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FAMM flap reconstruction of the inferior lip vermilion: Surgery during early infancy
Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 425e427
CASE REPORT
FAMM flap reconstruction of the inferior lip vermilion: Surgery during early infancy A. Baj*, D. Rocchetta, G. Beltramini, A.B. Giannı` Department of Maxillofacial Surgery, Graduate School of Medicine, Milan University, Milan, Italy Received 1 December 2004; accepted 30 March 2006
KEYWORDS Facial trauma; Lip avulsion; Lip reconstruction; FAMM flap; Paediatric surgery
Summary The lips are complex, laminated structures consisting of skin, subcutaneous tissue, muscle, submucosa and mucosa. Clearly when the lip is lost through injury or disease, it presents a complex reconstructive challenge. The facial artery muscular mucosal flap (FAMM), harvested from lateral cheek, is a composite flap with many features which make it an excellent option for lip and vermilion reconstruction. The authors present a review of literature and a case of a 2-year-old girl with medial lower-lip vermilion avulsion, reconstructed with a FAMM flap. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The vermilion represents a particularly important aspect of the lip for two basic reasons: from a functional point of view, the lip vermilion is essential in the articulation of all the lip phonemes and its anatomical integrity is essential for the containment of food and saliva in the oral cavity. From a cosmetic point of view, the vermilion is the characteristic component of the lips giving the oral region its own particular aesthetic harmony. Various reconstruction techniques are used in the correction of defects affecting over 1/3rd of the inferior lip and, in particular, the vermilion: tongue flaps, cross-lip, advancement flaps, etc. The main obstacle in obtaining optimum results using such techniques in paediatric patients is the lack of collaboration; it is virtually impossible to keep the patient from fully opening the mouth for approximately 20 days, as some techniques require.
* Corresponding author. E-mail address: [email protected] (A. Baj).
In this work the authors present a case of FAMM flap reconstruction of the inferior lip vermilion in a 2-year-old patient who lost 3/4th of the central lip vermilion due to traumatic excision during a fall.
Patient and methods On 20 February 2003, a 2-year-old girl was brought to the A&E Department of the Galeazzi Institute in Milan. The little girl had accidentally excised 3/4th of her lower-lip vermilion during a fall. The damage was attributed to the accidental biting of the lower lip; in fact the central position and the curvature of the excision suggested that on falling onto her mandible and biting down with her upper incisors onto her lower lip, the little girl had completely excised the central portion of vermilion. After carrying out haemostasis, cleaning of the wound and verifying the absence of fractures to the visceral cranium, the patient was admitted to hospital and placed under antibiotic
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.03.071
426 treatment. The following day she was taken into the operating theatre for the reconstruction of her lip vermilion. The defect was repaired using a FAMM flap which, being tailored from the inside of the left cheek, guaranteed an immediate reconstruction of the open wound with a flap whose thickness and colour promised instant good results. Twenty days later, once the flap had completely grafted, the pedicle was cut and cheiloplastic surgery was carried out. The aesthetic and functional results already exceeded our expectations at this stage and they continued to improve as nature took its course. Now, 14 months after the operation the little girl has normal lip containment, she eats normally and is beginning to pronounce her first words correctly. From an aesthetic point of view, the results appear satisfactory and no further operations are foreseen. The patient’s progress will, however, be checked periodically throughout her growth to ensure no asymmetry or loss of lip tone develops.
