- Email: [email protected]
The commissure-based triangular flap for lip revision following reconstruction of a through-and-through defect
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 271e277
CORRESPONDENCE AND COMMUNICATIONS The commissure-based triangular flap for lip revision following reconstruction of a through-andthrough defect Management of lip deformities following free-flap reconstruction for head and neck cancer represents a particular challenge. Ideal restoration must provide not only mucosal
lining and outer skin, but must also reestablish a labial sulcus and adequate oral sphincter function to prevent drooling.1,2 While commissure reconstruction can be attempted by vermillion advancement or other local flaps, the limitation of many of these approaches lies in the failure to create an adequate sulcus and provide for enough lower lip support.3 We therefore describe a novel technique for secondary commissuroplasty and lip revision using a commissure-based triangular flap and anterior z-plasty following anterolateral thigh free-flap reconstruction for a large perioral defect.
Figure 1 (A) Schematic diagram depicting flap markings for commissure-based triangular flap and lower lip z-plasty. (B) Intraoperative schematic demonstrating triangular flap elevation and transposition. (C) Final inset of flap and vermillion with lower lip z-plasty.
272
Correspondence and communications
Figure 2 (A) Photograph of patient following tumour resection and primary reconstruction with anterolateral thigh flap. (B) Postoperative photograph of patient following commissure-based triangular flap, flap debulking, and lower lip z-plasty.
The base of the horizontally oriented triangular flap was positioned using the location of the contralateral commissure. The height of the flap was 1 cm and the initial length was 5 cm, extending to the end of the original anterolateral thigh flap. A full-thickness triangular flap was then raised and the flap was directly debulked. Following this, the lower lip was mobilized including skin, muscle, and mucosa. The triangular flap was trimmed and inset intraorally beneath the lower lip (Figure 1). Anteriorly, a lower z-plasty was performed to provide lip support and repositioning. Postoperatively, the patient reported improved lip function with elimination of drooling (Figure 2). There was also no change in inter-incisal distance and the patient was able to tolerate a regular diet. Restoration of sphincter continuity and shape of the lip may be difficult to achieve, particularly when considering the need for postoperative radiation and flap contracture. While vermillion advancement is a popular technique, this does little to restore the sulcus and has the tendency to induce inward bulging of the flap.4,5 Alternatively, the arrow-headed commissuroplasty technique may be employed to reposition the commissure and lower lip, but insufficient lip support and sulcus restoration similarly yield suboptimal results.4 In contrast, the commissure-based triangular flap allows for proper repositioning of the commissure with simultaneous achievement of three reconstructive goals: restoration of a sulcus, lower lip support, and minimalization of inward flap bulging. Using this approach, both functional and aesthetic goals were readily accomplished in our patient. Importantly, however, given defect variability and adequacy of initial reconstruction, the commissure-based triangular flap cannot be universally adopted for all secondary commissuroplasties. This strategy may be limited in larger defects in which
minimal or no lower lip remains and also cannot be used to correct for postoperative microstomia.
Funding None.
Conflict of interest None.
References 1. Luce EA. Reconstruction of the lower lip. Clin Plast Surg 1995; 22:109e21. 2. McGregor IA. Reconstruction of the lower lip. Br J Plast Surg 1983;36:40e7. 3. Closmann JJ, Pogrel MA, Schmidt BL. Reconstruction of perioral defects following resection for oral squamous cell carcinoma. J Oral Maxillofac Surg 2006;64:367e74. 4. Chang KP, Lai CS, Lin SD. Recontouring commissuroplasty after reconstruction of large defects after resections for head and neck cancer with commissure involvement using an anterolateral thigh flap. Scand J Plast Reconstr Surg Hand Surg 2009;43:256e9. 5. Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of concomitant lip and cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip. Plast Reconstr Surg 2004;113:491e8.
