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Reverse Yús flap for upper lip reconstruction
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e148ee150
SURGICAL TIP
´s flap for upper lip Reverse Yu reconstruction* Many methods have been reported for repair of fullthickness defects between one third and two thirds the total upper lip length concerning the commissure, the nasolabial fold and the philtrum. Two major techniques are available to reconstruct these defects: transoral cross lip flaps (Abbe1 and Estlander) and circumoral advancement-rotation flaps (Karapandzic2 and Gillies3). In 1989, Yu reported a new method for the lower lip reconstruction that combined flap rotation and flap advancement.4 The rotation flap took the skin from the lateral area of the nasolabial fold, whereas the remaining lower lip was advanced across incisions in the oral commissure. The labial vermilion reconstruction was carried out through oral mucosal flaps. However, this method has been scarcely documented in the literature.5 In the last 5 years we have performed more than 20 rotation-advancement Yu ´s flaps for lower lip reconstruction. The very good aesthetic and functional outcomes achieved encouraged us to design a modification of Yu’s flap as a reverse one to repair an upper half-lip defect.
Case report A 66-year-old man presented with a squamous cell carcinoma of the left upper lip. Under general anaesthesia a full-thickness left upper lip resection in a heart-shape design was performed. The defect measured 35 35 mm (Figure 1a). A 4-cm horizontal incision was made running laterally from the left corner of the mouth. This incision was continued slightly curved and parallel to the nasolabial fold 1.5 cm in a superior direction and 3 cm in an inferior direction. From the end of the curved lower part, an incision was drawn almost perpendicular to the horizontal line, which was about half the distance between them. The horizontal line on its medial half was composed of full-
* This case study was presented at the XIXth Congress of the European Association for Cranio-Maxillofacial Surgery, 09e12 September 2008.
thickness tissue of oral mucosa. At this point the medial half of the orbicularis oris muscle was cut at the commissure while the lateral half of the muscle was kept intact (Figure 2). The lateral half included skin and subcutaneous tissue, superficial to the underlying musculature. The reconstruction provided skin and muscle in the more medial part and skin only in the lateral part. The new labial vermilion was created by means of an oral mucosa flap in the shape of a parallelogram coming from the commissure. The flap was sutured layer-to-layer (Figure 1b). There were no significant postoperative complications. Two years after surgery, the aesthetic and functional results have been extremely satisfactory (Figure 1c).
Discussion The multiple methods have been reported in the plastic surgery literature for the upper lip reconstruction of larger defects suggest that there is no a completely satisfactory procedure of repair. Restoring functionality and appearance of the upper lip is difficult to achieve due to its composite functions, the many anatomical subunits, and the limited availability of adjacent skin. Transposition flaps like Abbe and Estlander are preferred in medium size defects and have an excellent cosmetic result when it is used to replace the entire philtrum. The AbbeeEstlander flap can also be used in lateral defects including the commissure. This repair takes two surgeries and many times requires a second procedure of commissurotomy to assure a sufficient oral access and maintain commissure competence. Major defects involving one half of the upper lip can be reconstructed using the rotation flaps like Gillies and Karapandzic, which restore lip continuity in one stage procedure. However they have the main disadvantages of shortening the lip and altering the oral commissure. Gillies flap has some inconveniences like an adverse effect on sensation, microstoma, and difficulty matching up the vermillion border. Karapandzic flap preserves sensation and oral competence. The foremost problems with this flap are that it can create a very small mouth opening and distort the commissure in a rounded appearance. The modification of the Yu ´s flap described is a very reliable new technique that combines the advantages of
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.06.006
Surgical Tip
e149
Figure 2 Diagram of the method used, showing the left orbicularis oris muscle partially cut. The arrows indicate the flap rotation and advancement.
operative procedure acceptable functional and aesthetic effects. This closure had a very good functional outcome since it re-established the circumferential nature of the lip muscles, which allowed for the oral competence, continuity of vermillion border, and adequate size of the opening. This design recreated the normal structure of the upper lip central and lateral subunit not distorting the commissure. The scars were placed in the vertical line extending from the central vermillion border to the base of the nose, and in the nasolabial fold and the commissure grooves, simulating a symmetrical upper lip with minimal donor site deformity. Another goal was to avoid colour differences between the reconstructed skin and the remaining original skin of the lip. The thickness of the half reconstructed lip matched the original dimensions of the opposite upper half-lip.
Conflict of interest Figure 1 (a) View after tumour resection with the beginning of the unilateral reconstruction of the upper half-lip. (b) Total closure and reconstruction completed. (c) Reconstruction 2 years after the procedure.
We do not have any conflict of interest either of financial, ethical or other nature and there were no grants or funds from any source.
References reconstruction using both rotation and advancement flaps. This flap may be a versatile procedure to reconstruct defects comprising as far as the 50% of the lateral upper lip including the commissure, allowing in one
1. Abbe R. A new plastic operation for the relief of deformity due to double harelip. Plast Reconstr Surg 1968; 42:481e3.
e150 2. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93e7. 3. Gillies HD, Millard DR. The Principles and Art of Plastic Surgery. London: Butterworth; 1957. 4. Yu JM. A new method for the reconstruction of the lower lip after tumour resection. Eur J Plast Surg 1989;12:155e9. 5. Lopez AC, Ruiz PC, Campo FJ, et al. Reconstruction of lower lip defects after tumour excision: an aesthetic and functional evaluation. Otolaryngol Head Neck Surg 2000;123:317e23.
