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Complex lower face reconstruction using a combined technique of Estlander flap and subscapular artery system free flaps
Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, e366ee369
CASE REPORT
Complex lower face reconstruction using a combined technique of Estlander flap and subscapular artery system free flaps Atsumori Hamahata a,*, Takashi Saitou a, Takeshi Beppu b, Satoshi Shirakura b, Akio Hatanaka b, Takashi Yamaki c, Hiroyuki Sakurai c a
Division of Plastic and Reconstructive Surgery, Saitama Cancer Center, Saitama, Japan Division of Head and Neck Surgery, Saitama Cancer Center, Saitama, Japan c Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medical University, Tokyo, Japan b
Received 14 May 2013; accepted 2 June 2013
KEYWORDS Lip reconstruction; Switch flap; Mandibular defect; Scapular flap
Summary When advanced mandibular carcinoma is resected, the defect may include lip and oral commissure. Free flap insertion is commonly used to reconstruct the lip defect. Although improvements in the oral reconstructive method via free flap use have been reported, functional and aesthetic results of the oral sphincter remain limited. This case report describes two individuals presenting with massive lower face defects, including a lower lip defect and a mandibular bone defect. Reconstruction was accomplished using the Estlander flap and free subscapular system of flaps. In both cases, the free subscapular artery system flap was elevated from the mandibular bone defect and other mucosal defect. The lower lip and oral commissure defect was reconstructed via Estlander flap. Free flaps survived 100% and both cases healed without complication. Patients regained good oral sphincter function with no reports of drooling. Thus, in cases involving massive lower face resection, including that of the lower lip and mandibular bone, this method of reconstruction when combined with lip-switch flap and subscapular artery system flap can prove to be useful. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Division of Plastic and Reconstructive Surgery, Saitama Cancer Center, 818 Komuro, Inamachi Kitaadachigunn, Saitama, Japan. Tel.: þ81 48 722 1111; fax: þ81 48 722 1129. E-mail address: [email protected] (A. Hamahata). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.06.009
A combined technique of Estlander flap and free flap Reconstruction of massive lower face defects e including lower lip and mandibular bone defects e remains challenging for reconstructive surgeons. Single free flap or double free flaps are typically used to reconstruct massive lower face defects. Although limitations for oral sphincter function and some unaesthetic results have been noted, improvements in free flap reconstruction for oral reconstruction have been observed.1,2 Nonetheless, some patients complain of untoward side effects including drooling and free flap tissue numbness. Drs. Corderio and Jeng have reported that a combination method of local flap for lip reconstruction and free flap has been beneficial for patients presenting with massive middle and lower face defects.3e5 Dr. Jeng applied a small, rotated full-thickness upper lip flap for reconstruction of a lower lip defect. For massive lower face defects, including small to middle lower lip defects (<60%), the small, rotated full-thickness upper lip flap continues to prove useful. However, for massive lower face defects, including slightly larger lower lip defects, the Estlander flap combined with free subscapular artery system flap appears to be a useful method. This case report describes two individuals who had massive lower face defects, including defect of the lower lip and mandibular bone. Reconstruction was accomplished via Estlander flap combined with a free subscapular artery system flap.
Patient reports Patient 1 A 57-year-old woman was referred to us with an advanced tumour in her gingival carcinoma, which invaded the mandibular bone and mentum skin (Figure 1). The TNM classification was T4aN0M0. The tumour lesion e including mouth floor mucosa, mandibular bone and mentum skin e was excised under general anaesthesia. The lower lip defect size was approximately 70%. The subscapular artery system free flap was elevated in a semi-lateral position. In this case, a combination flap of scapular bone with
Figure 1 Advanced gingival carcinoma with mandibular bone and mentum skin involvement observed preoperatively.
e367 parascapular flap was harvested. After securing the scapular bone to the remaining mandibular bone, microanastomoses were performed and the flap was revascularised. Subsequently, a 2.5ecm-wide switch-lip flap was designed with oral sphincter and commissure reconstruction achieved by transposing the flap to the lower lip (Figures 2 and 3). The gap area of the parascapular cutaneous flap was de-epithelised and the flap was then sutured to the mucosa of floor of oral and mentum skin. The flap survived totally and the patient began an oral liquid food diet on postoperative day 12 following removal of tracheotomy tube. Soft food was allowed on postoperative day 14 and the patient was discharged uneventfully. The patient had some microstomia (on two fingers), but oral competence was adequate and fully functional 6 months postoperation (Figure 4). The patient regained speech articulation and resumed her job 6 months postoperation.