Chung-Kan Tsaoa The Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kuei-Shan, Taoyuan 33305, Taiwan, ROC E-mail address: [email protected]
Correspondence and communications Derrick C. Wana The Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kuei-Shan, Taoyuan 33305, Taiwan, ROC Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 257 Campus Loop Drive, Stanford, CA 94305-5148, USA Wei-Fan Chen Dennis S. Kao The Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kuei-Shan, Taoyuan 33305, Taiwan, ROC Benjamin Levi Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 257 Campus Loop Drive, Stanford, CA 94305-5148, USA ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.007
A simple way for salvage of zone IV deep inferior epigastric perforator flap using pre-tie sutures and serial delayed closure The free deep inferior epigastric artery perforator flap (DIEP) was first described by Koshima and Soeda in 1989.1 This flap provides a large amount of skin and soft tissues for reconstructive purposes with a minimal donor site morbidity and a resulting scar similar to an addominoplasty procedure. When the flap is harvested, both superficial epigastic veins are interrupted and all the venous drainage is redistributed into the deep system by the venae comitantes accompanying the perforator. Venous complications could be due to venae comitantes too small or injured during the surgical dissection.2 Furthermore venous congestion often involves zone IV, the part of the flap farthest across the midline from the perforators. Consequently zone IV is considered unreliable and is frequently discarded. We present this case to report an easy way for the salvage of zone IV demonstrating that inclusion of zone IV may be reliable, even if only a single perforator is incorporated into the flap.3
a
These authors contributed equally to this manuscript.
273 A 36 year old female with hemangioma was admitted to the China Medical Hospital, Taiwan. At the age of 6 a right lower thigh hemangioma was noted as a reddishepurple raised sore lesion on the skin. In 1991 the patient underwent sclerotherapy treatment obtaining a partial regression of the lesion and associated symptoms. Due to the constant pain the patient came to the department of Plastic Surgery. A light purple skin lesion (15 9 cm) was localised at the anterior right thigh (Figure 1A). An MRI confirmed the diagnosis of hemangioma and the patient was prepared for the excision of the tumor and free DIEP flap reconstruction of the defect. The lesion was totally removed above the fascia level. The final tissue defect was 12 15 cm (Figure 1B) thus requiring to include the zone IV in the flap (Figure 1C). The DIEP flap was raised based on a single perforator of the inferior left epigastric vessel and transferred to the right thigh. End-to-end microvascular anastomoses using 10e0 sutures were performed between the descending branch of lateral circumflex femoral vessels and the inferior epigastic vessels. The flap was then sutured to the defect. After few minutes zone IV become congested and mottled (Figure 1D). Therefore sutures from this part of the flap were removed allowing the skin’s flap to turn pink again. The pinkish color of the flap was stable after 30 minutes (Figure 2A). Once a normal color of the skin’s flap and a normal refill test were recovered, pre-applied sutures were applied in the area where were previously removed to decrease the congestion (Figure 2B). Starting from 4 days after surgery, serial ligation of the pre-applied sutures was performed achieving a complete suture of the flap on the 7th day (Figure 2B). One month after surgery a complete survival of the flap, including the zone IV, was obtained (Figure 2D). The DIEP flap was first described by Koshima and Soeda1 and then popularized by Allen and Blondeel for breastreconstruction. The amount of tissue provided, its reliable vascular supply, a long pedicle and a limited donor site morbidity, make it an useful alternative free flap even for non breast-reconstruction cases. A feared complication of DIEP flap is venous congestion occuring between 2 and 27%, often involving the zone IV that is considered unreliable and is normally discarded.4,5 During elevation of the DIEP flap many of the interconnecting perforators are interrupted. Subsequently if the drainage through the deep venous system is inadequate the flap may develop congestion despite the patency of the venous anastomosis.4 To relieve congestion many authors point out the necessity of performing a bypass between the superficial epigastric vein and the deep system or another recipient vein thus providing an additional drainage.3e5 In breast surgery many alternative outflow vessels have been used for anastomosis. Nho V. et al. suggested to perform a bypass between the superficial epigastric vein and any one of the chest wall veins5; Guzzetti reports fashioning a venous bypass using ipsilateral basilica vein and superficial epigastric vein; Wechselberger et al. suggested using the thoracodorsal, the lateral thoracic and the intercostal
CORRESPONDENCE AND COMMUNICATIONS The commissure-based triangular flap for lip revision following reconstruction of a through-andthrough defect Management of lip deformities following free-flap reconstruction for head and neck cancer represents a particular challenge. Ideal restoration must provide not only mucosal
lining and outer skin, but must also reestablish a labial sulcus and adequate oral sphincter function to prevent drooling.1,2 While commissure reconstruction can be attempted by vermillion advancement or other local flaps, the limitation of many of these approaches lies in the failure to create an adequate sulcus and provide for enough lower lip support.3 We therefore describe a novel technique for secondary commissuroplasty and lip revision using a commissure-based triangular flap and anterior z-plasty following anterolateral thigh free-flap reconstruction for a large perioral defect.
