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Results of a modified staircase technique for reconstruction of the lower lip
Journal of Cranio-Maxillofacial Surgery (1997) 25, 239-244 © I997 European Association for Cranio-MaxinofacialSurgery
Results of a modified staircase technique for reconstruction of the lower lip J. J. Kuttenberger, N. Hardt
Clinicfor Oral and Maxillofacial Surgery (Head: Prof. N. Hardt), Kantonsspital Luzern, Switzerland S U M M A R Y . Our experience with a modified staircase technique for closure of lower lip defects is reported. The procedure is based on the original technique of Johanson et al. (1974). However, the integrity of the orbicularis oris muscle is respected when advancing lower lip flaps. Twenty patients with squamous cell carcinoma of the lower lip were treated using this modified reconstruction technique. The size of the defects ranged from 30-60% of lower lip width. No recurrences were observed during a 3-year to 5-year follow-up. All patients showed symmetrical lip movement, an adequate buccal sulcus and intact labial commissures. No symptomatic microstomia was seen and the aesthetic results were excellent. The surgical technique is explained in detail. Four types of flap are presented according to the size and location of lip defects. Lower lip defects up to 60% of the lip width can be dosed easily, with good aesthetic results. The technique is also applicable to upper lip reconstruction.
defects of the lower lip. After rectangular excision of the lesion, reconstruction of the lip is performed with lateral advancement flaps from the remaining parts of the lower lip and chin prepared by stepwise-formed incisions. Defects of the lip can be closed with either unilateral or bilateral flaps. In the original description (Johanson et al., 1974), the step incisions are carried through the full thickness of the lower lip. The rectangles below the steps are also excised through the full thickness of the lip (Sullivan, 1978), whereas the lateral triangle is excised at a plane superficial to the muscle layer. We modified this technique and do not make the staircase incisions through the full thickness of the lower lip but in a plane superficial to the orbicularis oris muscle (Dado and Angelats, 1985; Stiernberg, 1992). Only skin and subcutaneous tissue are excised in the area of the rectangles below the steps. The orbicularis oris and depressor labii inferioris muscles and the mucosa are left intact (Hardt and Gottsauner, 1994). After removal of the lesion in a rectangular fashion, the specimen is sent for frozen section checks of all margins. Once the defect has been created, the staircase incisions and the skin rectangles which have to be removed are calculated and marked. Central and paramedian defects are closed using bilateral flaps. Lateral lower lip defects less than 2 cm in width can be closed with an unilateral flap. Symmetrical staircase incisions are outlined for the closure of central defects (Fig. 1). The first step is made parallel to the vermilion border and is one half of the width of the defect. The following steps are gradually reduced in width. Their size can be calculated from the number of steps and the size of the defect (Sullivan, 1978). An example is given in
INTRODUCTION Reconstruction techniques for subtotal and total resection defects of the lower lip can be classified according to the different donor sites. Defects of less than one third of the lower lip width can be closed by direct approximation in combination with a Z-plasty. Closure of subtotal or total lip defects can be achieved by a multiplicity of techniques, using either unilateral or bilateral transposition flaps (Bernard, 1852; Freeman, 1958; Webster et al., 1960; Grimm, 1966; Fries, 1973) or rotation flaps from the neighbouring cheek (Gillies and Millard, 1957; Karapandzic, 1974; McGregor, 1983; Nakajima et al., 1984) or with lip switch flaps (Estlander, 1872; Abbd, 1898). Many of these different transposition and rotation flaps bear the inevitable disadvantage that parts of the orbicularis otis muscle have to be transsected and transposed causing disorientation and denervation of the muscle fibres. Despite reinnervation of the transsected orbicularis oris muscle in most techniques, the muscle fibres remain disoriented and lip movement is often asymmetrical (Sullivan, 1978; Dado and Angelats, 1985). Loss of sensibility may result after reconstruction of the lower lip. In the case of lateral transposition flaps, even disturbances of upper lip sensibility may arise. With Abbd-Estlander-type flaps, the upper lip is violated and the commissure is altered so that secondary commissuroplasties are often necessary. SURGICAL TECHNIQUE
Johanson et al. (1974) were the first to use the staircase technique for the closure of full-thickness 239
240
Journalof Cranio-Maxillofacial Surgery
t"
\
J \
(
I
M_J
J \
) Defect = 24 mm = 3mm per step
ncement ~m ~lm 6 mm 3 mm
Fig. 1 - Modified staircase technique for central defects with symmetrical bilateral flaps, a and b measure half the width of the defect and equal A and B.