Patient 2 A 68-year-old woman was referred to us with a recurrent tumour in her gingival carcinoma, which invaded the mandibular bone, tongue and mentum skin. Tumour resection and radiation therapy previously had been performed. The tumour lesion e including whole tongue, larynx, mandibular bone and mentum skin e was excised under general anaesthesia. The lower lip defect size was approximately 65%. The subscapular artery system free flap was elevated in a semi-lateral position, and the combination of scapular bone flap with latissimus dorsi flap was harvested. After securing the scapular bone to the remaining mandibular bone, microanastomoses were performed and the flap was revascularised. Subsequently, a 2.5-cm-wide Estlander flap was designed and the oral sphincter and oral commissure were reconstructed by transposing the flap to the lower lip. The flap survived
Figure 2 The lower lip defect size was approximately 70 percent. An Estlander flap of 2.5 cm width was designed.
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A. Hamahata et al.
Figure 3
The flap was transposed to the lower lip.
totally and the patient began an oral liquid diet on postoperative day 13 following tracheotomy tube removal. Soft food was administered on postoperative day 16, and the patient was discharged uneventfully. The patient exhibited slight microstomia (on 2.5 fingers), but her oral competence was adequate and fully functional 6 months postoperation.
Discussion When massive middle and lower face defects extend to the upper and lower lip, patients’ oral competences are severely deteriorated. Although surgical methods for free flap reconstruction of the oral circumference have improved,1,2 oral reconstruction using the free flap still presents
Figure 4
Appearance six months postoperation: open mouth.
limitations, for example, flap numbness, drooling and oral competence. Free radial forearm flap combined with palmaris longus often are used, but such reconstruction results in adynamic and non-sensory reconstruction. Although free gracilis muscle flap combined with forearm flap has been successful in dynamic reconstruction, the reconstructive method modifications have been limited.6,7 Moreover, for patients with massive lower face defects, usage of free flap reconstruction for oral circumferences complicates surgical operations without commensurate benefit. Drs. Corderio and Jeng have recommended combining the local flap for lip reconstruction and free flap for other reconstruction areas. Many oral reconstructive methods and their modifications have been reported. The Gillies fan flap, Abbe flap, Estlander flap, Johanson flap, Karapandzic flap and Webster flap are the most commonly used local flaps for oral reconstruction. Dr. Corderio reported on the usefulness of Estlander flap combined with free flap for upper lip reconstruction in patients with massive middle face defects.3 Similarly, Dr. Jeng reported the usefulness of a small rotated full-thickness upper lip flap for the lower lip reconstruction when combined with free flap in patients with massive lower face defects.4 The benefits of lip reconstruction using local flap are considerable in terms of operation duration, oral dynamic function, sensory recovery and aesthetic result e all of which have been documented in case studies. For small to middle defects (<60%) of the lower lip, the small rotated flap used by Dr. Jeng is considered to be very useful. However, for slightly largersized face defects (60e80%), the small rotated flap is insufficient. Consequently, the Estlander flap presents a greater benefit than the small rotated flap, although patients may exhibit limited microstomia. To maintain local flap reconstruction for the oral circumference, we used the Estlander flap for a larger-sized lower lip defect in patients presenting with massive lower defects. Patient outcomes included a two-finger-sized mouth-opening limitation; nonetheless, patients exhibited good oral intake and their condition was improved by oral rehabilitation. For the mandibular bone reconstruction, several reconstructive methods have been reported. Typically, fibular bone, scapular bone and iliac bone reconstructions have been used for the mandibular defect. Among the merits of such reconstructions, the use of the subscapular artery system flap allows for the simultaneous combination of bone segments and larger soft-tissue flaps in massive lower face defects including mandibular defects. For such massive lower face defects, double free flaps are required, which in turn necessitate double sets of microanastomoses. This resulting doubling of surgical time also doubles surgical complication risks, although improvements have been noted for the microanastomosis technique. Nonetheless, the use of the free subscapular artery system flap allows surgeons to reconstruct a large soft-tissue defect and mandibular bone with a single set of microanastomoses. A drawback of this flap usage includes positioning change for flap harvest; recent studies, however, have demonstrated that flap elevation can be easily and safely performed in the semi-lateral position without changing surgical drapes.8,9 The use of this flap elevation method is often preferred because of the shortened operational duration, in turn resulting in fewer surgical complications.
