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A single stage reconstruction of upper and lower lip by modified Bernard technique
Britbh Journal of’ Plastic Surgerv (1986) 39, 386389 0 1986 The Trustees of British Association of Plastic Surgeons
A single stage reconstruction of upper and lower lip by modified Bernard technique P. A. V. KUMAR and M. TOPNO Jawharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
Summary-A single stage reconstruction of the upper and lower lip by a modification of the Bernard .technique is described. The nasolabial flaps which are discarded in the original procedure are raised as island flaps based on the facial arteries and used with advantage to reconstruct the upper lip and the lower gingivobuccal sulcus.
The aim of reconstruction of the lower lip is to obtain a continent mouth, with an adequate stoma and normal sensation. Its red margin should be restored and it should match the upper lip. The Bernard procedure with its subsequent improvements by Freeman (19%) Webster et al. (1960), McGregor (1966) and the Fan Flap (Gillies and Millard, 1957) and its modification by McGregor (1983) are commonly used procedures which satisfy many of these requirements. The essentials of the Bernard
procedure as modified by Webster et al. are the advancement of two quadrangular flaps from the cheek to reconstruct a rectangular defect in the lower lip, minimal division of the muscle to preserve function, the use of mucosal flaps to reconstruct the red margin and the excision of redundant upper lip tissue along the nasolabial fold. We have modified the procedure further to enable us to use this nasolabial tissue to reconstruct the upper lip and the lower gingivolabial sulcus.
Fig. 1 Figure
I-The
preoperative
labial and alveolar
deficiency.
Fig. 2
I Fig. 5
Fig. 3 Fig. 6
Fig. 4
Figure 2-The preoperative markings of the incisions. FA= facial artery; dotted lines (one marked M) = mucosal incisions. Figure 3-Elevation of the right nasolabial tlap supertlcially at its apex and down to the zygomaticus major and risoreus at the base. The left flap is being passed through a subcutaneous tunnel to the defect in the upper lip. Figure &-The left nasolabial flap is being sutured into place. The right flap is being’brought to the alveolar defect through a sub-mucosal tunnel. Figure 5The right nasolabial flap is being sutured into the lower alveolar defect. The lower lip Raps are being advanced medially. Figure &The final suture lines.
388
BRITISH
Case report An 18-year-old male sustained a blast injury, resulting in a full thickness loss of the middle one-third of the upper lip and the middle half of the lower lip. He also had multiple lacerations of the lip and tongue, loss of all incisors and canine teeth and a midline fracture of the mandible. He had primary debridement, skin to mucosal suture of the lip defect and direct wiring of the fractured mandible. When we saw him again two months later (Fig. 1) he had, besides the labial deficiency, loss of gingiva in the incisor region and resultant osteomyelitis of the mandible. He had continuous drooling of saliva and his speech was unintelligible. Operative Technique
The lower lip was reconstructed by Webster’s modification of Bernard’s procedure. The following modifications were made to reconstruct the upper lip and resurface the mandibular alveolus. Two triangular island nasolabial flaps were marked based on each facial artery, which was traced by a Doppler probe (Fig. 2). Each flap was raised superficial at its apex and deeper to the zygomaticus major and risorius at the base in order to preserve the facial vessels which were mobilised as required (Fig. 3). The left nasolabial flap was brought to the upper lip through a subcutaneous tunnel, trimmed to fit the defect and sutured. Lining was formed by turn down hinge flaps of mucosa (Figs. 4 and 5). The right flap was
result at 6 months.
OF PLASTIC
SURGERY
brought through a submucosal tunnel to cover the mandibular defect and add depth to the lower gingivolabial sulcus (Figs. 4 and 5). The repair was completed as in Webster’s modification of Bernard’s technique. A Zplasty was incorporated in the free border of the lower lip to prevent notching (Fig. 6). Subsequently, minor adjustments were done to improve the cosmetic result.
