatment strategy, which included either a barrel-shaped excision or the Webster modification of the Bernard operation. We report on the surgical outcomes based on our treatment strategy.

Methods

This study included 26 patients who underwent lower lip reconstructive surgery from September 1996 to September 2010. The operation was done using either a barrel-shaped excision or the Webster modification, considering the location of the defect, the size of the defect, and the amount of residual tissue on the lateral side of the vermilion after excision.

Results

In our series, 3 patients underwent a single barrel-shaped excision, and nine patients underwent a double barrel-shaped excision. In addition, the unilateral Webster modification was performed on in 6 patients, and there were eight cases of bilateral Webster modification. All of the patients except one were satisfied with the postoperative shape of the lip. In one case both recurrence and dehiscence occurred. One patient had a good postoperative lip shape, but had difficulty wearing a denture, and also underwent commissuroplasty. Furthermore, there were two patients who complained of drooling, and 4 with paresthesia.

Conclusions

A soft tissue defect resulting from wide excision of a lower lip malignancy can be successfully reconstructed using only one of two surgical methods: the barrel-shaped excision or the Webster modification of the Bernard operation.

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.

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.

Lower lip reconstruction with neck flaps as a salvage procedure

There are many surgical reconstructive techniques after lower lip ablation. As the lower lip defect gets larger, the required reconstructive techniques become more complex. Despite the indication of free flaps, some situations require local flaps for reconstruction. These situations may be donor and/or recipient vessel problems or systemic disorders of the patient. In this article, a total lower lip reconstruction technique using the neck skin was described. The technique was applied successfully in 2 cases. An acceptable cosmetic result was obtained, and there were no early or late surgical complications in 2 years' follow-up. The patients were satisfied with the results. Lower lip reconstruction with the neck flaps must be kept in mind as a quicker alternative and a salvage method when the free flaps cannot be applied.

Lip reconstruction with local m-shaped composite flap

The primary management of lip malignancies is radiotherapy or complete surgical resection. Surgical resection brings a full-thickness defect of lip tissues, and management of the resulting lip defect needs a surgical technique that maximizes functional and cosmetic outcomes. The use of local tissue flaps forms the basic concept of lip reconstruction. There are many techniques reported using the remaining lip and local adjacent tissues. Almost all of these techniques emphasize the innervated sphincter function after lip reconstruction. Authors present their experience in lip reconstruction by an M-shaped local composite flap. An M-shaped flap presents an incision line lying on the labiomental sulcus of the lower lip; on this line, 2 half-thickness Burrow triangles are created. The Burrow triangle allows tissue transposition to close the postsurgical defect. A similar surgical technique is presented also for the upper lip. Functional sphincteric recovery is assured by the integrity of the orbicularis oris muscle because of minimal alteration in the orientation of the muscle and the reconstruction muscular anatomic plane; moreover, such flap preserves the integrity of the corner of the mouth, preserves the sensibility of the lip, and has minimal aesthetic impact due to the camouflage of scar on the labiomental sulcus.

Reverse facial artery flap from the submental region

BACKGROUND

Of all the local flaps that allow elevation of a sufficiently large-sized flap while also leaving an inconspicuous donor-site scar, the submental island flap is frequently used for the reconstruction of a defect in the lower two-thirds of the face. However, this flap has certain disadvantages such as the technique being slightly difficult to perform and, more importantly, that it carries a significant risk of injury to the facial nerve.

METHODS

Here, we propose the reverse facial artery flap, elevated from the submandibular region. Our method creates a flap that includes only the platysma under the skin island, without either the submental or facial artery. However, above the superior border of the skin island, the flap includes the facial artery along with subcutaneous soft tissue. The blood circulation of the skin island is in a random pattern and that of the subcutaneous pedicle is in an axial pattern.

RESULTS

Four cases were treated using our method. There were no complications in all four cases, and the results were also cosmetically very good.

CONCLUSIONS

As compared to the submental island flap, our method is easier to perform and carries a much lower risk of damage to the marginal mandibular branch of the facial nerve, as the facial artery crosses over the facial nerve at only one point. In addition, the method produces a thin flap. Therefore, when considering correction of a small-sized defect in the lower two-thirds of the face, our method has a number of advantages over the submental island flap.

Reconstruction of a red lip that has a defect in one half, using the remaining red lip

It is difficult to reconstruct the red lip and achieve good functional results such as normal sphincter force, sensitivity and movement of the lip. In addition, it is also difficult to attain colour and texture matches. We reconstruct a red lip that has a defect in one half, using the remaining red lip. Using the technique reported herein, we can achieve excellent functional and aesthetic results. Functionally, sphincter force and sensation recover early and the movement of the lip returns to normal. In addition, the reconstructed lip develops a symmetrical and natural appearance.

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.

Reconstruction of sphincteric function after dysfunctional total lower lip reconstruction using free muscle graft technique

Many techniques can be used in primary reconstruction of total lower lip defects and most of them are functional. If a total lower lip defect is reconstructed with a static, dysfunctional technique, then the patient is prone to some problems such as drooling and gingival show. In order to restore sphincteric function in a previously reconstructed lower lip, we used the free muscle graft technique, which has been firstly used by Thompson for the treatment of facial paralysis. We obtained a satisfactory result, such that symptoms of drooling and gingival show have disappeared, and a minimal purse-stringing movement has been restored. To our knowledge, this is the first time of a free muscle graft application in this type of an indication. According to our result, the use of free muscle graft technique can be a good alternative method in patients, who suffer from drooling and gingival show following dysfunctional total lower lip reconstruction.

