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Reconstruction of large lower lip defects: A new method
Reconstruction of large lower lip defects: A new method HAYATI AKBAS, MD, and NACI KARACAOGLAN, MD, Samsun, Turkey
Lower lip defects may be due to some congenital or acquired problems, such as congenital naevi, hemangiomas, tumors, traumas, or infectious disease. The degree of substance loss may be skin, muscle, or mucoso, or a combination of one or all layers. In large defects of the lower lip, the challenge is to accomplish a result that meets the criteria of successful reconstruction. We present 3 patients with large defects of the lower lip from tumor ablation who underwent satisfactory reconstruction with a new method not previously descried in the English-language literature. (Otolaryngol Head Neck Surg 2001;124:456-8.)
cations of regional or distant metastasis. The resection was full thickness of the lip with margins of 2 to 3 cm in each case. The resulting defects were reconstructed with servicofacial flaps raised with supraomohyoid neck dissections and anterior based dorsal tongue flaps. The cervicofacial flap was used to replace the skin of the lower lip, and the tongue flap was used to replace the mucosal surface and the vermilion. The tongue flap was separated from its pedicle after 3 weeks. All patients were satisfied with the results both functionally and cosmetically. The patients have been followed for an average of 12 months (range, 11 to 14 months). Frozen sections before the reconstruction confirmed adequacy of the resection margins.
Defects of the lower lip may be due to tumors, trauma,
Patient 1
infectious diseases, vasculitis, congenital nevi, hemangiomas, or clefts. The tissue loss may be skin, muscle, mucosa, or a combination of 1 or all layers.1 The principal function of the lips is oral competence. The lips also play a role in deglutition and articulation, as well as being a symbol of beauty and appeal. Defects of up to one third of the lower lip can be closed primarily, but larger defects require more complex techniques.2,3 The use of the tongue flap for reconstruction of the lip is not new. Guerrero Santos and Bakamjian independently reported the use of the tongue flap in lip reconstruction in 1964.3 We present 3 patients with large defects of the lower lip from tumor ablation who underwent reconstruction with a new method not previously described in the English-language literature. We treated these patients with a local cervicofacial flap for reconstruction of the skin defect combined with a tongue flap for mucosal lining and reconstruction of the vermilion border.
A 68-year-old man presented with an 8-month history of a tumor on the left side of his lower lip. He previously had an excision and reconstruction for a squamous cell tumor of the nose. The new primary squamous cell tumor of the lip measuring 3 × 3.5 cm was excised full thickness with 2- to 3-cm margins. A left supraomohyoid neck dissection was carried out that contained no positive lymph nodes. The defect of the lower lip was reconstructed with a left posterosuperior-based cervicofacial flap and an anterior-based dorsal tongue flap. The donor area of the cervicofacial flap was replaced with a superior-based pedicle skin flap from the contralateral neck to prevent retraction of the lip. The postoperative course was uneventful, and the results were satisfactory both functionally and cosmetically. Eleven months after the procedure, no sign of recurrence has been observed.
