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Functional lower lip reconstruction with the modified Bernard–Webster flap
Accepted Manuscript Functional lower lip reconstruction with the modified Bernard-Webster flap Rafael Denadai, MD, Cassio Eduardo Raposo-Amaral, MD, PhD, Celso Luiz Buzzo, MD, MSc, Cesar Augusto Raposo-Amaral, MD PII:
S1748-6815(15)00351-4
DOI:
10.1016/j.bjps.2015.07.019
Reference:
PRAS 4705
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 30 April 2015 Accepted Date: 12 July 2015
Please cite this article as: Denadai R, Raposo-Amaral CE, Buzzo CL, Raposo-Amaral CA, Functional lower lip reconstruction with the modified Bernard-Webster flap, British Journal of Plastic Surgery (2015), doi: 10.1016/j.bjps.2015.07.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Functional lower lip reconstruction with the modified Bernard-Webster flap
Rafael Denadai, MD;a Cassio Eduardo Raposo-Amaral, MD, PhD; a
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Celso Luiz Buzzo, MD, MSc; a
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Running head: Functional lower lip reconstruction
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Cesar Augusto Raposo-Amaral, MDa,*
From the aInstitute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, São
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Paulo, Brazil
*Corresponding author. Institute of Plastic and Craniofacial Surgery, SOBRAPAR
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Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo CEP: 13084-880, Brazil.
E-mail adress: [email protected] (CA Raposo-Amaral)
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ACCEPTED MANUSCRIPT SUMMARY BACKGROUND: Lower lip defects after squamous cell carcinoma (SCC) excisions have been repaired by several surgical techniques. However, the functional reconstruction of fullthickness defects of the lower lip remains a therapeutic challenge. We therefore evaluated
thickness lower lip defects after SCC excisions.
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functional results of the modified Bernard-Webster flap for the reconstruction of full-
METHODS: A prospective study was performed on all patients with lower lip full-thickness
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defects after SCC excisions greater than 1/3 of the lip, reconstructed with the modified Bernard-Webster flap in 2011-2013. Functional (sphincter, motor, and sensory functions)
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postoperative results were evaluated according to criteria previously adopted. RESULTS: Twelve lower lip defects were reconstructed without complications, except for two (16.7%) wound dehiscence successfully managed. Ten (83.3%) patients presented transient and permanent functional abnormalities in the recent and late postoperative
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assessments. Ten (83.3%) patients classified the late functional results as satisfactory. CONCLUSIONS: The modified Bernard-Webster flap proved to be an excellent alternative to repair full-thickness lower lip defects with more than 1/3 of the lower lip length, as it
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allowed the use of similar neighboring tissues, could be performed in one stage, and was
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functionally effective.
Key words: Lower lip reconstruction, Bernard-Webster flap, Functional reconstruction
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ACCEPTED MANUSCRIPT INTRODUCTION Squamous cell carcinoma (SCC) is the most common malignancy of the lower lip, and depending on its size, can be infiltrative and destructive1. Surgical excision with tumor-free margins may cause a major defect that requires complex surgical reconstruction1-3. Therefore,
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appropriate preoperative planning and choosing a meticulous surgical technique are essential to recreate an aesthetically pleasing and functional lower lip1-3. Considering a wide variation of soft-tissue tumor compromise, each surgical approach should be selected according to the
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extent, location, and thickness of the lower lip defect2,3.
Full-thickness defects larger than 1/3 of the lower lip length require complex
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reconstructive procedures such as described by several authors4-10. In 1845, Dieffenbach4 was the first to suggest the reconstruction of lower lip defects using the medial advancement of bilateral cheek flaps. Bernard6, in 1853, described a bilateral Burow’s triangle full-thickness resection in the nasolabial fold, allowing the medial advancement of cheek flaps. In 1960,
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Bernard’s surgical approach6 was modified by Webster9; the triangular resection became of partial thickness, and the mucosal flaps were applied to either reconstruct the lip vermilion or to advance the paranasal skin region, using principles previously described by Schuchardt11.
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Since then, the Bernard-Webster flap9 with further technical modifications has been used in lower lip reconstructions worldwide2,6,12-21.
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Interestingly, divergent functional outcomes have been described after modified16,18-21
Bernard-Webster’s9 techniques, namely Fries’15 modification (a curved incision in the labiomental fold and an excision of Burow’s triangles in the submental region) and Wechselberger’s16 modification (preservation of the innervated muscle fibers of the oral orbicularis muscle by dissection and careful tissue handling, without complete muscle transection at the level of the commissures). As the modifications proposed by Fries15 were not directly focused on the sensory and muscle components of lower lip function, we 3
ACCEPTED MANUSCRIPT hypothesized that the technical refinements described by Wechselberger et al.16, could determine satisfactory functional results in the postoperative assessments. The purpose of the study was to evaluate the functional results after lower lip
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reconstruction using the modified16 Bernard-Webster flap9.
METHODS
A prospective study of consecutive patients with full-thickness lower lip defects with
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more than 1/3 of lower lip length after SSC excision, and who underwent lower lip reconstruction with the modified16 Bernard-Webster flap9, was conducted at a single plastic
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and craniofacial surgery unit between 2011 and 2013. Demographic, clinical, and surgical data were collected via medical records, clinical photographs, and interviews with all patients. All patients with the following criteria were excluded from the study: partial-thickness lower lip defects, lower lip defects with less than 1/3 of the lower lip length, and/or incomplete
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medical records/follow-up. Patients with a medical history that could interfere with the sensitivity of the perioral region (diabetes mellitus, previous facial trauma, prior perioral surgical intervention, and established neurosensory disorders) were also excluded.
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All subjects were enrolled upon a signed consent form, in accordance with the Helsinki Declaration of 1975, as amended in 1983. A local institutional research ethics board
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approval was obtained for this study.
Surgical approach
In our center, all full-thickness lower lip defects with more than 1/3 of the lower lip length after SCC excisions and with no oral commissure involvement have been reconstructed with the modified16 Bernard-Webster flap9. Besides the traditional Bernard-Webster principles9, the preservation of the muscles constituting the modiolus was the modification16 4
ACCEPTED MANUSCRIPT adopted in all patients. In summary, spreading of orbicularis oris muscles and surrounding muscles with delicate scissors along their fibers allowed perioral soft tissue advancement with preservation of muscle innervations16. Unilateral or bilateral flaps have been adopted based on the location of the lower lip defects (predominantly lateral defects or predominantly central
quantification method described by Jeng et al.22.