A combined technique of Estlander flap and free flap In summary, for massive lower defects including those of the lower lip and the mandibular bone, the combination flap of Estlander flap and subscapular system flap facilitates the reconstruction of this complex structure and improves resulting functionality.
Conflict of interest/funding None.
Acknowledgements We thank Jeffrey D. Meserve for his editorial assistance.
References 1. Martin T, Sury F, Goga D, et al. Reconstruction of large defects of the lips and commissure using a composite radial forearm palmaris longus free flap associated with a lengthening temporalis myoplasty. Ann Plast Surg 2012;69:169e72. 2. Sadove RC, Luce EA, McGrath PC. Reconstruction of the lower lip and chin with the composite radial forearm-palmaris longus free flap. Plast Reconstr Surg 1991;88:209e14.
e369 3. Cordeiro PG, Santamaria E. Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg 1999;103:1850e6. 4. 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. 5. Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of extensive composite mandibular defects with large lip involvement by using double free flaps and fascia lata grafts for oral sphincters. Plast Reconstr Surg 2005;115: 1830e6. 6. Ninkovic M, Spanio di Spilimbergo S, Kim Evans KF. Lower lip reconstruction using a functioning gracilis muscle free flap. Semin Plast Surg 2010;24:212e8. 7. Ueda K, Oba S, Nakai K, et al. Functional reconstruction of the upper and lower lips and commissure with a forearm flap combined with a free gracilis muscle transfer. J Plast Reconstr Aesthet Surg 2009;62:e337e40. 8. Nishimura T, Furukawa M, Koshima I. Scapular bone flap harvests of patients in a supine position. Laryngoscope 2004;114: 1130e2. 9. Clark JR, Vesely M, Gilbert R. Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: defect, reconstruction, shoulder function, and harvest technique. Head Neck 2008;30:10e20.
CASE REPORT
Complex lower face reconstruction using a combined technique of Estlander flap and subscapular artery system free flaps Atsumori Hamahata a,*, Takashi Saitou a, Takeshi Beppu b, Satoshi Shirakura b, Akio Hatanaka b, Takashi Yamaki c, Hiroyuki Sakurai c a
Division of Plastic and Reconstructive Surgery, Saitama Cancer Center, Saitama, Japan Division of Head and Neck Surgery, Saitama Cancer Center, Saitama, Japan c Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medical University, Tokyo, Japan b
Received 14 May 2013; accepted 2 June 2013
KEYWORDS Lip reconstruction; Switch flap; Mandibular defect; Scapular flap
Summary When advanced mandibular carcinoma is resected, the defect may include lip and oral commissure. Free flap insertion is commonly used to reconstruct the lip defect. Although improvements in the oral reconstructive method via free flap use have been reported, functional and aesthetic results of the oral sphincter remain limited. This case report describes two individuals presenting with massive lower face defects, including a lower lip defect and a mandibular bone defect. Reconstruction was accomplished using the Estlander flap and free subscapular system of flaps. In both cases, the free subscapular artery system flap was elevated from the mandibular bone defect and other mucosal defect. The lower lip and oral commissure defect was reconstructed via Estlander flap. Free flaps survived 100% and both cases healed without complication. Patients regained good oral sphincter function with no reports of drooling. Thus, in cases involving massive lower face resection, including that of the lower lip and mandibular bone, this method of reconstruction when combined with lip-switch flap and subscapular artery system flap can prove to be useful. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Division of Plastic and Reconstructive Surgery, Saitama Cancer Center, 818 Komuro, Inamachi Kitaadachigunn, Saitama, Japan. Tel.: þ81 48 722 1111; fax: þ81 48 722 1129. E-mail address: [email protected] (A. Hamahata). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.06.009
A combined technique of Estlander flap and free flap Reconstruction of massive lower face defects e including lower lip and mandibular bone defects e remains challenging for reconstructive surgeons. Single free flap or double free flaps are typically used to reconstruct massive lower face defects. Although limitations for oral sphincter function and some unaesthetic results have been noted, improvements in free flap reconstruction for oral reconstruction have been observed.1,2 Nonetheless, some patients complain of untoward side effects including drooling and free flap tissue numbness. Drs. Corderio and Jeng have reported that a combination method of local flap for lip reconstruction and free flap has been beneficial for patients presenting with massive middle and lower face defects.3e5 Dr. Jeng applied a small, rotated full-thickness upper lip flap for reconstruction of a lower lip defect. For massive lower face defects, including small to middle lower lip defects (<60%), the small, rotated full-thickness upper lip flap continues to prove useful. However, for massive lower face defects, including slightly larger lower lip defects, the Estlander flap combined with free subscapular artery system flap appears to be a useful method. This case report describes two individuals who had massive lower face defects, including defect of the lower lip and mandibular bone. Reconstruction was accomplished via Estlander flap combined with a free subscapular artery system flap.
