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Nasolabial flap in intraoral reconstruction
Nasolabial Flap in Intraoral Reconstruction Review of 55 Cases
Raymond F. Morgan, MD, Baltimore, Maryland Robert G. Chambers, MD, Baltimore, Maryland Darrell A. Jaques, MD, Baltimore, Maryland John E. Hoopes, MD, Baltimore, Maryland
The nasolabial flap can be traced back to 600 B.C. [I]. Many modifications have been made since then. Thiersch [2] repaired a palatal fistula in 1868 with a superiorly based nasolabial flap. Rosenthal [3] in 1916 and Esser [4] in 1918 avoided the problem of transferring hair into the mouth by using an inferiorly based nasolabial flap for palatal reconstruction. Wallace [5] in 1966 used an inferiorly based nasolabial flap and deepithelialized the pedicle within the cheek, thus allowing a single stage procedure. Georgiade et al [6] in 1969 stressed the usefulness of the superiorly based nasolabial flap for reconstruction of the anterior palate, septum, columella and upper lip. Elliott [7] in 1976 stressed the advantages of a single stage repair when using the inferiorly based nasolabial flap. He also advocated the tapered design of the flap, which facilitates linear closure of the donor area. Others have advocated a triangularshaped flap [B-12]. Herbert and Harrison [13] in 1975 stated that the flap should be based inferiorly or laterally to assure an adequate blood supply. Gewirtz et al [12], however, in 1978 noted a dual blood supply from both facial and ophthalmic arteries which allows it to be based inferiorly or superiorly with confidence. Technique After surgical ablation is completed and the nasolabial flap is chosen for reconstruction, the flap is designed on the nasolabial fold on the same side as the defect. About 15 cm2 of lining can be supplied by From the Division of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, Maryland. Requests for reprints should be addressed to Raymond F. Morgan, MD, Division of Plastic Surgery, The Johns Hopkins Hospital, Saitimore. Maryland 21205. Presented at the 27th Annual Meeting of the Society of Head and Neck Surgeons, Phoenix, Arizona, March 9-11, 1991.
448
the flap. If the defect is larger, bilateral flaps may be used. The medial incision lies in the nasolabial fold. The flap design may be up to 3 cm in width and extend from the inferior border of the mandible to within 1 cm of the medial canthus. For the inferiorly based flap the inferior portion below the pedicle is deepithelialized and closed primarily. This diamond-shaped design allows a neat linear closure of the donor defect. The skin and subcutaneous tissue are elevated and tunnelled through the cheek. The deepithelialized pedicle within the cheek is left in place permanently. The tunnel is then checked for adequate width to avoid compression on the pedicle (Figures 1 and 2). Clinical
Material
Fifty-five patients were treated with a total of 68 nasolabial flaps for intraoral reconstruction from 1970 to 1980. Three were superiorly based and 65 inferiorly based. Nineteen of the earlier flaps in the series were done as a two-stage procedure. The remaining 49 flaps were deepithelialized and done as a one-stage procedure. One flap in the earlier group of 19 flaps failed. In the later group of 49 flaps, 4 were partial or complete failures. The superiorly based flaps were used to reconstruct one palatal and two upper lip defects. The inferiorly based flaps were used to reconstruct anterior floor of mouth and alveolar defects. The patients ranged in age from 43 to 82 years (mean 61.8). Thirty-four were men and 21 women. Only 5 of the 68 nasolabial flaps were partial or complete failures due to ischemia and necrosis. Successful reconstruction without complication was obtained in 93 percent of the flaps. A minor complication of hair-bearing tissue transferred into the mouth was encountered with four flaps. None of these patients requested an epilation procedure for removal of the hair. An example of a patient who underwent reconstruction with bilateral nasolabial flaps is shown in Figures 3 through 6.
The American Journal of Surgery
Nasolabial
Flap
Figure 1, left. Design of an inferiorly based nasoiabial flap extendfng from the inferior border ot the mandible to 1 cm below the medial canthus. The medial incision is in the nasolabiaf told. Figure 2, right. The interior portion of the flap is deepithelialized and closed primarily, providing a smooth donor defect.
Comments Most workers have advocated a nasolabial flap which is triangular in design with its base at the level of the subcutaneous tunnel. In addition, most advocate a two-stage procedure with resection of the pedicle. By extending the triangular flap into the form of an elongated diamond and deepithelializing the inferior portion, the donor site can be closed in a long, smooth line. This gives an excellent cosmetic result. If adequate length for the flap is assured with the design, it can be inset without tension on the cheek. Without tension the permanently placed
Ffgure 3, left. Preoperative vfew of a 67 year old man before an anterior floor of mouth and partial mandtbular resection tar squamous cell cancer. Figure 4, right. lntraoperatfve view sho wtng the desfgn of one of the bilateral nasolablal flaps used for primary reconstruction.
Ftgure 5, left. Postoperattve resutt 1 year after resectton and primary reconstructton. Figure 6, right. Postoperative result at 7 year.
