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A new technique for the repair of lateral defects of the upper lip
128
J. max.-fac. Surg. 12 (1984)
J. max.-fac. Surg. 12 (1984) 128-130 © Georg Thieme Verlag Stuttgart • New York
A New Technique for the Repair of Lateral Defects of the Upper Lip Gerhard W. Paulus Clinic and Policlinic for Maxillo-Facial Surgery (Director: Prof. E. W. Steinh~iuser, M. D., D. D. S.) University of Erlangen, W.-Germany
Summary A new technique for the closure of lateral defects of the upper lip is described whereby a modified Estlander flap of the lower cheek area is used after a primary elongation of the oral aperture. Besides the introduction and description of the technique in a case report, different methods for the repair of lateral defects of the upper lip are discussed.
Key-Words Upper lip defect - Upper lip repair - Labial pedicled rotation flap - Reconstruction - Turnout
Accepted for publication 14. 9. 1983
Introduction
Case Report
Subtotal or total defects of the lower lip can be repaired by three layer transposition flaps from the lower cheek (Dieffenbach, 1845; Bernard, 1851; Fries, 1971) whereas the closure of similar defects of the upper lip by corresponding flaps from the upper cheek area is not so satisfactory because of the tightness of the tissue in that donor area. Small defects in the lateral part of the upper lip can be easily closed by rectangular or triangular nasolabial flaps. Estlander (1872) described the repair of lateral defects, using a triangular rotation flap from the opposite lip pedicled on the labial artery. However, reconstruction of the shape of the lip and elongation of the oral comissure are necessary in a second procedure. Converse (1976) employed a modified Estlander technique when a stump of the lateral vermilion border can be preserved. The use of this technique also leads to a reduction of the oral aperture and is restricted by the size of the defect. To overcome these disadvantages it became necessary to combine a primary elongation of the oral aperture with a rotation flap of a triangular or rectangular section of the lower cheek area according to the Estlander (1872) technique. This flap can be used for the repair of defects of the lateral upper lip as well as for the anterior portion of the floor of the nose.
A 73 year-old male underwent resection of the lateral part of the upper lip for a basal cell carcinoma. The resection included a rectangular full thickness defect which crossed the midline of the upper lip and extended to the anterior part of the nasal floor and the corner of the mouth (Fig. 2). Sections from the margins of the defect were taken for histo-pathological examination by the frozen-section techniques; the specimens were found to be free of tumour. Length and width of the defect were measured and the outline of the incision was transferred to the lower cheek area adjacent to the corner of the mouth (Fig. 3). First the elongation of the oral aperture was performed by a horizontal threeqayer incision through the corner of the mouth (Fig. 4). The repair of the vermilion of the lower lip was achieved by undermining and outward rotation of the cheek mucosa (Fig. 5). The rectangular flap, pedided at the corner of the mouth was then designed corresponding to the size of the defect. After the flap was rotated into the defect, the three layers of tissue were correspondingly sutured (Fig. 6). Fig. 7 shows the patient two months after the operative procedure; an upper denture was constructed and easily managed by the patient (Fig. 8).
Discussion and Conclusion Technique The size of the defect is measured and the oral aperture is elongated by a three-layer incision at the side of the defect (Fig. 1 a, b). The outline of the incision corresponds to the length of the defect. The lengthened lower lip is covered with mucosa by outward advancement or by a transposition flap of cheek or vestibular mucosa (Fig. 1 c). Then a triangular or rectangular flap pedicled at the corner of the mouth is outlined (Fig. 1 d) and rotated into the defect of the upper lip. The various sides of the tri- or rectangle should be identical with the borders of the defect. At the side of the nasal floor the flap should be cut in an oblique manner for an adequate approximation with the vestibular lining of the nose. Finally a threeqayer closure of the defect is desirable for a good functional result. In particular the vestibular lining should be sutured in a careful manner so as to avoid oronasal fistulae and to provide an adequate vestibule for a denture. The defect in the donor area is closed by direct approximation (Fig. I e).