Patient reports Patient 1 A 57-year-old woman was referred to us with an advanced tumour in her gingival carcinoma, which invaded the mandibular bone and mentum skin (Figure 1). The TNM classification was T4aN0M0. The tumour lesion e including mouth floor mucosa, mandibular bone and mentum skin e was excised under general anaesthesia. The lower lip defect size was approximately 70%. The subscapular artery system free flap was elevated in a semi-lateral position. In this case, a combination flap of scapular bone with
Figure 1 Advanced gingival carcinoma with mandibular bone and mentum skin involvement observed preoperatively.
e367 parascapular flap was harvested. After securing the scapular bone to the remaining mandibular bone, microanastomoses were performed and the flap was revascularised. Subsequently, a 2.5ecm-wide switch-lip flap was designed with oral sphincter and commissure reconstruction achieved by transposing the flap to the lower lip (Figures 2 and 3). The gap area of the parascapular cutaneous flap was de-epithelised and the flap was then sutured to the mucosa of floor of oral and mentum skin. The flap survived totally and the patient began an oral liquid food diet on postoperative day 12 following removal of tracheotomy tube. Soft food was allowed on postoperative day 14 and the patient was discharged uneventfully. The patient had some microstomia (on two fingers), but oral competence was adequate and fully functional 6 months postoperation (Figure 4). The patient regained speech articulation and resumed her job 6 months postoperation.
Patient 2 A 68-year-old woman was referred to us with a recurrent tumour in her gingival carcinoma, which invaded the mandibular bone, tongue and mentum skin. Tumour resection and radiation therapy previously had been performed. The tumour lesion e including whole tongue, larynx, mandibular bone and mentum skin e was excised under general anaesthesia. The lower lip defect size was approximately 65%. The subscapular artery system free flap was elevated in a semi-lateral position, and the combination of scapular bone flap with latissimus dorsi flap was harvested. After securing the scapular bone to the remaining mandibular bone, microanastomoses were performed and the flap was revascularised. Subsequently, a 2.5-cm-wide Estlander flap was designed and the oral sphincter and oral commissure were reconstructed by transposing the flap to the lower lip. The flap survived
Figure 2 The lower lip defect size was approximately 70 percent. An Estlander flap of 2.5 cm width was designed.
e368
A. Hamahata et al.
Figure 3
The flap was transposed to the lower lip.
totally and the patient began an oral liquid diet on postoperative day 13 following tracheotomy tube removal. Soft food was administered on postoperative day 16, and the patient was discharged uneventfully. The patient exhibited slight microstomia (on 2.5 fingers), but her oral competence was adequate and fully functional 6 months postoperation.
Discussion When massive middle and lower face defects extend to the upper and lower lip, patients’ oral competences are severely deteriorated. Although surgical methods for free flap reconstruction of the oral circumference have improved,1,2 oral reconstruction using the free flap still presents
Figure 4
Appearance six months postoperation: open mouth.
