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

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.

Intraoral nasolabial flap for lower lip augmentation following post-radiation contracture

The nasolabial flap (NLF) has been reported extensively for reconstruction of various intraoral and extraoral defects resulting from trauma or ablative surgery. However, it has not been described for post-radiation lip augmentation. Herein, we present the case of a 74-year-old female who previously underwent a subtotal glossectomy and free flap reconstruction followed by radiotherapy. While oncologically the patient did well, she developed a significant lower lip contracture which compromised oral intake, denture placement, lip excursion, and psychosocial well-being. The patient underwent release of the scar contracture and a NLF was utilized intraorally to act as a spacer between the gingiva and inner lip mucosa to augment the soft tissue deficit. The patient went on to regain oral intake and placement of her dentures, while reporting significant satisfaction with the post-procedural benefits.

Infolding of Nasolabial Flap: An Excellent Surgical Technique for Full-Thickness Defect of the Lip

To find out the usefulness of the infolding technique of nasolabial flap to reconstruct full-thickness defects of the lower lip. It is a retrospective analysis of 5 surgically operated cases. The infolding nasolabial flaps were utilized for the full thickness defect over the lower lip in carcinoma of the oral cavity from January 2018 to July 2019. The patients were followed up for a minimum period of 12 months, and the outcomes were evaluated. The mean age of the patients was 39.72 ± 7.58 years (range 30-52 years). The infolding nasolabial flap has used each case for the reconstruction of the lower lip. The average length and breadth of the flaps were 65 mm (range 60-75 mm) and 35 mm (range 30-40 mm), respectively. One patient presented with partial necrosis of the flap its tip. The functional and cosmetic outcomes were found satisfactory till 12 months of follow-up, and none of the patients had a recurrence of the disease. Infolding of the nasolabial flap can be a good surgical technique for the reconstruction of the full-thickness defect of the lower lip, ensuring satisfactory functional and cosmetic outcomes without causing major intraoperative/postoperative complications in patients with carcinoma of the lower lip.

Single-stage reconstruction of traumatic lower lip defects with chin island myocutaneous and labial mucosal flap

In the present study of eight cases of traumatic lower lip defects, the reconstruction was achieved in a single stage by V-Y advancement island chin myocutaneous flap and labial mucosal advancement flap. There are many methods described for the reconstruction of small-to-large size of lower lip defects from straight-line closure of small defects to local flaps and free flaps for large defects. V-Y advanced chin flap has been reported previously also for the repair of lower lip defect with varying results. The vermilion reconstruction in others reported cases was done with the free mucosal grafts, V-Y labial mucosa advancement, or pedicled tongue flaps. Tongue flap is a two-stage procedure with esthetically unnatural look and an irregular surface of the vermilion. The free mucosa graft showed necrosis partial or complete resulting in irregular surface of vermilion and notching in the lip. V-Y labial mucosa advancement was done more for a small defect of the lip only. In the present series, we have repaired the vermilion of the lip by labial mucosal advancement flap, muscle by advancement of orbicularis oris from chin flap, and skin by V-Y advancement of island myocutaneous chin flap. Our results showed normal oral size with no evidence of microstoma or commissural distortion; oral competence was good with normal sphincteric function. The vermilion reconstructed had normal color and sensation. Lip seal was very good without notching defect in the vermilion. Drooling of saliva or speech defect was not noticed. The facial expressions and the look of the face were near normal. Hence, esthetically and functionally, the results were good without any irregularity or notching of the lip along with no incidence of drooling of saliva. We think that this technique may be considered as a procedure of choice for managing the moderate-to-large post traumatic defects of the lower lip. It is good esthetically and functionally besides being single stage for reconstructing moderate-to-large defects of the lower lip and is satisfying to the patient.

Functional and aesthetic outcome of different methods of reconstruction of full thickness lip defects

Background: The lip has functional and aesthetic importance. Lip defects occur due to the variety of etiology and the choice of their reconstruction has profound effect on functions and cosmesis. There are multiple options available for reconstruction according to defect size, but superiority of one method over another is still debated and hence the methods and their outcome were analyzed prospectively. Material and method: Twenty-one patients with all sizes and locations of defects in upper and lower lip with acquired etiology were included in the evaluation. Reconstruction was performed according to defect size, availability of local/regional and distant donor tissue, defect location, patients' comorbid conditions and patients' preference. Patients were assessed at 1 month and 6 months postoperatively. Observers' and patients' input were also taken into account for outcome. Results: Out of 21 patients, 5 free radial artery forearm flap reconstructions, 4 nasolabial flap reconstructions, 5 primary closures of defect, 4 Estlander flap reconstructions, 2 lip advancements, and one Karapandzic flap reconstruction were done. Free flap and nasolabial flap had hypoesthesia and incompetence if commissure is reconstructed and problem of bulk, restricted mobility and vermilion mismatch. Local and lip flaps were associated with decreased stoma size and some form of local scarring and asymmetry. However, all patients were satisfied with the functional and aesthetic outcome. Conclusion: Local flaps are better in terms of functional and aesthetic outcome but with some degree of microstomia which was well tolerated by most patients. Regional and distant flaps provide reconstruction where no other option is available and provide good functional support and acceptable cosmesis.

