Lower Face Reconstruction Using the Visor Flap

Total lower lip reconstruction: a review of recent advances

PURPOSE OF REVIEW

This review describes the fundamental principles and recent advances in the reconstruction of total lower lip defects to restore peri-oral aesthetic and function.

RECENT FINDINGS

Modifications to the Abbe flap and visor flap have recently been described. Recent advances to free flap techniques have focused on dynamic restoration of lower lip sling function after reconstruction. This involves the transfer of innervated or noninnervated muscle tissue to reconstruct the lower lip to restore the sphincter function of the lips.

SUMMARY

The reconstructive goals for a full thickness lower lip defect are to restore a functional oral sphincter, replace mucosal and external skin, and maintain a functional size of the oral aperture. Local flap reconstruction of sub-total lower lip defects is possible, but use of local flaps for total lip reconstruction often leads to microstomia. Several static and dynamic free tissue transfer options exist for lower lip reconstruction and have been summarized in this review.

Comparison of Visor Access Approach with Lower LIP Split Approach in Resection of Oral Cancers

Purpose

There is high prevalance of oral cancers particularly buccal mucosa and lower gingivobuccal sulcus in our region. These can be approached by both Lower lip split and by Visor approach. Anteriorly placed oral cancers can be resected by visor approach, retaining oral competence and lower lip vascularity. Visor approach is challenging in locally advanced oral cancers requiring reconstruction. We compared outcome of resection of lateralized oral cancers by lower lip split approach and visor approach with regard to duration of surgery, adequacy of exposure of tumour, access for reconstruction, resection margins and complications.

Methodology

66 Patients with T2 & T3 staged oral squamous cancers were randomized into two groups. Following neck dissection, Group A underwent composite resection by lower lip split, and Group B by visor approach. Variables mentioned above were compared between two groups.

Results

This study included patients with T2(58%)and T3 (42%) oral cancers. Except 3 patients in Group B, adequacy of exposure was similar in both groups. Operating time was longer in Group B. Close margins anteriorly were more frequent in Group A. Axial flaps(98.5% ) and radial forearm free flaps(1.5%) were used for reconstruction. Suturing bulky flaps was difficult in Group B( 9.1%).Most common complication in both groups was orocutaneous fistula.

Conclusion

Adequacy of exposure, resected margins, surgical outcome with regards to healing and complications were similar between lower lip split and visor approach in oral cancers. Visor approach for resection of oral cancers is preferred option in tumours close to oral commissure.

The Use of Infrared Thermography in Determining Timing for Early Pedicle Division of the Preexpanded Bipedicled Visor Flap after Ischemic Preconditioning

Background

The preexpanded bipedicled visor flap, supported by the bilateral superficial temporal vessels, stands as an ideal choice for upper and lower lip reconstruction in males. However, the bilateral tissue bridges after flap transfer caused patients significant cosmetic deformity and psychological burden. Early division of bilateral pedicles reduced the length of hospitalization and expenses. In this study, infrared thermography (IRT) was used to guide the early pedicle division after ischemic preconditioning.

Methods

This study retrospectively analyzed patients who underwent preexpanded bipedicled visor flap surgery from April 2018 to October 2021. Pedicle division was scheduled at two weeks postflap transfer. Ischemic preconditioning was initiated 3-5 days in advance by repeatedly clamping both pedicles. The temperature alteration of the flap and the temperature difference compared to the normal adjacent tissue were evaluated by IRT. The division surgery was not scheduled until the perfusion assessment indicated adequate. This comprised of subjective examination and indocyanine green angiography. The threshold of temperature difference to determine the pedicle division was analyzed based on the temperature changes between the clamps.

Results

A total of 8 male patients successfully conducted the pedicle division without any complications. The delay period after ischemic preconditioning ranged from 14 to 19 days (average 16 days). Through ischemic preconditioning training, the average temperature of the flap gradually increased from 31.85 ± 0.36°C to 33.89 ± 0.50°C, and the temperature difference with the normal surrounding tissues decreased from 2.89 ± 0.30°C to 1.15 ± 0.46°C (95% confidence interval (1.5, 0.8)). The temperature difference stayed unchanged after pedicle division.

Conclusion

Ischemic preconditioning shortens the perioperative period to pedicle division. Monitoring the temperature change reflects the revascularization between the flap and the recipient site, thus guiding the pedicle division. The temperature difference less than 1.5°C after clamping both pedicles can be set as the safe threshold for pedicle division.