Figure 1 (A) Schematic diagram depicting flap markings for commissure-based triangular flap and lower lip z-plasty. (B) Intraoperative schematic demonstrating triangular flap elevation and transposition. (C) Final inset of flap and vermillion with lower lip z-plasty.
272
Correspondence and communications
Figure 2 (A) Photograph of patient following tumour resection and primary reconstruction with anterolateral thigh flap. (B) Postoperative photograph of patient following commissure-based triangular flap, flap debulking, and lower lip z-plasty.
The base of the horizontally oriented triangular flap was positioned using the location of the contralateral commissure. The height of the flap was 1 cm and the initial length was 5 cm, extending to the end of the original anterolateral thigh flap. A full-thickness triangular flap was then raised and the flap was directly debulked. Following this, the lower lip was mobilized including skin, muscle, and mucosa. The triangular flap was trimmed and inset intraorally beneath the lower lip (Figure 1). Anteriorly, a lower z-plasty was performed to provide lip support and repositioning. Postoperatively, the patient reported improved lip function with elimination of drooling (Figure 2). There was also no change in inter-incisal distance and the patient was able to tolerate a regular diet. Restoration of sphincter continuity and shape of the lip may be difficult to achieve, particularly when considering the need for postoperative radiation and flap contracture. While vermillion advancement is a popular technique, this does little to restore the sulcus and has the tendency to induce inward bulging of the flap.4,5 Alternatively, the arrow-headed commissuroplasty technique may be employed to reposition the commissure and lower lip, but insufficient lip support and sulcus restoration similarly yield suboptimal results.4 In contrast, the commissure-based triangular flap allows for proper repositioning of the commissure with simultaneous achievement of three reconstructive goals: restoration of a sulcus, lower lip support, and minimalization of inward flap bulging. Using this approach, both functional and aesthetic goals were readily accomplished in our patient. Importantly, however, given defect variability and adequacy of initial reconstruction, the commissure-based triangular flap cannot be universally adopted for all secondary commissuroplasties. This strategy may be limited in larger defects in which
minimal or no lower lip remains and also cannot be used to correct for postoperative microstomia.
Funding None.
Conflict of interest None.
References 1. Luce EA. Reconstruction of the lower lip. Clin Plast Surg 1995; 22:109e21. 2. McGregor IA. Reconstruction of the lower lip. Br J Plast Surg 1983;36:40e7. 3. Closmann JJ, Pogrel MA, Schmidt BL. Reconstruction of perioral defects following resection for oral squamous cell carcinoma. J Oral Maxillofac Surg 2006;64:367e74. 4. Chang KP, Lai CS, Lin SD. Recontouring commissuroplasty after reconstruction of large defects after resections for head and neck cancer with commissure involvement using an anterolateral thigh flap. Scand J Plast Reconstr Surg Hand Surg 2009;43:256e9. 5. Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of concomitant lip and cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip. Plast Reconstr Surg 2004;113:491e8.