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Functional assessments
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defects, respectively), and all lower lip defects have been stratified according to the
Functional results were investigated during each post-surgery visit (7, 14, 21, 30, and
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60 days postoperatively and then every three months). The standardized clinical examination consisted of an evaluation of the orbicular ring function including: opening the mouth, pouting the lips, lip at rest for lip continence, speech, and neurosensitivity according to similar previous investigations8,20-21,23. Oral continence (incompetence, sialorrhoea at rest,
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sialorrhoea formed with fluid intake, and complete competence) and lip mobility (symmetric/asymmetric by observing pouting and mouth-opening movements) were verified according to a previous study21. The speech was evaluated during conversations with all
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patients, and all patients were questioned about their difficulties with oral communication after lower lip surgery23. Self-assessment of altered sensation was classified as hypoesthesia
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present or hypoesthesia absent21. The objective neurosensory evaluations of the cheek, nasolabial folds, upper and lower lips, and chin regions were tested by determination of the light touch threshold detection with Semmes-Weinstein monofilaments (North Coast Medical, Inc., San Jose, CA, USA), according to the previously described standard method24,25. Both sides of the face were tested separately, and the Semmes-Weinstein monofilament 3.22 was adopted as the upper limit of normality for the threshold detection of the anatomical sites investigated24,25. All patients were tested pre- and postoperatively. The neurosensory 5
ACCEPTED MANUSCRIPT impairment was defined as “abnormal test” in the postoperative period. The permanent neurosensory deficit was defined as “abnormal clinical test” with at least 12 months postoperatively24,25. All patients were questioned about their overall satisfaction (satisfied,
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partially satisfied, or dissatisfied) with the late functional results23.
RESULTS
A total of 12 patients met the inclusion criteria (Table 1). The bilateral and unilateral
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modified Bernard-Webster flaps were performed in the ten (83.3%) and two (16.7%) patients, respectively. No direct injury of the muscles forming the orbicularis oris and modiolus,
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mental nerves, nerve branches in the Burow’s triangles, or vascular structures was observed during surgical procedures (Figure 1). No hematoma, necrosis, infection, or oro-cutaneous fistula were seen in these series of patients. Wound dehiscence occurred in two (16.7%) patients; one (8.3%) patient demonstrated simple re-suturing of the skin; and another (8.3%)
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patient was initially treated with re-suturing of the skin, but showed further complete dehiscence and was then managed with local advancement and rotation flaps. Ten (83.3%) patients presented some type of functional impairment (i.e., oral
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incompetence for liquids, sialorrhoea with fluid intake, asymmetric pouting/mouth-opening movements, difficulty in mouth-opening, ingestion disorder, oral hygiene, speech
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abnormality, and/or subjective neurosensory abnormalities) in the postoperative period (Table 2). None of the patients experienced total numbness/anesthesia of the lip or chin. All patients were able to return to their usual diet and normal oral hygienization 30-45 days after surgical interventions. Complete oral competence, normal subjective neurosensitivity, normal subjective mouth opening, and normal pronunciation were detected in all patients on an average of three months postoperatively. No patient presented microstomia or distortion of facial features in the late postoperative evaluations (Figure 2). 6
ACCEPTED MANUSCRIPT All objective neurosensory tests were normal in the preoperative period. Postoperatively, neurosensory deficit was found in ten (83.3%) patients. The following areas showed deficits in neurosensory tests: bilateral chin region (three patients; 25%), left part of chin region (two patients; 16.7%), central part of lower lip (three patients; 25%), left part of
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lower lip (one patient; 8.3%), and both chin and lower lip regions (two patients; 16.7%). All patients presented normal objective neurosensory tests 55.3±31.7 (21-120 days) days after lower lip reconstructions, with no permanent neurosensory deficit in the postoperative follow-
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up period analyzed. Ten (83.3%) patients were satisfied with the late functional results (Table
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2).
DISCUSSION
To date, no surgical technique provides all of the requirements for an ideal lip reconstruction26,27. The Karapandzic8 and the Bernard-Webster9 flaps with its modifications
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have been two of the most adopted reconstructive options for the management of large lower lip defects. Both flaps8,9 are single-stage procedures26; however, as the Karapandzic flap8 has the potential risk of microstomia and blunting of the oral commissure27, the modified
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Bernard-Webster flap16 has been the first choice for reconstruction of full-thickness lower lip defects with more than 1/3 of the lower lip length in our center, as adopted in other
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institutions16,21,26.
We and others16,21,26 adopt the reconstructive technique based on Bernard-Webster’s
principles9 because it can be applied to the restoration of extensive full-thickness lower lip defects, including patients with limited residual lower lip – as it does not completely depend on the remaining lower lip tissue to rebuild a new lower lip2,27. In addition, this particular flap has been considered ideal for the elderly, due to skin laxity, as well as for those patients using
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ACCEPTED MANUSCRIPT dental prosthesis21 (the advancement of cheek flaps considerably reduces the risk of microstomia2,17,26,27), as shown in our results and other results16,21,26. In the literature, the potential disadvantages of the Bernard-Webster flap9 include notching of the central lip incision and effacement of the gingivobuccal sulcus2. Additionally,
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according to a seminal manuscript by Webster9, the orbicularis oris and buccinator muscles are cut with lateral incisions from the oral commissure, and very few innervated muscle fibers are left. Consequently, reconstruction of patients with this approach9 may be accompanied by
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functional deficits such as oral incontinence for liquids21. In addition, different reports18,20 have presented unsatisfactory functional results with modified Bernard-Webster flaps. We
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hypothesized that these unsatisfactory results were probably due to the lack of careful local muscle manipulation using only particular modifications of the Bernard-Webster technique18,20, as there are satisfactory functional data21,26 with the adoption of the modifications proposed by Wechselberger et al.16. In fact, as oral competence is ensured by
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the contraction of the orbicularis oris muscle and by the function of other muscles attached to the modiolus21, Wechselberger et al.16, in 2002, proposed refinements of the Bernard-Webster flap9 (namely, the preservation of the muscles constituting the modiolus, especially the
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orbicularis oris), aiming to accomplish normal innervation of the lower lip, oral competence, and neurosensory functions.