Figure2. The steps usually measure 7 - 1 0 m m vertically. The rectangles which have to be excised should be slightly less wide than the steps. The incision ends with a Burow triangle with an inferiorly located apex. It is not necessary to undermine the soft tissue beneath the flaps which are advanced into the defect (Fig. 3). Closure of the lip is performed in four layers. For paramedian defects, asymmetric steps are outlined (Fig. 4) with a shorter horizontal limb on the lateral side of the defect (approximately 2/5 of the defect width) and a longer limb medially (3/5 of the defect width). The width of the steps can be calculated from the defect width and the number of steps (Figs. 5 & 6). Lateral defects close to the commissure are reconstructed with a unilateral flap with staircase incisions made on the medial side of the defect (Fig. 7). The length of the first horizontal incision corresponds to the width of the defect. The number of steps necessary (usually 3-4) depends on the size of the defect and the tension of the lip tissue. Defects involving the commissure can be closed by using a unilateral flap combined with a Gillies fan flap. Although the staircase technique is usually used for lower lip reconstruction, central defects up to one half of the upper lip can also be easily closed with
Fig. 2 - Calculation of step width and amount of advancementat each levelfor a proposed bilateral symmetricalstaircase repair. The defectmeasures24 mm in width, four steps are planned per flap, the advancementis 3 mm per step.
Fig. 3 - Bilateral symmetricalstaircase flaps for closureof a central lower lip defectin a 57-year-oldpatient. Situationafter tumour resectionand advancementof flaps. Note preservationof orbicularis oris muscle (arrow). this technique and aesthetically good results obtained
(Dado and Angelats, 1984) using a slightly modified incision (Fig. 8). According to size and location of the area to be reconstructed, alternative techniques for upper lip reconstruction (Webster, 1955; Gillies and Millard, 1957) have to be chosen individually for each defect.
Reconstruction of the lower lip
f
241
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Fig. 6 - Flaps advanced and defect closed.
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c"-) )
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F i g . 4 - Modified staircase technique for paramedian defects with asymmetrical bilateral flaps, a measures 2/5 the width of the defect and equals A; b measures 3/5 the width of the defect and equals B.
F i g . 7 - Modified staircase technique for lateral defects with unilateral flap. A corresponds to the width of the defect and equals a. F i g . $ - 64-year-old patient with paramedian squamous cell carcinoma of the lower lip. Bilateral asymmetrical flaps outlined.
INDICATION The modified staircase technique is indicated for subtotal lower lip reconstruction when direct closure is n o t possible and regional flaps are not necessary. According to Johanson et al. (1974), defects o f up to 2/3 o f the lower lip can be closed with the staircase technique, whereas Sullivan (1978) does n o t apply
this technique to defects o f m o r e than half o f the lip width. Hardt and Gottsauner (1994) have been using their modified technique without functional or aesthetic drawbacks for the repair o f lower lip defects o f up to 60% o f the lip width.
RESULTS D u r i n g the last 5 years, 20 patients with s q u a m o u s cell carcinoma o f the lower lip have been treated
242
Journalof Cranio-Maxillofacial Surgery
f
The loss of sensation around the lip repair was minimal and normal lower lip sensibility usually returned within 6-12 weeks. The postoperative muscle function normalized within 6-10 days. During the long-term follow-up, all patients showed symmetrical lip mobility during function and at rest without disturbances of facial nerve activity (Figs. 9 & 10). None of the patients showed an inadequate vestibular sulcus or a microstomia that prevented the insertion of dentures (Fig. 11). No secondary commissurotomies were necessary.