Discussion Many techniques for the reconstruction of lip vermilion have been described in the literature. As far back as 1894, Schulten1 proposed the possibility of using a bi-pedunculated flap from the upper lip to reconstruct the loss of substance of the lower lip. The use of a tongue flap, still frequently used even today, was introduced by Lexer in 1909.2 Numerous authors have successfully used different techniques which involved the rotation and advancement of local flaps.3e8 Defects of the lip vermilion have been tackled by various authors who have proposed numerous surgical techniques. In 1984, Mazzola and Lupo9 and Standoli10 described the use of cross-lip, a technique which uses the internal portion of the upper lip mucosa to reconstruct the loss of vermilion tissue in the lower lip. The use of mucosa from the opposite lip was then proposed by Kawamoto11 in 1979, and then by Lew et al. in 1987.12 The use of rotated flaps taken from the genial mucosa for the reconstruction of lip vermilion goes back to Di Rayner in 1987. In 1989, Bozzola, after an anatomical study of the vascular network of the genial mucosa, identified a mucosal flap which was no longer random as its predecessors had been, but based on the buccal artery.13 It is in 1992, however, that Pribaz presents in great detail his FAMM flap, made up of mucosa and a portion of buccinator muscle, with an axial pedicle based entirely on the facial artery.14,15 Over the last few years various publications have illustrated the possible applications of this flap for the reconstruction of the perioral region.16,17 Reconstructing defects limited to lip vermilion, caused both by trauma and by resection in the treatment of benign and malignant pathologies, is a particularly difficult challenge due to the importance lip vermilion has for the sphincteral function and the articulation of labial phonemes. Not to be underestimated is the obvious importance lip vermilion has on the aesthetic harmony of the lips, mouth and face as a whole. What strongly emerges from close examination of available literature is how the application of this flap for the reconstruction of lip vermilion has proved to be particularly efficacious.
A. Baj et al. The objectives which must be set when lip vermilion reconstruction is undertaken are to achieve a reconstruction that is correct in its dimensions in order to obtain good mouth closure with positive repercussions on pronunciation and containment, and a reconstruction which is not cumbersome, thus creating harmonious movements and a suitable lip colour for pleasing aesthetic results. The choice of technique becomes almost compulsory when dealing with a paediatric patient as in the case described here. In such cases, apart from the usual surgical difficulties, there is the added problem of not being able to use certain techniques which could be applied to an adult patient. The main aims of paediatric reconstructive surgery must be to limit the number of possible follow-up operations and to guarantee optimum functional and aesthetic results. Furthermore, in paediatric patients it is necessary to immediately re-establish lip containment, essential for correct nutrition, and correct lip closure, so as not to impede the learning of speech, which is of fundamental importance at this delicate age. When choosing the reconstruction technique for a paediatric patient, as well as the above mentioned considerations, we must also take into account the possible lack of collaboration from the patient, which is often essential for obtaining successful results in lip vermilion reconstruction. Therefore cross-lip and tongue flap techniques and any technique which limits the opening of the mouth cannot be used efficaciously. The FAMM flap, considering the particular needs of a paediatric patient becomes, in our opinion, the most favourable technique for the following reasons: the flap is rotated from the cheek and therefore does not interfere with mouth opening; the pedicle passes outside the dental arch and therefore cannot be damaged by biting; the thickness of the flap and its colour are particularly suitable for correcting this kind of defect; the cheek and facial movements are totally unaffected by the end results. We therefore consider the FAMM flap, for its functional and aesthetic applications, together with minimum if not absent morbidity of the donor site, the ideal technique for vermilion reconstruction in paediatric patients.
References 1. Schulten MV. En methodatt erstta en defekt af ena lappen medelst en bryggformad lamba fran den anra. Fin Lakaresallsk Handl 1894;35:859. 2. Lexer E. Wangenplastik. Dtsch Z Chir 1909;100:206. 3. Spira M, Stal S. VeY advancement of a subcutaneous pedicle in vermilion lip reconstruction. Plast Reconstr Surg 1983;72:562e4. 4. Kolhe PS, Leonard AG. Reconstruction of the vermilion after ‘lip-shave.’. Br J Plast Surg 1988;41:68e73. 5. Sakai S, Soeda S, Terayama I. Bilateral island vermilion flaps for vermilion border reconstruction. Ann Plast Surg 1988;20:459e61. 6. Iwahira Y, Yataka M, Maruyama Y. The sliding door flap for repair of vermilion defects. Ann Plast Surg 1998;41:300e3. 7. Ahuja RB. Vermilion reconstruction with labia minora graft. Plast Reconstr Surg 1993;92:1418. 8. Rayner CR, Arscott GD. A new method of resurfacing the lip. Br J Plast Surg 1987;40:454e8. 9. Mazzola RF, Lupo G. Evolving concepts in lip reconstruction. Clin Plast Surg 1984;11:583e617. 10. Standoli L. Cross lip flap in vermilion reconstruction. Ann Plast Surg 1994;32:214e7.