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In this context, we carefully evaluated the functional results after lower lip
reconstruction with the modified16 Bernard-Webster flap, to reassess previous data16,21,26, and to support our simplified treatment protocol in which full-thickness lower lip defects with more than 1/3 of the lower lip length and with no oral commissure involvement have been exclusively reconstructed by this particular surgical technique16. We assessed perioral neurosensitivity, because this particular function must be preserved or restored after lower lip reconstruction to provide a proprioceptive mechanism for 8
ACCEPTED MANUSCRIPT movement, speech, and salivary continence2. Previous comparative studies23,28 have shown that there are no differences in neurosensory tests after lower lip reconstruction with innervated flaps versus noninnervated flaps, but the Bernard-Webster flap or its modifications were not investigated23,28. Reports16,18-21 that enrolled modified Bernard-Webster flaps
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demonstrated mixed neurosensory results (i.e., satisfactory and unsatisfactory results) in the postoperative evaluations. Several factors (e.g., differences in postoperative time, tools for evaluating neurosensory disorders, size of the lower lip defects, and technical modifications)
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are among the possible explanations for these previous mixed findings16,18-21. Therefore, in order to reduce potential limitations, we prospectively evaluated two postoperative periods,
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and we also adopted a previously validated objective tool (pressure thresholds) for evaluating neurosensory disorders with evidence to support its validity and reliability in cutaneous neurosensory measurements24,25,29-32.
We observed transient neurosensory deficit in the chin and lower lip regions in ten
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(83.3%) patients. These neurosensory deficits were completely resolved in the late postoperative period, and no permanent neurosensory deficit was evidenced, as previously highlighted, that neurosensitivity can slowly return in patients with a reconstructed lower
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lip23. Thus, our primary hypothesis has proven to be right. We believe that with appropriate visualization and preservation of vascular-nervous and muscular systems during tissue
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mobilization, the modified16 Bernard-Webster flap9 adopted by our group is safe from a neurosensory point of view, mirroring and reinforcing previous data16,21,26. Additionally, we evaluated further lower lip functions, and it demonstrated ten
(83.3%) patients with impairments in the oral competence and pouting/mouth-opening movement in the recent postoperative analyses. Most of these functional abnormalities were not detected or reported in the late postoperative period, as previously reported in
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ACCEPTED MANUSCRIPT investigations on lower lip reconstruction with different local flaps12,21, including the surgical technique16,21 used in the present study. As adopted in other centers16,21,26, our simplified therapeutic approach is an adaptation of more extensive algorithms19,26,27. As the modified16 Bernard-Webster flap9 is a
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reproducible surgical procedure with satisfactory oncological and functional results16,21,26, this simplified approach facilitates successful surgical management of a wide spectrum of fullthickness lower lip defects with the exception of oral commissure involvement. In this
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context, Ünsal Tuna et al.21, reported persistent sialorrhoea and apparent asymmetry in mouth movement in patients with tumor involvement of the oral commissure, and no muscle
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preservation during lower lip reconstruction with the similar surgical technique adopted by us. Contrary to this group21, we have not approached patients with compromise of the oral commissure using the modified16 Bernard-Webster9 flap. We believe that careful and conservative manipulation and excision of soft-tissues in the oral commissure region may
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jeopardize the oncological outcomes and should be cautioned.
Our study has some caveats that should be addressed. Although our functional analysis was grounded in previously published methods8,20-25, we did not adopt all existing tools to
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measure lower lip function. An additional limitation is the absence of a control group (different surgical techniques for lower lip reconstructions), although this report is not a
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comparative study. Further research may confront or ratify our data and also try to solve these drawbacks.
CONCLUSION This study demonstrated that the modified Bernard-Webster flap is a safe alternative for the oncological and functional reconstruction of full-thickness lower lip defects with more than 1/3 of the lower lip length after SCC surgical excision. 10
ACCEPTED MANUSCRIPT Conflict of interest: None / Sources of funding: None
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patients. J Oral Maxillofac Surg 2007;65:675–9
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of squamous cell carcinoma of the lip: analysis of a 10-year experience in 223
2. Baumann D, Robb G. Lip reconstruction. Semin Plast Surg 2008;22:269–80
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3. Ebrahimi A, Maghsoudnia GR, Arshadi AA. Prospective comparative study of lower lip defects reconstruction with different local flaps. J Craniofac Surg 2011;22:2255–9
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4. Dieffenbach JF. Chirurgische Erfahrungen, besonders ueber die Wiederherstellung Zerstoerter Theile des menschlichen Koerpers nach neuen methoden. Bedim: TC.F. Enslin,1829;34–8
5. Burow A. Zur Blepharoplastik. Monatsschr. Med Augenheilkd Chir 1838;1:57–61.
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6. Bernard C. Cancer de la levre inferieur opere par un procede nouveau. Bull Soc Chir Paris 1853;3:357–60