Chung-Kan Tsaoa The Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kuei-Shan, Taoyuan 33305, Taiwan, ROC E-mail address: [email protected]
Correspondence and communications Derrick C. Wana The Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kuei-Shan, Taoyuan 33305, Taiwan, ROC Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 257 Campus Loop Drive, Stanford, CA 94305-5148, USA Wei-Fan Chen Dennis S. Kao The Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kuei-Shan, Taoyuan 33305, Taiwan, ROC Benjamin Levi Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 257 Campus Loop Drive, Stanford, CA 94305-5148, USA ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.007
A simple way for salvage of zone IV deep inferior epigastric perforator flap using pre-tie sutures and serial delayed closure The free deep inferior epigastric artery perforator flap (DIEP) was first described by Koshima and Soeda in 1989.1 This flap provides a large amount of skin and soft tissues for reconstructive purposes with a minimal donor site morbidity and a resulting scar similar to an addominoplasty procedure. When the flap is harvested, both superficial epigastic veins are interrupted and all the venous drainage is redistributed into the deep system by the venae comitantes accompanying the perforator. Venous complications could be due to venae comitantes too small or injured during the surgical dissection.2 Furthermore venous congestion often involves zone IV, the part of the flap farthest across the midline from the perforators. Consequently zone IV is considered unreliable and is frequently discarded. We present this case to report an easy way for the salvage of zone IV demonstrating that inclusion of zone IV may be reliable, even if only a single perforator is incorporated into the flap.3
a
These authors contributed equally to this manuscript.
273 A 36 year old female with hemangioma was admitted to the China Medical Hospital, Taiwan. At the age of 6 a right lower thigh hemangioma was noted as a reddishepurple raised sore lesion on the skin. In 1991 the patient underwent sclerotherapy treatment obtaining a partial regression of the lesion and associated symptoms. Due to the constant pain the patient came to the department of Plastic Surgery. A light purple skin lesion (15 9 cm) was localised at the anterior right thigh (Figure 1A). An MRI confirmed the diagnosis of hemangioma and the patient was prepared for the excision of the tumor and free DIEP flap reconstruction of the defect. The lesion was totally removed above the fascia level. The final tissue defect was 12 15 cm (Figure 1B) thus requiring to include the zone IV in the flap (Figure 1C). The DIEP flap was raised based on a single perforator of the inferior left epigastric vessel and transferred to the right thigh. End-to-end microvascular anastomoses using 10e0 sutures were performed between the descending branch of lateral circumflex femoral vessels and the inferior epigastic vessels. The flap was then sutured to the defect. After few minutes zone IV become congested and mottled (Figure 1D). Therefore sutures from this part of the flap were removed allowing the skin’s flap to turn pink again. The pinkish color of the flap was stable after 30 minutes (Figure 2A). Once a normal color of the skin’s flap and a normal refill test were recovered, pre-applied sutures were applied in the area where were previously removed to decrease the congestion (Figure 2B). Starting from 4 days after surgery, serial ligation of the pre-applied sutures was performed achieving a complete suture of the flap on the 7th day (Figure 2B). One month after surgery a complete survival of the flap, including the zone IV, was obtained (Figure 2D). The DIEP flap was first described by Koshima and Soeda1 and then popularized by Allen and Blondeel for breastreconstruction. The amount of tissue provided, its reliable vascular supply, a long pedicle and a limited donor site morbidity, make it an useful alternative free flap even for non breast-reconstruction cases. A feared complication of DIEP flap is venous congestion occuring between 2 and 27%, often involving the zone IV that is considered unreliable and is normally discarded.4,5 During elevation of the DIEP flap many of the interconnecting perforators are interrupted. Subsequently if the drainage through the deep venous system is inadequate the flap may develop congestion despite the patency of the venous anastomosis.4 To relieve congestion many authors point out the necessity of performing a bypass between the superficial epigastric vein and the deep system or another recipient vein thus providing an additional drainage.3e5 In breast surgery many alternative outflow vessels have been used for anastomosis. Nho V. et al. suggested to perform a bypass between the superficial epigastric vein and any one of the chest wall veins5; Guzzetti reports fashioning a venous bypass using ipsilateral basilica vein and superficial epigastric vein; Wechselberger et al. suggested using the thoracodorsal, the lateral thoracic and the intercostal