\
DISCUSSION Any technique for lower lip reconstruction should prevent violation or transsection of the depressor anguli oris and orbicularis otis muscles. Using the staircase advancement technique, neither the orbicularis otis muscle nor the depressor anguli oris and
Fig. 8 - Modified staircase technique for upper lip defects, a and b measure half the width of the defect and equal A and B.
using this technique. The TN-classification of the tumours is shown in Table 1. The tumour size ranged from 0.8 cm to 2.8 cm with a median size of 1.2 cm. In 9 patients, the carcinoma was located in the middle third of the lower lip, in 8 patients in the left third, and in 3 patients in the right third. The central defects were closed with symmetrical bilateral flaps, 9 lateral defects were closed with asymmetrical bilateral flaps, and 2 lateral defects with unilateral flaps. In 8 patients, the resection of the tumour was done without lymph node dissection; in 12 patients a simultaneous bilateral suprahyoid neck dissection was carried out. During the mean follow-up period of 3½ years, no local recurrences or nodal metastases were observed. The lip tissue excised ranged from 30-60% of the lower lip width. All margins were free of tumour in frozen section checks. The rectangles excised below the steps were examined in serial sections and no tumour cells could be found.
Fig. 9 - Patient 2 years after excision of central lower lip lesion and reconstruction with bilateral symmetrical staircase flaps. Scars are almost invisible and follow the labiomental groove (same patient as in Fig. 3).
Table 1 - TN-Classifieation of 20 patients with lower lip carcinomas
No N1 N2 Total
T1
T2
T3
Total
9 2 0 11
2 4 1 7
1 1 0 2
12 7 1 20
Fig. 10 - Symmetrical lip movement 2 years after t u m o u r excision and reconstruction with bilateral flaps. Note excellent muscle function and absence of microstomia (same patient as in Fig. 3).
Reconstruction of the lower lip
Fig. l l - Adequate vestibular sulcus 2 years after reconstruction with bilateral flaps (same patient as in Fig. 3).
labii inferioris muscles are transsected (Fig. 3). The direction of the muscle bundles and their innervation are preserved and excellent muscle realignment is achieved by advancing the flaps medially (Johanson et al., 1974). This is the reason why the reconstructed lip shows a more symmetrical mobility than that achieved by alternative methods (Gillies and Millard, 1957), where often a transsection of sensory or motor nerves is inevitable. Preservation of the nerve supply to the lip flaps and good muscle realignment can also be achieved by using the Karapandzic-technique. Violation of branches of the facial nerve leads to more severe functional disorders than transsection of the orbicularis oris muscle. This muscle is cut through when using the techniques of Gillies and Millard (1957), Fries (1973), McGregor (1983) or Nakajima et al (1984). The staircase incision of the modified Johanson technique prevents contractures which are often associated with long straight scars. After lip reconstruction according to the Johanson technique, the scars tend to round out, follow the natural labiomental grooves and become inconspicuous after 5-6 months (Fig. 9). Our cases show that subtotal defects of up to 60% of the lower lip can be successfully closed using the modified staircase technique. This is due to postoperative stretching of the perioral tissues, which prevents microstomia and loss of lower lip projection (Dado and Angelats, 1985). These results are in accordance with Johanson et al. (1974), whereas Sullivan (1978) restricts the staircase technique to defects of up to ½ of the horizontal lower lip width. Our long-term observations show that not only lip width but also lip height is completely maintained. Due to meticulous reconstruction of the orbicularis oris muscle, the circular integrity of the oral sphincter is preserved and downward muscle pull and scar contracture are limited to a minimum.