Volume 142, October 1981
one-stage flap has given results comparable to those of the two-stage procedure, which requires later excision of the pedicle. Summary The nasolabial skin flap has proved very useful in reconstruction of anterior intraoral defects after ablation for cancer. The technique allows immediate single-stage reconstruction with local tissue. Minimal functional or cosmetic deformity results at the donor site. Fifty-five consecutive patients who underwent anterior intraoral reconstruction with 68 nasolabial
Morgan
et al
flaps were followed up for 1 to 10 years. Only two flaps were total failures. Three flaps had partial tissue loss. Successful reconstruction without complication was obtained with 93 percent of the flaps. Technical refinements and considerations in flap design are presented. References 1. Pers M. Cheek flaps in partial rhinoplasty. Stand J Plast Reconstr Surg 1967;1:37. 2. Thiersch C. Verschluss eines loches im harten gaumen durch die weichtheile der wange. Arch Heilkunde 1868;9:159. 3. Rosenthal W. Verschluss traumatischer gaumendefekte durch weischteile des gesichts. Zentrabl Chir 1916;43:596. 4. Esser JF. Deckung von gaumendefekten mittels geslielter naso-labialhautlappen. Deutsche Ztschr Chir 1918;147: 128. 5. Wallace AF. Esser’s skin flap for closing large palatal fistulae. Br J Plast Surg 1966;19:322.
450
6. Georgiade N, Mladick R, Thorne F. The nasolabial tunnel flap. Plast Reconstr Surg 1969;43:463. 7. Elliott RA. Use of nasolabial skin flap to cover intraoral defects. Plast Reconstr Surg 1976;58:201. 8. Cohen IK, Theogaraj SD. Nasolabial flap reconstruction of the floor of the mouth after extirpation of oral cancer. Am J Surg 1975;130:479. 9. Kelly JM. Reconstruction of the oral cavity after obliterative surgery for cancer. South Med J 1976;69: 1164. 10. Sharzer LA, Horton CE, Adamson JE, et al. Intraoral reconstruction in head and neck cancer surgery. In: Clinics in plastic surgery. Philadelphia: WB Saunders, 1976:495509. 11. Jabaley ME. Reconstruction in patients with oral and phat-yngeal cancer. In: Ravitch MM, ed. Current problems in surgery. Chicago: Year Book Medical, 1977:1-65. 12. Gewirtz HS, Eilber FR, Zaren HA. Use of the nasolabial flap for reconstruction of the floor of the mouth. Am J Surg 1978; 136508. 13. Herbert D, Harrison R. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg 1975;28:85.
The
American Journal
of Surgery
Raymond F. Morgan, MD, Baltimore, Maryland Robert G. Chambers, MD, Baltimore, Maryland Darrell A. Jaques, MD, Baltimore, Maryland John E. Hoopes, MD, Baltimore, Maryland
The nasolabial flap can be traced back to 600 B.C. [I]. Many modifications have been made since then. Thiersch [2] repaired a palatal fistula in 1868 with a superiorly based nasolabial flap. Rosenthal [3] in 1916 and Esser [4] in 1918 avoided the problem of transferring hair into the mouth by using an inferiorly based nasolabial flap for palatal reconstruction. Wallace [5] in 1966 used an inferiorly based nasolabial flap and deepithelialized the pedicle within the cheek, thus allowing a single stage procedure. Georgiade et al [6] in 1969 stressed the usefulness of the superiorly based nasolabial flap for reconstruction of the anterior palate, septum, columella and upper lip. Elliott [7] in 1976 stressed the advantages of a single stage repair when using the inferiorly based nasolabial flap. He also advocated the tapered design of the flap, which facilitates linear closure of the donor area. Others have advocated a triangularshaped flap [B-12]. Herbert and Harrison [13] in 1975 stated that the flap should be based inferiorly or laterally to assure an adequate blood supply. Gewirtz et al [12], however, in 1978 noted a dual blood supply from both facial and ophthalmic arteries which allows it to be based inferiorly or superiorly with confidence. Technique After surgical ablation is completed and the nasolabial flap is chosen for reconstruction, the flap is designed on the nasolabial fold on the same side as the defect. About 15 cm2 of lining can be supplied by From the Division of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, Maryland. Requests for reprints should be addressed to Raymond F. Morgan, MD, Division of Plastic Surgery, The Johns Hopkins Hospital, Saitimore. Maryland 21205. Presented at the 27th Annual Meeting of the Society of Head and Neck Surgeons, Phoenix, Arizona, March 9-11, 1991.