Discussion Rarely is one required to reconstruct the upper and lower lips simultaneously. Techniques using local tissue are usually not satisfactory for the purpose. Karapandzic (1974) described local arterial based flaps to reconstruct both upper and lower lips in 2 cases. Although both his cases were elderly they still had microstomia. This technique would have been unsuitable in our patient who was a young man. By modifying the Bernard technique we preserved the nasolabial flaps, and used them to reconstruct the upper lip and the lower gingivolabial sulcus. The latter flap covered the exposed and infected mandible; this helped to heal the fracture by controlling infection. It also added depth to the sulcus which enabled proper fitting of dentures. The cosmetic result was satisfactory (Fig. 7). As re-
Fig. 7 Figure 7- -Postoperative
JOURNAL
A SINGLE STAGE RECONSTRUCTION
OF UPPER AND LOWER LIP
gards function he was able to close his mouth and prevent drooling, he could hold a fair amount of liquid in his mouth and swallow it without spilling. In brief he had a continent mouth with an adequate stoma.
Acknowledgements The authors wish to thank Miss Lesley Skeates of the Royal Hospital for Sick Children, Edinburgh, for the drawings.
References Bernard,C. (1853). Cancer de la levre op&re par un pro&de nouveau. Gazeire des HGpitaux 44. Freeman, B. S. (1958). Myoplastic modification of Bernard cheiloplasty. Plastic and Reconstructive Surgery, 21,453. Gillies, H. D. and Millard, D. R. (1957). The Principles and Art of Plastic Surgery. London: Butterworth.
389
Karapandzic, M. (1974). Reconstruction of lip defects by local arterial flaps. British Journal of Plastic Surgery, 27,93. McGregor, I. A. (1966). The tongue flap in lip surgery. British Journal of Plastic Surgery, 19,253.
McGregor, I. A. (1983). Reconstruction of the lower lip. British Journal of Plastic Surgery, 36,40. Webster, R. C., Coffey, R. J. and KeUeher, R. E. (1960). Total
and partial reconstruction of the lower lip with innervated muscle bearing flap. Plastic and Reconstructive Subgerv, 25, 360.
The Authors P. A. Vinod Kumar, MS, MCL, MNAMS, Associate Professor and Head of Plastic Surgery. Margaret Topno, MS, Senior Resident in Plastic Surgery. Jawharlal Institute of Postgraduate Medical Education and Research, Pondicherry. Requests for reprints to: Dr P. A. Vinod Kumar, Jawaharlal Institute of Postgraduate Medical Education and Research. Pondicherry, Pin. 605006, India.
A single stage reconstruction of upper and lower lip by modified Bernard technique P. A. V. KUMAR and M. TOPNO Jawharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
Summary-A single stage reconstruction of the upper and lower lip by a modification of the Bernard .technique is described. The nasolabial flaps which are discarded in the original procedure are raised as island flaps based on the facial arteries and used with advantage to reconstruct the upper lip and the lower gingivobuccal sulcus.
The aim of reconstruction of the lower lip is to obtain a continent mouth, with an adequate stoma and normal sensation. Its red margin should be restored and it should match the upper lip. The Bernard procedure with its subsequent improvements by Freeman (19%) Webster et al. (1960), McGregor (1966) and the Fan Flap (Gillies and Millard, 1957) and its modification by McGregor (1983) are commonly used procedures which satisfy many of these requirements. The essentials of the Bernard
procedure as modified by Webster et al. are the advancement of two quadrangular flaps from the cheek to reconstruct a rectangular defect in the lower lip, minimal division of the muscle to preserve function, the use of mucosal flaps to reconstruct the red margin and the excision of redundant upper lip tissue along the nasolabial fold. We have modified the procedure further to enable us to use this nasolabial tissue to reconstruct the upper lip and the lower gingivolabial sulcus.
Fig. 1 Figure
I-The
preoperative
labial and alveolar
deficiency.
Fig. 2
I Fig. 5
Fig. 3 Fig. 6
Fig. 4
Figure 2-The preoperative markings of the incisions. FA= facial artery; dotted lines (one marked M) = mucosal incisions. Figure 3-Elevation of the right nasolabial tlap supertlcially at its apex and down to the zygomaticus major and risoreus at the base. The left flap is being passed through a subcutaneous tunnel to the defect in the upper lip. Figure &-The left nasolabial flap is being sutured into place. The right flap is being’brought to the alveolar defect through a sub-mucosal tunnel. Figure 5The right nasolabial flap is being sutured into the lower alveolar defect. The lower lip Raps are being advanced medially. Figure &The final suture lines.