243
Pelly and Tan (1981) recommended a combination of an unilateral staircase flap with double divergent flaps from the opposite side to prevent lip asymmetry for closure of lateral lower lip defects. We did not observe lip asymmetry in our cases with lateral defects when using bilateral modified staircase flaps for closure. Considering aesthetics and function, the unilateral flap should therefore only be used in small lateral lower lip defects. In large lateral defects, bilateral asymmetric flaps are to be preferred. Symmetry of the commissures is another advantage of the staircase technique. After unilateral reconstruction with a Gillies fan flap, the corner of the mouth on the operated side is located higher and the commissure is rounded. Using the McGregor technique, the asymmetry of the commissure is only visible when opening the mouth. Sufficient mouth opening is an important factor in lower lip reconstruction. In our cases, macrostomia was not found, as occasionally occurs after using the Fries technique, nor did we observe severe microstomia. With the Fries technique, a sufficiently wide lower lip can be reconstructed. However, the vestibular sulcus is inadequate and tight perioral tissues may result. The modified staircase technique avoids undue tension in the reconstructed lower lip. All our patients had an adequate vestibular sulcus postoperatively (Fig. 11). This is most important for any necessary prosthetic rehabilitation. As the staircase flaps are advanced from the neighbouring area of the lower lip and chin, the thickness of the reconstructed lip corresponds well to the original lip dimensions. Looked at from this point of view, the staircase technique is in accordance with the methods of Bernard (1853), Gillies and Millard (1957), Fries (1973) and Karapan&ic (1974). After reconstruction, the lower lip should not be too narrow and too tight. With bilateral Gillies fan-flaps, a small but symmetrical lower lip results. With the 90 ° cheek rotation o f the McGregor technique, the reconstructed lower lip shows adequate width. However, especially in unilateral reconstruction, the volume of the cheek flaps makes the lip appear very thick. The modified staircase technique can be easily combined with a bilateral suprahyoid neck dissection. In our early cases, the neck dissection was done in tumour levels higher than T1 and in lymph node stages higher than No. Considering the investigations of Machtens (1992) and Mast et al. (1992), we now perform prophylactic suprahyoid neck dissection in the No neck and also in T1 lesions.
CONCLUSION The modified staircase technique can be used successfully for reconstruction of lower lip defects of up to
244
Journal of Cranio-Maxillofacial Surgery
60% o f the h o r i z o n t a l w i d t h o f the lip. H o w e v e r , for t o t a l lower lip r e c o n s t r u c t i o n different m e t h o d s have to be used. C o m p a r e d with m a n y o t h e r techniques for s u b t o t a l lip r e c o n s t r u c t i o n , the m o d i f i e d staircase technique has the following advantages: (1) it is technically simple, (2) it p r o v i d e s excellent aesthetic a n d f u n c t i o n a l results, (3) it preserves b o t h m o t o r a n d sensory nerve s u p p l y in the r e c o n s t r u c t e d lip a n d p r o v i d e s excellent muscle r e a l i g n m e n t a n d (4) it is sound from an oncological standpoint and provides g o o d l o n g - t e r m results.
References Abbd,/~: A new plastic operation for the relief of deformity due to
double harelip. Med. Rec. New York 53 (1898)477 Bernard, C.: Cancer de la L6vre Inf6rieure: Restauration/t l'Aide