FAMM flap reconstruction of the inferior lip vermilion 11. Kawamoto Jr HK. Correction of major defects of the vermilion with a cross-lip vermilion flap. Plast Reconstr Surg 1979;64:315e8. 12. Lew D, Clark R, Jimenez F, et al. The bipedicled lip flap for reconstruction of the vermilion border in the patient with a severe perioral burn. Oral Surg Oral Med Oral Pathol 1987;63:526e9. 13. Bozola AR, Gasques JAL, Carriquiry CE, et al. The buccinator musculomucosal flap: anatomic study and clinical application. Plast Reconstr Surg 1989;84:250e7. 14. Pribaz J, Meara JG, Wright S. Lip and vermilion reconstruction with the facial artery musculomucosal flap. Plast Reconstr Surg 2000;105:864e72.
427 15. Pribaz J, Stephens W, Crespo L, et al. A new intraoral flap: facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg 1992;90:421e9. 16. Ono I, Gunji H, Tateshita T, et al. Reconstruction of defects of the entire vermilion with a buccal muscolomucosal flap following resection of malignant tumors of the lower lip. Plast Reconstr Surg 1997;100:422e30. 17. Hatoko M, Kuwahara M, Tanaka A, et al. Use of facial artery musculomucosal flap for closure of soft tissue defects of the mandible vestibule. Int J Oral Maxillofac Surg 2002;31: 210e1.
CASE REPORT
FAMM flap reconstruction of the inferior lip vermilion: Surgery during early infancy A. Baj*, D. Rocchetta, G. Beltramini, A.B. Giannı` Department of Maxillofacial Surgery, Graduate School of Medicine, Milan University, Milan, Italy Received 1 December 2004; accepted 30 March 2006
KEYWORDS Facial trauma; Lip avulsion; Lip reconstruction; FAMM flap; Paediatric surgery
Summary The lips are complex, laminated structures consisting of skin, subcutaneous tissue, muscle, submucosa and mucosa. Clearly when the lip is lost through injury or disease, it presents a complex reconstructive challenge. The facial artery muscular mucosal flap (FAMM), harvested from lateral cheek, is a composite flap with many features which make it an excellent option for lip and vermilion reconstruction. The authors present a review of literature and a case of a 2-year-old girl with medial lower-lip vermilion avulsion, reconstructed with a FAMM flap. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The vermilion represents a particularly important aspect of the lip for two basic reasons: from a functional point of view, the lip vermilion is essential in the articulation of all the lip phonemes and its anatomical integrity is essential for the containment of food and saliva in the oral cavity. From a cosmetic point of view, the vermilion is the characteristic component of the lips giving the oral region its own particular aesthetic harmony. Various reconstruction techniques are used in the correction of defects affecting over 1/3rd of the inferior lip and, in particular, the vermilion: tongue flaps, cross-lip, advancement flaps, etc. The main obstacle in obtaining optimum results using such techniques in paediatric patients is the lack of collaboration; it is virtually impossible to keep the patient from fully opening the mouth for approximately 20 days, as some techniques require.
* Corresponding author. E-mail address: [email protected] (A. Baj).
In this work the authors present a case of FAMM flap reconstruction of the inferior lip vermilion in a 2-year-old patient who lost 3/4th of the central lip vermilion due to traumatic excision during a fall.