METHODS AND PATIENTS This series comprises 3 patients with extensive squamous cell carcinoma of the lower lip. None of these cases had indi-
From the Ondokuzmayis University medicine faculty, Department of Plastic and Reconstructive Surgery. Presented at 19th National Plastic and Reconstructive Surgery Congress, Antalya Province of Turkey, September 2-7, 1997. Reprint requests: Dr Hayati Akbas, Ondokuzmayis Universitesi Tip Fakultesi, Plastik ve Rekonstruktif Cerrahi Anabilim Dali, Kurupelit-Samsun, Turkey; e-mail, [email protected]. Copyright © 2001 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/77/114676 doi:10.1067/mhn.2001.114676 456
Patient 2 A 71-year-old man presented with a 6-month history of an enlarging tumor on the left side of his lower lip. A 4 × 4-cm squamous cell carcinoma was resected full thickness through his lip with 2- to 3-cm margins. A left supraomohyoid lymph node dissection was also performed. All nodes in the resected specimen were free of tumor. The defect of the lower lip was reconstructed with a left posterosuperior-based cervicofacial flap and an anterior-based dorsal tongue flap. The donor area of the cervicofacial flap was replaced with a contralateral superiorly based cervical skin flap. This flap was used to prevent inferior retraction of the reconstructed lip. Thirteen months after the procedure, the patient is free of recurrent tumor and has a satisfactory cosmetic and functional result. Patient 3 A 74-year-old man presented with a slowly enlarging tumor that over the preceding 12 months had replaced his entire lower
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C C Fig 1. A, Photograph of 76-year-old man with squamous cell carcinoma of lower lip measuring 6 × 3 cm. B, Postoperative view 8 months after total lower lip reconstruction. C, Oral aperture and appearance of tongue was normal at 8 month after reconstruction.
lip (Figs 1 and 2). Excision of the 6 × 3 cm squamous cell carcinoma with 2- to 3-cm margins required removal of the entire lower lip as well as the oral commissures. The resulting defect was reconstructed with posterosuperior-based cervicofacial flaps and an anterior-based dorsal tongue flap. The donor areas
Fig 2. A, Drawing shows appearance of the defect. B, Rotation and advancement of the cervicofacial flaps (x and y flaps). C, Appearance of reconstructed lower lip with tongue flap (z) and cervicofacial flaps (x and y).
of the cervicofacial flaps were covered with advancement of the anterior cervical skin flaps. A bilateral supraomohyoid dissection was performed with no evidence of metastasis to the adjacent lymph nodes. Satisfactory results were obtained. DISCUSSION
The successful reconstruction of the lower lip must meet certain criteria. The reconstructed lip should be sensate, retain sphincter or muscle function, oppose ver-
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milion to the vermilion of the upper lip in a watertight continent seal, allow sufficient opening for food and dentures, and be of acceptable aesthetic appearance. On occasion, particularly in subtotal and total resections, not all of these criteria can be met. Defects of up to one third of the lip can be closed primarily, but large defects require tissue transfer. The preferred donor site is an adjacent cheek, upper lip, or tongue.2 In large defects of the lower lip, the challenge is to accomplish a result that meets the criteria of successful reconstruction. A widely used technique is the advancement of cheek tissue by the Webster-Bernard approach. Although the initial result obtained may be satisfactory, the continued chronic tension of the closure has frequently resulted in a tight lip that functions poorly. A more satisfactory procedure for defects of this magnitude has been the karapandzic rotation flap, although a microstomia is inevitable.2,4 Other applications for the reconstruction of large full thickness defects of the lower lip include double cross lip flaps, rotation flaps with various modifications, and free composite grafts.4-7 Reconstruction of the large defects of the lower lip continues to be a formidable challenge. For extensive or total defects of the lower lip, the reconstructive surgeon must use regional tissue or a combination of local flaps to achieve an acceptable result. The primary aims of the reconstructive effort are the functional considerations of oral competence, articulation, speech, and the role of lips in mastication. The secondary aim is an aesthetic result that approaches normal appearance and should also be kept in mind.8 Use of the anterior-based dorsal tongue flap provides greater mobility of the tongue because the pedicle is on the free end of the tongue.1 The central position, mobility, and excellent blood supply of the tongue permit a great variation in the repair of defects of the lip. By using the cervicofacial and tongue flap simultaneously, the reconstruction can be completed in 2 stages during a 3-week period. The second stage division of the lip flap can be performed with the patient under local anesthesia on an outpatient basis. In the 3 cases presented, our results were satisfactory both cosmetically and functionally. In each case, the