de Lambeaux Quadrilataires-Lat6reaux, Querison, Scalpel 5 (1852) 162-164 Dado, D. V., J. Angelats: Upper and lower lip reconstruction using the step technique. Ann. Plast. Surg. 15 ( 1985) 204-211 Estlander, J. A.." Eine Methode, aus der einen Lippe Substanzverluste der anderen zu ersetzen. Arch. Klin. Chir. 14 (1872) 622-631 Freeman, B. S.: Myoplastic modification of the Bernard cheiloplasty. Plast. Reconstr. Surg. 21 (1958) 453-460 Fries, R.: Advantages of a basic concept in lip reconstruction after tumour resection. J. Maxillofac. Surg. 1 (1973) 13-18 Gillies, H. D., D. R. Millard: Principles and Art of Plastic Surgery, Little, Brown & Co., Boston, 1957, 507-508 Grimm, G.." Eine neue Methode der Nahlappenplastk zum Ersatz tumorbedingter totaler Unterlippendefekte. Zentralbl. Chir. 91 (1966) 1621-1625 Hardt, N., A. Gottsauner: Experience with a modified step-
technique for reconstruction of the lower lip. (Abstract) J. Cranio-Maxillofac. Surg. 22 Suppl. 1 (1994) 72 Johanson, B., E. Aspelund, U. Breine, H. HolrnstrOm: Surgical treatment of non-traumatic lower lip lesions with special reference to the step technique. Scand. J. Plast. Reconstr. Surg. 8 (1974) 232-240 Karapandzic, M.: Reconstruction of lip defects by local arterial flaps. Br. J. Plast. Surg. 27 (1974) 93-97 Machtens, E.: Die chirurgische Therapie des Lippeukarzinoms, In: K. Vinzenz, H. W. Waclawiczek (eds): Chirurgische Therapie von Kopf-Hals-Karzinomen, Springer, Wien 1992, 51-56 Mast, G., G. Egerter, N. Schwenzer, M. Ehrenfeld, P. Cornelius:
Ergebnisse der Behandlung des Lippenkarzinoms. Fortschr. Kiefer- und Gesichtschir. 37 (1992) 72-75 McGregor, I. A.: Reconstruction of the lower lip. Br. J. Plast. Surg. 36 (1983) 40-47 Nakajima, T., T. Yoshimura, T. Kami: Reconstruction of the lower lip with a fan-shaped flap based on the facial artery. Br. J. Plast. Surg. 37 (1984) 52-54 Pelly, A. D., E.-P. Tan: Lower Lip Reconstruction. Br. J. Plast. Surg. 34 (1981) 83-86 Stiernberg, C. M.: Reconstruction of medium-sized lip defects. In: K. H. Calhoun, C. M. Stiernberg: Surgery of the lip. Thieme, Stuttgart 1992, 35-41 Sullivan, D. E.: 'Staircase' closure of lower lip defects. Ann. Plast. Surg. 1 (1978) 392-397 Webster, J. P.: Crescentic peri-alar cheek excision for upper lip flap advancement with a short history of upper lip repair. Plast. Reconstr. Surg. 16 (1955) 434-458 Webster, R. C., R. Coffey, R. E. Kelleher: Total and partial reconstruction of the lower lip with innervated muscle-bearing flaps. Plast. Reconstr. Surg. 25 (1960) 360-371 Johannes J. KuttenbergerMD, DMD Clinic for Oral and Maxillofacial Surgery Kantonsspital Luzern Spitalstrage CH-6000 Luzern Switzerland Paper received 10 April 1997 Accepted 5 July 1997
Results of a modified staircase technique for reconstruction of the lower lip J. J. Kuttenberger, N. Hardt
Clinicfor Oral and Maxillofacial Surgery (Head: Prof. N. Hardt), Kantonsspital Luzern, Switzerland S U M M A R Y . Our experience with a modified staircase technique for closure of lower lip defects is reported. The procedure is based on the original technique of Johanson et al. (1974). However, the integrity of the orbicularis oris muscle is respected when advancing lower lip flaps. Twenty patients with squamous cell carcinoma of the lower lip were treated using this modified reconstruction technique. The size of the defects ranged from 30-60% of lower lip width. No recurrences were observed during a 3-year to 5-year follow-up. All patients showed symmetrical lip movement, an adequate buccal sulcus and intact labial commissures. No symptomatic microstomia was seen and the aesthetic results were excellent. The surgical technique is explained in detail. Four types of flap are presented according to the size and location of lip defects. Lower lip defects up to 60% of the lip width can be dosed easily, with good aesthetic results. The technique is also applicable to upper lip reconstruction.