388
BRITISH
Case report An 18-year-old male sustained a blast injury, resulting in a full thickness loss of the middle one-third of the upper lip and the middle half of the lower lip. He also had multiple lacerations of the lip and tongue, loss of all incisors and canine teeth and a midline fracture of the mandible. He had primary debridement, skin to mucosal suture of the lip defect and direct wiring of the fractured mandible. When we saw him again two months later (Fig. 1) he had, besides the labial deficiency, loss of gingiva in the incisor region and resultant osteomyelitis of the mandible. He had continuous drooling of saliva and his speech was unintelligible. Operative Technique
The lower lip was reconstructed by Webster’s modification of Bernard’s procedure. The following modifications were made to reconstruct the upper lip and resurface the mandibular alveolus. Two triangular island nasolabial flaps were marked based on each facial artery, which was traced by a Doppler probe (Fig. 2). Each flap was raised superficial at its apex and deeper to the zygomaticus major and risorius at the base in order to preserve the facial vessels which were mobilised as required (Fig. 3). The left nasolabial flap was brought to the upper lip through a subcutaneous tunnel, trimmed to fit the defect and sutured. Lining was formed by turn down hinge flaps of mucosa (Figs. 4 and 5). The right flap was
result at 6 months.
OF PLASTIC
SURGERY
brought through a submucosal tunnel to cover the mandibular defect and add depth to the lower gingivolabial sulcus (Figs. 4 and 5). The repair was completed as in Webster’s modification of Bernard’s technique. A Zplasty was incorporated in the free border of the lower lip to prevent notching (Fig. 6). Subsequently, minor adjustments were done to improve the cosmetic result.
Discussion Rarely is one required to reconstruct the upper and lower lips simultaneously. Techniques using local tissue are usually not satisfactory for the purpose. Karapandzic (1974) described local arterial based flaps to reconstruct both upper and lower lips in 2 cases. Although both his cases were elderly they still had microstomia. This technique would have been unsuitable in our patient who was a young man. By modifying the Bernard technique we preserved the nasolabial flaps, and used them to reconstruct the upper lip and the lower gingivolabial sulcus. The latter flap covered the exposed and infected mandible; this helped to heal the fracture by controlling infection. It also added depth to the sulcus which enabled proper fitting of dentures. The cosmetic result was satisfactory (Fig. 7). As re-
Fig. 7 Figure 7- -Postoperative
JOURNAL
A SINGLE STAGE RECONSTRUCTION
OF UPPER AND LOWER LIP
gards function he was able to close his mouth and prevent drooling, he could hold a fair amount of liquid in his mouth and swallow it without spilling. In brief he had a continent mouth with an adequate stoma.
Acknowledgements The authors wish to thank Miss Lesley Skeates of the Royal Hospital for Sick Children, Edinburgh, for the drawings.
References Bernard,C. (1853). Cancer de la levre op&re par un pro&de nouveau. Gazeire des HGpitaux 44. Freeman, B. S. (1958). Myoplastic modification of Bernard cheiloplasty. Plastic and Reconstructive Surgery, 21,453. Gillies, H. D. and Millard, D. R. (1957). The Principles and Art of Plastic Surgery. London: Butterworth.
389
Karapandzic, M. (1974). Reconstruction of lip defects by local arterial flaps. British Journal of Plastic Surgery, 27,93. McGregor, I. A. (1966). The tongue flap in lip surgery. British Journal of Plastic Surgery, 19,253.
McGregor, I. A. (1983). Reconstruction of the lower lip. British Journal of Plastic Surgery, 36,40. Webster, R. C., Coffey, R. J. and KeUeher, R. E. (1960). Total
and partial reconstruction of the lower lip with innervated muscle bearing flap. Plastic and Reconstructive Subgerv, 25, 360.
The Authors P. A. Vinod Kumar, MS, MCL, MNAMS, Associate Professor and Head of Plastic Surgery. Margaret Topno, MS, Senior Resident in Plastic Surgery. Jawharlal Institute of Postgraduate Medical Education and Research, Pondicherry. Requests for reprints to: Dr P. A. Vinod Kumar, Jawaharlal Institute of Postgraduate Medical Education and Research. Pondicherry, Pin. 605006, India.