limitations, for example, flap numbness, drooling and oral competence. Free radial forearm flap combined with palmaris longus often are used, but such reconstruction results in adynamic and non-sensory reconstruction. Although free gracilis muscle flap combined with forearm flap has been successful in dynamic reconstruction, the reconstructive method modifications have been limited.6,7 Moreover, for patients with massive lower face defects, usage of free flap reconstruction for oral circumferences complicates surgical operations without commensurate benefit. Drs. Corderio and Jeng have recommended combining the local flap for lip reconstruction and free flap for other reconstruction areas. Many oral reconstructive methods and their modifications have been reported. The Gillies fan flap, Abbe flap, Estlander flap, Johanson flap, Karapandzic flap and Webster flap are the most commonly used local flaps for oral reconstruction. Dr. Corderio reported on the usefulness of Estlander flap combined with free flap for upper lip reconstruction in patients with massive middle face defects.3 Similarly, Dr. Jeng reported the usefulness of a small rotated full-thickness upper lip flap for the lower lip reconstruction when combined with free flap in patients with massive lower face defects.4 The benefits of lip reconstruction using local flap are considerable in terms of operation duration, oral dynamic function, sensory recovery and aesthetic result e all of which have been documented in case studies. For small to middle defects (<60%) of the lower lip, the small rotated flap used by Dr. Jeng is considered to be very useful. However, for slightly largersized face defects (60e80%), the small rotated flap is insufficient. Consequently, the Estlander flap presents a greater benefit than the small rotated flap, although patients may exhibit limited microstomia. To maintain local flap reconstruction for the oral circumference, we used the Estlander flap for a larger-sized lower lip defect in patients presenting with massive lower defects. Patient outcomes included a two-finger-sized mouth-opening limitation; nonetheless, patients exhibited good oral intake and their condition was improved by oral rehabilitation. For the mandibular bone reconstruction, several reconstructive methods have been reported. Typically, fibular bone, scapular bone and iliac bone reconstructions have been used for the mandibular defect. Among the merits of such reconstructions, the use of the subscapular artery system flap allows for the simultaneous combination of bone segments and larger soft-tissue flaps in massive lower face defects including mandibular defects. For such massive lower face defects, double free flaps are required, which in turn necessitate double sets of microanastomoses. This resulting doubling of surgical time also doubles surgical complication risks, although improvements have been noted for the microanastomosis technique. Nonetheless, the use of the free subscapular artery system flap allows surgeons to reconstruct a large soft-tissue defect and mandibular bone with a single set of microanastomoses. A drawback of this flap usage includes positioning change for flap harvest; recent studies, however, have demonstrated that flap elevation can be easily and safely performed in the semi-lateral position without changing surgical drapes.8,9 The use of this flap elevation method is often preferred because of the shortened operational duration, in turn resulting in fewer surgical complications.
A combined technique of Estlander flap and free flap In summary, for massive lower defects including those of the lower lip and the mandibular bone, the combination flap of Estlander flap and subscapular system flap facilitates the reconstruction of this complex structure and improves resulting functionality.
Conflict of interest/funding None.
Acknowledgements We thank Jeffrey D. Meserve for his editorial assistance.
References 1. Martin T, Sury F, Goga D, et al. Reconstruction of large defects of the lips and commissure using a composite radial forearm palmaris longus free flap associated with a lengthening temporalis myoplasty. Ann Plast Surg 2012;69:169e72. 2. Sadove RC, Luce EA, McGrath PC. Reconstruction of the lower lip and chin with the composite radial forearm-palmaris longus free flap. Plast Reconstr Surg 1991;88:209e14.
e369 3. Cordeiro PG, Santamaria E. Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg 1999;103:1850e6. 4. 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. 5. Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of extensive composite mandibular defects with large lip involvement by using double free flaps and fascia lata grafts for oral sphincters. Plast Reconstr Surg 2005;115: 1830e6. 6. Ninkovic M, Spanio di Spilimbergo S, Kim Evans KF. Lower lip reconstruction using a functioning gracilis muscle free flap. Semin Plast Surg 2010;24:212e8. 7. Ueda K, Oba S, Nakai K, et al. Functional reconstruction of the upper and lower lips and commissure with a forearm flap combined with a free gracilis muscle transfer. J Plast Reconstr Aesthet Surg 2009;62:e337e40. 8. Nishimura T, Furukawa M, Koshima I. Scapular bone flap harvests of patients in a supine position. Laryngoscope 2004;114: 1130e2. 9. Clark JR, Vesely M, Gilbert R. Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: defect, reconstruction, shoulder function, and harvest technique. Head Neck 2008;30:10e20.