7. Abbe R. A new plastic operation for the relief of deformity due to double harelip.
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Plast Reconstr Surg 1968;42(5):481–3
8. Karapandzik M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg
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1974;27:93–7
9. Webster RC, Coffey R, Kelleber RE. Total and partial reconstruction of the lower lip with innervated muscle-bearing flaps. Plast Reconstr Surg Transplant Bull 1960;25:360–71 10. Fujimori R. Gate flap for the total reconstruction of the lower lip. Br J Plast Surg 1980;33:340–5
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ACCEPTED MANUSCRIPT 11. Schuchardt K. Operationen im Gesicht und im kieferbereich. Operationen an den Lippen. In: Bier, Braun, Krummel (eds) Chirurgishche Operationslehre. J.A. Barth: Leipzig, 1954
Neck Surg 1993:4:46–53
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12. Cupp CL, Larrabee WF. Reconstruction of the lips. Oper Tech Otolaryngol-Head
13. Konstantinovic VS. Refinement of the Fries and Webster modifications of the Bernard repair of the lower lip. Br J Plast Surg 1996;49:462–5
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14. Zilinsky I, Winkler E, Weiss G, Haik J, Tamir J, Orenstein A. Total lower lip reconstruction with innervated muscle-bearing flaps: a modification of the Webster
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flap. Dermatol Surg 2001;27:687–91
15. Fries R. Advantages of a basic concept in lip reconstruction after tumour resection. J Maxillofac Surg 1973;1:13–8
16. Wechselberger G, Gurunluoglu R, Bauer T, Piza-Katzer H, Schoeller T. Functional
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lower lip reconstruction with bilateral cheek advancement flaps: revisitation of Webster method with a minor modification in the technique. Aesthetic Plast Surg 2002;26:423–8
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17. Hamahata A, Saitou T, Ishikawa M, Beppu T, Sakurai H. Lower lip reconstruction using a combined technique of the webster and johanson methods. Ann Plast Surg
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2013;70:654–6
18. Roldán JC, Teschke M, Fritzer E, Dunsche A, Härle F, Wiltfang J, Terheyden H. Reconstruction of the lower lip: rationale to preserve the aesthetic units of the face. Plast Reconstr Surg 2007;120:1231–9 19. Faulhaber J, Géraud C, Goerdt S, Koenen W. Functional and aesthetic reconstruction of full-thickness defects of the lower lip after tumor resection: analysis of 59 cases and discussion of a surgical approach. Dermatol Surg 2010;36:859–67 12
ACCEPTED MANUSCRIPT 20. Schüller M, Gosau M, Müller S, Gerken M, Rohrmeier C, Legal S, Schreml S, Ettl T. Long-term outcome and subjective quality of life after surgical treatment of lower lip cancer. Clin Oral Investig 2015;19:1093–9 21. Unsal Tuna EE, Oksüzler O, Ozbek C, Ozdem C. Functional and aesthetic results
lip cancers. J Plast Reconstr Aesthet Surg 2010;63:981–7
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obtained by modified Bernard reconstruction technique after tumour excision in lower
22. Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of concomitant lip and
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cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip. Plast Reconstr Surg 2004;113:491–8
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23. Civelek B, Celebioglu S, Unlu E, Civelek S, Inal I, Velidedeoglu HV. Denervated or innervated flaps for the lower lip reconstruction? Are they really different to get a good result? Otolaryngol Head Neck Surg 2006;134:613–7 24. Sarmento GS, Denadai R, Somensi RS, Giancolli AP, Junqueira Neto JG, Buzzo CL,
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Raposo-do-Amaral CA, Raposo-do-Amaral CE. Evaluation of neurosensory disturbance in patients with craniofacial syndrome subjected to horizontal chin advancement. Rev Bras Cir Plást 2013;28:205–11
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25. Essick GK. Comprehensive clinical evaluation of perioral sensory function. Oral Maxillofac Surg Clin North Am 1992;4:503–26
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26. Seo HJ, Bae SH, Nam SB, Choi SJ, Kim JH, Lee JW, Bae YC. Lower lip reconstruction after wide excision of a malignancy with barrel-shaped excision or the webster modification of the bernard operation. Arch Plast Surg 2013;40:36–43
27. Eskiizmir G, Baker S, Cingi C. Nonmelanoma skin cancer of the head and neck: reconstruction. Facial Plast Surg Clin North Am 2012;20:493–513
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ACCEPTED MANUSCRIPT 28. Ayhan Oral M, Zeynep Sevim K, Görgü M, Yücel Öztan H. Sensory recovery with innervated and noninnervated flaps after total lower lip reconstruction: a comparative study. Plast Surg Int 2013;2013:643061
Clin North Am 1981;61:303–19
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29. Omer GE Jr. Methods of assessment of injury and recovery of peripheral nerves. Surg
30. Posnick JC, Zimbler AG, Grossman JA. Normal cutaneous sensibility of the face. Plast Reconstr Surg 1990;86:429–33
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31. Vriens JP, van der Glas HW. Extension of normal values on sensory function for facial
Surg 2009;38:1154–8
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areas using clinical tests on touch and two-point discrimination. Int J Oral Maxillofac
32. Siemionow M, Gharb BB, Rampazzo A. The face as a sensory organ. Plast Reconstr
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Surg 2011;127:652–62
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ACCEPTED MANUSCRIPT FIGURE LEGENDS
FIGURE 1. (Above) Intraoperative photograph showing the marking of tumor excision and the bilateral modified Bernard-Webster flap. (Center) Intraoperative photograph revealing a
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large full-thickness lower lip defect, partial-thickness triangular excisions lateral to the nasolabial folds and in the labiomental groove, and preservation of the muscles constituting
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the modiolus. (Below) Immediate postoperative photograph showing the lines of closure.
FIGURE 2. (Left) Preoperative frontal photographs of three patients with lower lip squamous
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cell carcinomas. (Center and Right) Late postoperative frontal photographs after lower lip
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reconstructions with the modified Bernard-Webster flap shows normal lip movements.
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ACCEPTED MANUSCRIPT Table 1 - Demographic, clinical, and oncological characteristics of the patients with functional lower lip reconstruction after squamous cell carcinoma excisions (n=12).
Variables
Patients
Gender n (%) 11 (91.7%) / 1 (8.3%)
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Male / Female Age M±SD (range)
64.3±12.3 years (44-88 years) 12 (100%)
Occupational sun exposure n (%)
10 (83.3%)
Smoking n (%)
8 (66.7%)
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Fitzpatrick skin-type I-III n (%)
Time course of lesion range
6-50 months
Lower lip location n (%) Central
12 (100%)
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Normal cervical lymph nodes n (%)
10 (83.3%)
Lateral
2 (16.7%)
Oral commissure
-
Lesion size range
20-50 mm
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Defect size * M±SD (range)
62.5±14.9% (40-90%)
Histopathologic diagnosis n (%) Squamous cell carcinoma Well-differentiated pattern
12 (100%) 6 (50%) 6 (50%)
Neoplasia-free surgical margins
12 (100%)
Vascular or perineural invasion
-
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Moderately differentiated pattern
T2N0M0 ** n (%)
Postoperative follow-up M±SD (range) Recurrence / New lip lesion
12 (100%) 26.3±10.8 months (12-48 months) -
n, number of patients; M, mean; SD, standard deviation; *, Jeng grading system22; **, 7th American Joint Committee on Cancer Staging Manual
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ACCEPTED MANUSCRIPT Table 2 - Functional lower lip results obtained by the modified Bernard-Webster flap after lower lip squamous cell carcinoma excisions (n=12).