Converse (1959) and Kazanjian (1974) stressed the importance of local flaps of the cheek, the nasolabial area or of the lower lip, which should be used preferrentially for the repair of lateral defects of the upper lip before distant flaps of the forehead, scalp or neck are utilized. Local flaps have the advantages of similar thickness and colour of the skin compared to the surrounding parts of lip and cheek. Distant flaps often shrink and curl inwards due to the lack of any muscular function. Three-layer local flaps also show good functional results because of reinnervation and a high degree of functional restitution of the orbicularis muscle. A return of myotonic function was noted by Smith (1960) in the area of repaired defects 6-12 months postoperatively when local three-layer flaps were used. Fries (1973) described some modifications of the original Bernard (1851) repair as the "Universal Procedure" for the closure of defects in the upper and lower lip. Our experience with the Bernard~Fries technique for the repair of defects of the lower lip was much more satisfactory than for defects of the upper lip, because it leads - when a transposi-
A New Technique for the Repair of Lateral Defects of the Upper Lip
Fig, 1 a
Fig. 1 b
Fig lc
J. max.-fac. Surg. 12 (1984)
Fig. 1 d
/
[
129
[
Fig. 1 Schematic description of closure of a lateral defect of the upper lip. 1a 1b lc ld le
Lateral defect of the upper tip. Outline of length of defect lateral to the corner of the mouth. Elongation of the oral aperture and reconstruction of the vermilion by outward rotation of mucosa from the cheek. Outline of the rotation flap corresponding to the size of the defect. Three-layered closure after rotation of the pedicted flap.
Fig. 2 Lateral defect of the upper lip after resection of a basal ceil carcinoma.
Fig. 3
Fig. 4
Fig. 5 Reconstruction of the vermilion border by outward rotation of mucosa from the cheek.
Elongation of the oral aperture.
tion flap is used from this donor area - to a stretched upper lip. The lower part of the cheek is more appropriate for transposition or rotation flaps because of a surplus of tissue in this area; this is true not only in older patients.
Outline of the rotation flap.
When techniques are utilized where sections of the lower lip are taken for the closure of defects of the upper lip (Estlander, 1872), second operative procedures are necessary for the elongation of the oral aperture or division and separa-
130
J. max.-fac. Surg. 12 (1984)
G. W. Paulus: A N e w Technique for the Repair o f Lateral Defects o f the Upper Lip
Fig. 6 Three-layered closure after rotation of the pedicted rectangular flap; direct approximation and closure of the donor area.
Fig. 7
Situation two months postoperatively.
The technique described gives g o o d aesthetic and functional results when lateral defects of the upper lip have to be repaired, whereas for defects of the lower lip we prefer the technique of Bernard (1851) and Fries (1971).
Fig. 8 The denture can be easily managed by the patient.
tion of the lips. M o s t of the techniques which have been described for the reconstruction of the corner of the mouth and elongation of the oral aperture (Kazanjian and Roopenian, 1954; Converse, 1959; Gillies and Millard, 1957; Fries, 1962) can also be used in the one stage procedure described. Applying our technique we were able to close even larger defects which crossed the midline of the upper lip. It seems possible that complete loss of the upper lip can also be closed by this technique using flaps from both corners of the mouth. N o problems were encountered in a series of 6 cases in regard to the b l o o d supply of the pedicled flap as well as in the direct a p p r o x i m a t i o n of large d o n o r defects. If the pedicle of the flap is large the corner of the mouth will have a r o u n d shape whereas a small one will lead to a more natural appearance. On the other h a n d the angle of the oral aperture can be changed by the insertion of some sutures near the corner of the mouth. By this final a d a p t a t i o n sufficient symmetry in regard to the other side can be achieved.