defects of the lower lip. After rectangular excision of the lesion, reconstruction of the lip is performed with lateral advancement flaps from the remaining parts of the lower lip and chin prepared by stepwise-formed incisions. Defects of the lip can be closed with either unilateral or bilateral flaps. In the original description (Johanson et al., 1974), the step incisions are carried through the full thickness of the lower lip. The rectangles below the steps are also excised through the full thickness of the lip (Sullivan, 1978), whereas the lateral triangle is excised at a plane superficial to the muscle layer. We modified this technique and do not make the staircase incisions through the full thickness of the lower lip but in a plane superficial to the orbicularis oris muscle (Dado and Angelats, 1985; Stiernberg, 1992). Only skin and subcutaneous tissue are excised in the area of the rectangles below the steps. The orbicularis oris and depressor labii inferioris muscles and the mucosa are left intact (Hardt and Gottsauner, 1994). After removal of the lesion in a rectangular fashion, the specimen is sent for frozen section checks of all margins. Once the defect has been created, the staircase incisions and the skin rectangles which have to be removed are calculated and marked. Central and paramedian defects are closed using bilateral flaps. Lateral lower lip defects less than 2 cm in width can be closed with an unilateral flap. Symmetrical staircase incisions are outlined for the closure of central defects (Fig. 1). The first step is made parallel to the vermilion border and is one half of the width of the defect. The following steps are gradually reduced in width. Their size can be calculated from the number of steps and the size of the defect (Sullivan, 1978). An example is given in
INTRODUCTION Reconstruction techniques for subtotal and total resection defects of the lower lip can be classified according to the different donor sites. Defects of less than one third of the lower lip width can be closed by direct approximation in combination with a Z-plasty. Closure of subtotal or total lip defects can be achieved by a multiplicity of techniques, using either unilateral or bilateral transposition flaps (Bernard, 1852; Freeman, 1958; Webster et al., 1960; Grimm, 1966; Fries, 1973) or rotation flaps from the neighbouring cheek (Gillies and Millard, 1957; Karapandzic, 1974; McGregor, 1983; Nakajima et al., 1984) or with lip switch flaps (Estlander, 1872; Abbd, 1898). Many of these different transposition and rotation flaps bear the inevitable disadvantage that parts of the orbicularis otis muscle have to be transsected and transposed causing disorientation and denervation of the muscle fibres. Despite reinnervation of the transsected orbicularis oris muscle in most techniques, the muscle fibres remain disoriented and lip movement is often asymmetrical (Sullivan, 1978; Dado and Angelats, 1985). Loss of sensibility may result after reconstruction of the lower lip. In the case of lateral transposition flaps, even disturbances of upper lip sensibility may arise. With Abbd-Estlander-type flaps, the upper lip is violated and the commissure is altered so that secondary commissuroplasties are often necessary. SURGICAL TECHNIQUE
Johanson et al. (1974) were the first to use the staircase technique for the closure of full-thickness 239
240
Journalof Cranio-Maxillofacial Surgery
t"
\
J \
(
I
M_J
J \
) Defect = 24 mm = 3mm per step
ncement ~m ~lm 6 mm 3 mm
Fig. 1 - Modified staircase technique for central defects with symmetrical bilateral flaps, a and b measure half the width of the defect and equal A and B.
Figure2. The steps usually measure 7 - 1 0 m m vertically. The rectangles which have to be excised should be slightly less wide than the steps. The incision ends with a Burow triangle with an inferiorly located apex. It is not necessary to undermine the soft tissue beneath the flaps which are advanced into the defect (Fig. 3). Closure of the lip is performed in four layers. For paramedian defects, asymmetric steps are outlined (Fig. 4) with a shorter horizontal limb on the lateral side of the defect (approximately 2/5 of the defect width) and a longer limb medially (3/5 of the defect width). The width of the steps can be calculated from the defect width and the number of steps (Figs. 5 & 6). Lateral defects close to the commissure are reconstructed with a unilateral flap with staircase incisions made on the medial side of the defect (Fig. 7). The length of the first horizontal incision corresponds to the width of the defect. The number of steps necessary (usually 3-4) depends on the size of the defect and the tension of the lip tissue. Defects involving the commissure can be closed by using a unilateral flap combined with a Gillies fan flap. Although the staircase technique is usually used for lower lip reconstruction, central defects up to one half of the upper lip can also be easily closed with
Fig. 2 - Calculation of step width and amount of advancementat each levelfor a proposed bilateral symmetricalstaircase repair. The defectmeasures24 mm in width, four steps are planned per flap, the advancementis 3 mm per step.
Fig. 3 - Bilateral symmetricalstaircase flaps for closureof a central lower lip defectin a 57-year-oldpatient. Situationafter tumour resectionand advancementof flaps. Note preservationof orbicularis oris muscle (arrow). this technique and aesthetically good results obtained
(Dado and Angelats, 1984) using a slightly modified incision (Fig. 8). According to size and location of the area to be reconstructed, alternative techniques for upper lip reconstruction (Webster, 1955; Gillies and Millard, 1957) have to be chosen individually for each defect.
Reconstruction of the lower lip
f
241
\
)
\
Fig. 6 - Flaps advanced and defect closed.