Postoperative follow-up period n (%) Variables Late
Hypoesthesia
4 (33.3)
Normal
8 (66.7)
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Recent
2 (16.7)
12 (100)
(<3 months)
-
12 (100)
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Subjective neurosensitivity
(≥12 months)
Objective neurosensory test
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Normal
5 (41.7)
-
Sensory deficit in lower lip region
4 (33.3)
-
Sensory deficit in both regions
2 (16.7)
-
4 (33.3)
-
-
-
2 (16.7)
-
6 (50)
12 (100)
1 (8.3)
1 (8.3)
11 (91.7)
11 (91.7)
No
10 (83.3)
12 (100)
Yes
2 (16.7)
-
> 40 mm
12 (100)
12 (100)
< 40 mm
-
-
Normal
10 (83.3)
12 (100)
Abnormal
2 (16.7)
-
Sensory deficit in chin region
Competence
Sialorrhea at rest
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Incompetence
Sialorrhea with fluid intake Complete competence
Pouting/mouth-opening movements
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Asymmetric Symmetric
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Limited subjective mouth opening
Maximal mouth opening
Comprehensive pronunciation
Ingestion disorder 2
No
8 (66.7)
12 (100)
Yes
4 (33.3)
-
Normal
8 (66.7)
12 (100)
Hampered
4 (33.3)
-
Possible
7 (87.5)
Not possible
1 (12.5)
Microstomia
-
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Oral hygiene
Dental prosthesis use *
1 (12.5) -
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Functional results
7 (87.5)
Satisfied
10 (83.3)
Partially satisfied
NA
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Dissatisfied
2 (16.7) -
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n, number of patients; *, eight (66.7%) patients used dental prosthesis; NA, not applicable
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S1748-6815(15)00351-4
DOI:
10.1016/j.bjps.2015.07.019
Reference:
PRAS 4705
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 30 April 2015 Accepted Date: 12 July 2015
Please cite this article as: Denadai R, Raposo-Amaral CE, Buzzo CL, Raposo-Amaral CA, Functional lower lip reconstruction with the modified Bernard-Webster flap, British Journal of Plastic Surgery (2015), doi: 10.1016/j.bjps.2015.07.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Functional lower lip reconstruction with the modified Bernard-Webster flap
Rafael Denadai, MD;a Cassio Eduardo Raposo-Amaral, MD, PhD; a
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Celso Luiz Buzzo, MD, MSc; a
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Running head: Functional lower lip reconstruction
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Cesar Augusto Raposo-Amaral, MDa,*
From the aInstitute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, São
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Paulo, Brazil
*Corresponding author. Institute of Plastic and Craniofacial Surgery, SOBRAPAR
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Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo CEP: 13084-880, Brazil.
E-mail adress: [email protected] (CA Raposo-Amaral)
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ACCEPTED MANUSCRIPT SUMMARY BACKGROUND: Lower lip defects after squamous cell carcinoma (SCC) excisions have been repaired by several surgical techniques. However, the functional reconstruction of fullthickness defects of the lower lip remains a therapeutic challenge. We therefore evaluated
thickness lower lip defects after SCC excisions.
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functional results of the modified Bernard-Webster flap for the reconstruction of full-
METHODS: A prospective study was performed on all patients with lower lip full-thickness
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defects after SCC excisions greater than 1/3 of the lip, reconstructed with the modified Bernard-Webster flap in 2011-2013. Functional (sphincter, motor, and sensory functions)
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postoperative results were evaluated according to criteria previously adopted. RESULTS: Twelve lower lip defects were reconstructed without complications, except for two (16.7%) wound dehiscence successfully managed. Ten (83.3%) patients presented transient and permanent functional abnormalities in the recent and late postoperative
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assessments. Ten (83.3%) patients classified the late functional results as satisfactory. CONCLUSIONS: The modified Bernard-Webster flap proved to be an excellent alternative to repair full-thickness lower lip defects with more than 1/3 of the lower lip length, as it
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allowed the use of similar neighboring tissues, could be performed in one stage, and was
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functionally effective.
Key words: Lower lip reconstruction, Bernard-Webster flap, Functional reconstruction
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ACCEPTED MANUSCRIPT INTRODUCTION Squamous cell carcinoma (SCC) is the most common malignancy of the lower lip, and depending on its size, can be infiltrative and destructive1. Surgical excision with tumor-free margins may cause a major defect that requires complex surgical reconstruction1-3. Therefore,
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appropriate preoperative planning and choosing a meticulous surgical technique are essential to recreate an aesthetically pleasing and functional lower lip1-3. Considering a wide variation of soft-tissue tumor compromise, each surgical approach should be selected according to the
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extent, location, and thickness of the lower lip defect2,3.
Full-thickness defects larger than 1/3 of the lower lip length require complex
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reconstructive procedures such as described by several authors4-10. In 1845, Dieffenbach4 was the first to suggest the reconstruction of lower lip defects using the medial advancement of bilateral cheek flaps. Bernard6, in 1853, described a bilateral Burow’s triangle full-thickness resection in the nasolabial fold, allowing the medial advancement of cheek flaps. In 1960,
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Bernard’s surgical approach6 was modified by Webster9; the triangular resection became of partial thickness, and the mucosal flaps were applied to either reconstruct the lip vermilion or to advance the paranasal skin region, using principles previously described by Schuchardt11.
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Since then, the Bernard-Webster flap9 with further technical modifications has been used in lower lip reconstructions worldwide2,6,12-21.
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Interestingly, divergent functional outcomes have been described after modified16,18-21
Bernard-Webster’s9 techniques, namely Fries’15 modification (a curved incision in the labiomental fold and an excision of Burow’s triangles in the submental region) and Wechselberger’s16 modification (preservation of the innervated muscle fibers of the oral orbicularis muscle by dissection and careful tissue handling, without complete muscle transection at the level of the commissures). As the modifications proposed by Fries15 were not directly focused on the sensory and muscle components of lower lip function, we 3
ACCEPTED MANUSCRIPT hypothesized that the technical refinements described by Wechselberger et al.16, could determine satisfactory functional results in the postoperative assessments. The purpose of the study was to evaluate the functional results after lower lip
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reconstruction using the modified16 Bernard-Webster flap9.
METHODS
A prospective study of consecutive patients with full-thickness lower lip defects with
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more than 1/3 of lower lip length after SSC excision, and who underwent lower lip reconstruction with the modified16 Bernard-Webster flap9, was conducted at a single plastic
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and craniofacial surgery unit between 2011 and 2013. Demographic, clinical, and surgical data were collected via medical records, clinical photographs, and interviews with all patients. All patients with the following criteria were excluded from the study: partial-thickness lower lip defects, lower lip defects with less than 1/3 of the lower lip length, and/or incomplete
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medical records/follow-up. Patients with a medical history that could interfere with the sensitivity of the perioral region (diabetes mellitus, previous facial trauma, prior perioral surgical intervention, and established neurosensory disorders) were also excluded.
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All subjects were enrolled upon a signed consent form, in accordance with the Helsinki Declaration of 1975, as amended in 1983. A local institutional research ethics board
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approval was obtained for this study.