Surgical Tip Rodolfo Belmonte-Caro Pedro Infante-Cossio Alberto Garcia-Perla-Garcia Eusebio Torres-Carranza Department of Oral and Maxillofacial Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013-Sevilla, Spain E-mail address: [email protected]
SURGICAL TIP
´s flap for upper lip Reverse Yu reconstruction* Many methods have been reported for repair of fullthickness defects between one third and two thirds the total upper lip length concerning the commissure, the nasolabial fold and the philtrum. Two major techniques are available to reconstruct these defects: transoral cross lip flaps (Abbe1 and Estlander) and circumoral advancement-rotation flaps (Karapandzic2 and Gillies3). In 1989, Yu reported a new method for the lower lip reconstruction that combined flap rotation and flap advancement.4 The rotation flap took the skin from the lateral area of the nasolabial fold, whereas the remaining lower lip was advanced across incisions in the oral commissure. The labial vermilion reconstruction was carried out through oral mucosal flaps. However, this method has been scarcely documented in the literature.5 In the last 5 years we have performed more than 20 rotation-advancement Yu ´s flaps for lower lip reconstruction. The very good aesthetic and functional outcomes achieved encouraged us to design a modification of Yu’s flap as a reverse one to repair an upper half-lip defect.
Case report A 66-year-old man presented with a squamous cell carcinoma of the left upper lip. Under general anaesthesia a full-thickness left upper lip resection in a heart-shape design was performed. The defect measured 35 35 mm (Figure 1a). A 4-cm horizontal incision was made running laterally from the left corner of the mouth. This incision was continued slightly curved and parallel to the nasolabial fold 1.5 cm in a superior direction and 3 cm in an inferior direction. From the end of the curved lower part, an incision was drawn almost perpendicular to the horizontal line, which was about half the distance between them. The horizontal line on its medial half was composed of full-
* This case study was presented at the XIXth Congress of the European Association for Cranio-Maxillofacial Surgery, 09e12 September 2008.
thickness tissue of oral mucosa. At this point the medial half of the orbicularis oris muscle was cut at the commissure while the lateral half of the muscle was kept intact (Figure 2). The lateral half included skin and subcutaneous tissue, superficial to the underlying musculature. The reconstruction provided skin and muscle in the more medial part and skin only in the lateral part. The new labial vermilion was created by means of an oral mucosa flap in the shape of a parallelogram coming from the commissure. The flap was sutured layer-to-layer (Figure 1b). There were no significant postoperative complications. Two years after surgery, the aesthetic and functional results have been extremely satisfactory (Figure 1c).
Discussion The multiple methods have been reported in the plastic surgery literature for the upper lip reconstruction of larger defects suggest that there is no a completely satisfactory procedure of repair. Restoring functionality and appearance of the upper lip is difficult to achieve due to its composite functions, the many anatomical subunits, and the limited availability of adjacent skin. Transposition flaps like Abbe and Estlander are preferred in medium size defects and have an excellent cosmetic result when it is used to replace the entire philtrum. The AbbeeEstlander flap can also be used in lateral defects including the commissure. This repair takes two surgeries and many times requires a second procedure of commissurotomy to assure a sufficient oral access and maintain commissure competence. Major defects involving one half of the upper lip can be reconstructed using the rotation flaps like Gillies and Karapandzic, which restore lip continuity in one stage procedure. However they have the main disadvantages of shortening the lip and altering the oral commissure. Gillies flap has some inconveniences like an adverse effect on sensation, microstoma, and difficulty matching up the vermillion border. Karapandzic flap preserves sensation and oral competence. The foremost problems with this flap are that it can create a very small mouth opening and distort the commissure in a rounded appearance. The modification of the Yu ´s flap described is a very reliable new technique that combines the advantages of
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.06.006
Surgical Tip
e149
Figure 2 Diagram of the method used, showing the left orbicularis oris muscle partially cut. The arrows indicate the flap rotation and advancement.
operative procedure acceptable functional and aesthetic effects. This closure had a very good functional outcome since it re-established the circumferential nature of the lip muscles, which allowed for the oral competence, continuity of vermillion border, and adequate size of the opening. This design recreated the normal structure of the upper lip central and lateral subunit not distorting the commissure. The scars were placed in the vertical line extending from the central vermillion border to the base of the nose, and in the nasolabial fold and the commissure grooves, simulating a symmetrical upper lip with minimal donor site deformity. Another goal was to avoid colour differences between the reconstructed skin and the remaining original skin of the lip. The thickness of the half reconstructed lip matched the original dimensions of the opposite upper half-lip.
Conflict of interest Figure 1 (a) View after tumour resection with the beginning of the unilateral reconstruction of the upper half-lip. (b) Total closure and reconstruction completed. (c) Reconstruction 2 years after the procedure.
We do not have any conflict of interest either of financial, ethical or other nature and there were no grants or funds from any source.
References reconstruction using both rotation and advancement flaps. This flap may be a versatile procedure to reconstruct defects comprising as far as the 50% of the lateral upper lip including the commissure, allowing in one
1. Abbe R. A new plastic operation for the relief of deformity due to double harelip. Plast Reconstr Surg 1968; 42:481e3.
e150 2. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93e7. 3. Gillies HD, Millard DR. The Principles and Art of Plastic Surgery. London: Butterworth; 1957. 4. Yu JM. A new method for the reconstruction of the lower lip after tumour resection. Eur J Plast Surg 1989;12:155e9. 5. Lopez AC, Ruiz PC, Campo FJ, et al. Reconstruction of lower lip defects after tumour excision: an aesthetic and functional evaluation. Otolaryngol Head Neck Surg 2000;123:317e23.
Surgical Tip Rodolfo Belmonte-Caro Pedro Infante-Cossio Alberto Garcia-Perla-Garcia Eusebio Torres-Carranza Department of Oral and Maxillofacial Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013-Sevilla, Spain E-mail address: [email protected]