Patient and methods On 20 February 2003, a 2-year-old girl was brought to the A&E Department of the Galeazzi Institute in Milan. The little girl had accidentally excised 3/4th of her lower-lip vermilion during a fall. The damage was attributed to the accidental biting of the lower lip; in fact the central position and the curvature of the excision suggested that on falling onto her mandible and biting down with her upper incisors onto her lower lip, the little girl had completely excised the central portion of vermilion. After carrying out haemostasis, cleaning of the wound and verifying the absence of fractures to the visceral cranium, the patient was admitted to hospital and placed under antibiotic
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.03.071
426 treatment. The following day she was taken into the operating theatre for the reconstruction of her lip vermilion. The defect was repaired using a FAMM flap which, being tailored from the inside of the left cheek, guaranteed an immediate reconstruction of the open wound with a flap whose thickness and colour promised instant good results. Twenty days later, once the flap had completely grafted, the pedicle was cut and cheiloplastic surgery was carried out. The aesthetic and functional results already exceeded our expectations at this stage and they continued to improve as nature took its course. Now, 14 months after the operation the little girl has normal lip containment, she eats normally and is beginning to pronounce her first words correctly. From an aesthetic point of view, the results appear satisfactory and no further operations are foreseen. The patient’s progress will, however, be checked periodically throughout her growth to ensure no asymmetry or loss of lip tone develops.
Discussion Many techniques for the reconstruction of lip vermilion have been described in the literature. As far back as 1894, Schulten1 proposed the possibility of using a bi-pedunculated flap from the upper lip to reconstruct the loss of substance of the lower lip. The use of a tongue flap, still frequently used even today, was introduced by Lexer in 1909.2 Numerous authors have successfully used different techniques which involved the rotation and advancement of local flaps.3e8 Defects of the lip vermilion have been tackled by various authors who have proposed numerous surgical techniques. In 1984, Mazzola and Lupo9 and Standoli10 described the use of cross-lip, a technique which uses the internal portion of the upper lip mucosa to reconstruct the loss of vermilion tissue in the lower lip. The use of mucosa from the opposite lip was then proposed by Kawamoto11 in 1979, and then by Lew et al. in 1987.12 The use of rotated flaps taken from the genial mucosa for the reconstruction of lip vermilion goes back to Di Rayner in 1987. In 1989, Bozzola, after an anatomical study of the vascular network of the genial mucosa, identified a mucosal flap which was no longer random as its predecessors had been, but based on the buccal artery.13 It is in 1992, however, that Pribaz presents in great detail his FAMM flap, made up of mucosa and a portion of buccinator muscle, with an axial pedicle based entirely on the facial artery.14,15 Over the last few years various publications have illustrated the possible applications of this flap for the reconstruction of the perioral region.16,17 Reconstructing defects limited to lip vermilion, caused both by trauma and by resection in the treatment of benign and malignant pathologies, is a particularly difficult challenge due to the importance lip vermilion has for the sphincteral function and the articulation of labial phonemes. Not to be underestimated is the obvious importance lip vermilion has on the aesthetic harmony of the lips, mouth and face as a whole. What strongly emerges from close examination of available literature is how the application of this flap for the reconstruction of lip vermilion has proved to be particularly efficacious.