/
\
f
J
t
\
")
k..J
c"-) )
\
I
F i g . 4 - Modified staircase technique for paramedian defects with asymmetrical bilateral flaps, a measures 2/5 the width of the defect and equals A; b measures 3/5 the width of the defect and equals B.
F i g . 7 - Modified staircase technique for lateral defects with unilateral flap. A corresponds to the width of the defect and equals a. F i g . $ - 64-year-old patient with paramedian squamous cell carcinoma of the lower lip. Bilateral asymmetrical flaps outlined.
INDICATION The modified staircase technique is indicated for subtotal lower lip reconstruction when direct closure is n o t possible and regional flaps are not necessary. According to Johanson et al. (1974), defects o f up to 2/3 o f the lower lip can be closed with the staircase technique, whereas Sullivan (1978) does n o t apply
this technique to defects o f m o r e than half o f the lip width. Hardt and Gottsauner (1994) have been using their modified technique without functional or aesthetic drawbacks for the repair o f lower lip defects o f up to 60% o f the lip width.
RESULTS D u r i n g the last 5 years, 20 patients with s q u a m o u s cell carcinoma o f the lower lip have been treated
242
Journalof Cranio-Maxillofacial Surgery
f
The loss of sensation around the lip repair was minimal and normal lower lip sensibility usually returned within 6-12 weeks. The postoperative muscle function normalized within 6-10 days. During the long-term follow-up, all patients showed symmetrical lip mobility during function and at rest without disturbances of facial nerve activity (Figs. 9 & 10). None of the patients showed an inadequate vestibular sulcus or a microstomia that prevented the insertion of dentures (Fig. 11). No secondary commissurotomies were necessary.
\
DISCUSSION Any technique for lower lip reconstruction should prevent violation or transsection of the depressor anguli oris and orbicularis otis muscles. Using the staircase advancement technique, neither the orbicularis otis muscle nor the depressor anguli oris and
Fig. 8 - Modified staircase technique for upper lip defects, a and b measure half the width of the defect and equal A and B.
using this technique. The TN-classification of the tumours is shown in Table 1. The tumour size ranged from 0.8 cm to 2.8 cm with a median size of 1.2 cm. In 9 patients, the carcinoma was located in the middle third of the lower lip, in 8 patients in the left third, and in 3 patients in the right third. The central defects were closed with symmetrical bilateral flaps, 9 lateral defects were closed with asymmetrical bilateral flaps, and 2 lateral defects with unilateral flaps. In 8 patients, the resection of the tumour was done without lymph node dissection; in 12 patients a simultaneous bilateral suprahyoid neck dissection was carried out. During the mean follow-up period of 3½ years, no local recurrences or nodal metastases were observed. The lip tissue excised ranged from 30-60% of the lower lip width. All margins were free of tumour in frozen section checks. The rectangles excised below the steps were examined in serial sections and no tumour cells could be found.
Fig. 9 - Patient 2 years after excision of central lower lip lesion and reconstruction with bilateral symmetrical staircase flaps. Scars are almost invisible and follow the labiomental groove (same patient as in Fig. 3).
Table 1 - TN-Classifieation of 20 patients with lower lip carcinomas
No N1 N2 Total
T1
T2
T3
Total
9 2 0 11
2 4 1 7
1 1 0 2
12 7 1 20
Fig. 10 - Symmetrical lip movement 2 years after t u m o u r excision and reconstruction with bilateral flaps. Note excellent muscle function and absence of microstomia (same patient as in Fig. 3).
Reconstruction of the lower lip
Fig. l l - Adequate vestibular sulcus 2 years after reconstruction with bilateral flaps (same patient as in Fig. 3).