References Bernard, C.: Cancer de la l~vre inf~rieure: restauration ~ l'aide de lambeaux quadrilaterires - lateraux querison. Scalpel, Liege 5 (1851-1853) 162 Converse, J. M.: Technique of elongation of the oral fissure and restoration of the angle of the mouth. In: Kazanjian, V. H. and Converse, J. M.: The Surgical Treatment of Facial Injuries. Williams & Wilkins, Baltimore 796 (1959) Converse, J. M.: The bridge flap for reconstruction of a full-thickness defect of the upper lip. Hast. Reconstr. Surg. 57 (1976) 422 Dieffenbach, J. F.: Die operative Chirurgie. Brockhaus, Leipzig (1845-1848) Estlander, J. A.: Eine Methode aus der einen Lippe Substanzverluste der anderen zu ersetzen. Arch. Klin. Chit. 14 (1872) 622 Fries, R.: Ober eine neue Methode der primfiren Wiederherstellung des Mundwinkels nach Karzinomexstirpation. Ost. Z. Stomat. 59 (1962) 366 Fries, R.: Vorzug der Bernardschen Operation als Universalverfahren zur Rekonstruktion der Unterlippe nach Karzinomresektion. Chir. plastica I (1971) 45 Fries, R.: Advantages of a basic concept in lip construction after tumour resection. J. max.-fac. Surg. 1 (1973) 13 Gillies, H. D., D. R. Millard Jr.: Principles and Art of Plastic Surgery. Little, Brown, Boston (1957) Kazanjian, V. H., A. Roopenian: The treatment of lip deformities resulting from electric burns. Am. J. Surg. 88 (1954) 844 Kazanjian, V. H., J. M. Converse: The Surgical Treatment of Facial Injuries. Williams & Wilkins, Baltimore 3~ded. (1974) Smith, J. W.: The anatomical and physiologic acclimatization of tissue transplanted by the lip switch technique. Hast. Reconstr. Surg. 26 (1960) 40
G. W. Paulus, M.D., D.M.D. Kantonsspital Luzern Abt. Kiefer-Gesichts-Chirurgie CH-6004 Luzern
J. max.-fac. Surg. 12 (1984)
J. max.-fac. Surg. 12 (1984) 128-130 © Georg Thieme Verlag Stuttgart • New York
A New Technique for the Repair of Lateral Defects of the Upper Lip Gerhard W. Paulus Clinic and Policlinic for Maxillo-Facial Surgery (Director: Prof. E. W. Steinh~iuser, M. D., D. D. S.) University of Erlangen, W.-Germany
Summary A new technique for the closure of lateral defects of the upper lip is described whereby a modified Estlander flap of the lower cheek area is used after a primary elongation of the oral aperture. Besides the introduction and description of the technique in a case report, different methods for the repair of lateral defects of the upper lip are discussed.
Key-Words Upper lip defect - Upper lip repair - Labial pedicled rotation flap - Reconstruction - Turnout
Accepted for publication 14. 9. 1983
Introduction
Case Report
Subtotal or total defects of the lower lip can be repaired by three layer transposition flaps from the lower cheek (Dieffenbach, 1845; Bernard, 1851; Fries, 1971) whereas the closure of similar defects of the upper lip by corresponding flaps from the upper cheek area is not so satisfactory because of the tightness of the tissue in that donor area. Small defects in the lateral part of the upper lip can be easily closed by rectangular or triangular nasolabial flaps. Estlander (1872) described the repair of lateral defects, using a triangular rotation flap from the opposite lip pedicled on the labial artery. However, reconstruction of the shape of the lip and elongation of the oral comissure are necessary in a second procedure. Converse (1976) employed a modified Estlander technique when a stump of the lateral vermilion border can be preserved. The use of this technique also leads to a reduction of the oral aperture and is restricted by the size of the defect. To overcome these disadvantages it became necessary to combine a primary elongation of the oral aperture with a rotation flap of a triangular or rectangular section of the lower cheek area according to the Estlander (1872) technique. This flap can be used for the repair of defects of the lateral upper lip as well as for the anterior portion of the floor of the nose.