oral aperture was sufficient. There was no contracture of the lip because we used a superiorly based cervical skin flap for the donor site. The inferior buccal sulcus was sufficient to avoid drooling, and the vermilion was of almost normal appearance. Based on our experience, we would recommend consideration of this method of reconstruction for other patients with similar problems. SUMMARY
Defects of the lower lip may be due to tumors, trauma, infectious diseases, vasculitis congenital nevi, hemangiomas, or clefts. Many different methods have been used to repair large defects in this area. In this article, we described a combined dorsal anterior-based tongue flap and local cervicofacial flap for this purpose. Tongue flaps were used for the vermilion and the mucosal lining, whereas the cervicofacial flaps were used for skin coverage. We were unable to find a description of a similar procedure in the English-language literature. Three cases are described of patients with defects caused by resection of lower lip tumors satisfactorily reconstructed with this method. We especially thank Dr Howard Korn, plastic and reconstructive surgeon at Good Samaritan Hospital, Corvallis, Oregon, for his improvements in this article. REFERENCES 1. Barry MZ. Deformities of the lips and cheek. In: McCarthy JG, ed. Plastic surgery, 2nd ed, Philadelphia: WB Saunders Co; 1990. p. 2009-56. 2. Edward AL. Reconstruction of the lower lip. Clin Plast Surg 1995;1:109-21 3. Diaz FJ, Dean A, Alamillos FJ, et al. Tongue flaps for reconstruction of the oral cavity. Head Neck 1994:16:550-4. 4. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93-7. 5. Parson RW. Reconstruction of the lower face and lips. Clin Plast Surg 1975;2:551-7. 6. Bowers DG. Double cross lip flaps for lower lip reconstruction. Plast Reconst Surg 1971;47:209-14. 7. Nakajima T, Yoshimura Y, Kami T. Reconstruction of the lower lip with a fun shaped flap based on the facial artery. Br J Plast Surg 1984;37:52-4. 8. Williams EF, Setzen G, Mulvaney MJ. Modified Bernard-Burrow cheek advancement and cross lip flap for total lip reconstruction. Arch Otolaryngol Head Neck Surg 1996;122:1253-8
Lower lip defects may be due to some congenital or acquired problems, such as congenital naevi, hemangiomas, tumors, traumas, or infectious disease. The degree of substance loss may be skin, muscle, or mucoso, or a combination of one or all layers. In large defects of the lower lip, the challenge is to accomplish a result that meets the criteria of successful reconstruction. We present 3 patients with large defects of the lower lip from tumor ablation who underwent satisfactory reconstruction with a new method not previously descried in the English-language literature. (Otolaryngol Head Neck Surg 2001;124:456-8.)
cations of regional or distant metastasis. The resection was full thickness of the lip with margins of 2 to 3 cm in each case. The resulting defects were reconstructed with servicofacial flaps raised with supraomohyoid neck dissections and anterior based dorsal tongue flaps. The cervicofacial flap was used to replace the skin of the lower lip, and the tongue flap was used to replace the mucosal surface and the vermilion. The tongue flap was separated from its pedicle after 3 weeks. All patients were satisfied with the results both functionally and cosmetically. The patients have been followed for an average of 12 months (range, 11 to 14 months). Frozen sections before the reconstruction confirmed adequacy of the resection margins.
Defects of the lower lip may be due to tumors, trauma,
Patient 1
infectious diseases, vasculitis, congenital nevi, hemangiomas, or clefts. The tissue loss may be skin, muscle, mucosa, or a combination of 1 or all layers.1 The principal function of the lips is oral competence. The lips also play a role in deglutition and articulation, as well as being a symbol of beauty and appeal. Defects of up to one third of the lower lip can be closed primarily, but larger defects require more complex techniques.2,3 The use of the tongue flap for reconstruction of the lip is not new. Guerrero Santos and Bakamjian independently reported the use of the tongue flap in lip reconstruction in 1964.3 We present 3 patients with large defects of the lower lip from tumor ablation who underwent reconstruction with a new method not previously described in the English-language literature. We treated these patients with a local cervicofacial flap for reconstruction of the skin defect combined with a tongue flap for mucosal lining and reconstruction of the vermilion border.