Reconstruction of Subtotal Defect of the Lower Lip: Combined Use of Karapandzic and Nasolabial Flap

Subtotal reconstruction of the lower lip after excision of the tumor is always a challenge for surgeons. It is because of the difficulty in  regaining the function of the lip, including the oral competency and restoring the aesthetic subunit. A 46-year-old patient presented with an ulceroproliferative growth involving 70% of the lower lip, including the right commissure. After the confirmation to be a malignancy, patient underwent excision of the tumour and reconstruction of the lower lip using the left Karapandzic flap and right nasolabial flap. The patient was on regular follow-up in the postoperative period to assess the surgical outcomes. The combined use of Karapandzic flap and the nasolabial flap can be reliably used for subtotal reconstruction of the lower lip in advanced oral cavity malignancy, involving one of the commissures. Later can ensure good postoperative results in terms of aesthetic and functional lip reconstruction without any significant intraoperative or postoperative complications.

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.

Split zygomaticus major muscle sling reconstruction for significant lower lip defects

Defects to the lower lip remain surgically challenging to reconstruct. Restoration of aesthetics and function are crucial, of which the aims include restoring the tissues of the lower lip, maintaining oral competence, speech articulation, and restoring lip height and the vermillion. Further surgical techniques continue to be explored, with local flap surgery being the generally preferred method. However, many reconstructions leave the patient with pronounced deformity and morbidity. In this case report, we describe a new technique for the reconstruction of an 80% lower lip defect with an ipsilateral split zygomaticus major muscle sling, nasolabial flap, and facial artery musculomucosal flap. The reconstruction provided good oral competence, speech articulation and aesthetics, in addition to maintaining the oral commissure and lower lip height/length. Iatrogenic microstomia was avoided and zygomaticus functioning was normal. We are confident this technique will be useful to reconstructive surgeons in select cases of significant lip defects.

Reconstruction of Full-Thickness Defects of the Lower Lip With a Double Overlying Cervical Flap

Reconstruction of full-thickness total or subtotal lower lip defects represents a challenge for the reconstructive surgeon because of the difficulty to create a functional and aesthetically good lip. Many surgical techniques, going from local to free flaps, have been reported, each of them having its own advantages and disadvantages. In particular, the free fascio-cutaneous flaps in most cases are the first reconstructive option, even though several disadvantages such as the complexity of the procedure, longer operative times, morbidity, longer hospitalization, and conspicuous donor-site scar. To avoid these problems, especially in aged patients and in presence of low compliance and/or comorbidities, the Authors propose a single stage reconstruction with a double overlying cervical flap.

Total lower lip reconstruction by bilateral Fujimori technique-A case report

Squamous cell carcinomas are the most common type of lower lip cancer. In cases where the tumour involves less than on third of the lower lip, direct suture maintains the physical appearance of a normal mouth with few adverse effects. Squamous cell carcinomas involving more than half or even most of the lower lip are not common. We report a successful case of complete lower lip reconstruction after recurrent squamous cell carcinoma involving most of the lower lip by use of bilateral Fujimori technique.

CASE

We present a case of full-thickness squamous cell cancer located to the vermillion border initially, but progressing rapidly in two months during radiotherapy to a state in which most of the lower lip, including the angles of the mouth, were affected.

DISCUSSION

Surgical management ensuring a functional and aesthetic acceptable outcome is a challenge in patients with large tumours including all of the lower lip. Several methods for reconstruction of the entire lower lip are discussed.

CONCLUSION

Bilateral Fujimori one-stage flaps can be used in cases of squamous cell carcinomas involving most of the lower lip, including the commissures of the mouth. A limitation of the method is an eventual lack of local tissue when preparing the flap.

Extended Karapandzic Flap Technique for Reconstruction of Lower Lip and Chin Defect

PURPOSE

Near total defect of the lower lip adjacent to the chin remains a reconstructive challenge for surgeons in function and esthetics. The objective of this study was to present a modified extended Karapandzic technique for reconstruction of near total defects of the lower lip adjacent with the chin.

MATERIALS AND METHODS

From 2000 to 2013, patients with lip cancer or oral cavity cancer who required subtotal lower lip and chin resection and subsequently underwent reconstruction with an extended Karapandzic flap were included in this retrospective study. Patient demographics, histopathology, tumor stage, localization, tumor extension, method of reconstruction, and postoperative complications were extracted from patients' documentation.

RESULTS

Reconstruction of the lower lip and chin was performed in 21 patients using a combination of double local extended Karapandzic flaps with microvascular free flaps for intraoral and mandibular reconstruction. There was no flap necrosis; the main complications were fistula and exposure of the osteosynthesis plate. All lips were functional and the esthetic result was pleasing. All patients returned to a peroral diet, although a variable degree of microstomia was present.

CONCLUSION

The extended Karapandzic flap technique provides superior results for esthetic and functional lip reconstruction and chin reconstruction compared with any other regional or free flap. Free flaps should be reserved for oral cavity and mandibular reconstruction, if needed.

Delayed Carotid Dissection Following Lower Lip Revascularization in the Setting of Hyoid Fracture--A Case Report and Review of the Literature

Traumatic injuries to the lip are common, but injuries that require revascularization of the lower lip are infrequent and pose a major challenge to the reconstructive surgeon. This report describes the case of a 53-year-old woman who sustained a lower lip avulsion injury, a comminuted mandibular parasymphyseal fracture, and a hyoid bone fracture secondary to a bicycle accident. Trauma workup included computed tomographic angiography of the head and neck, which did not show vascular injury. Despite successful revascularization of the lower lip, on postoperative day 11 the patient developed a large internal carotid artery dissection and middle cerebral artery stroke. This case highlights the importance of careful postoperative monitoring after high-energy facial trauma, particularly in the setting of vascular and bony injuries.

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.