A 73 year-old male underwent resection of the lateral part of the upper lip for a basal cell carcinoma. The resection included a rectangular full thickness defect which crossed the midline of the upper lip and extended to the anterior part of the nasal floor and the corner of the mouth (Fig. 2). Sections from the margins of the defect were taken for histo-pathological examination by the frozen-section techniques; the specimens were found to be free of tumour. Length and width of the defect were measured and the outline of the incision was transferred to the lower cheek area adjacent to the corner of the mouth (Fig. 3). First the elongation of the oral aperture was performed by a horizontal threeqayer incision through the corner of the mouth (Fig. 4). The repair of the vermilion of the lower lip was achieved by undermining and outward rotation of the cheek mucosa (Fig. 5). The rectangular flap, pedided at the corner of the mouth was then designed corresponding to the size of the defect. After the flap was rotated into the defect, the three layers of tissue were correspondingly sutured (Fig. 6). Fig. 7 shows the patient two months after the operative procedure; an upper denture was constructed and easily managed by the patient (Fig. 8).
Discussion and Conclusion Technique The size of the defect is measured and the oral aperture is elongated by a three-layer incision at the side of the defect (Fig. 1 a, b). The outline of the incision corresponds to the length of the defect. The lengthened lower lip is covered with mucosa by outward advancement or by a transposition flap of cheek or vestibular mucosa (Fig. 1 c). Then a triangular or rectangular flap pedicled at the corner of the mouth is outlined (Fig. 1 d) and rotated into the defect of the upper lip. The various sides of the tri- or rectangle should be identical with the borders of the defect. At the side of the nasal floor the flap should be cut in an oblique manner for an adequate approximation with the vestibular lining of the nose. Finally a threeqayer closure of the defect is desirable for a good functional result. In particular the vestibular lining should be sutured in a careful manner so as to avoid oronasal fistulae and to provide an adequate vestibule for a denture. The defect in the donor area is closed by direct approximation (Fig. I e).
Converse (1959) and Kazanjian (1974) stressed the importance of local flaps of the cheek, the nasolabial area or of the lower lip, which should be used preferrentially for the repair of lateral defects of the upper lip before distant flaps of the forehead, scalp or neck are utilized. Local flaps have the advantages of similar thickness and colour of the skin compared to the surrounding parts of lip and cheek. Distant flaps often shrink and curl inwards due to the lack of any muscular function. Three-layer local flaps also show good functional results because of reinnervation and a high degree of functional restitution of the orbicularis muscle. A return of myotonic function was noted by Smith (1960) in the area of repaired defects 6-12 months postoperatively when local three-layer flaps were used. Fries (1973) described some modifications of the original Bernard (1851) repair as the "Universal Procedure" for the closure of defects in the upper and lower lip. Our experience with the Bernard~Fries technique for the repair of defects of the lower lip was much more satisfactory than for defects of the upper lip, because it leads - when a transposi-
A New Technique for the Repair of Lateral Defects of the Upper Lip
Fig, 1 a
Fig. 1 b
Fig lc
J. max.-fac. Surg. 12 (1984)
Fig. 1 d
/
[
129
[
Fig. 1 Schematic description of closure of a lateral defect of the upper lip. 1a 1b lc ld le
Lateral defect of the upper tip. Outline of length of defect lateral to the corner of the mouth. Elongation of the oral aperture and reconstruction of the vermilion by outward rotation of mucosa from the cheek. Outline of the rotation flap corresponding to the size of the defect. Three-layered closure after rotation of the pedicted flap.
Fig. 2 Lateral defect of the upper lip after resection of a basal ceil carcinoma.
Fig. 3
Fig. 4
Fig. 5 Reconstruction of the vermilion border by outward rotation of mucosa from the cheek.
Elongation of the oral aperture.
tion flap is used from this donor area - to a stretched upper lip. The lower part of the cheek is more appropriate for transposition or rotation flaps because of a surplus of tissue in this area; this is true not only in older patients.