448
the flap. If the defect is larger, bilateral flaps may be used. The medial incision lies in the nasolabial fold. The flap design may be up to 3 cm in width and extend from the inferior border of the mandible to within 1 cm of the medial canthus. For the inferiorly based flap the inferior portion below the pedicle is deepithelialized and closed primarily. This diamond-shaped design allows a neat linear closure of the donor defect. The skin and subcutaneous tissue are elevated and tunnelled through the cheek. The deepithelialized pedicle within the cheek is left in place permanently. The tunnel is then checked for adequate width to avoid compression on the pedicle (Figures 1 and 2). Clinical
Material
Fifty-five patients were treated with a total of 68 nasolabial flaps for intraoral reconstruction from 1970 to 1980. Three were superiorly based and 65 inferiorly based. Nineteen of the earlier flaps in the series were done as a two-stage procedure. The remaining 49 flaps were deepithelialized and done as a one-stage procedure. One flap in the earlier group of 19 flaps failed. In the later group of 49 flaps, 4 were partial or complete failures. The superiorly based flaps were used to reconstruct one palatal and two upper lip defects. The inferiorly based flaps were used to reconstruct anterior floor of mouth and alveolar defects. The patients ranged in age from 43 to 82 years (mean 61.8). Thirty-four were men and 21 women. Only 5 of the 68 nasolabial flaps were partial or complete failures due to ischemia and necrosis. Successful reconstruction without complication was obtained in 93 percent of the flaps. A minor complication of hair-bearing tissue transferred into the mouth was encountered with four flaps. None of these patients requested an epilation procedure for removal of the hair. An example of a patient who underwent reconstruction with bilateral nasolabial flaps is shown in Figures 3 through 6.
The American Journal of Surgery
Nasolabial
Flap
Figure 1, left. Design of an inferiorly based nasoiabial flap extendfng from the inferior border ot the mandible to 1 cm below the medial canthus. The medial incision is in the nasolabiaf told. Figure 2, right. The interior portion of the flap is deepithelialized and closed primarily, providing a smooth donor defect.
Comments Most workers have advocated a nasolabial flap which is triangular in design with its base at the level of the subcutaneous tunnel. In addition, most advocate a two-stage procedure with resection of the pedicle. By extending the triangular flap into the form of an elongated diamond and deepithelializing the inferior portion, the donor site can be closed in a long, smooth line. This gives an excellent cosmetic result. If adequate length for the flap is assured with the design, it can be inset without tension on the cheek. Without tension the permanently placed
Ffgure 3, left. Preoperative vfew of a 67 year old man before an anterior floor of mouth and partial mandtbular resection tar squamous cell cancer. Figure 4, right. lntraoperatfve view sho wtng the desfgn of one of the bilateral nasolablal flaps used for primary reconstruction.
Ftgure 5, left. Postoperattve resutt 1 year after resectton and primary reconstructton. Figure 6, right. Postoperative result at 7 year.
Volume 142, October 1981
one-stage flap has given results comparable to those of the two-stage procedure, which requires later excision of the pedicle. Summary The nasolabial skin flap has proved very useful in reconstruction of anterior intraoral defects after ablation for cancer. The technique allows immediate single-stage reconstruction with local tissue. Minimal functional or cosmetic deformity results at the donor site. Fifty-five consecutive patients who underwent anterior intraoral reconstruction with 68 nasolabial
Morgan
et al
flaps were followed up for 1 to 10 years. Only two flaps were total failures. Three flaps had partial tissue loss. Successful reconstruction without complication was obtained with 93 percent of the flaps. Technical refinements and considerations in flap design are presented. References 1. Pers M. Cheek flaps in partial rhinoplasty. Stand J Plast Reconstr Surg 1967;1:37. 2. Thiersch C. Verschluss eines loches im harten gaumen durch die weichtheile der wange. Arch Heilkunde 1868;9:159. 3. Rosenthal W. Verschluss traumatischer gaumendefekte durch weischteile des gesichts. Zentrabl Chir 1916;43:596. 4. Esser JF. Deckung von gaumendefekten mittels geslielter naso-labialhautlappen. Deutsche Ztschr Chir 1918;147: 128. 5. Wallace AF. Esser’s skin flap for closing large palatal fistulae. Br J Plast Surg 1966;19:322.
450
6. Georgiade N, Mladick R, Thorne F. The nasolabial tunnel flap. Plast Reconstr Surg 1969;43:463. 7. Elliott RA. Use of nasolabial skin flap to cover intraoral defects. Plast Reconstr Surg 1976;58:201. 8. Cohen IK, Theogaraj SD. Nasolabial flap reconstruction of the floor of the mouth after extirpation of oral cancer. Am J Surg 1975;130:479. 9. Kelly JM. Reconstruction of the oral cavity after obliterative surgery for cancer. South Med J 1976;69: 1164. 10. Sharzer LA, Horton CE, Adamson JE, et al. Intraoral reconstruction in head and neck cancer surgery. In: Clinics in plastic surgery. Philadelphia: WB Saunders, 1976:495509. 11. Jabaley ME. Reconstruction in patients with oral and phat-yngeal cancer. In: Ravitch MM, ed. Current problems in surgery. Chicago: Year Book Medical, 1977:1-65. 12. Gewirtz HS, Eilber FR, Zaren HA. Use of the nasolabial flap for reconstruction of the floor of the mouth. Am J Surg 1978; 136508. 13. Herbert D, Harrison R. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg 1975;28:85.
The
American Journal
of Surgery