A 68-year-old man presented with an 8-month history of a tumor on the left side of his lower lip. He previously had an excision and reconstruction for a squamous cell tumor of the nose. The new primary squamous cell tumor of the lip measuring 3 × 3.5 cm was excised full thickness with 2- to 3-cm margins. A left supraomohyoid neck dissection was carried out that contained no positive lymph nodes. The defect of the lower lip was reconstructed with a left posterosuperior-based cervicofacial flap and an anterior-based dorsal tongue flap. The donor area of the cervicofacial flap was replaced with a superior-based pedicle skin flap from the contralateral neck to prevent retraction of the lip. The postoperative course was uneventful, and the results were satisfactory both functionally and cosmetically. Eleven months after the procedure, no sign of recurrence has been observed.
METHODS AND PATIENTS This series comprises 3 patients with extensive squamous cell carcinoma of the lower lip. None of these cases had indi-
From the Ondokuzmayis University medicine faculty, Department of Plastic and Reconstructive Surgery. Presented at 19th National Plastic and Reconstructive Surgery Congress, Antalya Province of Turkey, September 2-7, 1997. Reprint requests: Dr Hayati Akbas, Ondokuzmayis Universitesi Tip Fakultesi, Plastik ve Rekonstruktif Cerrahi Anabilim Dali, Kurupelit-Samsun, Turkey; e-mail, [email protected]. Copyright © 2001 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/77/114676 doi:10.1067/mhn.2001.114676 456
Patient 2 A 71-year-old man presented with a 6-month history of an enlarging tumor on the left side of his lower lip. A 4 × 4-cm squamous cell carcinoma was resected full thickness through his lip with 2- to 3-cm margins. A left supraomohyoid lymph node dissection was also performed. All nodes in the resected specimen were free of tumor. The defect of the lower lip was reconstructed with a left posterosuperior-based cervicofacial flap and an anterior-based dorsal tongue flap. The donor area of the cervicofacial flap was replaced with a contralateral superiorly based cervical skin flap. This flap was used to prevent inferior retraction of the reconstructed lip. Thirteen months after the procedure, the patient is free of recurrent tumor and has a satisfactory cosmetic and functional result. Patient 3 A 74-year-old man presented with a slowly enlarging tumor that over the preceding 12 months had replaced his entire lower
Otolaryngology– Head and Neck Surgery Volume 124 Number 4
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C C Fig 1. A, Photograph of 76-year-old man with squamous cell carcinoma of lower lip measuring 6 × 3 cm. B, Postoperative view 8 months after total lower lip reconstruction. C, Oral aperture and appearance of tongue was normal at 8 month after reconstruction.
lip (Figs 1 and 2). Excision of the 6 × 3 cm squamous cell carcinoma with 2- to 3-cm margins required removal of the entire lower lip as well as the oral commissures. The resulting defect was reconstructed with posterosuperior-based cervicofacial flaps and an anterior-based dorsal tongue flap. The donor areas
Fig 2. A, Drawing shows appearance of the defect. B, Rotation and advancement of the cervicofacial flaps (x and y flaps). C, Appearance of reconstructed lower lip with tongue flap (z) and cervicofacial flaps (x and y).