Denervated or innervated flaps for the lower lip reconstruction? Are they really different to get a good result?

OBJECTIVE

This study compares innervated and denervated flaps for the lower lip reconstruction in terms of oral sphincter function and sensation.

STUDY DESIGN AND SETTING

A prospective trial.

METHODS

This study was carried out on 31 patients with lower lip carcinoma. They were divided in 2 groups: 18 patients with denervated local flaps and 13 patients with innervated flaps. During the follow-up period, all patients were evaluated by electromyography tests and an assessment of the sensation on the lower lip and sphincter function was undertaken by clinical parameters.

RESULTS

Compound muscle action potential (CMAP) was obtained in all patients. The amplitudes of CMAP were below normal and the values for distal motor latency (DML) were slightly longer than normal values. Interference patterns were observed on whistling in all cases. There were no differences in terms of sphincteric function in each group.

CONCLUSIONS

The denervated random local flaps used for the lower lip reconstruction have no functional inferiority when compared to the innervated-pedicled local flaps.

SIGNIFICANCE

This study demonstrates that denervated flaps can be employed for a functional lip reconstruction.

EBM RATING

B-2b.

One-stage reconstruction of a large defect of the lower lip and oral commissure

Large lower lip defects including the oral commissure are very difficult to reconstruct and obtain an aesthetic appearance and an acceptable function. We report two patients who had a large defect in the lower lip including oral commissure and were treated using free radial forearm flap and temporal muscle transfer in one-stage. For the cutaneous defects, in one a local flap was elevated from the adjacent cheek and in the other a turned over area of the forearm flap was used. In each case, the reconstructed lower lip could maintain adequate elevation of oral the commissure using the temporal muscle was worked. The first case which used a local flap externally could avoid sialorrhea and had good sensation, and could close the mouth firmly soon after surgery. The appearance was acceptable. In the other case, leakage of oral contact and air occurred at the oral commissure because of the thickness of the forearm flap but improved after minor correction some 8 months after the surgery.

Total lower lip functional reconstruction with a prefabricated gracilis muscle free flap

Total lower lip reconstruction was performed in an 18-month-old boy following a dog bite. In order to obtain an optimal functional result and to avoid any additional facial scarring, a prefabricated gracilis muscle free flap was used in a two-stage procedure. Firstly, the muscle was delayed on its main pedicle, a 'tendinous' strip was inserted along its free border and a silicone sheet was slid under its predicted intraoral side. At the time of reconstruction, the neomucosal lining obtained in this way reconstituted the labial vestibule. Furthermore, the muscle, reinnervated by the mandibular branch of the facial nerve, was also put under minimal tension and suspended between the two modioli using the 'tendon' graft. This allowed both lip occlusion and normal speech development to be restored without any impairment of mandibular growth during a 4-year follow-up.

Functional lower lip reconstruction with bilateral cheek advancement flaps: revisitation of Webster method with a minor modification in the technique

Major defects of the lower lip have been repaired in many ways. Of these, some employed flaps from the chin, cheek or upper lip. Some of these procedures employed flaps without regard for the facial grooves or landmarks. Some methods required incisions through nerves supplying the orbicularis oris and the flaps used for the lower lip reconstruction. Of the many methods of reconstruction that have been reported, we believe that the Webster technique should be considered as the first choice for lower lip defects larger than 80% of the total. Because this technique interferes minimally with the sensation of the lower lip and a satisfactory cosmetic outcome with a functional lower lip is achieved, the sensation and muscle function of the upper lip are unaffected. In addition to discussing the advantages of the Webster method, in this paper we present a minor modification in the dissection of the orbicularis oris muscle in an attempt to improve the motor innervation and to provide adequate oral competence and labial functioning in expression and speaking. Motor function and innervation of the lips after reconstruction was documented by clinical findings as well as electrophysiological methods.

Total lower lip reconstruction with innervated muscle-bearing flaps: a modification of the Webster flap

BACKGROUND

Mohs surgery and other surgical techniques are used for the removal of squamous cell carcinoma of the lower lip and may leave a large defect in the vermilion and underlying tissue. When nearly the entire lower lip is excised, reconstruction of this defect is a challenge. Repair requires the matching of vermilion color, maintenance of oral sphincter function and mouth opening size, and retention of sensation. Several techniques have been suggested. We present a modification of the Webster flap for total lower lip reconstruction using innervated muscle-bearing flaps.

OBJECTIVE

To present a surgical technique for the reconstruction of total lower lip defects after excision of squamous cell carcinoma.

METHODS

Innervated muscle-bearing flaps are used and demonstrated in one case. The surgical technique is discussed in detail.

RESULTS

The reconstructive results were excellent. There were no postoperative complications.

CONCLUSION

The use of innervated muscle-bearing flaps is a useful and effective option for the reconstruction of total lower lip defects.