labii inferioris muscles are transsected (Fig. 3). The direction of the muscle bundles and their innervation are preserved and excellent muscle realignment is achieved by advancing the flaps medially (Johanson et al., 1974). This is the reason why the reconstructed lip shows a more symmetrical mobility than that achieved by alternative methods (Gillies and Millard, 1957), where often a transsection of sensory or motor nerves is inevitable. Preservation of the nerve supply to the lip flaps and good muscle realignment can also be achieved by using the Karapandzic-technique. Violation of branches of the facial nerve leads to more severe functional disorders than transsection of the orbicularis oris muscle. This muscle is cut through when using the techniques of Gillies and Millard (1957), Fries (1973), McGregor (1983) or Nakajima et al (1984). The staircase incision of the modified Johanson technique prevents contractures which are often associated with long straight scars. After lip reconstruction according to the Johanson technique, the scars tend to round out, follow the natural labiomental grooves and become inconspicuous after 5-6 months (Fig. 9). Our cases show that subtotal defects of up to 60% of the lower lip can be successfully closed using the modified staircase technique. This is due to postoperative stretching of the perioral tissues, which prevents microstomia and loss of lower lip projection (Dado and Angelats, 1985). These results are in accordance with Johanson et al. (1974), whereas Sullivan (1978) restricts the staircase technique to defects of up to ½ of the horizontal lower lip width. Our long-term observations show that not only lip width but also lip height is completely maintained. Due to meticulous reconstruction of the orbicularis oris muscle, the circular integrity of the oral sphincter is preserved and downward muscle pull and scar contracture are limited to a minimum.
243
Pelly and Tan (1981) recommended a combination of an unilateral staircase flap with double divergent flaps from the opposite side to prevent lip asymmetry for closure of lateral lower lip defects. We did not observe lip asymmetry in our cases with lateral defects when using bilateral modified staircase flaps for closure. Considering aesthetics and function, the unilateral flap should therefore only be used in small lateral lower lip defects. In large lateral defects, bilateral asymmetric flaps are to be preferred. Symmetry of the commissures is another advantage of the staircase technique. After unilateral reconstruction with a Gillies fan flap, the corner of the mouth on the operated side is located higher and the commissure is rounded. Using the McGregor technique, the asymmetry of the commissure is only visible when opening the mouth. Sufficient mouth opening is an important factor in lower lip reconstruction. In our cases, macrostomia was not found, as occasionally occurs after using the Fries technique, nor did we observe severe microstomia. With the Fries technique, a sufficiently wide lower lip can be reconstructed. However, the vestibular sulcus is inadequate and tight perioral tissues may result. The modified staircase technique avoids undue tension in the reconstructed lower lip. All our patients had an adequate vestibular sulcus postoperatively (Fig. 11). This is most important for any necessary prosthetic rehabilitation. As the staircase flaps are advanced from the neighbouring area of the lower lip and chin, the thickness of the reconstructed lip corresponds well to the original lip dimensions. Looked at from this point of view, the staircase technique is in accordance with the methods of Bernard (1853), Gillies and Millard (1957), Fries (1973) and Karapan&ic (1974). After reconstruction, the lower lip should not be too narrow and too tight. With bilateral Gillies fan-flaps, a small but symmetrical lower lip results. With the 90 ° cheek rotation o f the McGregor technique, the reconstructed lower lip shows adequate width. However, especially in unilateral reconstruction, the volume of the cheek flaps makes the lip appear very thick. The modified staircase technique can be easily combined with a bilateral suprahyoid neck dissection. In our early cases, the neck dissection was done in tumour levels higher than T1 and in lymph node stages higher than No. Considering the investigations of Machtens (1992) and Mast et al. (1992), we now perform prophylactic suprahyoid neck dissection in the No neck and also in T1 lesions.
CONCLUSION The modified staircase technique can be used successfully for reconstruction of lower lip defects of up to
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Journal of Cranio-Maxillofacial Surgery
60% o f the h o r i z o n t a l w i d t h o f the lip. H o w e v e r , for t o t a l lower lip r e c o n s t r u c t i o n different m e t h o d s have to be used. C o m p a r e d with m a n y o t h e r techniques for s u b t o t a l lip r e c o n s t r u c t i o n , the m o d i f i e d staircase technique has the following advantages: (1) it is technically simple, (2) it p r o v i d e s excellent aesthetic a n d f u n c t i o n a l results, (3) it preserves b o t h m o t o r a n d sensory nerve s u p p l y in the r e c o n s t r u c t e d lip a n d p r o v i d e s excellent muscle r e a l i g n m e n t a n d (4) it is sound from an oncological standpoint and provides g o o d l o n g - t e r m results.
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