A. Baj et al. The objectives which must be set when lip vermilion reconstruction is undertaken are to achieve a reconstruction that is correct in its dimensions in order to obtain good mouth closure with positive repercussions on pronunciation and containment, and a reconstruction which is not cumbersome, thus creating harmonious movements and a suitable lip colour for pleasing aesthetic results. The choice of technique becomes almost compulsory when dealing with a paediatric patient as in the case described here. In such cases, apart from the usual surgical difficulties, there is the added problem of not being able to use certain techniques which could be applied to an adult patient. The main aims of paediatric reconstructive surgery must be to limit the number of possible follow-up operations and to guarantee optimum functional and aesthetic results. Furthermore, in paediatric patients it is necessary to immediately re-establish lip containment, essential for correct nutrition, and correct lip closure, so as not to impede the learning of speech, which is of fundamental importance at this delicate age. When choosing the reconstruction technique for a paediatric patient, as well as the above mentioned considerations, we must also take into account the possible lack of collaboration from the patient, which is often essential for obtaining successful results in lip vermilion reconstruction. Therefore cross-lip and tongue flap techniques and any technique which limits the opening of the mouth cannot be used efficaciously. The FAMM flap, considering the particular needs of a paediatric patient becomes, in our opinion, the most favourable technique for the following reasons: the flap is rotated from the cheek and therefore does not interfere with mouth opening; the pedicle passes outside the dental arch and therefore cannot be damaged by biting; the thickness of the flap and its colour are particularly suitable for correcting this kind of defect; the cheek and facial movements are totally unaffected by the end results. We therefore consider the FAMM flap, for its functional and aesthetic applications, together with minimum if not absent morbidity of the donor site, the ideal technique for vermilion reconstruction in paediatric patients.
References 1. Schulten MV. En methodatt erstta en defekt af ena lappen medelst en bryggformad lamba fran den anra. Fin Lakaresallsk Handl 1894;35:859. 2. Lexer E. Wangenplastik. Dtsch Z Chir 1909;100:206. 3. Spira M, Stal S. VeY advancement of a subcutaneous pedicle in vermilion lip reconstruction. Plast Reconstr Surg 1983;72:562e4. 4. Kolhe PS, Leonard AG. Reconstruction of the vermilion after ‘lip-shave.’. Br J Plast Surg 1988;41:68e73. 5. Sakai S, Soeda S, Terayama I. Bilateral island vermilion flaps for vermilion border reconstruction. Ann Plast Surg 1988;20:459e61. 6. Iwahira Y, Yataka M, Maruyama Y. The sliding door flap for repair of vermilion defects. Ann Plast Surg 1998;41:300e3. 7. Ahuja RB. Vermilion reconstruction with labia minora graft. Plast Reconstr Surg 1993;92:1418. 8. Rayner CR, Arscott GD. A new method of resurfacing the lip. Br J Plast Surg 1987;40:454e8. 9. Mazzola RF, Lupo G. Evolving concepts in lip reconstruction. Clin Plast Surg 1984;11:583e617. 10. Standoli L. Cross lip flap in vermilion reconstruction. Ann Plast Surg 1994;32:214e7.
FAMM flap reconstruction of the inferior lip vermilion 11. Kawamoto Jr HK. Correction of major defects of the vermilion with a cross-lip vermilion flap. Plast Reconstr Surg 1979;64:315e8. 12. Lew D, Clark R, Jimenez F, et al. The bipedicled lip flap for reconstruction of the vermilion border in the patient with a severe perioral burn. Oral Surg Oral Med Oral Pathol 1987;63:526e9. 13. Bozola AR, Gasques JAL, Carriquiry CE, et al. The buccinator musculomucosal flap: anatomic study and clinical application. Plast Reconstr Surg 1989;84:250e7. 14. Pribaz J, Meara JG, Wright S. Lip and vermilion reconstruction with the facial artery musculomucosal flap. Plast Reconstr Surg 2000;105:864e72.
427 15. Pribaz J, Stephens W, Crespo L, et al. A new intraoral flap: facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg 1992;90:421e9. 16. Ono I, Gunji H, Tateshita T, et al. Reconstruction of defects of the entire vermilion with a buccal muscolomucosal flap following resection of malignant tumors of the lower lip. Plast Reconstr Surg 1997;100:422e30. 17. Hatoko M, Kuwahara M, Tanaka A, et al. Use of facial artery musculomucosal flap for closure of soft tissue defects of the mandible vestibule. Int J Oral Maxillofac Surg 2002;31: 210e1.