Surgical approach
In our center, all full-thickness lower lip defects with more than 1/3 of the lower lip length after SCC excisions and with no oral commissure involvement have been reconstructed with the modified16 Bernard-Webster flap9. Besides the traditional Bernard-Webster principles9, the preservation of the muscles constituting the modiolus was the modification16 4
ACCEPTED MANUSCRIPT adopted in all patients. In summary, spreading of orbicularis oris muscles and surrounding muscles with delicate scissors along their fibers allowed perioral soft tissue advancement with preservation of muscle innervations16. Unilateral or bilateral flaps have been adopted based on the location of the lower lip defects (predominantly lateral defects or predominantly central
quantification method described by Jeng et al.22.
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Functional assessments
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defects, respectively), and all lower lip defects have been stratified according to the
Functional results were investigated during each post-surgery visit (7, 14, 21, 30, and
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60 days postoperatively and then every three months). The standardized clinical examination consisted of an evaluation of the orbicular ring function including: opening the mouth, pouting the lips, lip at rest for lip continence, speech, and neurosensitivity according to similar previous investigations8,20-21,23. Oral continence (incompetence, sialorrhoea at rest,
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sialorrhoea formed with fluid intake, and complete competence) and lip mobility (symmetric/asymmetric by observing pouting and mouth-opening movements) were verified according to a previous study21. The speech was evaluated during conversations with all
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patients, and all patients were questioned about their difficulties with oral communication after lower lip surgery23. Self-assessment of altered sensation was classified as hypoesthesia
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present or hypoesthesia absent21. The objective neurosensory evaluations of the cheek, nasolabial folds, upper and lower lips, and chin regions were tested by determination of the light touch threshold detection with Semmes-Weinstein monofilaments (North Coast Medical, Inc., San Jose, CA, USA), according to the previously described standard method24,25. Both sides of the face were tested separately, and the Semmes-Weinstein monofilament 3.22 was adopted as the upper limit of normality for the threshold detection of the anatomical sites investigated24,25. All patients were tested pre- and postoperatively. The neurosensory 5
ACCEPTED MANUSCRIPT impairment was defined as “abnormal test” in the postoperative period. The permanent neurosensory deficit was defined as “abnormal clinical test” with at least 12 months postoperatively24,25. All patients were questioned about their overall satisfaction (satisfied,
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partially satisfied, or dissatisfied) with the late functional results23.
RESULTS
A total of 12 patients met the inclusion criteria (Table 1). The bilateral and unilateral
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modified Bernard-Webster flaps were performed in the ten (83.3%) and two (16.7%) patients, respectively. No direct injury of the muscles forming the orbicularis oris and modiolus,
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mental nerves, nerve branches in the Burow’s triangles, or vascular structures was observed during surgical procedures (Figure 1). No hematoma, necrosis, infection, or oro-cutaneous fistula were seen in these series of patients. Wound dehiscence occurred in two (16.7%) patients; one (8.3%) patient demonstrated simple re-suturing of the skin; and another (8.3%)
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patient was initially treated with re-suturing of the skin, but showed further complete dehiscence and was then managed with local advancement and rotation flaps. Ten (83.3%) patients presented some type of functional impairment (i.e., oral
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incompetence for liquids, sialorrhoea with fluid intake, asymmetric pouting/mouth-opening movements, difficulty in mouth-opening, ingestion disorder, oral hygiene, speech
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abnormality, and/or subjective neurosensory abnormalities) in the postoperative period (Table 2). None of the patients experienced total numbness/anesthesia of the lip or chin. All patients were able to return to their usual diet and normal oral hygienization 30-45 days after surgical interventions. Complete oral competence, normal subjective neurosensitivity, normal subjective mouth opening, and normal pronunciation were detected in all patients on an average of three months postoperatively. No patient presented microstomia or distortion of facial features in the late postoperative evaluations (Figure 2). 6
ACCEPTED MANUSCRIPT All objective neurosensory tests were normal in the preoperative period. Postoperatively, neurosensory deficit was found in ten (83.3%) patients. The following areas showed deficits in neurosensory tests: bilateral chin region (three patients; 25%), left part of chin region (two patients; 16.7%), central part of lower lip (three patients; 25%), left part of
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lower lip (one patient; 8.3%), and both chin and lower lip regions (two patients; 16.7%). All patients presented normal objective neurosensory tests 55.3±31.7 (21-120 days) days after lower lip reconstructions, with no permanent neurosensory deficit in the postoperative follow-
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up period analyzed. Ten (83.3%) patients were satisfied with the late functional results (Table
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2).
DISCUSSION
To date, no surgical technique provides all of the requirements for an ideal lip reconstruction26,27. The Karapandzic8 and the Bernard-Webster9 flaps with its modifications
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have been two of the most adopted reconstructive options for the management of large lower lip defects. Both flaps8,9 are single-stage procedures26; however, as the Karapandzic flap8 has the potential risk of microstomia and blunting of the oral commissure27, the modified
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Bernard-Webster flap16 has been the first choice for reconstruction of full-thickness lower lip defects with more than 1/3 of the lower lip length in our center, as adopted in other
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institutions16,21,26.
We and others16,21,26 adopt the reconstructive technique based on Bernard-Webster’s
principles9 because it can be applied to the restoration of extensive full-thickness lower lip defects, including patients with limited residual lower lip – as it does not completely depend on the remaining lower lip tissue to rebuild a new lower lip2,27. In addition, this particular flap has been considered ideal for the elderly, due to skin laxity, as well as for those patients using
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ACCEPTED MANUSCRIPT dental prosthesis21 (the advancement of cheek flaps considerably reduces the risk of microstomia2,17,26,27), as shown in our results and other results16,21,26. In the literature, the potential disadvantages of the Bernard-Webster flap9 include notching of the central lip incision and effacement of the gingivobuccal sulcus2. Additionally,
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according to a seminal manuscript by Webster9, the orbicularis oris and buccinator muscles are cut with lateral incisions from the oral commissure, and very few innervated muscle fibers are left. Consequently, reconstruction of patients with this approach9 may be accompanied by
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functional deficits such as oral incontinence for liquids21. In addition, different reports18,20 have presented unsatisfactory functional results with modified Bernard-Webster flaps. We
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hypothesized that these unsatisfactory results were probably due to the lack of careful local muscle manipulation using only particular modifications of the Bernard-Webster technique18,20, as there are satisfactory functional data21,26 with the adoption of the modifications proposed by Wechselberger et al.16. In fact, as oral competence is ensured by
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the contraction of the orbicularis oris muscle and by the function of other muscles attached to the modiolus21, Wechselberger et al.16, in 2002, proposed refinements of the Bernard-Webster flap9 (namely, the preservation of the muscles constituting the modiolus, especially the
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orbicularis oris), aiming to accomplish normal innervation of the lower lip, oral competence, and neurosensory functions.