of the cervicofacial flaps were covered with advancement of the anterior cervical skin flaps. A bilateral supraomohyoid dissection was performed with no evidence of metastasis to the adjacent lymph nodes. Satisfactory results were obtained. DISCUSSION
The successful reconstruction of the lower lip must meet certain criteria. The reconstructed lip should be sensate, retain sphincter or muscle function, oppose ver-
458
Otolaryngology– Head and Neck Surgery April 2001
AKBAS and KARACAOGLAN
milion to the vermilion of the upper lip in a watertight continent seal, allow sufficient opening for food and dentures, and be of acceptable aesthetic appearance. On occasion, particularly in subtotal and total resections, not all of these criteria can be met. Defects of up to one third of the lip can be closed primarily, but large defects require tissue transfer. The preferred donor site is an adjacent cheek, upper lip, or tongue.2 In large defects of the lower lip, the challenge is to accomplish a result that meets the criteria of successful reconstruction. A widely used technique is the advancement of cheek tissue by the Webster-Bernard approach. Although the initial result obtained may be satisfactory, the continued chronic tension of the closure has frequently resulted in a tight lip that functions poorly. A more satisfactory procedure for defects of this magnitude has been the karapandzic rotation flap, although a microstomia is inevitable.2,4 Other applications for the reconstruction of large full thickness defects of the lower lip include double cross lip flaps, rotation flaps with various modifications, and free composite grafts.4-7 Reconstruction of the large defects of the lower lip continues to be a formidable challenge. For extensive or total defects of the lower lip, the reconstructive surgeon must use regional tissue or a combination of local flaps to achieve an acceptable result. The primary aims of the reconstructive effort are the functional considerations of oral competence, articulation, speech, and the role of lips in mastication. The secondary aim is an aesthetic result that approaches normal appearance and should also be kept in mind.8 Use of the anterior-based dorsal tongue flap provides greater mobility of the tongue because the pedicle is on the free end of the tongue.1 The central position, mobility, and excellent blood supply of the tongue permit a great variation in the repair of defects of the lip. By using the cervicofacial and tongue flap simultaneously, the reconstruction can be completed in 2 stages during a 3-week period. The second stage division of the lip flap can be performed with the patient under local anesthesia on an outpatient basis. In the 3 cases presented, our results were satisfactory both cosmetically and functionally. In each case, the
oral aperture was sufficient. There was no contracture of the lip because we used a superiorly based cervical skin flap for the donor site. The inferior buccal sulcus was sufficient to avoid drooling, and the vermilion was of almost normal appearance. Based on our experience, we would recommend consideration of this method of reconstruction for other patients with similar problems. SUMMARY
Defects of the lower lip may be due to tumors, trauma, infectious diseases, vasculitis congenital nevi, hemangiomas, or clefts. Many different methods have been used to repair large defects in this area. In this article, we described a combined dorsal anterior-based tongue flap and local cervicofacial flap for this purpose. Tongue flaps were used for the vermilion and the mucosal lining, whereas the cervicofacial flaps were used for skin coverage. We were unable to find a description of a similar procedure in the English-language literature. Three cases are described of patients with defects caused by resection of lower lip tumors satisfactorily reconstructed with this method. We especially thank Dr Howard Korn, plastic and reconstructive surgeon at Good Samaritan Hospital, Corvallis, Oregon, for his improvements in this article. REFERENCES 1. Barry MZ. Deformities of the lips and cheek. In: McCarthy JG, ed. Plastic surgery, 2nd ed, Philadelphia: WB Saunders Co; 1990. p. 2009-56. 2. Edward AL. Reconstruction of the lower lip. Clin Plast Surg 1995;1:109-21 3. Diaz FJ, Dean A, Alamillos FJ, et al. Tongue flaps for reconstruction of the oral cavity. Head Neck 1994:16:550-4. 4. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93-7. 5. Parson RW. Reconstruction of the lower face and lips. Clin Plast Surg 1975;2:551-7. 6. Bowers DG. Double cross lip flaps for lower lip reconstruction. Plast Reconst Surg 1971;47:209-14. 7. Nakajima T, Yoshimura Y, Kami T. Reconstruction of the lower lip with a fun shaped flap based on the facial artery. Br J Plast Surg 1984;37:52-4. 8. Williams EF, Setzen G, Mulvaney MJ. Modified Bernard-Burrow cheek advancement and cross lip flap for total lip reconstruction. Arch Otolaryngol Head Neck Surg 1996;122:1253-8