Outline of the rotation flap.
When techniques are utilized where sections of the lower lip are taken for the closure of defects of the upper lip (Estlander, 1872), second operative procedures are necessary for the elongation of the oral aperture or division and separa-
130
J. max.-fac. Surg. 12 (1984)
G. W. Paulus: A N e w Technique for the Repair o f Lateral Defects o f the Upper Lip
Fig. 6 Three-layered closure after rotation of the pedicted rectangular flap; direct approximation and closure of the donor area.
Fig. 7
Situation two months postoperatively.
The technique described gives g o o d aesthetic and functional results when lateral defects of the upper lip have to be repaired, whereas for defects of the lower lip we prefer the technique of Bernard (1851) and Fries (1971).
Fig. 8 The denture can be easily managed by the patient.
tion of the lips. M o s t of the techniques which have been described for the reconstruction of the corner of the mouth and elongation of the oral aperture (Kazanjian and Roopenian, 1954; Converse, 1959; Gillies and Millard, 1957; Fries, 1962) can also be used in the one stage procedure described. Applying our technique we were able to close even larger defects which crossed the midline of the upper lip. It seems possible that complete loss of the upper lip can also be closed by this technique using flaps from both corners of the mouth. N o problems were encountered in a series of 6 cases in regard to the b l o o d supply of the pedicled flap as well as in the direct a p p r o x i m a t i o n of large d o n o r defects. If the pedicle of the flap is large the corner of the mouth will have a r o u n d shape whereas a small one will lead to a more natural appearance. On the other h a n d the angle of the oral aperture can be changed by the insertion of some sutures near the corner of the mouth. By this final a d a p t a t i o n sufficient symmetry in regard to the other side can be achieved.
References Bernard, C.: Cancer de la l~vre inf~rieure: restauration ~ l'aide de lambeaux quadrilaterires - lateraux querison. Scalpel, Liege 5 (1851-1853) 162 Converse, J. M.: Technique of elongation of the oral fissure and restoration of the angle of the mouth. In: Kazanjian, V. H. and Converse, J. M.: The Surgical Treatment of Facial Injuries. Williams & Wilkins, Baltimore 796 (1959) Converse, J. M.: The bridge flap for reconstruction of a full-thickness defect of the upper lip. Hast. Reconstr. Surg. 57 (1976) 422 Dieffenbach, J. F.: Die operative Chirurgie. Brockhaus, Leipzig (1845-1848) Estlander, J. A.: Eine Methode aus der einen Lippe Substanzverluste der anderen zu ersetzen. Arch. Klin. Chit. 14 (1872) 622 Fries, R.: Ober eine neue Methode der primfiren Wiederherstellung des Mundwinkels nach Karzinomexstirpation. Ost. Z. Stomat. 59 (1962) 366 Fries, R.: Vorzug der Bernardschen Operation als Universalverfahren zur Rekonstruktion der Unterlippe nach Karzinomresektion. Chir. plastica I (1971) 45 Fries, R.: Advantages of a basic concept in lip construction after tumour resection. J. max.-fac. Surg. 1 (1973) 13 Gillies, H. D., D. R. Millard Jr.: Principles and Art of Plastic Surgery. Little, Brown, Boston (1957) Kazanjian, V. H., A. Roopenian: The treatment of lip deformities resulting from electric burns. Am. J. Surg. 88 (1954) 844 Kazanjian, V. H., J. M. Converse: The Surgical Treatment of Facial Injuries. Williams & Wilkins, Baltimore 3~ded. (1974) Smith, J. W.: The anatomical and physiologic acclimatization of tissue transplanted by the lip switch technique. Hast. Reconstr. Surg. 26 (1960) 40
G. W. Paulus, M.D., D.M.D. Kantonsspital Luzern Abt. Kiefer-Gesichts-Chirurgie CH-6004 Luzern