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In this context, we carefully evaluated the functional results after lower lip
reconstruction with the modified16 Bernard-Webster flap, to reassess previous data16,21,26, and to support our simplified treatment protocol in which full-thickness lower lip defects with more than 1/3 of the lower lip length and with no oral commissure involvement have been exclusively reconstructed by this particular surgical technique16. We assessed perioral neurosensitivity, because this particular function must be preserved or restored after lower lip reconstruction to provide a proprioceptive mechanism for 8
ACCEPTED MANUSCRIPT movement, speech, and salivary continence2. Previous comparative studies23,28 have shown that there are no differences in neurosensory tests after lower lip reconstruction with innervated flaps versus noninnervated flaps, but the Bernard-Webster flap or its modifications were not investigated23,28. Reports16,18-21 that enrolled modified Bernard-Webster flaps
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demonstrated mixed neurosensory results (i.e., satisfactory and unsatisfactory results) in the postoperative evaluations. Several factors (e.g., differences in postoperative time, tools for evaluating neurosensory disorders, size of the lower lip defects, and technical modifications)
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are among the possible explanations for these previous mixed findings16,18-21. Therefore, in order to reduce potential limitations, we prospectively evaluated two postoperative periods,
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and we also adopted a previously validated objective tool (pressure thresholds) for evaluating neurosensory disorders with evidence to support its validity and reliability in cutaneous neurosensory measurements24,25,29-32.
We observed transient neurosensory deficit in the chin and lower lip regions in ten
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(83.3%) patients. These neurosensory deficits were completely resolved in the late postoperative period, and no permanent neurosensory deficit was evidenced, as previously highlighted, that neurosensitivity can slowly return in patients with a reconstructed lower
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lip23. Thus, our primary hypothesis has proven to be right. We believe that with appropriate visualization and preservation of vascular-nervous and muscular systems during tissue
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mobilization, the modified16 Bernard-Webster flap9 adopted by our group is safe from a neurosensory point of view, mirroring and reinforcing previous data16,21,26. Additionally, we evaluated further lower lip functions, and it demonstrated ten
(83.3%) patients with impairments in the oral competence and pouting/mouth-opening movement in the recent postoperative analyses. Most of these functional abnormalities were not detected or reported in the late postoperative period, as previously reported in
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ACCEPTED MANUSCRIPT investigations on lower lip reconstruction with different local flaps12,21, including the surgical technique16,21 used in the present study. As adopted in other centers16,21,26, our simplified therapeutic approach is an adaptation of more extensive algorithms19,26,27. As the modified16 Bernard-Webster flap9 is a
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reproducible surgical procedure with satisfactory oncological and functional results16,21,26, this simplified approach facilitates successful surgical management of a wide spectrum of fullthickness lower lip defects with the exception of oral commissure involvement. In this
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context, Ünsal Tuna et al.21, reported persistent sialorrhoea and apparent asymmetry in mouth movement in patients with tumor involvement of the oral commissure, and no muscle
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preservation during lower lip reconstruction with the similar surgical technique adopted by us. Contrary to this group21, we have not approached patients with compromise of the oral commissure using the modified16 Bernard-Webster9 flap. We believe that careful and conservative manipulation and excision of soft-tissues in the oral commissure region may
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jeopardize the oncological outcomes and should be cautioned.
Our study has some caveats that should be addressed. Although our functional analysis was grounded in previously published methods8,20-25, we did not adopt all existing tools to
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measure lower lip function. An additional limitation is the absence of a control group (different surgical techniques for lower lip reconstructions), although this report is not a
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comparative study. Further research may confront or ratify our data and also try to solve these drawbacks.
CONCLUSION This study demonstrated that the modified Bernard-Webster flap is a safe alternative for the oncological and functional reconstruction of full-thickness lower lip defects with more than 1/3 of the lower lip length after SCC surgical excision. 10
ACCEPTED MANUSCRIPT Conflict of interest: None / Sources of funding: None
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9. Webster RC, Coffey R, Kelleber RE. Total and partial reconstruction of the lower lip with innervated muscle-bearing flaps. Plast Reconstr Surg Transplant Bull 1960;25:360–71 10. Fujimori R. Gate flap for the total reconstruction of the lower lip. Br J Plast Surg 1980;33:340–5
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ACCEPTED MANUSCRIPT 11. Schuchardt K. Operationen im Gesicht und im kieferbereich. Operationen an den Lippen. In: Bier, Braun, Krummel (eds) Chirurgishche Operationslehre. J.A. Barth: Leipzig, 1954
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12. Cupp CL, Larrabee WF. Reconstruction of the lips. Oper Tech Otolaryngol-Head
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14. Zilinsky I, Winkler E, Weiss G, Haik J, Tamir J, Orenstein A. Total lower lip reconstruction with innervated muscle-bearing flaps: a modification of the Webster
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15. Fries R. Advantages of a basic concept in lip reconstruction after tumour resection. J Maxillofac Surg 1973;1:13–8
16. Wechselberger G, Gurunluoglu R, Bauer T, Piza-Katzer H, Schoeller T. Functional
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lower lip reconstruction with bilateral cheek advancement flaps: revisitation of Webster method with a minor modification in the technique. Aesthetic Plast Surg 2002;26:423–8
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17. Hamahata A, Saitou T, Ishikawa M, Beppu T, Sakurai H. Lower lip reconstruction using a combined technique of the webster and johanson methods. Ann Plast Surg
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2013;70:654–6
18. Roldán JC, Teschke M, Fritzer E, Dunsche A, Härle F, Wiltfang J, Terheyden H. Reconstruction of the lower lip: rationale to preserve the aesthetic units of the face. Plast Reconstr Surg 2007;120:1231–9 19. Faulhaber J, Géraud C, Goerdt S, Koenen W. Functional and aesthetic reconstruction of full-thickness defects of the lower lip after tumor resection: analysis of 59 cases and discussion of a surgical approach. Dermatol Surg 2010;36:859–67 12
ACCEPTED MANUSCRIPT 20. Schüller M, Gosau M, Müller S, Gerken M, Rohrmeier C, Legal S, Schreml S, Ettl T. Long-term outcome and subjective quality of life after surgical treatment of lower lip cancer. Clin Oral Investig 2015;19:1093–9 21. Unsal Tuna EE, Oksüzler O, Ozbek C, Ozdem C. Functional and aesthetic results
lip cancers. J Plast Reconstr Aesthet Surg 2010;63:981–7
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obtained by modified Bernard reconstruction technique after tumour excision in lower
22. Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of concomitant lip and
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cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip. Plast Reconstr Surg 2004;113:491–8
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23. Civelek B, Celebioglu S, Unlu E, Civelek S, Inal I, Velidedeoglu HV. Denervated or innervated flaps for the lower lip reconstruction? Are they really different to get a good result? Otolaryngol Head Neck Surg 2006;134:613–7 24. Sarmento GS, Denadai R, Somensi RS, Giancolli AP, Junqueira Neto JG, Buzzo CL,
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Raposo-do-Amaral CA, Raposo-do-Amaral CE. Evaluation of neurosensory disturbance in patients with craniofacial syndrome subjected to horizontal chin advancement. Rev Bras Cir Plást 2013;28:205–11
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25. Essick GK. Comprehensive clinical evaluation of perioral sensory function. Oral Maxillofac Surg Clin North Am 1992;4:503–26
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27. Eskiizmir G, Baker S, Cingi C. Nonmelanoma skin cancer of the head and neck: reconstruction. Facial Plast Surg Clin North Am 2012;20:493–513
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ACCEPTED MANUSCRIPT 28. Ayhan Oral M, Zeynep Sevim K, Görgü M, Yücel Öztan H. Sensory recovery with innervated and noninnervated flaps after total lower lip reconstruction: a comparative study. Plast Surg Int 2013;2013:643061
Clin North Am 1981;61:303–19
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29. Omer GE Jr. Methods of assessment of injury and recovery of peripheral nerves. Surg
30. Posnick JC, Zimbler AG, Grossman JA. Normal cutaneous sensibility of the face. Plast Reconstr Surg 1990;86:429–33
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31. Vriens JP, van der Glas HW. Extension of normal values on sensory function for facial
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areas using clinical tests on touch and two-point discrimination. Int J Oral Maxillofac
32. Siemionow M, Gharb BB, Rampazzo A. The face as a sensory organ. Plast Reconstr
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Surg 2011;127:652–62
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ACCEPTED MANUSCRIPT FIGURE LEGENDS
FIGURE 1. (Above) Intraoperative photograph showing the marking of tumor excision and the bilateral modified Bernard-Webster flap. (Center) Intraoperative photograph revealing a
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large full-thickness lower lip defect, partial-thickness triangular excisions lateral to the nasolabial folds and in the labiomental groove, and preservation of the muscles constituting
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the modiolus. (Below) Immediate postoperative photograph showing the lines of closure.
FIGURE 2. (Left) Preoperative frontal photographs of three patients with lower lip squamous
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cell carcinomas. (Center and Right) Late postoperative frontal photographs after lower lip
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reconstructions with the modified Bernard-Webster flap shows normal lip movements.
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ACCEPTED MANUSCRIPT Table 1 - Demographic, clinical, and oncological characteristics of the patients with functional lower lip reconstruction after squamous cell carcinoma excisions (n=12).
Variables
Patients
Gender n (%) 11 (91.7%) / 1 (8.3%)
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Male / Female Age M±SD (range)
64.3±12.3 years (44-88 years) 12 (100%)
Occupational sun exposure n (%)
10 (83.3%)
Smoking n (%)
8 (66.7%)
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Fitzpatrick skin-type I-III n (%)
Time course of lesion range
6-50 months
Lower lip location n (%) Central
12 (100%)
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Normal cervical lymph nodes n (%)
10 (83.3%)
Lateral
2 (16.7%)
Oral commissure
-
Lesion size range
20-50 mm
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Defect size * M±SD (range)
62.5±14.9% (40-90%)
Histopathologic diagnosis n (%) Squamous cell carcinoma Well-differentiated pattern
12 (100%) 6 (50%) 6 (50%)
Neoplasia-free surgical margins
12 (100%)
Vascular or perineural invasion
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Moderately differentiated pattern
T2N0M0 ** n (%)
Postoperative follow-up M±SD (range) Recurrence / New lip lesion
12 (100%) 26.3±10.8 months (12-48 months) -
n, number of patients; M, mean; SD, standard deviation; *, Jeng grading system22; **, 7th American Joint Committee on Cancer Staging Manual
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ACCEPTED MANUSCRIPT Table 2 - Functional lower lip results obtained by the modified Bernard-Webster flap after lower lip squamous cell carcinoma excisions (n=12).
Postoperative follow-up period n (%) Variables Late
Hypoesthesia
4 (33.3)
Normal
8 (66.7)
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Recent
2 (16.7)
12 (100)
(<3 months)
-
12 (100)
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Subjective neurosensitivity
(≥12 months)
Objective neurosensory test
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Normal
5 (41.7)
-
Sensory deficit in lower lip region
4 (33.3)
-
Sensory deficit in both regions
2 (16.7)
-
4 (33.3)
-
-
-
2 (16.7)
-
6 (50)
12 (100)
1 (8.3)
1 (8.3)
11 (91.7)
11 (91.7)
No
10 (83.3)
12 (100)
Yes
2 (16.7)
-
> 40 mm
12 (100)
12 (100)
< 40 mm
-
-
Normal
10 (83.3)
12 (100)
Abnormal
2 (16.7)
-
Sensory deficit in chin region
Competence
Sialorrhea at rest
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Incompetence
Sialorrhea with fluid intake Complete competence
Pouting/mouth-opening movements
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Asymmetric Symmetric
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Limited subjective mouth opening
Maximal mouth opening
Comprehensive pronunciation
Ingestion disorder 2
No
8 (66.7)
12 (100)
Yes
4 (33.3)
-
Normal
8 (66.7)
12 (100)
Hampered
4 (33.3)
-
Possible
7 (87.5)
Not possible
1 (12.5)
Microstomia
-
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Oral hygiene
Dental prosthesis use *
1 (12.5) -
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Functional results
7 (87.5)
Satisfied
10 (83.3)
Partially satisfied
NA
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Dissatisfied
2 (16.7) -
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n, number of patients; *, eight (66.7%) patients used dental prosthesis; NA, not applicable
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